Every finding on record at Laurels of Mt Vernon the

Based on review of resident medical records, staff interviews, and review of a facility policy, the facility failed to monitor a bruise after a fall for Resident #27. This affected one resident (#27) out of one resident reviewed for general skin conditions. Additionally, the facility failed to complete daily weight monitoring as ordered for Resident #81. This affected one resident (#81) out of one resident sampled for daily weight monitoring. The facility census was 68. Findings include: 1. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] and had diagnoses that included vascular dementia and anemia.Review of Resident #27's physician orders dated 04/23/26 revealed that Resident #27 was prescribed aspirin, an antiplatelet medication, 81 milligrams chewable tablet, one tablet daily. Review of Resident #27's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 00, indicative of severe cognitive impairment. Resident #27 was assessed as needing substantial maximal assistance with transfers. Review of Resident #27's care plan dated 08/06/26 revealed that Resident #27 was at risk for cardiovascular decline related to antiplatelet blood-thinning medication. A goal listed was to be free from adverse reactions from use of blood-thinning medication. Listed approaches included administering medications as ordered and monitoring for adverse reactions and assess, document and report blood thinning medications, including bruising. Review of Resident #27's nursing progress notes dated 08/18/26 revealed that Resident #27 had a fall in her room. Review of Resident #27's nursing progress notes dated 08/22/26 revealed that Resident #27 had a fall in her room. Review of progress notes 08/23/26 at 6:43 P.M., 08/24/26 at 6:03 A.M., 08/25/26 at 6:38 A.M. and 2:27 P.M. revealed that Resident #27 had no injuries after her falls. An observation of Resident #27 at 08/24/26 at 10:47 A.M. and 08/25/26 at 1:51 P.M. revealed that Resident #27 had a bruise on her left shoulder going down her bicep area that was purple in color in the middle and yellow in color on the outside. An interview with Licensed Practical Nurse (LPN) #167 on 08/25/26 at 1:51 P.M. confirmed the presence of the bruise on Resident #27's left shoulder and confirmed that it was not being monitored by nursing staff. 2. Review of a resident medical record revealed that Resident #81 was admitted to the facility on [DATE] and had diagnoses that included congestive heart failure and chronic passive congestion of liver. Review of Resident #81's physician orders dated 06/24/26 revealed that Resident #81 was ordered daily weights. Review of Resident #81's treatment administration record for June 2026 and July 2026 revealed that daily weights were not obtained by the facility from 06/30/26 through 07/02/26. Resident #81's daily weight on 07/03/26 was not a significant change from Resident #81's daily weight obtained on 06/29/26. An interview with the Director of Nursing (DON) on 08/27/26 at 12:16 P.M. confirmed that the facility did not obtain daily weights for Resident #81 from 06/30/26 through 07/02/26. The DON revealed that Resident #81's daily weight was important to monitor due to Resident #81's history of congestive heart failure. Review of the facility policy dated May 2015 titled, Weights Policy, revealed that obtaining weights is vital for the nutrition assessment of each resident and can be used as a basis for medical and nutritional interventions. This deficiency represents non-compliance investigated under Master Complaint Number 3177404.

Based on record review, staff interviews, and facility policy review, the facility failed to investigate an incident of potential resident-to-resident abuse for two residents. This affected two residents (#15 and #48) out of three residents reviewed for abuse. The facility census was 68. Findings include: 1. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] and had diagnoses that included senile degeneration of the brain, dementia, anxiety disorder, and unspecified mood disorder. Review of Resident #15's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) score of 03, indicative of severe cognitive impairment. Review of Resident #15's mood care plan dated 11/20/25 revealed Resident #15 had an actual behavior problem related to physical and verbal behavioral symptoms and verbal aggression directed towards others. Interventions listed included observing behavior episodes and attempt to determine underling cause. Review of Resident #15's nursing progress notes dated 06/10/26 revealed that Resident #15 was hit on the right shoulder by a peer. Resident #15 was checked for injury. No injury was noted and the provider was notified with no new orders. Review of the Ohio Department of Health Certification and Licensure System revealed that a facility self-reported incident was not filed with the State Agency for the resident-to-resident potential abuse incident that occurred on 06/10/26. 2. Review of the medical record revealed Resident #48 was admitted to the facility on [DATE] and had diagnoses that included unspecified dementia, obsessive compulsive behavior, and major depressive disorder. Review of Resident #48's MDS 3.0 assessment dated [DATE] revealed Resident #48 had moderately impaired daily decision-making skills. Review of Resident #48's mood care plan dated 12/16/20 revealed that Resident #48 had an actual behavioral problem related to dementia, including physical outbursts. An intervention listed included to observe behavior episodes and attempt to determine the underlying cause. Review of Resident #48's nursing progress notes dated 06/10/26 revealed Resident #48 hit a peer on the shoulder/chest. Resident #48 continued to be yelling at other guests, No injury was noted and Resident #48 was separated from other guests. The provider was notified. Review of the Ohio Department of Health Certification and Licensure System revealed that a facility-reported incident was not filed with the State Agency for the resident-to-resident potential abuse incident that occurred on 06/10/26. An interview with Licensed Practical Nurse (LPN) #288 on 08/26/26 at 9:19 A.M. revealed that Resident #48 had on and off behaviors on 06/10/26. On that day, Resident #15 was observed to be having sundown syndrome symptoms and having verbalizations that were irritating Resident #48. Resident #48 was observed hitting Resident #15 on the right shoulder. Resident #48 expressed that she hit Resident #15 because, she wouldn't shut up. An interview with the Director of Nursing (DON) on 08/26/26 at 5:35 P.M. revealed that she felt that the incident was not intentional and confirmed that the resident-to-resident altercation was not investigated formally. Review of the facility policy published 07/11/24 and reviewed on 07/22/26 titled, Ohio Resident Abuse Policy, revealed that the definition of abuse includes actions such as the willful infliction of injury. For each case of resident-to-resident abuse, the facility will refer the matter to the facility's interdisciplinary team to determine the appropriate intervention. The facility staff must immediately report all allegations to the Administrator. The Administrator will immediately begin an investigation and notify the applicable local and state agencies. The investigation will be completed within five work days from the alleged occurrence. All residents, the accused, and witnesses will be interviewed. Written statements will be obtained and the resident's record will be reviewed. Evidence of the investigation will be documented, a conclusion will be reached, and the final report will be submitted to the State agency.This deficiency represents non-compliance investigated under Complaint Number 3042764.

Based on resident record review, interview, and facility policy review, the facility failed to implement physician orders and interventions for Resident #2's stage four pressure ulcer. Additionally, the facility failed to comprehensively assess a new pressure ulcer for Resident #29. This affected two residents (#2 and #29) of three residents sampled for pressure ulcers. The facility census was 68.Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 04/30/25. Diagnoses included acute and chronic respiratory failure with hypoxia, type 2 diabetes mellitus with diabetic neuropathy, flaccid hemiplegia affecting the left nondominant side, chronic embolism and thrombosis of other specified veins, other acute osteomyelitis (unspecified site), and mild protein-calorie malnutrition. Review of the admission nursing assessment identified Resident #2 was admitted with a stage four pressure ulcer (indicating a wound with full-thickness tissue loss with directly exposed muscle, tendon, bone, or fascia) of the sacral region. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/17/26, revealed the resident had intact cognition. The resident required extensive assistance of staff for bed mobility and was dependent on staff for transfer and ambulation. The assessment indicated the resident had a Stage four pressure ulcer. Review of the plan of care dated 07/17/26 revealed the resident was at risk for pressure ulcers due to disease process and limited mobility. Interventions included to complete skin assessments per facility policy and to encourage and reposition the resident as needed. Review of the Consultant's Report, dated 03/31/26, completed by Resident #2's wound Advance Practice Registered Nurse, (APRN), identified orders for Resident #2's primary dressing to be changed to Zetuvit, a super-absorbent wound dressing, because the wound provider noted the resident's outer dressing in place at the time of the appointment was very moist. Review of physician orders followed by the facility staff, dated 03/31/26 revealed the wound dressing order as a foam dressing to be used for the wound's outer dressing, not reflecting the wound provider's order change. Review of the Consultant's Reports, issued after the resident's wound provider appointments from 04/07/26 through 07/09/26, when Resident #2 was discharged from the wound provider's practice, identified orders for the resident's wound outer dressings to continue with the Zetuvit dressing. Review of physician orders followed by the facility staff from 04/07/26 through 07/09/26 revealed the wound dressing order remained as a foam dressing to be used for the wound's outer dressing, and was not changed to the Zetuvit dressing which was ordered. Review of the progress notes of Resident #2, and the wound provider's consultant reports from 03/31/26 through 07/09/26 did not reveal the wound provider had been notified of the facility's revision of the wound provider's orders for the wound dressing. During an interview with the Assistant Director of Nursing (ADON) #101 on 08/26/26 at 4:47 P.M., she stated she was not aware of the change to Resident #2's wound orders from the foam dressing to the Zetuvit. ADON #101 stated even if the facility was unable to get the Zetuvit from their supplier, they have other highly absorbent dressings they could have used. 2. Review of Resident #29's medical record revealed an admission date of 06/19/24 with diagnoses that included but were not limited to alcohol dependent dementia, malignant neoplasm of the mouth, hepatic encephalopathy and depression. Review of Resident #29's MDS assessment dated [DATE] revealed he was cognitively intact and required independent to supervision assist from staff with his activities of daily living. Further review revealed he had no pressure ulcers present at the time of the assessment. Review of Resident #29's evaluations revealed a skin check and skin issues assessment was completed on 06/24/26 with no skin issues noted. Review of Resident #29's progress notes dated 07/26/26 revealed staff reported to the nurse the resident had a new open area on his right hip. Further review revealed the nurse applied foam dressing encouraged the resident to turn and reposition every two hours and the provider was made aware and to follow-up on 07/27/26. Further review revealed no evidence of follow-up by the provider. Review of Resident #29's skin integrity event dated 07/26/26 revealed no documentation of the wound type or staging; the description of the skin issue was described as open area and size of area: length x width x depth (L x W x D) was documented as dime sized. Review of Resident #29's weekly wound management revealed the first wound assessment entry was dated 07/31/26. Interview on 08/26/26 at 4:30 P.M. with ADON #101 revealed nurses are to open an event upon discovery of a new wound. The event contains wound assessment, provider notification, and treatments are documented. She then adds the wounds for tracking into wound management. Interview on 08/27/26 at 9:04 A.M. with ADON #101 verified the skin event on 07/26/26 for Resident # 29 had no wound type or staging and measurement as recorded as dime sized. ADON #101 confirmed the assessment was not comprehensive. Review of the facility's policy Skin and Wound Care Best Practices, dated 03/12/21, revealed pressure injuries and wounds will be treated with evidence-based interventions as ordered by the provider. This deficiency represents non-compliance investigated under Master Complaint Number 3177404.

Based on review of resident medical records, staff interviews, and facility policy review, the facility failed to report an incident of potential resident-to-resident abuse to the State Agency for two residents. This affected two residents (#15 and #48) out of three residents reviewed for abuse. The facility census was 68. Findings include: 1. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] and had diagnoses that included senile degeneration of the brain, dementia, anxiety disorder, and unspecified mood disorder. Review of Resident #15's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) score of 03, indicative of severe cognitive impairment. Review of Resident #15's mood care plan dated 11/20/25 revealed Resident #15 had an actual behavior problem related to physical and verbal behavioral symptoms and verbal aggression directed towards others. Interventions listed included observing behavior episodes and attempt to determine underling cause. Review of Resident #15's nursing progress notes dated 06/10/26 revealed that Resident #15 was hit on the right shoulder by a peer. Resident #15 was checked for injury. No injury was noted and the provider was notified with no new orders. Review of the Ohio Department of Health Certification and Licensure System revealed that a facility self-reported incident was not filed with the State Agency for the resident-to-resident potential abuse incident that occurred on 06/10/26. 2. Review of the medical record revealed Resident #48 was admitted to the facility on [DATE] and had diagnoses that included unspecified dementia, obsessive compulsive behavior, and major depressive disorder. Review of Resident #48's MDS 3.0 assessment dated [DATE] revealed Resident #48 had moderately impaired daily decision-making skills. Review of Resident #48's mood care plan dated 12/16/20 revealed that Resident #48 had an actual behavioral problem related to dementia, including physical outbursts. An intervention listed included to observe behavior episodes and attempt to determine the underlying cause. Review of Resident #48's nursing progress notes dated 06/10/26 revealed Resident #48 hit a peer on the shoulder/chest. Resident #48 continued to be yelling at other guests, No injury was noted and Resident #48 was separated from other guests. The provider was notified. Review of the Ohio Department of Health Certification and Licensure System revealed that a facility-reported incident was not filed with the State Agency for the resident-to-resident potential abuse incident that occurred on 06/10/26. An interview with Licensed Practical Nurse (LPN) #288 on 08/26/26 at 9:19 A.M. revealed that Resident #48 had on and off behaviors on 06/10/26. On that day, Resident #15 was observed to be having sundown syndrome symptoms and having verbalizations that were irritating Resident #48. Resident #48 was observed hitting Resident #15 on the right shoulder . Resident #48 expressed that she hit Resident #15 because, she wouldn't shut up. An interview with the Director of Nursing (DON) on 08/26/26 at 5:35 P.M. confirmed that the incident between Resident #15 and Resident #48 on 06/10/26 was not reported to the State Agency. Review of the facility policy published 07/11/24 and reviewed on 07/22/26 titled, Ohio Resident Abuse Policy, revealed that facility staff must immediately report all allegations to the Administrator. The Administrator will immediately begin an investigation and notify the applicable local and state agencies. The investigation will be completed within five work days from the alleged occurrence. All residents, the accused, and witnesses will be interviewed. Written statements will be obtained and the resident's record will be reviewed. Evidence of the investigation will be documented, a conclusion will be reached, and the final report will be submitted to the State agency. This deficiency represents non-compliance investigated under Complaint Number 3042764.

Based on interview and record review the facility failed to ensure residents had the right to privacy. This affected one resident (Resident #83) out of three residents reviewed for increased staff supervision. The facility census was 84.Findings include:Review of the medical record for Resident #83 revealed an admission date of 12/04/24 with diagnoses of borderline personality disorder, major depressive disorder, anxiety, and insomnia.Review of the care plan dated 07/10/25 revealed Resident #83 had potential for mood fluctuations related to major depressive disorder, anxiety disorder, insomnia, and a history of amputation. Interventions included observing and reporting concerns to the physician, providing one to one monitoring if the resident expressed a desire to harm self or others, following suicide protocol, and notifying the physician.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #83 is cognitively intact and rejects care one to three days each week.Review of the psychiatry note dated 03/10/26 revealed Resident #83 expressed frustration regarding staff monitoring and reported he felt targeted and harassed due to being checked on every 15 minutes. The provider documented the resident had not displayed recent threats or aggressive behaviors, denied suicidal or homicidal ideation, did not appear to be an acute risk to himself or others, and recommended discontinuing the 15 minute checks.Review of the psychiatry note dated 03/13/26 revealed Resident #83 was pink slipped (substantial risk of harm to self or others) and transported to the local hospital for medical clearance before being admitted to inpatient psychiatry. Resident #83 denied suicidal or homicidal thoughts, appeared calm and pleasant, expressed hopefulness, and agreed to medication adjustments including a mood stabilizer. The resident was cleared from the pink-slip and discharged back to the facility that same day.Review of the physician orders dated 03/13/26 through 03/16/26 revealed no order for fifteen minute checks.Review of behavior monitoring from 03/13/26 through 03/18/26 revealed no behaviors exhibited such as crying, repeated movements, yelling, hitting, pushing, grabbing, biting, abusive language, threatening behaviors or rejection of care. Review of the progress note dated 03/13/26 at 10:33 P.M. revealed Resident #83 returned to the facility. Staff removed potentially harmful objects from the room and initiated fifteen minute checks. An order for Depakote (used to stabalize mood) was also started.Review of guest location visual check documentation dated 03/13/26 revealed fifteen minute checks were initiated at 8:30 P.M. and continued through 6:45 A.M. on 03/14/26.Review of guest location visual check documentation dated 03/14/26 revealed the fifteen minute checks were reinitiated at 3:00 P.M. and continued through 6:45 A.M. on 03/15/26.Review of progress notes dated 03/14/26 at 6:35 A.M. and 2:08 P.M. revealed Resident #83 exhibited no behaviors and expressed frustration about not having access to his personal belongings.Review of the progress note dated 03/14/26 at 2:26 P.M. revealed the unit manager notified staff that Resident #83 could receive his belongings.Review of the progress note dated 03/15/26 at 2:35 P.M. revealed Resident #83 reported headaches, nausea, and feeling like a zombie related to new medication. The resident was educated on his right to refuse medication.Review of the progress note dated 03/16/26 at 12:33 P.M. by Registered Nurse #109 revealed Resident #83 remained on fifteen minute checks until the end of shift and exhibited no behaviors.Interview on 04/09/26 at 11:28 A.M. with the Director of Nursing, Administrator and interim Administrator confirmed the medical record did not contain a physician order for fifteen minute checks. They also confirmed the medical record revealed the resident was not exhibiting any concerning behaviors, and reported the hospital cleared him from the pink-slip therefore he was not a safety risk to himself or others, therefore 15 minutes checks were not warranted. Interview on 04/09/26 at 12:10 P.M. with the Administrator revealed that being checked on every fifteen minutes could feel annoying or excessive to some residents and may understandably cause frustration. The Administrator confirmed there was no consistent documentation supporting why the fifteen minute checks were initiated or continued. The Administrator also confirmed Resident #83 did not receive his belongings in a timely manner and that the checks continued longer than necessary and up until 03/16/26.Interview on 04/09/26 at 12:16 P.M. with Certified Nursing Assistant (CNA) #144 and Registered Nurse #107 revealed both staff were aware of Resident #83's history, including previous hospital transfers for suicidal ideations. They stated that during the fifteen minute checks, staff were instructed to visually confirm the resident's safety by laying eyes on him.Interview on 04/09/26 at 1:05 P.M. with Registered Nurse #109 revealed the fifteen minute checks continued until approximately 2:00 P.M. on 03/16/26. The nurse stated Resident #83 was acting normal at that time and there were no safety concerns. The nurse reported the resident often voiced concerns impulsively but believed these concerns should still be taken seriously. The nurse stated Resident #83 tends to have explosive episodes and becomes easily annoyed and did not feel the routine checks were not necessary. This deficiency represents non-compliance investigated under Complaint Number 2791144.

Based on observation, schedule review, activity calendar review and interviews, the facility failed to provide comprehensive, resident centered services to ensure dementia care needs were met and promote resident well-being on the specialty unit. This affected two residents (Resident #18 and #24) and had the potential to affect the remaining 20 residents (#1, #2, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #19, #20, #21, #22, #23, #25, and #27) who resided on the specialty care dementia unit. The facility census was 86.Findings include: Review of the staffing schedules revealed on 07/30/25, 07/31/25, and 08/01/25 there was one certified nursing assistant (CNA) and one nurse scheduled to work on the memory care unit. An observation on 08/06/25 at 8:41 A.M. revealed Resident #24 was sitting at a table with a large amount of oatmeal on the underside of her right sweater sleeve. The oatmeal was smeared on the table as the resident moved her arm. At the time of the observation, the nurse was at the nurse's station and the CNA was giving residents showers.An additional observation on 08/06/25 at 9:34 A.M. revealed Resident #24 was still wearing the sweater with oatmeal on the sleeve. An activities calendar in the dining room/activity room revealed activities on 08/06/25 included morning stretches at 9:30 A.M., coffee and daily chronicle at 10:00 A.M., coloring at 11:00 A.M. and snack and chat at 2:00 P.M. An observation on 08/06/25 at 9:34 A.M. revealed residents sitting in the dining/activity room and no staff were in the room. Morning stretches were on the activity schedule to take place at this time. However, the activity was not occurring. An observation on 08/06/25 at 10:43 A.M. revealed a unit manager was in an office on the memory care unit (out of sight of the dining/activity room and hallway) and no other staff were observed. Coffee and daily chronicle were on the activity schedule for 10:00 A.M. and coloring scheduled to begin at 11:00 A.M. There was no observed activity occurring at this time.An observation on 08/06/25 at 2:25 P.M. revealed Resident #18 (female) entered Resident #9 and #10's (males) room. Resident #18 closed the door. This writer knocked and entered the room. Resident #9 was sitting in a chair and Resident #10 was lying in bed. Resident #18 was standing by Resident #10's bed, holding Resident 10's hand. This writer notified the nurse that Resident #18 was in Resident #9 and #10's room. On 08/06/25 at 2:27 P.M. LPN #115 verified Resident #18 should not be in Resident #9 and #10's room. LPN #115 and the CNA were at the nurse's station and were not aware Resident #18 had gone into Resident #9 and #10's room. LPN #115 redirected Resident #18 to the dining/activity room however, there were no activities occurring at that time.An interview on 08/06/25 at 2:28 P.M. with CNA #135 verified there was one nurse and one CNA working on the memory care unit this date. CNA #135 stated a float CNA did come on the unit around lunch time to ask if she needed help passing meal trays but had not been back any other times. CNA #135 verified no one from activities had been on the memory care unit to provide the residents with activities as indicated on the activity schedule. CNA #135 stated she completed nine showers on 08/06/25. CNA #135 verified Resident #24 had oatmeal on her sleeve, but stated other residents had removed incontinence briefs and required showers and assistance and she needed to address those things first. CNA #135 stated Residents #2, #10, #15, and #27 required two staff assist for care and this was difficult with only an aide and a nurse to coordinate when they both could provide care to the residents. An observation on 08/06/25 at 2:39 P.M. revealed activity staff arrived at the memory care unit to make residents root beer floats. Interview on 08/06/25 at 2:41 P.M. with Activities Aide #137 and #160 verified they had not been on the memory care unit until they brought the root beer floats. Activities Aide #137 stated a coffee cart with coffee and juice was provided to the dementia unit and the nursing staff were to provide the residents with the drinks. Coloring pages were printed off and left in the dining room/activity room for residents to color. They stated root beer floats were being provided so the snack and chat was not done at 2:00 P.M. but soft cookies would be provided later. Activities staff verified the scheduled activities on the calendar were not provided as scheduled on 08/06/25.Interview on 08/06/25 at 5:14 P.M. with the Administrator revealed recently there was one CNA scheduled on the memory care unit and one CNA that was to float to the unit as needed. The Administrator (LNHA) stated several staff were pregnant and could not work on the memory care unit, limiting the number of staff they had available to schedule on the memory/dementia care unit. The LNHA revealed there was an activity director and two activity aides and usually one of the activity aides was on the memory care unit to help supervise and provide activities for the residents, but a new activity aide had started and was receiving training off the memory care unit so that support was not always available on the dementia unit despite also having issues with not having adequate nursing staff numbers on the unit. This deficiency represents non-compliance investigated under Master Complaint Number 2577719.

Based on record review and interview, the facility failed to complete neurological checks for Resident #2 after two falls with injuries occurred. This affected one (Resident #2) out of six residents reviewed for incidents with injuries. The facility census was 86.Findings include:Review of the medical record revealed Resident #2 was admitted on [DATE] with diagnoses that included but limited to dementia, degenerative disease of nervous system, major depressive disorder, and generalized anxiety disorder.A change in condition note dated 06/05/25 at 9:16 A.M. revealed Resident #2 was found sitting on the floor in her room. Neurological checks were completed as Resident #2 would allow. A change in condition note dated 06/06/25 at 4:34 P.M. revealed Resident #2 was pushed to the floor by Resident #1. Resident #2 hit the back of her head on the floor. Resident #2 had a laceration to the back of her head. Pressure was applied to the back of Resident #2's head and Resident #2 was transferred to the hospital for evaluation.The hospital records dated 06/06/25 revealed Resident #2 had a 2.5-centimeter irregular contusion to the left posterior occiput. A nurse note dated 06/07/25 at 12:55 A.M. revealed Resident #2 returned to the facility.Review of Certified Nurse Practitioner progress note dated 06/10/25 revealed Resident #2 was shoved by another resident and fell backward and hit her head. The staff reported when Resident #2's head hit the floor; it made a loud sound and there was blood on the floor. Resident #2 was transported to the hospital and medical glue was applied to the left posterior occiput. Resident #2 continued to have hematoma, but staff reported it was beginning to recede. Resident #2 likely had a concussion, and vital signs, neurological checks, fall precautions, and monitoring were to continue per protocol. The significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #2 had severe cognitive impairment. An interview on 08/07/25 at 9:03 A.M. Licensed Nursing Home Administrator (LNHA) verified there was no evidence of neurological checks being done when Resident #2 returned from the hospital on [DATE]. This deficiency is an incidental finding discovered during the complaint investigation.

Based on record review and interview, the facility failed to revise plans to provide comprehensive, resident centered care related to agitation and/or aggression. This affected two (Resident #1 and #24) of six residents reviewed. The facility census was 86. Findings include:1. Review of the medical record revealed Resident #1 was admitted on [DATE] with diagnoses that included but not limited to anxiety disorder, major depressive disorder, and Alzheimer's disease. A care plan dated 05/19/23 revealed Resident #1 was at risk for decline in cognition and had impaired cognitive function or impaired thought processes related to impaired decision making, and impulsivity. Interventions included provide a homelike environment and notify the nurse of any changes in cognitive function.A care plan dated 06/19/24 revealed Resident #1 had an actual behavior problem of hoarding food items such as sour cream, cream cheese, butter and salad dressings in her nightstand. Interventions included, if reasonable, discuss the resident's behavior, explain/reinforce why the behavior is inappropriate and/or unacceptable to the resident.A nurse's note dated 05/24/25 at 9:39 A.M. authored by Licensed Practical Nurse (LPN) #116 revealed Resident #1 became verbally aggressive towards staff today during care. Resident stated, I'm sick of that woman coming in her all the time. Resident #1 was referring to another resident. Resident #1 was easily redirected. Resident #1 let staff provide care and was pleasant. A nurse's note dated 05/24/25 at 10:42 A.M. authored by LPN #116 revealed Resident #1 was agitated and took the nurse to the window and stated Resident #1 was going outside. Resident #1 attempted to stand up and mess with the window. Resident #1 was redirected but became agitated. A nurse's note dated 05/24/25 at 12:02 P.M. authored by LPN #116 revealed Resident #1 attempted to get out of the main doors. Redirection was unsuccessful and Resident #1 was agitated. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had severe cognitive impairment. The MDS also revealed Resident #1 had verbal behaviors directed at others for one to three days during the assessment period.A nurse's note dated 06/06/25 at 6:07 P.M. revealed Resident #1 had a hold of another resident's (Resident #2) arm. A certified nurse assistant (CNA) asked Resident #1 multiple times to let go of Resident #2's arm. When Resident #1 decided to let go of Resident #2, Resident #1 pushed Resident #2 on the floor. Resident #2 fell and hit her head on the floor.A nurse's note dated 06/25/25 at 10:16 A.M. authored by LPN #116 revealed Resident #1 was restless and very agitated. Resident #1 was exit seeking and unable to be redirected. A nurse's note dated 06/25/25 at 1:52 P.M. authored by LPN #116 revealed Resident #1 was very agitated and restless. Resident #1 had set off the door alarms multiple times in the last hour. Resident #1 became more agitated when redirected. Staff attempted to take Resident #1 out for fresh air. Resident #1 grabbed the tables and started yelling. Resident #1 was brought back to the memory care unit because Resident #1 was uncooperative with staff. A nurse's note dated 06/25/25 at 2:54 P.M. authored by LPN #116 revealed Resident #1 was taken outside for fresh air. Resident #1 was cooperative. Resident #1 was currently relaxing and listening to music.An interview on 08/06/25 at 8:46 A.M. Licensed Practical Nurse (LPN) #101 revealed Resident #1 was upset with a family member prior to the incident with Resident #2. An interview on 08/06/25 at 2:28 P.M. Certified Nursing Assistant (CNA) #135 revealed Resident #1 was easily agitated. CNA #135 stated she tried to keep Resident #1 separated from other residents and would put music on that Resident #1 enjoyed. An interview on 08/06/25 at 5:14 P.M. Licensed Nursing Home Administrator (LNHA) verified Resident #1's care plan did not address agitation or aggression. 2. Review of the medical record revealed Resident #24 was admitted on [DATE] with diagnoses that included but limited to Alzheimer's disease, psychosis, major depressive disorder, and adjustment disorder with disturbance of conduct.A care plan dated 04/01/25 revealed Resident #24 was exit seeking and/or wandering. Interventions included to apply a Wander Guard (bracelet to alert caregivers when a resident has wandered from a protected zone) to the right ankle, observe wandering and attempt diversional interventions when wandering into inappropriate locations, and provide structured activities as needed.The quarterly MDS dated [DATE] revealed Resident #24 had severe cognitive impairment. The MDS also revealed Resident #24 had physical and verbal behaviors directed towards others one to three days during the assessment period. A nurse's note dated 03/25/25 at 12:34 P.M. revealed Resident #24 went into another resident's (Resident #14) room. Resident #14 asked Resident #24 three times to leave Resident #14's room. Resident #24 started yelling at Resident #14. Resident #24 then slapped Resident #14 on the abdomen. Resident #14 then slapped Resident #24 on the right arm. A CNA removed Resident #24 from Resident #14's room. The nurse did a skin check and noted Resident #24 had redness to the right upper arm. Resident #24 was placed on one-on-one supervision. An interview on 08/06/25 at 5:14 P.M. LNHA verified Resident #24's care plan did not address agitation or aggression. This deficiency is an incidental finding discovered during the complaint investigation.

Based on review of medical records, review of facility investigations, review of the abuse policy, and interview, the facility failed to thoroughly investigate allegations of abuse for Residents #1, #2, #14, and #24. This affected four (Residents #1, #2, #14, and #24) out of six residents reviewed for abuse investigations. The facility census was 86.Findings include:1. Review of the medical record revealed Resident #1 was admitted on [DATE] with diagnoses that included but not limited to anxiety disorder, major depressive disorder, and Alzheimer's disease. A nurse's note dated 06/06/25 at 6:07 P.M. revealed Resident #1 had a hold of another resident's (Resident #2) arm. A certified nurse assistant (CNA) asked Resident #1 multiple times to let go of Resident #2's arm. When Resident #1 decided to let go of Resident #2, Resident #1 pushed Resident #2 on the floor. Resident #2 fell and hit her head on the floor.Review of self-reported incident (SRI) #261328 dated 06/06/25 revealed Resident #1 was observed holding Resident #2 in the activity room of the memory care unit. When staff asked Resident #1 to let go of Resident #2, Resident #1 shoved Resident #2 as she let go which resulted in Resident #2 falling backwards. Resident #2 had a laceration to the back of the head and was sent to the hospital for evaluation. Resident #1 was placed on 15-minute checks. Review of the incident and accident investigation form revealed on 06/06/25 at 5:00 P.M. Resident #1 was holding onto Resident #2 in the memory care unit before the supper meal. When staff asked Resident #1 to let go of Resident #2, Resident #1 shoved Resident #2 as she let go. Resident #2 fell backwards. The investigation form revealed staff witnessed the incident. Resident #1 was put on 15-minute checks and Resident #2 was sent to the hospital. The form indicated resident files were not reviewed, no other documentation was reviewed, and no additional interviews were conducted. A brief description of conclusion revealed Resident #1 and Resident #2 were separated immediately. Resident #2 was sent to the hospital for evaluation and Resident #1 was placed on 15-minute checks. Resident #1 and Resident #2 did not remember the incident. A review of others that may be at risk was marked as yes but no information was provided indicating what review was completed. The plan to avoid this situation in the future was to redirect away from each other during meals and the nursing staff and Director of Nursing would monitor the corrective action. Review of the medical record revealed the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had severe cognitive impairment. The MDS also revealed Resident #1 had verbal behaviors directed at others for one to three days during the assessment period.An interview on 08/06/25 at 5:14 P.M. Licensed Nursing Home Administrator (LNHA) verified the investigation did not include witness statements and the information on the incident and accident investigation form was obtained from the nurse's note dated 06/06/25 at 6:07 P.M. LNHA verified a complete and thorough investigation was not completed. Review of the Abuse Prohibition Policy revised 09/09/22 revealed it is the responsibility of all staff to provide a safe environment for the residents. Allegations of resident abuse, exploitation, neglect, misappropriation of property, adverse events, or mistreatment shall be thoroughly investigated and documented by the LNHA. The investigation may consist of (as appropriate) a review of the completed incident report, an interview with the person reporting the incident, and interview with the resident, if possible, an interview with staff members who had contact with the resident during the period/shift of the alleged incident, and a review of all circumstances surround the incident. 2. Review of the medical record revealed Resident #24 was admitted on [DATE] with diagnoses that included but limited to Alzheimer's disease, psychosis, major depressive disorder, and adjustment disorder with disturbance of conduct.A nurse's note dated 03/25/25 at 12:34 P.M. revealed Resident #24 went into another resident's (Resident #14) room. Resident #14 asked Resident #24 three times to leave Resident #14's room. Resident #24 started yelling at Resident #14. Resident #24 then slapped Resident #14 on the abdomen. Resident #14 then slapped Resident #24 on the right arm. A CNA removed Resident #24 from Resident #14's room. The nurse did a skin check and noted Resident #24 had redness to the right upper arm. Resident #24 was placed on one-on-one supervision. Review of SRI #258622 dated 03/25/25 revealed Resident #24 wandered into Resident #14's room. Resident #14 tried to get Resident #24 to leave, and Resident #24 struck Resident #14 in the stomach and Resident #14 struck Resident #24 on the arm. Residents #14 and #24 were immediately separated and no injuries occurred. Resident #14 stated they were not afraid of Resident #24. Resident #24 could not describe what happened. Resident #24 was placed on one-on-one observation and was transferred to a behavior facility for evaluation and treatment on 03/26/25. Resident #14 was placed on 15-minute checks. Review of the incident and accident investigation form dated 03/25/25 at 11:40 A.M. revealed Resident #24 entered Resident #14's room and was rummaging through Resident #14's things. Resident #14 asked Resident #24 to leave his room. Resident #24 became agitated and hit Resident #14 in the abdomen. Resident #14 then hit Resident #24 in the right upper arm. Staff entered the room and separated the residents as Resident #14 was hitting Resident #24. Staff became aware of the incident when Resident #14 was yelling for Resident #24 to get out of his room. Resident #14 was questioned about the incident. CNA #100 was interviewed about the incident. Resident #14 was placed on 15-minute checks and Resident #24 was placed on one-on-one observation. No injuries were noted other than redness to Resident #24's right arm and redness to Resident #14's abdomen. A review of others that may be at risk was marked as yes but no information was provided indicating what review was completed. The plan to avoid this situation in the future was to place a stop sign on Resident #14's door because it was a reoccurring issue of other residents wandering into Resident #14's room even if the door was closed. No information was provided on how and who would monitor the corrective action. An interview summary revealed Resident #24 was unable to describe what happened. An interview with CNA #100 revealed Resident #14 was yelling to get Resident #24 to leave his room. Resident #14 was in the motion of hitting Resident #24 because Resident #24 was hitting Resident #14. Residents #14 and #24 were separated and Resident #24 was removed from Resident #14's room. The quarterly MDS dated [DATE] revealed Resident #24 had severe cognitive impairment. The MDS also revealed Resident #24 had physical and verbal behaviors directed towards others one to three days during the assessment period. An interview on 08/06/25 at 5:14 P.M. LNHA verified the investigation did not include a witness statement from Resident #14 and most of the information on the incident and accident investigation form was obtained from the nurse's note dated 03/25/25 at 12:34 P.M. LNHA verified a complete and thorough investigation was not completed. Review of the Abuse Prohibition Policy revised 09/09/22 revealed it is the responsibility of all staff to provide a safe environment for the residents. Allegations of resident abuse, exploitation, neglect, misappropriation of property, adverse events, or mistreatment shall be thoroughly investigated and documented by the LNHA. The investigation may consist of (as appropriate) of a review of the completed incident report, an interview with the person reporting the incident, and interview with the resident, if possible, an interview with staff members having contact with the resident during the period/shift of the alleged incident, and a review of all circumstances surrounding the incident. This deficiency is an incidental finding discovered during the complaint investigation.

Based on record review, review of the abuse policy and Quality Assurance Performance Improvement (QAPI) Committee policy, and interview, the facility failed to implement policies and procedures to communicate and coordinate with the QAPI program regarding situations of abuse, neglect, and misappropriation of resident property, and exploitation. This affected four residents (#1, #2, #14, and #24) and had the potential to affect all 86 residents residing in the facility. The facility census was 86.Findings include:1. Review of the medical record for Resident #1 revealed the resident was admitted to the facility on [DATE] with diagnoses including anxiety disorder, major depressive disorder, and Alzheimer's disease. Review of an incident and accident investigation form revealed on 06/06/25 at 5:00 P.M. Resident #1 was holding onto Resident #2 in the memory care unit before the supper meal. When staff asked Resident #1 to let go of Resident #2, Resident #1 shoved Resident #2 as she let go. Resident #2 fell backwards. The investigation form revealed staff witnessed the incident. Resident #1 was put on 15-minute checks and Resident #2 was sent to the hospital. The form indicated resident files were not reviewed, no other documentation was reviewed, and no additional interviews were conducted. A brief description of conclusion revealed Resident #1 and Resident #2 were separated immediately. Resident #2 was sent to the hospital for evaluation and Resident #1 was placed on 15-minute checks. Resident #1 and Resident #2 did not remember the incident. A review of others that may be at risk was marked as yes but no information was provided indicating what review was completed. The plan to avoid this situation in the future was to redirect away from each other during meals and the nursing staff and Director of Nursing would monitor the corrective action. The facility abuse prohibition policy revised 09/09/22 revealed allegations of resident abuse, exploitation, neglect, misappropriation of property, adverse events, or mistreatment shall be thoroughly investigated and documented by the Administrator, and reported to the appropriate state agencies, physician, families, and/or representative. The subject of abuse should be routinely and openly discussed. Guests/residents would be educated concerning the commitment of the facility to deal quickly and effectively with abuse or suspected abuse incidents on admission and at least annually. The Administrator, Director of Nursing or designee would compile a final summary of all investigations and report the findings at the facility QAPI committee meeting(s).The QAPI Committee policy revised 03/05/25 revealed the QAPI committee oversees and identifies all efforts that improved the quality of care in the facility by monitoring performance measures, developing and implementing appropriate performance improvement plans to correct quality concerns, and evaluating the effectiveness of the performance improvement plans. The following reports, logs and similar documents were created by or at the direction of, and for use by, the QAPI committee. These reports logs and similar documents were used to determine improvement priorities based on facility-identified concerns. These reports, logs and similar documents were: incident/accident summary reports, incident/accident logs and other related data, and all investigations including adverse events and medical errors. The QAPI committee shall collect and analyze data about the facility's performance and present findings to the committee. An interview on 08/06/25 at 5:14 P.M. Licensed Nursing Home Administrator (LNHA) revealed a log of incidents were verbally discussed during QAPI; however, there was no documentation of what was discussed or what the findings of the discussion were as they pertained to the incident involving Resident #1 and Resident #2. 2. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, psychosis, major depressive disorder, and adjustment disorder with disturbance of conduct. Review of an incident and accident investigation form dated 03/25/25 at 11:40 A.M. revealed Resident #24 entered Resident #14's room and was rummaging through Resident #14's things. Resident #14 asked Resident #24 to leave his room. Resident #24 became agitated and hit Resident #14 in the abdomen. Resident #14 then hit Resident #24 in the right upper arm. Staff entered the room and separated the residents as Resident #14 was hitting Resident #24. Staff became aware of the incident when Resident #14 was yelling for Resident #24 to get out of his room. Resident #14 was questioned about the incident. Certified Nursing Assistant (CNA) #100 was interviewed about the incident. Resident #14 was placed on 15-minute checks and Resident #24 was placed on one-on-one observation. No injuries were noted other than redness to Resident #24's right arm and redness to Resident #14's abdomen. A review of others that may be at risk was marked as yes but no information was provided indicating what review was completed. The plan to avoid this situation in the future was to place a stop sign on Resident #14's door because it was a reoccurring issue of other residents wandering into Resident #14's room even if the door was closed. No information was provided on how and who would monitor the corrective action. An interview summary revealed Resident #24 was unable to describe what happened. An interview with CNA #100 revealed Resident #14 was yelling to get Resident #24 to leave his room. Resident #14 was in the motion of hitting Resident #24 because Resident #24 was hitting Resident #14. Residents #14 and #24 were separated and Resident #24 was removed from Resident #14's room. The facility abuse prohibition policy revised 09/09/22 revealed allegations of resident abuse, exploitation, neglect, misappropriation of property, adverse events, or mistreatment shall be thoroughly investigated and documented by the Administrator, and reported to the appropriate state agencies, physician, families, and/or representative. The subject of abuse should be routinely and openly discussed. Guests/residents would be educated concerning the commitment of the facility to deal quickly and effectively with abuse or suspected abuse incidents on admission and at least annually. The Administrator, Director of Nursing or designee would compile a final summary of all investigations and report the findings at the facility QAPI committee meeting(s).The QAPI Committee policy revised 03/05/25 revealed the QAPI committee oversees and identifies all efforts that improved the quality of care in the facility by monitoring performance measures, developing and implementing appropriate performance improvement plans to correct quality concerns, and evaluating the effectiveness of the performance improvement plans. The following reports, logs and similar documents were created by or at the direction of, and for use by, the QAPI committee. These reports logs and similar documents were used to determine improvement priorities based on facility-identified concerns. These reports, logs and similar documents were: incident/accident summary reports, incident/accident logs and other related data, and all investigations including adverse events and medical errors. The QAPI committee shall collect and analyze data about the facility's performance and present findings to the committee. An interview on 08/06/25 at 5:14 P.M. Licensed Nursing Home Administrator (LNHA) revealed a log of incidents were verbally discussed during QAPI; however, there was no documentation of what was discussed or what the findings of the discussion were as they pertained to the incident involving Resident #24 and Resident #14. This deficiency is an incidental finding discovered during the complaint investigation.

Based on observations and interviews the facility failed to ensure the smoking area was maintained in a clean and safe manner. This had the potential to affect all 89 residents. Findings include: Observation on 02/03/25 at 12:03 P.M. of the smoking area located in the courtyard revealed a smoking area not maintained properly. There were numerous cigarette butts located on the ground and not in the designated ashtrays. Observation on 02/06/25 at 9:18 A.M. with the Administrator revealed that there were approximately 25 cigarette butts around the courtyard and a pile of cigarette butts that looked like someone dumped an ashtray on the ground. Interview on 02/06/25 at 9:18 A.M. with the Administrator verified the condition of the smoking area located in the courtyard. Review of the undated facility policy titled, Smoking Policy, revealed the facility permits smoking in the designated area outside the facility, compliant with state regulations. Review of the facility document revealed the facility did not implement the policy.

Based on observation and staff interview the facility failed to maintain a clean and sanitary environment for Resident #15, #16, #27, and #73. This four residents (#15, #16, #27, and #73) our of 19 residents reviewed for environment. Findings include: Observation on 02/03/25 at 10:30 A.M. revealed that Resident #73's privacy curtain had black marks and blue stains on it. This was verified by Certified Nursing Assistant (CNA) #260 on 02/03/25 at 10:31 A.M. An environmental tour was conducted with the Administrator on 02/06/25 between 9:03 A.M. and 9:30 A.M. which revealed the rooms belonging to Residents #15, #16, and #27 contained privacy curtains that were stained to various degrees by unknown substances. These findings were observed and verified by the Administrator during the environmental tour. Review of the housekeeping schedule revealed that resident rooms are scheduled to be deep cleaned every 30 to 45 days.

Based on observation, interview, review of medications manufactures guidelines, and facility policy review the facility failed to ensure medication was dated and discarded properly. This affected six residents (Resident #12, Resident #39, Resident #48, Resident #136, Resident #139, and Resident #290) out of 22 residents reviewed for medication storage and had the potential to affect all 89 residents in the facility. Findings include: 1. On 02/05/25 at 9:00 A.M. observation of the medication storage area for the 300-400 hall revealed the following: Resident #12 had an opened bottle of Morphine Sulfate (concentrate) solution 20 milligrams per milliliter (MG/ML), give 0.25 ml by mouth every hour as needed for pain. Per the pharmacy label, the medication was dispensed on 01/24/25 however, the bottle was not dated when it was opened. Resident #39 had Morphine Sulfate (concentrate) solution 20 milligrams per MG/ML, give 0.25 ml by mouth every hour as needed for pain. Per the pharmacy label, the medication was dispensed on 01/25/25, however the bottle was not dated when opened. On 02/06/25 at 09:00 A.M., interview with Registered Nurse (RN) #284 confirmed medications were not dated when opened. 2. On 02/06/25 at 09:30 A.M. observation of the medication storage area for 200 hall revealed the following: Resident #48 had an opened bottle of Cromolyn 4% ophthalmic solution (used in the eye to treat certain disorders of the eye caused by allergies). According to the pharmacy storage guide the medication was dispensed on 11/11/24, and the bottle was labeled with an open date of 11/19/24. According to manufacturers' insert provided in the box with the medication, the medication should be discarded 30 days after opening. The medication storage room had a multi vial Tuberculin purified protein derivative dispensed on 01/30/25 and the vial was not dated when opened. According to manufacturers' insert located in the box with the vial revealed the vial should be discarded 30 days after opening/expires 30 days after opening (and should be discarded). Review of new admission since the date the Tuberculin was dispensed reveaeld Resident #290, Resident 139, Resident # 136 were admitted since 01/30/25. On 02/06/25 at 09:30 A.M., interview with Licensed Practical Nurse (LPN) #395 confirmed the Cromolyn eye solution and the tuberculin was not dated when they were opened.

Based on medical record review, review of fall investigations, staff interview and review of facility policy and procedure, the facility failed to ensure the residents guardian was notified of all falls. This affected two (Resident #39 and #76) of three residents reviewed for falls. The census was 89. Findings include: 1. Review of Resident #76's medical record revealed she was admitted to the facility 07/30/24. Diagnoses included encephalopathy, Alzheimer's Dementia, mood disorder, psychosis, restlessness, agitation, anxiety, suicidal ideation's and major depression. Review of the quarterly Minimum Data Set (MDS( dated 11/06/24 revealed her cognition was not intact. She required set up or clean up assistance with eating, supervision or touching assistance with oral hygiene, and partial/moderate assistance with toileting, shower/bathing, dressing, personal hygiene and turning and repositioning. Resident identified as having falls without major injury. Review of the fall assessment dated [DATE] revealed Resident #76 was at risk for falls. Review of the fall investigations and nursing progress notes revealed Resident #76 had a fall on 08/08/24 at 8:05 P.M She was witnessed sitting down on the floor by a CNA. She was on her hands and knees by the locked door that leads to the 200 hall. She proceeded to go from her knees to her buttocks. There was no documentation the guardian was notified. Review of the fall investigations and nursing progress notes revealed Resident #76 had a fall on 08/14/24 at 10:45 P.M. She was attempting to get up out of the recliner and slid off of the recliner on to the floor on her bottom. There was no documentation the guardian was notified. Review of the fall investigations and nursing progress notes revealed Resident #76 had a fall on 09/02/24 at 6:48 P.M. She was found on the floor in front of her dresser. She was wearing nonslip socks, and stated she was dizzy and fell . There was no documentation the guardian was notified. Review of the fall investigations and nursing progress notes revealed Resident #76 had a fall on 09/12/24 at 9:40 P.M. She placed herself on the floor, somersaulted and stood up. Then walked down the hall. There was no documentation the guardian was notified. Review of the fall investigations and nursing progress notes revealed Resident #76 had a fall on 09/13/24 at 7:45 P.M. She was on all fours in the hallway, got to her feet, before staff could reach her. She revealed she just slipped. There was no documentation the guardian was notified. Review of the fall investigations and nursing progress notes revealed Resident #76 had a fall on 01/20/25 at 10:20 P.M. She was found on the floor by a walker. She could not recall what happened or what she was trying to do. There was no documentation the guardian was notified. Interview on 02/05/25 at 2:04 P.M. with Director of Nursing verified there was no evidence Resident #76's guardian was notified of the falls. Review of the Notification of Change policy and procedure dated 12/19/22 revealed a change in status would include an accident involving the resident, revealed changes in the residents status or any unusual occurrences, the licensed nurse will notify the residents representative, unless otherwise dictated by the resident. 39333 2. Review of the medical record for Resident #39 revealed an admitted [DATE] with diagnoses included but not limited to Huntington's disease, generalized anxiety disorder, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #39 had severely impaired cognition and was dependent for activities of daily living (ADLs). Review of the fall investigation dated 10/24/24 revealed Resident #39 was found on the floor between the bed and the wall. Fall investigation stated that no notifications were found under the section of agencies/people notified. Interview on 02/05/25 at 3:17 P.M. with Director of Nursing (DON) verified that notification was not given to power of attorney (POA) in reference to the unwitnessed fall on 10/24/24.

Based on medical record review, observation and staff interview, revealed the facility failed to ensure accuracy of assessments. This affected one (Resident #47) of two residents reviewed for dental assessments. The census was 89. Findings include: Review of Resident #47 revealed they were admitted on [DATE]. Diagnoses included alcoholic cirrhosis of the liver, alcohol dependence with alcohol induced persisting dementia, acute kidney failure, viral hepatitis C, severe protein calorie malnutrition, and anxiety. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed his cognition was not intact, was independent with eating, turning and reposition, required supervision or touching assistance with oral hygiene, toileting, bathing/showering, dressing and personal hygiene, with no obvious or likely cavity or broken natural teeth. Observation on 02/03/25 at 3:49 P.M. revealed his lower teeth were broken and missing with decay of teeth. Interview on 02/05/25 at 2:04 P.M. with Director of Nursing verified the Admission MDS for 11/25/24 was incorrect in regard to Resident #47's dental status. On 02/05/25 at 2:33 P.M. Interview with Social Service Assistant #335 revealed the resident's dentist comes to the facility quarterly and was last at the facility on 12/04/24. She revealed Resident #47 had not been referred to her to see the dentist and she was not aware of any dental issues. On 02/06/25 at 10:28 A.M. observation of Resident #47's teeth revealed broken, missing and decay of the teeth. This was verified with Licensed Practical Nurse #213 at the time of the observation and she asked him if he had seen a dentist since he had been here and he revealed he has not.

Based on medical record review, observation and staff interview, the facility failed to develop a comprehensive care plan for Resident #47's dental needs. This affected one (Resident #47) of two residents reviewed for dental care. Findings include: Review of Resident #47 revealed they were admitted on [DATE]. Diagnoses included alcoholic cirrhosis of the liver, alcohol dependence with alcohol induced persisting dementia, acute kidney failure, viral hepatitis C, severe protein calorie malnutrition, and anxiety. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed his cognition was not intact, was independent with eating, turning and reposition, required supervision or touching assistance with oral hygiene, toileting, bathing/showering, dressing and personal hygiene, with no obvious or likely cavity or broken natural teeth. Review of Resident #47's medical record revealed no evidence the facility developed a comprehensive care plan for dental care. Observation on 02/03/25 at 3:49 P.M. revealed his lower teeth were broken and missing with decay of teeth. On 02/05/25 at 2:33 P.M. Interview with Social Service Assistant #335 revealed the dentist comes to the facility quarterly and was last at the facility on 12/04/24. She revealed Resident #47 had not been referred to her to see the dentist and she was not aware of any dental issues. She also revealed she thinks nursing would be responsible for the dental plan of care and verified Resident #47 did not have a dental plan of care.

Based on medical record review, observation and staff interview, the facility failed to ensure pressure reduction interventions were in place at all times for Resident #53. This affected one resident (Resident #53) of three residents reviewed for pressure ulcer prevention. Findings include: Review of the medical record for Resident #53 revealed an admitted [DATE] with diagnoses including but not limited to injury of left Achilles tendon, muscle wasting, and bradycardia. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #53 had moderately impaired cognition, required dependent for activities of daily living (ADLs) and had a surgical wound. Review of the care plan dated 01/08/25 revealed Resident #53 was at risk for impaired skin integrity. Interventions included but not limited to encourage to float heels while in bed and assist as needed. Review of the physician's orders for February 2025 revealed an order for heel elevation boots to bilateral feet while in bed, as guest tolerates. Observation on 02/03/25 at 11:00 A.M. revealed that Resident #53 was not wearing her boots. Interview at time of observation with Licensed Practical Nurse (LPN) #385 verified that Resident #53 did not have elevation boots on her feet. Review of the facility policy with an effective date of 09/19/24 titled, Skin Management, revealed that practice guidelines state residents admitted with skin impairment will have appropriate interventions implemented to promote healing.

Based on observation, medical record review and interview the facility failed to ensure fall interventions were in place for Resident #60. This affected one resident (Resident #60) of one reviewed for falls. The facility census was 89. Findings include: Review of the medical record for Resident #60 revealed an admitted [DATE] with diagnoses including end stage renal disease, obstructive uropathy, chronic kidney disease stage four, osteoarthritis, major depressive disorder and paroxysmal atrial fibrillation. Review of Resident #60 dated 10/26/23 revealed Resident #60 was at risk for fall related injury and falls related to muscle weakness with limited mobility and end stage renal disease (ERSD), psychoactive medication use antidepressant for depression, antianxiety for anxiety. Interventions included activities to access for in-room activities and preferences, encourage the resident to wear appropriate footwear, call light within reach, commonly used items within reach, move closer to nurses' station for closer observation by staff; observe for fatigue and/or unsteadiness and encourage rest periods as needed; offer resident to get up in wheelchair, when restless, perimeter mattress to bed at all times, nonskid strips to right side of bed, visual cues to remind resident to ask for assistance for transfers. Review of fall investigation report dated 01/06/25 revealed resident was ambulating to the bathroom and while attempting to open the door, his hand slipped off the handle and he fell , landing on his left shoulder. gripper socks were in place. The new intervention was to move his room closer to the nurses' station. Review of Resident #60 quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 13 out of 15 indicating mild cognitive impairment. The resident was assessed to require set up for meals and substantial assistance for activity of daily living (ADL'S) such as dressing, personal hygiene and bathing. Resident #60 required moderate assistance for bed mobility and transfers. Resident #60 utilized a wheelchair for mobility. Resident # 60 experienced a fall prior to admission and experienced two falls since admission to the facility, one with major injury and one without injury. On 02/05/25 at 11:43 A.M. Resident #60 was observed resting in bed. The non-skid strips were not observed on the floor and there were no visual signs posted to remind Resident #60 to ask for help. On 02/05/25 at 11:52 A.M. interview with Licensed Practical Nurse (LPN)# 266 confirmed non-skid strips were not in place and there was no signage reminding the resident to ask for help. Review of fall policy dated 05/01/10, revised 09/22/23, revealed the interdisciplinary team will review all the resident falls within 24-72 hours and at the clinical operations meeting to evaluate/investigate the circumstances and probable cause for the fall, review/modify the plan of care to minimize repeat falls and link to the resident's Kardex as needed.

Based on observations, medical record review, interview, and facility policy review the facility failed to ensure proper storage of Resident #8 and Resident #78 respiratory equipment, and failed to implement an order for a breathing improvement device for Resident #286. This affected three residents (Resident #8, Resident #78, and Resident #286) out of four residents reviewed for respiratory care. The facility census was 89. Findings Include: 1. Review of the medical record for Resident #8 revealed an admitted [DATE] and re-admitted [DATE] with the following diagnoses including but not limited to acute respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), sleep apnea, and type two diabetes mellites. Resident #8 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of nine out of a possible 15. Resident #8 required assistance for completion of Activities of Daily Living (ADLs) tasks including medication administration and the use of a wheelchair for mobility. Review of Resident #8's physician orders revealed an order dated 12/04/24 for Oxygen (02) 4 liters per minute via nasal cannula to maintain 02 blood saturation (SP02) between 88% to 92% every day and night shift for shortness of breath. Review of Resident #8 Medication Administration Record (MAR) dated 01/01/25 to 01/31/25 revealed the completed order for Oxygen (02) 4 liters per minute via nasal cannula to maintain 02 blood saturation (SP02) between 88% to 92% every day and night shift for shortness of breath. Review of Resident #8's SP02 readings dated 01/21/25 to 02/02/25 revealed SP02 results ranged from 93% to 98%. Review of Resident #8's admission Minimum Data Set (MDS) dated [DATE] revealed Section O - Special Treatments, Procedures, and Programs was marked as Resident #8 using oxygen therapy. An observation on 02/03/25 from 10:00 A.M. to 11:15 A.M. revealed Resident #8 sitting at a table in the lounge/activity room in a wheelchair. There was an oxygen concentrator plugged into the wall behind where Resident #8 was sitting at the table. There was oxygen tubing attached to the concentrator which was laying on the floor and stretched across the aisle to where Resident #8 sat in the wheelchair with the nasal cannula in place. The concentrator was set at 4 liters. There was a portable oxygen tank in a storage bag hanging on the back of Resident #8's wheelchair. A review of the facility policy titled, Use of Oxygen dated 08/17/21 revealed, To promote guest/resident safety in administration of oxygen. The tubing should be kept off the floor. An interview on 02/03/25 at 11:22 A.M. with the Director of Nursing (DON) confirmed Resident #8 was sitting at a table in the lounge/activity room with the oxygen concentrator plugged into the wall with the oxygen tubing laying on the floor and stretched across the aisle. The DON stated the oxygen tubing should be off the floor and secured in a bag. 51074 2. Review of the medical record for Resident #78, revealed an admitted [DATE]. Diagnoses included trisomy 21 (down syndrome), hypothyroidism, pulmonary embolism, displaced bimalleolar fracture of the right lower leg, Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of one out of 15 indicating severe cognitive impairment. The resident was assessed and required set up with meals and dependent on staff for all other activities of daily living (ADL's) such as bathing, dressing, hygiene, bed mobility and transfers. Review of Resident #78's plan of care dated 01/12/25 for a potential difficulty breathing and at risk for respiratory complications. Interventions included administer medications and treatment as ordered by physician, monitor for ineffectiveness, side effects and adverse reactions, report abnormal findings to the physician. Oxygen as needed, nebulizer as ordered, pulse pximetry, elevate head of bed, identify and eliminate sources of respiratory irritation such as cigarette smoke, pollen, perfumes, observe for difficulty breathing (dyspnea) on exertion. Observe for signs and symptoms of acute respiratory insufficiency: anxiety, confusion, restlessness, shortness of breath at rest, cyanosis, somnolence. Report abnormal findings to the physician. Review of Resident #78's physician orders revealed Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (three) milligrams/ milliliter (MG/ML) (Ipratropium-Albuterol) three ml inhale every six hours as needed for shortness of breath or wheezing, oxygen one to three liters per minute by nasal cannula as needed for short of breath and to maintain oxygen saturation greater than 92%. On 02/03/25 at 01:49 P.M. observation of Resident #78 room revealed respiratory equipment laying in the chair without a bag. On 02/04/25 at 08:40 A.M., observation was made of a nebulizer and oxygen concentrator in Resident #78 room. Tubing for the nebulizer and oxygen mask was laying in the chair beside the bed without a bag, and the resident's oxygen nasal cannula was observed on the floor. On 2/04/25 at 10:24 A.M., interview with certified nursing assistant (CNA) #256 confirmed tubing should be in a bag not lying in chair or hanging off of concentrator. On 02/04/25 at 12:00 P.M., interview with Director of Nursing (DON) confirmed oxygen equipment and tubing should be in a bag and not laying in the chair or on the floor. Review of the facility policy Use of Oxygen revised 01/17/21 revealed oxygen tubing should be changed and dated weekly. The tubing should be kept off the floor. The oxygen cannula or mask, when not in use, should be stored in a clean bag. Bags should be changed weekly. 3. Review of the medical record for Resident #286 revealed an admitted [DATE] with diagnoses including influenza A and pneumonia, unspecified organism. Review of the plan of care dated 01/29/25 revealed interventions to observe for signs and symptoms of respiratory infection: elevated temp, change in level of consciousness, malaise, chills, increase in sputum (document the amount, color and consistency), chest pain, increased difficulty breathing (dyspnea), increased coughing and wheezing. Report abnormal findings to the physician. Review of physician orders revealed orders for Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) milligram per activation (MCG/ACT) two puffs: inhale every six hours as needed for shortness of breath or wheezing and droplet precautions dated 01/29/25 for influenza A. Review of Resident #286's physician orders, Medication Administration Record, and Treatment Administration Record for January through February 2025 revealed no order for a Aerobika device or incentive spirometer. On 02/04/25 at 10:13 A.M. observation of Resident #286's room revealed he had a Aerobik oscillating positive expiratory pressure device (a medical device used to improve airway clearance and reduce symptoms in patients with respiratory conditions) and incentive spirometer (a handheld medical device used to help patients improve the functioning of their lungs) on Resident #286 over the bed table. Resident # 286 demonstrated how it is used and stated he uses the Aerobika twice a day. Interview on 02/04/25 at 10:53 A.M. with Assistant Director of Nursing (ADON) #391 confirmed there were no orders for Aerobika or incentive spirometer were present in physicians orders or plan of care and she was unaware he had them.

Based on medical record review, interview and facility policy review the facility failed to ensure non-pharmacological pain interventions were implemented for one resident. This affected one resident (Resident #237) out of two residents reviewed for pain management. The facility census was 89. Findings Include: A review of Resident #237's medical record revealed admitted [DATE] with the following diagnoses including but not limited to acute kidney failure, pulmonary emboli (clot), alcohol abuse, bipolar disorder, and weakness. Resident #237 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 14 out of a possible 15 dated 01/22/25. Resident #237 required assistance from staff to complete Activities of Daily Living (ADL) tasks including transfers and personal hygiene tasks. Resident #237 was non-ambulatory and used a wheelchair for mobility. A review of Resident #237's physician orders revealed an order dated 01/22/25 with a revision date of 02/04/25 for pain medication Oxycodone HCL oral tablet 10 milligrams (MG) give one tablet by mouth every four hours as needed (PRN) for pain. The revision of this order was the addition of document non-pharmacological interventions used: 1) Massage, 2) Meditation/Relaxation, 3) Positioning, 4) Ice/cold pack, 5) Diversional Activity, 6) Guided imagery, 7) Rest, 8) social interaction. A review of Resident #237's Medication Administration Record (MAR) dated 01/15/25 to 01/31/25 revealed Resident #237 was administered PRN pain medication Oxycodone on the following dates; 01/22/25 two times, 01/23/25 two times, 01/24/25 three times, 01/25/25 two times, 01/26/25 two times, 01/27/25 two times, 01/28/25 three times, 01/30/25 two times, and 01/31/25 four times. There was no documentation of non-pharmacological interventions being attempted or provided prior to the administration of the pain medication Oxycodone. A review of Resident #237's MAR dated 02/01/25 to 02/05/25 revealed Resident #237 was administered on the following dates; 02/01/25 one time, 02/02/25 two times, 02/03/25 three times there was no documentation of non-pharmacological interventions being attempted or provided prior to the administration of the pain medication Oxycodone. Following the revision of the order dated 02/04/25, Resident #237 was administered the PRN pain medication Oxycodone one time on 02/04/25 and on 02/05/25 the non-pharmacological interventions were marked as nonapplicable (NA). A review of Resident #237's admission evaluation and baseline care plan dated 01/16/25 revealed the pain interview with Resident #237 was marked as generalized pain with pain level of 10 out of 10 possible pain scale. Non-pharmacological interventions included rest and medication for relieving the pain. A review of Resident #237's Plan of Care (POC) dated 01/17/25 revealed Resident #237 was at risk for pain related to weakness, impaired mobility, bipolar disorder, and history of alcohol abuse. An interview on 02/05/25 at 1:37 P.M. with the Director of Nursing (DON) confirmed there were no non-pharmacological interventions documented on the initial pain medication Oxycodone order dated 01/22/25. The DON also confirmed the revised order dated 02/04/25 did have the non-pharmacological interventions added to the order with documentation marked as NA on Resident #237's MAR dated 02/04/25 and 02/05/25. The DON stated when pain medication orders are implemented there should be non-pharmacological interventions included and should be attempted and documented prior to administering the pain medication. Review of the facility's policy titled, Pain Management revised 04/11/23 revealed, Individualized interventions related to that resident's individual control of pain management should include both pharmacological, non-pharmacological and include Complementary and Alternative Medicine (CAM) pain management interventions.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memos, Nursing Home Guidance from the Centers for Disease Control (CDC), review of facility policy and procedures, review of communication with local health department, interviews with local health department, observations, staff interviews and record reviews, the facility failed to implement effective and recommended infection control practices, including the implementation of appropriate use of personal protective equipment (PPE) and isolation and quarantine procedures to prevent the spread of the coronavirus (COVID-19) within the facility. This resulted in Immediate Jeopardy when the facility's lack of adequate and proper infection control measures resulted in a COVID-19 outbreak affecting 18 residents (#1, #2, #3, #5, #6, #8, #9, #11, #12, #13, #17, #18, #19, #22, #23, #24, #25, and #28) who tested positive for COVID-19 from 12/31/21 through 01/19/22. On 12/31/21, a resident who tested positive for COVID-19 on the 200 hall remained roommates with a resident who tested negative for COVID-19. The resident who tested negative on 12/31/21 tested positive three days later, on 01/03/22. On 01/13/22, observation of the memory care unit (100 hall) revealed the facility had COVID-19 positive and COVID-19 negative residents residing on the same hallway. On 01/13/22 observations on the 100 hallway revealed residents were observed dining in the dining room, the residents were not encouraged to utilize PPE and they were not social distancing. Residents were observed wandering in the halls without encouragement or actions to keep COVID-19 positive residents away from COVID-19 negative residents. One resident in quarantine for presumptive positive COVID-19 due to being a new admission (housed on the 200 hall), had no signage posted on his room doors alerting visitors to see the nurse prior to entering the rooms or for staff identification of what type of isolation the residents required, resulting in staff being unaware of the type of isolation required when entering this room. Staff on the 200 hall were observed not utilizing the appropriate PPE and also not utilizing PPE correctly. The lack of current effective infection control practices during a COVID-19 outbreak in the facility placed all 85 residents at risk for the likelihood of hospitalization , harm, complications and/or death. The facility census was 85 residents. On 01/13/22 at 3:30 P.M., Administrator, Floating Administrator #395, and Regional Nurse/Infection Preventionist (IP) #397 was notified Immediate Jeopardy began on 12/31/21 when a COVID-19 outbreak occurred in the facility affecting 18 residents and 22 staff. On 12/31/21, Resident #19 tested positive for COVID-19 via rapid test, and he continued to room with his roommate Resident #22 who tested negative for COVID-19, until 01/03/22 when Resident #22 also tested positive. The COVID-19 outbreak was correlated to a lack of effective and proper infection control practices by staff which resulted in the spread of COVID-19. The Immediate Jeopardy was removed on 01/14/22 when the facility implemented the following corrective actions: · On 01/13/22, beginning at the dinner meal, the facility implemented a second seating of mealtimes on the memory care unit. The COVID-19 negative residents would eat first, the dining room would be disinfected, the COVID-19 positive residents would eat second, and the dining room would be disinfected again. Residents would be redirected to their rooms when noted to be wandering, and redirected to wear a face mask when noted without one. · On 01/13/22 Regional Nurse/IP #397 and Registered Nurse (RN) #30 reviewed all 85 residents care plans and updated them as needed. · On 01/13/22 all residents in the facility had temperature checks and respiratory screens for signs of COVID-19, completed by Regional Nurse/IP #397, Director of Nursing (DON) and Licensed Practical Nurse (LPN) #398. No new issues were identified. · On 01/13/22 all residents were reviewed by the Regional Nurse/IP #397 for being COVID-19 positive with a COVID-19 negative roommate (outside of the memory care unit) and no new concerns were found. · On 01/13/22, an isolation sign placed on Resident #30's door. · On 01/13/22 at approximately 6:00 P.M. an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Interdisciplinary Team (IDT) consisting of Administrator, Floating Administrator #395, the DON, Regional Nurse/IP #397, the Medical Director (MD) #400, Business Office Manager (BOM) #387, Payroll (AP) #388, Therapy Director #352, RN #307, and Activity Director #373, to review the immediate jeopardy, the interventions and plan to prevent reoccurrence, and they discussed the facility COVID-19 policies and procedures titled, Coronavirus (COVID-19), dated January 2022. · On 01/13/22, Regional Nurse/IP #397, provided education to the Certified Dietary Manager (CDM) #369, BOM #387, AP/Payroll #388, Housekeeping Supervisor #383, Therapy Director #352, and RN #307. The education consisted of facility policy titled, Coronavirus (COVID-19), dated January 2022, the facilities new procedures for the memory care unit, and appropriate PPE. They conducted in-house training to staff present in the facility, trainings via phone to staff who were not present, and the training continued at each shift change for on-coming staff and for each agency personnel. Two hundred and twenty staff (in-house and agency) were identified as educated as of 01/18/22. · On 01/13/22 an audit tool was created and would be completed five times weekly for four weeks, then weekly for four weeks, then monthly for three months by the Administrator/DON/ or designee by way of observation on the memory care unit during one meal daily to ensure intermingling of COVID positive residents and COVID negative residents does not occur. Any issues identified would be addressed. · On 01/13/22 the facility implemented a plan for audits to be completed five times weekly for four weeks via record review of 10% of residents by DON/designee to ensure that any residents not on the COVID unit with signs or symptoms of COVID-19, receive a COVID test and if the COVID test is positive, that the resident is placed on transmission-based precautions and moved to the COVID unit, unless that resident is on the memory care unit, they will be isolated in place. Any identified issues from audits would be addressed. · On 01/13/22 the facility implemented a plan for audits to be reviewed monthly by the QAPI committee for review and recommendations. The administrator is responsible for sustained compliance. · On 01/14/22, all residents on the memory care unit were co-horted, positive COVID-19 residents with positive COVID-19 residents and negative COVID-19 residents with negative COVID-19 residents. Rapid COVID-19 testing for all memory care residents and terminal cleaning was completed prior to the room moves. Although the Immediate Jeopardy was removed on 01/14/22, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the Centers for Medicare and Medicaid (CMS) QSO-20-39-NH memo, revised 11/12/21 revealed Nursing homes have been severely impacted by COVID-19, with outbreaks causing high rates of infection, morbidity, and mortality. The vulnerable nature of the nursing home population combined with the inherent risks of congregate living in a healthcare setting have required aggressive efforts to limit COVID-19 exposure and to prevent the spread of COVID-19 within nursing homes. 1. Interview on 01/13/22 at 8:10 A.M. with Licensed Practical Nurse (LPN) #310 revealed the unit was housing/intermingling COVID-19 positive with COVID-19 negative residents and she didn't agree with the way the facility was handling the outbreak on the memory care unit. Review of the facility contact tracing for the memory care unit residents revealed on 01/03/22, Resident #2 and Resident #18 tested positive via rapid test and a PCR test was sent to the lab the same day for confirmation. On 01/05/22, Resident #5 tested positive via rapid test and a PCR test was sent to the lab the same day for confirmation. On 01/06/22 all residents were tested with a PCR test due to the facility obtaining an agreement with a new lab company, as the original lab company was taking many days to receive results. On 01/10/22, Resident #2, #3, #8, and #18 were confirmed positive by the lab company. On 01/10/22, Resident #1, #9, #12, #13, and #17 were found to be positive. On 01/14/22, Resident #11 was found to be positive during rapid testing of all residents on the memory care unit. On 01/17/22 Resident #6 was determined positive. Interview on 01/13/22 at 8:35 A.M. with LPN #396 and State tested Nurse Assistant (STNA) #336 revealed there were only five residents on the memory care unit who were currently positive for COVID-19 (#2, #5, #9, #13 and #18). Observation of the dining room on 01/13/22 from 8:35 A.M. through 8:56 A.M. revealed Resident #5 and Resident #16 were sitting across from each other at a shared table. Resident #3 and Resident #18 were sitting across from each other at a shared table. Resident #11 was at the table next to Resident #3 and #18, with her back inches from Resident #3's back. Resident #13 was sitting alone. Resident #1 and Resident #14 were sitting across from each other at a shared table. Resident #2 was walking around the dining room. In the hallway outside of the dining room, Resident #4 was sitting in the hallway in her wheelchair and Resident #13 walked right past her after leaving the dining room. Resident #2 and Resident #6 were observed wandering the halls at the same time. None of the residents observed were utilizing PPE or social distancing. Although multiple staff were observed in the area, no staff were observed to redirect or educate the residents related to COVID-19 and isolation precautions. COVID-19 positive and negative residents were sharing rooms. The doors to the rooms for the COVID-19 residents had a sign to see the nurse before entering. Additional observations revealed each COVID-19 positive resident was allotted a PPE storage container in their rooms with readily available PPE for staff use and a biohazard container to discard visibly soiled PPE prior to leaving each resident's room. Interview on 01/13/22 at 8:45 A.M. with STNA #336 revealed the residents eat all of their meals in the dining room, the residents will wander in and sit in their specific seats and if they try to move them, they will go back to their normal seats. She stated they try to ensure they wear masks but they take them off. STNA #336 confirmed the residents were not being encouraged to utilize appropriate PPE at that time, they were not social distancing, and confirmed the COVID-19 positive residents were intermingled with COVID-19 negative residents. She stated she didn't think it was appropriate to keep the COVID-19 positive residents with the COVID-19 negative residents. Interview on 01/13/22 at 8:50 A.M. with LPN #396 confirmed the staff are unable to properly isolate the residents on the memory care unit due to their wandering. Interview on 01/13/22 at 12:27 P.M. with the [NAME] County Health Department Deputy Health Commissioner (KCHDDHC)#399 revealed he was not aware the facility was combining positive and negative residents on the memory care unit, and he further stated he hadn't physically seen the facilities plans for COVID. His understanding was that they were having questions related to the memory care unit and keeping it as an isolation area and he thought he was being consulted for, if they close the door to the memory care unit, it would create a barrier or if they would need plastic barriers. He stated it was never once explained to him that there were COVID-19 negative, and positives intermingled. He revealed he didn't agree with that, and he would recommend them to isolate that person. He stated this was a two-minute conversation and that he didn't have much communication with the facility. Review of the email chain dated 01/13/22, revealed Regional Nurse/IP #397 emailed KCHDDHC #399 stating she needed a letter from him stating that he was okay with the facilities decision to consider the locked memory care unit a COVID positive unit secondary to guests who wander and once in the unit, all staff would be required to wear full PPE. KCHDDHC #399 replied that he agreed in consultation with the facilities decision to make the memory care unit a COVID isolation area due to the scope of the incident and the audience within and utilizing the doors as barriers in lieu of plastic, allowed functional needs of said positive cases to be enabled. Interview on 01/13/22 11:28 A.M. with the Medical Director #400 revealed he had a long conversation with the regional office regarding the memory care unit and its COVID positive residents intermingled with COVID negative residents. He stated he was aware of the facility intermingling the two, but he told them to isolate the residents though it may not be feasible. He stated he told the facility to do the best they can do, such as encouraging social distancing and utilizing PPE per standard protocols. Interview on 01/18/22 at 11:55 A.M. with STNA #336 confirmed she was only aware of the five COVID-19 positive residents on the memory care unit on Thursday 01/13/22 and no one notified her of the additional five (#1, #3, #8, #12, #17) residents who were positive at that time. Interview on 01/19/22 at 10:20 A.M. with Regional Nurse/IP #397 revealed during contact tracing, it was possible that an STNA who became positive on 12/20/21 possibly exposed residents on the 100/memory care unit, and a Housekeeper who tested positive on 01/03/22, possibly exposed residents on the 100/memory care unit. Interview on 01/19/22 at 12:27 P.M. with Regional Nurse/IP #397 revealed on 01/13/22 she started daily meetings via note/phone call if there were changes in who is positive and who is negative, between herself, the nurse on the memory care unit and the dietary manager. 2. Record Review of Resident #20 revealed this resident was considered unvaccinated and admitted to the facility on [DATE] with the following medical Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #20's admission Minimum Data Set (MDS) Assessment, dated 01/12/22, revealed the resident's cognition was intact. Review of Resident #20's physician orders, dated 01/18/22, revealed the resident was on contact and droplet precautions related to COVID-19. Record Review of Resident #30 revealed this resident was considered unvaccinated and was admitted to the facility on [DATE] with the following medical Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #30's admission Minimum Data Set (MDS) Assessment, dated 01/14/22, revealed the resident's cognition was intact. Review of Resident #30's medical record revealed no physician orders for droplet precautions. Interview on 01/13/22 at 4:13 P.M. with Agency STNA #393 revealed today was her first day at the facility and she was not trained in COVID-19 procedures by the facility or by her agency, she was just expected to keep up on the CDC guidance herself. She further stated the appropriate PPE in the droplet precaution rooms was full PPE and she explained further that full PPE meant a gown, gloves, eye protection and a surgical mask. Observation on 01/13/22 at 4:22 P.M. revealed Agency STNA #393 donned a gown and gloves in addition to her eye protection and her surgical mask, and she entered Resident #30's room to respond to a call light. STNA #393 adjusted the resident's pillow and adjusted the resident's bed controls to his comfort, doffed the PPE, and exited his room. Outside of Resident #30's room, in the hallway, revealed a donning station full of gowns, gloves, wipes, and surgical masks, with N95 masks sitting on top of the donning station. There was no sign outside of the resident's room stating he was in any sort of isolation/droplet precaution. Interview and observation on 01/13/22 at 4:31 P.M. with Agency STNA #393 confirmed she had a surgical mask on and did not utilize the N95 mask when she assisted Resident #30. She stated she didn't do it because there weren't any N95 masks on his donning cart. Surveyor pointed out the N95's on top of the cart and she confirmed the N95 masks were on top of the donning cart. STNA #393 also confirmed the resident did not have a sign outside of his door stating that he was in isolation/precautions due to being a new admission and not being fully vaccinated. Observation on 01/13/22 at 4:32 P.M. revealed Resident #20's call light was going off and Agency STNA #393 donned a N95 mask she found from behind the nurses station. She put this N95 overtop of her surgical mask, and began donning her gown and gloves. Resident #20 had a droplet isolation sign along with a PPE cart in the hallway next to her door. Interview and observation on 01/13/22 at 4:40 P.M. with Floating Administrator #395 confirmed Resident #30 was to be in quarantine and there was no sign outside of his room stating he was in droplet precautions. Interview on 01/13/22 at 4:46 P.M. with DON revealed she spoke to Agency STNA #393 who told her that she thought it was appropriate procedure to utilize only a surgical mask because she was fully vaccinated. She stated she retrained her at that time. Interview on 01/18/22 at 9:46 A.M. with Certified Nursing Assistant (CNA) #323 revealed some staff don't utilize appropriate masks in the facility and sometimes they don't utilize eye protection. She stated it was usually the agency staff and they also don't doff their PPE appropriately; they will wear it outside of the resident rooms. 3. Record Review of Resident #19 revealed this resident was admitted to the facility on [DATE] with the following medical Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #19's quarterly Minimum Data Set (MDS) Assessment, dated 12/03/21, revealed the resident's cognition was intact. Record Review of Resident #22 revealed this resident was admitted to the facility on [DATE] with the following medical Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 22's admission Minimum Data Set (MDS) Assessment, dated 12/23/21, revealed the resident's cognition was intact. Review of the facility contact tracing revealed on 12/31/21, Resident #19 tested positive for COVID-19 via a rapid test and a PCR test was sent to the lab the same day for confirmation. Resident #22 (Resident #19's roommate) was also tested via rapid test and tested negative. The residents remained in the same room under isolation precautions together. On 01/03/22, Resident #22 began showing symptoms of COVID-19 and he tested positive via rapid test and a PCR was sent out to the lab the same day for confirmation. On 01/10/22 the PCR results for Resident #19 and Resident #22 were received which confirmed both residents were positive for COVID-19. The residents remained in the same room (on the 200 hall) and the COVID-19 unit was initiated on 01/03/22. The end of the 200 hall was already the designated COVID-19 area for if an outbreak were to occur. Interview on 01/13/22 at 9:54 A.M. with Regional Nurse/IP #397 revealed when Resident #19 tested positive with a rapid COVID test on 12/31/21, they automatically quarantined the resident and his roommate (Resident #22) together. She stated they completed a rapid test on Resident #22 who was negative and they completed PCR tests on both of the residents. She stated Resident #19 wasn't confirmed positive because the rapid tests have been known to be false, once they received the PCR lab result as positive, that's when it was confirmed. She stated they isolated them together because if Resident #19 was actually positive, Resident #22 was already exposed. She stated there were other open rooms at that time. Interview on 01/13/22 11:28 A.M. with Medical Director #400 revealed he did not know why the facility would allow a COVID-19 positive resident to be roommates with a COVID-19 negative resident. He stated they should have isolated that person and that seemed pretty straight forward. He further stated he would have expected anyone in contact with that COVID-19 positive person to be isolated as well. Interview on 01/18/22 at 6:00 P.M. with Regional Nurse/IP #397 revealed prior to the outbreak, they were only testing residents if symptomatic, vaccinated staff if symptomatic, and any nonvaccinated staff were tested twice weekly. As of 12/20/21, they had been in outbreak testing so they were testing residents three to seven days apart and staff testing was completed on Mondays and Thursdays for all staff unless they have had COVID in last 90 days. On 01/19/22 at 10:20 A.M. interview with Regional Nurse/IP #397 revealed the facility conducted mass testing for COVID-19 for all residents after the initial staff was positive on 12/20/21. Regional Nurse/IP #397 revealed during contact tracing, it was possible that an STNA who became positive on 12/20/21 possibly exposed residents on the 200 hall causing Resident #19 to become positive. Review of the county community COVID-19 positivity rate, dated 12/27/21 and 01/03/22, revealed the community transmission rate (for [NAME] county) was red/high and the facility was in a county with a positivity rate of 16.7 %. Review of the Centers for Disease Control (CDC) guidelines revealed for residents with new-onset suspected or confirmed COVID-19 test results the facility should: Ensure the resident was isolated and cared for using all recommended COVID-19 PPE. Place the resident in a single room if possible pending results of [CONDITION(S)]-CoV-2 testing. Cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected residents (e.g., residents who have fever, for example, due to a non-COVID-19 illness could be put at risk if moved to a COVID-19 unit). If cohorting symptomatic residents, care should be taken to ensure infection prevention and control interventions were in place to decrease the risk of cross transmission. If the resident was confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit. Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [CONDITION(S)]-CoV-2 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). Review of the CDC guidelines related to Sparkling Surfaces: Stop COVID-19's Spread revealed the virus that causes COVID-19 can be spread by indirect contact with contaminated surfaces. Surfaces that were touched frequently increase the chance that germs could be spread to residents and staff. On surfaces which look clean, pathogens might be present. The coronavirus causing COVID-19 has been shown to survive on surfaces from several hours to days. Review of the facility policy titled, Coronavirus (COVID-19), dated January 2022, revealed appropriate measures would be utilized for the prevention and control of COVID-19. It stated the incubation period is two to 14 days and the virus may be mild, moderate, or severe and can be life threatening. The virus is thought to spread mainly from person to person between people who are in close contact with one another (within about six feet). The core principles of COVID-19 Infection Prevention were for the residents to utilize face coverings/masks and physical distancing at least six feet between people in accordance with CDC guidance, appropriate staff use of PPE, and effective co-horting of residents (e.g., separate dedicated COVID-19 care area). It stated all recommended COVID-19 PPE should be worn during the care of residents under observation or in Transmission Based Precautions, which includes the use of an N95 or higher-level respirator, eye protection, gloves and gown. If a resident presents with symptoms consistent with COVID-19, they should be placed in Transmission Based Precautions, and tested for the virus. They should be placed in a private room and if they're confirmed to have COVID-19, the should be transferred to a designated COVID-19 unit. All unvaccinated residents who are new admissions should be placed in a 14-day quarantine even if they have a negative test upon admission. They should be on transmission-based precautions with a sign placed on their door for 14 days. The policy stated that communal dining would be conducted with alterations to adhere to the guidelines for preventing transmission, based on CDC and CMS guidance, they must adhere to the core principles of COVID-19 infection preventions, they may eat in the same room with physical distancing, and they should use face coverings when not eating and should physically distance from others. This deficiency substantiates Complaint Number OH 777.

Based on observation, record review and interview the facility failed to promptly identify, complete comprehensive assessments at least weekly and failed to provide adequate care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Actual harm occurred when Resident #79 developed a right heel pressure ulcer on 08/31/21 which was not comprehensively assessed until 09/09/21 and declined to a stage three pressure ulcer on 09/23/21. The assessment by the wound nurse practitioner on 09/30/21 indicated there was a decline in the pressure ulcer, however the assessment was incomplete. On 10/02/21, Resident #79 was clammy and lethargic and his right heel pressure ulcer was noted to have a foul odor and he was transferred to the emergency room . Resident #79 was admitted and remained hospitalized until 10/10/21 for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the medical record revealed Resident #79 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly minimum data set 3.0 assessment dated [DATE] revealed Resident #79 was alert, oriented and had intact cognition, required extensive assistance of two staff members for bed mobility, transfers, toilet use and personal hygiene. Resident #79 was incontinent of bladder and bowel and was assessed to have a stage one pressure ulcer (an observable alteration of intact skin which may involve a change in tissue temperature, firmness or boggy to touch, pain/itching, and/or a defined area of persistent redness in lightly pigmented skin or red, blue or purple hues in darkly pigmented skin), a stage two pressure ulcer (a full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not into, underlying fascia and presents as a crater or blister area) and an unstageable pressure ulcer (a full-thickness tissue loss with exposed bone, tendon or muscle with slough/eschar present which prevents accurate staging of the ulcer and often include undermining and tunneling) present upon admission. Review of the nurse's notes dated 03/12/21 at 8:38 A.M. revealed Resident #79 had a new skin area noted to his right heal. The note indicated it was an unstageable, deep tissue injury (DTI) and the wound nurse and his wife were notified. A deep tissue injury is defined as a persistent non-blanchable deep red, purple or maroon colored areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissue from areas of pressure for a prolonged period of time. The treatment was for skin prep to be applied to his heels and encourage him to wear moon boots, a device that straps to the foot/lower leg to offload pressure. This note indicated Resident #79 denied any pain or discomfort. Review of the Skin & Wound Evaluation dated 03/12/21 revealed Resident #79's DTI pressure injury to his right heel was acquired in the facility on 03/12/21 and measured 1.7 centimeters (cm) long by 1.4 cm wide with an undetermined depth. Review of the nurse's note dated 03/18/21 at 12:53 P.M. revealed the wound nurse practitioner (NP) was in the facility and indicated Resident #79 had a stage two pressure ulcer to his coccyx and an unstageable pressure ulcer to his right heel with a dark fluid filled blister. New orders were received for barrier cream to be applied to his coccyx and [MEDICATION(S)] applied daily to his right heel. There was no documentation of any measurements of his right heel pressure injury. Review of the wound nurse practitioner note dated 03/18/21 revealed Resident #79 had an unstageable right heel ulcer with intact skin, no drainage and the peri-wound was intact. There was no documentation of any measurements for this pressure ulcer. A physician's ordered dated 03/19/21 revealed Resident #79 was to have [MEDICATION(S)] applied to the pressure ulcer on his right heel every day. Review of the medical record revealed no measurements or assessments of the right heel pressure ulcer on 03/26/21 for Resident #79. Review of the Skin & Wound Evaluation dated 03/31/21 revealed Resident #79's DTI pressure ulcer to his right heel measured 2.3 cm long by 3.0 cm wide with an undetermined depth and progress had stalled. The wound nurse practitioner was notified. This evaluation revealed Resident #79's pressure ulcer was larger from the previous measurements which were recorded 19 days prior. Review of the Skin & Wound Evaluation dated 06/03/21 revealed Resident #79's DTI pressure ulcer to his right heel was healed. Review of the Braden scale for determining risk for development of pressure ulcers dated 08/17/21 revealed Resident #79 was at moderate risk for developing pressure ulcers. Review of the Skin and Wound Total Body Skin Assessments dated 08/19/21 and 08/26/21 revealed Resident #79 had no new pressure ulcers. Review of the physician's order dated 08/31/21 revealed Resident #79 had a new order to apply Medi-honey to the wound bed of the right heel, cover with a bordered gauze dressing daily and as needed for wound care. Review of the nurse's notes from 08/30/21 to 09/09/21 revealed no assessments or measurements for a right heel wound/pressure ulcer for Resident #79. Review of the Skin & Wound Evaluation dated 09/09/21 revealed Resident #79 had a stage two pressure ulcer which was acquired in the facility. This pressure ulcer measured 1.4 cm long by 1.3 cm wide with an undetermined depth. There was no documentation on this evaluation to indicate the location of the pressure ulcer, the date of origination or that a comprehensive assessment of the pressure ulcer was completed including presence of any drainage, odor, pain, appearance of the wound bed and the peri-ulcer assessment. Review of the Skin & Wound Evaluation dated 09/16/21 revealed Resident #79 had a stage two pressure ulcer. This evaluation indicated the pressure ulcer was acquired in the facility on 06/05/21. The pressure ulcer measured 1.4 cm long by 1.1 cm wide, with an undetermined depth and presented with 50 percent slough (dead, devitalized tissue) covering the wound bed with moderate drainage. There was no documentation recorded to indicate the location of this pressure ulcer. Review of the Skin & Wound Evaluation dated 09/23/21 revealed Resident #79's stage two pressure ulcer was on his right heel and measured 1.3 cm long by 1.0 cm wide with an undetermined depth. This assessment revealed the pressure ulcer declined and there was 100 percent slough in the wound bed with heavy drainage and an area of maceration around the edges of the pressure ulcer measuring 2.5 cm. Review of the plan of care updated initiated on 08/11/20 and updated on 09/23/21 revealed Resident #79 had actual impaired skin integrity related to actual pressure injuries and indicated he did not choose to wear the moon boots, did not reposition and did not want an air mattress to his bed. The refusals on this care plan were not added for approximately a month after the development of the heel pressure ulcer as the treatment was ordered on 08/31/21. There were no resident refusals of these pressure reliving devices recorded in the nurse's notes during this time period. The physician's order dated 09/24/21 revealed new treatment orders for Resident #79's right heel pressure ulcer. Nursing staff were to cleanse the right heel with normal saline, pat dry, apply calcium alginate (treatment to help debride devitalized tissue and absorb drainage) to the wound bed only, cover with gauze and wrap with Kerlix every other day and as needed if soiled. Review of the medical record through 09/30/21 revealed no comprehensive assessment or measurements for Resident #79's right heel pressure ulcer since 09/23/21. Review of the wound nurse practitioner note dated 09/30/21 revealed Resident #79's right heel pressure ulcer declined and was now assessed to be a stage three pressure ulcer (a full-thickness skin loss in which adipose or fat tissue is visible in the ulcer and granulation tissue and rolled wound edges are often present along with slough/eschar, tunneling and undermining). This examination indicated there was slough in the wound bed, no drainage and the peri-wound was intact. There was no documentation of the pressure ulcer measurements or if the wound had any odor. Review of the summary dated 10/02/21 at 6:36 P.M. revealed per nursing observations, Resident #79 appeared clammy and tired that morning, his blood sugar was elevated at 451, an odor was noted with his pressure ulcer dressing change and later he became unable to use fine motor skills. A new physician order was obtained to send Resident #79 to the emergency room . Resident #79 was admitted to the hospital and remained there from 10/02/21 to 10/09/21. Review of the hospital history and physical dated 10/02/21 revealed Resident #79 had a right heel decubital (pressure) ulcer about 1.0 cm with some purulent (pus) drainage coming from it. The resident was very lethargic. The assessment indicated Resident #79 had altered mental status with leukocytes and elevated [MEDICATION(S)] without fever, suspected secondary to diabetic right heel wound infection. The facility had not classified this pressure ulcer as a diabetic ulcer. Review of the hospital laboratory results dated [DATE] revealed Resident #79 had moderate growth of the organism Proteus Mirabilis, a gram negative bacteria, in his pressure ulcer. Review of the facility Nursing Comprehensive Evaluation dated 10/10/21 revealed Resident #79 was readmitted with a stage three pressure ulcer to his right heel and a healed pressure ulcer wound to the left heel. The nurse's note dated 10/10/21 at 10:10 P.M. revealed Resident #79 was on an antibiotic for the infected foot ulcer. Observation of Resident #79's pressure ulcer care on 12/29/21 at 1:00 P.M., with Licensed Practical Nurse (LPN) #104 revealed the ulcer on his right heel was approximately the size of a quarter, the wound bed was completely covered with yellow slough, the peri wound was reddened, and there was a moderate amount of tannish drainage on the old dressing. Interview on 12/30/21 at 1:01 P.M. with Clinical Transition Specialist #200 verified she was unable to find the missing skin grids/assessments because she was not at the facility during those time frames. She indicated she was looking to see if there were other assessments completed on paper forms but had completed a quick audit of the wound nurse practitioner. Clinical Transition Specialist #200 verified she identified the wound nurse practitioner did not always measure the wounds. Interview on 12/30/21 at 1:35 P.M. with Clinical Transition Specialist #200 verified Resident #79's assessments were not thorough and were not completed at least every seven days as required. Review of the facility policy titled, Skin Management, dated 07/21, revealed it was the facility policy to identify and implement interventions to prevent development of clinically unavoidable pressure injuries. Resident with wounds and/or pressure injury and those at risk for skin compromise were to be identified, evaluated, and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation were provided to ensure optimal resident outcomes. The licensed nurse would initiate documentation in the electronic health record (EHR), which included a description of the skin impairment. The licensed nurse would document on the skin and wound evaluation for pressure injury and vascular ulcer and would document weekly until the area was resolved. This deficiency substantiates Complaint Number OH 453.

Based on record review and interview the facility failed to safely transfer one resident (Resident #52) with two staff members as assessed to need. Actual harm occurred when Resident #52 fell and sustained a right knee fracture while being transferred by one staff member. This affected one resident (Resident #52) of two residents reviewed for falls. Findings include: Review of the medical record revealed Resident #52 was admitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) 3.0 dated 03/01/19 revealed Resident #52 was cognitively intact and required extensive assistance of two for transfers. Review of nurse note dated 04/02/19 at 9:50 A.M. revealed the nurse was summoned to Resident #52's room by State tested Nursing Assistant (STNA) #34. Resident #52 was lying on the floor on her left side. STNA #34 stated he safely lowered Resident #52 to the floor. Resident #52 voiced complaints of hip and knee pain. An x-ray of the resident's bilateral hips and pelvis was ordered. The x-ray results dated 04/02/19 of the resident's bilateral hips and pelvis were negative for a fracture. Review of the incident report dated 04/02/19 revealed Resident #52 was being transferred using a walker and the assistance of one staff. The resident lost her footing, and was lowered to the floor without injury. A written interview with STNA #34 dated 04/02/19, revealed he provided care for Resident #52 most days. STNA #34 stated while transferring the resident, the resident lost her footing and was safely lowered to the floor. A physician note dated 04/04/19 at 11:44 A.M. revealed Resident #52 requested to be seen because of right leg pain following a fall to the floor. The resident stated the pain was mainly in her right lateral knee and right thigh. Due to the resident's obesity, bedridden status, and location of the pain, a venous doppler of the right leg and an x-ray of the resident's right knee were ordered. The radiology results report dated 04/05/19 at 7:11 A.M., revealed Resident #52 had a right knee fracture. A nurse's note dated 04/05/19 at 9:00 A.M. revealed Resident #52 was transferred to the hospital. Interview on 04/25/19 at 11:13 A.M. with Resident #52 revealed she told the male STNA he was not strong enough to transfer her from the bed to the wheelchair by himself. Resident #52 stated she had been in bed the previous two months and was very week. Per Resident #52, STNA #34 picked her up in a bear hug but was not able to transfer her. The resident stated she slid off the bed and went down on her knee. Resident #52 stated she had pain in her knee and it took the facility three to four days to get an x-ray identifying the fracture. Interview on 04/25/19 at 11:21 A.M. with STNA #34 revealed Resident #52 was starting therapy and he was getting her ready. STNA #34 verified he did not check the care card to see how much assistance the resident needed and attempted to transfer the resident by himself. STNA #34 also verified he did not use a gait belt. Interview on 04/25/19 at 2:10 P.M. with the Administrator revealed Resident #52 did not have pain at the time of the fall so it took awhile to identify the fracture. Per the Administrator, STNA #34 received disciplinary action due to transferring Resident #52 without the number of staff required for assistance with transfer.

Based on record review and interview the facility failed to provide Resident #63 adequate assistance and supervision during a shower resulting in a fall. Actual harm occurred when Resident #63 was left unattended during the shower and fell out of a shower chair while reaching for shower equipment. Resident #63 sustained fractures of the right superior and inferior pubic rami. This affected one resident (Resident #63) of one resident reviewed for accidents. Findings include: Review of Resident #63's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admissions Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #63 was cognitively intact. The assessment revealed the resident required extensive assistance from two staff for bed mobility, extensive assist of one staff for transferring, dressing, walking and physical help in part of bathing activity. The assessment revealed Resident #63 had a fall in the last mouth prior to admission. Review of the Nursing Comprehensive Evaluation, dated 12/13/2017 revealed Resident #63 had three or more falls in the last three months prior to admission. Resident #63 was chair bound, had balance problems while walking, jerking and decreased muscle coordination. The evaluation revealed Resident #63 was at risk for falls. On 12/13/17 a fall plan of care was developed. The goal was for the resident to be free from injury daily utilizing fall precautions through the review date. Interventions included to lock wheels on wheelchair prior to transfers, complete fall risk per protocol, assist resident as needed, keep items of frequent use within reach and observe for fatigue and/or unsteadiness and encourage rest periods. The care plan revealed the resident required assistance with activities of daily living (ADL) and to provide extensive assist with bathing/dressing. Review of a progress note, dated 01/13/18 at 2:21 P.M. by Licensed Practical Nurse (LPN) #5 revealed Resident #63 slid out of the shower chair while reaching for an object during her shower at 11:20 A.M. The resident complained of right hip pain, as needed [MEDICATION NAME] (pain medication) was given and 911 was called. Resident #63 was transferred tp the emergency room . Review of a radiology report, dated 01/13/18 revealed Resident #63 sustained nondisplaced fractures of the right superior and inferior pubic rami. On 01/13/18 at 5:22 P.M. Resident #63 returned to facility. The nurse practitioner was notified and pain medication was changed from every 8 hours to every 4 hours as needed. Review of the facility investigation revealed on 01/13/18 at 11:20 A.M. Resident #63 was reaching for the shower head and slid out of the shower chair, falling to the floor. State tested Nursing assistant (STNA) #10 was in the shower room at the time of the fall. STNA #10 stated she was reaching for an object and she went one way and the chair went the other way. On 02/21/18 at 3:48 P.M. interview with Resident #63 revealed on 01/13/18 she had fallen in the shower room when she was taking a shower. She stated STNA #10 was giving her and another resident a shower at the same time that day. Resident #63 stated she had asked if this was ok to do two showers at one time and STNA #10 said yes. Resident #63 stated she was washing herself and STNA #10 was assisting the other resident. She had dropped the shower head, so she reached down to pick up the shower head, the shower chair was not locked and she fell out of the shower chair. Resident #63 stated STNA #10 was not with her when she fell . Resident #63 stated she was having indescribable pain in the right hip area after the fall. She stated the pain was unbearable. Resident #63 stated it was her opinion that if STNA #10 would have been assisting her with her shower she would have not tried to pick up the shower head on her own. Resident #63 stated they had to get the physician to give her more pain medication due to the unbearable pain she was having after the fall and stated the pain was unbearable for about three to four weeks. Resident #63 stated STNA #10 told her he got written up for giving two showers at one time. On 02/21/18 at 4:31 P.M. interview with LPN #5 revealed on 01/13/18 Resident #63 fell in the shower room when she reached too far. LPN #5 stated there was another resident in the shower room at the time of the fall. LPN #5 stated STNA #10 was the only staff member in the shower room when Resident #63 fell . LPN #5 stated she immediately started an investigation and had determined Resident #63 reached too far and fell out of the shower chair and staff supervision at the time of the fall was not safe. LPN #5 stated Resident #63 was not independent with shower. On 02/21/18 at 4:45 P.M. interview with the Interim Director of Nursing (DON) verified Resident #63 sustained a fall from the shower chair and subsequent fractures on 01/13/18 when she was left unattended while taking a shower. The DON verified the resident's current fall care plan and MDS assessment dated [DATE] revealed the resident was not independent with showers and required one staff to assist with ADL's. Review of an Employee Disciplinary Record for STNA #10, dated 01/13/18 at 11:20 A.M. revealed rule violation safety. The record further specified that only one guest should be in the shower at a time. The employee refused to sign the disciplinary action. On 02/22/18 at 9:15 A.M. interview with STNA #10 revealed on 01/13/18 he was the only STNA on the 300-Hall and that everyone on the hall was scheduled to have a shower, so he had to put two residents in the shower at one time to be able to complete his showers for that day. STNA #10 stated he would put two residents in the shower together that did not need much assistance with bathing. STNA #10 verified Resident #63 was not independent with showers. Resident #63 was in the shower with another resident in the other shower area and he was the only aide in the shower room for both residents. STNA #10 stated Resident #63 was washing herself while sitting in a shower chair and he was assisting the other resident getting dressed when Resident #63 fell out of the shower chair. STNA #10 stated Resident #63 was reaching down to pick up the shower head and slid out of the shower chair while he was assisting another resident getting dressed. STNA #10 stated LPN #5 came in assessed Resident #63 and 911 was called. STNA #10 stated that management knew this was how the shower had to be done, to complete the scheduled showers. STNA #10 stated he was written up for providing two residents showers at the same time.

Based on review of medical records, resident and staff interviews and review of the employee handbook, the facility failed to provide privacy for a female resident when a male nurse took photos of wounds located near the resident's genital area with a personal cell phone. Harm occurred to Resident #10 who felt violated and was upset about who would be able to view the pictures. The facility also failed to provide privacy for a resident in the bathroom. This affected two (Resident #10 and Resident #16) of three residents reviewed for privacy. The facility census was 98. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact. Interview with Resident #10 on 06/24/15 at 11:30 A.M. revealed she was upset about a male nurse, Registered Nurse (RN #13), who took a picture of her crotch the day she was admitted . The resident stated she had a large wound near her private area and during the dressing change on admission, Resident #10 stated a male nurse told her he was going to take pictures, he proceeded to take the pictures with his personal cell phone. The resident revealed I know he showed the pictures to other people because other people told me they have seen the pictures. The resident did not know who told her they saw the pictures. Resident #10 revealed I thought about it later, about the pictures, and I just didn't feel it was right because they were on his personal cell phone. I feel like I was violated. I feel like he has the (pictures) out there and I am upset because I don't know who can see them. Resident #10 stated she reported the incident to RN #2 on 06/19/15. The resident revealed she did not give consent for the pictures to be taken. Interview with the Administrator, Director of Nursing (DON) and Unit Manager #2 on 06/24/15 at 3:14 P.M. revealed Unit Manager #2 reported to the DON that RN #13 took pictures of Resident #10 with his cell phone. The DON stated she was informed of the incident on 06/19/15 but did not speak to RN #13 until 06/20/15. The DON indicated she instructed RN #13 to delete the pictures. The DON verified she did not ensure RN #13 deleted these pictures. The Administrator also verified she did not ensure the pictures were deleted from RN #13's personal cell phone. The DON revealed she did not view the pictures and was unsure of what the content of the pictures were. RN #13 was brought into the interview and admitted to taking the pictures. RN #13 revealed he asked the resident is it okay if he took pictures and the resident stated it was okay. RN #13 stated he was going to use the pictures to show the resident a before and after of her wound but RN #13 admitted the resident stated she did not want to see the pictures. RN #13 revealed the pictures of Resident #10 were still on his phone and indicated he would delete them. RN #13 was observed pushing buttons on his cell phone while in the room. RN #13 stated he was not told by the DON to delete the pictures on 06/20/15 and revealed the DON never talked to him about it. The DON verified she did not complete an investigation of the incident, did not discipline RN #13 and had no documentation related to the pictures of Resident #10's private area. On 06/24/15 at 3:45 P.M. the surveyor asked RN #13 if the pictures were still on his phone. RN #13 verified the pictures were still on his phone. Observation of RN #13's personal cell phone revealed two pictures of Resident #10; one was a close up of the wound located near the vaginal area and the second was a picture of the wound and the resident's pubic hair. On 06/24/15 at 4:15 P.M. interview with the Administrator revealed we should have done a better job with this incident. The Administrator also verified the DON should have documented her conversation with RN #13 after the pictures were taken and the pictures should have been deleted. The Administrator verified she was unable to determine if the pictures could be found in another format such as an internet Icloud storage. Review of the employee handbook revealed employees are not permitted at any time to use or carry personal cellular telephones in patient care areas unless authorized by your supervisor. Review of the House Rules (HIPPA section A) revealed taking photographs of residents without permission or authorization and the use of video/picture telephones within the facility or facility grounds can result in disciplinary action up to termination. 2. Review of the medical record for Resident #16 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Interview with Resident #16 on 06/25/15 at 9:30 A.M. revealed she was upset with Certified Occupational Therapy Assistant (COTA) #13. The resident stated COTA #13 refused to leave her room when she asked him to leave. The resident explained COTA #13 came to get her for therapy, the resident asked COTA #13 to come back in 20 minutes because she needed to use the bathroom. Resident #16 revealed she was already in the bathroom when the therapist arrived. COTA #13 stated he would wait in the room. Resident #16 told COTA #13 she wanted him to come back so she could have privacy. The resident explained she couldn't use the bathroom knowing someone was out there in her room waiting. Interview with RN #2 on 06/25/15 at 10:35 A.M. revealed she was aware Resident #16 was upset that COTA #13 did not step out of the room when the resident asked for privacy. RN #2 indicated the rehabilitation director was made aware of the concern and COTA #13 was no longer permitted to care for Resident #16. Interview with COTA #13 at 1:15 P.M. on 06/25/15 revealed he went to get Resident #16 for therapy when she was in the bathroom. COTA #13 stated he told her he would help her with toileting as this was part of her therapy. COTA #13 verified he did not leave Resident #16's room when asked and he should have complied with the wishes of the resident. This deficiency substantiates Complaint Number OH 432.