Every finding on record at Laurels of Norworth the

Based on record review, observations, interviews, review of wound notes, review of hospital records and policy review, the facility failed to prevent the development of pressure ulcers and failed to ensure interventions were in place as ordered to prevent new or worsening pressure ulcers for Residents #20, #10, and #30. Actual harm occurred on 12/16/25 when it was discovered that Resident #20, who was at risk for skin breakdown with no pressure ulcers upon admission, developed an avoidable facility acquired unstageable (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound) pressure ulcer injury to the right heel. On 01/27/26, Resident #20 developed a facility acquired unstageable pressure injury to coccyx that was previously documented as Moisture Associated Skin Damage (MASD). This affected three residents (Residents #20, #10, and #30) of three reviewed for pressure ulcers. The facility census was 116. Findings include: 1.Review of the medical record for Resident #20 revealed an admission date of 10/18/25. Diagnoses included Alzheimer's disease, depression, spinal stenosis and primary generalized osteoarthritis. Review of the admission nursing comprehensive evaluation dated 10/18/25 for Resident #20 revealed the resident required total assistance with bed mobility. Review of the plan of care initiated 10/19/25 for Resident #20 revealed the resident is at risk for impaired skin integrity/pressure injury related to: weakness, decreased mobility, and Alzheimer's disease. Interventions included a pressure reduction mattress to bed and when the resident chooses not to reposition as often as needed, explain consequences and continue to attempt to get them to comply. There was no intervention for assistance to turn and reposition in bed. Review of Resident #20's Braden Scale for Predicting Pressure Sore Risk dated 10/21/25 revealed a score of 13, moderate risk for skin breakdown. The scale was six (high risk) to 23 (no risk).Review of the most recent Minimum Data Set (MDS) assessment, dated 10/25/25, revealed Resident #20 had severe cognitive impairment. The resident required substantial/maximal assistance with bed mobility, and total dependence on toilet hygiene, shower/bathe self, and transfers. This resident was frequently incontinent with bladder and bowel and was at risk for developing pressure ulcers. Review of Resident #20's Braden Scale for Predicting Pressure Sore Risk dated 11/11/25 revealed a score of 18, no risk for skin breakdown.Review of the skin check assessment dated [DATE] for Resident #20 completed by Registered Nurse (RN) #2323 revealed no skin issues. Review of the Physician Note dated 12/15/25 for Resident #20 by Physician # 200 revealed the resident was unable to care for self and has generalized weakness being bed bound for the previous few weeks with bilateral heel pain. Assessment of the feet revealed scaling/dry skin. Review of the progress note dated 12/15/25 at 9:04 P.M., documented by RN #2345 revealed a skin injury on the right heel which was painful to touch. The heel was cleansed with normal saline and covered with clean, dry dressing. Facility wound nurse Licensed Practical Nurse (LPN) #1500 was notified. Review of the medical record from admission to 12/15/25 for Resident #20 revealed no documented refusals and reinforcement of turning and repositioning while in bed. Review of the skin issues assessment dated [DATE] at 6:00 P.M. for Resident #20 by LPN #1500 revealed an in-house facility acquired right heel unstageable pressure ulcer measuring 1.38 centimeters (cm) by 1.19 cm by 0.1cm with wound bed tissue composition 10 percent granulation and 90 percent slough (a yellowish, stringy dead tissue.) Additional care to turning/repositioning program and educated the resident on turning every two hours. Review of the assessment evaluations dated 12/16/25 for Resident #20 revealed no reevaluation of the Braden Scale for Predicting Pressure Sore Risk and no unavoidable pressure ulcer injury assessment. Review of the physician orders dated 12/17/25 revealed an air pressure mattress to bed, check placement and function every shift, and bilateral off-loading boots while in bed, check placement every shift. There were no settings for the air mattress listed. Review of the plan of care initiated on 12/17/25 revealed the resident had an actual impaired skin integrity related to an in-house pressure injury of the right heel. Interventions did not include assisting to turn and reposition in bed or elevating heels while in bed if the resident refuses the offloading boots. Review of the wound consult visit notes dated 12/23/25 revealed Resident #20 was seen by Wound Nurse Practitioner (WNP) #300. The right heel was an unstageable pressure ulcer measuring 1.28 cm by 1.02 cm with no depth with the wound bed tissue composition 90 percent slough and 10 percent granulation. A treatment plan to continue current treatment orders and to continue supportive care of turn and reposition frequently, support with pillows or a wedge to prevent pressure on the wound, heels should be elevated off the bed and continue proper nutrition and hydration for healing. Review of the wound consult visit notes dated 12/30/25 revealed Resident #20 was seen by WNP #300. The right heel unstageable pressure ulcer was stable, measuring 1.25 cm by 0.93 cm with no depth with the wound bed tissue composition 70 percent slough and 30 percent granulation. A treatment plan to continue current treatment orders and to continue supportive care of turn and reposition frequently, support with pillows or a wedge to prevent pressure on the wound, heels should be elevated off the bed and continue proper nutrition and hydration for healing. Review of the medical record from 12/16/25 through 01/04/26 for Resident #20 revealed no documented refusals and reinforcement of turning and repositioning while in bed. Resident #20 was hospitalized for an unrelated health issue from 01/04/26 through 01/08/26. Review of the progress note dated 01/08/26 at 3:19 P.M. revealed Resident #20 returned to the facility from the hospital. Review of the discharge hospital documentation dated 01/08/26 for Resident #20 revealed no instructions for wound care. Review of the admission nursing comprehensive evaluation dated 01/08/26 revealed Resident #20 had an open area on the right heel and a blanchable area on the coccyx. Resident #20 required two people to assist with bed mobility. Review of the care plan, revised on 01/08/26, revealed Resident #20 was at risk for impaired skin integrity/pressure injury related to weakness, decreased mobility, and Alzheimer's disease. Interventions included an air pressure mattress still in place. No Interventions to assist to turn and reposition in bed or elevating heels while in bed if the resident refuses the offloading boots. Review of the physician orders dated 01/08/26 revealed no physician's order was in place for settings for the air pressure mattress to bed and for bilateral off-loading boots while in bed. Review of the progress note dated 01/09/26 at 12:51 P.M. for Resident #20 revealed a second skin sweep was completed by LPN #1500. Resident #20 had moisture associated skin damage (MASD) on the coccyx with blanchable redness with no drainage. There were no measurements documented and no treatment in place. Review of Resident #20's Braden Scale for Predicting Pressure Sore Risk dated 1/10/26 revealed a score of 15, mild risk for skin breakdown. Review of the progress note dated 01/12/26 at 12:07 P.M. by LPN #1500 for this resident revealed the right heel prior wound was still present. There were no ulcer stages or measurements documented. Review of the physician orders dated 01/12/26 for Resident #20 revealed an air pressure mattress to bed, check placement and function every shift and bilateral off-loading boots while in bed, check placement every shift. No air mattress settings were listed. Review of the skin issues assessment dated [DATE] at 2:50 P.M. for Resident #20 by LPN #1500 revealed a right heel stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) acquired in house on 12/16/25, measuring 0.67cm by 1.18 cm by 0.1 cm with a wound bed tissue composition 70 percent granulation and 30 percent slough. Odor noted after being cleansed. Additional care to turning/repositioning program, mattress with pump, heel suspension/ protection device and educate the resident on turning every two hours. Review of WNP #300's progress note dated 01/14/26 revealed Resident #20 had a pressure injury of the right heel. Encourage suspension boots to bilateral lower extremities and offloading to heels. There was no documentation of MASD of the coccyx. Review of the plan of care, revised on 01/15/26, revealed Resident #20 had an actual impaired skin integrity related to an in-house pressure injury of the right heel and MASD to the coccyx. There were no interventions listed related to assisting to turn and reposition in bed or elevating the heels while in bed. Review of the skin issues assessment dated [DATE] at 12:05 P.M., by LPN #1500 revealed Resident #20 had a stable right heel stage III pressure ulcer measuring 0.90cm by .92 cm by 0.1 cm with a wound bed tissue composition 100 percent granulation. Odor noted after being cleansed. Additional care to turning/repositioning program, mattress with pump, heel suspension/ protection device and educate the resident on turning every two hours. Review of the progress note dated 01/20/26 at 5:01 P.M. by LPN #1500 revealed Resident #20 had MASD to bilateral buttocks stable at this time. Continue current treatment. Review of the medical record dated 01/20/26 revealed no treatment order was in place for MASD to the bilateral buttocks and no measurement or assessment of the area was completed. There was no wound consult visit note by WNP #300 and no physician, Nurse Practitioner or Registered Nurse assessment of the MASD to the coccyx. Review of Resident #20's Braden Scale for Predicting Pressure Sore Risk dated 1/23/26 revealed a score of 16, mild risk for skin breakdown. Review of the skin issues assessment dated [DATE] at 11:50 A.M., documented as a late entry by LPN #1500 revealed Resident #20 had an in-house facility acquired unstageable pressure ulcer to the coccyx measuring 3.32 cm by 3.18 cm by 0.1 cm. The wound bed tissue composition of 10 percent granulation and 90 percent slough.Review of the medical record from Resident #20's readmission date of 01/08/26 to 01/27/26 for revealed no documented refusals and reinforcement of turning and repositioning while in bed. During an observation on 01/27/26 at 11:06 A.M., Resident #20 was resting with her eyes closed. She was lying in bed on her back, on an air mattress with setting options based on weight only, set to 350 pounds. She was not wearing offloading boots and her heels were not elevated. During an observation on 01/27/26 at11:41 A.M., LPN #1500 and LPN #1111 changed the right heel pressure ulcer dressing. Resident #20's offloading boots were in the room on a chair. LPN #1500 measured and staged the right heel pressure ulcer as stage III measuring 0.38 cm by 0.65. cm by 0.1 cm. During an interview at this time, LPN #1500 verified the Resident #20's air mattress was set to 350 pounds and the resident weighed112.9 pounds. It was also verified Resident #20 was not wearing the offloading boots and her heels were not elevated. LPN #1500 stated the facility utilizes several types of air mattresses and no education has been provided to maintain them. The physician order should have settings to follow for the air mattresses, and it is the responsibility of the nurse who is caring for the resident to maintain the air mattress per physician order. It is the responsibility of the Certified Nursing Assistant (CNA) to apply the offloading boots and to elevate the resident's heels per their plan of care. The nurse who is caring for the resident is responsible for following up. During an interview on 01/27/26 at 12:03 P.M., LPN #1500 stated the facility had a consulting Wound Nurse Practioner, WNP #300, coming to the facility every Tuesday, but she has not been to the facility for the past several Tuesdays. When she was rounding, LPN #1500 would round with her and take verbal orders for changes to residents she treated as her notes were not always entered into the electronic medical record for several days. Since WNP #300 has not been rounding, LPN #1500 has been rounding on Tuesdays, assessing, staging and evaluating pressure ulcers and other skin alterations. LPN #1500 verified no physician, nurse practitioner or RN rounds with her and verified she is assessing the pressure ulcers. She stated based on her assessment, nursing judgment, and what treatment the resident should receive, she discusses it with the physician and/or nurse practitioner. The process of a resident being admitted with a pressure ulcer is documented on their admission assessment with a brief description. The unit managers are responsible for a second skin sweep, but no measurements are obtained at that time with brief descriptions. She is notified of the pressure ulcer from the unit manager, and the Wound Nurse Practitioner would evaluate, stage and measure on Tuesday. If the Wound Nurse Practitioner is unable to round, then it is her responsibility to round. When it comes to MASD areas, she does document in the progress notes if the area is better, worse or the same, but there are no measurements or descriptions of the area. During an interview on 01/27/26 at 1:31 P.M., the DON stated when a resident gets admitted , the admitting nurse on the floor documents any skin alterations under the admission assessment, but it is a general description as they are not allowed to stage and assess pressure ulcers. On the second skin sweep, completed by the unit managers, areas are documented under the progress notes, and no measurements are obtained regardless of what they are as in MASD, skin tear or a pressure ulcer. WNP #300 visits on Tuesdays and would round on pressure ulcer areas only and assess, stage and measure the area. If she is unavailable, LPN #1500 completes the rounds. If she is out, it is herself, or she has LPN #1111 round. The DON verified the WNP #300 has not been at the facility for a few weeks as she is on leave from the company and no replacement has been sent. The facility is in the process of finding another company, so for residents with pressure ulcers who need treatments, LPN#1500 assesses and relays the information about the areas to the providing team and they order the treatments. To her knowledge, the team provided does not assess the areas unless asked to by the staff, so orders are based on an assessment of LPN #1500. With other skin alterations, measurements are taken within a week of admission, but MASD does not get measured and has no descriptions documented in resident's medical records except on a weekly progress note indicating if it is better, worse or the same by the rounding nurse on Tuesday. The DON verified if there are no measurements and assessments documented on MASD, the floor nurse is unable to notify a provider if the area is deteriorating. The DON stated LPN #1500 has been rounding for the past several weeks in the absence of WNP #300. LPN #1500 has been assessing, staging, and measuring the areas with no verification of accuracy from a physician, nurse Practitioner or RN. The facility utilizes several different kinds of air mattresses and has not educated the staff on how each air mattress functions. Resident #20 did obtain an in-house facility acquired pressure area to the right heel on 12/15/25 with LPN #1500 assessing, staging and measuring the area on 12/16/25 and another Braden scale was not completed at this time. No interventions were in place on the plan of care from admission to 12/15/25 to assist with turning and repositioning as the resident was assessed to be substantial/maximal assistance with bed mobility. It was also verified that the plan of care did not have assist to turn and reposition and air mattress settings from 12/17/25 to current. The plan of care did indicate if the resident chooses not to turn to attempt to get her to comply and that should be documented as well as refusals to turn and reposition. Resident #20 has no documented refusals to turn and reposition. Resident #20 was readmitted to the facility on [DATE] with a right heel open area and blanchable coccyx, with ongoing assessments of the right heel completed only by LPN#1500 as a stage III pressure ulcer. The MASD has also only been documented on in the progress notes weekly by LPN#1500 with no measurements and assessments and was erroneously documented on 01/20/26 as bilateral buttocks instead of the coccyx. During an observation on 01/27/26 at 2:44 P.M. revealed Resident #20 in bed on her back. During an interview at 2:49 P.M., CNA #101verified Resident #20 was on her back and has been most of the day and does need assistance to turn in bed. She charts in the computer when a resident is turned and refuses, but only when she has time, so it doesn't always get charted. She is unsure if a resident is assessed to need to be turned as the Kardex for the residents does not indicate if a resident needed turned and repositioned every two hours. During an interview on 01/27/26 at 2:51 P.M., RN #2325 stated the CNAs are responsible for turning and repositioning residents. She is unsure if a resident has been turned as the aides don't always chart residents being turned on the computer. She doesn't always visualize her residents every two hours to verify they are being turned. If one of her residents is assessed as needing to be turned and repositioned every two hours, there are no orders to indicate that for her to check to make sure they are and the care plans do not indicate that on them. If a resident refuses and or needs reminded to turn and reposition, that should be documented. She is aware that Resident #20 does need assistance to be turned and repositioned and verified she has been on her back all day in bed. RN #2325 stated she has several residents on air pressure mattresses and has not received education for them. If issues arise, she reaches out to the unit manager, but she does not know what settings they are to be on for each resident, the orders are to check them for function. 2. Review of the medical record for Resident #10 revealed an admission date of 05/28/25. Diagnoses included chronic pain, type 2 diabetes without complications, venous insufficiency and a new diagnosis of vascular dementia with the date of 09/15/25. Review of the most recent MDS assessment, dated 12/06/25, revealed Resident #10 was cognitively intact. The resident required substantial/maximal assistance with bed mobility, and total dependence on toilet hygiene, shower/bathe self, and transfers. This resident was always incontinent with bladder and bowel. Review of the care plan, last revised on 9/09/25, revealed Resident #10 was at risk for impaired skin integrity/pressure injury related to weakness and decreased mobility. Interventions included offloading boots to bilateral lower extremities as ordered. Review of the progress note dated 11/14/25 revealed Resident #10 complained of pain to the right heel. Upon assessment, a deep tissue injury (purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue) was discovered. No measurements or descriptions were documented. Review of the wound consult visit notes dated 11/18/25 revealed Resident #10 was seen by WNP #300 and the right heel deep tissue injury was measured and described for the first time. Resident #10 was hospitalized for an unrelated health issue from 12/06/25 through 12/11/25. Review of the admission nursing comprehensive evaluation dated 12/11/25 for Resident #10 revealed a right heel open area and bilateral buttocks were red and blanchable. Review of the progress note dated 12/12/25 revealed a second skin sweep completed on Resident #10 with the right heel assessed as an unstageable pressure ulcer and the bilateral buttocks as MASD. No measurements or descriptions were documented. Review of the wound consult visit notes dated 12/16/25 revealed Resident #10 was seen by WNP #300 on 12/16/25. The right heel deep tissue injury was measured and described for the first time. No assessment of the MASD was completed. Review of the progress note dated 12/16/25 and 12/23/25 by LPN #1500 revealed the MASD to the bilateral buttocks was improving. No measurements or descriptions were documented. Resident #10 was hospitalized for an unrelated health issue from 12/30/25 through 01/20/25. Review of the admission nursing comprehensive evaluation dated 01/20/26 revealed Resident #10 no longer had the right heel deep tissue injury and bilateral buttocks MASD. Review of the physician orders upon readmission to the facility on [DATE] through 01/27/26 for Resident #10 revealed no order for offloading boots to be applied to bilateral lower extremities. Review of Resident #10's Braden Scale for Predicting Pressure Sore Risk dated 01/23/26 revealed a score of 18, no risk for skin breakdown. During an observation on 01/27/26 at 11:03 A.M. and 12:54 P.M., Resident #10 was resting in bed with his eyes closed. He was lying on his back and no off-loading boots were on his feet. During an observation at 2:31 P.M., Resident #10 was still lying in bed on his back, with no off-loading boots on his feet. During an interview at that time, Resident #10 said he does not remember the last time he had the off-loading boots on his feet. He is on his back a lot in bed. He has a lot of pain and is weak and needs help to turn in bed but only gets turned if he asks the staff. During an interview on 01/27/26 at 2:35 P.M., CNA #101 verified Resident #10 was on his back and needs assistance in bed to turn. She verified he was not wearing the off-loading boots. CNA #101 was not sure if he needed the boots and said she would have to look at the Kardex. During an interview on 01/27/26 at 2:13 P.M., the DON stated Resident #10 does have a history of a right heel deep tissue injury that was facility acquired. She verified that no measurements or a description of the heel ulcer was completed upon discovery. Upon readmission on [DATE], no measurements and assessments of the right heel open area were completed until 12/16/25. While the resident had bilateral buttocks MASD from 12/11/25 through 12/30/25, no measurements and descriptions were completed. Resident #10 does have the off-loading boots but there is no active order. He has been in and out of the hospital several times since the offloading boots were originally ordered, and orders do not carry over. It is the unit manager's responsibility to review past orders and plans of care to reorder and reinitiate them. The order is for the caring nurse to verify the boots are on and off as ordered and the care plan for the aides to know to apply them. 3. Review of the medical record for Resident #30, revealed an admission date of 01/02/26. Diagnoses included severe protein calorie malnutrition, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, muscle weakness and a stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer of the sacral region. Review of the most recent MDS assessment dated [DATE] revealed Resident #30 was rarely or never understood. The resident was totally dependent on staff for bed mobility, transfers, bathing and toilet hygiene. Review of the discharge hospital documentation dated 01/02/26 for Resident #30 revealed a sacrum stage IV pressure ulcer. Review of the admission nursing comprehensive evaluation dated 01/02/26 for Resident #20 revealed a coccyx pressure ulcer and Resident #30 was totally dependent on bed mobility. Review of the wound consult visit notes dated 01/06/26 revealed Resident #30 was seen by WNP #300. The note documented the sacrum pressure ulcer measured 0.88 cm by 0.52 cm by 0.4 cm. Review of the plan of care dated 01/02/26 for Resident #30 revealed this resident has an actual impaired skin integrity related to pressure injury with intervention including but not limited to when resident chooses not to reposition as often as needed, explain consequences and continue to attempt to get them to comply, but no intervention for assistance to turn and reposition. Further review of the care plan revised on 01/05/26 for this resident revealed at risk for impaired skin integrity/pressure injury related to right side hemiparesis, and pressure injuries. Interventions included but were not limited to an air pressure mattress. No intervention added for offloading boots bilaterally to lower extremities. There were no settings for the air mattress listed. Review of the physician orders dated 01/05/26 for Resident #30 revealed an air pressure mattress, to check placement and function every shift, and offloading boots to bilateral lower extremities every shift. There were no air mattress settings listed. Review of the skin issues assessment dated [DATE] for Resident #30 by LPN #1500 revealed the sacrum ulcer was a stage IV, measuring 4.82 cm by 2.2 cm by 0.3 cm and had deteriorated. Review of CNP #330's note dated 01/14/26 revealed Resident #30 was bed bound and unable to reposition on her own. Staff needed to assist with repositioning frequently. Review of the skin issues assessment dated [DATE] by LPN #1500 revealed Resident #30's sacrum ulcer was a stage IV and measured 4.82 cm by 1.55 cm by 0.3 cm. Review of CNP #330's note dated 01/20/26 revealed Resident #30 was bed bound and unable to reposition on her own. Staff needed to assist with repositioning frequently. During an observation on 01/27/26 at 11:35 A.M., Resident #30 was in bed on her left side. She did not have off-loading boots on her feet. The air mattress was leaning against the wall in her room. During an interview at the time of the observation, CNA #102 verified Resident #30 was not wearing the boots and did not know why the air mattress was not on the bed. During an observation on 01/27/26 at 12:58 P.M., Resident #30 now had the air mattress on her bed. The air mattress setting was 10, maximum firmness. During an interview at the time of the observation, LPN #1550 stated the mattress was for comfort and Resident #30 could not communicate comfort settings for the air mattress. This was a new mattress as the old one had malfunctioned. LPN #1550 stated the physician was not notified of the change in mattress and she was not sure what the setting should be on. She stated she has never received education on the function of the air mattresses and the facility does utilize several types. During an interview on 01/27/26 at 2:39 P.M., the DON stated that when a resident requires an air pressure mattress, the resident's height, weight and skin condition are sent to one of their supply companies and an air mattress is sent based on that information. They are set up by the supply company. Orders from the physicians are obtained to maintain and check function, but settings are based on the type of air pressure mattress. The DON verified staff have not been educated to maintain the different types of air pressure mattresses the facility uses. During an observation on 01/27/26 at 2:54 P.M., Resident #30 was still on her left side in bed. CNA #102 verified at that time Resident #30 was still on her left side and was totally dependent on turning and repositioning. CNA #102 stated he does not always have time to document in the computer if a resident is turned or if they refuse. During an interview on 01/27/26 at 2:57 P.M., LPN #1550 stated Resident #30 was still on her left side and stated the resident like that side and would move herself. Review of the facility policy titled Skin Management, revised 08/14/24, revealed the facility should identify and implement preventions to prevent the development of clinically unavoidable pressure injuries. Upon admission/readmission, all residents are evaluated for skin integrity and documented in the medical record which includes the location, measurements and characteristics. Appropriate preventative measures will be implemented on residents identified at risk and the interventions are documented on the care plan. The Braden Scale will be completed with significant changes to determine the risk of pressure injury development. This deficiency represents non-compliance investigated under Complaint Number OH00270375.

Based on medical record reviews, interviews, and facility job descriptions, the facility failed to ensure Licensed Practical Nurses (LPN's) acted within their professional standards and their scope of training related to pressure ulcer wound assessments and staging of wounds. This affected two residents (#20 and #30) of three residents reviewed. The facility census was 116.1. Review of the medical record for Resident #20, revealed an admission date of 10/18/25. Diagnoses included but were not limited to Alzheimer's disease, depression, spinal stenosis and primary generalized osteoarthritis. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 03 (00 to 15) indicated severe cognitive impairment. The resident was assessed to require substantial/maximal assistance with bed mobility, and total dependence on toilet hygiene, shower/bathe self, and transfers. This resident was also assessed to be frequently incontinent of bladder and bowel and to be at risk for developing pressure ulcers. Review of the skin issues assessment dated [DATE] for Resident #20 by Licensed Practical Nurse (LPN) #1500 revealed an in-house facility acquired right heel unstageable (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound) pressure ulcer measured 1.38 centimeters (cm) by 1.19 cm by 0.1 with the wound bed tissue composition 10 percent granulation and 90 percent slough. Review of the skin issues assessment dated [DATE] for Resident #20 by LPN #1500 revealed a right heel stage 3 (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcer, acquired in house on 12/16/25, measured .67 cm by 1.18 cm by 0.1 cm with a wound bed tissue composition 70 percent granulation and 30 percent slough. Review of the skin issues assessment dated [DATE] for Resident #20 by LPN #1500 revealed a stable right heel stage 3 pressure ulcer measured .90 cm by .92 cm by 0.1 cm with a wound bed tissue composition 100 percent granulation. Observation and interview on 01/27/26 at 11:41 A.M. with LPN#1500 of Resident #20 revealed for the right heel pressure ulcer measured and staged as a stage 3 with measurements of .38 cm by .65. cm by .1 cm. Verified she staged and measured the right heel and will be documenting the assessment in the residents chart. Interview on 01/27/26 at 12:03 P.M. with LPN #1500 verified she stages and measures pressure ulcers for residents on Tuesdays if the Wound Nurse Practitioner #300 cannot do so. Interview on 01/27/26 at 1:31 P.M. with the Director of Nursing (DON) verified Resident #20's pressure ulcer to the right heel was staged and measured by LPN #1500 only on 12/16/25, 1/13/26, and 1/20/26. 2. Review of the medical record for Resident #30, revealed an admission date of 01/02/26. Diagnoses included but were not limited to severe protein calorie malnutrition, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, muscle weakness and a stage 4 pressure ulcer of the sacral region. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of never/rarely understood. The resident was assessed to require total dependence on bed mobility, transfers, shower/bathe self and toilet hygiene. Review of the skin issues assessment dated [DATE] for Resident #30 by LPN #1500 revealed a sacrum stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer measured 4.82 cm by 2.12 cm by 0.3 cm with the wound bed tissue composition 60 percent granulation and 30 percent slough. Review of the skin issues assessment dated [DATE] for Resident #30 by LPN #1500 revealed a sacrum stage 4 pressure ulcer measured 4.72 cm by 1.55 cm by 0.3 cm with the wound bed tissue composition 80 percent granulation and 20 percent slough. Interview on 01/27/26 at 2:37 P.M. with the Director of Nursing (DON) verified LPN #1500 assessed, staged and measured Resident #30's sacrum stage 4 pressure ulcer on 01/13/26 and 01/20/26. Review of the facility job description for the job title Treatment Nurse in the Nursing Department with no date, revealed no pressure ulcer wound assessments which include measuring, staging and assessments to be part of their position summary and essential functions and responsibilities. Review of the facility job description for the job title Unit Manager in the Nursing Department with no date, revealed no pressure ulcer wound assessments which include measuring, staging and assessments to be part of their position summary and essential functions and responsibilities. The facility was unable to provide a job description for their Licensed Practical Nurses. This deficiency represents non-compliance investigated under Complaint Number OH00270375.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEYBased on resident interview, medical record review, review of the self-reported incident (SRI) investigation and witness statements, review of hospital records, policy review, and review of the facility plan of correction documents, the facility failed to ensure a resident requiring transfers with a medical lift was transferred safely and with two staff assistance. Actual Harm occurred on 09/02/25 when Resident #60, who was dependent upon two staff for mechanical lift transfers, was being transferred via one staff assistance in a mechanical lift. The lift fell resulting in the resident sustaining a right femur fracture and subsequent surgery. This affected one (Resident #60) of three residents reviewed for injuries of unknown origin. The facility census was 106.Findings include: Record review revealed Resident #60 was initially admitted to the facility on [DATE] with diagnoses including chronic diastolic (congestive) heart failure, age-related osteoporosis without current pathological fracture, multiple sclerosis, other symptoms and signs involving cognitive functions and awareness.Review of the physician order dated 06/05/23 for Resident #60 revealed staff may use a mechanical lift for transferring the resident.Review of the nursing progress note dated 09/02/25 at 8:57 A.M. and 8:59 A.M. revealed Resident #60 had a rectangular purple bruise to [initially reported as the left thigh and then corrected] the right inner thigh. Resident #60 was unable to describe what happened however the roommate said she thought resident had fallen. The progress note indicated an investigation was to follow.Review of the post fall evaluation, undated and completed by the Director of Nursing (DON), revealed Resident #60 was lowered into wheelchair from a mechanical lift and landed on the wheelchair armrest with her right hip.Review of the facility's Self-Reported Investigation Report (SRI) dated 09/02/25 at 6:04 P.M. revealed that staff noted Resident #60 had a bruise of unknown origin and was unable to describe what had happened. The report said the roommate was interviewed and had heard a thud noise from behind the privacy curtain but did not see a fall.Review of the facility timeline and interview documentation by the DON from the SRI dated 09/02/25 revealed Resident #60 was in her wheelchair when staff arrived for the day shift on 09/02/25. Licensed Practical Nurse (LPN) #446 saw Resident #60 up in her chair in the morning and there were no signs of pain or discomfort. Per the written statements, no incident or accident was reported to the nurse until the afternoon when Certified Nursing Assistant (CNA) #283 reported to the DON that she noticed a new bruise on Resident #60 and that Resident #60 cried out in pain when being transferred. When interviewed, the night shift aide, CNA #286, admitted that he had transferred Resident #60 into her wheelchair using a mechanical lift without assistance, when her chair tipped to the left side. He tried to catch the chair and quickly lower her into it, but she landed on the right side of the wheelchair arm instead. He stated he did get her posture corrected in the chair and did not notice an injury at that time. He asked her if she was okay and she said yes. He said the roommate asked if she fell and he said no, she landed on the chair. He said he did not alert the nurse as he was able to transfer the resident successfully and was not aware at the time an injury had occurred.Review of the Medication Administration Record (MAR) for September 2025 revealed Resident #60 had an order for Acetaminophen Tablet 650 milligrams (mg) to be given every four hours as needed for mild pain. No pain was noted in the medical record on 09/02/25. Review of the facility Situation Background Assessment Recommendation (SBAR) Communication note dated 09/02/25 at 5:30 P.M. revealed Resident #60 had new pain and was described as having occasional labored breathing, short periods of hyperventilation, repeated troublesome calling out, such as loud moaning or groaning. The note documented the primary care physician had recommended hospitalization.Review of the facility transfer form dated 09/02/25 at 5:38 P.M. revealed Resident #60's pain ranged from the right hip to the right knee, and a behavioral note that stated the resident did normally say ouch when receiving care so that was not abnormal however, the resident seemed to be in more pain than usual with noted bruising and pain upon moving the extremity.Review of the emergency room Provider Note dated 09/02/25 at 9:07 P.M. revealed Resident #60 was reportedly either dropped out of bed or out of her chair around 5:30 A.M. and presented to the emergency room at 7:00 P.M. with a possible hip deformity. The note documented they were unable to get any history from the resident.Review of the History and Physical (H&P) Note from the hospital dated 09/02/25 at 10:33 P.M. revealed Resident #60 had an acute femoral neck (hip) fracture with osteoporosis. The H&P noted that Resident #60 was non-ambulatory at baseline. The physician author noted the resident was oriented to name, winced occasionally, and was unable to describe where the pain was or how she ended up in the hospital.Review of the Orthopedic Consult Note dated 09/03/25 at 6:46 A.M. revealed results for Resident #60's computed tomography (CT) of the right hip result included an acute slightly impacted right subcapital femoral neck fracture with underlying suspected osteoporosis. The X-ray of the right hip also revealed a displaced subcapital fracture of the of the right femoral neck. The Orthopedic Surgeon noted he had discussed risks and benefits with the Power of Attorney (POA) who had agreed for Resident #60 to have surgical fixation with right hip hemiarthroplasty.Review of the care plan dated 09/03/25 revealed Resident #60 required two person assistance with toileting and the assistance of two people for transfers using a mechanical lift. Review of the disciplinary action record document dated 09/03/25 revealed CNA #286 was given a final written warning on 09/03/25 with the explanation that staff members shall follow safety rules and report unsafe conditions to the supervisor. The employee improperly utilized a mechanical lift with a resident. The plan for improvement was stated as education on the mechanical lift policy, mechanical lift competency and follow up audits to ensure compliance with safety rules. The disciplinary document was signed by CNA #286 and the DON on 09/03/25.Review of the nursing progress note dated 09/05/25 at 2:50 P.M. revealed Resident #60 returned [from the hospital] at 1:35 P.M. via stretcher accompanied by emergency medical services and had a surgical wound on right hip and bruises on the right thigh and bilateral upper extremities.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was severely cognitively impaired and she was dependent on staff for bed to chair transfers. During an interview on 12/10/25 at 8:09 A.M., LPN #446 said that due to Resident #60's osteoporosis, it was not unusual for Resident #60 to cry out when receiving personal care, however, that day, her cries were different. LPN #446 said she was doing medication pass and a CNA [#283] came to notify her regarding the bruise and the change in Resident #60's baseline response to personal care. LPN #446 said she notified the manager they assessed the pain and were able to identify the area in which Resident #60 was sore. During an interview on 12/10/25 at 9:27 A.M., CNA #286 revealed there was nothing wrong with the mechanical lift, but rather the wheelchair had slipped. He said he normally was with another CNA when using a mechanical lift, however, he admitted he was alone on the morning of 09/02/25 when he was using the mechanical lift to transfer Resident #60. He said the chair slipped because one side was not locking, but he did say they fixed the brakes on the chair. He stated he did not know at the time that she was hurt. During an interview on 12/10/25 at 9:12 A.M., the Administrator confirmed that CNA #286 had operated the manual lift by himself on 09/02/25. She said that because CAN #286 had mentioned that the brakes gave out on the wheelchair, she had the maintenance manager check all the wheelchair brakes. She said CNA #286 was suspended while they completed the investigation, he was retrained on the mechanical lift and the importance of only operating it with two people and given a final written warning. Review of the facility policy titled, Lippincott procedures Transfer with a mechanical lift, long-term care, undated, revealed all mechanical lifts require two staff members when moving a resident.The deficient practice was corrected on 09/04/25 when the facility implemented the following corrective actions: -On 09/02/25 all residents who required a mechanical lift to transfer, who resided on the same unit, were audited/evaluated by the Assistant Director of Nursing (ADON) to ensure they had no new skin impairments.-On 09/03/25 the Quality Assurance Performance Improvement Committee (QAPI) met to review the incident and determined the cause of the fracture was related to one staff utilizing the mechanical lift instead of two. -On 09/03/25 the Director of Nursing met with CNA #286, educated him on the mechanical lift policy, tested him for competency and gave him a written final warning. -On 09/03/25 the Assistant Director of Nursing (ADON) provided education to all facility CNA's on the mechanical lift policy and required the CNA's to perform a return demonstration via competency checks before their next scheduled shift.-On 09/04/25 the Maintenance Manager #473 performed an audit on all of the wheelchairs in the facility, including the wheelchair used by Resident #60, with no concerns noted. -Ongoing, the Director of Nursing completed compliance audits three times a week for four weeks, weekly for three weeks and random audits thereafter. No concerns were noted with the audits.

Based on interviews, medical record review, review of the State agency reporting system (CALS), review of emergency medical services (EMS) reports, review of police reports, review of facility emails, and policy review, the facility failed to timely report allegations of inappropriate sexual behavior made by four residents to the state agency and/or local law enforcement. This affected four residents (#33, #58, #77, #97) out of five residents reviewed for abuse. The facility census was 106.Findings include:1. Review of the record for Resident #33 revealed the resident was admitted to the facility on [DATE]. Pertinent diagnoses included epilepsy, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), type two diabetes, chronic kidney disease stage four (CKD4), acquired left leg absence above right knee, and depression.Review of the Minimum Data Set (MDS) dated [DATE] for Resident #33 revealed she was moderately cognitively impaired, was dependent on staff for toileting, toilet transfers and chair transfers and required substantial/maximum assistance for showering, lower body dressing and putting on footwear.Review of the social work progress note dated 11/19/25 at 10:18 A.M. revealed the social services note author provided comfort to Resident #33, as resident presented as agitated and sad. The note went on to say the resident declined for her power of attorney to be contacted and that she had to wait for the police to come take her.Review of the certified nurse practitioner (CNP) progress note dated 11/20/25 at 12:00 A.M. revealed Resident #33 was seen for general laboratory follow up in the context of Resident #33's multiple medical issues. Resident #33 was noted to be alert and oriented times three and calm at the time of the appointment that day. The CNP noted Resident #33 had some dysuria (urinary pain) but tested negative for urinary tract infection. Pyridium was ordered for three days for symptom management. Review of the Change in Condition Evaluation dated 11/24/25 at 12:56 P.M. revealed Resident #33 was identified to have altered mental status, behavioral symptoms of agitation and psychosis, had been refusing medications and needed more assistance with activities of daily living (ADL). The note indicated the primary care physician had recommended for Resident #33 to be sent to the hospital.Review of the nurses progress note dated 11/24/25 at 1:46 P.M. noted Resident #33 was sent to the hospital for further evaluation, the residents power of attorney was notified of the transfer. Resident #33 was picked up by the ambulance company for altered mental status at 1:37 P.M. and transported to the hospital. There was no documentation in this note or any other progress note of any allegations made on this date.Review of the emergency medical services (EMS) run report for 11/24/25 for the transport of Resident #33 revealed Resident #33 was described as agitated and aggressive. Per the note, the EMS staff had difficulty with getting the residents blood pressure and the facility Registered Nurse (RN) #505 offered to assist when Resident #33 turned to RN #505 and said that he had raped her and that she was leaving her blood on her face so that they will know what he did.Review of the transport incident report dated 11/24/25 at 5:37 P.M. revealed Resident #33 screamed at the facility RN [#505] and to EMS how she had been raped by the RN. The resident stated you raped me, to RN #505.Review of the hospital medical records for Resident #33 from 11/24/25 to 12/04/25 revealed no indication that a Sexual Assault Forensic Exam was completed.Review of the Certification and Licensure System (CALS) revealed the sexual abuse allegation made by Resident #33 towards RN #505 on 11/24/25 was not reported to the State agency.Interview on 12/03/25 at 5:43 P.M. with Emergency Medical Technician (EMT) #701 confirmed the details of the written reports and described in detail the experience of preparing Resident #33 to go to the hospital. She said that when RN #505 attempted to assist EMT with getting the resident's blood pressure, the resident stated the allegation to RN #505, Do you think I forgot? I know you raped me. You [explicit] raped me. You used your fingers and put blood all over my face. EMT #701 said that RN #505 looked distraught and stepped back when the resident made her statements. EMT #701 said a female staff member wearing grey went up to RN #505 as if to console him. EMT #701 said she had no doubt that RN #505 had heard the accusation as Resident #33 was screaming. EMT #701 also shared that since Resident #33 was so agitated, they had to call a second level emergency crew to provide a higher level of care, however, she chose to ride with the resident in order for her to have a familiar face and also so EMT #701 could report the allegation to the hospital. She said she made sure the hospital nurse at the emergency room knew what was said. She said she did not get the name of the hospital nurse.Interview on 12/04/25 at 7:54 A.M. with RN #505 revealed that he heard the accusation that Resident #33 made that he raped her. He said that because of the statement she made, he made a point to tell the second EMS crew about her agitation towards him and suggested they might want to avoid having male caregivers due to her emotional state. He said that he told Unit Manager #461 afterwards. Interview on 12/04/25 at 9:40 A.M. with Unit Manager #461 revealed that RN #505 did not tell her that Resident #33 accused him of rape. She said she would expect RN #505 to tell her if an accusation like that had happened. She denied consoling RN #505 during the allegation. She did say that she apologized to the EMT crew for the resident scratching them. She said that if RN #505 had told her that Resident #33 had made an allegation of rape, she would have reported it.Interview on 12/04/25 at 9:45 A.M. with both RN #505 and Unit Manager #461. RN #505 said to Unit Manager #461 that he did tell her about the allegation. Unit Manager #461 denied that he did. He said he told her at the doorway, however, he admitted that he didn't confirm that she heard him. He repeated that he even updated the EMS crew that the resident was afraid of men. Unit Manager #461 said again that if she had been told, she would have reported it. RN #505 said he should have documented what was said.During a telephone interview on 12/04/25 at 10:45 A.M. Resident #33's family stated that he had not heard Resident #33's allegation that she had been raped, however, she had previously made statements to him that someone at the facility had hurt her. He went on to say that with her current mental state, he didn't know what was true. He said he did not think she had been raped. Interview on 12/04/25 at 12:20 P.M. with the Director of Nursing confirmed that the allegation had not been reported to the State agency. She said that they would report an allegation of rape or assault and they always error on the side of caution.2. Review of the record for Resident #97 revealed the resident was initially admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including Alzheimer's disease with late onset, hypertensive heart and chronic kidney disease with heart failure and chronic systolic (congestive) heart failure.Review of the Brief Interview for Mental Status (BIMS) results dated 05/14/25 for Resident #97 indicated a score of 13, which is defined as cognitively intact.Review of the social services progress note dated 05/14/25 at 1:29 P.M. revealed Resident #97 had approached the social services worker and stated that her roommate touched her private part with her toes. The social worker documented that she notified the Director of Nursing regarding the matter and the two roommates were separated. The social worker charted that she called the resident's daughter to offer for the resident to be transported to the hospital for an exam and for a police report to be filed. The daughter declined, noting she did not believe her mother, given a conflict the days prior in which the resident was angry and made accusations that the daughter was homosexual.Review of the facility self-reported incident investigation typed witness statement dated 05/14/25 revealed the Director of Nursing had documented that when she interviewed Resident #97 and the resident said that when she walks by the roommate, she pinches her on the butt. The typed statement said that the Resident #97 had said that her roommate was homosexual and that she was not sleeping well and had bad dreams and woke up to see people standing over her.Further review of the investigation documentation revealed no evidence that the police were notified regarding the allegation of sexual assault. Interview on 12/04/25 at 12:20 P.M. with the Director of Nursing who said she did not report the allegation of sexual assault to law enforcement because the daughter had said she did not want it to be reported. 3. Review of Resident #18's record revealed he was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, type two diabetes mellitus, chronic kidney disease, and bipolar disorder.Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #18 revealed he was cognitively intact and needed partial/moderate assistance with toileting, showering and lower body dressing. Resident #18 was assessed to need supervision or touching assistance to walk 50 feet and was assessed to be independent with use of wheelchair for 50 feet.a. Review of the nursing progress note for Resident #18 dated 07/24/25 at 6:24 P.M. revealed the nurse was notified that Resident #18 was smoking outside with other guests when he stood up, brought out his penis and urinated in front of other guests. Per the note, the guest was educated about using bathrooms or urinal, call for help when in need and to not urinate in front of guests.Review of nursing progress note dated 07/24/25 at 6:51 P.M. revealed all residents in the courtyard were interviewed and had no complaints at the time.Review of facility documentation revealed no documented evidence regarding what residents were interviewed about the incident or if any other residents in the building within sight of the window were interviewed.Interview on 12/09/25 at 8:40 A.M. with the facility Administrator confirmed she did not file an incident report or police report regarding the public urination on 07/24/25. She referenced the nurse having documented that there were no complaints about the incident, however, she relayed that she had asked the nurse and the nurse had not documented and did not remember what residents she spoke with. She confirmed there was no documentation that any residents within view of the courtyard through the window were interviewed.b. Review of the medical record revealed Resident #77 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, polyneuropathy, bipolar disorder, anxiety disorder, and post-traumatic stress disorder (PTSD).Review of the police report dated 08/07/25 revealed the Administrator had called the police per report from Resident #77 who said that Resident #18 had exposed himself to Resident #77 while urinating in the courtyard on 08/05/25. The police report did not have documentation of an interviews with residents. The police officer documented that he was told by the facility Administrator that the resident likely did not know what he was doing and that he was being treated for cognitive impairments and that she was buying pants that fit the resident to mitigate the situation from happening in the future. Interview on 12/03/25 at 9:38 A.M. with Resident #77 revealed it happened three times to her where she saw Resident #18's penis and she felt like Resident #18 knew what he was doing. She said she felt disrespected by staff and that they didn't take her seriously that it was upsetting to her.c. Review of the police report dated 11/08/25 at 5:25 P.M. revealed the officer was investigating a sexual offense and that Resident #58 had filed the report because Resident #18 had urinated in front of others in the past and Resident #58 was sick of it and wanted Resident #18 charged. The officer noted he spoke with Social Services Supervisor #520, whom he incorrectly identified as the Administrator. The officer noted that Social Services Supervisor #520 said that Resident #18 had behavioral and mental disabilities and had loose fitting clothes that sometimes fell down. The officer noted Social Services Supervisor #520 said they were working on getting him better fitting clothes. The report states the offense was public indecency [exposure] and the incident was coded as a sexual offense.Review of the email documentation dated 11/08/25 at 6:27 P.M. authored by Social Services Supervisor #520 and sent to the Administrator and the DON revealed that the Social Services Supervisor #520 was notified by a nurse that Resident #18 had been found urinating in the courtyard in front of other residents. She said that she spoke with Resident #77 and Resident #58 and they were frustrated by the reoccurring incidents, and that Resident #77 had grandchildren visiting and she did not want her grandchildren to see that. The email noted that Resident #58 had called the police. The email went on to say that Social Services Supervisor #520 had spoken with Resident #18 who admitted that he urinated in the courtyard because he was unable to hold it. She said she recommended that he use the restroom prior to going to the courtyard to smoke.Review of the Certification and Licensure System (CALS) revealed the sexual abuse allegation made by Resident #58 towards Resident #18 on 11/08/25 was not reported to the State agency.Review of psychiatric note for Resident #18 dated 11/13/25 at 1:45 P.M. revealed Resident #18 had a diagnosis of schizophrenia. The note referenced the incident of indecent exposure in the courtyard and said that Resident #18 stated he urgently needed to urinate and ensured his back was turned away from other residents.Review of progress note dated 11/23/25 at 10:08 P.M. for Resident #18 revealed Resident #18 was seen walking outside his room unclothed and exposing his private areas. Per the progress note, witnesses stated that he intentionally exposed himself. Before this, nursing staff and caregivers attempted multiple times to dress the resident however he repeatedly removed his clothes.Interview on 12/04/25 at 11:12 A.M. with Columbus Police Sexual Assault Unit Detective #702 confirmed that public urination was considered public indecency [exposure] and the incident was coded as a sexual offense. Interview on 12/08/25 at 8:46 A.M. with the Administrator revealed she was unaware of the incident on 11/08/25 with Resident #18 or that there was a police report. She said she would expect to be told this type of information.During an interview on 12/08/25 at 12:52 P.M., Social Services Supervisor #520 acknowledged that Resident #58 and Resident #77 both had sexual trauma history and that it was understandable that they were concerned regarding the multiple incidents with Resident #18 exposing himself. Interview on 12/08/25 at 4:35 P.M. with Social Services Supervisor #520 stated that she did not know why an incident report wasn't filed with the State agency for the 11/08/25 incident with Resident #18 as she had sent a detailed email to both the Administrator and the DON. Interview on 12/08/25 at 5:36 P.M. with Resident #18 revealed he admitted to urinating in the courtyard where the smoking area was. He said he wore Depends and didn't like to go in them and sometimes when he was outside he didn't think he'd make it to the toilet. He said he tried to turn away so that other residents didn't see anything. Review of the facility policy titled, Abuse Prohibition Policy, dated 09/09/22, revealed allegations of verbal, physical, mental, sexual abuse and mistreatment must be reported to the Administrator and then an incident report will be completed. It also noted that any allegation of sexual abuse would be reported to local law enforcement per state law. The policy further stated that allegations of abuse would be thoroughly investigated and documented by the Administrator and reported to the State agency. The policy stated the Administrator, or designee, would notify the State agency of allegations per state guidelines (two hours if abuse allegation or serious injury; all others no later than 24 hours). This deficiency represents non-compliance investigated under Complaint Number OH2680058.

Based on interviews, medical record review, review of facility emails, review of self-reported incident investigations (SRI) and review of facility policy, the facility failed to thoroughly investigate incidents involving allegations of inappropriate sexual behavior. This affected two residents (#58 and #77) out of five residents reviewed for abuse. The facility census was 106.Findings include:1. Review of Resident #18's record revealed he was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, type two diabetes mellitus, chronic kidney disease, and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #18 revealed he was cognitively intact and needed partial/moderate assistance with toileting, showering and lower body dressing. Resident #18 was assessed to need supervision or touching assistance to walk 50 feet and was assessed to be independent with use of wheelchair for 50 feet.Review of the nursing progress note for Resident #18 dated 07/24/25 at 6:24 P.M. revealed the nurse was notified that Resident #18 was smoking outside with other guests when he stood up, brought out his penis and urinated in front of other guests. Per the note, the guest was educated about using bathrooms or urinal, call for help when in need and to not urinate in front of guests. Review of nursing progress note dated 07/24/25 at 6:51 P.M. revealed all residents in the courtyard were interviewed and had no complaints at the time. Review of facility documentation revealed no documented evidence regarding what residents were interviewed about the incident or if any other residents in the building within sight of the window were interviewed. Interview on 12/09/25 at 8:40 A.M. with the facility Administrator confirmed she did not file an incident report or police report regarding the public urination on 07/24/25. She referenced the nurse having documented that there were no complaints about the incident, however, she relayed that she had asked the nurse and the nurse had not documented and did not remember what residents she spoke with. She confirmed there was no documentation that any residents within view of the courtyard through the window were interviewed.2. Review of the police report dated 11/08/25 at 5:25 P.M. revealed the officer was investigating a sexual offense and that Resident #58 had filed the report because Resident #18 had urinated in front of others in the past and Resident #58 was sick of it and wanted Resident #18 charged. The officer noted he spoke with Social Services Supervisor #520, whom he incorrectly identified as the Administrator. The officer noted that Social Services Supervisor #520 said that Resident #18 had behavioral and mental disabilities and had loose fitting clothes that sometimes fell down. The officer noted Social Services Supervisor #520 said they were working on getting him better fitting clothes. The report states the offense was public indecency [exposure] and the incident was coded as a sexual offense.Review of the email documentation dated 11/08/25 at 6:27 P.M. authored by Social Services Supervisor #520 and sent to the Administrator and the DON revealed that the Social Services Supervisor #520 was notified by a nurse that Resident #18 had been found urinating in the courtyard in front of other residents. She said that she spoke with Resident #77 and Resident #58 and they were frustrated by the reoccurring incidents, and that Resident #77 had grandchildren visiting and she did not want her grandchildren to see that. The email noted that Resident #58 had called the police. The email went on to say that Social Services Supervisor #520 had spoken with Resident #18 who admitted that he urinated in the courtyard because he was unable to hold it. She said she recommended that he use the restroom prior to going to the courtyard to smoke.Review of facility information revealed no documented evidence of an investigation into Resident #58 and Resident #77's allegations towards Resident #18.Interview on 12/08/25 at 8:46 A.M. with the Administrator revealed she was unaware of the incident on 11/08/25 with Resident #18 and confirmed there was no formal investigation. Interview on 12/08/25 at 4:35 P.M. with Social Services Supervisor #520 revealed she had sent a detailed email to both the Administrator and the DON about the 11/08/25 incident. Review of the facility policy titled, Abuse Prohibition Policy, dated 09/09/22, revealed allegations of verbal, physical, mental, sexual abuse and mistreatment must be reported to the Administrator and then an incident report will be completed. The policy further stated that allegations of abuse would be thoroughly investigated and documented by the Administrator and reported to the State agency. This deficiency represents non-compliance investigated under Complaint Number OH2680058.

Based on observations, staff interview, and facility policy review, the facility failed to serve food in a safe and sanitary manner. This had the potential to affect 115 of 115 residents who receive food from the kitchen. The census was 115. Findings include: Observations on 02/13/25 from 11:46 A.M. to 12:15 P.M. revealed the following: [NAME] #215 was serving food on the serving line from the steam table, wearing disposable gloves. Each time [NAME] #215 scooped pasta into the service ladle, he would use one of his gloved hands to balance the pasta in the spoon prior to serving it on to the plate. He did not change his gloves at all during the observation period. Also, after touching the pasta each time, he touched the following items in between without changing his gloves: meal plate, multiple serving utensils of other food on the tray line, dirty steam table counter, serving trays, warming lids to the plates, soup bowl, aluminum foil covering food that was in the steamer, and a hot dog bun. Observations on 02/13/25 from 11:54 A.M. to 12:00 P.M. revealed Dietary Manager #271 assisting the dietary staff with serving lunch. He had disposable gloves on and touched the following items without changing his gloves: plastic bag holding hot dog buns, hot dog bun, serving plate, aluminum foil, inside of the oven mitt, food pans, serving ladle, door to the steamer, plastic bag holding the hot dog buns, and then one more hot dog bun. At 12:00 P.M., he took his gloves off and put new ones on. Observations on 02/13/25 from 12:03 P.M. to 12:05 P.M. and 12:06 P.M. to 12:12 P.M. revealed Dietary Manager #271 touching multiple hot dog buns and retouching the above items; following the same process. He changed his gloves and put new ones on at 12:05 P.M. and 12:12 P.M., but not prior to touching hot dog buns and then multiple other items prior to changing his gloves. Interview with [NAME] #215 on 02/13/25 at 12:10 P.M. stated they were to change their gloves when they become soiled, ripped, or otherwise contaminated. He also confirmed if he touches a food item, he was to immediately change his gloves before touching anything else. Interview with Dietary Manager #271 on 02/13/25 at 12:24 P.M. confirmed dietary staff were to change their gloves frequently. He confirmed dietary staff were to have clean gloves on if they touch any food item and after they touch the food item, they were to change their gloves as well. Review of the facilities Glove Use policy, dated 11/19/21, revealed it is the facility policy that gloves will be worn when handling food except when washing fresh produce, to ensure bacteria is not transferred from the food handler's hands to the food product being served. Gloves will be changed and hands will be washed after they become soiled or touch a contaminated surface including: after handling anything soiled, after handling boxes, crates, or packages, or anytime you touch a contaminated surface.

Based observation and staff interview, the facility failed to maintain a clean and sanitary environment. This affected four resident rooms (room numbers #60, #90, #215, and #226) and the northwest hallway. This had the potential to affect 54 residents residing in these resident rooms and who were near the northwest hallway. Findings include: An environmental tour was conducted on 02/13/25 between 10:15 A.M. and 11:25 A.M. with the Administrator. The following concerns were observed and verified at the time of observation with the Administrator: A. Observation of room [ROOM NUMBER] revealed there was wall tile hanging loose behind toilet pipe right at the flushing component/handle, dead bugs in bathroom light fixture cover, sink faucet with steady leak/drip, and a broken window ledge (made of marble) section fractured in three small pieces that were loose and jagged. B. Observation of ceiling tiles in the northwest hall (outside room [ROOM NUMBER], in front of the egress door) sagging out of the frames near the ceiling vent outlet and discolored with black dry substance affecting seven separate ceiling tiles. C. Observation of room [ROOM NUMBER] revealed the east wall in the room, the sheet rock or dry wall was gouged and ripped open (approximately five feet), and there was wallpaper tearing off the wall in the bathroom and hanging free. D. Observation of room [ROOM NUMBER] revealed the main toilet pipe (water supply) at the lower coupling, was shooting water straight up when flushing the toilet which sprayed onto the toilet and floor. There was a steady drip/leak from the sink faucet.

Based on medical record review and staff interview, the facility failed to ensure the Pre-Admission Screening and Resident Review (PASARR) documents were accurate to the resident's conditions and diagnoses. This affected two (Residents #4 and #75) of three residents reviewed for PASARR assessments. The facility census was 115. Findings include: 1. Review of the medical record for Resident #4 revealed an admitted [DATE] with diagnoses that included cerebral infarction due to embolism in the right middle cerebral artery, schizophrenia, and bipolar disorder. Updated diagnosis on 10/25/24 showed vascular dementia. Review of Resident #4's care plan, dated 01/11/23, noted a risk for impaired skin, pain, and functional ability deficits due to the diagnosis of vascular dementia. Review of the PASARR identification screen dated 02/28/23 revealed that under Section D: Medical diagnosis, question one asked, Does the individual have a diagnosis of dementia? The facility selected no. Interview on 02/13/25 at 2:16 P.M. with Social Services Assistant (SSA) #334 confirmed the PASARR screening completed on 02/28/23 was inaccurate because it did not include the diagnosis of dementia. 2. Review of the medical record for Resident #75 revealed an admitted [DATE] with diagnoses including psychoactive substance abuse, insomnia, and depression. The updated diagnoses on 07/2020 revealed anxiety disorder, and on 07/16/24, post-traumatic stress disorder was added. Review of the significant change in condition PASARR identification screen dated 11/06/24 for Resident #75 revealed Resident #75 had the mental health diagnoses of mood disorders, panic or other severe anxiety disorders, and post-traumatic stress disorder. Insomnia was not marked as a diagnosis that Resident #75 had. Interview on 02/13/25 at 2:16 P.M. with Social Services Assistant (SSA) #334 confirmed the PASARR screening completed for Resident #75 on 11/06/24 was inaccurate because it did not include the diagnosis of insomnia in the mental health disorders section. Review of PASARR policy dated 12/15/22 revealed the PASARR process is used to screen all individuals admitted for nursing care to ensure that needs are met to assist the individual in reaching their highest potential, all seriously mentally ill and/or have an intellectual/developmental disability are required to be evaluated. An updated PASARR is required for incorrect review completed, mental status change not related to delirium, acute psychiatric episode, symptoms of new mental health diagnosis, newly evident or possible serious disability or change in need for nursing facility level of care.

Based on record review, review of the facility policy, and staff interview the facility failed to ensure they timely followed up with state mental health agency for level two evaluation for Resident #22. This affected one (Resident #22) of four residents reviewed for pre-admission screening and resident review (PASARR) identification screenings. The facility census was 115. Findings include: Review of the medical record for Resident #22 revealed an admitted [DATE] with diagnoses including bipolar disorder and schizophrenia. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 02/06/25, revealed Resident #22 was cognitively intact. Review of the pre-admission screening and resident review (PASARR) for Resident #22 revealed a change of condition PASARR was completed on 11/14/24 with a PASARR results letter on 11/14/24 indicating level II evaluation was required. There was no evidence the level II evaluation was coordinated with the state mental health agency from 11/15/24 to to 02/12/25. Review of the progress notes for Resident #22 revealed on 02/13/25 at 10:33 A.M., Social Services Assistant (SSA) #334 wrote she checked for PASSAR results following a level II No results have been uploaded at this time. Will check at a later date. There was no follow up completed to determine if level II services were required until 02/13/25. Interview on 02/13/25 at 2:14 P.M. with SSA #334 confirmed the only coordination for requesting the level II evaluation from the state mental health agency was not completed until on 02/13/25. Review of the Pre-Admission Screening and Guest/Resident Review - PASARR Ohio Policy revealed if the responses to the Level I screening indicate the presence of a mental illness and/or intellectual/developmental disability, the person is referred to the local community mental health program for comprehensive screening, Level 2.

Based on record review, staff interview, resident interview, and policy review, the facility failed to obtain vision services in a timely manner for Resident #60. This affected one (Resident #60) of two residents reviewed for vision. The facility census was 115. Findings include: Review of Resident #60's medical record revealed an admitted [DATE] with diagnoses including localization-related (focal) idiopathic epilepsy and epileptic syndromes with seizures of localized onset. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #60 did not have corrective lenses and was cognitively intact. The MDS did not trigger for visual function. Review of the progress notes revealed on 08/13/24 at 6:18 P.M., a Nurse Practitioner (NP) documented Resident #60 needed an eye exam and new glasses to address vision impairment, which could contribute to fall risks. On 08/15/24 at 4:02 P.M., a nurse contacted Optometry #500 to schedule an appointment. Review of the after-visit summary (AVS) from Resident #60's eye appointment at an Eye Institute on 08/28/24 revealed a glasses prescription were as follows: Right eye: Sphere +1.25, Cylinder +0.25, Axis 010, Add +2.50 Left eye: Sphere +1.50, Cylinder +0.75, Axis 165, Add +2.50. These findings indicated impaired vision. Review of the physician orders for Resident #60 dated 09/25/24 revealed an order to schedule an eyewear appointment at Optometry #500. The physician order was later discontinued on 10/14/24. There was no documentation Resident #60 received eyeglasses from 08/29/24 to 02/10/25 and/or seen at Optometry #500 for eyewear appointment from 09/25/24 to 02/10/25. On 09/28/24, Social Services Assistant (SSA) #279 documented she requested services from Optometry #600 and Optometry #700 but did not conduct any follow-up with either provider. During an interview on 02/11/25 at 7:43 A.M., Resident #60 stated he needed glasses and had not received them since arriving at the facility. He reported informing staff about his vision concerns and expressed worry about signing documents he could not read. He also stated he did not feel able to participate in activities due to his vision impairment. During an interview on 02/12/25 at 12:05 P.M., Social Worker (SW) #291 explained when a resident requires dental or vision services, they assist in setting up appointments through two different optometry companies. SW #291 stated SSA #334 was responsible for coordinating ancillary services and would check why Resident #60 had not yet received glasses. During an interview on 02/12/25 at 3:02 P.M., SSA #279 confirmed Resident #60 was seen in August 2024 for an eye exam and prescription. SSA #279 stated in September 2024, Resident #60 opted to be seen by the in-house eye doctor, but she was unsure why he was not seen sooner. SSA #279 stated transportation was arranged in February 2025 for the resident to go to Optometry #800 for new glasses, but Optometry #800 was unable to fulfill the prescription. She was unsure why transportation was not scheduled until February 2025. During a subsequent interview on 02/12/25 at 4:08 P.M., SSA #279 stated once a resident required ancillary services is admitted , they were added to the Optometry #600 list. She reported Optometry #600 visits the facility once a month and last visited on 02/10/25 and sometime in November. SSA #279 admitted she had not been following up with Optometry #600 to ensure residents received necessary vision services but stated she would begin doing so. She also revealed the Optometry #600 consent form for Resident #60 was signed on 09/28/24 but was not sent to the appropriate parties until 10/08/24. Review of the Social Services Referral to Outside Providers policy revealed the following requirements: A physician's order must be obtained by nursing. Consent to receive services must be sought from the resident or their representative before initiating services. Social services must make the referral to the outside provider and provide demographics and signed consent as needed. Progress notes from the service provider must be obtained and placed in the resident's medical record. The resident's physician, family, and/or representative must be informed of the service results, and any recommendations should be reviewed with the physician. The provider's recommendations must be integrated into the resident's care plan. Recommendations for interventions should be communicated to direct care staff. Follow-up visits should be scheduled as needed.

Based on record review, staff interview, and facility policy review, the facility failed to appropriately monitor the resident's significant weight loss and timely follow the registered dietitian's recommendations and facility policy. This affected two (Residents #87 and #94) of six residents reviewed for nutrition monitoring. The facility census was 115. Findings include: 1. Review of the medical record revealed Resident #94 was readmitted to the facility on [DATE]. Diagnoses included chronic kidney disease, diverticulosis of small and large intestines and clostridium difficile (C-diff). Review of the Minimum Data Set (MDS) assessment, dated 12/19/24, revealed Resident #94 was cognitively intact. Resident #94's was readmitted to the facility on [DATE], following a hospitalization . Review of the Resident #94's weights, dated 12/07/24 to 02/10/25, revealed the following weights: 12/13/24 at 132.2 pounds (lbs)), 01/09/25 at 119.0 lbs., 02/06/25 at 114.8 lbs., and 02/10/25 at 114.0 lbs. There was no weight obtained on re-admission on 12/07/24 and weekly weights were not completed per facility policy. The weight change from 12/13/24 to 01/09/25 was a 13.2 pound weight loss, a 10% significant weight loss in approximately one month. Review of Resident #94's weight change note, dated 01/09/25, revealed a significant weight loss from 12/13/24 to 01/09/25. The dietitian requested a re-weight on the date this note was written to ensure accuracy. Review of Resident #94's nutritional notes, dated 01/09/25 to 01/21/25, revealed the only attempted re-weight was on 01/21/25, which Resident #94 refused. There were no other documented attempts to obtain the re-weight prior to 01/21/25. Interview with Registered Dietitian (RD) #103 on 02/18/25 at 11:48 A.M. confirmed Resident #94 should have weekly weights obtained following his return from the hospital on 12/07/24. RD #103 also confirmed he should have had a re-weight taken within 72 hours after a significant weight change has been identified, as the case was on 01/09/25. She confirmed the attempted weight check on 01/21/25 was too late. Review of the facilities Weight Management policy, dated 09/22/23, revealed residents will be weighed upon admission/re-admission; each week for the first four weeks after admission/readmission, and then monthly thereafter or as indicated by the physician. Re-weights are initiated for a five-pound variance if the resident is greater than five pounds. Re-weights will be completed within 48 to 72 hours. 49039 2. Review of the medical record for Resident #87 revealed an admitted [DATE], with diagnoses including type II diabetes mellitus, anxiety, gastro-esophageal reflux disease (GERD) without esophagitis, hyperlipidemia, anemia, and major depressive disorder. Review of the care plan dated 07/11/24 revealed Resident #87 was at risk for nutrition and/or dehydration related to diabetes mellitus type II, anxiety, GERD, hyperlipidemia, insomnia, and vitreous hemorrhage. Interventions included obtaining the resident's weight at least monthly and reporting any significant weight change of 5% or more over a month to the physician and dietitian. Review of Resident #87's weights revealed on 11/08/24, the resident weighed 220.4 pounds (lbs). On 12/17/24, the weight decreased to 208.8 lbs, showing a significant weight loss of 5.26% over one month. Review of the dietary progress notes dated 12/17/24 at 2:20 P.M. revealed weight loss was likely due to variable meal intakes. It was noted the resident accepted the boost supplement (high calorie nutritional supplement) well. A recommendation was made to increase the boost supplement to 237 milliliter twice a day for weight gain, with a plan to notify the physician of the weight loss and add the resident to the weekly weight list. Review of the physician order dated 12/17/24 for Resident #87 indicated a prescription for boost supplement twice a day as a supplement. Resident #87 did have weekly weights recorded from 12/18/24 to 01/19/25. Review of the Minimum Data Set (MDS) 3.0 assessment completed 01/15/25 showed Resident #87 had moderate cognitive impairment. Resident #87 had no swallowing disorder, had a weight loss of 5% or more over the last month and was not on a physician-prescribed weight-loss regimen. Review of weekly weight task for Resident #87 from 01/27/25 to 02/17/25 revealed weight and scale information marked as not applicable. Interview on 02/19/25 at 8:58 A.M. with Registered Dietitian (RD) #353 confirmed after Resident #87's significant weight loss was observed on 12/17/24, RD #353 recommended increasing the boost supplement and initiating weekly weight checks. This recommendation was communicated in the progress notes and discussed during the weekly meeting of the same week. RD #353 confirmed facility staff did not begin obtaining weekly weights until 01/19/25, and Resident #87 was removed from the weekly weight list on 02/06/25. Interview on 02/19/25 at 9:12 AM with Restorative Certified Nursing Assistant (RCNA) #278 confirmed her responsibility for obtaining weekly weights, with a list provided weekly by management. RCNA #278 stated Resident #87 was not included on the weight list for the weeks of 12/17/24. RCNA #278 explained she was not working in the facility from mid-December 2024 through part of January 2025 and was unsure whether another staff member was assigned to obtain the weekly weights as requested by the dietitian. Interview on 02/19/25 at 9:27 AM with the Director of Nursing (DON) confirmed Resident #87 was not added to the weekly weights list on 12/17/24, but was added on 12/26/24. The DON acknowledged weight records for 12/23/24, 12/30/24, 01/05/25, and 01/12/25 had n/a (not applicable) marked. Weekly weights began being obtained on 01/19/25. Review of facilities Weight Management policy dated 09/22/23 revealed residents determined to have significant weight changes will be weighed on a weekly basis examples of those residents include residents with insidious weight loss and are noted with 5% in one month, 7.5% in three months and 10% in six months.

Based on medical record review and staff interview, the facility failed to provide planning, treatment, and oversight to resident behaviors regarding catheter care. This affected one (Resident #62) of one resident reviewed for behavior monitoring. The facility census was 115. Findings include: Review of Resident #62's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included paraplegia, anxiety disorder, insomnia, chronic pain syndrome, bipolar disorder, intermittent explosive disorder, and post traumatic stress disorder. Review of the Minimum Data Set (MDS) assessment, dated 12/22/24, revealed Resident #62 was cognitively intact. Review of the current physician orders for February 2025 revealed Resident #62 had an order to have a straight catheter procedure to be complete every six hours. Review of Resident #62's current behavioral care plan revealed no documentation, interventions, or plans related to Resident #62's behavior of performing his own straight catheter procedures every two hours, refusing for staff to perform his catheter care, and getting verbally aggressive with staff regarding his catheter care. Review of Resident #62's psychiatric notes, dated June 2024 to February 2025, revealed no documentation to support discussion, care planning, or interventions related to Resident #62 performing straight catheter procedures every two hours. Also, there was no discussion, planning, or interventions related to behaviors exhibited when staff tried to assist with the straight catheter process and no discussion or root cause analysis as to why Resident #62 had to perform straight catheter procedures every two hours, as opposed to every six hours as ordered by his physician. Interview with Director of Nursing (DON) on 02/18/25 at 11:00 A.M. and 12:00 P.M. stated Resident #62 attends psychiatric appointments on a routine basis. She confirmed there was no documentation that Resident #62 behavior of performing self straight catheter procedures every two hours instead of every six hours as ordered. She confirmed they have not documented his behaviors of performing self catheterization every two hours. She confirmed he will yell, scream, and get aggressive with staff when they try to monitor or assist with his catheterization process. She confirmed they do not document those behaviors when related to performing his self catheterization. She confirmed they probably should be.

Based on medical record review, staff interview, and facility policy review, the facility failed to provide parameters for as needed pain medication. This affected one (Resident #62) of five residents reviewed for unnecessary medications. The facility census was 115. Findings include: Review of Resident #62's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included paraplegia and chronic pain syndrome. Review of the Minimum Data Set (MDS) assessment, dated 12/22/24, revealed Resident #62 was cognitively intact. Review of Resident #62's physician orders, dated December 2024 to February 2025, revealed an order for acetaminophen 650 milligrams (mg) every four hours as needed (PRN) for pain or fever. Also, there was an order for Oxycodone (narcotic pain medication) 15 mg every four hours as needed for pain. Neither medication had parameters as to which pain medication should be administered and what pain level each medication should be given at. Review of Resident #62's medication administration record (MAR), dated 01/01/25 to 02/18/25, revealed the following as needed pain medications were administered: in January 2025, acetaminophen was administered twice for pain levels five and eight (from a pain level scale of zero (no pain) to ten (most severe pain), and then Oxycodone was administered a total of 61 times for pain levels between one to seven. Also, review of February 2025 MAR, acetaminophen was not administered and Oxycodone was administered a total of 31 times for pain levels between one to seven. Interview with Registered Nurse (RN) #227 and RN #236 on 02/19/25 at 10:20 A.M. and 10:25 A.M. confirmed there should be parameters for the as needed pain medication. If there were no parameters, they will use nursing judgement and the resident's pain level to determine which pain medication to give. They confirmed if the pain levels were one to five, they will first administered the lower strength pain medication, such as acetaminophen. If the pain level was six to ten, they will administer the higher strength pain medication, such as tramadol or Oxycodone. RN #236 confirmed Resident #62 did not have pain parameters in place and Oxycodone was being administered for pain levels between one to seven and acetaminophen was administered for pain levels of five to eight. Review of facility Pain Management policy, dated 04/11/23, revealed the facility will observe the resident for indicators of pain. They will ask the resident and observe to determine the intensity of pain. Following the pain evaluation, notify the physician if indicated and implement new orders as received. The licensed nurse, when administering PRN pain medications, will record the drug administration on the PRN MAR. Document the date, time, and effectiveness of PRN pain medication on the PRN administration record.

Based on record review and staff interview, the facility failed to monitor behaviors and did not provide appropriate justification for a psychotropic medication for one (Resident #80) of five residents reviewed for unnecessary medications. The facility census was 115. Findings include: Review of the medical record for Resident #80 revealed an admitted [DATE] with diagnoses including vascular dementia with behavioral disturbances. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #80 had severe cognitive impairment, and documentation of verbal behaviors. Review of the physician orders for Resident #80 revealed the following medication: Seroquel (Quetiapine Fumarate) 50 milligrams (mg) - Administered twice daily for vascular dementia behaviors, ordered on 10/31/24 with no stop date. Ativan (Lorazepam) 0.5 mg - Administered every four hours as needed for anxiety and agitation, with multiple renewal orders from 11/12/24 through 02/12/25. Trazodone HCl 50 mg - Administered nightly for insomnia, ordered on 10/09/24. Review of the treatment administration record (TAR), from 10/07/24 to 11/01/24, revealed Resident #80 had only seven of 25 nights with behaviors. Review of the progress notes for Resident #80 revealed on 12/26/24 at 1:33 P.M., staff documented the Ativan order was renewed due to intermittent yelling and screaming. However, the note stated the resident did not appear to be in distress and smiled simultaneously. On 01/16/25 at 2:46 P.M., a resident-at-risk note indicated the resident continued to display behaviors despite verbal reassurance and staff interventions. It was also noted the resident exhibited increased lethargy when Seroquel was scheduled. Review of the Omnicare Pharmacy consultation report completed for January 2024 for Resident #80 revealed it was recommended to attempt a gradual dose reduction (GDR) of Seroquel 50 mg at bedtime but was declined by the Certified Nurse Practitioner (CNP) due to risk of declines with GDR with no further explanation. Review of the viaquest psychiatric note completed on 01/07/25 for Resident #80 confirmed the psychiatric history was limited to vascular dementia. Review of the psychoactive medication quarterly evaluation completed on 01/17/25 stated the diagnoses pertaining to the psychoactive medications were insomnia, anxiety, vascular dementia behaviors, and agitation indicating there was not an appropriate justification for Seroquel. Additionally, it stated the resident will continue current dosage, no GDR clinically recommended at this time. Interview on 02/13/25 at 9:51 A.M. with the Director of Nursing (DON) stated Resident #80 was admitted to the facility on Seroquel with the diagnosis of depression but the physician changed the diagnosis justification to dementia with behaviors. The DON stated from 10/07/24 to 11/01/24, the facility attempted a GDR and claimed the behaviors increased during this time. The DON confirmed during this time there was not adequate documentation of increased behaviors due to the reduction of the Seroquel. Interview on 02/13/25 at 11:38 A.M. with Psychiatric Nurse Practitioner (PNP) #400, stated due to Resident #80's age she would not meet the criteria for schizophrenia making Seroquel use difficult to justify. She stated the family was resistant to a GDR and had requested a different medication such as Haldol. She confirmed vascular dementia behaviors was not an appropriate diagnosis for Seroquel but stated Resident #80 seemed happier on Seroquel. PNP #400 also confirmed the staff need to do a better job at monitoring behaviors to determine if a GDR is truly successful and will have a psych all staff to educate on observing behaviors and documenting appropriately.

Based on record review, resident and staff interview, observation , review of policy, and review of the resident agreement, the facility failed to timely obtain routine dental services for residents. This affected two (Resident #60 and Resident #103) of two residents reviewed for dental services. The facility census was 115. Findings include: 1. Review of the medical record for Resident #103 revealed an admitted [DATE] with diagnoses of epilepsy, type two diabetes mellitus, chronic kidney disease, mild cognitive impairment, and personal history of transient ischemic attack. Review of the Minimum Data Set (MDS) 3.0 assessment completed 12/17/24 revealed Resident #103 had moderate cognitive impairment and Resident #103 has no natural teeth or tooth fragments. Review of the care plan dated 12/12/24 revealed Resident #103 was at risk for infection, pain, or bleeding in the oral cavity. Resident #103 has no teeth present, and dentures were at home. Interventions included dental consult as needed, observation for oral/dental problems, provision of diet as ordered, and referral to dietician as needed. Review of the progress note dated 12/16/24 revealed Resident #103 had complete upper and lower dentures but cannot eat well without them. It was noted they were damaged in a recent motor vehicle crash. The dentures required replacement and follow-up with a dentist for new dentures. Review of physician orders dated 12/17/24 revealed a consistent carbohydrate diet, regular texture/consistency, and resident request for soft foods/mashed potatoes. There was no documentation in the medical record regarding a follow up to a replacement of dentures and/or dentist following the 12/16/24 progress note through 02/11/25. Interview on 02/11/25 at 10:30 A.M. with Resident #103 stated he had concerns about his ability to eat meals. The resident explained that he has to gum most of his food in order to consume it. He reported that his dentures were damaged during his accident and has not received any updates or assistance regarding the replacement. He mentioned that his previous dentist had kept an extra mold to create a new set of dentures, but he was uncertain whether the facility staff have contacted the office for further action. Interview on 02/12/25 at 3:16 P.M. with Social Services Assistant (SSA) #279 confirmed Resident #103 has been in need of dentures since admission, but they were unable to receive coverage for these services until he obtains a new guardian and was approved for Medicaid. SSA #279 stated the guardianship paperwork for Resident #103 has been sent out, and they were in the process of submitting his emergency Medicaid application. Interview on 02/18/25 at 9:24 A.M. with SSA #279 revealed the ward clerk was responsible for contacting the hospital and Resident #103's previous dentist office to gather additional information regarding the whereabouts of his dentures or explore potential solutions. SSA #279 stated they were working on the emergency Medicaid application, which should soon provide the necessary coverage. Interview on 02/19/25 at 12:34 P.M. with [NAME] Clerk #245 denied any knowledge of Resident #103's missing dentures. She confirmed she had not been instructed to call the hospital for belongings or reach out to the previous dentist office for assistance with the issue. Review of the admission agreement undated revealed the facility will provide services, included in the daily rate, to the resident. In addition to the included services, the facility will provide additional non-routine services and supplies that may incur an extra charge to the resident. The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. 51068 2. Review of Resident #60's medical record revealed an admitted [DATE], with diagnoses including localization-related (focal) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, age-related osteoporosis, and gastroesophageal reflux disease (GERD). Review of Resident #60's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #60 was cognitively intact. Review of the nursing note on 09/23/24 at 10:34 A.M. revealed Resident #60 complained of a sore mouth, especially when eating food. The resident stated he doesn't have teeth and his gums were painful when chewing food. The Medical Director (MD) was made aware, and new orders for a dietician and dentist were set up. A report was given to the in-house dietician and ancillary certified nursing assistant (CNA) to follow up. There was no documentation in the medical record that Resident #60 was seen by a dentist from 09/24/24 to 02/12/25. There was no evidence the facility followed up regarding Resident #60's dentures from 09/24/24 to 02/12/25. During an interview on 02/11/25 at 7:58 A.M. with Resident #60, he stated he needs molds and new dentures made. He reported eating regular food until his gums become sore, at which point the facility places him on a mechanical soft diet until his gums feel better. Resident #60 was observed not to have teeth in at the time of the conversation. During an interview on 02/12/25 at 12:05 P.M., Social Worker (SW) #291 explained when a resident requires dental or vision services, they assist in setting up appointments through Ancillary Company #600 or Ancillary Company #700 . She stated Social Service Assistant (SSA) #279 was responsible for coordinating ancillary services and would check why Resident #60 had not yet received dentures or additional follow-up dental appointments. During an interview on 02/12/25 at 4:08 P.M. with SSA #279, she stated the consent form for Ancillary Company #700 was signed by Resident #60 on 09/28/24 but not sent until 10/08/24. SSA #334 stated she follows up for dentistry services but was unsure why Resident #60 had not been seen by a dentist to obtain new dentures. SSA #279 further explained that once she sends the consent forms to Ancillary Company #700, she does not follow up to determine if the residents have been seen or if the concerns have been addressed. Review of the Social Services Referral to Outside Providers policy revealed the following requirements: A physician's order must be obtained by nursing. Consent to receive services must be sought from the resident or their representative before initiating services. Social services must make the referral to the outside provider and provide demographics and signed consent as needed. Progress notes from the service provider must be obtained and placed in the resident's medical record. The resident's physician, family, and/or representative must be informed of the service results, and any recommendations should be reviewed with the physician. The provider's recommendations must be integrated into the resident's care plan. Recommendations for interventions should be communicated to direct care staff. Follow-up visits should be scheduled as needed.

Based on medical record review, review of the facilities infection control log, staff interview, and facility policy review, the facility failed to to follow appropriate antibiotic stewardship protocols. This affected two (Residents #39 and #90) of five residents reviewed for unnecessary medications. The facility census was 115. Findings include: 1. Record review revealed Resident #39 was admitted to the facility on [DATE]. Diagnoses included osteomyelitis of vertebra, paraplegia, and neuromuscular dysfunction of bladder. Review of the Minimum Data Set (MDS) assessment, dated 01/27/25, revealed Resident #39 was cognitively intact. Review of Resident #39's physician orders, dated October and November 2024, revealed the following antibiotics were ordered and administered: Hiprex one gram (gm) for prophylaxis, Amoxicillin 875-125 milligrams (mg) twice daily for wound infection for seven days starting on 11/23/24, bactrim 800-160 mg twice daily for prevention for 10 days starting on 11/25/24, and Doxycycline 100 mg twice daily for chronic osteomyelitis/prophylactic. Review of Resident #39's Medication Administration Record (MAR), dated November 2024, revealed from 11/25/24 to 11/27/24, Resident #39 was administered four separate antibiotics at the same time. Three of the medications (Hiprex, Bactrim, and Doxycycline) were documented as being for prophylactic/prevention reasons. Review of Resident #39's progress notes, dated 11/25/24, revealed his white blood cell count increased from the initial order of amoxicillin, so he was ordered Bactrim to cover for possible Methicillin-resistant Staphylococcus aureus (MRSA). Resident #39's medical record did not have any test, culture, or other further examination to confirm he had MRSA to justify the addition of bactrim on 11/24/24. Review of Resident #39 's physician review/report document, dated 11/26/24, revealed the resident was recently managed with new onset of increased C-Reactive Protein (CRP) and sacral wound worsening. Alert and oriented times four. The resident went out to the doctor appointment as well. He denies shortness of breath and chest pain, denies nausea and vomiting, and denies lethargy, dizziness, or headache. Illeus much improved, However given his recent labs, he started bactrim and augmentin (amoxicillin) as prophylaxis. There was no documentation within the report as to a specific justification for the use of bactrim or amoxicillin. Review of Resident #39's physician orders, dated 02/11/25, revealed he was scheduled, ordered, and administered the following antibiotics: Hiprex one gm for prophylaxis and doxycycline 100 mg twice daily for chronic osteomyelitis/prophylactic. Neither antibiotic had proper justification for the prolonged use. Interview with Director of Nursing (DON) on 02/13/25 at 2:15 P.M. and 02/18/25 at 9:30 A.M. and 1:00 P.M. confirmed in November 2024, Resident #39 was ordered four separate antibiotic medications. She confirmed Resident #39 was ordered amoxicillin on 11/23/24 related to signs and symptoms of an infection. She confirmed the nursing staff contacted the on-call physician and amoxicillin was ordered. She also confirmed that two days later, they contacted Resident #39's physician due to increased white blood cell counts, and bactrim was ordered to cover possible MRSA. She confirmed there was no evidence the facility or physician ordered testing to determine if he had MRSA. Also, there was no clear documentation if all four antibiotics were to be administered at the same time from 11/25/24 to 11/27/24. She confirmed three of the antibiotic medications were ordered/had justification as prophylactic. Review of the facility's Antibiotic Stewardship policy, dated 10/14/22, revealed antibiotic stewardship refers to coordinated interventions designed to improve and measure the appropriate use of antimicrobials, by promoting the selection of the optimal anti-microbial drug regimen, dose, duration of therapy, and route of administration. The medical director and director of nursing will use his/her influence as medical and nursing leaders to help ensure antibiotics are prescribed only when appropriate. The use of prophylactic antibiotic treatment, long term antibiotic maintenance use for chronic infections, and treatment with broad spectrum antibiotics while a culture is pending, should be discouraged by the medical director and consultant pharmacist. 51068 2. Review of the medical record for Resident #90 revealed an admitted [DATE], with a re-entry date of 08/10/24. Diagnoses included diffuse large B-cell lymphoma systolic congestive heart failure, and cardiomyopathy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/30/24, revealed Resident #30 had intact cognition. Review of the physician orders for Resident #90 revealed multiple orders for Bactrim DS (800 - 160 milligrams (mg)). On 05/17/24 at 11:15 A.M., the initial justification for prescribing Bactrim was for a urinary tract infection (UTI). It was discontinued on 05/17/24. Subsequent orders for Bactrim DS were 05/29/24 to 06/17/24 and 07/31/24 to 02/18/25 revealed there was for prophylaxis. Review of the medical record revealed no documentation to support the necessity of continued Bactrim prophylaxis after the UTI was treated. Review of the geriatrics follow-up notes, dated 05/20/24 to 02/11/25, consistently referenced Bactrim use without clinical indication or reassessment of necessity. During an interview on 02/18/25 at 9:56 A.M., the Director of Nursing (DON) stated prophylactic antibiotic use was reviewed only during monthly physician visits, with no evidence of routine reassessments based on clinical indicators. Review of the facilities infection control logs from July 2024 to February 2025 revealed the facility failed to document Resident #90's Bactrim use, indicating a lack of systemic monitoring for effectiveness, adverse reactions, or necessity. Review of the facility's infection control and antibiotic stewardship policy revealed the following expectations: The program will encourage appropriate prescribing and reduce adverse effects, which often include gastrointestinal complications, C. difficile diarrhea, yeast infections, and antibiotic resistance in aging adults. The Medical Director and DON are responsible for ensuring antibiotics are prescribed only when appropriate. The consultant pharmacist is expected to analyze infections, prescribing patterns, antibiotic duration, and patient outcomes monthly through the Medication Management Review (MMR). The use of prophylactic antibiotic treatment, long-term antibiotic maintenance for chronic infections, and broad-spectrum antibiotic treatment while awaiting culture results should be discouraged by the Medical Director and consultant pharmacist.

Based on personnel record review, staff interview, and policy review, the facility failed to ensure the social worker had the proper qualifications of one year of supervised social work experience in a health care setting for a facility with 126 beds. This had the potential to affect all 115 residents residing in the facility. Findings include: Review of the personnel file for Social Worker (SW) #291 revealed a hire date of 01/09/23. SW #291 has received her Masters in Social Work (MSW) but there was no evidence that she has had one year of supervised healthcare experience. The personnel file included a reference check from Long Term Care (LTC) Facility #1 where LSW #291 held a Social Services Director position. On the reference check, there was no indication of whether or not SW #291 was supervised during this experience. Interview on 02/18/25 at 9:23 A.M. with the Administrator confirmed SW #291 was hired when the previous Administrator was working and they would know if she was hired with supervised experience but were unable to reach them to confirm. She stated there was a Social Service Liaison who was a Licensed Social Worker (LSW) that oversees the social service program. Interview on 02/18/25 at 11:43 A.M. with Social Service Liaison (SSL) #401 confirmed she was not signing off on any work that was being completed by the social service department at the facility. Interview on 02/18/25 at 1:00 P.M. with Director of Nursing (DON) confirmed they do not have any evidence that SW #291 was supervised prior to her employment at the facility or former employment.

Based on observation, staff interview, medical record review and review of facility policy, the facility failed to ensure pureed foods were prepared in a manner to maintain nutritive value. This affected one (#46) of three residents reviewed for diet orders. The facility identified two residents with physician ordered pureed diets. The facility census was 112. Findings include: Review of the medical record for Resident #46 revealed an admitted [DATE]. Diagnoses included cerebral infarct (stroke), epilepsy, malnutrition, dementia and heart disease. Review of a physician order dated 08/02/24 revealed Resident #46 had an order for pureed diet. Review of the care plan dated 08/02/24 revealed Resident #46 had a nutritional risk related to mechanically altered diet and requiring assistance with meals. Interventions included to provide diet as ordered (regular diet, puree texture.) Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 was severely cognitively impaired and required supervision/touch assistance with eating. The assessment also revealed the resident received a mechanically altered diet. Observation on 11/12/24 at approximately 3:00 P.M. of puree turkey burger preparation revealed Kitchen Manager (KM) #60 placed an unmeasured amount of turkey meat in the blender, along with one and a half hamburger buns, an unmeasured amount of broth (the container the broth was poured from contained approximately one quart of broth and over half of the broth was poured in the blender) and an unmeasured amount of thickener. Concurrent interview with KM #60 revealed he was preparing two servings, to have extra available, and estimated he used six to eight ounces of turkey meat, two and one-half cups of broth and two tablespoons of thickener. While blending the mixture, KM #60 added two more tablespoons of thickener, followed by an additional two tablespoons of thickener and finally added one more tablespoon of thickener, for a total of seven tablespoons for thickener. Continuous observation of the turkey burger puree revealed it lacked turkey flavor and tasted like paste/starch. Interview 11/12/24 at 5:42 P.M. with Resident #46 revealed she received the puree turkey burger. Resident #46 stated the turkey burger did not taste like turkey and the pureed food tasted awful. Interview on 11/13/24 at 11:00 A.M. with Dietician #59 revealed puree foods should be thickened to the right consistency by blending the food first then adding either liquid or thickener to reach the desired consistency. Interview on 11/13/24 at 11:08 A.M. with Regional Dietician (RD) #58 revealed staff should not add a significant amount of fluid or thickener when preparing pureed foods. Food should be blended to see what you have (baseline) and then add either liquid or thickener to reach desired consistency, but preparation should not include both. Review of the facility policy titled Pureed Food Preparation, undated, revealed the facility shall prepare puree foods in a manner that sustains nutritive value and taste. Puree foods shall be made from regular menu items to assure similar taste and nutritional quality and recipes would be followed for production. The puree procedures included: portion out the number of puree items needed to prepare, place food in processor to be blended to proper consistency, when blending meats liquid may need to be added and liquids should be used sparingly. If puree meats were served, portion one slice per three ounces (oz) meat and remember to increase serving size to four oz when served in this manner. This deficiency represents non-compliance investigated under Complaint Number OH00159365.

Based on observation, medical record review, review of a dietary meal ticket and staff interview, the facility failed to ensure diet textures were served per physician orders. This affected one (#77) of three residents reviewed for diet orders. The facility identified two residents with physician ordered pureed diets. The facility census was 112. Findings include Review of the medical record for Resident #77 revealed an admitted [DATE]. Diagnoses included respiratory failure with hypoxia, diabetes, chronic kidney disease, failure to thrive, vascular dementia, pneumonia muscle weakness and dysphasia. Review of the care plan dated 10/03/24 revealed Resident #77 had a nutritional risk related to mechanically altered/therapeutic diet and required assistance with meals. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77 was severely cognitively impaired and required supervision/touching assistance with eating. The assessment also revealed the resident received a mechanically altered diet. Review of a physician order dated 11/11/24 revealed Resident #77 was ordered a mechanical texture diet with puree vegetables. Review of Resident #77's meal ticket dated 11/12/24 revealed Resident #77 received a mechanical soft diet with pureed vegetables. Further review revealed no indication of any vegetables Resident #77 could receive without being pureed. Observation on 11/12/24 at 6:12 P.M. revealed Resident #77 received her dinner meal tray. Resident #77's meal tray included pureed green beans and a cup of shredded lettuce. Interview on 11/12/24 at 6:20 P.M. with the Director of Nursing (DON) confirmed Resident #77 had a cup of shredded lettuce on her meal tray. The DON verified shredded lettuce should not have been served to Resident #77 due to her diet order for pureed vegetable. The DON removed the item from the resident's meal tray. Interview on 11/13/24 at 11:00 A.M. with Dietician #59 revealed puree should be smooth consistency, without chunks or pieces. Interview on 11/13/24 at 11:08 A.M. with Regional Dietician (RD) #58 revealed staff should provide all menu items as ordered. RD #58 stated if a resident was approved to eat an item that went against their diet restriction or texture recommendations it would be written on their meal ticket. This deficiency represents non-compliance investigated under Complaint Number OH00159365.

Based on observation, medical record review, review of Enhanced Barrier Precautions (EBP) signage, staff interview and review of facility policy, the facility failed to follow infection prevention guidelines for EBP when staff failed to wear appropriate personal protective equipment (PPE). This affected one (#28) of three residents reviewed for infection control. The facility census was 112. Findings include: Review of Resident #28's medical record revealed an admitted [DATE] with pertinent diagnoses of: cerebral infarction, type two diabetes mellitus, chronic kidney disease and gastrostomy status. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/27/24, revealed Resident #28 was cognitively intact and used a wheelchair to aid in mobility. Further review revealed Resident #28 was always incontinent of bowel and bladder and used a feeding tube. Review of a physician order dated 08/01/24 revealed Resident #28 had an order to cleanse percutaneious endoscopic gastrostomy (PEG) tube (feeding tube placed through the stomach wall) site with wound cleanser and apply dry dressing. Observation on 11/18/24 at 12:40 P.M. revealed an EBP sign outside Resident #28's door. The sign stated to wear gloves and gown for high contact resident care activities, which included device care or use: feeding tube. Observation on 11/18/24 at 12:40 P.M. of Resident #28's PEG tube care revealed Licensed Practical Nurse (LPN) #90 gathered supplies, performed hand hygiene and donned gloves. LPN #90 did not don a gown. LPN #90 cleansed Resident #28's PEG tube site and applied dressing per physician orders and exited the resident's room. Interview on 11/18/24 at 12:52 P.M. with LPN #90 confirmed Resident #28 was on EBP due to having a PEG tube. LPN #90 verified she did not don a gown prior to providing PEG tube care for Resident #28 and further stated she should have worn a gown. Review of a facility policy titled Enhance Barrier Precautions dated 03/26/24 revealed it was the intent of the facility to use EBP in addition to standard precautions in preventing the transmission of targeted multidrug-resistant organisms (MDROs). EBP were indicated for residents with an infection or colonization with a targeted MDRO when contact precautions do not otherwise apply or for a wound or indwelling medical device, even if the resident was not known to be infected or colonized with a MDRO, and should remain in place for the duration of a resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that place them at higher risk. Indwelling medical devices include central lines, urinary catheters, feeding tubes and tracheotomies. This deficiency represents non-compliance investigated under Complaint Number OH00159038.

Based on medical record review, review of a resident risk management meeting document, review of Quality Assurance Performance Improvement meeting documents, staff and resident interviews, and review of the facility's smoking policy, the facility failed to ensure Resident #135 exhibited safe smoking practices, stored his smoking materials appropriately, and did not smoke while near oxygen. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm and/or injuries when Resident #135 lit his lighter in his room while in bed and with his supplemental oxygen on and being delivered via nasal cannula. Resident #135's oxygen ignited, resulting in second-degree burns (burns involving the first two layers of skin) that covered one-fourth of the resident's face, both nostrils, and burnt a portion of Resident #135's bedding. This affected one (#135) of five residents reviewed for smoking. Additionally, the facility failed to ensure resident smoking materials were safely secured per facility policy for two (#12 and #30) of five residents reviewed for smoking which placed the residents at risk for the potential for more than minimal harm that was not Immediate Jeopardy. The facility identified 19 residents (#01, #07, #08, #11, #12, #17, #21, #26, #30, #34, #38, #39, #43, #47, #61, #76, #87, #93 and #105) who smoke independently and four residents (#50, #64, #69, and #72) who required supervision with smoking. The facility census was 108. On 03/13/24 at 10:18 A.M., the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on 12/26/23 at 5:30 A.M. when Resident #135, who utilized supplemental oxygen therapy via nasal cannula, lit his lighter in his room resulting in the oxygen igniting. Review of Resident #135's nursing progress note dated 12/26/23 at 7:57 A.M. written by Licensed Practical Nurse (LPN) #150 revealed there was a strange sound heard in the hallway with a burning smell noted. State tested Nurse Aide (STNA) #194 discovered it was coming from Resident #135's room. Resident #135 was seen in the room panicking and anxiously gasping for air with a burned face. Resident #135 and his roommate (Resident #76) were safely taken out of the room to the nurse's station. The oxygen in the room was turned off. There was a cigarette butt, lighter, and a burned blanket that were found in the resident's room. The physician progress notes revealed the resident sustained second-degree burns that covered one-fourth of the right side of Resident #135's face and nostril. The facial burns were secondary to the resident using a lighter with supplemental oxygen on. Resident #135 refused to go to the hospital and the risk of serious infection was explained to the resident, but Resident #135 did not want to leave the facility. The Immediate Jeopardy was removed on 12/27/23 when the facility implemented the following corrective actions: On 12/26/23 at 7:57 A.M., the DON spoke with Resident #135 and his roommate, Resident #76, regarding details of the incident and verified that no smoking materials were in the room at that time. Resident #135 stated he did not wish to continue to smoke and declined nicotine replacement. On 12/26/23, the DON provided Resident #135 education regarding the facility smoking policy with Resident #135 expressing understanding of the education. On 12/26/23 at 9:00 A.M., the Administrator and Social Worker (SW) #184 conducted room searches on all 25 residents who smoke with the permission of the residents and collected any smoking paraphernalia that was found. Re-education was provided to all 25 residents who smoke on the smoking policy and the proper storage of smoking materials by the Administrator and SW #184 on 12/26/23 with all 25 residents signing acknowledgement of the education on the smoking policy and procedure which included adherence to the facility smoking policy and procedure. On 12/26/23 from 9:00 A.M. through 4:00 P.M., the DON along with Unit Manager (UM) LPN #166, UM LPN#165, and Assistant Director of Nursing (ADON) #250 completed new smoking evaluations on all 25 residents who smoke to determine safety risk and need for supervision on 12/26/23. On 12/26/23 all facility staff were re-educated on the smoking policy and the designated locations for smoking materials. Facility staff education continued prior to working their next scheduled shift by the DON and ADON #250 on the smoking policy and designated storage areas for smoking materials with all staff education completed on 12/27/23. Ongoing weekly audits were conducted by SW #184 and the Administrator on 01/03/24, 01/09/24, 01/17/24, 01/24/24 and 01/31/24. Department managers have continued to complete random audits of resident rooms for smoking paraphernalia. Any issues identified will be immediately corrected. All audits to be reviewed by the Quality Assurance Performance Improvement (QAPI) committee for review and recommendations. Interviews with STNA #251, STNA #207, STNA #225 and Registered Nurse (RN) #176 on 03/13/24 at 2:48 P.M. revealed they were educated regarding the facility smoking policy after the incident took place with Resident #135, and verified they were knowledgeable about the content of the education. Observation on 03/14/24 at 12:01 P.M. of the scheduled smoke break revealed staff and residents were outside in the designated smoking area and staff was providing supervision to all residents present in the smoking area. There were no oxygen tanks or unsafe smoking practices observed. Although the Immediate Jeopardy was removed on 12/27/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings included: 1) Review of Resident #135's medical record revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), anxiety, depression, and chronic respiratory failure with hypoxia. Resident #135 was discharged on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #135 was assessed as cognitively intact. Further review revealed the resident had no impairment to his upper or lower extremities and used a wheelchair. Resident #135 was assessed as independent for eating and bed mobility and required supervision or touching assistance for transfers. Review of the care plan dated 03/02/22 revealed Resident #135 wished to use smoking products and was assessed as being safe to smoke with supervision only. The resident reported he no longer wanted to smoke and will not be smoking and if he does, he must have supervision. Interventions were to assess the resident's ability to smoke safely, educate family and friends not to provide cigarettes directly to the resident, educate resident that oxygen use was prohibited in the smoking area, educate the resident on the smoking policy, and the staff will manage all smoking materials for unsafe and safe smokers. Review of the most recent smoking assessment dated [DATE] revealed Resident #135 was alert, consistent with decision ability, could grasp and hold a cigarette, and had quick response to fallen ashes. The resident could safely light and hold the cigarette, dispose of ashes, and extinguish the cigarette safely. Resident #135 removed his oxygen tubing before coming into the smoking area, and also followed the smoking guidelines per policy including smoking in the designated area and returning the smoking paraphernalia to the appropriate person/location. Resident #135 was assessed as a safe smoker and could smoke independently if he wished. Review of Resident #135's nursing progress note dated 12/26/23 at 7:57 A.M. written by LPN #150 revealed there was a strange sound heard in the hallway with a burning smell noted. STNA #194 discovered it was coming from Resident #135's room. Resident #135 was seen in the room panicking and anxiously gasping for air with a burned face. Resident #135 and his roommate (Resident #76) were safely taken out of the room to the nurse's station. The oxygen in the room was turned off. There was a cigarette butt, lighter, and a burned blanket that were found in the room. Resident #135 refused to be sent to the hospital and denied pain. A cold compress was applied to his face with Plurogel cream (a cream used to heal burns). The physician ordered Silvadene one (1) percent (%) cream (an antimicrobial cream used to treat and prevent wound sepsis from second- and third-degree burns) to be applied twice a day and Resident #135 refused for family to be notified. Review of a physician progress note dated 12/28/23 at 12:00 P.M. revealed there was a partial thickness burn to Resident #135's face. The resident had second-degree burns that covered one-fourth of the right side of Resident #135's face and nostril. The facial burns were secondary to the resident using a lighter with supplemental oxygen on. Resident #135 refused to go to the hospital and the risk of serious infection was explained to the resident, but Resident #135 did not want to leave the facility. Review of nursing progress notes dated 01/07/24 revealed Resident #135 had smoking materials found in his room and the items were removed. Resident #135 was educated on the smoking policy and on supervised smoking times, and the resident verbalized understanding. Review of nursing progress notes dated 01/09/24 revealed Resident #135 was found outside in the facility courtyard smoking without supervision and without staff knowledge. At that time, Resident #135 was placed on one-to-one supervision for continued non-compliance with the smoking policy. Review of the resident risk management meeting dated 01/25/24 revealed Resident #135 exhibited non-compliance with smoking policy on numerous occasions and he was currently on one-to-one supervision to ensure his safety due to his need for continuous oxygen and desire to continue smoking. Smoking cessation was offered on numerous occasions and Resident #135 declined. The resident was currently receiving Remeron for depression, and Xanax and Hydroxyzine for anxiety. Resident #135 was issued a 30-day discharge notice due to putting the safety of himself and others at risk and plans to appeal this decision but does express a desire to discharge from the facility. Further review of the documentation from the resident risk management meeting revealed to continue Resident #135 on one-to-one supervision for safety, ensure the resident was compliant with the smoking policy, and offer psychiatric services as needed. Review of a QAPI meeting document dated 01/29/24 revealed the smoking incidents related to Resident #135 were discussed as well as a review of safety of residents who smoke and the list of residents who smoke was reviewed. Interview with LPN #150 on 03/12/24 at 1:18 P.M. revealed on 12/26/23 at 5:30 A.M., STNA #194 discovered there was cigarette smoke and a burning smell coming from Resident #135's room. LPN #150 stated she and STNA #194 ran to the room and discovered Resident #135's face, nasal cannula, oxygen tubing, and part of the resident's blanket was burnt. LPN #150 verified there was a cigarette butt and a lighter lying on the bed. LPN #150 continued that Resident #150 was anxious because he did not have his supplemental oxygen on, so she took the resident out into the hall, placed his oxygen on, and asked him what he was doing. LPN #150 stated the resident indicated he lit his lighter to look for a pill he dropped in the bed and the oxygen ignited. LPN #150 stated there could not have been any pills in the bed because she watched the resident take all of his medications on 12/26/23 at 4:33 A.M. Concurrent interview with the Administrator and the DON on 03/12/24 at 2:30 P.M. confirmed Resident #135 ignited his oxygen tubing on 12/26/23 and burned his face, nostrils, and part of his blanket. Both the Administrator and the DON confirmed the resident was an independent smoker at the time and got the lighter and cigarettes from a visitor or family member, but did not know exactly who it was, and denied there was any documentation regarding this. The Administrator and the DON stated Resident #135's smoking materials were supposed to be handed back to the nurse at the nursing station to put them away for the next smoking time of the resident's choice. The Administrator and the DON stated they placed Resident #135 on supervised smoking, which meant someone would take the resident out to smoke beginning on 12/26/23 following the incident. Interview with Resident #76 on 03/13/24 at 7:48 A.M. revealed he was Resident #135's roommate when Resident #135 resided in the facility. Resident #76 stated, on 12/26/23 between 5:30 A.M. and 6:00 A.M., he was awakened by a poof sound and the smell of plastic, and he heard Resident #135 yell that he could not breathe because he had burnt the nasal cannula when it ignited with his cigarette lighter. Resident #76 denied he smelled cigarette smoke. Resident #76 stated the nursing staff came and took both him and Resident #135 out of the room. Resident #76 stated he did not see any fire but saw Resident #135's blanket was burnt, and the resident had burns on his face. Resident #76 stated he believed Resident #135 was trying to find his narcotic pain pill, oxycodone, in the bed and lit his lighter to look in the covers. Resident #76 stated Resident #135 smoked in the room multiple times and did not want to listen to anyone regarding smoking in the room. Resident #76 further stated Resident #135 did not feel like he needed to follow the rules and kept his smoking materials in the room with him. Interview with the Administrator on 03/13/24 at 2:30 P.M. revealed on 12/26/23 Resident #135 did not want to smoke anymore because he was scared and a smoking cessation patch and an inhaler were offered, but the resident refused them. The Administrator stated Resident #135 was caught with smoking materials on 01/07/24 in his room and the resident was re-educated on the smoking policy, advised of the designated smoking times, and was informed he would be supervised. The Administrator stated on 01/09/24 Resident #135 was caught in the courtyard smoking unbeknownst to staff and was advised he would be on one-to-one supervision for smoking until he discharged from the facility. Resident #135 was issued a 30-day discharge notice on 01/22/24, and the Administrator stated the delay in the discharge notice was due to the resident's family not wanting Resident #135 to live with them, but one family member changed their mind and allowed Resident #135 to live with them. Interview with STNA #194 on 03/13/24 at 3:11 P.M. revealed on 12/26/23 at 5:30 A.M., she smelled cigarette smoke in the hallway and heard Resident #135 screaming. STNA #194 stated she went into Resident #135's room and the resident's cheeks, nostrils, forehead, and nasal cannula were burnt, and the nasal cannula was laying on the floor. STNA #194 confirmed she saw a cigarette butt and a lighter on Resident #135's bed along with a partially burnt blanket. STNA #194 stated Resident #135 denied smoking in his room. STNA #194 stated while collecting trash in the resident's room on another unspecified date she discovered cigarettes butts and reported them to the supervisor but could not specifically remember who she reported it to. 2) Medical record review for Resident #30 revealed an admitted [DATE]. Diagnoses included after care for knee and hip replacement and viral hepatitis. Review of the quarterly MDS assessment dated [DATE] revealed Resident #30 was assessed as cognitively intact. Resident #30 was independent for eating, bed mobility, transfers, and toileting. Review of the care plan dated 12/12/23 revealed Resident #30 wished to use smoking products and was assessed as being a safe smoker. The resident was educated on the smoking policy and was given a copy for his records. Interventions were to assess the resident's ability to smoke safely, educate family and friends not to provide cigarettes directly to the resident, educate the resident that oxygen use was prohibited in the smoking area, educate the resident on the smoking policy, and the staff will manage all smoking materials for unsafe and safe smokers. Review of the smoking evaluation dated 12/27/23 revealed Resident #30 was alert and consistent. The resident was able to grasp and hold a cigarette and had quick response to falling ashes. Resident #30 was safe to light smoking materials and held the materials safely. The resident disposed of the ashes in the ashtray and extinguished his cigarette safely. Resident #30 was deemed as a safe smoker. The evaluation was updated on 03/13/24 to show the resident was an unsafe smoker and had to be supervised because he would not turn in his smoking materials. Interview with the DON on 03/13/24 at 1:17 P.M. verified Resident #30 had smoking materials in his room that had to be removed. Interview with Resident #30 on 03/14/24 at 8:05 A.M. revealed he rolled his own cigarettes and kept his tobacco, rolling machine, and tubes in his room. Resident #30 stated the Administrator asked him to keep his smoking materials in the activity room and he could roll his cigarettes there when he needed to. Resident #30 stated he purchased the smoking supplies at the tobacco store. 3) Medical record review for Resident #12 revealed an admitted [DATE]. Diagnoses included type two diabetes, depression, and asthma. Review of the quarterly MDS assessment dated [DATE] revealed Resident #12 was assessed as cognitively intact. The resident was independent for eating, toileting, bed mobility, and transfers. Review of the care plan dated 12/13/23 revealed Resident #12 wished to use smoking products and was assessed as being a safe smoker. The resident was educated on the smoking policy and was given a copy for his records. Interventions were to assess the resident's ability to smoke safely, educate family and friends not to provide cigarettes directly to the resident, educate the resident that oxygen use was prohibited in the smoking area, educate the resident on the smoking policy, and the staff will manage all smoking materials for unsafe and safe smokers. Review of the smoking evaluation dated 12/27/23 revealed Resident #12 was alert and consistent. The resident was able to grasp and hold a cigarette and had quick response to falling ashes. The resident was safe to light smoking materials and held the materials safely. Resident #12 disposed of the ashes in the ashtray and extinguished his cigarette safely. Resident #12 was deemed as a safe smoker. On 03/13/24 the evaluation was updated to show the resident was an unsafe smoker and had to be supervised because he would not turn in his smoking materials. Interview with Resident #12 on 03/14/24 at 8:12 A.M. denied the staff found any smoking materials in his possession. Interview with the DON on 03/14/24 at 8:15 A.M. revealed the facility found a lighter in Resident #12's possession on 03/13/24, and stated the resident probably got the lighter at the gas station down the street, because the DON sees the resident there on a regular basis. Review of policy titled, Smoking Policy, dated 10/17/23, revealed residents may smoke under limited circumstances outlined in this policy but only in a designated outside smoking area, if this facility has in its sole discretion, designated such an outdoor smoking area. Staff members will maintain all smoking paraphernalia for all unsafe and safe smokers, for example cigarettes, cigars, pipes, lighters, lighter fluid, or any other matter or substance that contains a tobacco product. Staff members will distribute smoking materials to residents that are unsafe to smoke at the designated smoking times, and to residents that are deemed safe to smoke and may smoke independently, at their request. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interviews, physician interview, review of the facility's Self-Reported Incident (SRI), review of the facility's elopement investigation, review of the police report, and facility policy review, the facility failed to provide adequate supervision of a severely cognitively impaired resident to prevent the resident from leaving the facility unsupervised. Actual Harm occurred to Resident #113 when she went unsupervised for approximately five hours, was found 0.4 miles from the facility by a Good Samaritan, which lead to being hospitalized and treated for a closed head injury, facial laceration with stitches, hematoma of face, left knee injury, and left hand injury. This affected one (Resident #113) of one resident reviewed for supervision. The facility census was 112. Findings include: Review of the medical record for Resident #113 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease with late onset, dementia with severe behavioral disturbance, hypertensive heart disease, anxiety disorder, and osteoarthritis. Review of the care plan dated 06/26/19 revealed Resident #113 was at risk for a decline in cognition and had impaired cognitive function or impaired thought processes to rule out dementia, impaired decision making, inability to recall current season, location of room, staff names and faces, placement in nursing home, long term memory loss, and short-term memory loss. The care plan with a revision date of 11/17/22 revealed Resident #113 required 24-hour care/long-term care (LTC) placement related to dementia and no family support. Interventions included to observe for risk/desire to elope. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 08/04/23, revealed Resident #113 had severe cognitive impairment and has no behavioral symptoms, no wandering indicated, and no rejection of care indicated. Resident #113 required supervision from staff for bed mobility, transfers, dressing, toilet use, and personal hygiene and was independent for walking in room, corridor and on and off unit. Resident #113 did not utilize a cane/crutch, walker, wheelchair, and/or limb prosthesis. Review of the progress notes, dated 08/27/23, revealed Resident #113 self-reported that she fell off the sidewalk curb while ambulating outside. She sustained a laceration to her left eyebrow with surrounding hematoma, a laceration to her left hand at the base of her pinky, and an abrasion to her left knee. She was transported to the emergency room (ER) for further evaluation and treatment. The progress note did not mention Resident #113 was not supervised and was unable to be located from 7:00 A.M. to 12:00 P.M. Review of the police report dated 08/27/23 revealed at 9:45 A.M., the caller (a Good Samaritan) reported a person (Resident #113) was found down at Bank #500 (which was 0.4 miles from the facility). The caller reported blood was everywhere, the person's eye was black, and the person was scared. Police and emergency services arrived on scene at 9:47 A.M. and subsequently transferred Resident #113 to the hospital. Review of the hospital notes dated 08/27/23 revealed Resident #113 was found down outside a bank that day (08/27/23) and arrived at the ER at 10:21 A.M. for evaluation and treatment. Resident #113 was a made a level two trauma given her age and obvious head injury and confusion. Resident #113 had no recollection of what happened. Resident #113 received seven stitches to the left hand, a hematoma and three stitches to the left eye, and a bruise and scabs on her left knee. On 08/28/23, Resident #113 was discharged from the hospital to the facility. Review of the progress note dated 08/28/23 at 1:00 P.M. revealed Resident #113 returned from the hospital at 12:35 P.M. Resident #113 had a bruise and stitch wound on the left eye measuring 2.5 centimeter (cm) by 0.2 cm with three stitches, a bruise and stitch wound on the left hand measuring 5.5 cm by 2.1 cm with seven stitches, and a bruise and scabs on the left knee. On 08/29/23 and 08/30/23, the progress notes mentioned status post fall monitoring. On 08/31/23, Resident #113 went to the ER due to status post fall on 08/27/23. She returned to the to the facility with injuries. A wander guard was placed for the resident's safety. Review of the facilities SRI control number 238548 revealed the facility submitted on SRI on 08/27/23 at 3:04 P.M. regarding an injury of unknown source origin. Resident #113 reported that she sustained these injuries after falling off the sidewalk. The Administrator and Director of Nursing (DON) interviewed all staff on day shift and all employees stated they did not witness the incident. Resident #113 had severe cognitive impairment and a diagnosis of severe dementia without behavioral disturbance. The facility unsubstantiated the allegation of injury of unknown origin. The injuries to the resident appeared consistent with a fall from standing onto her left side. Review of the facilities elopement investigation dated 08/27/23 revealed all day shift staff were interviewed and no staff had seen Resident #113 during their shift, which started at 7:00 A.M. Registered Nurse (RN) #289 noticed Resident #113's breakfast tray was not touched. RN #243 did not see her but realized Resident #113 did not come down to ask for her breakfast like she usually did around 10:30 to 11:00 A.M. State tested Nursing Assistant (STNA) #365 did not see Resident #113 at 7:00 A.M. and didn't realize she was missing until her breakfast tray was uneaten. STNA #360 did not recall seeing her at all in the morning. STNA #281 did not see Resident #113 walking the halls. The facility's investigation did not reveal what time the initial search for Resident #113 began inside the facility. The day shift staff reported they started to look for Resident #113 within the facility then notified the DON. The DON was notified by Licensed Practical Nurse (LPN) #240 on 08/27/23 at 12:02 P.M. that Resident #113 was missing. The DON initiated the search for Resident #113 following the facility's Elopement policy. Review of the facility's Incident and Accident Investigation Form dated 08/27/23 revealed Resident #113 was located at the address of Bank #500 on 08/27/23 at 9:47 A.M. Resident #113 walked out of the facility without an assistive device and was found down on the sidewalk bleeding from the left hand and left eye. Licensed Practical Nurse (LPN) #240 notified the Director of Nursing (DON) on 08/27/23 at 12:02 P.M. when Resident #113 was unable to be located in the facility. Interview with Administrator on 10/17/23 at 12:47 P.M. revealed he had placed the call to the police department on 08/27/23 sometime after 12:00 P.M. to find out if they had any information on the whereabouts of Resident #113. The police reported Resident # 113 was found at Bank #500 with injuries and was transported to the ER. With the knowledge of Resident #113's location, he updated staff, who were searching for Resident #113, and proceeded to go to the hospital to verify the status of Resident #113. A telephone interview with LPN #240 on 10/17/23 at 9:20 A.M. revealed LPN #240 was unable to locate Resident #113 for morning medication administration on 08/27/23 but could not recall the time she was unable to locate Resident #113. LPN #240 verified she did not see Resident #113 at the start of her shift at 7:00 A.M. A search was started for Resident #113, and she was unable to state the time, and was unable to be located. LPN #240 notified the DON to inform her Resident #113 was missing but was not able to recall the time she notified the DON. A telephone interview with STNA #228 on 10/17/23 at 9:54 A.M. revealed the staff began to be concerned for Resident #113's location on 08/27/23 when her breakfast was not eaten when clearing trays from breakfast. STNA #228 could not recall the time they identified Resident #113's location could not be determined. STNA #228 stated she did not see Resident #113 at the beginning of her shift, and confirmed she helped search for the missing resident, but again she was unsure of the time. Interview with the DON on 10/17/23 at 11:52 A.M, stated on 08/27/23, the DON began providing immediate education to all staff on shift after the search and subsequent location of Resident #113. An immediate investigation was started. The DON verified the facility failed to identify the length of time that Resident #113 was missing from the facility. Interview on 10/17/23 at 1:26 P.M. with Physician #417 verified Resident #113 always required supervision, required long-term care for severe cognitive deficits, and the inability to understand safety concerns of surrounding because of the progressive dementia diagnosis. Review of the facility's policy on Elopement, last revised on 04/26/22, revealed it is the policy of the facility to prevent to the extent reasonably possible, the elopement of guests/residents from the facility. The definition of elopement was defined when a guest/resident who needs supervision leaves a safe area without authorization and/or necessary supervision to do so. Rounds of all guests/residents are made at the beginning of the shift, at mealtimes, and at the end of the shift at a minimum by direct care staff and licensed nurses. Certified nursing assistant (CNA)/STNA or nurse can achieve this through the medication administration pass, mealtime passes, and during care rounds. The deficient practice was corrected on 08/29/23 when the facility implemented the following corrective actions: On 08/27/23, the DON and Administrator initiated an investigation of Resident #113's elopement from the facility. On 08/28/23, Resident #113 returned from the hospital. Resident #113 was assessed to be at risk for elopement and a wander guard was placed on Resident #113's right ankle for her safety. Resident #113's care plan was updated to reflect the resident's risk for elopement and a wander guard was implemented. On 08/28/23, all current resident's elopement evaluation scores were reviewed to identify any resident at risk for elopement. All residents who were identified at risk for elopement were audited to ensure the completion of the following items: the residents had the appropriate interventions for the risk of elopement, care plans were updated, a physician order for intervention(s), and had current information in elopement risk binders. This was completed by the DON/designee. On 08/28/23, all licensed nurses checked the residents who have a wander guard bracelet for placement and function. On 08/28/28, the DON/designee completed an in-service of the facility's elopement policy and procedures for all staff. All staff were educated on the frequency of visual checks of the residents. On 08/28/23, all alarmed doors were verified for functioning, alarm signaling with wander guard bracelets, and subsequently daily checks performed. On 08/29/23 at 2:15 P.M. and 9:00 P.M., the maintenance department completed elopement drills. No concerns were identified. On 08/29/23, the DON/designee will audit all new admissions and residents due for quarterly elopement evaluation completion and implementation of intervention applicable weekly for four weeks and report finding to the facility's Quality Assurance (QA) committee. This was an incidental finding discovered during the course of the complaint investigation.

Based on observation, record review, interview, and facility policy and procedure review, the facility failed to implement interventions to prevent the development of a pressure ulcer for Resident #10. Actual harm occurred on 05/13/22 when Resident #10, who was severely cognitively impaired, was identified to have a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling), pressure ulcer to the right heel. There was no evidence the facility had adequate interventions in place to prevent the development of the ulcer. The facility failed to ensure the pressure ulcer was timely identified prior to being found as a Stage III with slough (Non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed.) This affected one (Resident #10) of five residents reviewed for pressure ulcers. The facility census was 114. Findings Include: Review of Resident #10's medical record revealed an initial admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing comprehensive evaluation dated 12/30/21 revealed the resident was admitted to the facility with a small blister to the left elbow. Further review revealed the resident had no pressure ulcers upon admission to the facility. Review of the plan of care dated 12/30/21 revealed the resident was at risk for skin impairment related to weakness, decreased mobility, incontinence and use of assistive devices. Interventions included Braden scale per protocol, conduct weekly head-to-toe skin assessments, document and report abnormal findings to the physician, follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Braden scale dated 03/31/22 revealed a score of 14 indicating the resident was at moderate risk for skin breakdown. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech, sometimes understands others, and has a severe cognitive deficit. The resident required extensive assistance of one for bed mobility, transfers, toilet use and personal hygiene. The assessment indicated the resident was frequently incontinent of bladder and always incontinent of bowel. The resident was assessed as being at risk for skin breakdown and had no pressure ulcers/injuries but had moisture associated skin damage (MASD). The facility implemented the interventions pressure reducing device for bed and applications of ointments/medications other than to feet. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurses note dated 05/13/22 at 5:36 P.M. revealed the resident had moisture associated skin damage (MASD) measuring 2.0 centimeters (cm) by 2.0 cm by 0.1 cm to the coccyx and an open area was noted to the right heel measuring 1.5 cm by 2.0 cm by 0.1 cm. The nurses note had no staging or description of the wound. Review of the plan of care dated 05/16/22 revealed the resident had actual skin impairment related to Stage III pressure ulcer to the right heel. Interventions included conduct skin assessment weekly, measure and document weekly, consult wound clinic as ordered, follow resident at risk protocol, observe for signs of discomfort with dressing change and administer pain medication as ordered, observe for signs of infection, obtain laboratory results as ordered and report abnormal findings to physician, refer to dietitian as needed, refer to potential skin impairment care plan for skin interventions, treatment as ordered and when resident chooses not to reposition as often as needed, explain consequences and continue to attempt to get them to comply. Review of the medical record failed to provide a written assessment of the right heel wound until the contracted wound physician's progress note dated 05/17/22 revealed the resident had a Stage III pressure ulcer to the right heel measuring 1.4 cm by 1.3 cm by 0.2 cm. The wound was described as being 30% granulation tissue and 70% slough. The treatment implemented was to cleanse wound to right heel with wound cleanser, pat dry, apply [MEDICATION(S)] and cover with an abdominal (ABD) pad and wrap with Kerlix. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the weekly skin and wound evaluation dated 05/24/22 revealed the Stage III pressure ulcer to the right heel measured 0.2 cm by 0.5 cm by 0.6 cm 100% granulation tissue and light amount of exudate. Review of the weekly skin and wound evaluation dated 05/31/22 revealed the Stage III pressure ulcer to the right heel measured 2.8 cm by 1.5 cm by 0.3 cm 50% granulation tissue and 50% slough and light amount of exudate. Review of the weekly skin and wound evaluation dated 06/07/22 revealed the Stage III pressure ulcer to the right heel measured 1.1 cm by 1.4 cm by unable to determine (UTD) 10% granulation tissue and 90% slough and light amount of exudate. Review of the weekly skin and wound evaluation dated 06/14/22 revealed the Stage III pressure ulcer to the right heel measured 1.1 cm by 1.4 cm by UTD 10% granulation tissue and 90% slough, and light amount of exudate. Review of the weekly skin and wound evaluation dated 06/21/22 revealed the Stage III pressure ulcer to the right heel measured 1.1 cm by 0.7 cm by 0.5 cm 10% granulation tissue and 40% slough with [MEDICATION(S)] and moderate amount of exudate. Review of the weekly skin and wound evaluation dated 06/28/22 revealed the Stage III pressure ulcer to the right heel measured 1.1 cm by 0.9 cm by 1.2 cm 10% granulation tissue and 90% slough with [MEDICATION(S)] and moderate amount of exudate. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the weekly skin and wound evaluation dated 07/05/22 revealed the Stage III pressure ulcer to the right heel measured 0.8 cm by 0.7 cm by 0.6 cm 20% granulation tissue and 40% slough with a scab and light amount of exudate. Review of the weekly skin and wound evaluation dated 07/05/22 revealed the Stage III pressure ulcer to the right heel measured 0.9 cm by 0.5 cm by 0.3 cm 60% granulation tissue and 40% slough and light amount of exudate. On 07/13/22 at 10:50 A.M., observation of Licensed Practical Nurse (LPN) #788 and LPN #743 providing the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Both LPN's washed their hands and donned a pair of gloves. LPN #743 opened the boot and cut the soiled dressing from the resident's right foot. She then cleansed the wound with NS and a 4 X 4. She then changed her gloves without washing or sanitizing her hands and packed the wound with Mesalt, applied an ABD pad and wrapped his foot with Kerlix. On 07/13/22 at 2:59 P.M., interview with the Director of Nursing (DON) verified the resident's pressure ulcer was not found until a Stage III with slough and should have been found prior to the wound reaching a Stage III pressure ulcer. Review of the facility's policy titled, Skin Management, dated 07/14/22 revealed it is the policy that the facility should identify and implement interventions to prevent development of clinically avoidable pressure injuries.

Based on observations, record review, review of the facility's policy, and resident and staff interviews, the facility failed to ensure the environment was as free from accident hazards as possible for the residents on 300-hall. Actual Harm occurred on 03/14/22 when Resident #98 tripped on a broken floor tile in the hallway, twisted his ankle, and sustained a fracture to his right ankle. This affected one (Resident #98) of three residents reviewed for accidents. The facility identified 30 residents residing on the 300-hall. The facility census was 107. Findings include: Record review for Resident #98 revealed the resident was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)] ([CONDITION(S)]), [CONDITION(S)], displaced avulsion fracture of tuberosity of right calcaneus, and hypertensive heart disease. Review of the care plan, dated 09/09/21, revealed Resident #98 was at risk for falls related injury and falls due to weakness, decreased mobility, and use of [CONDITION(S)] medications. Interventions included to keep the resident's environment as safe as possible with even floors, free from spills and or clutter, adequate lighting, call light within reach, commonly used items within reach, avoid repositioning furniture, and keep the bed in the appropriate position. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/12/22, revealed Resident #98 had intact cognition. Resident #98 was assessed to require one person assist with mobility and toileting, setup supervision with transfer, not steady, but able to stabilize without staff assistance with balance during transition and walking. Review of the progress notes dated 03/14/22 revealed the physician saw Resident #98 due to a right ankle injury and wound dehiscence. Resident #98 reported three days ago he twisted his right ankle. Resident #98 stated his pain level was four out of 10 pain scale (zero was no pain and ten being the most severe pain) over his right lateral malleolus. Resident #98 was able to take a few steps on the ankle but stated it was painful. The plan was to order an x-ray of his right ankle that day. Review of the incident report dated 03/14/22 revealed Resident #98 was complaining of pain to his right ankle. Resident #98 self-reported the incident. Resident #98 was authorized to be at the location of the incident. It was not marked if there was any property or equipment involved. There was no statement from Resident #98 nor any other staff. The immediate intervention was for Resident #98 to be non-weight bearing and an orthopedic consult. Review of the x-ray report dated 03/15/22, revealed interval proximal posterior superior calcaneal avulsion distraction injury (type of fracture where the bone fragment is pulled away from its main body by soft tissue that is attached to it). Unchanged mild [CONDITION(S)]. Review of the physician's order dated 03/15/22, revealed Resident #98 was ordered a [NAME] boot (a foam lined brace to provide support and protection to the foot, ankle, or lower leg) for the right foot/ankle one time only for right calcaneal avulsion fracture for one month. Resident #98 was to be non-weight bearing of his right foot. Resident #98 needed an appointment made with Orthopedic physician as soon as possible, ortho consult for right heel possible re-fracture. Review of the progress notes dated 03/17/22 revealed the physician saw Resident #98 to follow-up with his x-ray from 03/15/22. The x-ray of his right ankle was visualized and interpreted by radiology as interval proximal posterior superior calcaneal avulsion injury. An appointment was made with his orthopedist, and Resident #98 was able to see the Orthopedic physician yesterday (03/16/22). A posterior short leg cast was placed. He was non-weightbearing currently. Resident #98 ha a follow-up appointment with the orthopedist on 04/06/22. He denied any other complaints and was resting comfortably in a chair in the therapy gym in no distress. Interview with Resident #98 on 03/21/22 at 2:08 P.M. revealed he was heading to therapy when he tripped on a broken tile on the hallway and twisted his right ankle. He revealed it did not bother him and he did not pay much attention to it at that moment. He further stated that he did not tell anyone about the incident until later when he started to feel the pain. He revealed the pain was unbearable that he told the physician when he saw him. He further revealed the physician ordered an x-ray to see what was going on. Resident #98 stated he now has broken ankle as result of that and will delay his plan to be discharged home. Resident #98 expressed concerns where there was tile missing in the hallway by his room. Resident #98 stated he was concerned for other residents because it was in the middle of the hallway, and it appeared to be getting worse. Resident #98 stated he talked with maintenance regarding the concern of the tile a few days ago. Observation on 03/21/22 at 2:08 P.M. of the hallway where Resident #98 confirmed he twisted his ankle revealed a broken and chipped off tile about the size of three tennis ball also showing dented bare ground. The broken and chipped off tile was located in the middle of the hallway, outside of Resident #98's room. Interview with the Unit Manager Licensed Practical Nurse (LPN) #820 on 03/21/22 at 2:15 P.M. stated Resident #98 told him that he twisted his ankle but did not tell him what happened or where it happened. LPN #820 denied asking any further questions to the circumstances surrounding Resident #98's incident. During the observation with Maintenance Supervisor (MS) #700 and measuring of the damaged floor on the 300-hall on 03/21/22 at 2:24 P.M. revealed the floor had missing tile measuring five and three-fourths centimeters (cm) by four and three and three fourths cm dent and uneven surface. Interview with MS #700 during the observation confirmed noticing the floor damaged for about four days ago but has not had the chance to fix it because he was busy with the electricity power outage problem the facility was having that day. MS #700 was not informed of the broken tile in the hallway and had not had any work order put for the damaged floor. MS #700 stated he noticed the damage last Thursday (03/17/22) and has not been able to fix it due to the planned power outage on 03/21/22. MS #700 stated the damage was caused by a water leak. MS #700 stated it would be an easy fix and could get it done in a few hours when the power was turned back on. Interview on 03/21/22 from 2:50 P.M. to 2:57 P.M. with Housekeeping Staff #430 and State tested Nursing Aide (STNA) #43 revealed they have seen the floor tile damage and stated they did not inform anyone. STNA #43 stated he noticed it over the weekend and Housekeeping Staff #430 stated it has been there for at least two weeks. Subsequent interview on 03/21/22 at 3:00 P.M. with the Unit Manager LPN #820 verified he did inform the DON about the damaged floor but did not know what the Director of Nursing (DON) did with the information. Unit Manager LPN #820 was unable to state how long the damaged floor has been that way, but the DON was aware of it. He also revealed Resident #98 did not informed him of the location of his incident and verified he did not ask Resident #98 about how he twisted his ankle. Unit Manager LPN #820 stated he did not complete an incident report for Resident #98. Unit Manager LPN #820 stated the DON completed the incident report for Resident #98. Interview on 03/21/22 at 3:18 P.M. with the DON revealed she has been aware of the damaged floor for at least a month. The DON stated that she had brought it up to corporate and in the Quality Assurance (QA) meeting that was held 02/25/22. The DON stated she even had a picture of the floor sent to the maintenance supervisor and asked if he has seen it and informed him of it being a tripping hazard. The DON stated she was not aware of the incident until after the physician had seen Resident #98, and that was when she spoke with the physician and was informed of the resident's twisted his ankle. She stated she informed Unit Manager LPN #820 to complete an incident report immediately. Review of the facility's policy titled Maintenance Department dated 08/17/21 revealed the department will do on-going monitoring of the facility for areas needing repair and, if needed, will report to the supervisor for approval of the repairs needed. This was an incidental finding during the course of the complaint investigation.

Based on medical record review, staff interview, review of the incident, review of the facility investigation, and review of the hospital records the facility failed to ensure residents were appropriately transferred according to the plan of care from the bed to the chair. This resulted in actual harm when State tested Nursing Assistant (STNA) #22 and STNA #36 failed to use the care planned transfer method of the mechanical lift and instead used a two person stand and pivot method for Resident #97 who sustained a fracture of the left lateral femoral condyle during the transfer. This affected one resident (#97) of three residents reviewed for transfers. The facility census was 95. Findings include: Review of the medical record for the Resident #97 revealed an admitted [DATE]. Diagnoses included end stage [CONDITION(S)], chronic heart failure, [CONDITION(S)], [CONDITION(S)], tremor, left femur fracture, fracture of prosthetic left knee joint, muscle weakness, dysphagia, [CONDITION(S)], [CONDITION(S)]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #97 was cognitively intact and required extensive assistance of two staff members and was totally dependent for transfers. Review of the plan of care dated 03/25/19 revealed Resident #97 had an activities of daily living (ADL) deficit and required assistance with ADLs and mobility. Transfer interventions included the use of two staff for transfers using the mechanical lift. Review of the progress notes dated 04/03/21 at 1:14 P.M. by the Physician Assistant revealed the resident had complained of knee and ankle pain after they were twisted when the aide was getting her out of bed for [CONDITION(S)]. It was reported from the nurse that Resident #97 had swelling around the knee. New orders were written for a STAT knee and ankle x-rays and pain medication. Review of the progress note dated 04/03/21 at 4:43 P.M. written by Licensed Practical Nurse (LPN) #52 revealed the x-ray results had been reviewed by the Physician Assistant and determined that Resident #97 had a fracture to the left knee and the left ankle and was being transferred to the hospital for further evaluation. Review of the progress note dated 04/03/21 at 4:58 PM by the Physician Assistant revealed being notified of the x-ray results, which revealed a left lateral femoral condylar fracture with lipohemarthrosis (a collection of fat and fluid (blood) within the joint usually following a trauma) and a possible [MEDICATION(S)] fracture of distal left tibial metaphysis. The resident was sent to the local hospital for immobilization and pain control. Review of the incident report dated 04/03/21 revealed STNA #22 and STNA #36 completed the transfer from the bed to the chair which caused the injury to the knee and the ankle of Resident #97. Review of the facility investigation report revealed statements were obtained. STNA #22s incident statement revealed he had not worked with Resident #97 often, however the last time was about two months prior and a mechanical lift was not used. STNA #22 revealed that Resident #97 reported pain in her knee during the transfer but was not crying. STNA #36s incident statement revealed STNA #22 requested assistance with care and was informed by STNA #22 that Resident #97 was a two person assist for transfers. STNA #36 reported the transfer method had not been verified prior to transferring the resident. Review of the hospital record orthopedic surgery consult dated 04/03/21 revealed Resident #97 was diagnosed with a periprosthetic distal femur fracture after a twisting injury during a transfer from the bed to the wheelchair. The hospital records revealed the resident reported getting tangled up and having immediate pain to the left knee which radiated to the ankle. No obvious fracture was found at the ankle. The physical exam from the orthopedic surgeon found the left knee to be mildly swollen laterally with diffuse [CONDITION(S)] from the knee to the ankle with tenderness to the touch. Interview on 05/04/21 at 7:50 A.M., with STNA #36 revealed that she was assisting STNA#22 with a resident transfer around 5:30 A.M. STNA#36 admitted she had not checked the care plan and mobility assistance requirements before assisting STNA #22 with the resident's transfer. STNA #36 revealed that she was not aware of any injury to Resident #97 until she received a call that afternoon after she left work. Interview on 05/03/21 at 11:58 A.M., LPN #65 revealed that typically STNA's complete resident transfers however they will help when needed. LPN #65 verified training occurred during new hire orientation, however, was unsure of the last time she attended a training regarding resident transfers. Interview on 05/03/21 at 12:25 P.M., STNA #29 also revealed that training occurred at new hire orientation and denied any recent training regarding resident transfers. STNA #29 denied participating in trainings that occurred after the incident with Resident #97. Interview on 05/03/21 at 1:44 P.M., the Director of Nursing revealed that when Resident #97 returned from [CONDITION(S)], she complained of pain of her left knee. The DON revealed that on 04/03/21 when getting Resident #97 ready for [CONDITION(S)] transportation, two STNA's transferred her from the bed to the wheelchair using a stand and pivot two person assist method. The DON revealed that STNA #22 was the assigned aid and was unaware she required a mechanical lift device for transfers. The DON verified that STNA #22 and STNA #36 failed to review care plan for transfers requirements. The DON reported that an investigation took place and both STNA 22 and STNA #36 were suspended and retrained on proper policy and procedures. DON confirmed that daughter was notified by both bedside RN and DON with updates on the incident and subsequent transfer to the hospital on 04/03/21. Interview on 05/04/21 at 10:48 A.M., the LPN #60 revealed the facility had not completed training for the nurses in the last month regarding safe resident transfers and about the use of the care plan. LPN #60 reviewed the training log attendance records and verified she was not listed in attendance. Interview on 05/04/21 at 11:00 A.M., the STNA #18 revealed that the facility provided enough staffing for staff to be able to review the care needs before providing care. STNA #18 also revealed that she has completed training in the past for safe transfers of residents but was uncertain of specific date of this training. STNA #18 reviewed the training log attendance records and verified she was not listed in attendance. Interview on 05/04/21 at 11:57 A.M., the Registered Nurse (RN) 356 revealed that RN's would assist with transfers when requested. RN #56 reported that the facility may have offered training on safe transfers in the last 6 months including mechanical lift, sit to stand, and two person assist, but denied any recent training in the last month covering safe transfers of residents and regarding use of the care plan. During a follow-up interview on 05/04/21 at 2:04 P.M., the DON verified not all staff were trained and had been working on the floor providing direct care for residents. The expectation was for the staff to be trained on the use of the care plan and transfers after the incident with Resident #97. Interview on 05/05/21 at 11:17 A.M., STNA #22 verified he had not checked the care plan before transferring Resident #97 from her bed to the wheelchair on 04/03/21. STNA #22 further reported that he had not worked with this resident often and the last time he transferred her she was a two-person assist. STNA #22 reported that Resident #97 complained of pain in her knee after the transfer but her vital signs were normal and she had asked for her coat and purse to take to [CONDITION(S)] so he thought she was fine to go to [CONDITION(S)]. This deficiency substantiates complaint number OH 028.

AMENDED 12/11/18 Based on clinical record review, hospital record review, staff interview, laboratory staff interview, review of State tested Nurse Aide documentation, review of the laboratory contract, and policy review, the facility failed to obtain physical assessments and obtain physician ordered immediate (STAT) laboratory testing during a change in health condition for one resident (#112). This resulted in actual harm for one resident (#112) when the resident had a change in condition exhibited as weakness and change of mental status, was not assessed by the nursing staff, physician orders [REDACTED]. The resident was transferred to the local hospital for decreased blood pressure, decreased level of consciousness and admitted with a critical high white blood count (WBC) and septic shock. Three residents were reviewed for change of condition. The facility census was 111. Findings included: Record review revealed Resident #112 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 09/06/18, revealed he had intact cognition, trouble falling asleep, no behaviors, required supervision or set up for all activities of daily living (ADL), was occasionally incontinent, had shortness of breath, and took opioids every day. Review of the nurse notes dated 10/22/18 revealed Resident #112 was sent to the local emergency room for [MEDICAL CONDITION] (decreased oxygen levels) and decreased level of consciousness. He returned on 10/24/18 on the antibiotic [MEDICATION NAME] for a upper respiratory infection. Review of the State tested Nursing Assistant (STNA) task documentation dated 11/02/18 revealed Resident #112 was independent with care. On 11/03/18 the resident required assistance from staff for eating, drinking and toileting. Review of the physician order [REDACTED].M. revealed an order was obtained for a chemistry seven and a complete blood count (CBC) laboratory (lab) test to be obtained STAT. Review of the nurse notes dated 11/03/18 at 6:48 P.M., revealed STAT chemistry seven and CBC labs were being drawn. At 10:19 P.M., the note read the basic metabolic profile (BMP), which was interchangeable for the chemistry seven, results were in and the facility was still waiting on the CBC. There was no evidence an assessment was completed of the resident's condition at the time of the physician order, when his ability to complete ADLs declined, or during any intervals for the remainder of 11/03/18. Review of the nurse notes on 11/04/18 at 8:06 A.M. documented Resident #112 continued on antibiotic therapy, continued to decline with ADLs, and required asssistance of one or two staff with various needs. Fluids were encouraged and pushed. The resident had no chest pain or shortness of breath noted. There was no evidence a physical assessment of the resident was completed. Review of the nurse notes on 11/04/18 at 5:20 P.M. documented the contracted laboratory was contacted by the facility, there was a issue with the CBC, and the lab failed to notify the facility of the sample hemolyzing and being unusable. The lab indicated they reordered the STAT CBC and it would be obtained yet on 11/04/18. At 10:00 P.M., the laboratory staff attempted to draw the CBC. After three attempts they were unable to obtain and it was rescheduled for the next day. The notes contain no evidence an assessment of Resident #112's physical condition was obtained or the physician was made aware of the inability to obtain the CBC. Review of the STNA task documentation dated 11/04/18 revealed Resident #112 was totally dependent on staff for eating, drinking and toileting. Review of the nurse notes on 11/05/18 at 2:00 A.M. documented Resident #112 was sent to the local emergency room for [MEDICAL CONDITION], altered mental status and decreased level of consciousness. Review of the change in condition form dated 11/05/18 at 2:00 A.M., revealed the resident had low blood pressure of 57/52 millimeters of mercury (mmHg), decreased level of consciousness, altered mental status and lethargy. The on call physician was notified and he was sent to the local emergency room . Review of the hospital records dated 11/05/18 revealed Resident #112 was admitted to the hospital for septic shock and had a critical high WBC of 24.17 thousand per microliter (K/mcl) where the normal range was 4.50-11.00 K/mcl. Interview on 11/20/18 at 10:00 A.M., STNA #208 stated she took care of Resident #112. Before his decline he was independent with all areas of ADLs. STNA #208 stated the weekend of 11/03/18 and 11/04/18 on the day shift, the resident was not himself. She knew something was wrong as he was out of it, reaching for and talking to people who were not there. The resident was urinating all over himself and kept trying to get up. His hands were cold and he was sweating. STNA #208 said she reported these findings to Licensed Practical Nurse (LPN) #205 at least three times. STNA #208 observed the LPN go into the room but did not know what she had done. Interview on 11/20/18 at 11:53 A.M., the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) #204 stated they were unaware of the laboratory not completing the CBC for Resident #112. They verified there were several assessments not documented for the resident, including the original change of condition on 11/03/18 when the lab tests were order by the on call physician. They verified there was no evidence the on call physician was notified of the laboratory tests not being completed. They would expect the nurses to assess and have continued ongoing monitoring of the resident when there is a change in their condition. Interview on 11/20/18 at 12:28 P.M., Laboratory Supervisor #210 stated they received the requisition to draw a CBC and a BMP STAT on 11/03/18. Since it was a Saturday they would have been required to call the facility with the results. The results of the BMP were faxed to the facility on [DATE] at 8:13 P.M. There was no documentation to support the laboratory staff contacted the facility and spoke to the nursing staff of the failure to obtain the CBC. On 11/04/18 they attempted to redraw the CBC, however it was unable to be obtained. Interview on 11/20/18 at 1:06 P.M., LPN #206 stated he kept asking for the CBC results and the lab kept faxing over the BMP results. He finally called the lab on the evening of 11/04/18 and spoke to Laboratory Representative #211 who told him after searching for the results and calling the local hospital where all STAT orders are dropped, the sample hemolyzed and they were unable to run the test for the CBC. LPN #206 indicated the lab failed to notify the facility of this and they sent someone to redraw the CBC stat on 11/04/18, but were unable to obtain the sample for the test. Interview on 11/20/18 at 3:11 P.M., Certified Nurse Practitioner (CNP) #209 stated Resident #112's WBC level on 11/05/18 at the hospital was very high. It meant the antibiotic was not working or something else was going on with the resident's health. CNP #209 stated if he had been on call during the weekend Resident #112 became ill he would have sent him immediately. He also stated he would have expected to be notified if the laboratory tests were not obtained in order to allow him to decide on the next course of action. One of the options may have been to transport the resident to the hospital to have the lab test obtained. Also there should have been supporting documentation to give a clinical impression of the resident. CNP #209 indicated there was no supporting documentation of the change in his condition as to why the STAT tests were ordered. Interview on 11/20/18 at 3:47 P.M., STNA #212 stated she worked the afternoon shift on 11/03/18 and 11/04/18. She said Resident #112 required more assistance, he was very weak, tired and urinating all over himself, which was unusual. Review of the policy titled Lab System Protocol, dated (MONTH) 2005, documented the facility must establish and maintain a procedure, in conjunction with the facility's contract lab, which facilitates and ensures timely compliance with physicians' lab orders. Review of the Nursing Facility Laboratory Agreement contract effective date 03/01/17 documented they provided STAT (life threatening situation) service 24 hours per day, 365 days per year. Laboratory STAT testing will be reported within five hours. The menu of available STAT tests included CBC and BMP. Critical and STAT results will be phoned to the facility when they are available. STAT testing and other testing ordered at special times will be ordered with extreme discretion and only when medically necessary. This deficiency substantiates allegations contained in Complaint OH 074.

AMENDED 12/11/18 Based on clinical record review, hospital record review, staff interview, laboratory staff interview, review of State tested Nurse Aide documentation, review of the laboratory contract, and policy review, the facility failed to obtain physician ordered immediate (STAT) laboratory testing during a change in health condition for one resident (#112). This resulted in actual harm for one resident (#112) when the resident had a change in condition exhibited as weakness and change of mental status and physician orders [REDACTED]. The resident was transferred to the local hospital for decreased blood pressure, decreased level of consciousness and admitted with a critical high white blood count (WBC) and septic shock. Three residents were reviewed for obtaining laboratory tests. The facility census was 111. Findings included: Record review revealed Resident #112 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 09/06/18, revealed he had intact cognition, trouble falling asleep, no behaviors, required supervision or set up for all activities of daily living (ADL), was occasionally incontinent, had shortness of breath, and took opioids every day. Review of the nurse notes dated 10/22/18 revealed Resident #112 was sent to the local emergency room for [MEDICAL CONDITION] (decreased oxygen levels) and decreased level of consciousness. He returned on 10/24/18 on the antibiotic [MEDICATION NAME] for a upper respiratory infection. Review of the State tested Nursing Assistant (STNA) task documentation dated 11/02/18 revealed Resident #112 was independent with care. On 11/03/18 the resident required assistance from staff for eating, drinking and toileting. Review of the physician order [REDACTED].M. revealed an order was obtained for a chemistry seven and a complete blood count (CBC) laboratory (lab) test to be obtained STAT. Review of the nurse notes dated 11/03/18 at 6:48 P.M., revealed STAT chemistry seven and CBC labs were being drawn. At 10:19 P.M., the note read the basic metabolic profile (BMP), which was interchangeable for the chemistry seven, results were in and the facility was still waiting on the CBC. There was no evidence an assessment was completed of the resident's condition at the time of the physician order, when his ability to complete ADLs declined, or during any intervals for the remainder of 11/03/18. Review of the nurse notes on 11/04/18 at 8:06 A.M. documented Resident #112 continued on antibiotic therapy, continued to decline with ADLs, and required asssistance of one or two staff with various needs. Fluids were encouraged and pushed. The resident had no chest pain or shortness of breath noted. There was no evidence a physical assessment of the resident was completed. Review of the nurse notes on 11/04/18 at 5:20 P.M. documented the contracted laboratory was contacted by the facility, there was a issue with the CBC, and the lab failed to notify the facility of the sample hemolyzing and being unusable. The lab indicated they reordered the STAT CBC and it would be obtained yet on 11/04/18. At 10:00 P.M., the laboratory staff attempted to draw the CBC. After three attempts they were unable to obtain and it was rescheduled for the next day. The notes contain no evidence an assessment of Resident #112's physical condition was obtained or the physician was made aware of the inability to obtain the CBC. Review of the STNA task documentation dated 11/04/18 revealed Resident #112 was totally dependent on staff for eating, drinking and toileting. Review of the nurse notes on 11/05/18 at 2:00 A.M. documented Resident #112 was sent to the local emergency room for [MEDICAL CONDITION], altered mental status and decreased level of consciousness. Review of the change in condition form dated 11/05/18 at 2:00 A.M., revealed the resident had low blood pressure of 57/52 millimeters of mercury (mmHg), decreased level of consciousness, altered mental status and lethargy. The on call physician was notified and he was sent to the local emergency room . Review of the hospital records dated 11/05/18 revealed Resident #112 was admitted to the hospital for septic shock and had a critical high WBC of 24.17 thousand per microliter (K/mcl) where the normal range was 4.50-11.00 K/mcl. Interview on 11/20/18 at 10:00 A.M., STNA #208 stated she took care of Resident #112. Before his decline he was independent with all areas of ADLs. STNA #208 stated the weekend of 11/03/18 and 11/04/18 on the day shift, the resident was not himself. She knew something was wrong as he was out of it, reaching for and talking to people who were not there. The resident was urinating all over himself and kept trying to get up. His hands were cold and he was sweating. STNA #208 said she reported these findings to Licensed Practical Nurse (LPN) #205 at least three times. STNA #208 observed the LPN go into the room but did not know what she had done. Interview on 11/20/18 at 11:53 A.M., the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) #204 stated they were unaware of the laboratory not completing the CBC for Resident #112. They verified there were several assessments not documented for the resident, including the original change of condition on 11/03/18 when the lab tests were order by the on call physician. They verified there was no evidence the on call physician was notified of the laboratory tests not being completed. They would expect the nurses to assess and have continued ongoing monitoring of the resident when there is a change in their condition. Interview on 11/20/18 at 12:28 P.M., Laboratory Supervisor #210 stated they received the requisition to draw a CBC and a BMP STAT on 11/03/18. Since it was a Saturday they would have been required to call the facility with the results. The results of the BMP were faxed to the facility on [DATE] at 8:13 P.M. There was no documentation to support the laboratory staff contacted the facility and spoke to the nursing staff of the failure to obtain the CBC. On 11/04/18 they attempted to redraw the CBC, however it was unable to be obtained. Interview on 11/20/18 at 1:06 P.M., LPN #206 stated he kept asking for the CBC results and the lab kept faxing over the BMP results. He finally called the lab on the evening of 11/04/18 and spoke to Laboratory Representative #211 who told him after searching for the results and calling the local hospital where all STAT orders are dropped, the sample hemolyzed and they were unable to run the test for the CBC. LPN #206 indicated the lab failed to notify the facility of this and they sent someone to redraw the CBC stat on 11/04/18, but were unable to obtain the sample for the test. Interview on 11/20/18 at 3:11 P.M., Certified Nurse Practitioner (CNP) #209 stated Resident #112's WBC level on 11/05/18 at the hospital was very high. It meant the antibiotic was not working or something else was going on with the resident's health. CNP #209 stated if he had been on call during the weekend Resident #112 became ill he would have sent him immediately. He also stated he would have expected to be notified if the laboratory tests were not obtained in order to allow him to decide on the next course of action. One of the options may have been to transport the resident to the hospital to have the lab test obtained. Also there should have been supporting documentation to give a clinical impression of the resident. CNP #209 indicated there was no supporting documentation of the change in his condition as to why the STAT tests were ordered. Interview on 11/20/18 at 3:47 P.M., STNA #212 stated she worked the afternoon shift on 11/03/18 and 11/04/18. She said Resident #112 required more assistance, he was very weak, tired and urinating all over himself, which was unusual. Review of the policy titled Lab System Protocol, dated (MONTH) 2005, documented the facility must establish and maintain a procedure, in conjunction with the facility's contract lab, which facilitates and ensures timely compliance with physicians' lab orders. Review of the Nursing Facility Laboratory Agreement contract effective date 03/01/17 documented they provided STAT (life threatening situation) service 24 hours per day, 365 days per year. Laboratory STAT testing will be reported within five hours. The menu of available STAT tests included CBC and BMP. Critical and STAT results will be phoned to the facility when they are available. STAT testing and other testing ordered at special times will be ordered with extreme discretion and only when medically necessary. This deficiency substantiates allegations contained in Complaint OH 074.

Based on observation, record review, staff and family interview, and facility policy review, the facility failed to prevent falls and implement interventions after a fall for one resident. Harm occurred when Resident #259, who was admitted with a traumatic brain injury (TBI), had an unwitnessed second fall with head injury. This affected one (Resident #259) of three residents reviewed for falls. The facility also failed to maintain a safe environment by leaving medications at Resident #256's bedside. This had the potential to affect twelve cognitively impaired residents that are ambulatory. Facility census was 109. Findings include: 1. Review of the clinical record for Resident #259 revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital discharge paperwork for Resident #259, dated 10/23/14, revealed he sustained a bilateral subdural hematoma and sub-arachnoid hemorrhage from a fall at home on 09/26/14. He subsequently developed delirium in the hospital, and medical causes were ruled out, so the delirium was thought to be caused by the traumatic brain injury sustained during the fall in the shower. Review of the Nursing Admission Assessment, dated 10/29/14, revealed a score of 27 on the fall risk assessment, with any score 10 or above indicating a fall risk. The assessment revealed Resident #259 had intermittent confusion, one or more falls in the past three months, poor vision, no behaviors, one or two predisposing diseases, balance problems while walking and standing, and changes in gait while walking through the door. Review of the admission orders [REDACTED]. Review of the interim care plan related to falls/safety precautions, dated 10/29/14, revealed interventions including evaluate for unsteady gait, orthostatic hypotension precautions, ambulation devices as necessary, instruct guest on appropriate safety measures, observe cognitive status for ability to ask assistance, observe guest footwear for fit and non-skid soles, a sensor alarm, mat to bedside, bed against the wall, low bed, and deep perimeter mattress. The interim care plan related to restraints was also marked and included interventions to refer to behavior management program, release/reposition every two hours, and keep call light and personal articles in easy reach. The specific type of restraint was absent from the care plan. Review of the physician progress notes [REDACTED]. Depakote, a mood stabilizing medication, was ordered. The Certified Nurse Practitioner (CNP) note, dated 10/31/14, revealed Resident #259 had a fall that morning out of the bed onto the mat and staff denied head trauma and the resident's Seroquel was weaned. No new interventions were noted related to the fall. The next CNP note revealed the resident was not assessed again until 11/04/14, at which time staff reported the resident was not sleeping at night, and the resident's wife wanted the Seroquel discontinued. The CNP weaned the Seroquel and ordered melatonin for insomnia. The resident was noted to make attempts to get out of the wheelchair. No new fall interventions were ordered. Review of the physician note, dated 11/06/14, revealed the Resident #259 was taken off the Depakote, which was noted to have been started for delusions. A recent fall with right eyelid laceration was noted, and fall precautions were ordered. Review of the treatment administration record revealed orders for a bed mat to the floor, a sensor alarm to the bed and chair at all times, and a low bed were ordered on [DATE]. All four interventions were marked as not completed on 10/31/14 night shift. Orders for bilateral half side rails and a concave mattress to the bed were ordered on [DATE]. Review of the nursing notes from 10/29/14 thorough current revealed no fall was documented on 10/31/14. The notes revealed Resident #259 attempted to get up out of bed and out of the wheelchair unassisted on multiple occasions. A note dated 11/01/14 at 8:00 A.M. revealed Resident #259 was found on the floor that morning at 5:45 A.M., bleeding from his left eyebrow. He was drowsy and neuro checks were started. The on-call CNP was contacted and instructed staff to place the resident on bed rest and continue neurological checks. The nurses note revealed "guest was placed on special mattress that will make it difficult for him to get out of bed". Review of the facility's fall investigation, which was a quality assurance document, related to the fall on 10/31/14, revealed Resident #259 fell out of bed at 6:15 A.M. onto the floor mat. The investigation was not complete and did not indicate if the fall was witnessed or not. At 11/05/14 at 4:45 P.M., the Corporate Registered Nurse (RN) #161 confirmed no interventions were put into place after the fall on 10/31/14. Review of the facility's fall investigation related to the fall on 11/01/14, the morning after the previous fall, revealed Resident #259 fell out of bed at 6:15 A.M. onto the floor during an attempted transfer. He was not using an assistive device and there was one nurse and one aide working the unit at the time. It stated the alarm was in use, but did not indicate if it was alarming or not. The report revealed restraints and side rails were not in use and that the guest was not compliant with alarm use. The report revealed the lighting was adequate, the wheelchair or bed was locked, and the call light was off. The report revealed the bed was adjustable, but did not indicate if it was up or down. This post-fall report was completed on 11/4/14, after surveyor request for the document. The Director of Nursing (DON) confirmed the report was completed after it was requested by the surveyor on 11/04/14 at 3:55 P.M. Review of the clinical record for assessments on 11/03/14 revealed no restraint assessments. Restraint assessments were provided on 11/05/14 by the facility for Resident #259. The restraint evaluation for the deep perimeter mattress, dated 10/31/14, the day before it was put on the resident's bed and five days prior to the order, revealed the guest does not understand safety with standing or transfer, and that occurs constantly at all times. The form noted the resident's Depakote was added and Seroquel was decreased, and since those changes the resident had experienced falls. Interventions attempted were individualized toileting program, medication review, and therapy evaluation. The form states all interventions listed were attempted, although only three of 13 were attempted. The evaluation revealed the resident could attempt to stand, attempt to sit on the edge of the bed, and could do those things with the device that he could do without it. The form assessed the deep perimeter mattress as an enabler, not a restraint. The low bed, bed to wall, and bilateral half side rails were assessed on 11/04/14 as enablers. On 11/04/14 at 9:32 A.M., an observation of Resident #259 in his room revealed he had a bandage above his right eyebrow and bruises on both forearms, along with dressings to both upper forearms. He was unable to keep his eyes open, and was slurring his words, unable to answer any questions. On 11/04/14 at 4:25 P.M., an observation revealed Resident #259 in his wheelchair in the hall, near the nurse medication cart. He was attempting to stand up from his wheelchair. The wheelchair brakes were not locked and the foot pedals were down. On two attempts to stand the wheelchair rolled backwards and the resident sat back down. On the third attempt, he was able to stand upright. A maintenance man grabbed his wheelchair to prevent it from rolling while RN #86 grabbed onto Resident #259's arm. A chair alarm was noted in the wheelchair and did not alarm when the resident rose. Approximately 30 seconds later the alarm sounded. RN #86 confirmed the delay in alarm. On 11/05/14 at 10:00 A.M., an observation revealed Resident #259 in bed asleep, with all the lights in the room out. Additional observations at 11:18 A.M., 11:58 A.M., and 2:15 P.M. revealed Resident #254 still in bed asleep, in the dark. On 11/05/14 at 2:42 P.M., an observation of Resident #259 revealed he was very difficult to wake up and would not respond to nursing staff trying to get him up in the wheelchair. At 3:15 P.M., during an interview with the resident's wife, he began to lift his arms as if to pick things out of the air. His wife revealed he had been having that behavior since he was admitted to the facility. She revealed he had been very sleepy since admission to the facility, and had not been so when he was at the hospital prior to admission. During this interview, the wife asked Licensed Practical Nurse (LPN) #104 to get Resident #259 up to walk. Despite repeated attempts at rising to a sitting position on his own, the resident was unable to lift his legs over the side of the mattress. LPN #104 had to physically lift Resident #259's legs up and over the perimeter of the mattress, and then the resident was able to rise to a seated position and attempted to stand. LPN #104 confirmed at this time that the resident could not get his legs over the mattress. On 11/06/14 at 11:11 A.M., an interview with Physician #162 revealed he was just notified of the injury related to fall on 11/01/14. He stated that a head injury would be something he would expect staff to call and notify him with. Review of the facility's "Fall Awareness Program" policy, dated 10/10, revealed each fall will be assessed by completing the post-fall evaluation and the incident/accident policy will be followed. The policy states care plans will be reviewed with appropriate update of interventions within 24 to 72 hours of each new occurrence. The "Fall Risk Assessment" policy, dated 04/02, revealed that interventions to prevent falls should be immediately established for those guests identified to be at risk. 2. Review of Resident #256's medical record revealed an admission date of [DATE] [DIAGNOSES REDACTED]. Further review of medical record revealed a physician's order for Senokot S two tablets twice a day. Observation on 11/03/14 at 2:45 P.M. of Resident # 256's room revealed two brown colored medications in a medication (med) cup on Resident #256's beside table. Resident #256 stated that the medications were her stool softeners from last night and she did not take them. Interview on 11/03/14 at 3:25 P.M. with Registered Nurse (RN) #160 verified that Resident #256 had two brown colored tablets at bedside. RN #160 confirmed that the medications were plain Senokot. RN #160 stated that he gave Senokot S this morning and verified that Senokot S is an orange colored tablet. Review of the facility policy titled "Medication Administration", dated July 2009, revealed the procedure is to remain with the guest while administering oral medications to verify their consumption.

Based on observations, record review, staff and family interview, the facility failed to ensure one resident was free from unnecessary medication. Harm occurred when Resident #259 was given double the ordered dose of [MEDICATION NAME], a mood stabilizing medication, sustained two falls, one with a head injury, and experienced a decline in level of consciousness since admission from the hospital. This affected one (Resident #259) of five residents reviewed for unnecessary medications. The facility census was 109. Findings include: Review of the clinical record for Resident #259 revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital discharge paperwork, dated 10/29/14, revealed Resident #259 was assessed as alert and oriented to person, place, and time. He was assessed as walking occasionally with minimal assistant, being full weight bearing, and using a two-wheeled walker. He was noted to be receiving [MEDICATION NAME], an antipsychotic, related to acute [MEDICAL CONDITION] in the hospital. The recommendation was to continue his once a day dose and continue non-pharmacological interventions to reduce [MEDICAL CONDITION], such as frequent re-orientations, a sun-lit room, and minimizing narcotics and deliriogenic medications. The hospital recommended a medication review of the [MEDICATION NAME] on 10/31/14. Review of the physician orders [REDACTED]. Review revealed an order to begin [MEDICATION NAME], a mood stabilizing medication, at 500 mg twice a day. Review revealed a physician order, dated 10/31/14, for a decrease in [MEDICATION NAME] to 250 mg twice a day. This order was signed off by the physician but not the nursing staff. [MEDICATION NAME]'s side effects include [MEDICAL CONDITION], headache, asthenia (abnormal lack of energy), and feeling nervous. [MEDICATION NAME]'s precautions include that the elderly may require dosage reduction because of somnolence, reduced nutritional intake and weight loss. An order to decrease the [MEDICATION NAME] to 12.5 mg was noted on 11/03/14. Review of the electronic Medication Administration Record [REDACTED]. This was signed as administered by nursing staff twice a day from 10/31/14 through 11/03/14. However, a physician order, dated 10/31/14, decreased the [MEDICATION NAME] to 250 mg twice a day. The Medication Administration Record [REDACTED]. Review of the clinical record on 11/04/14 revealed Resident #259 had two falls in the seven days since admission, both occurring since the initiation of the [MEDICATION NAME]. Review of the Skilled Nursing Assessments revealed on 10/29/14 at 7:21 P.M., 10/30/14 at 11:16 A.M. and 6:31 P.M., 11/01/14 at 12:45 P.M. and 7:01 P.M., 11/02/14 at 1:19 P.M. and 7:50 P.M., 11/03/14 at 10:16 P.M., and 11/05/14 at 2:10 P.M. Resident #259 slept all night, with attempts to get up from the bed or wheelchair unassisted noted four times. The assessments revealed on 10/31/14 at 11:32 A.M., 11/04/14 at 1:20 P.M., and 11/06/14 at 6:36 A.M. revealed Resident #259 slept intermittently and attempted to get out of bed without assistance. The assessments revealed on 11/03/14 at 4:08 P.M. and 11/05/14 at 8:02 P.M. revealed Resident #259 was awake all night and on 11/03/14 attempted to stand without assistance. No other behaviors were noted. All nursing notes revealed the resident was confused, alert, and only oriented to person. Review of the unit behavioral log revealed no behavior tracking was being completed for Resident #259. Review of the physician orders [REDACTED]. Additionally, an order dated 10/30/14 revealed a basic metabolic panel was ordered to be completed 11/03/14. Review of the clinical record revealed these laboratory tests were not completed as ordered for Resident #259. A note dated 11/01/14 at 8:00 A.M. revealed Resident #259 was found on the floor that morning at 5:45 A.M., bleeding from his left eyebrow. He was drowsy and neuro checks were started. On 11/04/14 at 8:17 A.M., an interview with the Director of Nursing (DON) confirmed the physician order [REDACTED]. She verified Resident #259 had received double the ordered dosage seven times over four days. On 11/04/14 at 9:32 A.M., an observation of Resident #259 in his room revealed he had a bandage above his right eyebrow and bruises on both forearms, along with dressings to both upper forearms. He was unable to keep his eyes open, and was slurring his words. On 11/04/14 at 2:41 P.M., an observation of Resident #259 revealed he was in his wheelchair by the nurses' station. He was unable to keep his eyes open, and leaned forward in the wheelchair twice before the nurse asked an aide to take him and lay him down. On 11/05/14 at 10:00 A.M., an observation revealed Resident #259 in bed asleep, with all the lights in the room out. Additional observations at 11:18 A.M., 11:58 A.M., and 2:15 P.M. revealed Resident #254 still in bed asleep, in the dark. On 11/05/14 at 2:42 P.M., an observation of Resident #259 revealed he was very difficult to wake up and would not respond to nursing staff trying to get him up in the wheelchair. At 3:15 P.M., during an interview with the resident's wife, he began to lift his arms as if to pick things out of the air. His wife revealed he had been having that behavior since he was admitted to the facility. She revealed he had been very sleepy since admission to the facility, and had not been so when he was at the hospital prior to admission. On 11/05/14 at 6:06 P.M., an interview with Resident #259 revealed he was "so tired" and just wanted to go back to sleep. Review of the basic metabolic panel results, added to the blood draw on 11/06/14 at 9:28 A.M., revealed Resident #259 had a high BUN of 152 milligrams/deciliter (mg/dL), with normal range being 8-24 mg/dL, and a high creatinine of 2.6 mg/dL, with normal range being 0.3-1.4 mg/dL. As a result, the physician ordered an intravenous line be placed and intravenous fluids were started related to acute kidney injury. The kidneys act to filter out toxins from the body, which includes medications. If the kidneys are not functioning properly, as evidenced by increased BUN and creatinine, the medication the resident has taken can build up in the body. On 11/06/14 at 9:01 A.M., the DON confirmed the basic metabolic panel had not been obtained as ordered, and was missed again when the labs ordered 10/31/14 were drawn late. At 1:27 P.M. she verified Resident #259 was receiving intravenous fluids related to high laboratory values, indicative of decreased kidney function.

Based on record review and staff interview, the facility failed to ensure two residents were free from significant medication errors. This affected one (Resident #259) of five residents reviewed for unnecessary medications and one (Resident #254) of one resident reviewed for infections. This resulted in harm for Resident #259 when he received double the ordered dose of [MEDICATION NAME], experienced a declined in level of consciousness and sustained a fall with a head injury. Facility census was 109. Findings include: 1. Review of the clinical record for Resident #259 revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review revealed a physician order, dated 10/31/14, for a decrease in [MEDICATION NAME] to 250 mg twice a day. This order was signed off by the physician but not the nursing staff. [MEDICATION NAME]'s side effects include [MEDICAL CONDITION], headache, asthenia (abnormal lack of energy), and feeling nervous. [MEDICATION NAME]'s precautions include that the elderly may require dosage reduction because of somnolence, reduced nutritional intake and weight loss. Review of the electronic Medication Administration Record [REDACTED]. This was signed as administered by nursing staff twice a day from 10/31/14 through 11/03/14. However, a physician order, dated 10/31/14, decreased the [MEDICATION NAME] to 250 mg twice a day. The Medication Administration Record [REDACTED]. On 11/04/14 at 9:32 A.M., an observation of Resident #259 in his room revealed he had a bandage above his right eyebrow and bruises on both forearms, along with dressings to both upper forearms. He was unable to keep his eyes open, and was slurring his words. On 11/05/14 at 10:00 A.M., an observation revealed Resident #259 in bed asleep, with all the lights in the room out. Additional observations at 11:18 A.M., 11:58 A.M., and 2:15 P.M. revealed Resident #254 still in bed asleep, in the dark. On 11/05/14 at 2:42 P.M., an observation of Resident #259 revealed he was very difficult to wake up and would not respond to nursing staff trying to get him up in the wheelchair. At 3:15 P.M., during an interview with the resident's wife, he began to lift his arms as if to pick things out of the air. His wife revealed he had been having that behavior since he was admitted to the facility. She revealed he had been very sleepy since admission to the facility, and had not been so when he was at the hospital prior to admission. On 11/04/14 at 8:17 A.M., an interview with the Director of Nursing (DON) confirmed the physician order [REDACTED]. She verified Resident #259 had received double the ordered dosage seven times over four days. 2. Review of the clinical record for Resident #254 revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. diff), [MEDICAL CONDITIONS], hypertension, and diabetes mellitus. Review of the hospital admission paperwork, dated 10/22/14, revealed Resident #254 was prescribed [MEDICATION NAME], an antibiotic, to treat his [DIAGNOSES REDACTED] infection, with a 14 day treatment course to be completed on 11/05/14. Antibiotic treatment should be completed as ordered, as the infection may not completely go away if not completed. Review of the physician orders [REDACTED]. The last dose was to be given on 11/05/14 at 12:00 P.M. Review of the electronic Medication Administration Record [REDACTED].M. and 1:00 P.M. and on 11/03/14 at 9:00 A.M. and 1:00 P.M. On 10/31/14 at 9:36 A.M., the nurse noted pharmacy was called and the medication would be drop shipped and given when sent. On 10/31/14 at 12:21 P.M., the nurse noted the medication will be given when sent. On 11/03/14 at 8:32 A.M. the nurse noted the medication will be given when sent. On 11/03/14 at 1:08 P.M., the nurse noted the pharmacy would send the medication in the afternoon. The four missed doses were out of 16 ordered doses, meaning one quarter of the [MEDICATION NAME] doses were missed and not administered. On 11/06/14 at 1:21 P.M., the DON and Corporate Registered Nurse (RN) #161 revealed they were unaware of the missed doses of [MEDICATION NAME] for Resident #254. They confirmed a quarter of the ordered doses were not given with no documentation as to if they were given at a later time. At 1:36 P.M., a follow up interview with the DON and RN #161 verified the antibiotic was not given four times, as verified by the nurses who held the doses.