Every finding on record at Laurels of West Columbus, The

Based on staff interviews, policy review, and record review, the facility failed to ensure a resident who was dependent on staff assistance with showers received routine showers. This affected one (#64) of three residents reviewed for activities of daily living (ADL). The facility census was 88.Findings include: Review of Resident #64's medical record revealed the resident was admitted on [DATE]. Diagnoses included type II diabetes mellitus with chronic kidney disease, chronic obstructive pulmonary disease, heart failure, and osteoarthritis.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 had intact cognition and required partial to moderate assistance from staff with showering and bathing.Review of the care plan revised 06/14/26 revealed Resident #64 has a functional ability deficit and required assistance with self-care and mobility.Review of Resident #64's Documentation of Survey Report dated from 05/01/26 through 06/30/26 revealed the resident's showers were scheduled for Tuesday and Friday nights. There were no showers documented as completed on 05/08/26, 05/15/26, 05/19/26, 05/22/26, 05/26/26, 06/02/26, 06/09/26, 06/16/26, and 06/19/26. During this review period, only one additional shower was documented as completed on 06/06/26 (Saturday).Interview on 07/22/26 at 3:15 P.M. with the Administrator and Director of Nursing (DON) confirmed no showers were documented as completed on 05/08/26, 05/15/26, 05/19/26, 05/22/26, 05/26/26, 06/02/26, 06/09/26, 06/16/26, and 06/19/26. The DON and Administrator stated they would investigate the documentation of shower completion for Resident #64. Interview on 07/22/26 at 4:35 P.M. with the Administrator confirmed the facility had no documentation of completed showers for the above-mentioned dates.Review of facility policy titled PM Care Policy dated 11/05/25 revealed nursing staff will offer evening/PM care to residents to promote personal hygiene, comfort, relaxation, and safety.This deficiency represents non-compliance investigated under Complaint Numbers 3040492 and 3049605.

Based on observation and staff interviews, the facility failed to ensure bags of enteral nutrition product and water for tube feeding were labeled and dated appropriately for Residents #56 and #79. This affected two (#56 and #79) of two residents in the facility with active orders for tube feeding. The facility census was 79.Findings include:1. Review of the medical record for Resident #56 revealed the resident was admitted to the facility on [DATE] with diagnoses that included type two diabetes mellitus, adult failure to thrive, mild protein-calorie malnutrition, and gastrostomy status (a gastrostomy is a surgical opening in the abdominal wall, often for the use of a feeding tube). Further review of the medical record for Resident #56 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Additional review of Resident #56's medical record revealed physician orders for a nothing by mouth diet, with an enteral (tube) feeding order for Osmolite 1.2 to start daily in the evenings at 6:00 P.M. and run at 100 milliliters (mL) per hour for 14 hours with flushes of water through the feeding tube running at 40 mL per hour. Resident #56 also had an active order for enhanced barrier precautions related to enteral feedings.Observations on 04/08/26 at 6:16 P.M. revealed two full bags, one of enteral nutrition and one bag of water hanging on a pole next to Resident #56's bedside, with lines attached to both bags though not hooked up to the resident. Observation revealed the enteral nutrition formula was not hung on the pole in its original packaging, rather the formula appeared to have been poured into an unlabeled plastic bag used for tube feeding. The feeding tube pump was not running. Observation revealed neither bag was labeled at all, including no label or marking available to indicate the date/time the water and tube feed formula was poured into the bags, and no label marked on the bag of tube feeding formula to indicate which type of tube feeding formula was in the bag, nor was there any marking to indicate the amount of formula to be administered per hour or over a set amount of time to reflect the rate ordered by the physician. Further observation at this time revealed the door to resident #56's room was marked with an enhanced barrier precautions sign and personal protective equipment (PPE) was available outside the door.Observation on 04/08/26 at 6:26 P.M. revealed Licensed Practical Nurse (LPN) #101 entered Resident #56's room to start the 6:00 P.M. tube feeding. Further observation at this time revealed LPN #101 accessed Resident #56's feeding tube and then proceeded to flush the feeding tube using a syringe of water and then connecting the unlabeled bags of tube feeding formula and water to the resident's gastrostomy site.Observation on 04/08/26 at 6:28 P.M. revealed LPN #101 had started the tube feeding pump without labeling or date-marking the enteral nutrition formula or the water being used in the tube feeding.Observation on 04/08/26 at 6:30 P.M. revealed LPN #101 started to walk out of Resident #56's room and stated, thank you, see you in the morning, to Resident #56, while the tube feeding was running and there was still no date or time marked on either the water or the enteral nutrition bag.Interview on 04/08/26 at 6:30 P.M. with LPN #101 revealed bags of enteral nutrition and bags of water used for tube feeding should both be labeled with the date and time the bags were prepared. Further interview with LPN #101 at this time verified neither of the bags being used for Resident #56's tube feeding were properly labeled. 2. Review of the medical record for Resident #79 revealed the resident was admitted to the facility on [DATE] and had diagnoses that included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting the right dominant side, dysphagia (difficulty swallowing) following cerebral infarction, unspecified protein-calorie malnutrition, and gastrostomy amongst other diagnoses. Further review of Resident #79's medical record revealed the resident had a BIMS score of 12 indicating moderate cognitive impairment. Additional review of Resident #79's medical record revealed physician orders pertinent to their tube feeding included Glucerna 1.5 at 55 mL per hour continuously running through a feeding tube, with 50 cubic centimeters (cc) of water to flush through the feeding tube every hour. Resident #79's medical record also contained an order to change the tube feeding bag and tubing every night shift, and instructions that read must put name, date, time, amount per hour on new bag/bottle. This also applies to water.Observation on 04/08/26 at 5:50 P.M. at Resident #79's bedside revealed the bag of water hung next to the enteral nutrition bag was not labeled with date/time while actively running and flushing the tube feeding line for Resident #79.Interview on 04/08/26 at 6:40 P.M. with Registered Nurse (RN) #134 verified the bag of water that was actively running and flushing the tube feeding line for Resident #79 was not labeled with the date and time of preparation. Further interview with RN #134 revealed the bag of water is usually prepared at the same time as the bag of enteral nutrition formula (which was labeled with date/time) but each individual bag should still be labeled with time and date of preparation. Additional interview with RN #134 revealed they did not prepare the bag of water, but they believed it was likely prepared at the same time as the enteral nutrition formula, which was labeled 0600 04/08/26.This deficiency represents non-compliance investigated under Complaint Number 2795632.

Based on observation, staff interviews, and review of facility policy regarding enhanced barrier precautions, the facility failed to ensure infection control protocols were followed during the use of a tube feeding device for Resident #56. This affected one (#56) of two residents reviewed for tube feeding infection control. The facility census was 79.Review of the medical record for Resident #56 revealed the resident was admitted to the facility on [DATE] with diagnoses that included type two diabetes mellitus, adult failure to thrive, mild protein-calorie malnutrition, and gastrostomy status (a gastrostomy is a surgical opening in the abdominal wall, often for the use of a feeding tube). Further review of the medical record for Resident #56 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Additional review of Resident #56's medical record revealed physician orders for a nothing by mouth diet, with an enteral (tube) feeding order for Osmolite 1.2 to start daily in the evenings at 6:00 P.M. and run at 100 milliliters (mL) per hour for 14 hours with flushes of water through the feeding tube running at 40 mL per hour. Resident #56 also had an active order for enhanced barrier precautions related to enteral feedings.Observation on 04/08/26 at 6:26 P.M. revealed Licensed Practical Nurse (LPN) #101 entered Resident #56's room to start the 6:00 P.M. tube feeding. Further observation at this time revealed LPN #101 washed their hands and donned gloves, but they did not don a gown prior to accessing Resident #56's feeding tube and then proceeding to flush the feeding tube using a syringe of water and then connecting the unlabeled bags of tube feeding formula and water to the resident's gastrostomy site.Interview on 04/08/26 at 6:32 P.M. with LPN #101 revealed they don't typically wear a gown while providing care such as starting a tube feeding pump, working with a tube feeding line, or administering medications through a resident's tube feeding site. Further interview at this time revealed LPN #101 was not aware that the enhanced barrier precautions signage on Resident #56's door directed staff to wear a gown and gloves while providing high contact resident care services, such as using a feeding tube. Review of the facility policy titled Enhanced Barrier Precautions (EBP), last revised 03/05/25 revealed enhanced barrier precautions are indicated for residents with a wound or indwelling medical device, even if the resident is not known to be infected or colonized with a multi drug resistant organism (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 places them at higher risk. Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheotomies. Further review of this policy revealed health care personnel caring for residents on Enhanced Precautions should wear gloves and gowns during high contact resident care, and examples of high contact resident care activities requiring glove and gown use include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator), and wound care: chronic wounds.

Based on medical record review, staff interview, resident family interview, and review of self-reported incidents, the facility failed to conduct an investigation and report an allegation of potential neglect related to a resident elopement to the State Survey Agency. This affected one (#94) of three residents reviewed for elopements. The census was 89.Findings include:Review of the medical record for Resident #94 revealed an admission date of 08/29/25. Diagnoses included senile degeneration of the brain, chronic kidney disease, hypertension, diabetes, and heart failure.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 had impaired cognition. The resident was assessed as independent for ambulation. Review of the nursing notes dated 09/05/25 at 3:26 P.M. revealed on that date, a staff member reported seeing a resident (#94) in her power wheelchair outside of a pizza restaurant down the street from the facility. Staff located the resident on [NAME] Road and escorted her back to the facility by 2:08 P.M. Resident #94 was assessed with no visible injuries but appeared confused and indicated she was trying to find her son's house and got lost. Further review revealed earlier the resident asked staff to remove her oxygen so she could go outside to smoke, and was last seen near the facility around 1:00 P.M.During an interview with Certified Nurse Aide (CNA) #164 on 10/05/25 at 3:17 P.M. confirmed she was off duty on 09/05/25 and was running errands about a mile away from the facility. She noticed Resident #94 riding away on her electric scooter from the facility. CNA #164 stated she called the facility staff to report the sighting of Resident #94 and the facility staff admitted to not realizing Resident #94 was outside the facility.Interview on 10/15/25 between 11:30 A.M. and 4:00 P.M. with three staff members who were working at the facility on 09/05/25 (Maintenance Director #136, Receptionist #119, and Licensed Practical Nurse (LPN) #179) all confirmed Resident #94 was found by staff about a mile from the facility on the afternoon of 09/05/25, and she appeared confused. During an interview with LPN #179 at 3:34 P.M. on 10/15/25, she stated she was not aware Resident #94 was outside of the facility prior to receiving the telephone call from CNA #164. She also confirmed Resident #94 had not signed herself out of the facility that day to notify the nursing staff that was leaving.During an interview with Resident #94's Family Member on 10/15/25 at 5:21 P.M., confirmed she was notified by the facility of Resident #94's elopement from the facility on 09/05/25. She confirmed Resident #94 had dementia and when Resident #94 was found by facility staff, the resident did not know where she was.Review of self-reported incidents submitted to the State Survey Agency from September and October 2025 revealed no submissions related to potential allegations of neglect regarding Resident #94's elopement from the facility on 09/05/25. No documentation was provided related to an investigation into the elopement.The elopement investigation file and the self-reported incident information were requested from the facility staff during the complaint investigation on 10/15/25 and 10/16/25. Interview on 10/15/25 at 2:40 P.M. with Regional Leader #800 confirmed a formal investigation did not commence regarding Resident #94's elopement and the incident was not reported to the State Survey Agency. Regional Leader #800 stated it was not reported because to his knowledge because Resident #94 had taken a temporary leave of absence from the facility by signing herself out at the nurses' station.This deficiency represents non-compliance investigated under Complaint Number 2642442.

Based on medical record review, staff interview, and facility policy review, the facility failed to provide residents and representatives with discharge summaries to ensure a safe and orderly discharge from the facility. This affected one (#92) of three residents reviewed for discharge. The census was 89.Findings Include:Review of Resident #92's medical record revealed the resident was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Review of Resident #92's progress notes dated 09/27/25 revealed her son came to the facility and stated he wanted to take his mother home. The note revealed the nurse told her son he would need to sign against medical advice (AMA) documents prior to taking Resident #92 home. Further review revealed there was nothing else listed in the progress note about Resident #92 leaving the facility to go home. The note also revealed a nurse practitioner was made aware of the AMA decision. Review of Resident #92's progress note dated 09/28/25 revealed Resident #92 was in her wheelchair, in a taxi to leave, but there was no information to support Resident #92 was actually discharged from the facility. Review of Resident #92's medical documents found no documentation to support required discharge information, including a discharge summary, was offered or sent with Resident #92 or her family, and there was no documentation to support the facility attempted to have Resident #92 or her family sign any AMA documents. Interview with Licensed Practical Nurse (LPN) #129 on 10/16/25 at 2:15 P.M. confirmed there was no documentation to support a safe and orderly discharge was completed for Resident #92. She confirmed there should have been documentation to support a discharge summary was reviewed prior to leaving. Review of a facility transfer and discharge policy, dated 2025, revealed the transfer and discharge process must provide sufficient preparation and orientation of residents to ensure a safe and orderly transfer or discharge from the facility. The contents of the notice must have the reason for the transfer or discharge, the effective date of transfer or discharge, the specific location to which the resident is transferred or discharged , a statement of the resident's appeal rights, and the contact name, address, and telephone number of the ombudsman. When an anticipated discharge is scheduled, the post discharge plan of care and summary is developed prior to his or her discharge. Social services/designee will review the plan with the resident and, with consent, the resident's representative, at least 24 hours prior to discharge or as soon as practicable of the resident's discharge from the facility. Nursing is to document the discharge or transfer in the progress note. This deficiency represented non-compliance investigated under Complaint Number 2622442.

Based on medical record review and staff interview, the facility failed to ensure treatments for care of spine incisions were completed as ordered. This affected one (#91) of three residents reviewed for treatments. The census was 89.Findings Include:Review of the medical record revealed Resident #91 was admitted to the facility on [DATE]. Diagnoses included infection and inflammatory reaction, fusion of the spine, chronic obstructive pulmonary disease, alcohol dependence, atherosclerotic heart disease, congestive heart failure, hypertensive heart disease, presence of coronary angioplasty implant and graft, hyperlipidemia, anemia, hypo-osmolality and hyponatremia, depression, cardiomyopathy, and other seizures. Review of Resident #91's Minimum Data Set (MDS) assessment, dated 09/19/25, revealed the resident was cognitively intact.Review of Resident #91 After Visit Summary dated 09/17/25 revealed instructions to check his cervical spine incision daily for redness or drainage. Further review revealed the resident needed to keep the wound covered with a Medipore island dressing to be changed daily or as needed. Also, for the Jackson Pratt (JP) drain (a thin, flexible tube with a bulb on the end that drains fluid away from a wound after surgery), basic care was instructed as cleaning around the tube exit site daily.Review of Resident #91 treatment administration records (TAR), dated September 2025, revealed an order for staff to cleanse his incision to the cervical spine with normal saline and patted dry then apply a conventional compress dressing (CCD) to the site. The treatment was to be completed daily. Also for Resident #91's JP drain site, it was to be cleansed with normal saline and patted dry then apply a sponge to site. This was to be completed daily. Both of these treatments were ordered and entered into Resident #91's medical record to be completed starting 09/20/25. Further review revealed Resident #91 was discharged from the facility on 09/19/25, so for the entirety of his stay, 09/17/25 to 09/19/25, he did not have either treatment/dressing change completed.Interview with Licensed Practical Nurse (LPN) #129 on 10/16/25 at 2:15 P.M. confirmed the orders for the treatments listed above for Resident #91 should have been in place and completed at the time he was admitted , but were not completed, and confirmed she was not sure why the orders were not confirmed at the time of admission and put in place to be completed.This deficiency represented non-compliance investigated under Complaint Number 2622442 and continued non-compliance from the survey dated 09/08/25 .

Based on medical record review, staff interview, and policy review, the facility failed to ensure residents were free from significant medication errors. This effected one (#93) of three residents reviewed for medication administration. The facility census was 89.Findings include:Record review for Resident #93 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, dysphagia, orthostatic hypertension, and chronic heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #93 had intact cognition and was assessed to require self-care assistance.Review of physician orders for Resident #93 revealed medication orders including three furosemide (Lasix) 20 milligram (mg) oral tablets once daily, ordered on 09/27/25 and discontinued 09/30/25 for a diuretic. In addition, there was an order for one furosemide 80 mg oral tablet once daily, beginning 09/29/25 and discontinued 10/06/25.Review of the September 2025 medication administration record (MAR) for Resident #93 revealed that both orders of furosemide (three 20 mg tablets and one 80 mg tablet) were administered on 09/29/25 and 09/30/25.During an interview with Medical Director #1 (Resident #93's physician) on 10/16/25 at 1:48 P.M. confirmed the order for three furosemide 20mg oral tablets once daily should have been discontinued on 09/29/25, when the second order (one furosemide 80mg oral tablet once daily) was initiated on 09/29/25. Medical Director #1 stated Resident #93 should have received 80 mg of furosemide per day, and not 140 mg total, which she received on 09/29/25 and 09/30/25 and confirmed the resident received the additional doses of the medication on 09/29/25 and 09/30/25.Review of the facility policy titled, Medication Administration, revised 10/17/23, revealed medications are to be administered in accordance with the orders of the attending physician.This deficiency represents non-compliance investigated under Complaint Number 2642442.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, staff interview, Power of Attorney (POA) interview, closed medical record review, review of a facility submitted Self-Reported Incident (SRI), review of hospital records and review of the facility policy, the facility failed to ensure Resident #83, who had a diagnosis of dementia, had a previous elopement attempt from the facility, and had a Wanderguard (wearable bracelet that triggers alarms at the doors to alert when a resident attempts to exit) applied to his left ankle, did not elope from the facility without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury and/or death when on 08/03/25 Resident #83 was able to exit the facility through an unknown facility door and staff reported they did not hear the door alarms sound. Resident #83 was subsequently found lying in the local hospital parking lot, approximately one mile from the facility, by the hospital security staff. The resident was missing for an undetermined length of time and facility staff were unaware the resident was missing until the hospital staff called to notify them that the resident was in their emergency department (ED). This affected one (#83) of three residents reviewed for elopement. The facility identified three (#83, #52 and #84) residents at risk for elopement. The facility census was 79. On 08/21/25 at 2:46 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 08/03/25 when Resident #83 was able to exit the facility at an unconfirmed time during the early morning hours, through locked doors, without the door alarms sounding, and without staff knowledge. The facility did not have camera surveillance to verify which door the resident exited through or how the resident was able to elope without the door alarms sounding. Licensed Practical Nurse (LPN) #326 stated she believed she last saw Resident #83 at approximately 4:00 A.M. Resident #83 traveled with his walker down a four to five lane road with posted speed limits of 40 miles per hour (MPH) that was under construction and had manhole covers protruding from the ground. The local hospital ED staff contacted the facility at approximately 5:30 A.M., after the resident was found lying in their parking lot by their security staff. Although the Immediate Jeopardy was removed on 08/04/25, 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) until the deficient practice was corrected on 08/18/25 when the facility implemented the following corrective actions: On 08/03/25 at 8:00 A.M., Resident #83 returned to the facility. Licensed Practical Nurse (LPN) #303 assessed the resident and no new injuries were identified. On 08/03/25, Unit Manager (UM) #307 reassessed Resident #83's elopement risk and identified the resident at high risk for elopement. UM #307 reviewed Resident #83's care plan to ensure the accuracy of the resident's needs and interventions. On 08/03/25, UM #307 reassessed all residents for elopement risk and updated care plans as needed. Evidence was received verifying elopement risk assessments were completed and care plans were updated, as needed, on 08/03/25. On 08/03/25, Resident #83 was placed on one-to-one (1:1) staff supervision. The resident remained on 1:1 staff supervision until 08/13/25, when he discharged to another facility with a secured memory care unit. On 08/03/25 at 8:30 A.M., the Administrator performed a Root Cause Analysis and determined staff failed to provide adequate supervision to prevent Resident #83's elopement. Staff working at the time of the incident stated they did not hear the door alarm and did not see the resident exit the facility. On 08/03/25 at 9:00 A.M., Director of Maintenance (DOM) #331 checked all current residents (#52, #83, and #84) with Wanderguards for placement and functionality, with no negative findings. Evidence was received verifying this was completed on 08/03/25. On 08/03/25, DOM #331 checked all 11 of the facility's egress doors to ensure Wanderguard door alarms were operational, with no negative findings. Evidence was received verifying this was completed on 08/03/25. On 08/03/25, DOM #331 changed the access codes for all of the facility's egress doors. Evidence was received verifying this was completed on 08/03/25. On 08/03/25, the Administrator or designee conducted an elopement drill on each of the facility's two shifts, with no negative findings. DOM #331 or designee will continue to conduct elopement drills one-time weekly on each shift for four weeks. Any concerns will be addressed immediately. Evidence was received verifying elopement drills were completed on 08/03/25 on first and second shift, 08/09/25 on first and second shift, and 08/13/25 on first and second shift. Beginning on 08/03/25 and completed by 08/04/25, the Administrator or designee provided education to all staff on the facility's elopement policy, specifically the alarm activation procedure, code search investigation procedure (missing resident procedure), and control of the egress door codes to ensure non-employees do not have access to the door codes. Evidence was received verifying education was completed by 08/04/25. Beginning on 08/03/25, DOM #331 or designee will audit all egress doors daily, Monday through Friday, to ensure functionality of the Wanderguard alarms. This will be part of daily routine maintenance. Evidence was received verifying audits were completed daily on 08/03/25, 08/04/25, 08/05/25, 08/06/25, 08/07/25, 08/08/25, 08/09/25, 08/10/25, 08/11/25, 08/12/25, 08/13/25, 08/14/25, 08/15/25, 08/16/25, 08/17/25 and 08/18/25. Beginning on 08/03/25, the DON or designee will audit elopement risk assessments for all new admissions weekly for four weeks to ensure accuracy. Evidence was received verifying all new admissions and readmissions were audited for accuracy of elopement risk assessments from 08/03/25 through 08/18/25. On 08/04/25, an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review Resident #83's elopement and the corrective action implemented. In attendance were the DON, the Administrator, Assistant Director of Nursing (ADON) #300, UM #324, Maintenance #325, Transportation #327, UM #307, Housekeeping Supervisor (HS) #380, Human Resources (HR) #349, DOM #331, Medical Director (MD) #800, Social Services (SS) #409, SS #388, Director of Admissions (DA) #378, Registered Nurse Minimum Data Set (RNMDS) #348, RNMDS #349, and Activities Director (AD) #355. Beginning on 08/04/25, the Interdisciplinary team (IDT) consisting of the Administrator, the DON, ADON #300, UM #324, UM #307, RNMDS #348, RNMDS #349, SS #409, SS #388, and Therapy Director (TD) #600, will audit all incidents for a significant change Monday through Friday, to ensure appropriate assessments are completed and accurate, and care plans are updated as needed. Evidence was received verifying monitoring was completed Monday through Friday on 8/04/25, 08/05/25, 08/06/25, 08/07/25, 08/08/25, 08/11/25, 08/12/25, 08/13/25, 08/14/25, 08/15/25, 08/18/25. Review of one (#84) additional closed resident medical record and one (#52) open resident medical record, reviewed for elopement, revealed no additional concerns. Findings include: Review of a facility submitted SRI, completed on 08/08/25, revealed on 08/03/25, a local hospital contacted the facility at approximately 5:30 A.M. stating that Resident #83 was found in their parking lot. The resident was evaluated in the ED, with no injury, and returned to the facility on [DATE]. Resident #83 had a Wanderguard in place prior to the event and upon return to the facility. Facility staff were interviewed and stated they heard no door alarms sound and did not see the resident exit the facility. Review of Resident #83's closed medical record revealed an admission date of 06/04/25. Diagnoses included acute respiratory failure, paroxysmal atrial fibrillation, anemia, dementia, major depression, osteitis deformans unspecified bone, glaucoma, and insomnia. Resident #83 discharged on 08/13/25 to a facility with a secured memory care unit. Review of the elopement risk assessment, dated 07/18/25, revealed Resident #83 had an elopement risk score of 10, indicating the resident was not at risk for elopement. Resident #83 was noted to be cognitively impaired and did not wander. Review of the significant change Minimum Data Set (MDS) assessment, dated 07/23/25, revealed Resident #83 had a Brief Interview of Mental Status (BIMS) score of 01, indicating the resident was severely cognitively impaired. The MDS indicated Resident #83 had behaviors of wandering. Resident #83 had functional limitations with range of motion on both lower extremities, one side upper extremity, and utilized a walker for ambulation. Review of the plan of care revealed a focus area was initiated on 07/24/25 that Resident #83 was at risk for exit seeking due to disorientation to place, impaired safety awareness, and wandered aimlessly. Interventions included to apply Wanderguard and check placement, function and expiration date per facility protocol; approach in a slow, calm manner and redirect away from exit doors; and distract the resident when wandering into inappropriate areas by offering pleasant diversions, structured activities, food, and conversations. On 08/03/25, Resident #83's care plan was revised to include 1:1 (staff supervision). Review of hospital documents, dated 08/03/25, revealed Resident #83 arrived at the ED at 5:24 A.M. to be evaluated after being found by security lying on the ground in the hospital parking lot from a fall. The resident stated that he walked very far today and was very tired and fatigued. Resident #83 stated he was discharged from a nursing home yesterday afternoon and did not want to be home alone because his wife was out of town. Nursing staff subsequently knew the resident's name and that he was a resident of a local nursing care facility. Nursing staff were able to reach the facility where the resident resided, and they stated that they were unaware the resident left the facility. Upon arrival, the resident had complaints of right-side rib and shoulder pain and denied head injury. A computed tomography (CT) scan was completed, showing acute/subacute fracture deformities of the lateral right sixth through ninth ribs. Resident #83 discharged with family back to the facility with no new orders. Review of facility document titled, Incident and Accident Investigation Form, dated 08/03/25 at 6:30 A.M., revealed that Resident #83 was at a local hospital ED. The hospital contacted the facility and reported that Resident #83 was found in the parking lot of the hospital. The facility staff were interviewed and reported providing care and assistance to the resident at approximately 4:30 A.M. Staff stated that the door alarm did not sound to alert them that the resident left out of an exit door of the facility. Resident #83's Wanderguard was in place and was checked for function, with no concerns. The hospital contacted the resident's family. Review of the facility elopement risk assessment, dated 08/03/25, revealed Resident #83 had elopement risk of 13, indicating the resident was at risk for elopement and exhibited wandering behavior. Review of a nursing progress note, dated 08/04/25 and authored by LPN #601, revealed she placed an identification (ID) band on Resident #83's left wrist. Resident #83 had a skin tear to the left elbow. The resident denied pain. Resident #83's right shoulder was seen with nonpitting edema (swelling that does not leave an indentation when pressure is applied to the area), only when moved. Resident #83 had nonpitting edema to the right elbow. Bruises were found from the right forearm to above the elbow and the resident stated he had pain when he extended his arm. Resident #83's right hip had a purple bruise over a previous surgical scar. The resident's wife was present in the room and aware. Observation on 08/20/25 at approximately 8:00 A.M. revealed the area surrounding the facility and the local hospital included four to five lane roads with posted speed limits of 40 MPH. The roads were under construction, with the pavement scraped and manhole covers protruding from the road. Interview on 08/20/25 at 2:00 P.M. with Certified Nursing Assistant (CNA) #320 revealed Resident #83 eloped during the night approximately two weeks ago. CNA #320 stated all of the staff had different stories about what happened, with one saying the door alarm was going off because of their food being delivered and another one said the resident had been checked on and there was no way he got out. CNA #320 stated Resident #83 got hurt while he was out of the facility and had a bruised rib. Interview on 08/20/25 at 2:47 P.M. with the Administrator revealed Resident #83 eloped from the facility on the morning of 08/03/25. At 5:30 A.M., the local hospital called and spoke with LPN #326 and notified her that the resident was in the ED after being found in their parking lot. The Administrator stated the resident was evaluated in the ED and returned to the facility by 8:00 A.M. The Administrator stated LPN #326 last saw the resident around 4:30 A.M. A follow-up interview on 08/20/25 at 3:30 P.M. with the Administrator revealed she interviewed all of the staff who worked the night/early morning hours of 08/03/25, when Resident #83 eloped, and each denied the door alarm sounded during the hours in which the resident could have possibly eloped. The Administrator stated she educated staff on not giving the door access code to residents who smoked. The Administrator was uncertain of the exact time that the resident left the facility or how he was able to exit through the door. The Administrator stated both LPN #326 and CNA #400 stated the resident was last seen in the facility around 4:30 A.M. The Administrator reported Resident #83 discharged to a facility with a secured memory care unit on 08/13/25. Interview on 08/21/25 at 6:37 A.M. with LPN #357 revealed some residents knew the access codes to exit the facility because staff gave it to them so they could go outside and smoke. Interview on 08/21/25 at 6:49 A.M. with CNA #343 revealed she provided 1:1 staff supervision for Resident #83 after he returned to the facility from the hospital on [DATE]. CNA #343 stated the resident kept repeating that someone had picked him up in a car and dropped him off at the hospital. CNA #343 stated that when she provided care for the resident, he complained that his ribs hurt from some accident he had, and he had bruises all over his abdomen. Interview on 08/21/25 at 6:53 A.M. with LPN #346 revealed she did not work on 08/03/25. LPN #346 stated that Resident #83 was confused, alert to self, and ambulated with a walker. LPN #346 stated Resident #83 did not sleep and moved around all night. LPN #346 stated Resident #83 started looking for coffee every day at 5:00 A.M. Interview on 08/21/25 at 7:02 A.M. with CNA #402 revealed she worked on 08/03/25. CNA #402 stated Resident #83 had very bad sundowners (increased confusion and restlessness beginning in the late afternoon/early evening) and would pace around the facility. CNA #402 stated she last saw Resident #83 around 4:00 A.M. on the morning that he eloped. Interview on 08/21/25 at 7:22 A.M. with CNA #329 revealed she worked on the skilled care unit on 08/03/25 and was not assigned to provide care for Resident #83. CNA #329 denied she heard the doors alarm during her shift. CNA #329 stated that sometimes residents who were alert were given the door code to enter and exit the facility, or the residents remembered the code from watching staff enter it. Interview on 08/21/25 at 8:09 A.M. with CNA #403 revealed she did not remember anything from 08/03/25. CNA #403 denied providing care for Resident #83 on the night of 08/02/25 into the morning of 08/03/25. Interview 08/21/25 at 8:45 A.M. with Resident #83's Power of Attorney (POA) revealed she received a phone call from the police on the morning of 08/03/25, who stated the resident was being evaluated because he was found in the hospital parking lot. The POA reported Resident #83 kept stating that he was picked up by someone in a car and dropped off at the hospital. Resident #83's POA stated the Administrator told her they needed better security (at the facility). Interview on 08/21/25 at 8:57 A.M. with CNA #401 revealed she worked on 08/03/25 and was assigned to the back hall and Resident #83 resided on the front hall. CNA #401 stated that the last time she saw Resident #83 was around 1:00 A.M., as he was walking past the nurses' station. CNA #401 stated the resident was worried about his wife, who he believed had an affair with another man. CNA #401 stated that if a door alarm was sounding and she was providing care in a resident's room, she would not have heard it behind closed doors. Interview on 08/21/25 at 11:15 A.M. with CNA #400 revealed on 08/03/25, she was not assigned to provide care for Resident #83 and CNA #403 was the resident's assigned aide. CNA #400 stated she did not hear any door alarms that night but did recall seeing Resident #83 in the halls, confused; however, she could not recall what time she had last seen him. CNA #400 denied telling the Administrator she last saw the resident at 4:30 A.M. and further denied being interviewed by the Administrator regarding the incident at all. Interview on 08/21/25 at 11:52 A.M. with LPN #326 revealed at the beginning of her shift on 08/02/25 and into the morning hours of 08/03/25, Resident #83 was pacing in the halls. LPN #326 stated the resident had a history of exit seeking behavior. LPN #326 stated she told the Administrator that she had last seen Resident #83 sometime between 4:00 A.M. and 5:30 A.M. Further interview revealed LPN #326 did not know how the resident left the facility and denied the door alarm sounded. LPN #326 confirmed the facility was unaware the resident was missing until the hospital called at 5:30 A.M. LPN #326 stated the Administrator interviewed her regarding the elopement and she told the Administrator the resident eloped around 4:00 A.M. Interview on 08/25/25 at 3:01 P.M. with the Administrator revealed Resident #83 had previously attempted to leave the facility, which was when the Wanderguard was implemented, and the facility began exploring alternative placement for the resident. The Administrator confirmed the facility was unable to determine exactly how Resident #83 was able to exit the facility on 08/03/25 or verify the time Resident #83 eloped, but CNA #403 documented care was provided to the resident at 3:30 A.M. The Administrator stated CNA #403 had a language barrier and may not have understood what the surveyor was asking her when she stated she did not provide care for Resident #83 on the morning of 08/03/25. Upon the resident's return to the facility, he was placed on 1:1 staff supervision until a secured memory care placement could be found for him. The resident discharged to a more appropriate placement on 08/13/25. Review of the facility policy titled, Elopement Policy, dated 09/01/10, revealed it was the policy of the facility to prevent, to the extent reasonably possible, the elopement of guests/residents from the facility. This deficiency represents noncompliance investigated under Complaint Number 2586350.

Based on medical record review, staff and resident interviews, and policy review, the facility failed to ensure residents received necessary care and services so they could attend outside medical appointments. This affected two (#14, #81) of three residents reviewed for appointments. The census was 79. Findings include: Medical record review for Resident #14 revealed an admission date of 04/26/25. Medical diagnoses included malignant neoplasm of part of right bronchus lung, cancer, malnutrition, depression, and history of falling. Review of fax from the chemotherapy physician dated 07/31/25 revealed to draw these labs on 08/01/25 and every other Friday. The labs were B-12 Folate, Iron study with ferritin, Cortisol random, Thyroid Stimulating Hormone (TSH) with reflex, free T-4, Comprehensive Metabolic Panel (CMP), Complete Blood Count (CBC) with differential, and Adrenocorticotropic Hormone Blood Test (ATCH). Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #14 was cognitively intact. His functional status was partial/moderate assistance for eating, dependent for toileting, substantial/maximal assistance for bed mobility, and transfers were non-applicable. He was occasionally incontinent of bladder and frequently incontinent for bowel. He was coded for a feeding tube. Review of the chemotherapy appointments for Resident #14 revealed he had one scheduled for 08/21/25. Further review for this appointment revealed it had to be rescheduled due to labs done incorrectly. Interview with Resident #14 on 08/28/25 at 10:32 A.M. revealed he has missed a chemotherapy treatment due to the labs not being collected correctly but couldn't remember the dates. Interview with Licensed Practical Nurse (LPN) #250 on 08/28/25 at 10:45 A.M. revealed Resident #14's labs were messed up on 08/18/25 when they came out to draw blood, they got a PT and INR and that was wrong. Then she ordered them to come back on 08/19/25 and she put in a STAT lab so the facility could get the resident to chemotherapy, but the lab drew everything except the CMP. She reported his 08/21/125 appointment had to be cancelled and rescheduled for 08/26/25. She confirmed the resident missed his appointment due to the lab work not being collected properly. 2. Review of records for Resident #81 revealed admission date 09/13/22. discharge date [DATE]. Diagnoses included chronic diastolic heart failure, hypertension, chronic kidney disease stage two, irritable bowel syndrome, non-pressure chronic ulcer right calf with fat layer exposed, anxiety disorder, and overactive bladder. Review of quarterly MDS dated [DATE] revealed that Resident #81 was cognitively intact. She required setup or clean-up for meals, and dressing upper body. Resident #81 was substantial to maximum for dressing lower body and putting on and off shoes. Resident #81 was partial to moderate assistance for bathing, personal hygiene, toileting, and oral hygiene. Resident #81 used a wheelchair and ambulating with no assistance at the facility. Review of physician orders dated 08/26/25 revealed Calcitriol Capsule 0.5 microgram (mcg) to give one a day for low calcium at 9:00 A.M. Review of the medical appointments for Resident #81 revealed she had one dated 09/02/25 at 11:15 A.M. for a bone density testing. Interview with Resident #81 on 09/02/25 at 10:08 A.M. revealed she wasn't going to her appointment for a bone density at 11:15 A.M. because the staff gave her a calcium medication last night. Interview with LPN #200 on 09/02/25 at 10:15 A.M. confirmed Resident #81's appointment had to be rescheduled for 09/04/25 because there wasn't an order to hold the Calcitriol before the appointment and the resident was given medication on 09/01/25. Review of policy entitled Resident Rights dated 09/13/25 revealed the facility must protect and promote the rights of each resident. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. This deficiency represents non-compliance investigated under Complaint Number 2599291.

Based on medical record review and staff interview, the facility failed to ensure tube feeding was provided as physician ordered. This affected one (#14) of two residents reviewed for tube feeding. The census was 79.Findings include: Medical record review for Resident #14 revealed an admission date of 04/26/25. Medical diagnoses included malignant neoplasm of part of right bronchus lung, cancer, malnutrition, depression, and history of falling. Review of the care plan dated 04/26/25 revealed Resident #14 was unable to nutritionally consume adequate food or fluids by mouth. He required a tube feeding related to malnutrition and weight loss. Intervention was to administer tube feeding as ordered. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #14 was cognitively intact. His functional status was partial/moderate assistance for eating, dependent for toileting, substantial/maximal assistance for bed mobility, and transfers were non-applicable. He was occasionally incontinent of bladder and frequently incontinent for bowel. He was coded for a feeding tube. Review of the admission orders dated 07/29/25 revealed Resident #14 was to be on an Enteral Feed Order one time a day Jevity 1.5 at 70 milliliters per hour (mL/hrs), at night (nocturnally) from 8:00 P.M. to 6:00 A.M. via PEG, via pump. Further review of Resident #14's medical record revealed on 07/31/25 the Jevity 1.2 was initiated for the resident, rather than the ordered Jevity 1.5. Interview with Licensed Practical Nurse (LPN) #250 on 08/28/25 at 12:56 P.M. revealed Resident #14 was admitted on [DATE] at 2:30 P.M. with orders for enteral feed for nighttime. LPN #250 stated the facility was out of the Jevity 1.5, so she asked if he could get the Jevity 1.2 until the Jevity 1.5 came in. LPN #250 confirmed he went without the Jevity 1.5 for two nights and the Jevity 1.2 was started on 07/31/25. This deficiency represents non-compliance investigated under Complaint Number 2599291.

Based on medical record review, observations and staff and resident interviews, the facility failed to ensure medications were available from the pharmacy for administration. This affected one (#81) out of three residents reviewed for medication administration. The facility census was 79. Findings included: Review of the medical record for Resident #81 revealed the resident had a recent admission date 07/23/25. Diagnoses included chronic diastolic heart failure, hypertension, chronic kidney disease stage two, irritable bowel syndrome, non-pressure chronic ulcer right calf with fat layer exposed, anxiety disorder, and overactive bladder. Review of plan of care dated 09/22/22 revealed that Resident #81 was at risk for discomfort or adverse side effects related to receiving diuretics therapy related to congestive heart failure. Inventions included administering medication as ordered, encouraging residents to drink fluids, observe possible side effects every shift, and observing and reporting to physician dehydration or no urine. Review of plan of care dated 12/08/22 revealed that Resident #81 had risk for potential complications related to having ileostomy. Interventions included administer medication as ordered, use colostomy bag frequently, observe for diarrhea and report, and observe ostomy functioning every shift and amounts of stool passed. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #81 had Brief Interview of Mental Status (BIMS) of 15 that indicated cognitively intact. Resident #81 required setup or clean-up for meals, and dressing upper body. Resident #81 was substantial to maximum for dressing lower body and putting on and off shoes. Resident #81 was partial to moderate assistance for bathing, personal hygiene, toileting, and oral hygiene. Resident #81 used a wheelchair and ambulating with no assistance at the facility. Review of the physician order dated 08/25/25 at 4:30 P.M. revealed Resident #81 had an order for Lomotil 2.5-0.025 mg to give one tablet by mouth every four hours as needed for diarrhea. Observation on 08/25/25 at 11:01 A.M. with Resident #81 who asked for Lomotil 2.5-0.025 mg tablet from Licensed Practical Nurse (LPN) #284 during medication pass. Resident #81 told LPN #284 she asked last night with the night nurse and still had diarrhea. Interview on 08/27/25 at 11:03 A.M. with LPN #284 who stated Resident #81's Lomotil 2.5-0.025 mg tablets were not in her medication cart. LPN #284 verified that there was a physician orders active dated 08/25/25 for Lomotil for Resident #81. Interview on 08/27/25 at 11:05 A.M. with Director of Nursing (DON) stated that she expected staff to drop ship order the medication from pharmacy when ordering medication that was necessary. DON stated that the drop ship usually took four hours to receive the medication. Interview on 08/27/25 at 11:10 A.M. with Resident #81 stated she requested the Lomotil 2.5-0.025 mg tablet last night from the nurse, who stated it was not in stock. Resident #81 stated she would like Lomotil medication right now, because she was still having diarrhea. Interview on 08/27/25 at 4:07 P.M. with DON who stated that she called pharmacy about Resident #81 Lomotil 2.5-0.025 mg tablet. DON stated that Resident #81 arrived to the facility returning from the hospital on [DATE] at 5:34 P.M. DON stated she called the pharmacy who stated they needed a new prescription for Lomotil 2.5-0.025 mg tablet. DON stated the Lomotil 2.5-0.025 mg had not arrived at the at the facility yet. DON stated that the nurses were instructed for any resident who had medication that needed dropped shipped. DON stated that when medication was delivered was what the pharmacy was expecting in time frame. DON stated she had no facility policy on when facility had pharmacy delivering medication. This deficiency represents non-compliance investigated under Complaint Numbers 2597140 and 2567001.

Based on medical record review and staff and resident interviews, the facility failed to ensure laboratory testing was completed as physician ordered. This affected one (#14) of three residents reviewed for laboratory testing. This census was 79. Findings include: Medical record review for Resident #14 revealed an admission date of 04/26/25. Medical diagnoses included malignant neoplasm of part of right bronchus lung, cancer, malnutrition, depression, and history of falling. Review of fax from the chemotherapy physician dated 07/31/25 revealed to draw these labs on 08/01/25 and every other Friday. The labs were B-12 Folate, Iron study with ferritin, Cortisol random, Thyroid Stimulating Hormone (TSH) with reflex, free T-4, Comprehensive Metabolic Panel (CMP), Complete Blood Count (CBC) with differential, and Adrenocorticotropic Hormone Blood Test (ATCH). Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #14 was cognitively intact. His functional status was partial/moderate assistance for eating, dependent for toileting, substantial/maximal assistance for bed mobility, and transfers were non-applicable. He was occasionally incontinent of bladder and frequently incontinent for bowel. He was coded for a feeding tube. Review of lab results dated 08/18/25 revealed the above labs were supposed to be collected, but a Prothrombin Time (PT) and International Normalized Ratio (INR) was collected. On 08/19/25 the above lab orders were supposed to be collected but all were collected except for CMP. Further review of the lab orders revealed to collect a CMP on 08/21/25. Interview with Resident #14 on 08/28/25 at 10:32 A.M. revealed he has missed a chemotherapy treatment due to the labs not being collected correctly but couldn't remember the dates. Interview with Licensed Practical Nurse (LPN) #250 on 08/28/25 at 10:45 A.M. revealed the labs were messed up on 08/18/25 when they came out to draw blood, they got a PT and INR and that was wrong. Then she ordered them to come back on 08/19/25 and she put in a STAT lab so the facility could get the resident to chemotherapy, but the lab drew everything except the CMP. She reported she had to get the CMP ordered for 08/21/25. She confirmed the labs were not collected properly. This deficiency represents non-compliance investigated under Complaint Number 2599291.

Based on observation, staff interviews, review of Centers for Disease Control and Prevention (CDC) guidance, and review of the facility policy, the facility failed to appropriately clean and disinfect a glucometer between resident use. The affected one (Resident #28) of four residents observed for medication administration. The facility identified seven residents who received blood glucose monitoring utilizing the shared glucometer on A Hall. The facility census was 88. Findings include: Observation on 06/04/25 at 6:28 A.M. revealed Licensed Practical Nurse (LPN) #155 checked a blood sugar for Resident #33 and proceeded to prepare medications for Resident #28. Resident #28 also needed a blood sugar test prior to administering insulin. There was no observation of cleaning the glucometer and the same glucometer was used for both residents. Interview on 06/04/25 at 6:34 A.M. with LPN #155 confirmed the glucometer was not cleaned between Residents #33 and #29. LPN #155 stated the standard practice was to clean the medication cart, glucometer, and blood pressure cuff when done with the medication round. LPN #155 also confirmed there were usually Sani wipes on the cart to clean equipment but not that day (06/04/25). Interview on 06/04/25 at 10:00 A.M. with the Director of Nursing (DON) confirmed the expectation was to clean and disinfect multiple patients use items, including glucometers, between each use. Review of the facility policy titled Cleaning and Disinfecting Multi-Use Resident Equipment dated 02/28/25 confirmed reusable resident care items should undergo cleaning and disinfection when they are visibly soiled and on a regular schedule that includes after each use, daily, or weekly as needed. Review of the CDC's guidance titled Considerations for Blood Glucose Monitoring and Insulin Administration dated 08/07/24 and found at https://www.cdc.gov/injection-safety/hcp/infection-control/index.html revealed one of the key points was to assign blood glucose meters to a person unless the device is assigned for use in professional settings and is cleaned and disinfected after every use. The summary of recommendations included to clean and disinfect blood glucose meters after every use, per the manufacturer's instructions.

Based on record review and staff interview, the facility failed to ensure the use of antipsychotic medication was based on a clinically supported diagnosis. This affected one (Resident #81) of five residents reviewed for antipsychotics. The facility census was 88. Findings include: Record review for Resident #81 revealed an admission date of 04/25/25. Diagnoses included bipolar disorder, psychoactive substance abuse, and nicotine dependence. Review of the physician orders dated 04/26/25 revealed Venlafaxine HCL extended release 150 milligrams (mg) to be administered once daily for depression. The physician order dated 04/30/25 revealed Quetiapine Fumarate 200 mg at bedtime for depression. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 was cognitively intact and had no symptoms of depression. Interview with the Director of Nursing on 06/05/25 at 1:40 P.M. confirmed Resident #81 does not have a current diagnosis of depression in the medical record and there was no care plan related to depression in place. Review of the facility's Psychoactive Medication Management policy dated 04/28/25 revealed staff must verify orders for psychoactive medications are supported by appropriate clinical diagnoses and/or behavioral symptoms. When pharmacological interventions are indicated, the licensed staff will verify the physician order includes the appropriate clinically supported diagnosis and/or behavior symptoms.

Based on interview, medical record review, review of Self-Reported Incident (SRI), and review of facility policy, the facility failed to prevent Resident #76's controlled substances from being misappropriated. This affected one (#76) of two residents reviewed for misappropriation. The facility census was 88. Findings include: Review of the medical record for Resident #76 revealed an admission date of 04/28/25 and a discharge date of 05/16/25. Diagnoses included malignant neoplasm of anus, depression, neoplasm related pain, depression, insomnia, and osteoarthritis. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #76 had intact cognition. Review of the facilities SRI dated 04/24/25 revealed on 04/24/25, a nurse reported the narcotics were missing for Resident #76. The nurse went to dispense the medications, and they were unavailable. The nurse reported the concern to the Director of Nursing (DON). The pharmacy was asked to provide proof of delivery, and they sent the documentation, the medication delivery was signed for by an agency nurse working on the prior shift. The agency was contacted and was asked to drug screen and provide statement from agency nurse. The agency reported the drug screen was negative. Other nurses working on the unit were drug screened and the results were negative. Other nurses interviewed stated they were given other medications from the delivery but did not receive the narcotics. The resident's medication was pulled from Omnicell and given according to the order. The facility reordered the medication and paid for the replacement. Medication Administration Records (MAR) were reviewed for all residents on the med care unit and no missed doses were noted. Out of an abundance of caution, the facility filed a police report and reported agency nurse to the Ohio Board of Nursing and educated licensed nurses on the controlled substances policy. Review of the incident and accident form dated 04/23/25 revealed the resident involved was Resident #76, the alleged perpetrator was Agency Nurse #318, and employees involved were Registered Nurse (RN) #120 and Licensed Practical Nurse (LPN) #330. Agency Nurse #318 was assigned to the skilled unit, he accepted a pharmacy shipment at 3:05 P.M. and signed for narcotics. The narcotics in question were not available to dispense by the night nurse LPN #159. She called the pharmacy and stated they had been delivered. The pharmacy was asked to provide proof of delivery and they sent documentation signed by Agency Nurse #318. The DON examined the medication carts and medication room and reviewed the resident's file. RN #120 and LPN #330 were interviewed as well as Agency Nurse #318's agency. Employees were drug tested and were negative. The investigation was inconclusive. Agency Nurse #318 signed for medications and handed non-narcotic medications to RN #120 who gave them to LPN #300. The paperwork that accompanied the narcotics were not found either. Review of Omnicare's Proof of Delivery dated 04/24/25 revealed Oxycodone (narcotic pain medication) 10 milligrams (mg) six pills and Diazepam (controlled substance) five mg 30 pills were sent on 04/23/25. Agency Nurse #318's initials were written on the page. Review of the witness statement dated 04/24/25 revealed on 04/23/25, LPN #330 received from the agency nurse at 3:05 P.M. the non-controlled prescriptions for Resident #76. He indicated he did not receive any controlled prescriptions. Review of the witness statement dated 04/24/25 by RN #120 revealed Agency Nurse #318 handed her the medications to give to LPN #330. There were no opioids or narcotic sheets with the cards she received, just regular medications. Review of the drug tests for LPN #330, RN #120, and Agency Nurse #318 revealed they were negative. Interview on 06/05/25 at 10:00 A.M. with the DON and Administrator verified Resident #76's medications were missing and Agency Nurse #318 was suspected of taking the controlled substances. Review of the facilities Abuse Prohibition Policy dated 10/14/22 revealed each guest/resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. This deficiency represents non-compliance investigated under Complaint Number OH00165729.

Based on staff interview, medical record review, policy review, and review of Self-Reported Incident (SRI), the facility failed to thoroughly investigate Resident #76's missing controlled substances. This affected one (#76) of two residents reviewed for misappropriation. The facility census was 88. Findings include: Review of the medical record for Resident #76 revealed an admission date of 04/28/25 and a discharge date of 05/16/25. Diagnoses included malignant neoplasm of anus, depression, neoplasm related pain, depression, insomnia, and osteoarthritis. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #76 had intact cognition. Review of the facilities SRI dated 04/24/25 revealed on 04/24/25, a nurse reported the narcotics were missing for Resident #76. The nurse went to dispense the medications, and they were unavailable. The nurse reported the concern to the Director of Nursing (DON). The pharmacy was asked to provide proof of delivery, and they sent the documentation, the medication delivery was signed for by an agency nurse working on the prior shift. The agency was contacted and was asked to drug screen and provide statement from agency nurse. The agency reported the drug screen was negative. Other nurses working on the unit were drug screened and the results were negative. Other nurses interviewed stated they were given other medications from the delivery but did not receive the narcotics. The resident's medication was pulled from Omnicell and given according to the order. The facility reordered the medication and paid for the replacement. Medication Administration Records (MAR) were reviewed for all residents on the med care unit and no missed doses were noted. Out of an abundance of caution, the facility filed a police report and reported agency nurse to the Ohio Board of Nursing and educated licensed nurses on the controlled substances policy. Review of the incident and accident form dated 04/23/25 revealed the resident involved was Resident #76, the alleged perpetrator was Agency Nurse #318, and employees involved were Registered Nurse (RN) #120 and Licensed Practical Nurse (LPN) #330. Agency Nurse #318 was assigned to the skilled unit, he accepted a pharmacy shipment at 3:05 P.M. and signed for narcotics. The narcotics in question were not available to dispense by the night nurse LPN #159. She called the pharmacy and stated they had been delivered. The pharmacy was asked to provide proof of delivery and they sent documentation signed by Agency Nurse #318. The DON examined the medication carts and medication room and reviewed the resident's file. RN #120 and LPN #330 were interviewed as well as Agency Nurse #318's agency. Employees were drug tested and were negative. The investigation was inconclusive. Agency Nurse #318 signed for medications and handed non-narcotic medications to RN #120 who gave them to LPN #300. The paperwork that accompanied the narcotics were not found either. Review of Omnicare's Proof of Delivery dated 04/24/25 revealed Oxycodone (narcotic pain medication) 10 milligrams (mg) six pills and Diazepam (controlled substance) five mg 30 pills were sent on 04/23/25. Agency Nurse #318's initials were written on the page. Review of the witness statements reviewed only two staff were interviewed, LPN #330 and RN #120. Review of the drug tests revealed only LPN #330, RN #120, and Agency Nurse #318 were tested. Review of the schedule for 04/23/25 revealed there were seven aides and six nurses scheduled for day shift. Interview on 06/05/25 at 10:00 A.M., 11:11 A.M., and 11:30 A.M. with the DON verified she only interviewed the three involved nurses, she did not feel that the nurse aides would have been aware of any issues. She interviewed LPN #159 but did not obtain a witness statement. She reported she interviewed and assessed Resident #76 but verified there was no evidence of this. The DON additionally verified they only drug tested the two nurses. Review of the facilities Abuse Prohibition Policy dated 10/14/22 revealed allegations of abuse, which included misappropriation, shall be thoroughly investigated and documented by the Administrator, and reported to the appropriate state agencies, physician, families, and/or representative. Allegations by anyone who becomes aware of abuse, mistreatment, neglect, exploitation, involuntary seclusion or misappropriation of property must immediately report it to his/her Administrator. The DON or designee will complete an assessment of guest(s)/resident(s) and document the findings in the medical record.

2. Record review for Resident #26 revealed the resident was admitted to the facility on [DATE]. Diagnoses included non-chronic pressure ulcer of the left heel, encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, and depressive disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had intact cognition. Review of the Wound Care Clinic visit note dated 04/28/25 revealed Resident #26 was to have a follow up appointment with the clinic in one week. There was no evidence in Resident #26's medical record that Resident #26 attended an appointment at the Wound Care Clinic one week after his appointment on 04/28/25. Interview with Resident #26 on 06/05/25 at 11:02 A.M. confirmed they attended appointments at the Wound Care Clinic on Mondays and had missed an appointment on 05/05/25 due to the facility not scheduling transportation to the appointment. Interview with the Director of Nursing (DON) on 06/05/25 at 2:41 P.M. confirmed Resident #29 missed a scheduled appointment at the Wound Care Clinic on 05/05/25. 3. Review of the medical record for Resident #12 revealed an admission date of 12/20/23. Diagnoses included peripheral vascular disease, anxiety disorder, a history of thrombus/embolism, and chronic pain syndrome. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had intact cognition and received a antiplatelet medication. Review of Resident #12's physician orders revealed on 07/05/24, Clopidogrel Bisulfate (an antiplatelet medication) oral tablet 75 milligrams (mg) was ordered to be administered by mouth one time a day for blood thinner. On 07/05/24, there was an order to monitor for signs and symptoms of bleeding and notify the provider of any changes. Review of Resident #12's treatment administration record (TAR) for May and June 2025 revealed documentation of no bleeding or bruising was indicated for all of May and June 2025. Observation and interview with Resident #12 on 06/02/25 at 10:47 A.M. revealed bruises on the back of both hands. Bruises on the right hand took up most of the back of the hand while there were two quarter size bruises on the back of her left hand near the wrist. Resident #12 stated has had several bruises on her arms and hands. Resident #12 does not know how she got the bruises and stated she bruises easily. Resident #12 stated no one follows or monitors her bruising. Interview and observation on 06/03/25 at 2:11 P.M. with Licensed Practical Nurse (LPN) #208 confirmed bruises appeared to Resident #12's back of her hands LPN #208 confirmed they were not previously noted and she was unaware of where they came from. Interview and observation on 06/04/25 at 9:00 A.M. with Unit Manager (UM) #206 and the Director of Nursing (DON) confirmed Resident #12 had discolored areas on the back of her right hand and smaller area on left hand and confirmed they were bruises. The DON instructed UM #206 to be sure there was an order to monitor for signs and symptoms of bleeding or bruising and the order was being followed. Interview on 06/04/25 at 11:00 A.M. with the DON and the Administrator confirmed Resident #12 shared with them that Resident #12's family noted the bruising on her hands last Saturday (05/31/25). The Administrator and DON confirmed that every shift monitoring for bleeding and bruising in Resident #12's TAR reflected no signs or symptoms of bleeding or bruising noted as being present on the resident's hands. This deficiency represents non-compliance identified during the investigation of Complaint OH00165422. Based on resident and staff interviews, observations and record review, the facility failed to ensure timely coordination with the physician for the removal of staples and did not ensure the residents attended their scheduled appointments. Additionally, the facility failed to timely identify and monitor a resident's bruising. This affected three (Residents #12, #26 and #252) reviewed for care and coordination and bruising. The facility census was 88. Findings include: 1. Review of the medical record for Resident #252 revealed an admission date of 05/15/25. Diagnoses included surgical after following surgery on the digestive system. Review of the discharge hospital records revealed on 04/29/25, Resident #252 underwent a exploratory laparotomy with midline abdominal incision, including staples and island dressing. The after visit summary revealed there was guidance to schedule an appointment with primary care provider as soon as possible and establish patient visit with nephrology on 06/23/25. Review of the nursing comprehensive evaluation dated 05/15/25 revealed Resident #252 had current skin condition, with 18 staples located on the abdomen and gastrostomy tube. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #252 had intact cognition. Skin conditions were present upon admission which included a surgical wound. Review of the skin assessment dated [DATE] revealed surgical wound present with 18 staples, incision approximated, present on admission measuring 7.1 centimeters (cm) in length by 11.9 cm wide by 0.9 cm depth. The wound was described as no drainage or odor with attached edges. Interview on 06/02/25 at 10:47 A.M. with Resident #252 stated they had concerns for staples located in his abdomen. The resident stated licensed nursing staff were aware of staples which have been present for over four weeks, however they have not heard when the staples will be removed. The skin assessment dated [DATE] revealed the surgical wound was present with 18 staples, incision approximated as 6.7 cm in length by 11.2 cm wide by 1.0 cm in depth. The wound was described as no drainage or odor with attached edges. Interview on 06/04/25 at 1:09 P.M. with the Director of Nursing (DON) confirmed Resident #252 has had midline staples present since admission, which were initially placed on 04/29/25 during an exploratory surgery. The DON confirmed the staples would be removed per physician order. Interview on 06/04/25 at 1:17 P.M. with Nurse Practitioner (NP) #342 confirmed Resident #252 currently has staples in which were from a surgery completed on 04/29/25. NP #342 confirmed staples were to be removed seven to 10 days after surgery. NP #342 confirmed the staples were in place longer than intended and she thought the resident was following up with gastrointestinal (GI) for removal. NP #342 was unsure if he has any appointments with GI scheduled in the future. There were no physician orders to remove Resident #252's staples until 06/04/25. The physician order dated 06/04/25 revealed the abdominal staples were to be removed.

Based on observations, staff interviews, and record review, the facility failed to ensure residents who were dependent on staff for activities of daily living (ADLs) received timely and adequate staff assistance with showers and personal hygiene. This affected one (Resident #53) of four residents reviewed for ADL care. The facility identified 24 residents who were dependent on staff for bathing. Findings include: Review of the medical record for Resident #53 revealed an admission date of 04/24/25. Diagnoses included left knee effusion, depression, anxiety disorder, and chronic kidney disease. Review of the care plan dated 04/24/25 revealed Resident #53 has a functional ability deficit and required assistance with self-care and mobility related to altered mobility. Interventions revealed the resident prefers baths at 10:30 A.M., was dependent on staff for bathing, and required partial to moderate assistance with personal hygiene, including shaving. Review of the facility's hygiene guest preferences form dated 04/25/25 revealed Resident #53's scheduled bed baths were on Mondays and Thursdays during the day shift. Review of admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #53 was cognitively intact. Resident #53 was dependent on staff for bathing and required partial to moderate assistance with personal hygiene including shaving. Review of the shower/bath task from 05/06/25 through 06/05/25 revealed there was no documentation showing Resident #53 received a bath or shaving during this period. Observation on 06/02/25 at 10:47 A.M. revealed Resident #53 had mustache and chin hairs approximately half an inch in length. Subsequent observations on 06/04/25 at 11:57 A.M. and 06/05/25 at 8:09 A.M. revealed Resident #82's facial hair remained present. Interview on 06/05/25 at 11:06 A.M. with Certified Nursing Assistant (CNA) #177 revealed Monday and Thursday were the scheduled bathing days for Resident #53. CNA #177 stated if a resident refuses shaving during bathing, the refusal was documented and nursing staff were promptly notified. Interview on 06/05/25 at 11:11 A.M. with Licensed Practical Nurses (LPN) #113 and #18 revealed Resident #53's medical record contained no documentation of a shower or bath in the past 30 days. LPN #113 confirmed CNAs were expected to offer shaving services during scheduled bathing days. Observation on 06/05/25 at 11:23 A.M. with LPN #113 revealed Resident #82 had mustache and chin hair present. When asked about preference for removal, Resident #82 gave an inappropriate response. Interview on 06/05/25 at 1:52 P.M. with the Director of Nursing (DON) revealed residents requiring shaving were expected to receive this service on their scheduled bathing days. The DON also confirmed baths and showers were documented electronically only in the shower/bath task. This deficiency represents non-compliance investigated under Complaint Number OH00166265.

Based on medical record review and staff interview, the facility failed to ensure Resident #28 had a care plan for a diuretic and Resident #81 had a care plan for smoking. This affected one resident (#28) of five residents reviewed for unnecessary medications and one resident (#81) of one resident reviewed for smoking. The facility census was 88. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 12/14/21. Diagnoses included chronic obstructive pulmonary disease. Review of Resident #28's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had intact cognition. Review of Resident #28's physician order dated 04/23/25 revealed an order for Furosemide (a diuretic) 20 milligrams, one tablet by mouth twice a day. Review of Resident #28's plan of care revealed it did not address his diuretic use. Interview on 06/04/25 at 3:20 P.M. with the Director of Nursing (DON) verified the care plan did not address his diuretic use. 2. Review of the medical record for Resident #81 revealed an admission date of 04/25/25. Diagnoses including nicotine dependence and psychoactive substance abuse. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #81 had intact cognition. Review of the progress note note dated 05/14/25 revealed Resident #81 was encouraged to quit smoking but expressed no interest and continued smoking approximately half a pack of cigarettes daily. The nursing staff had notified the physician that Resident #81 had been observed smoking in front of the building. Review of Resident #81's care plan revealed Resident #81's smoking was not addressed in his care plan. Interview on 06/02/25 at 2:30 P.M. with Licensed Practical Nurse (LPN) #113 confirmed Resident #81 was non-compliant with the facility's no-smoking rule but consistently exits the building to smoke outside. LPN #113 also stated this behavior had been discussed with facility management and was unsure if it was included in the plan of care. Interview on 06/05/25 at 1:37 P.M. with the Director of Nursing confirmed Resident #81's non-compliance with the facility smoking policy was not currently addressed in the resident's care plan and acknowledged the care plan should have been updated to reflect this behavior.

2. Review of the medical record for Resident #12 revealed an admission date of 12/20/23. Diagnoses included type two diabetes mellitus, anxiety disorder, depression, osteoarthritis and chronic pain syndrome. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had intact cognition. Resident #12 had limited functional range of motion noted on both sides for both upper and lower extremities and was staff dependent for personal hygiene needs. Review of Certified Nursing Assistant (CNA) documentation in the task section of the medical record from 05/01/25 to 05/31/25 revealed Resident #12 was documented to have shower/bath/bed baths on 05/06/25, 05/14/25. 05/17/25, 05/20/25, and 05/24/25. It was documented no shower/bath/ bed bath was provided on 05/10/25 and 05/28/25 and refused on 05/31/25. Interview on 06/03/25 at 10:56 A.M. with Resident #12 stated she has never refused her shower; the aides tell her there were no Hoyer lift pads available to get her up onto the shower bed so they will just give her a bed bath. Resident #12 stated the aides did not wash her hair and only washed her privates and armpits during a bed bath. Interview on 06/03/25 and 1:03 P.M. with Unit Manager (UM) #206 revealed UM #206 was unable to confirm whether Resident #12 had a shower or a bed bath, stating only the task documentation only indicated a shower/bath/bed bath was provided Resident #12 and did not differentiate what was actually provided to Resident #12. UM #206 was unable to provide any documentation or evidence confirming if Resident #12 received a shower or bed bath. When requested to see the Hoyer pad used for transferring the resident to the shower, LPN #206 was unable to locate the resident's specific bariatric Hoyer pad. When LPN #206 went to the laundry area to look for the Hoyer pads, she was unable to locate any and stated they must be somewhere, but could not identify their location. Interview on 06/03/25 at 2:25 P.M. with Certified Nursing Assistant (CNA) #200 confirmed an issue with the number of Hoyer Lift Pads were available. CNA #200 stated there seems to be a miscalculation of how many Hoyer pads they have vs how many they need. CNA #200 explained they have several residents who get up and down a couple of times a day, so the pad remains with them all day. Resident #12 liked to get up and shower but the facility does not have enough Hoyer pads to go around recently to get her up on the shower bed. Interview on 06/04/25 at 6:02 A.M. with CNA #133 stated the CNAs feel there was no trouble with showers at night, but there were issues not enough Hoyer pads and slings for the Hoyer lift with residents who were larger. CNA #133 stated the residents who were larger do receive with bed baths. Interview on 06/04/25 at 9:00 A.M. with Resident #12 confirmed she did not receive a shower last night on her scheduled shower day. Resident #12 stated she received a bed bath but her hair was not washed, Resident #12 emphasized she wants a shower not a bed bath to feel clean and have her hair washed. Based on record review, observations, and resident and staff interviews, the facility failed to ensure two residents (Residents #12 and #23) out of three residents reviewed for bathing received their preferred method of bathing or showering. The facility census was 88. Findings include: 1. Review of Resident #23's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, morbid obesity with alveolar hypoventilation, hemiplegia following cerebral infarction, contractures of the left upper extremity, depression, and bipolar disorder. The resident was non-ambulatory and was dependent on staff for all transfers and most activities of daily living. She used a specialty wheelchair and required two-person physical assistance with a mechanical lift for transfers. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact, required total dependence for all transfers and hygiene tasks, had bilateral upper and lower extremity impairments, and was always incontinent of bowel and bladder. Review of the care plan, revised on 05/23/25, revealed Resident #23 preferred to receive showers on Wednesdays and Saturdays at 3:00 P.M. and identified shower as her preferred bathing method. Review of the physician's order dated 05/23/25 revealed a weekly skin assessment with shower every Saturday night shift. Review of the Activities of Daily Living (ADL) documentation from 05/01/25 to 06/01/25 revealed Resident #23 did not receive showers per her preference. There were no showers documented on 05/08/25 and 05/17/25, and there were no progress notes indicating refusals on those dates. Showers were documented only on 05/10/25, 05/14/25, 05/22/25, 05/25/25, 05/29/25, and 06/01/25. Review of the bathing task documentation from 04/01/25 to 06/01/25 revealed Resident #23 did not receive a bed bath on 04/17/25, 04/24/25, 05/01/25, 05/08/25, and 05/17/25, with no documentation of refusals in the progress notes. Additionally, the task entries did not specify whether the resident received a bed bath or a shower, and there was no evidence elsewhere in the medical record to confirm which method of bathing, if any, had been provided. Interview on 06/02/25 at 10:06 A.M. with Resident #23 stated she was not receiving showers and could not recall the last time she had one. She stated her hair had not been washed in a while and reported wanting to get up for lunch, but staff would not assist her out of bed. Interview on 06/03/25 at 11:14 A.M. with Licensed Practical Nurse (LPN) #143 stated Resident #23 was scheduled to receive two showers per week, but often refused one. LPN #143 stated the refusals were supposed to be documented in progress notes and the resident had received a shower earlier that week. Interview on 06/03/25 at 11:34 A.M. with Clinical Coordinator #305 stated only completed showers were documented in task records, and refusals were not consistently recorded. She acknowledged the absence of reliable documentation showing whether a shower had been offered or refused. Interview on 06/03/25 at 11:41 A.M. with Resident #23 stated she had not received an actual shower in months and reported the staff did not offer her the opportunity to shower. She stated she was typically only provided with bed baths and reiterated her preference for showers. Interview on 06/03/25 at 11:44 A.M. with Certified Nursing Assistant (CNA) #111 stated the last time he recalled Resident #23 receiving a shower was in January. He stated all documentation regarding showers or refusals should have been found in the progress notes but was unable to confirm any such entries. Interview on 06/03/25 at 11:47 A.M. with Unit Manager #206 stated Resident #23 was scheduled to receive showers on Wednesday and Saturday nights. She confirmed documentation of showers should have been included in progress notes, but she was unable to provide records confirming whether the resident had received a shower or a bed bath. Observation on 06/03/25 at 12:44 P.M. revealed Resident #23 was lying in bed. When she lifted her head, her hair appeared stiff and matted from oil buildup and did not move naturally, suggesting that it had not been washed recently. Interview on 06/03/25 at 1:03 P.M. with Resident #23 and Unit Manager #206 together revealed the resident again reported she had not received a shower and expressed that she preferred showers over bed baths. The Unit Manager stated the only documentation available was under a general task labeled Shower/Bath/Bed Bath, and she could not confirm what type of bathing had been provided. She was unable to produce documentation confirming a completed shower or bed bath. When asked to locate the bariatric Hoyer pad needed to transfer the resident to the shower, the Unit Manager was unable to find it. She searched the laundry area and stated the pads must be somewhere, but could not identify their location. Observation on 06/03/25 at 1:59 P.M. revealed Unit Manager #206 later produced two Hoyer pads with the resident's name written on them but stated they had been missing for about a week.

Based on record review, resident and staff interview, and review of the facility policy, the facility failed to timely and adequately address Resident #50 complaints of pain. This resulted in Actual Harm when Resident #50's pain become severe enough she expressed thoughts of self-harm. This affected one (#50) out of three residents reviewed for pain management. The facility census was 88. Findings Include Review of the medical record for Resident #50 revealed readmitted to the facility on [DATE] following a hospital stay for acute chronic pancreatitis, acute urinary tract infection (UTI) and community-acquired pneumonia. Other diagnoses included cellulitis of right lower limb, hypokalemia, chronic obstructive pulmonary disease, asthma, heart failure, hypertensive heart disease, chronic pancreatitis, depression, anemia, and hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/07/23, revealed Resident #50 was cognitively intact. Further review of the MDS assessment revealed Resident #50 required extensive assistance from staff with bed mobility, bed transfers, dressing, and personal hygiene. Resident #50 required supervision with eating. Review of Resident #50's nursing progress notes, dated 03/12/23, resident started complaining at the beginning of the shift that her spleen was hurting, and she (Resident #50) was in pain. Resident #50's vitals revealed her blood pressure was documented at 133/65 millimeters of mercury (mm/Hg), pulse was 89 beats per minute, and her temperature was 97.6 degrees Fahrenheit. Further review of the nursing progress notes revealed Resident #50, came back again at the nurse's station and asked for her pain medication and it was given. Resident #50 voiced concern regarding her pancreas hurting and the nurse documented she contacted the nurse practitioner; however, the nursing notes stated, Resident #50 was determined to go to the emergency room to be evaluated by a physician. Further review of the progress notes for Resident #50 stated, the nurse advised Resident #50 to let the medication kick in and she was going to give her nitroglycerin. Resident #50 called the paramedics and was discharged to the hospital and admitted for pancreatitis and a UTI. Review of Resident #50's progress notes revealed Resident #50 returned to the facility on [DATE] at 3:58 P.M. with a diagnosis of acute pancreatitis and UTI. On 03/16/23, at 11:25 P.M. the nurse documented Resident #50 was given a dose of pregabalin (Lyrica) and Resident #50 requested her hydromorphone (Dilaudid). Further review of the nursing progress notes for Resident #50 revealed the nurse stated to Resident #50 she is unable to administer both medications at one time and Resident #50 was told she would have to wait at least two hours to have a dose of the hydromorphone. Resident #50 started complaining and the nurse documented the nurse left Resident #50's room. Further review of the nursing progress notes revealed Resident #50 went to the nurse's station at 1:00 A.M. threatening to call the authorities, the on-call manager or Director of Nursing (DON), and Resident #50 threatened to kill herself in order to get her pain medication (hydromorphone). The nurse documented Resident #50 was crying and stated the nurse was being unfair to her. The nurse stated it was her nursing judgement to have Resident #50 wait for two-hour window, prior to administering the hydromorphone. The nurse told Resident #50 unless the nurse obtained an order from the physician to give the Lyrica and Hydromorphone together the nurse could not proceed with administering the medications. Review of the nursing progress note for Resident #50, dated 03/17/23, revealed a physician's order, Hydromorphone HCI Oral liquid ONE MG /ML-give three ml every four hours for pain, may be given with other medications including, Lyrica. Review of Resident #50's Medication Administrator Report (MAR) revealed an order for Pregabalin Oral Capsule 75 milligram (mg), give one capsule by mouth two times a day for neuropathy start date 03/16/23 at 9:00 P.M. was signed off as given by the nurse. Hydromorphone HCI oral liquid one mg per milliliter (ml), give three ml by mouth every four hours as needed for pain was not signed off on the MAR for 03/16/23. Review the controlled substance log for Resident #50 revealed Pregablin 75 mg was administered on 03/16/23 at 11:30 P.M. Further review of the controlled substance log for Resident # 50 revealed she Hydromorphone was administered on 03/16/23 at 4:00 P.M. Review of Resident #50's Medication Administration Record (MAR) revealed Resident #50 did not have any doses of Hydromorphone administered to her on 05/20/23. Review of the form titled, Controlled Substance Record, for the month of June 2023 for Resident #50 revealed she was administered Hydromorphone on 05/19/23 at 4:06 P.M. and her next dose was administered on 05/20/23 at 5:45 A.M. Review of the facility SRI, dated 05/22/23 revealed Resident #50 reported an allegation of neglect to the psychiatric nurse regarding the facility failing to provide her pain medication as ordered. Further review of the facility SRI revealed Resident #50 was interviewed by the Director of Nursing (DON) in regard to the concern reported by the psychiatric nurse about the alleged neglect regarding Resident #50's pain medication. The DON reported Resident #50 was informed by the floor nurse on 05/19/23 that Resident #50 was out of pain medication. Resident #50 stated she became tearful and stated Resident 50 stated the psychiatric nurse misrepresented what Resident #50 said. Further review of a Note regarding a Narrative Summary of Incident dated 05/22/23 revealed Resident #50 was interviewed by DON in regards to concerns reported by Pscyh services about alleged neglect with staff over the weekend in regards to pain medication and care. Resident #50 states she was informed Friday evening that her pain medication script ran out but that the nurse did contact on-call and that the e-script was sent to the pharmacy. Interview on 06/20/23 on 8:54 A.M. with the General Manager (GM) #601 of the pharmacy for the facility confirmed Resident #50's Hydromorphone was delivered to the facility and signed acceptance of delivery by License Practical Nurse (LPN) #31 on 05/20/23 at 5:47 A.M. Interview on 06/20/23 at 10:47 A.M. with the DON regarding Resident #50' nursing progress notes dated, 03/16/23, confirmed LPN #600 used her nursing judgement and decided not to administer pain medication with the pregabalin medication. The DON confirmed she would have contacted the physician and clarified the orders of administering the medications at the same time. The DON stated, that is why I called the physician the next day. The DON confirmed Resident #50 made statements of wanting to kill herself on 03/16/23 when she was unable to obtain her pain medication with the Lyrica. The DON stated Resident #50 stated she was suicidal because she did not get the pregabalin (Lyrica) and hydromorphone at the same time. Interview on 06/20/23 at 12:30 P.M. with Resident #50 revealed she had returned to the facility from the hospital on 03/16/23 and requested her pain medication at 11:30 P.M. when she was given her Pregablin. Resident #50 stated the nurse told her she could not receive the Pregablin and the hydromorphone together; however, this had not been an issue in the past. Resident #50 stated by 1:00 A.M. she just lost it and stated she would kill herself if she did not get her medication. Resident #50 stated she was depressed over the pain she was in. Resident #50 further revealed she was upset by the incident that occurred in May 2023 regarding the facility had ran out of her pain medication. Resident #50 stated she did not understand how a facility could let someone run out of pain medication, why not just order when it was low. Resident #50 stated she contacted the psychiatric nurse and expected the conversation to be confidential. Resident #50 stated she did say that she was suicidal from the pain caused from not receiving her pain medication. Interview on 06/20/23 at 5:48 P.M. with LPN #600 confirmed she did not contact the physician on 03/16/23 at 1:00 A.M. regarding administering both medications (pregabalin and hydromorphone) at the same time. LPN #600 stated she waited until the next morning and discussed it with the DON and then the physician was contacted. Interview on 06/21/23 at 9:56 A.M. with the Administrator revealed a message was left on the facility phone from the psychiatric nurse on the weekend prior to 05/22/23 and it stated Resident #50 was suicidal because the facility neglected to administer her pain medication over the weekend. The Administrator stated the facility opened the SRI because the psychiatric nurse stated Resident #50 used the word neglect. The Administrator stated the facility did not substantiate the SRI because Resident #50 told the DON the psychiatric nurse did not report the message correctly. However, the Administrator confirmed Resident #50 did indicate she was suicidal for not having her pain medication on 05/20/23. Review of the facility policy titled, Medication Administration, dated 09/09/23, revealed Physician's Orders - Medications are administered in accordance with written orders of the attending physician. If a dose is inconsistent with the guest's/resident's age and condition or a medication order is inconsistent with the guest's/resident's current diagnosis or condition, contact the physician for clarification prior to administration of the medication. Document the interaction with the physician in the progress notes and elsewhere in the medical record, as appropriate. This deficiency represents non-compliance investigated under Complaint Number OH00143730.

Based on record review, staff interview, review of the facility's fall investigation and policy review, the facility failed to provide adequate supervision to prevent accidents and ensure staff followed facility procedure with fall management. This resulted in Actual Harm when a staff member was providing care to Resident #73 and left the room leaving Resident #73 in an unsafe position in bed resulting in the resident falling from the bed. Resident #73 subsequently fractured her right femur requiring hospitalization and surgical repair. Additionally, the facility failed to ensure Resident #89 was provided adequate supervision during care resulting in an avoidable fall which placed the resident at risk for more than minimal harm that did not result in actual harm to the resident. This affected two (#73 and #89) out of four residents reviewed for falls. The census was 88. Findings include: 1. Review of the medical record for Resident #73 revealed an admitted [DATE]. Diagnoses included fracture of neck of right femur, depression, Parkinson's disease, and dysphagia. Review of the five-day Medicare Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 14. Resident #73 was assessed to require two-person extensive assistance with transfers, dressing, and toileting, independent with eating, and two-person total dependence with bathing. Review of the care plan dated 12/24/22 revealed Resident #73 was at risk for fall related injury and falls related to history of falls, weakness, and impaired mobility. Interventions included administer medications as ordered. Staff to anticipate and meet needs as needed. Staff to apply bilateral grab bars. Staff to assess the risk level for falls on admission and as needed. Staff to encourage to wear non-skid footwear when out of bed. Staff to ensure call light was within reach and encourage to use for assistance as needed. Review of the progress note dated 05/25/23 revealed nurse practitioner (NP) #70 assessed Resident #73 related to a fall. Resident #73 was seen and examined while resting in bed. Resident #73 was alert and oriented to person, place, and time on exam. Resident #73 stated she rolled out of bed overnight landing on her right hip and hitting her head. Resident #73 had a large bruise to right forehead. Upon exam, right hip had swelling and bruising noted. No notable deformities. Resident #73 reported pain to her right hip rating a six out of ten. NP #70 discussed with nursing staff and Resident #73's son to send to emergency room (ER) for further evaluation. Review of the progress note dated 05/25/23 at 10:26 A.M. revealed Resident #73 complained of pain to right hip with passive range of motion (PROM). NP #70 notified and ordered a stat x-ray. Review of the progress note dated 05/25/23 at 12:11 P.M. revealed Resident #73's son was in the facility requesting a computed tomography (CT) for Resident #73. NP #73 gave order for CT. Review of the progress note dated 05/25/23 at 12:58 P.M. revealed Resident #73 was picked up by Critical Care Transport and taken to Hospital #1 to be evaluated. Review of the progress note dated 05/30/23 at 4:12 P.M. revealed Resident #73 was readmitted to the facility. Resident #73 had a right hip intramedullary nailing on 05/26/23. Incision site to right hip had 15 staples. Area to right hip revealed staples were intact and well-approximated with no drainage. Review of Hospital #1's paperwork dated 05/25/23 revealed Resident #73 had a right femur fracture resulting in hospitalization and surgical repair. Review of the facility's timeline dated 05/25/23 revealed approximately between 5:00 A.M. and 5:30 A.M. State tested Nurse's Aide (STNA) #15 entered Resident #73's room to provide incontinence care. STNA #15 turned Resident #73 on right side and then left the room to address a concern. Resident #73 was left on her side and reported she was slipping. Resident #73 fell on to floor and hit her right side of her face and body. STNA #15 returned to the room and found Resident #73 on the floor. STNA #15 left the room and returned with the Hoyer lift and put Resident #73 back into bed. At approximately 8:15 A.M. STNA #13 entered Resident #73's room and noticed swelling and bruising to the right side of Resident #73's face. STNA #13 asked what happened, and Resident #73 said she fell out of bed around 5:00 A.M. At approximately 8:20 A.M., STNA #13 notified Licensed Practical Nurse (LPN) #26 of what she was told. LPN #26 assessed Resident #73 and notified unit manager LPN #25. LPN #25 assessed Resident #73. During range of motion, Resident #73 complained of pain to right leg. Approximately between 8:30 A.M. and 12:00 P.M., staff were interviewed and Resident #73's son was notified. LPN #25 began calling night shift staff to understand what occurred and why the fall was not reported. LPN #25 notified Director of Nursing (DON). At approximately 12:11 P.M., Resident #73 was transported to Hospital #1 by ambulance for evaluation. At approximately 3:32 P.M., Resident #73's son reported Resident #73 was diagnosed with a hip fracture. At approximately 6:36 P.M., STNA #15 spoke with DON and denied Resident #73 had rolled out of bed the morning of 05/25/23. Review of the witness statement dated 05/25/23 from STNA #15 revealed she took care of Resident #73. STNA #15 denied Resident #73 rolled out of bed during her shift. STNA #15 denied using the Hoyer lift on Resident #73 during care on 05/24/23 and 05/25/23. Review of the witness statement dated 05/25/23 from STNA #13 revealed Resident #73 reported she fell on floor and hit head on wheel of bedside table. Resident #73 reported to be on the floor for a while and yelling. Review of the witness statement dated 05/25/23 from LPN #26 revealed STNA #13 came and got her to assess Resident #73. Resident #73 reported STNA #15 left to get supplies, and she rolled out of bed. STNA #15 came back, and Resident #73 was on the floor. LPN #25 attempted range of motion on right leg but Resident #73 yelled out in pain. Interview on 06/20/23 at 9:41 A.M. with STNA #13 revealed Resident #73 put her light on around 8:10 A.M. on 05/25/23. STNA #13 stated she went into Resident #73's room, and she was crying. STNA #13 reported Resident #73 had a purple bruise on the right side of her face. STNA #13 asked what happened, and Resident #73 said she fell . STNA #13 went to get LPN #26 to assess Resident #73. STNA #13 explained Resident #73 reported she fell out of bed when STNA #15 left the room. STNA #15 used the Hoyer lift to get Resident #73 back into bed by herself. STNA #13 revealed unit manager LPN #25 was notified and assessed Resident #73. Interview on 06/20/23 at 9:56 A.M. with unit manager LPN #25 revealed STNA #13 and LPN #26 came to her regarding the findings involving Resident #73. LPN #25 assessed Resident #73 and noted a bruise on the right side of her head into hairline. Resident #73 reported she fell out of bed when STNA #15 left the room, and she hit her head on the bedside table when she fell . LPN #25 voiced she completed range of motion on Resident #73 and reported pain to the right hip. LPN #25 notified son. LPN #25 stated Critical Care Transport transported Resident #73 to Hospital #1. Interview on 06/20/23 at 11:05 A.M. with the Administrator and DON revealed LPN #25 notified them regarding the incident with Resident #73. STNA #15 was providing care to Resident #73 and left the room. Resident #73 slipped out of bed and fell on to the floor. STNA #15 put Resident #73 back into bed via Hoyer lift without the help of other staff. Resident #73 had a fracture to the right hip. STNA #15 was suspended pending investigation. STNA #15 denied the fall occurring. STNA #15 refused to speak with the DON regarding the incident. About a week later, STNA #15 reached out to the DON. STNA #15 continued to deny the fall, and she was terminated. 2. Review of the medical record for Resident #89 revealed an admitted [DATE], a readmission on 05/21/23 and a discharge date of [DATE]. Diagnoses included malignant neoplasm of upper lobe, right bronchus, secondary malignant neoplasm of brain, emphysema, chronic obstructive pulmonary disease (COPD), and type two diabetes mellitus (DM II) with diabetic polyneuropathy. Review of the Admission MDS assessment dated [DATE] revealed Resident #89 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11. Resident #89 was assessed to require two-person limited assistance with transfers, one-person extensive assistance with dressing and toileting, supervision with eating, and one-person total dependence with bathing. Review of the care plan dated 05/10/23 revealed Resident #89 was at risk for fall related injury and falls related to general weakness and psychotropic medication use. Interventions included encourage to wear appropriate footwear as needed. Staff to keep environment as safe as possible with floors free from spills and/or clutter, adequate lighting, call light within reach, and commonly used items within reach. Staff to put call light within reach and encourage to use it for assistance. Physical therapy and occupational therapy to evaluate and treat as ordered and as needed. Review of the progress note dated 05/28/23 at 7:38 A.M. revealed STNA #10 was changing Resident #89 when STNA #10 turned to get depends from the table. When STNA #10 turned she saw Resident #89 rolling to the floor before STNA #10 could stop her. Resident #89 had rolled to the floor. The bed was lowered but not in lowest position. STNA #10 reported Resident #89 hit her head on the trash can but not very hard. LPN #23 came into room and found Resident #89 lying on right side beside her bed. LPN #23 assessed Resident #89 for injuries. Vital signs and range of motion were within normal limits. No injuries or complaint of pain noted upon assessment. LPN #23 educated STNA #10 on the importance of keeping bed in lowest position when leaving bedside. On-call provider, Director of Nursing notified, and Resident #89's daughter were notified of the incident. Review of the progress note dated 05/28/23 at 1:05 P.M. revealed neurological checks were completed on Resident #89 after fall and within normal limits. Blood sugar was 108 before breakfast, dropped to 67 after breakfast, and then orange juice and med pass were given. Blood sugar increased to 99. Resident #89 was more confused and lethargic with a raised area on right side of forehead. Physician was notified and gave orders to send to be evaluated at the emergency room . Resident #89's daughter requested to send Resident #89 to Hospital #2. Resident #89 was sent to Hospital #2's emergency room . Review of the fall investigation report dated 05/28/23 revealed STNA #10 called LPN #23 into Resident #89's room. LPN #23 found Resident #89 lying on right side on floor next to bed. LPN #23 assessed Resident #89, which revealed no injuries, vital signs and range of motion were within normal limits, and no complaint of pain. Predisposing environmental factors revealed bed height was not appropriate. Physician and Resident #89's daughter were notified of the incident. Interview on 06/14/23 at 3:25 P.M. with DON revealed she attempted to reach STNA #10 to get a statement regarding the incident on 05/28/23 with Resident #89. The DON revealed STNA #10 would not return the DON's phone calls. The DON reported STNA #10 did not show up for her shifts after the incident on 05/28/23 with Resident #89. The DON explained due to STNA #10 never showing up to the facility again or returning any calls, STNA #10 was terminated. Attempted interview on 06/14/23 at 4:01 P.M. and 4:50 P.M. with STNA #10 was unsuccessful with no return call. Attempted interview on 06/14/23 at 4:03 P.M. and 4:55 P.M. with LPN #23 was unsuccessful with no return call. Review of the facility policy titled, Fall Management, dated 08/18/22 revealed the facility identified hazards and resident risk factors and implement interventions to minimize falls and risk of injury related to falls. When a fall occurred, the licensed nurse will evaluate the resident for injury. Do not move the individual until he/she had been examined by a nurse. The first responder will summon a nurse after ensuring the resident was safe. A fall huddle would be held to determine the root cause of the fall. The licensed nurse would notify the attending physician and the responsible party of the fall and document the notification in the medical record. This deficiency represents non-compliance investigated under Complaint Number OH00143261.

Based on medical record review, staff interview, and facility policy review, the facility failed to properly evaluate and monitor a pressure ulcer. This resulted in actual harm when Resident #3's pressure ulcer to her coccyx, which was not open, was not monitored and/or assessed, was not assessed by the wound physician, and was found to have opened on 11/26/22. Additionally, the facility failed to properly monitor and evaluate a pressure ulcer and ensure pressure reducing interventions were implemented timely for Resident #84. This resulted in actual harm when Resident #84 was found to have coccyx redness on 12/10/22 which was not monitored or assessed until 01/04/23 when the coccyx wound was determined to be a stage three pressure ulcer. Furthermore, Resident #84 was not provided timely pressure relieving interventions. This affected two residents (#3 and #84) out of four residents reviewed for pressure ulcers. The facility census was 89. Findings include: 1. Review of Resident #3's medical record revealed Resident #3 was admitted on [DATE] and discharged on [DATE]. Resident #3 had medical diagnoses including but not limited to malignant neoplasm of unspecified site of left female breast, seizures, and dysphagia. Review of Resident #3's plan of care, dated 10/29/22, revealed Resident #3 was at risk for impaired skin integrity and pressure injury related to a current deep tissue injury on the coccyx, decreased mobility, and incontinence. Interventions included conducting weekly skin assessments, turning to reposition self as needed, following facility policies for prevention and treatment of impaired skin integrity, diet as ordered, and turning and repositioning as needed. Review of Resident #3's hospital transfer form, dated 11/04/22, revealed Resident #3 was being sent to the hospital at 2:00 P.M. There was no documentation related to an area on Resident #3's coccyx. Review of Resident #3's hospital notes, dated 11/08/22, revealed during Resident #3's hospital stay on 11/05/22 at 9:40 A.M. Resident #3 was noted to have a purple pressure ulcer. Review of Resident #3's progress note, dated 11/08/22, revealed Resident #3 returned from the hospital. During a skin assessment, it was revealed Resident #3's coccyx was red with excoriation. Review of Resident #3's progress note, dated 11/09/22, revealed a second skin sweep was done on Resident #3 and a deep tissue injury (DTI) was noted to her coccyx. The area was to be monitored. Review of Resident #3's physician order, dated 11/09/22 to 11/26/22, revealed an order to cleanse Resident #3's DTI with soap and water and pat dry, then apply zinc barrier cream. Review of Resident #3's Minimum Data Set (MDS) assessment, dated 11/15/22, revealed Resident #3 had moderately impaired cognition. Resident #3 was coded as having one deep tissue injury and an open lesion. Review of Resident #3's progress note, dated 11/26/22, revealed Resident #3's area on her coccyx had started to open. It was documented that Resident #3's wound needed to be seen by the wound doctor. Review of Resident #3's physician order, dated 11/27/22, revealed an order to cleanse Resident #3's DTI with soap and water and to pat dry, then apply calcium alginate and conventional daily dressings (CDD). Review of the facilities skin and wound evaluations dated 11/02/22, 11/09/22, 11/16/22, 11/23/22, and 11/30/22, revealed no documentation related to an area on Resident #3's coccyx. Review of the wound doctor notes dated 11/02/22, 11/09/22, 11/16/22, 11/23/22, and 11/30/22, revealed no evidence the wound doctor was notified or was aware of any areas on Resident #3's coccyx. There were no notes related to Resident #3's coccyx. Review of the transfer to the hospital form, dated 12/05/22, revealed Resident #3 had a small open area on her coccyx. Interview on 02/01/23 at 12:42 P.M. and on 02/02/23 at 10:57 A.M. with the Director of Nursing (DON) revealed it had been a Licensed Practical Nurse (LPN) who called Resident #3's area a DTI, and she was not qualified to do so. She stated staff were inconsistent in stating what the coccyx area was, but the area did open at one point. The DON confirmed Resident #3's coccyx wound opened on 11/26/22. The DON confirmed the area went from closed to open with no monitoring of the area and the wound doctor never saw Resident #3 for the coccyx wound. The DON reported a 'resident at risk' meeting had not been held since March 2022. 2. Review of the medical record revealed Resident #84 was admitted to the facility on [DATE] with diagnoses including but not limited to severe protein-calorie malnutrition, cerebral infarction, and Alzheimer's disease. Review of Resident #84's nursing comprehensive evaluation, dated 12/05/22, revealed Resident #84 had redness to her coccyx that blanched. Review of Resident #84's progress note, dated 12/10/22, revealed an area was noted to Resident #84's coccyx and new orders were in place. Review of Resident #84's physician order, dated 12/10/22, revealed an order to cleanse Resident #84's coccyx with normal saline and pat dry, then apply with calcium alginate and cover with conventional daily dressing. Review of Resident #84's physician order, dated 12/10/22, revealed Resident #84 was to have a wound consult with the physician. Review of Resident #84's plan of care, dated 12/16/22, revealed Resident #84 was at risk for impaired skin integrity and pressure injury related to incontinence, history of anemia, fragile skin, decreased mobility, and being on an antipsychotic. Interventions included conducting weekly skin assessments, cuing to reposition self as needed, obtaining labs as ordered, obtaining a weight at least monthly, providing diet as ordered, and turning and repositioning the resident as needed. Review of Resident #84's plan of care, dated 12/16/22, revealed Resident #84 had an actual impairment to skin integrity related to having a wound on the coccyx. Interventions included conducting weekly skin assessments, encouraging good nutrition and hydration, following facility protocols for treatment of injury, observing for signs of infection, observing location, size, and treatment of skin injury, providing treatment as ordered, and turning and repositioning. Review of Resident #84's physician wound note, dated 01/04/23, revealed Resident #84 had a wound on her coccyx. The physician had been asked to do a wound care assessment and evaluation. The wound was a stage three pressure ulcer with moderate serous exudate and measured 0.9 centimeters (cm) by 0.5 cm by 0.1 cm with 100 percent (%) granulation tissue (new connective tissue that forms when a wound is healing). The treatment plan was alginate calcium to be applied once daily for 30 days with a gauze island with a border. Additional recommendations included to elevate Resident #84's legs, float her heels in bed, offload the wound, and reposition Resident #84 according to facility protocol. Review of Resident #84's quarterly MDS assessment, dated 01/06/23, revealed Resident #84 had severely impaired cognition. Resident #84 was coded as having one stage three pressure ulcer. Review of Resident #84's physician wound note, dated 01/11/23, revealed the stage three pressure ulcer to her coccyx remained and had improved. The wound measured 0.7 cm by 0.2 cm by 0.3 cm with 50% slough (dead tissue) and 50% granulation tissue. Resident #84's physician orders and recommendations for the wound remained the same. Review of Resident #84's physician wound note, dated 01/18/23, revealed the stage three pressure ulcer to the coccyx remained and had improved. The wound measured 1.0 cm by 0.2 cm by 0.1 cm. There was moderate serous exudate, with 50% slough and 50% granulation tissue. The wound was debrided (the surgical removal of dead tissue from a wound), and the orders and recommendations for the wound remained the same. Review of Resident #84's physician wound note, dated 01/23/23, revealed the stage three pressure ulcer to the coccyx had deteriorated. The wound measured 1.4 cm by 0.3 cm by 0.1 cm. The treatment and orders for the wound remained the same. Review of Resident #84's skin and wound evaluations revealed there were no wound evaluations until 01/04/22. Review of Resident #84's skin and wound evaluations dated 01/04/23, 01/11/23, 01/18/23, and 01/25/23 revealed they matched the physician's wound notes. Observation on 01/31/23 from 8:56 A.M. to 2:15 P.M. revealed Resident #84 was up in her wheelchair. Interview on 01/31/23 at 2:15 P.M. with LPN #127 confirmed Resident #84 had been up in her chair since the morning. She reported she was not sure what was being done to offload pressure to Resident #84's bottom while she was in her chair. Observation on 02/01/23 at 11:12 P.M. of Resident #84 revealed she was in bed and her bed was not a pressure reducing bed. Interview on 02/01/23 at 12:42 P.M. with the DON verified Resident #84 did not have a pressure reducing mattress in place and had not had one in place but should have. The DON was unsure what was being done to offload pressure to Resident #84's wound while she was up in her chair. The DON reported Resident #84's wound assessments were missing due to changes in nursing management. Review of the policy titled Skin Management, dated 12/15/22, revealed any residents who were admitted with skin impairments will have appropriate interventions to promote healing, a physician's order for treatment, and wound location, measurements and characteristics documented. The nurse was to document this in the electronic health record until the area was resolved. The nurse was to monitor, evaluate and document changes regarding skin condition in the medical record. A weekly total body skin evaluation was to be completed and documented. A Resident at Risk (RAR) meeting was to be held at least monthly, during the meeting the team was to evaluate skin changes. This deficiency represents noncompliance investigated under Complaint Number OH00138384.

Based on medical record review, review of the Incident Report, review of the hospital records, staff interview, and policy review, the facility failed to provide the necessary assistance to a resident during incontinence care. This resulted in Actual Harm when Resident #20 sustained an acute impacted left femoral neck fracture, likely subcapital, requiring an emergency room visit for an avoidable fall when State tested Nursing Assistant (STNA) #312 provided incontinence care without the assistance of a second staff member and rolled Resident #20 away from her out of the raised bed onto the floor. This affected one (Resident #20) of three residents reviewed for falls. The facility census was 83. Findings include: Review of the medical record for Resident #20 revealed an admitted [DATE]. Diagnoses included [CONDITION(S)], diabetes mellitus Type II, coronavirus disease 2019, [CONDITION(S)], chronic obstructive pulmonary disease, idiopathic [CONDITION(S)], transient ischemic attacks, and chronic kidney disease. Review of the plan of care dated 12/27/21 revealed Resident #20 has an Activity of Daily Living (ADL) self-care performance deficit and required assistance with ADL's and mobility related to decreased mobility. Interventions included bed mobility required extensive assistance of two staff to reposition and turn in bed. Physical Therapy and Occupational Therapy evaluation and treatment as ordered. The resident requires extensive to total assistance of one to two staff to use toilet. Review of the physician orders dated 03/22/22 revealed bilateral enabler bars every shift for bed mobility. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident required extensive assistance of two plus persons for bed mobility, transfers, toilet use, and personal hygiene. The resident required the use of a wheelchair. Review of the nursing notes dated 05/08/22 at 1:38 P.M. revealed at approximately 11:15 A.M. State tested Nursing Assistant (STNA) #312 was providing care to Resident #20. STNA #312 stated while providing care she turned Resident #20 to her left side. Resident #20 lost balance and STNA #312 could not hold her. The nurse completed a head-to-toe assessment. Resident #20's face was against the chair or recliner by the bed. She was lying on her chest and the left shoulder was between the bed and the chair. The nurse repositioned Resident #20 and placed her on her back. Resident #20 complained of left hip pain and left shoulder pain, staff nurses assisted the resident to bed. Vital signs were obtained, neurological checks started immediately, and contacted the Certified Nurse Practitioner (CNP) #406 on-call. Telephone orders were received to send the guest to the emergency room for more evaluation, family and Power Of Attorney (POA) aware and visited prior to Emergency Medical Technician (EMT) staff arrival. Review of the Incident Report dated 05/08/22 revealed at 11:15 A.M., Resident #20 had a witnessed fall from the bed in the resident's room. Resident #20 was taken to a local hospital via an ambulance on 05/08/22 at 12:00 P.M. Immediate interventions included Resident #20 must have two-person assistance when providing care and staff education. Review of the Hospitalist Physician Progress Note dated 05/16/22 revealed Resident #20 presented with left hip pain after a fall. A closed hip fracture of the left hip. The X-ray of the pelvis and the left hip showed an acute impacted left femoral neck fracture, likely subcapital fracture. No dislocation noted. Pathological fracture of the left femoral neck due to a combination of osteopenia and trauma that alone would not have caused the fracture. Status post left hip hemiarthroplasty (a rare surgery performed under unique circumstances, replacing half of a hip joint usually done after a rare traumatic injury in which the femoral head is fractured) on 05/10/22. Interview on 05/16/22 at 3:17 P.M., STNA #312 stated she had changed Resident #20 per usual and Resident #20 was able to help with turns. She stated she was not sure if the resident required two-person assistance for turns. She stated during her training she was told Resident #20 could turn herself. STNA #312 stated she should have looked at the care plan. Interview on 05/17/22 at 10:22 A.M., Therapy Director #229 stated they had evaluated Resident #20 on 01/28/22 for dressing, bed mobility, and seated balance. He stated Resident #20 was total dependence of two persons for bed mobility. He said the facility had not initiated therapy treatment because Resident #20 had no significant change from the prior therapy evaluation. A follow-up interview on 05/17/22 at 10:28 A.M., STNA #312 stated she had rolled Resident #20 away from herself while she was providing incontinence care. She said the bed was raised to a height between her mid-thigh and hip, as she was taught. STNA #312 estimated the height of the bed at two to two and a half feet high. STNA #312 said she had crossed Resident #20's right leg over the left to make it easier for herself and the resident to roll to her left side. She held the resident at about her waist while she cleaned her. She said the resident rolled off the side of the bed and had rolled onto her stomach on the floor. The resident was alert and started yelling for help. Interview on 05/17/22 at 11:30 A.M., the Director of Nursing (DON) stated she requested updates from the hospital and Resident #20 was stable. The DON stated Resident #20's chart revealed she had a left hemiarthroplasty, a surgical procedure that involved replacing half of the hip joint, on 05/10/22. Review of the facility policy titled Standards of CNA/STNA Practice, revised 10/01/19 revealed Certified Nursing Assistants CNA)/State tested Nurse Assistants (STNA) provide services and care for guests/residents under the direction and supervision of the licensed nurse. The CNA/STNA follows standards and procedures in the provision of services and care for guests/residents. The CNA/STNA assists the guest/resident in activities of daily living such as feeding, drinking, turning and positioning, ambulating, transferring, transportation within the facility, bathing, grooming, toileting, dressing, nail care and socialization. This deficiency substantiates Complaint Numbers OH 87 and OH 503.