Every finding on record at Legends Care Rehabilitation and Nursing Center

Based on medical record review and staff interview, the facility failed to ensure care conferences were held timely. This affected one (Resident #55) out of three residents reviewed for care conferences. The facility census was 52 residents.Findings include:Review of the medical record for Resident #55 revealed an admission date of 03/08/26 with diagnoses including kidney stones, quadriplegia, and depression and a discharge date of 03/12/26. Review of the Minimum Data Set (MDS) assessment for Resident #55 dated 03/12/26 revealed the resident had intact cognition and was dependent on staff for all activities of daily living (ADLs.) Review of the progress notes for Resident #55 dated 03/28/26 through 03/12/26 revealed there was no documentation of an initial care conference meeting. Interview on 05/04/26 at 12:02 P.M. with the Regional Director of Operations (RDO) confirmed care conference meetings are to be held within the first 72 hours after admission. Interview on 05/04/26 at 12:04 P.M. with Social Service Designee (SSD) #803 verfied she did not hold a care conference within the first 72 hours after admission for Resident #55. This deficiency represents non-compliance investigated under Complaint Number 2996725.

Based on medical record review, observation, and staff interview, the facility failed to ensure there was a phone available for residents to use. This affected one (Resident #55) out of three residents reviewed for telephone communication. The facility census was 52 residents. Findings include:Review of the medical record for Resident #55 revealed an admission date of 03/08/26 with diagnoses including kidney stones, quadriplegia, and depression and a discharge date of 03/12/26. Review of the Minimum Data Set (MDS) assessment for Resident #55 dated 03/12/26 revealed the resident had intact cognition and was dependent on staff for all activities of daily living (ADLs.) Observation on 05/04/26 at 11:58 A.M. revealed there were no phones which were accessible for Resident #55. Interview on 05/04/26 at 12:00 P.M. with the Administrator confirmed Resident #55 did not tolerate getting out of bed due to his medical condition and the phones the facility provided for resident use were not accessible to the resident. Interview on 05/04/26 at 12:02 P.M. with the Regional Director of Operations (RDO) confirmed the facility did not have an accessible phone for Resident #55's use. The RDO stated staff had been using their personal cell phones to help Resident #55 when he needed to make a call. The RDO confirmed the facility had accessible phones available for all residents and staff should not have to use their personal cell phones for residents to make calls. This deficiency represents noncompliance investigated under Complaint Number 2802574 and Complaint Number 2802583.

Based on record review, interview, facility investigation review, and policy review, the facility failed to timely report an allegation of misappropriation to all required entities. This affected one resident (Resident #73) out of three residents reviewed for misappropriation of narcotics. Facility census 65. Findings include:Review of the closed medical record for Resident #73 revealed an admission date of 01/12/16 and a discharge date of 01/14/26. Diagnoses included but were not limited to hemiplegia, malignant neoplasm of bladder and prostate. Review of the Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #75 had impaired cognition. Review of the Physician orders for January 2026 revealed an order for Fentanyl (opioid drug) Transdermal Patch 72 hour 50 microgram/hour (MCG/HR) apply patch transdermally one time a day every 2 days for chronic pain and remove per schedule.Review of the investigation report revealed on 01/14/26 with no time included, revealed former Director of Nursing (DON) #401 was notified by the night nurse, Licensed Practical Nurse (LPN) #222, of two missing Fentanyl patches, a powerful synthetic opioid which is about 50 to 100 times more potent than morphine, approved for treating severe, chronic, or acute pain. The alleged misappropriation was not reported to the Ohio Department of Health (ODH) through a Self-Reported Incident (SRI). The facility did not report the incident to the police or pharmacy. Interview on 03/05/26 at 12:19 P.M. with LPN #226 confirmed she received the medications from the pharmacy delivery of two Fentanyl patches in the pharmacy bag, pulled out the baggie and counted the two Fentanyl Patches and signed the pharmacy delivery slip. LPN #226 reported she then took the pharmacy bag with the medications to include the narcotics, two Fentanyl patches and handed them to LPN #228.Interview on 03/05/26 at 12:36 P.M. with LPN #228 revealed she did not receive the two Fentanyl patches from LPN #226. LPN #228 reported she didn't know she was supposed to have two Fentanyl patches. Interview on 03/05/26 at 12:57 P.M. and on 03/09/26 at 8:27 A.M. with Registered nurse (RN) #400 confirmed the two Fentanyl patches for Resident #73 were never found and it should have been reported to the ODH with a SRI initiated for misappropriation, police called, and all nursing staff working should have provided statements and drug tested. Interview on 03/09/26 at 7:51 A.M. with former DON #401 confirmed there were two missing Fentanyl patches, narcotic for pain for Resident #73. DON #401 confirmed the missing Fentanyl patches should have been reported to the ODH with a SRI should have been initiated immediately for misappropriation of narcotic medications and police notified. Former DON #401 reported she was told by corporate not to report the incident as a SRI or to police. During this interview former DON #401 revealed she received a text from Administrator regarding the Fentanyl patches just at the time of interview stating it's not misappropriation because it was the facilities property as the facility paid for the patch, therefore they can't misappropriate their own property. Interview on 03/09/26 at 10:06 A.M. with Regional RN #403 revealed she doesn't know why an SRI wasn't done on Resident #73 with the missing narcotics and would have to check with the Administrator.Interview on 03/09/26 at 5:25 P.M. with Pharmacist #406 confirmed he did not receive notification from the facility regarding any missing narcotics, to include Fentanyl patch 50 mcg for Resident #73 and he should have. He confirmed the Fentanyl patches are available in the Pixus at the facility, and they would just need to call to receive authorization to pull the medication.Interview on 03/10/26 7:14 A.M. with LPN #200 revealed she worked on 01/13/26 as a night nurse and in the morning LPN #226 brought back the pharmacy medication bags which she signed for and tried to give to her. LPN #200 reported she refused because day shift LPN #228 was with the medication cart and keys. LPN #200 reported LPN #226 handed the pharmacy bag off to LPN #228 and she counted the narcotic medications with RN #400. LPN #200 reported she received a call from former DON #401 with some questions regarding the missing Fentanyl patches for Resident #73 and was drug tested days later.Review of the facility policy, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, revised November 01 2019, revealed it is the facilities policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of resident, or misappropriation of Resident Property. Further states staff should immediately report all such allegations to the Administrator/designee and to the Ohio Department of Health (ODH) and in cases where a crime is suspected should report to local law enforcement. The policy included the investigation should be documented. Review of the facility policy, Controlled Substances, revised December 2012, revealed the facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule 2 and other controlled substances. Controlled substances must be counted upon delivery and the nurse receiving the medication, along with the person delivering the medication must count the controlled substance together. Both individuals must sign the designated controlled substance record. Nurses must document and report any discrepancies to the DON. DON must consult with the pharmacy and administrator. This deficiency represents noncompliance investigated under Complaint Number 2726333.

Based on record review, interview, facility investigation review, and policy review, the facility failed to ensure a thorough investigation was completed for missing narcotic medication. This affected one resident (Resident #73) out of three residents reviewed for misappropriation of narcotics. Facility census was 65. Findings include:Findings include:Review of the closed medical record for Resident #73 revealed an admission date of 01/12/16 and a discharge date of 01/14/26. Diagnoses included but were not limited to hemiplegia, malignant neoplasm of bladder and prostate. Review of the Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #75 had impaired cognition. Review of the Physician orders for January 2026 revealed an order for Fentanyl (opioid drug) Transdermal Patch 72 hour 50 microgram/hour (MCG/HR) apply patch transdermally one time a day every 2 days for chronic pain and remove per schedule.Review of the investigation report revealed on 01/14/26 with no time included, revealed former Director of Nursing (DON) #401 was notified by the night nurse, Licensed Practical Nurse (LPN) #222, of two missing Fentanyl patches, a powerful synthetic opioid which is about 50 to 100 times more potent than morphine, approved for treating severe, chronic, or acute pain. The investigation included only four statements from Registered Nurse (RN) #400, LPN #200, LPN #228, and LPN #226. There was no statement form LPN #222 who reported the missing Fentanyl Patches. There was no statement from LPN #209 who oriented with LPN #226. There was an email from the Administrator to former DON #401, dated 01/14/26 at 5:48 P.M. reporting this was LPN #226's statement with no signature on it. The investigation revealed only three staff were drug tested two days later on 01/16/26, to include LPN #200, LPN #226, and LPN #228. RN #400 who counted the narcotics with LPN #228 was not drug tested, LPN #209, who oriented with LPN #226 (who signed for the two missing Fentanyl patches) was not drug tested. There was a typed form signed by former DON #401, dated 01/16/26, revealed The investigation for the two Fentanyl patches has proven inconclusive. Patches believed to be disposed of when bags thrown away. The misappropriation was not reported to the Ohio Department of Health (ODH) through a Self-Reported Incident (SRI). The facility did not report the incident to the police or pharmacy. Interview on 03/05/26 at 12:19 P.M. with LPN #226 confirmed she received the medications from the pharmacy delivery of two Fentanyl patches in the pharmacy bag, pulled out the baggie and counted the two Fentanyl Patches and signed the pharmacy delivery slip. LPN #226 reported she then took the pharmacy bag with the medications to include the narcotics, two Fentanyl patches and handed them to LPN #228.Interview on 03/05/26 at 12:36 P.M. with LPN #228 revealed she did not receive the two Fentanyl patches from LPN #226. LPN #228 reported she didn't know she was supposed to have two Fentanyl patches. Interview on 03/05/26 at 12:57 P.M. and on 03/09/26 at 8:27 A.M. with Registered nurse (RN) #400 confirmed the two Fentanyl patches for Resident #73 were never found and it should have been reported to the ODH with a SRI initiated for misappropriation, police called, and all nursing staff working should have provided statements and drug tested. RN #400 confirmed a thorough investigation was not completed. RN #400 reported not all nurses who worked that evening gave statements and only three nurses were drug tested days later. RN #400 reported staff should have been drug tested immediately. RN #400 reported she wrote a full page statement and then last Wednesday, after this surveyor entered the facility, was asked to write a statement, which is in the investigation. RN #400 reported she checked with the Administrator who reported she didn't know where the original statement was. RN #400 confirmed there was no statement in the investigation for LPN #222, LPN #209, and LPN #226 statement was an email from the administrator not signed.Interview on 03/09/26 at 7:51 A.M. with former DON #401 confirmed there were two missing Fentanyl patches, narcotic for pain for Resident #73. DON #401 confirmed the missing Fentanyl patches should have been reported to the ODH with a SRI should have been initiated immediately for misappropriation of narcotic medications and police notified. Former DON #401 reported she was told by corporate not to report the incident as a SRI or to police. During this interview former DON #401 revealed she received a text from Administrator regarding the Fentanyl patches just at the time of interview stating it's not misappropriation because it was the facilities property as the facility paid for the patch, therefore they can't misappropriate their own property. Former DON #401 reported all nursing staff should have provided statements and all nurses drug tested. Former DON reported only LPN #200, LPN #226, and LPN #228 were drug tested.Interview on 03/09/26 at 10:06 A.M. with Regional RN #403 revealed she doesn't know why an SRI wasn't done on Resident #73 with the missing narcotics and would have to check with the Administrator.Interview on 03/09/26 at 5:25 P.M. with Pharmacist #406 confirmed he did not receive notification from the facility regarding any missing narcotics, to include Fentanyl patch 50 mcg for Resident #73 and he should have. He confirmed the Fentanyl patches are available in the Pixus at the facility, and they would just need to call to receive authorization to pull the medication.Interview on 03/10/26 7:14 A.M. with LPN #200 revealed she worked on 01/13/26 as a night nurse and in the morning LPN #226 brought back the pharmacy medication bags which she signed for and tried to give to her. LPN #200 reported she refused because day shift LPN #228 was with the medication cart and keys. LPN #200 reported LPN #226 handed the pharmacy bag off to LPN #228 and she counted the narcotic medications with RN #400. LPN #200 reported she received a call from former DON #401 with some questions regarding the missing Fentanyl patches for Resident #73 and was drug tested days later.Review of the facility policy, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, revised November 01 2019, revealed it is the facilities policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of resident, or misappropriation of Resident Property. Further states staff should immediately report all such allegations to the Administrator/designee and to the Ohio Department of Health (ODH) and in cases where a crime is suspected should report to local law enforcement. The policy included the investigation should be documented. Review of the facility policy, Controlled Substances, revised December 2012, revealed the facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule 2 and other controlled substances. Controlled substances must be counted upon delivery and the nurse receiving the medication, along with the person delivering the medication must count the controlled substance together. Both individuals must sign the designated controlled substance record. Nurses must document and report any discrepancies to the DON. DON must consult with the pharmacy and administrator. This deficiency represents noncompliance investigated under Complaint Number 2726333.

Based on interview, record review, observation, and hospital record review, the facility failed to ensure surgical wound dressing orders were in place and provided as ordered, and failed to ensure post operative intervention was place to prevent blood clots. This affected three residents (#70, #71 and #72) our of three residents reviewed wound care, and two residents (#70 and #71) out of three residents reviewed for anticoagulant medication. The facility census was 65.Findings include: 1.Review of the closed medical record for Resident #70 revealed an admission date of 01/02/26 and a discharge date of 01/13/26. Diagnoses included but not limited to displaced fracture of base of neck of right femur, nicotine dependence, and obesity.Review of the Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 had intact cognition. Review of the Resident #70's physician orders for 01/02/26, 01/03/26, and 01/04/26 revealed there were no orders for a surgical wound dressing. Review of the orders for 01/05/26 for Resident #70 revealed an order for a dry dressing change to right hip, change daily, as needed (PRN) for soilage, one time a day for wound healing and every 12 hours PRN for surgical wound. There were no prior orders for dressing changes. The treatment was first implemented on 01/06/26.Interview on 02/26/26 at 1:39 P.M. with Resident #70 revealed her surgical wound was seeping and when the facility removed the band aid they never covered it back up until two days later. Resident #70 revealed when she took a shower and the dressing came off and the facility never covered it again. Resident #70 revealed the doctor and nurses never even looked at the wound.Interview on 03/09/26 at 1:52 P.M. with Registered Nurse (RN) #400 confirmed there were no orders for the surgical wound for Resident #70 until 01/06/26, four days later and the admitting nurse should have clarified with the physician and put in orders for a post surgical repair of hip fracture.Interview on 03/04/26 at 3:30 P.M. Regional RN #404 confirmed there were no orders for the surgical wound for Resident #70 until 01/06/26, four (4) days later and the admitting nurse should have clarified with the physician and put in orders for a post surgical repair of hip fracture to at least monitor site.Review of the facility policy, Wound Care, revised October 2010, revealed the purpose of this procedure is to provide guidelines for the care of wounds to promote healing and to verify a physician order.2. Review of the closed medical record for Resident #71 revealed an admission date of 01/05/26 and a discharge date of 01/16/26. Diagnoses included but were not limited to displaced intertrochanteric fracture of right femur.Review of the Medicare 5-day MDS assessment dated [DATE] revealed Resident #71 had intact cognition. Review of the physician orders for 01/05/36 revealed there were no orders for a surgical wound dressing changes or orders to monitor the surgical site.Review of the Medication Administration Records (MARS) and Treatment Administration Records (TARS) for Resident #71 for January 2026 revealed there were no surgical wound dressing orders or to monitor the wound site. Interview on 03/09/26 at 1:52 P.M. with RN #400 confirmed there were no orders for the surgical wound for Resident #71 and the admitting nurse should have clarified with the physician and put in orders for a post surgical repair of hip fracture.Interview on 03/04/26 at 3:30 P.M. Regional RN #404 confirmed there were no orders for the surgical wound for Resident #71 and there should have been orders. The admitting nurse should have clarified with the physician and put in orders for a post surgical repair of hip fracture to at least monitor site.Review of the facility policy, Wound Care, revised October 2010, revealed the purpose of this procedure is to provide guidelines for the care of wounds to promote healing and to verify a physician order.3. Review of the medical record for Resident #72 revealed an admission date of 03/03/26. Diagnosis included but were not limited to atrioventricular blood, complete, bradycardia, and presence of cardiac pacemaker.Review of the Medicare 5-day MDS assessment dated [DATE] revealed Resident #72 had intact cognition. Review of the Physician orders for 03/03/26 revealed on admission there were no orders for care of the surgical site of the pacemaker. Orders were entered on 03/04/36 at 7:00 P.M. by Regional RN #404 after surveyor intervention.Interview on 03/04/26 at 3:30 P.M. Regional RN #404 confirmed there were no orders for the surgical wound care for Resident #72 and there should have been orders. The admitting nurse should have clarified with the physician and put in orders for a post surgical wound to at least monitor the site.Interview on 03/09/26 at 1:52 P.M. with RN #400 confirmed there were no orders for the surgical wound dressing changes or care for Resident #72 until 03/04/26 at 7:00 P.M. RN #400 confirmed the admitting nurse should have clarified with the physician and put in orders for a post surgical wound.Review of the facility policy, Wound Care, revised October 2010, revealed the purpose of this procedure is to provide guidelines for the care of wounds to promote healing and to verify a physician order.4. Review of the closed medical record for Resident #70 revealed an admission date of 01/02/26 and a discharge date of 01/13/26. Diagnoses included but were not limited to displaced fracture of base of neck of right femur, nicotine dependence, and obesity.Review of the hospital papers dated 12/30/26 revealed Resident #70 was ordered Enoxaparin 40 milligrams (MG), (Lovenox a blood thinning anticoagulant medication), every 24 hours subcutaneously (SQ). Review of Resident #70's hospital Operative/Procedure Report, dated 12/30/26 revealed the postoperative plan after surgery was to include six weeks total of chemical deep vein thrombosis (DVT) prophylaxis of Lovenox, AC (anticoagulant). Review of Resident #70's physician orders revealed there were no orders for an anticoagulant, used to help prevent deep vein thrombosis after surgery.Review of Resident #70's medical record contained no evidence of preventive measures the facility was taking to prevent blood clots post surgery.Review of the Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 had intact cognition.Interview on 02/26/26 at 1:39 P.M. with Resident #70 revealed the facility never gave her blood thinners as she should have since day one of admission.Interview on 03/04/26 at 3:30 P.M. Regional Registered Nurse (RN) #404 confirmed there were no orders for anticoagulant medication for Resident #70. Regional RN #404 revealed the hospital should have been called by the admitting nurse for clarification on the AC. Regional RN #404 revealed after post operative hip surgery an AC is prescribed unless contraindicated.Interview on 03/09/25 at 1:52 P.M. with RN #400 confirmed Resident #70 should have been on an AC at the nursing home. RN #400 confirmed the admitting facility nurse should have contacted the Physician regarding clarification of the AC. RN #400 revealed after post operative hip surgery an AC is prescribed unless contraindicated.Review of facility policy, Anticoagulation -Clinical Protocol, revised September 2012, revealed the physician will identify individuals who are currently anticoagulated, to include those who have had a recent joint replacement surgery. Review of facility policy, Administering Medications, revised December 2012, revealed medications shall be administered in a safe and timely manner, and as prescribed.5. Review of the closed medical record for Resident #71 revealed an admission date of 01/05/26 and a discharge date of 01/16/26. Diagnoses included but were not limited to displaced intertrochanteric fracture of right femur,Review of the Medicare 5-day MDS assessment dated [DATE] revealed Resident #71 had intact cognition.Review of the hospital inpatient progress note dated 12/31/26 revealed Venous Thromboembolism prevention, are medical measures taken to prevent blood clots from forming in deep veins (DVT) or traveling to the lungs (PE). The progress note further stated VTE prophylaxis, means after hip surgery with an AC to prevent life-threatening venous thromboembolism (VTE) is appropriate, which includes DVT and PE. The preventive treatment is critical for up to 35 days post surgery. Review of the hospital referral records dated 01/05/26 revealed Resident #71 had a right hip fracture and right foot fracture and was ordered Enoxaparin 40 mg injection, Lovenox, every 24 hours SQ on 12/31/26.Review of Resident #71's physician orders revealed there were no orders for AC medications.Review of Resident #71's medical record contained no evidence of preventive measures the facility was taking to prevent blood clots post surgery.Interview on 03/05/26 at 3:30 P.M. with Regional RN #404 confirmed there were no orders for anticoagulant medication for Resident #71. Regional RN #404 revealed the hospital should have been called by the admitting nurse for clarification on the AC. Regional RN #404 revealed after post operative hip surgery a AC is prescribed unless contraindicated.Interview on 03/09/25 at 1:52 P.M. with RN #400 confirmed Resident #71 should have been on Lovenox, AC at the nursing home. RN #400 revealed the admitting nurse should have contacted the hospital regarding clarification of the AC.Review of facility policy, Anticoagulation -Clinical Protocol, revised September 2012, revealed the physician will identify individuals who are currently anticoagulated, to include those who have had a recent joint replacement surgery. Review of facility policy, Medication Utilization and Prescribing - Clinical Protocol, revised July 2016, revealed staff will ensure medications are given appropriately. This deficiency deficiency represents noncompliance investigated under Complaint Number 2723756.

Based on observation, interview with staff, and review of facility policy, the facility failed to maintain a sanitary kitchen and failed to properly date food items when opened. This affected all the residents in the facility except three residents (Resident #2, #18 and #57) who did not eat their meals from the kitchen. Findings Include:Observations of the kitchen during the initial tour with [NAME] #114 on 01/20/26 at 8:25 A.M. revealed the following concerns:a. In the food preparation room there was food debris and pieces of cardboard boxes on the floor, an uncooked/raw biscuit that was stepped on and smashed on the floor, the steel table had a large amount of food debris on the lower shelf, there was pieces of food debris and dried brown and white liquids splashed onto the wall behind the food preparation table and sink, and there were two trays of bowls filled with dried cereal on a cart with no date as to when they were poured or prepared.b. In the refrigerator there was a large round plastic container with an unknown red liquid in it with no date as to when it was made or what it was, there was a square container of cherry tomatoes with no date as to when they were placed in the container, and a large five pound bag of salad mix was open to air and had no date as to when it was opened.c. In the freezer there was a large plastic container of an unknown type of soup with no date as to when in was made or placed in the freezer, there were two three-tiered black plastic carts with food debris and a dark brown liquid spilled on them, the wall behind the steamer was dirty with dried liquid splashed on it and running down the wall, and the floor behind the steamer was dirty with a large buildup of black dirt. On 01/21/26 at 8:40 A.M. an interview with [NAME] #114 verified all the above concerns. Review of the undated facility policy titled, Food Storage, revealed sufficient storage facilities were provided to keep food safe, wholesome and appetizing. Food was stored, prepared and transported at an appropriate temperature and by methods designed to prevent contamination. Leftover food was stored in covered containers or wrapped carefully and securely. Items stored for a period of 24, or more, hours should be clearly labeled and dated before being refrigerated. Leftover food was to be used within two to six days,Review of the undated facility policy titled, Cleaning and Sanitizing Dietary Areas and Equipment revealed all kitchen areas and equipment should be maintained in a sanitary manner and be free of buildup of food, grease and other soil. The facility would provide sanitary food service that met the State and federal regulations. This deficiency represents non-compliance investigated under Complaint Number 2579510.

Based on observation, review of the medical record, interview with staff, and review of facility policy, the facility failed to maintain and medication error rate of less than five percent (%). Nine medications were given in error out of 25 opportunities for error, to equal an error rate of 36%. This affected one resident (Resident #18) out of four observed for medication administration.Findings Include: Review of the medical record revealed Resident #18 was admitted to the facility on [DATE]. Diagnoses included lupus, acute respiratory failure, moderate protein-calorie malnutrition, gastrostomy status, and dysphagia.Review of the January 2026 physician's orders revealed Resident #18 had orders due at 9:00 A.M. for acidophilus 500 million units daily, Bactrim DS 800/160 milligrams (mg) daily, prednisone 10 mg daily, Protonix 40 mg Delayed Release (DR) daily, zinc sulfate 220 mg daily, Mucinex 600 mg twice daily, senna plus 8.6/50 mg twice daily, baclofen 10 mg three times daily, and oxycodone 10 mg three times daily. Further review of the physician orders revealed orders for his medication to be given via percutaneous endoscopic gastrostomy (PEG) tube (a tube that is inserted through the abdomen into the stomach, used to provide long term nutritional support) however, the resident did not have an order for his medication to be cocktailed (mixed together) and given all at once.Observation on 01/21/26 at 8:30 A.M. revealed Licensed Practical Nurse (LPN) #127 prepared one capsule of acidophilus 500 million units, one tablet of Bactrim DS 800/160 mg, one tablet of prednisone 10 mg, one tablet of Protonix 40 mg, one tablet of zinc sulfate 220 mg, one tablet of Mucinex 600 mg, one senna plus 8.6/50 mg, one tablet of baclofen 10 mg and one tablet oxycodone 10 mg for Resident #18. LPN #127 crushed all the medication and placed the powdered medications into one medication cup mixed together and prepared to administer the medications to the resident. She verified at this time Resident #18 was to receive all his medication via a PEG tube however he did not have an order to cocktail his medication and administer them all at the same time. Review of the facility policy titled, Administering Medication through an Enteral Tube, dated 03/2015 revealed the purpose of the procedure was to provide guidelines for a safe administration of medication through an enteral tube. General guidelines were to not mix medication together prior to administration through an enteral tube unless there was a physician's order stating otherwise with a rationale. It noted to administer each medication separately unless there was a physician's order stating otherwise.

Based on review of the medical record and interview with staff, the facility failed to ensure radiologic study recommendations were scheduled and addressed in a timely manner for Resident #58. This affected one resident (Resident #58) of three reviewed for a change in condition.Findings Include:Review of the medical record revealed Resident #58 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, chronic obstructive pulmonary disease, chronic bronchitis, acute respiratory failure, atherosclerotic heart disease, hypertension, congestive heart failure, ischemic cardiomyopathy and vision loss. Resident #58 was sent to the emergency room on [DATE].Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #58 had intact cognition.Review of the Progress Note dated 09/15/25 at 4:18 P.M. revealed Resident #58 was resting in bed. The resident complained of being more tired than usual. The resident ' s family called into the facility stating he must go to the hospital. The nurse explained to the family member that the facility was able to work-up the resident at the facility. The family was in agreement. The physician was notified and ordered a comprehensive metabolic panel, complete blood count, and a chest x-ray. Review of the September 2025 physician ' s orders revealed Resident #58 had orders for complete blood count (CBC), Comprehensive metabolic panel (CMP) and urinalysis, urine culture, and a chest x-ray for complaints of shortness of breath.Review of the chest x-ray results for Resident #58 dated 09/15/25 revealed suboptimal evaluation due to rotation, linear opacities were seen in the left lower zone which was possible fibro-atelectatic changes. Prominence of both pulmonary hila and attenuation of broncho-vascular markings were seen in the bilateral lungs representing congestion. Elevations of left dome of the diaphragm was seen. The scan recommended a follow up for a high-resolution computer tomography (HRCT) lung scan which produced highly detailed images of the lungs.Review of the Progress note dated 09/16/25 at 10:38 A.M. revealed the chest x-ray results for Resident #58 revealed linear opacities were seen in the left lower zone which was possible fibro-atelectatic changes. Prominence of both pulmonary hila and attenuation of broncho-vascular markings were seen in the bilateral lungs representing congestion. Elevations of left dome of the diaphragm were seen. The resident's family (Family Member #250) and doctor were aware. On 01/21/26 at 10:20 A.M. an interview with the Director of Nursing (DON) revealed the facility had completed a skilled assessment each day on Resident #58, and they completed a chest x-ray which was sent to the physician to review. She stated she did not recall if she spoke to the physician about the recommendation for the chest x-ray and verified there was no evidence of a follow up or that the HRCT lung scan was ordered or set up. On 01/21/26 at 12:50 P.M. an interview with Physician #253 revealed he did not remember what had occurred with Resident #58 and he would have to review his notes. He stated he did look at the resident ' s chest x-ray today again and he did not see anything acute that needed addressed. He stated the DON did also mention on this day about the recommendation for the HRCT scan and he confirmed that it was a recommendation, however he did not believe it would have been necessary at that moment. On 01/21/26 at 5:03 P.M. an interview with Family Member #250 revealed she was not aware of the recommendation for a CT-scan of his lungs.This deficiency represents non-compliance investigated under Complaint Number 2631680.

Based on review of the medical record and interview with staff, the facility failed to ensure the concerns of the family of Resident #58 were addressed timely. This affected one resident (Resident #58) of three reviewed for change in condition.Findings Include:Review of the medical record revealed Resident #58 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, chronic obstructive pulmonary disease, chronic bronchitis, acute respiratory failure, atherosclerotic heart disease, hypertension, congestive heart failure, ischemic cardiomyopathy and vision loss. Resident #58 was sent to the emergency room on [DATE] were he later passed away.Review of the face sheet for Resident #58 revealed Family Member #250 was the emergency contact.Review of the Health Care Power of Attorney (HCPOA) paperwork, dated and notarized on 08/11/25, revealed Family Member #250 was the HCPOA for Resident #58. This information was submitted to the facility on [DATE]. Review of the Do-Not-Resuscitate (DNR) form dated 08/27/25 revealed Resident #58 was a DNR comfort care arrest (CC-A). Review of the Brief Interview of Mental Status dated 08/27/25 revealed Resident #58 had moderately impaired cognition. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #58 had intact cognition.Review of the Vital Signs documented on 09/15/25 at 10:27 A.M. revealed the vital signs for Resident #58 were blood pressure 126/85 millimeters of Mercury (mmHg) (normal ranges around 120/80 mmHg), pulse 88 beats per minute (bpm) (normal ranges from 60 to 100 bpm), respirations 18 breaths per minute (normal ranges from 12 to 20 breaths per minute), oxygen level 92 percent (%) on room air (normal ranges from around 95% to 100%) and temperature was 97.6 degrees Fahrenheit (F) (normal ranges from around 97 degrees F to 99 degrees F).Review of the Progress Note dated 09/15/25 at 4:18 P.M. revealed Resident #58 was resting in bed. The resident complained of being more tired than usual. The resident's family member called into the facility stating he must go to the hospital. The nurse explained to the resident's family that the facility was able to work-up the resident at the facility. Family Member #250 was in agreement. The physician was notified and ordered a comprehensive metabolic panel, complete blood count, chest x-ray. Review of the September 2025 physician's orders revealed Resident #58 had orders for a complete blood count (CBC), Comprehensive metabolic panel (CMP) and urinalysis, urine culture, and a chest X-ray for complaints of shortness of breath.Review of the chest x-ray results for Resident #58 dated 09/15/25 revealed suboptimal evaluation due to rotation, linear opacities were seen in the left lower zone which was possible fibro-atelectatic changes. Prominence of both pulmonary hila and attenuation of broncho-vascular markings were seen in the bilateral lungs, representing congestion. Elevations of the left dome of the diaphragm was seen. Recommend a follow up high resolution computer tomography (HRCT) lung scan which produced highly detailed images of the lungs. Review of the Progress note dated 09/16/25 at 10:38 A.M. revealed the chest x-ray results for Resident 358 revealed linear opacities were seen in the left lower zone which was possible fibro-atelectatic changes. Prominence of both pulmonary hila and attenuation of broncho-vascular markings were seen in the bilateral lungs, representing congestion. Elevations of left dome of the diaphragm were seen. The resident's family member and doctor were aware. Review of the Change in Condition Summary dated 09/21/25 at 7:47 A.M. revealed the vital signs for Resident #58 were blood pressure 149/98 mmHg, pulse 89 bpm, respirations 24 breaths per minute, temperature 97.3 degrees F and oxygen level 98 % on room air. Review of the Progress Note dated 09/21/25 at 8:07 A.M. revealed Resident #58 was noted to have right sided facial droop, was aphasic and had a decreased mental status at 7:40 A.M. Nine-one-one (911) was activated immediately. The physician, Director of Nursing (DON) and emergency contact were contacted. The resident was sent to the hospital for stroke-like symptoms. Report was called to the hospital.On 01/20/26 at 10:20 A.M. an interview with Family Member (FM) #250 revealed she had asked several times for Resident #58 to be sent to the hospital because he was not acting right. She stated he was slurring his speech when she spoke to him on 09/15/25 and he normally called her several times a day and he had not called her in a couple days. She stated Resident #58 had told her he had wanted to go to the hospital. She stated when she spoke to Licensed Practical Nurse (LPN) #121 she was under the impression they were going to send Resident #58 to the hospital, however she received a call from LPN #121 stating he had spoken to the DON and they were going to just do a workup at the facility. She stated they were going to do a CBC, CMP and urinalysis, urine culture, and a chest x-ray. She stated she called the DON and questioned why they were not sending him out to the hospital like she had requested and was told she was not the MPOA and he was not exhibiting any signs of a change in condition that warranted him being sent out to the hospital. FM #250 stated she explained to the DON she completed the proper paperwork at the hospital to become his MPOA, however the DON stated they did not have that paperwork. She stated she had emailed the Social Worker several times concerning the MPOA paperwork. She stated she found the paperwork on 09/17/25 and sent it to both the Social Worker and DON. She stated they still did not send him to the hospital until 09/21/25 for stroke-like symptoms and he passed away at the hospital. She stated she lived in [NAME] Virginia and could not drive to the facility. On 01/20/26 at 11:34 A.M. an interview with LPN #121 revealed Resident #58 was alert but confused most of the time. He stated he remembered Resident #58 had been giving the staff a hard time about taking his medications, he had fallen and he was on fall precautions. LPN #121 stated he sent Resident #58 out [to the hospital] on 09/21/25 because he was showing signs of having a stroke. He stated he did not know when he worked with him prior to that day. He stated the resident's family member had requested Resident #58 to be sent out to the hospital prior to that, but he had explained to her they could do a full work up of him at the facility and he did not need to be sent out.On 01/21/26 at 10:20 A.M. an interview with the DON revealed the facility had completed a skilled assessment each day on Resident #58, they completed a chest x-ray which was sent to the physician to review. She stated a urine was sent and did not show any abnormal so they did not have to complete a culture. She stated Resident #58 refused to have his lab work done. She stated he had albuterol aerosols as needed ordered on admission but verified none were given for his shortness of breath. On 01/21/26 at 12:50 P.M. an interview with Physician #253 revealed he did not remember what had occurred with Resident #58 and he would have to review his notes. He stated he did look at the resident's chest x-ray today again and he did not see anything acute that needed addressed. He stated the DON also mentioned today the recommendation for the HRCT scan and that it was a recommendation, but he did not believe it would have been necessary at that moment. He stated he was not aware the resident's family had requested the patient be sent to the hospital because he was acting differently. He stated the information must not have been communicated to him because he would always send a patient out if the family stated the resident was not acting right, because they were the ones who knew the resident the best.On 01/21/26 at 3:00 P.M. a second interview with the DON revealed she could not recall what she told the physician on 09/15/25. She stated she knew all of Resident #58's interventions were in place, and his vital signs were stable. She stated she did not feel Resident #58 needed sent out on 09/15/25 because his vital signs were stable and the facility did not have the proper paperwork to prove Family Member #250 was the MPOA, and she did not know the person she was speaking to on the telephone. She stated she assessed the resident and did not feel he needed to be sent out and she did not feel he was having slurred speech or having a stroke. She stated they put interventions in place to do lab work, the chest x-ray and urinalysis. She stated the resident declined lab work but did verify he was confused. She stated Resident #58 never mentioned to her he wanted to go to the hospital but she did not recall if she ever spoke to him about going to the hospital or how many times she actually spoke to him or saw him. She verified she never documented her assessment in his progress notes and did not recall if she spoke to the physician or if LPN #121 was the one to call him on 09/15/25. On 01/22/26 at 11:20 A.M. a second interview with LPN #121 revealed he believed the DON had called the physician on 09/15/25 for Resident #58. He stated he went back thorough his telephone and could not find a call or text that day to the physician and that was how he communicated with the physician, from his personal cell phone. He stated the day he spoke to the resident's family member he had planned to send him out to the hospital, but he could not remember why he did not send him out. He stated the plans must have changed. He stated he had no issues sending someone out to the hospital if the family requested they be sent out, especially if they were concerned about the resident's condition. He stated he did assess him after he got off the telephone with Family Member #250 and he appeared normal for him. He stated he was not having any slurred speech or shortness of breath on 09/15/25. He stated if he had been showing any of the signs of a stroke, he would have been out the door [indicating to the hospital]. He stated he did not notice a decline or change in condition from 09/15/25 to when he sent him out on 09/21/25. He stated the late entry skilled note from 09/16/25 for 09/15/25 was mainly due to the fact he did not have the time to get it completed the day prior. On 01/22/26 at 2:15 P.M. an interview with Social Service Designee #153 revealed she spoke to FM #250 about Resident #58 several times. She stated she got FM #250's name and the residents neighbor's name from the resident upon admission as his emergency contact, and their phone number from his hospital paperwork. She stated the residents family member was very upset that they were not sending Resident #58 out to the hospital. She stated she had contacted the hospital to get the MPOA paperwork, but they never sent it to her and the paperwork was never sent with his admission paperwork. She stated FM #250 even wanted him sent out after they received the MPOA however she could not remember the date, she stated she still wanted him sent out. She stated FM #250 told her the resident was complaining he could not breathe at night and nobody was giving him his aerosol treatments. She stated she told the DON, and they had gone to check on him, and he had an aerosol treatment on at that time, so she let the family member know that. She stated she told the family member the resident was not telling them the same thing he was telling her. She stated she updated the DON every time the family member had a concern about his condition because she knew the DON had been speaking to the family member about his care. She verified she had not documented any of her conversations with FM #250 in his medical record. She stated that her and FM #250 emailed a lot.This deficiency represents non-compliance investigated under Complaint Number 2631680.

Based on review of the medical record and interview with staff the facility failed to notify the family of Resident #58 when he was ordered a psychotropic medication. This affected one resident (Resident #58) of three reviewed for medication administration. Findings Include:Review of the medical record revealed Resident #58 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, chronic obstructive pulmonary disease, chronic bronchitis, acute respiratory failure, atherosclerotic heart disease, hypertension, congestive heart failure, ischemic cardiomyopathy and vision loss. Resident #58 was sent to the emergency room on [DATE].Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #58 had intact cognition.Review of the Health Care Power of Attorney (HCPOA) paperwork, dated and notarized on 08/11/25, revealed Family Member #250 was the HCPOA for Resident #58. This information was submitted to the facility on [DATE]. Review of the Progress note dated 09/19/25 at 8:09 A.M. revealed the physician gave an order for Resident #58 to start on Remeron (antidepressant) 7.5 milligrams at bedtime for decreased appetite. There was no documentation the resident's representative was notified. On 01/21/26 at 5:03 P.M. an interview with Family Member #250 revealed she was never told Resident #58 was started on Remeron. She stated if the facility started him on Remeron it was to sedate him versus appetite, because Resident #58 never had any issues with his appetite and he enjoyed eating. She stated if he was having a decrease in his appetite, which she was never told, then it was likely due to him having pneumonia or change in condition.On 01/22/26 at 12:10 P.M. an interview with the Director of Nursing revealed she spoke to Licensed Practical Nurse (LPN) #136 who wrote the order for the Remeron for Resident #58, and LPN #136 stated Resident #58 had good days and bad days eating. She stated LPN #136 told her the resident ate better when the friend brought him in homemade food and he was not eating as well and she did not want him to lose any weight, so she called the physician to get an order for Remeron. She verified there was no documentation of a rationale as to why Resident #58 was started on the Remeron or that the representative was notified.On 01/22/26 at 12:30 P.M. an interview with LPN #136 revealed she had noticed Resident #58 had not been eating as much over the couple days leading up to her getting the order. She stated he was consuming less than 50 percent of his meals so she notified the physician because she did not want him to lose any weight. She stated she could have spoken to the dietitian however the dietitian had not been at the facility on that day, so she just called the physician, and he ordered the Remeron. She stated he did not have an order for health shakes, but she had attempted to give him protein shakes off her medication cart, but he did not like them, and he was not ordered any other supplement. She stated she spoke to the two emergency contacts on his chart numerous times about his care and she was sure she told them about the Remeron however she verified she failed to chart it. She stated she did not see any decline in his condition other than his not eating as much as before prior to him being sent out for a stroke. This deficiency represents non-compliance investigated under Complaint Number 2631680.

Based on review of the medical record and interview with staff the facility failed to notify the family of Resident #58 when he was ordered a psychotropic medication. This affected one resident (Resident #58) of three reviewed for medication administration. Findings Include:Review of the medical record revealed Resident #58 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, chronic obstructive pulmonary disease, chronic bronchitis, acute respiratory failure, atherosclerotic heart disease, hypertension, congestive heart failure, ischemic cardiomyopathy and vision loss. Resident #58 was sent to the emergency room on [DATE].Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #58 had intact cognition.Review of the Health Care Power of Attorney (HCPOA) paperwork, dated and notarized on 08/11/25, revealed Family Member #250 was the HCPOA for Resident #58. This information was submitted to the facility on [DATE]. Review of the Progress note dated 09/19/25 at 8:09 A.M. revealed the physician gave an order for Resident #58 to start on Remeron (antidepressant) 7.5 milligrams at bedtime for decreased appetite. There was no documentation the resident's representative was notified. On 01/21/26 at 5:03 P.M. an interview with Family Member #250 revealed she was never told Resident #58 was started on Remeron. She stated if the facility started him on Remeron it was to sedate him versus appetite, because Resident #58 never had any issues with his appetite and he enjoyed eating. She stated if he was having a decrease in his appetite, which she was never told, then it was likely due to him having pneumonia or change in condition.On 01/22/26 at 12:10 P.M. an interview with the Director of Nursing revealed she spoke to Licensed Practical Nurse (LPN) #136 who wrote the order for the Remeron for Resident #58, and LPN #136 stated Resident #58 had good days and bad days eating. She stated LPN #136 told her the resident ate better when the friend brought him in homemade food and he was not eating as well and she did not want him to lose any weight, so she called the physician to get an order for Remeron. She verified there was no documentation of a rationale as to why Resident #58 was started on the Remeron or that the representative was notified.On 01/22/26 at 12:30 P.M. an interview with LPN #136 revealed she had noticed Resident #58 had not been eating as much over the couple days leading up to her getting the order. She stated he was consuming less than 50 percent of his meals so she notified the physician because she did not want him to lose any weight. She stated she could have spoken to the dietitian however the dietitian had not been at the facility on that day, so she just called the physician, and he ordered the Remeron. She stated he did not have an order for health shakes, but she had attempted to give him protein shakes off her medication cart, but he did not like them, and he was not ordered any other supplement. She stated she spoke to the two emergency contacts on his chart numerous times about his care and she was sure she told them about the Remeron however she verified she failed to chart it. She stated she did not see any decline in his condition other than his not eating as much as before prior to him being sent out for a stroke. This deficiency represents non-compliance investigated under Complaint Number 2631680.

Based on review of the medical record, review of the fall investigation, interview with the staff, and review of facility policy, the facility failed to ensure Resident #58 had fall inventions in place. This affected one resident (Resident #58) of three reviewed for falls.Findings Include: Review of the medical record revealed Resident #58 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, chronic obstructive pulmonary disease, chronic bronchitis, acute respiratory failure, atherosclerotic heart disease, hypertension, congestive heart failure, ischemic cardiomyopathy and vision loss. Resident #58 was sent to the emergency room on [DATE]. Review of the Morse Falls assessment dated [DATE] revealed Resident #58 was a high risk for falls. Review of the care plan dated 08/27/25 revealed Resident #58 was at risk for falls related to deconditioning and gait/balance problems. Interventions included anticipate and meet the resident's needs, be sure the residents call light was within reach and encourage the resident to use it, ensure the resident was wearing appropriate footwear when ambulating or mobilizing in the wheelchair, frequently used items to be close to the resident, gripper socks to be wore when not wearing proper fitting shoes (initiated 09/07/25), therapy to evaluate and treat, and a toileting plan before and after each meal and at bedtime. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #58 had intact cognition and had no falls. Review of the Progress notes dated 09/05/25 at 8:30 P.M. revealed Resident #58 stood up from his bed and was reaching for his nightstand when he stepped forward with his left foot and lost his balance. This was witnessed and he had not hit his head. Resident #58 reported he was trying to see what clothing were on his nightstand, he was wearing only socks. Resident #58 was educated on proper footwear and using his call light to ask for assistance. He demonstrated proper use of the call light. Review of the Fall Scene Investigation Report dated 09/05/25 at 8:15 P.M. revealed Resident #58 was not wearing shoes only socks. The new intervention was to encourage him to use proper footwear and to ask for assistance prior to getting up. Review of the Progress note dated 09/07/25 at 3:12 P.M. revealed the Intradisciplinary team met to review a fall. Resident #58 was observed reaching and stepping forward to look at an item and landed on his bottom. He was assisted up with two staff assistance and placed in the chair. He had no visual or verbal signs of pain at the time and no apparent injury. He was not wearing gripper socks only regular socks. Gripper socks were to be worn when not wearing proper fitting shoes and his frequently used items to be closer to the resident. He was unable to be educated due to his Brief Interview for Mental Status only being a nine out of 15. The family and doctor were made aware. Review of the physician's orders revealed Resident #58 had an order for gripper socks to be worn when not wearing proper fitting shoes, check each shift to assure proper placement dated 09/07/25. Review of the Progress note dated 09/14/25 at 1:43 A.M. revealed the nurse was called into the room of Resident #58 by his roommate. The resident was lying on the floor outside of the bathroom. Resident #58 stated he was walking back to bed from the bathroom and lost his balance and fell. He stated he did not hit his head. The resident was checked for injuries with a noted bruise to his left thigh. He was assisted off the floor with two staff assistance and walked back to bed. Vital signs were taken and neurological checks were started. The resident was placed in non-skid socks. The resident was to have non-skid socks on at all times when out of bed. The physician, on-call nurse and niece were notified. Resident to use non-skid socks while out of bed. Review of the undated Fall Scene Investigation Report revealed Resident #58 was found on the floor right outside if the bathroom. He was coming back from the bathroom in his socks, and he had been given a laxative. The conclusion was to place the resident on a toileting plan before and after meals. He had socks on at the time of the fall. Further review of the physician's orders revealed Resident #58 had an order for non-skid socks while out of bed dated 09/14/25 however it was discontinued the same day on 09/14/25. On 01/22/26 at 12:10 P.M. an interview with the Director of Nursing verified Resident #58 did not have gripper socks on as ordered when he fell however she stated he changed them himself. She verified there was no documentation he removed his clothes or would change his gripper socks into regular socks. Review of the facility policy titled, Assessing Falls and Their Causes, dated 10/2010 revealed the purpose of the procedure was to provide guidelines for assessing a resident after a fall and to assist the staff in identifying causes of the fall.

Based on observation, record review and interview, the facility failed to ensure the fingernails on Resident #205's bilateral hands were assessed and treated timely. This finding affected one (Resident #205) of one resident reviewed for activities of daily living (ADL). Findings include: Review of Resident #205's medical record revealed the resident was admitted on [DATE] with diagnoses including end stage renal disease, displaced comminuted fracture of the shaft of the right humerus and lack of coordination. Review of Resident #205's ADL care plan dated 05/15/25 revealed to check the resident's nail length. Trim and clean on bath days and report any changes to the nurse. Review of Resident #205's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition and the resident was dependent for toileting, showering/bathing as well as partial/moderate assistance for personal hygiene. Review of Resident #205's Weekly Skin Assessment form dated 05/19/25 did not address the resident's fingernails. Review of Resident #205's Weekly Skin Assessment form dated 05/27/25 did not address the resident's fingernails. Observation on 06/02/25 at 11:21 A.M. revealed Resident #205's fingernails on the bilateral hands appeared yellowed and thickened with debris underneath of the nails. Interview on 06/03/25 at 2:24 P.M. with Resident #205 revealed staff did not address his fingernails. Interview on 06/03/25 at 2:28 P.M. with Licensed Practical Nurse (LPN) Unit Manager (UM) #857 of Resident #205's fingernails revealed the resident's fingernails on his bilateral hands appeared yellowed and thick with debris underneath of the nails. Interview on 06/04/25 at 7:39 A.M. with LPN Wound Nurse (WN) #819 revealed she had assessed Resident #205 weekly while completing wound care on his second right toe. LPN WN #819 confirmed she did not notice the thick yellowed fingernails on the resident's bilateral hands or the debris underneath of the resident's fingernails. Review of the Care of Fingernails/Toenails policy dated 10/2010 revealed the purpose of the procedure was to clean the nail bed, to keep the nails trimmed, and to prevent infections. Watch for and report any changes in the color of the skin around the nail bed, blueness of the nails, and any signs of poor circulation, cracking of the skin, evidence of ingrown nails, infections, pain or if the nails were too hard or too thick to cut with ease.

Based on interview, record review, and facility policy review, the facility failed to ensure residents received trauma-informed care that accounted for the resident's experiences and preferences in order to minimize or eliminate triggers that may cause re-traumatization of the residents. This affected one resident (Resident #15) of one resident reviewed for behavioral and emotional care. The facility census was 49. Findings include: Review if the medical record for Resident #15 revealed an initial admission date of 03/20/25 and a re-entry date of 05/20/25. Diagnoses included type two diabetes mellitus, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, primary hypertension, chronic stage three kidney disease, anxiety disorder, heart failure, cognitive communication deficit, depression, muscle wasting and atrophy, and post-traumatic stress disorder (PTSD). Review of the admission minimum data set (MDS) 3.0 assessment completed on 03/27/25 revealed Resident #15 had moderately impaired cognition and no noted behaviors. Further review of the MDS revealed Resident #15 had psychiatric and/or mood disorders listed, including anxiety disorder, depression, and PTSD. Review of the assessment titled Discharge Planning Review completed on 04/17/25 revealed the trauma review section had all boxes marked as not applicable for all listed trauma categories, including physical assault, sexual assault, captivity, serious injury or harm, and other very stressful events. Review of the Social Services Assessment completed on 04/17/25 upon admission revealed Resident #15's psychosocial adjustment factors included a distressed mood, homelessness or housing concerns, financial concerns, deficits in communication, and deficits in controlling body function. Review of the follow-up Social Services Assessment completed on 05/19/25 upon re-entry revealed the psychosocial assessment was blank and did not contain any assessment data or selections under social factors. Review of the Social Services Progress Notes from 03/20/25 through 06/04/25 revealed no notes related to Residents diagnosis of PTSD, how it impacted her daily living, identified or reported triggers, or interventions to prevent re-traumatization. Review of the care plan with last review date completed 04/08/25 revealed no care plan related to PTSD. Review of the open care plan initiated 03/19/25 with next review date due 07/05/25 revealed a care plan problem was created on 04/10/25 by MDS Coordinator #837 indicating Resident #15 had a past traumatic event; however, the traumatic event was not specified, emotional triggers or stressors were not identified, and there were no person-centered specific interventions to mitigate triggers. Interview on 06/02/25 at 11:40 A.M. of Resident #15 conducted revealed Resident #15 had PTSD from being physically abused by a spouse. A second interview on 06/03/25 at 4:28 P.M. with Resident #15 confirmed a 10-year history of physical abuse with subsequent PTSD and night terrors. Resident #15 reported that emotional triggers included being forced or coerced to do anything against her will, having anything wrapped around her, and anything that may feel restricting to her body or her movement, such as wearing that get caught up and twisted under her. Resident #15 further revealed night terrors continue while at the facility. Interview on 06/04/25 at 11:57 A.M. with Certified Nurse Aides (CNA) #852 revealed no knowledge of Resident #15's PTSD diagnosis or any triggers that caused Resident #15 emotional stress. Interview on 06/04/25 at 3:52 P.M. with CNA #810 revealed an awareness that Resident #15 had a diagnosis of PTSD, but had no knowledge of underlying causes, triggers, or specific interventions to prevent additional stress or re-traumatization. Interview on 06/04/25 at 3:59 P.M. with CNA #864 revealed a belief Resident #15 may have acquired PTSD while in another facility due to something that may have happened there but uncertainty about what caused the PTSD or what could trigger Resident #15's PTSD symptoms. Further interview revealed one potential intervention might be for Resident #15 to have no male caregivers but could not confirm that was a PTSD related intervention.

Based on observation, record review and interview, the facility failed to ensure medications were administered as ordered. A total of 31 medications were administered with two errors for a medication error rate of 6.45%. This finding affected two (Residents #19 and #40) of three residents observed for medication administration. Findings include: 1. Review of Resident #19's medical record revealed the resident was admitted on [DATE] with diagnoses including type two diabetes, morbid obesity and chronic obstructive pulmonary disease. Review of Resident #19's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed moderate cognitive impairment. Review of Resident #19's physician orders revealed an order dated 04/13/24 to administer Humalog via a KwikPen sq (subcutaneous) and inject as per sliding scale. Using a Humalog KwikPen, inject four units for a sliding scale of 200 to 250; six units for a sliding scale of 251 to 300; eight units for a sliding scale of 301 to 350; 10 units for a sliding scale of 351 to 400 and twelve units for a sliding scale of 401 to 450 before meals and at bedtime for diabetes. Call the physician for a blood sugar greater than 450. Observation on 06/02/25 at revealed Licensed Practical Nurse (LPN) #827 obtained Resident #19's blood sugar with a result of 293. LPN #827 administered six units of Humalog short acting insulin via a Humalog KwikPen to Resident #19. LPN #827 did not dial up a two unit air shot prior to dialing up the six units to administer to the resident. Interview on 06/02/25 at 11:14 A.M. with LPN #827 confirmed she did not dial up a two unit air shot for Resident #19's Humalog insulin prior to administering six units to the resident. Review of the Instructions for Use Humalog KwikPen injection including pulling the pen cap straight off, check the liquid in the pen, select a new needle, push the capped needle straight onto the pen and twist the needle on until it was tight, pull off the outer needle shield, prime the pen by turning the dose knob to select two unit, hold the pen with the needle point up and tap the cartridge holder gently to collect air bubbles at the top, continue holding the pen with needle point up and push the dose knob in until it stop and the zero was observed in the dose window, select the required dose and administer to the resident. 2. Review of Resident #40's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including anxiety disorder, schizophrenia and depression. Review of Resident #40's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #40's physician orders revealed an order dated 02/05/25 to administer Vitamin E oral capsule 100 units, give one capsule by mouth one time a day for a supplement. Observation on 06/03/25 at 8:01 A.M. revealed LPN Wound Nurse (WN) #819 administered four medications to Resident #40 including Vitamin E 180 mg (milligrams) or 400 iu (international units). Interview on 05/03/25 at 8:27 A.M. with LPN WN #819 confirmed she did not administer the correct dose of Vitamin E to Resident #40 during the medication administration. A total of 31 medications were administered with two errors for a medication error rate of 6.45%. Review of the Administering Medications policy revised 12/2012 revealed medications shall be administered in a safe and timely manner, and as prescribed.

Based on medical record review, hospital records, facility policy review and staff interviews, the facility to complete a timely investigation and self-reported incident following an injury of unknown origin for one resident (Resident #243). This had the potential to affect all 51 residents residing at the facility. Findings include: Review of the medical record for Resident #243 revealed an admitted [DATE]. Diagnoses included but were not limited to type II diabetes mellitus with hyperglycemia, Alzheimer's dementia, unspecified disorder of muscle, Trisomy 21, severe intellectual disabilities, adjustment disorder, dysphagia, localization-related idiopathic epilepsy and epileptic syndromes with seizures, tremors, and hearing loss. Review of the Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] revealed Resident #243 had a severe cognitive impairment. Resident #243 was noted to rarely be understood. Resident #243 was noted to use a wheelchair, required moderate assistance for ADLs. Resident #234 was also noted to receive antipsychotics, antidepressants and anticonvulsants. Review of the care plan dated 02/12/25 for Resident #243 revealed he was at risk for falls related to weakness. Interventions included non-skid footwear (02/12/25), helmet to be worn during waking hours (04/11/25), keeping bed in lowest position and call light in reach (02/12/25). A focus dated 02/12/25 revealed Resident #243 was noted to have an ADL self-care performance deficit and requires staff assistance for bed mobility, dressing and transfers. Resident #243 was noted to have behavioral problems such as getting in and out of wheelchair, sitting on the floor and crawling on the floor and attempting to pull himself up with furniture. Resident #243 was noted to refuse to wear helmet and hipsters (04/25/25). Interventions were to anticipate and meet resident needs, explain all procedures before starting and allow the resident to express himself, and ensure resident safety. Resident #243 noted to have impaired cognitive function or impaired thought process related to development delays. Interventions were to ask yes/ no questions, speak clearly and slowly. Resident #243 was also noted to be at risk for falls due to poor communication/ comprehension and unsteady gait. Interventions were hipsters to be worn (04/08/25), helmet to be worn (04/16/25), offer pillow under head when laying on couch (04/23/25). Review of the weekly skin evaluation dated 04/19/25 at 7:46 A.M. revealed Resident #243 had a bruise above his left eye. No further details were listed. Review of the nursing progress note dated 04/19/25 timed at 12:50 P.M. written by Licensed Practical Nurse #533 revealed Resident #243 was noted to have a bruise above his left eye during shift change. Neuro checks were started. The on-call nurse, physician, and the resident's guardian were notified. Review of the general progress note dated 04/21/25 timed at 12:29 P.M. revealed the interdisciplinary team met to review Resident #243. Resident #243 was noted to have discoloration to the left periorbital area with 50% dark brown and 50% green colored. Skin was intact, no noted edema noted. Resident #243 was unable to verbalize how this occurred due to diagnosis of Trisomy 21, Alzheimer's dementia, and severe cognitive impairment. Review of the weekly skin evaluation dated 04/26/25 for Resident #243 revealed noted bruising over left eye. No further details were listed. Review of the 04/28/25 general progress noted timed at 9:22 A.M. revealed Resident #243 was noted to have two black eyes and a painful and swollen left hand. An x-ray of Resident #243's skull and left hand were ordered. Review of the general progress note dated 04/28/25 and timed at 10:52 A.M. for Resident #243 revealed IDT team noted 50% green and 50% brown discoloration to the resident's right periorbital (eye) area. Resident #243's skin was noted to be intact to the right periorbital area and the resident's left hand was edematous with intact skin. Resident #243 was also noted to be unable to state what occurred. A head-to-toe skin assessment revealed no further areas of concern. Review of the weekly skin assessment dated [DATE] and timed 1:42 P.M. for Resident #243 revealed various stages of bruising to bilateral eyes and bilateral knees were noted. Review of the portable x-ray result dated 04/28/25 for Resident #234 revealed an acute non-displaced fifth proximal phalanx fracture and no definite displaced or depressed calvaria fracture. Nondisplaced fracture is possible and computed tomography (CT) scan was recommended. Review of the CT scan report dated 04/28/25 for Resident #234 revealed no gross fracture of dislocation of hip joints, no fracture of dislocation of the left hand or wrist, no evidence of acute intracranial hemorrhage, no gross fracture or dislocation of the cervical spine, no evidence of acute fracture of facial bones, orbits or sinuses. Review of the facility self-reported incident (SRI) #259780 for Resident #243 revealed it was opened on 04/28/25 at 11:29 A.M. for an injury of unknown source which was reported by staff. Resident #243 was noted on 04/28/25 at 9:30 A.M. to be observed with two swollen eyes and a swollen hand. It was noted to be unknown how it occurred. Review of the facility's investigation of the Resident #243's injury of unknown origin, dated 04/28/25, revealed Resident #243 was noted to have two swollen eyes and a swollen left hand. Resident #243 was unable to state how it occurred due to severe cognitive impairment. Staff statements were obtained, and no staff or residents stated they had witnessed a fall or injury for Resident #243. A skin check was completed on 04/28/25 and did not reveal any other injuries. The resident's physician and guardian were notified. No alleged perpetrator was identified. The facility believed Resident #243 self-inflicted these bruises due to extensive history of placing himself to the floor on his own and crawling around on the floor. Resident #243 was noted to refuse to wear his helmet and at times had become angry when staff attempt to put the helmet back on. Resident #243 was also noted to put his face/head on overbed table or any table or any item close to him. Pillows and blankets are to be placed under his head. Questionnaires with staff and other residents revealed no concerns. Abuse education was provided to all staff. Interview on 05/05/25 at 2:22 P.M. was attempted with Resident #243 but due to severe cognitive impairment, it was unable to be conducted to obtain useful information. Interview on 05/06/25 at 7:15 A.M. with the DON revealed on 04/19/25, Resident #243 was noted to have bruising to the left periorbital area which was 50% dark brown and 50% green in color. The skin was intact with no noted edema or evidence of pain. The DON stated they equated it to a fall or him hitting his head but was unaware of anyone who witnessed a fall or injury. The DON stated they did not open an SRI because they thought it was from Resident #243 putting his face on the table. On 04/28/25, when Resident #243 was observed with bruising to both eyes, they opened an SRI and got x-rays for his skull and left hand. Upon receiving the results, Resident #243 was sent out for a CT scan which came back normal. Phone interview on 05/06/25 at 8:25 A.M. with Licensed Practical Nurse (LPN) #533 revealed he observed Resident #243 on 04/19/25 around 6:30 A.M. with a bruise over his left eye which appeared to be fresh, purple in color, and he reported it to Registered Nurse (RN) #532. LPN #533 stated he did not notice any further bruising until 04/28/25, when he noticed bruising to both of Resident #243's eyes. LPN #533 stated he did not see Resident #243 fall and was unaware of any other staff who observed a fall for Resident #243. LPN #533 stated following observation on 04/19/25 and 04/28/25, he immediately reported it to management. Interview on 05/06/25 at 9:45 A.M. with Registered Nurse (RN) #532 revealed she became aware of the bruise above Resident #243's left eye on 04/19/25 when LPN #533 notified her. RN #532 instructed LPN #533 to write the incident up as a fall. RN #532 confirmed Resident #243 was unable to say what happened and was not aware of anyone who had observed the resident fall. RN #532 confirmed it was an injury of unknown origin since no one had witnessed it, and Resident #243 was unable to state what happened. RN #532 stated she did not notify any other management since she thought it was from a fall. When she became aware of the additional injuries on 04/28/25, management was already aware and had started an investigation. Interview on 05/06/25 at 11:23 A.M. with the Administrator and DON confirmed they were unable to provide evidence in Resident #243's medical record indicating how Resident #243's injury occurred on 04/19/25 and were unable to provide evidence an investigation of the injuries was started until 04/28/25. Review of the facility policy called; Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 10/27/17 revealed it is the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of a resident or misappropriation of resident property, including injuries of unknown source, in accordance with this policy. Facility staff should immediately report all such allegations to the Administrator/designee and to the Ohio Department of Health in accordance with the procedures in this policy. An injury is classified as an 'injury of unknown source' when both the following conditions are met: the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time. This deficiency represents non-compliance investigated under Control Number OH00165239.

Based on observation, medical record review, review of hospital records, review of facility Self-Reported Incidents (SRI), review of facility abuse investigations, review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property, review of the facility policy titled Resident Rights, and interviews, the facility failed to ensure Resident #23 and Resident #38 were free from incidents of resident to resident physical and verbal abuse. This resulted in Immediate Jeopardy and actual harm beginning on 02/04/25 at approximately 8:30 P.M. when Resident #38 was abused by Resident #15, a resident who was identified to not like other residents in his space or touching his things. On 02/04/25 Resident #15 verbally threatened and then physically assaulted Resident #38 by dragging Resident #38 out of his bed, throwing Resident #38 from his room, resulting in Resident #38 falling to the floor in the hallway causing a closed compression fracture of L5 vertebra (lower back). As a result of the incident, Resident #38 was no longer able to independently ambulate. The Immediate Jeopardy and actual harm continued on 02/10/25 at 9:51 P.M. when Resident #23 was physically assaulted by Resident #15 when Resident #15 stabbed the resident with a fork in the hand causing the resident to bleed and sustain puncture wounds. This affected two residents (#23 and #38) reviewed for physical abuse and had the potential to affect an additional four residents (#7, #9, #19, and #40) the facility identified who were cognitively impaired and independently mobile who could be subject to abuse by Resident #15 or any other physically abusive resident. The facility census was 53. On 03/13/25 at 4:06 P.M., the Administrator, Director of Nursing (DON), Unit Manager #322, Regional Director of Clinical Services (RDCS) #328 and the Regional Director of Operations #330 were notified Immediate Jeopardy began on 02/04/25 at approximately 8:30 P.M., when the facility failed to develop and implement the necessary care, supervision and interventions to prevent incidents of resident to resident abuse initiated by Resident #15. Resident #15 was identified to have a history of wandering and a history of becoming aggressive when other residents enter his space. The facility failed to develop a comprehensive and individualized plan of care to address these behaviors and to ensure the safety of other residents. On 02/04/25 at 8:30 P.M., Resident #38 wandered into Resident #15's room and laid on Resident #15's bed. Resident #15 entered the room and was verbally and physically aggressive with Resident #38 to move out of his space. Resident #15 threw Resident #38 out of his room and Resident #38 flew onto the hallway floor resulting in a fall sustaining a closed compression fracture of L5 vertebra (lower back). Resident #38 is now confined to a wheelchair for mobility. On 02/10/25 at 9:51 A.M., Resident #15 and Resident #23 were noted to be sitting next to each other in the dining room. Resident #23 reached over to Resident #15's space to obtain a spoon and Resident #15 physically assaulted Resident #23 with a fork in the hand causing Resident #23's to bleed and sustain puncture wounds. The Immediate Jeopardy was removed on 03/13/25 when the facility implemented the following corrective actions: On 02/04/25 at 8:30 P.M., Registered Nurse (RN) #301 observed Resident #38 laying on the floor outside of (Resident #15's room) laying on her back. Resident #38 was holding her head saying she was in a lot of pain. Emergency (911) was called, and Resident #38 was transported to Hospital #339 at 8:45 P.M. On 02/10/25 at 8:07 A.M., it was reported Resident #15 stabbed Resident #23 with a fork. Resident #23 and Resident #15 were immediately separated. On 02/10/25 at 8:09 A.M., Resident #23 was taken to the nurse for first aid. The nurse cleaned the puncture wound with normal saline and applied clean dry dressing for his hand. Resident #23 received a small break in the skin during the incident with Resident #15. On 02/10/25 at 2:15 P.M., Resident #15 was seen by Psychiatric-Mental Health Nurse Practitioner (PMHNP) #338 with new orders received to increase Zoloft to 50 milligrams (mg) daily for anxiety and agitation. Start hydralazine 25 mg by mouth twice daily for anxiety/agitation for 14 days. On 02/11/25 an action plan was developed due to the facility failing to appropriately manage residents' behavior/change in condition. The DON initiated education to licensed nursing staff on behavioral management and appropriate management of interventions. The DON reviewed all nursing progress notes for the past seven days to ensure that all behaviors/change of condition were documented in the facility's electronic medical record with appropriate interventions. On 02/11/25 the facility implemented a plan for the DON to conduct an audit five days a week for four weeks reviewing nursing progress noted to monitor for any change in condition or any behaviors that did not have an intervention in place and ensure that the physician was notified. By 02/14/25 at 4:30 P.M., the facility implemented a plan for skin assessments to be completed on all nonverbal residents by the Wound Nurse. On 03/13/25 at 5:30 P. M., Resident #15 was placed on 1:1 supervision to ensure the resident's safety and to protect other residents with diagnosis with dementia to prevent them from entering Resident #15's personal space by the Administrator. Resident #15 would continue to be followed by psychiatric services. On 03/13/25 at 5:35 P. M., the Unit Manager placed a stop sign on Resident #15's door to deter other residents from entering the room. On 03/13/25 at 5:45 P. M., a whole house audit was completed identifying six residents, Resident #7, #9, #19, #23, #38, and #40 with a dementia diagnosis and were also self-ambulatory to identify the potential risk of these residents entering Resident #15's personal space. These findings led the facility to implement 1:1 supervision for Resident #15. In addition, a whole house audit was completed of all residents' records to determine if any residents had aggressive or violent behaviors. The audit revealed that one resident, Resident #40 had a diagnosis of aggressive behavior prior to admitting to the facility due to the resident not taking prescribed medications. However, as of this date Resident #40 had not displayed any aggressive behaviors while residing in the facility and had been taking his prescribed medications for aggressive behaviors. On 03/13/25 at 6:10 P.M., RDCS #328 educated the staff present in the facility on interventions implemented for Resident #15 which included: 1:1 supervision until Resident #15 was discharged , placing a stop sign on Resident #15's room door and that Resident #15 would eat at a separate table in the dining room for meals. On 03/13/25 at 6:26 P.M., RDCS #328 informed Resident #15's family/responsible party the resident had been placed on 1:1 supervision, a stop sign was placed on Resident #15's door and he would be eating at separate table for meals. On 03/13/25 at 6:49 P. M., an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held to discuss interventions for Resident #15 to ensure resident's safety and to protect other residents (including those with a diagnosis of dementia) to prevent them from entering Resident #15's personal space. The meeting was held with Medical Director #331 via telephone, Administrator, Director of Nursing (DON), Unit Manager #322, Wound Nurse#332, Business Office Manager (BOM) #310, Social Worker/Admissions #203, Dietary Manager #212, MDS Nurse #303, Central Supply/Scheduler #224, Activities Director #231, Human Resources Director #226, RDCS #328, and Regional Director of Operations #330. On 03/13/25 at 7:12 P.M., all facility staff were educated by DON/Designee on the facility policy and procedure for abuse (including resident-to-resident abuse) and immediate action to take. The facility would monitor/audit/document aggressive and violent behavior to ensure appropriate interventions are implemented timely. All staff were also educated that Resident #15 was to be on 1:1 supervision until Resident #15 was discharged , a stop sign was placed on Resident #15's room door and Resident #15 would eat at a separate table at meals. Resident #15's interventions were implemented to prevent the six identified residents with dementia and who were ambulatory, from entering Resident #15's personal space to prevent physical abuse. Staff education of three RNs, 10 licensed practical nurses (LPNs), 28 certified nursing assistants (CNAs), five housekeepers, one laundry personnel, six dietary staff, one activities personnel, and 11 department heads was completed. Beginning 03/13/25, the facility implemented a plan for the Administrator/Designee to audit resident behaviors by reviewing clinical documentation and implementation of interventions to ensure the safety of others, five times weekly for four weeks. Beginning 03/13/25, the facility implemented a plan for the Administrator/Designee to interview three staff members three times a week for four weeks to identify any observations of physically abusive behaviors. If behaviors were identified, the facility would put appropriate resident centered interventions in place. Beginning 03/13/25 the facility implemented a plan for the Administrator/Designee to audit that Resident #15's interventions of 1:1 supervision, eating at separate table for meals, and stop sign were in place at Resident #15's room door five times a week for four weeks. Beginning 03/13/25 the facility implemented a plan that all findings would be submitted to the QAPI Committee for review and recommendations for six months. Although the Immediate Jeopardy was removed on 03/13/25, the deficiency remained at a Severity Level II (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure on-going compliance. Findings include: 1. Record review revealed Resident #38 was readmitted to the facility on [DATE] with diagnoses including Parkinson's disease without dyskinesia, dementia, Alzheimer's disease, and attention deficit disorder. Review of the care plan dated 09/28/23 revealed Resident #38 was an elopement risk/wanderer disoriented to place, history of attempt to leave the facility unattended, and had impaired safety. Interventions included distracting the resident from wandering by offering pleasant diversions, activities, food, conversation, television, reading material. Identify pattern of wandering, divert as needed and intervene as appropriate. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was severely cognitively impaired. Resident #38 had no impairment of the upper or lower extremities, Resident #38 did not use a wheelchair and required supervision or touch assistants with ambulation. Resident #38 had no verbal or physical symptoms directed towards others. Review of the progress notes for Resident #38 dated 02/04/25 at 8:58 P.M. completed by RN #301 revealed Resident #38 was observed at 8:30 P.M. lying on the floor outside of Resident #15's room laying on her back. The note included the resident's fall was observed by a CNA (#329) who stated Resident #38 hit her head on the ground. Resident #38 was holding her head saying she was in a lot of pain. Emergency 911 was called, and Resident #38 was transported to Hospital #339 at 8:45 P.M. Review of the Hospital After Visit Summary for Resident #38 dated 02/04/25 (untimed) revealed Resident #38 was seen by Physician #337 at Hospital #339. The reason for the visit was due to a fall and diagnosis of closed compression fracture of L5 vertebra. There were no new orders. Review of a facility self-reported incident (SRI) dated 02/04/25 at 8:58 P.M. revealed the facility reported an allegation of physical abuse involving Resident #15 and Resident #38 to the State agency. The SRI noted here were no witnesses. Resident #15 with a low cognitive function allegedly pushed Resident #38 who also had low cognitive function. A CNA (#329) reported she was walking down the hallway when she saw a female resident (Resident #38) fall backwards losing contact with the floor out of a male resident's room (Resident #15). The facility concluded evidence was inconclusive and abuse was not suspected. The progress note dated 02/05/25 at 11:11 A.M. completed by RN #301 revealed Resident #38 returned from Hospital #339 at 10:15 A.M. Resident #38 complained of pain to her back, as needed (PRN) tramadol (opioid pain medication to treat moderate to severe pain) was administered with effective results. The progress note dated 02/05/25 at 1:27 P.M. completed by RN #301 revealed Resident #38's emergency room (ER) diagnosis was closed compression fracture of L5 vertebra with no intervention needed. The progress note dated 02/06/25 at 1:24 P.M. completed by DON revealed Resident #38's fall was reviewed in safety meeting. The note revealed Resident's fall was observed by CNA #329. Resident #38 fell backwards and hit her head on the floor. Resident #38 complained of head/neck hurting. The physician orders dated 02/12/25 revealed Resident #38's Tramadol was increased from 50 milligrams (mg) PRN to 100 mg three times a day for pain. Interview on 03/12/25 at 1:52 P.M. with LPN #208 revealed Resident #15 had been aggressive with Resident #38 and Resident #38 fractured her back as a result of the incident. The LPN revealed Resident #38 was confused, wandered in his (Resident #15's) room, got in his bed, he pulled her by the hair and pulled her out of the room. The LPN revealed Resident #15 was not violent unless someone goes in his space, his roommate (#6) stays on his own side. Everyone knows not to go in Resident #15's space, or he would get violent. The LPN stated Resident #38 was a wanderer, she used to walk everywhere all day long but now since Resident #15 assaulted Resident #38, she can't walk because she was in a wheelchair. Interview on 03/12/25 at 3:46 P.M. with RN #301 revealed she was the charge nurse on 02/04/25 when Resident #38 fell and fractured her back in front of Resident #15's doorway. RN #301 stated Resident #15's roommate (Resident #6) was there and witnessed everything when the incident occurred. RN #301 stated Resident #6 was very alert and oriented. Observation on 03/12/25 at 3:55 P.M. revealed Resident #15 resided in the same room as Resident #6. Based on the layout of the room, Resident #15's bed was against the wall and Resident #6 would have a clear view of Resident #15's bed and the doorway. Interview with Resident #6 at the time of the observation revealed he remembered what happened regarding Resident #38's fall that day (02/04/25) very well. Resident #6 stated Resident #38 came into their room and sat in Resident #15's bed. Resident #15 came in and said get out of my bed. Resident #38 did not respond, and Resident #15 said get up or I am going to hurt you. Resident #15 grabbed Resident #38 by the shoulders moved her to the doorway and pushed her in the hall. Resident #6 stated he saw the whole thing. Resident #38 screamed. Resident #6 stated he felt so bad for Resident #38. Resident #6 stated he was not afraid of Resident #15 because he knew Resident #15 only gets aggressive when provoked, meaning if you get near his things or get in his space, otherwise he doesn't say anything or do anything. Resident #6 stated he stays to himself in his area of the room. Resident #6 stated the facility staff did not interview him or ask for a statement regarding Resident #15's assault with Resident #38. Interview on 03/12/25 at 5:41 P.M. with the DON revealed the DON recalled the incident on 02/04/25 between Resident #15 and Resident #38. The DON stated the incident happened on an off shift, and all they knew was Resident #38 was found outside Resident #15's door. Resident #38 had fallen backwards, she was injured and fractured her back. They immediately sent Resident #38 to the hospital, but no one saw the fall. The DON stated no one said anything that it might be Resident #15 who pushed Resident #38, and the staff just said he (Resident #15) was in his room. The DON confirmed she read Resident #38's nurses notes (as noted above) and reiterated there were no witnesses to the incident. The DON confirmed she did not interview Resident #6 who was present at the time of Resident #38's fall. The DON confirmed Resident #6 was alert and oriented to the person, place and time and stated she did not interview him because she was not sure if he saw it. The DON stated she could not answer why she didn't interview Resident #6. Observation on 03/12/25 at 4:37 P.M. revealed Resident #38 was sitting up in the wheelchair in the lounge area. Resident #38 was pleasantly confused and rambled incoherent sentences unrelated to the questions asked by the surveyor. Resident #38 was unable to participate in the conversation or follow simple direction when asked. Interview on 03/12/25 at 5:06 P.M. with Occupational Therapy Assistant (OTA) #342 confirmed prior to Resident #38's fall, Resident #38 ambulated frequently throughout the facility. Resident #38 received physical therapy services from 02/06/25 through 03/07/25. She was discharged because she met her maximum potential. OTA #342 confirmed Resident #38 was no longer able to ambulate independently and required moderate assistance to transfer safely since the incident with Resident #15 on 02/04/25. Interview on 03/17/25 at 9:10 A.M. with CNA #329 revealed on 02/04/25 she witnessed the incident with Resident #15 and #38. CNA #329 stated she actually saw the incident. CNA #329 stated she wrote up a statement describing what she saw when Resident #38 flew out of Resident #15's room. Two days after the incident occurred, the Administrator and Unit Manager called her on the telephone. The Administrator said the verbiage on the witness statement was too strong, it made it sounded like it was a lot. The Administrator told CNA #329 that she did not physically see Resident #15 push Resident #38. CNA #329 replied to the Administrator that she did see Resident #38 and Resident #38 fly through the air, she flew right through the doorway and flew to the ground. Resident #15 was standing right there in the doorway. CNA #329 stated she asked Resident #15 what happened, and Resident #15 said Resident #38 was in his bed, so he got her out of his room. The Administrator and Unit Manager typed up a different statement for CNA #329; however, CNA #329 stated she refused to sign the witness statement they wrote. Interview on 03/18/25 at 12:28 P.M. with Physical Therapist (PT) #343 revealed Resident #38 was up ad lib with a steady gait prior to the fall on 02/04/25. Resident #38 was discharged from therapy requiring the use of a wheelchair for mobility due to the resident exhibiting no progression with ambulation. PT #343 confirmed Resident #38 did not have aggressive behaviors during therapy. 2. Record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including dementia, altered mental status, lack of coordination, and muscle wasting and atrophy. Review of the quarterly MDS assessment dated [DATE] revealed Resident #23 was severely cognitively impaired. Resident #23 had no impairment of the upper or lower extremities, used a wheelchair for mobility, required supervision or touch assist with mobility and with eating. A progress notes for Resident #23 dated 02/10/25 at 7:00 A.M. completed by LPN #327 revealed Residents #15 and #23 were sitting in the dining room at the same table. Resident #15 stated he thought Resident #23 was trying to steal his spoon so Resident #15 stabbed Resident #23 with a fork in his left hand. The residents were immediately separated, and Resident #23 was taken to the nurse for first aid on his left hand. Review of the Wound Tool for Resident #23 dated 02/10/25 at 10:05 A.M. completed by Unit Manager #207 revealed left back of hand skin tear first observation measured two centimeters (cm) in length by 0.4 cm wide by less than 0.1 cm in depth. Cleanse with normal saline and apply clean, dry dressing. Change bandage daily and PRN. Review of a facility SRI dated 02/10/25 revealed the facility reported an allegation of physical abuse involving Resident #15 and Resident #23. The residents were both in the dining room sitting at the table when Resident #15 took a fork and struck Resident #23's hand due to thinking Resident #23 was going to take Resident #15's spoon. Both residents were separated to ensure they did not come into each others space. Resident #15 was placed on 1:1 supervision. Resident #23 received first aid treatment. Stat laboratory work was ordered for Resident #15. Resident #15 also received a physician order for medication changes and would now receive plastic cutlery. The facility concluded the evidence was inconclusive due to Resident #15 having low cognitive function and had no willful intent to harm Resident #23. Interview on 03/12/25 at 1:52 P.M. with LPN #208 revealed Resident #23 and #15 were in the dining room a few weeks ago and they sat at the same table. Resident #23 was reaching into Resident #15's space and Resident #15 stabbed Resident #23's hand with the fork, and it created a wound. Interview on 03/12/25 at 2:05 P.M. with CNA #395 revealed she took care of Resident #15 every day when she worked. During the interview, the CNA revealed Resident #15 had become aggressive with both Resident #23 and Resident #38. CNA #395 stated Resident #15 becomes aggressive if any resident gets in his space. CNA #395 stated she witnessed the dining room incident (involving Resident #23). She stated she was passing breakfast, and she heard Resident #23 say ouch. CNA #395 looked over and saw Resident #15 with the fork in his hand with a stabbing motion. Resident #23 sustained three puncture marks, and his hand was bleeding. Resident #15 said he didn't do it, Resident #23 said yes you did, you got my hand right here. Resident #15 said he shouldn't have grabbed his spoon. Resident #15 then acted normal again like nothing happened. CNA #395 stated residents do not have designated seats in the dining room, and they sit wherever they want. On 03/12/25 at 5:15 P.M. an interview with the DON while observing the dining room confirmed residents, including Resident #15 did not have assigned seating in the dining room and residents were permitted to sit where they wanted. Observation revealed Resident #15 ambulated independently with no assistance. Resident #15 used plastic silverware. The fork had pointed prongs and sharp ends. Interview on 03/12/25 at 5:41 P.M. with the DON revealed the DON recalled the incident on 02/10/25 between Resident #15 and #23. Resident #15 stabbed Resident #23 in the hand with a fork. The DON stated, Yea it happened, they were separated, and psych services were called. Unit Manager #322 then entered the room and joined the interview. Unit Manager #322 and the DON confirmed there were additional residents residing at the facility who had a diagnosis of dementia and were independently mobile who would be at risk for incidents of resident to resident abuse (including Resident #7, #9, #19 and #40). The DON stated she did not know what was done to protect the other residents who might enter Resident #15's space. The DON asked Unit Manager #322 what was being done, Unit Manager #322 stated Resident #15 was placed on 1:1 observation for a while. Neither DON nor Unit Manager #322 were sure about how long Resident #15 had been on 1:1 supervision as a result of these incidents; however, the resident was not on 1:1 at this time. Unit Manager #322 revealed they had also obtained a urinalysis for Resident #15 which was negative. Both the DON and Unit Manager #322 confirmed residents who had a diagnosis of dementia and were independently mobile had individualized interventions in place to prevent incidents of resident to resident abuse or to prevent them from inadvertently getting into Resident #15's personal space and potentially being harmed. Review of Resident #15's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, anxiety disorder, and mood disorder due to known physiological condition with depressive features. Review of the modification of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was severely cognitively impaired. Resident #15 had little interest or pleasure in doing things. Resident #15 had behavioral symptoms that occurred one to three days such as hitting or scratching self, pacing, rummaging, public sexual acts, throwing or smearing food or bodily wastes, or verbal vocal symptoms such as screaming, disruptive sounds. The presence of wandering also occurred one to three days. Resident #15 had no impairment to the upper or lower extremities. Record review revealed a plan of care related to behaviors was not initiated until 02/05/25 which revealed Resident #15 had a behavior problem of physical aggression of pushing other residents out of room. The plan also noted Resident #15 had a behavior of physical aggression of stabbing another resident. Interventions included encouraging the resident to express feelings appropriately and stop and talk with him passing by. Resident #15's care plan and medical record did not identify Resident #15 did not like anyone in his personal space and there were no interventions on how to prevent residents from entering his personal space to prevent incidents of resident to resident abuse. Review of the facility policy titled Resident Rights revised December 2016 revealed Federal and State Laws guarantee certain basic rights to all residents of this facility. These rights include the right to be treated with respect, kindness and dignity and the right to be free from abuse, neglect, misappropriation of property and exploitation. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property revised 11/01/19 revealed for prevention and identification, the facility's procedure will include the assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other residents rooms, residents with self-injurious behaviors, residents with communication disorders, and those who require heavy nursing care and or are dependent on staff. This deficiency represents non-compliance investigated under Complaint Number OH00162589.

Based on closed record review, facility policy review and interview, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) or call 911 for Emergency Medical Services (EMS) for Resident #60, who was found unresponsive, without a pulse/heartbeat and was identified to have advance directives reflecting the resident was a Full Code status. This resulted in Immediate Jeopardy and serious life-threatening harm/death on [DATE] when staff failed to initiate CPR or call 911 for medical services assistance when the resident was found unresponsive. Resident #60 subsequently passed away. This affected one resident (#60) of three residents reviewed for death in the facility. The facility census was 53 residents. On [DATE] at 4:11 P.M., the Administrator, Director of Nursing (DON), Regional Director of Clinical Services (RDCS) #328, Regional Director of Operations (RDO) #330, and Unit Manager #322 were notified Immediate Jeopardy began on [DATE] at approximately 8:30 A.M. when Licensed Practical Nurse (LPN) #313 found Resident #60, who had an advanced directive for a Full Code status, in her bed unresponsive and absent of vital signs. On [DATE] at 8:30 A.M., LPN #313 left the room and asked Registered Nurse (RN) #301 to confirm Resident #60 had expired. RN #301 found Resident #60 without a pulse and blood pressure. LPN #313 and RN #301 confirmed the absence of Resident #60's vital signs but failed to initiate CPR or call 911. LPN #313 indicated she did not think to check Resident #60's medical record to determine code status, initiate CPR or call 911 because Resident #60 received hospice services. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 8:30 A.M., Resident #60 was found absent from vital signs. On [DATE] at 2:30 P.M., RDCS #328 identified that CPR was not initiated when Resident #60, who was a Full Code, was found absent from vital signs on [DATE] at 8:30 A.M. On [DATE] at 5:03 P.M., education on CPR/code status was completed by the DON for all licensed nurses to include residents receiving hospice services have the right to determine their own code status, which may include Full Code status. On [DATE] at 5:10 P. M., a whole house audit of 54 residents was completed by RDCS #328 verifying code status, care plans and signed DNR forms. On [DATE] at 5:30 P.M., the crash cart (cart with emergency supplies/equipment) was audited by the DON to ensure all supplies were in stock and available. On [DATE] at 5:45 P.M., RDCS #328 verified all licensed nursing staff (three RNs and 10 LPNs) had valid CPR certifications. On [DATE] at 5:47 P.M., all nursing staff present when Resident #60 expired were interviewed by the Administrator, DON, and RDCS #328 regarding details of the event and nursing staff statements were obtained. The investigation revealed LPN #313 and RN #301 failed to check the code status of Resident #60 and did not perform CPR. On [DATE] at 6:00 P. M., an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was completed to discuss CPR and Code Status for all residents. The outcome of the meeting was the development of education pertaining to code status and location of code status. Also, the development of education of the residents who are under Hospice care have the right to choose to be Full Code status. The meeting also addressed developing audits to address the root cause of failing to not follow advanced directives. The meeting was held with Medical Director #331 via telephone, Administrator, DON, Unit Manager #322, Wound Nurse #322, Business Office Manager (BOM) #310, Social Worker/Admissions #203, Dietary Manager (DM) #312, and Central Supply/Scheduler #224. On [DATE] at 9:00 A.M., all department managers were educated by RDCS #328 and RDO #330 on the differences in code status and resident code status location. All future employees would be educated during orientation. On [DATE] at 7:05 P.M., all staff were educated on CPR, code status and the location of code status. Staff trained included three RNs, 10 LPNs, 28 certified nursing assistants (CNA), five housekeepers, one laundry personnel, six dietary staff, one activities personnel, and 11 department heads. On [DATE] at 7:30 P.M., Resident #60's physician (#331) was notified Resident #60 did not receive CPR per her (advance directives) code status. An attempt to reach Resident #60's listed family members revealed the telephone numbers were no longer in service. On [DATE] at 7:30 P. M., an Ad Hoc QAPI meeting was held to discuss the differences in code status and resident code status location, as well as to review the State agency findings and develop an abatement to address the specifics of the Immediate Jeopardy template. The meeting was held with Medical Director #331 via telephone, Administrator, DON, Unit Manager #322, Wound Nurse #322, BOM #310, Social Worker/Admissions #203, DM #312, Minimum Data Set (MDS) Nurse #303, Central Supply/Scheduler #224, Activity Director #231, Human Resources Director #226, RDCS #328, and RDO #330. On [DATE] at 11:29 A.M., LPN #313 was terminated from services related to not following policy and procedure regarding advanced directives. RN #301 received one-on-one education provided by RDCS #328 regarding failing to confirm Resident #60's code status. Beginning [DATE], the facility implemented a plan for the DON/Designee to conduct code drills on alternating shifts weekly for four weeks. Administrator/Designee would audit all deaths that occur in the facility to ensure the resident's advanced directives were facilitated per preference five times a week for four weeks. All findings would be submitted to the QAPI Committee for review and recommendations for six months. Although the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at Severity Level 2 (the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective actions and monitoring for effectiveness and on-going compliance. Findings include: Review of the closed medical record for Resident #60 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), esophageal obstruction, and cerebrovascular disease. Review of a plan of care plan created [DATE] revealed Resident #60's advanced directives were for the resident to be a Full Code (full life-saving measures to be taken in the event of cardiac/respiratory arrest). Interventions included assess advanced directives upon admission, quarterly, annually and with significant change to ensure the resident's wishes maintained. Respect resident regarding code status decisions. Review of Resident #60's physician's orders dated [DATE] revealed the resident was a Full Code (advance directives). The physician orders dated [DATE] revealed an order for Hospice Provider #333 to provide services for Resident #60 for a diagnosis of COPD with lower obstruction. Review of the modification of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was moderately cognitively impaired. The assessment indicated the resident did have a condition or chronic disease that would result in a life expectancy of less than six months. Review of the progress notes for Resident #60 revealed no progress notes were documented for February 2025. Review of the first progress note documented for [DATE] revealed it was dated [DATE] at 8:30 A.M. and completed by RN #301. The progress note stated Resident #60 was absent of vital signs at 8:30 A.M. This was verified by RN #301 and nurse on duty (LPN #313) for Resident #60. The progress notes dated [DATE] at 8:30 A.M. completed by LPN #313 revealed Hospice Provider #333 was notified Resident #60 was not responding. Hospice Provider #333 stated they would send a nurse to the facility. The progress note dated [DATE] at 9:30 A.M. completed by LPN #313 revealed Resident #60 was absent of vital signs at 8:30 A.M. and this was verified by two nurses (LPN #313 and RN #301). Hospice Provider #333 and Physician #331 were notified. The note included hospice would call the family and funeral home. The progress note dated [DATE] at 10:23 A.M. completed by LPN #313 revealed Hospice Provider #333 present in the facility. The progress note dated [DATE] at 10:25 A.M. completed by LPN #313 revealed time of death was now 10:25 A.M. Interviews during the survey revealed facility staff including LPN #313 could not explain why LPN #313 changed the time of death to 10:25 A.M. The progress note dated [DATE] at 11:06 A.M. completed by LPN #313 revealed the nurse from Hospice Provider #333 called the funeral home to come get Resident #60's body. Interview on [DATE] at 1:52 P.M. with LPN #208 revealed Resident #60 received Hospice services so she would have been a Do Not Resuscitate (DNR) so no CPR would have been done when Resident #60 was found to be absent of vital signs. Interview on [DATE] at 3:46 P.M. with RN #301 revealed on [DATE], she was working on the other side of the facility. LPN #313 was Resident #60's nurse that day. Resident #60 received Hospice services. RN #301 stated LPN #313 approached her and stated Resident #60 passed and requested her to verify absence of vital signs. RN #301 stated she verified Resident #60 had no pulse or blood pressure and stated she was not Resident #60's nurse, and she did not know Resident #60 was a Full Code. RN #301 stated she should have checked for her code status. RN #301 confirmed no CPR was done and EMS were not notified to come to the facility. RN #301 stated she never asked the code status because Resident #60 was on hospice services. RN #301 confirmed Resident #60 had an order for a Full Code status and confirmed CPR should have been initiated immediately when Resident #60 was found to have no pulse. Interview of [DATE] at 4:06 P.M. with the DON and RDCS #328 confirmed on [DATE], Resident #60 was Full Code status. On [DATE], Resident #60 was found with no vital signs and confirmed CPR was not initiated. RDCS #328 stated because Resident #60 received Hospice services, the nurses assumed she was a DNR status. RDCS #328 confirmed CPR should have been initiated, and CPR was not initiated for Resident #60. Interview on [DATE] at 10:07 A.M. with Clinical Manager #335 at Hospice Provider #333 confirmed any resident could receive hospice services and still choose to be a Full Code status. Clinical Manager #335 confirmed Resident #60 received hospice services through their company and was a Full Code at time of death. Interview on [DATE] at 2:28 P.M. with RDCS #328 confirmed there was no documentation in Resident #60's medical record to reveal what led to Resident #60's absence of vital signs and no documentation of Resident #60's primary physician being notified when Resident #60 was found to have absence of vital signs. RDCS #328 confirmed the physician should have been notified immediately and stated only a physician could pronounce a resident's time of death. Review of the facility policy titled Emergency Procedure - Cardiopulmonary Resuscitation revised [DATE] revealed if an individual was found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest was likely, begin CPR: Instruct a staff member to activate the emergency response system (code) and call 911. Verify or instruct a staff member to verify the DNR or code status of the individual. Initiate the basic life support (BLS) sequence of events. The BLS sequence of events is referred to as C-A-B (Chest compressions, airway, breathing). Review of the facility policy titled Resident Rights revised [DATE] revealed Federal and State Laws guarantee certain basic rights to all residents of the facility. These rights include the residents' right to choose an attending physician and participate in decision making regarding his or her care. This deficiency represents non-compliance investigated under Complaint Number OH00163552.

Based on resident and staff interview, observation, medical record review, review of the Self-Reported Incident (SRI) and investigation, and review of the facility policy, the facility failed to thoroughly investigate an allegation of resident-to-resident physical abuse. This affected two (Residents #15 and #38) of three residents reviewed for abuse. The facility census was 53. Findings include: Record review for Resident #15 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, anxiety disorder, and mood disorder due to known physiological condition with depressive features. Review of the modification of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was severely cognitively impaired. Resident #15 had little interest or pleasure in doing things. The presence of wandering also occurred one to three days. Review of the progress note dated 02/04/25 at 8:58 P.M. completed by the Director of Nursing (DON) revealed Resident #15 was seen pushing another resident in the hallway. Another resident (Resident #38) fell to the ground. Resident #15 was immediately escorted from the area and went back into his room, where he laid down in bed, and visual checks were performed every 15 minutes. Record review for Resident #38 revealed a re-admitted [DATE]. Diagnoses included Parkinson's disease without dyskinesia, dementia, Alzheimer's disease, and attention deficit disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #38 was severely cognitively impaired. Review of the progress notes for Resident #38 dated 02/04/25 at 8:58 P.M. completed by Registered Nurse (RN) #301 revealed Resident #38 was observed at 8:30 P.M. lying on the floor outside of Resident #15's room laying on her back. Resident's fall was observed by a certified nursing assistant (CNA) (#329) who stated Resident #38 hit her head on the ground. Resident #38 was holding her head saying she was in a lot of pain. Emergency 911 was called, and Resident #38 was transported to Hospital #339 at 8:45 P.M. Review of the Hospital After Visit Summary for Resident #38 dated 02/04/25 revealed the reason for the visit was due to a fall and diagnosis of closed compression fracture of L5 vertebra. The progress note dated 02/05/25 at 1:27 P.M. completed by RN #301 revealed the emergency room (ER) diagnosis was closed compression fracture of L5 vertebra with no intervention needed. The progress note dated 02/06/25 at 1:24 P.M. completed by DON revealed Resident #38's fall was reviewed in safety meeting. Resident's fall was observed by CNA #329. Resident #38 fell backwards and hit her head on the floor. Resident #38 complained of head/neck hurting. Review of the SRI dated 02/04/25 at 8:58 P.M. revealed the facility reported an allegation of physical abuse involving Resident #15 and Resident #38. There were no witnesses. Resident #15 with a low cognitive function allegedly pushed Resident #38 who also had low cognitive function. A CNA (#329) reported she was walking down the hallway when she saw a female resident (Resident #38) fall backwards losing contact with the floor out of a male resident's room (Resident #15). The facility concluded the evidence is inconclusive and abuse was not suspected. The facility's investigation did not include any resident interviews, including Resident #15's roommate (Resident #6) who was cognitively intact and witnessed the resident-to-resident abuse on 02/04/25. The facility's investigation did not have a witness statement signed by CNA #329, who also witnessed the incident. Interview on 03/12/25 at 3:46 P.M. with RN #301 stated she was the charge nurse on 02/04/25 when Resident #38 fell and fractured her back in front of Resident #15's doorway. RN #301 stated Resident #15's roommate (Resident #6) was there and witnessed everything when the incident occurred. RN #301 stated Resident #6 was very alert and oriented. Observation and interview on 03/12/25 at 3:55 P.M. revealed Resident #15 resided in the same room as Resident #6. Resident #15's bed was against the wall and Resident #6 would have a clear view of Resident #15's bed and the doorway. Interview with Resident #6 stated he remembered what happened regarding Resident #38's fall that day very well. Resident #6 stated Resident #38 came into their room and sat in Resident #15's bed. Resident #15 came in and said get out of my bed. Resident #38 did not respond, and Resident #15 said get up or I am going to hurt you. Resident #15 grabbed Resident #38 by the shoulders moved her to the doorway and pushed her in the hall. Resident #6 stated he saw the whole thing. Resident #38 screamed. Resident #6 stated he felt so bad for Resident #38. Resident #6 stated he was not afraid of Resident #15 because he knows Resident #15 only gets aggressive when provoked, meaning if you get near his things or get in his space, otherwise he doesn't say anything or do anything. Resident #6 stated he stays to himself in his area of the room. Resident #6 stated the facility staff did not interview him or ask for a statement regarding Resident #15's assault with Resident #38. Interview on 03/12/25 at 5:41 P.M. with the DON revealed the DON recalled the incident on 02/04/25 with Residents #15 and #38. The DON stated the incident happened on an off shift, and all they knew was Resident #38 was found outside Resident #15's door. Resident #38 had fallen backwards, she was injured and fractured her back. They immediately sent Resident #38 to the hospital, no one seen the fall. No one said anything that it might be Resident #15 who pushed Resident #38, and the staff just said he was in his room. The DON confirmed she read Resident #38's nurses notes and reiterated there were no witnesses. The DON confirmed she did not interview Resident #6 who was present at the time of Resident #38's fall. The DON confirmed Resident #6 was alert and oriented to the person, place and time and stated she did not interview him because she was not sure if he saw it. The DON stated she could not answer why she didn't interview Resident #6. Interview on 03/17/25 at 9:10 A.M. with CNA #329 stated on 02/04/25 she witnessed the incident with Resident #15 and #38. CNA #329 stated she actually seen the incident. CNA #329 stated she wrote up a statement describing what she saw when Resident #38 flew out of Resident #15's room. Two days after the incident occurred, the Administrator and Unit Manager called her on the telephone. The Administrator said the verbiage on the witness statement was too strong, it made it sounded like it was a lot. The Administrator told CNA #329 that she did not physically see Resident #15 push Resident #38. CNA #329 replied to the Administrator that she did see Resident #38 and Resident #38 fly through the air, she flew right through the doorway and flew to the ground. Resident #15 was standing right there in the doorway. CNA #329 stated she asked Resident #15 what happened, and Resident #15 said Resident #38 was in his bed, so he got her out of his room. The Administrator and Unit Manager typed up a different statement for CNA #329 and CNA #329 refused to sign the witness statement that they wrote. Interview on 03/17/25 at 10:03 A.M. with the Administrator confirmed her and Unit Manager #322 called CNA #329 on the phone to discuss the witness statement she wrote due to the statement was not 100% accurate. The Administrator stated she wanted to clarify the written statement because it did not reflect exactly what happened. The typed statement was the conversation on the telephone and CNA #329 agreed it was accurate on the phone. The Administrator confirmed CNA #329's original handwritten statement was not in the investigation file. The Administrator stated she would check to see if it was in her office. The Administrator never returned with the original statement. Review of the facilities policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property revised 11/01/19 included once the Administrator and ODH are notified, an investigation of the allegation violation will be conducted. Interview the resident, the accused and all witnesses. Witnesses generally include anyone who: witnessed or heard the incident, came in close contact with the resident the day of the incident (including other residents) and employees who worked closely with the accused employee and or alleged victim the day of the incident. Obtain a statement from the resident, if possible, the accused, and each witness. This deficiency represents non-compliance investigated under Complaint Number OH00162589.

Based on staff interview, record review, and facility policy review, the facility failed to notified the resident's family/responsible party and the physician timely upon the death of two residents (#60 and #61). This affected two residents (#60 and #61) of three residents reviewed for death. The facility census was 53. Findings include: 1. Review of the closed medical record for Resident #60 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), esophageal obstruction, and cerebrovascular disease. Review of Resident #60's physician's orders dated 06/15/21 revealed the resident was a Full Code (advance directives). The physician orders dated 04/30/24 revealed an order for Hospice Provider #333 to provide services for Resident #60 for a diagnosis of COPD with lower obstruction. Review of the progress notes for Resident #60 dated 03/01/25 at 8:30 A.M. and completed by Registered Nurse (RN) #301 revealed Resident #60 was absent of vital signs at 8:30 A.M. This was verified by RN #301 and nurse on duty (Licensed Practical Nurse (LPN) #313) for Resident #60. The progress notes dated 03/01/25 at 8:30 A.M. completed by LPN #313 revealed Hospice Provider #333 was notified Resident #60 was not responding. Hospice Provider #333 stated they would send a nurse to the facility. The progress note dated 03/01/25 at 9:30 A.M. completed by LPN #313 revealed Resident #60 was absent of vital signs at 8:30 A.M. and this was verified by two nurses (LPN #313 and RN #301). Hospice Provider #333 and Physician #331 were notified. The note included hospice would call the family and funeral home. Interview on 03/13/25 at 10:07 A.M. with Clinical Manager #335 at Hospice Provider #333 stated the facility nurses at the facility to call the physician for the time of death. Interview on 03/17/25 at 2:28 P.M. with Regional Director of Clinical Services (RDCS) #328 confirmed there was no documentation in Resident #60's medical record of Resident #60's primary physician being notified or the family being notified when Resident #60 was found to have absence of vital signs. RDCS #328 confirmed the physician and family should have been notified immediately. 2. Review of the closed medical record for Resident #61 revealed an admitted [DATE]. Diagnoses included vascular dementia and cerebrovascular disease . Review of the physician orders for Resident #61 dated 10/03/24 revealed an order to admit to Hospice #336 for cerebrovascular disease. An additional physician order dated 04/02/24 for Resident #61 included do not resuscitate comfort care (DNRCC). Review of the progress note for Resident #61 dated 11/02/24 at 5:20 A.M. completed by Licensed Practical Nurse (LPN) #229 revealed Resident #61 without vital signs and this was verified by second nurse. Hospice notified. Review of the progress note dated 11/02/25 at 6:18 A.M. completed by LPN #229 revealed Hospice Registered Nurse (RN) in and called time of death at 6:15 A.M. Hospice is notifying family. Interview on 03/18/25 at 11:55 A.M. with Medical Director #331 confirmed a resident's time of death was at the time of absence of vital signs. Interview and record review on 03/20/25 at 1:25 P.M. with Regional Director of Clinical Services (RDCS) #328 confirmed Resident #61 had no documentation or evidence of the physician or family being notified regarding his death by the facility and in a timely manner. Review of the facility policy titled Death of a Resident, Documentation revised July 2017 revealed the Nurse Supervisor/Charge Nurse will inform the resident's family of the resident's death. Review of the facility policy titled Change in Resident's Condition or Status revised May 2017 revealed the facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the residents medical/mental change and or status. This was an incidental finding during the complaint investigation.

Based on record review and interview the facility failed to provide adequate intervention and update Resident #61's care plan related to the resident's known use of a bed remote control to prevent a fall with injury. This affected one resident (#61) of four reviewed for person centered care planning. The facility census was 58. Actual harm occurred on 04/20/24 at approximately 2:30 A.M. when Resident #61, who had impaired cognition and a history of using the bed remote control to place her bed in the highest position without having the cognitive ability to lower the bed, was found on the floor yelling out in pain with both of her legs bent behind her with bones protruding from the skin. Resident #61's bed was noted in the high position when she was found on the floor. The resident was transferred to the hospital and subsequently passed away. Review of the Coroner's Report dated 04/22/24 revealed the cause of death as hypovolemic shock (sudden loss of blood or fluid), bilateral femur fractures and fall from bed. Findings include: Review of Resident #61's closed medical record revealed an admitted [DATE]. The resident passed away on 04/22/24. Resident #61's diagnoses included muscle weakness, falls and obesity. Review of Resident #61's care plan dated 01/23/23 revealed Resident #61 had self-care deficits with interventions including two staff assist with bed mobility. The care plan also reflected Resident #61 was at risk for falls with an intervention to keep bed in lowest position. Review of Resident #61's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 had impaired cognition and required moderate assistance with toileting, bathing, personal hygiene, and bed mobility. Review of progress note dated 04/20/24 authored by Licensed Practical Nurse (LPN) #202 revealed Resident #61's bed was observed to have been in a high position. Review of progress note dated 04/20/24 authored by Licensed Practical Nurse (LPN) #202 revealed an aide stated she needed assistance because Resident #61 was on the floor and was in need of an ambulance. Upon LPN #202 entering Resident #61's room, Resident #61 was observed with her head toward the foot of the bed and her legs were bent back in an unnatural position. Resident #61's bed was in the high position. Review of progress note dated 04/22/24 authored by the Director of Nursing (DON) revealed on 04/20/24 at approximately 2:36 A.M. Resident #61 was observed on the floor with her head toward the foot of the bed and both legs were bent back in an unnatural position. Resident #61's bed was noted to be in the highest position. The note further indicated Resident #61 manipulated the bed remote herself. The progress note indicated prior to the fall Resident #61's bed was in the lowest position. Review of the facility's updated fall investigation revealed Resident #61's bed was in the high position. Resident #61 was last seen at approximately 2:10 A.M. and the bed was in the lowest position at that time. Review of the revised care plan dated 04/22/24 revealed Resident #61 had an actual fall with major injury with interventions including keeping bed in lowest position and do not leave the bed remote within Resident #61's reach. Review of Coroner's report dated 04/22/24 revealed cause of death as hypovolemic shock (sudden loss of blood or fluid), bilateral femur fractures and fall from bed. Interview on 05/01/24 at 12:08 P.M. with Resident #61's daughter revealed she was at the facility to collect Resident #61's belongings because the resident fell at the facility, was sent to the hospital, and subsequently passed away. Resident #61's daughter stated on 04/20/24 Resident #61 fell out of bed and broke both of her femurs. Resident #61's daughter stated Resident #61 was not able to get out of bed on her own and required staff assistance to move in bed. Interview on 05/01/24 at 2:19 P.M. with State tested Nursing Assistant (STNA) #221 revealed Resident #61 was able to use the bed controls and used them to place her bed in a high position and once in the high position the resident could not lower the bed. Interview on 05/02/24 at 5:35 A.M. with Licensed Practical Nurse (LPN) #202 revealed she was present on the evening of 04/19/24 through 04/20/24 from approximately 6:30 P.M. to 7:00 A.M. LPN #202 stated at approximately 2:36 A.M. on 04/20/24, the STNA told her Resident #61 was on the floor. LPN #202 immediately entered Resident #61's room and observed Resident #61 on the floor with both of her legs bent behind her and her bones were sticking out and she was yelling out in pain. LPN #202 asked Resident #61 what happened, and Resident #61 had told her she needed to go to the bathroom. LPN #202 told Resident #61 she was not able to get up by herself and Resident #61 stated Oh I forgot. LPN #202 did not move Resident #61 and immediately called 911. Telephone interview on 05/02/24 at 12:59 P.M. with STNA #266 revealed she was present on 04/19/24 through 04/20/24 from approximately 10:30 P.M. to 7:00 A.M. STNA #266 stated she was charting at the nurses' station at approximately 2:30 A.M. when she heard Resident #61 yell out I'm gonna fall, and then Resident #61 yelled I'm on the floor. STNA #266 immediately went into Resident #61's room and observed Resident #61 on the floor with her legs completely behind her. STNA #266 stated STNA #269, and LPN #202 also responded. STNA #266 stated Resident #61 was not capable of turning herself in bed, but she could get her legs off the bed which may have caused the fall out of bed. STNA #266 stated Resident #61 was known on previous occasions to move her bed to the high position and not be able to put it back down. Telephone interview on 05/05/24 at 9:50 A.M. with STNA #269 revealed she was the assigned aide for Resident #61 on 04/19/24 through 04/20/24 from 10:30 P.M. to 6:30 A.M. STNA #269 stated she had provided care for Resident #61 approximately five minutes prior to her fall on 04/20/24. STNA #269 had repositioned Resident #61 and placed the bed in the lowest position. STNA #269 stated Resident #61 often moved her bed into a high position and then could not put it back down. Interview on 05/06/24 at 3:14 P.M. with Director of Nursing (DON) confirmed Resident #61's care plan was updated after her fall on 04/20/24 to include keeping the bed remote control out of Resident #61's reach. The DON also confirmed Resident #61 had a history of using the remote control to place the bed in the highest position without the ability to lower the bed. There was no evidence during the investigation, the facility implemented comprehensive and individualized interventions prior to the fall that occurred on 04/20/24 to address this safety/fall risk in order to prevent the fall from occurring. This deficiency represents non-compliance investigated under Complaint Number OH00153683 and OH00153514.

Based on observation, record review, facility policy and procedure review and interview the facility failed to prevent the worsening of a surgical wound for Resident #4 and failed to ensure wound treatment was provided as ordered for Resident #4 and Resident #2. This affected two residents (#4 and #2) of four residents reviewed for non-pressure skin wounds. Actual Harm occurred on 07/21/22 when Resident #4, who was cognitively impaired, and at risk for skin breakdown was found to have a worsening ulceration of a surgical wound, located on the lower, left, lateral leg. The facility failed to provide wound care as ordered and the wound worsened and subsequently required treatment and debridement at a wound clinic. On 09/01/22, the wound located on the lower, left, lateral leg was reclassified from a surgical wound to a grade 2, diabetic venous ulcer (penetration through the subcutaneous tissue, which may expose bone, tendon, ligament, or joint capsule). Findings include: 1. Medical record review revealed Resident #4 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan, initiated on 03/04/22, revealed Resident #4 had actual skin injury related to a surgical wound of the left lateral leg with interventions including to monitor/document location, size, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Minimum Data Set (MDS) 3.0 assessment, dated 07/14/22 revealed Resident #4's Brief Interview for Mental Status (BIMS) score was 11, which indicated the resident was moderately cognitively impaired. There were no behaviors or rejection of care identified on the assessment. The MDS assessment revealed Resident #4 required extensive, one-person assistance with dressing and personal hygiene, and limited, one-person assistance with bed mobility and toileting. The MDS revealed there was one surgical wound with no additional wounds. Review of Resident #4's physician order, dated 07/29/22, revealed to cleanse left lower extremity (LLE) with normal saline, apply a nickel-thick layer of Santyl (enzymatic debrider), calcium alginate and cover with foam dressing daily and as needed (prn) every day shift. Review of a Wound-Weekly Observation Tool, dated 08/25/22, revealed Resident #4 was identified to have a surgical wound, located on the left, lateral leg, with an onset date of 12/16/21. The wound measured 2.0 centimeters (cm) length (L) by 3.5 cm width (W) x 0.2 cm depth (D). The wound was assessed to be worsening, with 50 percent granulation tissue and 50 present slough (dead tissue) present. There was a moderate amount of serosanguineous (fresh blood produced by an open wound) drainage and no odor. The treatment was to cleanse with normal saline and apply thick nickel-thick layer of Santyl then calcium alginate and cover with foam daily and prn. Review of a NP Wound Consult, dated 09/01/22, revealed Resident #4's wound was worsening and visualized to have the wrong treatment in place on examination. The wound measured 2.2 cm L x 4.2 cm W x 0.2 cm D. The wound had 50 present granulation tissue and 50 percent slough present. There was a moderate amount of serous drainage and no odor. The wound was reclassified from a surgical to a vascular wound. The treatment was to cleanse with normal saline and apply thick nickel-thick layer of Santyl, calcium alginate and cover with foam daily and prn. The resident was referred to a wound clinic, an x-ray to rule out [CONDITION(S)] (bone infection), and a vascular consult was ordered. Review of the Wound Clinic Progress note dated 09/06/22 revealed instructions to elevate legs when sitting and elevate legs above the heart three times per day. Under Physician Plan indicated [CONDITION(S)] control was discussed because the patient had significant [CONDITION(S)] to bilateral lower extremities. Stressed importance of elevating the limb at above heart level as much as patient could. Review of the Wound Clinic Progress Note, dated 09/13/22, revealed a Wagner Grade 2, diabetic ulcer of the left, lateral leg. The wound measured 2.6 cm L by 3.9 cm W x 0.2 cm D. The site assessment was described as yellow, granulation, sloughing, and pink with adipose (fat) exposed. The wound bed had 20 percent granulation tissue and 80 percent slough present. There was a moderate amount of yellow-tan drainage. The peri-wound assessment revealed [CONDITION(S)] and [CONDITION(S)]. 100 percent of the wound was debrided down to and including muscle fascia. On 10/12/22 at 10:10 A.M., Resident #4 was observed sitting in her room, in her wheelchair, with her feet resting on the ground. The resident's legs were not elevated. During interview on 10/13/22 at 1:50 P.M., NP #239 confirmed during her examination of Resident #4's wound, she observed the wrong treatment was in place and the wound had worsened from the previous week. NP #239 stated she could not recall what the incorrect treatment was, but the dressing applied was not as ordered. NP #239 stated her last visit with Resident #4 was on 09/22/22 as the resident was now being treated by the wound clinic. During interview on 10/13/22 at 2:05 P.M., the Director of Nursing (DON), confirmed the recommendations from the wound clinic on 09/06/22 to elevate the legs when sitting and to elevate the legs above the heart three times per day were not initiated as ordered by the physician. During observation and interview on 10/13/22 at 3:35 P.M., Resident #4 stated there had been times that her dressing changes had not been done by the facility staff and she had reported this to the nurse. The resident was observed sitting in her room, in her wheelchair, with her feet resting on the ground. The resident's legs were not elevated. During interview on 10/13/22 at 3:38 P.M., Licensed Practical Nurse (LPN) #203 confirmed Resident #4's legs were not elevated and stated the resident spent the majority of her time out of the bed and sitting in her wheelchair, in her room. During the annual recertification survey, the facility failed to provide evidence that comprehensive and individualized interventions were being provided for Resident #4 to prevent the worsening of the vascular wound. Review of the facility policy titled Wound Care, dated October 2010, revealed the purpose of this procedure was to provide guidelines for the care of wounds to promote healing including to verify the physician's order and to review the resident's care plan to assess for any special needs of the resident. 2. Medical record review revealed Resident #2 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) 3.0 assessment, dated 07/05/22 revealed Resident #2's Brief Interview for Mental Status (BIMS) score was 15, which indicated intact cognition. There were no behaviors or rejection of care identified on the assessment. The MDS assessment revealed the resident required extensive, one-person assistance with personal hygiene, and limited, one-person assistance with bed mobility and toileting. The MDS revealed there were pressure ulcers or skin issues. The resident was always continent of bowel and bladder. Review of a nursing progress note, dated 07/16/22 at 3:21 P.M., revealed Resident #2 had a skin tear on her buttocks, 5.0 centimeters (cm) length (L) by 3.0 cm width (W). The wound was cleansed with normal saline and covered with a foam dressing. Review of a Wound-Weekly Observation Tool, dated 07/21/22, revealed Resident #2 was identified to have an abrasion, located on the left, upper buttock, with an onset date of 07/20/22. The wound measured 4.0 cm L x 3.0 cm W x 0.2 cm D. The treatment was to cleanse with normal saline and apply silver alginate and cover with foam daily and as needed (prn). Review of a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record (TAR), dated 07/22/22, revealed the dressing change to Resident #2's buttock wound was not performed on 07/23/22 and 07/27/22 due to the resident sleeping. Review of the Care Plan, initiated on 08/18/22, revealed Resident #2 had actual impairment to skin integrity of the upper buttock area with interventions including to monitor/document location, size, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] During interview on 10/11/22 at 3:15 P.M., Resident #2 stated her dressing changes were not done during one week in July. Resident #2 could not recall the exact dates. During interview on 10/13/22 at 3:36 P.M., the Director of Nursing (DON) confirmed Resident #2's TAR documentation revealed dressing changes were not completed on 07/23/22 and 07/27/22 due to the resident being asleep. The DON said the nurse should have completed the dressing changes when the resident awakened. Review of the facility policy titled Wound Care, dated October 2010, revealed the purpose of the procedure was to provide guidelines for the care of wounds to promote healing including to verify the physician's order and to review the resident's care plan to assess for any special needs of the resident. This deficiency represents non-compliance investigated under Complaint Number OH 375 and OH 555.

Based on review of the skin grids, the physicians orders, the narcotic count sheets, review of the medication treatment records, observations of Resident #10's dressing change, and interviews the facility failed to ensure nursing staff provided Resident #10 with pain medications prior to her dressing changes, which resulted in her moaning, calling out in pain, and trying to moving away from the staff. The harm occurred when the facility failed to ensure Resident #8 was medicated for pain, as ordered, prior to the dressing change. This had the potential to affect two Residents, #8 and #10, out of three reviewed. Findings include: 1. Resident #10 was admitted on [DATE] with the following Diagnoses: [REDACTED]. She was transferred to the hospital on [DATE] and re-admitted on [DATE] with unstageable sacral wound with tunneling measuring three centimeters (cm) by three cm by two and a half cm and tunneling of one cm. Resident #10 was not interviewable. Review of Resident #10's physicians orders dated 01/12/15 revealed she had an order for [REDACTED]. Review of Resident #10's care plan for skin/wounds revealed the staffs are to administer medications according to the physician's orders [REDACTED]. Observations of Resident #10's dressing change on 02/18/15 at 6:05 A.M. with registered nurse (RN) #1 and RN #2 revealed Resident #10 was heard from the hall yelling out and moaning loudly. RN #1 and #2 revealed Resident #10 yells out and moans all day. RNs #1 and #2 prepared for Resident #10's dressing change, both nurses washed their hands and set up the supplies. Upon entering the room Resident # 10 was lying on her left side, moaning loudly and shaking her left arm; she did not respond to questions and statements from the nurses. RNs #1 and #2, for a second time revealed Resident #10 moans like this all the time, all day. After setting up the supplies, RN #2 removed her blanket, moved her Foley and positioned Resident #10 on her left side up against blankets and the bed rails. During the repositioning, Resident #10 moaned loudly and yelled out "OH OH". RN #2 washed her hands, and proceeded to removed tape and dressing, Resident #10 moaned loudly, both RN #1 and #2 tried to comforted and explained what they were doing. Resident #10 had a large wound on her coccyx with tunneling, the area was not measured at this time, as the nurse practitioner had measured the wound on 02/17/15. When RN #2 removed the tape and part of the dressings, Resident #10 yelled out "OH OH" and jerked forward towards RN #1 who was holding her. RNs #1 and #2 both commented she yells like that all day. RN #2 washed hands and put on new gloves, and continued to removed the dressings in the tunneling portion of the wound by inserting her fingers into the wound and pulling the packing out. Resident #10 moved away and yelled out loudly "OH OH". RN #2 cleaned the wound with normal saline, as she squirted the normal saline into wound, and Resident #10 jerked back and yelled loudly "OH OH". At this time a strong odor emendated from wound. RN #1 said she could not smell anything, "I guess I am used to it". The wound was approximately seven centimeters by seven centimeter by four centimeters deep with tunneling in pockets. The periphery of the wound was red/pink with numerous smaller open area around the large wound. The small areas measured two centimeters by one centimeters and were pink, red and raw. RN #2 revealed the smaller areas are from the tape being removed; there are orders was to cover the smaller areas with a dry dressing an no tape. RN #2 proceeded to removed additional dressings in the tunneling portion of the wound with her fingers and Resident #10 yelled out "OH OH". Both RN #1 and #2 were questioned regarding Resident #10's pain medication. Both, RN #1 and RN #2 said she was medicated earlier; she has an anti anxiety medication and a narcotic [MEDICATION NAME] medication. As RN #2 dried the wound area, Resident #10 was yelling out, her tone fluctuating with severity. RN #2 packed the wound with a dressing (mesalt), Resident #10 jumped as the wound was packed and moaned. The dressing was secured with tape. After the dressing change, RN #1 and RN #2 remained to reposition Resident #10, Resident #10 continued to moan loudly. Review of the medication treatment record revealed Resident #10 was not medicated prior to the dressing change, she received her pain medication at 12:45 A.M. RN#2 verified Resident #10 was not medicated for the dressing change by the night nurse. Review of the treatment records, the medication treatment records, the narcotic count sheets and the physician's orders [REDACTED].M., revealed Resident #10 had a dressing change every three days. The dressing changes were done on the third shift from 11:00 P.M. to 6:00 A.M. The dressing changes were completed on 01/15/15, 01/17/15, 01/19/15, 01/21/19, 01/23/15, 01/26/15, 01/28/15, 01/30/15, 02/01/15, 02/02/15, 02/03/15, 02/04/15, 02/05/15, 02/06/1502/07/15, 02/08/15, 02/11/15, 02/12/15, 02/14/15, and 02/17/15. Resident #10 was not medicated for pain or agitation prior to her dressing changes. Review of the narcotic count sheets with the DON 02/18/15 at 8:00 A.M. revealed Resident #10 her schedule narcotic included a pain reliever ([MEDICATION NAME]) 50 mg three times a day. From 02/12/13 to 02/18/13, Resident #10 did not received the schedule medication three times a day on four days. On 02/13/15 she received the medication at 8:00 A.M. and 12:00 P.M. On 02/14/15 she received the medication at 12:00 P.M. and 5:00 P.M. On 02/16/15, she received the medication at 12:00 P.M. and 8:00 P.M. On 02/17/15, she received the medication at 12:00 P.M. and 5:00 P.M. The DON verified that Resident #10 yells out and moans all day and she has a large wound to her coccyx. The DON had no additional information as to why Resident #10 was not medication for agitation and pain during the day and night; or why the narcotic like pain reliever ([MEDICATION NAME]) was not administered per the physicians order. 2. Resident #8 was admitted on [DATE] with the following Diagnoses: [REDACTED]. Review of his skin/wound care plan date 02/26/15 revealed staff were required to monitor Resident #8 for pain during his treatments and to treat his pain per orders. Resident #8 had a left eschewal and a right sacral pressure areas. On 01/13/15, the physician ordered a dressing change three times a week and as needed. Resident #8 had a physician's orders [REDACTED]. Review of the skin grids and the medication treatment records with the DON on 02/18/15 at 8:57 A.M. revealed Resident #8 's dressing changes were completed on third shift 11:00 P.M. to 6:30 A.M. Resident #8's dressing changes were completed on 01/13/15, 01/15/15, 01/17/15, 01/20/15, 01/22/15, 01/23/15, 01/24/15, 01/27/15, 01/29/15, 01/31/15, 02/04/15, 02/06/15, 02/09/15, 02/11/15 (wound nurse), 02/13/15, and on 02/14/15. Review of the medication treatment records revealed Resident #8 did not receive his ordered pain medication on 01/13/15, 01/15/15, 01/17/15, 01/23/15, 01/24/15, 01/29/15, 01/31/15, and 02/01/15. Interview with Resident # 8 on 02/18/15 at 9:57 A.M. revealed when the nurse's complete his dressing change, "it hurts a lot when they wipe it and put the dressing on. Not sure what I get for pain medication." On 02/18/15 at 8:00 A.M. the DON verified Resident #8 was not medicated for his dressing changes. The citation substantiated the Complaint Number OH 852.

Based on observation, record review, review of the facility policy and interview, the facility failed to ensure ordered interventions were implemented to promote the healing of pressure ulcers. This resulted in actual harm for Resident #36 who developed unstagable pressure ulcers to the right and left heels. The deficient practice affected two (Resident #36 and #54) of four residents reviewed for pressure ulcers. The census was 53 residents. Findings include: 1. Resident #36 had [DIAGNOSES REDACTED]. Review of the care plan dated 03/30/09 regarding a self care deficit indicated the resident required assistance with personal hygiene, dressing and grooming. The care plan dated 03/30/09 revealed the resident was at risk for skin breakdown related to cognitive status. The interventions included the heels were to be off loaded (elevated off the bed). Review of the pressure sore risk assessment indicated the resident was at moderate risk for developing pressure ulcers. The minimum data set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. The assessment also revealed the resident required extensive assistance to total dependence of one to two people for activities of daily living. The pressure ulcer record indicated a Stage II pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) was discovered on 06/11/13 on the right heel. The wound was a blister that measured 5.0 centimeters (cm) long and 3.0 cm wide. The physician orders dated 06/10/13 indicated skin prep was to be applied to the right heel, the heel was to be padded and wrapped twice daily and as needed. The pressure ulcer record dated 07/01/13 revealed the right heel pressure ulcer remained as a Stage II measuring 3.0 cm long and 2.5 cm wide. Review of the pressure ulcer record indicated a Stage II pressure ulcer was discovered on the left heel on 06/29/13. The wound was described as a serum filled blister that measured 5.0 cm long and 4.0 cm wide. Review of the physician orders dated 06/29/13 revealed a Prevalon Boot (a boot to help heal or prevent pressure ulcers) was to be worn by the resident on both lower extremities. The physician orders dated 06/29/13 revealed the left heel treatment was to apply sure prep, pad the wound and wrap it twice a day and as needed. Review of the pressure ulcer care plan dated 06/11/13 indicated the resident had pressure ulcers to the right and left heels. The interventions included to off load the heels. The care plan regarding pressure ulcers dated 03/30/09 and updated 06/29/13 had interventions including Prevalon Boot bilaterally to the lower extremities. Review of the pressure ulcer record dated 07/01/13 revealed the left heel wound remained a Stage II pressure ulcer that measured 5.0 cm long and 4.0 cm wide. There was no other description of the wound. Observations made on 07/02/13 at 2:20 P.M. with the director of nursing (DON) revealed the resident was in bed with her heels flush against the mattress, a pillow placed between her legs that did not float the heels and no Prevalon Boots. The DON verified the heels should have been floating off the mattress and the Prevalon Boots should have been on the lower extremities. Observations made at 2:47 P.M. revealed the DON began to change the bilateral heel dressings after washing her hands, placing the supplies on the over bed table without cleaning the table or placing a barrier on the table. She put on gloves. She removed the dressings that were on both heels and placed them on the bed near the resident's heels. The right heel pressure ulcer presented as dried brown tissue. The wound bed was not visible. The DON stated the wound was discovered as a blister and verified she was documenting the wound as a Stage II pressure ulcer. She verified the wound bed was not visible due to the discolored tissue over the wound bed. The left heel pressure ulcer presented as a blister that was partially fluid filled, purple in color with scattered black areas and surrounded by red tissue. The DON stated the pressure ulcer was discovered as a blister and verified she was documenting the wound as a Stage II pressure ulcer. She verified the wound bed was not visible due to the purple color and the black areas. The DON proceeded with the dressing change to both heels wearing the same gloves she wore to remove the dressings. She secured the dressing with a roll of tape that had been on the over bed table and on the resident's bed. She dated the dressings with a pen that had been on her right pant pocket with the same gloves and placed it back on the pocket. The Prevalon Boots were placed on the lower extremities. At the completion of both dressing changes she disposed of the previous dressings, removed the gloves and washed her hands. She placed the roll of tape in her pocket. An interview on 07/02/13 at 3:15 P.M. with the DON verified the roll of tape that was on the over bed table and on the resident's bed was not left in the resident's room and the pen she used to date the dressings was never sanitized after its use. She also verified the wound beds were not visible which would have been Unstageable pressure ulcers rather than Stage II pressure ulcers. She verified she only washed her hands prior to the removal of the prior dressings and wore the same gloves to remove the dressings, perform both heel dressings and date them with the pen on her pocket. Review of the facility policy and procedures regarding dressing changes revised on 01/01/09 revealed the nurse was to remove the soiled dressings and dispose of them, remove the gloves, wash hands and apply new disposable gloves. 2. Resident #54 was admitted with [DIAGNOSES REDACTED]. Review of the assessment for risk of developing pressure ulcers that was undated indicated the resident was high risk. Review of the physician orders dated 02/22/13 revealed the resident had a urinary catheter. Review of the physician orders dated 02/25/13 revealed the resident was ordered Inzo cream (a barrier cream) to be applied to bilateral buttocks every shift and as needed. Review of the non-decubitus skin condition record with an initial date of 02/26/13 indicated the resident was excoriated on bilateral buttocks. There was no definitive assessment regarding the cause or extent of the excoriation. Review of the documentation on the treatment sheet for May 2013 revealed the treatment was not done on the evening shift on 05/20/13, the day shift on 05/21/13, the day and evening shift on 05/22/13, the day shift on 05/23/13, the evening shift on 05/24/13, the day and evening shift on 05/25/13, 05/26/13, 05/27/13 and 05/28/13, the day shift on 05/29/13 and the day and evening shift on 05/30/13. The resident was discharged on [DATE] according to the care management discharge summary and guide. An interview with the DON on 07/03/13 at 10:55 A.M. verified the treatment to the bilateral buttocks was not documented that the resident received the treatment every shift as ordered. She verified the documentation revealed the resident did not receive the treatment on the above dates and shifts. The DON verified the assessment of the excoriated areas on the bilateral buttocks did not include the possible cause or the extent of the excoriated areas. This deficiency substantiates Complaint Number OH 684.