Every finding on record at Liberty Nursing Center of Colerain Inc

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to provide proper nail care. This affected two (Residents #41 and #56) of three residents reviewed for activities of daily living (ADL) care. The facility census was 59 residents. Findings include: 1. Review of the medical record for Resident #41 revealed an admission date of 03/28/25 with diagnoses including femur fracture, atrial fibrillation, depression, dementia, and cecum cancer. Review of the Minimum Data Set (MDS) assessment for Resident #41 dated 04/27/26 revealed the resident had intact cognition and required maximum staff assistance with personal hygiene. Observation on 07/22/26 at 10:55 A.M. revealed Resident #41's fingernails were excessively long, extending approximately one-half inch beyond the tip of the resident's finger, with chipped nail polish on some nails and dirt under all of the resident's nails. Interview on 07/22/26 at 10:56 A.M. with Resident #41 confirmed her fingernails were too long and had jagged edges. Resident #41 stated staff gave her showers twice weekly but no one had offered her nail care. Interview on 07/23/26 at 10:55 A.M. with Licensed Practical Nurse (LPN) #261 verified Resident #41's nails were long and dirty and appeared as if they hadn't been trimmed in some time. 2. Review of the medical record review for Resident #56 revealed and admission date of 04/08/26 with diagnoses including cerebral infarction, hemiplegia and hemiparesis, and rectal cancer. Review of the MDS assessment for Resident #56 dated 04/21/26 revealed the resident had moderate cognitive impairment and required staff assistance with ADLs. Observation on 07/22/26 at 3:22 P.M. of Resident #56 revealed the resident's fingernails were long, extending approximately one-half inch beyond the top of the resident's finger. Interview on 07/22/26 at 3:23 P.M. of Resident #56 verified his nails were too long and no one had offered to trim them. Interview on 07/22/26 at 3:36 P.M. with Certified Nursing Assistant (CNA) #219 confirmed Resident #56's fingernails were too long and needed attention. Review of the facility policy titled Care of Fingernails/Toenails undated revealed nail care included daily cleaning and regular trimming of nails. This deficiency represents noncompliance investigated under Complaint Number3072675.

Based on medical record review, observation, staff interview, and review of facility documents and policy, the facility failed to provide or arrange for proper foot care. This affected one (Resident #15) of three residents reviewed for foot care. The facility census was 59 residents. Findings include: Review of medical record for Resident #15 revealed an admission date of 03/21/26 with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes, and congestive heart failure (CHF.) Review of the Minimum Data Set (MDS) assessment for Resident #15 dated 07/02/26 revealed the resident had moderate cognitive impairment and required staff assistance with personal hygiene. Observation on 07/23/26 at 8:13 A.M. revealed the toenails to Resident #15's great toes were both overgrown. Interview on 07/23/26 at 8:14 A.M. with Licensed Practical Nurse (LPN) #115 verified both of Resident #15's feet had overgrown toenails on both great toes and the nails needed to be trimmed. LPN #115 stated he thought Resident #15 was seen by podiatry who would cut her toenails. Interview on 07/22/26 at 3:27 P.M. with Social Service Designee (SSD) #263 stated Resident #15's family had opted not to enroll the resident to be seen by the facility podiatrist during the resident's admission care conference. Interview on 07/23/26 at 12:39 P.M. with Lead Certified Nursing Assistant (CNA) #219 confirmed she thought Resident #15 had her foot care done by the consulting podiatrist. CNA #219 stated if a resident was not on the list to be seen by podiatry the facility nursing staff should take care of the resident's feet and cut her toenails as needed. Interview on 07/23/26 at 3:40 P.M. with the Director of Nursing (DON) confirmed nursing staff were ultimately responsible for foot care and facility nurses should be doing regular skin checks which would involve observing residents' feet. Nursing should address any issues that are discovered. Review of the facility's ancillary services list revealed Resident #15 was not on the list to see podiatry. Review of the facility policy titled Care of Fingernails and Toenails undated revealed nailcare should occur daily with cleaning and regular trimming. CNAs were not to trim nails of diabetic residents or resident with circulatory problems. Any changes in color of skin around nail bed, blue colored nails, cracking of the skin between the toes and any swelling or bleeding should be reported to the nurse. This deficiency represents noncompliance investigated under Complaint Number 3072675.

Based on medical record review, observation, and staff interview, the facility failed to provide appropriately textured food which resident was able to tolerate. This affected one resident (Resident #15) of three residents reviewed for specialized diets. The facility census was 59 residents. Findings include: Review of the medical record for Resident #15 revealed an admission date of 03/21/26 with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes, and congestive heart failure (CHF.)Review of the admission orders for Resident #15 revealed the resident had an order for a regular diet. Review of the Minimum Data Set (MDS) assessment for Resident #15 dated 07/02/26 revealed the resident had moderate cognitive impairment and had no natural teeth. Observation on 07/22/26 at 1:18 P.M. revealed resident was trying to eat a pork chop which had been cut into one-inch squares. Resident #15 placed a piece of the pork into her mouth and chewed for several minutes before spitting out the piece of pork into her napkin. Interview on 07/22/26 at 1:20 P.M. with Resident #15 confirmed she had no natural teeth and meats were impossible for her to chew. Interview on 07/23/26 at 1:23 P.M. with Certified Nursing Assistant (CNA) #297 confirmed Resident #15 had no natural teeth and was unable to chew meats. Interview on 07/22/26 at 1:29 P.M. with Licensed Practical Nurse (LPN) #261 verified she was unaware Resident #15 had no teeth nor was she aware the resident was served meat which the resident was unable to eat. LPN #261 stated therapy would evaluate residents with no teeth to determine what type of diet was most appropriate. Interview on 07/23/26 at 8:44 A.M. with Speech Therapist (ST) #287 confirmed therapy had not seen Resident #15 to determine if the resident was on the proper diet. ST #287 stated therapy had not received a referral for Resident #15 to be evaluated. Interview on 07/23/26 at 12:47 P.M. with the Director of Nursing (DON) confirmed Resident #15 had been admitted with orders for a regular diet. The DON stated the facility was going to get Resident #15's diet order changed to regular diet with minced meat. Interview on 07/23/26 with Dietitian #298 confirmed she was unaware Resident #15 was having issues with chewing meat. Dietitian #298 stated she relied on nursing staff to alert her if there was an issue with a resident's diet, and residents without natural teeth should be evaluated by speech therapy for proper diet. This deficiency represents noncompliance investigated under Complaint Number 3072675.

Based on interview, record review and policy review, the facility failed to monitor and evaluate residents in response to a change in condition. This affected one (Resident #2) of three residents reviewed for change in condition. The facility census was 55 at the time of survey.Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] and discharged to home with family on 02/27/2026. Diagnoses included chronic obstructive pulmonary disorder (COPD), chronic kidney disease (stage 3), Alzheimer's Disease, gastroesophageal reflux disease, and unspecified abdominal pain.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated revealed the resident was moderately cognitively impaired with a BIMS of 09 out of 15, had no behaviors, and did not reject care.Review of the progress notes for Resident #2 revealed that Resident #2 complained of abdominal pain and chocolate colored emesis on 02/12/2026 at 10:40 A.M. The physician was notified and ordered monitoring and a clear liquid diet x2 days as noted in the progress note. On 02/12/2026 at 6:53 P.M. a progress note was entered stating No further emesis noted this shift. No further progress notes or monitoring were performed until 02/14/2026 at 12:30 P.M. when Resident #2 complained of chest pain and abdominal pain. Resident #2 was sent to the local emergency department (ED) for further evaluation.No orders for monitoring or clear liquid diet were entered for Resident #2. Interview with Director of Nursing (DON) on 03/17/2026 at 11:57 A.M. confirmed that orders should have been entered for monitoring and clear liquid diet and verified there were no progress notes on monitoring for Resident #2 from 02/12/26 at 6:53 P.M. through 12/14/26 at 12:30 P.M. Review of facility policy titled Charting and Documentation dated July 2017 states All services provided to the resident, progress toward the care plan goals or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.This deficiency represents non-compliance investigated under Complaint Number 2792957.

Based on interview, record review, and facility policy review, the facility failed to administer medications in a safe and timely manner. This affected one (Resident #3) of three residents reviewed for medications. The facility census was 55.Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] for aftercare following explantation of hip joint prosthesis and discharged to hospital on [DATE]. Diagnoses included infection and inflammatory reaction due to orthopedic prosthetic devices, acute embolism and thrombosis of deep veins, type II diabetes mellitus, and radiculopathy of the lumbosacral region.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was severely cognitively impaired, was rarely/never understood, had no behaviors, and did not reject care.Review of physician orders for Resident #3 revealed medication orders including:Seroquel Oral Tablet (Quetiapine Fumarate) - Give 12.5 milligrams (mg) via J-tube three times a day for bipolarCiprofloxacin HCL Oral Tablet 750 mg - Give 1 tablet via J-tube every 12 hours for infectionReview of medication administration audit report for Resident #3 revealed that on 12/24/2025 the 9:00 A.M. dose of Seroquel and ciprofloxacin were administered at 12:59 P.M. On 12/25/2025 the 9:00 A.M. doses were administered at 12:17 P.M. On 12/26/2025 the 9:00 A.M. doses were administered at 12:32 P.M.Interview with Director of Nursing (DON) on 03/18/2026 at 1:00 P.M. revealed that nurses have one hour before and one hour after scheduled administration time to administer medications. DON confirmed that medications were given outside of the parameters of safe medication administration.Review of Resident Council meeting minutes for February and March of 2026 revealed resident complaints of medications being administered late.Review of facility policy titled Documentation of Medication Administration dated April 2007 revealed Administration of medication must be documented immediately after it is given.This deficiency represents non-compliance investigated under Complaint Number 2717426.

Based on staff interview and review of staff job descriptions, the facility failed to designate a dedicated Registered Nurse (RN) to serve as the full time Director of Nursing (DON.) This had the potential to affect all of the residents residing in the facility. The facility census was 67 residents.Findings include: Interview on 08/19/25 at 9:30 A.M. with the Administrator confirmed the Director of Nursing (DON) was on medical leave and had not been working in the facility since 07/22/25. The Administrator confirmed the facility designated Registered Nurse (RN)#300 who was the facility's sole Minimum Data Set (MDS) nurse to also serve as the interim DON. Interview at 08/21/25 at 9:16 A.M. with Social Services Director (SSD) #339 confirmed RN #300 was the facility's full time MDS Nurse who was also responsible for maintaining the care plans for all of the residents in the facility. Interview on 08/21/25 08/21/25 at 12:42 P.M. with the Assistant Director of Nursing (ADON) stated the DON had a medical emergency and had been unable to work since 07/22/5.The ADON verified the facility had designated RN #300 to serve as the acting DON while still performing full-time MDS duties. The ADON verified RN #300 was the facility's only MDS nurse.Interview on 08/25/25 at 1:40 P.M. with RN #300 confirmed she was the facility's only MDS Nurse. RN #300 verified the facility had designated her to be the acting DON during the DON's absence, but she already had a full-time position with the facility as the MDS nurse. Review of the job description for the DON revealed the DON's primary purpose was planning, organizing, developing, and directing the day-to-day functions of the nursing department in accordance with rules, regulations, and guidelines that govern the long-term care facility and ensuring that all nursing personnel are following their respective job descriptions.

Based on medical record review, review of facility communication with outside entities, staff interview, and review of the facility policy, the facility failed to ensure confidentiality of residents' private health information. This affected one (Resident #82) of three residents reviewed for confidentiality. The facility census was 67 residents.Findings include: Review of the medical record for Resident #82 revealed an admission date of 04/29/21 with diagnoses including end stage renal disease, type two diabetes mellitus, and congestive heart failure and a discharge date of 05/14/25. Review of the Minimum Data Set (MDS) assessment Resident #82 revealed the resident had moderately impaired cognition and required supervision with activities of daily living (ADLs.) Review of a written facility communication regarding Resident #82 dated 06/12/25 to the Better Business Bureau (BBB) (a private, non-profit organization with no governmental authority) revealed the letter contained Resident #82's name, diagnoses, weights, prescribed medications, and additional confidential information. Interview on 08/21/25 at 1:28 P.M. with the Administrator confirmed the facility received communication via the mail from the BBB regarding a complaint about the facility made by Resident #82's family. The Administrator stated he spoke with the BBB representative who said the facility did not have to respond to the complaint. The Administrator confirmed he consulted the corporate office and was given direction to respond to the BBB regarding the complaint made by Resident #82's family. The Administrator stated he emailed the response to the BBB dated 06/12/25 and verified the response contained private health information about Resident #82. Review of the facility policy titled Confidentiality of Information and Personal Privacy dated October 2017 revealed the facility would safeguard the personal privacy of all resident personal and medical records and access to resident personal and medical records would be limited to authorized staff and business associates.This deficiency represents noncompliance investigated under Complaint OH00164348 (iQIES 1393019)

Based on medical record review, staff interview, and review of the facility policy, the facility failed to develop individualized comprehensive resident care plans. This affected one (Resident #80) of 11 residents reviewed for care plans. The facility census was 67 residents.Findings include:Review of the medical record for Resident #80 revealed an admission date of 12/16/22 with diagnoses including end stage renal disease, diabetes mellitus type two, and chronic obstructive pulmonary disease and a discharge date of 08/02/25. Review of hospital records for Resident #80 dated 06/06/25 to 06/08/25 revealed an x-ray of the resident's left foot showed a fracture to the resident's left ankle. Orthopedics evaluated Resident #80, splinted the resident's left lower extremity, and scheduled the resident for follow-up with an orthopedist for 06/10/25. Review of physician's orders for Resident #80 dated 06/08/25 to 08/02/25 revealed there were no orders for care of the left foot nor for care of a splint to the left foot. Review of the care plan for Resident #80 revealed it did not include a care plan for the resident's left ankle fracture, a splint to the left foot, and care to be provided to the left foot. Review of Minimum Data Set (MDS) assessment for Resident #80 dated 07/16/25 revealed the resident was cognitively intact and required assistance with mobility and toileting. Interview on 08/19/25 at 3:05 P.M. with the Assistant Director of Nursing (ADON) confirmed Resident #80 had a splint on her left lower extremity upon return from the hospital on [DATE] but there were no orders or care plan in the resident's medical record that reflected the presence or care of the splint. Interview on 08/25/25 at 1:40 P.M. with Registered Nurse (RN) #300 confirmed Resident #80's care plan did not reflect the presence of the resident's left ankle fracture, the splint to the left foot, and/or care for the fracture. Review of the facility policy titled Medical Device Related Pressure Injury dated January 2018 revealed the use of medical devices should be reflected on the care plan, and if a device is not to be removed, then the orders should reflect that.This deficiency represents noncompliance investigated under Complaint Number OH00164348 (iQIES 1393019.)

Based on medical record review and staff interview, the facility failed to ensure dependent residents received appropriate bathing assistance. This affected one (Resident #85) of three residents reviewed for bathing assistance. The facility census was 67 residents. Findings include: Review of the medical record for Resident #85 revealed an admission date of 02/21/25 with diagnoses including an open wound of the abdominal wall with a discharge date of 05/22/25.Review of the Minimum Data Set (MDS) assessment for Resident #85 dated 03/14/25 revealed the resident had moderate cognitive impairment and required assistance with bathing, toileting, and dressing. Review of the care plan for Resident #85 dated 03/21/25 revealed the resident required assistance by staff with bathing/showers per schedule and as necessary and to provide a sponge bath when a full bath or shower could not be tolerated. Review of shower sheets for Resident #85 from 04/01/25 to 05/22/25 revealed the resident had four recorded baths on the following dates: 04/06/25, 04/12/25, 05/01/25, and 05/22/25. Interview on 08/26/25 at 3:00 P.M. with the Assistant Director of Nursing (ADON) confirmed there were only four shower/bath sheets completed for Resident #85. The ADON confirmed the expectation was residents would be offered at least two baths/showers per week as scheduled, which should have been 15 showers/baths during the reviewed time period.This deficiency represents noncompliance investigated under Complaint Number 2576092 and Complaint Number OH00166049 (iQIES 1393018) and Complaint Number OH00164348 (iQIES 1393019)

Based on medical record review and staff interview, the facility failed to implement physician orders for fracture and splint care and failed to implement orders for wound care. This affected two Residents (#80, #82) of 11 residents reviewed for quality of care. The facility census was 67 residents.Findings include: 1.Review of the medical record for Resident #80 revealed an admission date of 12/16/22 with diagnoses including end stage renal disease, diabetes mellitus type two, and chronic obstructive pulmonary disease and a discharge date of 08/02/25 Review of hospital records for Resident #80 dated 06/06/25 to 06/08/25 revealed an x-ray of the resident’s left foot showed a fracture to the resident’s left ankle. Orthopedics evaluated Resident #80, splinted the resident’s left lower extremity, and scheduled the resident for follow-up with an orthopedist for 06/10/25. Review of physician’s orders for Resident #80 dated 06/08/25 to 08/02/25 revealed there were no orders for care of the left foot nor for care of a splint to the left foot. Review of the care plan for Resident #80 revealed it did not include a care plan for the resident’s left ankle fracture, a splint to the left foot, and care to be provided to the left foot. Review of Minimum Data Set (MDS) assessment for Resident #80 dated 07/16/25 revealed the resident was cognitively intact and required assistance with mobility and toileting. Interview on 08/19/25 at 3:05 P.M. with the Assistant Director of Nursing (ADON) verified Resident #80 returned from the hospital with a splint on her left lower extremity and no orders were present in her records at the facility to reflect the presence or care of the splint or leg. Interview on 08/25/25 at 1:40 P.M. with Registered Nurse (RN) #300 verified Resident #80’s physician orders did not include orders for a non-removable left leg splint. 2. Review of the medical record for Resident #82 revealed an admission date of 04/29/21 with diagnoses including end-stage renal disease, cerebral infarction, and type two diabetes mellitus and discharge date of 05/14/25. Review of the MDS assessment for Resident #82 dated 03/20/25 revealed the resident had moderately impaired cognition and required supervision with activities of daily living (ADLs.) Review of a hospital after visit summary for Resident #82 dated 03/26/25 revealed the resident visited the hospital for a wound check and was diagnosed with an ulcer to the right leg. Instructions included to apply a wet-to-dry dressing to the right lower leg and change every eight hours. Review of a nurse progress note for Resident #82 dated 03/26/25 revealed the resident returned from the hospital and the daughter informed staff the hospital wanted a wet-to-dry dressing changed every eight hours. The nurse documented there was handwriting on the after-visit summary, but no signature. The note did not include documentation of contact with the physician or hospital for order clarification. Review of the readmission physician’s orders for Resident #82 revealed they did not include orders for wound care for the ulcer to the right lower leg. Review of a nurse progress note for Resident #82 dated 03/27/25 revealed the resident went outside of the facility for a wound consult and received orders for wound care daily to the ulcer on the right lower leg which included the following: clean wound with normal saline, pack gauze coated with Medihoney into wound, cover with ABD pad, tape in place. Review of the physician’s orders for Resident #82 revealed the order from the wound clinic for the treatment to the resident’s right lower leg ulcer were not implemented until 03/29/25 at 7:00 P.M. Interview on 08/26/25 at 12:18 P.M. with Licensed Practical Nurse (LPN) #373 verified Resident #82 returned from the hospital on [DATE] with a non-pressure wound to the right lower leg. The orders in the hospital after visit summary for a wet to dry dressing were not implement. LPN #373 confirmed Resident #82 returned from a wound clinic on 03/27/25 with updated orders for wound care to the right lower leg ulcer which were not implemented until 03/29/25. This deficiency represents noncompliance investigated under Complaint Number 2576092 and Complaint Number OH00166049 (iQIES 1393018) and Complaint Number OH00165759 (iQIES 1393020) and Complaint Number OH00164258 (iQIES 1393015) and Complaint Number OH00164348 (iQIES 1393019)

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure falls were investigated in a timely manner. This affected two (Residents #82 and #84) of four residents reviewed for falls. The facility census was 67 residents.Findings include:1.Review of the medical record for Resident #84 revealed an admission date of 02/28/25 with diagnoses including convulsions, dementia, and bipolar disorder and a discharge date of 06/04/25. Review of the Minimum Data Set (MDS) assessment for Resident #84 dated 04/20/25 revealed the resident had moderate cognitive impairment. Review of the document titled unwitnessed fall for Resident #84 dated 06/01/25 at 10:20 P.M. revealed the resident was found on the floor next to the bed and was unable to give a description of how she fell. The resident was taken to a local hospital for evaluation. Review of the medical record for Resident #84 revealed it did not include a fall investigation for the resident’s fall on 06/01/25. Interview on 08/19/25 at 2:39 P.M. with the Assistant Director of Nursing (ADON) confirmed the facility had no record of an interdisciplinary team (IDT) fall investigation regarding Resident #84’s fall on 06/01/25. The ADON verified that the facility should complete an investigation including a root cause analysis of each resident fall and should determine actions to prevent recurrence. 2. Review of the medical record for Resident #82 revealed an admission date of 04/29/21 with diagnoses including end-stage renal disease, cerebral infarction, and type 2 diabetes mellitus and a discharge date of 05/14/25. Review of the fall risk assessment for Resident #82 dated 02/10/25 revealed the resident was at moderate risk for falls. Review of the MDS assessment for Resident #82 dated 03/20/25 revealed the resident had moderately impaired cognition and required supervision with activities of daily living (ADLs). Review of a progress note for Resident #82 dated 04/08/25 revealed the resident was found on the floor in a sitting position. The resident stated she was trying to go to the restroom and fell down. The resident had no injuries. Review of an the fall investigation note for Resident #82 dated revealed the IDT met to discuss the resident’s fall on 04/08/25. The resident was noted attempting to go to the restroom and did not have any shoes or socks on at the time. A new intervention was implemented for non-skid socks during time of transfers.Review of a progress note for Resident #82 dated 04/15/25 revealed while waiting on transportation the resident went back to her room and fell sustaining a laceration and knot on her scalp. The nurse assessed Resident #82 and the resident was sent to the hospital via ambulance. Review of the medical record for Resident #82 revealed it did not include a fall investigation for the resident’s fall on 04/15/25. Interview on 08/26/25 at 3:50 P.M. with Licensed Practical Nurse (LPN) #373 confirmed the facility had not completed an investigation of Resident 82’s fall on 04/08/25 until 04/14/25 and the facility had not completed a fall investigation for the resident’s fall on 04/15/25. Review of the facility policy titled Falls-Clinical Protocol dated March 2018 revealed following a fall, the staff and the practitioner should begin to try and identify possible causes within 24 hours of the fall and, based on the assessment of the fall, staff and the physician will identify pertinent investigations to try to prevent subsequent falls and address the risks of clinically significant consequences of falling. This deficiency represents noncompliance investigated under Complaint Number OH00163748 (iQIES 1393014) and Complaint Number 2576092 and Complaint Number 2566204 and Complaint Number OH00166770 (iQIES 1393017) and Complaint Number OH00166404 (iQIES 1393016) and Complaint Number OH00165759 (iQIES 1393020) and Complaint Number OH00164258 (iQIES 1393015) and Complaint Number OH00164348 (iQIES 1393019).

Based on observations, staff interviews, and policy review, the facility failed to properly label and store food as well as ensure expired products were disposed of. This had the potential to affect all residents in the facility except for Residents #12, #18, and #165 that were identified by the facility as having a diet of nothing by mouth. The facility census was 66. Findings include: Observations of the kitchen's walk-in refrigerator on [DATE] from 6:33 P.M. to 6:40 P.M., revealed half of a ham in a plastic zip lock bag that was not dated, shredded lettuce wrapped in plastic wrap undated, tomato soup in a storage container undated,, a metal container filled with small plastic cups with lids that contained shredded cheese that were undated, a carton of [NAME] slaw undated, and green bell peppers wrapped in plastic wrap that were undated. There was a gallon of milk with an expiration date of [DATE]. Interview on [DATE] at 6:40 P.M. with Dietary Staff #48, verified the undated items as well as the expired milk. Observations of the kitchen's walk-in refrigerator on [DATE] at 6:42 P.M. of the walk-in freezer in the kitchen revealed a box of beef patty fritters that were opened, and the plastic bag containing the fritters were open and not dated. A box of veal patties was also opened, and the plastic bag with the patties had not been properly secured or dated. Interview at the time of the observation with Dietary Staff #48 verified the findings. Review of the undated policy titled Refrigerated Storage, revealed refrigerated items shall bear a label indicating the product name and date (month, day, and year) product was received, used, or first opened. Review of the undated policy titled Date Marking revealed all food shall be used or discarded on or before their manufacturer's use by date.

Based on record review, staff interview, and policy review, the facility failed to ensure resident records were updated to reflect a change in their advance directives. This affected one Resident (#52) of the eight residents reviewed for advance directives. The facility census was 66. Findings include: Review of the medical record for Resident #52 revealed an admitted [DATE]. Diagnoses included quadriplegia, cerebral infarction, congestive heart failure (CHF), paroxysmal atrial fibrillation, unspecified severe protein-calorie malnutrition, chronic obstructive pulmonary disease (COPD), anemia, insomnia, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #52 had moderately impaired cognition. Resident #52 was assessed to be dependent on staff for eating, oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility, and transfer. Review of the physician orders in the electronic medical record (EMR) for Resident #52 dated 12/27/24 revealed the resident was to be a full code. Review of the completed Do Not Resuscitate (DNR) form dated 01/29/25, revealed Resident #52 had an advance directive of DNR Comfort Care - Arrest (DNR-CCA). Interview on 02/12/25 at 10:27 A.M. with Assistant Director of Nursing (ADON) #42, revealed she updated Resident #52's advance directive to reflect the DNR order. ADON #42 stated the hospice provider uploaded the DNR form into Resident #52's medical record, and the facility was unaware the change in advance directive had occurred. Review of the policy titled Advance Directives, revised 12/2016, revealed information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.

Based on record review and staff interview, the facility failed to routinely monitor the dialysis access site. This affected one Resident (#15) of two residents reviewed for dialysis. The facility census was 66. Findings include: Review of the medical record for Resident #15 revealed an admitted [DATE]. Diagnoses included end stage renal disease (ESRD), type two diabetes mellitus with diabetic chronic kidney disease, dependent on renal dialysis, chronic pain syndrome, hypertension, anorexia, hyperkalemia, depression, and unspecified dementia, unspecified severity, with agitation. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 had moderately impaired cognition. Resident #15 was assessed to require supervision for oral hygiene, toileting, personal hygiene, and transfer, substantial/maximal assistance for bathing, and bed mobility, was independent for eating, and dependent on staff for dressing. Review of the plan of care dated 03/03/23, revealed Resident #15 required hemodialysis related to ESRD. Interventions included: encourage the resident to go for the scheduled dialysis appointments, check and change dressing daily at access site and document, monitor for dry skin and apply lotion as needed, monitor intake and output, monitor laboratory results (labs) and report to the doctor as needed, and monitor vital signs and notify doctor of significant abnormalities. Review of the active February 2025 physician orders for Resident #15, revealed no current order for routine monitoring of the dialysis site. Interview on 02/12/25 at 5:10 P.M. with Assistant Director of Nursing (ADON) #42, verified no documentation of routine monitoring of Resident #15's dialysis access site.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of the facility incident report, staff interviews and policy review, the facility failed to ensure staff appropriately disposed of an insulin needle after use. This had the potential to affect one (#70) out of three residents reviewed for infection control. The facility census was 61. Findings include: Review of the facility incident report dated 05/05/24 revealed while State tested Nursing Assistant (STNA) #44 was emptying the trash can in Resident #70 bathroom when she was stuck by a hypodermic insulin needle. The investigation noted the facility was unsure who threw the needle away or who the needle was used on prior to being disposed of in Resident #70's bathroom. Interview with the Director of Nursing (DON) on 07/08/24 at 2:00 P.M. revealed an investigation ensued and all staff were educated to prevent any further incidents following STNA #44's needle stick on 05/05/24. The DON confirmed Resident #70 does not have orders for insulin or injections so the needle in the bathroom trash can did not belong to this resident. The DON further noted the facility could not identify who put the needle in the trash can and could not identify which resident it was used for prior to it being placed in Resident #70's trash can. The DON confirmed needles are to be properly disposed of in sharps containers. Review of the Infection Control Policy undated for disposal of sharp materials revealed no sharps should be thrown in the trash. Sharps should not be capped and placed in the sharps containers. As a result of the incident, the facility took the following actions to correct the deficient practice by 05/12/24: On 05/05/24, the facility immediately began an investigation regarding the used needle found in Resident #70's room. On 05/05/24, all sharps containers were checked and replaced if needed by the DON and Infection Preventionist #14. On 05/05/24, the DON and Infection Preventionist #14 started all staff education regarding proper disposal of needles, sharps and hazardous waste. The education was completed on 05/12/24. On 05/05/24, DON and Infection Control Preventionist # 14 began trash monitoring which continued daily through 05/12/24 with no further incidents. Observations of nurses during medication passes on 07/01/24 and 07/08/24 revealed sharps containers on each medication cart. The sharps containers were not over flowing. Staff were observed appropriately disposing of needles in sharps containers. This deficiency represents non-compliance investigated under Complaint Number OH00154496.

Based on medical record review, staff interview and policy review, the facility failed to ensure a resident was provided with appropriate assistance and supervision during bed mobility which resulted in the resident having an avoidable fall from the bed. This affected one (#23) out of four residents reviewed for accidents. Facility census was 61. Findings Include: Review of Resident #23's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include chronic obstructive pulmonary disease, mood disorder, dementia, unsteady feet, and lack of coordination. Review of the comprehensive Minimum Data Set, (MDS) assessment dated [DATE] revealed Resident #23 had severely impaired cognition and was required total staff assistance for bed mobility, transfers, locomotion, dressing, toileting and personal hygiene. Review of plan of care for Resident #23 dated 08/07/23 revealed the resident required total care. Review of Resident #23 plan of care revealed there was an update on 09/21/23 which instructed staff to use two assist for bed mobility. Review of nursing progress note dated 09/17/23 at 1:00 A.M. revealed the State tested Nurse Aide, (STNA) #50 reported to Registered Nurse, (RN) #56 that Resident #23 fell in his/her room. RN #56 found Resident #23 on the floor between the window and the bed, with the resident head at the foot of the bed. Resident #23 was alert and able to speak. Resident #23 complained of pain on left side of the head and body. Blood was noted under left side of face. The emergency squad transported Resident #23 to the hospital at 1:20 A.M. Resident #23's guardian and Director of Nursing, (DON) were notified. On 09/17/23 at 5:00 A.M., Resident #23 returned from the hospital with a band-aid over superficial laceration measuring 0.5 centimeters by 0.5 centimeters (cm) by (x) 0.1 cm on the left zygoma, (cheekbone). There was no bleeding and no other injuries. Review of hospital records dated 09/17/23 at 2:00 A.M. revealed the Resident #23 arrived at the emergency room with a head laceration from a fall. Resident #23 was alert and had dried blood to the left anterior forehead. Wound care was completed, and the resident departed the emergency room at 3:56 A.M. There were no follow-up orders. Review of the Interdisciplinary Team documentation of 09/18/23 at 12:03 P.M., revealed the fall follow up investigation revealed the STNA #50 informed the RN #56 of the Resident #23 fall. STNA #50 reported the resident was rolled on her side in bed, when STNA #50 stepped away a few feet to the sink to obtain a towel Resident #23 rolled out of the bed onto the floor. The new intervention was to require a two person assist and STNA education. Review of skin assessment dated [DATE] revealed Nurse Practitioner, (NP) #100 assessed Resident #23 left brow laceration as dry and measured 0.5 cm x 0.5 cm x 0.1 cm. Review of physician orders dated 09/19/23 to 10/03/23 revealed Resident #23 an order to treat head laceration with betadine daily and leave open to air daily. There was an order for two people to assistance with care dated 09/20/23. Interview on 10/16/23 at 12:35 P.M. the Director of Nursing, (DON) verified on 09/17/23 at 1:00 A.M. STNA #50 was providing care to Resident #23 in bed. STNA #50 rolled the resident onto the resident's side. STNA #50 walked into the bathroom, approximately 10 feet from the resident's bed, and Resident #23 rolled onto the floor, sustaining a laceration to the left eye. The DON stated RN #56 was notified, completed an assessment and Resident #23 was sent to the emergency room at 1:20 A.M. The DON stated Resident #23 return to the facility at 5:00 A.M. with a wound measuring 0.5 cm x 0.5 cm x 0.1 cm above the left eye. There was a first aid treatment the wound. The wound was healed on 10/03/23. The DON verified STNA #50 should not have left Resident #23 unattended while the resident was rolled his/her left side. Review of facility policy titled, Bath, Bed, dated March 2021, revealed the staff are to place all supplies at the bedside so they can easily be reached. This deficiency represents non-compliance investigated under Master Complaint Number OH00146660 and Complaint Number OH00146536.

Based on observation, medical record review, review of facility policy, review of hospital records, review of facility investigation, review of employee personnel files and staff and resident interview, the facility failed to ensure Resident #29 was provided adequate assistance and the use of required footrests during transport to prevent an avoidable injury. This resulted in Actual harm on 06/27/23 when Occupational Therapist (OT) #700 was transporting the resident in a wheelchair without proper footrests being in place. During the transport, the resident's right leg fell to the ground and went under the wheelchair. The resident complained of pain and was noted to have swelling to the area. An x-ray, obtained on 06/28/23 (a day after the incident) revealed the resident had a closed displaced fracture of the medial malleolus of the right tibia. This affected one resident (#29) of three residents reviewed for accidents. The facility census was 63. Findings include: Review of the medical record for Resident #29's revealed an admitted [DATE]. Resident #29 had diagnoses including multiple sclerosis (MS), morbid obesity due to excess calories, difficulty in walking, muscle weakness, and other symbolic dysfunctions. Review of the care plan for Resident #29 dated 10/02/22, revealed the resident had limited physical mobility related to MS and muscle weakness. Interventions included the resident used a wheelchair and was totally dependent on staff for locomotion. Review of a facility document titled Certificate of Medical Necessity dated 10/31/22 for Resident #29, revealed the resident had history of MS, impaired coordination, inability to complete mobility and contracture to right knee with impaired ability to self-propel. The document revealed the resident required a customized wheelchair. Resident #29 required elevated leg rests due to increased edema in the bilateral lower extremity, and she was unable to bend her right knee past 10 degrees due to knee contracture. Therefore, the document indicated the resident must keep her right leg straight at all times and in order to get right leg off the ground, the facility must use an elevated leg rest. The resident's leg had to be off the ground in order for her to be able to self-propel. The resident was ordered an Access Tilt in Space wheelchair through Sunrise medical. The customized wheelchair was equipped with reclining back, elevated leg rests due to resident's 10-degree right knee flexion and a larger back gap. The document was signed by Physician #901. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #29 revealed the resident was cognitively intact. The assessment revealed Resident #29 required total dependence of two (staff) for transfers and extensive assistance of one (staff) for locomotion. Review of the occupational therapy evaluation dated 06/26/23 for Resident #29, revealed the resident was being seen with goals to increase activity tolerance for functional activities of choice, improve ability to wheel at least 50 feet, make two turns once seated in the wheelchair, safely self-propel her wheelchair in her room and to safely negotiate obstacles while self-propelling her wheelchair. Resident #29 was dependent for safely wheeling at least 50 feet and making two turns, required substantial or maximum assistance for self-propelling her wheelchair in her room and negotiating obstacles while self-propelling her wheelchair. Review of the controlled drug record dated 06/27/23 for Resident #29, revealed the resident was given Tramadol 50 milligrams (mg) one tablet by mouth for pain on 06/27/23 at 6:00 P.M. Review of a progress note dated 06/27/23 at 6:40 P.M. for Resident #29, revealed the resident was being transferred in her wheelchair by the therapist when the resident's right foot got caught under the wheelchair. Resident #29 complained of pain being a five out of ten (zero was no pain and 10 was severe pain) and pain medication (over the counter Tylenol) was administered. The note revealed Resident #29's range of motion was at baseline. Review of an undated Occupational Therapist (OT) #700's witness statement revealed on 06/27/23, OT #700 was pushing Resident #29 down the hall in her wheelchair and Resident #29 was holding her legs up because her legs have trouble bending enough to use the leg rests. While moving down the hallway, Resident #29 dropped her legs without warning and her right leg twisted under the chair. OT #700 immediately backed the chair up and brought her leg in front of her. OT #700 got her footrests and elevated both legs as best she could and returned Resident #29 to her room. OT #700 was delayed in speaking to the nurse immediately about the incident but spoke with her within approximately a half an hour. Review of a progress note dated 06/28/23 at 9:24 A.M. for Resident #29, revealed the facility notified the nurse practitioner (NP) of Resident #29's right foot being swollen and painful post a wheelchair incident on 06/27/23. A new order was obtained for an x-ray. Review of an imaging report dated 06/28/23 for Resident #29, revealed the resident had an acute appearing medial malleoli fracture with soft tissue swelling. Review of a progress note dated 06/29/23 at 8:39 A.M. for Resident #29, revealed the facility notified the NP of the right foot x-ray results and obtained orders for Resident #29 to be treated. Resident #29 was transferred to the hospital for further evaluation and treatment of her right ankle per Resident #29 and her family's request. The NP, Resident #29 and the resident's family were made aware of the new orders, and all were in agreement with plan of care. Review of a progress note dated 06/29/23 at 12:55 P.M. for Resident #29, revealed the wheelchair company was to come in to assess the wheelchair. Review of a progress note dated 06/29/23 at 7:17 P.M. for Resident #29, revealed the resident returned to the facility by stretcher and a fracture was noted to Resident #29's right foot. Oxycodone 5/325 (narcotic /pain) milligrams (mgs) one to two tablets by mouth every six hours as need for five days was ordered and a follow up appointment with the orthopedic surgeon was ordered as soon as possible. Review of a progress note dated 06/29/23 at 12:43 P.M. for Resident #29, revealed the interdisciplinary team (IDT) met regarding the incident. Upon investigation, the IDT found that Resident #29 was being wheeled in a wheelchair by therapist (identified as Occupational Therapist #700) to the therapy room. During wheelchair transportation, Resident #29 said to the therapist that her foot was caught under wheelchair. Resident #29 stated the therapist did not hear her and was still pushing her when resident yelled out that her foot hurt. The therapist then stopped pushing resident. Resident #29's foot was adjusted. The nurse assessed the resident, range of motion was initiated, and a pain assessment performed with a score of a four to five out of ten. Pain medication was given, and ice was offered but Resident #29 declined as she stated she was always cold and cold hurts. Resident #29 was put to bed and the foot of bed was elevated. Staff education was provided an x-ray was obtained. Review of the hospital records dated 06/29/23 for Resident #29, revealed the resident presented to the emergency room for evaluation of right leg, ankle, and foot pain. Resident #29 stated that she was wheelchair bound with a history of MS. Resident #29 was doing physical therapy and her foot got caught in the wheelchair and she heard a pop and had pain. Resident #29 had an x-ray of her ankle done on 06/28/23 and it showed a fracture. Resident #29 stated she was having some significant pain. An x-ray was taken and showed a non-displaced or minimally displaced fracture of the medial malleolus of the right ankle. Resident #29 was diagnosed with a closed displaced fracture of the medial malleolus of right tibia. Resident #29 was placed in an ace wrap and an air cast, was given a prescription for Oxycodone for pain control and ordered to schedule an appointment with orthopedic as soon as possible. Review of RN #902's disciplinary notice dated 06/29/23, revealed the nurse failed to follow proper procedures by not notifying the physician of an acute physical change or incident involving a resident and the family was not notified. Review of Registered Nurse (RN) #902's witness statement dated 06/29/23, revealed while RN #902 was doing rounds on 06/27/23, Resident #29 called her into her room and asked her if the therapist told her what happened. RN #902 stated no and Resident #29 proceeded to tell her that while she was being wheeled to therapy in her wheelchair by the therapist, her right foot got caught under the wheelchair and the therapist did not know and kept wheeling. The resident then yelled for the therapist to stop, and the therapist then rolled her back to her room. RN #902 told Resident #29 she did not hear anything from the therapist and that she would reach out. The resident was still sitting in her chair. She raised her foot up and down and flexed back and forth and it was not red or swollen but was tender. RN #902 administered as needed pain medication and Resident #29 refused ice because of her arthritis. RN #902 asked the resident if she felt like she needed an x-ray and the resident stated no. RN #902 told Resident #29 she would get an x-ray if it was still bothersome when she came back to work on 06/28/23. As she went back to the nursing station, she saw the therapist in the hallway asked if she had something to say to her because Resident #29 told her what happened. The therapist stated I'm sorry, I forgot to tell you her foot was caught in her wheel underneath it. I meant to tell you. RN #902 proceeded to chart the situation and she was due back the next day. RN #902 gave report to the night shift nurse and the next morning the unit manager ordered the x-ray. Review of a physician order dated 06/30/23 for Resident #29, revealed the resident had an order to follow up with orthopedics on 07/24/23 at 8:30 A.M. Review of OT #700's verbal warning disciplinary action form dated 06/30/23 revealed OT #700 failed to report the incident with Resident #29 immediately to nursing staff and OT #700 failed to use foot pedals when transporting residents at all times. Interview on 07/03/23 at 10:56 A.M. with OT #700, revealed she was wheeling Resident #29 down the hallway and Resident #29 was holding both of her legs up in the air. OT #700 stated the leg and footrests were not on the wheelchair due to Resident #29's legs not fitting properly on her current leg and footrests. OT #700 stated Resident #29 dropped her legs unexpectedly while she was pushing her down the hall and Resident #29's right leg and foot got caught and twisted in the wheelchair. Interview on 07/03/23 at 11:00 A.M with Therapy Manager #900, revealed Resident #29 had a specialized wheelchair, and she was aware that her legs did not fit on the wheelchair leg and footrests appropriately prior the incident due to her knee not bending. Therapy Manager #900 stated the wheelchair company was scheduled to come and look at the wheelchair since the incident occurred. Interview on 07/03/23 at 11:29 A.M. with Resident #29, revealed the resident broke her right ankle and stated the therapist was pushing her wheelchair on the way to therapy. Resident #29 reported she had her right leg up on her left leg because the right leg did not work well, and the right leg fell off the left leg and went under the wheelchair. Resident #29 stated she did not have leg and footrests on her wheelchair at the time of the incident because her legs did not stay on them correctly. Resident #29 reported she wanted to use the leg and footrests on her wheelchair. Observation at the same time, revealed Resident #29's customized wheelchair being stored in her room with two leg rests sitting on the wheelchair. Interview on 07/03/23 at 3:48 P.M. with the Director of Nursing (DON), revealed OT #700 was pushing Resident #29 down the hallway on 06/27/23 at an unknown time when the resident stated ouch. The DON reported OT #700 did not hear the resident and Resident #29 yelled out again and OT #700 stopped. The DON stated Resident #29's foot was twisted under the wheelchair. The DON reported OT #700 returned Resident #29 to her room and did not notify the nurse. Resident #29 was talking about the incident to another resident and RN #902 overheard them talking about the incident. The nurse assessed the resident for pain on 06/27/23 and Resident #29 had no initial signs of swelling and was given as needed pain medication. The DON stated RN #902 told Resident #29 that she would contact the doctor the next day if her foot hurt. The DON reported RN #902 did not contact the doctor, family, or management on 06/27/23 regarding the incident which was against the facility's policy. The DON stated management found that RN #902 charted about the 06/27/23 incident on 06/28/23 and the family and physician were contacted based upon that progress note. The DON reported Resident #29 was ordered an x-ray on 06/28/23 and the results came back on 06/29/23 and found Resident #29 had an ankle fracture. Resident #29's family and physician were notified on 06/29/23 and Resident #29 was sent to the hospital for evaluation. The DON stated RN #902 was terminated for failing to notify the physician or family of the incident on 06/27/23 involving Resident #29 and OT #700 was written up for failing to notify the nurse and pushing Resident #29 in a wheelchair without the leg and footrests. The DON reported the facility educated therapy staff on change in condition, but the facility did not educate any other staff on the use of leg and footrests. The DON also stated the facility did not evaluate all resident wheelchairs for leg and footrests or proper functioning. Telephone interview on 07/05/23 at 12:07 P.M. with RN #902, revealed she was doing her rounds on 06/27/23 at around 5:30 P.M. or 6:00 P.M. when Resident #29 told her about the injury. Resident #29 told RN #902 that she was being pushed in a wheelchair by the therapist when her foot went underneath it because she did not have foot or leg rests on her wheelchair and the therapist was not aware until she told her to stop. RN #902 stated the therapist never reported the incident to her. RN #902 reported she assessed Resident #29's foot and found that it was not red or swollen but Resident #29 stated it was slightly painful. RN #902 reported that she provided Resident #29 an as needed Tramadol (narcotic/pain) and informed the night shift nurse of the incident. RN #902 stated she did not notify the family or doctor. RN #902 reported she found the therapist about 10 minutes after she spoke with Resident #29 and the therapist stated that Resident #29's foot got tangled in the wheelchair when she was taking her to therapy in her wheelchair. Telephone interview on 07/05/23 at 12:21 P.M. with OT #700, revealed the incident occurred between 12:30 P.M. and 1:00 P.M. on 06/27/23 and she did not observe Resident #29's leg or foot tangled under her wheelchair because she backed the wheelchair up after she felt resistance and the resident yelled out. OT #700 stated she notified the nurse approximately 30 minutes after the incident and she returned Resident #29 to her room instead of doing therapy with her. OT #700 reported she got Resident #29's leg and footrests from her room to transport Resident #29 back to her room, but Resident #29's right leg did not fit on the foot plate properly due to her knee not bending so she propped it up on the foot plate. Review of OT #700's personnel file revealed OT #700 was hired by the therapy company at the facility on 11/08/21 and was educated on accident prevention on 09/20/22. Review of the facilities in service on reporting acute physical and mental changes of incidents dated 06/29/23 revealed therapy staff including OT# 700 were educated on reporting changes. Review of the facility's change in condition policy dated February 2021, revealed the facility will notify the resident, his or her attending physician and the resident representative of changes in the resident's medical condition. This deficiency represents non-compliance investigated under Complaint Number OH00143879.

Based on observations, interviews, record review, and policy review, the facility failed to ensure residents received food that was palatable and appetizing to them and which met their nutritional recommendations. This affected 15 residents (#1, #3, #4, #5, #18, #20, #33, #34, #35, #38, #48, #50, #55, #59, and #60) who received food on the 200-unit. The facility census was 63. Findings include: Review of the resident council meeting minutes dated 05/16/23 revealed residents stated the food was coming out cold. Review of the resident council meeting minutes dated 06/20/23 revealed the temperature of the food was cold. Observation of the facility's kitchen on 07/03/23 at 8:14 A.M. revealed Dietary Staff #05 to be serving resident meal trays from items that were held on top of the stove in the kitchen. Observation of Dietary Staff #05 taking the temperature of the food items revealed the boiled eggs were 95 degrees Fahrenheit, the bacon was 99.5 degrees Fahrenheit, the sausage links were 122.5 degrees Fahrenheit, the mechanical sausage was 110.5 degrees Fahrenheit, and the grits were 107.9 degrees Fahrenheit. Dietary Staff #05 continued to serve the food items that were held in between 41 degrees Fahrenheit and 135 degrees Fahrenheit without taking the temperature of the food items again. Interview at the same time with Dietary Staff #05, verified the temperatures of the food being held. Dietary Staff #05 also verified she continued to serve the food items without taking the temperatures again while they were in the danger zone. Observations on 07/03/23 at 8:42 A.M. revealed a test tray left the kitchen on the 200-unit cart. All resident trays were retrieved from the meal cart on 07/03/23 at 8:56 A.M. The test tray revealed the scrambled eggs were 111 degrees Fahrenheit, the sausage was 103.5 degrees Fahrenheit, and the oatmeal was 107.5 degrees Fahrenheit and food items were cold to taste. Interview with Dietary Staff #13 and interim Dietary Manager #800 at the same time verified the scrambled eggs, sausage and oatmeal were not palatable and were served below the 135 degrees Fahrenheit holding temperature prior to leaving the kitchen. Interview on 07/03/23 at 11:26 A.M. with Resident #04 revealed the food was cold at times. Interview on 07/03/23 at 11:35 A.M. with Resident #38 revealed meals were often served cold. Review of the facility's undated food temperatures policy revealed all hot items must be cooked to the appropriate internal temperatures and be held and served at a temperature of at least 135 degrees Fahrenheit. Hot food items may not fall below 135 degrees Fahrenheit after cooking unless it is an item which is to be rapidly cooled to 41 degrees Fahrenheit and reheated to at least 135 degrees Fahrenheit. Review of the facility's undated dining experience policy revealed the facility will provide nourishing, palatable and attractive meals that meet the daily nutritional needs and are served at a safe and appetizing temperature. This deficiency represents non-compliance investigated under Complaint Number OH00143586.

Based on observation, interview and review of facility policy, the facility failed to ensure the food thermometer was properly sanitized while obtaining food temperatures. This had the potential to affect 61 of 63 residents of the facility, excluding residents (#06 and #21) who the facility identified as receiving no food by mouth (NPO). The facility census was 63. Findings include: Observation of the facility's kitchen on 07/03/23 at 8:14 A.M. revealed Dietary Staff #05 to be serving resident meal trays from items that were held on top of the stove in the kitchen. Dietary Staff #05 was observed to put the temperature probe in the boiled eggs that were 95 degrees Fahrenheit and then put the temperature probe in the bacon that was 99.5 degrees Fahrenheit without sanitizing the temperature probe. Dietary Staff #05 was then asked if she had any wipes to sanitize her temperature probe and Dietary Staff #05 continued to wipe the temperature probe on a white washcloth that had a brown color on it that was sitting on the kitchen preparation table prior to placing it in the scrambled eggs. The sausage links were 122.5 degrees Fahrenheit, and the mechanical sausage was 110. 5 degrees Fahrenheit which were observed to be mixed in the same container. Interview at the same time with Dietary Staff #05, verified the temperatures of the food being held. Dietary Staff #05 also verified she did not sanitize her temperature probe between the boiled eggs the bacon it. Dietary Staff #05 also verified she wiped the temperature probe on a white washcloth that had a brown color on it that was sitting on the kitchen preparation table prior to placing it in the scrambled eggs. Review of the facility's undated taking accurate temperatures policy revealed thermometers should be sanitized according to the manufacture instructions. In between uses at one meal, an alcohol swab may be used to sanitize the thermometer. This deficiency represents non-compliance investigated under Complaint Number OH00143586.

Based on record review, staff interview, and policy review, the facility failed to notify the physician and resident's representatives when resident had a change of condition. This affected one resident (#29) out of three residents reviewed. The facility census was 63. Findings include: Review of the medical record for Resident #29's revealed an admitted [DATE]. Resident #29 had diagnoses including multiple sclerosis (MS), morbid obesity due to excess calories, difficulty in walking, muscle weakness, and other symbolic dysfunctions. Review of the care plan for Resident #29 dated 10/02/22, revealed the resident had limited physical mobility related to MS and muscle weakness. Interventions included the resident used a wheelchair and was totally dependent on staff for locomotion. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #29 revealed the resident was cognitively intact. The assessment revealed Resident #29 required total dependence of two (staff) for transfers and extensive assistance of one (staff) for locomotion. Review of a progress note dated 06/27/23 at 6:40 P.M. for Resident #29, revealed the resident was being transferred in her wheelchair by the therapist when the resident's right foot got caught under the wheelchair. Resident #29 complained of pain being a five out of ten (zero was no pain and 10 was severe pain) and pain medication (over the counter Tylenol) was administered. The note revealed Resident #29's range of motion was at baseline. The progress note revealed no documented evidence the resident's representative, or the physician was contacted. Review of an undated Occupational Therapist (OT) #700's witness statement revealed on 06/27/23, OT #700 was pushing Resident #29 down the hall in her wheelchair and Resident #29 was holding her legs up because her legs have trouble bending enough to use the leg rests. While moving down the hallway, Resident #29 dropped her legs without warning and her right leg twisted under the chair. OT #700 immediately backed the chair up and brought her leg in front of her. OT #700 got her footrests and elevated both legs as best she could and returned Resident #29 to her room. OT #700 was delayed in speaking to the nurse immediately about the incident but spoke with her within approximately a half an hour. Review of a progress note dated 06/28/23 at 9:24 A.M. for Resident #29, revealed the facility notified the nurse practitioner (NP) of Resident #29's right foot being swollen and painful post a wheelchair incident on 06/27/23. A new order was obtained for an x-ray. Review of Resident #29's imaging report dated 06/28/23 revealed Resident #29 had an acute appearing medial malleoli fracture with soft tissue swelling. Review of Registered Nurse (RN) #902's witness statement dated 06/29/23, revealed while RN #902 was doing rounds on 06/27/23, Resident #29 called her into her room and asked her if the therapist told her what happened. RN #902 stated no and Resident #29 proceeded to tell her that while she was being wheeled to therapy in her wheelchair by the therapist, her right foot got caught under the wheelchair and the therapist did not know and kept wheeling. The resident then yelled for the therapist to stop, and the therapist then rolled her back to her room. RN #902 told Resident #29 she did not hear anything from the therapist and that she would reach out. The resident was still sitting in her chair. She raised her foot up and down and flexed back and forth and it was not red or swollen but was tender. RN #902 administered as needed pain medication and Resident #29 refused ice because of her arthritis. RN #902 asked the resident if she felt like she needed an x-ray and the resident stated no. RN #902 told Resident #29 she would get an x-ray if it was still bothersome when she came back to work on 06/28/23. As she went back to the nursing station, she saw the therapist in the hallway asked if she had something to say to her because Resident #29 told her what happened. The therapist stated I'm sorry, I forgot to tell you her foot was caught in her wheel underneath it. I meant to tell you. RN #902 proceeded to chart the situation and she was due back the next day. RN #902 gave report to the night shift nurse and the next morning the unit manager ordered the x-ray. Review of RN #902's disciplinary notice dated 06/29/23 revealed the nurse failed to follow proper procedures by not notifying the physician of an acute physical change or incident involving a resident and the family was not notified. Corrective action included immediate termination due to the nurse being aware of proper procedures of notifying the physician and family of acute changes in resident's the mental and physical status. Interview on 07/03/23 at 10:56 A.M. with OT #700, revealed she was wheeling Resident #29 down the hallway and Resident #29 was holding both of her legs up in the air. OT #700 stated the leg and footrests were not on the wheelchair due to Resident #29's legs not fitting properly on her current leg and footrests. OT #700 stated Resident #29 dropped her legs unexpectedly while she was pushing her down the hall and Resident #29's right leg and foot got caught and twisted in the wheelchair. Interview on 07/03/23 at 11:29 A.M. with Resident #29, revealed the resident broke her right ankle and stated the therapist was pushing her wheelchair on the way to therapy. Resident #29 reported she had her right leg up on her left leg because the right leg did not work well, and the right leg fell off the left leg and went under the wheelchair. Resident #29 stated she did not have leg and footrests on her wheelchair at the time of the incident because her legs did not stay on them correctly. Interview on 07/03/23 at 3:48 P.M. with the Director of Nursing (DON), revealed OT #700 was pushing Resident #29 down the hallway on 06/27/23 at an unknown time when the resident stated ouch. The DON reported OT #700 did not hear the resident and Resident #29 yelled out again and OT #700 stopped. The DON stated Resident #29's foot was twisted under the wheelchair. The DON reported OT #700 returned Resident #29 to her room and did not notify the nurse. Resident #29 was talking about the incident to another resident and RN #902 overheard them talking about the incident. The nurse assessed the resident for pain on 06/27/23 and Resident #29 had no initial signs of swelling and was given as needed pain medication. The DON stated RN #902 told Resident #29 that she would contact the doctor the next day if her foot hurt. The DON verified RN #902 did not contact the doctor, family, or management on 06/27/23 regarding the incident which was against the facility's policy. The DON stated management found that RN #902 charted about the 06/27/23 incident on 06/28/23 and the family and physician were contacted based upon that progress note. Telephone interview on 07/05/23 at 12:07 P.M. with RN #902, revealed she was doing her rounds on 06/27/23 at around 5:30 P.M. or 6:00 P.M. when Resident #29 told her about the injury. Resident #29 told RN #902 that she was being pushed in a wheelchair by the therapist when her foot went underneath it because she did not have foot or leg rests on her wheelchair and the therapist was not aware until she told her to stop. RN #902 stated the therapist never reported the incident to her. RN #902 reported she assessed Resident #29's foot and found that it was not red or swollen but Resident #29 stated it was slightly painful. RN #902 reported that she provided Resident #29 an as needed Tramadol (narcotic/pain) and informed the night shift nurse of the incident. RN #902 stated she did not notify the family or doctor. RN #902 reported she found the therapist about 10 minutes after she spoke with Resident #29 and the therapist stated that Resident #29's foot got tangled in the wheelchair when she was taking her to therapy in her wheelchair. Telephone interview on 07/05/23 at 12:21 P.M. with OT #700, revealed the incident occurred between 12:30 P.M. and 1:00 P.M. on 06/27/23 and she did not observe Resident #29's leg or foot tangled under her wheelchair because she backed the wheelchair up after she felt resistance and the resident yelled out. OT #700 stated she notified the nurse approximately 30 minutes after the incident and she returned Resident #29 to her room instead of doing therapy with her. Review of the facility's change in condition policy dated February 2021 revealed the facility will notify the resident, his or her attending physician and the resident representative of changes in the resident's medical condition. This deficiency represents non-compliance investigated under Complaint Number OH00143879.

Based on record review, observation, staff interviews, review of facility policy, and review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure physician-ordered and/or care planned interventions were implemented for the treatment of pressure ulcers, failed to thoroughly assess a resident's skin and failed to identify a resident's pressure ulcers until they had already reached an advanced stage. This resulted in Actual Harm to Resident #34 who was admitted to the facility without pressure ulcers and developed two avoidable unstageable pressure ulcers to the left foot. This affected one (#34) of three residents reviewed for pressure ulcers. The facility census was 68. Findings include: Review of the medical record for Resident #34 revealed an admitted [DATE] with a diagnoses including cerebral infarction, dementia, and diabetes mellitus (DM). Review of the Minimum Data Set (MDS) for Resident #34 dated 10/27/22 revealed the resident was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADL's). Review of the pressure ulcer risk assessment for Resident #34 dated 04/12/22 revealed the resident was at moderate risk for the development of pressure ulcers. Review of the care plan for Resident #34 updated 11/25/22 revealed the resident was at risk for pressure related ulcers due to insulin-controlled diabetes, hemiparesis, limited mobility, dependence on staff for repositioning and turning, and urinary incontinence. Resident #34 had a diagnosis of expressive aphasia and was not able to indicate her need for repositioning. Resident #34 developed a deep tissue injury (DTI) to the underside of her left first metatarsal and the underside of her left great toe which was first identified on 11/15/22. Interventions included the following: soft preventative boots on as tolerated by resident (added 11/25/222), treat areas as ordered by wound nurse practitioner (NP), encourage/assist to shift weight in wheelchair frequently, turn and reposition often and as needed, administer medications as ordered, monitor/document for side effects and effectiveness, administer treatments as ordered and monitor for effectiveness, apply lotion to dry skin areas after bathing, do not massage over bony prominence's and use mild cleansers for peri-care/washing, treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort, pressure relieving mattress. Review of the weekly skin observation tool for Resident #34 dated 10/25/22 revealed the resident had no new areas of skin impairment. Review of the medical record for Resident #34 revealed there were no weekly skin observations conducted between 10/25/22 and 11/15/22. Review of the wound NP note for Resident #34 dated 11/15/22 revealed on 11/01/22 the facility reported no new open areas for resident. Resident #34 had an unstageable pressure ulcer to her left great toe which measured 2.5 centimeters (cm) in length by 1.5 cm in width by 0.1 cm in depth and an unstageable pressure ulcer to her left foot which measured 2.0 cm in 1.5 width by 0.1 cm in depth. Offloading boots were recommended to promote healing. Review of the facility pressure ulcer assessment for Resident #34 dated 11/16/22 revealed the resident developed a pressure ulcer to her left toe which was classified as a suspected deep tissue injury (DTI) and measured 2.5 centimeters (cm) in length by 1.5 cm in width by 0.1 cm in depth and a pressure ulcer to her left foot which was also classified as a suspected DTI which measured 2.0 cm in 1.5 width by 0.1 cm in depth. Treatment plan included skin prep as ordered to the areas and to offload resident's heels. Review of the November 2022 monthly physician orders for Resident #34 revealed orders dated 11/25/22 for staff to apply skin prep to areas to left foot once per shift and an order for resident to have pressure preventative boots on her feet at all times. Review of the November 2022 Treatment Administration Record (TAR) for Resident #34 revealed the skin prep treatments to resident's left foot were not documented as administered until 11/25/22. The heel boots were not documented as applied until 11/25/22. Observation on 11/28/22 at 10:47 A.M. of Resident #34 revealed the resident was in bed and her heel boots were sitting on the dresser and were not on resident's feet. Interview on 11/28/22 at 10:53 A.M. with State tested Nursing Assistant (STNA) #480 confirmed Resident #34 did not have heel boots on her feet. STNA #480 confirmed she was not Resident #34's aide. Interview on 11/28/22 at 10:54 A.M. of Licensed Practical Nurse (LPN) #180 confirmed Resident #34 did not have heel boots on her feet and she was supposed to have them on at all times. LPN #180 confirmed she thought STNA #490 was the aide for Resident #34 and suggested surveyor interview STNA #490 regarding resident's heel boots. Interview on 11/28/22 at 11:01 A.M. with STNA #490 confirmed she was not the aide for Resident #34 and had not provided any care for her on 11/28/22 and had not been in her room. Interview on 11/28/22 at 11:02 A.M. with LPN #180 and STNA #480 confirmed there was a misunderstanding regarding the schedule, and STNA #480 was the assigned aide for Resident #34. STNA #480 confirmed she had been working since 7:00 A.M. on 11/28/22. STNA #480 stated she provided incontinence care to Resident #34 at approximately 7:15 A.M. and delivered her breakfast tray but she had not applied resident's heel protectors because she was not the resident's assigned aide. Interview on 11/28/22 11:42 A.M. with Registered Nurse (RN) #540 confirmed Resident #34 had pressure ulcers to her left foot and left great toe which were first identified on 11/15/22. RN #540 confirmed resident had a physician's order to wear the heel boots at all times as tolerated. RN #540 confirmed resident was unable to don and doff the boots per self. Observation on 11/29/22 at 8:34 A.M. of Resident #34 revealed the resident was in bed and her heel boots were sitting on the dresser and were not on resident's feet. Interview on 11/29/22 at 8:34 A.M. of STNA #500 confirmed Resident #34 was in bed and her heel boots were sitting on the dresser and were not on the resident's feet. STNA #500 confirmed she was her aide for the day and had started work at approximately 7:00 A.M. and she had not attempted to don the boots to resident's feet. Interview on 11/29/22 2:38 P.M. with wound NP #811 confirmed Resident #34 had developed two unstageable pressure ulcers to her left foot approximately two weeks prior. NP #811 confirmed Resident #34 dug her heels into her mattress due to contracture's to the lower extremities. NP #811 confirmed Resident #34 should have heel boots on at all times. Observation of wound care on 11/29/22 at 4:08 P.M. for Resident #34 per RN #540 and LPN #814 revealed the resident was resting in bed with her heel boots in place. Observation revealed RN #540 measured a wound to the underside of Resident #34's left great toe which measured 2.0 cm in lengthy by 1.0 cm in width. RN #540 then measured a wound to the underside of Resident #34's left metatarsal which measured 1.5 cm in length by 1.5 in width. There was no depth to the wounds and both wound beds were reddish-brown in color. RN #540 applied skin prep to Resident #34's wounds. Interview on 12/01/22 at 7:59 A.M. with RN #540 confirmed the facility nurses should conduct a weekly skin assessment and document the results in the residents' electronic medical record. RN #540 confirmed the facility had not conducted Resident #34's weekly skin assessments from 10/25/22 until 11/16/22. RN #540 confirmed the skin assessment on 10/25/22 revealed Resident #34 had no new open areas, and the next subsequent skin assessment was not conducted until 11/16/22 and the resident was found to have developed two pressure ulcers to her left foot. RN #540 confirmed the treatment order for skin prep and the order for heel boots were not initiated until 11/25/22. Review of the facility policy titled Wound, and Skin Prevention Program dated January 2018 revealed a weekly skin assessment should be done by the charge nurse and any skin issues identified should be assessed and a treatment plan should be initiated. Further review of the policy revealed recognizing the need for wound and skin preventative care was everyone's responsibility including STNA's. Review of the NPUAP guidelines dated 2014 pages 70-71 at https://npiap.com/general/custom.asp?page=2014Guidelines revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominence's. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominence's including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. Review of the NPUAP guidelines dated 2014 page 115 revealed ideally, heels should be free of all pressure, a state sometimes called floating heels. Pressure can be relieved by elevating the lower leg and calf from the mattress by placing a pillow under the lower legs, or by using a heel suspension device that floats the heel. Consequently, the pressure will instead spread to the lower legs, and the heels will no longer be subjected to pressure.

Based on record review, observations, staff interview, review of facility policy, review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), and review of an online resources regarding pain in dementia residents, the facility failed to provide pain management interventions in accordance with the resident's care plan. This resulted in Actual Harm to Resident #34 who had acute fractures to her right distal tibia/fibula and two unstageable pressure ulcers to her left foot and the resident was not medicated for pain prior to wound care which resulted in the resident exhibiting signs of severe pain. This affected one (#34) of one residents reviewed for pain management. The facility census was 68. Findings include: Review of the medical record for Resident #34 revealed an admitted [DATE] with a diagnoses including cerebral infarction, dementia, and diabetes mellitus (DM.) Review of the Minimum Data Set (MDS) for Resident #34 dated 10/27/22 revealed resident was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADL's). Review of the care plan for Resident #34 dated 12/27/21 revealed the resident was on pain medication therapy related to chronic pain and contracture's. Interventions included the following: administer analgesic medications as ordered by physician, monitor/document side effects and effectiveness every shift, review for pain medication efficacy, assess whether pain intensity is acceptable to resident or if change in regimen is required, report/consult physician as needed to obtain desired outcome. Review of the care plan for Resident #34 updated 11/25/22 revealed the resident was at risk for pressure related ulcers due to insulin-controlled diabetes, hemiparesis, limited mobility, dependence on staff for repositioning and turning, and urinary incontinence. Resident #34 had a diagnosis of expressive aphasia and was not able to indicate her need for repositioning. Resident #34 developed a deep tissue injury (DTI) to the underside of her left first metatarsal and the underside of her left great toe which was first identified on 11/15/22. Interventions included the following: administer medications as ordered, monitor/document for side effects and effectiveness, administer treatments as ordered and monitor for effectiveness, treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. Review of nurse progress note for Resident #34 dated 11/15/22 revealed the aide notified the nurse the resident had a bruise to the right inner foot. Nurse assessed Resident #34 and noted the resident's right ankle and foot were swollen. The attending physician was notified and gave an order for an x-ray to the right foot. Review of nurse progress note for Resident #34 dated 11/15/22 revealed the x-ray to the right foot indicated acute distal tibia/fibula fractures were noted. Review of x-ray report for Resident #34 dated 11/15/22 revealed there were distal tibia/fibula fractures to the right ankle with slight malalignment, soft tissue swelling, and joint space narrowing. Review of the November 2022 monthly physician orders for Resident #34 revealed orders dated 11/08/22 for resident to receive MS Contin tablets twice daily routinely for pain and morphine sulfate (liquid concentrate) every four hours as needed for pain. Review of the November 2022 Medication Administration Record (MAR) for Resident #34 revealed the resident was offered routine MS Contin on 11/29/22 at 8:00 A.M. but refused the medication. Further review of the MAR revealed Resident #34 did not receive any as needed doses of morphine sulfate liquid on 11/29/22 prior to wound care. Reviewed of the controlled substance sheets for Resident #34 for MS Contin tablets and morphine sulfate liquid revealed the resident did not receive these medications on 11/29/22 prior to wound care. Observation of wound care on 11/29/22 at 4:08 P.M. for Resident #34 per Registered Nurse (RN) #540 and Licensed Practical Nurse (LPN) #814 revealed the resident cried out in pain when nurses repositioned the resident in the bed prior to wound care to her left foot. RN #540 and LPN #814 did not conduct an assessment of Resident #34's pain and assured the resident they would perform treatment as quickly as possible. Resident #34 cried and moaned continuously as staff removed heel protectors, measured wounds to left foot, applied wound treatment, and reapplied heel protectors. Tears were noted running down Resident #34's face during care. Interview on 12/01/22 at 4:20 P.M. with RN #540 confirmed Resident #34 was not able to rate her pain using a numerical scale but the facility rated her pain based on an observation of her objective symptoms including breathing, negative vocalization, facial expression, body language, and consolability consistent with the Pain Assessment in Advanced Dementia (PAINAD) scale. RN #540 confirmed Resident #34's pain during the treatment administration was severe and rated it as a seven to 10 on a scale of zero to 10 with 10 being the worst pain. RN #540 further confirmed Resident #34 had increased pain due to a fracture to her right ankle which was identified on 11/15/22 and pressure ulcers to her left foot which were identified on 11/16/22. RN #540 confirmed she did not assess Resident #34's pain prior to wound care, nor did she offer her pain medication or other interventions prior to wound care. RN #540 confirmed she was aware Resident #34 was in severe pain during wound care, but she continued to provide care and tried to work quickly because the resident was in pain. Interview on 12/01/22 at 4:22 P.M. with LPN #180 confirmed Resident #34 was not able to rate her pain using a numerical scale. LPN #180 confirmed Resident #34 had refused her routine dose of MS Contin at 8:00 A.M. on 12/01/22, and she had not observed the resident exhibiting any signs of pain during random observations of the resident throughout the day. LPN #180 confirmed Resident #34 had not received any pain medication on 12/01/22 prior to wound care at 4:08 P.M. Review of the facility policy titled Pain Clinical Protocol dated March 2018 revealed staff would use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. The nursing staff would identify any situations or interventions where an increase in the resident's pain may be anticipated, for example, wound care, ambulation, or repositioning. Review of the NPUAP guidelines dated 2014 page 161 at https://npiap.com/general/custom.asp?page=2014Guidelines in the section regarding Pain Management for Residents with Pressure Ulcers revealed staff should organize care delivery to ensure that it is coordinated with pain medication administration and that minimal interruptions follow. Set priorities for treatment. Pain management includes performing care after administration of pain medication to minimize pain experienced and interruptions to comfort for the individual. Review of online resource at https://www.mdapp.co/pain-assessment-in-advanced-dementia-painad-scale-calculator-550/ revealed the Pain Assessment in Advanced Dementia Scale (PAINAD) scale was a reliable tool for pain evaluation in dementia patients. The original study defines scores between zero and 10, where zero means no pain and 10 means severe pain. The scale administrator is asked to observe the patient for five minutes, either at rest, during a relaxing activity, during caregiving activities or administration of pain medication. PAINAD items include descriptions of breathing (independent of vocalization), negative vocalization, facial expression, body language, and consolability.

Based on medical record review, review of the hospital record, staff interview, review of the education, and review of the fall investigation, the facility failed to provide safe bed mobility during incontinence care. This resulted in Actual Harm when Resident #79 sustained a subdural hematoma requiring an emergency room visit, when State tested Nursing Assistant (STNA) #122 rolled Resident #79 away from her and the resident fell out of the raised bed onto the floor. This affected one resident (#79) of three residents reviewed for falls. The facility census was 80. Findings include: Review of the medical record revealed Resident #79 was admitted to the facility on [DATE]. Diagnoses included hypertension, depression, dementia, and anxiety. Resident #79 discharged from the facility on 07/11/22. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 had impaired cognition. The resident required extensive care of one staff for bed mobility, dressing, and toilet use and was dependent for transfers. The assessment indicated the resident was always incontinent of bowel and bladder. Review of the plan of care dated 07/05/22 revealed Resident #79 had a self-care deficit and was at risk for falls due to weakness and impaired mobility. Interventions included to assist with daily hygiene, grooming, dressing, oral care and eating as needed, assist to reposition, have commonly used articles within easy reach, keep the bed in a low position, lay down after meals and keep the resident in common areas when up. Review of a progress note dated 05/14/22 at 1:49 A.M. revealed Resident #79 was being changed and fell out of bed after STNA #122 turned the resident over away from her and Resident #79 fell to the floor from a high position. The resident was transferred to the hospital due to complaints of a headache, a large hematoma, and swelling of her face. Review of the local hospital emergency room notes dated 05/14/22 revealed Resident #79 had a subdural hematoma in the right frontal area. Review of the facility fall investigation dated 05/14/22 revealed the Director of Nursing (DON) was notified of Resident #79's fall. After a full investigation and root cause analysis it was determined during routine care STNA #122 turned the resident away from her to provide incontinence care and the resident moved her shoulders forward and rolled out of bed. Immediately following the head-to-toe assessment Resident #79 was sent to the emergency room for an evaluation. Interview with the DON on 07/27/22 at 1:00 P.M., revealed STNA #122 was from an agency. The DON noted STNA #122 should not have turned Resident #79 away from her. Residents should always be turned toward the person giving care. The DON also noted the bed was raised to the high position. Review of the education titled Bed Mobility During Care, revealed always, turn the resident towards you. Make sure there is plenty of room to roll the resident without being on the edge. This deficiency substantiates Complaint Number OH 175.

Based on medical record review, staff and physician interviews, review of facility policies, review of facility investigation, and review of the hospital records, the facility failed to provide Resident #100 with necessary and appropriate assistance with bed mobility during incontinence care resulting in the resident falling out of bed. This resulted in Actual Harm when Nurse Aide (NA) #45 was providing incontinence care to Resident #100 without the appropriate level of assistance, the resident rolled out of the bed, was sent to the hospital, and subsequently sustained a fracture to right tibia and fibula which required surgical interventions. This affected one (#100) of the three residents reviewed falls. The facility census was 70. Findings included: Review of the closed medical record for the Resident #100, revealed an original admitted [DATE] and was discharged on [DATE]. Diagnoses included, but not limited to cerebral infarction (Stroke), cerebral vascular accident ([CONDITION(S)]), [CONDITION(S)], contracture left hand, delusional disorders, Dementia without behavioral disturbances, convulsions, hypertension ([CONDITION(S)]), [CONDITION(S)] on left side and [CONDITION(S)]. The diagnoses was silent for Osteopenia and or [CONDITION(S)] joint disease (DJD). Review of the quarterly and most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 had severely impaired cognition, had no behaviors, did not reject care, did not wander, was dependent for transfers, toileting and bathing and required two plus person extensive physical assistance for bed mobility, eating, personal hygiene and resident was always incontinent of bowel and bladder. Review of plan of care last updated 01/07/22 indicated resident was incontinent of bowel and bladder, required total care with activities of daily living (ADLS) and rarely participated in her care and resident had limited physical mobility related to refusing to get out of bed. Plan of care revealed resident was resistive to care related to dementia, was at risk for falls due to [CONDITION(S)], poor body control, dementia, and dependent on staff for mobility and transfers. Interventions last updated for bed mobility dated 11/15/19 indicated resident was an extensive assist of one to two persons to turn and reposition, keep bed in lowest position when providing care, and anticipate resident's needs. Review of the most recent Morse Fall Scale for Resident #100 dated 04/06/21 revealed resident was at moderate risk for falling. An updated Morse Fall Scale was completed on 02/18/22 at 7:33 A.M. which indicated resident was at high risk for falling. Review of physician orders for Resident #100 dated 05/12/21 revealed resident was ordered to be transferred by Hoyer lift for all transfers and air mattress to bed to reduce pressure and to reduce risk for pressure related wounds. Orders dated 02/18/22 revealed resident was ordered to be sent to hospital for evaluation and treatment. Review of orders were silent for any orders related to incontinence/personal care for resident. Review of Temporary (Nurse's Aide) NA job description for NA #45 dated 11/16/21 revealed aides would perform certain services for the facility's residents for which they had been trained and found to be competent in performing and the aide was to perform and direct patient care job functions. Descriptions included check resident routinely to ensure their personal care needs were being met and seek additional help when needed and follow established safety precautions in the performance of all duties. Review of most recent weight for Resident #100 dated 02/11/22 revealed resident weighed 191 pounds. Review of Licensed Practical Nurse (LPN) #34 witness statement dated 02/18/22 at 5:30 A.M. indicated she was notified by NA #45 that resident had slid out of bed during care. Notes indicated LPN #34 discovered resident on the side of the bed closest to residents left side, between bed and window, resident was on her knees facing the head of bed and resident was leaning towards the bed holding on the grab bar. Notes indicate resident was complaint of pain in knees. Notes indicated resident was assisted to the floor and resident was noted with high anxiety about touched or moved and voicing fear of falling. Notes indicated resident had no deformities, vital signs normal and no change in mental status and resident and NA stated resident did not hit her head. Notes indicated resident continued to complain of right knee and hip pain. Notes indicated resident was administered Tylenol (pain), physician was notified, and LPN was educated on NAs to use two persons assist with all care of residents. Notes indicated frequent checks were completed and bruising appeared just below right knee and resident continued to be afraid of being touch and fear of falling during attempted assessments. Notes indicated NAs reported resident continued to yell and tell them not to touch her. Notes indicated resident son was notified, day shift nurse was given report and was awaiting response from physician. Review of incident/accident log date 02/18/22 at 5:35 A.M. indicated Resident #100 had a fall during staff assist. Review of pain Tool document for Resident #100 dated 02/18/22 at 7:34 A.M. revealed resident complained of pain in right lower leg and bruising was noted, and leg, right hip, and left hip with no noted deformities. Notes indicated resident was very difficult to assess due to behaviors and pain was worse with range of motion. Review revealed no previous pain tool assessments for resident. Review of the nurse progress notes for Resident #100 dated 02/18/22 at 8:04 A.M. by LPN #34 revealed the physician and resident's son were notified and was awaiting response from physician. Progress notes at 11:54 A.M. by LPN #32 indicated resident complained of right knee pain upon movement, physician was in the facility, assessed resident's knee and ordered resident to be sent hospital via 911. Notes indicated the hospital and family was called. Progress notes were silent for any documentation by LPN #34 which detailed the incident or resident assessment. Review of physician notes for Resident #100 dated 02/18/22 indicated resident was weak, had decreased range of motion and physician discussed findings with staff. Notes dated 02/18/22 indicated Physician # 50 arrived in facility, assessed Resident #100 for fall for which she indicated she was not notified of fall. Notes indicated right knee had deformities, bruising and resident had decreased range of motion in and pain and tenderness in right knee and resident was ordered to be transferred to hospital. Review of hospital notes for Resident #100 dated 02/18/22 indicated resident was evaluated in the emergency room for fall and resident stated everything hurt. Computerized tomography (CT) of right femur indicated resident had impacted nondisplaced right proximal tibia fracture centered at the metaphysis and nondisplaced fibular neck fracture. X-ray of the right knee indicated mildly displaced impacted right proximal tibial fracture centered at the metaphysis and fibular neck fracture. Hospital notes indicated there was a subtle cortical step off at the right femoral neck intertrochanteric region. Hospital notes indicated a surgical consult was completed and resident was admitted , preoperative orders were placed for surgical interventions were scheduled the following day to repair fractures. Review of the facility investigation dated 02/18/22 indicated Director of Nursing (DON) collected witness statements from NA #45, LPN #34 and DON made statements regarding the fall/incident. Review of STNA #45's witness statement dated 02/18/22 and untimed indicated she was changing resident when NA asked resident to roll over and NA grabbed the lift sheet, pulled it towards her and the resident slid off bed feet first while holding on to rail. Review handwritten note by DON dated 02/18/22 and untimed indicated she spoke with LPN #34 and facility needed a witness statement of incident. Notes also indicated DON instructed LPN #34 to make sure the DON was notified any falls and LPN was required to complete a progress note for any incidents. Same handwritten note indicated DON spoke to NA #45 about the incident with resident. Notes indicated NA explained the incident which matched her witness statement. Notes indicated NA #45 was educated on using two persons assist for resident and with residents who were more complex and bigger residents. Review of handwritten note from DON dated 02/21/22 and untimed indicated resident had osteopenia, [CONDITION(S)] joint disease, on multiple medications which cause weakness to bones and bone loss. Notes indicated the way the resident fell , how she leaned, given her weight, flaccid left side and being on left side, the type of break as well as being on low air loss mattress (regular size), her investigation led to being an accident and not out of any malice or intent. Interview with LPN #32 on 02/28/22 at 12:29 P.M. indicated she was assisting nursing staff on 02/18/22 when she heard something happened to Resident #100 during a staff assist. LPN #32 resident was complaining of pain and when physician arrived to do rounds, LPN #32 asked Physician #50 to see resident. LPN #32 stated resident was assessed and immediately sent to the hospital for leg pain and injuries. LPN #32 initially stated she did not know about the incident, but then stated she learned the incident happened during the night on 02/17/22 when a NA rolled the resident in bed while providing care and resident slid into floor and resident was hanging on to assist bar. LPN #32 stated resident was on an air mattress, and they are very slick, and resident slid out of bed during care. LPN #32 stated she did not know much about the details and surveyor would have to talk to DON and she could relay more details of the incident. LPN #32 stated resident was sent to hospital and never returned Interview with DON on 02/28/22 at 12:50 P.M. indicated she investigated the 02/18/22 incident by interviewing staff and indicated she collected witness statements from the nurse on duty and the NA who was providing care at time of incident. DON stated she discovered NA #45 was in Resident #100's room providing incontinence care by herself at approximately 5:00 A.M. when NA #45 rolled resident to the left side (weak side), so resident could use her right arm (strong side) to hold on to the assist rails. DON stated resident's legs slid off the bed and landed on floor while resident hung on to the assist rail with her right arm. DON stated when Agency LPN #34 entered resident's room, resident's feet were in the floor holding her up and resident was hanging on to bed with right arm complaining of pain in legs. DON stated resident was placed back in bed by staff, and the physician and family was called. DON stated the facility physician made rounds later that morning, assessed resident and sent resident to hospital where she was diagnosed with right fibula neck fracture, displaced tibia, and fracture at metaphysis tibia fibular, admitted to hospital and had surgery for injuries. DON concluded resident was care planned for one to two persons assist, was on a low air loss mattress (LLAM) bed which made surface slick and contributed to resident sliding off the bed on and the incident was an accident and not any type of malice or intent. DON stated resident had history of osteopenia from the hospital records which could lead to bones being fractured easier and resident received numerous medications that could have decreased bone mass causing an easier fracture. DON stated she immediately added a two person assist for all care, educated staff on using two persons assist for Resident #100, ordered a bariatric bed, and added interventions to check on resident more often. DON stated resident never returned to the facility. DON verified there were no documented assessments or progress notes from the incident. DON also verified NA #45 provided incontinence by herself, resident had a fall, was transferred to the hospital, and ended up requiring surgical interventions secondary to the fall. Interview with LPN #34 on 02/28/22 at 2:47 P.M. indicated she was called to resident's rooms on 02/28/22 around 5:30 A.M. and found resident on the side of bed of bed closest to the window, on her knees and right arm was hanging on to the assist bar. LPN #34 stated resident was twisted facing bed and knees were toward the head of the bed. LPN #34 stated they lowered resident to floor, put a flat sheet under her and four staff members lifted her back into bed. LPN #34 stated resident was very anxious and panicky over incident. LPN #34 stated when staff were laying resident down to floor resident kept stating I am falling and more anxious. LPN #34 stated she did a pain assessment once resident was back in bed on resident and resident freaked out when she attempted to touch legs or hip. LPN #34 stated she attempted to do a range of motion assessment and resident freaked out again complaining of pain. LPN #34 stated NA #45 completed incontinence care by herself at time of incident and LPN #34 stated she was not very familiar with resident due to being agency but had been told resident was a very difficult to provide care for and should have been a two person assist. LPN #34 stated she reported the fall to the oncoming shift nurse, sent a message to the physician via the MatchMD (electronic reporting system) and called the family around 8:00 A.M. LPN #34 stated when she was getting ready to leave, the physician had not called back yet, so she created a note so others would know the physician had been contacted. LPN #34 additionally stated resident had some bruising on her knee, but her assessment did not lead to resident needing to be sent to the hospital at the time of incident and was going to leave the decision to the physician from her message on the MatchMD. LPN #34 verified she forgot to put in a progress note or an assessment of the fall and stated she did not notify administration. Interview with NA #45 on 02/28/22 at 4:04 P.M. indicated she provided incontinence care for Resident #100 on 02/18/22 around 5:30 A.M. when she rolled resident towards the window (left weak side) when residents legs slid off the bed and resident slid into the floor. NA #45 indicated resident was on her knee and was holding on to the assist bar with her strong arm (right). NA #45 stated she immediately left to get the nurse. NA #45 stated resident's legs were twisted under her and somewhat holding her up along with resident holding onto assist bar and resident was complaining of pain and yelling help me. NA #45 stated LPN #34 had to twist resident while she rested on her legs as they tried to get resident on the floor to be able get resident back in bed. NA #45 stated she had to get two additional staff members to assist getting resident back in bed. NA #45 stated they laid resident flat in floor, put a sheet under her and lifted her into the bed. NA #45 stated the nurse checked her vitals, gave her pain medications. NA #45 stated the DON questioned her a few hours later and asked her to complete a statement. NA #45 stated she did not know how many staff were ordered to provide care or how many staff were care planned to provide incontinence care, but STNA stated she often provided care by herself due to low staffing, but resident should have had two staff members due to resident's weight and resident often resisted and pushed away. NA #45 stated she was the only NA on the hallway. Phone interview with MDS/Registered Nurse (RN) #21 on 03/01/22 at 10:40 AM indicated she was tasked with doing MDS assessments and updating residents care plans. RN #21 stated Resident #100 was able to hold the assist rail some days and others she was too weak to assist with care. RN #21 stated she updated the care plan after the incident on 02/18/22 to indicate resident was a two person for all care. During review of the care plan at same time, revealed RN #22 last updated the care plan on 01/07/22 which indicated resident was a total care with ADLS and rarely participated in her care. Additional review of care plan during the interview, revealed interventions updated 11/5/19, revealed resident was listed as extensive assist of one to two person to turn and reposition. RN #21 stated she was behind on updating care plans and must have forgotten. RN #21 verified resident was very weak and rarely participated in care. Phone interview with facility Physician #50 on 03/01/22 at 3:00 P.M. indicated she was making her regular rounds in the facility and was asked by the Unit Manger/LPN #32 to see Resident #100 due to knee pain. Physician #50 indicated she was never contacted by staff at time of fall and was unaware of any injuries until she arrived in the facility. Physician #50 stated she assessed resident and immediately sent her out due to deformity, bruising and increased pain. Physician #50 stated she was told a NA was changing her in bed and rolled her too far and resident ended up in the floor. Physician #50 stated she also assessed Resident #100 in the hospital and was determined she had fractures in lower right leg because of the fall and required surgery the following day to repair the fractures. Review the personnel record for the unlicensed NA #45 revealed NA #45 was hired on 11/15/21 under the waiver from CMS for nurse's aide being licensed. Notes indicated NA #45 completed online temporary nurse aide training on 05/11/20. NA #45 completed all required hiring requirements. Review of Temporary Nurse Aide Skills competency checklist revealed NA #45 was observed and checked off for positioning, moving a resident and restorative care on 11/16/21 by Unlicensed NA #43. Review of facility policy titled Acute Condition Changes - Clinical Protocol dated 03/01/2018 revealed the direct care staff would be training in recognizing subtle but significant changes in residents. Review of 07/01/17 facility policy titled Accidents and Incidents -Investigating and Reporting revealed all accidents or incidents involving residents occurring on the premises shall be investigated and reported to the Administrator. This deficiency substantiates Complaint Number OH 378.

Based on medical record review, hospital record review, observation, staff interviews, resident interview, review of the National Pressure Ulcer Advisory Panel (NPUAP) pressure ulcer staging guide, and review of facility policy, the facility failed to initiate and consistently follow physician ordered treatments to prevent the development of avoidable pressure ulcers and/or promote the healing of three (#42, #03, #60) of five residents reviewed for facility acquired pressure ulcers. This resulted in Immediate Jeopardy for two (#42 and #03) of five residents reviewed who suffered serious tissue damage and subsequent complications as follows: (1) Resident #42 acquired an avoidable unstageable pressure ulcer to his coccyx without evidence of weekly skin assessments as ordered by the physician. The area to the coccyx was debrided and subsequently deteriorated, due to treatments for the wound that were not being completed consistently as ordered, and the wound became infected with bone palpable requiring negative-pressure wound therapy (wound vac) and antibiotic therapy; (2) Resident #03 acquired an in facility Stage III pressure ulcer to the right gluteus, and a Stage IV pressure ulcer to the coccyx resulting in hospitalization with [DIAGNOSES REDACTED]. Additionally, one (#60) of three residents was placed at risk for more than minimal harm that is not Immediate Jeopardy when Resident #60 acquired an unstageable pressure ulcer to the left heel in the facility without evidence the facility consistently completed wound treatments as ordered by the physician. The facility census was 70. On 11/01/18 at 12:19 P.M., the Licensed Nursing Home Administrator (LNHA), Corporate Director of Nursing (CDON) and Corporate Registered Nurse (CRN) #83 were notified Immediate Jeopardy began on 08/14/18 when staff documented Resident #42 had an unstageable necrotic pressure ulcer measuring a surface area of 8.1 centimeters (cm) length (L) x 12.0 cm width (W) to the left mid buttock natal cleft (coccyx), with no evidence the physician ordered weekly skin assessments had been completed. The last documented weekly skin assessment on 07/11/18 noted the resident's skin was intact. There was no evidence of the implementation of comprehensive pressure ulcer care to promote healing, prevent further breakdown, and no evidence physician ordered medications and treatments were consistently provided as ordered. The Immediate Jeopardy continued on 09/06/18 when Resident #03 was identified as having a small open area noted to the coccyx measuring 0. L x 0.1 cm W x 0.1 cm depth (D) with multiple wound orders obtained, with some never initiated on the Treatment Administration Record (TAR) and those initiated were not consistently completed, resulting in an infected Stage III right gluteus pressure ulcer, and a Stage IV coccyx pressure ulcer resulting in hospitalization [MEDICAL CONDITION]. The Immediate Jeopardy was removed on 11/05/18 when the facility implemented the following corrective actions: · On 11/01/18 beginning at 1:00 P.M. through 11/02/18 at 7:00 P.M., skin assessments were completed for all residents in the building by the CDON and CRN #83. · On 11/01/18, the CDON and CRN #83 ensured all necessary supplies and equipment were available for wound treatments. · On 11/02/18, the CDON, CRN #83 and Minimum Data Set/Licensed Practical Nurse (LPN) #92 reviewed all resident medical records to ensure weekly skin assessment orders were in place. · On 11/02/18 at 8:30 A.M., Corporate Wound Nurse (CWN) #85 assessed all wounds identified in the facility and in-serviced all staff on duty for proper wound treatment and preventative measures. · On 11/02/18, the CDON, CRN #83, and LPN #92 reviewed all skin related treatment orders to ensure accuracy and appropriate formatting on the TAR. · Beginning 11/02/18 through 11/05/18 at 7:00 P.M., the CDON, CRN #83 and CWN #85 provided in-service education for all nursing staff covering preventative skin care measures, proper transcription and entering of treatment orders into the Electronic Health Record (EHR), and proper wound treatment procedures. Nursing staff not scheduled during that time will be in-serviced by phone prior to working their next scheduled shift. · Beginning 11/01/18 through 11/09/18, the CDON, CRN #83 and LPN #92 will conduct daily monitoring of treatment records to ensure completion of treatments and appropriate documentation. The monitoring will continue weekly thereafter for four weeks. Although the Immediate Jeopardy was removed on 11/05/18, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: 1. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact with no behaviors or refusal of care noted. The MDS revealed the resident required an extensive one-person assistance with bed mobility, dressing, toileting, and personal hygiene. The MDS skin assessment revealed Resident #42 was at risk for pressure ulcers, however, had no pressure areas, venous or arterial ulcers, or any other ulcers, wounds, or skin problems noted. Review of the weekly skin assessment dated [DATE] revealed Resident #42's skin was intact. Review of the next weekly assessment for Resident #42 was dated 08/14/18 by LPN #105. The assessment revealed an unstageable left mid buttock natal cleft(coccyx) pressure ulcer measuring 3.5 cm L x 2.5 cm W, with a surface area of 8.1 cm x 12.0 cm squared, with slough (dead tissue), yellow/black eschar necrotic tissue, and a left mid buttock Moisture Associated Skin Damage (MASD) area measuring 2.5 cm W, with a surface area of 12.1 x 24.0 cm squared, and 2 cm in depth, with granulation tissue and a moderate amount of drainage noted. The resident was also noted with another MASD area on the right lower buttock measuring 9 cm L x 1.5 cm W x 2 cm depth, with 75% yellow slough tissue, and a moderate amount of drainage. The physician was faxed requesting a treatment order. Review of the TAR revealed an order dated 08/14/18 for Santyl (wound cream) and dry dressing to the buttock, to be applied daily for fourteen days, reposition and check for urinary incontinence every two hours. Review of Resident #42's physician order dated 08/16/18 revealed orders to send the resident to the emergency room (ER) related to altered mental status. Review of the summary for hospitalization revealed Resident #42 was admitted to the hospital on [DATE]. The resident was admitted with wounds including an unstageable wound measuring 3.5 cm L x 2.5 cm W and 8.75 cm squared. A right/left buttock diabetic wound measuring 7 cm L x 1.5 cm W, with slough tissue and a small amount of mild odor and drainage noted. The unstageable wound was debrided with new measurements of 5 cm L x 4 cm W x 2.3 cm in depth. Discharge instructions included to apply a Negative Pressure Wound Therapy (wound vac) to the gluteal surgical wound at the nursing home facility, upon arrival, with dressing changes to be completed on Monday, Wednesday, and Friday. Orders were also noted for Intravenous (IV) Meropenem (antibiotic) 1 gram (g), every eight hours, for 21 days. The resident was discharged back to the facility on [DATE]. There was no evidence in Resident #42's medical record the hospital's discharge instructions were acted upon until a treatment order dated 08/26/18 revealed to cleanse the gluteal surgical wound with normal saline and apply wet to dry dressing every shift (A.M. and P.M.) until the would vac was available. Review of the TAR revealed the wound care was not started until 08/27/18 on the P.M. shift. Review of the nursing progress note dated 08/27/18 revealed the first treatment completed for Resident #42 was three days after the resident was discharged from the hospital. The surgical wound was documented as red/bloody tissue with large amounts of drainage noted, with a foul odor. Review of the Wound Care Recommendation dated 08/29/18 revealed Certified Wound Registered Nurse (CWRN) #110 applied the wound vac to Resident #42's wound. CWRN #110 documented the wound to the right of the coccyx measured 5.5 cm L x 3.0 cm W x 2.0 cm in depth, with undermining up to 5.0 cm in depth, with a small amount of drainage noted. The right wound was now 4.0 cm L x 0.8 cm W x 0.2 cm in depth, with a yellowish base, and both wounds had an enormous amount of fungus. CWRN #110 recommended for continued wound vac if able, and if the wound vac would not stay in place to notify the physician. The recommendation for treatment to the wound, if the wound vac would not stay on, was to apply alginate dressing to the coccyx, cover with gauze, and change daily, and as needed. CWRN #110 also recommended for the right buttock to have a [MEDICATION NAME] or foam dressing every three days, and as needed. Review of Resident #42's nursing progress note, and physician orders dated 08/30/18 revealed the wound vac wound not adhere due to Resident #42's incontinence. Orders were received to cleanse the coccyx wound with normal saline, mild soap, pat day, pack with alginate dressing, cover with gauze, change daily and as needed. Also, new orders were received to cleanse open area on the resident's right buttock with normal saline, mild soap, pat dry, apply [MEDICATION NAME], or foam dressing, every three days, and as needed. There was no evidence the orders were put in the EHR, resulting in no wound treatments being completed. Review of Resident #42's Medication Administration Record [REDACTED]. There was no evidence the antibiotic was given on 08/29/18 at 7:00 P.M., on 08/30/18 at 7:00 P.M.,, on 09/04/18 at 11:00 A.M., or 7:00 P.M.,, on 09/05/18 at 7:00 P.M., on 09/06/18 at 11:00 A.M., or 7:00 P.M., on 09/12/18 at 7:00 P.M., and on 09/13/18 at 7:00 P.M. Review of Resident #42's physician order dated 09/05/18 revealed an order for [REDACTED].M., on 09/10/18, 09/13/18, 09/17/18, or on 09/25/18. Review of Resident #42's TAR revealed orders dated 09/05/18, for wound care to be completed twice a day, revealed no documentation the wound treatments were completed from 09/05/18 through 09/10/18. Review of the Wound Clinic instructions dated 09/07/18 revealed Resident #42 was seen at the wound clinic with orders to apply [MEDICATION NAME] (moisture barrier) ointment to excoriated areas on the buttocks. If the wound vac was not available, apply alginate dressing, cover with gauze, and change the dressing three times a week to the sacrum wounds. If the wound vac was in place, keep at 125 pressures setting continuously with black foam dressing, and change three times a week on Monday, Wednesday and Friday. Review of Resident #42's TAR revealed from 09/07/18 through 10/03/18, the [MEDICATION NAME] was not applied as ordered during the A.M. shifts on 09/08/18, 09/09/18, 09/12/18, 09/13/18, 09/14/18, 09/17/18, 09/19/18, 09/20/18, 09/26/18, or 10/02/18. The [MEDICATION NAME] was not applied on the P.M. shifts on 09/10/18, 09/13/18, 09/14/18, 09/22/18, 09/24/18, or 10/02/18. Further review of Resident #42's medical record revealed no documentation as to whether the wound vac was in place, and if dressing changes were initiated, or completed as ordered by the physician. Review of Resident #42's physician orders entered on 09/11/18 to the TAR revealed to discontinue the current treatment to the resident's pressure ulcer and to cleanse the ulcer with normal saline, apply silver alginate to the wound base, and cover with gauze on Monday, Wednesday, Friday, and as needed. The wound treatment was not completed as ordered on [DATE], 09/14/18, 09/17/18, 09/19/18, 09/21/18, and 10/01/18. Review of Resident #42's skin assessment dated [DATE] revealed the wound to the residents left mid buttock measured 6 cm L x 4 cm W x 6 cm in depth. The wound had a greenish-yellow slough granulation tissue, with heavy drainage noted. There was no evidence in the medical record the physician was notified the wound had heavy drainage. Review of the weekly skin assessment dated [DATE] revealed Resident #42's right lower buttock wound measured 3 cm L x 2.5 cm W, with moderate amount of drainage noted. Also, Resident #42's wound to the left buttock was noted to be very moist with 100% granulation and was macerated from fungus. Review of Resident #42's TAR revealed an order was entered on 09/18/18 to apply skin prep to a blister on the left bottom of the resident's foot and apply dry dressing every morning until resolved. There was no other documentation regarding the wound to the foot, no measurements, or how it was obtained. On 09/21/18 the wound assessment revealed the wound to the bottom of the resident's left foot was a fluid blister measuring 4.0 cm x 6.1 cm. The treatment was to apply skin prep and a Kerlix dressing. Review of the TAR revealed from 09/19/18 through 10/03/18 wound treatments to the resident's foot were not completed on 09/19/18, 09/20/18, 09/26/18, or on 10/02/18. Further review of the wound assessment dated [DATE] revealed the wound to Resident #42's coccyx was documented as worsening and was unable to be staged. The wound measured 5.0 cm W x 6.0 cm L, area with green slough. Review of the wound assessment dated [DATE] revealed the area to Resident #42's left mid buttock measured 5.5 cm L x 5.0 cm W x 3.0 cm in depth, with moderate drainage and greenish-yellow slough with some granulation tissue noted. Review of the left lower buttock wound revealed it measured 2.0 cm L x 2.1 cm W. There was no evidence the physician was notified of the wound drainage. Review of the nursing progress notes dated 10/03/18 at 3:18 P.M., revealed Resident #42 was sent to the ER for critical laboratory (lab) results. The lab results indicated Resident #42 had a critically high White Blood Cell count of 25,300 (leukocytes per microliter of blood), indicating infection (normal is 4,500 to 10,500). Additionally, the resident had a critical Blood Urea Nitrogen (BUN) level of 73 milligrams per deciliter (mg/dl). Review of the hospital after visit summary dated 10/13/18 revealed Resident #42 was admitted to the hospital from 10/03/18 to 10/13/18 with a primary [DIAGNOSES REDACTED]. While hospitalized , the sacral wound was debrided and measured 12 cm L x 9 cm W x 4 cm in depth. The resident's left foot ulcer was measured as 6 cm L x 2 cm W x 0.2 cm in depth. Resident #42 was sent back to the facility on [DATE] with a wound vac in place, ordered to be changed every Monday, Wednesday and Friday. Review of Resident #42's physician orders and TAR revealed an order for [REDACTED]. There was also an order for [REDACTED].M., dose on 10/15/18, 10/16/18, 10/21/18, 10/30/18, or the 10:00 P.M. dose on 10/24/18 and 10/25/18. Review of the TAR revealed the orders for the wound care treatments to the left plantar foot were not completed as ordered on [DATE], 10/16/18, 10/17/18, or 10/19/18. Continued review of the TAR revealed the orders to change the wound vac dressing Monday, Wednesday, and Friday, revealed the order was not completed on 10/15/18, 10/19/18, 10/24/18, or 10/29/18. Review of the facility wound notes dated 10/25/18 revealed Resident #42's wound on the bottom left foot was noted with eschar tissue present and measured 3 cm L x 3 cm W. The wound to the coccyx measured 10 cm L x 10 cm W x 4 cm in depth, with granulation tissue and the bone palpable and visible. Observation and interview on 10/30/18 at 4:34 P.M. with LPN # 96 revealed the LPN completed a dressing change to Resident #42's left foot. LPN #96 revealed the resident was in isolation for an infected wound to his coccyx. LPN #96 revealed she was unsure of how the resident got the wound to his left foot, however, it had been there for a while. LPN #96 stated the resident had two wounds, a large wound to the coccyx with a wound vac which was ordered to be changed Monday, Wednesday and Friday. Observation of wound dressing change to the resident's left foot revealed the dressing was completed as ordered. Interview on 10/31/18 at 11:37 A.M. with LPN #92 revealed Resident #42's wound to his bottom was acquired in the facility. LPN #92 revealed the wound on his bottom started as moisture with orders for a fungal cream. LPN #92 verified Resident #42 had no documentation for wound assessments from 07/11/18 when the resident's skin was intact, until 08/14/18 when the wound was found to his bottom. LPN #92 further verified there was no evidence the resident ever refused care or incontinence care. Interviews on 11/01/18 at 11:00 A.M. with the CDON and LPN #92 both confirmed there was no documentation as to how, or when Resident #42 developed the wound to his left foot. Both staff verified treatments to the resident's pressure ulcers on his lower left buttock and mid left buttock were not completed as ordered due to the orders not being entered correctly in the EHR by some nurses. They both revealed the orders did not transfer to the TAR, therefore the nurses did not know to complete them. The CDON further verified the orders for treatments which were entered correctly were not consistently completed as ordered. 2. Review of the medical record revealed Resident #03 was admitted to the facility 10/06/15 with [DIAGNOSES REDACTED]. The resident was noted with a current order for skin assessments to be completed and documented weekly on Thursdays. Review of the nursing progress notes dated 09/06/18 revealed Resident #03 had a small open area on the coccyx measuring 0.1 cm L x 0.1 cm W x 0.1 cm in depth. Orders were faxed to the physician requesting to apply a border gauze with adhesive wound dressing, to apply daily, and as needed, until healed. On 09/07/18 orders were received for the treatment to the coccyx. The physician orders were not put in the EHR; therefore, the resident did not receive the ordered treatments to the coccyx. Continued review of the TAR for (MONTH) (YEAR) revealed Resident #03 also had an order for [REDACTED].M. shift on 09/01/18, 09/07/18, 09/15/18, 09/18/18 or on 09/27/18. Review of the weekly skin assessment dated [DATE] revealed Resident #03's wound to the right mid buttock measured 0.1 cm L x 0.4 cm W. The wound was damp and not open. An order was received to cleanse right buttock area with normal saline, pat dry, and apply border gauze daily in the A.M., and as needed. Review of the TAR revealed the treatment order was never put in the EHR; therefore, it was not completed. Review of nursing progress note dated 09/21/18 at 2:59 P.M. revealed Resident #03 had an area of excoriation noted to her right buttock measuring 3.5 cm L x 1.5 cm W. Cream was applied. The resident was also noted with an area to the left buttock with pin point excoriation measuring 0.5 cm L x 0.5 cm W. Additionally, the resident was noted with an area to the coccyx measuring 1.0 cm L x 1.0 cm W x 0.1 cm in depth. Cream was applied to the area. Review of Resident #03's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive two-person assistance with bed mobility, dressing, and toileting. The assessment further revealed the resident was at risk for pressure, with no pressure areas noted, except for moisture associated skin damage. Review of a request for physician orders dated 09/26/18 revealed a request was sent to the physician for an order for [REDACTED]. Review of Resident #03's wound assessment and nursing progress note dated 09/27/18, revealed Resident #03's wound to the buttock had drainage. The right lower buttock measured 1.0 cm L x 0.8 cm W and had pink [MEDICATION NAME] tissue with light drainage. The wound to the coccyx measured 1.0 cm L x 0.8 cm W x 2.5 cm in depth and was reddened with heavy drainage noted. There was no evidence the physician was notified of the wounds deterioration. Review of Resident #03's TAR revealed the treatment of [REDACTED].M. shift. Further review of the TAR revealed the treatments were not applied as ordered on the A.M. shift on 10/02/18, 10/03/18, 10/04/18, 10/07/18, and 10/08/18. Review of Resident #03's wound assessment dated [DATE] revealed Resident #03's wounds to the right and left buttock areas were closed and to continue to use [MEDICATION NAME]. The coccyx wound was noted as 2.0 cm L x 1.0 cm W x 2.5 cm in depth, with heavy drainage. The coccyx was noted to be reddened and was warm to the touch. The wound was documented as being worse. A new order was received to cleanse the coccyx with normal saline, apply Santly to the wound, loosely pack with gauze, and cover with foam pad daily. An order was also received for [MEDICATION NAME] (antibiotic) 500 milligram (mg) by mouth daily, for ten days, for infected wound. Review of the TAR revealed the treatment to Resident #03's coccyx was not completed as ordered on [DATE] or 10/08/18. Review of the note from the wound clinic dated 10/09/18 revealed Resident #03 now had a right gluteus Stage III pressure ulcer which measured 0.4 cm L x 0.6 cm W x 0.2 cm in depth, with a medium amount of serosanguinous (yellowish with blood) drainage noted. The wound was documented at a full thickness skin loss with slough covered. The wound to the coccyx was noted as a Stage IV pressure ulcer and required debridement. The wound measured pre-debridement at 2 cm L x 0.9 cm W x 3 cm in depth, and post debridement the measurement was 2.1 cm L x 1.0 cm W x 3.0 cm in depth. The wound was noted to be large and deep with elevated wound edges and extensive tissue necrosis with undermining. The wound bed was noted with tissue loss and brittle exposed bone, with concern of osteo[DIAGNOSES REDACTED] (bone infection). Deep tissue cultures were taken. The discharge instructions from the wound clinic included to cleanse right gluteus and coccyx wounds with normal saline, apply [MEDICATION NAME] (wound dressing) cover with dry 4 x 4 gauze, and secure with [MEDICATION NAME] tape daily to both wounds. Discharge instructions also included to use an Ensure type product (nutritional supplement) three times per day to increase protein in the resident's diet. Orders were also written for labs to be drawn and to be faxed to the wound clinic prior to the next appointment on 10/16/18. An order was also received for an Magnetic Resonance Imaging (MRI). Review of Resident #03's TAR revealed no treatments were documented as completed on the TAR for the wounds on 10/11/18 for the Stage III gluteus pressure ulcer. Continued review of the TAR revealed no documentation the treatments to the coccyx were completed as ordered on [DATE] or 10/14/18. On 10/15/18, four days later, an order clarification was noted to complete the ordered dressing change to now include both the right gluteus and coccyx. Review of the discharge instructions from the wound clinic dated 10/16/18 revealed the treatment was changed to irrigate both wounds with ¼ strength Dakin's solution daily, rinse with saline if needed, but the actual dressing change orders remained unchanged. It was requested again for Resident #03 to use an Ensure supplement three times daily, to increase protein in her diet. Further review of the wound care discharge instructions revealed the wound cultures from 10/09/18 were positive for Escherichia coli (E. coli), Proteus, and [MEDICATION NAME] Faecalis bacteria (serious infection) in the coccyx wound. Orders were written for the house physician to review the lab results and order antibiotics. Review of Resident #03's physician order dated 10/16/18 revealed an order for [REDACTED]. Review of Resident #03's nursing progress note dated 10/17/18 revealed the resident was not acting herself and had a blood glucose reading of 411 milligrams/deciliter (mg/dL). The resident was noted to be lethargic and slow to respond. An order was received to send the resident to the hospital. The resident's Power of Attorney (POA) was made aware. Review of the hospital admission record revealed Resident #03 was admitted to the hospital's Intensive Care Unit (ICU) on 10/17/18 with [DIAGNOSES REDACTED]. The resident's Stage IV sacral wound was debrided on 10/19/18, and the post debridement wound measured 8 cm W x 10 cm L x 3 cm in depth. Telephone interview on 10/29/18 at 9:39 A.M. with Resident #03's POA revealed he went to the resident's wound clinic appointment on 10/09/18. The POA revealed the wound clinic was adamant the resident needed a nutritional supplement added to her diet. The POA revealed the facility did not add the nutritional supplement until 10/15/18 (five days later). Interview conducted on 10/31/18 at 1:27 P.M. with LPN #92 revealed the orders dated 09/13/18 for Resident #03's wound care were entered in the EHR incorrectly; therefore, the treatment orders never carried over to the TAR and were never completed. LPN #92 stated some staff in the facility were not familiar with the EHR and this had been a problem. LPN #92 confirmed the order for the nutritional supplement was not ordered until 10/15/18. LPN #92 further confirmed Resident #03's POA was not notified of the resident's wounds until 10/04/18, and they were discovered by the facility on 09/06/18. 3. Review of the medical record revealed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated [DATE] revealed the resident had mild cognitive impairment and required extensive two-person assistance with bed mobility, transfer, extensive one-person assistance with personal hygiene, dressing, locomotion, total one-person assist with toileting, and supervision and setup with eating. Review of the MDS skin assessment revealed the resident had an unstageable pressure ulcer with eschar tissue, surgical wound and moisture associated skin damage. Review of the facility's Pressure Injury Report revealed the facility identified Resident #60 had facility acquired wounds, including an unstageable wound to the left heel. Review of Resident #60's wound assessment dated [DATE] revealed the resident had a necrotic left heel wound measuring 3.3 cm L x 6 cm W, with no drainage noted. Review of Resident #60's TAR dated 09/18 revealed treatment orders to cleanse bilateral heels with normal saline, paint with [MEDICATION NAME], and wrap with kerlix daily. There was no evidence the treatment was completed as ordered on [DATE], 09/12/18, 09/14/18, 09/15/18, 09/17/18, 09/19/18, and 09/29/19. Review of Resident #60's wound assessment dated [DATE] revealed the left heel unstageable wound now measured 4.0 cm L x 5.0 cm W. Review of Resident #60's wound assessment dated [DATE] revealed the left heal wound now had sloughing yellow tissue, with light drainage measuring 2.7 cm L x 2.5 cm W. Review of Resident #60's TAR for 10/18 revealed no evidence the treatment to the resident's bilateral heels were completed on 10/01/18 and 10/03/18. Review of Resident #60's wound assessment dated [DATE] revealed the pressure area on the left heel had worsened, became larger, and measured 3.7 cm L x 3.5 cm W, with slough necrotic eschar tissue with a moderate amount of drainage noted. There was no evidence the physician was notified of the worsening wound with drainage. Review of the TAR revealed no evidence the treatments to Resident #60's bilateral heels were completed on 10/04/18, 10/05/18, 10/07/18, 10/08/18, or 10/09/18. Review of Resident #60's wound assessment dated [DATE] revealed the wound to the left heel with necrotic eschar tissue and light drainage noted, and measured 3 cm L x 1.5 cm W. A new order was received to continue to use [MEDICATION NAME], and now leave open to air, and float heels. Review of Resident #60's TAR revealed there was no evidence the new treatment was completed on 10/20/18 or 10/23/18. Review of Resident #60's wound assessment dated [DATE] revealed wound to the left heel increased in size again, measuring 3 cm L x 3.5 cm W, with eschar tissue present with some slough noted at the bottom of the wound. Review of Resident #60's wound assessment dated [DATE] revealed wound to the left heel had again increased in size, measuring 4.0 cm L x 3.0 cm W, with a small amount of eschar tissue present; however, mostly yellow slough tissue with a moderate amount of drainage noted. Review of Resident #60's TAR revealed a physician order dated 10/24/18 to cleanse the left heel with normal saline, apply medhoney wound dressing, and cover with bordered gauze dressing every A.M. shift. There was no evidence the treatments were completed as ordered on the A.M. shift on 10/24/18, 10/31/18, and on the P.M. shift on 10/28/18 or 10/30/18. Interview on 11/01/18 at 9:10 A.M. with LPN # 92 verified missing documentation in the MAR's and TAR's for Residents #42, #03, and #60. LPN #92 verified if the treatments were not documented as being completed, they were not done. She further confirmed multiple treatments ordered for Residents #42, #03, and #60 were never correctly entered in the EHR; therefore, they were not completed as ordered. Interview on 11/01/18 at 4:40 P.M. with Resident #60 revealed his wound dressing changes to his bilateral feet were not completed daily as ordered. Review of the NPUAP revealed a Stage III pressure ulcer was full-thickness skin loss in which fat was visible in the ulcer and granulation tissue. Slough and eschar may be visible. A Stage IV pressure ulcer was a full-thickness skin and tissue loss with exposed, or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. An unstageable pressure ulcer was defined as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer could not be confirmed because it was obscured by slough or eschar. Review of the facility policy titled, Wound and Skin Care Treatment Program, revised 01/2018 revealed when skin injury