Every finding on record at Madeira Healthcare Center

Based on medical record review, staff interview, resident interview, and policy review, the facility failed to conduct quarterly resident care conferences. This affected five (Residents #40, #22, #29, #32 and #49) of five residents reviewed for care conferences. The facility census was 96 residents. Findings include: 1. Review of the medical record for Resident #40 revealed an admission date of 07/17/25 with diagnoses including intervertebral degeneration of discs in lumbar region, diabetes mellitus type two, morbid obesity and chronic obstruction pulmonary disease. Review of the Minimum Data Set (MDS) assessment for Resident #40 dated 06/12/26 revealed the resident #40 had intact cognition and required set up assistance and supervision with activities of daily living (ADLs.) Review of care conference documentation for Resident #40 revealed the facility held an initial care conference on 07/30/25 and a quarterly care conference on 03/10/26. The facility did not provide care conferences for Resident #40 for the fourth quarter of 2025 (October to December) and the second quarter of 2026 (April to June). Interview on 08/13/26 at 9:01 A.M. with the Director of Social Services (DSS) verified the facility had not held quarterly care conference for the fourth quarter of 2025 (October to December) and the second quarter of 2026 (April to June) for Resident #40. The DSS stated care conferences should be held upon admission and quarterly. 2. Review of the medical record for Resident #29 revealed an admission date of 02/18/22 with diagnoses including depression, anxiety disorder, and hypertensive heart disease. Review of the care conference documentation for Resident #29 revealed the only care conference held for the resident in the past year was dated 01/21/26. Interview on 08/10/26 at 4:20 P.M. with the DSS verified the facility had held only one care conference for Resident #29 in the past year. 3. Review of the medical record for Resident #49 revealed an admission date of 07/28/22 with diagnoses including depression, schizoaffective disorder, and morbid obesity. Review of the care conference documentation for Resident #49 revealed the only care conferences held for the resident in the past year were dated 04/14/25 and 07/03/25. Interview on 08/10/26 at 4:20 P.M. with the DSS verified the facility had held only two care conferences in the past year for Resident #49. 4.Review of the medical record for Resident #32 revealed an admission date of 12/28/24 with diagnoses including end stage renal disease, type one diabetes, and adjustment disorder. Review of the care conference documentation for Resident #32 revealed the only care conferences held for the resident in past year were dated 04/02/25 and 04/10/26. Interview on 08/10/26 at 12:07 P.M. with Resident #32 verified the facility had not been offering her quarterly care conferences. Resident #32 stated she had a care conference in April 2025 and then recently had one around March or April of this year. Interview on 08/13/26 at 9:01 A.M. with Director of Social Services #715 verified that there were no documented care conferences being completed between 04/02/25 and 04/10/26. 5.Review of the medical record for Resident #22 revealed an admission date of 07/15/26 with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, peripheral vascular disease. Review of the medical record for Resident #22 revealed the facility did not hold an admission care conference for the resident. Interview on 08/13/26 at 7:41 A.M. with the DSS # 715 verified the facility had not held an admission care conference for Resident #22. Review of the facility policy titled Plan of Care Overview dated 2017 revealed care plans were reviewed quarterly and/or with a significant change in care. The resident/representative had a right to participate in the development and implementation of his/her own plan of care. This deficiency represents noncompliance investigated under Complaint Number 2585653.

Based on medical record review, staff interview, and facility policy review, the facility failed to report an injury of unknown origin to the state agency. This affected one (Resident #51) of four residents reviewed for incidents/accidents. The facility census was 96 residents. Findings include: Review of the medical record for Resident #51 revealed an admission date of 02/14/25 with diagnoses including epilepsy, vascular dementia, and adult failure to thrive. Review of the Minimum Data Set (MDS) assessment for Resident #51 revealed the resident had severe cognitive impairment and required substantial assistance from staff with activities of daily living (ADLs.) Review of the progress note for Resident #51 dated 06/29/26 revealed had a fall without injury and no complaints of pain or discomfort and was able to move all extremities without pain. Review of the progress notes for Resident #51 dated 06/30/26 through 07/16/26 revealed they did not include documentation of complaints of resident pain or discomfort. Review of the radiology report for Resident #51 dated 07/17/26 revealed the resident had an acute fracture of the distal femur. Review of the nurse progress note for Resident #51 dated 07/18/26 revealed the resident began complaining of pain on 07/17/26, the facility got an order for an x-ray, and the resident was found to have an acute fracture of the left distal femur. Attempted to interview Resident #51 on 08/10/26 at 11:36 A.M. and the resident was unable to provide any meaningful information. Interview on 08/12/26 at 2:25 P.M. with Registered Nurse (RN) #412 confirmed Resident #51 had swelling of the left knee and complained of increased pain to the area on 07/17/26 and the facility obtained an x-ray on 07/17/26. Interview on 08/13/26 at 9:20 A.M. with the Director of Nursing (DON) confirmed the facility did not report Resident #51's left knee fracture to the state agency through the SRI system as an injury of unknown origin because the facility presumed Resident #51's fracture had occurred related to a fall which had occurred on 06/29/26. The DON verified Resident #51 had no recent falls prior to the identification of the fracture on 07/17/26 and Resident #51 was not able to report how the fracture had occurred. Review of the facility incident and accident log dated July 2026 revealed there were no falls or incidents listed for Resident #51. Review of the facility Self-Reported Incident (SRI) reports dated 07/17/26 to 08/13/26 revealed there was no investigation of injury of unknown origin for Resident #51. Review of the facility policy titled Ohio Abuse, Neglect, and Misappropriation undated revealed each occurrence of injury of unknown origin will be identified and reported to the state agency immediately. This deficiency represents noncompliance investigated under Complaint Number 2976514.

Based on staff interview, record review, review of facility self-reported incidents (SRI), and facility policy review, the facility failed to thoroughly investigate an injury of unknown origin. This affected one (Resident #51) of four reviewed for accidents. The facility census was 96 residents. Findings include: Review of the medical record for Resident #51 revealed an admission date of 02/14/25 with diagnoses including epilepsy, vascular dementia, and adult failure to thrive. Review of the Minimum Data Set (MDS) assessment for Resident #51 revealed the resident had severe cognitive impairment and required substantial assistance from staff with activities of daily living (ADLs.) Review of the progress note for Resident #51 dated 06/29/26 revealed had a fall without injury and no complaints of pain or discomfort and was able to move all extremities without pain. Review of the progress notes for Resident #51 dated 06/30/26 through 07/16/26 revealed they did not include documentation of complaints of resident pain or discomfort. Review of the radiology report for Resident #51 dated 07/17/26 revealed the resident had an acute fracture of the distal femur. Review of the nurse progress note for Resident #51 dated 07/18/26 revealed the resident began complaining of pain on 07/17/26, the facility got an order for an x-ray, and the resident was found to have an acute fracture of the left distal femur. Attempted to interview Resident #51 on 08/10/26 at 11:36 A.M. and the resident was unable to provide any meaningful information. Interview on 08/12/26 at 2:25 P.M. with Registered Nurse (RN) #412 confirmed Resident #51 had swelling of the left knee and complained of increased pain to the area on 07/17/26 and the facility obtained an x-ray on 07/17/26. Interview on 08/13/26 at 9:20 A.M. with the Director of Nursing (DON) confirmed the facility did not report Resident #51's left knee fracture to the state agency through the SRI system as an injury of unknown origin because the facility presumed Resident #51's fracture had occurred related to a fall which had occurred on 06/29/26. The DON verified Resident #51 had no recent falls prior to the identification of the fracture on 07/17/26 and Resident #51 was not able to report how the fracture had occurred. The DON stated the facility completed an investigation of Resident #51's fracture which was identified on 07/17/26. Interview on 08/13/26 at 12:20 P.M. with the DON confirmed on 07/17/26 through 07/19/26 she interviewed 30 employees regarding Resident #51'S left knee fracture as part of the investigation. Review of employee interview list provided by the DON dated 07/17/26 revealed there were 30 employee names listed who had been interviewed regarding Resident #51's fracture. The 30 employees included RN #356, Licensed Practical Nurse (LPN) #307, and LPN #367. Interview on 08/13/26 at 12:32 P.M. with RN #356 verified neither the DON nor facility administrative staff had interviewed her regarding Resident #51. Interview on 08/13/26 at 12:45 P.M. with LPN #307 verified neither the DON nor facility administrative staff had interviewed her regarding Resident #51. Interview on 08/13/26 at 1:54 P.M with LPN #367 verified neither the DON nor facility administrative staff had interviewed her regarding Resident #51. Review of the facility incident and accident log dated July 2026 revealed there were no falls or incidents listed for Resident #51. Review of the facility Self-Reported Incident (SRI) reports dated 07/17/26 to 08/13/26 revealed there was no investigation of injury of unknown origin for Resident #51. Review of facility investigation of Resident #51's left knee fracture dated 07/17/26 revealed the facility interviewed staff who may have had knowledge of the incident. Review of the facility policy titled Ohio Abuse, Neglect, and Misappropriation undated revealed each occurrence of injury of unknown origin will be identified and investigated. The investigation should include written statements from staff who were working at the time of the incident. Witness statements should be signed and dated at the time of writing. This deficiency represents noncompliance investigated under Complaint Number 2976514 and Complaint Number 2586772.

Based on medical record review, staff interview, and policy review, the facility failed to timely assess the resident, notify the physician and arrange for transfer to the hospital following a change in condition. This affected one (Resident #2) of five residents reviewed for hospitalizations. The facility also failed to follow physician orders to remove a central catheter line. This affected one (Resident #109) of five residents reviewed for implementation of physician orders. The facility census was 96 residents. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 0/23/26 with diagnoses including myopathy, end stage renal disease, and type one diabetes. Review of the Minimum Data Set (MDS) assessment for Resident #2 dated 08/02/26 revealed Resident #2 was cognitively impaired and required staff assistance with activities of daily living. (ADLs.) Review of the dialysis hand off communication report for Resident #2 dated 07/14/26 revealed the resident #2 had low blood pressure and they were unable to remove fluid. Review of the medical record for Resident #2 dated 07/14/26 revealed it did not include documentation of the resident's low blood pressure and the resident being unable to receive a full dialysis treatment on 07/14/26. Review of the alert note for Resident #2 dated 07/15/26 at 6:29 A.M. revealed the facility contacted the physician due to resident's altered mental status. Review of the nurse progress note for Resident #2 dated 07/15/26 at 9:48 P.M. revealed the resident was admitted to the hospital for hypotension and hypokalemia. Interview on 08/13/26 at 12:04 P.M. with Divisional Director of Risk Management (DDRM) #721 verified when the nurse received the dialysis communication report on 07/14/26, the provider should have been notified. DDRM #721 stated there was no documentation of Resident #2's change in condition or notification to the provider prior to 07/15/26. Review of the undated facility policy titled Notification of Change in Condition revealed the medical practitioner is promptly notified of significant changes in condition, and the medical record must reflect the notification, response, and interventions implemented to address the resident's condition. 2.Review of the closed medical record for Resident #109 revealed an admission date of 03/03/26 and a discharge date of 05/28/26 with diagnosing including encephalopathy, acute kidney failure, chronic kidney disease, necrotizing fasciitis, and type two diabetes mellitus. Review of the MDS assessment for Resident #109 dated 04/30/26 revealed the resident had moderately impaired cognition and required staff assistance with ADLs. Review of the physician's orders for Resident #109 revealed an order dated 03/31/26 to discontinue the peripherally inserted central catheter (PICC) line that was used for an intravenous antibiotic. Review of the hospital paperwork for Resident #109 dated 04/15/26 revealed the resident was transferred to the emergency room for a change in condition and it was noted the PICC line had not been removed. Interview on 08/12/26 at 9:33 A.M. with DDRM #721 confirmed the facility staff had not removed the PICC line for Resident #109 as ordered by the physician on 03/31/26. Review of the facility policy titled Physician Orders undated revealed the nurse that received the physician's order would be responsible for executing the order or relaying the information to the next nurse. This deficiency represents non-compliance investigated under Complaint Number 3008636, 2980177, 2805443, 1369461, 1369460, and 1369457.

Based on medical record review, staff interview, and policy review, the facility failed to ensure medications were available for administration. This affected one (Resident #112) of five residents reviewed for medication administration. The facility census was 96 residents. Findings include: Review of the medical record for Resident #112 revealed an admission date of 12/18/25 and a discharge date of 02/12/26. Diagnoses included metabolic encephalopathy, post traumatic seizures, unspecified convulsions, and hypertension. Review of the physician's orders for Resident #112 revealed an order dated 12/18/25 for Vimpat 200 milligrams (mg) to be given via feeding tube twice a day for seizures. Review of the Medication Administration Record (MAR) for Resident #112 dated December 2025 for Vimpat revealed the resident missed one dose on 12/18/25, two doses on 12/19/25, and one dose on 12/20/25 because the facility had not ensured the medication was available for administration. Review of the Minimum Data Set (MDS) assessment for Resident #112 dated 01/05/26 revealed the resident was severely cognitively impaired and dependent on staff assistance with activities of daily living (ADLs.) Interview on 08/12/26 at 12:12 P.M. with Divisional Director of Risk Management (DDRM) #721 verified the missed doses of Resident #112's Vimpat in December 2025. Review of the facility policy titled Receiving Controlled Substances dated 09/2025, revealed controlled substances prescribed for a specific resident would be delivered to the facility only if a valid prescription had been received by the pharmacy prior to dispensing.This deficiency represents non-compliance investigated under Complaint Number 2976514, 2700216, 2639729, 2586672, 2585653, 1369461, and 1369459.

Based on review of personnel records and staff interview, the facility failed to provide a qualified activities director. This had the potential to affect all of the residents residing in the facility with the exception of 14 facility- identified residents (#3, #8, #12, #36, #45, #50,#51, #62, #67, #73, #78, #81, #82, and #89 ) who did not participate in facility activities. The facility census was 91 residents.Findings include: Review of the personnel record for Activities Director (AD) #100 revealed a hire date of 04/02/26. Further review of the personnel record for AD #100 revealed she did not meet the qualifications required to be an activity director in the facility. Interview on 04/23/26 at 6:00 P.M. with the Regional Director of Clinical Operations confirmed AD#100 was hired 04/02/26 and did not meet the requirements to be employed as a qualified activity director in the facility.

Based on record reviews, interviews, and policy review, the facility failed to conduct quarterly care conferences. This affected eight (#2, #7, #9, #22, #33, #39, #60, and #63) out of eight residents reviewed for care planning. The facility census was 82. Findings include: 1. Review of the medical record for Resident #39 revealed an admitted [DATE]. Diagnoses included Alzheimer's Disease, depression, anxiety disorder, hyperlipidemia, and obsessive-compulsive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had intact cognition. Resident #39 was assessed to require setup assistance for eating, oral hygiene, toileting, bathing, dressing, personal hygiene, and bed mobility, and supervision for transfer. Review of the care conference forms revealed care conferences were held for Resident #39 on 01/24/24 and 06/19/24. Review of the progress notes from 08/01/24 to 03/26/25 revealed no documentation related to care conferences held for Resident #39. Interview on 03/26/25 at 3:55 P.M. with Regional Director of Clinical Operations (RDCO) #200 verified the last documented care conference for Resident #39 was 06/19/24. 40471 2. Review of records for Resident #2 revealed an admitted [DATE] with diagnoses including end stage renal disease, heart transplant, kidney transplant, and Alzheimer's Disease. Review of MDS dated [DATE] revealed Resident #2 had severe cognitive impairment and required assistance with activities of daily living (ADLs). Review of progress notes revealed no documentation of care conferences being performed. Interview on 03/25/25 at 1:42 P.M. Regional Director of Clinical Operations (RDCO) #200 verified the lack of documentation for care conferences as required. 3. Review of records for Resident #7 revealed an admitted [DATE] with diagnoses including multiple sclerosis (MS), extended spectrum beta lactamase (ESBL) resistance, and contracture of hand. \ Review of MDS dated [DATE] revealed Resident #7 had some cognitive impairment. Further review of the medical record revealed care conferences documented on 05/03/22 and 02/09/23, no care conferences were documented for 2024 or 2025. Interview on 03/25/25 at 1:42 P.M. Regional Director of Clinical Operations (RDCO) #200 verified the lack of documentation for care conferences as required. 4. Review of Resident #33's records revealed an admitted [DATE] with diagnoses including cerebral infarction, type two diabetes (DM2), and end stage renal disease. Review of MDS dated [DATE] revealed Resident #33 had significant cognitive impairment and required assistance with activities of daily living (ADLs). Review of progress notes revealed one documented care conference dated 07/30/24. Interview on 03/25/25 at 1:42 P.M. RDCO #200 verified the lack of documentation for care conferences as required. 5. Review of records for Resident #63 revealed an admitted [DATE] with diagnoses including schizophrenia and suicidal ideation. Review of MDS dated [DATE] revealed Resident #63 was cognitively intact and required assistance with ADLs. Review of progress notes revealed care conferences on 08/24/22 and 04/17/24. Interview on 03/25/25 at 1:42 P.M. RDCO #200 verified the lack of documentation for care conferences being performed as required. 49771 6. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of non-infective gastroenteritis and colitis, end-stage renal disease with dependence on renal dialysis, diabetes mellitus type II, cerebral infarction with right (dominant side) hemiparesis and hemiplegia, kidney transplant status and the need for assistance with personal care. Review of the MDS assessment dated [DATE] revealed Resident #9 had intact cognition and was always incontinent of bowel and bladder. The resident required supervision with eating and oral and personal hygiene, was dependent for toileting, bathing and dressing and maximal assistance with bed mobility and transfers. Review of the medical record revealed no documentation the facility completed an initial care conference with Resident #9 and/or the resident's representative. Interview on 03/26/25 at 12:34 with Resident #9 revealed no knowledge of the facility completing an initial care conference with her. Interview on 03/26/25 at 2:12 P.M. with the Regional Director of Clinical Operations #200 revealed she could not locate documentation the facility completed an initial care conference with Resident #9. Interview on 03/26/25 at 4:16 P.M. with Social Services Director #36 verified an initial care conference was not held with Resident #9. 7. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses of end-stage renal disease with dependence on renal dialysis, diabetes mellitus type II, gas gangrene and hypertension. Review of the MDS quarterly assessment dated [DATE] revealed Resident #22 had intact cognition and was frequently incontinent of bowel and bladder. The resident required set up assistance with eating, supervision with oral hygiene and bed mobility, maximal assistance with toileting, bathing, dressing and personal hygiene and dependent for transfers. Review of the medical record revealed no documentation the facility completed care conferences with Resident #22 in the first (January, February and March), second (April, May and June), third (July, August and September) and fourth (October, November and December) quarters of 2024. Interview on 03/26/25 at 2:12 P.M. with the Regional Director of Clinical Operations #200 revealed she could not locate documentation the facility completed care conferences with Resident #9 in the first (January, February and March), second (April, May and June), third (July, August and September) and fourth (October, November and December) quarters of 2024. Interview on 03/26/25 at 4:16 P.M. with Social Services Director #26 verified the facility had no documentation of care conferences for Resident #22 in the first (January, February and March), second (April, May and June), third (July, August and September) or fourth (October, November and December) quarters of 2024. 8. Review of the medical record revealed Resident #60 was admitted to the facility on [DATE] with diagnoses of Down syndrome, anoxic brain damage, tracheostomy, gastrostomy and cerebrovascular disease with right (dominant side) hemiplegia and hemiparesis. Review of the MDS quarterly assessment dated [DATE] revealed Resident #60 had severe cognitive impairment and was always incontinent of bowel and bladder. The resident was dependent for eating (gastrostomy tube), oral and personal hygiene, toileting, bathing, dressing, bed mobility and transfers. Review of the medical record revealed no documentation the facility completed care conferences with Resident #60 in the first (January, February and March), second (April, May and June), third (July, August and September) and fourth (October, November and December) quarters of 2024. Interview on 03/26/25 at 2:12 P.M. with the Regional Director of Clinical Operations #200 revealed she could not locate documentation the facility completed care conferences with Resident #60 in the first (January, February and March), second (April, May and June), third (July, August and September) and fourth (October, November and December) quarters of 2024. Interview on 03/26/25 at 4:16 P.M. with Social Services Director #26 verified the facility had no documentation of care conferences for Resident #60 in the first (January, February and March), second (April, May and June), third (July, August and September) or fourth (October, November and December) quarters of 2024. Review of the policy titled, Plan of Care Overview, dated 2017, revealed residents/representatives will be informed of their plan of care in the most understandable manner possible; that residents/representatives will be offered opportunities to voice their view; and that residents/representatives will have the right to participate in the development and implementation of his/her own plan of care. Additionally, the facility will review care plans quarterly and/or with significant changes in care and schedule the meeting to accommodate a resident's representative that may include conference calls, video conference sessions or live sessions.

Based on observation, staff interviews, and policy review, the facility failed to prevent food contamination. This affected one (Resident #7) of two residents observed being fed in the dining room. The facility census was 82. Findings include: Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses of multiple sclerosis, dysphagia, morbid obesity and major depressive disorder. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #7 had moderate cognitive impairment and was always incontinent of bowel and had a urostomy. The resident was dependent for eating, oral and personal hygiene, toileting, bathing, dressing, bed mobility and transfers. Observation on 03/24/25 at 1:02 P.M. of the lunch meal service revealed Resident #7 was being fed by Certified Nursing Assistant (CNA) #8. On the resident's plate was a cheese quesadilla, mashed potatoes and mixed vegetables. During the observation, CNA #7 used his bare fingers to tear off a bite sized piece of the quesadilla and then proceeded to stick it with a fork, add some sour cream and place it in the resident's mouth. Interview on 03/24/25 at 1:03 P.M. with CNA #8 verified he used his bare fingers to tear off a bite sized piece of the cheese quesadilla and feed it to Resident #7. Interview on 03/24/25 at 2:12 P.M. with the Regional Director of Clinical Operations #200 verified staff should not handle resident's food with their bare fingers. Review of the policy titled, Meal Distribution, revised 02/23, revealed proper food handling techniques to prevent contamination will be used for point of service dining.

Based on medical record review, observation, staff interview, and review of a facility policy, the facility failed to ensure residents were treated with dignity and respect during incontinence care by protecting a resident's private space. This affected one (#19) of three residents reviewed for dignity. The census was 87. Findings include: Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses of intracerebral hemorrhage, hemiplegia and hemiparesis, morbid (severe) obesity, encephalopathy, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 was cognitively intact and was always incontinent of bowel and bladder. The resident required set up assistance for eating, was dependent for dressing, and required maximal assistance for oral and personal hygiene, toileting, bathing, bed mobility, and transfers. Observation on 01/22/25 from 11:20 A.M to 11:50 A.M. revealed Resident #19 was receiving incontinence care while in bed from Certified Nurse Aide (CNA) #575 with Licensed Practical Nurse (LPN) Unit Manager #405 providing stand-by assistance. Continued observation revealed Resident #19's body was partially exposed and CNA #575 was actively providing incontinence care when LPN #425 opened to door to Resident #19's room and entered without knocking or asking permission to enter the room. Resident #19 resided in a private room with no privacy curtain; therefore, the door to the resident's bedroom was the only privacy barrier. Interview on 01/22/25 at 3:04 P.M. with LPN Unit Manager #405 verified LPN #425 did not knock and ask permission before entering the room of Resident #19. Review of the undated policy titled, Resident Rights, revealed care for residents will be provided in a safe and respectful manner that includes care in a private setting, as appropriate. When providing care, staff will knock before entering the resident's room if the door was closed. If there was no answer, the staff member will knock a second time before entering and announce the entrance into the room. This deficiency represents an incidental finding discovered during the course of this complaint investigation.

Based on medical record review, review of hospital documentation, staff interview, and policy review, the facility failed to timely implement pressure ulcer prevention interventions as ordered. This affected one (#002) of three residents reviewed for wounds. The facility census was 87. Findings include: Review of the medical record revealed Resident #002 was admitted to the facility on [DATE], after being hospitalized from 08/30/24 to 12/13/24, with diagnoses of traumatic brain injury (TBI), multiple sclerosis, Huntington's disease, chronic kidney disease stage III, acute kidney injury, lupus, cirrhosis, hypertension, anemia, and hyperlipidemia. The resident was discharged on [DATE]. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #002 had severe cognitive impairment, no range of motion impairments, and was always incontinent of bowel and bladder. The resident required total assistance with eating, oral and personal hygiene, toileting, bathing, dressing, bed mobility and transfers. The resident was identified with a stage I (non-blanchable erythema of intact skin) and a stage II (partial-thickness skin loss with exposed dermis) pressure ulcers on admission. Review of hospital discharge orders dated 12/13/24 revealed Resident #002 was ordered to have a low air loss mattress and heel lift boots. Review of the assessment to predict pressure ulcer development dated 12/13/24 revealed Resident #002 was at high risk for the development of pressure ulcers. Review of the admission nursing assessment dated [DATE] revealed Resident #002 had identified skin integrity impairments including moisture associated skin damage (MASD) to the groin, bruising to the chest and bilateral upper and lower extremities, redness on the buttocks, and scabs to the left upper extremity and right chest. Review of the December 2024 treatment administration record (TAR) revealed no documentation Resident #002 had a low loss air mattress from admission on 12/13/24 to discharge on 12/24/24 and no documentation of heel protector devices implemented until 12/17/24. Review of skin and wound notes dated 12/17/24 at 7:34 P.M., written by Wound Care Nurse Practitioner (WCNP) #900 revealed Resident #002 had a stage II pressure injury to the right heel measuring 7.0 centimeters (cm) long by 4.0 cm wide by 0.10 cm deep. The wound base was 100 percent (%) epithelial tissue with the peri-wound intact and no odors. Further review revealed recommendations were to cleanse the wound with wound cleanser, apply skin prep, and leave open to air, and ongoing pressure reduction and turning and repositioning precautions per protocol including pressure reduction to the heels and all bony prominences. All prevention measures were discussed with the staff and staff were to float the resident's heels while in bed with use of heel boots. Interview on 01/23/25 at 11:24 A.M. with (WCNP) #900 revealed she did not know Resident #002 had a right heel pressure wound prior to seeing her on 12/17/24. WCNP #900 stated Resident #002's right heel was identified as a facility acquired pressure ulcer. She described the wound to the right heel as being a fully intact blister, filled with a clear fluid that she categorized as a stage II pressure ulcer. WCNP #900 stated a wound such as that would occur in just one to two days, and had it initiated as a deep tissue injury the blister would have been filled with a blood-tinged fluid. WCNP #900 stated she did not recall seeing any skin recommendations from the hospital and could not recall if the resident had a low air loss mattress in place. WCNP #900 stated she was not aware of the discharge orders from the hospital on 12/13/24 and she made the recommendation for the resident to have heel protectors on 12/17/24. Interview on 01/23/25 at 3:20 P.M. with Regional Director of Clinical Operations #3030 verified there was no documentation that Resident #002 had a low air loss mattress in place from 12/13/24 to 12/24/24 and heel protectors were not documented as placed on the resident until 12/17/24. Review of the undated facility policy titled, Skin Care and Wound Management, revealed the facility strives to prevent skin impairment and to promote the healing of existing wounds. This deficiency represents non-compliance investigated under Complaint Number OH00161160.

Based on medical record review, observation, and staff interview, the facility failed to maintain adequate infection control practices during incontinence care. This affected one (#19) of one residents observed for incontinence care. The facility census was 87. Findings include: Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses of intracerebral hemorrhage, hemiplegia and hemiparesis, morbid (severe) obesity, encephalopathy, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 was cognitively intact and was always incontinent of bowel and bladder. The resident required set up assistance for eating, was dependent for dressing, and required maximal assistance for oral and personal hygiene, toileting, bathing, bed mobility, and transfers. Observation on 01/22/25 from 11:20 A.M to 11:50 A.M. revealed Resident #19 was receiving incontinence care while in bed from Certified Nurse Aide (CNA) #575 while Licensed Practical Nurse (LPN) Unit Manager #405 provided stand-by assistance. Resident #19 was noted to be incontinent of bowel and bladder. Continued observation revealed, after cleaning, rinsing, and drying Resident #19, CNA #575 did not change her soiled gloves and touched the resident's clean incontinence brief, clean linens, clean gown, head pillow, call light cord, and bed control cord. Interview on 01/22/25 at 2:55 P.M. with CNA #575 verified she did not change her gloves after completing incontinence care. Interview on 01/22/25 at 3:04 P.M. with LPN Unit Manager #405 verified CNA #575 should have changed her gloves after completing incontinence care on Resident #19 and before touching the resident's clean incontinence brief, gown, bed linens, pillow, call light cord, and bed control cord. This deficiency represents non-compliance investigated under Master Complaint Number OH00161670.

Based on observation, medical record review, staff interviews, review of a police report, and review of the facility policy, the facility failed to provide adequate supervision and implement timely interventions for exit-seeking behaviors for Resident #37, who was cognitively impaired, had a history of wandering and exit seeking behavior and who resided in a secured unit, to prevent his elopement from the facility without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death on [DATE] when Resident #37 left the secured unit, got in a car in the parking lot which had the keys inside and drove approximately 8.2 miles away from the facility. Resident #37 was missing from the facility for approximately two hours before staff were notified the resident had been located by the police and would be returned to the facility. This affected one (Resident #37) of three residents reviewed for elopement risk. The facility identified 21 residents (#25, #26, #27, #28, #29, #30, #32, #33, #35, #36, #37 #39, #40, #41, #42, #44, #46, #47, #48, #49 and #51) on the secured unit who were at risk for elopement. Additionally, the facility identified nine residents (#01, #02, #05, #08, #10, #15, #17, #19, #21) residing in the unsecured area of the facility who were at risk for elopement. The total facility census was 93 residents. On [DATE] at 3:25 P.M., the Administrator, the Director of Nursing (DON), and Divisional Director of Clinical Operations (DDCO) #200 were notified Immediate Jeopardy began on [DATE] at 6:00 P.M. when Resident #37 eloped from the facility without staff knowledge. On [DATE] at approximately 7:30 P.M., Certified Nurse Aide (CNA) #166 discovered Resident #37 was not present on the secured unit when completing her rounds and reported the missing resident to Licensed Practical Nurse (LPN) #181. Staff completed a search of the unit and checked the logs to ensure the resident had not been signed out. As the staff were beginning to expand the search for Resident #37, they received a call from the police notifying them the resident had been located and would be returned to the facility. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at approximately 5:45 P.M., Resident #37 was observed on the secure unit as his dinner tray was retrieved. On [DATE] at approximately 6:00 P.M., a visitor who was visiting her father reported her car had been stolen from the front parking lot of the nursing home. On [DATE] at approximately 7:30 P.M., CNA #166 was completing her rounds, was not able to find Resident #37, notified LPN #181 and a search was conducted of the secured unit. A head count revealed 93 residents were present out of 94 with Resident #37 unable to be located. On [DATE] at approximately 8:00 P.M., LPN #181 was notified the police had located Resident #37 and would return him to the facility. On [DATE] at approximately 8:10 P.M., the nurses on each unit conducted a head count of all residents in the facility. All residents except for Resident #37 were in the facility. Staff checked the doors on the memory care unit and verified the doors were securely locked and the keypads were in working order. Staff checked all windows and found them all intact with no broken windows. On [DATE] at 8:10 P.M., Clinical Manager (CM) #146 notified Resident #37's family of the situation. Immediately after, the physician was notified with no new orders obtained. On [DATE] at 8:15 P.M., the DON provided verbal education on elopement to all staff working in the facility via telephone. On [DATE] at 8:25 P.M., Resident #37 returned to the facility and was placed immediately on one-on-one supervision. LPN #181 completed a physical assessment of Resident #37 with no adverse findings. The nurse notified Resident #37's family and physician of the assessment with no new orders recommended by the physician. On [DATE] at 9:00 P.M., the DON began reassessing residents for wandering/elopement risk. The facility identified 21 residents (#25, #26, #27, #28, #29, #30, #32, #33, #35, #36, #37 #39, #40, #41, #42, #44, #46, #47, #48, #49 and #51) on the secured unit who were at risk for elopement. Additionally, the facility identified nine residents (#01, #02, #05, #08, #10, #15, #17, #19, #21) residing in the unsecured area of the facility who were at risk for elopement. On [DATE] at 7:00 A.M., Maintenance Director #106 completed an audit/evaluation of all egress doors in the building with no adverse findings. The code to the stairwell exiting to the front parking lot from the secured memory care unit was changed. On [DATE] at 8:00 A.M., the DON and the Administrator began educating all staff regarding elopement policies, procedures and prevention. On [DATE] at 8:05 A.M., Director of Social Services (DSS) #114 completed a new Brief Interview of Mental Status (BIMS) evaluation for Resident #37. The resident scored two out of 15 possible points which indicated severe cognitive impairment. On [DATE] at 10:00 A.M., the Interdisciplinary Team (IDT) met and conducted a Quality Assurance and Performance Improvement (QAPI) review with Medical Director (MD) #205, Nurse Practitioner (NP) #112, and Psychiatric NP #216 present. The team reviewed Resident #37's care plan, orders and medical history and determined the resident should remain on one-on-one supervision with no new orders recommended. On [DATE] at 10:30 A.M., Clinical Manager (CM) #125 completed a Wanderguard audit with no adverse findings. The facility identified three residents (#01, #17 and #21) residing on the unsecured area of the facility with orders for Wanderguards. On [DATE] at 11:00 A.M., the Administrator audited the elopement binder with preliminary findings from the wandering/elopement risk assessments and determined no changes were needed. On [DATE] at 1:00 P.M., the DON and Unit Manager (UM) #190 completed wandering and elopement risk assessments. They held a meeting with Minimum Data Set Nurse (MDS Nurse) #107 regarding care planning. The IDT reviewed care plans for all like residents and agreed upon interventions. On [DATE] at 2:45 P.M., the Administrator posted signs on the entry doors indicating visitors should not leave cars running unattended in parking lot. On [DATE] at 3:45 P.M., MDS Nurse #107 completed a review and updated all of the care plans for residents identified to be at risk for elopement. On [DATE] at 4:00 P.M., the Administrator reviewed the elopement binders again to verify all resident information was updated and current. On [DATE] at 4:50 P.M., the facility conducted an elopement drill during mealtime. No concerns were observed during or after the completion of the drill. On [DATE] at 7:15 P.M., the Administrator and the DON completed all staff re-education on elopement policies, procedures and prevention for all staff in facility with signatures obtained. The facility does not use agency staff and there were no staff on leave at the time of the incident involving Resident #37. Beginning [DATE], to monitor for ongoing compliance, the DON or ED will conduct elopement drills twice weekly on random shifts for four weeks, and then monthly. On [DATE] at 9:30 A.M., the DON and the Administrator reported to the QAPI committee findings related to compliance. The QAPI committee consisted of the Administrator the DON, Registered Dietitian (RD) #220, DSS #114, MDS Nurse #107, Therapy Director (TD) #224, MD #205, NP #215, and Psych NP #216. Beginning [DATE], the Administrator, the DON and department leaders will complete random audits of at least five staff per day to determine comprehension of elopement policies, procedures and prevention techniques. Beginning [DATE], Maintenance Director #106 and/or designee will complete daily audits of the secured doors in the facility to ensure proper functioning and security. Daily audits will continue for at least 90 days and then be referred to the facility QAPI team to review for further monitoring recommendations. On [DATE] at 10:00 A.M., the IDT met to review Resident #37's need for ongoing one-on-one observation with MD #205 present. The IDT agreed to continue one-on-one observation for the resident. Interviews on [DATE] between the hours of 11:16 A.M. and 11:42 A.M. with Registered Nurse (RN) #148 and CNAs #147 and #169 and on [DATE] between the hours of 9:40 A.M. and 1:00 P.M. with LPN #181 and CNA #166 confirmed they were educated and verbalized knowledge of the facility's elopement policies and procedures and guidelines for monitoring residents who have been placed on one-on-one supervision. On [DATE] at 4:15 P.M., Maintenance Director #106 changed the remaining two door codes to the stairwells and the elevator code for the secured unit. The facility will change the door codes monthly moving forward. Resident #37 was placed on immediate one-on-one observation and will be reviewed by the facility IDT/QAPI team weekly to determine appropriate interventions. On [DATE] the surveyor completed review of the medical records for Residents #41 and #47 identified as elopement risks and revealed no concerns related to actual elopement from the facility, elopement risk assessments were current and accurate, and care plans were initiated and updated with appropriate interventions to prevent elopement. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility had not changed the door codes on all of the doors and is still in the process of implementing their corrective action plan and monitoring to ensure ongoing compliance. Findings include: Review of the medical record for Resident #37 revealed an admitted [DATE] with diagnoses including dementia, insomnia, hypertension, personal history of traumatic brain injury, congestive heart failure, anxiety disorder, and malignant neoplasm of prostate. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #37 dated [DATE] revealed the resident had severe cognitive impairment and was independently mobile without an assistive device. Review of the wandering observation tool for Resident #37 dated [DATE] revealed the resident had a history of wandering and the resident's family reported he might try to leave. Further review of the tool revealed Resident #37 was not accepting of his current living arrangements and expressed a desire to leave the facility. Resident #37 had no history of elopement but wandered without a sense of purpose and had the additional risk factor of dementia and poor safety awareness and was determined to be at risk of elopement. Review of the care plan for Resident #27 dated [DATE] revealed the resident wandered the unit looking for an exit to get home, had agitation, was restless and exit-seeking and was at risk for elopement and noted to exit seek by pushing on doors and trying to get onto the elevator. Interventions included the following: one-on-one observation, assess and meet needs, assist to call family when exit seeking or if the resident is not easily redirected, educate the resident and representative on the need for secured unit, involve the resident in listening to music, attending activities and getting a snack, increased supervision when ambulating in the hallways, and place identifying information in the elopement book. Interview on [DATE] at 3:15 P.M. with the Administrator and the DON confirmed Resident #37 lived on the secured unit and had been living at home with his wife, went to the hospital and was admitted from the hospital to the facility's secured unit which had three stairwell doors and one elevator which required codes to get out. Further interview confirmed Resident #37 eloped from the facility without staff knowledge on [DATE] and was returned hours later by police. The facility was unable to determine how the resident exited the facility, but they suspected he might have gone down the stairwell door to the left of the nurses' station. They did not think he had exited the unit via the elevator because he would have had to walk past the reception desk which was attended by staff to go out the front door. They stated they did not think the resident was cognitively capable of memorizing the code and surmised the resident pushed buttons and somehow entered the correct code which they characterized as being an easy code (1245). Further interview confirmed an aide discovered Resident #37 was missing from the unit on [DATE] at approximately 7:30 P.M. Staff began to search for Resident #37 without success and the staff were preparing to expand their search at 8:00 P.M. when the facility was notified the police had located the resident and would bring him back to the facility. The Administrator and DON reported they thought Resident #37 had left around 6:00 P.M. as an aide had last seen the resident around 5:45 P.M. as she was picking up his dinner tray. At 6:00 P.M., a family member of another resident reported they had their car stolen from the facility ' s front parking lot. Police found Resident #37 in the visitor's car which had been reported stolen and the resident was approximately 8.2 miles from the facility on a busy road. Observation on [DATE] at 9:45 A.M. revealed two of the stairwell doors opened using the same code,1245, which had been the code at the time of Resident #37's elopement. Further observation revealed the door at the bottom of the stairwell opened to the outside and allowed egress with no additional code required or an alarm to the door. Interview on [DATE] at 10:38 A.M. with Maintenance Director #106 confirmed he was notified of Resident #37's [DATE] elopement on the morning of [DATE]. Maintenance Director #106 confirmed the elevator and three stairwells to the unit all had codes to prevent residents from exiting, but on [DATE] he only changed the code to one of the stairwells and had left the elevator code and two of the stairwell codes unchanged. Interviews on [DATE] between the hours or 11:16 A.M. and 11:42 A.M. with Registered Nurse (RN)#148 and CNAs #147 and #169 confirmed Resident #37 had not seemed agitated or actively exit-seeking prior to leaving the building on [DATE] but had been displaying his usual level of wandering. They reported last seeing him around 5:45 P.M. when gathering dinner trays. Interview on [DATE] at 9:40 A.M. with LPN #181 confirmed she was notified by CNA #166 at around 7:30 P.M. that Resident #37 was not present on the unit. They searched the unit and as CNA #166 was coming back from checking if Resident #37 had been signed out, they received notification that the police had located the resident and were bringing him back to the facility. LPN #181 stated she assessed Resident #37, and he had no injuries. Interview on [DATE] at 12:10 P.M. with the Administrator confirmed following Resident #37 ' s elopement on [DATE] it was her understanding and intent that Maintenance Director #106 would change the codes to all three stairwells and the elevator on the secured unit as the facility was unsure how Resident #37 had been able to exit the facility without staff knowledge or supervision on [DATE]. The Administrator confirmed awareness that Maintenance Director #106 had only changed the code on [DATE] to the stairwell to the left of the nurses' station. Interview on [DATE] at 1:00 P.M. with CNA #166 confirmed she was doing rounds at approximately 7:15 P.M. on [DATE] when she noted Resident #37 was not present. As she was coming back upstairs from checking the front desk sign out log, another staff reported the police had located Resident #37 and would return him to the facility. She stated when Resident #37 returned, he was assessed with no injury and was laughing and stated the police had caught him stealing his father's car. Observations on [DATE] and [DATE] revealed Resident #37 was in his room and was on droplet isolation due to COVID -19 and also remained on one-on-one supervision with no wandering or exit seeking behavior exhibited. Review of a police report from the city in which the facility was situated dated [DATE] revealed an unlocked vehicle with the keys inside parked in front of the facility on [DATE] was reported stolen. The owner of the vehicle had last seen the car parked in front of the facility on [DATE] at 5:20 P.M. and at 6:05 P.M. the car was gone. Local police found the vehicle at an address which was 8.2 miles away. The vehicle was equipped with a device which allowed police to turn off the vehicle remotely rendering it undrivable and thus preventing a possible crash. The device also enabled police to locate the vehicle and Resident #37 to bring him back to the facility. Review of the facility policy titled Elopement Prevention and Management, undated, revealed elopement was defined as a resident leaving the premises or safe area without authorization and necessary supervision putting them at risk. The procedure entailed identifying residents who were at risk for elopement and what factors might contribute to their elopement. The facility would develop and document individualized interventions to manage resident risk factors and modify interventions as needed. In the event a resident eloped, the facility would announce a resident was missing, form a search team and search all areas of the facility, then the grounds and broaden the search until the resident was found. The facility would notify law enforcement as needed to assist with the search. This deficiency represents noncompliance investigated under Complaint Number OH00159871.

Based on record review, observation, staff interview, and review of the facility policy, the facility failed to ensure wound care was provided in a sanitary manner. This affected one (Resident #15) of three residents reviewed for pressure ulcers. The facility identified six residents with pressure ulcers. The facility census was 90. Findings include: Review of the medical record for Resident #15 revealed an admitted [DATE]. Diagnoses including multiple sclerosis (MS) and atherosclerotic heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was cognitively impaired and was totally dependent on the assistance of one to two staff with activities of daily living (ADLs). Resident was coded as negative for behaviors including rejection of care. Resident was coded as at risk for the development of pressure ulcers and was coded for the presence of two stage IV pressure ulcers (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed.) not present upon admission. Review of the pressure ulcer risk assessment dated [DATE] revealed Resident #15 was at high risk for the development of pressure ulcers. Review of the care plan dated 12/06/22 revealed Resident #15 had the potential for impaired skin integrity related to diagnosis of MS, neurogenic bladder, depression, obesity, the resident was total assist with her ADL's, resident has a urostomy, incontinent of bowel, and has stage IV pressure ulcers to sacrum and left ischium and a deep tissue injury (DTI) to her right great toe. Interventions included the following: to administer treatments as ordered and monitor for effectiveness, assess/record/monitor wound healing, wound bed and healing progress, assist with toileting, and provide incontinence care as needed. Review of December 2022 monthly physician orders for Resident #15 revealed an orders dated 11/29/22 to cleanse the sacral and left ischium wound with normal saline, apply Medihoney fluffed gauze, and cover with dry dressing. Review of the wound nurse practitioner's (NP) notes dated 12/01/22 revealed Resident #15 had a stage IV pressure ulcer to her sacrum which was acquired in the facility and measured 2.11 centimeters (cm) in length by 1.39 cm width by 0.8 cm in depth and a stage IV pressure ulcer to her left ischial tuberosity which was acquired in the facility and measured 3.07 cm in length by 1.57 cm in width by 1.0 cm in depth. Observation on 12/08/22 at 11:09 A.M. of wound care for Resident #15 per Licensed Practical Nurse (LPN) #185 with State tested Nursing Assistant (STNA) #525 revealed LPN #185 and STNA #525 positioned Resident #15 on her side in the bed with STNA #525 holding and supporting the resident in place. Resident #15 was noted to have been incontinent of a large amount of soft unformed dark stool. LPN #185 began to remove the stool from resident's buttocks using wipes. There was an intact dressing to resident's sacrum dated 12/07/22 and intact dressing to resident's left ischium. While there was still a moderate amount of stool remaining, LPN #185 removed the intact dressings to the resident's sacrum and ischium and then continued wiping away the stool. Interview on 12/08/22 at 11:47 A.M. with LPN #185 confirmed the dressings to Resident #15's sacrum and left ischium were intact when she began removing stool from resident's buttocks using wipes. LPN #185 confirmed she removed the dressings to the resident's sacrum and ischium while there was still a moderate amount of soft unformed stool present to the resident's buttocks. LPN #185 confirmed there was a potential for resident's wounds to come in contact with stool, so she tried to wipe away from the wounds as she finished incontinence care. LPN #185 confirmed she hadn't thought of the potential for introducing stool into the wound until she had already removed the intact dressings dated 12/07/22. LPN #185 confirmed she should have completed incontinence care, washed her hands, and donned clean gloves before removing the intact dressings dated 12/07/22. Review of the facility's procedure titled Competency: Simple Wound Dressing Change, undated, revealed once the dressing is removed the staff should avoid sneezing or talking while the wound is exposed to minimize the risk of infection. This deficiency represents non-compliance investigated under Complaint Number OH0137357.

Based on record review, observation, staff interview, review of the facility's policy, and review of an online wound resource by the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure pressure ulcer prevention interventions were in place as ordered and in accordance with the resident's plan of care. This affected one (Resident #15) of three residents reviewed for pressure ulcers. The facility identified six residents with pressure ulcers. The facility census was 90. Findings include: Review of the medical record for Resident #15 revealed an admitted [DATE] with diagnoses including multiple sclerosis (MS) and atherosclerotic heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was cognitively impaired and was totally dependent on the assistance of one to two staff with activities of daily living (ADLs.) Resident #15 was coded as negative for behaviors including rejection of care. Resident #15 was coded as at risk for the development of pressure ulcers and was coded for the presence of two stage IV pressure ulcers (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed.) not present upon admission. Review of the pressure ulcer risk assessment dated [DATE] revealed Resident #15 was at high risk for the development of pressure ulcers. Review of the care plan dated 12/06/22 revealed Resident #15 had the potential for impaired skin integrity related to diagnosis of MS, left hand contracture, hypercholesterolemia, dysphagia, neurogenic bladder, depression, obesity, cataracts, coronary artery disease, resident is total assist with her ADLs, the resident has a urostomy, incontinent of bowel, and has stage IV pressure ulcers to sacrum and left ischium and a deep tissue injury (DTI) to her right great toe. Interventions included the following: administer treatments as ordered and monitor for effectiveness, assess/record/monitor wound healing, assess and document status of wound perimeter, wound bed and healing progress, report improvements and declines to the physician, assist with repositioning, assist with toileting, provide incontinence care as needed, encourage and assist the resident to keep heels off of the bed, heel boots to bilateral lower extremities, encourage the resident to turn and reposition, and a low air loss mattress to bed. Review of December 2022 monthly physician orders for Resident #15 revealed an order dated 11/18/22 for bilateral heel boots in place at all times as tolerated and an order dated 12/02/22 to elevate bilateral heels at all times on soft pillow as tolerated. Review of the December 2022 Treatment Administration Record (TAR) for Resident #15 revealed the orders for bilateral heel boots and elevating heels on a soft pillow were signed off as completed. Review of the wound nurse practitioner's (NP) notes dated 12/01/22 revealed Resident #15 had a stage IV pressure ulcer to her sacrum which was acquired in the facility and measured 2.11 centimeters in length by 1.39 cm width by 0.8 cm in depth, and a stage IV pressure ulcer to her left ischial tuberosity which was acquired in the facility and measured 3.07 cm in length by 1.57 cm in width by 1.0 cm in depth, and a deep tissue injury-unstageable pressure ulcer to her right great toe which was 100 percent (%) slough and eschar to the wound bed which measured 1.50 cm in length by 1.62 in width. The NP note indicated part of the treatment plan was for staff to float the resident's heels. Review of the staff assignment sheet for Resident #15 revealed it did not include information regarding heel boots for resident and/or elevating the heels on pillows. Review of the online Kardex for Resident #15 revealed it included the following interventions: encourage and assist the resident to keep heels off of the bed, and encourage the resident to turn and reposition. Observation and interview on 12/08/22 at 9:36 A.M. with State tested Nursing Assistant (STNA) #525 revealed Resident #15 was in bed and her heel boots were not in place. Resident #15's heels were resting directly on the mattress. STNA #525 found the heel boots in the resident's closet. STNA #525 confirmed Resident #15's heels were resting directly on the mattress and Resident #15 was not wearing heel boots. STNA #525 confirmed she had been at the facility since 7:00 A.M. and she had not attempted to put the heel boots on the resident or elevate her heels. STNA #525 confirmed she was not aware Resident #15 had an order for heel boots and the staff assignment sheet she was provided by the facility did not mention any pressure prevention devices. STNA #525 confirmed the heel boots were in the resident's closet. Interview on 12/08/22 at 11:08 A.M. with Licensed Practical Nurse (LPN) #485 confirmed Resident #15 had an order for heel boots on at all times as tolerated and to elevate heels on pillows when in bed. Review of the facility's policy titled Pressure Ulcer Prevention: High Risk, dated 04/20/17, revealed the facility should develop a care plan for pressure ulcer prevention. If a resident was at high risk the following interventions were indicated: position with pillows/support devices to assist in maintaining position and comfort, protect/elevate elbows and heels as indicated 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. This deficiency represents non-compliance investigated under Complaint Number OH0137357.

Based on record review, observation, staff interview, review of the facility policy, and review of an online medication resource, the facility failed to ensure residents were appropriately monitored prior to medication administration. This affected one (Resident #41) of three residents reviewed for medications. The facility census was 90. Findings include: Review of the medical record for Resident #41 revealed an admitted [DATE] with diagnoses including encephalopathy, atrial fibrillation, and cerebral amyloid angiopathy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was cognitively intact. Review of the care plan dated 07/14/22 revealed Resident #41 had altered cardiovascular status, paroxysmal atrial fibrillation. Interventions included the following: to administer medications per medical provider's orders, observe for side effects and effectiveness, report abnormal findings to medical provider, monitor vital signs, and report abnormal findings to physician. Review of the December 2022 monthly physician orders for Resident #41 revealed an order dated 09/08/22 for Digoxin (treats heart failure and abnormal heart rhythm) give one 125 microgram (mcg) tablet by mouth in morning. Observation on 12/08/22 at 9:05 A.M. revealed Licensed Practical Nurse (LPN) #325 administered a 125 mcg Digoxin tablet to Resident #41. LPN #325 did not check resident's pulse prior to administration. Interview on 12/08/22 at 9:11 A.M. with LPN #325 confirmed she had not checked Resident #41's pulse prior to Digoxin administration, nor had she checked his pulse or other vital signs at any time during the shift on 12/08/22. LPN #325 confirmed she didn't check the resident's pulse because there was no physician's order to do so. Interview on 12/08/22 at 1:20 P.M. with the Director of Nursing (DON) confirmed the resident's pulse should be monitored prior to administration of Digoxin. Review of the Davis Drug Guide on 12/08/22 and online medication reference on 12/08/22 at https://nursing.unboundmedicine.com/nursingcentral/view/Davis-Drug-Guide/51218/all/digoxin revealed the nurse should monitor apical pulse for one full minute before administering Digoxin. Nurse should withhold the dose and notify health care professional if pulse rate is less than 60 beats per minute and should also notify health care professional promptly of any significant changes in rate, rhythm, or quality of pulse. Review of the facility's policy titled Medication Administration, dated 01/05/22 revealed the facility will ensure staff administer medications safely and as prescribed. This deficiency represents non-compliance investigated under Complaint Number OH0136862.

Based on record review, observation, resident interview, staff interview, review of facility policy, and review of the National Pressure Ulcer Advisory Panel (NPUAP) guidance, the facility failed to adequately assess and monitor a resident's skin resulting in actual harm when Resident #05 developed a Deep Tissue Injury (DTI) pressure ulcer to her foot from a splint. Additionally, the facility failed to implement wound treatments for Resident #05 based on the Wound Nurse Practitioner's (WNP) #430 recommendations, leading to the ulcer deteriorating. Lastly, the facility failed to adequately assess and monitor Resident #90's skin resulting in actual harm when Resident #90 developed an unstageable pressure ulcer to his heel. Additionally, the facility failed to implement interventions to prevent Resident #90's skin breakdown. This affected two (#05 and #90) of three residents reviewed for pressure ulcers. The facility census was 88. Findings include: 1. Review of the medical record for Resident #05 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #05 was cognitively impaired and required extensive assistance with Activities of Daily Living (ADLs). The resident was coded at risk for the development of pressure ulcers. Review of the care plan for Resident #05 initiated 02/20/22 and updated 08/05/22 revealed the resident had impaired skin integrity and was at risk for altered skin integrity. Interventions included the following: administer medications as ordered, monitor for side effects and effectiveness, administer treatments as ordered by medical provider, assist with repositioning, complete weekly skin checks, and educate resident/resident representative on need for turning and repositioning. Review of the nurse's progress note for Resident #05 dated 07/13/22 revealed the resident had a fall while self-transferring which resulted in fractures to her left metatarsal (foot). Resident #05 was transported to the hospital for evaluation. Review of the hospital note for Resident #05 dated 07/13/22 revealed x-rays done at the hospital confirmed multiple closed fractures to the left foot. The hospital put a short leg splint on the resident's left foot and recommended follow up with an orthopedic doctor. The only instructions for the splint were to keep it clean, dry, and in place. Review of the weekly skin assessment for Resident #05 dated 07/14/22 revealed the resident's skin was intact. Review of the July 2022 Treatment Administration Record (TAR) for Resident #05 revealed an order dated 07/14/22 for staff to complete circulatory skin check to Left Lower Extremity (LLE) every shift due to metatarsal fractures/soft splint cast in place, monitor for increased redness, swelling, discoloration and popliteal/pedal pulse, document findings, and notify physician for adverse signs and symptoms. Facility staff initialed checks as completed. Further review of the July 2022 TAR revealed an order dated 07/14/22 for a soft splint cast to LLE at all times due to left foot metatarsal fractures. Notify physician as needed if removed, damaged, loose, or heavily soiled. Review of the TAR revealed there were no checks of the resident's skin underneath the splint documented. Review of the nurse's progress notes for Resident #05 from 07/13/22 through 07/21/22 revealed the record did not include an assessment of the resident's skin underneath the splint. Review of the WNP #430's visit note for Resident #05 dated 07/15/22 revealed the provider examined the resident as a follow-up to the fall on 07/13/22. Documentation of inspection of the resident's skin did not include information regarding the presence of a splint to the resident's LLE and the only recommendation regarding the fall was for the resident to follow up with an orthopedic doctor. Review of the progress note for Resident #05 per WNP #430 dated 07/21/22, revealed the note did not include documentation regarding the splint to Resident #05's LLE or an assessment of the skin underneath the splint. Further review of the note revealed CNP #430 observed no open wounds during the skin assessment and a prior wound to the buttocks had resolved. Review of the visit note for Resident #05 per the orthopedic surgeon dated 07/21/22, revealed the resident had an office visit for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The surgeon placed the resident in a soft shoe and gave orders for the resident to bear weight as tolerated, follow-up in six weeks, and consult with the facility's wound nurse/physician (WNP #430) regarding the pressure ulcer to the left heel. Review of the July 2022 TAR for Resident #05 revealed an order dated 07/22/22 was implemented and signed off as completed to cleanse left heel with normal saline, pat dry, and paint with [MEDICATION(S)] every shift. Review of the weekly skin assessment for Resident #05 dated 07/22/22 revealed the resident's skin was intact. Further review of the medical record for Resident #05 revealed no assessments or descriptions of the resident's pressure ulcer to the left heel from 07/21/22 through 07/25/22. Review of the progress note for Resident #05 per WNP #430 dated 07/26/22 revealed the resident had a pressure ulcer to her left heel measuring 1.6 centimeters (cm) in length by 1.75 cm in width by 0.1 cm in depth. There was 100 percent (%) slough and eschar to the wound, and it was classified as in-house acquired suspected deep tissue injury due to the placement of the splint to the resident's left foot. The treatment recommended by WNP #430 was to cleanse with normal saline, apply Venelex gel and cover with dry dressing. Review of the August 2022 TAR for Resident #05 revealed the order dated 07/22/22 was signed off as completed to cleanse left heel with normal saline, pat dry, and paint with [MEDICATION(S)] every shift. Review of the progress note for Resident #05 per WNP #430 dated 08/04/22 revealed the pressure ulcer to the resident's left heel had increased in size and measured 3.71 cm in length by 3.17 cm in width and 0.1 cm in depth with 100% slough/eschar. The treatment recommended by WNP #430 was to cleanse with normal saline, apply Venelex gel and cover with dry dressing. Interview on 08/08/22 at 1:23 P.M. with the Director of Nursing (DON) confirmed the pressure ulcer to Resident #05's left heel was identified by the orthopedic surgeon on 07/21/22. The DON reported she was not sure if the facility had completed an assessment of the wound from 07/21/22 to 07/25/22. The DON confirmed she thought the wound was first assessed and measured by WNP #430 on 07/26/22. The DON further reported Licensed Practical Nurse (LPN) #155 was the Clinical Manager for the unit where Resident #05 resided, and she had been involved with follow-up care for the fracture and the facility-acquired pressure ulcer. Interview on 08/08/22 at 1:36 P.M. with LPN #155 revealed the hospital visit note for Resident #05 dated 07/13/22 documented to keep the splint to the resident's left foot clean and dry, and in place meant it should not be removed until the resident had a follow-up with the orthopedic surgeon. LPN #155 confirmed she put a nursing order in the July 2022 TAR for staff to conduct circulation checks to the resident's LLE every shift, but the checks did not include inspecting the resident's skin underneath the splint. LPN #155 further verified the facility had not conducted an assessment of the in-house acquired pressure ulcer to the resident's left heel from 07/21/22 to 07/25/22. The first assessment of the pressure ulcer was completed on 07/26/22 by WNP #430. LPN #155 reported the facility did not have the splint which had been applied to Resident #05's foot at the hospital on 07/13/22. Resident #05 had returned from the orthopedic appointment on 07/21/22 wearing a soft shoe instead. Interview on 08/08/22 at 2:06 P.M. with WNP #430 revealed she completed a skin assessment for Resident #05 on 07/21/22, prior to the resident going to the orthopedic appointment later the same day. WNP #430 confirmed she did not remove the splint to the resident's LLE on 07/21/22 because staff told her it was not supposed to be removed. Interview on 08/09/22 at 10:54 A.M. with Medical Assistant (MA) #435 confirmed she worked with the orthopedic surgeon who saw Resident #05 on 07/21/22. MA #435 reported the resident arrived at the appointment wearing a splint, which had been placed to her LLE by the hospital on 07/13/22. MA #435 confirmed the splint was removable and could have been removed and reapplied as needed in order to conduct checks of the resident's skin. MA #435 further confirmed the splint had minimal padding and when it was removed there was a sore on the back of the resident's heel, which was about the size of a silver dollar. MA #435 further confirmed the doctor's office notified the facility of the pressure ulcer and gave orders for the resident to follow-up with the facility's wound nurse for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 08/09/22 at 10:58 A.M. with LPN #170 and with State tested Nursing Assistant (STNA) #275 confirmed they did not remove Resident #05's splint to the LLE from 07/13/22 to 07/21/22 because they thought it was supposed to stay in place at all times. Interview on 08/09/22 at 10:59 A.M. with Resident #05 revealed she had a fall on 07/13/22 and broke her foot. Resident #05 confirmed a splint was placed to her left foot on 07/13/22. Resident #05 confirmed staff checked her skin to make sure she could wiggle her toes, but staff did not remove the splint at any time. Resident #05 confirmed the splint was removed on 07/21/22 at the orthopedic surgeon's office and they told her she had a sore on her heel from the splint. Observation of wound care on 08/09/22 at 11:00 A.M. for Resident #05 per LPN #170 revealed the resident had a silver dollar sized pressure ulcer to the posterior aspect of her left heel. There was visible eschar in the wound bed. LPN #170 cleansed the wound with normal saline, patted dry, painted the wound bed with [MEDICATION(S)], and covered with a gauze pad and wrapped the resident's foot with Kerlix. Interview on 08/09/22 at 11:10 A.M. with LPN #170 confirmed the wound to Resident #05's left heel was silver dollar sized. LPN #170 confirmed the etiology of the wound was pressure from the splint which had been applied in July 2022. LPN #170 confirmed WNP #430 was responsible for staging the wound, but he did confirm the wound bed was covered with eschar. Interview on 08/09/22 at 11:23 A.M. with the DON confirmed WNP #430 had recommended on 07/26/22 the resident's wound be treated with Venelex gel. The DON confirmed the facility had not implemented the order because LPN #155 called WNP #430 on 08/09/22 to obtain clarification if it was okay to treat the wound with [MEDICATION(S)] instead of Venelex and WNP #430 had said that was okay. Interview on 08/09/22 at 11:28 A.M. with WNP #430 confirmed she first assessed Resident #05's wound on 07/26/22 and she classified the wound as a DTI and recommended Venelex gel for treatment. WNP #430 confirmed the facility called her on 08/09/22 to ask if it was okay to use [MEDICATION(S)] for the wound and she told them it was okay to use [MEDICATION(S)] until the facility could obtain Venelex gel, but the Venelex gel was the preferred treatment. WNP #430 further confirmed the [MEDICATION(S)] tended to [NAME] the eschar in the wound and the Venelex would promote increased blood flow to the tissue. WNP #430 confirmed Resident #05's wound had gotten larger from 07/26/22 to 08/02/22. 2. Review of the medical record for Resident #90 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE] revealed Resident #90 was cognitively intact, required extensive assistance of one staff with ADLs, was coded for the presence of a Stage II pressure ulcer present upon admission and was at risk for the development of pressure ulcers. Review of the pressure ulcer risk assessment for Resident #90 dated 04/19/22 revealed the resident was at risk for the development of pressure ulcers. Review of the care plan for Resident #90 dated 04/13/22 revealed the resident had impaired skin integrity and was at risk for altered skin integrity. The resident was admitted with a Stage II pressure ulcer to his sacrum. Interventions included the following: administer treatments as ordered by medical provider, apply barrier creams post incontinent episodes, assist with repositioning, assist with toileting, bilateral assist bars to bed, complete skin at risk assessment upon admission/readmission, complete weekly skin checks, ensure residents are turned and repositioned, monitor meal intake, monitor vital signs, obtain laboratory results (labs) as ordered, nutritional consult as needed, dietary supplements as ordered, diet as ordered, peri care as needed to prevent skin breakdown due to incontinence, and therapy as ordered. The care plan did not include pressure reduction interventions specific to the resident's feet and heels. Review of the weekly skin check for Resident #90 dated 04/22/22 revealed there were no skin conditions or changes, ulcers, or injuries noted. Review of the weekly skin check for Resident #90 dated 05/03/22 revealed the skin check was not completed due to the resident being at [CONDITION(S)]. Review of the nurse's progress note for Resident #90 dated 05/05/22 revealed the nurse was called to the resident's room by therapy staff to assess an area to resident's right heel. Resident #90 had a large pressure area containing clear blood-tinged fluid to the right heel. The surrounding skin area was normal in color and warm to touch. The area was cleaned with normal saline and covered with dry dressing then wrapped with Kerlix. Review of the May 2022 TAR for Resident #90 revealed an order dated 05/06/22 to cleanse right heel with normal saline, apply calcium alginate, cover with ABD pad, and wrap with Kerlix every night shift. Further review of the May 2022 TAR revealed the order to the right heel was changed on 05/19/22 to cleanse right heel with normal saline, apply Venelex ointment, cover with Xeroform and ABD pad and wrap with Kerlix every night shift. Review of the wound visit note per WNP #430 dated 05/06/22 revealed Resident #90 had a blister to his right heel which measured 7.7 cm in length by x 6.35 cm in width. Review of the nurse progress note for Resident #90 dated 05/11/22 revealed the resident was sent to the hospital for [CONDITION(S)] and did not return until 05/13/22. Review of the subsequent wound visit note for Resident #90 per WNP #430 dated 05/19/22 revealed the blister to the resident's right heel was now classified as an unstageable pressure ulcer and measured 6.05 cm in length by 6.21 cm in width. Review of the nurse progress note for Resident #90 dated 05/20/22 revealed the therapist notified the nurse that resident had a new open area on left heel. Pictures of the wound were sent to the wound care nurse and an order was obtained for a wound care consult. Review of photographs provided by the Administrator revealed two pictures of a darkened silver-dollar sized area to resident's left heel with Resident #90's name dated 05/20/22. Review of the May 2022 TAR for Resident #90 revealed an order dated 05/20/22 to cleanse left heel with normal saline, pat dry, apply Venelex ointment and cover with dry dressing. The treatments were not signed off as completed for 05/21/22 and 05/22/22 in which the nurse had indicated, see nurses notes. Review of the nurse progress note for Resident #90 dated 05/23/22 revealed Venelex ointment was not available for administration. Further review of the medical record for Resident #90 revealed there was no assessment or measurements of the wound to the left heel from 05/20/22 through 05/25/22. Review of the wound visit note for Resident #90 per WNP #430 dated 05/26/22 revealed the unstageable pressure ulcer to the resident's right heel measured 5.80 cm in length by 5.63 cm in width. Continued review revealed the resident had a DTI with surrounding blister to the left heel with a surrounding blister which measured 7.6 cm in length by 7.49 cm in width by 0.1 cm in depth. Review of the May 2022 TAR for Resident #90 revealed the wound treatments to the resident's right heel were not signed off as completed on 05/27/22, 05/28/22, and 05/29/22. Continued review revealed the wound treatments to the resident's left heel were not signed off as completed on 05/27/22, 05/28/22, and 05/29/22. Review of the nurse progress notes for Resident #90 dated 05/27/22 through 05/29/22 revealed the notes did not include documentation of treatment to the resident's right heel being completed nor did they include documentation of rationale for why the treatment was not being completed. Further review revealed no documentation of treatment to the resident's left heel being completed nor did they include documentation of rationale for why the treatment not being completed. Review of the wound visit note for Resident #90 per WNP #430 dated 06/02/22 revealed the unstageable pressure ulcer to the resident's right heel measured 4.03 cm in length by 6.03 in width. The left heel wound had increased in size and measured 8.6 cm in length by 9.05 cm in width by 0.1 cm in depth and was now classified as a pressure ulcer suspected DTI. Interview on 08/10/22 at 12:22 P.M. with the DON confirmed Resident #90's care plan did not include interventions specific to offloading the resident's heels. The DON confirmed Resident #90 did not have a skin check documented from 04/23/22 to 05/05/22. The DON verified therapy staff identified the pressure area to Resident #90's right heel on 05/05/22. The DON verified the treatment to the right heel was not documented as administered as ordered for Resident #90 on 05/27/22, 05/28/22, and 05/29/22. The DON confirmed the treatment was not administered as ordered for the left heel on 05/21/22, 05/22/22, and 05/23/22 due to the Venelex not being available. The DON confirmed the treatment to resident's left heel was not documented as administered on 05/27/22, 05/28/22, and 05/29/22. The DON confirmed the resident's wound to the left heel increased in size from 05/26/22 to 06/02/22 following the three days of missed treatments. Review of the facility policy titled, Skin Care & Wound Management Overview, dated 04/20/17 revealed the facility would prevent resident skin impairment and would promote the healing of existing wounds. The interdisciplinary team would work with the resident/patient and/or family/responsible party to identify and implement interventions to prevent and treat potential skin integrity issues. The interdisciplinary team would evaluate, and document identified skin impairments and pre-existing signs to determine the type of impairment, underlying condition(s) contributing to it and description of impairment to determine appropriate treatment. Review of the NPUAP guidelines dated 2014 pages 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, [CONDITION(S)], 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 [CONDITION(S)] (redness of the skin) was the first component of every skin inspection. Skin redness and tissue [CONDITION(S)] resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences 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. This deficiency substantiates Complaint Numbers OH 399 and OH 786.

Based on record review, staff interview, observation, and review of the facility policy, the facility failed to ensure medications were administered per professional standards and as ordered by the physician. This affected eight (Residents #26, #28, #29, #31, #34, #39, #40, and #89) of eight residents reviewed for medications. The census was 88. Findings include: 1. Observation on 08/08/22 at 8:00 A.M. revealed there were seven plastic cups of medications on top of the Plaza II Cart One medication cart which was parked outside Resident #24's room. Licensed Practical Nurse (LPN) #415 had visual control of the cart and was exiting Resident #24's room when surveyor approached nurse for an interview. Interview on 08/08/22 at 8:00 A.M. with LPN #415 confirmed there were seven plastic cups of resident medications for the following residents: Resident #26, #28, #29, #31, #34, #39, and #40. LPN #415 further confirmed she had prepared medications for all seven residents at approximately 7:45 A.M. and had started administering medications to the residents. LPN #415 confirmed this was not an acceptable medication administration practice. Interview on 08/08/22 at 1:23 P.M. with the Director of Nursing (DON) confirmed nurses should never pre-pull or pre-pour medications, and to prevent possible medication errors, medications should be prepared and immediately administered to the resident, one resident at a time. Review of the facility policy titled, Medication Administration, dated 04/20/17 revealed medications must be prepared just prior to administration. 2. Review of the medical record for Resident #29 revealed an admitted [DATE] with a diagnosis of diabetes mellitus (DM.) Review of the Minimum Data Set (MDS) for Resident #29 dated 07/13/22 revealed the resident was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADLs). Review of the August 2022 monthly physician orders for Resident #29 revealed an order dated 04/01/22 for the resident to receive [MEDICATION(S)] insulin via subcutaneous injection 12 units with meals. Observation on 08/08/22 at 8:22 A.M. of medication administration with LPN #415 revealed there was no [MEDICATION(S)] available for administration. Interview on 08/08/22 at 8:22 A.M. with LPN #415 confirmed [MEDICATION(S)] was not available for administration for Resident #29, and she had ordered it from the pharmacy the day before. Review of the August 2022 Medication Administration Record (MAR) for 08/08/22 revealed [MEDICATION(S)] was initialed off by LPN #415 as administered. Interview on 08/08/22 at 11:27 A.M. with LPN #415 confirmed she had taken insulin from an [MEDICATION(S)] vial belonging to Resident #52 and administered 12 units of insulin to Resident #29 at approximately 10:00 A.M. because Resident #29's insulin had not arrived from the pharmacy. Observation on 08/08/22 at 11:27 A.M. with LPN #415 revealed the cart contained an open vial of [MEDICATION(S)] insulin for Resident #52. Bottle was dated as opened on 07/15/22. Review of the medical record for Resident #52 revealed an admitted [DATE] with a diagnosis of DM. Review of physician order history for Resident #52 revealed an order for [MEDICATION(S)] insulin dated 05/29/22, and the order was discontinued on 07/19/22. Interview on 08/08/22 at 1:23 P.M. with the DON confirmed medications should never be, borrowed from another resident and Resident #52's insulin should not have been administered to Resident #29. Review of the facility policy titled, 'Medication Administration, dated 04/20/17 revealed medications will be administered as prescribed, and the nurse should ensure he/she has the right medication for the right resident prior to administration. 3. Review of the medical record for Resident #89 revealed an admitted [DATE] with a diagnosis of [CONDITION(S)]. Review of the MDS for Resident #89 dated 07/23/22 revealed the resident was cognitively intact and required extensive assistance of one to two staff with ADLs. Review of the July 2022 monthly physician orders for Resident #89 revealed an order for [MEDICATION(S)] 15 milligrams (mg) routinely at 9:00 A.M. and 9:00 P.M. Review of the nurse progress notes for Resident #89 dated 07/11/22 revealed [MEDICATION(S)] was not available for administration and the nurse contacted the pharmacy. Review of the controlled substance sheets for [MEDICATION(S)] for Resident #89 revealed the resident did not receive [MEDICATION(S)] as ordered on 07/11/22 and he missed two routine doses of [MEDICATION(S)] for pain. Interview on 08/10/22 at 12:22 P.M. with the DON confirmed Resident #89 did not receive [MEDICATION(S)] as ordered on 07/11/22. Review of the facility policy titled, 'Medication Administration, dated 04/20/17 medications will be administered as prescribed. This deficiency substantiates Complaint Number OH 399.

Based on record review, observation, staff interview, review of facility policy, and review of Centers for Disease Control (CDC) guidance, the facility failed to ensure staff wore facemasks and eye protection to potentially prevent the spread of Coronavirus (COVID-19). This had the potential to affect all residents residing on the Rehab I Hall (#53, #54, #55, #56, #57, #58, #59, #60, #61, and #62) and all residents residing on Plaza II Hall (#24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #45, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52). Additionally, the facility failed to ensure staff properly sanitized a glucometer, affecting Resident #29, and failed to ensure staff wore gloves during insulin injection administration, which affected Resident #38. This had the potential to affect the other diabetic residents on Plaza II (#24, #25, #43, #47, #52). The census was 88. Findings include: 1. Observation on 08/08/22 at 7:46 A.M. revealed signs were posted at the entrance of the facility indicating staff should wear eye protection and facemasks upon entry. Face shields and surgical masks were available at a table adjacent to the front door in the lobby. Observation on 08/08/22 at 7:50 A.M. revealed Nursing Staff Scheduler (NSS) #330 approached the surveyor in the front lobby and she was wearing a surgical facemask but was not wearing eye protection. NSS #330 began to tour surveyor through the building starting on Rehab I Hall. Interview on 08/08/22 at 7:50 A.M. with NSS #330 confirmed staff were required to wear surgical facemasks upon entry to the facility and in resident areas but eye protection was not required at this time. Observation on 08/08/22 at 7:52 A.M. revealed Housekeepers #405 and #410 were walking down the hall on the Rehab I Hall in an area accessible to residents and were not wearing facemasks or eye protection. Interview on 08/08/22 at 7:52 A.M. with Housekeepers #405 and #410 confirmed they had entered the building through the front entrance but did not think there were any masks available, so they did not put on masks. Housekeepers confirmed they thought eye protection was optional at this time. Observation on 08/08/22 at 8:00 A.M. revealed Licensed Practical Nurse (LPN) #415 was in Resident #24's room and speaking with the resident. LPN #415 was wearing a facemask which was pulled below her chin, exposing her nose and mouth, and was not wearing eye protection. LPN #415 did not pull her mask up over her nose until she was requested to do so by the surveyor prior to conducting an interview. Interview on 08/08/22 at 8:01 A.M. with LPN #415 confirmed masks were supposed to be worn to cover the nose, mouth, and chin. LPN #415 also confirmed staff were not required to wear eye protection in resident care areas at this time. Observation on 08/08/22 at 8:23 A.M. revealed State tested Nursing Assistant (STNA) #420 was passing breakfast trays to resident rooms and was wearing a facemask but was not wearing eye protection. Interview on 08/08/22 at 8:23 A.M. with STNA #420 confirmed she did not think eye protection was required at this time and she had been the only aide on the floor since 7:00 A.M. and had not worn eye protection. Observation on 08/08/22 at 8:44 A.M. revealed STNA #425 was collecting breakfast trays and assisting residents and was wearing a facemask but was not wearing eye protection. Interview on 08/08/22 at 8:44 A.M. with STNA #425 confirmed she had just arrived to work and was not wearing eye protection. STNA #425 confirmed she did not think it was necessary to wear eye protection. Observation on 08/08/22 at 8:49 A.M. revealed Social Worker (SW) #210 entered the resident area wearing a facemask and a face shield. SW #210 had several face shields with him and distributed them to LPN #415 and STNAs #420 and #425 and told them face shields were required to be worn in the facility at all times due to the current high transmission rate of COVID-19. Interview on 08/08/22 at 8:49 A.M. with SW #210 confirmed all staff were required to wear facemasks and face shields in resident areas at this time to help prevent the spread of COVID-19 Interview on 08/08/22 at 9:02 A.M. with the Administrator confirmed staff were required to wear facemasks at all times in resident care areas and eye protection was recommended but not required. Interview on 08/08/22 at 1:23 P.M. with the Director of Nursing (DON) confirmed staff were required to wear facemasks and eye protection at all times in resident care areas to help prevent the spread of COVID-19 and the current transmission rate of COVID-19 per the CDC for the county in which the facility was located in was high. Review of the facility policy titled, Use of PPE While in the Facility, updated 03/02/22 revealed all employees in all departments must wear a surgical mask at all times. Eye protection is required when county transmission levels are substantial to high or per state specific guidance. Review of online resource per the CDC at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html revealed CDC's COVID-19 Community Levels recommendations do not apply in healthcare settings, such as hospitals and nursing homes. Instead, healthcare settings should continue to use community transmission rates and continue to follow CDC's infection prevention and control recommendations for healthcare settings. Further review revealed even as nursing homes resume normal practices, they must sustain core infection prevention and control (IPC) practices and remain vigilant for [CONDITION(S)]-CoV-2 infection among residents and healthcare personnel (HCP) in order to prevent spread and protect residents and HCP from severe infections, hospitalization s, and death. The CDC recommend nursing homes should implement universal use of personal protective equipment (PPE) for HCP and additionally, HCP working in facilities located in counties with substantial or high transmission should also use eye protection (i.e., goggles or a face shield that covers the front of the face.) Review of the online COVID-19 tracker per the CDC at https://covid.cdc.gov/covid-data-tracker/#county-view?list_select_state=Ohio&data-type=Risk&null=Risk&list_select_county= revealed the community transmission rate for facility in which the facility was located in was high as of 08/04/22. 2. Review of the medical record for Resident #29 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Minimum Data Set (MDS) for Resident #29 dated 07/13/22 revealed the resident was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADLs.) Observation on 08/08/22 at 8:22 A.M. revealed LPN #415 checked Resident #29's blood sugar using a glucometer. After use LPN #415 set the glucometer directly on top of the medication cart and did not sanitize or clean the glucometer. LPN #415 continued to administer medications. Observation on 08/08/22 at 8:36 A.M. revealed LPN #415 picked up the glucometer on top of the medication cart and headed towards Resident #38's room to check his blood sugar. LPN #415 did not clean or sanitize the glucometer until prompted to do so by the surveyor. There were no bleach wipes available to clean the glucometer and the nurse had to lock the cart and go to the medication room to retrieve a canister of bleach wipes. Interview on 08/08/22 at 8:36 A.M. with LPN #415 confirmed she placed the glucometer directly on top of the medication cart after checking Resident #29's blood sugar. LPN #415 confirmed she had not cleaned or sanitized the glucometer after using it to check Resident #29's blood sugar. LPN #415 reported she did not usually clean the glucometer after use, as she did not think it was necessary. LPN #415 confirmed she would clean the glucometer if the surveyor thought it was necessary. Interview on 08/08/22 at 1:23 P.M. with the DON confirmed glucometers should be cleaned and sanitized immediately after use with a bleach wipe. Review of the facility policy titled, Cleaning and Disinfection of the Glucose Meter, dated 02/24/22 revealed staff should clean and disinfect the glucose meter after each use and should not place a contaminated glucometer on top of the medication cart or other surface without a clean protective barrier. Staff should use an Environmental Protection Agency (EPA)- approved disinfectant. 3. Review of the medical record for Resident #38 revealed and admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the MDS for Resident #38 dated 06/30/22 revealed the resident was cognitively intact and required supervision and physical assistance of one staff with ADLs. Observation on 08/08/22 at 8:41 A.M. revealed LPN #415 administered insulin via injection to Resident #38 and was not wearing gloves. Interview on 08/08/22 at 8:42 A.M. with LPN #415 confirmed she was not wearing gloves while administering the insulin injection to Resident #38. Interview on 08/08/22 at 1:23 P.M. with the DON confirmed nurses should wear gloves while administering injections. Review of the facility policy titled, Injection Subcutaneous, dated 02/07/22 revealed staff should perform hand hygiene and don (put on) gloves prior to administering injection.

Based on record review, staff interview, and review of facility policy, the facility failed to complete an investigation regarding an abuse allegation in a timely manner, including failing to suspend the alleged staff member pending an investigation. This affected one (Resident #93) of one resident reviewed for abuse. The facility census was 88. Findings include: Record review for Resident #93 revealed an admitted [DATE] and the resident was discharged to the hospital on 07/03/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #93 was cognitively intact as evidenced by her brief interview for mental status (BIMS) score of 15. Further review of the MDS assessment revealed she required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #93 required supervision from staff with eating. Review of the Self-Reported Incident (SRI) # 2 dated 06/06/22 revealed Resident #93 reported while State tested Nurse Aide (STNA) #450 was providing her care on 06/04/22 the STNA, Shoved her into bed. Further review of the SRI revealed Resident #93 asked Licensed Practical Nurse (LPN) #440 for another STNA to provide care reporting STNA #450 was rough when turning her (Resident #93) in bed. Interview on 08/09/22 at 3:32 P.M. STNA #450 denied the allegations made by Resident #93 reporting the resident was upset and confused the evening of the alleged incident. STNA #450 confirmed the incident allegation occurred on 06/04/22 and her shift ended at 7:00 A.M. STNA #450 confirmed she remained clocked in and worked until the end of her shift. Review of STNA #450's timecard revealed she worked two twelve hours shifts on 06/04/22 and 06/05/22. Interview on 08/09/22 at 3:40 P.M. with LPN #440 revealed on 06/04/22 between 6:15 A.M. and 6:30 A.M. Resident #93 reported STNA #450 was rough and rude while providing care to her. LPN #440 verified STNA #450 was allowed to continue working and provided care to other residents until the end of her shift. LPN #440 reported she told Resident #93, she (LPN #440) would provide care for her until the end of the shift. LPN #440 reported the allegation to the Director of Nursing (DON) the same day. Interview on 08/10/22 at 9:00 A.M. with the Administrator revealed she, Heard about the situation between STNA #450 and Resident #93. The Administrator confirmed she could not remember how she, 'heard,' of the incident, however, she was told it was a customer service issue. The Administrator confirmed she spoke with LPN #440 either on 06/04/22 or 06/05/22 but could not say which day. The Administrator stated she remembered the situation presented to her as a customer service issue and personality conflict between Resident #93 and STNA #450. The Administrator stated it was the process of the facility to interview the resident following a customer service issue on the next business day following the alleged incident. The Administrator stated she asked the facility's Licensed Social Worker (LSW) #200 to interview the resident regarding the incident on the following Monday, 06/06/22. The Administrator stated the information given to her by the social worker following his interview resulted in an investigation of alleged abuse on 06/06/22. Interview on 08/10/22 at 9:00 A.M. the former DON #300 denied receiving a call from LPN #440 regarding the incident between STNA #450 and Resident #93. Interview on 08/10/22 at 9:35 A.M. LSW #210 confirmed he met with Resident #93 on 06/06/22. Resident #93 reported on 06/04/22 STNA #450 threw her into bed. LSW #210 reported the allegation to the Administrator. LSW #210 could not recall if he was asked to meet with the resident or if he was checking in with the resident when she reported the allegation. Review of the facility policy titled, Ohio Abuse, Neglect, & Misappropriation, dated 10/27/22 revealed during an investigation of an alleged incident, the staff member will be interviewed by the nurse on duty. The staff member will be escorted off of the premises by another staff member. The accused staff member will be suspended, by the Executive Director or designee, pending the outcome of the investigation of the incident.

Based on record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff monitored resident's vital signs as ordered, prior to medication administration. This affected one (Resident #34) of seven residents observed for medication administration. The census was 88. Findings include: Review of the medical record for Resident #34 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment for Resident #34 dated 04/29/22 revealed the resident was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADLs). Review of August 2022 monthly physician orders for Resident #34 revealed an order dated 04/16/22 for [MEDICATION(S)], give one tablet by mouth once daily for [CONDITION(S)], hold if blood pressure is less than 110/60. Observation of medication administration for Resident #34 on 08/08/22 at 8:32 A.M. per Licensed Practical Nurse (LPN) #415 revealed the nurse did not take the resident's blood pressure prior to administration of [MEDICATION(S)]. Interview on 08/08/22 at 8:33 A.M. with LPN #415 confirmed she had not taken Resident #34's blood pressure prior to administration of [MEDICATION(S)], but she would take the resident's blood pressure later in the morning. Interview on 08/08/22 at 1:23 P.M. with the Director of Nursing (DON) confirmed if a resident had orders with parameters to withhold a medication based on vital sign results, the nurse should take the vital signs prior to administration to determine if the medication should be administered. Review of the facility policy titled, Medication Administration, dated 04/20/17 revealed medications will be administered as prescribed. This deficiency substantiates Complaint Number OH 399.