Every finding on record at Main Street Care Center

Based on resident representative and staff interviews, record review, review of the National Pressure Injury Advisory Panel 2025 guidelines and review of facility policy, the facility failed to evaluate and identify risk factors and define and implement interventions to prevent avoidable pressure injuries. Additionally, the facility failed to initiate treatment timely to the newly identified avoidable pressure injury. Actual Harm occurred on 07/19/25 when Resident #125 developed an avoidable deep tissue injury (Purple or maroon area of discolored intact skin due to damage of underlying soft tissue.) to her right knee from an immobilizer that was not physician ordered or identified by the facility to be in place. This affected one (Resident #125) of three residents reviewed for wounds. The facility census was 113.Findings include:Review of Resident #125's medical record revealed an admission date of 01/14/25 and a discharge date of 02/20/26. Diagnoses included Alzheimer's Disease with late onset and dementia.Review of the care plan dated 01/15/25 and revised on 07/22/25 revealed Resident #125 had the potential for impairment of skin integrity including a history of deep tissue injury (DTI) to right buttock, history of moisture associated skin damage (MASD) to the buttocks, pressure injuries to the right and left heel, and history of area to the right knee. Goals included skin intervention/preventative measures to be maintained, and Resident #125 would have no avoidable skin breakdown. Interventions included minimizing pressure on bony prominences.Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #125 had severe cognitive impairment and utilized a wheelchair. Resident #125 was dependent on staff for lower body dressing.Review of the progress note dated 07/07/25 revealed Resident #125 fell. Certified Nurse Practitioner (CNP) #430 was notified and a new order for a two-view x-ray to the right lower extremity and right hip was placed.The progress note dated 07/08/25 revealed Resident #125 complained of pain this morning (07/08/25) and advised Resident #125 would remain in bed and non-weight bearing (NWB) until x-ray results were known. Resident #125's right lower extremity was immobilized.The physician progress note dated 07/08/25 revealed Resident #125 had an acute hip fracture and to continue NWB status. There was no recommendation for an immobilizer to the right knee.Review of Resident #125's physician orders and progress notes dated 07/08/25 through 07/14/25 revealed there was no evidence a knee immobilizer was ordered. There was no evidence Resident #125 had a right knee immobilizer or if the skin was assessed in the right knee area.The physician progress note dated 07/09/25 at 10:09 A.M. revealed CNP #430 did not mention or recommend an immobilizer to the right knee.From 07/14/25 to 07/18/25, Resident #125 was in the hospital for right hip fracture with surgical repair. There were no recommendations for a right knee immobilizer.The progress note dated 07/18/25 revealed Resident #125 arrived at the facility from status post-surgical repair of the right hip. Resident #125 had a right knee abrasion measuring 6.0 centimeters (cm) in length by 0.5 cm in width with no depth and staging was marked not applicable. There was no mention of a right immobilizer or pressure injury present on the right knee.The progress note dated 07/19/25 revealed Resident #125's daughter was questioning nursing about markings on her right knee from an immobilizer that was on Resident #125 when she went to the hospital on [DATE] from her ortho appointment. Resident #125's daughter mentioned that she had no knowledge Resident #125 had a brace on until the surgeon called her prior to Resident #125's right hip surgery (07/14/26) and asked her why Resident #125 had a brace on. The medical record did not mention a right knee immobilizer/brace. A progress note dated 07/15/25 at 10:42 A.M. mentioned a right knee immobilizer being in place. (Resident #125 was in the hospital at this time.) Resident #125's daughter was advised immobilizers were generally ordered per ortho or if an immobilizer was ordered at the facility, physical therapy (PT) would have an order written for. The order was not found in Resident #125's medical record. Resident #125's daughter was encouraged to view Resident #125's video footage from her room to see if someone placed a knee immobilizer on Resident #125. Resident #125's daughter agreed that she would view the camera footage. Resident #125's right knee region was assessed with Resident #125's daughter present and areas of linear, closed indentations were present to the medial and lateral aspect of the knee to the back of the knee. Resident #125 denied pain to the area. Resident #125's right knee area would be assessed on 07/21/25 by Wound CNP (WCNP) #433.There was no physician order to treat the new area until 07/21/25.Review of Resident #125's Wound Care Notes dated 07/21/25 at 9:04 A.M. and written by WCNP #433 revealed Resident #125 had a deep tissue pressure injury (DTPI) to her right knee extending circumferentially which appeared to be from a brace. Nursing reported they were looking into what type of brace was applied and by who. The DTPI was present on admission (There was no documentation upon re-admission on [DATE] there was a pressure injury) and was full thickness. Measurement was 32.0 cm in length, 1.0 cm in width, and depth was unable to be determined. The clustered wound with intact skin bridge present. The wound was 40 percent purple or maroon discoloration and 30 percent epithelial. Linear dark purple and maroon discoloration extending circumferentially around the knee. Skin was intact and non-blanching. Treatment was to cleanse with normal saline, apply skin prep and leave open to the air.The facilities Wound Tracker dated 08/11/25 revealed Resident #125's right knee wound was resolved.Interview on 04/14/26 at 10:50 A.M. with Power of Attorney (POA) #431 revealed Resident #125 had a fall and fractured her right hip. POA #431 indicated Resident #125's leg and hip were hurting her and a brace was put on her right knee. POA #431 did not know Resident #125 had a right knee brace put on and the surgeon called her to ask if something was wrong with her knee because Resident #125 had a knee brace on. The orthopedic surgeon thought he missed something and x-rayed her right knee to make sure everything was okay. POA #431 revealed the facility staff denied the facility put a brace on Resident #125.Interview on 04/16/26 at 1:13 P.M. with Director of Rehabilitation (DOR) #434 revealed there was nothing in Resident #125's therapy notes about donning an immobilizer. DOR #434 indicated therapy did not issue an immobilizer, they would put it on but not issue it, and the immobilizer usually came from the hospital. Resident #125 was discharged from Physical Therapy (PT) on 07/07/25. DOR #434 indicated it was possible an immobilizer could be put on too tight, and it had to be snug to provide support. DOR #434 reviewed Resident #125's progress notes and stated after reviewing the notes, he thought Physician #432 ordered the immobilizer. Resident #125's progress notes also stated non-weight bearing to the right lower extremity unless Resident #125 had an ortho appointment. DOR #434 indicated PT #435 provided Resident #125's therapy and if she put the immobilizer on, she did not document it. PT #435 no longer worked at the facility. Interview on 04/16/26 at 2:44 P.M. with DOR #434 and PT #435 revealed PT #435 did not remember much about the situation with Resident #125. PT #435 indicated nursing told her Resident #125 had a fall with injury and either Physician #432 or CNP #430 told her to hold off doing anything regarding therapy and asked her to put an immobilizer on Resident #125's right knee. PT #435 was told to put the immobilizer on and either Physician #432 or CNP #430 would put the order in. PT #435 was not sure how long the immobilizer was supposed to be on, she thought until the x-ray results were reported, and put Resident #125's immobilizer on per physician orders. PT #435 stated she did not know anything else about the immobilizer.Interview on 04/20/26 at 4:36 P.M. with Wound Nurse (WN) #325 confirmed there were no orders in Resident #125's medical record about a right knee immobilizer. WN #325 indicated he heard Resident #125's right knee wound was from an immobilizer, but he did not remember a lot about the situation and was not sure why there was no order. WN #325 revealed Resident #125 was readmitted to the facility on [DATE] and was not seen by WNP #433 until 07/21/25.Review of the National Pressure Injury Advisory Panel 2025 guidelines for the International Guidelines for Prevention and Treatment of Pressure Ulcers/Injuries revealed regardless of age or clinical setting, a resident should be considered at risk for a pressure injury as soon as a medical device is applied. Further review of the guidelines revealed staff should frequently evaluate and where feasible, resize or reposition medical devices used in residents at risk. Continued review of the guidelines revealed the provider should develop standardized protocols for reducing the risk of device related pressure injuries based on the device type.Review of the facility policy titled Wound Prevention and Management Policy revised 10/2022 revealed it was the policy of the facility that, upon admission, all residents would have a comprehensive skin assessment to identify current skin breakdown and identify pressure ulcer risk factors. A preventative plan of care and intervention would be initiated for any residents determined to be at risk, to reduce the possibility of further breakdown.This deficiency represents non-compliance investigated under Complaint Number 2572317.

Based on resident representative and staff interviews, record review, policy review, and review of the National Institute for Health's National Library of Medicine (NIH) publications, the facility failed to ensure a resident who was at a high risk for falls was assessed for the cause of falls and ensure interventions were implemented to prevent additional falls. Actual Harm occurred on 04/10/25 when Resident #125 was found on the floor in her room and sustained a closed compression fracture of lumbar 3 (L3) vertebra. The facility stated the fall was related to orthostatic hypotension (sudden drop in blood pressure occurring when standing up from a sitting or lying position defined as a systolic drop of greater than or equal to 20 millimeters of mercury (mm Hg) or diastolic greater than or equal to 10 mm Hg within three minutes); however, there was no evidence the resident was assessed to have orthostatic hypotension. Resident #125 fell again on 05/10/25 with no injuries, 06/02/25 with no injuries, 06/04/25 went to the emergency room (ER) and received two staples on top of her head, 07/07/25 sustained a right hip fracture requiring surgery, and on 02/13/26 with multiple fractures including a closed fracture of multiple ribs to the left side, a closed fracture of left wrist, and a facial laceration requiring eight sutures. Resident #125 had purple ecchymosis (a large bruise caused by blood leaking from broken vessels into subcutaneous tissue) to the left cheek and red ecchymosis to the left shoulder and scattered ecchymosis to right upper extremity and bilateral lower extremities. Resident #125 passed away on 02/20/25 and the Death Certificate stated the manner of death was accident and the underlying cause was due to sequelae of blunt impacts to the head, trunk, and left arm with fractures and soft tissue injuries due to falls. This affected one (Resident #125) of three residents reviewed for falls. The facility census was 113.Findings include:Review of Resident #125's medical record revealed an admission date of 01/14/25 and a discharge date of 02/20/26. Diagnoses included Alzheimer's disease with late onset, paroxysmal atrial fibrillation, fracture of carpal bone of the left wrist, multiple fractures of the ribs on the left side, laceration of head, dementia, and anxiety disorder.Review of the care plan dated 01/15/25 revealed Resident #125 had a safety concern and the potential for falls, injury. Resident #125's safety would be maintained, and she would have minimal risk of injury and falls. An intervention on 01/15/25 included to encourage non-skid footwear at all times; an intervention on 04/10/25 included encourage Resident #125 to be in the common areas while awake; on 05/10/25 an intervention was initiated to encourage Resident #125 to lay in her recliner while she was in her room every shift; on 06/03/25 an intervention to place a reminder sign in Resident #125's room to remind her to use the call light for assistance; and on 02/13/26, an intervention to complete visual checks every 30 minutes for three days was initiated.The care plan dated 01/15/25 revealed Resident #125 had the potential for altered behavior patterns, disruptive interactions, agitation and/or anxiety. Resident #125 reached for objects not present and fidgeted in her chair. Resident #125 would be calm in a secure environment, and her safety would be maintained. Interventions included a fidget blanket starting on 02/17/26. Review of Resident #125's Falls Risk assessment dated [DATE] revealed Resident #125 was at a higher risk for falls.Review of Resident #125's progress notes dated 04/10/25 at 10:54 A.M. revealed the nurse was alerted by the housekeeper (unidentified) that Resident #125 was on the floor in her room. Resident #125 was found sitting on the floor. Resident #125 stated she heard voices in the hall and fell when she went to check on this. Resident #125 denied pain or discomfort and was able to move all extremities with no issues. Resident #125's vital signs were checked and the resident had orthostatic hypotension. (There was no evidence in the medical record of orthostatic hypotension at the time of the fall.) The physician ordered Resident #125 to be transported to the ER for evaluation.The progress note dated 04/10/25 revealed a follow up investigation that was completed for the fall, and the immediate intervention was orthostatic blood pressures. Other interventions were to encourage Resident #125 to be in the common areas while awake and therapy screening for safety.The comprehensive fall investigation was not available to view including witness statements because they were quality assurance protected information (QAPI). The facility did not show the fall was investigated thoroughly, to ensure fall interventions were in place at the time of the fall, determine Resident #125's orthostatic blood pressure by obtaining vital signs, and determine the cause of the fall.Review of the After Visit Summary for a hospital stay from 04/10/25 through 04/12/25 revealed Resident #125 was admitted for a fall and proctitis (inflammation of the rectum's lining). Resident #125 had an unwitnessed fall and stated in the ER that her head, lower back and legs hurt. Resident #125 had a computed tomography (CT) scan of the abdomen and pelvis and a closed compression fracture of L3 vertebra was found. Resident #125 was admitted for observation to control her lumbar fracture pain and to monitor overnight for bright red blood per rectum and receive intravenous antibiotics for proctitis. Resident #125 improved and her symptoms resolved. Review of Resident #125's physician orders dated 04/13/25 revealed to always encourage non-skid footwear every shift. The fall plan of care revealed on 01/15/25, there was already an intervention for non-skid footwear.Review of Resident #125's physician orders dated 04/30/25 revealed single room isolation, and contact precautions for Clostridioides difficile (C. diff). The order was discontinued on 05/27/25.The progress note dated 05/10/25 at 9:01 P.M. revealed the nurse was called to the room due to Resident #125 was sitting on the floor in front of her wheelchair. It was reported that Resident #125 was very restless all day and trying to stand up by herself. Resident #125 had full range of motion with no skin concerns and no evidence of injury. The daughter requested that Resident #125 was put in her recliner more often with her legs elevated.The comprehensive fall investigation was not available to view including witness statements because they were QAPI. The facility did not show that the fall was investigated thoroughly, to ensure fall interventions were in place at the time of the fall including proper footwear, address Resident #25's restlessness, and determine the cause of the fall.The progress note dated 06/02/25 at 3:08 P.M. revealed Resident #125's daughter-in-law stated she was watching the camera and Resident #125 was walking around the room, sitting on the arm of the recliner then fell onto the floor. Resident #125's daughter-in-law called to notify the nurse that Resident #125 was on the floor. Resident #125's range of motion was within normal limits, neuro checks were initiated and no injury was noted. An intervention was to wear proper footwear or non-slip socks while out of bed. (The fall plan of care revealed on 01/15/25, there was already an intervention for non-skid footwear and on 04/13/25, there was a physician order for non-skid footwear.)The comprehensive fall investigation was not available to view because they were QAPI. The facility did not show the fall was investigated thoroughly, to ensure fall interventions were in place at the time of the fall including the previous fall intervention of non-skid footwear (care plan intervention on 01/15/25 and physician order on 04/13/25), determine the cause of the fall, and implement appropriate interventions which could have included staff education and/or discipline to ensure fall interventions were implemented.The progress note dated 06/04/25 at 8:43 A.M. revealed Resident #125 was found on the floor of her room lying on her right side next to the rollator (wheeled walker). Resident #125 had a gash to the top of her head, and a bruise was noted to her right wrist. Resident #125 was sent to the ER due to being on a blood thinner per an unidentified Certified Nurse Practitioner (CNP). A new intervention was to place Resident #125 on every 15-minute checks while on isolation precautions (Isolation precautions were discontinued on 05/27/25).The comprehensive fall investigation was not available to view including witness statements because they were QAPI. The facility did not show the fall was investigated thoroughly, to ensure fall interventions were in place at the time of the fall and determine the cause of the fall.The progress note dated 06/04/25 revealed Resident #125 returned from the ER with two staples on top of her head. Resident #125 denied pain or discomfort.The progress note dated 07/07/25 at 9:09 P.M. revealed while she was assisting another resident (unidentified) the nurse (unidentified) heard Resident #125 yelling for help. Resident #125 was leaning on the scheduler's door and sitting on the floor in front of her wheelchair. Resident #125 stated she was getting help to get up and fell and hit her head. Resident #125's vital signs were stable, and her range of motion was abnormal to the right lower extremity and right hip. Resident #125 stated it was painful and no deformity or discoloration was noted. Resident #125's head did not have bumps, lacerations or discoloration. Two staff assisted Resident #125 to her wheelchair then into bed. CNP #430 was notified and a new order for a two-view x-ray to the right lower extremity and right hip was placed.The comprehensive fall investigation was not available to view including witness statements because they were QAPI. The facility did not show the fall was investigated thoroughly, to ensure fall interventions were in place at the time of the fall and to determine the cause of the fall.The progress note dated 07/08/25 at 1:21 P.M. revealed Power of Attorney (POA) #431 was contacted and Resident #125's x-ray results (right hip fracture) were discussed with her. POA #431 was asked if she wanted to send Resident #125 out or she would like an orthopedic appointment set up for her. A hospice consultation or palliative care consultation was also discussed. POA #431 indicated she wanted to call her siblings to discuss the situation and would call back. The progress note dated 07/08/25 at 1:41 P.M. revealed POA #431 called and stated she would like for the facility to set up an orthopedic appointment for Resident #125. POA #431 also stated she would like a hospice to consult to be set up.The progress note dated 07/08/25 at 1:43 P.M. revealed Resident #125 was non-weight bearing (NWB) per CNP #430 and a new physician's order was written for Resident #125 to use a mechanical lift until her follow-up appointment was completed.The progress note dated 07/08/25 at 4:00 P.M. revealed an immediate intervention related to the fall on 07/07/25 was for a dump wheelchair (the measurement of how much lower the rear of a seat is compared to the front, enhancing stability. It helps maintain pelvic position, prevent sliding forward, and aids propulsion.) for positioning.The physician progress note dated 07/08/25 and written by Physician #432 revealed Resident #125 had an acute hip fracture, continue NWB status. Recommended evaluation in the hospital to discuss surgical versus non-surgical options; however, the family was deciding on hospice versus evaluation in the hospital. A new order for a hospice consultation was placed.The physician progress note dated 07/09/25 at 10:09 A.M. written by CNP #430 revealed Resident #125 had an acute intertrochanteric right femoral fracture as noted. Resident #125's family did not want her sent to the hospital and were agreeable to a hospice consultation. Resident #125 would be monitored for pain and NWB orders were in place.The progress note dated 07/14/25 at 5:52 P.M. revealed POA #431 was contacted, and she reported that Resident #125 was being taken for emergency surgery and would not be returning that day (07/14/25).The care plan dated 07/22/25 included Resident #125 had altered family acceptance, Do Not Resuscitate (DNR) status, hospice services and impending loss of life. Resident #125's wishes would be honored, comfort maintained and death would be with dignity. Interventions included reporting verbal distress, position for comfort and reporting increased restlessness.Review of the significant change Minimum Data Set assessment dated [DATE] revealed Resident #125 was unable to complete the Brief Interview for Mental Status (BIMS). Resident #125 used a wheelchair and was dependent on staff for activities of daily living (ADLs) including mobility, transferring, toileting hygiene, lower body dressing, and personal hygiene.The progress notes dated 02/13/26 at 6:56 A.M. revealed the nurse was in the middle medication pass and saw Resident #125 in the dining room with another resident. Licensed Practical Nurse (LPN) #364 administered medication to an unidentified resident and when she returned to the dining area, Resident #125 was laying on her left side, her glasses were smashed and blood was noted from her left eyebrow. Resident #125 complained of left sided hip pain. Tylenol was offered, the staff did not move Resident #125, and they waited with her until Emergency Medical Services (EMS) arrived. Resident #125 was moved onto the stretcher and transported to the local hospital.Review of Resident #125's late entry progress notes dated 02/13/26 revealed Resident #125 experienced an unwitnessed fall. Resident #125's care plan was updated to reflect a wedge cushion for assistance with seating and every 30-minute checks for three days. Hospice, family and the provider agreed with the interventions.The progress notes dated 02/13/26 at 6:00 P.M. included Resident #125 returned from the ER at 10:00 A.M. Resident #125 was diagnosed with closed fracture of multiple ribs to the left side, closed fracture of left wrist, and a facial laceration with eight sutures in place and the area was draining a large amount of serosanguinous drainage. Resident #125 was to follow up with orthopedic. Resident #125 had purple ecchymosis to the left cheek and red ecchymosis to the left shoulder and scattered ecchymosis to right upper extremity and bilateral lower extremities. Resident #125 appeared to be anxious and in pain with facial grimacing, moaning and calling out. As needed anxiety and pain medication were provided with effect. Splint in place to left upper extremity. Resident #125's family was at the bedside.The comprehensive fall investigation was not available to view including witness statements because they were QAPI. The facility did not show the fall was investigated thoroughly, to ensure fall interventions were in place at the time of the fall, revealing how long Resident #125 was lying on the ground to determine adequate supervision and rule out neglect, and determine the cause of the fall.The progress notes dated 02/20/26 revealed at 2:21 A.M., Resident #125's skin was warm to touch, and she had an absence of vital signs and pupillary response and was pronounced by two nurses. Hospice services were notified.Review of the Certificate of Death dated 02/20/26 revealed Resident #125 had adult failure to thrive, and the manner of death was accident. The place of injury was the nursing home memory care unit dining area and the injury date and time were 02/13/26 at approximately 5:20 A.M. The underlying cause was due to sequelae of blunt impacts to the head, trunk, and left arm with fractures and soft tissue injuries due to falls. Other significant conditions contributing to the death but not resulting in underlying causes were dementia, recent hip fracture, atrial fibrillation, hypertension, chronic kidney disease, and osteoporosis. During an interview on 04/14/26 at 10:50 A.M., Power of Attorney (POA) #431 revealed Resident #125 experienced a broken hip in July 2025 and fell again on 02/13/26. POA #431 stated Resident #125 had fallen on her face first out of her padded wheelchair. Resident #125 had broken multiple ribs, had a broken arm, a broken wrist and had a huge laceration on the side of her face. POA #431 indicated Resident #125 passed away on 02/20/26 at the facility. POA #431 revealed this was the fourth fall that required an ER visit. The other three falls were on 04/10/25, Resident #125 had a fall and was found to have a lumbar fracture. In June 2026, Resident #125 got up from her wheelchair, fell and hit her head, was transported to the ER and had to have staples near the back of her head. On 07/07/25, Resident #125 was found by the nursing station on the floor and had fallen and had a hip fracture. During an interview on 04/16/25 at 8:45 A.M., the Administrator revealed she was unable to provide Resident #125's comprehensive fall investigations including witness statements because they were QAPI. The Administrator stated she was unable to read the investigations to the surveyor because the investigations were QAPI. During an interview on 04/16/26 at 9:20 A.M., the Administrator, the Director of Nursing (DON) and Director of Clinical Services (DCS) #429 revealed DCS #429 reviewed the investigations and answered questions but did not let the surveyors review the fall investigations and did not read the investigations to the surveyors. Resident #125 had a fall on 04/10/25 and she was trying to ambulate on her own in the room without staff assistance. Resident #125 heard voices and was trying to see what was happening in the hall. The immediate intervention was to encourage Resident #125 to be in the common area when she was awake. DCS #429 indicated the root cause of the fall was due to orthostatic hypotension blood pressure but confirmed she did not see an orthostatic blood pressure recorded in Resident #125's progress notes when she had the fall. DCS #429 was unable to provide details of events leading up to the fall such as when Resident #125 was last seen etcetera (etc.). DCS #429 confirmed Resident #125 was wearing footwear when she fell. On 05/10/25, Resident #125 was found sitting on the floor in front of her wheelchair. DCS #429 indicated Resident #125 wanted to come out of her room, but she was in isolation and was restless. DCS #429 stated the intervention was the staff staying with Resident #125 until she was no longer restless. On 06/02/25, DCS #429 revealed Resident #125's daughter called to notify the nurse that Resident #125 sat on the arm of her recliner and fell to the floor. DCS #429 confirmed Resident #125 was not wearing proper footwear and had nothing on her feet. The immediate intervention was non-slip socks. DCS #429 revealed the predisposing factors were impaired memory, confusion, weakness, gait imbalance, improper footwear and she had a C Diff infection. The DON indicated Resident #125 was antsy and restless because she could not come out of her room for C. diff. When asked what interventions were provided when Resident #125 had restlessness and was being antsy, the DON said she had a fidget blanket but confirmed the fidget blanket was not initiated until 02/17/26. No additional interventions were provided related to Resident #125's restlessness and being antsy. DCS #429 revealed Resident #125 was often antsy and restless even when she wasn't in isolation for C Diff. Resident #125 had an unwitnessed fall on 06/04/25 and she was moved to a room closer to the nursing station for more interaction and oversight. DCS #429 stated Resident #125 was self-ambulating, fell and was found next to her rollator. Resident #125 was last seen about 10 minutes prior to the fall. An intervention was to complete safety checks every 15 minutes while Resident #125 was in isolation and when asked for the evidence that the safety checks were completed the DON and DCS #429 indicated they would look for the safety checks. No evidence was provided that showed the safety checks were completed every 15 minutes while Resident #125 was in isolation for C Diff. DCS #429 indicated on 07/07/25, Resident #125 was taken off the secured unit because she was not ambulating, not exit seeking and the daughter agreed and assisted with the move. Resident #125 had a fall by the nursing station and was observed sitting in front of the scheduler's door and leaning on the door. Resident #125 was last seen about 20 minutes prior to the fall sitting in her padded wheelchair. Resident #125 said she was getting help with getting up. The new intervention was a dump wheelchair. Resident #125 had an intertrochanteric right femoral fracture and was not transported to the hospital because the family did not want her to be sent to the ER. The family wanted her to have an orthopedic appointment and to consult hospice services. On 07/14/25, the facility found out Resident #125 was transported from the orthopedic appointment to the hospital and was going to have emergency surgery for her hip fracture. DCS #429 revealed on 02/13/26, Resident #125 had a fall early in the morning in the dining area of the secured unit. The nurse was passing medications and when she walked back to the dining area, she found Resident #125 on the floor. Resident #125 stated her face and hip hurt and she was transported to the ER. Resident #125 returned to the facility on [DATE]. DCS #429 indicated she was not sure what caused the fall. A new intervention was a wedge cushion to the left side of the padded wheelchair to help with positioning. DCS #429 indicated Resident #125 passed away on 02/20/26. An email was sent on 04/16/26 at 4:20 P.M. to the DON and the Administrator and requested the fall investigation to determine if the facility completed comprehensive investigations and determined the root cause for the falls pertaining to the following dates: 04/10/25, 05/10/25, 06/02/25, 06/04/25, 07/01/25, 07/07/25 and 2/13/26. There was no response to the email, and investigations were not provided during the survey.During an interview on 04/20/26 at 3:19 P.M., Certified Nursing Assistant (CNA) #357 revealed she was working on 02/13/26 when Resident #125 experienced a fall. CNA #357 revealed LPN #364 was very busy administering medications and providing treatments and couldn't watch residents closely. CNA #357 indicated on 02/13/26 when Resident #125 fell, there was one other aide (CNA #314) and a nurse (LPN #364) working. CNA #357 revealed CNA #314 and herself were providing morning care to residents and assisting them out of bed. Resident #125 was assisted out of bed at around 5:30 A.M. and taken to the dining room and was put in a relaxed position in her padded wheelchair. Resident #125 was sitting in a semi reclined position but not tilted back. CNA #357 revealed LPN #364 was in the dining room and she was in Resident #55's room with CNA #314 when they heard LPN #364 yell. LPN #364 was yelling out that a resident was on the floor. LPN #364 told CNA #357 that she took medication to a (unidentified) resident and heard a thud and found Resident #125 on the floor. CNA #357 revealed when the day shift aides came in for work and found out Resident #125 had fallen and been taken to the ER; they told her Resident #125 had been restless in her chair during the day shift on 02/12/26. CNA #357 indicated the day shift aides did not tell her that in report when they were leaving for the day (02/12/26). CNA #357 stated she received report from the day shift CNA, but they did not tell her Resident #125 was scooting forward and trying to get out of her chair. Resident #125 was trying to reach for something in the air that was not there. During an interview on 04/20/26 at 4:10 P.M., the DON confirmed Resident #125 was not wearing proper footwear when she fell on [DATE].During a telephone interview on 04/22/26 at 9:09 A.M., CNA #347 revealed on 02/13/26, LPN #364 last saw Resident #125 about five to ten minutes before she fell and CNA #347 last saw Resident #125 about 10 to 15 minutes before she fell. CNA #347 indicated she assisted Resident #125 to the dining room and made sure the wheelchair was locked before she walked away. No activity was provided because Resident #125 appeared to go back to sleep and was not moving around in her chair. CNA #347 did not remember if Resident #125's wheelchair was dumped, but she was in a reclining, relaxed position, and not tilted back. CNA #347 indicated Resident #84 was in the dining room with Resident #125 when Resident #125 fell.Review of an email sent from the Administrator dated 04/22/26 revealed the Administrator stated Resident #125 was last seen within approximately ten minutes before she fell on [DATE], her chair was a dump chair and presented at baseline in the dining room prior to the fall.Attempts to interview LPN #364 and CNA #314 during the survey were unsuccessful.Review of the facility policy titled Fall Management and Incident Intervention Protocol revised 07/2022 revealed it was the policy of the facility to conduct an investigation into the potential causative factors for each resident incident, including those classified as a fall. In addition, residents would be assessed as to their risk of sustaining a fall. Interventions would be implemented and evaluated in order to decrease the incidence of residents, including falls, and to minimize the risk of injury. New interventions would be added to the resident plan of care and would be communicated to the relevant nursing staff. All falls would be reviewed by the Focus Group. Members would review events of the incident and discuss possible recommendations and alterations to the resident's plan of care. Review of the National Institute for Health's National Library of Medicine publication titled Can Agitated Behavior of Nursing Home Residents with Dementia be Prevented With the Use of Standardized Stimuli dated June 2023, included studies have shown that non-pharmacological interventions could be effective in decreasing agitation without the risk of the potential side-effects of medication, while simultaneously address the underlying unmet needs of the older person. As most nursing home residents spend much of their time unoccupied, a significant portion of their agitation is attributable to unmet needs related to boredom and confusion. Studies have found music, using simulated animal-assisted therapy such as a stuffed or robotic animal, social contact, structured activities, and self-identity interventions show effects in lowering agitation.This deficiency represents non-compliance investigated under Complaint Number 2572317.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure residents meals were palatable and at a appetizing temperature. This had the potential to affect all 113 residents receiving meals from the kitchen. The facility identified there were no residents who were nothing by mouth. The facility census was 113.Findings include:Observation on 04/14/26 at 11:48 A.M. with [NAME] #407 of steam table food temperatures revealed ground beef 150 degrees Fahrenheit (F), Spanish rice degrees 173 F, pureed ground beef degrees 145 F, pureed Spanish rice 166 degrees F, gravy 160 degrees F.Observation on 04/14/26 at 11:53 A.M. revealed tray line was initiated. First resident room tray cart for the 500-hall left the serving station at 12:05 P.M. Second resident room tray cart for the 200-hall left at 12:14 P.M. Third resident room tray cart for the 100-hall left at 12:20 P.M. The 200-hall dining room resident meals were finished at 12:52 P.M.A test tray was completed on 04/14/26 at 12:53 P.M. with [NAME] #407. Temperatures taken were as follows: ground beef was 118 degrees F, Spanish rice was 115 degrees F, pureed ground beef was 125 degrees F, and pureed Spanish rice was 117 degrees F. Following tasting the ground beef, Spanish rice, pureed ground beef, and puree Spanish rice, [NAME] #407 confirmed the Spanish rice was warm, but would have preferred it to be warmer. The pureed beef was well seasoned but was not warm enough and the pureed Spanish rice was also not warm enough for preference. Review of the facility policy titled Food Preparation and Service dated 10/2014 revealed food will be prepared by methods which ensure retention of flavor, appearance and nutrients. Food will be maintained at proper temperatures during service and transported in a sanitary manner. Food will be served at acceptable temperatures, each type of food having an appropriate temperature.

Based on observations, staff interviews and review of facility policy, the facility failed to ensure staff followed proper hand hygiene and personal hygiene in the kitchen when serving food. This had the potential to affect 57 residents who resided on the 100, 200 and 500 halls and were receiving meals from the 200 hall serving station. The facility indicated no residents received nothing by mouth. The facility census was 113.Findings include:Observation and interview on 04/14/26 at 11:38 A.M. in the 200-hall dietary serving station which serviced 100, 200 and 500 hall residents revealed [NAME] #407, who had a beard, was not wearing a beard net. [NAME] #407 confirmed he was not wearing a beard net and stated he had to go to the main kitchen to get one since there were none in the 200 serving station.Observations and interview on 04/14/26 at 12:29 P.M. revealed Cooks #401 and #407 leaving the kitchen carrying three resident plates each with their gloved hands to deliver to the dining room. At 12:32 P.M., Cooks #401 and #407 opened the kitchen door with their gloved hand and returned to the serving line. They did not perform hand hygiene and change gloves. [NAME] #401 and #407 confirmed they had not washed their hands or changed gloves after leaving the kitchen prior to going back to their serving stations in the kitchen.Observation and interview on 04/14/26 at 12:49 P.M. revealed Dietary Aide #333 entered the serving area of the kitchen and walked back to the back of the room where the dish machine was and did not put on a hair net. [NAME] #407 confirmed Dietary Aide #333 was supposed to have a hair net on in the kitchen.Review of the undated facility policy titled Plastic Gloves revealed hands are to be washed when entering the Dietary Department and before putting on the plastic gloves. Review of the undated facility policy titled Sanitation and Food Handling revealed personnel will observe personal cleanliness and exercise satisfactory food handling techniques. Employees must wash their hands and this included when returning to the dietary department for any reason and before serving food. Review of the undated facility policy titled Personnel Management/Dress Code revealed hair restraints must be used when in the kitchen. Men with beards must use a covering over the facility hair when serving food or preparing food. Hands must be washed when entering the kitchen.

Based on record review, staff interviews, observations, and review of the facility policy, the facility failed to ensure residents received the food according to the menu, recipe, and therapeutic spreadsheet. This affected Residents #9, #14, #19, #22, #47, #53, #63 and #115. The facility identified two residents were on a pureed diet. The facility census was 113.Findings include:Review of the facility menu for week four-day 24 lunch revealed the menu listed soft shell beef tacos, lettuce, tomatoes, shredded cheese, salsa, Spanish rice, and a cookie to be served.a. Review of the facility recipe called Beef Tacos Soft Shell revealed recipes ingredients listed were ground beef, taco seasoning mix, water, six-inch flour tortilla, finely shredded cheddar cheese, fresh diced tomato, shredded lettuce, sour cream and taco sauce. Assemble each taco with 1.5 ounces of meat, 0.25 ounces of shredded cheese, 0.5 ounces of diced tomatoes, one-fourth cup of shredded lettuce and one tablespoon of sour cream. Place the sour cream on the edge of the tortilla and then roll it up. Observation and interview on 04/14/26 at 11:44 A.M. with [NAME] #334 confirmed salsa and sour cream were on the menu for lunch but the facility was out the sour cream and salsa and were not sending it with the trays. Observation on 04/14/26 at 12:23 PM revealed an unidentified aide came to the door and asked for salsa for Resident #19 and was told they did not have any salsa in the serving station to give the resident. Observation on 04/14/26 at 12:35 P.M. revealed the dietary staff ran out of diced tomatoes for the eight remaining resident trays. The following residents meals were not provided the option to have tomatoes on their tacos: Residents #9, #22, #47, #53, #63, and #115. Two additional residents did not have the option to receive tomatoes and were unable to be identified. [NAME] #334 confirmed they ran out of tomatoes for tray service at the time of the observation. Interview on 04/14/26 at 1:06 P.M. with Dietary Manager #384 confirmed salsa and sour cream were listed on the menu and stated she was unsure why staff had not gone to the main kitchen to get it for meal service. Dietary Manager #384 also stated maybe the cook had put the salsa into the meat when cooking the beef and confirmed it was not listed as an ingredient on the cooking portion of the recipe.b. Review of the facility production sheet for Week four, day 24 lunch revealed the pureed diets were supposed to receive a #40 scoop (1.6 tablespoon) of pureed peanut butter cookie. Observation and interview on 04/14/26 at 12:45 P.M. revealed Resident #14, who had a pureed diet order, was not provided with the pureed cookie listed on the menu. [NAME] #334 confirmed they did not make the pureed cookies and usually give the residents on a pureed diet a magic ice cream cup instead. Interview on 04/14/26 at 1:06 P.M. with Dietary Manager #384 confirmed physician ordered diets were to be followed and dietary staff were to provide the items listed on the dietitian approved menus.Review of the facility policy titled 'Food Preparation and Service dated 10/2014 revealed portion control will be achieved through: portions are indicated on a regular and therapeutic diet menus.Review of the facility policy titled Mechanically Altered Diets Policy dated 04/2022 revealed pureed diet will receive all food pureed until smooth according to the standardized recipe. The mechanical soft and pureed diets are specified on the spreadsheet with the items and portions to be served for each diet.

Based on observation, staff interview, and facility policy review, the facility failed to ensure refrigerated medications were kept in a safe and sanitary manner in accordance with accepted professional practices to maintain the efficacy of medication and ensure expired medications were not kept past the recommended expiration date. This affected Residents #5, #9, #12, #18, #19, #32, #38, #50, #51, and #96 and had the potential to affected residents who receive medications from the 200-hall storage area. The facility census was 113.Findings include:Observation on 04/15/26 at 11:46 A.M. with Registered Nurse (RN) #397 revealed the 200 Hallway medication storage area had one stock bottle of Nicotinamide Adenine Dinucleotide (NAD) (vitamin) 1,000 milligram (mg) tablets that expired on 03/2026. The 200 Hallway medication refrigerator in the medication storage area had a large frozen meal was in the freezer compartment and a large clear plastic bag which contained an unidentified sandwich and fruit that was placed in the medication refrigerator alongside the resident's refrigerated medications. The resident's refrigerated medications included: two Adalimumab injectors (treats autoimmune disorders for Residents #32 and #51), one Mounjaro auto injector (weight loss medication for Resident #19), four Pantoprazole suspension bottles (treats acid reflux for Resident #12), one Ozempic auto injector (weight loss medication for Resident #19), five Lantus Insulin auto injector pen (treats high blood sugars for Residents #5, #12, #18, #96, and facility stock), nine Humalog Insulin (treats high blood sugars for Residents #9, #12, #38, #40), one Lispro insulin auto injector pen (treats high blood sugars for Resident #9), facility stock supply of five boxes of Tylenol suppositories (rectal insert to treat fever and pain), facility stock of bisacodyl suppositories (aides in bowel movement), and one each of facility stock Novolog and Lantus Insulins. Interview with RN #397 on 04/15/26 at 11:50 A.M. confirmed all findings of expired stock bottle of NAD and presence of food in the refrigerator and freezer in the designated medication refrigerator. Review of the facility policy titled Medication Storage Policy revised 8/2021 revealed all medications are maintained behind a locked door that cannot be accessed by unlicensed personnel. The policy did not refer to medication refrigerator storage protocols. The facility policy titled Medication Administration Policy, revised 03/2022, revealed all medications are administered in a safe and sanitary manner.

Based on observation, medical record review, resident and staff interviews, and interview with optometry staff, the facility failed to ensure a resident received eye glasses in a timely manner. This affected one (Resident #81) of two residents reviewed for ancillary services. The facility census was 113.Findings include:Review of the medical record for Resident #81 revealed an admission date of 01/03/25. Diagnoses included chronic obstructive pulmonary disease and diabetes mellitus. Review of Resident #81's care plan dated 01/06/25 and last revised on 06/02/25 revealed under the area of resident care, there was an intervention to encourage Resident #81 to wear glasses when out of bed and to assist with care of glasses as needed.Review of the optometry note dated 10/06/25 revealed Resident #81's chief complaint was blurry vision. New glasses prescription was updated and new frames were selected for bifocals, distance and near vision. Glasses were to be ordered and shipped to the home once insurance once verified. If glasses were not covered by insurance, a self pay option would be offered to Resident #81 to have an option for the glasses order to be fulfilled. Review of the Social Service Designee (SSD) #314's optometry list revealed Resident #81 was last seen on 10/06/25.Review of the annual Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #81 was cognitively intact. Resident #81 could see adequately with appliance.From 10/06/25 to 04/13/26, there were no additional notes with a follow up to Resident #81's new eye glasses that optometrist said would be ordered. Interview and observation of Resident #81 on 04/13/26 at 10:30 A.M. revealed she was waiting for new glasses and had been on the list for months. She held up a pair of glasses missing a stem. She stated she was seen by the eye doctor but never received a new pair of glasses. Interview with SSD #314 on 04/16/26 at 3:02 P.M. revealed she was not aware Resident #81 was waiting on a pair of glasses.Telephone interview on 04/20/26 at 12:50 P.M. with third party Eyewear Coordinator (EC) #428 verified Resident #81 was seen on 10/06/25 and was to get new glasses after insurance verification. She stated the facility emailed her on 04/16/26 asking her to look into this during annual survey. EC #428 verified she did not have any evidence Resident #81 received a private pay notification after insurance denial in October. She stated private pays take a few days longer but it was hard to keep up with private pay letters due to the volume of patients they had. She stated she was communicating with SSD #414 on the cost of the glasses to expedite delivery. She verified it should not take six months to get eye glasses.Subsequent interview on 04/20/26 at 2:34 P.M. with SSD #414 revealed she did not receive progress notes from the 10/06/26 optometry visit nor did she follow-up with EC #428 regarding visit outcome in a timely manner. Review of the facility policy titled Vision and Hearing Policy, dated 08/2019, revealed the facility would ensure residents received proper treatment and assistive devices to maintain vision and hearing abilities.

Based on medical record review, staff interview, hospice staff interview, review of the facility hospice agreement, and review of facility policy, the facility failed to ensure hospice was part of the care conference and a hospice provided care plan was part of the medical record for Resident #28. This affected one (Resident #28) of one reviewed for hospice. The facility identified 17 residents who were on hospice. The facility census was 113.Findings include:Review of the medical record for Resident #28 revealed an admission date of 03/27/26. Diagnoses included malignant neoplasm of unspecified bronchus or lung, palliative care. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #28 had moderate cognitive impairment and was receiving hospice services.The resident's care plan did not have evidence of a hospice provided care plan with specified care needs, and who would provide the needed care for Resident #28. Review of the physician order dated 03/27/26 for Resident #28 revealed an order to admit to hospice services with a diagnosis of lung cancer with metastasis with six months or less to live.Review of the social services progress note dated 04/01/26 for Resident #28 revealed a care conference with facility department managers and Resident #28. Hospice was not noted to be a part of the care conference.Review of the facility's hospice binder revealed a signed hospice agreement for Resident #28 dated 03/27/26. No hospice provided care plan was found in the binder.Interview on 04/16/26 at 2:56 P.M. with Registered Nurse (RN) #356 revealed the hospice nurse or aide makes their visit notes in their own electronic medical record but staff do not have access to it. If hospice writes order, they write them in the hard chart. RN #356 confirmed the hospice binder and medical record for Resident #356 did not have a hospice care plan.Interview on 04/20/26 at 11:29 A.M. with the Director of Nursing (DON) revealed the hospice nurse will communicate with the nurse and verbally give updates or write orders if there were changes for the resident. The DON stated hospice does not print hospice visit summaries unless the facility requests them and also confirmed no visit summaries were found in the electronic or paper medical record for Resident #28.Interview on 04/20/26 at 12:22 P.M. with Hospice Nurse #427 confirmed the hospice care plan was not in the hospice binder or in the medical record as required.Interview on 04/20/26 at 2:16 P.M. with Social Services Designee (SSD) #414 confirmed a resident receiving hospice will have a care conference upon admission, quarterly and as needed for significant changes. SSD #414 confirmed she does not usually communicate with hospice and also confirmed hospice was not a part of the care conference for Resident #28 on 04/01/26.Review of the facility hospice agreement revealed an agreement dated 04/01/22 by the facility with the hospice company. Under letter A titled Services revealed the facility will provide facility basic services, inpatient acute care, and/or respite care to hospice patients 24 hours a day, seven days a week in accordance with the hospice plan of care. Under section B2 Hospice Responsibilities revealed hospice shall furnish facility a copy of the hospice patient's Hospice Plan of Care. Hospice will specify to the facility the care to be provided to the hospice patient by the facility. The designated coordinator of the interdisciplinary group (IDG) will assess conformance with the Hospice Plan of Care. Review of the facility policy titled Hospice dated August 2014 revealed meeting will be held between Hospice staff, staff and family/resident/representative for care plan generation and continuity of care.

Based on medical record review, interview, and facility policy review, the facility failed to report an incident of possible neglect involving Resident #195 to the State Agency as required. This affected one (Resident #195) of three residents reviewed for elopement. The facility census was 101. Findings include: Review of the medical record for Resident #195 revealed an admitted [DATE]. Diagnoses included but were not limited to cerebrovascular disease, palliative care, vascular dementia, insomnia, dementia, type II diabetes mellitus with chronic kidney disease, and anxiety disorder. Review of 12/13/24 admission Minimum Data Set (MDS) 3.0 for Resident #195 revealed a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment with no behaviors noted. Review of activities of daily living (ADLs) revealed Resident #195 used a walker and wheelchair and was noted to walk 50 feet with partial moderate assistance and was independent to wheel his wheelchair 150 feet independently. Review of the facility incident tracking log for December 2024 revealed on 12/24/24 at 8:45 P.M. Resident #195 was noted to have an unwitnessed fall with the location noted as other with no noted injuries and the origin established. Review of witness statement dated 12/24/24 at 8:50 P.M. from CNA #59 revealed he had last seen Resident #195 at 8:35 P.M. in the dining room and then went on break. CNA #59 stated when he came back from break, CNA # 56 told him Resident #195 had fallen through the window in an unoccupied room, was observed outside, and was brought back inside the building safely. Review of the witness statement dated 12/24/24 timed at 8:50 P.M. from CNA #56 revealed she had last seen Resident #195 around 8:30 P.M. in the dining room. She was assisting Licensed Practical Nurse (LPN) #58 and then started walking down the 500 hall and Resident #199 stated a man was outside her window yelling for help. CNA #56 went to Resident #199's room and observed Resident #195 laying on the grass outside of Resident #199's window. CNA #56 ran to get LPN #58 and called for help from CNA #57, and they went outside. CNA #56 stated Resident #195 was confused and stated he got tangled in the window screen and pushed through it. Review of the nursing progress note for Resident #195 created on 12/25/24 at 6:37 A.M. dated 12/24/24 timed at 8:50 P.M. entered by the Director of Nursing (DON) revealed Resident was noted on the ground/floor attempting to crawl outside through window. Able to redirect resident. Assessed for injuries, not noted. Unable to state what he was doing due to the resident had a dementia diagnosis. Resident moved to secure unit and wander guard placed. Interview on 01/06/25 at 7:57 A.M. with Resident #199 confirmed she was unsure of the date, but after dinner she heard someone yelling for help outside of her window and heard something hit the window but was unsure what caused the noise. Resident #199 told the aide who was in the hall but was unsure of her name. Interview on 01/06/25 at 10:31 A.M. with the ADON revealed she received a text on 12/25/24 at 3:24 A.M. from LPN #58 stating Resident #195 had exited through a facility window, fell , and was found outside lying on the grass. The ADON confirmed Resident #195 was found outside and stated to initiate 15-minute checks. The ADON stated she would notify administration and obtain further instructions. The ADON notified the Director of Nursing (DON) on 12/25/24 at 3:34 A.M. and received a return call at 3:36 A.M. from the DON who stated she would contact the covering Administrator. Phone interview on 01/06/25 at 11:10 A.M. with Certified Nurse Assistant (CNA) #56 revealed she last saw Resident #195 around 8:00 P.M. in the dining room. Shortly before 9:00 P.M. she was walking in the hall and Resident #199 told her she heard someone yelling outside her window. CNA #56 went to Resident #199's room and upon lifting the blinds so Resident #195 lying on the grass outside the window. CNA #56 immediately went to get Licensed Practical Nurse (LPN) #58. LPN #58, CNA#56 and CNA #57 went outside to assist Resident #195. CNA #56 stated Resident #195 did not complain of pain and no injuries were observed. Phone interview on 01/06/25 at 11:45 A.M. with LPN #58 revealed he had last seen Resident #195 around 7:00 P.M. Shortly before 9:00 P.M. CNA #56 came to him stating Resident #195 was outside. LPN #58 and CNA #56 went outside and found Resident #195 lying on his left side on the grass outside of Resident #199's window. Resident #195 was assessed without noted injuries. LPN #58 confirmed he should have notified management immediately but did not contact the ADON till after 3:00 A.M. on 12/25/24. Interview on 01/06/25 at 12:55 P.M. with the DON revealed on 12/24/24 at 8:45 P.M. Resident #195 had an unwitnessed fall and was told he was found in an unoccupied room tangled in the window screen found on the floor. DON stated she was never told Resident #195 was found outside of the facility. DON confirmed she reviewed the staff witness statements and confirmed the statement from CNA #59 stated he was told Resident #195 was found outside of the building and brought back in safely. DON confirmed the witness statement completed by CNA #56 stated she observed Resident #195 through the window of the unoccupied room and observed the resident outside of the building lying on the ground. DON confirmed she was notified by the ADON on 12/25/24 at approximately 4:00 A.M. and she made the Administrator on call aware. Resident #195 was moved to the secured unit for safety. DON confirmed LPN #58 did not complete a nursing progress note and did not write a witness statement following the incident and staff were unaware Resident #195 was outside of the facility until Resident #199 told CNA #56. DON confirmed no other witness statements were obtained. DON also confirmed if a resident is found outside it would be considered an elopement. DON stated she did not complete an elopement incident investigation or a self-reported incident report to the State Agency because it was a new behavior and thought it was a change in status. Review of the 01/2022 revised facility policy called; Missing Person/Elopement Policy revealed an elopement is identified as an unauthorized exit from the facility involving a resident whose cognitive status and safety awareness are impaired. Once it is established a resident is missing, the following staff members are notified immediately: Charge nurse, Administrator, Director of Nursing and Quality Assurance. In the absence of Nursing Administration, the charge nurse will be responsible for keeping the above-mentioned informed of the progress of the search. When the resident is located and safety is assured, the Nursing Supervisor or Charge Nurse will perform and document a detailed physical, mental and emotional assessment of the resident. All persons listed above will be informed of the resident's status. A detailed investigation as to the circumstances surrounding the elopement will be completed by the Director of Nursing, Administrator, or designee following each incidence of resident elopement from the facility premises. Staff education will be provided during the orientation process, annually and on an as needed basis. Education will include a missing person drill on each shift to ensure understanding of the missing person/elopement policy and procedure. Review of the 02/2022 revised facility protocol called; Reporting of Key Facility Events Protocol revealed it the facility protocol that the on-call nurse will be notified immediately if an elopement event occurs. The on-call nurse will be responsible to notify the facility Administrator and/or Director of Nursing. It is the protocol that the DON or Administrator will notify the corporate team timely. The policy listed an elopement to incide any exit outside of the skilled nursing facility door, even if only for a moment. This deficiency represents non-compliance investigated under Complaint Number OH00161157.

Based on medical record review, interviews, facility incident report review, the facility failed to maintain an accurate medical record. This affected one (Resident #195) of three residents reviewed for accuracy of medical records. The facility census was 101. Findings include: Review of the medical record for Resident #195 revealed an admitted [DATE]. Diagnoses included but were not limited to cerebrovascular disease, palliative care, vascular dementia, insomnia, dementia, type II diabetes mellitus with chronic kidney disease, and anxiety disorder. Review of 12/13/24 admission Minimum Data Set (MDS) 3.0 for Resident #195 revealed a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment with no behaviors noted. Review of activities of daily living (ADLs) revealed Resident #195 used a walker and wheelchair and was noted to walk 50 feet with partial moderate assistance and was independent to wheel his wheelchair 150 feet independently. Review of the facility incident tracking log for December 2024 revealed on 12/24/24 at 8:45 P.M. Resident #195 was noted to have an unwitnessed fall with the location noted as other with no noted injuries and the origin established. Review of the 12/24/24 fall assessment timed at 4:18 A.M. completed by the Assistant Director of Nursing (ADON) for Resident #195 revealed he was high risk for falls. Review of the 12/24/24 safety assessment timed at 4:20 A.M. completed by the ADON for Resident #195 revealed the resident had an unwitnessed fall on 12/24/24 at 12:00 A.M. No injuries were noted. Intervention was to place Resident #195 on the secured unit. Review of the nursing progress note for Resident #195 created on 12/25/24 at 6:37 A.M. dated 12/24/24 timed at 8:50 P.M. entered by the Director of Nursing (DON) revealed Resident was noted on the ground/floor attempting to crawl outside through window. Able to redirect resident. Assessed for injuries, not noted. Unable to state what he was doing due to the resident had a dementia diagnosis. Resident moved to secure unit and wander guard placed. Review of witness statement dated 12/24/24 at 8:50 P.M. from CNA #59 revealed he had last seen Resident #195 at 8:35 P.M. in the dining room and then went on break. CNA #59 stated when he came back from break shortly after 9:00 P.M., CNA # 56 told him Resident #195 had fallen through the window in room [ROOM NUMBER] and was brought back inside the building safely. Review of the witness statement dated 12/24/24 timed at 8:50 P.M. from CNA #56 revealed she had last seen Resident #195 around 8:30 P.M. in the dining room. She was walking down the 500 hall and Resident #199 stated a man was outside her window yelling for help. CNA #56 went to Resident #199's room and observed Resident #195 laying on the grass outside of Resident #199's window. CNA #56 ran to get LPN #58 and called for help from CNA #57, and they went outside. CNA #56 stated Resident #195 was confused and stated he got tangled in the window screen and pushed through it. Interview on 01/06/25 at 7:57 A.M. with Resident #199 confirmed she was unsure of the date, but after dinner she heard someone yelling for help outside of her window and heard something hit the window but was unsure what caused the noise. Resident #199 told the aide who was in the hall but was unsure of her name. Interview on 01/06/25 at 10:31 A.M. with the ADON revealed she received a text on 12/25/24 at 3:24 A.M. from LPN #58 stating Resident #195 had exited through a facility window, fell and was found outside lying on the grass. ADON confirmed Resident #195 was found outside and stated to initiate 15-minute checks. ADON stated she would notify administration and obtain further instructions. ADON notified the Director of Nursing (DON) on 12/25/24 at 3:34 A.M. of the elopement and received a return call at 3:36 A.M. from the DON who stated she would contact the covering Administrator. Phone interview on 01/06/25 at 11:10 A.M. with Certified Nurse Assistant (CNA) #56 revealed she last saw Resident #195 around 8:00 P.M. in the dining room. Shortly before 9:00 P.M. she was walking in the hall and Resident #199 told her she heard someone yelling outside her window. CNA #56 went to Resident #199's room and upon lifting the blinds so Resident #195 lying on the grass outside the window. CNA #56 immediately went to get Licensed Practical Nurse (LPN) #58. LPN #58, CNA#56 and CNA #57 went outside to assist Resident #195. CNA #56 stated Resident #195 did not complain of pain and no injuries were observed. Phone interview on 01/06/25 at 11:30 A.M. with CNA #57 confirmed he received a call from CNA #56 for assistance around 9:00 P.M. on 12/24/24. He observed Resident #195 lying on the ground outside of the facility. CNA #57 went to get Resident #195's wheelchair and then assisted LPN #58, and CNA #56 to get Resident #195 up and back into the facility. Phone interview on 01/06/25 at 11:45 A.M. with LPN #58 revealed he had last seen Resident #195 around 7:00 P.M. Shortly before 9:00 P.M. CNA #56 came to him stating Resident #195 was outside. LPN #58 and CNA #56 went outside and found Resident #195 lying on his left side on the grass outside of Resident #199's window. Resident #195 was assessed without noted injuries. LPN #58 confirmed he should have notified management immediately but did not contact the ADON till after 2:00 A.M. on 12/25/24. Interview on 01/06/25 at 12:55 P.M. with the DON revealed on 12/24/24 at 8:45 P.M. Resident #195 had an unwitnessed fall and she was told he was found in room [ROOM NUMBER] tangled in the window screen found on the floor. DON stated she was never told Resident #195 was found outside of the facility. DON confirmed she reviewed the staff witness statements and confirmed the statement from CNA #59 stated he was told Resident #195 was found outside of the building and brought back in safely. DON confirmed the witness statement completed by CNA #56 stated she observed Resident #195 through the window of Resident #199's room outside of the building lying on the ground. DON confirmed she was notified by the ADON on 12/25/24 at approximately 4:00 A.M. and she made the administrator on call aware. DON also confirmed if a resident is found outside it would be considered an elopement. DON stated she did not complete an elopement incident investigation or a self-reported incident report to the State Agency because it was a new behavior and thought it was a change in status. Interview on 01/06/24 at 1:31 P.M. with the ADON confirmed she erroneously entered the fall risk and safety assessment on 12/24/24 at 4:18 A.M. and 4:20 A.M. and both assessments were completed on 12/25/24 at the respective times listed. This deficiency represents non-compliance investigated under Complaint Number OH00161157.

Based on medical record review, interviews, facility incident report review, and facility policy review, the facility failed to provide adequate supervision to prevent the elopement of one resident (Resident #195) out of three residents reviewed for elopements. The facility census was 101. Findings include: Review of the medical record for Resident #195 revealed an admitted [DATE]. Diagnoses included but were not limited to cerebrovascular disease, palliative care, vascular dementia, insomnia, dementia, type II diabetes mellitus with chronic kidney disease, and anxiety disorder. Review of the 12/06/24 admission fall assessment for Resident #195 revealed he was alert and oriented to time and place, required adaptive equipment, had dementia, and had noted unsteady gait. Intervention was a reminder sign to ask for assistance when ambulating or transferring. Review of the 12/06/24 elopement risk assessment for Resident #195 revealed a diagnosis of dementia and no noted attempts to exit facility. Resident #195 was noted to be mobile in a wheelchair and was not noted to be at risk for elopement. Review of the plan of care dated 12/07/24 revealed no indication Resident #195 was at risk for elopement/wandering. Resident #195 was noted to have knowledge deficit and require assistance with decision making as needed. Review of 12/13/24 admission Minimum Data Set (MDS) 3.0 for Resident #195 revealed a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment with no behaviors noted. Review of activities of daily living (ADLs) revealed Resident #195 used a walker and wheelchair and was noted to walk 50 feet with partial moderate assistance and was independent to wheel his wheelchair 150 feet independently. Review of the 12/24/24 fall assessment timed at 4:18 A.M. completed by the Assistant Director of Nursing (ADON) for Resident #195 revealed he was high risk for falls. Review of the 12/24/24 safety assessment timed at 4:20 A.M. completed by the ADON for Resident #195 revealed the resident had an unwitnessed fall on 12/24/24 at 12:00 A.M. No injuries were noted. Intervention was to place Resident #195 on the secured unit. Review of the facility incident tracking log for December 2024 revealed on 12/24/24 at 8:45 P.M. Resident #195 was noted to have an unwitnessed fall with the location noted as other with no noted injuries and the origin established. Review of the witness statement dated 12/24/24 at 8:50 P.M. from Certified Nursing Assistant (CNA) #59 revealed he had last seen Resident #195 at 8:35 P.M. in the dining room and then went on break. CNA #59 stated when he came back from break, CNA # 56 told him Resident #195 had fallen through the window in an unoccupied room, was observed outside, and was brought back inside the building safely. Review of the witness statement dated 12/24/24 timed at 8:50 P.M. from CNA #56 revealed she had last seen Resident #195 around 8:30 P.M. in the dining room. She was assisting Licensed Practical Nurse (LPN) #58 and then started walking down the 500 hall and Resident #199 stated a man was outside her window yelling for help. CNA #56 went to Resident #199's room and observed Resident #195 laying on the grass outside of Resident #199's window. CNA #56 ran to get LPN #58 and called for help from CNA #57, and they went outside. CNA #56 stated Resident #195 was confused and stated he got tangled in the window screen and pushed through it. Review of the nursing progress note for Resident #195 created on 12/25/24 at 6:37 A.M. dated 12/24/24 timed at 8:50 P.M. entered by the Director of Nursing (DON) revealed Resident was noted on the ground/floor attempting to crawl outside through window. Able to redirect resident. Assessed for injuries, not noted. Unable to state what he was doing due to the resident had a dementia diagnosis. Resident moved to secure unit and wander guard placed. Interview on 01/06/25 at 7:57 A.M. with Resident #199 confirmed she was unsure of the date, but after dinner she heard someone yelling for help outside of her window and heard something hit the window but was unsure what caused the noise. Resident #199 told the aide who was in the hall but was unsure of her name. Interview on 01/06/25 at 10:09 A.M. with Resident #195 was attempted but did not recall any fall or being outside of the facility. Interview on 01/06/25 at 10:31 A.M. with the ADON revealed she received a text on 12/25/24 at 3:24 A.M. from LPN #58 stating Resident #195 had exited through a facility window, fell , and was found outside lying on the grass. The ADON confirmed Resident #195 was found outside and stated to initiate 15-minute checks. The ADON stated she would notify administration and obtain further instructions. The ADON notified the DON on 12/25/24 at 3:34 A.M. and received a return call at 3:36 A.M. from the DON who stated she would contact the covering Administrator. Phone interview on 01/06/25 at 11:10 A.M. with CNA #56 revealed she last saw Resident #195 around 8:00 P.M. in the dining room. Shortly before 9:00 P.M. she was walking in the hall and Resident #199 told her she heard someone yelling outside her window. CNA #56 went to Resident #199's room and upon lifting the blinds so Resident #195 lying on the grass outside the window. CNA #56 immediately went to get LPN #58. LPN #58, CNA #56 and CNA #57 went outside to assist Resident #195. CNA #56 stated Resident #195 did not complain of pain and no injuries were observed. Resident #195 was safely returned into the building. Phone interview on 01/06/25 at 11:30 A.M. with CNA #57 confirmed he received a call from CNA #56 for assistance around 9:00 P.M. on 12/24/24. He observed Resident #195 lying on the ground outside of the facility. CNA #57 went to get Resident #195's wheelchair and then assisted LPN #58, and CNA #56 to get Resident #195 up and back into the facility. Phone interview on 01/06/25 at 11:45 A.M. with LPN #58 revealed he had last seen Resident #195 around 7:00 P.M. Shortly before 9:00 P.M. CNA #56 came to him stating Resident #195 was outside. LPN #58 and CNA #56 went outside and found Resident #195 lying on his left side on the grass outside of Resident #199's window. Resident #195 was assessed without noted injuries. LPN #58 confirmed he should have notified management immediately but did not contact the ADON till after 3:00 A.M. on 12/25/24. Interview on 01/06/25 at 12:55 P.M. with the DON revealed on 12/24/24 at 8:45 P.M. Resident #195 had an unwitnessed fall and was told he was found in an unoccupied room tangled in the window screen found on the floor. DON stated she was never told Resident #195 was found outside of the facility. DON confirmed she reviewed the staff witness statements and confirmed the statement from CNA #59 stated he was told Resident #195 was found outside of the building and brought back in safely. DON confirmed the witness statement completed by CNA #56 stated she observed Resident #195 through the window of the unoccupied room and observed the resident outside of the building lying on the ground. DON confirmed she was notified by the ADON on 12/25/24 at approximately 4:00 A.M. and she made the Administrator on call aware. Resident #195 was moved to the secured unit for safety. DON confirmed LPN #58 did not complete a nursing progress note and did not write a witness statement following the incident and staff were unaware Resident #195 was outside of the facility until Resident #199 told CNA #56. DON confirmed no other witness statements were obtained. DON also confirmed if a resident is found outside it would be considered an elopement. DON stated she did not complete an elopement incident investigation or a self-reported incident report because it was a new behavior and thought it was a change in status. Review of the 01/2022 revised facility policy Missing Person/Elopement Policy revealed an elopement is identified as an unauthorized exit from the facility involving a resident whose cognitive status and safety awareness are impaired. This deficiency represents non-compliance investigated under Complaint Number OH00161157.

Based on closed record review, staff interview, and review of the facility policy, the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #202) of three residents reviewed for medication administration. The facility census was 101. Findings include: Review of the closed medical record for Resident #202 revealed an admitted [DATE] with medical diagnoses including Parkinson's disease, dementia, and adjustment disorder with mixed anxiety and depressed mood. Resident #202 was admitted for a short, few-day respite stay. Review of Resident #202's physician's orders revealed an order dated 12/20/24 was placed for Carbidopa/Levodopa 23.75 milligrams (mg)-95 mg capsule, take one capsule by mouth four times daily for treatment of Parkinson's disease. Review of Resident #202's Medication Administration Record (MAR) for December 2024 revealed on 12/20/24, Resident #202 was administered Carbidopa/Levodopa one capsule at lunch and dinner and hour of sleep (hs). On 12/21/24, Resident #202 was administered Carbidopa/Levodopa 23.75-95 mg one capsule at breakfast, lunch, dinner, and hs. On 12/22/24, Resident #202 was administered Carbidopa/Levodopa 23.75-95 mg one capsule at breakfast, lunch, dinner, and hs. On 12/24/24, Resident #202 was administered Carbidopa/Levodopa 23.75-95 mg at breakfast. Review of the facility's Medication Error Log for December 2024 revealed a medication error occurred for Resident #202 on 12/23/24. The error was listed as having reaching the resident but had no listed adverse outcome. Review of the Medication Incident Report, dated 12/23/24, revealed Resident #202 was supposed to receive three capsules of Carbidopa/Levodopa 23.75-95 mg, four times a day. Resident #202 only received one capsule with each dose, equaling one-third of the ordered dose. The report indicated Resident #202 required increased monitoring, but the error led to no actual harm. The report listed education and counseling was provided to RN #64. Review of Resident #202's progress notes revealed an order dated 12/23/24 at 7:51 A.M. indicating the resident was found declined from baseline. The provider was alerted and agreeable to send the resident to a local hospital for evaluation. A subsequent note dated 12/23/24 at 11:52 A.M. noted the resident was observed with an altered mental status, talked/communicated less, was drowsy, and had decreased mobility. A third note dated 12/23/24 at 4:18 P.M. revealed a conversation with Resident #202's wife who communicated Resident #202 was admitted to the hospital for observation overnight, and the wife would be taking the resident home from the hospital at discharge. Interview on 01/09/25 at 9:00 A.M. with the DON and Administrator revealed Resident #202 was admitted to the facility on [DATE] by Registered Nurse (RN) #64. The admission paperwork was reviewed by the DON on Monday morning 12/23/24, and she identified a discrepancy when RN #64 transcribed Resident #202's admission order of Carbidopa/Levodopa 23.75-95 mg. The written admission orders called for Resident #202 to receive Carbidopa/Levodopa 23.75-95 mg, take three capsules by mouth four times a day at 7:00 A.M., 11:00 A.M., 3:00 P.M. and 7:00 P.M. RN #64 transcribed the order into the electronic health record as Carbidopa/Levodopa 23.75-95 mg one capsule to be given by mouth four times a day. The DON confirmed Resident #202 only received one-third of his ordered dose from 12/20/24 to 12/23/24. Interview on 01/13/25 at 2:26 P.M. with RN #64 revealed she was the nurse on duty and admitted Resident #202 on 12/20/24. RN #64 stated she transcribed the resident's medication incorrectly upon admission. She felt terrible when the DON told her she found a medication transcription and subsequent administration error for Resident #202 on 12/20/24, 12/21/24, 12/22/24 and 12/23/24. RN #64 noted a change in Resident #202's mental status on 12/23/24. She notified the provider, family, and sent the resident to the hospital. Resident #202 did not return to the facility. Review of the Medication Administration Policy, dated 03/22 revealed licensed nurses will ensure the six medication rights are followed: right resident, right drug, right dose, right time, right route, and right documentation. Any errors should be reported to the DON, resident physician, and resident/resident representative. Review of the Physician Order Policy dated 07/14 revealed the facility's policy is to follow physicians' orders as directed by the attending physician. Written orders obtained from the physician will be transcribed into the electronic health record for delivery. This deficiency represents non-compliance investigated under Master Complaint Number OH00161334.

Based on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #56 received care and services to prevent prolonged pressure to her bilateral buttocks resulting in pressure injury. Actual Harm occurred on 06/24/24 at 10:00 A.M. when Resident #56, who was at risk for developing pressure ulcers and required assistance on staff for incontinence care, was left on a bed pan for a unknown length of time resulting in a deep tissue pressure injury (a serious type of pressure injury that occurred when prolonged pressure and shear forces damage the tissues beneath the skin) to her bilateral buttocks. This affected one resident (Resident #56) out of three residents reviewed for pressure injuries. The facility census was 110. Findings include: Review of Resident #56's medical record revealed an admitted [DATE] and diagnoses included atherosclerotic heart disease of native coronary artery with unstable angina pectoris, type two diabetes, wedge compression fracture of T5-T6 vertebra, and moderate protein calorie malnutrition. Review of Resident #56's Braden Scale for Predicting Pressure Sore Risk dated 06/21/24 revealed Resident #56's risk was very high. Review of Resident #56's Pressure Injury Investigation dated 06/24/24 at 6:53 P.M. included Resident #56's Pressure Ulcer was discovered on 06/24/24, was a new area and in house acquired, the location of the wound was her bilateral buttocks and measurements were length 23.2 cm, width 30.0 cm, and depth was UTD (unable to be determined). The new wound was unstageable related to suspected Deep Tissue Injury (DTI). Area to bilateral buttocks, full thickness, 10 percent pink, 40 percent purple, maroon discoloration, 50 percent epithelial tissue, no drainage, peri wound moist, macerated, no signs and symptoms of infection. Unable to determine progress related to new area. Treatment ordered was cleanse with normal saline, pat dry, apply zinc oxide, leave open to air, apply every shift and as needed. Resident #56 had chronic bowel incontinence and continuous urinary incontinence or voiding dysfunction. Resident #56's HOB (head of bed) was elevated most days due to medical necessity. Resident #56 was receiving routine prevention daily (turning and repositioning, pressure relief, skin care, kept clean and dry), her care plan was appropriate and implemented consistently, and Resident #56 was compliant with her care. The section under Summary Statement of Wound was not completed. Resident #56's risk was very high for Braden Scale for Predicting Pressure Sore Risk. Resident #56's physician and family were notified. Initial evaluation with Wound Nurse Practitioner (WNP) #209 was completed, follow up in one week. Review of Resident #56's late entry progress notes dated 06/25/24 at 9:56 P.M. for 06/24/24 at 9:48 A.M. revealed Resident #56's Admission skin assessment was completed with WNP #209. During assessment it was noted that Resident #56 had an area to her bilateral buttocks caused by the bed pan. Treatment orders and interventions were put in place. Nurse Practitioner (NP) #210, the care team, and Resident #56's son were notified. Resident #56's Braden Scale was 9 (very high risk for developing a pressure ulcer, injury). Review of Resident #56's Wound Care Notes dated 06/24/24 at 10:00 A.M. and completed by WNP #209 included Resident #56 was being seen today for an initial consultation for wound care services in the setting of a Skilled Nursing Facility (SNF). Resident #56 was a [AGE] year-old female, and was a new admit from the hospital. Resident #56 had a fall and broke her T6. Resident #56 had urinary retention and a Foley (indwelling) catheter. Resident #56 was pleasantly confused, resting in bed and agreeable to care. Further review revealed Resident #56 had a DTPI (Deep Tissue Pressure Injury) to her bilateral buttocks. Depth Exposure was full thickness. Wound size measurements were length 23.2 cm (centimeters), width 30.0 cm, depth was UTD, clustered wound with intact skin bridge present. Wound base was 10 percent pink, 40 percent purple or maroon discoloration, 50 percent epithelial. There was no exudate, the peri wound was moist, macerated. The wound status was initial evaluation, linear purple discoloration from left to right buttock. Skin had a moist and macerated appearance with a small area of exposed pink tissue to the left buttock. Skin was dry in between with no exposed tissue to right buttock. Treatment was cleanse area with normal saline, apply zinc oxide to protect skin and keep dry, and leave open to air every shift and as needed. The treatment was chosen to help promote autolytic (breakdown of cells or tissues by enzymes produced by the cells themselves) debridement of the wound. Review of Resident #56's Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #56 was unable to complete the interview for Brief Interview for Mental Status. Resident #56 was dependent for toileting hygiene, bathing, and lower body dressing. Resident #56 was dependent to roll left and right, sit to lying, lying to sitting on side of bed, chair, bed-to-chair transfers and toilet transfers. Resident #56 had an indwelling catheter and was occasionally incontinent of bowel. Resident #56 had a pressure ulcer, injury and was at risk of developing pressure ulcer, injuries. Review of Resident #56's care plan dated 06/28/24 included Resident #56 had impairment of skin integrity related to weakness, impaired mobility, DTI of her bilateral buttocks. Resident #56's skin interventions, preventative measures were maintained. Resident #56 would have no avoidable skin breakdown. Interventions included turn and reposition every two hours while in bed (initiated 06/25/24); minimize pressure on bony prominences, pressure reducing mattress to bed (initiated 06/25/24). Further review did not reveal a care plan related to noncompliance with interventions related to DTPI of her bilateral buttocks. Review of Resident #56's Wound Report dated 07/01/24 at 12:30 P.M. revealed Resident #56 had an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed), originated as DTPI, was full thickness, measurements were length 20.1 cm, width 18.7 cm, and UTD depth, it was a clustered wound, with intact skin bridge present. Wound base was 20 percent granulation, 20 percent slough, 20 percent purple or maroon discoloration, 40 percent epithelial, with moderate serosanguinous drainage, peri wound was moist, macerated. The wound status had declined, Resident #56 was poorly compliant with offloading, poor nutritional intake, dementia, confusion, incontinence, and overall poor medical condition making the presence of the wound unavoidable (although the resident was identified to be on a bedpan contributing to the wound). Left buttock with dark purple discoloration as well as granulation tissue exposed. There was an area of slough to the upper left buttock which was debrided today. The wound was now more accurately identified as unstageable. Apply alginate silver to decrease bacterial colonization and manage drainage and apply zinc oxide to peri wound to protect skin and keep dry. Review of Resident #56's progress notes Wound Track documentation dated 08/26/24 at 8:52 A.M. included Resident #56's unstageable pressure ulcer related to suspected DTI had a length of 1.6 cm, width 0.5 cm, depth 0.2 cm, was in house acquired on 06/24/24, was unavoidable and Resident #56 was not compliant with interventions, had a red, yellow wound bed with scant amount of serous drainage, slough 30 percent, 70 percent granulation. Review of Resident #56's progress notes dated 07/28/24 through 08/27/24 revealed no evidence in the nursing progress notes or care plan Resident #56 was not compliant with interventions. Review of Resident #56's aide charting in the electronic record dated 08/26/24 at 6:41 P.M. through 08/28/24 at 4:15 P.M. did not reveal evidence Resident #56 was turned and repositioned. Review of Resident #56's Treatment Administration Record (TAR) dated 08/27/24 revealed it was documented on day shift by Licensed Practical Nurse (LPN) #214 that Resident #56 was turned and repositioned. Observation on 08/27/24 from 10:00 A.M. through 1:00 P.M. revealed Resident #56 was in bed, lying on her back with her eyes closed. There was no observation of any staff entering Resident #56's room and offering to turn and reposition her. Interview on 08/27/24 at 1:04 P.M. with State tested Nurse Aide (STNA) #212 revealed she worked in the facility Assisted Living area and sometimes helped out in the Nursing Home. STNA #212 stated on 08/27/24, day shift, she was assigned to work in the Assisted Living area, but went to the Nursing Home nursing unit Resident #56 resided on to help from 8:00 A.M. until 10:00 A.M. STNA #212 stated while she was assigned to the nursing unit Resident #56 resided on, she did not check or change Resident #56's incontinence brief or turn and reposition her. Observation on 08/27/24 from 1:07 P.M. until 1:57 P.M. of Resident #56 revealed Resident #56 was lying on her back, the head of her bed was elevated, and her eyes were closed. No staff entered Resident #56's room and offered to turn and reposition her. Observation on 08/27/24 from 2:11 P.M. through 2:58 P.M. of Resident #56 revealed she was lying on her back, the head of her bed elevated, eyes closed. No staff entered Resident #56's room and offered to turn and reposition her. Observation on 08/27/24 at 2:58 P.M. revealed STNA #213 gathered incontinence care supplies and entered Resident #56's room to provide care. STNA #213 stated she arrived for work at 10:00 A.M. today, and this was the first time she entered Resident #56's room to provide care including turning and repositioning. STNA #213 stated she was too busy until now to assist Resident #56 with turning and repositioning and incontinence care. STNA #213 proceeded to provide Resident #56's incontinence care, and during the observation a long curving line on Resident #56's left buttock could be seen. The line was a purplish red in color and along the line about midway a small opening about a half inch by three quarters of an inch could be seen, and the wound bed was dark red. Resident #56's right buttock was reddened with no open area. Resident #56 did not resist or refuse to have STNA #213 provide incontinence care. Interview on 08/28/24 at 9:08 P.M. with Nurse #215 revealed on 06/24/24 Resident #56 was found lying on a bedpan when WNP #209 entered her room with Nurse #215 to evaluate Resident #56's pressure injuries which were present on admission to the facility. Nurse #215 stated the length of time Resident #56 was on the bedpan was unknown because it was first thing in the morning and when they entered Resident #56's room to assess her they found her with the bedpan underneath her. Nurse #215 stated the bedpan was left underneath Resident #56 from the night shift, and with the amount of agency staff in the building it could not be determined how the situation happened, or who caused the situation. Nurse #215 stated Resident #56 was treated for the injury caused by the bedpan. Nurse #215 stated we were both pretty mortified that something like that could happen, and the marks on her left buttock had the impression from the bedpan. Nurse #215 stated the injury was a DTI which progressed. Interview on 08/28/24 at 9:23 A.M. with NP #210 confirmed Resident #56 was found on a bedpan which caused a pressure injury. NP #210 stated she did not know the details, and did not look at the wound because WNP #209 was taking care of it and ordered treatments. Interview on 08/28/24 at 10:46 A.M. with STNA #216 revealed she was assigned to care for Resident #56 today and had taken care of her previously. STNA #216 stated Resident #56 was compliant with her care and she lets us do what we need to do. Interview on 08/28/24 at 2:06 P.M. with WNP #209 revealed on 06/24/24 she was at the facility in the morning to evaluate Resident #56's wound. WNP #209 stated she was told about the bedpan and her job was to evaluate the wound. WNP #209 stated Resident #56 had a DTI on her buttocks which was caused by prolonged pressure for an extended period of time. WNP #209 stated anything that pushes could cause a DTI. WNP #209 stated Resident #56 had issues with declining health, something could have happened with the bedpan, and she heard Resident #56 was on the bedpan for a prolonged period of time, and I am sure it contributed. Review of the facility policy titled Wound Prevention and Management Policy dated 10/2022 included a Wound Track Assessment would be documented at the time of discovery of the skin breakdown and then weekly thereafter. A care plan would be initiated and updated as necessary until the area was resolved. A preventative plan of care and intervention would be initiated for any residents determined to be at risk, to reduce the possibility of further breakdown. This deficiency represents non-compliance investigated under Complaint Number OH00156926.

Based on observation, interview, record review and review of the manufacturers instructions and facility policy the facility failed to ensure appropriate incontinence care was provided for Resident's #43, #48 and #56. This affected three residents (#43, #48, and #56) and had the potential to affect resident residing in the facility who were incontinent. The facility census was 110. Findings include: 1. Review of Resident #48's medical record revealed an admitted [DATE] and diagnoses included type two diabetes mellitus, major depressive disorder, anxiety disorder, and alcohol abuse. Review of Resident #48's Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #48 had moderate cognitive impairment. Resident #48 was dependent for toileting hygiene and was frequently incontinent of urine and bowel. Observation on 08/27/24 at 1:26 P.M. of State tested Nursing Assistant (STNA) #213 revealed she gathered supplies and entered Resident #48's room to provide incontinence care. Resident #48 stated she was getting really frustrated because she needed incontinence care and wanted to go to the activity with animals, and she was afraid she was going to miss the activity, and she really loved animals. STNA #213 asked Resident #48 how much help she needed and Resident #48 stated she could not lift her bottom, she had not been changed today, and was wearing a liner and a pull up for incontinence. STNA #213 proceeded to provide Resident #48 incontinence care, and observation of her bottom revealed a small open abrasion area on her right lower buttocks. Resident #48 stated she did not get changed timely and that was why she wanted two liners in her pull up before she went to see the animals. Resident #48 stated she often had to wait a long time before her call light was answered and her incontinence pull up and liners were changed, and if she only had one liner her leggings would be soaked by the time someone came to change her. Resident #48 stated she did not want her leggings to get wet and that was why she requested two liners. Resident #48 stated by the time she peed three times the urine gets on her leggings. Resident #48 indicated the two liners in her pull up made it look like she had a penis, but that was okay because she would be dry. Review of the facility incontinence liners manufacturers instructions included two incontinence liners should not be worn at the same time, and you should not wear more than one liner at a time. Wearing multiple pads could cause hard edges that could damage skin and be uncomfortable. Using more than one pad did not provide extra absorbency. Leakage from the first product would overflow into the second product, causing both products to leak more quickly. The first product would leak onto the second and both would become less absorbent. Wearing more than one pad was considered bad practice. Review of the facility policy titled Protocol Related to Assessment of Bowel and Bladder Incontinence revised 10/2014 included the policy was a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. If continence assessment identified a resident as incontinent of bowel, bladder, the facility would initiate appropriate interventions to help maintain dryness and the resident's right to dignity. 2. Review of Resident #56's medical record revealed an admitted [DATE] and diagnoses included atherosclerotic heart disease of native coronary artery with unstable angina pectoris, type two diabetes, wedge compression fracture of T5-T6 vertebra, and moderate protein calorie malnutrition. Review of Resident #56's Admission MDS 3.0 assessment dated [DATE] revealed Resident #56 was unable to complete the interview for mental status. Resident #56 was dependent for toileting hygiene. Review of Resident #56's aide charting in the electronic record from 08/26/24 at 6:42 P.M. through 08/28/24 at 4:15 P.M. revealed there was no evidence Resident #56 was provided incontinence care and her incontinence brief and liners were changed. Observation on 08/27/24 at 2:58 P.M. of STNA #213 revealed she gathered incontinence supplies and entered Resident #56's room to provide incontinence care. STNA #213 proceeded to provide incontinence care and Resident #56 was observed to have one incontinence brief and two liners on inside her brief. The incontinence liners and incontinence brief were wet with urine. Resident #56's perineal area and buttocks were red and irritated looking. STNA #213 stated she arrived to work at 10:00 A.M. and this was the first time she checked and changed Resident #56's incontinence brief and liners. STNA #213 was unable to complete Resident #56's incontinence care without help because Resident #56 was afraid of falling on the floor. STNA #213 made Resident #56 comfortable and left the room to find someone to assist her. Observation on 08/27/24 at 3:33 P.M. STNA #213 arrived back to Resident #56's room with the Director of Nursing (DON) to help her complete Resident #56's incontinence care. STNA #213 placed two incontinence liners on Resident #56, and did not use panties. The Director of Nursing confirmed Resident #56 was wearing two incontinence liners. Interview on 08/27/24 at 4:24 P.M. with the DON and Wound Nurse (WN) #222 revealed Resident #56 preferred an incontinence liner over a brief. When asked if two incontinence liners was appropriate the DON did not answer the question directly. Review of the facility incontinence liners manufacturers instructions included two incontinence liners should not be worn at the same time, and you should not wear more than one liner at a time. Wearing multiple pads could cause hard edges that could damage skin and be uncomfortable. Using more than one pad did not provide extra absorbency. Leakage from the first product would overflow into the second product, causing both products to leak more quickly. The first product would leak onto the second and both would become less absorbent. Wearing more than one pad was considered bad practice. Review of the facility policy titled Protocol Related to Assessment of Bowel and Bladder Incontinence revised 10/2014 included the policy was a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. If continence assessment identified a resident as incontinent of bowel, bladder, the facility would initiate appropriate interventions to help maintain dryness and the resident's right to dignity. 3. Review of Resident #43's medical record revealed an admitted [DATE] and diagnoses included Alzheimer's Disease, rheumatoid arthritis, and retention of urine. Review of Resident #43's Quarterly MDS 3.0 assessment dated [DATE] revealed Resident #43 had severe cognitive impairment. Resident #43 was dependent for bathing, personal hygiene and toileting hygiene. Resident #43 was frequently incontinent of urine and always incontinent of bowel. Observation on 08/27/24 at 3:43 P.M. of STNA's #213 and #223 revealed they entered Resident #43's room to provide incontinence care. STNA #213 stated this was the first time since she arrived to work at 10:00 A.M. that she checked Resident for incontinence and changed her incontinence brief. STNA's #213 and #223 proceeded to provide Resident #43's incontinence care, and when the soiled incontinence brief was removed a soiled incontinence liner was observed. Resident #43's bottom was reddened over most of her perineum and buttocks, and she had a moderate bowel movement and it looked like feces was dried on her skin, and STNA #223 had to scrub back and forth on Resident #43's skin to remove the feces. STNA #223 stated the bowel movement looked fresh to her. STNA's #213 and #223 finished with Resident #43's care and placed a clean incontinence brief and incontinence liner on her. Review of the facility incontinence liners manufacturers instructions included two incontinence liners should not be worn at the same time, and you should not wear more than one liner at a time. Wearing multiple pads could cause hard edges that could damage skin and be uncomfortable. Using more than one pad did not provide extra absorbency. Leakage from the first product would overflow into the second product, causing both products to leak more quickly. The first product would leak onto the second and both would become less absorbent. Wearing more than one pad was considered bad practice. Review of the facility policy titled Protocol Related to Assessment of Bowel and Bladder Incontinence revised 10/2014 included the policy was a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. If continence assessment identified a resident as incontinent of bowel, bladder, the facility would initiate appropriate interventions to help maintain dryness and the resident's right to dignity. This deficiency represents non-compliance investigated under Complaint Number OH00156926.

Based on interview, record review and review of facility policy the facility failed to ensure care planned interventions were implemented to treat Resident #75's substance abuse. This affected one resident (Resident #75) out of three residents reviewed for substance abuse. The facility census was 110. Findings include: Review of Resident #75's medical record revealed an admitted [DATE] and diagnoses included congestive heart failure (CHF), alcohol dependence with alcohol-induced mood disorder, and bipolar disorder. Review of Resident #75's Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #75 was cognitively intact. Resident #75 required substantial to maximal assistance with toileting hygiene, bathing, lower body dressing, and putting on and taking off footwear. Resident #75 required partial to moderate assistance to walk 10 feet, walking further and car transfer was not attempted due to medical condition or safety concerns. Review of Resident #75's physician orders dated 07/08/24 revealed no LOA (leave of absence) except for Dr. appointments until further notice per MD #216. The order was discontinued on 08/16/24. Review of Resident #75's progress notes dated 07/30/24 at 6:50 P.M. included after Resident #75's girlfriend was at the facility for a visit Resident #75 was sleeping in his room. After dinner Resident #75 woke up and appeared to be inebriated. Resident #75 stated his girlfriend gave him a bottle. There was an empty water bottle in Resident #75's trash that smelled of liquor. Information passed on to the nightshift nurse and Physician made aware. Review of Resident #75's progress notes dated 07/30/24 at 10:00 P.M. included the nightshift nurse was informed Resident #75 was intoxicated, went to happy hour and may have had one drink. Resident #75 told the nurse he had one drink. The nurse told Resident #75 she needed an honest answer for his safety. Resident #75 stated his girlfriend came to visit, and asked him to go to her car because she had a gift. Resident #75's caretaker gave him a bottle with vodka in it when he went with her to the car. Resident #75 pointed to the empty water bottle in his trash when asked where the bottle was. The nurse removed the water bottle which smelled like alcohol. Resident #75's nurse practitioner was made aware and he was being watched for safety. Call light within reach. Review of Resident #75's care plan with a target date of 10/03/24 included Resident #75 had a risk for harm, injury to self, non compliance. Resident #75 drinks ETOH (alcohol) to excess and had a physician order to only have one to two beers at happy hour, which was discontinued on 08/19/24. Resident #75's resident rights would be respected, Resident #75 would accept reason why to be compliant, Resident #75 would have decreased episodes of non compliance and his safety would be maintained. Interventions included one to one visit as needed, involve family and make referrals as needed; acknowledge Resident #75's right to not comply, provide positive feedback for compliance; identify reasons for noncompliance such as lack of understanding, cultural differences and emphasize positives. The care plan was revised and included Resident #75 remained non compliant with ETOH use despite education on negative effects, continued to go on LOA where ETOH was potentially involved, MD prefers LOA be only for medical appointment. The Goal and Interventions were unchanged. Review of Resident #75's medical record including orders and progress notes dated 07/30/24 through 08/15/24 did not reveal evidence of care planned interventions being implemented after Resident #75 used alcohol on 07/30/24. Review of Resident #75's progress notes dated 08/16/24 at 5:16 P.M. revealed a call was placed to MD #217's office regarding Resident #75's request to have LOA and to fishing this weekend. Return call received and orders noted that resident may resume LOA's. Resident #75 was educated on safety on LOA and dangers of consuming alcohol excessively. Resident #75 verbalized understanding. Review of Resident #75's physician orders dated 08/16/24 through 08/28/24 did not reveal further orders related to Resident #75's LOA's, including MD prefers Resident #75 to only go on medical appointments. Interview on 08/28/24 at 2:41 P.M. with Director of Nursing (DON) revealed she only knew about one episode of Resident #75 drinking, was not aware Resident #75 had another episode of inebriation, and did not know about Resident #75's girlfriend bringing him vodka in a water bottle on 07/30/24. The DON stated she spoke with Resident #75 today, and he stated he had no problem, saw an outside psych counselor, and did not want to see anyone else. Interview on 08/28/24 at 3:19 P.M. with Licensed Practical Nurse (LPN) #220 revealed she worked night shift on 07/30/24 and was told by the day shift nurse Resident #75 went to happy hour, seemed like he had more than one drink, was very intoxicated and not able to stand. Resident #75 stated the nurse told her there was an empty water bottle in his room that smelled like alcohol. LPN #220 stated Resident #75's caretaker brought the water bottle with vodka when she came to visit, and Resident #75's physician was notified of the situation and did not give further instructions or orders. Interview on 08/28/24 at 3:57 P.M. with Social Services Designee (SSD) #221 revealed Resident #75 had a drinking problem in the past, and he said he was an alcoholic. SSD #221 stated she was aware of one situation where Resident #75 became drunk, and she had to follow up with him, but did not know he had another episode of drinking on 07/30/24. SSD #221 stated when she talked to MD #217 she was told MD #217 was restricting LOA's until further notice, but Resident #75 could participate in happy hour at the facility because alcohol consumption was limited. SSD #221 indicated she did not offer Resident #75 psych services because she only knew of one time when Resident #75 became drunk, thought it was a one time issue, and if she knew about the second episode she would have offered services including a psychology consult. Resident #75 received psych services from an outside hospital and SSD #221 would have contacted his outside provider social worker so the appropriate services could be provided. SSD #221 stated she was not notified the second drinking situation happened, and usually nursing reviewed progress notes and the DON would bring it to her attention. Interview on 08/28/24 at 4:19 P.M. with MD #217 revealed she was notified about Resident #75's caretaker bringing him vodka on 07/30/24. MD #217 stated Resident #75's LOA should have been revoked, and he should not have been allowed to go on LOA for a fishing trip due to safety reasons. MD #217 stated she did not know who called from her office and told the facility Resident #75 could go on a LOA for a fishing trip. A request was made for the facility substance abuse treatment policy and an illegal substance policy was provided. A substance abuse treatment policy was not provided for review. This deficiency represents non-compliance investigated under Complaint Number OH00156926.

Based on interview, record review and review of facility policy the facility failed to ensure appropriate placement and interventions were in place to ensure Resident #111's choice and safety were maximized. This affected one resident (Resident #111) out of three residents reviewed for behavioral health services. The facility census was 110. Findings include: Review of Resident #111's medical record revealed an admitted [DATE] and diagnoses included Parkinson's Disease without dyskinesia, without mention of fluctuations, dementia with agitation, hallucinations, and wedge compression fracture of third lumbar vertebra. Resident #111 was discharged from the facility on 08/09/24. Review of Resident #111's hospital notes for his admission from 07/17/24 through 07/24/24 included Resident #111 was brought to the ED for wandering away from his home. Resident #111 had Parkinson's disease and dementia, and his ton stated Resident #111 was not very compliant with his medications. EMS stated they were called to the home because Resident #111 was found wandering. On arrival to the ED Resident #111 was awake, alert, oriented, he knew where he was. Resident #111's son stated Resident #111 cooked, cleaned and seemed to take care of himself very well, but did have an occasional instance where he had hallucinations and wandered away from home. Resident #111's son stated at this time he felt Resident #111 was safe to reside in his home by himself, they checked on him periodically. Resident #111's son was given information for services that could provide additional assistance with the home. Resident #111's son stated he felt there were no acute findings today and Resident #111 could be discharged and return to his home. Resident #111 was referred to follow up with his family physician for reevaluation or placement if desired in the future. Review of Resident #111's After Visit Summary for hospital stay 07/16/24 through 07/24/24 included Resident #111 was unable to ambulate. Resident #111's mental status was disoriented, alert, and wax and wane. Resident #111 used a walker and needed assistance with walking. Safety concerns were sundowners syndrome, history of falls in past 30 days and was at risk for falls. Resident #111 was discharged to the facility due to he required a Skilled Nursing Facility for less than 30 days. There were no orders for Resident #111 to be placed in a secured nursing unit. Review of Resident #111's physician orders dated 07/24/24 revealed MD (Medical Doctor) #217 approved placement, continued placement in secured unit. Review of Resident #111's Elopement Risk assessment dated [DATE] revealed Resident #111 was not at risk for elopement. Review of Resident #111's progress notes Admission assessment dated [DATE] at 6:16 P.M. included Resident #111 was alert and oriented times three (time, place, person), MD #217 notified of admission and orders verified. Resident #111 was able to explain his current diagnosis of Parkinson's disease and he was at the facility to receive therapy and get his strength back up. Review of Resident #111's care plan dated 07/25/24 included Resident #111 had the potential for impaired adjustment. Resident #111 identified inability to adequately adjust and cope. Resident #111 would adjust to new environment with minimal frustration. Interventions included to assess Resident #111's interests and strengths and encourage activity particiation; to encourage expression of feelings; one on one visits as needed, allow to vent feelings related to placement, involve family in care and update as needed. Review of Resident #111's progress notes dated 07/27/24 at 11:03 P.M. included Resident #111 was alert and oriented times two (person, place), and at times seemed to be oriented times two to three. Resident #111 voiced being able to leave and go home. Resident #111 was reminded he needed to be at the facility to get stronger. Review of Resident #111's progress notes dated 07/28/24 at 10:20 A.M. revealed Resident #111 was alert and oriented times one to two. Resident #111 insisted he needed to call his bank to check on his account. It was explained to Resident #111 that his son would be handling all his financial needs while he was in the facility. Resident #111 was very upset and stated he had to get out of here,and continuously paced throughout the secured unit. Review of Resident #111's progress notes dated 07/28/24 at 4:18 P.M. revealed at approximately 3:15 P.M. Resident #111 was alert and oriented times four (person, place, time, situation) went to walk outside the facility for air and did not notify the nurse or staff. Resident #111 returned and the leave of absence policy was reviewed by the nurse and Resident #111 was educated on courtyard adherence. Resident #111 was last seen at the nurse's station at around 2:30 P.M., was asking to use the telephone and call the bank. Resident #111's sons and MD #217 were notified. Review of Resident #111's progress notes dated 07/28/24 at 6:03 P.M. revealed Resident #111 was not confused and family aware Resident #111 calling bank was normal behavior for financial concerns. Family and MD #217 noted Resident #111 did not need to be on a dementia unit at this time and at no risk at present. Review of Resident #111's Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #111 was cognitively intact. Resident #111 used a walker, and required supervision or touching assistance for toileting and personal hygiene, and lower body dressing. Resident #111 was independent for putting on and taking off footwear, and upper body dressing. Resident #111 required supervision with assistance for walking 10 feet to 150 feet. Resident #111's ability to walk 10 feet on uneven surfaces was not attempted due to medical condition or safety concerns. Observation on 08/27/24 at 10:17 A.M. of Resident #111's former room with Assistant Director of Nursing (ADON) #202 revealed there were two metal brackets secured to the window frame on both sides of the window, and above the metal brackets on both sides of the window revealed two black brackets attached above the metal brackets. ADON #202 stated the metal brackets and the black brackets were to prevent the window from being opened. ADON #202 stated we thought Resident #111 was an elopement risk and needed the secured unit. ADON #202 indicated Resident #111 could do things on his own, could manage his money and after a lengthy conversation it was noticed Resident #111 was a bit confused. ADON #202 stated Resident #111 was adamant about moving, got out and said he was not like these people. ADON #202 stated Resident #111 was found wandering at home and taken to the hospital. Interview on 08/27/24 at 10:43 A.M. of Maintenance Assistant (MA) #208 revealed the Maintenance Supervisor was on vacation and she was called into the facility when Resident #111 left via his window. MA #208 stated he was not sure how Resident #111 opened his window and exited the facility, but he put a second set of black brackets on the window. MA #208 stated the Maintenance Supervisor put new metal brackets on the window until the black brackets could be installed. Interview on 08/27/24 at 12:23 P.M. of Licensed Practical Nurse (LPN) #206 revealed she was working the day Resident #111 left the secured unit via his window. LPN #206 stated the metal brackets on the window were very loose and Resident #111 was able to move them and push the window up. LPN #206 stated she saw Resident #111 when he was coming back in the window and she saw his foot come in through the window. LPN #206 indicated Resident #111 told her he was only gone a short time, only went to the parking lot and back, and just needed some air. LPN #206 stated Resident #111 was not exit concerned, he was more tired of other residents, and said he was not like these people and why am I here on this unit. LPN #206 indicated Resident #111 was upset and stated he had to get out of here. LPN #206 stated the Director of Nursing (DON) told her to move Resident #111 out of the secured unit because he should not be on the unit due to a BIMS (Brief Interview for Mental Status) of 14. LPN #206 stated Resident #111 did not have an order to be on the unit and MD #217 told her it was okay to move him. LPN #206 indicated Resident #111 told her they were restraining me and had to let me go. Interview on 08/27/24 at 4:45 P.M. of MD #217 revealed Resident #111 was placed in a secured unit and he was transferred out of the unit to have the ability to have more freedom and would be less restless. MD #217 stated Resident #111 had a BIMS of 14 and was automatically placed on admission in the secured unit. MD #217 stated wherever he came from must have requested a secured unit, it must have been requested by the hospital, and she did not order him to be on a secured unit. Interview on 08/27/24 at 4:58 P.M. of Registered Nurse (RN) #218 revealed Resident #111 was placed on a secured unit because he was wandering at home, and admissions made the decision to place him on the unit. RN #218 stated she verified Resident #111's medication orders with MD #217, but not the secured unit order. RN #218 stated she did not take an order from MD #217 to place Resident #111 on the secured unit. RN #218 indicated she might have sent MD #217 a message stating Resident #111 was on the secured unit. RN #218 stated she did not know if the secured unit admission form was signed, and was not responsible to make sure the form was signed. RN #218 stated the secured unit order was a standard batch order, Resident #111 was admitted to the secured unit and batch orders were placed. RN #218 indicated an order for the secured unit was automatically placed under Resident #111's primary care providers name (MD #217). Interview on 08/27/24 at 5:06 P.M. of Admissions Director (AD) #205 revealed the hospital staff told Hospital Liason (HL) #219 that Resident #111 needed a secured unit, and HL #219 told her he needed the secured unit. AD #205 stated she had no written documentation Resident #111 needed a secured unit, and it was all done verbally. Interview on 08/27/24 at 5:10 P.M. of HL #219 revealed revealed Resident #111 was in the hospital for altered mental status. HL #219 stated there was some back and forth communication with the facility regarding the high cost of a medication, but she did not tell the facility Resident #111 needed to be in a secured unit, and the hospital did not say Resident #111 needed a secured unit. HL #219 stated Resident Rights were important and she would have requested psych notes, but the hospital did not think psych needed to be involved so she did not request them. Interview on 08/28/24 at 9:47 A.M. of the DON revealed Resident #111 was alert and oriented most of the time he was in the facility, and was independent. The DON stated she was called when Resident #111 left his room via the window, and when he returned she spoke to him and he told her he wanted to go outside for a breath of fresh air, walked up and down the sidewalk then came back in his window. Resident #111 stated he wanted to call the bank and pay his bills, and the DON spoke to his son who told her Resident #111 took care of his business at home and was fine to do it while he resided in the facility. Resident #111's son told the DON the only reason he was in the facility was because he needed therapy to get stronger, then he was going home. The DON stated Resident #111 was moved off the secured unit. The DON stated the hospital said he was noted walking around the community, he was confused, his labs were off, and the hospital treated him. The DON stated Resident #111's son felt he needed therapy, he was admitted to the facility for therapy, and the facility wanted to keep him safe and felt the secured unit was appropriate. The DON stated the family gave verbal consent for Resident #111 to be placed in the secured unit. The DON confirmed Resident #111 was placed in the secured nursing unit for four days. Interview on 08/28/24 at 3:10 P.M. of the Administrator revealed AD #205 forgot she had a signed form for Resident #111 to be in the secured unit and just found it. The Administrator handed a signed Secured Unit form to the surveyor which was dated 07/24/24 and electronically signed by Resident #111. Review of Resident #111's medical record dated 07/24/24 through 08/09/24 revealed although Resident #111 electronically signed the Secured Unit form there was no evidence it was clinically indicated he needed a secured unit. Review of the policy titled Secured Unit Placement assessment dated ,d+[DATE] included Residents with a diagnosis of dementia, behaviors, memory impairment and, or those resident that were exit seeking would be considered for placement on the secured unit. The resident representative, responsible party, POA, would sign the secured unit consent prior to placement on the unit, unless placement was needed in an emergency situation. This deficiency represents non-compliance investigated under Complaint Number OH00156926.

Based on observation and interview, the facility failed to ensure resident call lights were answered in a timely manner. This affected one (Resident #59) of one resident reviewed for call lights. The facility census was 106. Findings include: During an interview on 06/03/24 at 10:29 A.M., Resident #40 stated when she activated their call light, it took a long time for staff to respond. During an interview on 06/03/24 at 10:56 A.M., Resident #306 stated it sometimes took staff a long time to answer his call light. During an interview on 06/03/24 at 12:03 P.M., Resident #59 stated she activated her call light when she was incontinent of urine and/or bowel and her call light was often not answered timely. Resident #59 stated she would activate her call light button and staff would sometimes come into the room and turn it off without providing assistance. Resident #59 stated she yelled for help at times when waiting a long time for assistance. During an observation on 06/03/24 beginning at 12:21 P.M., Resident #59's call light was activated. The resident stated see, this is a perfect example, and stated a staff member had come into the room, turned the call light off, and said they would be back. Resident #59 continued to yell hello repeatedly. At 12:56 P.M., Agency State tested Nurse Aide (STNA) #611 entered Resident #59's room. Resident #59 told STNA #611 a staff member never came back to change her. STNA #511 stated she had just gotten to the facility and would return to the room in a few minutes. At 1:08 P.M., Resident #59 stated aloud I cant believe it--it's been an hour and they still haven't came in here. At 1:10 P.M., STNA #417 entered Resident #59's room while the call light was activated to deliver a meal tray for the lunch meal. Resident #59 stated she did not want to eat. STNA #417 stated no problem and returned the tray to the meal cart as the call light continued to be activated. During an observation on 06/03/24 at 1:11 P.M. an unidentified staff member delivered a meal tray to the roommate of Resident #59. At that time, Resident #59 stated she had been waiting to be changed for an hour. The staff member stated they did not know anything about that, turned the call light off, and exited the room. Resident #59 continued to notify staff that she needed assistance. On 06/03/24 at approximately 1:15 P.M., the resident received assistance from a nurse. During an interview following the observation, Resident #59 stated she refused her lunch because she was so upset at having to wait to be changed. During an interview on 06/03/24 at 1:28 P.M., Agency STNA #411 verified Resident #59's call light had been on for quite a while. STNA #411 reported that when receiving report, Resident #59 had asked her to come into the room when she had a chance but did not specify what they needed. STNA #411 stated she then got busy with assisting residents in getting up and delivering meal trays for the lunch meal.

Based on observation, record review, interview, facility policy and procedure review, self-reported incident (SRI) and investigation review, the facility failed to ensure bilateral bed bolsters (long firm narrow cushion used to prop, position and/ or support) were in place per the physician's orders and care plan prior to completing bed mobility and incontinence care resulting in Resident #63's fall with significant injuries. Actual Harm occurred on 01/31/24 at approximately 11:00 A.M. when Resident #63, who had a physician order to have bilateral bed bolsters to her mattress and was dependent on staff for activities of daily living (ADL), was provided incontinence care by Agency State tested Nursing Assistant (STNA) #600 and fell from her bed face down onto the floor resulting in having a neck injury, a tennis ball sized hematoma to the forehead, closed fracture of the nasal bone, closed nondisplaced fracture to her right wrist, contusion of the chest and abdominal wall, and skin tear to the right elbow. Resident #63 stated she requested Agency STNA #600 put her bed bolsters back on prior to providing care, but Agency STNA #600 did not listen to her and instead proceeded without the bolsters in place and pushed her too far over in bed resulting in her falling out of the bed. This affected one resident (#63) out of three residents reviewed for falls. The facility identified 13 residents (#17, #24, #30, #31, #37, #39, #52, #59, #63, #64, #70, #81, and #94) who had physician's orders for bed bolsters. The facility census was 96. Findings Include: Review of the medical record for Resident #63 revealed an admitted [DATE] and diagnoses included asthma, diabetes, chronic kidney disorder, anxiety, colitis, and osteoarthritis. Review of the undated care plan revealed Resident #63 had an ADL selfcare-deficit. Interventions included check and change every two hours and as needed, transfer with two-person assist for safety, and assist with ADL as needed. Review of the undated care plan revealed Resident #63 had impaired skin integrity. Interventions included turning and repositioning every two hours while in bed and low air loss mattress with bilateral bolsters. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 had intact cognition as her Brief Interview for Mental Status (BIMS) was a 13 of 15 . She was dependent on staff to assist with toileting, rolling left to right, sitting to lying, lying to sitting, and transfers. She was always incontinent of bowel and bladder. Review of the Fall Risk assessment dated [DATE] and completed by Licensed Practical Nurse (LPN) #618 revealed Resident #63 was at high risk for falls as she was incontinent, non-ambulatory, and required assistance with transfers. Review of the physician order dated 01/10/24 revealed Resident #63 had an order to have a low air loss mattress with bilateral bolsters every shift. Review of the Physical Therapy Evaluation and Plan of Treatment dated 01/17/24 and completed by Physical Therapist (PT) #611 revealed therapy would be provided 12 times from 01/17/24 to 02/13/24. The evaluation revealed currently Resident #63 required maximum assistance with bed mobility. Review of SRI tracking number 243669 dated 01/31/24 revealed the facility filed an SRI for neglect involving Resident #63 and Agency STNA #600. The SRI revealed Resident #63 came back from an appointment and needed immediate care as she was incontinent. While providing care, the resident turned the wrong way and fell out of bed. The facility unsubstantiated the SRI for neglect. Review of undated witness statement completed by Agency STNA #600 revealed she and another aide, Agency STNA #607, went to complete care in Resident #63's room. (Agency STNA #607 provided care to Resident #63's roommate in the bathroom). Agency STNA #600 completed care for Resident #63 as she had come back from a doctor's appointment and requested to be changed. She proceeded to gather her stuff to provide care and Resident #63 stated not to forget to put her bolsters back on when she was done. She told Resident #63 that she would not forget. Resident #63 stated the paramedics took them out of her bed. She proceeded to roll the linen on the bed and asked the resident to turn. She proceeded to turn and placed the linen underneath her. She told her not to roll anymore but she rolled again, and Agency STNA #600 tried to catch her as she leaped onto her bed but Resident #63 fell to the floor. She told the Agency STNA #607 who went to get the nurse. Review of the progress note dated 01/31/24 at 10:58 A.M. and completed by Nurse Practitioner (NP) #606 revealed Resident #63 was examined due to the fall and hematoma. Resident #63 had a tennis ball sized hematoma to her forehead due to a fall from her bed to the floor. She had a skin tear on her right arm. Her neurological checks were within normal limits but due to blood thinners NP #606 recommended the resident be sent to the hospital. Review of the nursing note dated 1/31/24 at 5:13 P.M. and completed by Registered Nurse (RN) #605 revealed Resident #63 rolled out of bed onto the floor when turned on her side during care. She hit her face on the carpet causing large hematoma to the middle of her forehead, bruising to the bridge of her nose, bleeding from her nose, and a skin tear to her right elbow. Her vital signs were stable, and she was alert and oriented with no loss of consciousness. NP #606 was notified, and Resident #63 was sent to the emergency room (ER). Review of the After Visit Summary dated 01/31/24 revealed ER Physician #601 evaluated Resident #63 due to fall from bed. She was diagnosed with neck injury, closed fracture to her nasal bone, closed nondisplaced fracture to her right wrist, contusion of her chest and abdominal wall, and a skin tear to her right elbow. She was provided with a splint to her right wrist and an ordered antibiotic therapy. She also was scheduled to have follow up consults with Facial/ Plastic Physician #602 and Orthopedic Physician #603. Review of the nursing note dated 01/31/24 at 7:30 P.M. and completed by RN #604 revealed Resident #63 came back from the emergency room and had facial bruising, right wrist wrapped due to fracture, skin tear to right elbow, severe swelling to her face, hematoma above her eyes, and her eyes were black and blue. Review of the nursing note dated 02/01/24 at 1:49 A.M. and completed by RN #604 revealed Resident #63's face was swollen to the point her right eye was swollen shut. Review of the Visual/ Bedside Kardex Report as of 02/23/24 revealed Resident #63 was to have a low air loss mattress with bilateral bolsters. She required check and change every two hours and as needed. Interview on 02/23/24 at 8:52 A.M. with Agency STNA #607 revealed on 01/31/24 she was in Resident #63's bathroom during the incident with her roommate. She revealed Agency STNA #600 had gone in the room at the same time to provide Resident #63 incontinence care. (Agency STNA #600 was the only other staff member in the room providing Resident #63's care). While in the bathroom she heard a loud commotion, and Agency STNA #600 stated Resident #63 was on the floor. Agency STNA #607 went to get the nurse. Interview and observation on 02/23/24 at 9:26 A.M. revealed Resident #63 was lying on a low air loss mattress with bilateral bolsters and had a large hematoma to the center of her forehead, bruising covering almost her entire face of all different colors: yellow, brown, purple, and blue. She had a black splint on her right wrist. Resident #63 revealed when she went to the doctor's appointment, the paramedics removed the bolsters so that they could move her from the bed to the stretcher. When she returned, she told Agency STNA #600 to put her bumpers back on her bed before she changed her. Agency STNA #600 was in a big hurry and would not listen to her. Agency STNA #600 started changing her by pushing her over towards the doorway. Resident #63 told Agency STNA #600 to stop but she kept on pushing her until she fell out of bed onto the floor. Resident #63 fell on her face and broke her wrist. Observation on 02/23/24 at 10:47 A.M. of incontinence care for Resident #63 completed by Licensed Practical Nurse (LPN) #608, STNA #609, and Agency STNA #607 revealed Resident #63 was dependent on staff to assist in rolling her from side to side in bed to complete her incontinence care. She was on a low air loss mattress with bed bolsters. Interview on 02/23/24 at 12:27 P.M. with the Director of Nursing revealed Resident #63 had gone on an appointment on 01/31/24 and at that time the paramedics removed the bolsters because they were moving her from the bed to the cot. When Resident #63 returned from the appointment the bolsters were not put back on. She verified in Agency STNA #600's witness statement that Resident #63 had requested her bed bolsters be put on. She verified Agency STNA #600 provided care including rolling and incontinence care without the bed bolsters in place resulting in Resident #63 falling out of bed. Interview on 02/23/24 at 12:32 P.M. with Agency STNA #600 revealed Resident #63 had told her to put the bed bolsters back on when she got done with providing her incontinence care. She told Resident #63 that she would and that she would not forget. Agency STNA #600 then proceeded to raise the bed to her height and had Resident #63 roll towards the door because she needed a complete bed linen change. Resident #63 rolled fast right off the bed. Agency STNA #600 attempted to catch her but was unable, and she fell face down onto the floor. The other aide (STNA #607) was in the same room but in the bathroom providing care for Resident #63's roommate. STNA #607 went to get the nurse. Agency STNA #600 denied pushing Resident #63 stating, Resident #63 rolled on her own and did not require assistance. Agency STNA #600 was asked why she did not place the bolsters prior to providing care and she revealed because she was going to after she was done. Interview on 02/23/24 at 3:00 P.M. with Physical Therapy Assistant (PTA) #610 revealed she had provided Resident #63's therapy. Resident #63 required maximum assistance of one for bed mobility as she felt comfortable rolling her side to side by herself but with bed bolsters in place. If she was not positioned in the center of the bed and/or needed moved up in bed she would require two staff assist. Interview on 02/27/24 at 9:03 A.M. with RN #605 revealed she was assigned Resident #63's unit on 01/31/24. Staff had alerted her that Resident #63 had fallen out of bed. When RN #605 walked into her room Resident #63 was lying face down on the carpeted floor. They carefully rolled her over and she noticed a large hematoma to her front forehead, bruising already forming to her bridge of her nose, and her nose bleeding. NP #606 was in the facility, examined, and ordered her to go to the hospital for evaluation. Resident #63 stated Agency STNA #600 had rolled her right out of bed. RN #605 noticed after Resident #63 went to the hospital that she did not have her bed bolsters in place. RN #605 revealed Resident #63 had a doctor's appointment previously in the day and felt when she went to that appointment her bed bolsters were removed and not put back in place when Resident #63 returned. Interview on 02/27/24 at 9:38 A.M. with NP #606 revealed she was in the facility when Resident #63 fell out of bed. When NP #606 went to assess her, they had already gotten her back in bed. Resident #63 had tennis ball sized hematoma to her forehead and bruising already forming on her face. NP #606 was concerned because the resident was on blood thinners, so ordered her to be sent to the hospital for evaluation. Resident #63 was alert and stated that she told the aide to put her bolsters on before performing care, but that the aide did not listen to her. The aide then provided incontinence care, and she rolled her out of bed onto the floor. Interview on 02/27/24 at 9:57 A.M. with RN #604 revealed he was the nurse on duty 01/31/24 when Resident #63 returned from the hospital. He revealed she had a large hematoma to her forehead, bruising all over her face, her right eye was almost completely shut, right wrist fracture, and contusions to her abdominal and chest wall region. RN #604 revealed she had not talked about the incident, just that she was tired. Interview on 02/28/24 at 10:15 A.M. with the DON revealed the facility utilized many agency staff including nurses and STNAs. She was asked how agency staff were educated to prevent a similar incident. She stated, there was really no answer. There is really no answer like if they are here, I try but no I have nothing in place to ensure agency staff are educated prior to working especially regarding ensuring bed bolsters were in place and proper turning and repositioning during ADL care. She verified they had not figured out an effective training program to prevent another issue by agency staff. Review of the facility policy labeled, Fall Management and Incident Intervention Protocol, dated July 2022, revealed residents would be assessed as to their risk of sustaining a fall and interventions would be implemented to decrease the incidence of resident's incidents including falls ad to minimize the risk of injury. The policy revealed any interventions would be added to the resident plan of care and would be communicated to relevant nursing staff. This deficiency represents non-compliance investigated under Self-Reported Incident, Control Number OH00150879.

Based on medical record review, observation, resident interview, and staff interviews, the facility failed to ensure Resident #5's sacral pressure ulcer wound care was completed per the physician's order. This affected one (Resident #5) of three residents reviewed for pressure ulcers. The facility census was 99. Findings include: Review of Resident #5's medical record revealed the resident was admitted on [DATE] with diagnoses including unspecified dislocation of the left hip with encounter for other orthopedic aftercare, muscle weakness and difficulty in walking. Review of Resident #5's admission assessment dated [DATE] revealed the resident's skin was intact (with the exception of a surgical hip wound the resident was admitted with). Review of Resident #5's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition and required extensive two person assist for bed mobility and toilet use as well as extensive one person assist for dressing, personal hygiene, and bathing. Review of Resident #5's weekly skin check dated 08/02/23 revealed the resident had a recent left hip surgical site with a wound vac in place and was followed by the wound team. The resident did not have a pressure ulcer to the sacral area on this date. Review of Resident #5's initial wound track form dated 08/08/23 revealed the resident had a stage three sacral pressure wound (full-thickness skin loss with fat exposed) which measured 4.3 cm (centimeters) length by 7.6 cm width by 0.2 cm depth acquired 08/08/23. Current pressure prevention interventions included turning and repositioning the resident. New pressure prevention interventions included to elevate heel, low air-loss mattress and roho cushion to the wheelchair. Review of Resident #5's Wound Nurse Practitioner (NP) progress note dated 08/08/23 indicated the NP was consulted for evaluation of a pressure injury to the sacrum. Per the facility staff, the patient was non-compliant with skin checks, skin care and turning. Upon exam, the stage 3 pressure injury noted to the sacral region, contiguous with the bilateral buttocks, revealed a shallow, full thickness wound comprised primarily of red, moist tissue with some yellow, adherent tissue noted to the dermal layer as well. Review of Resident #5's skin integrity care plan dated 08/08/23 revealed the resident had a stage 3 pressure ulcer to the sacrum and interventions included to elevate the heels while in bed, a low air loss mattress with a perimeter overlay, moisture barrier after each incontinent episode, roho cushion to the wheelchair and turn and reposition in bed every two hours. Review of Resident #5's physician orders revealed an order dated 08/08/23 to cleanse the sacrum with vashe wound wash and gauze, pat dry, apply triad to wound, top with alginate and cover with a bordered foam dressing daily and as needed. Review of Resident #5's wound care progress note dated 08/23/23 revealed the resident had a stage 3 sacral pressure ulcer measuring 3.7 cm by 4.5 cm by 0.2 cm and the wound tissue color was 75% (percent) red and 25% yellow, adherent slough with a large amount of serosanguineous drainage. Review of Resident #5's Treatment Administration Records (TARS) from 08/08/23 to 09/20/23 revealed no evidence the sacral pressure ulcer wound care was completed on 08/10/23, 08/12/23, 08/29/23, 09/02/23, 09/15/23 and 09/16/23. Interview on 09/20/23 at 7:41 A.M. with Resident #5 indicated the facility staff did not change his sacral pressure dressing as ordered. Observation on 09/20/23 at 9:55 A.M. with Licensed Practical Nurse (LPN) #811, Nurse Practitioner (NP) #809 and LPN Wound Nurse #810 of Resident #5's incontinence care revealed the sacral pressure ulcer dressing was not in place at the time of the incontinence care. Interview on 09/20/23 at 10:05 A.M. with LPN Wound Nurse #810 confirmed Resident #5's TARS from 08/08/23 to 09/20/23 did not have evidence sacral pressure ulcer wound care was completed on 08/10/23, 08/12/23, 08/13/23, 08/29/23, 09/02/23, 09/15/23 and 09/16/23. A second interview on 09/20/23 at 10:11 A.M. with Resident #5 revealed he had a bowel movement in therapy at some point on 09/19/23 after breakfast and the State tested Nursing Assistant (STNA) provided him incontinence care. Resident #5 confirmed the nursing staff did not replace the sacral pressure ulcer dressing after the STNA removed the dressing during the incontinence care. Review of an undated witness statement authored by Registered Nurse (RN) #802 revealed Resident #5's sacral dressing was applied on night shift (09/19/23) after he was placed in bed. He was changed a few times during the night. Interview on 09/20/23 at 10:15 A.M. with LPN Treatment Nurse #811 confirmed Resident #5's sacral pressure ulcer dressing was not in place when the staff were providing incontinence care. Interview on 09/21/23 at 1:18 P.M. with Regional Director of Operations #817 indicated the facility completed a Quality Assurance and Performance Improvement (QAPI) plan on 08/08/23 following identification of Resident #5's stage 3 sacral pressure ulcer wound with interventions including daily skin checks, audits and licensed staff education. Review of the Wound Prevention and Management Policy revised 10/22 indicated upon admission, all residents would have a comprehensive skin assessment to identify current skin breakdown and identify pressure ulcer risk factors. This deficiency represents non-compliance investigated under Complaint Number OH00145950.

Based on observation, interview, record review and review of the facility activity calendar the facility failed to ensure activities were consistently provided for residents on the memory care unit. This affected two residents (Resident's #15 and #96) and had the potential to affect all 25 residents (Resident's #1, #3, #7, #11, #12, #15, #17, #23, #29, #46, #47, #53, #54, #55, #56, #60, #66, #71, #73, #74, #76, #81, #85, #88, #96) residing on the memory care unit. The facility census was 100. Findings include: 1. Review of Resident #15's medical record revealed an admitted [DATE] and diagnoses included Alzheimer's Disease, dementia with other behavioral disturbances, and atrial fibrillation. Review of Resident #15's Admission Activity assessment dated [DATE] included Resident #15's hobby was gardening. Resident #15's religion was Catholic, and she participated in church and religious activities. Resident #15 preferred to keep herself busy with a variety of individual and group activities of her choice when she was not involved in activities. Preferred participation was morning, afternoon, evening. Family interview revealed Resident #15 enjoyed spending time and visiting with family and friends, having her meal served in a social setting, pet therapy, resting and relaxing and a variety of individual and group activities of her choice. Review of Resident #15's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #15 had severe cognitive impairment. Resident #15's mood was not assessed. Review of Resident #15's activities schedule dated 07/07/23 through 07/31/23 revealed no arts and crafts activities were documented, cooking and food activity revealed on 07/21/23 she received juice from the juice cart, and on 07/28/23 Resident #15 received a snack, current event activity revealed on 07/20/23 Resident #15 watched television. Review of the game, puzzle activity revealed on 07/28/23 Resident #15 played bingo, the type of music attended on 07/21/23 was dinner music and on 07/23/23 musical guest was attended. Resident #15 did not have any one on one visits, activities or other activities documented. Resident #15 did not have any party, holiday activities documented. Resident #15 did not have any religious activities attended documented, even though the activity calendar stated they were offered every Sunday in July, 2023. Resident #15 did not have a visit activity including pet visit documented. There were no other activities documented. 2. Review of Resident #96's medical record revealed an admitted [DATE] and diagnoses included schizophrenia, Parkinson's Disease and type two diabetes mellitus. Review of Resident #96's Preferences for Everyday Living Inventory dated 10/29/22 included it was very important to Resident #96 to spend time by himself, to meet new people, to attend entertainment events in the facility, to do outdoor tasks, to watch sports, to play games, and to listen to music. Review of Resident #96's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #96 had severe cognitive impairment. Resident #96 required extensive assistance of one staff member for bed mobility, transfers, and locomotion on the unit. Resident #96's mood was not assessed. Review of the Activity Calendar for the Memory Care Unit dated 07/2023 revealed four to seven activities were provided each day, but activities actually documented for Resident's #15 and #96 were minimal. Resident #96 had eight activities documented from 07/07/23 through 07/31/23 and Resident #15 had six activities documented for the same time period. Review of Resident #96's activities dated 07/07/23 through 07/31/23 revealed no arts and crafts activities were attended. Review of the game, puzzle activity revealed balloon toss was attended on 07/26/23 and 07/27/23. Resident #96 attended cooking on 07/27/23, and received a snack on 07/28/23. Resident #96 received mail on 07/12/23. Resident #96 attended dinner music on 07/21/23 and musical guest on 07/23/23. Further review did not reveal any one on one visit, activity, or other activity was attended. Resident #96 did not attend any outside, community activity or any party, holiday activity. Resident #96 did not attend any type of religious activity. Resident #96 attended a pet visit on 07/11/23. No other activities were documented. Observation on 08/03/23 at 12:05 P.M. revealed Resident #15 sitting quietly at a table in the common area waiting to be served the lunch meal. Interview on 08/03/23 at 4:22 P.M. of Anonymous Individual (AI) #301 revealed the memory care nursing unit had very few activities conducted during 07/2023. AI #301 stated residents just sat with nothing to do. Observation on 08/03/23 at 4:30 P.M. revealed Resident #96 sitting quietly in his wheelchair in the common area. Resident #96 was unable to be interviewed. Interview on 08/07/23 at 11:38 A.M. of Social Services Designee (SSD) #280 revealed she recently changed positions in 06/2023 and was the facility Activity Director previous to the change. SSD #280 stated the Memory Care nursing unit (400 hall) had a separate activity calendar from the other nursing units in the facility. SSD #280 stated the facility had one Activity Director (AD #202) and one Activity Assistant (AA#200). SSD #280 stated all activities the residents' attended were documented in the resident's electronic medical record. SSD #280 stated documentation should be accurate because the activity staff were able to keep up with the documentation on a daily basis. Interview on 08/07/23 at 11:55 A.M. of State tested Nursing Assistant (STNA) #255 revealed there was a change of activity staff recently, and activities in Memory Care were not as often for awhile and there was a bit of a gap due to changes. STNA #255 stated activities for sure suffered for a few weeks in 07/2023 during the transition of activities from SSD #280 to AD #202. Interview on 08/07/23 at 12:30 P.M. of AD #202 revealed she became the Activity Director about two weeks ago and before that was an STNA on the Memory Care nursing unit. AD #202 stated she made sure activities were done every day, but was not sure if activities were getting charted, and she was going to make sure they were documented every day going forward. Interview on 08/07/23 at 3:02 P.M. of the Administrator and AA #200 revealed AA #200 worked on a part time basis until a week or two ago when she became a full time Activity Assistant. The Administrator stated an Activity Director was hired and started working in the facility around the beginning of 07/2023, worked a week and quit. The Administrator stated activities were always done in the Memory Care unit. Interview on 08/09/23 at 3:45 P.M. of Family Member (FM) #300 revealed she was unhappy with the activities Resident #15 attended while residing in the facility. FM #300 stated Resident #15 was not stimulated and was provided minimal if any activities. FM #300 stated she was supposed to have once a week face times which were frequently missed, and she was sad when the face times were missed because she very much enjoyed seeing her mother during the face time encounters. FM #300 indicated even if Resident #15 was at the end of life stage she should still be stimulated and have activities provided. Resident #15 stated when family visited they rarely saw activities conducted, and Resident #15 was usually sitting with no stimulation. Review of the facility census revealed Resident's #1, #3, #7, #11, #12, #15, #17, #23, #29, #46, #47, #53, #54, #55, #56, #60, #66, #71, #73, #74, #76, #81, #85, #88, #96 resided on the memory care unit.

Based on medical record review, hospital record review, staff interviews, review of a fall incident report, and policy review, the facility failed to ensure proper positioning in the bed occurred during care for a resident who required total assistance for bathing. This resulted in Actual Harm when Resident #114 was positioned too close to the edge of the bed while receiving bathing from a State tested Nursing Assistant (STNA) and rolled off the bed when the STNA turned away, resulting in a hospitalization for treatment of a comminuted intra-articular right proximal humerus fracture, mildly displaced anterior right 3rd through 10th rib fracture, a nondisplaced posterior right 11th rib fracture, impacted fractures of the left distal femoral metaphysis and proximal tibia metaphysis of uncertain etiology, manually displaced left fibular head fracture, and hematoma with fracture blisters of the left anterior lower leg. This affected one (#114) of three residents reviewed for falls. The facility census was 103. Findings include: Review of Resident #114's medical record revealed an admitted [DATE]. Diagnoses included diabetes mellitus, peripheral vascular disease, dysphagia, and weakness. Review of Resident #114's quarterly Minimum Data Set (MDS) assessment, dated 12/02/22, revealed the resident had a moderate cognitive function. She was coded as using an extensive two person assist for bed mobility and personal hygiene, and was dependent on two staff for transfers. Review of Resident #114's most recent care plan revealed she had a potential for falls or injury. Interventions included a perimeter mattress to the bed. Review of Resident #114's Fall Risk Assessment,t dated 01/12/23, revealed the resident was at high risk for falls. Review of Resident #114's health status note, dated 03/05/23 and timed 5:45 P.M. revealed the resident was receiving a bed bath. Per STNA #124's statement while laying on her left side having her back washed by the aide Resident #114 continued to roll off of her bed. The STNA immediately contacted the nurse. When the nurse entered the room the resident was on the floor with her feet facing the head of the bed and her head facing the doorway. Resident #114 stated that she was having pain in her left leg and right shoulder and was placed back into bed. Vital signs were blood pressure 140/86, pulse 88, respirations 20, and pulse oximetry was 97%. A hematoma was assessed to be present. A cool pack was placed on the resident's leg for 15 minutes on and 20 minutes off three times. The physician was texted and an order for an immediate leg and shoulder x-ray was received. During shift change Resident #114 complained of nausea and right shoulder pain which radiated down to her right ribs. She became diaphoretic and clammy. The decision to send Resident #114 to the hospital was made by both day and night shift nurses at that time. There was no further assessment in the record following the note regarding the fall. Review of Resident #114's hospital note, dated 03/06/23, revealed the resident arrived at the hospital at 8:06 P.M. and appeared to be critically ill with pallor, and cold skin. Resident #114 was awake, and following commands. Review of Resident #114's chest x-ray revealed a comminuted intra-articular right proximal humerus fracture, mildly displaced anterior right third through tenth rib fractures, and a nondisplaced posterior right 11th rib fracture. The resident was transferred to a trauma hospital at 9:39 P.M. Review of Resident #114's trauma physician note, dated 03/06/23, revealed the resident arrived by life flight helicopter from another local hospital. The resident was in a nursing facility and while being rolled in bed, fell off a side. She was initially hypotensive, was administered one unit of packed red blood cells and one liter of saline, and started on Levophed to raise her blood pressure. Upon review of all imaging and assessment she was found to have metabolic acidosis with elevated lactate and leukocytosis, right rib fractures of three through ten, right proximal humerus fracture, impacted fractures of the left distal femoral metaphysis and proximal tibia metaphysis of uncertain etiology, manually displaced left fibular head fracture, and hematoma with fracture blisters of the left anterior lower leg. Review of Resident #114's Fall Incident Report dated 03/05/23 at 3:00 P.M. revealed Resident #114 was with a STNA in the room receiving a bed bath when the resident rolled onto her left side by the aide and continued to roll off of the bed per the STNA that witnessed it. The nurse on duty stated the resident was on the floor when she entered the room and Resident #114 denied hitting her head. The resident had a large left shin hematoma, as well as complained of right shoulder pain. Range of motion was limited as Resident #114 was unable to move her left leg or raise her right arm. The resident received Tylenol for pain. The resident was sent to the hospital. Review of STNA #124's witness statement dated 03/05/23 revealed at the time of the fall the STNA was in the resident's room providing patient care. The resident's behaviors did not play a factor in the fall. STNA #124 stated she was giving Resident #114 a bed bath and went to turn her over to clean her back side and bottom. When the STNA was going to cover her up she fell over and out of the bed. The STNA called another STNA to ask for help. The nurse was alerted and they proceeded to lift the resident off of the floor to the bed. Interview with STNA #124 on 03/13/23 at 1:26 P.M. revealed the STNA Going to give Resident #114 a bed bath and thought she had everything ready. The STNA was going to dry her bottom and went to get a towel. When the STNA went to dry the resident's bottom she let go of Resident #114 to get a towel and that is when the resident rolled out of bed. STNA #124 stated the resident was in the middle of the bed but closer to the edge. She didn ' t realize the resident was so close to the side of the bed and it was too late to catch her. Telephone interview on 03/14/23 at 10:48 A.M., Licensed Practical Nurse (LPN) #143 stated STNA #124 informed her Resident #114 had fallen out of bed during a bed bath. The STNA had the resident on her left side and was washing her back and bottom when the resident rolled out of bed. When LPN #143 entered the room she found Resident #114 on the floor in pain with a pillow under her head. The resident did not hit her head but complained of pain to the right shoulder and left leg. On assessment a small hematoma was noted on the resident's left shin. Resident #114 requested to return to bed. At that point the nurse applied ice on the shin but Resident #114 continued to complain of pain to the shoulder and leg. The physician was contacted and ordered immediate x-rays. It was then shift change and the night nurse and LPN #143 chose to transfer Resident #114 to the hospital due to her feeling worse as time went on. The resident was having nausea, pain radiating down the right shoulder, and the left leg hematoma was becoming much larger, banana shaped, and working it's way down toward the ankle. LPN #143 verified the fall occurred between 3:00 P.M. and 3:30 P.M. and shift change occurred between 6:30 P.M. and 7:00 P.M. The immediate x-rays never occurred because the mobile unit would have come in the evening or the next morning. Review of facility policy titled Fall Management and Incident Intervention Protocol dated 07/22, revealed interventions will be implemented and evaluated in order to decrease the incidence of resident incidents, including falls, and to minimize the risk of injury. This is non-compliance discovered during the investigation of Complaint Number OH00140966.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of a facility Self-Reported Incident (SRI), staff interviews, interviews with local law enforcement, review of the news media release, review of the local police report, observation of the live photographic images, and review of the employee handbook on personal cellphone use, the facility failed to ensure cognitively impaired and cognitively intact residents rights to privacy and confidentiality were maintained by a facility staff member during provision of personal care. This resulted in Immediate Jeopardy and the potential for psychosocial harm for 13 Residents (#58, #59, #60, #63,#64, #67, #70, #71,#72, #74, #79,#80 and #81) when State tested Nurse Aide (STNA) #08 engaged in acts meant to humiliate and dehumanize the residents by taking unauthorized and inappropriate photos on her personal cellular device without permission and not in accordance with facility policy. The photos taken included residents that were nude, lying on the floor, in their beds, and on the toilet. The photos were then shared to a group text chat with three other facility staff (STNA #10, Licensed Practical Nurse (LPN) #09 and LPN #11) for the purpose of what the involved staff stated was communication, resulting in outcomes which one would expect a reasonable person in a similar situation to suffer, subsequently treating the resident as an inanimate object having no emotions or feelings and causing embarrassment and shame for the resident. This affected 13 residents (#58, #59, #60, #63, #64, #67, #70, #71, #72, #74, #79, #80 and #81) able to be identified in the photos of 21 who resided on the dementia unit. The facility identified 11 residents (#59, #60, #63, #64, #67, #70, #71, #74, #79, #80 and #81) of the 13 had severely impaired cognition and were unable to speak for themselves. There was a total of 25 images of residents on her personal phone. The facility census was 79. On [DATE] at 10:00 A.M., the facilities Administrator and Corporate Vice President #100 were notified that Immediate Jeopardy began on [DATE] when during an unrelated police investigation on [DATE], it was discovered that STNA #08 had taken unauthorized disturbing photos of residents nude in bed, walking around partially nude, lying in bed in gowns, tipped over in wheelchairs, partially nude shaking fists toward the camera, and then shared them in a group text message with co-workers (STNA #10, LPN #09 and LPN #11). The Immediate Jeopardy was removed on [DATE] when staff education was provided regarding the identification of abuse, the abuse policy and procedures, maintaining the residents' rights to privacy and confidentiality during the provision of personal care and utilization of cellular phones and/or photographing mobile devices. Additionally, head-to-toe assessments were completed on all the residents who resided on the dementia unit and residents able to make their needs known were interviewed. The deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on [DATE] when the facility implemented the following: · On [DATE] at approximately 4:30 P.M., the Administrator and Director of Nursing (DON) viewed the photos on STNA #08's phone. They identified 13 Residents (#58, #59, #60, #63, #64, #67, #70, #71, #72, #74, #79, #80 and #81) in the photos. · On [DATE] at 5:00 P.M., the Administrator and DON suspended STNAs #08 and #10 and LPNs #09 and #11 pending the outcome of the investigation. · On [DATE] between 5:00 P.M. and 8:00 P.M., the DON completed head-to-toe assessments on all residents who resided on the dementia unit (primary unit where STNA #08 and other involved staff members worked) with no negative findings. · On [DATE] at 5:00 P.M., the Administrator and DON in-serviced current staff working on its abuse policy and cellphone use policy and completed staff interviews regarding the incident. Staff interviewed denied knowledge of the situation and similar situations occurring at the facility. Staff who were not working were called and all staff were in-serviced and acknowledged receipt of training and had no knowledge of the incident by [DATE]. · On [DATE] at 9:00 A.M., the Administrator notified all residents and/or their responsible parties who were noted in the photos. · On [DATE], the Administrator and DON drafted an audit tool to monitor personal cell phone usage within the facility. The audits began on [DATE] by the Administrator and the DON. Monitoring will continue on three to four halls per week for four weeks, then randomly thereafter for a total of four months. · On [DATE] between 10:00 A.M. and 12:00 P.M., the DON interviewed Residents #58 and #72 (no other residents involved in the incident were able to be interviewed due to severe cognitive impairment) regarding the incident. Both residents reported feeling safe at the facility and had no concerns related to the incident. · On [DATE] between 8:00 A.M. and 5:00 P.M., the DON interviewed a random sample of residents (#09, #10, #13, #15, #16, #29, #39 and #54) who did not reside on the dementia unit with the staff involved in the incidents. All residents stated they felt safe at the facility and had never had any unauthorized photos taken. · On [DATE], the Administrator terminated STNA's #08 and #10 and LPN's #09 and #11 employment from the facility. · On [DATE] at 5:38 P.M., the Administrator drafted a letter and sent to all residents and family members notifying them of the incident and the facilities on-going corrective action. Findings Include: 1) Review of the medical record for Resident #58 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed the resident had severely impaired cognition. The resident required extensive assistance of two staff for bed mobility, transfers, ambulation and all other Activities of Daily Living (ADL). 2) Review of the medical record for Resident #59 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the most recent MDS 3.0 assessment, dated [DATE], revealed the resident had intact cognition. The resident was independent for bed mobility, transfers, ambulation and all other activities of daily living. 3) Review of the medical record for Resident #60 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the most recent MDS 3.0 assessment, dated [DATE], revealed the resident had severely impaired cognition. The resident required extensive assistance of one staff for bed mobility, transfers, ambulation and all other ADL care. 4) Review of the medical record for Resident #63 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the most recent MDS 3.0 assessment, dated [DATE], revealed the resident had severely impaired cognition. The resident required extensive assistance of two staff for bed mobility, transfers, ambulation and all other ADL care. 5) Review of the medical record for Resident #64 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the most recent MDS 3.0 assessment, dated [DATE], revealed the resident had severely impaired cognition. The resident required extensive assistance of one staff for bed mobility, transfers, ambulation and all other ADL care. 6) Review of the medical record for Resident #67 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the most recent MDS 3.0 assessment, dated [DATE], revealed the resident had severely impaired cognition. The resident required extensive assistance of two staff for bed mobility, transfers, ambulation and all other ADL care. 7) Review of the medical record for Resident #70 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the most recent MDS 3.0 assessment, dated [DATE], revealed the resident had severely impaired cognition. The resident required extensive assistance of two staff for bed mobility, transfers, ambulation and all other ADL care. 8) Review of the medical record for Resident #71 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the most recent MDS 3.0 assessment, dated [DATE], revealed the resident had severely impaired cognition. The resident required extensive assistance of two staff for bed mobility, transfers, ambulation and all other ADL care. 9) Review of the medical record for Resident #72 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the most recent MDS 3.0 assessment, dated [DATE], the resident had intact cognition. The resident required extensive assistance of one staff for bed mobility, transfers, ambulation and all other ADL care. 10) Review of the medical record for Resident #74 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the most recent MDS 3.0 assessment, dated [DATE], revealed the resident had severely impaired cognition. The resident required extensive assistance of one staff for bed mobility, transfers, ambulation and all other ADL care. 11) Review of the medical record for Resident #79 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the most recent MDS 3.0 assessment, dated [DATE], revealed the resident had severely impaired cognition. The resident required extensive assistance of two staff for bed mobility, transfers, ambulation and all other ADL care. 12) Review of the closed medical record for Resident #80 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Resident #80 was discharged to a local hospital on [DATE]. Review of the most recent MDS 3.0 assessment, dated [DATE], revealed the resident had severely impaired cognition. The resident required extensive assistance of two staff for bed mobility, transfers, ambulation and all other ADL care. 13) Review of the closed medical record for Resident #81 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Resident #81 expired at the facility on [DATE]. Review of the most recent MDS 3.0 assessment, dated [DATE], revealed the resident had impaired cognition. The resident required extensive assistance of two staff for bed mobility, transfers, ambulation and all other ADL care. Review of the SRI dated [DATE] and timed 4:19 P.M. revealed on [DATE] the Administrator was notified by local law enforcement of a police investigation which involved STNA #08. Detective #101 discovered unauthorized pictures of residents on STNA #08's personal cellular phone during an unrelated police investigation. The Administrator and the DON were able to identify 13 Residents (#58,#59, #60,#63, #64, #67, #70, #71, #72, #74, #79, #80 and #81) in the 28 photos taken which included residents nude, lying on the floor, in their beds and on the toilet. These photos were then shared to a group text message chat with three other facility staff (STNA #10 and LPNs #09 and #11). Review of the facility investigation completed from [DATE] through [DATE] revealed the Administrator and the DON interviewed STNA #08 on [DATE] at 5:00 P.M. regarding the photos found on her personal cell phone. STNA #08 verified she had taken the unauthorized photos and shared them with STNA #10 and LPNs #09 and #11 as part of a group text message chat to communicate resident needs. Review of the written statements dated [DATE] from STNA #10 and LPNs #09 and #11 verified they had received unauthorized photos on their personal cellular devices. Interview on [DATE] at 9:45 A.M., the Administrator verified the findings of the SRI. Interview on [DATE] at 9:15 A.M., Detective #101 verified an active investigation was currently in progress regarding STNA #08's actions involving taking inappropriate photos of residents who resided in the nursing home where she worked. Telephone interviews were attempted on [DATE] at 12:33 P.M. and [DATE] at 11:08 A.M., with STNA #08, STNA #10, LPN #09 and LPN #11 but were unsuccessful. Messages were left and there was no return contact made. Review of the local news media report dated [DATE] and timed 6:32 P.M. revealed STNA #08 was under investigation by local law enforcement after inappropriate photos of residents were found in her cell phone. Review of the police report dated [DATE] revealed on [DATE] the facilities local police department received a call from another local police department regarding STNA #08. After receiving consent to search STNA #08's phone during an unrelated crime investigation it was discovered STNA #08 had inappropriate photos of elderly persons in her phone. It was later discovered STNA #08 was an employee of a local long-term care facility for the past five years. The local police department began its own investigation and verified that on STNA #08's personal cellular phone were 28 live pictures, 13 of which were of various facility residents in various positions including one resident fully nude and exposed lying in her bed. Observation of the live photo images extracted from STNA #08's phone and verified by the local police department, using longitude and latitude coordinates, revealed the pictures had been taken at the facility and were dated from [DATE] (which was prior to the last annual survey) through [DATE]. Observation of the live photo (Image Number 1176) dated [DATE] at 3:25 A.M., revealed Resident #81 was tipped over backwards in a wheelchair. His legs were up in the air, he was wearing a hospital style gown which came up and had exposed his adult brief. His eyes were open, he was holding his head with his right hand and had a pillow underneath his head. Observation of the live photo (Image Number 1465) dated [DATE] at 9:02 P.M., revealed Resident #74 was wandering around the unit in her underwear holding a blue shirt against her nude torso. Observation of a second live photo (Image Number 2651) on [DATE] at 7:52 P.M., revealed the resident was taking medication. Review of a third live photo (Image Number 8554) on [DATE] at 12:07 P.M., revealed Resident #74 was lying in bed fully clothed with Resident #71 who was also fully clothed. Observation of the live photos (Image Numbers 1515 and 1519) dated [DATE] at 4:46 P.M., and at 5:34 P.M., revealed Resident #71 was walking laps around the dining room. The commentary on the live photo stated, she keeps going around in circles, this is like her fifth time doing it. There were five other unidentified residents captured on the live photo image. Observation of the live photo (Image Number 8555) dated [DATE] at 5:55 P.M., revealed the resident was dancing in her room and the voice on the live photo stated, shake that booty girl, shake that booty. Observation of the live photos (Image Numbers 1685 and 2095) dated [DATE] at 10:31 P.M., and [DATE] at 8:53 A.M., revealed Resident #64 was sitting backwards in an upholstered chair in what appeared to be a common area. Observation of the live photo (Image Number 1760) dated [DATE] at 4:59 P.M., revealed Resident #72 was dancing with what appeared to be an unknown facility staff member and their buttocks were touching doing dance moves. The commentary on the live photo while the dancing took place stated shake it ooh, ooh, ooh, ooh laughter was also heard in the background. Observation of the live photo (Image Number 1796) dated [DATE] at 1:20 A.M., revealed Resident #80 was sitting in a chair in a common area only wearing his underwear and socks. Observation of a second live photo (Image Number 2307) revealed the resident was sitting in a wheelchair fully clothed. Observation of the live photo (Image Number 2084) dated [DATE] at 9:09 P.M., revealed Resident #63 was sitting up in her wheelchair kicking her foot and the bedside table was tipped over on the floor. Observation of a second live photo (Image Number 2419) dated [DATE] at 7:08 P.M., revealed Resident #63 was lying nude in bed on her buttocks, resting on her left elbow facing the photographer. The resident was wearing only one sock on her left foot and her breasts and peri area were exposed. During the live photo, the resident reached her right arm across her body toward the photographer. Observation of a third live photo (Image Number 0982) dated [DATE] at 6:16 P.M. revealed the resident was lying in bed on her right side wearing a hospital gown and her left hip and buttocks were exposed. Observation of the live photo (Image Number 2052) dated [DATE] at 1:58 P.M., revealed Resident #58 was sitting up on the side of the bed wearing a hospital gown. Observation of the live photo (Image Number 2286) dated [DATE] at 5:23 P.M., revealed Resident #60 was walking toward the camera mumbling loudly and shaking her fists at eye level. The resident was wearing a shirt and an adult brief. Observation of a second photo (Image Number 2363) dated [DATE] at 12:10 P.M. revealed the resident was sitting on a toilet fully clothed. Observation of the live photo (Image Number 0873) dated [DATE] at 8:38 P.M., revealed Resident #70 was lying on the floor near a doorway in front of a high back wheelchair wearing plaid pajamas mumbling. Observation of the live photo (Image Number 0983) dated [DATE] at 6:19 P.M., revealed Resident #59 was in bed with the head of the bed elevated, she had a bedside tray across the bed with an uneaten meal tray and liquid spilled across the bedside table. The resident was wearing a hospital gown and was slumped over to the right side of the bed with a furrowed brow and facial grimacing. Observation of the live photo (Image Number 0984) dated [DATE] at 6:20 P.M., revealed Resident #67 was lying in bed covered with a blanket with her eye closed. Observation of the live photo (Image Number 0985) dated [DATE] at 6:21 P.M., revealed Resident #79 was lying in bed covered with a blanket with eyes closed and mouth open. Review of the employee handbook section titled Do not take pictures, videos or recordings of residents or disclose residents' protected health information dated [DATE] revealed employees are instructed under no circumstances to take pictures, videos or recordings of residents or disclose residents' protected health information (PHI). This deficiency substantiates Complaint Number OH 778.