Every finding on record at Mayfair Village Nursing Care Center

Based on observations, interviews and policy reviews, the facility failed to wear proper hair and beard restraints when serving and preparing food , practice safe storage of utensils when preparing beverages and practice safe handling of food to prevent cross contamination. This had the potential to affect all but 10 residents the facility identified as receiving enteral feeding. The census was 82.Findings include:Interview on 04/14/26 at 11:30 A.M. interview with Food Service Director # 204 confirmed dietary workers are to wear hair nets or hats to cover hair and beard restraints if they have facial hair.Observation on 04/14/26 at 11:30 A.M. of the main residents' dining room ice bin revealed a large serving utensil used to place ice in the residents' drinking cups inside the ice bin. During concurrent interview with Dietary Aide #245 it was confirmed the utensil used to scoop the ice was stored inside the ice bin. Observation with Food Service Director #204 on 04/14/26 at 11:45 A.M. of the kitchen revealed [NAME] #221 walked away from the stove top and opened oven door and steamer doors with gloved hands and proceeded to prepare a mechanical diet plate of corn beef. With gloved hands she took one hand and held the corn beef to the plate while cutting it. Interview with Food Service Director #204 verified [NAME] #221 touched food to be served to residents with her hand that had a soiled glove on it. Observation on 04/14/26 at 11:45 P.M. during lunch service Aide #525 from the Assisted Living facility walked behind the service line to the cook with two-to-go containers requesting food for Assisted Living Residents. Aide #475 was not wearing a hair net, or a beard restrained to cover his hair on his chin. Verified by [NAME] # 223.During the observation care aide # XXX from the assisted living was obwserved to enter the area and walk behind the service line to the cook with two meal to do containers requesting foood for assisted living residents. Care Aide # Xx did not have a beard or hair covering im place. Interview with [NAME] #223 at the time of othe observation confirmed the care aide was not wearing a beard of hair covering. Observation on 04/15/26 from 11:15 A.M. to 12:00 P.M. of lunch service line revealed [NAME] # 223 routinely pulled his beard covering up from neck to his chin, ensuing his beard was covered. He did not wash his hands after readjusting the cover. During concurrent interview with Food Service Director # 204 it was confirmed [NAME] #223 had to keep adjusting the beard covering during tray line to ensure his beard was covered and did so with his hand and did not perform hand hygiene after adjusting the beard covering. Review of the Facility's policy Prevention of Cross Contamination, dated 05/01/25 , Iced used in connection with food and drink will be obtained from a sanitary source and handled and dispensed in a sanitary manner. Ice scoop will be stored in a designated holder .Review of the Facility's policy Resident Dining Services , dated 04/29/25, during tray setup, food should not be handled with bare hands, gloves should be worn or utensils used to avoid any contact with bare hands and subsequent cross contamination. Review of the Facility's policy Safe Food Handling, Associates shall wash their hands accordance with the Hand Hygiene Policy and current Food Code Guidelines before handling or consuming food including working with clean equipment and utensils and after touching the hair or mouth, after handling soiled equipment or utensils and during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks.Review of the Facility's policy Associate Conduct and Dress Code, dated 04/28/25. Dietary staff must wear hair restraints(e.g., hairnet, hat, and /or beard restraint) to prevent hair from contacting food.

Based on observations, interviews and review of facility policy, the facility failed to report an allegation of reported sexual abuse for two (Resident #41and #61) of five residents reviewed for abuse. The census was 82. Findings include:Review of the medical record Resident #41 revealed an admission date of 03/09/24 diagnoses included Arnold Chiari Syndrome, hydrocephalus, mood disorder, depression, benign neoplasm of the brain and adult failure to thrive. Resident was cognitively intact with a Brief Interview on Mental status (BIMS) score of 15. Review of his care plan last updated on 02/23/26 revealed he was independent for activities of daily living and walks around the facility and in the community independently. He received psychological services with contracted counseling group including a Psychiatric Certified Nurse Practitioner (CNP) #271 every two weeks and a nurse visit every other week.Review of Resident #61's medical record revealed an admission date of 01/03/25 with diagnoses including chronic obstructive pulmonary disease, heart failure, anxiety disorder, bipolar disorder, depression, opioid abuse, chronic viral hepatitis C, and unspecified mood disorder.Review of Resident #61's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Resident #61 required minimal assistance with activities of daily living, and she utilized an electric wheelchair.Interview on 04/13/26 at 12:10 P.M. with Resident #61 revealed that facility staff accused her of having sexual relations with Resident #41. She was offended by this and reported she considered Resident #41 as her nephew and would never have done that. She said they used this as a reason to issue Resident #41 a pink slip (required emergency psychiatric care).Review of facility self reported incidents revealed there were no reports related to an allegation of sexual abuse between Resident #41 and Resident #61.Interview with Resident #41 on 04/13/26 at 12:19 P.M. confirmed he had been accused to having sexual relations with Resident # 61 in her room while her roommate was present. Resident #41 was hurt by the accusations and denied ever having such relations with Resident #61 or anyone else. He believed the allegation was to be used against him to get him pink slipped out of the facility.Interview on 04/15/26 at 1:09 P.M. with previous Director of Nursing (DON) # 267 confirmed on 02/03/26 she was approached by Regional Representative # 400 to initiate a pink slip for Resident #61 due to escalating behaviors and inappropriate sexual behaviors around other residents. Interview on 4/15/26 at approximately 1:32 P.M interview with the Ombudsman #485 confirmed he has an open case with Resident #61. He confirmed Resident #61 stated he was accused of having inappropriate sexual contact with another resident and he was very upset.Interview on 04/15/26 at 1:30P.M. with Registered Nurse (RN) #262 confirmed RR #400 requested for a pink slip to be initiated due to escalating behaviors and inappropriate sexual behaviors around other residents.Interview on 04/15/26 at 2:45 P.M. with RR #400 confirmed she was told by someone on night shift that Resident #61 was having inappropriate sexual behavior and confirmed she did not start an investigation or report it to the Ohio Department of Health.Interview on 04/20/26 at 9:30 A.M. with Regional Clinical Director #405 confirmed the Administration was aware of the allegations of inappropriate sexual activity, however after interviewing other employees regarding Resident #61's sexual activity and behaviors it was believed there was no merit to the allegation and they did not have to report the incident to the Ohio Department of Health, or investigate if in fact Resident #61 had inappropriate sexual activity that affected other residents in the facility.Interview with Medical Director # 270 on 4/20/26 at 10:20 A.M. confirmed it was mentioned to her Resident #61 had inappropriate sexual activity; however, she could not give any details.Review of the Resident #61 hospital progress notes dated 02/06/26 , revealed Licensed hospital Social Worker # 500 reported he spoke with the RR # 400 who reported Resident #61 had been acting paranoid, agitated, restless, pacing throughout the unit . He has been recklessly reporting he is exposing himself on the nursing unit and having consensual sex with another resident, however it is not in private places. Review the facility's policy, Abuse-Identification of Types dated 10/04/22 Sexual abuse is non-consensual sexual contact of any type with a resident.Review of the facility's Abuse-Reporting and Response dated 05/07/25, The facility will ensure reporting reasonable suspicion of crimes against a resident or individual receiving care from the facility within prescribed timeframes to the appropriate entities, consistent with Section 1150B of the Elder Justice Act. Each covered individual shall report immediately, but no later than two hours after forming the suspicion results in serious bodily injury, or no later than 24 hours if the events that cause the suspicion do not result in serious bodily injury.

Based on observations, interviews and policy review the facility failed to conduct an investigation when there was a report of suspected sexual abuse. This affected two residents (#41 and #61) of five reviewed for abuse. The census was 82.Findings include:Review of the medical record Resident #41 revealed an admission date of 03/09/24 diagnoses included Arnold Chiari Syndrome, hydrocephalus, mood disorder, depression, benign neoplasm of the brain and adult failure to thrive. Resident was cognitively intact with a Brief Interview on Mental status (BIMS) score of 15. Review of his care plan last updated on 02/23/26 revealed he was independent for activities of daily living and walks around the facility and in the community independently. He received psychological services with contracted counseling group including a Psychiatric Certified Nurse Practitioner (CNP) #271 every two weeks and a nurse visit every other week.Review of Resident #61's medical record revealed an admission date of 01/03/25 with diagnoses including chronic obstructive pulmonary disease, heart failure, anxiety disorder, bipolar disorder, depression, opioid abuse, chronic viral hepatitis C, and unspecified mood disorder.Review of Resident #61's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Resident #61 required minimal assistance with activities of daily living, and she utilized an electric wheelchair.Interview on 04/13/26 at 12:10 P.M. with Resident #61 revealed that facility staff accused her of having sexual relations with Resident #41. She was offended by this and reported she considered Resident #41 as her nephew and would never have done that. She said they used this as a reason to issue Resident #41 a pink slip (required emergency psychiatric care).Interview with Resident #41 on 04/13/26 at 12:19 P.M. confirmed he had been accused to having sexual relations with Resident # 61 in her room while her roommate was present. Resident #41 was hurt by the accusations and denied ever having such relations with Resident #61 or anyone else. He believed the allegation was to be used against him to get him pink slipped out of the facility.Interview on 4/15/26 at 1:30 PM interview with the Ombudsman #485 confirmed he has an open case with Resident #61. He confirmed Resident #61 stated he was accused of having inappropriate sexual contact with another resident and he was very upset.Interview on 04/15/26 at 2:45 P.M. with Regional Representative #400 confirmed she was told by someone on night shift that Resident #61 was having inappropriate sexual behavior and confirmed she did not start an investigation.Interview on 04/20/26 at 9:30 A.M. with Regional Clinical Director #405 confirmed the administration was aware of the inapproproiate sexual allegations, however, after interviewing other employees regarding Resident #61's sexual activity and behaviors, it was believed there was no merit to the allegation and they did not have to report the incident to the Ohio Department of Health, or investigate if in fact Resident #61 had inappropriate sexual activity that affected other residents in the facility.Interview with Medical Director # 270 on 4/20/26 at 10:20 AM confirmed it was mentioned to her Resident #61 had inappropriate sexual activity; however, she could not give any details.Review of the Resident #61 hospital progress notes dated 02/06/26 , revealed Licensed hospital Social Worker # 500 reported he spoke with the Region Representative # 400 who revealed Resident #61 had been acting paranoid, agitated, restless, and pacing throughout the unit. Stating Resident #61 had been recklessly reporting he was exposing himself on the nursing unit and having consensual sex with another resident, however it is not in private places. Review the facility's policy, Abuse-Identification of Types dated 10/04/22 Sexual abuse is non-consensual sexual contact of any type with a resident.Review of the facility's Abuse-Reporting and Response dated 05/07/25, No Crime Suspected dated 05/07/25 , all associates are mandated to immediately report suspected resident abuse and/or neglect to their immediate supervisor and /or facility representative. The facility should submit a copy of the facility report to the Compliance Department via facsimile or email. Facility shall use the Facility Reported Incident forms. The form should include any information pertinent to the incident . All phases of the investigation will be kept confidential .

Based on observation, medical record review, staff interview, and facility policy review, the facility failed to develop comprehensive care plans for three residents (Resident #04, Resident #56, and Resident #61) of 22 residents reviewed. The facility census was 82. Findings include: 1.Resident #04 was admitted [DATE] and had diagnoses that include obstructive uropathy, chronic kidney disease (stage IIIA), and chronic systolic congestive heart failure. Review of the Resident's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident was cognitively intact and had an active diagnosis of heart failure. Review of Resident #04's care plan completed by the facility on 02/05/26 revealed no care planning for a diagnosis of congestive heart failure. Interview with Nurse MDS Coordinator #154 at 8:48 A.M. on 4/16/26 confirmed the diagnosis of congestive heart failure was not included and addressed on the 02/05/26 care plan for Resident #04. 2.Resident #56 was admitted [DATE] and had diagnoses that include chronic obstructive pulmonary disease (COPD), incomplete paraplegia, and chronic respiratory failure. Review of the Resident's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicatesdthe resident was cognitively intact and used a non-invasive mechanical ventilator. Review of Resident #56's medical record revealed orders written on 09/24/25 for oxygen with CPAP/BiPAP (a non-invasive mechanical ventilator) delivered at 4 liters per minute (L/min) (pressure setting 10, size and type of mask 5) with a frequency of use of nightly. Observation of Resident #56's room on 04/15/2026 at 1:21 P.M. revealed a BiPAP machine next to Resident #56's bed. Interview with Resident #56 on 04/15/2026 at 1:21 P.M. confirmed he used the BiPAP machine. Review of Resident #56's care plan completed by the facility on 01/15/26 revealed no care planning for the use of the BiPAP machine. Interview with Nurse MDS Coordinator #273 at 8:53 A.M. on 4/16/26 confirmed the use of BiPAP machine was absent from Resident #56's 01/15/26 care plan. 3.Review of Resident #61's medical record revealed an admission date of 01/03/25 with diagnoses including chronic obstructive pulmonary disease, anxiety disorder, bipolar disorder, depression, opioid abuse, chronic viral hepatitis C, and unspecified mood disorder. Review of Resident #61's quarterly Minimum Data Set (MDS) 30 assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #61's physician orders revealed from 08/21/25 to 09/02/25, from 09/12/25 to 09/19/25, from 09/26/25 to 12/12/25, from 12/19/25 to 02/24/26, and from 02/27/26 to current Resident #61 had regularly received Ozempic (a weight loss drug) due to morbid obesity. Review of Resident #61's plan of care on 04/15/26 revealed it did not address weight loss medication or its potential side effects. Interview on 04/15/26 at 3:14 P.M. with Regional MDS #273 revealed Ozempic was a high risk medication that should have been addressed in the plan of care. Review of the facility policy titled Comprehensive Care Plans and Revisions (reviewed 8/29/25) states the facility will ensure the timeliness of each resident's person-centered, comprehensive care plan. Review of the facility policy titled BiPAP/CPAP administration policy (revised 02/03/26) states the facility must ensure that a resident who needs respiratory care is provided such care consistent with the comprehensive person-centered care plan.

Based on record review, interview, and review of facility policy the facility failed to revise resident care plans. This deficient practice effected three (Residents #16, Resident #28, and Resident #62) of five residents reviewed for care plans. The facility census was 83.Findings Include:1. Review of Resident #28's medical records revealed an admission date of 2/27/26 and medical diagnosis of parkinsonism, metabolic encephalopathy, dementia, severe protein-calorie malnutrition, muscle weakness, abnormal gait and mobility, cognitive communication deficit, dysphagia, dysarthria and anarthria, dysphagia, and overactive bladder. Review of Resident #28's minimum data set (MDS) last updated 02/27/26 revealed a Brief Interview of Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. Independence with self-care, indoor mobility, stairs, and the use of a wheel chair and walker for ambulation. Review of Resident #28's care plan last revised 3/15/26 revealed the resident has an activities of daily living (ADL) deficit related to impaired balance and limited mobility with interventions to provide one or two person assist with transfers. The resident had impaired cognitive ability/impaired thought process related to difficulty making decisions, impaired decision making related to Parkinson's with interventions to re-orient and supervise as needed;and the resident was at risk for falls due to impaired mobility with interventions to assisted with ADL's as needed, and offer assistance with toileting every two hours and as needed. Review of the facility incident accident log revealed Resident #28 sustained falls on 3/18/2026 at 6:39 P.M. and 3/27/26 at 2:00 P.M. Further review of Resident #28's care plan revealed no post fall interventions for the falls on 3/18/26 and 3/27/26. Interview on 4/16/26 with the Director of Nursing confirmed the facility failed to update the residents care plan to reflect the fall interventions implemented by the facility. 2.Review of the medical record Resident #16 revealed an admission date of 06/16/25 with a readmission date of 01/21/26 his BIMS score was 09 indicating cognitive deficits. His diagnoses included bipolar disorder, chronic obstructive pulmonary disease , chronic respiratory failure with hypoxia and very hard of hearing. Review of Resident #16's nurses progress notes revealed on 12/18/25 nurse walked into Resident #16's room and found him lying in bed with his call light wrapped tightly around his neck and the bed remote cord wrapped around his arm. He verbalized I want to die 911 was called. Resident #16 was transferred to the hospital where he received psychological services. Review of Resident #16's Psychiatric Nurse Practitioner # 271 visit noted dated 1/16/26 revealed Resident #16 uses psychotropic medication . Staff are to monitor side effects and implement stress management techniques and note any symptom changes. He is to continue psychiatric treatment, psychotherapy and monitor for mood, behavior changes. Review of his care plan last updated on 01/21/26 revealed he was dependent on transfers, required one person assist with dressing, personal hygiene, and transferred himself in the facility by a wheelchair. Interview on 04/14/26 at 1:50 P.M. with the Regional MDS Director # 273 confirmed there were no interventions in place for psychological services on Resident #16 Care Plan. 3. Review of Resident #62's medical record revealed that she was admitted on [DATE] with diagnoses that included congestive heart failure, obesity, Gastro Esophageal Reflux Disease (GERD) and restless leg syndrome. Review of Resident #62's fall risk assessment dated [DATE] revealed a fall risk score of 20. The evaluation report for the assessment indicated for scores of 10 or above interventions should be initiated. Review of Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15. The resident required assistance from staff with incontinence care and was coded as always incontinent of bowel and bladder. The resident also required assistance with toileting, showers and personal hygiene. Review of Resident #62's care plans updated 04/16/26 revealed no falls care plan. Interview on 04/16/26 at 8:45 A.M. with MDS Regional Nurse #273 confirmed Resident #62 required an at risk for falls care plan and it was not in her current care plans. Review of the facility policy, comprehensive Care Plans and Revisions last revised 8/29/25 revealed the facility will monitor the resident over time to help identify changes in the residents condition that may warrant an update to the person-centered plan of care and when these changes occur, the facility should review and update the plan of care to reflect the changes to chare delivery and can include additional interventions on existing problems, updating goal or problem statements, and adding a short-term problem, goal, and interventions.

Based on observation, interview, and record review the facility failed to ensure Resident #11 was offered activities and had a detailed activities assessment and care plan. This affected one resident (#11) of one resident reviewed for activities. The facility census was 82.Findings include: Review of Resident #11's medical record revealed an admission date of 11/01/25 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia, chronic heart failure, type two diabetes mellitus, and other frontotemporal neurocognitive disorder.Review of Resident #11's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was rarely or never understood. Review of Resident #11's plan of care dated 11/03/25 revealed the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs. Interventions included introducing residents to residents with similar background and interests, inviting to scheduled activities, and providing a program of activities of interest. Review of Resident #11's activity evaluation dated 11/03/25 revealed the resident was catholic and actively participated in his religion. Activities that were very important to him included pets and sports. Activities that were somewhat important to him included board games, community outings, current events, cultural events, educational programs, family or friend visits, group discussion, movies, music, television. and radio. He was interested in activities and was cooperative and cheerful.Observation on 04/14/26 at 7:47 A.M. revealed Resident #11 was awake, his room was dark and he had no entertainment. Observation at 1:14 P.M. revealed Resident #11 was watching television.Observation on 04/15/26 at 7:54 A.M. 9:50 A.M. and 1:10 P.M. revealed Resident #11 in a dark room with television on.Interview on 04/15/26 at 9:51 A.M. with Activities Assistant #134 revealed Resident #11 refused a lot of activities, he did not like to do what they offered him. Activities Assistant #134 verified the activities he was offered and refused were not documented, and there was limited activity documentation.Interview on 04/16/26 at 11:19 A.M. with Activities Assistant #133 and Activities Assistant #134 revealed they knew he liked trivia. They were unable to access the activity assessment and care plan. They were unsure of his specific preferences like what television and music he enjoyed. They were unaware he was catholic, Activities Assistant #133 reported they have people come in to visit the Catholics that resided in the facility and could add him to the list.

Based on medical record review, interview and facility policy review, the facility failed to notify the Psychiatric Certified Nurse Practitioner when a resident had behavior and mood changes. This afffected one resident (#41) of two residents reviewed for behavioral, mental and emotional health care and services. The census was 82. Findings include:Review of the medical record Resident #41 revealed an admission date of 03/09/24 with a Brief Interview ofr Mental Status (BIMS) score of 15 indicating no cognitive deficits. His diagnoses included Arnold Chiari Syndrome, hydrocephalus, mood disorder, depression, benign neoplasm of the brain and adult failure to thrive.Review of Resident #41's Psychiatric Certified Nurse Practitioner #271 psychiatric note on 01/30/26 revealed she indicated nursing follow up with the provider in 2-4 weeks, unless acute issue or concerns presents .Review of Resident # 41's progress notes dated 02/03/26 at 4:05 P.M. the Interdisciplinary Team recorded Resident #16 had escalating changes in mental status, behaviors, multiple recent hospitalizations related to increased confusion with significant decline in baseline, including not taking his medications, refusal of meals despite repeated encouragement, and active hallucinations and paranoid thought processes. The facility's Medical Director was notified and by telephone indicated Resident #16 should be sent to hospital via Application for an Emergency Hospitalization. The local police were contacted and arrived at the facility at 5:42 P.M. and denied the notification of the Application for an Emergency Hospitalization form and asked the resident if he would like to be escorted to the hospital for care. Resident #41 agreed and was transported to the hospital.Review of his care plan last updated on 02/23/26 revealed he was independent for activities of daily living and walks around the facility and in the community independently. He received psychological services with contracted counseling group including a Psychiatric Certified Nurse Practitioner # 271 every two weeks and a nurse visit every other week.Interview with Resident #41 on 04/13/26 at 2:00 P.M. confirmed Previous Director of Nursing # 267 came to his room on 02/03/26 in the afternoon and told him that they were pink slipping him that afternoon, because he needed to go to the hospital. He was unaware that he had a change in condition or was displaying different behaviors. When the police arrived, they spoke to him and he agreed to go to the hospital for care.Interview on 04/14/26 at 1:00 P.M. with the previous Director of Nursing #267 confirmed no one notified Resident #41's Psychiatric Certified Nurse Practitioner # 271 of behavior or mood changes prior to completing the Application for an Emergency Hospitalization form and notifying the police. Interview on 04/14/26 at 1:30 P.M. with Nursing Supervisor # 262 confirmed she was working with the previous Director of Nursing # 267 and Regional Representative # 400 when the pink slip was being completed, at no time did anyone notify Resident #41 Psychiatric Certified Nurse Practitioner # 271 of behavior or mood changes.Interview with the Psychiatric Certified Nurse Practitioner #271 on 04/20/26 at 9:10 A.M. confirmed she saw Resident #41 on 01/30/26 and at that time she was aware of the behaviors he was exhibiting , however, did not believe he needed to be sent to the hospital. She confirmed she was not notified of any behaviors or change in condition for Resident #41 or that he was sent to the hospital on [DATE] . She found out about his hospital admission when she saw him on 02/27/26.Review of the facility's , Changes in Resident's Condition or Status, dated 11/26/2018 the facility must notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status.

Based on interview and record review the facility failed to timely address Resident #79's Urinary Tract Infection (UTI). This affected one resident (#79) of two residents reviewed for UTI. The facility census was 82.Findings include:Review of Resident #79's medical record revealed an admission date of 12/10/25 with diagnoses including chronic kidney disease, osteoarthritis, cognitive communication deficit, adult failure to thrive, delirium, and vascular dementia. Review of Resident #79's progress note dated 03/03/26 at 8:29 P.M. revealed she complained of pain while urinating. The on-call nurse practitioner was notified and ordered urine to be collected for analysis.Review of Resident #79's physician order dated 03/03/26 revealed an order to collect urine for a urinary analysis with culture and sensitivity related to complaints of pain while urinating.Review of Resident #79's progress note dated 03/04/26 revealed Certified Nurse Practitioner (CNP) #266 saw the resident due to dysuria. A urinary analysis was pending. The resident appeared to have recurrent UTI's and she would consider adding cranberry.Review of Resident #79's progress note dated 03/04/26 at 9:45 A.M. revealed the resident's urine had been picked up by the lab.Review of Resident #79's urinary analysis dated 03/04/26 revealed her urine had been collected and the results were pending.Review of Resident #79's progress notes from 03/04/26 to 03/15/26 revealed the resident's potential UTI, urinary symptoms, and laboratory results were not addressed.Review of Resident #79's urinary analysis revealed her urine was collected on 03/09/26 and the results were reported on 03/13/26. The culture identified bacteria present in her urine that was susceptible to certain antibiotics.Review of Resident #79's progress note dated 03/16/26 at 2:52P.M. revealed CNP #266 followed up on the urine culture with positive reports and dysuria. The resident had complained of dysuria starting 03/03/26. The CNP ordered antibiotics following the results of the culture and sensitivity.Review of Resident #79's physician order dated 03/17/26 to 03/20/26 revealed an order for Cefitraxone sodium injection solution one gram (gm) injected intramuscularly one time a day for three days for a UTI.Review of Resident #79's physician order dated 03/17/26 revealed an order for Cranberry tablet 450 mg one time a day for recurrent UTI's.Review of Resident #79's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition. She was frequently incontinent of bowel and bladder. Review of Resident #79's plan of care on 04/15/26 revealed it did not address her risk for UTI's or her recurrent UTI's.Interview on 04/15/26 at 9:40 A.M. with the Director of Nursing (DON) revealed the laboratory threw out the urine that had been collected on 03/04/26 so it had to be redone. She verified there was no documentation related to this, when they were notified of this, and if the resident continued to have symptoms.Interview on 04/15/26 at 10:30 A.M. with CNP #266 revealed they had multiple issues with the current lab they were using. Often the facility received a report back from the lab saying they would not run the sample, this is what happened in this case. Resident #79 continued to have symptoms on and off, so they collected her urine again. On 03/13/26 the lab said they were not going to culture it, CNP #266 stated she requested a culture. The culture came in on 03/16/26 which is when she ordered antibiotics.Interview on 04/15/26 at 3:14 P.M. with Regional MDS #273 verified the residents recurrent UTI's should have been addressed in the plan of care.The facility did not have policies related to UTI.This violation represents noncompliance investigated under complaint 2746176.

Based on interview and record review the facility failed to ensure Resident #85's blood pressure medication was administered as ordered. This affected one resident (#85) of three residents reviewed for accidents. The facility census was 82.Findings include: Review of Resident #85's medical record revealed an admission date of 04/02/19 with diagnoses including dementia, dysphagia, and other peripheral vascular diseases.Review of Resident #85's medical record revealed the resident was rarely or never understood. Review of Resident #85's physician order dated 12/01/25 revealed the resident was to receive Metoprolol Tartrate (beta blocker) 50 milligrams (mg) by mouth two times a day for hypertension. The medication was to be held for systolic pressure less than 110 millimeters of mercury (mmHg).Review of Resident #85's Medication Administration Record (MAR) for March 2026 and 04/01/26 through 04/14/26 revealed the Metoprolol Tartrate was administered at 9:00 A.M. and 9:00 P.M. There was no evidence the resident's blood pressure was monitored around this time.Review of Resident #85's vital sign records revealed no evidence the blood pressure was monitored around 9:00 A.M. and 9:00 P.M.Interview on 04/16/26 at 8:33 A.M. with the Director of Nursing (DON) confirmed Resident #85's blood pressure was not being monitored as ordered.Review of policy 'Administration of Medications' dated 09/09/25 revealed when administering medications any parameters around drug administration should be noted.This violation represents noncompliance investigated under complaint 2746176 and 2693477.

Based on interview, record review, and review of the facility policy, the facility failed to ensure opioid medication was approved for the resident to take during a leave of absence for Resident #61. This resulted in an unobserved significant medication error for Resident #61. This affected one resident (#61) of one resident reviewed for pain. The facility census was 82.Findings include:Review of Resident #61's medical record revealed an admission date of 01/03/25 with diagnoses including opioid abuse, heart failure, anxiety disorder, bipolar disorder, depression, chronic viral hepatitis C, and unspecified mood disorder.Review of Resident #61's quarterly Minimum Data Set (MDS) 30 assessment dated [DATE] revealed the resident had intact cognition. Her medications included antianxiety, antidepressant, opioids, diuretics, and anticonvulsants.Review of Resident #61's plan of care dated 01/10/25 revealed the resident was on pain medication therapy related to pain. Interventions included administering analgesics as ordered, asking the physician to review medications if side effects persisted, monitoring for respiratory depression, observing and reporting for adverse reactions as needed, and pain medications to be crushed and put in applesauce. Review of Resident #61's plan of care dated 01/10/25 revealed the resident expressed pain or discomfort related to necrosis of right femur, right hip joint, and osteoarthritis. Interventions included evaluating the effectiveness of pain interventions, notifying the physician if interventions are unsuccessful, observing and reporting to the nurse any signs of nonverbal pain, pain medications as ordered, and observing and reporting to nurse resident complaints of pain. Review of Resident #61's physician order starting 09/10/25 revealed an order for Oxycodone 15 mg one tablet every four hours as needed.Review of Resident #61's note by Certified Nurse Practitioner (CNP) #266 dated 09/10/25 revealed the resident had returned from the hospital on [DATE] where she had been getting Oxycodone 20 mg and intravenous (IV) Dilaudid (opioid). They had significant difficulty weaning the resident off of IV medication in the hospital due to her refusal. The hospital had concerns with narcotic tolerance, and they recommended the facility wean her off of her oral pain medications. The physician discussed needing to decrease the dosage with the resident and she became very upset.Review of Resident #61's physician note dated 09/17/25 revealed they spoke with the resident regarding tapering her Oxycodone to 10 mg every four hours starting in two to four weeks.Review of Resident #61's progress note dated 11/21/25 at 7:40 P.M. revealed the resident was sent 17 Oxycodone pills to take home, on a leave of absence, and she left the facility with a family member.Review of Resident #61's controlled substance record revealed on 11/21/25 at 4:39 P.M. the resident received one Oxycodone and had 17 remaining. Written on this form was 'sent 17 pills with resident to home' with two signatures below it and 'resident received to take home 17 pill's with one signature below it.Interview on 04/16/26 at 12:28 P.M. with Regional Clinical Director #405 revealed the nurse and the resident signed the controlled substance record.Review of Resident #61's progress note dated 11/23/25 at 6:43 P.M. revealed Resident #61 called the facility and stated she was out of her pain pills and she was not given any other pills. She stated she would be returning to the facility later that day and she wanted to make sure the facility had her pain medication ordered when she returned.Review of Resident #61's progress note dated 11/24/25 at 2:04 P.M. revealed the resident returned to the facility and received as needed pain medication as requested.Review of Resident #61's medical record revealed no evidence the physician was notified that Resident #61 used 17 Oxycodone pills in less than 48 hours outside of the physician order. Review of Resident #61's physician note dated 12/12/25 revealed she continued on Oxycodone 15 mg every four hours as needed with a plan to wean as able.Interview on 04/15/26 at 10:30 A.M. with CNP #266 revealed Resident #61 went out to the hospital in September 2025, and her Oxycodone was increased with a plan to taper it. She reported the goal was to decrease the Oxycodone in the facility, however, this did not happen, she was unsure why. CNP #266 reported when the resident went on LOA's she was supposed to be getting half the frequency of Oxycodone. Since she was getting Oxycodone every four hours, she would get enough to have a dose every eight hours when she was out of the building. If she wanted to go on a LOA for more than two to three days, she would need to come back to the building to get more. CNP #266 confirmed she did not approve Resident #61 going on a LOA with 17 Oxycodone for Thanksgiving. She verified Resident #61 went through all 17 pills before she should have per her schedule. The physician should have been notified of this upon her return; however, the facility just returned her to her normal Oxycodone schedule.Interview on 04/15/26 at 1:30 P.M. with the Director of Nursing (DON) revealed there was no physician order to pull the Oxycodone for Resident #61's 11/21/26 LOA. The nurse said she got approval; however, this was not documented anywhere.Interview on 04/15/26 at 2:38 P.M. with Physician #270 revealed she was unavailable to talk at the time and would return the surveyor's call. No return contact was made for the duration of the survey.Interview on 04/16/26 at 10:59 A.M. with Licensed Practical Nurse (LPN) #183 revealed when a resident was going to go on a LOA for several days, they called the pharmacy and the pharmacy would send medications for the length of the absence. However, if a resident had narcotics the pharmacy would not make packages for it. The facility nurses would need to call the physician and get permission to send narcotics home and then they would send it from the resident's supply.Review of the policy 'Leave of Absence (Therapeutic Leave)' dated 09/09/25 revealed the facility will ensure continuity of care when a resident leaves the facility for therapeutic leave of absence. If medications were sent with the resident during a leave of absence the facility should complete the 'Release of Responsibility for Medication form.Interview on 04/16/26 at 12:28 P.M. with Regional Clinical Director #405 confirmed the LOA policy was not followed. This violation represented noncompliance investigated under complaint 2746176.

Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to follow infection control procedures for a resident requiring enhanced barrier precautions this affected one (#04) and the facility failed to ensure staff followed neutropenic precautions which affected one (#42) . Five residents were reviewed for infection control procedures. The facility census was 82. Findings Include: 1.Resident #04 was admitted [DATE] and had diagnoses that include obstructive uropathy, chronic kidney disease (stage IIIA), and chronic systolic congestive heart failure. Review of the Resident's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident was cognitively intact and had an indwelling catheter. Review of the Resident #04's care plan completed 02/05/26 revealed Resident #04 had an indwelling catheter related to urinary retention and was at risk of infections. Enhanced Barrier Precautions (EBP) are an intervention listed to reduce the risk of infections with an indwelling catheter. Review of Resident #04's medical record revealed orders for EBP due to Foley Catheter use written on 01/20/26. Observation of Resident #04's room was conducted on 04/14/2026 between 10:19 A.M. and 11:16 A.M. Certified Nurse Assistant (CNA) #177 was observed at 10:19 A.M. entering the room of Resident #04 and Resident #56 for the purpose of giving each resident a bed bath. CNA #177 was observed entering room with patient gowns and trash bags. Upon entering the room, CNA #177 was not wearing a gown and did not stop to don gown, gloves, or mask from drawers sitting outside the Residents' room. CNA #177 exited the Resident's room about 11:16 A.M. not wearing a gown and carrying three trash bags. Used gloves were visible in one of the trash bags. Interview with CNA #177 at approximately 11:16 A.M. on 04/14/26 confirmed that she had given both residents a bed bath and CNA #177 confirmed she did not wear a gown during the bed bath for Resident #04. Review of the facility policy titled Enhanced Barrier Precautions (revised 08/19/25) defines EBP as an infection control intervention that employs targeted gown in glove use during high contact resident care activities. The policy defines bathing as a high contact resident activity requiring gown and glove use. The policy states that residents with indwelling medical devices are indicated for EPB. 2.Review of Resident # 42's medical record revealed an admission date of 07/21/25 with diagnoses that included but were not limited to multiple myeloma, agranulocytosis secondary to cancer chemotherapy, hypertension, peripheral vascular disease, obesity and congestive heart failure. Review of Resident #42's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of nine indicating cognitive impairment. He required assistance from staff with transfers, toileting hygiene, bathing and mobility. Review of Resident # 42's progress notes dated 07/30/25 revealed orders for the resident to be placed on neutropenic precautions. Review of Resident # 42's physicians orders on 04/15/26 revealed no order for neutropenic precautions. Further review revealed an order for chemotherapy infusion every Thursday. Observation on 04/13/26 at 9:30 A.M. revealed Resident # 42's room door opened with neutropenic precautions signage on the door. Observation on 04/14/26 at 1:28 P.M. revealed Receptionist #152 walked into Resident #42's room with no mask and delivered a package. When Receptionist #152 exited the room, she verified she should have had a mask on and did not put wear one to go into Resident #42's room. Observation on 04/14/26 at 1:32 P.M. revealed Laundry Assistant #125 walked into Resident # 42's room with no mask and delivered his laundry. When Laundry Assistant # 125 was interviewed at the time of the observation and verified she entered the residents' room with no mask on adding she forgot to put on personal protective equipment. Interview on 04/14/26 at 1:39 P.M. with Resident # 42 revealed he was on neutropenic precautions because he goes out to chemotherapy twice a week. He stated sometimes staff wear masks and sometimes they don't. Resident # 42 also stated his room door used to be closed all the time and he preferred it to be left open. Interview on 04/14/26 at 1:45 P.M. with Director of Nursing (DON) confirmed staff should wear masks when entering neutropenic precautions rooms. She confirmed they were aware of staff entering with no masks and they plan to move signage for better view. Review of facility policy titled protective precautions (reverse isolation) dated 02/15/21 revealed protective precautions will be initiated at the recommendation of the attending or consulting medical provider. Also, a private room should be used when possible. Ideally, the door should be kept closed. The door may be left open if necessary, for resident safety. It also states personal protective equipment (PPE) will be worn in the room as needed by associates and visitors. This violation represents noncompliance investigated under complaint 2693477.

Based on observation, record review, interview and facility policy review the facility failed to maintain a medication error rate of five percent or less. This affected one resident (#45) of six residents observed during medication administration. The facility census was 86.Findings include: 1. On 11/26/25 at 9:00 A.M. through 11:16 A.M. and 12/01/25 from 8:08 A.M. through 8:21 A.M. medication pass was observed for six residents (#2, #30, #45, #73, #75, and #76) provided by five facility staff nurses. A total of 26 observations were made with two errors resulting in an error rate of 7.69%.Record review of Resident #45's medical record revealed an admission date of 04/02/2019. Diagnoses include unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, chronic kidney disease stage III, unspecified atrial fibrillation, other specified peripheral vascular diseases, essential (primary) hypertension, anemia, presence of cardiac pacemaker, dysphagia oropharyngeal phase, muscle weakness, edema, vitamin deficiency, nail dystrophy, presence of intraocular lens, and long term (current) use of anticoagulants.Review of Resident #45's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) could not be completed due to resident is rarely/never understood and confirms Resident #45's cognitive skills for daily decision making is severely impaired.Review of Resident #45's Medication Administration Record (MAR) dated 12/01/25 revealed Resident #45 had an order for Metoprolol Succinate Oral Capsule ER 24 Hour Sprinkle 100 milligrams (mg) instructions include give one capsule by mouth one time a day for hypertension and hold if systolic blood pressure is less than 110 with an order date of 12/23/24. Resident #45 had an order for Potassium (electrolyte) tablet instructions include give 20 milliequivalent (mEq) by mouth one time a day for hypokalemia with an order date of 12/22/19.Observation on 12/01/25 at 8:25 A.M. of Licensed Practical Nurse (LPN) #74 during medication administration revealed Resident #45 receive Metoprolol Succinate ER 100 mg, one tablet, Potassium CL ER 20 mEq, one tablet, and Eliquis (anticoagulant) 2.5 mg, one tablet. The three medication tablets were then crushed and placed in pudding and administered to Resident #45. Observation of medication cards for Metoprolol Succinate ER 100mg and Potassium CL ER 20 mEq were labeled do not crush on left upper corner.Interview 12/01/25 at 9:10 A.M. with LPN #74 confirmed the medications provided were crushed and administered to Resident #45.LPN #47 was observed to call Pharmacist #20 on speaker phone on 12/01/25 at 9:14 A.M. and Pharmacist #20 confirmed Metoprolol Succinate ER 100 mg tablet and Potassium CL ER 20 mEq tablet should not be crushed. Review of the facility's Administration of Medications policy dated 09/09/25 confirmed staff who are responsible for medication will adhere to the 10 rights of medications administration. Right drug, compare the order with the medication administration record (eMAR) for accuracy and compare the label on the drug to the information on the eMAR, three times. Verify the right resident. Right dose and if there is any doubt about the dose on the MAR or if there is a question on the drug, stop and verify all information before administering. Review of the facility's policy titled, Medication - Related Errors dated 05/01/10 confirms if a medication reaches a resident in error, the facility should, notify the pharmacy of ay possible dispensing occurrence; and notify physician/prescriber and obtain further instructions and/or orders. Facility staff should monitor the resident in accordance with physician/prescriber's instructions.

Based on observation, record review, and facility policy review the facility failed to administer medications as ordered for Resident #45. This affected one of five residents observed during medication administration. The facility census was 86.Findings include:Record review of Resident #45's medical record revealed an admission date of 04/02/2019. Diagnoses include unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, chronic kidney disease stage III, unspecified atrial fibrillation, other specified peripheral vascular diseases, essential (primary) hypertension, anemia, presence of cardiac pacemaker, dysphagia oropharyngeal phase, muscle weakness, edema, vitamin deficiency, nail dystrophy, presence of intraocular lens, and long term (current) use of anticoagulants.Review of Resident #45's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) could not be completed due to resident is rarely/never understood and confirms Resident #45's cognitive skills for daily decision making is severely impaired.Review of Resident #45's Medication Administration Record (MAR) dated 12/01/25 revealed Resident #45 had an order for Metoprolol Succinate Oral Capsule ER (antihypertensive) 24 Hour Sprinkle 100 MG instructions include give one capsule by mouth one time a day for hypertension and hold if systolic blood pressure is less than 110 with an order date of 12/23/24. Resident #45's Potassium (supplement) tablet instructions include give 20 mEq by mouth one time a day for hypokalemia with an order date of 12/22/19.Observation on 12/01/25 at 8:25 A.M. of License Practical Nurse (LPN) #74 during medication administration revealed Resident #45 receive Metoprolol Succinate ER 100mg one tablet, Potassium CL ER 20 mEq one tablet, and Eliquis 2.5 mg one tab. The three medication tablets were then crushed and placed in pudding and administered to Resident #45. Observation of medication cards for Metoprolol Succinate ER 100mg one tablet and Potassium CL ER 20 mEq one tablet were labeled do not crush on left upper corner.Interview 12/01/25 at 9:10 A.M. with LPN #74 confirmed the three medications were crushed and administered to Resident #45.Observation on 12/01/25 at 9:14 A.M. of LPN # 47's interview with Pharmacist #20 confirmed Metoprolol Succinate ER 100 mg tablet and Potassium CL ER 20 mEq tablet should not be crushed.LPN #47 was observed to call Pharmacist #20 on speaker phone on 12/01/25 at 9:14 A.M. and Pharmacist #20 confirmed Metoprolol Succinate ER 100 mg tablet and Potassium CL ER 20 mEq tablet should not be crushed. Review of the facility's Administration of Medications policy dated 09/09/25 confirmed staff who are responsible for medication will adhere to the 10 rights of medications administration. Right drug, compare the order with the medication administration record (eMAR) for accuracy and compare the label on the drug to the information on the eMAR, three times. Verify the right resident. Right dose and if there is any doubt about the dose on the MAR or if there is a question on the drug, stop and verify all information before administering. Review of the facility's policy titled, Medication - Related Errors dated 05/01/10 confirms if a medication reaches a resident in error, the facility should, notify the pharmacy of any possible dispensing occurrence; and notify physician/prescriber and obtain further instructions and/or orders. Facility staff should monitor the resident in accordance with physician/prescriber's instructions.This violation represents non-compliance investigated under Complaint Number 2647703.

Based on observation, interview and facility policy review the facility failed to properly label and store medications. This had the potential to affect all residents who receive medications from the facility. The census was 86.Findings include: 1. Observation on [DATE] at 9:39 A.M. with Licensed Practical Nurse (LPN) #52 during medication administration revealed a facility stock bottle of Thiamine B1 (vitamin) 100 milligram (mg) tablet which was opened and undated, a facility stock bottle of Famotidine (decreases acid in the stomach) 20 mg bottle which was opened and undated, and container of MiraLAX (laxative)17 mg which was opened and undated. Other facility stock medication bottles were observed in medication cart had open dates written on top of lid of medication bottle.Interview on [DATE] at 9:45 A.M. with LPN #52 confirmed the bottles of Thiamine, Famotidine, and MiraLAX were open but were not labeled with the open date. LPN #52 was observed labeling the bottles. 2. Observation on [DATE] at 11:25 A.M. of the medication storage room revealed unopened but expired items including a bottle of Fiber Powder Psyllium husk with the expiration of [DATE], a bottle of Vitamin A 3,000 mcg, B2 Riboflavin with an expiration date of [DATE], nasal spray moisturizing spray with an expiration date of [DATE], and nasal decongestant PE Phenylephrine HCL 10 mg expiration date of [DATE].Interview on [DATE] at 11:45 A.M. with the Assistant Director of Nursing (ADON) confirmed the medications were expired.Review of the facility's policy titled, Storage and Expiration Dating of Medications and Biologicals last revised on [DATE] confirms the facility should ensure medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines,: or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier.

Based on record review and interviews, the facility failed to provide assistance with bathing and shaving. This affected (Residents #42 and #44) of three residents reviewed for showers. The facility census was 80. Review of the medical record revealed Resident #42 was admitted on [DATE] with diagnoses that included acute embolism and thrombosis of left iliac vein, pulmonary embolism, severe protein-calorie deficiency, schizoaffective disorder, dementia, depression, and bipolar. The annual Minimum Data Set (MDS) dated [DATE] revealed it was very important for Resident #42 to choose the type of bathing. A care plan for activities of daily living dated 01/26/24 revealed Resident #42 required supervision with bathing/showering. Review of the electronic record, therapy notes, and paper documentation revealed in the last 30-days Resident #42 received a bed bath on 09/08/25 and 09/11/25, refused bathing with occupational therapy on 09/18/25, and received a sponge bath on 09/21/25. An observation and interview on 09/22/25 at 12:31 P.M. revealed Resident #42 was sitting in a chair in his room. Resident #42 had a short beard. Resident #42 stated he did not like having a beard and would like to be shaved. Resident #42 also verified he preferred receiving a shower over a bed bath. Interview on 09/22/25 at 2:05 P.M. a family of Resident #42 verified Resident #42 did not like having a beard. The family member also stated Resident #42 was only bathed once a week and preferred a shower. The family member stated they had taken Resident #42 home on a leave of absence so Resident #42 could shower at her house. An interview on 09/22/25 at 4:23 P.M. Director of Nursing (DON) verified Resident #42 was not being bathed and shaved per his preference. The DON verified there was a concerns with bathing being completed as scheduled. 2. Review of the medical record revealed Resident #44 was admitted on [DATE] with diagnoses that included dementia and atrial fibrillation. Review of the annual MDS dated [DATE] revealed Resident #44 had severe cognitive impairment and was dependent on staff for bathing. Review of the electronic record and paper documentation revealed in the last 30 days Resident #44 received a sponge bath on 08/28/25 and a shower on 09/01/25. Interview on 09/22/25 at 4:23 P.M. Director of Nursing (DON) verified there was a concern with bathing being completed as scheduled. This deficiency represents non-compliance investigated under Complaint Number 2584976.

Based on interview and record review, the facility failed to thoroughly assess a resident after a fall and timely notify the physician. This affected one resident (#3) of three residents reviewed for falls. The facility census was 80.Findings include: Review of Resident #3's medical record revealed an admission date of 07/10/25 with diagnoses including cognitive communication deficit, dementia, depression, anxiety and fracture of left femur on 08/21/25.Review of Resident #3's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had severely impaired cognition. Since the previous assessment Resident #3 had two falls or more without injury, two falls or more with injury, and one fall with major injury.Review of Resident #3's plan of care dated 07/11/25 revealed the resident was at risk for falls related to impaired balance and lack of safety awareness due to cognitive deficit related to dementia. Interventions included assisting out of bed before meals, assisting with toileting before bedtime, dycem to wheelchair, clearing a pathway in his room, fall mat, low bed, medication review, offering snacks when restless, offering toileting in advance of needs, toileting before laying down after meals, and visual reminder to call before you falls.Review of Resident #3's progress note dated 08/16/25 at 3:00 A.M. revealed staff heard yelling coming from the residents room. The residents roommate was calling for help after the resident fell. Resident #3 was found on the floor lying on his back next to his bed. He was unable to voice what happened. A head-to-toe assessment was completed and no visible injuries were noted. However, the resident was unable to stand and complained of left hip pain. Staff assisted the resident back in bed, groomed him and put him in his wheelchair. He was given as needed pain medication at that time.Review of Resident #3's fall investigation dated 08/16/25 revealed no evidence his range of motion was not assessed and the physician was not notified until 8:00 A.M.Interview on 09/22/25 at 11:10 A.M. with the Director of Nursing (DON) verified that range of motion was not assessed after his fall and should have been.Interview on 09/22/25 at 1:04 P.M. with Certified Nurse Practitioner (CNP) #270 verified they were not timely notified of the fall. The physician was notified of the fall at 7:45 A.M. and they should have been notified at the time of the fall so they could address any concerns at that time.This deficiency represents noncompliance investigated under Complaint Numbers 2593023 and 2584976

Based on interview, medical record review, and policy review, the facility failed to ensure Resident #3's pain was timely and appropriately addressed. This affected one resident (#3) of four residents reviewed for falls. The facility census was 80.Findings include: Review of Resident #3's medical record revealed an admission date of 07/10/25 with diagnoses including cognitive communication deficit, dementia, depression, anxiety and fracture of left femur on 08/21/25.Review of Resident #3's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had severely impaired cognition. Since the previous assessment Resident #3 had two falls or more without injury, two falls or more with injury, and one fall with major injury.Review of Resident #3's physician order dated 07/10/25 revealed an order for Acetaminophen Tablet 325 milligrams (mg) two tablets by mouth every four hours as needed for a fever above 101 degrees Fahrenheit.Review of Resident #3's physician order dated 07/10/25 revealed an order for Acetaminophen Suppository 650 mg, one suppository insert rectally every four hours as needed for pain. Review of Resident #3's plan of care dated 07/11/25 revealed the resident was at risk for pain and discomfort related to cancer and history of fractures. Interventions included educating the resident and family regarding pain management, notifying the physician if interventions are unsuccessful, observing and reporting to the nurse resident complaints of pain or requests for pain treatment, observing for probable cause of pain, pain medications as ordered, and reporting to the nurse any changes in usual activity.Review of Resident #3's plan of care dated 07/11/25 revealed the resident was at risk for falls related to impaired balance and lack of safety awareness due to cognitive deficit related to dementia. Interventions included assisting out of bed before meals, assisting with toileting before bedtime, dycem to wheelchair, clearing a pathway in his room, fall mat, low bed, medication review, offering snacks when restless, offering toileting in advance of needs, toileting before laying down after meals, and visual reminder to call before you fall.Review of Resident #3's progress note dated 08/16/25 at 3:00 A.M. revealed staff heard yelling coming from the resident's room. The residents roommate was calling for help after the resident fell. Resident #3 was found on the floor lying on his back next to his bed. He was unable to voice what happened. A head-to-toe assessment was completed and no visible injuries were noted. However, the resident was unable to stand and complained of left hip pain. Staff assisted the resident back in bed, groomed him and put him in his wheelchair. He was given as needed pain medication at that time.Review of Resident #3's progress note dated 08/16/25 at 3:10 A.M. revealed the resident was given acetaminophen 325 mg for left hip pain.Review of Resident #3's progress note dated 08/16/25 at 8:06 A.M. revealed the certified nurse practitioner (CNP) was notified of the residents' left hip pain after a fall, and an x-ray was ordered.Review of Resident #3's progress note dated 08/16/25 at 5:24 P.M. revealed the nurse was aware of Resident #3's unwitnessed fall where he landed on his left thigh. The resident had been noted moaning and groaning during their shift. The nurse notified the physician and was given an order to transfer them to the hospital.Review of Resident #3's progress note dated 08/17/25 at 3:53 A.M. revealed the resident returned from the hospital and his x-ray results were negative for fracture.Review of Resident #3's hospital after visit summary dated 08/16/25 revealed his diagnosis was closed fracture of the left hip. Handwritten on this after visit summary was 'no fx (fracture)'. In the hospital the resident had been given Fentanyl for pain.Review of Resident #3's CT exam of his pelvis revealed there was a previous fracture present, however, there was a new mildly displaced comminuted fracture along the lateral base of the left trochanter which extended to the anchoring stem of the unit.Review of Resident #3's CNP #270 note dated 08/18/25 revealed the resident reported left hip pain, he was sore, and it hurt to move. Resident #3 had a fall on 08/16/25 and was sent to the emergency room for left hip pain with a negative x-ray. She recommended the facility continue fall precautions, nursing interventions, and neurochecks. His medications were reviewed, his current medications had no concern for polypharmacy to cause sedation or side effects leading to falls. In an addendum on 08/19/25 CNP #270 indicated the hospital notes had a CT scan which revealed a nondisplaced greater trochanter fracture. Orthopedics recommended nonsurgical management, weight bearing as tolerated with walker until pain free, limited abduction, and follow up in three weeks.Review of Resident #3's progress note dated 08/19/25 revealed the resident had pain with turning and completing activities of daily living. CNP #270 was notified and gave a verbal order for new pain medications.Review of Resident #3's physician order dated 08/19/25 to 09/08/25 revealed an order for oxycodone five mg one tablet by mouth every six hours as needed for pain.Review of Resident #3's Medication Administration Record from 08/16/25 to revealed Acetaminophen 325 mg was given on 08/16/25 for no fever, Acetaminophen 650 mg was given on 08/28/25 for an unknown pain. There was no pain medication given from 08/17/25 through 08/19/25. Oxycodone was given on 08/20/25 for a pain of four, five, four, and six. It was given on 08/23/25, 08/24/25, 08/25/25, and 08/30/25 for a pain of six, and on 08/26/25 and 08/27/25 for a pain of five. On 08/17/25 the resident had a pain of three and two, and on 08/19/25 the resident had a pain of three.Review of Resident #3's progress note dated 08/20/25 at 1:00 A.M. revealed the resident received oxycodone for pain in his left hip.Review of Resident #3's CNP #270 note dated 08/20/25 revealed the resident appeared uncomfortable and was unable to complete activities of daily living. She recommended they use the oxycodone sparingly and only as needed due to concerns for falls. Per nursing the resident had reported significant left hip pain and did not want to move too much.Interview on 09/22/25 at 12:22 P.M. with Certified Nursing Assistant (CNA) #207 revealed she could not recall the details but believed the resident may have reported pain once a little over a month ago.Interview on 09/22/25 at 1:04 P.M. with CNP #270 verified the facility had initially not noted the resident's fracture until MedOne employees (physician services) reviewed the hospital notes on 08/19/25 and noted the CT scan. She reported she had been concerned about using opioids due to his falls. She verified she had noted he was in pain on 08/18/25 and had expected the facility staff to use the Acetaminophen that had been ordered to control his pain. When the facility reported ongoing pain on 08/19/25 she went ahead and ordered the oxycodone, she was unaware the acetaminophen had not been used.Interview on 09/22/25 at 4:20 P.M. with the Director of Nursing (DON) verified that from 08/17/25 to 08/19/25 nursing did not attempt to give Resident #3 Acetaminophen despite his reports of pain. This included not providing pain medication on 08/19/25 after requesting stronger pain medication due to the residents pain.Review of the policy, 'Pain Assessment and Management,' revised 04/22/25 revealed acute pain included pain that is usually sudden in onset and time limited with a duration of less than a month. It is often caused by injury, trauma, or medical treatments. It was the policy of the facility to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. The facility was to identify and use specific strategies for preventing or minimizing different levels of sources of pain or pain-related symptoms based on the resident specific assessment, preferences and choices, pertinent clinical rationale, and the residents goals.

Based on closed medical record review, hospital record review, toxicology report review, review of the facility admission policy, review of the facility assessment and interviews, the facility failed to ensure Resident #82 received adequate, timely and appropriate treatment and continuity of care following admission to the facility resulting in a situation of neglect. This resulted in Immediate Jeopardy and serious life-threatening harm/subsequent death beginning on [DATE] at 8:30 P.M. when Resident #82, who had been hospitalized prior to admission, arrived at the facility for placement and staff failed to obtain physician orders for medications/treatments or contact the physician/medical director regarding the resident's admission. From [DATE] through [DATE] the resident was not ordered and did not receive medications including blood pressure medication, blood thinning medication, or insulin. In addition, Resident #82 presented to the facility with a history of illegal drug use; however, the facility failed to adequately identify this history or implement comprehensive and individualized interventions to maintain the resident's safety (as it pertained to his history of drug abuse). On [DATE] at 1:39 A.M., Resident #82 activated his call light for complaints of shortness of breath. The resident's condition continued to deteriorate, and emergency medical services was called via nine-one-one (911). On [DATE] at 1:54 A.M., CPR (cardiopulmonary resuscitation) was initiated. Resident #82 was subsequently pronounced deceased by emergency medical service (EMS) staff on [DATE] at 2:19 A.M. After being pronounced deceased , the facility failed to provide timely and appropriate post-mortem care by allowing the resident's body to remain in the facility from 2:19 A.M. until 1:56 P.M. when his body was eventually transported to the morgue, as facility staff did not know how to proceed with the resident's deceased body. This affected one (#82) resident of three residents reviewed for death. The facility census was 81. On [DATE] at 2:48 P.M., the Administrator, Regional Registered Nurse (RRN) #481 and the Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 8:30 P.M. when facility staff admitted Resident #82 to the facility, after he had left AMA from the hospital, and neglected to notify the physician of the resident's admission to the facility and lack of admission orders to provide continuity of care to the resident with known comorbidities. Despite a known history of drug abuse, the facility did not have appropriate supervision in place to provide a safe environment. The resident experienced a rapid condition change on [DATE], which required CPR; however, the resident expired at the facility. Following the resident's death, his body remained at the facility 11 hours and 37 minutes before being transported to the morgue for further assessment and determination of his final resting place. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 2:19 A.M., Resident #82 expired at the facility. On [DATE] at 1:56 P.M., Resident #82's body was transferred to the morgue. On [DATE], in-person and/or by phone education was provided to the facility's 32 nurses which included 12 Registered Nurses (RN) and 20 Licensed Practical Nurses (LPN) by the DON and Staff Development Coordinator (SDC) #81 on the facility's admission policies, notification of the physician on admission, and physician orders, including medications. One-on-one education was provided to RN #15 and RN #35 as they were responsible for Resident #82's care during admission. On [DATE], the initial Self-Reported Incident (SRI) was submitted by the Administrator based on the allegation of neglect. The admitting nurse for Resident #82, RN #35, was suspended on [DATE] at 7:30 P.M. pending the outcome of the investigation. On [DATE], a whole house audit of 23 residents admitted within the last 30 days was conducted by the DON, RRN #481 and the Administrator to ensure physician orders were consistent with hospital discharge orders and physicians were notified of admission. The 23 residents reviewed were Resident #6, #12, #24, #25, #28, #29, #33, #43, #66, #82, #86, #87, #88, #89, #90, #91, #92, #93, #94, #95, #96, #97 and #98 and no discrepancies were identified. Weekly, all new admissions and re-admissions will be audited by the DON or designee for four weeks to ensure physician notification and physician orders are included. On [DATE], in person and/or by phone education was provided by the DON and/or SDC #81 to all 32 licensed nurses to communicate with facility leadership regarding changes that may occur to a resident's admission to the facility or with the hospital discharge plan, to seek further instruction and guidance; that residents with a history of drug abuse have a care plan with appropriate interventions in place; administration of an opioid reversal agent in suspected opioid overdose; the policy for postmortem care and pronouncement of death to include timely notification for release of a deceased resident and notification of the police and/or coroner as necessary. On [DATE], a whole house audit for residents with a drug abuse history diagnosis was completed by RRN #418/designee to ensure interventions were in place and care plans reflected updated interventions as needed. Staff can access the care plan and Kardex (information regarding the resident's care) through the electronic medical record. Three residents were identified (Residents #38, #44 and #74) and had appropriate care plans. Weekly audits of care plans will be completed by the DON/designee for four weeks to ensure care plans for all residents with a history of drug abuse are appropriate. On [DATE], audits of residents who have expired in the facility from [DATE] through [DATE] were reviewed by the DON/designee to ensure they were provided with timely and appropriate postmortem care with notifications of the coroner and police as appropriate. Weekly audits for four weeks will be completed by the DON or designee to ensure compliance. On [DATE] at 8:15 P.M., an Ad Hoc (not scheduled) Quality Assurance and Performance Improvement Plan meeting was held with the DON, Administrator and RRN #481 in person and Certified Nurse Practitioner #493 by phone to discuss the removal plan and root cause analysis (RCA). The RCA was identified as the admission process was not followed per protocol. On [DATE] at 9:21 P.M., the Medical Director was notified of and approved the QAPI plan. All audits will be conducted weekly for four weeks and results will be discussed at the monthly QAPI meeting. Although the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #82's hospital documentation (state agency requested as part of the onsite investigation) revealed the resident was admitted to the hospital on [DATE] after he had arrived at the emergency room via ambulance transport due to shortness of breath. Further review of the medical record revealed a history and physical dated [DATE] that revealed the resident experienced acute hypoxic (decreased oxygen levels) and hypercapnia (the body can't remove excess carbon dioxide from the blood so there is a buildup and the body can't maintain proper ventilation) respiratory failure, crack lung (an acute lung injury related to smoking crack cocaine and can cause lung injury, cough, difficulty breathing and even death) versus aspiration pneumonia (a substance from the stomach or mouth enters the lung and causes pneumonia) versus pulmonary edema (a condition caused by too much fluid in the lungs) exacerbation of chronic obstructive pulmonary disease, elevated troponin (a cardiac enzyme that becomes elevated when there is damage to heart muscle), suspect myocardial infarction (heart attack), acute metabolic encephalopathy (a condition where the brain's function is impaired due to an underlying metabolic condition), hyperglycemia (blood glucose was 342 milligrams per deciliter of blood ((mg/dL)) on admission. A healthy adult blood glucose level ranges between ,d+[DATE] mg/dL), polysubstance abuse (positive for cocaine and fentanyl on admission), lung nodule in the left lower lobe (of the lung), and right renal cystic lesion. The patient required hospitalization due to acute respiratory failure in the setting of recent crack cocaine use requiring intubation and mechanical ventilation. Further review of the requested hospital record revealed a cardiology progress note dated [DATE] indicating the resident developed paroxysmal atrial fibrillation with a rapid ventricular response, multifocal atrial tachycardia and supraventricular tachycardia (all heart rhythms where the heart doesn't have a normal signaling process telling the heart when to beat and the signaling is disorganized and parts of your heart beat out of sync and may cause blood clots or compromised blood flow throughout the body). The resident also had newly diagnosed cardiomyopathy (disease that affects the heart muscle and may cause the heart muscle to become weakened, thickened, or rigid, making it difficult for the heart to pump blood effectively) with the heart ejecting only ,d+[DATE]% of blood from the left ventricle. The resident was given Lasix intravenously and amiodarone (antiarrhythmic) intravenously (to treat heart failure and abnormal heart rate). Further review of the requested hospital records revealed Resident #82 was prescribed no medications prior to admission to the hospital. During Resident #82's stay at the hospital, he was prescribed medications including amiodarone 200 mg (milligrams) daily, Eliquis (blood thinner) 5 mg twice a day, Lipitor (cholesterol medication) 40 mg nightly, Plavix (antiplatelet medication that prevents platelets from clumping together into blood clots) 75 mg daily, folic acid (form of Vitamin B) 1 mg daily, Lasix (diuretic) 20 mg twice daily, insulin lispro (fast acting insulin) injection 1 to 6 units subcutaneous three times a day before meals, Lopressor (a beta-blocker that treats angina, high blood pressure and heart failure) 12.5 mg twice a day, NicoDerm CQ 21 mg/24 hours transdermal daily, MiraLAX (laxative) 17 grams twice daily, Seroquel (antipsychotic) 25 mg twice daily, and Xopenex (bronchodilator) 1.25 mg/0.5 ml nebulizer solution every 6 hours when needed. Review of the hospital discharge summary dated [DATE] revealed Resident #82 was going to leave the hospital against medical advice (AMA) because his dog had a tumor on his face. The physician presented at the bedside and discussed this would be against medical advice, discussed the risks including worsening heart failure, cardiovascular accident (CVA), ACS (acute coronary syndrome), hypoxia, ischemia (restriction in blood flow) and death. Resident #82 expressed understanding. He signed out AMA on [DATE]. Review of Resident #82's facility closed medical record revealed he was admitted on [DATE]. Diagnoses included metabolic encephalopathy, respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), pulmonary edema, substance abuse, prediabetes and cardiomyopathy. Further review revealed no documentation of any admission orders or communication with the medical director for Resident #82 during the resident's stay at the facility. The resident discharged from the facility on [DATE]. Review of the admission baseline care plan dated [DATE] revealed the resident was at risk for elopement and negative health outcomes related to continued substance use while at the facility. Interventions included encourage to participate in activities of interest and medications per orders. Review of the progress notes dated [DATE] at 10:04 P.M. revealed Resident #82 showed no signs and symptoms of distress, is able to make needs and wants known, no concerns noted. Resident is on continued monitoring. Review of the progress notes dated [DATE] at 10:49 P.M. revealed Resident #82 was resting in bed, respirations are even and unlabored, lung sounds are clear bilaterally, denies pain and is able to make his needs known. Resident #82 is on continued monitoring. Review of the admission Minimum Data Set (MDS) Assessment, dated [DATE], revealed the resident's cognition was not assessed. He was independent with eating, required setup or clean-up assistance for oral hygiene, toileting, shower/bathing and dressing. He was always continent of urine and always incontinent of bowel. cognition was not assessed. He was independent with eating, required setup or clean-up assistance for oral hygiene, toileting, shower/bathing and dressing. He was always continent of urine and always incontinent of bowel. Review of the progress notes, dated [DATE] at 1:39 A.M and authored by RN #15, revealed at 1:15 A.M. Resident #82 told this nurse that he was going to get snacks from the vending machine, and the nurse offered (to) help, but he refused. Resident #82 came back to his room; the nurse assisted him in bed. Further review of the progress notes revealed at 1:39 A.M., he turned on his call light, this nurse went to the patient's room, and he told the nurse that he was having shortness of breath but denied chest pain. Resident #82 was on oxygen with the head of the bed elevated, his vitals were Blood Pressure (BP) ,d+[DATE] millimeters of Mercury (mmHg) [normal ,d+[DATE] mmHg], pulse (rate) 85 (normal ,d+[DATE] beats per minute), respiration 18 (normal ,d+[DATE] breaths per minute), oxygen saturation (measures the oxygenation of the blood) was 95 % (,d+[DATE] % is normal) and temperature 97.8 Fahrenheit. A decline was noticed in his condition while in his room. Further review of the [DATE] progress notes revealed at 1:40 A.M., 911 was called while in the room with Resident #82, and he was put on a non-rebreather mask (provides more oxygen than a nasal cannula), at 1:47 A.M. the nurse recalled 911 because the resident's condition was declining. At 1:48 A.M., his vitals were BP ,d+[DATE], pulse 90, respiration 20, temperature 97.9 and oxygen saturation 90 %. At 1:50 A.M., 911 arrived BP ,d+[DATE], pulse 50, respiration 12, temperature 97.7 and oxygen saturation was 86%. Further review of the progress notes, dated [DATE], revealed at 1:54 A.M., 911 started chest compressions on patient. At 2:19 A.M., Resident #82 was pronounced deceased . The DON, Med One (the on-call medical provider service) and the patient's family/friend were notified about the incident. A crack pipe, (with) residue and a lighter were found in the patient's shoe. Further review of the progress notes dated [DATE] at 1:56 P.M. and authored by RN #71 revealed Resident #82's body transported from the facility at 1:36 P.M. by the coroner's office. Review of the Coroner's Report: Finding of Facts and Verdict, dated [DATE], revealed the immediate cause of death was cardiomyopathy as a consequence of recent and chronic cocaine use, the manner of death was accidental. Toxicology testing showed benzoylecgonine (cocaine metabolite that can be detected for several days after use of cocaine), nicotine and cotinine (nicotine metabolite). Drug paraphernalia at the scene was positive for cocaine. On [DATE] at 12:03 P.M., an interview with RRN #481 revealed Resident #82 had left the hospital AMA and just showed up here at the facility without any paperwork (A friend dropped him off) but the facility had scheduled to admit him. The facility had called the hospital and asked for discharge paperwork, but the hospital refused to give the facility any instructions due to him leaving AMA. Further interview revealed the facility received the hospital discharge summary on [DATE] and the directive given were to use his home medications (written on the AMA discharge summary). The nurses did not follow through with obtaining the orders, but they were disciplined (RN #15 and #35) and we put a plan in place, so it wouldn't happen again. On [DATE] at 2:35 P.M., an interview with Coroner #486 revealed an autopsy was not completed but an external examination, toxicology and the preliminary drug screen was positive. The coroner's office was treating the case as a drug overdose. He was pronounced dead at 2:19 A.M. and laid there (in the facility) almost 12 hours before they called me, and they collected all the evidence and moved it (referencing the crack pipe). The police were not called so Coroner #486 directed the facility to call the police. On [DATE] at 2:32 P.M., a follow-up interview with Coroner #486 revealed when she arrived at the facility for the assessment of Resident #82, rigor had set in, and his body was very stiff. She confirmed the resident's body was moved to the morgue from the facility. On [DATE] at 9:44 A.M., an interview with the DON revealed the reason Resident #82's body remained at the facility so long was because of a lack of knowledge from staff and they should have called the police. She stated the staff were waiting for the funeral home to open, as they shared with her, they had contacted the funeral home, but the message provided indicated the funeral home didn't open until 10:00 A.M. The DON verified she contacted the police and the coroner. The police had come but the coroner's office took all the drug paraphernalia, so there was nothing for them to take. The nurse on duty the night of the resident's admission said she called the hospital and was told he had left AMA, and the hospital wouldn't give the facility discharge instructions and none of the nurses followed up. The DON verified the staff should not have accepted the resident due to him leaving the hospital AMA. On [DATE] at 1:34 P.M. an interview with RRN #481 verified the facility had no documentation the medical director was contacted by the facility, and the facility did not have a policy for accepting residents with a drug abuse history. On [DATE] at 1:38 P.M. an interview with Social Service Director (SSD) #339 revealed admissions from the hospital are handled by Central Intake and the Admissions Department. SSD #339 revealed she was unaware Resident #82 was admitted until on [DATE]. On [DATE] at 1:41 P.M. an interview with Admissions Director (AD) #332 revealed she was not aware Resident #82 left the hospital AMA as he was a planned discharge at 6:00 P.M. on [DATE]. The AD stated she had left for the day at 5:30 P.M. ([DATE]) and found out about his admission and leaving the hospital AMA on [DATE]. The AD stated the hospital did not notify the facility the resident left AMA, but the facility was not to admit residents that leave the hospital AMA. The plan was either family or a taxi was to bring him to the facility. The hospital did not let the facility know he left AMA. The AD stated the facility did an onsite visit with the resident while he was in the hospital and the facility's expectations would be discussed with the resident by the hospital liaison. The AD verified the nurse should have contacted the medical director about the resident's admission, or the facility has central admission staff available 24 hours a day. On [DATE] at 1:53 P.M. an interview with the DON revealed she was not aware until Monday ([DATE]) that Resident #82 was admitted to the facility. There was no communication from the hospital he left AMA, but the nurse should have called the medical director. On [DATE] at 2:26 P.M. an interview with RN liaison #400 revealed she had gone to the hospital to see Resident #82 either [DATE] or [DATE] and discussed the facility no smoking, no drug, no alcohol policy and he said, don't worry I don't smoke. On [DATE] at 4:08 P.M. an interview with Risk Management RN #400 from the hospital where Resident #82 was a patient prior to admission to the facility, revealed the hospital did not contact the facility to let them know that the patient left AMA but it was on a Friday late ([DATE]), and it appeared that it was after the Case Manager or Social Worker left for the day or was not aware of the resident leaving AMA. The weekend team would not have known to follow up as he would have been out of the hospital (documentation) system. She verified the hospital was not planning on the resident discharging that day ([DATE]) since he was not medically cleared to discharge but was planning to discharge the next day ([DATE]) and the facility was aware of him coming the next day. The RN verified there was no record of the facility calling the hospital requesting the discharge paperwork or a report. The RN stated Resident #82 reported that he had an extensive substance abuse history to the hospital licensed social worker. On [DATE] at 11:01 A.M. an interview with RN #35 revealed when Resident #82 showed up at the facility, she was not aware he had left the hospital AMA. She had looked through his bag and found no discharge paperwork, so she called the hospital and spoke to the charge nurse on the floor he was on, but the hospital didn't have anything to provide. She verified she did not call the medical director but said she called and texted the Assistant Director of Nursing (ADON) #91 but never received any response. The RN stated she only worked on [DATE] but had no problems with Resident #82 (that night). On [DATE] at 11:04 A.M. an interview with the Medical Director revealed she was not aware, and no one contacted her team to notify anyone on her team that Resident #82 was admitted to the facility and did not find out until [DATE]. Her expectation would be for the facility to contact her (or her team) regarding admission. Further interview revealed when a resident who is admitted to a facility with a known history of drug abuse, generally they are already through the withdrawal window so usually all they (the facility) do is supportive care because this is their home. She also shared the facility was not a drug rehabilitation facility, so the facility didn't provide any type of supervision (related to drug use prevention). On [DATE] at 9:43 A.M. an interview with Records Manager #500 at the Columbus Police Department (CPD) revealed the facility called the CPD at 12:42 P.M. regarding drug paraphernalia. The CPD did not arrive at the facility until 3:40 P.M. and the call was cleared at 3:42 P.M. The records manager verified there was no report to review. Review of the Facility Assessment, revised [DATE], revealed the facility was able to provide care for residents with drug use or abuse (alcohol dependence/substance dependence). Review of the facility Admission Policy, dated [DATE] and revised [DATE], revealed a physician must personally approve, in writing, a recommendation that an individual be admitted to the facility. Each resident must remain under the care of a physician. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs. Review of the facility Abuse: Identification of Types policy and procedure, issued [DATE] and revised [DATE], revealed it is the policy of this facility to identify abuse, neglect, and exploitation of residents and misappropriation of resident property. This includes but is not limited to identifying and understanding the different types of abuse and possible indicators. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect includes cases where the facility's indifference or disregard for resident care, comfort or safety, resulted in or could have resulted in, physical harm, pain, mental anguish, or emotional distress. Neglect may be the result of a pattern of failures or may be the result of one or more failures involving one resident and one staff person. a. Neglect of goods or services may occur when staff are aware, or should be aware, of residents' care needs, based on assessment and care planning, but are unable to meet the identified needs due to other circumstances, such as lack of training to perform an intervention (e.g., suctioning, transfers, use of equipment), lack of sufficient staffing to be able to provide the services, lack of supplies, or staff lack of knowledge of the needs of the resident. This deficiency demonstrates non-compliance investigated under Complaint Number OH00163381.

Based on record review and staff interviews, the facility failed ensure care plans were comprehensive and addressed problems as stated in a self-reported incident (SRI). This affected one resident (#43) of three residents reviewed for care plans. The facility census was 81. Findings include. Review of the medical record for Resident #43 revealed an admitted [DATE]. The resident was admitted with diagnoses including idiopathic aseptic necrosis of left femur, unsteadiness on feet, history of falling, type II diabetes mellitus, and memory deficit following a cerebral infarction. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 was moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) of 11 out of a score of 15, indicating moderate cognitive impairment, and was dependent for showering/bathe self and lower body dressing. Resident #43 was independent for oral hygiene, toileting hygiene, putting on/taking off footwear, and personal hygiene. Review of SRI #257139 regarding physical abuse for Resident #43 dated 02/12/25 revealed the facility changed Resident #43's silverware to plastic and the resident had an updated care plan for aggressive behaviors and racial expletives. Review of the Care Plan dated 02/14/25 revealed plastic silverware, aggressive behaviors, and racial expletives were not reflected in the care plan. Interview on 03/06/2025 at 10:35 A.M. with the Director of Nursing (DON) revealed the aggressive behaviors should have been addressed in the care plan when the SRI indicated the information would be added to the resident's care plan. The DON also verified the plan was not updated for aggressive behaviors and racial expletives. Interview on 03/06/2025 at 3:59 P.M. with the DON revealed nursing staff were not aware of the intervention added in the SRI. She also revealed any intervention discussed should be on the care plan. Review of the Care Planning- Baseline, Comprehensive, and Routine Updates policy dated 11/25/24, stated Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan. The policy also stated Identify any current consequences and complications of the individual's situation, underlying condition and illnesses, etc. and clearly state the individual's issues and physical, functional, and psychosocial strengths, problems, needs, deficits, and concerns. This is an incidental finding discovered during the complaint investigation.

Based on medical record review, observation, staff interview and facility policy review, the facility failed to ensure comprehensive care related to tracheostomy care. This affected two (Resident #65 and #66) of three resident records reviewed for tracheostomy care. The census was 81. Findings include: 1. Review of Resident #65's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure, cerebral aneurysm, liver transplant, tracheostomy, dysphagia and Hepatitis C. Review of the quarterly MDS (minimum data set) assessment dated [DATE] revealed her cognition was rarely/never understood, she was dependent on staff for eating, oral hygiene, toileting, shower/bathing, dressing, personal hygiene and turning and repositioning. She was always incontinent of bowel and bladder. Review of the physician's orders dated 03/25 revealed no orders for tracheostomy care. There was no documented evidence of a plan of care for tracheostomy care or documentation on the treatment record tracheostomy care had been completed. 2. Review of Resident #66's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis. dysphagia, acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), protein calorie malnutrition, tracheostomy and history of cancer to the head, face and neck. Review of the admission MDS assessment dated [DATE] revealed her cognition was intact. She required setup or clean up assistance with eating, oral hygiene, partial/moderate assistance with toileting, shower/bathing, dressing, and personal hygiene and the resident was occasionally incontinent of urine and always incontinent of bowel. Review of the physician's orders dated 03/25 revealed no orders for tracheostomy care. There was no documented evidence of a plan of care for tracheostomy care or documentation on the treatment record tracheostomy care had been completed. On 03/06/25 at 3:25 P.M. interview with the Director of Nursing (DON) verified they did not have documentation on the treatment records or physician orders of tracheostomy/stoma care. This deficiency demonstrates non-compliance investigated under Complaint Number OH00163322.

Based on medical record review, hospital record review, policy review for Prevention of Pressure Injuries, review of the National Pressure Injury Advisory Panel (NPIAP) guidelines, and staff interviews, the facility failed to implement a comprehensive and effective pressure ulcer treatment program for one newly admitted resident (Resident #84). This resulted in Immediate Jeopardy and serious life-threatening harm and/or injuries on 09/14/22, when the facility failed to ensure Resident #84 had admission physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one (#84) of three residents reviewed for pressure sores. The facility identified nine current residents with pressure ulcers in a facility census of 83. On 10/31/22 at 4:40 P.M., the Administrator was notified Immediate Jeopardy began on 09/14/22, when Resident #84 had an identified buttock shearing and the right and left calf, and right and left hip had open areas which appeared to be pressure and/or [CONDITION(S)], were not provided physician ordered treatments. There were no assessments or measurements of the wounds completed upon admission. When the wounds were first assessed, the right hip had declined to unstageable, with slough and eschar. There were discharge orders from the hospital for wound dressings of the lower extremities and right hip, that were not put into place for the treatment and care of the wounds. No treatment was provided until 09/21/22, resulting in the right hip declining in condition, developing drainage and an odor. Nurse Practitioner #400 ordered an antibiotic and stat (immediate) wound consult at the clinic. The facility failed to immediately initiate the antibiotic and made an appointment for a week later with the wound clinic, resulting in Resident #84 being sent to the hospital with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Immediate Jeopardy was removed on 11/01/22 when the facility implemented the following corrective actions: On 09/26/22, Resident #84 was transferred and admitted to the hospital. On 10/31/2022, Registered Nurse (RN) Staff Development Coordinator #600 and/or designee in-serviced the nursing staff and rehabilitation personnel, on the facility ' s Skin Integrity and Pressure Ulcer/Injury Prevention and Management and Area of Focus: Basic Skin Management Policy. On 10/31/22, a house audit of all resident ' s skin will be completed by RN Staff Development Coordinator #600 and/or designee to ensure all wounds have been assessed and treatments obtained as needed. On 10/31/22, an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the interdisciplinary team and the plan of removal was reviewed and approved by the QAPI team. On 10/31/22, the Medical Director reviewed and approved the plan of removal. Beginning on 11/01/22, weekly audits will be completed by the Director of Nursing (DON) or designee to assure the ordered treatments are being completed, wounds are assessed and monitored three times a week for 12 weeks. Any issues identified will be addressed immediately and will be reviewed at the monthly QAPI meeting. On 11/01/22, the DON will educate all nursing and rehabilitation staff on the facility ' s Skin Integrity & Pressure Ulcer/Injury Prevention and Management and Area of Focus: Basic Skin Management Policy. On 11/01/22, the agency Licensed Nurse that was assigned the admission for Resident #84 was reported to the nursing agency and has not return to the facility. Beginning on 11/01/22, all agency staff and new hires will be in-serviced on the Skin Integrity & Pressure Ulcer/Injury Prevention and Management & Area of Focus: Basic Skin Management Policy prior to first working shift by RN Staff Development Coordinator #600 and/or designee. Although the Immediate Jeopardy was removed on 11/01/22, the deficiency remained at a Severity Level 2 (no actual harm with the potential for minimal harm that is not Immediate Jeopardy) as the facility was continuing to educate staff and was in the process of completing and reviewing audits to determine if further action is required and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #84 revealed an admitted [DATE] and a discharged date to the hospital on 09/26/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission skin assessment dated [DATE] for Resident #84 revealed the abdominal folds red, buttock shearing, right and left calf and right and left hip open; appears to be pressure or [CONDITION(S)]. No measurements or staging of wounds were documented. Review of the admission pressure ulcer risk dated 09/14/22 revealed Resident #84 was a mild risk for pressure ulcer. Review of a pressure ulcer assessment dated [DATE] revealed Resident #84 was at moderate risk for pressure ulcer. Review of the Aftercare Visit Summary, dated 09/14/22 for Resident #84, revealed wound care instructions included the following: for lower extremity wounds, irrigate wound with 1/4 strength of Dakin ' s (solution used to clean wound and regulate pH of wound); cover wounds with duoderm ([MEDICATION(S)] dressing for dry to lightly exuding wounds) or hydrogel if available; cover with abdominal (ABD) pad; wrap with kerlix and secure with Medi pore tape. For the right hip, cleanse wound with sterile saline; cover with large [MEDICATION(S)] ready blue border dressing (powerful antibacterial wound dressing); please keep in place five days or until you see white drainage on dressing. There was a new patient visit for Wound Care East Hospital for 09/16/22 at 2:45 P.M. Review of the skin assessment revealed bullae or blisters have expanded on medial left and right leg, with small tense bullae on arms but not in any particular distribution. Review of nurse ' s progress notes dated 09/17/22, for Resident #84, revealed the nurse performed a wound dressing change on the lateral right of resident ' s leg. Wound draining with foul smell. Also, wound team needs to evaluate resident wound and put treatment plan in place. As of now, there is no treatment plan in place for resident ' s wound. This nurse changed the dressing, cleansed with normal saline, and applied abdominal pad. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #84 revealed she was assessed as being cognitively intact. She had behaviors which include rejection of care which occurred one to three days a week. She required extensive assistance of two-person physical assist for toileting, bed mobility and transfer. She was occasionally incontinent of urine and always incontinent of bowel. The resident had one unstageable pressure ulcer which was present upon admission. She also received [CONDITION(S)]. Review of the Treatment Administration Record (TAR) for September 2022, for Resident #84, revealed no documentation of any wound treatments being completed from 09/14/22 through 09/21/22 for the hip, thigh, legs, or buttocks wounds. Review of the wound progress note dated 09/21/22, revealed the resident was seen for the side of the right thigh pressure area. The wound was an unstageable, slough and eschar. There was slough tissue present (yellow, tan, stringy) 100 percent (%) of wound bed, serosanguineous, measuring 20 centimeters (cm) by 10 cm by 0 cm and had a foul odor. Resident has pain of moaning with intervention of pain medications and repositioning. The current treatment plan is for the right hip cleanse wound with sterile saline cover with large [MEDICATION(S)] ready blue border dressing (please keep in place 5 days or until you see white drainage on dressing). For the right lower leg front pressure slough/eschar necrotic tissue 100% no drainage 3 cm by 3 cm by 0 cm. To the lower extremity wounds irrigate wound with 1/4 strength Dakin ' s. Cover wounds with duoderm or hydrogel if available. Cover with an ABD, wrap with Kerlix and secure with Medi pore tape. A wound of left lower leg with [CONDITION(S)] slough 20% small amount of drainage serosanguineous measuring 2 cm by 2 cm by 0 cm. The treatment is for lower extremity wounds irrigate wound with 1/4 strength Dakin ' s. Cover wounds with duoderm or hydrogel if available. Cover with an ABD, wrap with Kerlix and secure with Medi pore tape. This is the first observation by the wound team, and the doctor and family were notified. Review of the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was discontinued on 09/23/22 and a new order was written. Review of the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress notes dated 09/22/22 at 3:39 P.M., revealed Nurse Practitioner (NP) #550 was notified the resident ' s wound has drainage and odor. An order was given to start [MEDICATION(S)] one tablet by mouth twice a day for wound infection for ten days. Also, there was a stat (immediately) order for a wound clinic visit at hospital. Review of the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an order dated 09/22/22, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no signatures indicating the medication was ever administered to the resident. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .M. Review of the progress note dated 09/23/22 at 5:03 P.M., revealed the hip wound dressing was completed with foul malodor from wound, and 100 % tan slough to wound bed. Pocket of pus was noted draining from the wound. Patient currently on by mouth [MEDICATION(S)] and is scheduled for an appointment at the wound clinic on Friday (09/30/22). Will continue scheduled wound care. Review of the progress note dated 09/26/22 at 7:15 A.M., revealed this nurse was completing resident ' s dressing change and the wound had a foul odor with green fluid coming out of it. The DON was called, and the resident was sent out to hospital. Review of the plan of care dated 09/26/22 (day of discharge to hospital) revealed Resident #84 was admitted with an unstageable pressure ulcer to her left outer thigh area, [CONDITION(S)], and blisters to her bilateral lower extremities (BLE). The plan of care noted risk for infection, pain and delayed healing with interventions which included her wounds will show signs and symptoms of healing through review date and medications per orders. Review of the progress note dated 09/28/22 at 1:54 P.M. with MDS Nurse #500, revealed orders written on 09/22/22 for the [MEDICATION(S)] were entered into electronic medical record (EMR) but were not clarified so the medication was never started as prophylactic medication. Interview with MDS Nurse #500 at the time of the review, verified the [MEDICATION(S)] orders were not clarified and never started for Resident #84. Review of the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] =granulation, S=slough, E=eschar, Ep epithelization; Odor-Y=yes, N=no; Drainage-S=serous, Se=serosanguineous, B=bloody, P=purulent; Surrounding skin-P=pink, R=red, I=indurated, W=Warm; Wound Outcome-U=unchanged, I=improved, D=deteriorated). This order was written after the resident was discharged on [DATE], by Regional Nurse #600. Interview on 10/31/22 at 2:00 P.M. with Regional Nurse #600, revealed she was on vacation until the week of 10/21/22. She came to the facility and had initiated all residents with wounds to be reviewed. Regional Nurse #600 stated therefore Resident #84 did not have any wound measurements until this date. Regional Nurse #600 stated this is why the resident (Resident #84) slipped through the cracks due to lack of oversight with the facility not having a DON at the time. Review of the Emergency Department (ED) Provider Note, visit date 09/26/22, revealed patient presents with wound infection. Patient is hypotensive of 86 systolic and 38 diastolic on ED arrival. The patient was made a [CONDITION(S)] alert related to wound and [CONDITION(S)]. Resident #84 was admitted to the Intensive Care Unit (ICU) for further medical treatment and evaluation of [CONDITION(S)], wound infections and [CONDITION(S)]. Review of the Operative Report dated 09/26/22 at 2:49 P.M., revealed Resident #84 was diagnosed with necrotizing soft tissue infection of the right hip with the operative procedure being excision of large necrotizing soft tissue of right hip. The history of the wound was described as a wound on her right hip that has been present for an unknown length of time. She presents with increased pain. On examination, she had an area of soupy necrosis on the hip where the skin is obviously necrotic, and the area preoperatively measures probably 20 cm by 30 cm. Computerized tomography (CT) scan confirmed subcutaneous air, and she has obvious drainage and malodorous smell. Review of the Brief Post Operative Note dated 09/26/22, revealed the procedure was for incision and drainage right upper hip for [CONDITION(S)]. The debridement of right lateral thigh/hip [CONDITION(S)] measuring 35 cm by 35 cm debrided. Wound packed with four saline-dampened kerlix rolls, covered with total of six ABD pads and tape. The right thigh wound was not debrided but was just covered with kerlix roll wrap to protect skin. The description of the wounds included: a right pre-tibial and left pre-tibial unstageable deteriorating non-healing eschar covered wound with a small amount of foul purulent drainage; an acute deep tissue pressure injury (DTPI) to the mid sacral area which is non-healing and had a small amount of foul-smelling serosanguineous drainage; and an acute left and right buttock DTPI, which was non-healing with a moderate amount of serosanguineous drainage. The wound cultures grew proteus, pseudomonas, Providencia, Bacteroides, [NAME], Citrobacter, [CONDITION(S)] and Escherichia coli. Review of the policy titled Prevention of Pressure Injuries, revised April 2020, revealed the resident should be assessed on admission for existing pressure injury risk factors, repeating the risk assessment weekly, and upon any changes in condition. Staff should conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment as indicated according to the resident's risk factors, and prior to discharge. Staff should inspect the skin daily when performing or assisting with personal care or activities of daily living and inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.). The staff should evaluate, report, and document potential changes in the skin, and review the interventions and strategies for effectiveness on an ongoing basis. The nurses are required to complete a skin assessment to be performed weekly. Review of the NPIAP guidelines dated 2014 pages 70-71 at https://npiap.com/general/custom.asp?page=2014Guidelines revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, [CONDITION(S)], and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for [CONDITION(S)] (redness of the skin) was the first component of every skin inspection. Skin redness and tissue [CONDITION(S)] resulting from capillary occlusion was a response to pressure. Further review revealed an unstageable pressure injury is obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage three or Stage four pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. This deficiency represents noncompliance under Master Complaint Number OH 161 and Complaint Numbers OH 726 and OH 249 and is an example of continued noncompliance from the survey dated 09/15/22.

Based on observation, resident and staff interview, record review, and policy review, the facility failed to timely assess and provide treatments for a resident's pressure ulcer and failed to ensure interventions were implemented to prevent the development of a pressure ulcer. This resulted in Actual Harm when Resident #23 developed an unstageable pressure ulcer with eschar. A treatment was being applied to the ulcer without a physician order, no notification of the physician of the presence of the ulcer and no interventions implemented to prevent the pressure ulcer. This affected one (Resident #23) of three residents reviewed with pressure ulcers. The facility census was 87. Findings include: Review of medical record for Resident #23 revealed an admitted [DATE]. The resident was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission physician orders dated 08/23/22 revealed Resident #23 did not have any orders for wound treatment or interventions for prevention of pressure ulcers to the foot or heel. The only intervention was an air mattress. Review of the wound assessment completed on 08/24/22 in the electronic medical record revealed only surgical wounds were documented. There were no other wound assessments completed. Review of the care plans dated 08/25/22 revealed Resident #23 had breaks in skin integrity related to surgical incision to left ankle, left front thigh and skin tear to right arm. She had interventions which included treatments as ordered and weekly skin assessments. The Minimum Data Set (MDS) assessment, dated 08/29/22 for Resident #23, revealed the resident was cognitively intact. She was assessed for being at risk for developing a pressure ulcer and injury, had surgical wounds with dressings, required extensive assistance of two-person physical assistance with bed mobility and transfers and impaired bilateral lower extremities. Review of the pressure ulcer risk assessment, dated 08/30/22, revealed Resident #23 was at a moderate risk for the development of pressure ulcers. Review of the wound observation tool, dated 09/02/22, documented an unstageable pressure ulcer, deep tissue injury to the left heel. The ulcer measured four centimeters (cm) by three cm and had 60 percent necrotic tissue with a small amount of serosanguineous drainage. The treatment plan was to cleanse the heel, pat dry, apply calcium alginate and an adhesive bandage. The document stated the physician was not notified of this area until 09/09/22. No physician order was obtained for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Treatment Administration Record (TAR) for September 2022 revealed no documentation of any orders for any dressing changes to the resident's left heel. Record review revealed no documentation of any skin assessments since admission. During interview on 09/07/22 at 9:00 A.M., Resident #23 stated she was upset because her dressings had not been changed since 09/05/22 and were to be completed daily. During observation on 09/08/22 at 10:55 A.M., Licensed Practical Nurse (LPN) #200 revealed she removed a Xeroform dressing, an occlusive dressing, from the left heel of Resident #23. The dressing was dated 09/05/22. The left heel had an ulcer that was covered with eschar with reddened edges. LPN #200 cleansed the heel with normal saline and reapplied a Xeroform dressing. During interview on 09/08/22 at 2:30 P.M., the Assistant Director of Nursing (ADON) verified the weekly skin assessments were not completed for Resident #23. During interview on 09/08/22 at 2:45 P.M., Assessment Nurse #400 revealed there were no physician orders for treatment to an ulcer on the left heel. She did not have knowledge of a pressure ulcer for this resident which is why she did not care plan for a pressure wound. Review of the National Pressure Injury Advisory Panel 2019 Reference Guide revealed a good practice statement is for individuals with a Category/Stage III or greater heel pressure injury, elevate the heels using specifically designed heel suspension device offloading the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon and the popliteal vein. Guidelines related to Assessment of Pressure Injuries and Monitoring of Healing revealed to assess the pressure injury initially and re-assess at least weekly to monitor progress toward healing. Review of the facility policy titled Wound Assessment, revised 10/14/20, revealed the purpose to guide the associates and licensed nurse in the assessment of wounds to include pressure ulcer or injury. The procedure was for a wound assessment and documentation is required to occur at a minimum weekly. Review of the facility policy titled Prevention of Pressure Injuries, revised April 2020, revealed the resident should be assessed on admission for existing pressure injury risk factors, repeating the risk assessment weekly and upon any changes in condition. Staff should conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment as indicated according to the resident's risk factors, and prior to discharge. Staff should inspect the skin daily when performing or assisting with personal care or activities of daily living and inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.). The staff should evaluate, report, and document potential changes in the skin, and review the interventions and strategies for effectiveness on an ongoing basis. The nurses are required to complete a skin assessment to be performed weekly. This deficiency substantiates Complaint Number OH 581.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, policy and procedure review, employee in-service review, plan of correction review, staff and resident interviews, the facility staff failed to ensure mechanical (Hoyer) lift equipment was maintained to prevent an avoidable fall from a Hoyer lift during a transfer. This resulted in actual harm, when an Hoyer lift sling was not inspected as required, resulting in the sling strap breaking and a resident falling from the sling to the floor, fracturing the left tibia. This affected one (#1) of three residents reviewed for accidents. The facility identified 23 (#1,#3, #10, #11, #12, #13, #20, #22, #28, #30, #40, #44, #66, #67, #71, #74, #75, #77, #78, #79, #81, #84, #87) residents requiring the use of a mechanical lift. The facility census was 87. Findings include: Review of the medical record for Resident #1 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was intact, she did not ambulate and depended on two staff for mechanical lift transfers. Review of the nurse's note (observed on floor/fall) dated 08/30/18 at 8:45 P.M., revealed in the resident room, when the resident was being transferred, the Hoyer sling strap broke and resident slid to the floor not hitting her head. The resident stated the Hoyer pad broke and she was never using a Hoyer pad again. The resident complained of pain in the knees, aching at level 6 on scale of 1 to 10. No injuries noted and X-rays of hips ordered. The Hoyer pad sling was discarded. There was no obvious injury, notifications completed and physician ordered X-rays of both hips which were negative. Review of a witness statement dated 08/30/18, no time indicated, completed by Registered Nurse (RN) #107 documented while transferring the resident from the wheel chair to the bed, the straps were attached to the Hoyer. When lifting the resident up, the left rear strap broke, the resident slid out of the Hoyer lift and hit the floor landing on her knees. Review of a nursing note dated 08/31/18, no time indicated, revealed the resident was alert and oriented. Resident resting in bed at this time. Resident status [REDACTED]. X-rays ordered from fall, results came back negative for both bilateral femur fractures. No acute fractures or dislocation noted. Certified Nurse Practitioner (CNP) #125 in to see resident, new orders for scheduled [MEDICATION NAME] at 600 milligrams four times daily for seven days, change to [MEDICATION NAME] 50 milligrams for one to two tablets every six hours as needed for pain. Also new orders for ice to the knees three times daily. Pain medication and ice administered with positive effects. Resident aware of new orders. Resident resting in bed at this time. Review of nursing note dated 09/01/18, no time indicated, revealed the resident was alert and oriented. Resident was status [REDACTED]. Administered pain medication as needed and applied ice per order. Resident states relief. will continue to monitor. Review of the pain flow sheet revealed the resident's pain level on 09/01/18 was a four relieved with two [MEDICATION NAME], on 09/02/18 was seven relieved with one [MEDICATION NAME], and on 09/03/18 a six relieved with one [MEDICATION NAME]. Review of progress note dated 09/02/18 at 3:48 P.M., as needed medication for complaint of bilateral knee pain with positive effects, status [REDACTED]. Resident observed not transferring. Review of progress note date 09/03/18 at 6:25 P.M., revealed resident status [REDACTED]. Continues to receive schedule medications with no side affects. Review of the progress note dated 09/04/18 at 4:06 P.M., bilateral knee x-ray showed a fracture of left tibia, ordered by CNP. Resident in pain of 10 (on pain scale) with no relief from prescribed pain medication administered at 12:00 P.M. CNP notified. CNP request transfer to hospital. Resident fully compliant with transfer to hospital. Review of the Discharge Summary Form dated 09/04/18 at 10:13 P.M. revealed a new physician's orders [REDACTED]. Interview on 12/31/18 at 10:40 A.M., with the Central Supply State tested Nursing Assistant (STNA) #106 verified prior to 08/31/18, she was responsible for completing the Hoyer lift slings audits every six months for safety. The slings were discarded if they were too worn. The audit documentation prior to 08/30/18, revealed the last audit was completed on 01/22/18 which was more than seven months. Central Supply STNA #106 verified the last audit was completed on 01/22/18 prior to the resident's fall on 08/30/18. Phone interview on 12/31/18 at 11:00 A.M., with Registered Nurse (RN) #107 who was involved in the transfer when the resident fell on [DATE], revealed the other staff who completed the transfer was former STNA #115. The sling strap broke near the hook of the Hoyer when the resident was lifted above and in front of her wheelchair. The resident's body, not her head, hit the ground. Interview on 12/31/18 at 12:00 P.M., with Resident #1 revealed on 08/30/18 during a Hoyer transfer the strap of the sling broke. Resident #1 stated she fell and fractured her left tibia, which hurt when staff moved her. Resident #1 stated she starting taking the narcotic pain medication on 09/04/18. Review of the undated procedure titled Portable Patient Lift Sling: Using the Sling revealed slings were to be inspected every six months (in accordance with the instructions on the sling) for wear, tear and loose stitching of the sling. Bleached, torn, cut frayed, broken slings are unsafe and could result in injury. Discard IMMEDIATELY. Review of the policy titled Fall Management dated 12/18/17, revealed staff must ensure the resident's environment remain free of accident hazards. An accident referred to any unexpected or unintentional incident which resulted in an injury. An avoidable accident occurred when the staff failed to evaluate/analyze environmental hazards and risk and eliminate the hazard if possible. Interview with the Administrator on 12/31/18 at 1:00 P.M. verified the following action plan was implemented and audits were completed as stated. As a result of the incident, the facility took the following action to correct the deficient practice by date. 08/31/18: · On 08/30/18, Resident #1's care plan was updated reflecting the use of a new mechanical lift sling pad. · On 08/31/18, an audit was completed of mechanical lift slings used in the facility by the Central Supply STNA #106 to ensure slings were safe and functional. Audits completed monthly for compliance. The last Audit completed was 12/28/18. · On 08/31/18, all nurses and STNAs were educated by the former Director of Nursing (DON) on 08/31/18 regarding ensuring the slings and mechanical lifts are inspected prior to each use to ensure safe conditions. · On 08/31/18, RN #107 and former STNA #115 completed competency evaluations of Hoyer transfers with return demonstrations with a nursing preceptor. · Beginning 09/01/18, all STNAs and nurses using the mechanical lifts will complete competency evaluations for lift transfers with a nursing preceptor at orientation and/or prior to their annual evaluation. · Beginning 09/01/18, the DON and Administrator reviewed the monthly audits for the lifts and slings to ensure the lifts and slings continued to be safe on an ongoing basis. Falls and lift use were discussed at the quarterly quality assurance meetings. · On 12/31/18, observations of two Hoyer lift transfers of residents and the lift correct slings revealed no safety concerns. · On 12/31/18, interview with STNA #106 at 10:40 A.M. and STNAs #120 and #121 at 12:15 P.M. verified receiving training on the slings and lifts. The STNAs were able to verbalize the procedure on completing safety checks of slings and lifts prior to each use. This deficiency substantiated allegations contained in Master Complaint Number OH 740.