Every finding on record at Mentor Hills Post Acute

Based on record review, interview and facility policy review, the facility failed to ensure transportation to and from a planned physician appointment for Resident #94. This affected one (Resident #94) of three residents reviewed for transportation assistance. The facility census was 95. Findings include: Review of the medical record revealed Resident #94 was admitted to the facility on [DATE]. Medical diagnoses included malignant neoplasm of right lung, malignant neoplasm of lower right lung, cerebrovascular disease, hypertension, vertigo, hyperlipidemia, anxiety, major depression, gastro esophageal reflux, and abnormal gait. Review of facility document dated 03/25/25, revealed Resident #94 was to have an appointment on 05/02/25 for a CT (computed tomography) of the chest, abdomen, pelvis and a Radiation Oncology appointment to establish a new patient. In addition, on 05/08/25 Resident #94 was to have an appointment with Hematology and Oncology to establish Resident #94 and infusion therapy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #94's cognition was intact. Supervision was needed to transfer from bed to chair. Resident #94 did not have pain at present and life expectancy was not less than six months. Resident #94 received chemotherapy. Review of the care plan dated 04/19/25 revealed Resident #94 was at risk for complications related to the administration of chemotherapy. Interventions included encouraging fluids, following up with oncologist/hematologist, administering medication as ordered and monitoring for signs of activity intolerance such as fatigue, shortness of breath, pallor or cyanosis, vertigo, weakness. Review of facility document title Appointment Information dated 05/08/25 revealed Resident #94 was scheduled for a Hematology and Oncology visit for small cell right Atezolizumab (immunotherapy) infusion; but Resident #94 was documented as not seen. Review of facility Appointment Calendar dated May 2025, revealed Resident #94 was scheduled on 05/02/25 for an appointment with transportation, but no appointments were scheduled on 05/08/25. Review of Resident Grievance Form, dated 05/13/25, revealed Resident #94 had a concern regarding a missed appointment. Investigation findings revealed the appointment was missed due to transportation error. The resolution revealed the appointment was rescheduled. Interview on 06/04/25 at 2:00 P.M. with the Administrator revealed the Unit Manager was on vacation during the week of 05/08/25, therefore transportation was not scheduled for Resident #94's appointment. The Administrator verified Resident #94 missed the 05/08/25 infusion appointment. The interview on 06/04/25 at 3:00 P.M. with Unit Manager (UM) #309 revealed she was responsible for setting up residents outside appointments and transportation. UM #309 verified Resident #94 missed an infusion appointment in May 2025 because she did not see the appointment come through. Interview on 06/04/25 at 3:15 P.M. with the Social Worker # 301 revealed the nursing staff scheduled transportation for residents to outside appointments and verified Resident #94 missed her infusion appointment. An interview on 06/05/25 at 10:43 A.M. with UM #308 revealed the Unit Managers reviewed orders in the medical records and followed up with transportation for appointments. UM #308 stated she assumed UM #309 had taken care of all appointments prior to her vacation. Interview on 06/05/25 at 12:02 P.M. with the Director of Nursing (DON) verified Resident #94's family filed a grievance on 05/13/25 because Resident #94 missed the 05/08/25 appointment. The DON stated the appointment was missed and transportation was not set up because UM #309 was on vacation that week. The DON verified no physician order was placed in the electronic medical record for 05/08/25 and verified the transportation calendar did not have an appointment for Resident #94 on 05/08/25, and the facility was notified on 03/25/25 regarding the CT of chest, abdomen, pelvis and Radiation Oncology physician appointment on 05/02/25 and the Hematology and Oncology physician appointment with infusion scheduled for 05/08/25. Review of the undated facility policy Transportation, Social Services revealed the facility would help arrange transportation for residents as needed. This deficiency represents non-compliance investigated under Complaint Number OH00165684.

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines and facility policy review, the facility failed to use appropriate transmission-based precautions (TBP) for Resident #84, utilize enhance barrier precautions (EBP) when indicated for Residents #12, #57 and #58 and failed to perform wound care using appropriate infection control practices for Residents #1, #12, #41, and #57. This affected one resident (#84) out of two residents reviewed for TBP, affected three residents (#12, #57 and #58) of six residents reviewed for EBP and affected four residents (#1, #12, #41, and #57) of six residents reviewed for wound care. The facility reported 27 residents (#1, #5, #7, #9, #12, #15, #17, #21, #24, #25, #32, #34, #35, #38, #39, #40, #41, #42, #52, #53, #54, #58, #80, #84, #85, #91 and #302) who had EBP, and 23 residents (#1, #4, #7, #12, #17, #21, #24, #39, #40, #41, #42, #52, #53, #54, #57, #58, #77, #84, #85, #90, #91, #298 and #302) who had wounds. This had the potential to affect all 96 residents residing at the facility. Findings include: 1. Review of the medical record for Resident #84 revealed an admitted [DATE] with diagnoses including enterocolitis due to clostridium difficile (C-Diff) (a highly contagious bacterium that causes diarrhea and colitis (an inflammation of the colon), diabetes, end stage renal disease, and asthma. Review of the care plan dated 01/03/25 revealed Resident #84 had an activities of daily living (ADL) self-care deficit related to pelvic fracture, right below the knee amputation, and limited mobility. Interventions included staff assisting with ADL on a daily basis and monitoring for fatigue. Review of the care plan dated 01/24/25 revealed Resident #84 had a C-Diff infection and was at risk for complications including weakness. Interventions included administer medications as ordered, labs as ordered, private room if available, and contact precautions as indicated. Review of the Medicare five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #85 had intact cognition. She required supervision or touching assistance with toileting hygiene and transfers. She was occasionally incontinent of urine and frequently incontinent of bowel. Review of the February 2025 physician's orders revealed Resident #84 had an order dated 01/23/25 for contact precautions due to C-Diff and to post a sign to see the nurse before entering the resident's room. The order also revealed wearing gloves, masking, and gowning as needed and washing hands when touching the environment and with direct patient care. Resident #84 also had an order for EBP dated 01/24/25. Observation on 02/11/25 at 7:46 A.M. revealed upon entrance to Resident #84's room there was a personal protective (PPE) cart to the right of the door with an EBP sign posted. The EBP signage revealed that staff were to clean their hands including before entering and when leaving the room, wear gloves and gown for the following high contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting and device care. There was nothing on the signage including wearing PPE when touching environmental surfaces and/or cleaning of the environment. There was no contact precaution signage posted. Interview on 02/11/25 at 7:51 A.M. with Licensed Practical Nurse (LPN) #565 verified Resident #84 had C-Diff. She revealed she had discussed TBP with the Director of Nursing (DON) who indicated EBP was sufficient for the C-Diff infection. Interview and observation on 02/12/25 at 7:35 A.M. with Housekeeping #620 revealed she was assigned Resident #84's room today, 02/12/25, as well as having cleaned her room over the weekend, 02/08/25 and 02/09/25. She revealed if a resident had signage indicating EBP then she did not do anything special as that signage was more for when the aides completed direct care not for her duties as a housekeeper. She verified anytime she cleaned Resident #84's room she usually only wore gloves to clean and not a gown as Resident #84 only had signage indicating EBP precautions and was not aware of any other TBP needed. Housekeeping #620 verified on the outside of Resident #84's room, there was only EBP signage, and that was what she went by. Interview on 02/12/25 at 7:45 A.M. with Housekeeping #621 revealed she went by the signage on the outside of the resident door to indicate what PPE she needed to wear prior to entering. She revealed if there was signage indicating EBP; she wore gloves as that was what she wore into all rooms to clean, but she did not wear a gown or any other PPE. She revealed she was not aware of any other precautions Resident #84 was to have besides EBP. Interview on 02/12/25 at 8:00 A.M. with Housekeeping Supervisor #622 revealed he educated his housekeeping staff that if a resident had EBP signage on the outside of their room to wear gloves and usually a mask. He verified that residents on EBP, he instructed not to wear a gown and/or to take any precautions with the environment. He revealed he was not notified Resident #84 was on any other precautions other than EBP and/or that Resident #84 had C-Diff. Interview and observation on 02/12/25 at 8:10 A.M. with Registered Nurse (RN)/Wound Nurse (WN)/Infection Preventionist (IP) #568 verified that on the outside of Resident #84's room there was only signage for EBP. She verified Resident #84 had C-Diff but that she was always told that there were only two precautions used at the facility either EBP or respiratory droplet precautions. She verified she did not have signage for contact isolation. She verified under the EBP precautions that the precautions did not include anything regarding wearing a gown when entering the room, including touching environmental surfaces and/or cleaning of the environment. She verified she was unsure how housekeepers would be aware of using proper precautions as she stated, I did not think of that. Interview on 02/12/25 at 8:51 A.M. with the DON revealed that the facility had more than two signs to post on the outside of the doors, including signs for contact isolation. She verified Resident #84 had C-Diff, and she should have had contact isolation signage on the outside of her door to notify staff of proper precautions to take as ordered. She verified housekeepers should be wearing gowns to clean environmental surfaces when entering her room as well as to instruct any other staff or visitors that would encounter environmental surfaces. Review of the facility policy labeled, Isolation- Categories of Transmission- Based Precautions, dated 2001, revealed TBP precautions were initiated when a resident developed signs and symptoms of a transmissible infection, arrives for admission with symptoms of an infection, or had a lab confirmed infection or was at risk for transmitting the infection to other residents. The policy revealed TBP were additional measures that protect staff, visitors and other residents from becoming infected. There were three types of precautions: contact, droplet, and airborne. The policy revealed when a resident was placed on TBP appropriate notification was placed on the room entrance door so that personnel and visitors were aware of the type of precautions. The policy revealed for contact precautions staff and visitors wear disposable gowns upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing. Review of the undated, CDC C-Diff Guideline, revealed C-Diff spreads when people touch surfaces that were contaminated with bowel movement from an infected person or when people do not wash their hands with soap and water. The guideline revealed healthcare professionals should prevent C- Diff by rapidly identifying, isolating residents with C-Diff, wear gloves and gowns, and remembering that hand sanitizer does not kill C- Diff. 2. Review of the medical record for Resident #1 revealed an admitted [DATE] with diagnoses including chronic kidney disease, diabetes, and nontraumatic intracerebral hemorrhage affecting the right dominant side. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #1 had impaired cognition, and he had no pressure ulcers. Review of the February 2025 physician's orders revealed Resident #1 had an order to cleanse his left great toe with wound cleanser, apply calcium alginate (a type of wound dressing derived from seaweed that absorbs exudate and forms a moist gel), abdominal (ABD) pad, and Kerlix gauze daily. Review of the care plan dated 02/11/24 revealed Resident #1 had an open area to left great toe and was at risk for complications. Interventions included administer treatment as ordered, observe and report signs of infection, and wound consult as indicated. Observation on 02/12/25 at 9:09 A.M. of wound care for Resident #1 completed by RN/WN/IP #568 revealed she washed her hands, applied gloves and proceeded to remove Resident #1's dressing to his left foot revealing a nickel size open area that the facility was classifying as a diabetic ulcer that contained dried blood to the top of his left toe. She proceeded to cleanse his left toe with normal saline, applied calcium alginate, ABD, wrapped with Kerlix gauze and then washed her hands. Interview on 02/12/25 at 9:43 A.M. with RN/WN/IP #568 verified that she removed Resident #1's wound dressing to his left foot and proceeded to cleanse the wound without performing hand hygiene. Interview on 02/12/25 at 1:39 P.M. with the DON verified RN/WN/IP #568 should have performed hand hygiene after removing the old dressing. She also verified this was the procedure identified in their facility policy to follow. 3. Review of the medical record for Resident #41 revealed an admitted [DATE] with diagnoses including glycogen storage disease, diabetes, and kidney failure. Review of the care plan dated 12/18/23 revealed Resident #41 had alteration in skin integrity due to a pressure area. Interventions included check dressing for placement during provisional wound care, document wound status, and treatments as ordered. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #41 had intact cognition. He was at risk for pressure ulcers and had unhealed pressure ulcers. Review of the February 2025 physician's orders revealed Resident #41 orders included: cleanse with saline solution, pat dry and apply calcium alginate and cover with foam dressing every Monday, Wednesday, and Friday to right ischium wound, cleanse with saline solution, pat dry and apply collagen powder (specialized wound care product that promotes wound healing and tissue regeneration) to the wound bed and cover with foam dressing every Monday, Wednesday, and Friday to left ischium wound, and cleanse with saline solution, pat dry, and apply collagen powder and cover with foam dressing every Monday, Wednesday, and Friday to coccyx wound. Observation on 02/12/25 at 9:28 A.M. of wound care that was completed for Resident #41 by RN/WN/IP #568 and LPN #539 revealed RN/WN/IP #568 removed the old dressings to Resident #41's left and right ischium and his coccyx area and then proceeded to cleanse each wound with wound cleanser using a different four by four gauze dressing to clean each. RN/WN/IP #568 then proceeded to take her gloved fingers and placed into the collagen powder packet to remove the collagen with her gloved fingers. She packed the left ischium with the collagen. She then proceeded to reach back into the collagen powder packet and remove more collagen with her gloved fingers to pack the coccyx wound with the collagen. She then took the calcium alginate out of the package and placed it over the right ischium and then covered all wounds with foam dressing as ordered. She proceeded to wash her hands. Interview on 02/12/25 at 9:43 A.M. with RN/WN/IP #568 verified that she did not wash her hands after removing the old dressings. She also verified that she did not do each wound separately as she stated she always looked at the wounds prior and if they did not appear to show signs of infection then she completed all the wounds at the same time without washing her hands between each wound dressing. Interview on 02/12/25 at 1:39 P.M. with the DON verified when removing an old dressing, the nurse should have washed her hands before cleansing the wounds. The DON also verified that if a resident had more than one wound each wound was to be completed separately to avoid cross contamination. Review of the facility policy labeled, Wound Care, dated 2001, revealed staff was to wash their hands and put on gloves, loosen tape and remove the dressing. After removing the dressing, the nurse was to pull glove over the dressing and discard into appropriate receptacle and then wash their hands. The nurse was to put on gloves and proceed to cleanse the wound. There was nothing in the policy regarding wound care including the care of more than one wound. 41526 4. Review of the medical record for Resident #58 revealed an admitted [DATE] with diagnoses including left knee effusion, staphylococcal arthritis left knee, diabetes mellitus type two and methicillin susceptible staphylococcus aureus infection. Physician orders effective February 2025 indicated to flush the PICC (peripherally inserted central catheter) before and after medication administration, administer cefazolin (antibiotic) two grams intravenously every twelve hours for infection, and EBP of gown and gloves for high-contact resident care including care with any device (central line). Observation on 02/12/25 at 9:00 A.M. with LPN #565 of intravenous antibiotic administration via Resident #58's PICC line revealed LPN #565 wore only gloves and no gown during the procedure despite the EBP requirement. There was an EBP sign posted with a PPE cart at Resident #58's room entrance. Interview at the time of the observation with LPN #565 verified a gown was not used for EBP as required. 5. Review of the medical record for Resident #57 revealed an admitted [DATE] with diagnoses including closed fracture of radius, chronic combined systolic and diastolic congestive heart failure, atrial fibrillation, and pain in right knee. The physician wound assessment dated [DATE] specified a left heel unstageable (a full-thickness skin loss with the wound base covered by necrotic tissue) pressure ulcer covered by 100 percent necrotic tissue. Physician orders effective February 2025 indicated a left heel treatment to cleanse with wound cleanser, apply betadine and cover with an ABD followed by Kerlix gauze daily and as needed. There was no physician order for EBP related to the pressure ulcer. Observation on 02/12/25 at 8:21 A.M. with RN/WN/IP #568 of Resident #57's wound care revealed no EBP sign or cart with PPE located outside of the resident's room. RN/WN/IP #568 obtained the treatment cart and without cleaning the cart or top of the cart entered Resident #57's room with the cart and positioned it next to the bed. RN/WN/IP #568 then performed the following actions: a pair of scissors, an opened package of bulk gauze pads, a bottle of betadine, and closed packages each of an ABD and Kerlix gauze were removed from the treatment cart and placed on the cart top; hand hygiene was completed followed by application of gloves, but there was no gown donned as required for EBP; Resident #57's sock was removed from the left foot; the soiled dressing was cut open, removed while spraying the area with wound cleanser and placed laid open underneath Resident #57's suspended heel; without disposing of the soiled dressing, changing gloves or performing hand hygiene, placed a soiled gloved hand into the clean package of bulk gauze pads, obtained a small stack of gauze pads and cleansed the wound using the gauze and wound cleanser while the heel was suspended above the removed soiled dressing; placed the used gauze onto the soiled dressing, bundled it up, disposed of it, and rested the foot down onto the bed, not on a clean barrier; with both soiled gloved hands, opened each clean dressing package of an ABD and Kerlix gauze and laid the packages open on top of the treatment cart; opened the betadine bottle; reached inside the package of bulk gauze and obtained a small stack of clean gauze pads; poured betadine onto the bulk gauze and applied the betadine; while still wearing the same soiled gloves, picked up the clean ABD dressing and applied it; while still wearing the same soiled gloves, picked up the clean Kerlix gauze and applied it; inserted each soiled gloved hand into the right and left shirt pockets and upon removal held a pen and used it to date the clean dressing; picked up the resident's sock with the soiled gloved hands and applied it to the left foot and adjusted the blankets over the foot; the soiled gloves were removed followed by performing hand hygiene; the opened bulk package of gauze pads were placed back into the treatment cart with the betadine bottle; and the treatment cart was removed from the room. Interview at the time of the observation with RN/WN/IP #568 verified the above findings. Review of the facility policy, Wound Care, revised October 2010, revealed to place all items to be used during procedure on a clean field; remove dressing and discard into appropriate receptacle then wash hands and put on gloves; remove gloves and wash hands before repositioning bed covers or making the resident comfortable; and take only supplies necessary for the treatment into the room. Review of the facility policy, Enhanced Barrier Precautions, revised March 2024, revealed gloves and gown are applied prior to performing high contact resident care activity for wound care (pressure ulcers, diabetic foot ulcers, venous stasis ulcers, and unhealed surgical wounds) and device care or use (central lines). EBP signs are posted outside the resident room indicating the type of precautions and personal protective equipment (PPE) required. PPE is available outside resident rooms. 51073 6. Review of the medical record for Resident #12 revealed an admitted [DATE] with diagnoses including artificial left and right knee, peripheral vascular disease, senile degeneration of brain, spinal stenosis, and obstructive sleep apnea. Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #12 had impaired understanding, did not respond to questions, and had application of nonsurgical dressings to other than feet. Review of the left lateral knee wound assessment dated [DATE] revealed a non-pressure chronic ulcer of the left lateral knee having been present for approximately seven months. A physician's order effective 08/27/24 indicated a left lateral knee treatment to cleanse the wound, pat dry with gauze, and apply calcium alginate silver, and foam dressing daily and as needed. A physician's order effective 09/30/24 indicated EBP: use a gown and gloves for high contact resident care including dressing changes every shift to reduce the chance of spreading infection. A physician's order effective 10/22/24 indicated a left midline knee treatment to be cleansed with saline solution, pat dry with gauze, apply calcium alginate silver, and cover with foam dressing daily and as needed. Observation on 02/12/25 at 3:07 P.M. with RN/WN/IP #568 of Resident #12's wound care revealed an EBP sign and isolation cart holding supplies outside of the room. RN/WN/IP #568 performed the following steps: order was reviewed off printed copy of physician order for both dressing changes outside the room; supplies were brought into the room; the resident was positioned; RN/WN/IP #568 washed her hands and donned non-sterile gloves; the old dressing was removed; the dressing and gloves were disposed; new non-sterile gloves were donned; both wounds were cleansed and dried with separate gauze; calcium alginate silver was applied to only the left medial wound; both wounds were covered with a foam dressing; gloves were removed; the resident was covered; hands were washed. RN/WN/IP #568 did not apply a gown at the start of the procedure and did not change gloves after cleansing the wounds and prior to applying the calcium alginate silver and foam dressing. RN/WN/IP #568 only applied calcium alginate silver to the medial wound before covering both wounds with one foam dressing. Interview at the time of the observation with RN/WN/IP #568 verified the above findings. Review of the facility policy, Policies and Procedures - Infection Prevention and Control, dated 03/24, identified gloves and gown to be applied prior to performing wound care.

Based on review of record, interview and facility policy review, the facility failed to offer/hold quarterly care conference meetings for Resident #21 and/or her representative. This affected one resident (#21) of one resident reviewed for care conferences. The facility census was 96. Findings include: Review of the medical record for Resident #21 revealed an admitted [DATE]. Diagnoses included chronic diastolic heart failure, paraplegia, morbid obesity, fibromyalgia, and colostomy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/01/25, revealed Resident #21 had no memory impairment, was alert and cooperative with normal energy. Review of Resident #21's medical record revealed Interdisciplinary Team (IDT)/Care Conference Notes revealed the only documented evidence of care conferences were on 06/30/23, 03/23/24, and 10/07/24 only. Interview with Resident #21 on 02/10/25 at 8:36 P.M. revealed the resident understood what a care conference was. She denied attending a care plan meeting for a long time. In a follow-up interview with Resident #21 on 02/12/25 at 11:53 A.M. Resident #21 stated that she did not remember meeting with staff; however, she had talked to the person in charge of the kitchen in the hallway regarding food preferences. She also stated she had been invited to meet with a group of people in the dining room but turned down attending due to concern of being exposed to illness. Interview with Social Worker (SW) #606 verified that Resident #21 had care conferences, but they had not occurred quarterly. Resident #21 had attended meetings but also requested SW #606 call her daughter instead of attending. There was no documented evidence that the resident or her daughter were offered quarterly care conferences. Review of the undated facility policy, Care Planning - Interdisciplinary Team Policy revealed that every effort would be made to schedule care plan meetings at the best time of day for both resident and family.

Based on record review, staff interview and facility policy review, the facility failed to ensure a designated Grievance Officer was identified. This had the potential to affect all 96 residents residing in the facility. Findings include: Review of the Grievance Committee list revealed no staff member had been designated as the Grievance Officer. Interview on 02/12/25 at 10:18 A.M. with the Administrator revealed there was no designated Grievance Officer. Review of the facility policy titled Grievances/Complaints, Filing, updated April 2017, revealed the Administrator delegates a Grievance Officer.

Based on observation, interview and review of the menu and spreadsheet, the facility failed to provide the alternate entree at the appropriate portion size. This affected two residents (#24 and #73) of two residents observed to receive the alternate on lunch on 12/18/24 out of 98 residents receiving food from the kitchen (Resident #53 was ordered nothing by mouth). Facility census was 99. Findings include: Review of the menu for Week Two revealed a meal on Wednesday (corresponding to 12/18/24) lunch including cheese ravioli with marinara sauce with a portion size listed as one cup. Review of the diet guide spreadsheet for Day 11 Wednesday (corresponding to 12/18/24) lunch revealed the entree of cheese ravioli with marinara sauce was to be provided in a one-cup portion for those on a regular diet. Observation on 12/18/24 starting at 11:37 A.M. revealed trayline was set for the lunch meal consisting of chicken, cranberry orange sauce, Brussels sprouts, garden blend rice, dinner roll and an alternate of cheese ravioli in marinara sauce. Observation while Certified Dietary Manager (CDM) #399 took temperatures of the foods to be served revealed the ravioli had a green-handled spoodle in it that provided a four-ounce (half-cup) serving. Continued observation on 12/18/24 at 11:51 A.M. revealed meals began to be served for residents eating in the dining room. Two trays were observed to be plated receiving the ravioli entree and [NAME] #415 was observed to be providing one four-ounce scoop of the ravioli both times. Interview on 12/18/24 at 12:37 P.M. with CDM #399 and District Manager (DM) #398 verified eight ounces (one cup) of ravioli was supposed to be served at the lunch meal and if staff were going to use a four-ounce scoop to serve, then two scoops of ravioli were to be provided. Two residents were identified as receiving the alternate of ravioli, Resident #24 and Resident #73. Interview on 12/18/24 at 3:41 P.M. with Resident #73 verified he received ravioli at lunch this date. Interview on 12/18/24 at 3:56 P.M. with Resident #24 verified she received ravioli at lunch this date. This deficiency represents noncompliance investigated under Complaint Number OH00160242.

Based on observation, record review, interview, and facility policy review the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of pressure ulcers, to timely identify new pressure ulcers and to ensure wound care was completed as ordered. This affected two residents (#51 and #79) of four residents reviewed for pressure ulcers. The facility census was 102. Actual Harm occurred on 07/12/24 when Resident #51, who had a history of pressure ulcers, was dependent on staff assistance for most all activities of daily living (ADL) including toileting, hygiene, shower, dressing, transfers, and required partial to moderate assistance with rolling left and right in bed, was found to have an in-house acquired Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling) to his scrotal area that contained 50 percent slough/necrosis (dead tissue) requiring mechanical debridement (remove unhealthy tissue from a wound bed) per Wound Nurse Practitioner (NP) #692. On 07/15/24, Resident #51 was found to have another in-house acquired Stage III pressure ulcer to his coccyx area that also required mechanical debridement. The facility failed to provide documented evidence of effective, comprehensive, and adequate interventions being in place to prevent the development of these pressure ulcers and to ensure the pressure ulcers were identified before being found at a Stage III. Actual Harm occurred on 07/15/24 when Resident #79, who was dependent on staff for most all ADL care including toileting, hygiene, shower, dressing, transfers, and required partial to moderate assistance with rolling left and right in bed, was found to have an in-house acquired Stage III pressure ulcer to her right buttock that also required mechanical debridement to remove the devitalized tissue to healthy bleeding tissue. Observation of wound care on 07/22/24 revealed Resident #79's dressing was dated 07/19/24 indicating her daily wound care dressing was not completed on 07/20/24 or 07/21/24 as ordered by the physician. The facility failed to provide documented evidence of effective, comprehensive, and adequate interventions being in place to prevent the development of this pressure ulcer and to ensure the pressure ulcer was identified before being found at a Stage III. Findings include: 1. Review of the medical record for Resident #51 revealed an admitted [DATE] with diagnoses including diabetes, chronic pain syndrome, dysphagia, and glycogen storage disease (a rare condition that changes the way the body uses and stores sugar or glucose). Review of the care plan dated 12/18/23 revealed Resident #51 had an alteration in skin integrity as he had pressure ulcers to his ischium, sacrum, and buttocks. Interventions included checking dressing placement during routine care and services, encouraging the resident to get out of bed as tolerated, monitoring wounds for signs of infection, treatments as ordered, and document wound status weekly or as needed. Review of the care plan dated 03/17/24 revealed Resident #51 had the potential for altercation in skin integrity related to bruises easily, immobility, and incontinence. Interventions included administering treatments as ordered, offloading heels as tolerated, pressure redistribution cushion to chair, turning and repositioning as needed, and skin assessment weekly. Review of the care plan dated 04/01/24 revealed Resident #51 had an ADL self-care/ mobility/ functional ability performance deficit related to impaired mobility. Interventions included providing extensive assistance with bed mobility, dressing, and bathing, assist resident with proper body alignment while in bed using positioning devices as needed, and providing total assistance with a mechanical lift for transfers. Review of the C2) Weekly Ulcer/ Wound Documentation- V7 dated 05/02/24 and completed by Licensed Practical Nurse (LPN) #615 revealed Resident #51's coccyx (sacrum) wound was resolved. Review of the Quarterly Skin assessment dated [DATE] and completed by Registered Nurse (RN)/ Minimum Data Set (MDS) #650 revealed Resident #51 was at mild risk for developing pressure ulcers as he was occasionally moist, chairfast, slightly limited with mobility, and had a problem with friction and shear. Review of the C2) Weekly Ulcer/ Wound Documentation- V7 dated 06/06/24, 06/13/24, 6/20/24, 06/28/24, and 07/03/24 revealed no documented evidence that Resident #51 had any skin impairment to his coccyx (sacrum) or his scrotal area. Record review revealed the resident was receiving treatment for a pressure ulcer to the left ischium during this time period . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had intact cognition. The assessment revealed the resident was dependent on staff assistance for most all ADL care, including toileting, hygiene, shower, dressing, and transfers. He required partial to moderate assist with rolling left and right in bed. The assessment revealed the resident was at risk for pressure ulcers and had two Stage IV pressure ulcers (Full thickness tissue loss with exposed bone, tendon or muscle. Slough may be present on some parts of the wound bed. Often include undermining and tunneling.), and one was identified on admission. (The Stage IV pressure ulcers were noted to be the resident's ischium). Review of the C2) Weekly Ulcer/ Wound Documentation- V7 dated 07/12/24 and completed by Licensed Practical Nurse (LPN) #691 revealed on 07/12/24 Resident #51 was identified to have a Stage III pressure ulcer on his scrotal area that measured 8.4 centimeters (cm) length by 5.2 cm width with 0.2 cm depth post mechanical debridement. The wound contained 50 percent granulated tissue, 50 percent slough/ necrosis, and moderate drainage. A treatment was ordered to cleanse with wound cleanser, pat dry, apply tetracyte (a topical antibiotic to help wound healing) to wound bed followed by Medi honey (a medical- grade honey intended for wound care), oil emulsion, calcium silver alginate (dressing when in contact with wound exudates a gel was formed for easier dressing removal), and cover with abdominal (ABD) pad. There was no documented evidence that Resident #51 had any skin impairment to his sacrum/ coccyx area at this time. Review of Wound NP #692's progress note dated 07/12/24 revealed Resident #51 had a new Stage III pressure ulcer to his bilateral midline scrotal area that measured 8.39 cm length by 5.22 cm width with 0.1cm depth. Wound NP #692 evaluated the wound and noted the wound bed had full thickness that contained 50 percent (%) granulated tissue and 50% necrosis. Wound NP #692 mechanically debrided the devitalized tissue to the level of healthy bleeding tissue and ordered a treatment. Resident #51 had no documented evidence he had a pressure ulcer to his coccyx area at this time. Review of the C2) Weekly Ulcer/ Wound Documentation- V7 dated 07/15/24 and completed by LPN #691 revealed on 07/15/24 Resident #51 was identified to have a Stage III pressure ulcer to his coccyx area that measured 0.1 cm length by 0.3 cm width with 0.3 cm depth post mechanical debridement with 100 percent granulated tissue. A treatment was ordered to cleanse the wound with wound cleanser, pat dry, apply tetracyte drops, Medi honey, calcium alginate, and cover with border foam daily and as needed. Resident #51 continued to have a Stage III pressure ulcer to his scrotal area at this time. Review of the Wound NP #692 progress note dated 07/15/24 revealed Resident #51 had a Stage III pressure ulcer to his bilateral midline scrotal area that measured 7.83 cm length by 4.09 cm width with 0.1cm depth. Wound NP #692 evaluated the wound and noted the wound bed was full thickness and contained 50 percent granulated tissue and 50 percent necrotic tissue. Wound NP #692 mechanically debrided the devitalized tissue to the level of healthy bleeding tissue and ordered a treatment. Resident #51 was found to have a new Stage III pressure ulcer to his coccyx area that measured 0.1 cm length by 0.3 cm width with 0.2 cm in depth. Wound NP #692 evaluated and noted the wound bed was full thickness with 100 percent granulated tissue. A treatment was ordered to cleanse with wound cleanser, pat dry, apply tetracyte to wound bed followed by Medi honey, oil emission, calcium silver alginate, and cover with foam dressing. Observation on 07/22/24 at 1:27 P.M. revealed Resident #51 was lying in bed. An interview with the resident revealed he was unable to provide any details of how often and/or where he had wounds/pressure ulcers. Review of Wound NP #692's progress note dated 07/22/24 revealed Resident #51 continued to have a Stage III pressure ulcer to his scrotal area that measured 6.69 cm length by 2.97 cm width, with 0.1 cm depth. The wound contained 86 percent granulated tissue and 13 percent necrosis. NP #692 documented the wound was unchanged and mechanically debrided the devitalized tissue to the level of healthy bleeding tissue and ordered to continue the same treatment. There was no progress note regarding the evaluation of Resident #51's coccyx wound on 07/22/24. Interview on 07/23/24 at 3:23 P.M. with Regional RN #695 and the Director of Nursing (DON) verified per documentation on the C2) Weekly Ulcer/ Wound Documentation- V7 completed by LPN #691 and Wound NP #692's progress note on 07/12/24 Resident #51 was found to have a Stage III pressure ulcer to his scrotal area that contained 50 percent slough necrosis and needed mechanically debrided per Wound NP #692. Regional RN #695 and the DON indicated they believed Resident #51 had the pressure ulcer since admission to his coccyx/sacrum area but then verified on the C2) Weekly Ulcer/ Wound Documentation- V7 and the weekly wound NP #692 and #696 progress notes dated 6/06/24, 06/13/24, 6/20/24, 06/28/24, 07/03/24 and 07/12/24 there was no documented evidence he had any skin impairment to his coccyx/sacrum area. Regional RN #695 and the DON verified on 07/15/24, per documentation, Resident #51 was found to have a new Stage III pressure ulcer to his coccyx area per the C2) Weekly Ulcer/ Wound Documentation- V7 completed by LPN #691 and Wound NP #692's progress note. Regional RN #695 stated just going to be honest it all fell through the cracks and could not explain why except that there had many multiple changes in wound NPs and wound nurses at the facility. Interview on 07/24/24 at 11:10 A.M. with Wound NP #692 revealed she had identified Resident #51's Stage III pressure ulcer to his scrotal area on 07/12/24 during rounds when they turned him over to check his skin, the area was noted, and the wound nurse that she was rounding with had not known of him having this wound prior. She revealed the ulcer was definitely a Stage III pressure ulcer as the wound was full thickness and contained 50 percent slough that she had to mechanically debride down to the healthy tissue. She revealed on 07/12/24 Resident #51 did not have a pressure ulcer to his coccyx area at the time of her evaluation. She revealed she then consulted again on 07/15/24 and noted he continued to have the Stage III to his scrotal area as well as a new Stage III to his coccyx area. She revealed she felt Resident #51 possibly could have had a pressure ulcer at this site as he had scar tissue but when she asked the rounding wound nurse, she was unable to locate in his medical record any evidence that he had had one. She revealed she then had to classify this wound as a new wound instead of a re-opened wound and staged the wound as she had observed on 07/15/24 as a Stage III pressure ulcer. She revealed she had taken over the facility wound care just for the last three weeks and had found it very difficult as there had been multiple wound NPs and wound nurses at the facility, the documentation was not clear, and the wound nurses did not seem to know the residents well to provide thorough and accurate information. 2. Review of the medical record for Resident #79 revealed an admitted [DATE] with diagnoses including chronic kidney disease, diabetes, chronic obstructive pulmonary disease, and major depression. Review of the care plan dated 02/08/23 revealed Resident #79 required assistance for transferring from one position to another due to impaired mobility. Interventions included two staff assist with bed mobility and use of a mechanical lift for transfers. Review of the care plan dated 05/20/24 revealed Resident #79 had an alteration in skin integrity due to moisture associated skin damage (MASD) to back of left leg and a left leg laceration. Interventions included document wound status weekly and as needed, treatments as ordered, and refer to wound treatment specialist. Review of the quarterly skin assessment dated [DATE] and completed by RN/ MDS #667 revealed Resident #79 was at mild risk for developing pressure ulcers as she had occasionally moist skin, had limited mobility, was chairfast, and had a problem with friction and shear. Review of the July 2024 physician orders revealed an order dated 07/16/24 to cleanse open area to right buttocks with wound cleanser, pat dry, and apply dry dressing, an order dated 07/17/24 to cleanse bilateral buttocks with soap and water, pat dry, and apply protective barrier cream with nystatin cream daily and as needed, and an order dated 07/17/24 to clean her right buttock with normal saline, pat dry, apply tetracycline, Medi honey, oil emulsion and calcium alginate, cover with border foam dressing daily and as needed. She also had orders that included pressure redistribution cushion while in chair that was initiated 10/24/23, protective moisture barrier topically to perineal area every shift that was initiated 10/24/23, turn and reposition as tolerated and as needed using lift pad to minimize friction and shear that was initiated 10/24/23, and a low air loss mattress that was initiated on 12/18/23. Review of the quarterly MDS assessment dated [DATE] revealed Resident #79 had intact cognition. The assessment revealed the resident was dependent on staff assistance for most of her ADL care, including toileting hygiene, showers, and transfers. She required partial to moderate assistance with rolling left and right in bed. The assessment revealed the resident was at risk for pressure ulcers but had no pressure ulcers at the time of the assessment. Review of the weekly wound note dated 07/12/24 at 4:23 P.M. and completed by LPN #691 revealed Resident #79 continued to have a laceration to her left posterior knee. There was no documented evidence Resident #79 had any skin impairment to her buttocks. Review of the weekly wound note dated 07/15/24 at 2:23 A.M. and completed by LPN #691 revealed Resident #79 was found to have a Stage III pressure ulcer to her right buttocks that measured 0.9 cm length by 1.0 cm width with 0.2 cm depth post debridement. The note revealed mechanical debridement was completed and the wound base was visible with 100 percent granulation tissue present with minimal amount of thin, red drainage. Review of Wound NP #692's progress note dated 07/15/24 revealed Resident #79 had a new Stage III pressure ulceration to her right midline buttock that measured 0.9 cm length by 1.0 cm width with 0.1cm in depth. The wound was full thickness with 100 percent granulating tissue. The note revealed Wound NP #692 mechanically debrided, and the devitalized tissue was removed to the level of healthy bleeding tissue. NP #692 ordered the wound to her right buttock to be cleaned with normal saline, pat dry, apply tetracycline, Medi honey, oil emulsion, and calcium alginate, cover with border foam dressing daily and as needed. Review of the care plan dated 07/17/24 revealed Resident #79 had a potential for alteration in skin integrity related to immobility. Intervention included dry thoroughly between skin fold after cleansing, monitor between fold for redness, irritation, and bleeding, keep linens clean, dry, and wrinkle free, pressure redistribution cushion to chair, pressure redistribution mattress to bed, and moisturizing lotion. Review of the July 2024 Treatment Administration Record (TAR) revealed Resident #79's treatment dated 07/17/24 to clean her right buttock with normal saline, pat dry, apply tetracycline, Medi honey, oil emulsion and calcium alginate, cover with border foam dressing daily and as needed was signed off as completed daily from 07/17/24 to 07/21/24. Observation of wound care for Resident #79 on 07/22/24 at 11:03 A.M. completed by RN/ Wound Nurse #694 and Wound NP #692 revealed Resident #79's dressing to the right buttock was dated 07/19/24. RN/ Wound Nurse #694 and Wound NP #692 verified Resident #79's daily dressing had not been completed on 07/20/24 or 07/21/24 as ordered. Wound NP #692 assessed the right buttock pressure area stating previously it was a full thickness wound and now was partial thickness measuring 0.7 cm length by 0.6 cm width with 0.1 cm in depth. Wound NP #692 revealed no changes to the current treatment were necessary at this time. Interview on 07/22/24 at 11:07 A.M. and 11:10 P.M. with RN/ Wound Nurse #694 revealed this was her first week at the facility and first-time observing Resident #79's right buttocks wound. She was unable to provide any details regarding how Resident #79's wound was found except that per the documentation, the first documentation was that the wound was found as a Stage III pressure ulcer. Interview on 07/22/24 at 11:10 A.M. with Wound NP #692 revealed this was her third week coming to the facility and many times she had identified wound dressings (for residents) in place were dated indicating the dressings were not completed as ordered. She revealed today, 07/22/24, Resident #58's arterial wound dressing to his left ankle was the same dressing they had applied on 07/15/24 even though his order was to be changed daily (one week he went without having it changed). She verified Resident #79's wound was found at Stage III as the pressure ulcer (was full thickness) and she debrided the wound on her last visit. She stated, I hope with the new wound nurse, things will be fixed as there has been issues with dressings not being changed as ordered. Interview on 07/23/24 at 10:41 A.M. with Resident #79 revealed the nurses did not do her dressing all weekend (07/20/24 and 07/21/24) as stated it was supposed to be done daily. She revealed if her regular nurse was not working that her dressing change does not get done. Review of the facility policy labeled, Dressing Change (Clean) dated 11/30/23 revealed the purpose of the policy was to protect, prevent irritation, prevent infection, and promote healing. The policy described the procedure for changing the dressing and to document it in the medical record. The policy did not include anything regarding ensuring treatments were completed as ordered and/ or not documenting in the treatment record until after the treatment was completed. Review of the facility policy labeled; Skin Care Management dated 11/30/23 revealed the facility would assess residents for the potential for the risk of developing skin breakdown. Residents at risk for developing skin breakdown would be managed. Residents at minimum risk would have a daily evaluation and daily skin care. Residents with identified skin breakdown would be documented on the skin assessment weekly including wound description including measurements. This deficiency represents non-compliance investigated under Complaint Number OH00155127.

Based on observation, record review, interview, and facility policy review the facility failed to ensure resident treatments were completed and/ or documented as ordered. This affected two residents (#58 and #93) out of four residents reviewed treatments. This had the potential to affect 17 residents (#7, #14, #23, #27, #45, #48, #51, #58, #67, #73, #79, #85, #86, #89, #90, #91, and #99) identified by the facility with a treatment order other than barrier cream. The facility census was 102. Findings included: 1. Review of the medical record for Resident #58 revealed an admitted [DATE] with diagnoses including hypertension, anxiety disorder, abnormalities of gait and mobility, and weakness. Review of the care plan dated 07/18/23 revealed Resident #58 had an alteration in skin integrity due to left ankle arterial ulcer. Interventions included check dressing for placement during the provision of routine care and services, document wound status weekly, heel lift suspension boots to be worn as tolerated, and treatments per order. Review of the Wound Nurse Practitioner (NP) #692 progress note dated 07/12/24 revealed Resident #58 continued to have an arterial ulceration to his left lateral ankle that measured 1.0 centimeter (cm) in length, 0.9 cm in width and 0.1cm in depth. Wound NP #692 ordered to cleanse Resident #58's left lateral ankle with saline solution, pat dry, apply Tetracyte (a topical antibiotic to help wound healing) along with calcium alginate (dressing when in contact with wound exudates a gel was formed for easier dressing removal), and cover with border foam dressing daily and as needed. There was no order on this progress note to complete the dressing change every other day. Review of the July 2024 treatment administration record (TAR) revealed an order dated 07/13/24 to cleanse Resident #58's left lateral ankle with saline solution, pat dry, apply Tetracyte along with calcium alginate, and cover with border foam dressing daily and as needed. The order also included every evening shift every other day (conflicting with the above frequency). The TAR indicated the treatment was marked to be completed every other day and not daily even though the order had both instructions in it. The TAR indicated his treatment was documented as completed on 07/15/24, 07/17/24, 07/19/24, 07/21/24 and that Resident #58 had refused his treatment on 07/13/24. Review of the C2) Weekly Ulcer Wound Documentation- V7 dated 07/15/24 and completed by Licensed Practical Nurse (LPN) #691 revealed Resident #58 had an arterial ulcer to his left lateral ankle that measured 1.1 cm in length. 0.9 cm in width, and 0.2cm in depth post debridement. The assessment revealed the following treatment was to be completed: cleanse Resident #58's left lateral ankle with saline solution, pat dry, apply Tetracyte along with calcium alginate, and cover with border foam dressing daily and as needed. (There was nothing on the assessment that the treatment was to be completed every other day). Interview on 07/22/24 at 11:10 A.M. with Wound NP #692 stated that this was the third week coming to the facility and many times the wound dressings were dated indicating the dressing were not completed as ordered. She revealed today, 07/22/24, Resident #58's arterial wound dressing to his leg was the same dressing they had applied on 07/15/24 even though his order was to be changed daily (one week he went without having it changed). She stated, I hope with the new wound nurse things will be fixed as there has been issues with dressings not being changed as ordered. Interview on 07/22/24 at 11:12 A.M. with Registered Nurse (RN)/ Wound Nurse #694 verified Resident #58's dressing was dated 07/15/24, today 07/22/24, when they changed his dressing. She revealed she could not explain why his wound dressing was not completed as ordered as she stated this was her first week employed at the facility. Interview on 07/22/24 at 12:36 P.M. with Resident #58 revealed the nurses did not change his dressing as ordered to his left ankle. He revealed today, 07/22/24, RN/ Wound Nurse #694 and Wound NP #692 had changed his dressing but before that it had been almost a week since anyone had changed it. Interview on 07/22/24 at 4:26 P.M. with Regional RN #696 and the Director of Nursing (DON) revealed LPN #691 had come from another facility to assist with wound rounds. They verified in Wound NP #692 and in the C2) Weekly Ulcer Wound Documentation- V7 completed by LPN #691 he was to have his treatment completed daily. They verified on the TAR that the nurses had documented this was completed every other day. They had no explanation why when RN/ Wound Nurse #694 and Wound NP 692 changed his dressing today, 07/22/24, the dressing on Resident #58's left lateral ankle was dated 07/15/24 even though the nurses had signed off the dressing changes 07/15/24, 07/17/24, 07/19/24, and 07/21/24. 2. Review of the medical record for Resident #93 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, hypertension, and weakness. Review of the C2) Weekly Ulcer/ Wound Documentation- V7 dated 06/18/24 and completed by LPN #615 revealed Resident #93 bilateral buttocks fungal rash was resolved and there was a treatment to continue to cleanse her bilateral buttocks with soap and water, pat dry, apply antifungal cream and powder every shift. Review of the June 2024 physician orders revealed Resident #93 had an order dated 06/27/24 to cleanse her bilateral buttocks with soap and water, pat dry, apply antifungal cream and powder every shift and as needed. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #93 was rarely and/ or never understood. She was always incontinent of bowel and bladder. She had moisture associated skin damage (MASD). Review of the July 2024 TAR revealed there was no documentation that her treatment to cleanse her bilateral buttocks with soap and water, pat dry, apply antifungal cream and powder every shift was completed from 07/01/24 to 07/22/24 every shift. Observation on 07/22/24 at 10:38 A.M. of incontinence care completed by State tested Nurse Aide (STNA) #664 revealed Resident #93's perineal area was pink including a darker pink line where Resident #93's incontinence product laid in her groin area. Interview on 07/22/24 at 4:26 P.M. with Regional RN #696 and the DON verified Resident #93 had a physician order to cleanse her bilateral buttocks with soap and water, pat dry, apply antifungal cream and powder every shift and there was no documented evidence this was completed on the TAR. Review of the facility policy, Medication Administration- General Guidelines dated November 2021 revealed medication were to be administered as prescribed. The policy revealed that topical medications used in treatments were listed on the TAR and the individual who administers the medication records the administration of. Review of the facility policy labeled, Dressing Change (Clean) dated 11/30/23 revealed the purpose of the policy was to protect, prevent irritation, prevent infection, and promote healing. The policy described the procedure for changing the dressing and to document it in the medical record. The policy did not include anything regarding ensuring treatments were completed as ordered and/ or not documenting in the treatment record until after the treatment was completed. Review of the facility policy labeled; Skin Care Management dated 11/30/23 revealed the facility would assess residents for the potential for the risk of developing skin breakdown. Residents with identified skin breakdown would have a documented skin assessment weekly and treatments would be completed as ordered. This deficiency represents non-compliance investigated under Complaint Number OH00155127.

Based on observation, record review, interview, and facility policy review the facility failed to ensure medical records were maintained in an accurate manner including not documenting the completion of treatments that were not done as ordered. This affected two residents (#58, and #79) out of eight residents medical records reviewed for accuracy. The facility census was 102. Findings include: 1. Review of the medical record for Resident #58 revealed an admitted [DATE] with diagnoses including hypertension, anxiety disorder, abnormalities of gait and mobility, and weakness. Review of the care plan dated 07/18/23 revealed Resident #58 had an alteration in skin integrity due to left ankle arterial ulcer. Interventions included check dressing for placement during the provision of routine care and services, document the wound status weekly, heel lift suspension boots to be worn as tolerated, and treatments per order. Review of the Wound Nurse Practitioner (NP) #692 progress note dated 07/12/24 revealed Resident #58 continued to have an arterial ulceration to his left lateral ankle that measured 1.0 centimeter (cm) in length, 0.9 cm in width and 0.1cm in depth. Wound NP #692 ordered to cleanse Resident #58's left lateral ankle with saline solution, pat dry, apply Tetracyte (a topical antibiotic to help wound healing) along with calcium alginate (dressing when in contact with wound exudates a gel was formed for easier dressing removal), and cover with border foam dressing daily and as needed. There was no order on this progress note to complete the dressing change every other day. Review of the July 2024 treatment administration record (TAR) revealed an order dated 07/13/24 to cleanse Resident #58's left lateral ankle with saline solution, pat dry, apply Tetracyte along with calcium alginate, and cover with border foam dressing daily and as needed. The order also included every evening shift every other day. The TAR indicated the treatment was marked to be completed every other day and not daily even though the order had both instructions in it. The TAR indicated his treatment was documented as completed on 07/15/24, 07/17/24, 07/19/24, 07/21/24, and Resident #58 had refused his treatment on 07/13/24. Review of the C2) Weekly Ulcer Wound Documentation- V7 dated 07/15/24 and completed by Licensed Practical Nurse (LPN) #691 revealed Resident #58 had an arterial ulcer to his left lateral ankle that measured 1.1 cm in length. 0.9 cm in width, and 0.2cm in depth post debridement. The assessment revealed the following treatment was to be completed: cleanse Resident #58's left lateral ankle with saline solution, pat dry, apply Tetracyte along with calcium alginate, and cover with border foam dressing daily and as needed. (There was nothing on the assessment that the treatment was to be completed every other day). Interview on 07/22/24 at 11:10 A.M. with Wound NP #692 stated that this was the third week coming to the facility and many times the wound dressings were dated indicating the dressing were not completed as ordered. She revealed today, 07/22/24, Resident #58's arterial wound dressing to his left ankle was the same dressing they had applied on 07/15/24 even though his order was to be changed daily (one week he went without having it changed). She stated, I hope with the new wound nurse things will be fixed as there have been issues with dressings not being changed as ordered. Interview on 07/22/24 at 11:12 A.M. with Registered Nurse (RN)/ Wound Nurse #694 verified Resident #58's dressing was dated 07/15/24, today 07/22/24, when they changed his dressing. She could not explain why his wound dressing was not completed as ordered as she stated this was her first week employed at the facility. Interview on 07/22/24 at 12:36 P.M. with Resident #58 revealed the nurses did not change his dressing as ordered to his left ankle. He revealed today, 07/22/24, RN/ Wound Nurse #694 and Wound NP #692 had changed his dressing, but before that it had been almost a week since anyone had changed it. Interview on 07/22/24 at 4:26 P.M. with Regional RN #696 and the Director of Nursing (DON) revealed LPN #691 had come from another facility to assist with wound rounds. They verified in Wound NP #692 and in the C2) Weekly Ulcer Wound Documentation- V7 completed by LPN #691 he was to have his treatment completed daily. They verified on the TAR that the nurses had documented this was completed every other day. They had no explanation why when RN/ Wound Nurse #694 and Wound NP 692 changed his dressing today, 07/22/24, Resident #58's left lateral ankle was dated for 07/15/24 even though the nurses had signed off the dressing as being changed 07/15/24, 07/17/24, 07/19/24, and 07/21/24. 2. Review of the medical record for Resident #79 revealed an admitted [DATE] with diagnoses including chronic kidney disease, diabetes, chronic obstructive pulmonary disease, and major depression. Review of the care plan dated 05/20/24 revealed Resident #79 had an alteration in skin integrity due to moisture associated skin damage (MASD) to the back of the left leg and a left leg laceration. Interventions included document wound status weekly and as needed, treatments as ordered, and refer to the wound treatment specialist. Review of the July 2024 Physician Orders revealed an order dated 07/17/24 to clean Resident #79's right buttock with normal saline, pat dry, apply tetracycline, Medi honey, oil emulsion and calcium alginate, cover with border foam dressing daily and as needed. Review of the July 2024 TAR revealed Resident #79's treatment dated 07/17/24 to clean her right buttock with normal saline, pat dry, apply tetracycline, Medi honey, oil emulsion and calcium alginate, cover with border foam dressing daily and as needed was signed off as completed daily from 07/17/24 to 07/21/24. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 had intact cognition. She was dependent on staff assistance for most of her activities of daily living (ADL) including toileting, hygiene, showers, and transfers. She required partial to moderate assistance with rolling left and right in bed. She was at risk for pressure ulcers but had no pressure ulcers at the time of the assessment. Review of Wound NP #692's progress note dated 07/15/24 revealed Resident #79 had a new stage three pressure ulceration (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling) to her right midline buttock that measured 0.9 cm in length, 1.0 cm in width, and 0.1cm in depth. The wound was full thickness, with 100 percent granulating tissue. The note revealed Wound NP #692 mechanically debrided, and the devitalized tissue was removed to the level of healthy bleeding tissue. Wound NP #692 ordered the wound to be cleaned to her right buttock with normal saline, pat dry, apply tetracycline, Medi honey, oil emulsion and calcium alginate, cover with border foam dressing daily and as needed. Observation and interview of wound care for Resident #79 on 07/22/24 at 11:03 A.M. and completed by RN/ Wound Nurse #694 and Wound NP #692 revealed Resident #79's dressing was dated 07/19/24. RN/ Wound Nurse #694 and Wound NP #692 verified Resident #79's daily dressing had not been completed on 07/20/24 and 07/21/24 as ordered. Interview on 07/22/24 at 11:10 A.M. with Wound NP #692 stated that this was the third week coming to the facility and many times the wound dressings were dated indicating the dressing were not completed as ordered. She stated, I hope with the new wound nurse things will be fixed as there have been issues with dressings not being changed as ordered. Interview on 07/22/24 at 4:26 P.M. with Regional RN #696 and the DON revealed they had no explanation why when RN/ Wound Nurse #694 and Wound NP #692 changed her dressing today, 07/22/24, Resident #79's right buttock was dated for 07/19/24 even though the dressing was ordered daily, and the nurses had signed off the dressing as being changed 07/20/24 and 07/21/24. Interview on 07/23/24 at 10:41 A.M. with Resident #79 revealed the nurses did not do her dressing all weekend (07/20/24 and 07/21/24), and they were supposed to be done daily. She revealed if her regular nurse was not working, her dressing change does not get done. Review of the facility policy, Medication Administration- General Guidelines dated November 2021 revealed medication were to be administered as prescribed. The policy revealed that topical medications used in treatments were listed on the TAR and the individual who administers the medication records the administration of. Review of the facility policy labeled, Dressing Change (Clean) dated 11/30/23 revealed the purpose of the policy was to protect, prevent irritation, prevent infection, and promote healing. The policy described the procedure for changing the dressing and to document it in the medical record. The policy did not include anything regarding ensuring treatments were completed as ordered and/ or not documenting in the treatment record until after the treatment was completed. This deficiency represents non-compliance investigated under Complaint Number OH00155127.

Based on interview, observation, record review, and facility policy review the facility did not ensure Resident #3 received timely incontinence care. This affected one resident (#3) out of three residents reviewed for incontinence care. This had the potential to affect 41 residents (#2, #3, #8, #10, #11, #12, #14, #17, #19, #20, #22, #23, #24, #27, #28, #29, #31, #33, #34, #36, #38, #41, #45, #46, #47, #48, #50, #51, #52, #54, #57, #58, #60, #63, #71, #72, #74, #77, #78, #80, and #83) who were identified by the facility as incontinent. Findings include: Review of the medical record for Resident #3 revealed an admitted [DATE] with diagnoses including Lennox-Gastaunt Syndrome (LGS) with status epilepticus (type of seizure disorder with multiple different types of seizures), fracture of upper end of the left humerus, and cerebral palsy. Review of the undated care plan revealed Resident #3 had urinary incontinence related to impaired mobility, physical limitation, cognitive deficits, and resistance to care at times. Interventions included adjust toileting times to meet the resident's needs, apply skin moisturizer and barrier creams as needed, provide incontinence care as needed, and use absorbent products as needed. Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 had impaired cognition. He required extensive assistance of two staff with bed mobility, dressing, personal hygiene, and toileting. He was totally dependent of two staff for transfers. He was frequently incontinent of urine and always incontinent of bowel. Observation of incontinence care on 06/23/23 at 8:19 A.M. and completed by State tested Nursing Assistant (STNA) #600 and STNA #601 revealed Resident #3 had two incontinence briefs on and both briefs were saturated in urine. Observation revealed he was lying on two bath blankets folded as draw sheets underneath the briefs and both bath blankets were saturated with urine resulting in urine that soaked all the way through both bath blankets to his bottom fitted sheet. Observation revealed Resident #3's bottom fitted sheet had dried yellow round urine spots. Interview on 06/23/23 at 8:35 A.M. with STNA #600 and STNA #601 revealed when they came on duty on 06/23/23 at 7:00 A.M. the two STNA's from 11:00 P.M. to 7:00 A.M. shift had already left and that they did not get anything in report regarding Resident #3 refusing care and/or a reason why he had not been changed. They revealed they were supposed to do walking rounds with the off-going STNA's to check for incontinence but since the aides from the previous shift had left, they had not, and they were unsure when Resident #3 was changed last. They verified by the condition Resident #3 was found in he had not been changed for a long period of time and felt it was much longer than two hours. They asked Resident #3 when the last time he was changed while they were changing him but Resident #3 was unable to recall when he was changed last. Interview on 06/23/23 at 9:57 A.M. with STNA #603 revealed she primarily worked day shift and at times she had come in and found residents saturated in urine as their briefs as well as their sheets were urine soaked, and she felt staff from the 11:00 P.M. to 7:00 A.M. shift had not changed the residents as they should have been every two hours. She revealed they were supposed to do rounds with off going STNA's but most the time the staff just left without doing the rounds. Re-interview on 06/23/23 at 10:11 A.M. with STNA #600 revealed Resident #3 more than likely had urinated four or five times by the time they had changed him on 06/23/23 at 8:19 A.M. She revealed he had to have urinated four or five times because he had two incontinence briefs on that were soaked and then stated he had an inch thick of bath blankets underneath the two incontinence briefs that the urine had soaked all the way through both bath blankets then all the way down to the fitted sheet which then also was soaked. She revealed it appeared in her opinion that Resident #3 had not been changed almost all 11:00 P.M. to 7:00 A.M. or if he was changed it was at the beginning of that shift but that he had gone several hours without being changed. Interview on 06/23/23 at 11:56 A.M. with the Director of Nursing revealed Resident #3 should not have had two incontinence briefs in place. She revealed she had contacted Agency STNA #608 regarding the condition Resident #3 was found in. She revealed it was Agency STNA #608's first time at the facility and that Agency STNA #608 stated Resident #3 was sleeping on her last set of rounds prior to her leaving and that she had not attempted to awake him to provide incontinence care as per his plan of care. The Director of Nursing verified Resident #3 was incontinent of urine and was to be checked and changed every two hours and provided incontinence care as needed. She revealed she was unsure when Resident #3 was changed last on 06/23/23 prior to being changed at 8:19 A.M. but stated, obviously she did not do incontinence care and it was over two hours by how he was found. Review of the facility policy labeled Incontinence Care, dated 06/08/22, revealed the purpose of the policy was to keep resident's skin clean, dry, and free of irritation and odor. There was nothing in the policy regarding the frequency of incontinence care. This deficiency represents non-compliance investigated under Complaint Number OH00143579. This deficiency is an example of continued noncompliance to the survey completed on 06/01/23.

Based on medical record review, staff interview, observation, and policy review, the facility failed to ensure residents who were incontinent were provided incontinence care in a timely manner. This affected five (Resident #25, #33, #78, #90 and #91) out of six residents reviewed for timely incontinence care. The facility census was 86. Findings include: 1. Review of Resident #33's medical record revealed an admitted [DATE] and diagnoses which included dementia, anxiety disorder, spinal stenosis cervical region and difficulty in walking. Review of Resident #33's care plan, dated 03/10/16 and reviewed 04/26/23, revealed Resident #33 had an ADL (activity of daily living) self-care deficit related to generalized weakness, impaired mobility, chronic pain and refusal to get out of bed or participate in hygiene tasks. Resident #33 would receive the assistance necessary to meet ADL needs. Interventions included to assist to bathing and shower as needed. Resident #33 had urinary incontinence related to urge incontinence, functional incontinence, chronic pain, and refusal to get out of bed. Resident #33 would be maintained in as clean and dry as well as dignified state as possible. Interventions included to provide incontinence care as needed. Review of Resident #33's Quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/14/23, revealed Resident #33 was cognitively intact. Resident #33 required extensive assistance of two staff for bed mobility, transfers, personal hygiene and toilet use. Resident #33 was always incontinent of urine and bowel. Review of Resident #33's aide charting for night shift on 05/23/23 from 11:00 P.M. through 7:00 A.M. on 05/24/23 revealed no documentation that Resident #33 was provided incontinence care. Observation on 05/24/23 at 9:10 A.M. of Resident #33 revealed she asked State tested Nursing Assistant (STNA) #206 to assist her because she needed her incontinence brief changed. Resident #33 preferred the surveyor to stand outside the room during incontinence care. STNA #206 stated this was the first time he provided incontinence care for Resident #33 since he arrived at 7:00 A.M. because breakfast trays arrived around 7:30 A.M., and he helped pass meal trays and feed residents. STNA #206 indicated he started his incontinence rounds after breakfast was finished. After STNA #206 finished with incontinence care, he stated Resident #33's sheets and draw sheet were soiled with urine. Observation of the fitted sheet revealed it was wet with a large spot of urine and had dried urine around the edges, and the draw sheet had a large wet urine spot with dried urine on the edges. Resident #33's incontinence brief was soaked with urine and feces. STNA #206 stated due to the way Resident #33's incontinence brief, sheets, and draw sheet looked Resident #33's incontinence brief was probably not changed during the night shift. 2. Review of Resident #25's medical record revealed an admitted [DATE] and diagnoses which included Huntington's Disease, anxiety disorder, and major depressive disorder. Review of Resident #25's Quarterly MDS 3.0 assessment, dated 04/20/23, revealed Resident #25 was unable to have a Brief Interview for Mental Status conducted due to Resident #25 was rarely, never understood. Resident #25 required extensive assistance of two staff for bed mobility, transfers and required total dependence of two staff for toilet use. Resident #25 was always incontinent of urine and bowel. Review of Resident #25's care plan, reviewed 05/03/23, revealed Resident #25 had urinary incontinence related to immobility and had difficulty making needs known. Resident #25 would have no complications due to incontinence. Interventions included to provide incontinence care as needed. Review of Resident #25's aide charting for night shift on 05/23/23 from 11:00 P.M. through 7:00 A.M. on 05/24/23 revealed no documentation that Resident #25 was provided incontinence care. Observation on 05/24/23 at 10:29 A.M. of STNA #206 providing incontinence care for Resident #25 revealed Resident #25's incontinence brief was saturated with dark yellow urine and feces. STNA #206 stated he knew Resident #25 very well and Resident #25's incontinence brief was probably not changed all night from the way it looked. Interview on 05/24/23 at 4:52 P.M. with STNA #310 revealed she was from a staffing agency and on 05/23/23 night shift she was assigned with with STNA #311 to care for residents on the nursing unit where Resident #33 resided. STNA #310 stated she had Resident's #25 and #33 in her assignment. STNA #310 stated it was a very busy crazy night with a lot going on. STNA #310 stated eight or ten residents required two staff for incontinence care, she worked with STNA #311 to change the residents, but she might have missed a few residents including Resident's #25 and #33 who needed changed due to the very busy night. STNA #310 stated she did the best she could. Interview on 05/25/23 at 9:14 A.M. with STNA #311 revealed she worked on 05/23/23 night shift with STNA #310 and it was a busy night. STNA #311 indicated Resident #33 and Resident #25 were not in her assignment and STNA #310 had them in her assignment. STNA #310 told STNA #311 she was fine and did not need help changing any of her residents and STNA #311 took her word for it. STNA #311 stated she would have helped her change Resident #25 and #33 if she knew they needed their incontinence briefs changed. STNA #311 indicated she knew the residents on the hall well and if Resident #25's incontinence brief was wet that meant she was wet for a long time and probably was not changed on night shift. 3. Review of Resident #91's medical record revealed an admitted [DATE] and diagnoses which included alcoholic cirrhosis of liver with ascites, major depressive disorder, and anxiety disorder. Review of Resident #91's Admission Assessment and Baseline Care Plans, dated 05/28/23, revealed Resident #91 had cognitive impairment with poor decision-making skills (intermittent confusion, cognitive deficit, disoriented all the time). Review of Resident #91's care plan, dated 05/31/23, revealed Resident #91 had an ADL (activity of daily living) self-care performance deficit related to weakness, unsteady at times. Interventions included for staff to assist with completion of ADL's on a daily basis so needs are met, and provide limited assistance with toilet use. Review of Resident #91's aide charting on 05/29/23 from 11:00 P.M. until 05/30/23 at 7:00 A.M. revealed no documentation that Resident #91 was provided incontinence care during this time frame. Observation on 05/30/23 at 4:00 A.M. of STNA #312 revealed he was sleeping in a chair, covered with a blue blanket in the common area lounge on the skilled nursing unit with the lights off. Observation on 05/30/23 at 4:07 A.M. with Registered Nurse (RN) #313 revealed she was in the skilled nursing unit hall preparing to administer medications to the residents. A call light for the resident in room [ROOM NUMBER] was activated and RN #313 answered the call light. After answering the call light, RN #313 went to the lounge, woke STNA #312 up and told him the resident in room [ROOM NUMBER] needed his assistance. Interview on 05/30/23 at 4:10 A.M. with RN #313 revealed she was from a staffing agency and this was the first night she worked in the facility. RN #313 stated she was not sure how long STNA #312 was sleeping when she woke him up to assist the resident in room [ROOM NUMBER]. RN #313 stated it was a crazy night, she was busy answering call lights and administering medications for the residents, and was not sure what STNA #312 was doing. Interview on 05/30/23 at 4:10 A.M. with STNA #312 confirmed he was sleeping, was from a staffing agency and stated he was just dozing off and on. STNA #312 proceeded to room [ROOM NUMBER] to assist the resident. Observation on 05/30/23 at 4:24 A.M. of STNA #312 revealed he was back in the common area lounge with the lights off, sitting in a chair with his head to the side, and an electronic device was on and voices could be heard. Observation on 05/30/23 at 4:33 A.M. revealed STNA #312 sitting in a chair in the common area lounge on the skilled nursing unit with the lights off and voices could be heard from an electronic device he was looking at. Observation on 05/30/23 at 4:39 A.M. revealed RN #313 walked into the common area lounge to have STNA #312 come out on the floor to assist with answering call lights. Observation on 05/30/23 from 4:39 A.M. through 5:10 A.M. revealed STNA #312 did not provide incontinence care for any residents during this timeperiod. Observation on 05/30/23 from 5:10 A.M. through 5:29 A.M. of STNA #312 revealed he answered a couple call lights and brought juice to Resident's #83 and #84, but did not provide incontinence care for any residents. Observation on 05/30/23 from 5:29 A.M. through 5:41 A.M. of STNA #312 revealed he was in the common area lounge with the lights off watching an electronic device. At 5:41 A.M., STNA #312 walked out of the lounge and to the other side of the facility. Observation on 05/30/23 at 5:49 A.M. of STNA #312 revealed he was back in the common area lounge watching his electronic device. Observation on 05/30/23 at 5:52 A.M. revealed RN #313 walked into the common area and told STNA #312 residents were requesting ice water. STNA #312 left the lounge, prepared ice water for the residents and began passing it out to the residents. STNA #312 passed ice water until 6:18 A.M. Observation on 05/30/23 from 6:18 A.M. through 6:54 A.M. revealed STNA #312 was sitting in the common area lounge watching his electronic device. At 6:41 A.M., STNA #312 walked up and down the hall looking in resident rooms, but did not enter any room. Interview on 05/30/23 at 6:50 A.M. of RN #313 revealed she had to keep going in the common area lounge to get STNA #312 and it would be better if he stayed in the hall where the residents resided so he could hear if something happened and residents needed his assistance. RN #313 stated STNA #312 spent a lot of time in the lounge during the 11:00 P.M. to 7:00 A.M. shift. Interview on 05/30/23 at 5:54 A.M. of STNA #312 revealed he stated he provided incontinence care for residents at 5:30 A.M. even though there were no observations of this having occurred. STNA #312 stated the surveyor could check residents and it did not make me no difference. STNA #312 gathered his personal belongings and left the facility without waiting for the day shift aide to give report. Observation on 05/30/23 at 7:05 A.M. of STNA #314 providing incontinence care for Resident #91 revealed Resident #91 had two incontinence briefs on. STNA #314 removed the two incontinence briefs and stated Resident #91 should not have been wearing two incontinence briefs. Further observation revealed Resident #91's sheets were soiled with brown [NAME], which appeared to be feces, and STNA #314 stated Resident #91 required a complete bed strip. STNA #314 stated STNA #312 worked night shift, left the facility, and did not give her report before he left. Interview on 05/30/23 at 7:30 A.M. with the Director of Nursing revealed STNA #312 should not have been sleeping and staff found sleeping were terminated. 4. Review of Resident #90's medical record revealed an admitted [DATE] and diagnoses which included sepsis, hydrocephalus, major depressive disorder, and neuromuscular dysfunction of the bladder. Review of Resident #90's Admission Assessment and Baseline Care Plans, dated 05/22/23, revealed Resident #90 had cognitive impairment with poor decision-making skills (intermittent confusion, cognitive deficit, disoriented all the time). Resident #90 had an indwelling catheter. Review of Resident #90's care plan, dated 05/23/23, revealed Resident #90 had an ADL self-care deficit related to physical limitations, weakness, unsteady gait, and cognitive deficits. Resident #90 would receive assistance necessary to meet ADL needs. Interventions included to assist with daily hygiene, grooming, dressing, oral care and eating as needed. Review of Resident #90's aide charting on 05/29/23 at 11:00 P.M. through 05/30/23 at 7:00 A.M. revealed there was no evidence Resident #90 was provided incontinence care during this timeperiod. Observation on 05/30/23 at 7:20 A.M. of STNA #314 providing incontinence care for Resident #90 revealed Resident #90 had a large brown bowel movement. Observation of Resident #90 revealed the feces was dried on his buttocks and STNA #314 had to wipe the area multiple times to get the feces off. Resident #90's buttocks were red and STNA #314 stated the bowel movement was not fresh and had been there awhile. 5. Review of Resident #78's medical record revealed an admitted [DATE] and diagnoses which included permanent atrial fibrillation, aftercare following surgery for neoplasm, and heart failure. Review of Resident #78's Admission MDS 3.0 assessment, dated 05/13/23, revealed Resident #78 had moderate cognitive impairment. Resident #78 required extensive assistance of one staff member for bed mobility, transfers, and toilet use. Resident #78 was frequently incontinent of urine and always incontinent of bowel. Review of Resident #78's care plan, dated 05/08/23, revealed Resident #78 had an ADL self-care deficit related to physical limitations weakness, unsteady at times, recent surgery. Resident #78 would receive assistance necessary to meet ADL needs. Interventions included to assist with daily hygiene, grooming, dressing, oral care and eating as needed. Review of Resident #78's aide charting from 05/29/23 at 11:00 P.M. through 05/30/23 at 7:00 A.M. revealed no evidence Resident #78 was provided incontinence care during this timeframe. Interview on 05/30/23 at 9:30 A.M. of Nurse #216 and STNA #314 revealed they had just changed Resident #78's incontinence brief and Resident #78 was drenched with urine and needed to have his entire bed linens changed because all the linens including two blankets were saturated with urine. Nurse #216 stated it was very evident STNA #312 did nothing on night shift. Observation on 05/30/23 at 9:30 A.M. of Resident #78's bed linens and incontinence brief revealed Resident #78's gown, two bath blankets, fitted sheet, and incontinence brief were soaked with urine. Review of facility policy titled Incontinence Care, reviewed 06/08/22, revealed the purpose was to keep skin clean, dry, free from irritation and odors, to identify skin problems as soon as possible so treatment could be started, and to prevent skin breakdown and infection. This deficiency represents non-compliance investigated under Complaint Number OH00142518.

Based on medical record review, staff interview, and policy review, the facility failed to ensure care plans were revised after new fall interventions were implemented. This affected one Resident (#88) out of three residents reviewed for falls. The facility census was 86. Findings include: Review of the medical record for Resident #88 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included chronic kidney disease, depression, diabetes, hypertension, and sleep apnea. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 04/22/23, revealed Resident #88 had intact cognition. She required extensive assistance of two people for transfers and toilet use, and limited assistance of one person for transfers, dressing and hygiene. She had one fall in the past month and none since her admission to the facility. Review of a progress note, dated 05/03/23, revealed Resident #88 was found on the floor on her side and stated she fell trying to get to the bathroom. Review of Resident #88's fall review, dated 05/03/23, revealed Resident #88's fall interventions included keeping items within reach, a low bed, an alarm to her bed, and education about call light usage. Review of Resident #88's care plan, dated 04/15/23, revealed the resident was at risk for falls due to weakness and unsteady gait. Interventions included common items being in reach, encouraging call light use and therapy and treatment as needed. There was no evidence the use of a low bed or bed alarm were included in the care plan. Interview with the Director of Nursing (DON) on 05/23/23 at 11:35 A.M. verified Resident #88's care plan was not updated to reflect the current fall interventions which included the use of a low bed and bed alarm. Review of the facility policy titled Falls - Clinical Protocol, dated 06/08/22, revealed the care plan would be reviewed and revised after a fall as needed.

Based on medical record review and staff interview, the facility failed to ensure falls were thoroughly investigated to determine the root cause of the fall and whether interventions were in place at the time of the fall. This affected one (Resident #87) of three residents reviewed for falls. The facility census was 86. Findings include: Review of the medical record for Resident #87 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included alcohol abuse, orthostatic hypotension, and respiratory failure. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 05/04/23, revealed Resident #87 was rarely or never understood. He required extensive assistance of one person for bed mobility, dressing and hygiene, and limited assistance of one person for toilet use. Review of the care plan, dated 04/22/23, revealed Resident #87 was at risk for falls due to weakness and cognitive deficits. Interventions included keeping his bed in a low position, commonly used articles to be in reach, and reinforcing the need to call for assistance. Review of a progress note, dated 04/23/23, revealed the resident was found on the floor in his room. He stated he fell while trying to get up. He was assisted back to bed. Resident #87 had an open area to his head from the fall. Review of the fall investigation, dated 04/24/23, revealed the fall investigation did not thoroughly investigate the root cause of Resident #87's fall on 04/23/23 and did not include information as to whether all of Resident #87's fall interventions were in place at the time of the fall including whether the bed was in a low position and the call light was in reach at the time of the fall. Interview on 05/25/23 at 5:12 P.M. with the Director of Nursing (DON) confirmed the investigation for Resident #87's fall on 04/23/23 was provided in its entirety and there was no evidence the facility thoroughly investigated the root cause of the fall and whether all of Resident #87's fall interventions were in place during the fall. This deficiency represents non-compliance investigated under Complaint Number OH00142518.

Based on medical record review, staff interview, and policy review, the facility failed to ensure residents who required staff assistance with bathing were bathed as scheduled/requested. This affected two (Resident #41 and #78) of three residents reviewed for Activities of Daily Living (ADL)'s. The facility identified 52 residents who needed assistance with showers. The facility census was 86. Findings include: 1. Review of the medical record for Resident #41 revealed an admitted [DATE]. Diagnoses included depression, chronic obstructive pulmonary disease, hyperlipidemia, and atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/29/23, revealed Resident #41 required extensive assistance of two people for bed mobility, toilet use and hygiene, and required extensive assistance of one person for dressing. Resident #41 required assistance with bathing. The assessment indicated it was very important for Resident #41 to choose between a bed bath, tub bath and shower. Review of the care plan dated 03/30/23 revealed Resident #41 had a self-care deficit related to physical limitations. Interventions included assistance with bathing/showering as needed. Review of the shower schedule revealed Resident #41 was supposed to receive a shower on Wednesdays and Saturdays on first shift. Review of the State tested Nurses Aide (STNA) tasks, dated 05/02/22 through 05/21/23, revealed Resident #41 had a shower on 05/16/23. There was no evidence Resident #41 received additional showers during this timeframe outside of 05/16/23. 2. Review of the medical record for Resident #78 revealed an admitted [DATE]. Diagnoses included heart failure, diabetes, obesity and skin cancer. Review of the comprehensive MDS assessment, dated 05/13/23, revealed Resident #78 had moderately impaired cognition. He required extensive assistance of one person for bed mobility, transfers, dressing and toilet use, and limited assistance of one person for hygiene. Resident #78 required physical help from one person with bathing. It was very important for him to choose between a bed bath, tub bath and shower. Review of the shower schedule revealed Resident #78 was supposed to receive a shower on Tuesday and Friday evenings. Review of the STNA tasks, dated 05/07/22 through 05/22/23, revealed Resident #78 was provided a bed bath on 05/09/23 and 05/16/23. There was no evidence a shower was provided to Resident #78 on 05/12/23 and 05/19/23. Interview with the Director of Nursing (DON) on 05/23/23 at 11:35 A.M. confirmed showers/bathing was not provided to Resident #41 and Resident #78 as scheduled. Review of the facility policy titled Bed Bath/Shower, dated 06/08/22, revealed showers would be scheduled to accommodate resident preferences and would occur at least weekly. This deficiency represents non-compliance investigated under Complaint Number OH00142518.

Based on observation and interview the facility failed to maintain a clean and sanitary environment in the kitchen. This had the potential to affect all 95 residents provided food and beverages from the facility. The facility census was 95. Findings include: Observations on 09/12/22 from 10:10 A.M. to 10:24 A.M. during the initial tour of the kitchen with Dietary Manager #458 revealed the overhead vents above the grill top were greasy and dusty as was the back ledge behind the grill top, the light bulbs above the grill top, and the fire extinguisher nozzles. Inside the microwave was dirty. The sanitizer in one of the sanitizer buckets wasn't at a high enough concentration to be effective. The sanitizer was used for wiping down the counters. The ceiling had areas that were dirty/dusty. These findings were verified by Dietary Manager #458 at the time of the observations. On 09/14/22 at 12:20 P.M. Cook #454 used a gloved hand to reach into an open bag and place hamburger buns on the resident's plates. Use of a serving utensil was required. On 09/14/22 at 12:22 P.M. Dietary Manager #458 confirmed the cook was not using a utensil for the hamburger buns.

Based on record review, observations, and interviews the facility failed to maintain a sanitary environment. This affected nine (Resident's #9, #19, #27, #32, #36, #67, #68, #69 and #81) of 51 residents residing on the 200/300 hall. The facility also failed to clean wheelchairs. This affected five (Resident's #15, #34, #56, #62 and #84) of 59 residents who utilize wheelchairs. The facility census was 95. Findings Include: 1. Review of the medical record for Resident #9 revealed an admitted [DATE]. Diagnoses included adult failure to thrive, diabetes mellitus, and major depressive disorder. Resident # 9 had intact cognition. Review of the medical record for Resident #19 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus with diabetic [CONDITION(S)] and major depressive disorder. Resident #19 had intact cognition. Review of the medical record for Resident #27 revealed an admitted [DATE]. Diagnoses included [CONDITION(S)] disorder and anxiety disorder. Resident # 27 had intact cognition. Review of the medical record for Resident #32 revealed an admitted [DATE]. Diagnoses included unspecified dementia and heart failure. Resident # 32 had impaired cognition. Review of the medical record for Resident #36 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus with diabetic polyneuropathy, falls, and anxiety disorder. Resident #36 had intact cognition. Review of the medical record for Resident #67 revealed an admitted [DATE]. Diagnoses included major depressive disorder and migraines. Resident #67 had intact cognition. Review of the medical record for Resident #68 revealed an admitted [DATE]. Diagnoses included muscle weakness and age-related cognitive decline. Resident #68 had intact cognition. Review of the medical record for Resident #69 revealed an admitted [DATE]. Diagnoses included anxiety disorder and congestive heart failure. Resident #69 had intact cognition. Review of the medical record for Resident #81 revealed an admitted [DATE]. Diagnoses included [CONDITION(S)] and unspecified dementia. Resident #81 had impaired cognition. Initial observations on 09/12/22 from 11:25 A.M. through 12:35 P.M. revealed Resident's #9, #19, #36, #68, #69 and #81's room had debris covering the floor including food and paper. Observations on 09/12/22 at 3:09 P.M. revealed rooms for Resident's #9, #19, #36, #68, #69 and #81 were still dirty. Interview on 09/14/22 at 4:30 P.M., Licensed Practical Nurse (LPN) #406 verified the rooms for Resident's #9, #19, #68 and Resident #69 were dirty. Observations on 09/12/22 at 4:42 P.M. revealed Resident's #27, #32, #36, #67 and #81 room floors had debris covering the floor including food and paper. Interview on 09/14/22 at 4:30 P.M., LPN #409 verified the rooms for Resident's #27, #32, #36, #67 and #81 remained dirty. Interview on 09/14/22 at 5:50 P.M., the Administrator stated the facility was currently looking for a housekeeping supervisor and two housekeepers. The Administrator stated she knew there were concerns with housekeeping services due to lack of staff. The Administrator stated they sometimes utilized aides to clean the rooms. 2. Observation on 09/12/22 at 2:00 P.M. during smoke break revealed five (Resident's #15, #34, #56, #62 and #84) had cigarette ashes and other debris on all horizontal surfaces of their wheelchairs. Interview on 09/12/22 at 2:05 P.M. with the Resident Assessment Coordinator (RAC) #417 and Licensed Practical Nurse (LPN) #415 confirmed Resident's #15, #34, #56, #62 and #84 had cigarette ashes and other debris on the horizonal surfaces of their wheelchairs. RAC #417 and LPN #415 revealed wheelchairs were to be cleaned on night shift and no one held night shift accountable to ensure wheelchairs were cleaned. Interview with the Administrator on 09/15/22 at 11:44 A.M. revealed housekeeping and night shift aides were to clean wheelchairs.

Based on observation, interview, and record review the facility failed to ensure call light cords were accessible to residents. This affected four residents (Resident's #20, #51, #53, and #74) of 26 residents observed for appropriate call light cord placement. The facility census was 95. Findings include: 1. Review of the medical record for Resident #20 revealed an initial admitted [DATE], and a re-admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] for Resident #20 revealed the resident had moderate to severe cognitive impairment, required assistance with daily hygiene and oral care related to [CONDITION(S)]- left sided [CONDITION(S)]. Review of the care plan for Resident #20 indicated the resident required assistance to bathe/shower, and daily hygiene, grooming, dressing, oral care, and eating as needed. The resident also required the assistance of two staff for bed mobility. Observation of Resident #20 on 09/12/22 at 12:04 P.M., the call light cord was observed hanging from the wall down to the floor, and the end of the call light was wrapped several times around the base of a pole next to the resident's bed. Interview with Licensed Practical Nurse (LPN) #408 on 09/12/22 at 12:09 P.M. confirmed the call light cord for Resident #20 was hanging from the wall to the floor and wrapped around the base of a pole next to the resident's bed. LPN #408 secured the call light to the left side of the resident's bed. Resident #20 was asked if she could access the call light cord and stated she could not. LPN #408 then re-secured the call light cord to the resident's bedding over her abdominal region. 2. Review of the medical record for Resident #51 revealed an admitted [DATE], and a re-admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS 3.0 quarterly assessment dated [DATE] for Resident #51 revealed the resident had moderate cognitive impairment, required limited to extensive assistance to complete activities of daily living related to the resident's physical limitations, impaired mobility, and pain. Review of the care plan for Resident #51 indicated the resident required the assistance of one staff for daily hygiene, grooming, dressing, oral care, and eating as needed. The resident also required assistance of two staff for transfers. Observation of Resident #51 on 09/12/22 at 12:01 P.M., the call light cord was observed hanging from the wall down to the floor. Interview with LPN #408 on 09/12/22 at 12:09 P.M. confirmed the call light cord for Resident #51 was hanging from the wall down to the floor. LPN #408 secured the call light cord to the resident's bed. Resident #51 was asked if she could access her call light cord and was able to activate the call light by pulling gently on the cord. 3. Review of the medical record for Resident #74 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS 3.0 quarterly assessment dated [DATE] revealed Resident #74 had moderate to severe cognitive impairment, had impaired memory, problem solving, judgement, and safety awareness. The MDS assessment also revealed the resident required extensive assistance for most activities of daily living related to general weakness, impaired mobility, and poor safety awareness. Review of Resident #74's care plan revealed the resident required assistance from one staff member for daily hygiene, grooming, dressing, oral care, and eating as needed. The resident required assistance of two staff for bed mobility and Hoyer (mechanical) lift transfers. Observation of Resident #74 on 09/12/22 at 2:37 P.M. revealed the call light cord was observed attached to the bedding on the left lateral side of the mattress, near the bed frame. Resident #74 was informed where his call light was located and was asked to activate the call light. Resident #74 was lying supine in the bed and attempted to roll onto his left side to access the call light cord. The resident was unable to reposition himself in the bed to reach the call light cord. Interview with Nurse Aide #434 on 09/12/22 at 2:42 P.M. confirmed the call light cord was placed on Resident #74's bed in a location not accessible to the resident. Nurse Aide #434 repositioned and reattached the call light cord on Resident #74's bedding near the right side of his chest. Resident #74 was informed where the call light cord was positioned and was asked if he was able to pull the call light cord. The resident was able to locate and pull the call light cord to activate the call light. 4. Review of medical record for Resident #53 revealed an admitted [DATE] and a readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS 3.0 quarterly assessment dated [DATE] for Resident #53 revealed the resident was rarely/never understood, required extensive assistance to complete activities of daily living. Review of Resident #53's care plan dated 09/09/22 revealed the resident had expressed interest in some activities but preferred to stay in bed for comfort. The resident required assistance of two staff for mobility, transfers with use of a Hoyer lift, locomotion, dressing, toileting, and hygiene. Observation of Resident #53 on 09/12/22 at 2:37 P.M. revealed the call light cord was observed hanging from the wall down to the floor. Interview with Nurse Aide #434 on 09/12/22 at 2:42 P.M. confirmed the call light cord for Resident #53 was hanging from the wall down to the floor. Nurse Aide #434 secured the call light cord to the resident's bedding near his chest. Resident #53 was asked if he was able to access the call light cord. The resident was not able to perform this task during the interview.

Based on record review, observations, and interviews the facility failed to date and or document name on insulin vials/Kwik pens after opening. This affected six (Resident's #9, #18, #19, #36, #37 and #55) of 12 residents who required insulin. The facility census was 95. Findings include: 1. Review of the medical record for Resident #9 revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Review of the medical record for Resident #18 revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Review of the medical record for Resident #19 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #19 had intact cognition. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Review of the medical record for Resident #37 revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations on 09/14/22 at 11:33 A.M. revealed opened vials and used Kwik pens that were not dated, two Kwik pens had no name or date. Interview immediately after observations, Licensed Practical Nurse (LPN) #412 verified the findings. 5. Review of the medical record for Resident #36 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 36 had intact cognition. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 6. Review of the medical record for Resident #55 revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 55 had intact cognition. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations on 09/14/22 at 11:47 A.M. revealed four used Kwik pens that were not dated. Interview immediately after observations, LPN #410 verified the findings.

Based on record review, interview, and review of shower sheets revealed the facility failed to provide showers/bed baths as preferred. This affected two (Resident's #19 and #80) of five residents reviewed for showers. The facility census was 95. Findings include: 1. Review of the medical record for Resident #19 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #19 had intact cognition. Interview on 09/12/22 at 10:20 A.M., Resident #19 stated she does not receive showers on a regular basis. Review of the shower sheets revealed Resident #19 received five showers in August and September 2022. Staff did not provide any documented evidence indicating the resident refused showers. Review of progress notes revealed no documented evidence related to Resident #19 refusing showers. 2. Review of the medical record for Resident #80 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #19 had intact cognition. Review of the shower sheets revealed Resident #80 received five showers in August and September 2022. Interview on 09/15/22 at 11:45 A.M., the Charge Nurse #405 verified the missing documentation indicating the residents received showers as preferred.

Based on record review, self-reported incident (SRI) review, and interview the facility failed to secure narcotics to prevent misappropriation. This affected two (Resident's #85 and #291) of 31 residents receiving narcotic medications. The facility census was 95. Findings include: 1. Review of the medical record for Resident #85 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #85 had intact cognition. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of SRI tracking number (#) 0 dated 04/05/22 revealed facility staff observed two missing narcotic cards holding 30 pills of [MEDICATION(S)] 5 milligrams (mg). Two staff were counting the narcotics at shift change when the missing medications were revealed. Staff contacted the Director of Nursing (DON), and the facility initiated an investigation. 2. Review of the medical record for Resident #291 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #291 had intact cognition. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of SRI # 7 dated 04/05/22 revealed facility staff observed one missing narcotic card holding 30 pills of [MEDICATION(S)] 5 mg. Two staff were counting the narcotics at shift change when the missing medications were revealed. Staff contacted the DON, and the facility initiated an investigation. The first shift nurse Alleged Perpetrator (AP) #600 left the facility without speaking with the unit managers. Interview on 09/13/22 at 10:50 A.M., the DON stated the narcotic medications for Resident #85 were discontinued on 02/20/22; however, staff did not remove the narcotic cards from the narcotic box until 04/05/22. The medications for Resident #291 were current due to physician order.

Based on observation, interview, record review, review of the facility self-reported incident (SRI), and review of the facility policy the facility failed to ensure staff to resident verbal abuse did not occur. This affected one (Resident #50) of three residents reviewed for abuse. The facility census was 95. Findings include: Review of Resident #50's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #50's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #50 was cognitively intact and required extensive assistance of one staff for toilet use. Resident #50 was occasionally incontinent of urine and always incontinent of bowel. Resident #50 answered yes when questioned regarding feeling down, depressed, or hopeless, and had trouble falling or staying asleep, or sleeping too much. Review of Resident #50's care plan dated 08/11/22 included Resident #50 had bowel incontinence related to impaired mobility, impaired cognition, behaviors, and use of stool softeners. Interventions included Resident #50 would be maintained in as clean and dry dignified state as possible. Review of Resident #50's progress notes on 08/21/22 at 8:22 P.M. authored by Licensed Practical Nurse (LPN) #504 stated around 6:45 P.M. Resident #50 opened the door to his room. There was copious amount of bowel movement smeared all over the floor. Resident #50 went through his feces spreading it along down the hall, then he covered some of the feces with towels. When the nurse asked what happened, Resident #50 stated, I had an accident. I had a diarrhea. The feces didn't have a loose consistency. The incident was repetitive (the second day on a row), and the resident didn't have any sense of wrongdoing. Review of the facility SRI tracking number 0, dated 08/21/22, included the second shift nurse (LPN #409) reported that a third shift nurse (Registered Nurse (RN) #402) verbally abused Resident #50. The Administrator received a message that LPN #409 wanted to report that RN #402 was verbally abusive to Resident #50 after he had an accident with bodily fluids. Review of the Witness Statement for RN #402, dated 08/24/22, revealed she thought she needed to contact a lawyer and would call back to provide a statement. Review of the Witness Statement for State tested Nurse Aide (STNA) #425, dated 08/22/22 at 12:16 A.M., stated she arrived for work at 11:00 P.M. and was told by the second shift staff there was a mess in Resident #50's room. STNA #425 wrote there was feces all over Resident #50's room, including the walls and hall, on his wheelchair and on his person. STNA #425 stated RN #402 and I got upset and we can't leave patient room that way, and where is patient supposed to sleep? Resident #50 was told to wait in the hall numerous times while his room was being cleaned. Review of the Witness Statement for LPN #409, dated 08/24/22, stated she heard RN #402 tell Resident #50 his room was disgusting, and Resident #50 responded you are not my mom. RN #402 responded I am glad I am not your mom because your mom wouldn't want to clean up after you. RN #402 told Resident #50 he needed to stay in his room. LPN #409 heard RN #402 continuously talking over Resident #50 while he was trying to talk to her. RN #402 kept saying OK goodnight over and over. Observation on 09/15/22 at 10:30 A.M. of Resident #50 revealed he was sitting in a wheelchair near the nurse's station. Resident #50 was pleasant and answered questions. Resident #50 stated he did not remember any staff members talking to him in a rude manner. Interview on 09/15/22 at 2:06 P.M. with the Administrator revealed on 08/21/22 an incident occurred around the time of the transition from second shift to third shift. Resident #50 had an accident around 11:00 P.M. and the second shift STNA stated to leave the feces which was all over the bathroom and Resident #50's room for the day shift to clean up. The Administrator stated RN #402 was upset the STNA said to wait for day shift to clean up Resident #50's room, got loud, and stated we are not going to do that, the bowel movement needs cleaned now. RN #402 was yelling at the staff because she was upset, and LPN #409 thought RN #402 was yelling at Resident #50. The Administrator stated the statements from other staff members who were present during the incident did not indicated RN #402 was inappropriate towards Resident #50. The Administrator stated Resident #50 did not state RN #402 was mean or rude to him. Interview on 09/15/22 at 2:37 P.M. with LPN #504 revealed on 08/21/22 she worked second shift and Resident #50 had a bowel movement, and it was smeared all over the toilet bowl, the bathroom, and Resident #50's room including the floor. LPN #504 stated when the bathroom door opened it further smeared the bowel movement on the floor. LPN #504 stated Resident #50 covered the bowel movement with towels. LPN #504 stated after Resident #50 had the bowel movement he left his room and went to the dining room and bowel movement was noted on the floor in the hall. LPN #504 indicated she could not remember for sure but thought Resident #50 had the accident between 7:00 P.M. and 10:00 P.M. LPN #504 stated the second shift staff covered the bowel movement with towels but did not clean the bowel movement from the bathroom. LPN #504 stated I cannot say we cleaned everything, no we did not. LPN #504 indicated the bowel movement was noted on Resident #50's bed also. LPN #504 revealed 08/21/22 was a very busy night, there was not enough staff, and the residents residing on the hall Resident #50 resided on required a lot of help. LPN #504 stated she did not know who was going to clean up the mess and if it was going to be like that all night. Interview on 09/15/22 at 3:00 P.M. with LPN #409 revealed on 08/21/22 Resident #50 was in the hall and LPN #409 stated she heard RN #402 say she did not want Resident #50 out of his room. LPN #409 indicated RN #402 did not like Resident #50 out of his room because he gets on her nerves. LPN #409 stated she heard RN #402 tell Resident #50 she did not want to see him out here, she told him his room was disgusting, and Resident #50 stated well you are not my mother. RN #402 said I am glad I am not your mother, and your mother would not want to clean up after you. LPN #409 stated she felt bad for Resident #50 and heard STNA #425 tell Resident #50 he better go to his room because he knew how RN #402 was when he was out in the hall. LPN #409 stated STNA #512 was standing at the desk acting like it was ok for Resident #50 to be talked to that way. LPN #409 stated RN #402 was mad at Resident #50. LPN #409 stated a week earlier RN #402 told Resident #50 to go to his room, he was trying to talk to her, and RN #402 kept saying OK goodnight like ten times, like what he was saying did not mean anything, and get in your room I don't want to see you the rest of the shift. Interview on 09/15/22 at 3:10 P.M. with LPN #406 indicated LPN #406 could not remember the date but LPN #406 heard RN #402 very loudly talking to Resident #50 in a rude way and telling Resident #50 to go, go, go to your room, go, go. Interview on 09/16/22 at 11:50 A.M. with RN #402 revealed on 08/21/22 she cleaned up the mess from Resident #50 but did not remember anything else. Review of the facility policy titled Abuse, Neglect, and Intimate Partner Violence Inservice, dated 01/2019, included verbal abuse was defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability. It was the responsibility of every employee to be aware of possible signs of abuse and neglect and report concerns or suspicions to the supervisor immediately.

Based on record review, interviews with staff and review of the facility fall investigation, the facility failed to provide adequate staff assistance with bed mobility to prevent the fall of Resident #100, who required assistance of two staff with bed mobility. The facility failed to have an accurate Kardex and care plan indicating the resident required two staff assist to prevent falls. Actual Harm occurred on [DATE] when Resident #100 rolled out of bed onto the floor while being assisted by one staff member with bed mobility during incontinence care and sustained fractures of the right humerus and pelvis and expired in the facility on [DATE]. This affected one (Resident #100) of three residents reviewed for falls. The facility census was 99. Findings include: Review of the medical record revealed Resident #100 was admitted to the facility on [DATE] with diagnoses including hypertensive heart and [CONDITION(S)] with heart failure, congestive heart failure, chronic pain, [CONDITION(S)] heart disease of native coronary artery without [CONDITION(S)] pectoris, peripheral vascular disease, diabetes mellitus type two, and agoraphobia with panic disorder. The resident expired on [DATE]. Review of the Medicare Quarterly Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed the resident had intact cognition. The resident required extensive two staff assistance for bed mobility, dressing, and toileting and was dependent for transfers. The assessment indicated the resident was always incontinent of bowel and bladder. Review of the plan of care, dated [DATE], revealed the resident had a self-care deficit, received hospice care due to terminal illness of end stage congestive heart failure and [CONDITION(S)], and was at risk for falls due to weakness and impaired mobility. Interventions included to assist with daily hygiene, grooming, dressing, oral care and eating as needed; assist to reposition; to break activities of daily living (ADL) tasks into sub-tasks for easier patient performance; to reinforce need to call for assistance; to have commonly used articles within easy reach; to collaborate care with hospice; and on [DATE] after the resident fell , bed mobility was initiated to two staff assistance. The plan of care did not specify the number of staff assistance required prior to the fall. Review of the weight record, dated [DATE], revealed the resident weighed 290 pounds. Review of the fall risk assessment, completed [DATE], revealed the resident was at risk for falls. There was no fall risk assessment documented prior to [DATE]. Review of the resident Kardex, dated [DATE], revealed Resident #100 was a fall risk and required two staff assistance for bed mobility. There was no Kardex available for review prior to Resident #100's fall on [DATE]. Review of progress note, dated [DATE] at 3:16 A.M., revealed at 2:00 A.M. Resident #100 was being changed and fell out of bed after State tested Nurse Aide (STNA) #122 turned the resident over and asked the resident to turn back to the other side and lost her grip. The resident complained of intense pain to the right shoulder, right hand, right wrist and had low mobility to the right hand, bruises to the right anterior neck and right arm. Review of the imaging test results, dated [DATE] at 7:36 A.M., confirmed an acute displaced comminuted right proximal humeral fracture. Review of the progress note, dated [DATE] at 9:15 A.M., revealed Resident #100 refused to receive hospital treatment, and hospice services were notified. The resident made continued complaints of pain to the right shoulder. Review of the progress note, dated [DATE] at 2:04 P.M., revealed the facility placed an order for a bariatric bed with an air mattress. Review of the progress note for patient safety, dated [DATE] at 3:41 P.M., revealed Resident #100 rolled out of bed while performing incontinence care. The resident complained of pain to the right shoulder, right wrist, and right hand. The care plan was updated for two staff assistance with bed mobility, and a new bed was ordered. Review of the progress note, dated [DATE] at 5:40 P.M., revealed Resident #100 was medicated throughout the shift for right arm pain, an arm sling was ordered, and the resident received incontinence care with three staff assistance. Review of the progress notes, dated [DATE], revealed Resident #100 agreed for transfer to the hospital after complaints of severe pain and several emesis throughout the prior night, upon return from the hospital, it was reported the resident had a fractured shoulder and pelvis from the fall, but the resident refused surgical intervention and stated she wanted no life saving measures, only comfort measures. Review of the hospital emergency department discharge information, dated [DATE], revealed Resident #100 had a right humeral neck fracture which required a sling and a possible pelvic fracture which required a follow-up with outpatient orthopedics. Review of the progress note, dated [DATE] at 7:04 A.M., revealed Resident #100 was medicated for pain and nausea, was diagnosed with a right pelvis fracture, and denied surgical intervention. Review of progress note, dated [DATE] at 10:23 A.M., revealed Resident #100 expired in the facility. Review of the facility fall investigation for Resident #100, dated [DATE], revealed the Director of Nursing (DON) was notified of the fall on [DATE] and throughout investigation it was noted that the plan of care was not followed by the STNA resulting in a fall with injury; drill down as to reason for the failure to follow plan of care noted that the STNA did not view the patients Kardex to determine care needs and level of assistance. The Administrator was notified of the fall and lack of following the plan of care on [DATE]. The facility held a quality assurance meeting on [DATE] regarding failure to follow plan of care resulting in a fall with injury. The DON and Unit Managers initiated an audit of patient Kardex to ensure the appropriate level of assistance with bed mobility was identified. Review of facility fall investigation witness statement of Resident #100 revealed while STNA #122 was providing incontinence care, her grip slipped, and her leg fell over the bed and pulled her off onto the floor. Review of facility fall investigation witness statement of STNA #122 revealed Resident #100 was laying on her left side to receive incontinence care. Upon requesting the resident to roll to the right toward STNA #122, Resident #100 lost her grip on the left side of the bed and rolled forward off the left side of the bed onto the floor. Review of the facility fall Investigation Report, dated [DATE], revealed Resident #100 rolled out of bed during care at approximately 2:00 A.M. on [DATE], and the conclusion of the investigation was resident sustain a fall with injury related to rolling out of bed; throughout the investigation it was noted that the STNA did not follow the plan of care related to lack of reviewing the Kardex to determine the resident's level of care needs. Interview on [DATE] at 9:49 A.M. with the DON confirmed Resident #100 fell out of bed on [DATE] while being assisted with bed mobility during incontinence care by STNA #122. The DON verified after the fall investigation, it was concluded STNA #122 was at fault for not viewing the care plan or the resident Kardex information for bed mobility. The DON stated Resident #100's Kardex information at the time of the fall was no longer available for review but the current Kardex on file was updated to reflect the required two staff assistance for bed mobility. The DON confirmed Resident #100 was in bed on the left side without a transfer bar to hold, just the mattress; STNA #122 was also on the left side of the bed providing incontinence care then walked over to the right side of the bed; STNA #122 reached over the resident to pull the resident toward the STNA when Resident #100's hands slipped off the mattress and the weight of the resident's legs caused the resident to fall away from the STNA toward the left of the bed onto the floor. The DON verified Resident #100 refused several times to be transferred to the hospital until [DATE] when the pain was difficult to manage, and confirmed after an in-house x-ray and hospital testing, Resident #100 had a right humerus and pelvic fracture. Interview on [DATE] at 11:01 A.M. with Registered Nurse (RN) #119 verified Resident #100 required two staff assistance with bed mobility for safety and confirmed as a performance improvement plan, education was initiated to nursing staff on providing appropriate bed mobility assistance. Interview on [DATE] at 11:08 A.M. with RN #108 confirmed Resident #100 was extensive two staff assistance for all ADL including bed mobility, and indicated staff located ADL assistance either on the care plan or the resident Kardex which was generated from the care plan and could include additional information added by nursing staff. RN #108 verified Resident #100's care plan did not specify the required staff assistance needed for safe bed mobility assistance which would have transferred to Resident #100's Kardex for staff to reference, and stated it was a problem. RN #108 confirmed the care plan was updated on [DATE] with the required two staff assistance for bed mobility after Resident #100's fall. Interview on [DATE] at 11:38 A.M. with the Administrator verified the DON was the lead investigator for Resident #100's fall and indicated not knowing it was determined STNA #122 had improperly provided bed mobility assistance to Resident #100. Interview on [DATE] at 12:01 P.M. with STNA #39 confirmed Resident #100 required two staff assistance for bed mobility due to the size of the resident and stated it was not safe to move the resident alone. STNA #39 indicated Resident #100 did not have a bar to hold on to, just the edge of the mattress, and the resident Kardex was used to reference the required staff assistance for ADL. Interview on [DATE] at 3:22 P.M. with the DON confirmed there was no fall risk assessments for Resident #100 completed prior to the fall which occurred on [DATE] and stated fall risk assessments were not completed on admission unless residents had a history of falls or a change in condition. This deficiency substantiates Complaint Number OH 217.

Based on record review and staff interview, the facility failed to ensure proper technique was followed to place a peripherally inserted central catheter (PICC line) for one resident (Resident #111) with contractures. Actual Harm occurred when Resident #111 sustained a fractured humerus during the placement of a PICC line. This affected one of two residents reviewed for injuries. Findings include: Review of the medical record revealed Resident #111 was admitted to the facility on [DATE] and re-admitted on [DATE]. [DIAGNOSES REDACTED]. Resident #111 was assessed on the Minimum Data Set (MDS) assessment dated [DATE] as being totally dependent for locomotion, dressing, eating, personal hygiene and bathing, required the extensive assistance of two persons for bed mobility, transfers, and toilet use, and had functional impairment for range of motion with a limitation that interfered with daily functions or placed the resident at risk of injury. Impairment was on both upper extremities (shoulder, elbow, wrist, hand) and both lower extremities (hip, knee, ankle, foot). On 03/19/18 there was a positive urinalysis that indicated a urinary tract infection [MEDICAL CONDITION]. The physician ordered [MEDICATION NAME] antibiotic 500-125 milligrams (mg) via peg tube twice daily for seven days. After the physician reviewed the culture and sensitivity results on 03/20/18 the [MEDICATION NAME] was discontinued and there was a new order for intravenous (IV) [MEDICATION NAME] 2-0.25gram (gm)/50milliters (ml). Use 50 ml IV every eight hours for UTI for seven days. A progress note dated 03/20/18 at 8:03 P.M. indicated the facility's registered nurse (RN) was unable to place an IV because of the resident's hand and arm contractures. The Merriam-Webster dictionary defined contracture as a permanent shortening (as of muscle, tendon, or scar tissue) producing deformity or distortion. The physician was notified and ordered a PICC line. The facility notified an outside company who would come out to place the line the morning of 03/21/18. The PICC line was placed the morning of 03/21/18 and antibiotic therapy was initiated. A progress note dated 03/23/18 at 2:46 P.M. documented Resident #111 had swelling to the right elbow, bruising to the right elbow and forearm, and facial grimace with assessment of shoulder. The physician was notified and ordered an x-ray. An x-ray obtained 03/23/18 indicated a recent fracture involving right humeral neck (upper arm) with moderate displacement and angulation. Review of the statement obtained from Licensed Practical Nurse (LPN) #1 in regard to the incident revealed she noticed there was bruising and swelling on the right arm. The bruising was where the PICC line was inserted on the inside of the upper arm and around the elbow. The swelling was in the elbow area and the area was warm to the touch. LPN #1 had RN #5 assess the resident. RN #5 called the Director of Nursing (DON) who also assessed Resident #111. LPN #1 notified Resident #111's physician who ordered an x-ray. LPN #1 wrote that as she helped support Resident #111's arm during the PICC line insertion, the outside company's nurse, RN #4, placed the sterile field over them. Resident #111 pulled her arm towards her body and LPN #1 did not resist the movement and moved toward the resident's body. RN #4 immediately directed LPN #1 to move the arm more away from her body because he could not get to the site he needed. RN #4 then repositioned Resident #111's arm by pushing her arm away from her body. On 04/02/18 at 11:00 A.M. the surveyor interviewed LPN #1, who cared for Resident #111 on 03/21/18. LPN #1 stated RN #4 arrived at the facility on 03/21/18 to place the PICC line for Resident #111. RN #4 was in Resident #111's room for approximately 30 minutes, came to the nurses' station, informed LPN #1 he was unable to place the PICC line, and asked for assistance. LPN #1 entered Resident #111's room and stated her arm was out, away from her body and on the mattress. LPN #1 stated she had never seen Resident #111's arm out that far from her body. LPN #1 stated Resident #111's arm was usually significantly contracted and was always touching her body. LPN #1 stated the arm was positioned as if the resident raised it and was waving to someone. LPN #1 stated she helped support the arm and could feel Resident #111 pull the arm toward her body. LPN #1 stated the arm was in a position that she would have not thought possible for this resident. On 04/0218 at 11:38 A.M. the surveyor interviewed the unit manager, RN #2, on Resident #111's unit. RN #2 stated it was not possible to extend Resident #111's arm to allow PICC access without sustaining a fracture. RN #2 stated Resident #111's contractures were significant and her upper arms always touched her body. On 04/02/18 at 11:44 A.M. the Administrator stated the facility was still waiting for the statement about the incident from RN #4. The above was verified with the Administrator on 04/02/18 at 3:50 P.M. This deficiency substantiates Complaint Number OH 071 and Master Complaint Number OH 111.

Based on observation, record review and resident and staff interview, the facility failed to provide adaptive equipment for drinking per plan of care. This resulted in Actual Harm when Resident #9 spilled a staff-provided styrofoam cup of hot tea and sustained third degree burns on her shoulder and back. This affected one (Resident #9) of two residents reviewed with the [DIAGNOSES REDACTED]. Findings include: Review of the medical record revealed Resident #9 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Nutrition/Hydration care plan dated 12/05/15 identified the intervention for a sippy cup for adaptive equipment. A sippy cup is a firm cup with a lid, spout and place for straw. Review of nurses notes for December 2016 did not document the resident was noncompliant with using the adaptive sippy cup. Review of the facility investigation documented on 12/30/16 Resident #9 sustained a third degree burn to the right rear shoulder area. Resident #9 had requested a cup of hot tea, and staff provided the tea in a styrofoam cup with a lid. Review of the investigation dated 01/02/17 - 02/01/17 documented on 12/30/16 at approximately 8:00 P.M. the resident asked for a cup of tea. State tested Nurse Aide (STNA) #17 went to the dining room, obtained a styrofoam cup and got hot water from the Starbucks machine. She made the tea per resident's request. She placed a lid on the cup and went directly back to the resident's room. She placed the cup of hot tea on Resident's #9's bedside table. The aide talked with the resident for a minute and then left the room. On 12/30/16 at approximately 8:05 P.M. the resident took the cup that she noticed was smaller than the cups she had previously used and set the cup down next to her on the clinitron mattress. The lid came off the cup and it spilled on her sheets and on her gown. She stated the hot tea did not directly hit her skin but her sheets and gown were all wet. She then put on the call light and it took a while for staff to come in. On 12/30/16 at approximately 8:30 P.M. staff saw Resident #9's call light on. STNA #17 went into the room and the resident stated her tea spilled and she needed changed. The resident did not seem to be in any pain. The STNA went out and got assistance from STNA #18. STNA #18 noticed a red area on the resident's right upper back. STNA #17 stayed in the room with the resident and STNA #18 went out and reported to the nurse on the unit what he had observed. A complete gown and bed change was done. During this time the resident verbalized no complaints of pain to either of the STNAs. On 12/30/16 at approximately 8:35 - 8:45 P.M., Licensed Practical Nurse (LPN) #20 on the unit was made aware that the resident spilled hot tea while in her bed. LPN #20 assessed the resident's skin and noted red peeling skin and water blisters. LPN #20 then notified the shift supervisor, Registered Nurse (RN) #21. RN #21 and LPN #20 went into the resident's room and evaluated the resident's skin. RN #20 indicated there was a red area on the resident's right shoulder and it had peeled slightly. It looked like a blister may have broken. LPN #20 was directed to call the physician. On 12/30/16 approximately 9 P.M. - 9:30 P.M. LPN #20 notified the physician. Instructions were given to contact the wound team, clean the area, apply bacitracin and cover with a bandage and have the Certified Nurse Practitioner (CNP) evaluate the area in the morning. RN #21 and LPN #20 completed the treatment that evening. Review of the CNP's wound progress notes dated 12/31/16 at 1:17 P.M. documented Resident #9's chief complaint of hot water/tea burns, multiple sclerosis. The note indicated the burn covered a large area of the resident's right side, back and upper back/shoulder regions. The area was reddened with large blisters. The resident had multiple sclerosis so had decreased mobility and flexion. Under Musculoskeletal, the resident was documented to have decreased range of motion, myalgia and arthralgia. Under Neurological she was documented to have paresis, numbness and decreased sensitivity. Plan for wound treatment of [REDACTED]. Review of the nurse's note dated 01/01/17 at 2:39 P.M., revealed the pharmacy noted an allergy to silver sulfadiazine cream, so the unit nurse called and left a message for the physician regarding the allergy to silver sulfadiazine cream. The physician stated to call the pharmacy and ask for a replacement. Pharmacy changed the ointment to bacitracin ointment. The resident was notified. Review of the Eating/Swallowing care plan revealed on 01/03/17, the intervention to provide beverages hot/cold in personal cup with lid and straw was added. Also on 01/03/17, the STNA care plan was updated with the interventions of staff assist with feeding due to fine motor control impairments, provide beverages hot/cold in personal cup with lid and straw, and encourage compliance. Review of the nurse's note dated 01/04/17 at 1:30 P.M. revealed the wound to the back shoulder was evaluated by the the wound doctor/plastic surgeon. Review of the physician's progress notes documented on 01/04/17 a new burn from tea. Right posterior shoulder, area measured 5 centimeters (cm) by 10.5 cm by 0.1 cm, third degree burn, surrounding [DIAGNOSES REDACTED] peeling. Santyl and allevyn was recommended to the area daily. The resident's sister was updated. Review of physician progress notes [REDACTED]. Interview with STNA #17 on 02/01/17 at 5:15 P.M. indicated Resident #9 required to be fed but she has not fed Resident #9 in the past. She indicated the resident could drink fluids herself. She indicated on 12/30/16 around 8:00 P.M. she made Resident #9 a cup of hot tea with honey and lemon at the resident's request. She indicated she put it in a Styrofoam cup with a lid. She then took the cup of hot tea to Resident #9's room and left it on the bedside table. She indicated she talked to Resident #9 for about a minute and then left. She said she did not tell the resident the tea was hot. She said around 8:30 P.M. she saw the call light on and responded. The resident told her the tea had spilled. She went to get STNA #18 to assist changing the resident. STNA #18 noticed the resident's back was red. STNA #17 remained with the resident while STNA #18 went to get the nurse. They then did a gown and linen change for Resident #9. Interview with Resident #9 on 02/02/17 at 10:00 A.M. indicated she drank out of a large cup with handle and lid until it broke some time ago. She indicated she then used Styrofoam cups with a lid and straw for hot and cold drinks. She indicated she has not had a problem using the Styrofoam cups with lids in the past. On 12/30/16 she waited about five minutes after STNA #17 left the Styrofoam cup with lid on the bedside table to pick it up. She was unsure of the size of the cup. She placed the cup of tea next to her body on the clinitron bed. She indicated the lid came off the cup and spilled onto the sheets and her gown. She indicated the tea was hot. She indicated she turned the call light on and waited a while before it was answered. She indicated she now used the adaptive cups provided at meal times. She indicated a plastic water container with lid and straw was provided to her but it was too heavy to pick up and it did not have a handle for her to hold. Interview with RN #2 on 02/02/17 at 10:30 A.M. indicated Resident #9 was noncompliant with the adaptive sippy cup which was provided at mealtimes on her tray. She indicated the resident did not keep one at the bedside for drinking during the day. She indicated the resident had a personal cup with a lid but that broke but was unable to give time frame that it broke. She said she replaced the personal cup after the incident of 12/30/16. She said Resident #9 had not told her the personal cup with lid was too heavy for her to use. RN #2 said the STNA care tracker (STNA care plan) was updated after the incident to identify to use the personal cup with lid for the resident's liquids. Review of the care plan with RN #2 verified that the care plan under noncompliance did not identify the resident was noncompliant with using the adaptive cup. RN #2 said that STNA #17 received information on Hot Beverage Safety and signed it was received. She indicated she verbally reviewed the information with STNA #18. However, an inservice was not held with all staff. On 02/01/17 at 6:30 P.M., Resident #9 was up in a motorized wheelchair. She carried a styrofoam cup, with a towel wrapped around it. She indicated she was drinking coca cola. Observation of her dinner tray revealed a sippy cup was supplied. On 02/02/17 at 8:30 A.M., Resident #9 was observed at breakfast. Staff was feeding her. She had a sippy cup with coffee and cream in it on her tray. There was a straw in the middle of the cup. Staff held the cup for her to drink. She had a large personal cup that held 500 cubic centimeters of fluid. The resident said the personal cup was too heavy for her to use. This deficiency substantiates Complaint Number OH 077.

Based on record review and staff interview, the facility failed to properly transfer a resident who required the use of a two person mechanical lift (Hoyer Maxi lift). This resulted in Actual Harm when Resident #27 sustained fractured femurs of both legs. This affected one (Resident #27) of 32 residents in the facility who required mechanical lift transfers. Findings include: Review of the medical record revealed Resident #27 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was assessed on the Minimum Data Set (MDS) 3.0 dated 01/03/16 to require extensive assistance of two persons for bed mobility. Review of a care plan dated 01/14/16 that addressed the resident's impaired mobility listed an intervention of transfers using mechanical lift. Review of a bedside/Kardex report (a tool used by the nurse's aides to refer to a resident's care needs), undated, documented that Resident #27 was to use a two person assist maxi lift (a mechanical lift) for transfers. Review of a General Progress Note dated 02/23/16 at 6:24 P.M. documented Resident #27's right knee was swollen and the resident complained of mild pain. Review of a General Progress Note dated 02/23/16 at 10:06 P.M. documented the state tested nurse aide (STNA) noted a swollen right knee. An x-ray was done per doctor order. The right leg X-ray showed an acute fracture involving the right leg. The physician was notified and ordered Resident #27 sent to the emergency room . Resident #27 was admitted to the hospital. Review of a hospital note dated 02/24/16 indicated Resident #27 was in the intensive care unit with [DIAGNOSES REDACTED]. On 02/29/16 at 11:45 A.M. the facility assistant administrator (AA) stated that on 02/23/16 Resident #27 was noted to have a swollen right knee. An X-ray was ordered which indicated a fractured femur. The resident was sent to the hospital. The AA stated that he went to the hospital and met with the resident's family who informed him that the resident had bilateral fractured femurs. A thorough investigation was done which revealed that on the day before the fractured femur was found, there were two transfer incidents which caused concern. On 02/22/16 two male staff members, STNA #1 and Licensed Practical Nurse (LPN) #2 transferred Resident #27 using a two person arm and arm transfer, rather than using a Hoyer/maxi lift (a mechanical lift that lifts a patient in a sling for transfer). Resident #27 did not complain of pain before, during or after the transfer. A second transfer was done on 02/22/16 by the facility shower aide. The shower aide (STNA #3) gave a statement that she transferred the resident using a Hoyer lift with assistance from STNA #6. STNA #6 gave a statement and denied she assisted STNA #3 to transfer Resident #27 at all. STNA #3 then changed her statement and stated that she transferred Resident #27 by herself and used the Hoyer Maxi lift. A third person (unnamed) told the AA that STNA #3 told her that she transferred Resident #27 by herself and used the Sara lift ( a mechanical lift that assists a resident to stand and requires weight bearing ability and holding onto bars with the upper extremities). Review of the written employee statements revealed that STNA #3 signed a written statement on 02/24/16 that STNA #6 assisted her to get Resident #27 up for a shower and used the Maxi lift. An addendum was added on 02/26/16 that revealed STNA #6 was only present before the shower and a line was drawn through the statement that STNA #6 assisted. STNA #3 signed a statement on 02/25/16 that indicated she got Resident #27 up for a shower and used a lift by herself, but did not specify what kind of lift. STNA #3 signed a statement on 02/26/16 that she transferred Resident #27 by herself using the Maxi lift. STNA #3 stated that she did not recall having formal training in use of the lifts but had been using them and had full understanding of how to use them. The above data was verified on 02/29/16 at 1:30 P.M. by Assistant Director of Nursing (ADON) #4 and the AA. Both stated that in addition to the fractured femurs, Resident #27 had a large bruise to the left breast that was consistent with the strap on the Sara lift. A Sara lift was used only by someone who could bear weight on the legs and hold on the the bar with the upper extremities. The Sara lift was not to be used by someone who could not stand with assistance. ADON #4 stated that she tested the Sara lift herself and the strap was consistent with Resident #27's bruise and the pressure on the legs was consistent with someone who could not assist sustaining fractures. On 02/29/16 at 2:27 P.M. the surveyor interviewed the police detective from the local police department who was investigating the injuries. He stated that the injuries were consistent with improper transfer techniques and it appeared that STNA #3 transferred the resident by herself using the incorrect type of mechanical lift. This deficiency substantiated Complaint Number OH 813.

Based on record review and interview the facility failed to ensure timely and necessary care and services were provided to Resident #2 when the resident developed lower leg [MEDICAL CONDITION] which worsened. Harm occurred when Resident #2's bilateral lower extremity [MEDICAL CONDITION] was not promptly reported to any physician for six days at which time the resident was found to have multiple blood clots in his lower extremities which resulted in a hospitalization and subsequent surgery to insert an intravenous filter. This affected one resident (Resident #2) of four residents reviewed for a change in their condition. Findings include: Record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] indicated Resident had bilateral pedal [MEDICAL CONDITION] but no other specifics related to the severity of the [MEDICAL CONDITION] was documented by the nurse. The admission narrative nurse's note on 10/08/15 at 2:30 P.M. did not document any [MEDICAL CONDITION]. However, the next nurse's note on 10/08/15 at 3:26 P.M. indicated Resident #2 had 2-3+ pedal [MEDICAL CONDITION] (swelling of the feet/ankles). No [MEDICAL CONDITION] of the lower legs was specifically documented. There were no further nurse's notes documenting [MEDICAL CONDITION] until 10/10/15 at 11:14 A.M. This notes indicated Resident #2 had slight bilateral lower extremity [MEDICAL CONDITION]. On 10/11/15 at 2:26 P.M., the nurse's note indicated Resident #2 had bilateral lower extremity [MEDICAL CONDITION] with the left leg having more [MEDICAL CONDITION] than the right leg. This same information was documented in a nurse's note on 10/12/15 at 2:17 P.M. On 10/15/15 at 1:49 P.M., the nurse documented that Resident #2 had bilateral lower extremity [MEDICAL CONDITION] with the left leg having more [MEDICAL CONDITION] than the right leg. This nurse indicated she would pass on this information to the next nurse to notify the physician of the increased [MEDICAL CONDITION]. The nurse's note on 10/16/15 at 2:09 A.M. indicated the physician said she would see Resident #2 on Friday. October 16 was a Friday, so this would mean the physician visit would be a week later, the following Friday. There was no documentation by the nurse that indicated they specifically notified the doctor of the increased [MEDICAL CONDITION] in Resident #2's feet and legs. On 10/16/15 at 2:50 P.M., the nurse documented Resident #2 had a sudden onset of extreme and excruciating pain in his right hip. The surgeon's office who did Resident #2's back surgery was called and a message was left. At 3:47 P.M., the nurse's note indicated the surgeon's physician assistant called in increased Resident #2's pain medication and he was made aware of his bilateral lower leg swelling. This physician assistant ordered an ultrasound of both of Resident #2's lower extremities to rule out blood clots. The physician assistant directed the nurse to notify the attending medical physician about the swelling if the ultrasound was negative. This note indicated the family was now made aware of the swelling and the test ordered. The facility nurse's had not previously notified the physician or the DPOA of Resident #2's increased leg swelling. On 10/17/15 at 12:50 A.M., the nurse's note said the ultrasound results came back and Resident #2 had blood clots in both of his lower extremities. The surgeon and the attending physician were called and notified and Resident #2 was admitted to the hospital. Resident #2 remained at the hospital for treatment for [REDACTED]. Review of the physical therapy evaluation dated 10/21/15 indicated Resident #2 was referred back to therapy and the medical history section indicated Resident #2 had been [DIAGNOSES REDACTED]. This concern was reviewed and verified with the administrator on 12/01/15 at 9:30 A.M. This concern was reviewed and verified with the director of nursing on 12/01/15 at 11:10 A.M. and no additional information was provided. This deficiency substantiates Complaint Number OH 619.

Based on record review and interview, the facility failed to provide adequate supervision and ensure interventions were in place to prevent a fall for Resident #127. Harm occurred when the resident sustained [REDACTED]. The facility also failed to ensure medications were properly secured. This affected one resident (Resident #127) of three residents reviewed for falls and had the potential to affect two residents, residing on the 400 unit, who were identified by the facility to be cognitively impaired and independently mobile. Findings include: 1. Review of Resident #127's closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was assessed to be at risk for falls due to an unsteady gait, muscle weakness, diuretic use and urinary incontinence. Review of the initial Minimum Data Set (MDS) 3.0 assessment, dated 09/15/14 revealed the resident was cognitively intact but required extensive assistance of two people for bed mobility and transfers. The assessment indicated the resident's balance was unsteady, only being able to transfer from surface to surface or from seated to standing with staff assistance. Review of the fall plan of care, dated 09/09/14 revealed the resident was at risk for falls related to impaired balance, poor coordination,unsteady gait and history of falls, as well as due to the potential for medication side effects. Interventions include to encourage the resident to change positions slowly and to provide assistance to transfer. Review of the record did not reveal concerns with behavior or resistance to care. A nursing note, dated 09/30/14 at 2:27 P.M. revealed the resident required two staff to assist with transferring. A note dated 10/01/14 at 7:35 A.M. revealed the resident expressed she was having pain in her left shoulder. A nursing note dated 10/02/14 revealed the resident requested Tylenol to help with the left shoulder pain, and although she had a narcotic pain medication available for pain relief (Percocet) she stated that it made her feel "fuzzy." A nursing note, dated 10/08/14 at 12:29 A.M. revealed the resident received Percocet for pain. A nursing note, dated 10/08/14 at 4:13 A.M. revealed the resident had a complaint of chest pain, and she was medicated with Nitroglycerine (Nitro), a medication to treat cardiac/chest pain. After the resident received the Nitro dose, she stated to the nurse that she felt the pain was more in her arm and shoulder and requested Percocet, which she received at 12:29 A.M. A nursing note, dated 10/08/14 at 5:24 A.M. revealed the resident fell "before being pivot transferred for her daily weight." The note indicated the resident was uncooperative for the nursing assistant (STNA #6). The note stated she was sitting on the side of the bed and lunged forward, sustaining a two centimeter (cm) by one cm laceration to her forehead. The note indicated the wound site was covered with gauze and bandage, ice was applied and the resident was transferred to the emergency room by a transport company. The next note dated 10/08/14 at 11:27 A.M. indicted the resident had been admitted to the hospital for "acute coronary syndrome." The resident returned to the facility on [DATE] after a short stay at another long term care facility. Review of the fall investigation which was dated 10/08/14 at 4:40 A.M., contained in the assessment section of the computerized medical record, revealed the resident needed to rock her body or push off on arms of the chair when standing up from the chair, had difficulty maintaining standing position, had gait and musculoskeletal problems and had impaired balance during transitions. The assessment also indicated the resident had a decline in functional status, [DIAGNOSES REDACTED], vision and hearing impairments and impulsivity or poor safety awareness. The assessment indicated the resident required one to two person assist with transfers and that she fell prior to being transferred for her daily weight. The noted stated she was sitting on the side of the bed and lunged forward, was uncooperative with the nursing assistant. The assessment indicated the resident had earlier complained of chest pain and that the resident's son and the physician were notified of the fall. The physician ordered the resident to be sent out to the hospital for evaluation. Initial interview with registered nurse (RN) #5 on 01/16/15 at 1:55 P.M. revealed no other information existed in the record regarding the resident's fall. She stated the fall investigation was completed in the computer, which was reviewed. She stated the facility did not typically interview staff members after a fall if the injury was not severe and again indicated she was unaware of other documentation concerning this particular fall for Resident #127. Interview with the corporate nurse on 01/20/15 at 10:45 A.M. revealed that since no further information concerning the incident on 10/08/14 could be found, the facility interviewed staff involved, who still worked at the facility, to try to "re-create" the investigation. Review of the statement, obtained on 01/19/15 from the nursing assistant (STNA #6) who worked the day Resident #127 fell revealed the nurse had awakened the resident and the aide decided to get the resident's daily weight. The nurse left the room, and the resident was "set up on the side of the bed." The aide leaned to grab the remote to put down the head of the bed and the resident "scooted to the edge of the bed." The note stated she "went to scoot again and leaned forward and fell to the floor." The aide could not stop the fall. Based on the information obtained from STNA #6, there was no indication the resident had been uncooperative or exhibited behaviors that were a factor in the fall she sustained. Review of an investigation report that was dated 10/08/14, but not signed by the unit manager (RN #5) until 01/19/15 revealed STNA #6 was "educated on asking for assistance when needed. Interview with the corporate nurse on 01/20/15 at 10:45 A.M. verified the resident had a previous history of being unable to stabilize her balance when sitting and had experienced and been medicated earlier in the shift for shoulder pain. She verified the statement of STNA #6 did not reference the "uncooperative behavior" mentioned in the progress note dated 10/08/14 and that the STNA was not close enough to the resident when she was sitting on the side of the bed to prevent the fall forward, which resulted in a forehead laceration. She further verified the investigation report, which was dated 10/08/14 but was not signed until 01/19/15 indicated the STNA was educated on asking for assistance when needed. 2. A medication observation was completed on 01/14/15 at 8:05 A.M. During the medication observation, RN #2 dispensed medications from the medication cart. RN #2 then left the medication cart unattended without first locking the cart. The unlocked medication cart was in the 400 unit hallway. RN #2 proceeded to enter a resident room, administer medications to the resident, entered the resident's bathroom, washed her hands and then exited the resident room. RN #2 returned to the medication cart and verified she left the unlocked cart, unattended in the hallway at that time. Review of the facility policy for Medication and Treatment Administration Guidelines revised 12/2014 revealed: Medications and biologicals are securely stored in a locked cabinet, cart or medication room, accessible only to licensed nursing staff and maintained under a lock system when not actively utilized and attended to by nursing staff for medication administration, receipting or disposal. This deficiency substantiates Complaint Number OH 549.