Every finding on record at New Albany Care Center

Based on record review, policy review, and interviews, the facility failed to ensure one resident (#1) concern was timely addressed. This affected one resident (Resident #1). The facility census was 65.Findings include:Resident #1 was admitted to the facility 03/09/26. His diagnoses included chronic kidney disease stage III unspecified, Type II Diabetes, hypertension, anxiety, depression, coronary atherosclerosis, chronic gout, and chronic pain. Review of his minimum data set (MDS) assessment, dated 07/24/26, revealed he was cognitively intact. Interview on 07/27/26 at 4:30 P.M. with Resident #1 revealed resident's family brought him an unknown quantity of new T-shirts and shorts and items had been missing for 10 weeks. Resident stated CNA #186 was assisting him with locating the missing items. Interview on 07/28/2026 at 11:42 A.M. with Housekeeping and Laundry Manager #214 and Administrator #130 revealed that neither were aware Resident #1 was missing clothing items. Administrator #130 stated when resident was admitted he had bedbugs in his belongings and the items were sent back home with his family. Housekeeping and Laundry Manager #214 and Administrator #130 both stated they were not aware of resident's family bringing in any new clothing items. Housekeeping and Laundry Manager #214 stated the resident was given items from the lost and found because he had no other clothes. Administrator #130 stated if a resident was missing items, it was expected to be placed on the concern log. If items were not found, the facility would replace them. Interview on 07/29/2026 at 9:31 A.M. with CNA #186 revealed that Resident #1's clothing had bedbugs when he first arrived at facility. She confirmed that Resident #1's daughter did bring additional clothing to the facility. She stated the items did not get logged and labeled like they should have been and did end up missing. CNA #186 stated she was not aware of the missing items being placed on the concern log. She stated Resident #1 was given items from the facility lost and found. She stated the previous activities manager left abruptly and things fell through the cracks with replacing the items. She stated new Activities Manager #102 was in the process of replacing missing items. Interview on 07/29/2026 at 2:15 P.M. with Activities Manager #102 revealed that she has been working at the facility for three weeks. She stated she was not aware of any current missing items for Resident #1. She stated in the past staff have informed her that resident was missing items, but they were always found in the laundry. She stated if a resident was missing items the protocol was to add residents name to the concern log, complete an investigation, and notify the administrator if needed to possibly replace missing items. Interview on 07/30/2026 at 8:30 A.M. with Administrator #130 revealed that resident personal items/inventory log are expected to be updated every time they have new items brought into the facility. She stated there are no designated staff who update inventory logs and that any staff could do it. Review of facility Concern Logs from March 2026 to July 2026 confirmed Resident #1's name was not added to the concern log. Review of facility Concern (Grievance) Process Policy dated 11/2017, revised 5/31/24 revealed that facility should accept verbal complaints voiced by residents and transcribe them onto a concern form. Staff should take immediate actions needed to prevent resident right violations as well as forward the concern form to grievance officer for review and resolution. Designated staff are expected to make efforts to resolve the concern/grievance within 5-10 business days. Resident #1 was admitted to the facility 03/09/26. His diagnoses included chronic kidney disease stage III unspecified, Type II Diabetes, hypertension, anxiety, depression, coronary atherosclerosis, chronic gout, and chronic pain. Review of his minimum data set (MDS) assessment, dated 07/24/26, revealed he was cognitively intact. Interview on 07/27/26 at 4:30 P.M. with Resident #1 revealed resident's family brought him an unknown quantity of new T-shirts and shorts and items had been missing for 10 weeks. Resident stated CNA #186 was assisting him with locating the missing items. Interview on 07/28/2026 at 11:42 A.M. with Housekeeping and Laundry Manager #214 and Administrator #130 revealed that neither were aware Resident #1 was missing clothing items. Administrator #130 stated when resident was admitted he had bedbugs in his belongings and the items were sent back home with his family. Housekeeping and Laundry Manager #214 and Administrator #130 both stated they were not aware of resident's family bringing in any new clothing items. Housekeeping and Laundry Manager #214 stated the resident was given items from the lost and found because he had no other clothes. Administrator #130 stated if a resident was missing items, it was expected to be placed on the concern log. If items were not found, the facility would replace them. Interview on 07/29/2026 at 9:31 A.M. with CNA #186 revealed that Resident #1's clothing had bedbugs when he first arrived at facility. She confirmed that Resident #1's daughter did bring additional clothing to the facility. She stated the items did not get logged and labeled like they should have been and did end up missing. CNA #186 stated she was not aware of the missing items being placed on the concern log. She stated Resident #1 was given items from the facility lost and found. She stated the previous activities manager left abruptly and things fell through the cracks with replacing the items. She stated new Activities Manager #102 was in the process of replacing missing items. Interview on 07/29/2026 at 2:15 P.M. with Activities Manager #102 revealed that she has been working at the facility for three weeks. She stated she was not aware of any current missing items for Resident #1. She stated in the past staff have informed her that resident was missing items, but they were always found in the laundry. She stated if a resident was missing items the protocol was to add residents name to the concern log, complete an investigation, and notify the administrator if needed to possibly replace missing items. Interview on 07/30/2026 at 8:30 A.M. with Administrator #130 revealed that resident personal items/inventory log are expected to be updated every time they have new items brought into the facility. She stated there are no designated staff who update inventory logs and that any staff could do it. Review of facility Concern Logs from March 2026 to July 2026 confirmed Resident #1's name was not added to the concern log. Review of facility Concern (Grievance) Process Policy dated 11/2017, revised 5/31/24 revealed that facility should accept verbal complaints voiced by residents and transcribe them onto a concern form. Staff should take immediate actions needed to prevent resident right violations as well as forward the concern form to grievance officer for review and resolution. Designated staff are expected to make efforts to resolve the concern/grievance within 5-10 business days.

Based on medical record review, financial record review, and staff interview, the facility failed to provide proper oversight of resident funds to ensure they remained within Medicaid eligibility requirements. This affected one (Resident #57) of five resident financial Aecords reviewed. The census was 65.Findings Include:Resident #57 was admitted to the facility on [DATE]. Her diagnoses were senile degeneration of brain, blepharitis, pyelonephritis, atrial fibrillation, depression, hypokalemia, unspecified severe protein calorie malnutrition, anxiety disorder, insomnia, pressure ulcer of sacral region, osteomyelitis, heart failure, hypertension, hyperlipidemia, anemia, mild cognitive impairment, dysphagia, transient cerebral ischemic attack, and vascular dementia. Review of her minimum data set (MDS) assessment, dated 05/18/26, revealed she had a severe cognitive impairment.Review of Resident #57's insurance records found that she had Medicaid insurance for her cost of care and medical costs. Review of Resident #57's Patient Liability Transaction Report, dated 07/01/25 to 07/30/26, revealed she had a total credit/overage paid of $52,771.53. This included a monthly payment from Resident #57's guardian of $1,221.76, which was not needed due to Resident #57's cost of care costs being up to date. The $52,771.53 overage in a facility account was not in a qualified income trust (QIT). Interview with Business Office Manager (BOM) #135 on 07/30/26 at 10:34 A.M., 12:15 P.M., and 1:20 P.M. confirmed Resident #57 had a balance of $52,771.53 in her patient liability account. She stated Resident #57's guardian will send them a check for $1,221.76 each month to keep her QIT account under $2,000. She stated the guardian has told her that the facility can keep ahold of this money for Resident #57 and send it back to Medicaid when she expires. She confirmed Resident #57 has access to this money if she would need anything, but also acknowledged that if Medicaid reviewed Resident #57's financial accounts, she would possibly lose her Medicaid insurance because her accounts exceed to $2,000 Medicaid limit. She confirmed she has spoken with Resident #57's guardian and family, and they are hesitant about taking her off Medicaid insurance to private pay her cost of care, to reduce her financial account to less than $2,000, so for the time being, they will continue to accept the $1,221.76 from Resident #57's guardian.

Based on observation, staff interviews, and record review the facility failed to identify and treat a non-pressure skin issue in a timely manner for one resident, (#4) of three residents (#4, #1, and #57) reviewed for skin alterations. The facility census was 65.Findings include:Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE] and had diagnoses that included altered mental status, severe protein-calorie malnutrition, and insomnia. Further review of Resident #4's medical record revealed on admission the resident had non-pressure related skin issues including a skin tear to the right arm, abrasion to the left ankle, and other skin impairment to the right glute. Review of Resident #4's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was severely cognitively impaired with a Brief Mental Status (BIMS) score of seven.Observation on 07/28/26 at 8:58 A.M. revealed a small open wound, approximately one to two inches in length and approximately less than half an inch wide with red irregular borders was present on the posterior side of Resident #4's left forearm. This observation was made while the resident was lying in bed. Further observation at this time revealed the lesion appeared similar to a skin tear or abrasion. Additional observation at this time revealed there was no sign of any treatment to the area of broken skin noted on the left forearm.Interview on 07/28/26 at 9:00 A.M. with Resident #4 revealed they had hit their left arm on the bedside table just yesterday, and that this had caused the broken skin.Review of the skin assessment titled Skin- Total Body Eval V2 effective as of 07/28/26 at 11:29 P.M. and completed by Registered Nurse (RN) #112 revealed no skin abnormalities were found upon evaluation of Resident #4's skin.Review of Resident #4's medical record on 07/30/26 at approximately 12:00 P.M. revealed no mention of any broken skin areas, wounds, abrasions or skin tears to the resident's left arm.Observation on 07/30/26 at 12:05 P.M. of Licensed Practical Nurse (LPN) #172 performing a brief skin assessment of Resident #4's left arm revealed LPN #172 noted a scabbed abrasion to the resident's left arm upon visual inspection of the left posterior forearm. Further observation of Resident #4 at this time revealed the scabbed abrasion noted by LPN #172 was at the same site as the open skin that was observed on 07/28/26 at 8:58 A.M.Interview on 07/30/26 at approximately 12:05 P.M. with LPN #172 revealed the nurse did not have any prior knowledge of the lesion at Resident #4's left forearm.Interview on 07/30/26 at approximately 12:06 P.M. with LPN #172 revealed Resident #4 had just told them that the wound at his left forearm had occurred a couple of days ago after hitting their arm on the bedside table.Interview on 07/30/26 at 12:12 P.M. with LPN #172 revealed they would contact Resident #4's physician to obtain orders to treat and cover the scabbed wound, to protect the skin and promote healing.Interview on 07/30/26 at 12:49 P.M. with the Director of Nursing (DON) confirmed if Resident #4 had a wound or other skin issue that was present on 07/28/26 and not found or treated until 07/30/26, it was not accurately assessed or timely treated. Interview on 07/30/26 at 3:11 P.M. with LPN #172 confirmed based on the appearance of Resident #4's left forearm the abrasion being scabbed, the skin alteration didn't happen today.

Based on medical record review, staff interview, and facility policy review, the facility failed to adequately monitor significant resident weight loss. This affected two (Residents #9 and #47) of three residents reviewed for nutrition. The census was 65. Findings Include:1.Resident #9 was admitted to the facility on [DATE]. Her diagnoses were gastroparesis, disorder of muscle, acute kidney failure, acute metabolic acidosis, thrombosis due to vascular prosthetic devices, acute embolism and thrombosis of superficial veins of right upper extremity, pulmonary hypertension, obesity, type II diabetes, anemia, gout, chronic kidney disease, anemia, chronic obstructive pulmonary disease, insomnia, hypertension, congestive heart failure, cervicalgia, anxiety disorder, hyperlipidemia, and dyspnea. Review of her minimum data set (MDS) assessment, dated 07/14/26, revealed she was cognitively intact. Review of Resident #9 physician orders, dated 07/17/26, revealed the facility was to monitor her weight daily due to congestive heart failure. In addition to monitoring her weight daily, the facility is to notify the physician of a weight gain of three pounds in 24 hours or five pounds in 72 hours. Review of Resident #9's weights, dated 07/17/26 to 07/29/26, revealed the following weight changes: she weighed 196.3 pounds on 07/19/26 and then weighed 233.9 pounds on 07/20/26 (which was an increase of 37.6 pounds). On 07/24/26, she weighed 199.1 pounds and then weighed 228.9 pounds on 07/25/26 (which was an increase of 29.8 pounds). A second weight was taken on 07/25/26, which indicated she weighed 201.4 pounds, and then on 07/26/26, she weighed 222.7 pounds (which was an increase of 21.3 pounds). Finally, on 07/28/26, she had a weight of 200.1 pounds, but a re-weight was taken later and she weighed 220.1 pounds (which was an increase of 20 pounds). Review of Resident #9's progress notes, dated 07/17/26 to 07/30/26, revealed no progress notes to support the provider was notified of the significant weight increases as ordered. Interview with Regional Director #300 and Administrator on 07/29/26 at 3:20 P.M. confirmed there was no documentation to support the provider was notified of the significant weight increases as ordered. The facility verified they cannot confirm the accuracy of the weights either, but they will be educating the nursing staff on ensuring weights are accurate and the provider is notified with the significant increase as ordered. 2. Review of Resident #47's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included enterocolitis due to clostridium difficile, abdominal distention, and unspecified intestinal obstruction. Review of Resident #47's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. Review of weight measurements contained in Resident #47's medical record revealed the resident experienced significant weight fluctuations during their time at the facility without any reweights performed to confirm that the weight measurements were accurate. Further review of weight measurements in Resident #47's medical record revealed the resident was noted to weigh 140 pounds on 07/02/26, and then 161.6 pounds on 07/06/26, with no evidence that any re-weight was done to confirm the weight measurement of significant weight gain was accurate. Additional review of weight measurements contained in Resident #47's medical record revealed the resident was noted to weigh 161.6 pounds on 07/15/26, and then 122.8 pounds on 07/20/26 with no evidence that any re-weight was done to confirm the significant weight loss was an accurate measure. Interview on 07/30/26 at 2:27 P.M. with Registered Dietitian (RD) #118 revealed any re-weights that are taken in the facility are typically documented into the electronic health record. Interview on 07/30/26 at 2:29 P.M. with Regional Registered Nurse #300 revealed they did not believe the weight measurements documented in Resident #47's medical record appeared to be consistently accurate. Interview on 07/30/26 at 3:06 P.M. with RD #118 revealed Resident #47's weight was known to have fluctuated a significant amount while the resident was in the hospital immediately prior to their admission to the facility. Further interview with RD #118 at this time verified there was no evidence available to show that any re-weights were completed for Resident #47's significant weight changes on 07/06/26 or 07/20/26. Review of the facility policy titled Weights issued 05/03/22 and last revised 02/01/24 revealed reweights will be completed when a resident gains or loses five pounds if they weigh 100 pounds or greater.

Based on observation, staff interview, and review of the facility policy, the facility failed to properly store and date food items in the kitchen. This had the potential to affect 60 of 61 residents who resided in the facility who received foods prepared in the facility kitchen. The facility identified (Resident #45) who had an ordered was ordered a nothing by mouth diet. Findings include: Observation on 02/03/25 at 11:38 A.M. revealed there was an opened undated package of cherry gelatin powder wrapped in clear cellophane and placed in a plastic bag in the dry storage area. Observation on 02/03/25 at 11:44 A.M. revealed the following items were being stored in the refrigerator: a large metal tray of cooked roast beef uncovered and exposed to the air, a large metal tray of chicken with another metal tray that did not fully cover the kitchen and left it exposed to the air, a plastic bucket of scrambled eggs uncovered and exposed to the air. Observation on 02/03/25 at 11:52 A.M. revealed there was a large bag of opened undated onion rings in the freezer. Interview on 02/03/25 at 11:55 A.M. with Dining Services Manager (DSM) #157 confirmed the gelatin powder in the dry storage area and the onion rings in the freezer were opened and undated and food items should be dated upon opening. Further interview with DSM #157 confirmed the roast beef, chicken, and eggs in the refrigerator were not covered and foods should not be exposed to air during storage. Review of the facility policy titled Food Storage Guidelines dated 02/02/11 revealed cereal products, flour, sugar and broken lots of bulk foods were to be stored in plastic containers with tight fitting covers. All containers must be labeled and dated. All stock must be rotated and properly dated with each new order received. Old stock was always used first. All refrigerated and frozen foods should be covered, labeled and dated.

Based on review of resident funds accounts, staff interview, and review of the facility policy, the facility failed to obtain written authorizations to manage resident funds accounts. (Residents #123 and #124). This affected two (Residents #123 and #124) of five residents reviewed for resident funds accounts. The facility census was 61 residents. Findings include: Review of the banking records dated 02/06/25 revealed Resident #123 had a balance of $50.04 and Resident #124 had a balance of $67.03 in the resident trust accounts. Further review of the banking records for Resident #123 and #124 revealed they did not include written authorizations for the facility to manage the residents' funds. Interview on 02/06/24 at 5:15 P.M. with the Administrator confirmed the facility had not obtained written authorizations to manage resident fund accounts for Resident #123 or Resident #124. Review of the facility policy titled Resident Trust Account-Personal Needs Allowance dated 06/28/21 revealed the facility staff would ensure all resident fund accounts would have a written authorization per the resident and/or the resident's representative allowing the facility to manage the residents' funds.

Based on review of resident funds accounts, staff interview, and review of the facility policy, the facility failed to provide written notification for the need to spend down resident funds to residents and/or resident representatives. This affected one (Resident #22) of five residents reviewed for resident fund accounts. The facility census was 61 residents. Findings include: Review of the banking records dated 02/06/25 revealed Resident #22 had a balance of $2,482.60 in the resident fund account. Further review of the account for Resident #22 revealed there was no notification to the resident and/or resident's representative the account balance had exceeded the asset limit set by Medicaid. Interview on 02/06/25 at 5:15 P.M. with the Administrator confirmed the asset limit for Medicaid recipients was $2000 and residents and/or resident representatives should be notified in writing when the balance in the resident fund account was within $200 of the asset limit. The Administrator further confirmed the facility had not notified Resident #22 of the need to spend down the resident fund account to remain eligible for Medicaid assistance. Review of the document titled Ohio Medicaid Long-Term Care Eligibility for Seniors dated 2025 revealed the asset limit was $2,000 for a single applicant. Review of the facility policy titled Resident Trust Account-Personal Needs Allowance dated 06/28/21 revealed the facility staff were responsible for notifying the resident and/or the resident's representative via certified mail if the resident fund account balance reached within $200.00 of the state limit. A written notice would be provided to any resident who received Medicaid benefits and whose funds reached within $200 of the state limit. A copy of the notice should be retained in the resident's banking records.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to provide assistance with bathing and shaving to dependent residents. This affected one (Resident #2) of 41 facility-identified residents (#2, #4, #6, #11, #14, #20, #21, #22, #23, #24, #26, #27, #28, #29, #31, #32, #33, #34, #36, #41, #42, #43, #44, #45, #47, #48, #50, #53, #57, #61, #112, #114, #116, #119, #161, #165, #168, #170, #171, #174, #175) who required assistance with shaving. The facility census was 61 residents. Findings include: Review of the medical record for Resident #2 revealed an admitted [DATE] with diagnoses including acute respiratory failure with hypoxia, acute kidney failure, chronic diastolic heart failure, hypertension, chronic obstructive pulmonary disease, chronic pain syndrome, insomnia, polyosteoarthritis and major depressive disorder. Review of Minimum Data Set (MDS) assessment for Resident #2 dated 11/11/24 revealed the resident had moderate cognitive impairment and required partial/moderate staff assistance with personal hygiene. Review of the care plan for Resident #2 dated 04/25/25 revealed the resident had an activities of daily living (ADL) self-care performance deficit related to activity intolerance, impaired balance, limited mobility, pain, and shortness of breath. Interventions included one-person assistance with personal hygiene/oral care. Observation on 02/03/25 at 1:24 P.M. revealed Resident #2 had long facial hair and dark shadowing to her upper lip. Observation on 02/05/25 at 3:02 P.M. revealed Resident #2 had long facial hair and dark shadowing to her upper lip. Interview on 02/05/24 at 3:02 P.M. with Resident #2 confirmed she would like her facial hair removed when it was visible. Interview on 02/05/25 at 3:09 P.M. with Certified Nurse Assistant (CNA) #197 confirmed Resident #2 had long facial hair. CNA #197 confirmed Resident #2 had a bath on 02/04/25, but they did not shave her face. CNA #197 confirmed staff should always ask residents if they would like their face shaved. Observation on 02/06/25 at 9:01 A.M. revealed Resident #2 had long facial hair and dark shadowing at her upper lip. Interview on 02/06/25 at 9:58 A.M. with the Director of Nursing (DON) and Administrator confirmed staff should ask all residents if they would like their face shaved when needed or residents could request to be shaved. The DON and the Administrator confirmed the facility had no records indicating that Resident #2 had been shaved recently. Review of the facility policy titled Activities of Daily Living (ADL) dated 12/07/23 revealed residents would be provided with care, treatment, and services as appropriate. Daily personal needs included bathing, dressing, grooming, toileting, and oral care.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility staff failed to ensure residents received the proper treatment and assistive devices to maintain hearing. This affected two (Residents #15 and #48) of two residents reviewed for hearing. The facility census was 61 residents. Findings include: 1. Review of the medical record for Resident #15 revealed an admitted [DATE] with diagnoses including depression, endometrial hyperplasia, anxiety disorder, dysphagia, anemia, pulmonary embolism, type two diabetes mellitus, disorders of the pituitary gland, and unspecified hearing loss. Observation on 02/03/25 at 12:57 P.M. revealed Resident #15 was unable to adequately hear conversations unless parties who were speaking spoke close to her ears. Interview on 02/03/25 at 12:57 P.M. with Resident #15 confirmed her hearing aids had been lost from her bedside table approximately two years ago. The facility staff was notified, but the hearing aids were never found. Observation on 02/03/25 at 1:26 P.M. revealed Registered Nurse (RN) #119 administered medication to Resident #15 at the bedside. RN #119 spoke loudly and had to repeat instructions during the medication pass and had to lean over the bed and speak the information directly into Resident #15's left ear. Interview on 02/03/25 at 1:26 P.M. with RN #119 confirmed Resident #15 was extremely hard of hearing and sometimes reads lips. RN #119 stated she had not seen Resident #15 with hearing aids for at least a year, and if the facility couldn't find the hearing aids, the facility should replace the hearing aids. Interview on 02/03/24 at 2:39 P.M. with the Administrator confirmed that the facility would attempt to locate the hearing aids for Resident #15, and if not found, the facility should replace the hearing aids. 51524 2. Review of the medical record for Resident #48 revealed an admitted [DATE] with diagnoses including profound hearing loss in both ears, schizophrenia, mood affective disorder, and personality disorder. Review of the MDS assessment for Resident #48 dated 07/28/23 revealed the resident's hearing was highly impaired. Review of the audiology report for Resident # 48 dated 09/20/23 revealed the resident was a candidate for a cochlear implant, an electronic medical device that could improve hearing and speech perception in individuals who did not benefit from traditional hearing aids. Review of the therapy progress note for Resident #48 dated 09/11/24 revealed the resident missed having conversations with people, had inquired about hearing aids, and was still awaiting a response from the facility. Interview on 02/05/25 at 10:05 A.M with Resident #48 confirmed she had requested information about obtaining hearing aids. Resident #48 confirmed staff had discussed the possibility of a cochlear implant. Interview on 02/06/25 at 12:29 P.M. with Licensed Social Worker (LSW) #120 confirmed Resident #48 was not a candidate for hearing aids due to congenital deafness. LSW #120 confirmed the facility had no documentation the facility had discussed cochlear implants with Resident #48. Review of the facility policy titled Ancillary-Additional Services and Fees dated 02/14/13 revealed the facility would provide appropriate hearing services to residents.

Based on medical record review, observation, resident representative interview, resident interview, staff interview, and review of the facility policy, the facility failed to pressure ulcer interventions were implmented for residents with pressure ulcers. This affected one (Residents #25 ) of five residents reviewed for pressure ulcers. The facility census was 61 residents. Findings include: Review of the medical record for Resident #25 revealed an initial admitted on 01/03/25 and a readmitted on 02/02/25 with diagnoses including type two diabetes mellitus without complications, acute on chronic diastolic (congestive) heart failure, neuromuscular dysfunction of bladder, and morbid obesity. Resident #25 was hospitalized from 01/29/25 to 02/02/25. Review of the Minimum Data Set (MDS) assessment for Resident #25 dated 01/10/25 revealed the resident had intact cognition, required staff assistance with activities of daily living (ADLs), and had no pressure ulcers. Review of the care plan for Resident #25 dated 01/20/25 revealed the resident had an actual pressure injury to the coccyx noted 01/20/25. Interventions included adding a low air loss mattress to the resident's bed. Review of the physician's orders for Resident #25 revealed an order dated 01/24/25 for an air mattress to the resident's bed which was discontinued 01/30/25 the day after the resident was hospitalized . Review of the readmission physician's orders for Resident #25 dated 02/05/25 revealed an order to cleanse the coccyx wound with normal saline and pat dry and cover with calcium alginate and a foam dressing daily. There was no order for an air mattress upon readmission. Observations on 02/04/25 at 9:26 A.M. and 02/05/25 at 2:42 P.M. revealed Resident #25 did not have a low air loss mattress in place. Interview on 02/05/25 at 2:14 P.M. via telephone with Resident #25's representative confirmed Resident #25 had an open wound on his coccyx area. The resident's representative stated the resident had been laying on an air mattress prior to being hospitalized and did have an air mattress during his hospitalization . Resident #25's representative confirmed Resident #25 had not received an air mattress again since he returned to the facility. Interview on 02/05/25 at 2:42 P.M. with Resident #25 confirmed he had an air mattress at the facility prior to being hospitalized but he had not had an air mattress since he returned to the facility. Resident #25 stated he was on an air mattress during his hospitalization . Interview on 02/05/25 at 2:44 P.M. with Unit Manager (UM) #148 confirmed Resident #25 was not on an air mattress. UM #148 confirmed Resident #25 had an air mattress prior to going out to the hospital due to having an open wound on his coccyx area but the facility had not initiated an order for an air mattress since Resident #25 returned to the facility. Interview on 02/05/25 at 2:47 P.M. Licensed Practical Nurse (LPN) #192 confirmed Resident #25 had an order for an air mattress prior to being hospitalized and had an open pressure ulcer to his coccyx area with an active wound treatment in place. LPN #192 confirmed Resident #25 should have an air mattress to help prevent the pressure ulcer from worsening. Review of the facility policy titled Skin and Wound Guidelines revised 03/20/24 revealed the facility would implement individual interventions to reduce the resident's risk for new or worsening skin breakdown.

Based on medical record review, observation, and staff interviews, the facility failed to ensure oxygen was administered according to physician orders. This affected one resident (Resident #45) of two residents reviewed for oxygen administration. The facility identified 13 residents (#2, #28, #34, #41, #44, #45, #121, #122, #162, #165, #170, #173, #174) who were receiving oxygen. The facility census was 61 residents. Findings include: Review of the medical record for Resident #45 revealed an admitted [DATE] with diagnoses including chronic idiopathic constipation, hypertension, type two diabetes mellitus, dementia, osteomyelitis, occlusion and stenosis of bilateral carotid arteries, and respiratory failure. Review of Minimum Data Set (MDS) assessment for Resident #45 dated 01/20/25 revealed the resident was severely cognitively impaired and received oxygen therapy. Review of physician's orders for Resident #45 revealed an order dated 01/31/24 for humidified oxygen via nasal cannula at three liters per minute (LPM). Review of the care plan for Resident #45 dated 09/13/24 revealed the resident had a diagnosis of respiratory failure. Interventions included the following: monitor for signs or symptoms of respiratory distress or abnormal breathing patterns and report to the physician, administer oxygen via nasal cannula at three LPM. Observation on 02/04/25 at 4:41 P.M. revealed Resident #45's oxygen was set at 3.5 LPM. Observation on 02/05/25 at 11:14 A.M. revealed Resident #45's oxygen was set at 5.0 LPM. Observation on 02/05/25 at 3:04 P.M. revealed Resident #45's oxygen was at 5.0 LPM. Interview on 02/05/25 at 3:07 P.M. with Licensed Practical Nurse (LPN) #180 confirmed Resident #45's oxygen was incorrectly set at 5.0 LPM and should be set at 3.0 LPM. LPN #180 confirmed the oxygen setting may have been accidentally adjusted by a visitor or knocked out of place. LPN #180 relocated the unit to prevent accidental increases in oxygen level. Review of facility policy titled Administration of Oxygen dated 09/25/13 revealed the facility would manage residents utilizing oxygen according to physician orders and clinical best practices.

Based on medical records review staff interview the facility failed to respond in a timely manner to consultant pharmacist recommendations. This affected one (Resident #42) of five residents reviewed for unnecessary medications. The facility census was 61 residents. Findings include: Review of the medical record for Resident #42 revealed an admitted [DATE] with diagnoses including paraplegia, congestive heart failure, type two diabetes mellitus, hypothyroidism, bipolar disorder, depression, and sleep apnea. Review of the drug regimen review per the consultant pharmacist for Resident #42 dated 12/19/24 revealed a recommendation to reduce the anticoagulant, Eliquis, for the resident from 5 milligrams (mg) two times a day to 2.5 mg two times a day. The recommendation was not addressed until 02/06/25. Interview on 02/06/25 at 1:22 P.M. with the Regional Clinical Services Director (RCSD) confirmed that the facility missed the recommendation in December 2024 and had not addressed the recommendation for Resident #42 with the nurse practitioner until 02/06/25.

Based on medical record review, staff interview, and review of the facility policy, the facility staff failed to ensure residents were free from significant medication errors. This affected one (Residents #48) of five residents reviewed for unnecessary medications. The facility census was 61 residents. Findings include: Review of the medical record for Resident #10 revealed an admitted on 11/18/24 with diagnoses including type two diabetes mellitus, diastolic (congestive) heart failure, chronic kidney disease stage three, anxiety disorder, and essential primary hypertension. Resident #10 was discharged [DATE] and readmitted [DATE]. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 11/25/24 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs). Review of the physician's orders for Resident #10 revealed an order dated 11/19/24 for clonidine 0.1 milligrams (mg) one tablet by mouth daily for a systolic blood pressure greater than 160. Review of the blood pressure record for Resident #10 revealed the resident had a systolic blood pressure greater than 160 on the following dates: 11/26/24, 11/28/24, 12/01/24, 12/02/24, 12/06/24, and 12/17/24. Review of the Medication Administration Records (MARs) for Resident #10 dated November and December 2024 revealed the resident did not receive clonidine on the following dates: 11/26/24, 11/28/24, 12/01/24, 12/02/24, 12/06/24, and 12/17/24. Interview on 02/06/25 at 2:20 P.M. with Regional Nurse (RGN) #500 confirmed Resident #10 had not received clonidine on 11/26/24, 11/28/24, 12/01/24, 12/02/24, 12/06/24, and 12/17/24 even though the resident's systolic blood pressure was over 160 and the resident should have received the medication. Review of the facility policy titled Medication Administration dated 08/07/23 revealed the facility staff should administer medication in accordance with frequency prescribed by physician and per acceptable standards of practice.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure kitchen staff blended pureed food to an appropriate texture prior to serving to the residents. This affected two residents (Residents #32 and #33) of two residents with orders for a pureed diet. The facility census was 61 residents. Findings include: Observation on 02/06/25 at 10:30 A.M. of pureed food preparation per [NAME] #188 revealed the cook confirmed she would be making two servings of pureed lasagna. [NAME] #188 added two scoops of lasagna, one-quarter cup of water, and two plastic spoonfuls of thickener to the blender and started blending. At 10:38 A.M. [NAME] #188 stopped the blender, used a clean spatula to scrape the sides down and confirmed she felt the lasagna was an appropriate texture to serve to the residents. [NAME] #188 plated the pureed lasagna onto two plates and did not taste the food prior to plating it for resident consumption. Interview on 02/06/25 at 10:38 A.M. with [NAME] #188 confirmed the lasagna was ready to serve to the residents. Observation on 02/06/25 at 10:40 A.M. revealed the Surveyor tasted the pureed lasagna with a clean spoon and noted there were lumps of ground meat in the lasagna. Observation on 02/06/25 at 10:41 A.M. revealed Chef #166 tasted the pureed lasagna with a clean spoon. Interview on 02/06/25 at 10:41 A.M. with Chef #166 confirmed the pureed lasagna was not an appropriate texture to serve to the residents and directed [NAME] #188 to place the lasagna back into the blender to blend further prior to serving to the residents. Review of the facility policy titled Step by Step Guide to Puree Foods undated revealed staff should blend the food until it was formed into a pudding like or mashed potato consistency. Staff should taste the finished product using clean plastic spoons to assure the food was smooth prior to serving to the residents.

Based on observation, staff interview, and record review the facility failed to ensure that residents who were at risk for developing multidrug-resistant organisms (MDRO) were placed in enhanced barrier precautions (EBP) per facility policy. This affected one (Resident #57) of 23 residents reviewed for EBP. The facility census was 61 residents. Findings include: Review of the medical record for Resident #57 revealed an admitted [DATE] with diagnoses including sepsis, protein-calorie malnutrition and gastroesophageal reflux disease. Observation on 02/05/25 at 11:18 A.M. of Resident #57's room revealed there was no signage indicating the resident was on EBP nor was there personal protective equipment (PPE) outside or in the vicinity of the resident's room. Review of the physician's orders for Resident #57 dated February 2025 revealed the resident had wound care orders for an unstageable pressure wound to the left buttock. Interview on 02/05/25 at 11:32 A.M. with Unit Manager (UM) #148 confirmed that Resident #57 had an unstageable pressure ulcer which required the resident to be placed on EBP per facility policy. UM #148 stated that the order was erroneously discontinued, and Resident #57 should have been on EBP and had appropriate signage on the door to alert staff and visitors and PPE should have been available outside the resident's room. Review of the facility's policy titled Enhanced Barrier Precautions dated 03/28/24 revealed that EBP was an infection control intervention designed to reduce the transmission of MDROs. EBP involved gown and glove use during high-contact resident activities for residents with colonized MDRO infections or residents at increased risk of developing MDRO infections such as those with open wounds.

Based on medical record review, resident interview, staff interview and review of the facility the facility failed to arrange transportation for scheduled medical appointments. This affected one (Resident #112) of 25 sampled residents. The facility census was 61 residents. Findings include: Review of the medical record for Resident #112 revealed an admitted [DATE] with diagnoses including cerebral infarction, atrial fibrillation, chronic kidney disease stage four, type two diabetes mellitus, morbid obesity, hypertension, and depression. Review of the after-visit summary for Resident #112 dated 01/27/25 revealed discharge instructions that included a scheduled appointment at the wound care center on 01/28/25 at 8:00 A.M. Interview on 02/06/25 at 9:42 A.M. with Resident #112 confirmed he was upset he missed his follow up appointment with the wound care center scheduled for 01/28/25 because the facility did not provide him with transportation to the appointment. Interview on 02/06/25 at 10:50 A.M. with the Administrator confirmed the facility had a transport van and a driver but the facility did not provide transportation to Resident #112 for his appointment at the wound care center on 01/28/25. Review of the facility policy titled Offsite Diagnostic Services Transportation dated 08/08/13 revealed the facility would assist residents in arranging transportation to and from diagnostic appointments, and that the facility's designee was responsible to arrange the transportation if necessary or requested by the resident and/or the resident representative.

Based on closed medical record review, staff interview, and facility policy review, the facility failed to provide timely, adequate and necessary care, monitoring and treatment for Resident #62 who exhibited an acute change in condition. Actual harm occurred on 12/10/24 when Resident #62, who had an order for continuous use of oxygen, was noted to have an acute change in condition (decreased oxygen saturation levels and increased confusion) throughout the night that was not timely monitored or treated. In addition, there was no evidence the change in condition was reported timely to the physician. Per a facility fall investigation, on 12/10/24 at 5:45 A.M. the resident sustained an unwitnessed fall out of bed with low documented oxygen saturation levels. The resident was subsequently transported to the emergency room with a critically low oxygen saturation level of 64%. This affected one resident (#62) of three residents reviewed for change in condition. The census was 57. Findings Include: Review of Resident #62's closed medical record revealed an admitted [DATE]. Medical diagnoses included congestive heart failure, constipation, disorder of muscle, cognitive communication deficit, dilated cardiomyopathy, pleural effusion, hyperkalemia, acute kidney failure, chronic kidney disease, atrial fibrillation, major depressive disorder, insomnia, hypo-osmolality and hyponatremia, atherosclerotic heart disease, hypertension, peripheral vascular disease, anemia, type II diabetes, and personal history of pulmonary embolism. Review of Resident #62's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a mild cognitive impairment. Review of Resident #62's plan of care revealed she was at risk for respiratory complications related to her diagnosis of congestive heart failure, pleural effusion, and acute respiratory failure among other chronic health issues. Interventions for this care area included to administer oxygen as ordered by the physician, monitor and report to the physician any signs or symptoms of cardiovascular and/or respiratory complications such as shortness of breath, and obtain vital signs and notify physician as needed. Review of Resident #62's Fall Investigation form, dated 12/10/24, revealed the resident sustained a fall on 12/10/24 at 5:45 A.M. The resident was found on the floor, next to her bed, without her oxygen cannula. Her vital signs were taken, and her oxygen saturation levels were between 88% and 90%. The resident had no injuries and was placed back into her bed. Due to the fall being unwitnessed, the facility started neurological checks. An evaluation statement of the fall revealed the following: resident was noted to have decreased oxygen saturations throughout the night and increased confusion. Staff reported to spend majority of the night in the resident's room with the resident to ensure safety and to ensure the resident kept her oxygen nasal cannula on. Resident was documented as impulsive at times. Resident #62 was sent out to the hospital due to increased confusion and decreased oxygen saturations. Review of Resident #62's Neurological Evaluation Flowsheet, dated 12/10/24, revealed the following vital signs and checks were completed: level of consciousness, eye response, motor movement, communication/verbal responses, blood pressure, temperature, and respiration rate. Her oxygen saturation levels were not documented. Also, the documentation on the form confirmed the resident was confused at every monitoring time after the fall, until she was sent to the hospital. Review of Resident #62's progress note, dated 12/10/24, revealed the nurse entered her room at 7:00 A.M. Resident was noted to have labored breathing and pulse oxygen level was at 62%. Her lungs were moist in all fields. The physician was notified and the resident was transferred to the emergency room . Review of Resident #62's vital sign records, dated 12/09/24 to 12/10/24, revealed on 12/09/24 at 11:37 A.M. the resident's oxygen saturation was documented to be 94%, on 12/10/24 at 5:09 P.M. 94%, and 12/10/24 at 12:30 P.M. 64%. Further documentation provided by the facility revealed the oxygen saturation (pulse oximetry) level documented on 12/10/24 at 12:30 P.M. was actually obtained on 12/10/24 at 7:00 A.M. but documented as a late entry. Record review no evidence the resident's oxygen level was documented between 12/09/24 at 11:37 A.M. and 12/10/24 at 5:09 A.M. to show the resident was assessed/monitored and/or that her oxygen saturation levels were checked, even though there was documentation to indicate the resident had decreased oxygen saturation levels throughout the night of 12/10/24. Interviews with Certified Nursing Aide (CNA) #101 and Registered Nurse (RN) #102 on 12/17/24 at 12:45 P.M. and 1:00 P.M. revealed if a resident removed their oxygen cannula, and they appeared to be short of breath or their vital signs decrease, they would replace the oxygen cannula and then monitor the resident's oxygen saturation levels until they became appropriate and stable. Both staff during interview revealed they would check on the resident every 15 to 30 minutes until the resident's vital signs became stable. They also confirmed they would document the vital signs, including the oxygen saturation levels, in the resident's medical records to confirm they were monitoring the change in condition. Interview with the Director of Nursing (DON) on 12/17/24 at 1:15 P.M. revealed low oxygen saturation levels that would need to be addressed immediately would be any level below 90%. The DON confirmed Resident #62's oxygen saturation levels when she fell on [DATE] at 5:45 A.M. were between 88% and 90%, which she confirmed was deemed to be low. She confirmed there was no documentation during the overnight shift of 12/10/24 about Resident #62's oxygen saturation levels even though there was documentation within the fall investigation document from 12/10/24 that reflected Resident #62's oxygen saturation levels were decreased overnight, and her confusion was increased. The DON confirmed there was no documentation to support the physician was notified when the change in Resident #62's condition was first noted during the overnight shift of 12/10/24 (prior to the resident's fall). The DON also confirmed there was no documented evidence to indicate Resident #62 had a behavior of removing her oxygen cannula. Interview with Licensed Practical Nurse (LPN) #103 on 12/17/24 at 1:30 P.M. revealed Resident #62 had continued to take her oxygen cannula off during the night shift of 12/10/24. She confirmed she did not document these behaviors during that time. The LPN also indicated she reported Resident #62 was having decreased oxygen saturation levels and increased confusing during the night, which she thought was primarily because the resident was removing her oxygen cannula. The LPN confirmed she did not document or report what the resident's oxygen saturation levels were, only that she was short of breath and naturally confused because she took her oxygen cannula off. The LPN revealed she increased her observations of Resident #62 that night and checked on her about once an hour. However, she confirmed she did not contact the physician about the resident's change in condition/decreased oxygen saturation levels and increased confusion until her oxygen saturation levels reached 64% at approximately 7:00 A.M., with was an hour and 15 minutes after the resident sustained a from bed. Interview with the DON on 12/17/24 at approximately 2:00 P.M. revealed Resident #62 was admitted to the hospital with a diagnosis of SARS CoV-2 (COVID-19) pneumonia. Review of facility Change in Condition policy, dated 08/09/23, revealed the nurse would notify the resident, the resident's physician/practitioner, and the resident's designated representative of changes in the resident's medical/mental condition and/or status. The nurse would notify when the following occur: an accident or incident involving the resident which results in an injury and has the potential for requiring physician/practitioner intervention. The nurse will document in the resident's medical record information relative to the resident's change in medical/mental condition or status. This deficiency represents non-compliance investigated under Complaint Number OH00160665.

Based on medical record review, staff interview, and facility policy review, the facility failed to notify the physician and resident representative of a change in resident condition, in a timely manner. This affected one (Resident #62) of three residents reviewed for change in condition. Findings Include: Record review revealed Resident #62 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, constipation, disorder of muscle, cognitive communication deficit, dilated cardiomyopathy, pleural effusion, hyperkalemia, acute kidney failure, chronic kidney disease, atrial fibrillation, major depressive disorder, insomnia, hypo-osmolality and hyponatremia, atherosclerotic heart disease, hypertension, peripheral vascular disease, anemia, type II diabetes, and personal history of pulmonary embolism. Review of Resident #62's Minimum Data Set (MDS) assessment dated [DATE] revealed she had a mild cognitive impairment. Review of Resident #62's plan of care revealed she was at risk for respiratory complications related to her diagnoses of congestive heart failure, pleural effusion, and acute respiratory failure among other chronic health issues. Interventions for this care area included obtaining vital signs and notify physician as needed. Review of Resident #62's Fall Investigation form, dated 12/10/24, revealed she fell on [DATE] at 5:45 A.M. She was found on the floor, next to her bed, without her oxygen cannula. Her vital signs were taken and her oxygen saturation levels were between 88% and 90%. She had no injuries and was placed back into her bed. Because it was an unwitnessed fall, the facility started neurological checks. Evaluation statement of the fall revealed the following: resident was noted to have decreased oxygen saturation throughout the night and increased confusion. Staff reported to spend majority of the night in room with resident to ensure safety and keep oxygen on. Resident was impulsive at times. She was sent out to the hospital due to increased confusion and decreased oxygen saturation. There was no documentation to support the physician or resident representative were notified of the fall when it occurred, and were not notified of the decrease in oxygen saturation levels and increase confusion which were noted throughout the night of 12/10/24; prior to the fall. Review of Resident #62 progress notes, dated 12/09/24 to 12/10/24, revealed there was no documentation in the progress notes to support the physician and resident representative were notified of her decrease oxygen saturation levels and increased confusion during the night, and the fall that occurred on 12/10/24 at 5:45 A.M. Interview with the Director of Nursing (DON) on 12/17/24 at 1:15 P.M. confirmed there was no documentation to support the physician and resident representative were notified of the increased confusion and the decrease oxygen saturation levels, and there was no documentation the physician and resident representative were notified of the fall that occurred until she went to the hospital approximately 90 minutes after the fall and she had another change of condition. Interview with Licensed Practical Nurse (LPN) #103 on 12/17/24 at 1:30 P.M. confirmed she did not contact the physician about her decreased oxygen saturation levels and increased confusion until her oxygen saturation levels reached 64% at approximately 7:00 A.M., with was an hour and 15 minutes after her fall from bed. Review of facility Change in Condition policy, dated 08/09/23, revealed the nurse will notify the resident, the resident's physician/practitioner, and the resident's designated representative of changes in the resident's medical/mental condition and/or status. The nurse will notify when the following occur: an accident or incident involving the resident which results in an injury and has the potential for requiring physician/practitioner intervention. The nurse will document in the resident's medical record information relative to the resident's change in medical/mental condition or status. This deficiency represents non-compliance investigated under Complaint Number OH00160665.

Based on medical record review and staff interview, the facility failed to maintain a complete medical record regarding resident changes of condition that occurred. This affected one (Resident #62) of three residents reviewed for change in condition. Findings Include: Record review revealed Resident #62 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, constipation, disorder of muscle, cognitive communication deficit, dilated cardiomyopathy, pleural effusion, hyperkalemia, acute kidney failure, chronic kidney disease, atrial fibrillation, major depressive disorder, insomnia, hypo-osmolality and hyponatremia, atherosclerotic heart disease, hypertension, peripheral vascular disease, anemia, type II diabetes, and personal history of pulmonary embolism. Review of Resident #62's Minimum Data Set (MDS) assessment dated [DATE] revealed she had a mild cognitive impairment. Review of Resident #62's Fall Investigation form, dated 12/10/24, revealed she fell on [DATE] at 5:45 A.M. She was found on the floor, next to her bed, without her oxygen cannula. Her vital signs were taken and her oxygen saturation levels were between 88% and 90%. She had no injuries and was placed back into her bed. Because it was an unwitnessed fall, the facility started neurological checks. Evaluation statement of the fall revealed the following: resident was noted to have decreased oxygen saturation throughout the night and increased confusion. Staff reported to spend majority of the night in room with resident to ensure safety and keep oxygen on. Resident was impulsive at times. She was sent out to the hospital due to increased confusion and decreased oxygen saturation. There was no documentation to support the physician or resident representative were notified of the fall when it occurred, and no documentation the physician and resident representative were not notified of the decrease in oxygen saturation levels and increase confusion which were noted throughout the night of 12/10/24; prior to the fall. Review of Resident #62's progress notes, dated 12/09/24 to 12/10/24, revealed there was no documentation of Resident #62's fall in the medical records; the only documentation of the fall was listed in the facility's incident report record. Also, there was no documentation to support monitoring of Resident #62's decrease in oxygen saturation levels and increased confusion were completed. Review of Resident #62's vital signs documentation, dated 12/09/24 to 12/10/24, revealed there was no documentation of oxygen saturation levels between 12/09/24 at 11:37 A.M. and 12/10/24 at 5:09 A.M. There should have been documentation of those vital signs due to the nurse documenting in the fall incident report that Resident #62 was having decreased oxygen saturation levels and increased confusion throughout the night of 12/10/24. Interview with the Director of Nursing (DON) on 12/17/24 at 1:15 P.M. confirmed there was no documentation to support the physician and resident representative were notified of the increased confusion and the decrease oxygen saturation levels. She confirmed when there are changes in condition, there should be documentation in the resident's medical record to support that. Also, she confirmed there was no documentation to support the alleged on-going monitoring of Resident #62 decreased oxygen saturation levels and increase confusion. Finally, she confirmed there was nothing in Resident #62's medical records regarding her fall and post fall evaluations; the incident report was not readily available to anyone who wanted to review her medical records. Interview with Licensed Practical Nurse (LPN) #103 on 12/17/24 at 1:30 P.M. confirmed she did not document the oxygen saturation levels or monitoring of increased confusion for Resident #62. She also confirmed she did not complete a progress note for her fall, that occurred on 12/10/24 at 5:45 A.M. This deficiency represents non-compliance investigated under Complaint Number OH00160665.

Based on medical record review, facility investigation review, staff interview, and review of the facility fall management guide the facility failed to ensure Resident #25 was provided adequate assistance and supervision during the provision of personal care to prevent a fall with injury. Actual harm occurred on 10/23/24 when Resident #25, who had cognitive impairment and required staff assistance for personal care including toileting sustained a fall in the bathroom after being left on the toilet unattended. The resident was assessed to have a laceration to the head (as a result of the fall) and was transported to the hospital where she was admitted and received 15 sutures to the area. The resident was hospitalized from 10/23/24 until 10/28/24. This affected one resident (#25) of three residents reviewed for accidents. The census was 59. Findings Include: Record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including laceration to scalp, muscle weakness, hyperlipidemia, anemia, dementia, atrial fibrillation, pain, vitamin B12 deficiency, vitamin D deficiency, hypertension, history of falling (02/21/19), and personal history of transient ischemic attack and cerebral infarction without residual deficits. Review of Resident #25's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident exhibited cognitive impairment and required partial/moderate (staff) assistance for toilet use. Review of Resident #25's current care plan revealed the resident was at risk for falls and potential injuries. In addition, review of the plan of care revealed the resident had an activity of daily living (ADL) self-care deficit with an intervention to have one person assistance while using the bathroom/toilet. Review of Resident #25's progress note dated 10/23/24, revealed the nurse found Resident #25 lying on the bathroom floor with blood coming from her head. Emergency medical services (EMS) were called, and the resident was taken to the emergency room for evaluation. Review of Resident #25's progress note dated 10/28/24 revealed the resident returned from the hospital with 15 sutures to the right side of her head as a result of the fall on 10/23/24. Review of a facility self-reported incident (SRI), tracking number 253458 and facility investigation documents, dated 10/29/24, revealed Resident #25 was found in the bathroom (by herself) by Certified Nursing Assistant (CNA) #101 the evening of 10/23/24. The facility information included Resident #25 asked for privacy while she was going to the bathroom, so CNA #101 left the room to get incontinence care items to assist Resident #25 when she was finished toileting. After leaving the room, Resident #25's roommate yelled to state Resident #25 fell in the bathroom. Staff immediately went back in and found Resident #25 on the floor with blood coming from the right side of her head. EMS were called and the resident remained in the hospital for approximately five days. Review of the MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. Interview with the Director of Nursing (DON) on 11/20/24 at 12:30 P.M. and 1:55 P.M. revealed any resident who was deemed to be confused and/or a fall risk, was not to be left alone while in the bathroom. She confirmed a resident is deemed to be confused when they have a Brief Interview for Mental Status (BIMS) score of 12 or less out of a potential total score of 15. She confirmed Resident #25's BIMS score was five, which identified the resident exhibited confusion. The DON also confirmed Resident #25 was assessed to be a fall risk, because she had a care plan for the possibility of falling. Interview with Corporate MDS Nurse #102 on 11/20/24 at 1:10 P.M. confirmed if a resident was assessed/deemed to require one person assistance for toilet use via their MDS assessment, staff should not leave the resident on the toilet alone. Interviews with CNA #103, Licensed Practical Nurse (LPN) #104, and CNA #105 on 11/20/24 at 1:25 P.M. and 1:31 P.M. confirmed if a resident was at risk for falls, staff were not to leave the room if a resident was using the bathroom. If the resident asked for privacy, they were to go outside of the bathroom door, remain in the resident's room, and leave the bathroom door cracked so they could respond immediately if there is an issue. Review of facility Fall Management Guidelines, dated 12/13/23, revealed a fall was defined as unintentionally coming to rest on the ground, floor, or other level with or without injury to the resident, but not as a result of an overwhelming force. A fall risk evaluation would be completed for residents upon admission, readmission, quarterly, and with a significant change in condition. The licensed nurse would review the resident's medical record, speak with the resident and/or their representative, and evaluate the resident to determine the resident's fall risk factor. The facility staff, with input of the attending physician, would implement a resident centered comprehensive care plan that addresses the fall management program, the goal for fall management, individualized interventions to address the resident's modifiable fall risk factors, interventions to try to minimize the consequences of risk factors that are not modifiable, and the plan for reduction of risk and or risk for injury related to falls. This deficiency represents non-compliance investigated under Complaint Number OH00159691.

Based on record review, interview, observation and review of the facility Corporate Policy and Procedure on Skin Care, the facility's failure to consistently and accurately assess, monitor and implement interventions for skin breakdown resulted in actual harm to one of two residents (Resident #20), with the developement of an avoidable, unstageable pressure ulcer to the sternum. The facility also failed to ensure interventions were in place and assessments were accurate to promote the healing of a pressure ulcer for Resident #6. This affected two residents (Resident #20 and Resident #6) of three residents reviewed regarding pressure ulcers of three residents identified with pressure ulcers. The census was 64. Findings include: 1. Record review for Resident #20 revealed he was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a Minimum Data Set Assessment (MDS), dated [DATE], revealed the resident scored a 7 out of 13 on a Brief Interview for Mental Status assessment (impaired cognition). Further review of the MDS revealed Resident #20 required extensive assistance for bed mobility, transfers, dressing and hygiene. The MDS further revealed the resident was at risk for developing pressure sores, however, no pressure sores were present on admission. Review of the Plan of Care for Resident #20 related to skin integrity developed on 02/04/13 revealed a goal to have no incident of impaired skin integrity. Approaches to the goal included " Assess skin daily during care". Review of a Nursing Admission Observation form, dated 03/02/13, revealed Resident #20 had redness to his left groin and a skin tear to his right elbow. No other areas of skin impairment were noted. Further review of admission nursing progress notes dated 03/02/13 at 3:04 P.M. revealed the resident was noted with his neck to be in a chin tuck position and tilted to the right side. Review of facility Braden Skin Risk Assessments for predicting pressure sores revealed on 03/02/13 and on 03/08/13 Resident #20 was assessed a score of "16" (indicated a low risk for pressure sores). On 03/16/13 and 03/22/13 the resident was assessed as a moderate risk for skin impairment. Review of skilled nursing progress notes (General Nurse's Observation) revealed on 03/14/13 there was no evidence of skin breakdown to Resident #20' s sternum. Review of a nursing skin condition report dated 03/20/13 revealed a new pressure ulcer was present on Resident #20's sternum. The report revealed the area was unable to be accurately staged due to slough and/or eschar covering the area (dead tissue). The skin report revealed the wound was not present on admission and was an unstageable area noted to the upper chest area from the resident's chin lying on his chest as a result of his neck deformity/unnatural curvature of the spine. The area measured 1.5 (centimeters-cm) long by 1.5 cm. wide and the wound bed was slough covered, moist, and with a very scant amount of drainage. The skin area around the wound was described as red and with some discomfort noted when touched. The note stated the resident does utilize a soft neck brace when up in his chair to provide better neck positioning. The physician and family were notified and treatment orders were obtained from the physician. Further review of nursing skin condition reports revealed on 03/27/13 the wound remained unstageable and covered with slough tissue and measured 1.9 cm. by 1.9 cm. by 0.1 cm (deep). Odor was present and the physician was notified and ordered a culture of the pressure ulcer site. New treatment orders were also obtained for the wound. Review of laboratory results revealed a culture of Resident #20's pressure ulcer was obtained on 03/28/13 and on 04/01/13 the result of the culture revealed heavy growth of [MEDICAL CONDITION] (MRSA-a difficult to treat bacteria due to antibiotic resistance). Review of physician orders [REDACTED]. Further review of a nursing skin condition report revealed on 04/03/13 Resident #20's chest pressure ulcer remained unstageable, slough covered, measured 2.0 cm by 2.4 cm. by 0.2 cm. and had a moderate amount of yellow green drainage and odor present. The report revealed the resident remained on antibiotic therapy [MEDICAL CONDITION] to the wound and utilized a soft neck collar for positioning of the neck and to aid in relieving pressure to the site. The skin condition report further revealed the treatment to the pressure ulcer had been changed that week and an appointment was scheduled on 04/09/13 with a wound clinic for further follow up and treatment. Observation of Resident #20 revealed the following: On 04/05/13 at 11:40 A.M. Resident #20 was observed in a specialized wheelchair which was slightly tilted back. The resident had a severe neck contracture with his chin resting on his chest. On 04/05/13 at 11:55 A.M. Resident #20 was observed in his specialized wheelchair in his room with a neck collar support in place. The resident stated the collar hurt him. The surveyor alerted a nursing assistant who reported the finding to the floor nurse and the neck collar was removed. Interview with Registered Nurse # 4 at this time revealed the resident does refuse to wear the collar at times. On 04/05/13 at 12:25 P.M. and 2:35 P.M. Resident #20 was observed with his neck collar in place. On 04/06/13 at 2:00 P.M. Resident #20 was observed in bed. His neck collar was off and lying on his chest. On 04/06/13 at 3:30 P.M. Resident #20 remained in bed with his neck collar off, but positioned loosely under his chin. On 04/06/13 at 4:15 P.M. Resident #20 was observed up in his specialized wheelchair in the dining room with a glass of thickened juice. His brace was off while he was consuming fluids. On 04/06/13 at 4:55 P.M. pressure ulcer care for Resident #20 (completed by facility RN #3 and facility Assistant Director of Nursing RN #7) was observed. Upon removal of the dressing, a moderate amount of greenish/tan drainage with a small amount of blood tinged drainage was observed on the dirty dressing. RN #3 cleansed the ulcerated area with normal saline. The pressure ulcer measured 2.1 cm. long by 2.4 cm. wide, by 0.1 cm deep. The ulcerated area was a reddish pink color with a scant amount of yellow tissue adhered to the wound bed. RN #7 verified the ulcer was still unstageable due to the yellow tissue (slough) still present to the wound. Review of Nursing Assistant Skin Tool assessment documentation revealed on 02/20/13 a body examination was completed which included observation of red areas, pressure points or open areas. The form indicated to describe if examination noted any problems with the resident's skin. No problems were noted. The next date on the Nursing Assistant Skin Tool was 03/19/13 and completed by Nursing Assistant #6. The description noted an area to the left elbow. (Interview with the DON on 04/9/13 at 9:35 A.M. verified the nursing assistant who completed the Nursing Assistant Skin Tool was not necessarily the nursing assistant who provided the resident his shower that day). The next Nursing Assistant Skin Tool assessment was dated 03/20/13 by Nursing Assistant #16. The description noted a red area under the chin of the resident and a red area on his chest. Review of the staffing schedule and further Interview with the DON on 03/22/13 at 9:40 A.M. verified nursing assistant #16 did not work on 03/20/13 and the form may have been dated incorrectly. The Nursing Assistant Skin Tool described skin problems as the "same as 3-20". The Nursing Assistant Skin Tool had a line indicating "Nurse Initial". There was no evidence of nurse initials on any of the nursing assistant skin tool sheet to indicate they had been reviewed. An interview with Nursing Assistant #16 on 04/06/13 at 3:00 P.M. revealed she had given Resident #20 his bath on 03/20/13 (per review of the shower sheet) and noted a red area under his chin. She stated it was very hard to see the chest area because the resident cannot lift up his chin. She further stated it was hard to observe the area even when you raised his chin because the area was so tight. She stated at that time she reported the chin redness to the nurse. Interview with Occupational Therapy Assistant #100 on 04/10/13 at 10:15 A.M. verified she worked with Resident #20 in occupational therapy. Occupational Therapy notes from 04/14/13 through 04/19/13 revealed he received therapy related to meals and left and right arm range of motion. There was no evidence therapy had visualized the sternum area of Resident #20's chest. Further interview with Occupational Therapist #100 verified with the therapy the resident had received from 03/14/13 through 03/19/13 there would not necessarily have been opportunity to observe the resident's area of skin breakdown. Interview with the Director of Nursing (DON) on 04/06/13 at 2:20 P.M. verified a Braden skin assessment is completed upon admission of a resident and for the first four weeks. She further verified nursing assistants are to report any change noted in skin condition of a resident to the nurse. The DON further verified there was no evidence the pressure area on Resident #20's chest was observed or reported until 03/20/13 when found as an unstageable, slough covered ulcer. The DON verified the resident was identified [MEDICAL CONDITION] in the wound on 04/01/13. Further interview with the DON on 04/07/13 at 3:00 P.M. verified no other shower sheets (Nursing Assistant Skin Tool) could be located from the resident's readmission to the 03/19/13 and the identification of the red area under the chin of Resident #20 was documented on 03/20/13. Interview with facility Clinical Coordinator Licensed Practical Nurse (LPN) #10 on 04/08/13 at 8:00 A.M. verified the nursing assistants are to document on the Nursing Assistant Skin Tool when they provide bathing care to the resident's. She further verified the unit nurse is responsible to review and initial the skin tool. Clinical Coordinator #10 verified the required Nursing Skin Assistant Tool was to be completed on bath days (two times a week) was only completed on 02/20/13 and not again until 03/19/13 and no facility nurse had initialed or signed off that the review of the skin tool. Interview with the facility Medical Director #111 on 04/09/13 at 8:53 A.M. revealed he believed the pressure ulcer area on Resident #20's sternum was first noted when it was red. He stated he would not have anticipated the area would have a skin breakdown. The Medical Director verified a slough covered ulcer would not occur overnight. The Medical Director further stated the area should be identified by the staff with bathing. Further interview with Medical Director #111 verified there were no physician progress notes [REDACTED]. The Medical Director did have hand written notes from 03/28/13 indicating he did see Resident #20 (not part of clinical record as of time of interview), however, verified had had not documented a description of the wound appearance. Review of the facility Corporate Policy and Procedure on the Skin Care Program (revised 10/28/11) revealed Standard Procedure to include the following: Step Number 3 - The STNA's (State tested Nursing Assistant) will utilize the "Nursing Assistant Skin Tool" when giving a resident a bath or shower, and then the charge nurse will review (both the resident and form) and co-sign the skin tool. This will be completed twice a week per Bath Schedule or more often per the digression of the DON. The tool will be kept at the Nurses Station in a Notebook for easy access. This tool when completed will become part of the over flow chart then the Medical Record. 2. Resident #6 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Observation Record dated 12/17/12 revealed the resident had a bruise to her left and right hand, reddened sacrum, right heel with a scab, left heel mushy and a scab to her right middle calf, skin was noted to be pale, dry and warm. Mobility status was marked as unsteady gait. Skin treatment listed devices for bed and chair and turning/repositioning. The resident was identified on admission with a mushy left heel and admitted with an unstageable pressure ulcer to the right heel and right calf. Review of the progress note dated 01/06/13 at 11:00 by LPN #55, actual entry date 01/07/13, revealed treatment continued to the right lateral aspect of her lower leg and also to the inside of her right knee and her right heel. No changes observed. Moon boots in place and her lower extremities were elevated. This nurse observed left heel to be beefy red in color with a small area that was blackened in color, no drainage observed. The site was cleaned with normal saline, skin prep applied and then covered with a dry dressing. The resident was scheduled for an outpatient wound clinic. There were no measurements of the area that was identified on 01/06/13 and not entered in the progress notes until 01/07/13. Review of the skin condition report without images dated 01/09/13, revealed the following: "new present on the left heel is a pressure ulcer. Unable to accurately stage - Slough and/or eschar covered. Length in centimeters (cm) = 5, Width in cm = 4, Depth in cm = 0. Skin is not blancheable, no odor is apparent, no drainage is apparent, physician notified of the present status of this site. This wound was not present on admission." General Comments: "Resident presents with an unstageable, (Pressure ulcer is known but not stageable due to non-removable dressing/device or due to the coverage of the wound bed by slough or eschar) area to left heel measures 5 x 4 cm. No drainage. Skin black eschar to center of wound measures 2 x 2 cm. Heel does not blanch. Resident denies pain. Treatment, pad and protect. Heels floated per staff. Soft, Sage boots in place. Will monitor, family and physician aware." Observation on 04/06/13, at 2:00 P.M. revealed the resident was lying in bed, nursing assistant #33 pulled the sheet back with the resident's permission to observe her heel and there was no heel protector or lift on the heel. The resident had nothing on her foot or heel and the heel was not elevated off the mattress. There was a pale green/blue circular padded heel protector in the bed but not placed on the residents foot. The entire left heel was deep maroon/purple in color with a dark brown eschar/scab approximately 1.5 cm - 2 cm circular area on the back of her heel in the center of the maroon/purple area. Resident stated it hurts off and on but was not hurting at the time of this observation. Review of the Treatment Administration Record for December revealed the only intervention for the left mushy heel was an air mattress. There was no evidence of offloading or floating heels off the mattress on a consistent basis. There was no order or evidence that staff were offloading the heels off the mattress. There was an order for [REDACTED]. The facility was using a Spenco foot pillow which did not lift the heels or offload the heels off the mattress. Interview with LPN #4 on 04/07/13 at 8:44 A.M. was asked why the notes state this pressure ulcer was not present on admission, she stated it was probably clicked on in the computer by accident and once it is in there that way it cannot be corrected and every assessment would be incorrect after that. She stated there was no way to correct this in the computer. She did not know why the mushy heels on admission were not measured and/or monitored. She confirmed the Nursing assistant skin tools were not completed twice a week by the nursing assistants on the resident's bath days. She also confirmed the nurses were supposed to initial these sheets indicating they reviewed them and the sheets all did not have the nurse's initials on them. She confirmed the monitoring tool by the nursing assistants was incorrect because all of the ones that were done did not state the resident had any open areas. She confirmed there were many of the monitoring tools that were not completed. She stated these were to be done twice a week on the resident's bath days. She confirmed there were no measurements on admission regarding the mushy left heel and no measurements on 01/07/13 when the unstageable left heel ulcer was found by the nurse. She stated the nurse probably just decided to wait until Wednesday because that is when the skin areas are routinely measured. She stated the area should have been measured when it was identified. Review of the Nursing assistant skin tools from admission to present, revealed 19 skin assessment tools were not completed at all and 11 were completed. Of the 11 that were completed, none indicated the resident had any skin breakdown at all. The nurses did not sign/initial all of the skin assessments. Interview with the Director of Nursing on 04/07/13 at 10:45 A.M. revealed the sage boot that had been signed off by the nurses was not the boot that the resident had been wearing. She stated the resident had been wearing a Spenco foot pillow and provided literature with a picture. The Sage boot literature that was ordered revealed the boot helped to prevent heel ulcers by completely offloading the heel, delivering total continuous pressure relief. She also confirmed the boot/pillow they were using did not completely relief pressure and was what they have been using for her heels. Interview on 04/08/13 at with Doctor of Physical Therapy (DPT) #99 revealed the facility could use pillows to offload heels from the mattress. She stated in the supply room there was another type of device that could be used to offload the heels. She stated they could order a specialized PRAFO (pressure relief ankle foot orthosis) boot that completely lifts the heel or suspends the heel off the mattress. She confirmed that the foot pillow described to her by the surveyor that the resident is wearing does not offload pressure from the heels. On 04/09/13 at 9:00 A.M., interview with physician #111 revealed the resident was admitted with a fracture and had severe [MEDICAL CONDITION]. She had to have her right leg amputated due to non-healing. He stated he prefers staff to elevate the feet with the heels completely off the mattress.

Based on observation, review of the clinical record, staff interview and review of the fall policy and procedure, the facility's failure to ensure adequate supervision and interventions were implemented resulted in actual harm to one resident (Resident #8), when she fell and sustained a laceration to her forhead requiring sutures. This affected one of three residents reviewed for falls. The facility census was 64. Findings include: Review of the clinical record for Resident #8 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Plan of Care revealed the resident was identified as a fall risk due to impulsiveness. Goal was that resident will be free of falls or injury. Interventions were to assess for fall risk quarterly, assist when rising from sitting to standing position 09/24/12, bed and chair alarm sensor 09/24/12, call light, deep perimeter mattress, properly fitting shoes, glasses, fall matt beside bed and at foot of bed 9/24/12. Review of the physician's orders [REDACTED]. Review of the fall records revealed the resident sustained [REDACTED].M. when she was found on the floor. On 12/07/12 at 6:50 A.M. the resident had a fall with no injury. On 03/31/13 at 3:30 P.M., review of the fall investigation revealed the resident stated that she was trying to go to the restroom. The resident stated that she had gotten up out of bed to use the restroom and fell . The resident was in bed prior to fall. The fall investigation form labeled "medication section" revealed the resident was not on any of the medications listed on the form. There was no other information on the fall investigation. Review of employee statements revealed #1 was not not signed by the staff member and there was no name on the form. The form stated "around 3:30 P.M. today I was in room 406 helping resident into bed, when coming out of the room a coworker was calling me saying that Resident #8 had fell , I went to the room and seen the resident on the floor." Review of statement #2 from State tested Nursing Assistant (STNA) #222 dated 03/31/13 revealed "I was at nurses station and a visitor came up to me and said there is a lady on the floor and blood is everywhere. I went to the room of Resident #8 and she was lying on floor. She was on her side with pants 1/2 on and a cut on her hand and forehead, that I saw. I grabbed a couple pillows to put under her head and went to get nurse." Review of the statement from Licensed Practical Nurse #333 dated 03/31/13 revealed "An aide came and got me stated that Resident #8 was on the floor, when I entered the room bed alarm not sounding, not even on the bed, resident laying on the floor by the door with a laceration to the forehead, put cold compress on the forehead to stop the bleeding, resident attends and pants were at her ankles. Asked resident what happened, resident stated that she was going to the bathroom. Resident was taken to emergency department when resident got back this nurse took the alarm off her wheelchair and put it on the bed, the alarm was turned off and this nurse then turned it on." Review of the progress notes dated 03/31/13 at 5:58 P.M. revealed the resident was laying down after lunch, stated she was getting up to use the restroom, lost her balance and fell . The physician and family were notified, all questions were answered and the resident was transferred to the emergency department for evaluation. The progress note entry at 10:20 P.M. revealed the resident came back from emergency department with sutures. The resident was resting, fall precautions in place and neurological checks were started, call light with reach. There were no further interventions placed on the plan of care after the fall on 03/31/13. Observation on 04/06/13 at 12:30 P.M. revealed the resident was sitting in a wheelchair in the dining room. Chair alarm was on the back of the chair. Resident had several sutures on her forehead and was wearing grippy socks. An interview on 04/08/13 and 9:20 A.M. with the Director of Nursing (DON) revealed she interviewed the nursing assistant and the nursing assistant stated she was not the one that put the resident to bed after lunch. The DON told her that wasn't acceptable and the STNA was educated. The aide that put her to bed after lunch was educated as well. The DON confirmed there was no evidence to indicate whether the matt was on the floor beside the bed, if the resident shoes were on, if she was wearing grippy socks or when she had been toileted last. The DON didn't know what intervention they had put in place after the fall. She confirmed there was nothing recorded in the nurses notes or on the fall investigation of how the resident was treated/evaluated or moved from the floor after the fall and prior to being sent to the emergency department. Further interview with the DON on 04/09/13 at 2:55 P.M., revealed she did discipline the STNA. Review of the disciplinary action revealed the alarm was on the bed but not turned on, which was contradictory to the witness statements.