Every finding on record at New Lebanon Rehabilitation and Healthcare Center

Based on observations, staff interview and policy review, the facility failed to prepare, store, and distribute food in a safe manner. This had the potential to affect all 96 residents who received food from the facility. The facility census was 96Findings include:1.Observation on 09/22/25 at 8:23 A.M. revealed during the initial tour with the DM #155 revealed a swarm of flying gnats throughout the kitchen areas.Interview on 09/22/25 at 8:25 A.M. confirmed the facility has an ongoing issue with fruit flies and gnats. DM #155 stated she will check to ensure she does not have overripe bananas as she peered over a box of bananas and confirmed that is not the issue to cause the active gnats. DM #155 stated the facility has an ongoing issue with active gnats in the kitchen.2. Observation on 09/23/25 at 3:01 P.M. during the observation of purred and mechanical meal preparation revealed active black flies in the kitchen during meal preparation. Interview on 09/23/25 at 3:02 P.M. with DM #155 confirmed the active flies in the kitchen while the staff prepared the dinner meal. Interview with DM #155 on 09/23/25 at 5:20 P.M. confirmed the findings identified on the tray line. The facility confirmed all 96 residents residing in the facility receive their meals from the kitchen.Review of the facility policy titled Food Handling dated September 2021confirmed food will be stored, prepared, handled, and served so the risk of food borne illness will be minimized. This deficiency represents noncompliance investigated under Complaint Numbers 1260765 (OH00161730) and 1260763 (OH00161206).

Based on medical record review, observation, staff and resident interviews, and policy review, the facility failed to provide medical records to a resident upon his or her request. This affected one (#37) out of one residents reviewed for medical record request. The facility census was 96.Findings include:Medical record review for Resident #37 revealed she was admitted to the facility on [DATE]. Her diagnoses included candidiasis, multiple sclerosis, obstructive sleep apnea, obesity, essential primary hypertension, anemia, anxiety, post-traumatic stress disorder, asthma, major depressive disorder, and chronic obstructive pulmonary disease (COPD). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 37 was cognitively intact. Resident #37 was dependent on staff for medication administration. Resident #37 is independent with eating, upper body dressing, and personal hygiene. She required assistance with oral hygiene and supervision with toilet use, bathing, and lower body dressing. Interview on 09/24/25 at 1:33 P.M. with Resident #37 revealed she requested a copy of her medical records on 03/09/25, however, she has never received a copy of the records. Resident #37 stated she was told by the Medical Records Manager (MRM) #218 manager that the copy machine was broken, however, once repaired she would have copies. Interview with the MRM #218 on 09/24/25 at 3:17 P.M. confirmed Resident #37 had asked for medical records on 03/09/25. MRM #218 stated she told Resident #37 the copier was broken and MRM #218 confirmed she told Resident #37 she could have copies of Resident #37's medical records once it was repaired. However, MRM #218 pointed at a pile of records on a desk and revealed Resident #37 had never ask for her records again, so the record have been in the office. MRM #218 confirmed she had not offered the records to Resident #37 since the copier was repaired on 03/09/25. Observation on 09/24/25 at 3:17 P.M. revealed a stack of medical records copied for Resident #37 that had not been distributed to Resident #37. Review of the facility policy titled Release of Information dated September 2021 confirmed a resident has the right to access his/her medical records at any time.

Based on record review, resident, family and staff interviews, review of the grievance log, and policy review, the facility failed to complete thorough investigations for complaints of missing items. This affected one (#76) of two residents sampled for missing items. The facility census was 96.Findings include:Review of the medical record revealed Resident #76 was admitted to the facility on [DATE]. Diagnoses included morbid obesity, type II diabetes, unspecified anxiety disorder, and stage III chronic kidney disease.Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #76 was cognitively intact, had no behaviors, did not wander, and did not reject care. Review of the medical record revealed Resident #76 had no documented inventory list. Review of facility grievance log dated January 2025 to September 2025 revealed no entries for resident concerns or grievances. Review of handwritten document titled Clothing Inventory dated April 2025, updated May 2025, revealed a list of clothing including four (4) 2X long sleeved blouses, four (4) 2X solid-colored T-shirts, five (5) 2X with printed shirts with short sleeves , two (2) (2X solid-colored 3/4 sleeve shirts, four (4) 3X patterned shirts with 3/4 sleeves, three (3) 3X patterned gowns, six (6) white bras 42C, ten (10) pairs of socks, two (2) pairs solid-colored cotton capris, two (2) 2X leggings, one (1) 3X pair Mauve leggings, three (3) pairs jeans, six (6) sets 2X patterned pajamas, and one (1) Navy cable-knit sweater. Check marls were noted beside items including each of three (3) gowns and one (1) 2X pair of leggings described as gray with purple flowers. Review of handwritten document titled Woman Within 1(800) [PHONE NUMBER] Order Missing Clothing, no date, revealed a list of clothing items described by color and size, catalog order numbers, prices, tax, and shipping information. The ten items listed totaled $319.49.Review of handwritten document titled New Clothing Inventory revealed clothing items including five (5) bras, one (1) pair black capris with floral pattern, one (1) pajama set with moon and stars pattern, and four (4) 1X pairs leggings of various solid colors and patterns. Beside each item was a date ranging from 08/12/25 to 09/17/25.Review of handwritten document titled Missing Clothing, no date revealed items with dates including 08/12/25 Playtex 18-hour bra and 08/20/25 PJ top French blue with moon and stars. During an interview on 09/22/2025 at 3:18 P.M. Resident #76 stated she first noticed she had clothing missing while she was residing in the locked unit. The resident stated she [NAME] all her clothing from Woman Within catalog and had about $600 of stuff disappear. Resident #76 stated she reported the missing items to Social Services (SS) In April, who stated the items were sent home with family. The resident denied sending the items home and stated the facility did nothing further to investigate and refused to reimburse or replace the items. Resident #76 stated she provided SS a list of missing items and a list of items the facility could purchase to replace the missing items. Resident #76 stated since the incident has kept an inventory of clothing and continues to have items missing. Resident #76 stated she had a brand new white bra and a pajama top described as blue with [NAME] and stars pattern missing since August. Resident #76 stated the facility did her laundry and all clothing items were labeled with her full name. She described clothing items missing since April including one (1) Blue sweater, one (1) set pajamas mixed with love , one (1) set pajamas purple coffee please with coffee cups, one (1) set pajamas pink and blue flowers, three (3) nightgowns - spring colors, one (1) blouse tan with white insert, one (1) blouse lilac floral design, one (1) blouse Navy with stars, one (1) blouseshort-sleeved with navy and aqua bulbs, one (1) blouse lavender with purple flowers, four (4) solid-colored leggings, and one (1) leggings with floral pattern.During an interview on 09/23/2025 at 4:24 P.M. the Administrator confirmed Resident #76's family had reported clothing items were missing. The facility asked Resident #26's spouse to provide a list of missing items and never received a list. The Administrator stated the spouse continued to visit several times a week and never mentioned the missing items again. The administrator stated he did not follow up any further. During an interview on 09/25/2025 at 11:41 A.M. SS #231 verified she had six (6) copies of Resident #76's list of missing items. SS #231 stated Resident #231 approached her in May with a list of missing clothing items and gave a different list every day for three days. SS #231 looked in Resident #76's room and laundry and found some of the clothing. SS #231 marked off what was found on the list. SS #231 advised Resident #76 to speak to her husband about items potentially sent home or recently donated. SS #231 stated she never heard anything else about the remaining items and never followed up with Resident #76 or her husband to ensure the issue was resolved. SS #231 stated she assumed the issue was resolved since it was not mentioned again. During an observation on 09/25/2025 at 12:01 P.M. SS #231 showed Resident #76 the handwritten list titled Missing Items Resident #76 reviewed the list and verified to SS #231 the unchecked items on the list were still missing. During a telephone interview on 09/25/2025 at 12:10 P.M. revealed Resident #76's spouse stated he had purchased a bunch of clothing for Resident #76 from Woman Within, due to her size. The family labeled her clothing with her name. The facility did her laundry, and items kept coming up missing. The spouse stated he talked to the Administrator a few months ago, and he said they would check on it. The spouse stated Resident #76 had provided the facility a list of the missing clothing items. The family did not hear anything back, and the next time the spouse spoke to the Administrator, he said the facility would not reimburse for the clothing. The spouse stated the facility had always done Resident #76's laundry. He denied taking large amounts of clothing home with him and stated he had taken home a blouse and a pair of shoes to spot clean them since they did not provide stain removal services. The family had to replace all of Resident #76's missing clothing, worth around $600. During an interview on 09/25/2025 at 3:02 P.M. the Director of Nursing (DON) confirmed Resident #76 did not have a list of personal items and her concerns for missing items was absent but should have been listed on the grievance log. Review of policy titled Resident Grievances and Concerns dated 09/2021 revealed residents had the right to make complaints and voice grievances about any concern regarding the resident's stay. Upon receipt of any oral, written, or anonymous grievance submitted, the facility took immediate action to complete a timely investigation and prevent further potential violations.This deficiency represents noncompliance investigated under Complaint Numbers 2630213, 2618777, 2574379, 1260775 (OH00165907), 1260773 (OH00165246) and 1260770 (OH00163975).

Based on medical record reviews, staff interviews, and policy review, the facility failed to develop comprehensive person-centered care plans. This affected two (#49 and #76) residents out of 23 residents reviewed for comprehensive person-centered care plans. The facility census was 96. Findings include: 1.Review of the medical record for Resident #49 revealed an admission date of 02/04/25 with medical diagnoses of cerebral infarction, diabetes mellitus (DM), psychotic disorder with delusions, vascular dementia and hypertension (HTN). Review of the medical record for Resident #49 revealed a quarterly Minimum Data Set (MDS) assessment, dated 08/13/25, which indicated Resident #49 was cognitively intact and was independent with eating, bed mobility, and transfers, and required partial/moderate staff assistance with toilet hygiene and bathing. Review of the medical record for Resident #49 revealed a Smoking assessment dated [DATE], which indicated resident #49 was an unsupervised smoker. Review of the medical record for Resident #49 revealed a care plan, dated 07/27/25 which stated Resident #49 was a smoker and interventions included to monitor the resident's safety during smoking. The care plan did not have documentation to support Resident #49 was an independent smoker or where smoking materials are to be kept. Interview on 09/25/25 at 12:15 P.M. with Registered Nurse (RN) #194 confirmed Resident #49's smoking care plan did not include documentation to support Resident #49 was independent with smoking or where smoking supplies should be kept. 2. Review of the medical record revealed Resident #76 was admitted to the facility on [DATE]. Diagnoses included morbid obesity, type II diabetes, unspecified anxiety disorder, and stage III chronic kidney disease. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #76 was cognitively intact, had no behaviors, did not wander, and did not reject care. Resident #76 required maximum assistance with bathing. Review of care plan dated 04/01/2025 revealed Resident #76 had an ADL self-care performance deficit. Interventions included assisting with ADL's as needed. Resident #76 was independent with eating and bed mobility and required two-person assistance with toileting and transfers. There was nothing specific to level of assistance needed with bathing or personal hygiene in the care plan. During an interview on 09/25/2025 at 10:24 A.M. RN #194 verified Resident #76's care plan did not specify Resident #76's level of assistance needed for bathing. Review of policy titled Care Plans, Comprehensive Person-centered dated 09/2021 revealed care plans described services furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on review of the medical record, observations, resident and staff interviews, and policy review, the facility failed to ensure residents received showers. This affected three (#76, #37, and #92) of ten residents sampled for bathing assistance. The facility census was 96. Findings include: 1. Review of the medical record revealed Resident #76 was admitted to the facility on [DATE]. Diagnoses included morbid obesity, type II diabetes, unspecified anxiety disorder, and stage III chronic kidney disease. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #76 was cognitively intact, had no behaviors, did not wander, and did not reject care. Resident #76 required maximum assistance with bathing. Review of care plan dated 04/01/2025 revealed Resident #76 had an ADL self-care performance deficit. Interventions included assisting with ADL's as needed. Resident #76 was independent with eating and bed mobility and required two-person assistance with toileting and transfers. There was nothing specific to level of assistance needed with bathing or personal hygiene in the care plan. Review of task report dated June 2025 revealed Resident #76 had three showers documented in the month of June on 06/21/25, -6/25/25, and 06/28/25. Review of task reports dated April and May 2025 revealed Resident #76 no documentation related to bathing or showers. Review of shower sheets revealed Resident #76 received assistance with bathing on 04/02/25, 04/20/25, 06/28/25, 07/02/25, 07/09/25, 07/12/25, 07/16/25, 07/23/25, 07/26/25, 07/30/25, 08/02/25, 08/06/25, 08/12/25, and 08/15/25. During an interview on 09/22/2025 at 3:31 P.M. Resident #76 stated she had an issue, while she resided in the locked unit, during which she went 12 weeks without a shower. Resident #76 stated two young men on night shift repeatedly refused to give her a shower. Resident #23 stated she reported her concerns to the DON, but nothing changed until she was moved to a new unit. During an interview on 09/24/2025 at 10:14 A.M. the Director of Nursing (DON) stated Resident #76 complained to her in the beginning of May of not getting showers. The DON verified there were no shower sheets or documentation showing that Resident #76 received showers from 04/20/25 to 06/20/25. 2. Review of medical record for Resident #37 revealed admission date of 08/06/24. The resident was admitted with diagnoses including Multiple Sclerosis, Morbid Obesity, Chronic Obstructive Pulmonary Disease Asthma, urinary retention and major depressive disorder. The resident remained at the facility. The annual Minimum Data Set (MDS) dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. No behaviors were documented. She required set up assistance with toileting hygiene and was independent with eating, bed mobility and transfers. Record review of the electronic charting revealed documentation of independent bathing for Resident #37 on 09/07/25. Review of the shower sheet documentation revealed a shower was completed for Resident #37 on 09/05/25 and 09/19/25. A shower was documented as refused on 09/23/25. Interview on 09/29/25 at 1:52 P.M. with Resident #37 revealed she was scheduled for showers twice a week and voiced a concern did not always receive them. Interview on 09/29/25 at 3:24 P.M. with the Director of Nursing (DON) verified Resident #37 should receive bathing assistance twice weekly. The DON acknowledged the facility had documentation Resident #37 had received three showers and refused one from 09/01/25 through 09/29/25. 3. Review of the medical record for Resident #92 revealed an admission date of 01/29/25 with medical diagnoses of necrotizing fasciitis, chronic obstructive pulmonary disease, left spastic hemiplegia, cerebral infarction, and bipolar disorder. Review of the medical record for Resident #92 revealed a quarterly MDS assessment, dated 08/07/25, which indicated Resident #92 was cognitively intact and required substantial/maximum staff assistance with bathing/showers, partial/moderate staff assistance with transfers, and was dependent upon staff for toilet hygiene. Review of the medical record for Resident #92 revealed the August 2025 shower sheets which indicated Resident #92 did not receive his shower as scheduled on 08/07/25 due to short staffed. Review of Resident #92's shower sheets for September revealed documentation to support Resident received showers as scheduled. The shower sheets did not contain documentation to support the if facility staff shaved Resident #92. Interview with observation on 09/22/25 at 10:00 A.M. with Resident #92 stated he didn't get his showers as scheduled and they don't shave his face with showers. Resident #92 stated his face had not been shaved in several days. Observation of Resident #92 revealed facial hair stubble. Interview on 09/25/25 at 2:59 P.M. with Director of Nursing confirmed Resident #92 did not receive a shower as scheduled on 08/07/25. Review of the facility policy titled, Activities of Daily Living (ADLs) stated residents who are unable to carry out ADLs independently would receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The policy stated hygiene included bathing, dressing, grooming, and oral care. This deficiency represents non-compliance investigated under Complaint Numbers 2618777, 2582623, 1260777 (OH00167022), 1260775 (OH00165907), 1260770 (OH00163975), 1260768 (OH00163266), 1260767 (OH00163258) and 1260766 (OH00162690).

Based on medical record review, observations, staff interview, and policy review, the facility failed to provide activities designed to meet resident needs. This affected one (#29) resident of one resident reviewed for activities. The facility census was 96.Findings include:Review of the medical record for Resident #29 revealed an admission date of 08/20/18 with medical diagnoses of major depression, chronic obstructive pulmonary disorder, vascular dementia, and right sided spastic hemiplegia. Review of the medical record for Resident #29 revealed an annual Minimum Data Set (MDS) assessment, dated 07/11/25, which indicated Resident #29 had severely impaired cognition and was dependent upon staff for all activities of daily living. Further review of the MDS revealed Resident #70's indicated it was somewhat important to have books, newspapers, magazines to read, and to listen to music and it was very important to keep up with the news, do things with groups of people and do his favorite activity. Review of the medical record for Resident #29 revealed an at risk for altered activity [NAME] care plan related to bedfast, decreased in activity participation. The care plan indicated Resident #29 preferred independent activities but did not include the activities.Review of the medical record for Resident #29 revealed the August 2025 activity log which indicated Resident #29 refused one-on-one activity and group activities on 08/08/25 and participated with group activity on 08/12/25. Review of the August activity log revealed no other documentation to support Resident #29 was offered or participated in any other activities throughout the month. Review of Resident #29's September 2025 activity log revealed documentation to support Resident #29 was offered and participated with activities on 09/09/25, 09/10/25, 09/12/25, and 09/19/25. Review of the September activity log revealed no other documentation to support Resident #29 was offered or participated in any other activities throughout the month.Random observations made on 09/22/25 between 8:00 A.M. and 3:00 P.M. revealed Resident #29 had remained in bed, and no activities were noted. The observations revealed Resident #29 did not have the television on or music playing, no magazines, books or newspapers were present.Random observations made on 09/23/25 between 8:00 A.M. and 2:30 P.M. revealed Resident #29 remained in bed, and no activities were noted. The observations revealed Resident #29 did not have the television on or music playing, no magazines, books or newspapers were present. Observation on 09/23/25 at 3:00 P.M. revealed Resident #29 sitting in his wheelchair at the nurse's station. Interview on 09/25/25 at 8:19 A.M. with Activity Director (AD) #199 stated Resident #29 preferred independent activities and at times Resident #29 would sit at the nurse's station or sit in on group activities. AD #199 confirmed Resident #29 had severely impaired cognition and that Resident #29's preferences on the annual MDS assessment dated [DATE] were taken from past MDS assessments. AD #199 confirmed she had not contacted Resident #29's family to obtain activity preferences. AD #199 confirmed the facility did not have documentation to support Resident #29 was offered activities daily in August or September 2025. AD #199 also confirmed the activity staff are to offer one-on-one activities when residents refuse group activities.Review of the facility policy titled, Activities stated the facility would provide, based on comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities , both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. The policy stated for residents who have dementia preferences would be determined through communication with the residents, family, friends, and caregivers.

Based on medical record review, staff interviews, and review of facility timeline documentation, the facility failed to provide adequate interventions and/or supervision to ensure a resident who was assessed as being at risk for elopements did not elope from the facility. This affected one (#70) resident out of three residents reviewed for accidents. The facility census was 96.Findings include:Review of the medical record for Resident #70 revealed an admission date 06/20/25 with medical diagnoses of schizoaffective disorder, hypertension, dementia without behavioral disturbances, and bipolar disorder. The medical record indicated Resident #70 was sent to the hospital on [DATE] for behavior issues and returned to the facility on [DATE]. The medical record indicated Resident #70 discharged to another nursing facility on 09/12/25. Review of the medical record for Resident #70 revealed an admission Minimum Data Set (MDS) assessment, dated 06/26/25, indicated Resident #70 had severely impaired cognition and required supervision with bathing, toilet hygiene, and transfers. The MDS did not indicate Resident #70 had any behaviors. Review of the medical record for Resident #70 revealed a physician order dated 06/23/25 which stated resident had a mental disorder with behavioral disturbance and met the criteria for placement on the mental health unit and would benefit from the structure and activity-based care philosophy. Review of the medical record for Resident #70 revealed an elopement evaluation dated 08/06/25 which indicated Resident #70 was a high risk for elopement. Review of the medical record for Resident #70 revealed an at risk for elopement care plan related to exit seeking behaviors dated 07/14/25. The interventions included to calmly redirect, to distract resident, to promptly check when the alarm system goes off to ensure resident was safe and remained in the facility, resident was not to be taken off the unit for activities, and to encourage resident's family to not take resident off the unit. Review of the medical record for Resident #70 revealed a nurses' note dated 08/07/25 at 9:00 P.M. which stated Resident #70 was found in the lounge pushing on the courtyard door setting off the alarm while he was trying to get out. The note stated Resident #29 succeeded in opening the door and started to go outside but staff were able to get Resident #70 back into the facility. Further review of a nurse's note, dated 08/08/25 at 2:00 P.M., stated the Administrator was alerted that Resident #70 went out the front door and was walking down the sidewalk with two staff members directly behind him. The note stated the police were called and able to get Resident #70 back into the facility. Review of the nurses' note dated 08/11/25 at 11:25 A.M. stated Resident #70 was observed kicking on the exit door and staff attempted to redirect the resident. The note stated staff sat with Resident #70 in the courtyard and supervised Resident #70 smoking. Review of a nurses' note dated 08/11/25 at 1:12 P.M. stated Resident #70 pushed his way out the smoking exit door several times during the morning and Resident #70 tried to jump the fence in the smoking area. The note stated Resident #70 was redirected with extra smoke breaks but continued to exit seek. The note stated new orders for Ativan (antianxiety medication) 0.5 milligram (mg) one time along with Zyprexa (antipsychotic medication) 5 mg one time only were given. Review of a note dated 08/11/25 at 4:15 P.M. stated Resident #70 continued to aggressively exit seek by pushing on doors. The note stated non-pharmacological interventions and medications were not effective. The note stated an order was received to pink slip Resident #70 to a behavioral hospital. Review of a nurse's note dated 08/11/25 at 7:51 P.M. stated at 5:45 P.M. staff were alerted by an alarm going off at the end of the unit and that Resident #70 had exited the building. The note stated staff members did not see which direction Resident #70 went and staff began looking for Resident #70. The note stated the Administrator and police were notified. The note continued to state Resident #70 was found within 50 feet of the facility hiding behind bushes. Resident #70 was placed on one-on-one supervision, skin assessment was completed with no injuries noted, and no complaints of pain noted. A note dated 08/12/25 at 2:52 A.M. stated Resident #70 was sent to a behavioral hospital. Review of the facility timeline for Resident #70's elopement on 08/11/25 revealed the Resident #70 eloped from the mental health unit at 5:45 P.M. and was found at 6:45 P.M. The timeline indicated Resident #70 was evaluated by Emergency Medical Services at 6:50 P.M. and returned to the facility at 7:15 P.M. The timeline indicated Resident #70 was placed on one-one one supervision at 7:15 P.M. and discharged to the behavioral hospital on [DATE] at around 3:00 A.M.Interview on 09/29/25 at 9:46 A.M with Licensed Practical Nurse (LPN) #212 confirmed she was the nurse on the Mental Health Unit on 08/11/25 and that she was notified by staff that Resident #70 had eloped from the unit. LPN #212 confirmed Resident #70 had tried to leave the facility multiple times during the day on 08/11/25. LPN #212 stated the interventions in place at the time of Resident #70's elopement was for staff to provide redirection and for staff to keep a close eye on him. LPN #212 confirmed Resident #70 was not placed on one-on-one supervision until after his return to the facility on [DATE]. Interview on 09/29/25 at 10:06 A.M. with Administrator and Director of Nursing (DON) stated Resident #70 was on frequent staff checks on 08/11/25 due to his increase in behaviors. DON confirmed Resident #70 had not been placed on one-on-one supervision until after his elopement on 08/11/25. DON confirmed Resident #70 eloped from the facility on 08/11/25 at 5:45 P.M. and stated staff were unable to determine which direction he had gone because Resident #70 was fast and ran out of their site. DON confirmed Resident #70 was found on 08/11/25 at 6:45 P.M. in the bushes about 50 feet behind the building. DON confirmed Resident #70 was assessed and had no injuries noted. Administrator confirmed the facility elopement policy only indicated the process to following a resident elopement.This deficiency represents non-compliance investigated under Complaint Number 2574379.

Based on review of the medical record. staff interview and review of guidelines from the National Institute of Health, the facility failed to ensure non-rebreather masks were used according to professional standards. This affected one (#108) of one residents sampled for respiratory services. The facility census was 96.Findings include:Review of the medical record revealed Resident #108 was admitted to the facility on [DATE] and expire in the facility on 02/27/25. Diagnoses included type II diabetes, stage III kidney disease, and unspecified dementia. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #108 had moderately impaired cognition, had verbal behaviors, did not wander, and did not reject care. Review of care plan dated 12/16/2021 revealed Resident #108 had impaired respiratory status. Interventions included administer medications as ordered, change oxygen tubing weekly, monitoring for symptoms of respiratory distress, monitoring vital signs with pulse oximetry every shift and as needed, provide oxygen as ordered and titrate to keep saturation rates higher than 90%. Review of the medical record revealed Resident #108 had a physician order dated 02/27/205 at 6:34 P.M. for oxygen at 5 Liters per minute via non-rebreather mask. Review of progress note dated 02/27/25 at 1:11 P.M. while passing trays, a Certified Nursing Assistant (CNA), unspecified, notified Licensed Practical Nurse (LPN) #173 that Resident #108 looked unwell. LPN #173 assessed vital signs and found Resident #108 had oxygen saturation levels in the 60% range on 2 Liters of oxygen per minute via nasal cannula. Management was called to assist and the provider was notified. Nurse Practitioner (NP) #83 gave verbal orders for oxygen at 5 Liters per minute through a non-rebreather mask. LPN #173 documented the non-rebreather mask did not fit Resident #108 properly and saturation levels came up to 85%. Resident #108 was sent to the hospital via emergency services. Review of progress note dated 02/27/25 at 6:38 P.M. revealed Resident #108 returned to the facility. Admitting orders included oxygen at 5 Liters per minute via non-rebreather mask. During an interview on 09/25/25 at 3:17 P.M. LPN #210 stated she was called into the room to assist LPN #173 with Resident #108. LPN #210 stated Resident #108 was never completely unresponsive. LPN #210 stated she was aware a non-rebreather mask required high flow oxygen from at least 10 to 12 Liters of oxygen per minute. She stated the facility had concentrators that accommodated high flow oxygen up to 10 liters. LPN #210 verified Resident #108's order on 02/27/25 was for a non-rebreather mask at 5 Liters per minute and that the mask had been placed on the resident as ordered. During a telephone interview on 09/29/2025 at 9:23 A.M. LPN #173 stated she was floor nurse. LPN #173 stated an aide told her around lunchtime resident was not doing well. LPN #173 stated she assessed and had the aide get LPN #210 while she spoke to NP #83 who ordered the non-rebreather mask at 5 LPM. LPN #173 stated she was unaware what oxygen levels were standard of care for non-rebreather mask, and she followed the providers order. LPN #173 stated the non-rebreather mask did not fit properly around the resident's chin due to multiple skin folds in the neck. Staff had to hold the mask in place. During an interview on 09/29/2025 at 11:36 A.M. NP #83 initially stated he would an order for a non-rebreather max at the flow rate that was the maximum flow for Resident #108's concentrator which he believed was 6 liters per minute. He was not aware the facility had concentrators that supported 10 liters of oxygen per minute. He stated he asked the staff how high Resident #108's oxygen concentrator went and would have issued the order for the non-rebreather mask at the highest flow rate his concentrator would allow to raise his saturation levels. The facility did not have a policy specific to Non-rebreather masks. Review of guidelines from National Institute of Health: National Library of Medicine website at https://www.ncbi.nlm.nih.gov/books/NBK593208/table/ch11oxytherapy.T.settings_of_oxygenation/ revealed standard practice demonstrated a non-rebreather mask is to be used with a flow rate of 10 to 15 Liters per minute of oxygen. This deficiency represents non-compliance investigated under Complaint Number 1260767 (OH00163258).

Based on medical record review, staff interview, and policy review, the facility failed to administer medications as ordered. This affected one (#70) out of four residents reviewed for medication administration. The facility census was 96.Findings include:Review of the medical record for Resident #70 revealed an admission date 06/20/25 with medical diagnoses of schizoaffective disorder, HTN, dementia without behavioral disturbances, and bipolar disorder. The medical record indicated Resident #70 was sent to the hospital on [DATE] for behavior issues and returned to the facility on [DATE]. The medical record indicated Resident #70 discharged to another nursing facility on 09/12/25. Review of the medical record for Resident #70 revealed an admission Minimum Data Set (MDS) assessment, dated 06/26/25, indicated Resident #70 had severely impaired cognition and required supervision with bathing, toilet hygiene, and transfers. Review of the medical record for Resident #70 revealed physician orders dated 08/08/25 for lorazepam (antianxiety) 1 milligram (mg) one tablet by mouth at bedtime and an order for trazadone (antidepressant) 50 mg one tablet by mouth at bedtime.Review of the medical record for Resident #70 revealed the August 2025 Medication Administration Record (MAR) which indicated Resident #70 did not receive the lorazepam on 08/08/25 through 08/10/25 and did not receive the trazadone on 08/08/25 and 08/09/25. Interview on 09/29/25 at 1:24 P.M. with Director of Nursing (DON) confirmed Resident #70's medical record did not have documentation to support Resident #70 received the lorazepam on 08/08/25 through 08/10/25 or trazadone on 08/09/25 or 08/09/25 as ordered.Review of the facility policy titled, Administering Medications, stated medications shall by administered in a safe and timely manner, and as prescribed.This deficiency represents non-compliance investigated under Complaint Numbers 1260777 (OH00167022) and 1260763 (OH00161296).

Based on record review, observations, staff interviews and review of facility policy, the facility failed to ensure medications were stored appropriately. This affected two (#15 and #97) of five residents reviewed for medication storage. The facility census was 96. Findings include: Review of medical record for Resident #15 revealed admission date of 03/15/24. The resident was admitted with diagnoses including paraplegia, paranoid schizophrenia, depression, encephalopathy, and hypotension. The resident remained at the facility. The annual Minimum Data Set (MDS) dated [DATE] revealed he had a Brief Interview Mental Status (BIMS) score of 14 indicating intact cognition. He was independent with eating, dependent upon staff with toileting hygiene, bed mobility and transfers. He was documented to have four stage four pressure areas, two were present on admission. Review of Resident #15's medical record revealed there was no physician order, assessment, care plan or other documentation supporting the resident could keep medications at the bedside. Observation on 09/22/25 at 9:58 A.M. in Resident #15's room revealed the bedside table was placed diagonally over his bed. On top of the table a medicine cup was observed containing two round, lightly colored tablets. Observation on 09/22/25 at 10:05 A.M. with Licensed Practical Nurse (LPN) #198 verified the medication was at bedside. LPN #198 asked Resident #15 if the tablets were his TUMS (antacid) and Resident #15 acknowledged they were. LPN #198 informed Resident #15 the medication could not be left on the bedside table and removed the medication cup. Review of the facility policy, Storage of Medication dated 09/01/21 documented drugs would be stored in the packaging, containers, or other dispensing system in which they are received. 2. Review of the medical record for Resident #97 revealed an admission date of 08/21/25 with medical diagnoses of encephalopathy, chronic obstructive pulmonary disease, diabetes mellitus, and psychosis. Review of the medical record for Resident #97 revealed an admission Minimum Data Set (MDS) assessment, dated 08/27/25, which indicated Resident #97 had modified independence with decision making and was independent with eating, bed mobility, and toileting. The MDS indicated Resident #97 required supervision with bathing and received insulin. Review of the medical record for Resident #97 revealed a physician order dated 09/22/25 for Novolog solution 100 unit per ml (insulin Aspart) per sliding scale: if 201-250 = 3 units; 251-299=6 units; 301-350= 9 units; 351-400=12 units; 401-450=15 units, if over 450 to call the physician. Inject subcutaneously before meals and at bedtime. Observation on 09/23/25 at 8:00 A.M. of the North Front medication cart revealed an insulin ASPA (aspart) injection flexpen was unopened and in the top drawer of the medication cart. The insulin flexpen was labeled for Resident #97 and was in a pharmacy bag with a label to refrigerate until it was opened. Interview on 09/23/25 at 8:02 A.M. with Licensed Practical Nurse (LPN) #140 confirmed Resident #97's Insulin flexpen was unopened and not refrigerated. Review of the facility policy titled, Storage of Medications, dated 09/01/21, stated the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The policy stated the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals and all drugs should be returned t the dispensing pharmacy or destroyed. The policy stated each medication requiring refrigeration must be stored in a refrigerator located in the drug room at the nurse's station or other secured location. This deficiency represents non-compliance investigated under Complaint Number 1260763 (OH00161206).

Based on medical record reviews, observations, and resident and staff interviews, the facility failed to maintain a pest free environment. This affected three (#49, #61, and #96) residents out of six residents reviewed for pest control. The facility census was 96. Findings include: 1. Review of the medical record revealed Resident #61 was admitted to the facility on [DATE]. Diagnoses included unspecified psychosis, unspecified schizophrenia, and narcolepsy without catatonia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 had moderately impaired cognition, had verbal behaviors, did not wander, and routinely rejected care. Observation on 09/22/25 at 10:16 A.M. revealed Resident #61 lay in bed in a hospital gown with a sheet covering him. There were two flying insects observed on the the bed sheet, and one flying insect had landed on the privacy curtain. During an interview in 09/22/25 at 10:16 A.M. Activities Director #199 verified Resident #61 had three flying insects flying around his room and landing on the sheet covering his body as he lay in bed. 2. Review of the medical record revealed Resident #96 was admitted to the facility on [DATE]. Diagnoses included unspecified alcohol-induced pancreatitis, essential tremor, and major depressive disorder. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #96 was cognitively intact, had no behaviors, did not wander and did not reject care. Observation on 09/22/2025 at 10:51 A.M. revealed Resident #96 had fly paper hanging from ceiling which contained the bodies of 7 dead insects. Resident #96 had a plastic fly swatter on his bed. During an interview on 09/22/25 at 10:51 A.M. Resident #96 stated the facility was so overloaded with flies, one of the nurses was kind enough to bring that in the sticky fly trap about a month ago. The resident stated also had fly swatter in bed, and he called the area under his bed the graveyard because that was where he flung the dead bodies after swatting them. During interview conducted on 09/29/2025 from 10:38 A.M. to 10:40 A.M. with Housekeeper # 79, Registered Nurse (RN) #176 and the Administrator each verified Resident #96 had a fly paper hanging from ceiling near he bed which had several bodies of dead insects attached to it. The Administrator stated the fly paper was not there on 09/28/25 and he did not know from where it came since the facility did not carry that type of pest control device. 3. Review of the medical record for Resident #49 revealed an admission date of 02/04/25 with medical diagnoses of cerebral infarction, diabetes mellitus (DM), psychotic disorder with delusions, vascular dementia and hypertension (HTN). Review of the medical record for Resident #49 revealed a quarterly Minimum Data Set (MDS) assessment, dated 08/13/25, which indicated Resident #49 was cognitively intact and was independent with eating, bed mobility, and transfers, and required partial/moderate staff assistance with toilet hygiene and bathing. Observation with interview on 09/22/25 at 10:59 A.M. revealed Resident #49 sitting on the side of his bed in his room. The observation revealed multiple gnats flying around his room. Resident #49 stated he always has flies or gnats in his room. Observation on 09/22/25 at 11:22 A.M. revealed Resident #49 sleeping his in bed. The observation revealed three flies on Resident #49's comforter and two gnats on his pillow. Interview on 09/22/25 at 11:24 A.M. with Housekeeper #125 confirmed Resident #49 had three flies on his comforter and two gnats on his pillow.

Based on record review, observations, staff interviews and review of facility policy the facility failed to ensure smoking items were properly stored according to policy. This affected two (#49 and #16) of four residents reviewed for smoking. The facility census was 96. Findings include: Review of medical record for Resident #16 revealed admission date of 07/29/25. The resident was admitted with diagnoses including hemiplegia right dominant side following stroke, type two diabetes mellitus, dementia without behavior, anxiety, depression and congestive heart failure. The resident remained at the facility. The admission Minimum Data Set (MDS) dated [DATE] revealed he had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. He was independent with eating and required moderate assistance from staff with toileting hygiene, bed mobility Observation on 09/22/25 at 10:51 A.M. revealed an unopened pack of cigarettes located on the bedside table during an interview with Resident #16. Observation on 09/22/25 at 11:06 A.M. with Certified Nursing Assistant (CNA) #132 verified there was an unopened pack of cigarettes on Resident #16's bedside. At the time of the observation CNA #132 informed Resident #16 smoking supplies were to be kept in a locked box and removed the cigarettes from the table. 2. Review of the medical record for Resident #49 revealed an admission date of 02/04/25 with medical diagnoses of cerebral infarction, diabetes mellitus (DM), psychotic disorder with delusions, vascular dementia and hypertension (HTN). Review of the medical record for Resident #49 revealed a quarterly Minimum Data Set (MDS) assessment, dated 08/13/25, which indicated Resident #49 was cognitively intact and was independent with eating, bed mobility, and transfers, and required partial/moderate staff assistance with toilet hygiene and bathing. Review of the medical record for Resident #49 revealed a smoking evaluation, dated 09/08/25, which indicated Resident #49 was an unsupervised smoker. Observation with interview on 09/22/25 at 11:15 A.M. revealed Resident #49 open his nightstand and remove a pack of cigarettes and a lighter. Resident #49 stated he was allowed to smoke independently. Observation with interview on 09/22/25 at 11:29 A.M. with Director of Nursing (DON) revealed Resident #49 had one pack of cigarettes and two lighters in his bedside table. DON confirmed smoking materials are to be locked up in either a locked box or at the nurse's station even if the resident was an independent smoker. Review of the facility policy titled, Smoking, dated September 2022, stated upon admission all residents who smoke would have a smoking assessment completed. The policy stated for the residents who were deemed safe to smoke independently, per the smoking assessment, they may smoke at any time the resident chooses in the designated smoking areas. The policy continued to state the resident smoking materials would be retained and distributed by the facility staff to the residents during the designated smoking times and/or when independent resident chooses to smoke.

Based on record review, staff interview, review of the directive from Centers for Medicare and Medicaid Services (CMS), and facility policy review, the facility failed to notify the local health department of a COVID-19 facility outbreak that began on 11/16/24 and ended on 12/24/24. This had the potential to affect all residents in the facility. The facility census was 88. Findings include: Review of the facility infection control log and map confirmed the facility had an outbreak of COVID-19 on 11/16/24 through 12/24/24. Interview on 12/30/24 at 4:51 P.M. with the Administrator confirmed the facility experienced an outbreak of COVID-19 from 11/16/24 though 12/24/24. The Administrator confirmed the facility was not aware of a requirement to contact the local health department and failed to notify the local health department of the outbreak. Review of the directive from CMS titled, QSO-20-39-NH, dated May 08, 2023, revealed facilities are expected to contact their health department when responding to COVID-19 transmission within their facility. Review of the facility policy titled, Infection Prevention and Control Program, dated September 2022, confirmed the facility is required to utilize surveillance tracking tools for the occurrence of infections, frequency, detecting outbreaks and epidemics, monitoring employee infections, and detecting unusual pathogens with reaction control implications. Further review of the facility policy under the heading titled, Outbreak Management, confirmed the facility should report the outbreak to the appropriate public health authorities. This deficiency represents non-compliance investigated under Complaint Number OH00160332.

Based on medical record review, staff interview, review of hospital documentation, review of Omnicell (automatic medication dispensing cabinet) documentation, and policy review, the facility failed to administer medication as ordered. This affected one (#97) out of three residents reviewed for medication administration. The facility census was 96. Findings include: Review of the medical record for Resident #97 revealed an admitted [DATE] with medication diagnoses of staphylococcal arthritis of left ankle and foot, schizophrenia, anxiety, bipolar disorder, and mild cognitive impairment. Review of the medical record for Resident #97 revealed an admission Minimum Data Set (MDS) assessment, dated 09/20/24, which indicated Resident #97 had severe cognitive impairment and was independent with toilet hygiene, bed mobility, and transfers and required supervision with bathing. The MDS indicated Resident #97 received antipsychotic and antianxiety medications. Review of the medical record for Resident #97 revealed a nurse's progress note dated 09/25/24 at 3:32 A.M. written by Registered Nurse (RN) #111 which stated Resident #97 had shown signs of agitation, anxiety, and confusion. The note also stated Resident #97 had been crying out loud and screaming at staff and residents. The note continued to state Resident #97 was given a schedule dose of Ativan 1 milligram (mg) and an order for Haldol 5 mg intramuscular (IM) was given by the physician. The note stated the nurse was not able to obtain the dose of Haldol from the Omnicell because she did not have the appropriate access. The note stated Resident #97 was sent out to the hospital and family and physician were notified. Further review revealed a nurse's note, dated 09/25/24 at 4:10 A.M. which stated Resident #97 had returned from the hospital and was given a dose of Haldol at the hospital. The note stated Resident #97 was resting with no signs of discomfort. Review of the medical record for Resident #97 revealed no documentation to support the nurse entered the order for the Haldol 5 mg IM on 09/24/24 under physician orders. Review of the medical record for Resident #97 revealed a hospital emergency room (ER) note, dated 09/24/24, which stated Resident #97 was seen in the ER with agitation. The note stated Resident #97 was given Ativan at the facility but was unable to get the one-time dose of haloperidol (Haldol) because the night nurse did not have access to the medication. The ER note stated Resident #97 arrived at theER on [DATE] at 9:25 P.M., received a dose of haloperidol in the ER, and was discharged back to the facility on [DATE] at 3:39 A.M. Review of Omnicell medication list revealed two vials of haloperidol 5 mg per milliliter (ml) were available in the facility's Omnicell dispenser. Review of the Omnicell user list report revealed RN #111 had access to the Omnicell effective 09/20/24. Interview on 10/08/24 at 2:20 P.M. with Director of Nursing (DON) stated she was not notified Resident #97 was sent to theER on [DATE] until 09/25/24. DON stated she did not know why RN #111 was unable to access the Haldol 5 mg from the Omnicell on 09/24/24. DON confirmed Resident #97 was sent to the ER and received Haldol while at the ER. The DON confirmed RN #111 was not the only nurse in the facility on 09/24/24 so the haloperidol could have been obtained from the Omnicell dispenser if RN #111 was having difficulties accessing the device/medications. Review of the facility policy titled, Medication Administration, stated all medications shall be administered in a safe and timely manner, and as prescribed. This deficiency represents non-compliance investigated under Complaint Number OH00158398.

Based on medical record review, observation, staff interview, and policy review, the facility failed to follow infection control procedures during medication administration. This affected one (#09) out of the two residents observed for medication administration. The facility census was 96. Findings include: Review of the medical record for Resident #09 revealed an admitted [DATE] with medical diagnoses of right above the knee amputation, diabetes mellitus, asthma, schizoaffective disorder, and chronic respiratory failure. Review of the medical record for Resident #09 revealed a quarterly Minimum Data Set (MDS) assessment, dated 06/30/24, which indicated Resident #09 was cognitively intact and required partial/moderate staff assistance with toilet hygiene, bathing, bed mobility, and transfers. Review of the medical record for Resident #09 revealed physician orders dated 03/20/24 for Ascorbic acid 500 milligram (mg) one tablet by mouth two times per day, multivitamin one tablet by mouth two times per day, senna 8.6-50 mg one tablet by mouth two times per day, loratadine 10 mg one tablet by mouth daily, benztropine 1 mg two tablets by mouth daily, metformin 500 mg one tablet by mouth two times per day, and Depakote sodium 500 mg one tablet three times per day, an order dated 05/06/24 for metoprolol 50 mg one tablet by mouth two times per day, an order dated 06/20/24 for gabapentin 100 mg two tablets by mouth every eight hours, orders dated 07/17/24 for Eliquis 5 mg one tablet by mouth two times per day and lisinopril 2.5 mg one tablet by mouth daily, an order dated 08/05/24 for haloperidol 5 mg one tablet by mouth two times per day, and an order dated 10/08/24 for magnesium oxide 500 mg one tablet by mouth two times per day. Observation on 10/08/24 at 9:02 A.M. revealed Registered Nurse (RN) #103 prepare Resident #09's medications for administration. RN #103 was observed placing Resident #103's ascorbic acid, multivitamin, senna, loratadine, Benztropine, Depakote sodium, gabapentin, Eliquis, lisinopril, haloperidol and magnesium oxide tablets directly from medication card into medication cup. The observation revealed RN #103 placed Resident #09's metformin and metoprolol tablets directly into her bare hands prior to placing the medications into the medication cup. RN #103 was observed administering medications to Resident #09 and watched Resident #09 consume the medications. Interview on 10/08/24 at 9:15 A.M. with RN #103 confirmed she placed Resident #09's metformin and metoprolol tablets into her bare hands prior to placing the medications into the medication cup and administering to Resident #09. Review of the facility policy titled, Medication Administration, stated the facility staff shall follow established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the medication medications as applicable. This deficiency is based on incidental findings discovered during the course of this complaint investigation. This deficiency represents ongoing noncompliance from the survey dated 09/18/24.

Based on medical record reviews, staff interviews, observations, and pest control invoices, the facility failed to ensure resident rooms were free from flies and gnats. This affected two (#11 and #13) out of the three reviewed for environment. The facility census was 96. Findings include: 1. Review of the medical record for Resident #11 revealed an admitted [DATE] with medical diagnoses of cervical disc disorder with myelopathy, mood disorder, metabolic encephalopathy, diabetes mellitus, congestive heart failure, and hypertension. Review of the medical record for Resident #11 revealed a quarterly Minimum Data Set (MDS) assessment, dated 08/01/24, which indicated Resident #11 was cognitively intact and was dependent for toilet hygiene, bathing, bed mobility, and transfers. The MDS indicated Resident 311 was always incontinent of bladder, frequently incontinent of bowel, and refused care at times. 2. Review of the medical record for Resident #13 revealed an admitted [DATE] with medical diagnoses of emphysema, cerebral infarction, diabetes mellitus, vascular dementia, and chronic obstructive pulmonary disease. Review of the medical record for Resident #13 revealed an annual MDS assessment, dated 09/08/24, which indicated Resident #13 had moderate cognitive impairment and required partial/moderate assistance for bed mobility and substantial/maximum assistance with toilet hygiene, bathing, and transfers. The MDS indicated Resident #13 was frequently incontinent of bladder and bowel. Observation with interview on 10/08/24 at 10:35 A.M. with Resident #11 revealed the resident was lying in bed holding onto a fly swatter. The observation revealed gnats and a few flies flying around Resident #11 and her room. Interview with Resident #11 stated she had the fly swapper because of the flies and gnats in her room all the time. Observation on 10/08/24 at 1:33 P.M. of Resident #13's room revealed several flies and gnats in his room. The room also had a strong urine smell and the floor near Resident #13's bed appeared to have a dried sticky substance under the bedside table. Interview on 10/08/24 at 1:33 P.M. with State tested Nursing Assistant (STNA) #101 confirmed Resident #11 and Resident #13 had flies and gnats in their rooms. STNA #101 confirmed the floor to Resident #13's room had an area of sticky substance on the floor under the bedside table that appeared to be spilled juice that had dried and not been cleaned up. STNA #101 stated both Resident #11 and Resident #13 are incontinent and at times refuse cares. STNA #101 stated both residents had flies and gnats in their rooms for a while. Observation on 10/08/24 at 3:14 P.M. of Resident #11's room revealed gnats flying near the resident. Observation of Resident #13's room revealed flies near the resident and on the blinds. The room for Resident #13 had a strong urine odor. Interview on 10/09/24 at 7:23 A.M. with Licensed Practical Nurse (LPN) #107 confirmed Resident #11 and Resident #13 have had issues with flies and gnats in their rooms for a while. Review of a pest control company invoice, dated 09/25/24, stated the company provided pest treatment for food area, public areas, and perimeter. The invoice did not contain documentation that individual resident rooms were treated. Review of the pest control company invoice, dated 10/08/24, indicated Resident #11's room was provided with a treatment. This deficiency represents non-compliance investigated under Complaint Number OH00158674. This deficiency represents ongoing noncompliance from the survey dated 09/18/24.

Based on record review, interview, observation, nursing staff schedule review, facility assessment review, and policy review, the facility failed to maintain sufficient levels of state tested nursing staff and licensed nursing staff to meet the total care needs of all facility residents. This resulted in Immediate Jeopardy when on 08/26/24 at 7:00 A.M., there were three licensed practical nurses (LPN) and two state tested nurse aides (STNA) on duty to provide for the routine care, monitoring, medication administration, assessments, response to urgent resident needs and/or treatments for all 105 residents residing in the facility. The lack of nursing staff in the facility to provide nursing care and services resulted in actual and/or the potential for serious harm, injuries and/or negative health outcomes for residents related to the lack of care and services, activities of daily living (ADL), supervision of common areas, smoking areas and assistance with meal intake. This had the potential to affect all 105 residents. On 08/27/24 at 2:55 P.M. Regional Director of Operations (RDO) #224, Regional Clinical Nurse (RCN) #222, and the Administrator were notified that the Immediate Jeopardy began on 08/26/24 at 7:00 A.M. when the facility failed to ensure an sufficient nursing staff was on duty and present in the facility to provide for the routine care, monitoring, response to urgent resident needs and meal assistance for all 105 residents residing in the facility. The Immediate Jeopardy was removed on 08/28/24 when the facility implemented the following corrective actions: By 08/28/24, staffing levels will be increased to five nurses on day shift and four nurses on night shift, STNA ' s staffing levels will be increased to eight STNA ' s on first shift and six nursing assistants on night shift. Staffing levels will be increased by increasing hours for current staff, reassigning staff from sister facilities and signing contracts with two temporary staffing agencies. The shift charge nurse will authorize the use of the agency staff. By 08/28/24, the charge nurses will be provided with the agencies phone numbers and will be educated to call agency when there are call offs and our staff will not pick up open shifts. By 08/28/24, RDO #224 will develop a bonus structure for new hires. By 08/28/24, the RDO #224 will develop a bonus structure for staff that will pick up extra shifts. By 08/28/24, RDO #224 will develop a bonus structure for staff who refer new candidates. By 08/28/24, Human Resource (HR) Director #6 will call all applicants for the last 60 days to re-offer interviews. By 08/28/24, the Director of Nursing (DON) or designee will conduct resident assessments to identify those with pressure ulcers and extensive assist from two staff members with ADL to prioritize their care and ensure immediate needs are addressed. By 08/28/24, RDO #224 or designee will notify residents and their representatives about the staffing situation, the steps that are being taken to address the issue and what they can expect in terms of care. By 08/28/24, an ad hoc quality assurance (QA) committee meeting will be held to review the plan. By 08/28/24, [NAME] President of Human Resources (VPHR) #800 or designee will develop and implement a long-term plan to recruit and retain qualified staff including offering competitive wages, benefits and professional development opportunities. Beginning 08/28/24, RDO #224 or designee will review staffing levels daily and adjust as necessary depending on new admissions/discharges and significant changes. This may involve hiring additional permanent staff or adjusting the staff to resident ratio based on acuity levels. By 08/28/24, RDO #224 will educate the administrator, the DON and HR Director #6 on the appropriate staffing levels to meet the residents needs and to adjust the staffing levels depending on new admissions/discharges and significant changes. Weekly for four weeks, RDO #224 or designee will interview four residents and four direct care members to ensure appropriate staffing levels and quality of care. The data collected from the above audits and feedback will be used to make ongoing adjustments to the staffing plan and care protocols, ensuring compliance and that residents receive high-quality care. The audits will be submitted weekly to the QA committee for trending, tracking and recommendations. Although the Immediate Jeopardy was removed on 08/28/24, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. 1. Medical record review for Resident #41 revealed an admission on 03/15/17 with diagnoses including but not limited to traumatic hemorrhage of cerebrum, hemiplegia on right and left side, epilepsy, respiratory failure, coma, persistent vegetative state, acute cystitis without hematuria, hypertension, anxiety disorder, tracheostomy status and gastrostomy status. Review of the annual Minimum Data Set (MDS) assessment for Resident #41 revealed resident was in a persistent coma state. Resident #41 has physical impairments on both sides affecting arms and legs. Resident #41 is dependent for all care. Resident #41 has a gastrostomy (feeding tube) and receives 51 percent of calories through parenteral feedings. Resident #41 has a tracheostomy in place and receives oxygen via compressor at 20 pounds per square inch (PSI). Review of the plan of care for Resident #41 dated 03/19/22 revealed resident has an ADL self-care performance deficit related to motor vehicle accident (MVA) with brain injury resulting in comatose state. Interventions include assisting with activities of daily living requiring two staff members for the completion of bed mobility, transfers with a mechanical lift, and toileting. Resident #41 was dependent for eating with one staff member required for task involving enteral feedings. Review of the active physician orders for Resident #41 revealed an order for nothing by mouth dated 03/20/24, head support cushion under head as tolerated dated 03/20/24, Hoyer lift for all transfers dated 03/20/24, incontinence care every two hours and as needed, with house barrier cream after each incontinent episode dated 03/20/24 and keep head of bed elevated as tolerated dated 07/24/24. During an observation on 08/22/24 at 9:50 A.M., Resident #41 was lying in bed on her back, head of bed elevated to approximately 30 degrees, neck appeared to be in a contracted state leaning to the resident ' s right shoulder, tracheostomy in anterior neck and secured appropriately, linens clean and resident without odor. On 08/22/24 at 11:30 A.M., STNA #12 was observed to enter the room of Resident #41 and shut the door. At 11:51 A.M. STNA #12 was observed to exit the room. During an interview on 08/22/24 at 11:53 A.M. with STNA #12 verified Resident #41 was checked for incontinence and repositioned. STNA #12 stated she completed ADL and incontinent care for Resident #41. STNA #12 stated she had not had the time to provide care for Resident #41 since she arrived at the facility and clocked in at 7:00 A.M. STNA #12 stated she has 20 residents on her assignment at that time. STNA #12 received report and then started passing breakfast trays. STNA #12 stated she has had three total bed changes due to incontinence and changed eight resident incontinent garments before providing care for Resident #41. STNA #12 stated sometimes the nurses were able to help but the other STNA ' s were in the same situation that she was in and were not able to help at times either. 2. Medical record review for Resident #4 revealed an admitted [DATE] with diagnoses including but not limited to psychosis, dementia, major depressive disorder, and schizoaffective disorder. Resident #4 resided on the memory care unit. Review of the quarterly MDS assessment dated [DATE] revealed Resident #4 was not able to complete a Brief Interview for Mental Status (BIMS) because she was rarely/never understood. Resident #4 was dependent with eating, toileting, bathing, dressing, and transfers. Resident #4 required two staff members for toileting, transfers and bed mobility. Review of the plan of care for Resident #4 revealed resident has an ADL self-care performance deficit related to dementia with behaviors, cerebral palsy, seizures, schizophrenia, psychosis, major depressive disorder, cerebrovascular accident with right hemiparesis and hemiplegia. Interventions include assist with activities of daily living, two-staff member assistance is required with bed mobility, toileting and transfers. Resident #4 resides on a secured unit. Review of the care plan dated 07/26/24 revealed Resident #4 had impaired skin integrity as evidenced by pressure to coccyx. Interventions included assist with turning and repositioning as needed, complete skin inspection every seven to 10 days and as needed, complete wound evaluation to monitor the progress of skin condition, enhanced barrier precautions, medications per orders, and good nutrition and hydration. Review of the task log for Resident #4 revealed the resident has not gotten out of bed in the last three months. During an observation on 08/22/24 at 12:05 P.M., Resident #4 was sleeping in bed. Her lunch tray was in the room, but there were no staff available to feed her. Resident #4 was lying on her right side. At 12:22 P.M., no one had been in the room to feed Resident #4 her lunch. During an interview on 08/22/24 at 12:24 P.M., STNA #46 stated there are at least five residents that require assistance with meals and typically only one STNA assigned to the memory care unit. One STNA cannot feed five residents at the same time. STNA #46 stated at 12:30 P.M. Resident #4 ' s lunch tray was still sitting unattended due to not having staff available. STNA #46 stated there was no wound dressing on Resident #4 ' s coccyx, but dried gauze from a previous time. STNA #46 stated there has not been a dressing on the wound since she started training on this unit on 08/12/24. Resident #4 had a foul-smelling odor with two flies near the coccyx wound. During an observation on 08/22/24 at 12:42 P.M., Resident #4 was sleeping in bed and the lunch tray was still in the room. Resident #4 had not been fed her lunch meal. During an interview on 08/22/24 at 12:49 P.M., STNA #172 stated the wound dressing for Resident #4 was not in place this morning. STNA #172 stated they used to get residents up with the Hoyer lift because they had two staff members on this unit. STNA #172 stated now it's just one STNA on the memory care unit and the unit does not have Hoyer lift pads to get residents up with. STNA #172 stated the last time Resident #4 was out of bed was at least a month ago. STNA #172 stated she had six residents to feed on the memory care unit, and she was the only staff back there at the time of meal tray delivery. STNA #172 stated she fed the residents in the dining room first, and then she assisted with the residents in their room after the dining room residents were finished. On 08/22/24 at 12:55 P.M., STNA #172 entered Resident #4 ' s room to assist her with eating her lunch, which was 50 minutes after the lunch tray was observed in the resident ' s room at 12:05 P.M. 3. Medical record review for Resident #50 revealed an admitted [DATE] with diagnoses including but not limited to vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the comprehensive MDS assessment dated [DATE] for Resident #50 revealed staff assessment for memory indicated severe cognitive impairment. Resident #50 was not coded with any behaviors during the assessment period. Resident #50 requires set up for eating. Resident #50 was coded as dependent on staff for toileting, bed mobility and transfers. Resident #50 is incontinent for both bladder and bowel. Review of the plan of care for Resident #50 dated 03/18/22 and revised on 06/29/22 revealed resident has an ADL self-care performance deficit related to schizoaffective disorder and hemiparesis. Interventions include assist with ADL as needed, eating requires one staff member assistance, transfers with Hoyer lift with two staff members, toileting and bed mobility requires two staff members. During an observation on 08/26/24 at 9:48 A.M., Resident #50 was in bed and noted with dried food on his upper chest area. Resident #50 had a soaked incontinent brief, and the bed linen had a yellow wet circular area around the resident. During an observation on 08/26/24 at 9:48 A.M., there were two STNAs present working the floor at the current time. STNA #148 was covering all of 200 and 300 halls except the memory care unit and one covering the mental health unit. There were 40 residents on 200 hall, 10 residents on the 300 hall, and 25 residents on the mental health unit. During an interview on 08/26/24 at 9:55 A.M., STNA #148 stated she had not been in Resident #50 ' s room since 7:00 A.M., the start of the shift due to not enough staff this morning. There were only two STNA in the whole building at that time and since the start of the shift, one STNA covering mental health and one covering the rest of the building. STNA #148 confirmed Resident #50 had old, dried food on his chest, not the same food as breakfast that was served. She also confirmed Resident #50 was wet with urine and the bed linens were wet with a yellow ring surrounding the resident. 4. Review of the Facility Assessment for the year 2023-2024, dated 05/31/24, identified staffing and staffing assignments would be determined using various reports to analyze the number of patients, velocity of expected admission and discharges, diagnoses and the total number and types of tasks and services required of nursing, nursing assistants and ancillary personnel. The facility assessment did not address the staffing needs required for the specialized units, the memory care unit and mental health unit. During an interview on 08/26/24 at 8:24 A.M., the Administrator stated she was unaware of any other reports identified in the facility assessment that would be used to determine staffing. She ensures the facility meets the state licensure requirements of 2.5 hours of care per resident per day and used the punch detail to collect the data for that report. The facility does not use agency staff as they do not have a budget for it. The Administrator referred questions related to how staffing levels impact the residents to the Interim Director of Nursing (IDON). The Administrator stated she has not received any complaints from any residents in the last three months. They offer a bonus for shifts that are picked up and if they are not filled, they will pull facility staff that are STNAs to fill the open shifts. The Administrator stated the facility has a Registered Nurse (RN) in the facility to meet the eight-hour requirement daily. Review of the facility ' s Nursing Staff Daily Schedule dated June 2024 through August 2024 revealed the facility scheduled five STNA ' s consistently to care for up to 105 residents residing in the facility. Review of the facility ' s Nursing Staff Daily Schedule dated 08/26/24 for the day shift revealed STNAs #54, #102, #148, #34 and #46 were scheduled to work from 7:00 A.M. to 7:00 P.M. and LPNs #18, #32, #162, and #148 were scheduled to work from 7:00 A.M. to 7:00 P.M. Review of the facility ' s Punch Details for 08/26/24 from 7:00 A.M. to 7:00 P.M. revealed two STNA were in the facility for the day shift starting at 7:00 A.M. Additional STNA ' s clocked in at 7:33 A.M., 9:02 A.M., 10:53 A.M. and 11:58 A.M. Review of the day shift STNA schedule dated August 2024 revealed two STNA ' s were scheduled for 08/26/24. During an interview on 08/26/24 at 8:56 A.M., RCN #222, the acting Director of Nursing, stated she was not involved in the staffing determination. RCN #222 stated she has been in the DON position since the survey started and does not have extensive history of the facility. She stated the facility has had a staff scheduler in place for about three weeks. During an interview on 08/26/24 at 9:22 A.M., STNA #46 verified she was on the schedule for today and not called in for staff coverage. STNA #46 verified she was not present at 7:00 A.M. and arrived at the facility late. STNA #46 stated she was the only STNA on the assigned unit. STNA #46 stated she was looking through the Kardex for resident instructions as she had not worked in the area before. STNA #46 verified the nurse assigned to the area also had rooms on the outside of the locked memory care unit and was not available to confirm care and services required by the STNA. During an interview on 08/26/24 at 1:01 P.M., Certified Nurse Practitioner (CNP) #218 stated staffing is an issue in the facility, and it is possible that the in house acquired pressure ulcers occurred and worsened due to the facility staffing levels. The facility has always had a staffing concern which affects the care. Just like today, there is a staffing concern. During an interview on 08/27/24 at 8:50 A.M., STNA #10 stated she has twenty-five residents assigned to her today. STNA #10 stated she did not work yesterday and no one from the facility contacted her to see if she was able to come in. STNA #10 verified the facility has four STNA ' s at this time with three nurses for 105 residents. STNA #10 stated there have been times that she is unable to complete her assigned showers and will report it to the oncoming staff. STNA #10 stated it is very hard to supervise all the residents and provide care to them as well. Nurses will assist but they have forty residents sometimes and do not have time to help either. The nurses that are assigned the specialized units have residents in the other outside hallways as well. STNA #10 stated there have been times when the residents have complained about the length of time, they had to wait for help but nothing formal like a grievance that she is aware of. STNA #10 stated the residents here do not have family members looking after them or advocate for them. During an interview on 08/27/24 at 10:10 A.M., Facility Staffing Coordinator (FSC) #78 verified she has been in the current position for three weeks and is still learning the new position. FSC #78 states she was given the Nursing Staff Daily Schedule template and has been using that to schedule staff. FSC #78 stated the goal is to have all positions filled but they do not have the staff to reach that at the time but have been hiring additional staff recently. FSC #78 states she has not been given any other guidelines for staffing only the daily schedule template. FSC #78 stated the schedule template has seven positions for the STNAs and four positions for nurses for both twelve-hour shifts in a twenty-four-hour day. FSC #78 verified there were staff running late and one call off on 08/26/24, but she would have to check her paper to make sure she had her staffing numbers correct. During an observation on 08/27/24 at 2:10 P.M., STNA #210 took a meal tray out of the food cart and was walking down the South Hall. STNA #210 stated she had to help in the dining room for all meals to assist with resident meal selection, meal tray delivery and supervision. STNA #210 stated when the resident ' s trays are passed, she must stay in the dining area for supervision until they are finished. STNA #210 states then she can return to her assignment. STNA #210 stated the nurse realized what was going on today and started to help with tray delivery on the hall. STNA #210 stated the tray she is delivering is the last one. STNA #210 stated the resident requires assistance with all meals and she was not able to feed the resident until now. STNA #210 stated she has not completed all the baths scheduled for today and is not sure she will be able to get them all done before she goes home. STNA # 210 verified the lunch tray had to be heated up prior to serving. During an interview on 08/27/24 at 4:30 P.M., Unit Manager LPN #50 stated she assists with the facility nursing schedule but has not received any other training regarding staffing, how to assess for staffing needs or determine if more staffing is needed. LPN #50 stated she uses the daily template that allows us to have seven STNAs and four nurses for both twelve-hour shifts. LPN #50 verified the staffing has been very low at times on day shift with all the staff slots going unfilled. During an interview on 08/28/24 at 8:40 A.M., the Administrator stated she does not have any access to reports regarding staff or staffing level requirements. She has a budget that allows staffing levels from 2.5 hours to 2.75 hours per resident per day. A staffing report is run by the Administrator daily to ensure compliance with the staffing levels. She stated they have struggled to meet the state minimum staffing level at times in the last few weeks. She has requested a budget for agency staff and has been denied each time. If the facility is staffed over the 2.5 hours per resident per day, it is brought up in the operational meeting with staff from the corporate level staff. The Administrator said she was asked not to attend the daily staffing meetings approximately two to three months ago. She is only to attend on Mondays and Fridays and does not understand why she was asked to step away. During an interview on 08/28/24 at 9:00 A.M., Chief Executive Officer (CEO) #240 and [NAME] President of Clinical Operations (VPCO) #230 stated the facility has meetings with staff regarding concerns related to the facility. Corporate staff have meetings with the facility management to talk about the acuity of the residents and meeting the PDPM requirements. CEO #240 stated the corporate has a standard level of 2.75 hours per resident per day daily for the facilities. VPCO #230 stated the staffing numbers are run globally and not individually as that is the responsibility of the Administrator. Both CEO #240 and VPCO #230 stated they are adding staff to the schedule by utilizing agency and will have the signed contract in place soon. During an interview on 08/28/24 at 2:10 P.M., STNA #210 stated she did not work on 08/24/24 or 08/25/24 and no one from the facility contacted her to see if she was willing to come in to work on either day. STNA #210 stated the facility works with four STNAs a lot of the time. They will have a staff member that comes in at 11:00 A.M. and that is helpful, but they need more staff. STNA #210 stated the biggest problem is when she is helping another resident in a room, she cannot be in the common areas supervising the residents. Care is completed but it is not always timely or as thorough as it should be. During an interview on 08/28/24 at 3:30 P.M., LPN #50 stated she was not on call 08/24/24 through 08/25/24 but did see that requests came through on the WhatsApp( WhatsApp is a messaging app that uses the internet to send messages, images, audio or video) saying the facility needed help. The request was sent out to the Administrator, the MDS nurse and herself, along with a unit manager who no longer works for the facility. The facility staff in the building did not receive any contact from the Administrator, or MDS Nurse to come in and assist due to low staffing levels. LPN #50 verified the staff member identified as being on call is not employed by the facility at the time of the assignment. During an interview on 08/29/24 at 6:48 A.M., STNA #52 stated she is unable to get showers done because there is no one else to watch the residents when she is in the shower room for extended periods of time. They give bed baths, but the residents want showers at times, and they cannot provide them. STNA #52 stated she gave four showers last night because they had two staff members scheduled. STNA #52 stated there was only one nurse working in the memory care unit adding that she also had resident rooms in the rehabilitation area. STNA #52 stated it was difficult to provide good care, complete incontinence care and showers with only one staff member. STNA #52 has approached the management staff regarding concerns but there has been such staff turnover that issues do not get addressed. During an interview on 08/29/24 at 7:00 A.M., STNA #34 stated the facility does not have enough linen to provide care to the residents at times. STNA #34 stated the staff at night must do laundry to be able to provide care adding that the facility has three dryers, but only one is operational. STNA #34 stated she worked on 08/26/24 and heard the facility started out with only two STNA ' s during report from the nurse assigned to the hall. STNA #34 stated when she left at 7:00 P.M. there had been five aides to care for 105 residents in the facility. During an observation on 08/29/24 at 7:10 A.M, the linen room for the locked mental health unit contained no washcloths, no bath towels, no draw sheets, and only two blankets, and six bed sheets. During an interview on 08/29/24 at 7:45 A.M., the Administrator verified there was no linen available for use to provide care in the mental health unit. During an interview on 08/29/24 at 8:00 A.M., VPCO #230 verified the linen closet lacked sufficient linen supplies to complete care and services on the unit. During an observation on 08/29/24 at 9:21 A.M., the linen room for the locked mental health unit still had no linen. During an interview on 08/29/24 at 9:22 A.M., STNA #34 stated some of the residents had supplies in their room for incontinent care (disposable wipes), but they still had residents that were waiting for linens to be delivered to the unit for care. During an interview on 08/29/24 at 10:27 A.M., STNA #34 stated some of the residents were still waiting for clean linen to complete A.M. care. STNA #34 verified they borrowed linen from other units but if they took anymore the staff on those units would be waiting for linens as well. During a telephone interview on 08/29/24 at 11:25 A.M., Physician #232 stated there had been several people in the role of Director of Nursing in the last few months. Physician #232 stated he would follow-up with facility management but had mostly been engaging with the Administrator lately due to the changes with nursing management. He was aware of staffing challenges to a certain degree but had not been advised of any significant negative resident outcomes. During an interview on 08/29/24 at 3:27 P.M., Registered Nurse (RN) #166, the MDS nurse, stated the Administrator asked if she would fill in for the DON. RN #166 stated she never ended up taking any duties for the position, the last DON was only at the facility for a week before resigning. The facility couldn ' t keep a consistent DON or unit managers, and it affected the continuity of care. Things were being missed. She did not attend the morning meetings or QAPI (Quality Assurance and Performance Improvement) meetings, was not present for nutrition at risk meetings and was told MDS did not need to be involved. During an interview on 09/03/24 at 12:21 P.M., LPN #212 verified on 08/26/24 at 7:00 A.M., there were only two STNAs present to care for 105 residents residing in the facility. The nurse let management, and the staff scheduler know scheduled staff were not present at the start of the shift. LPN #212 stated the nurses present just started getting the residents awakened for breakfast, assisting with tray delivery and answering call lights as needed. LPN #212 verified that there were three nurses in the facility and that her current assignment consisted of 28 rooms, and she was not sure how many residents there were on that day. LPN #212 stated the facility uses an electronic application that has specific groups of management and staff. Staff send messages to the management group when there is a call off. The scheduler also receives the messages and works Monday through Friday. The scheduler is a trained STNA and will help when there is a call off as well. During an interview on 09/03/24 at 12:30 P.M., LPN #38 verified on 08/26/24 at 7:00 AM, there were only two STNAs present to care for 105 residents residing in the facility. LPN #38 stated there were more staff on the schedule, but she was unable to recall what had happened to each one that was not there. LPN #38 stated there were some managers in the facility because the surveyors were returning to the facility, and they were advised on the missing staff. LPN #38 stated there was only one nurse assigned to the mental health unit at the beginning of the shift and was there by herself until the staffing was figured out. LPN #38 stated the scheduler came out and covered a unit but was not sure what area she was assigned. LPN #38 stated it was very chaotic when the shift started. LPN #38 stated the assigned workload is heavy and it does not help when staffing is challenged to start with. LPN #38 stated the office staff that are STNAs will come to the floor and assist but they do not take a unit, they just get the bare minimum done. LPN #38 stated the recent staffing shortage occurred when the management left the facility, and they took their staffing with them. LPN #38 was unable to state if anything specific was not being completed for the residents just a lot of short cuts to get the basic care completed. LPN #38 stated she had 21 residents, or 14 rooms assigned to her on 08/26/24 with one STNA assigned to her unit. During an interview on 09/03/24 at 2:00 P.M. with FSC #78 stated she was only able to confirm staffing that was on the Daily Staff Schedules. FSC #78 stated she does not have access to the facility punches and does not keep track of what staff is working, where they are working and when there are changes made to the schedule. Initially she stated she was not working on the day in question (08/26/24), then recanted her statement stating she couldn ' t remember what happened every day. FSC #78 stated there were six STNAs scheduled for 08/26/24, there was one call off, and two staff members were running late. The sixth staff member was schedule for 11:00 A.M. to 7:00 P.M. FSC #78 stated she covered the memory care unit until the scheduled staff arrived at the facility at noon but was not sure of the exact time. FSC #78 verified the LPN scheduled for the mental health unit was the only staff member present until the STNA arrived at the facility at an unknown time. FSC #78 verified she was working in the memory care unit until the scheduled staff member showed up around noon. FSC #78 stated she was helping in both specialty units. When the nurse was passing medications in the memory care unit, she went to the mental health unit and assisted with breakfast trays and answered call lights. FSC #78 stated staff did not always call her when there was a call off initially, they were calling several different people and that is when errors were made. FSC #78 was unable to identify who staff was calling to notify when there was a call off, but they now use the mobile application called What ' s app. FSC #78 stated the facility uses the app to notify groups of management related to staffing needs. FSC #78 verified the nurses have a separate group as well as the STNAs. Not everyone in the facility is able to see comments on all the app groups. FSC #78 denied any knowledge of an RN working that day, adding she may have been assisting the corporate team. During an interview on 09/03/24 at 2:15 P.M., LPN #186 verified the facility had three nurses and two STNAs on 08/26/24 at the beginning of the shift. LPN #186 verified she was in the mental health unit caring for 25 residents and the South Hall caring for 16 residents until STNA #46 arrived about 9:00 A.M. STNA #46 was in

Based on record review, observation, interview, review of the National Pressure Ulcer Advisory Panel (NPUAP) information, and policy review, the facility failed to provide adequate care and services to prevent and timely identify pressure ulcers and injuries for Residents #37, #86, and #4. This resulted in Immediate Jeopardy and serious life-threatening harm, injuries, and/or negative health outcomes, when Resident #37 developed six facility acquired deep tissue pressure injuries and was hospitalized for osteomyelitis. Additionally, Resident #86 developed facility acquired unstageable (the base of the wound is covered by dead tissue) pressure ulcers to the coccyx, left heel, and left lateral ankle, and was hospitalized for osteomyelitis. Furthermore, Resident #4 developed facility acquired moisture associated skin damage (MASD), which healed, and was then found to have an unstageable pressure ulcer to the coccyx. This affected three (#86, #37, and #4) of six residents reviewed for pressure ulcers. The facility census was 105. On 08/27/24 at 2:55 P.M., Regional Director of Operations (RDO) #224, Regional Clinical Nurse (RCN) #222, and the Administrator were notified Immediate Jeopardy began on 04/05/24 when Resident #37 was identified with six facility acquired deep tissue pressure injuries and was subsequently hospitalized for osteomyelitis. In addition, Resident #86 was then identified to have unstageable pressure ulcers to the coccyx, left heel, and left lateral ankle, which required hospitalization that included surgical debridement and intravenous (IV) antibiotics due to osteomyelitis, and Resident #4 developed an unstageable pressure ulcer to the coccyx that was facility acquired. The Immediate Jeopardy was removed on 08/28/24, when the facility implemented the following corrective actions: On 08/27/24, Wound Nurse Practitioner (WNP) #228 assessed Resident #86 ' s wounds and ordered new treatments as indicated. On 08/27/24, the Director of Nursing (DON) reviewed Resident #86 ' s record and Resident #86 had the following interventions in place: Foley Catheter. Air mattress. Apply protective barrier cream after incontinent episodes and as needed. Assist with turning and repositioning as needed. Encourage Resident #86 to reposition self if able. Encourage/assist as needed to elevate heels off the mattress as tolerated. Pressure redistribution device in chair. Pressure reducing boots to bilateral feet as tolerated. May remove for care. Resident #86 uses half side rail for repositioning and bed mobility. By 08/28/24, the DON or designee implemented the following interventions for Resident #86: Limit time in chair to three hours, then back to bed for two hours before getting up again. ROHO (specialized seating cushion for pressure relief) cushion to wheelchair. Side to side turns only every two to three hours, which will be signed off in the treatment administration record when completed. On 08/27/24, WNP #228 assessed Resident #4 ' s wounds with no new orders given. On 08/27/24, the DON reviewed Resident #4 ' s record and Resident #4 had the following interventions in place: Assist with turning and repositioning as needed. Pressure reduction mattress. Provide incontinence care as needed. Place washcloths in bilateral hands, clean hands between washcloth replacements. Assist with toileting needs. Provide perineal care after each incontinent episode; apply house barrier cream. Pressure relieving boots to be worn for prevention as tolerated. By 08/27/24, the DON or designee implemented the following interventions for Resident #4: Air mattress. ROHO cushion to wheelchair. Turn and reposition side to side every two to three hours, which will be signed off in the treatment administration record when completed. Pressure relieving boots to both heels. On 08/27/24, WNP #228 assessed Resident #37 ' s wounds and ordered new treatments as indicated. On 08/27/24, the DON reviewed Resident #37 ' s record and Resident #37 had the following interventions in place: Apply protective barrier cream after incontinent episodes and as needed. Assist with turning and repositioning every two hours and as needed. Encourage/assist as needed to elevate heels off the mattress as tolerated. Provide a non-irritating surface to reduce friction or shearing forces. Provide incontinence care every two hours and as needed. Air mattress. Encourage Resident #37 to reposition self if able. Resident #37 uses half side rail for repositioning and bed mobility. Wheelchair with standard cushion with Dycem under cushion when out of bed for comfort and positioning. By 08/28/24, the DON or designee implemented the following interventions for Resident #37: No shoes until healed. Pressure reducing boots to bilateral feet. By 08/28/24, residents with turn and reposition interventions had a physician order, and it would be signed off in the treatment administration record when completed. By 08/28/24, the DON or designee completed a skin assessment on all residents to ensure all pressure areas had been identified and treatment initiated. By 08/28/24, the DON or designee audited all residents with orders for splints to ensure the skin around it is checked on the daily basis for signs of pressure. By 08/28/24, the DON or designee audited all residents to ensure each resident had a shower sheet completed in the last seven days. By 08/28/24, the DON or designee audited all residents to ensure all residents had an updated quarterly Braden Assessment (an assessment used to evaluate a resident ' s risk of developing pressure ulcers). By 08/28/24, the DON or designee audited all residents with moderate, high risk, and very high-risk Braden scores to ensure appropriate interventions are in place to prevent new pressure ulcers or worsening of present pressure ulcers. On 08/27/24, [NAME] President of Clinical (VPC) #230 developed a Skin/Wound Clinical Program Best Practice that included the following: A shower sheet addressing the resident ' s skin condition must be completed with each shower to timely identify new areas. A skin assessment must be accurately completed by the floor nurse weekly, to timely identify new areas. Any time a resident is at risk for skin breakdown, appropriate interventions must be implemented immediately to prevent new development or worsening of pressure ulcers. Any time there is a new pressure area identified; a wound care treatment must be immediately initiated. By 08/28/24, the nursing staff were educated by the DON or designee on the facility Skin/Wound Clinical Program Best Practice. By 08/28/24, an ad hoc Quality Assurance (QA) Committee Meeting was held to review the plan. Weekly for four weeks, the DON or designee will review four residents to ensure shower sheets were completed with each shower. Weekly for four weeks, the DON or designee will review four skin assessments to ensure that the assessments were completed accurately. Weekly for four weeks, the DON or designee will review four residents at risk for skin breakdown to ensure appropriate interventions were implemented. Weekly for four weeks, the DON or designee will review all new pressure ulcers to ensure a treatment was initiated immediately. Weekly for four weeks, the DON or designee will review the residents with splints to ensure that the skin around it is checked daily for signs of pressure. The audits will be submitted weekly to the QA Committee for tracking, trending, and recommendations. Although the Immediate Jeopardy was removed on 08/28/24, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of the medical record for Resident #86 revealed an admitted [DATE] with diagnoses of fracture of tibia or fibula following insertion of orthopedic implant, joint prosthesis, or bone plate, right leg and paraplegia. Review of the 5-Day Minimum Data Set (MDS) assessment, dated 03/21/24, revealed Resident #86 was cognitively intact, required set-up assistance with eating, required substantial assistance with oral hygiene, toileting hygiene, bed mobility, transfers, and wheelchair mobility up to 50 feet. Resident was dependent on staff assistance with bathing, dressing, and wheelchair mobility greater than 150 feet. Resident had no pressure ulcers and was at risk for developing pressure ulcers. Review of the Care Plan dated 03/16/24 revealed resident has impaired skin integrity with interventions for assist resident with turning and repositioning as needed, complete Braden Scale as needed, complete skin inspection every 7-10 days and as needed, complete wound evaluation to monitor the progress of the resident's skin condition, and consult dietitian as needed. Resident has an Activities of Daily Living (ADL) self-care deficit with an intervention of assistance of one person with bed mobility. Review of the discontinued physician orders revealed an order dated 03/19/24 for multi-podus boots on as tolerated. There was no physician order to remove the multi-podus boots and inspect the skin. Review of the task documentation completed by the state tested nurse aides (STNA) for Resident #86 from 04/01/24 to 04/30/24 revealed no new skin issues were observed from 04/16/24 to 04/19/24. The documentation lacked any information related to turning and repositioning of Resident #86. Review of the facility documentation revealed no shower sheets for Resident #86 from 04/15/24 to 05/01/24. Review of the facility assessment for Resident #86 titled Skin Inspection, dated 04/18/24, revealed no new skin issues were observed. Review of the Care Plan dated 04/18/24 revealed a new intervention for impaired skin integrity of pressure redistribution device in chair. Review of the Wound Evaluation Assessment completed on 04/19/24 revealed a pressure wound to Resident #86 ' s buttocks as in-house acquired measuring 4.7 centimeters (cm) by 4.3 cm. The depth was unable to be determined. Review of the Wound Evaluation Assessment completed on 04/25/24 revealed a pressure wound to Resident #86 ' s left heel as in-house acquired measuring 5 cm by 2 cm. The depth was unable to be determined. Review of an incident report dated 04/25/24 revealed the nurse discovered Resident #86 had a pressure area to the left heel when his boot was removed. The incident report indicated the root cause was related to immobility and bilateral boots to feet. Review of the Care Plan dated 04/25/24 revealed a new intervention for impaired skin integrity of encourage/assist as needed to elevate heels off the mattress as tolerated. Review of the Care Plan dated 04/25/24 revealed a new intervention for impaired skin integrity of encourage resident to reposition self if able. Review of the Wound Evaluation Assessment completed on 04/30/24 revealed a pressure wound to Resident #86 ' s left lateral ankle as in-house acquired measuring 1.6 cm by 1 cm. The depth was unable to be determined. Review of the April 2024 Treatment Administration Record (TAR) revealed an order dated 04/30/24 for Low Air loss Mattress for Wound Management when authorization approved. Review of the Care Plan dated 05/01/24 revealed a new intervention for impaired skin integrity of pressure reducing boots to bilateral feet as tolerated, may remove for care and an air mattress. Review of the Discharge Return Anticipated MDS assessment, dated 05/24/24, revealed Resident #86 was cognitively intact, required set-up assistance with eating, required substantial assistance with oral hygiene, toileting hygiene, bathing, bed mobility, transfers, dressing, and wheelchair mobility. Resident #86 was at risk for developing pressure areas and had five unstageable pressure areas. Review of the hospital referral for Resident #86, dated 05/28/24, revealed on 05/24/24, Resident #86 was admitted to the hospital for a wound check after the resident was noted with chills, sweats, nausea, and increased fatigue during wound care rounds at the facility. A decline of wounds was also noted. WNP #228 ordered the resident to be sent to the hospital. Resident #86 was seen by an emergency room physician and admitted to the hospital with diagnoses including sepsis, with sacrum wound being source of sepsis, requiring surgical debridement, and IV antibiotic treatment for osteomyelitis to the sacral wound. Review of the hospital paperwork dated 06/19/24 revealed Resident #86 was transferred from the hospital to a long-term acute care hospital on 06/06/24 for further care related to acute sacral osteomyelitis, left ankle osteomyelitis, and a stage four sacral decubitus ulcer. Resident #86 had an excisional debridement of sacrum with bone biopsy on 05/25/24 at the previous hospital, which was positive for multi drug-resistant Acinetobacter baumannii, Klebsiella pneumonia, E coli, and Proteus mirabilis. Resident #86 received IV antibiotics and treatment with a wound vacuum (uses suction to help heal wounds) while admitted to the long-term acute care hospital before being admitted to the facility again on 07/03/24. Review of physician orders revealed Resident #86 had a physician order dated 07/16/24 for wound care to the left heel, cleanse with Vashe wound cleanser and pat dry, apply Gentell Blue Foam (a dressing for full thickness wounds) to the wound bed and cover with bordered gauze dressing. Change three times weekly and as needed. During an observation on 08/19/24 at 4:00 P.M., Resident #86 was lying on his back in bed. During an observation on 08/20/24 at 2:30 P.M., Resident #86 was lying on his back in bed. Review of physician orders revealed an order dated 08/22/24 for wound care to the right lateral calf to cleanse with Vashe wound cleanser and pat dry, apply Xeroform (a non-adherent gauze occlusive dressing) to the wound bed and cover with bordered gauze dressing. Change three times weekly and as needed. Review of physician orders revealed an order dated 08/22/24 for wound care to the distal right lateral lower leg to cleanse with Vashe wound cleanser and pat dry, apply Betadine to wound bed and cover with bordered gauze. Change three times weekly and as needed. Review of physician orders revealed an order dated 08/22/24 for wound care to the sacrum to cleanse with Vashe wound cleanser and pat dry, apply skin prep to wound perimeter, lightly pack wound with Vashe-moistened gauze and cover with Composite (a multi layered dressing product) dressing. Change daily and as needed. Review of physician orders revealed an order dated 08/22/24 for wound care to the right lateral ankle, cleanse with Vashe wound cleanser and pat dry. Apply Xeroform to wound bed and cover with bordered gauze dressing. Change three times weekly and as needed. Review of physician orders revealed an order dated 08/22/24 for wound care to the left lateral ankle, cleanse with Vashe wound cleanser and pat dry. Apply Silver Alginate to wound bed. Cover with bordered foam dressing. Change three times weekly and as needed. Review of physician orders revealed an order dated 08/23/24 for wound care to right shin, cleanse with Vashe wound cleanser, pat dry, apply Xeroform to surgical incision. Cover with ABD pad and wrap with Kerlix. Change daily and as needed. During an observation on 08/22/24 at 11:07 A.M., Resident #86 had seven wounds, with three wounds currently classified as pressure ulcers. Bilateral heel lift boots were in place along with a low air loss mattress. Resident #86 had an indwelling urinary catheter in place. Licensed Practical Nurse (LPN) #50 completed wound care at this time. The left lateral ankle had an open wound with scant amount of serous drainage present, wound color pale pink in color, stage 3, cleansed with Vashe, patted dry, silver alginate and bordered foam. The left heel was an open wound with small amount of bloody drainage present, wound color pink in color, stage 4, cleansed with Vashe, patted dry, Gentell Blue and bordered foam. The sacrum was a large open wound with edges rolled under with bone exposed to the lower part of wound, moderate amount of serosanguinous drainage present, stage 4. Wound cleansed with Vashe, patted dry, skin prep applied around peri wound, wound lightly packed with Vashe soaked gauze, covered with composite dressing. During an interview on 08/26/24 at 11:10 A.M., STNA #12 stated it required two staff to turn and reposition Resident #86. There were not always two staff available, and Resident #86 was not being turned as he should be. During an observation on 08/26/24 at 11:15 A.M. of Resident #86 revealed he was lying on his back and sleeping. During an interview on 08/26/24 at 12:57 P.M., RCN #222 confirmed there were no shower sheets for Resident #86 from 04/15/24 to 05/01/24. During an interview on 08/26/24 at 1:01 P.M., Certified Nurse Practitioner (CNP) #218 stated staffing is an issue in the facility, and it is possible that the wounds occurred and worsened due to the facility staffing levels, the facility has always had a staffing concern which affects the care. Just like today, there is staffing concerns. During an interview on 08/26/24 at 1:20 P.M., RCN #222 verified there was no documentation related to Resident #86 ' s refusals of care. During an interview on 08/26/24 at 1:44 P.M., WNP #228 confirmed Resident #86 had an unstageable wound to his sacrum on 04/30/24, the first time the resident was seen for the sacrum wound. Resident #86 did not have an air mattress prior to the sacrum wound being found. The wound could have been prevented if the facility had put an air mattress on his bed and if the facility had not had the resident sitting up all day in the chair. The facility did not implement the air mattress due to payor type. During an interview on 08/26/24 at 4:08 P.M., RCN #222 confirmed there was no documentation related to turning and repositioning of Resident #86. During an observation on 08/26/24 at 4:36 P.M., Resident #86 revealed he was lying on his back in the same position. During an interview at that time, Resident #86 stated staff had not been in to reposition him, and he would like to get up into his wheelchair. During an interview on 08/26/24 at 6:15 P.M., RCN #222 confirmed there was no documentation that the multi-podus boots were removed to inspect Resident #86 ' s skin. RCN #222 stated the STNA should be assessing the skin when taking the boots on and off, and the nurses should be doing the same when completing their skin assessments. RCN #222 verified the incident report indicated the root cause of the pressure ulcer to the left heel was from the boots. RCN #222 confirmed the skin assessment on 04/18/24 indicated there were no skin issues, and the task documentation by the STNA under the area of skin observation also indicated there were no skin issues for Resident #86. During interview on 08/28/24 at 5:00 P.M., RCN #222 confirmed the facility has a Pressure Ulcers/Skin Breakdown - Clinical Protocol, but not a pressure ulcer prevention policy. 2. Review of the medical record for Resident #37 revealed an admitted [DATE] with diagnoses including peripheral vascular angioplasty status with implants and grafts, Type 2 diabetes mellitus without complications, and contractures of both knees. Review of the Care Plan dated 11/21/21 revealed resident was at risk for impaired skin integrity related to confined to a chair all or most of the time, Decreased sensation: PVD, DM, Neuropathy, Impaired mobility, Incontinence. Picks and scratches at her skin at times. Review of the Braden Scale assessment on admitted d 05/31/21 revealed resident was at risk for pressure wounds. Review of the annual MDS assessment, dated 02/02/24, revealed resident with severe cognitive impairment. Resident #37 was dependent on staff assistance with all ADLs except requires set-up assistance with eating and oral hygiene. No pressure ulcers present and was at risk for developing pressure ulcers. The care plan had interventions to assist resident with turning and repositioning and as needed and complete skin inspection every seven to ten days and as needed dated 04/05/24. The Braden Scale completed on 04/06/24 revealed resident was at high-risk for pressure wounds. There was no documentation of a Braden scale completed from May 2021 to 04/06/24. Review of physician orders revealed Resident #37 had an order dated 04/13/24 for a health shake (a nutritional supplement) with meals for suboptimal intakes, an order dated 05/07/24 for Pro-Stat supplement two times a day for increased protein needs, and an order dated 06/04/24 for Arginaid supplement two times a day for wound healing. Review of the Significant Change MDS assessment, dated 05/06/24, revealed resident with severe cognitive impairment. Resident was dependent on staff assistance with all ADLs except required set-up assistance with eating and required substantial assistance with oral hygiene. Resident had two Stage 3 pressure ulcers present. The care plan had interventions dated 05/08/24 to add an air mattress, consult dietitian as needed, encourage resident to reposition self, and encourage/assist as needed to elevate the heels off mattress as tolerated. Review of physician orders revealed treatment orders dated 06/04/24 for the right lateral ankle, left lateral ankle, right fifth toe, left fifth toe and right heel, cleanse with wound cleanser and pat dry. Paint with Betadine and cover with ABD/Kerlix. Change three times a week and as needed; left fourth toe, cleanse with wound cleanser and pat dry. Apply Adaptic to wound bed followed by Silver Alginate. Cover with ABD/Kerlix. Change three times a week and as needed. Review of physician orders revealed treatment orders dated 08/06/24 for wound care to the left heel, cleanse with wound cleanser and pat dry. Paint with Betadine and cover with ABD/Kerlix, secure with tape. Change three times a week and as needed. Review of physician orders revealed treatment orders dated 08/07/24 for wound care to the left great toe, cleanse with wound cleanser and pat dry. Apply Medi Honey to wound bed followed by Calcium Alginate. Cover with ABD/Kerlix, secure with tape. Change three times a week and as needed. During an observation on 08/22/24 at 11:56 A.M., Resident #37 had eight wounds present. She was laying on a low air loss mattress, on her right side, with one pillow under her right lateral ankle and one pillow between her knees. LPN #50, present during the observation, confirmed a pillow was under right lateral ankle against the air mattress, and it should not be between the wound and the air mattress. LPN #50 completed wound care. One wound to right lateral ankle revealed wound with 100 percent necrotic scab present, cleansed with wound cleanser, patted dry, betadine applied, covered with abdominal pad, and wrapped with Kerlix. One wound to right heel revealed wound with 100 percent necrotic scab present, cleansed with wound cleanser, patted dry, betadine applied, covered with abdominal pad, and wrapped with Kerlix. One wound to right 5th toe revealed wound with 100% granulated pink tissue present, cleansed with wound cleanser, patted dry, betadine applied, covered with abdominal pad, and wrapped with Kerlix. One wound to left great toe area (medial area) revealed open wound with moderate about of serosanguinous drainage with tendon exposed, peri-wound white, cleansed with wound cleanser, patted dry, applied Medi honey to wound bed, applied alginate over wound, covered with abdominal pad, and wrapped with Kerlix. One wound to left later ankle revealed wound with 100% brown necrotic tissue present, no drainage present, cleansed with wound cleanser, betadine applied, covered with abdominal pad, and wrapped with Kerlix. One wound to left heel revealed 100% brown necrotic tissue present, cleansed with wound cleanser, patted dry, betadine applied, covered with abdominal pad, and wrapped with Kerlix. One wound to left 4th toe revealed pink wound bed with granulation tissue present, cleansed with wound cleanser, applied Adaptic then sliver alginate, covered with abdominal pad, and wrapped with Kerlix. One wound to left 5th toe revealed pink wound bed with granulation tissue present, cleansed with wound cleanser, patted dry, betadine applied, apply abdominal pad, and wrapped with Kerlix. During an interview on 08/26/24 at 1:01 P.M., CNP #218 confirmed staffing is an issue in the facility, and it is possible that the wounds occurred and worsened due to the facility staffing levels, the facility has always had a staffing concern which affects the care. Just like today, there is staffing concerns. During an interview on 08/26/24 at 1:44 P.M., WNP #228 confirmed all the pressure wounds could have been prevented if the facility had implemented the intervention of an air mattress when the risk was there, instead of delaying the application of the air mattress. Interview also confirmed the facility did not implement the air mattress due to payor type. During an interview on 08/26/24 at 4:10 P.M., RCN #222 confirmed the resident ' s body assessment on 04/04/24 revealed no skin issues. Interview also confirmed on 04/05/24 the resident was found with six new skin concerns to her bilateral feet, with a new intervention to encourage/assist as needed to elevate heels off the mattress as tolerated. Interview also confirmed the care plan did not have any interventions to prevent a pressure ulcer until 05/08/24 when an air mattress was ordered and put on the care plan. Interview also confirmed on the point of care documentation, there was no documentation showing any skin areas present on 04/04/24 or 04/05/24. Interview also confirmed a Braden Scale was completed on 05/31/21 on admission assessment and the next Braden Scale wasn ' t completed until 04/06/24. During an interview on 08/26/24 at 4:21 P.M., LPN #186 confirmed she notified the in-house wound nurse and Wound Nurse Practitioner #228 on 04/05/24 to see the resident for new skin concerns. Interview also confirmed there wasn ' t documentation present in the medical record of Resident #37 having the skin issues prior to the Wound Nurse Practitioner #228 seeing the resident on 04/05/24 and that she did not open a wound assessment until after the Wound NP had seen the wounds and initiated treatments. 3. Review of the medical record for Resident #4 revealed an admitted [DATE]. Diagnoses included psychosis, dementia, major depressive disorder, and schizoaffective disorder. Review of the quarterly MDS assessment, dated 08/17/24 revealed Resident #4 was not able to complete a Brief Interview for Mental Status (BIMS) because she was rarely/never understood. This resident was assessed to require dependence with eating, toileting, bathing, dressing, and transfers. Review of the Braden scale dated 05/08/24 revealed Resident #4 was at high risk. Review of the skin inspection dated 06/17/24 revealed Resident #4 had no skin issues. Review of the wound evaluation dated 06/18/24 revealed Resident #4 had moisture associated skin damage (MASD) to her coccyx, which was in-house acquired, that measured 0.6 cm in length by 0.6 cm in width by 0.1 cm in depth. Tissue was 100 percent pink. Recommendations were pressure reduction mattress, reposition, and nutritional consult. Review of the physician order dated 06/18/24 revealed Resident #4 was ordered a treatment to cleanse coccyx with wound cleanser and pat dry. Apply thin layer of Triad paste (a hydrophilic wound dressing) to wound bed and cover with bordered gauze, and to change daily and as needed. Review of the wound progress note dated 06/25/24 revealed Resident #4 ' s MASD to the coccyx measured one cm in length by 0.6 cm in width by 0.1 cm in depth. Partial thickness noted with 100 percent pink tissue to the wound bed. Wound was unchanged. Review of the physician order dated 06/26/24 revealed Resident #4 was ordered a health shake (a nutritional supplement) two times a day. Review of the wound progress note dated 07/02/24 revealed Resident #4 ' s MASD to the coccyx had healed. Review of the wound progress note dated 07/09/24 revealed Resident #4 had MASD to coccyx with partial thickness that measured one cm in length by one cm in width by 0.1 cm in depth. Wound bed tissue was 100 percent pink. Review of the physician order dated 07/09/24 revealed Resident #4 was ordered a treatment to cleanse coccyx with wound cleanser and pat dry, apply thin layer of Triad paste to wound bed and cover with bordered gauze. Change three times a week (Monday, Wednesday, and Friday) and as needed. Review of the wound progress note dated 07/16/24 revealed Resident #4 had MASD to coccyx with partial thickness that measured one cm in length by one cm in width by 0.1 cm in depth. Wound bed tissue was 100% pink. Wound was unchanged. Review of the wound progress note dated 07/23/24 revealed Resident #4 ' s coccyx was now an unstageable pressure ulcer that measured 2.1 cm in length by 1.1 cm in width and unable to determine (UTD) the depth. Wound bed was 20 percent granulation tissue and 80 percent slough. The wound had declined. Review of the physician order dated 07/23/24 revealed to cleanse coccyx with wound cleanser and apply MediHoney to wound bed and cover with bordered foam dressing and change three times a week and as needed. Review of the care plan dated 07/26/24 revealed Resident #4 had impaired skin integrity as evidenced by an unstageable wound to the coccyx. Interventions included to assist resident with turning and repositioning as needed. Staff to complete skin inspection every seven to ten days and as needed. Staff to complete wound evaluation to monitor the progress of the resident's skin condition. Staff to consult dietitian. Staff to follow enhanced barrier precautions (EBP). Staff to complete treatment per physician orders. Review of the wound progress note dated 07/30/24 revealed Resident #4 had an unstageable pressure ulcer to the coccyx that measured 2.6 cm in length by 2.6 cm in width and UTD the depth. Wound bed was 20 percent granulation tissue and 80 percent slough. The wound had declined. Review of the physician order dated 07/30/24 revealed to cleanse coccyx with wound cleanser, pat dry, apply MediHoney to wound bed and cover with bordered gauze dressing, change daily and as needed. Review of the wound progress note dated 08/06/24 revealed Resident #4 had an unstageable pressure ulcer to the coccyx that measured 2.6 cm in length by 2.6 cm in width and UTD the depth. Wound bed was 10 percent granulation, 40 percent slough, and 50 percent necrotic tissue. The wound was unchanged. Review of the physician order dated 08/06/24 revealed Arginaid (a nutritional supplement for wounds) two times a day for wound healing for 60 days, mix with beverage of choice. Review of the wound progress note dated 08/13/24 revealed Resident #4 had an unstageable pressure ulcer to the coccyx that measured 2.6 cm in length by 4 cm in width and depth was unable to be determined. The wound bed was 60 percent necrotic and 40 percent purple or maroon discoloration. The wound had declined. Review of the physician order dated 08/13/24 revealed to cleanse the wound with 0.25% Dakins solution (an antise [TRUNCATED]

Based on record review, review of Quality Assurance Performance Improvement (QAPI) sign-in sheets, and staff interview, the facility failed to be administered in a manner to ensure proper care and services for residents. This had the potential to affect all 105 residents residing in the facility. The census was 105. Findings include: During the annual, extended survey, and complaint survey, many area of deficient practice were identified under resident quality of life and quality of care area. Those areas included providing residents with activities of daily living assistance, providing wound care, assisting residents with range of motion needs, preventing accidents and hazards, providing catheter care, obtaining resident weights to address nutritional needs, care of a gastrostomy tube, and treatment pressure ulcers which resulted in an Immediate Jeopardy. Additionally, the facility was identified deficient in the area of sufficient staffing which also resulted in an Immediate Jeopardy. Review of the QAPI sign-in sheets for 08/14/23, 12/04/23, 02/12/24, and 06/10/24 revealed multiple different people in the role of Director of Nursing (DON). The sheets also lacked information regarding the governing body's involvement with the QAPI meetings. Review of a list provided by the facility revealed there had been four individuals in the DON position since 09/21/23. Interview on 08/29/24 at 3:27 P.M. with Registered Nurse (RN) Minimum Data Set (MDS) Coordinator #166 revealed the Administrator had asked her to fill in as the Interim DON when the facility was between DONs, but that she had never taken on responsibilities of the position. RN MDS Coordinator #166 stated she had not attended QAPI meetings or participated in addressing concerns as she was informed she did not need to be involved. RN MDS Coordinator #166 reported the lack of consistency with nursing management affected continuity of care and contributed to resident care issues being missed.

Based on record review, review of Quality Assurance Performance Improvement (QAPI) sign-in sheets, staff interview, and policy review, the facility failed to have an effective governing body to oversee the functions of the facility. This had the potential to affect all 105 residents in the facility. The census was 105. Findings include: Review of the QAPI sign-in sheets for 08/14/23, 12/04/23, 02/12/24, and 06/10/24 revealed multiple people in the role of Director of Nursing (DON). The sheets also lacked information regarding the governing body's involvement with the QAPI meetings. Review of a list provided by the facility revealed there had been four individuals in the DON position since 09/21/23. Interview on 08/29/24 at 11:25 A.M. via telephone with Physician #232 verified there had been significant turnover in nursing management at the facility. Interview on 08/29/24 at 3:15 P.M. with [NAME] President of Operations (VPO) #242 revealed the information he was learning regarding staffing levels at the facility had given him great pause and concern. Interview on 08/29/24 at 3:27 P.M. with Registered Nurse (RN) Minimum Data Set (MDS) Coordinator #166 revealed the Administrator asked her to fill in as the Interim DON when the facility was between directors, but that she had never taken on responsibilities of the position. RN MDS Coordinator #166 stated she had not attended QAPI meetings or participated in addressing concerns as she was informed she did not need to be involved. RN MDS Coordinator #166 reported the lack of consistency with nursing management affected continuity of care and contributed to resident care issues being missed. Review of the facility policy titled, Governing Body Policy and Procedure, dated 2024, revealed the governing body was responsible for establishing and implementing facility-wide policies, appointing the facility's administrator, and for the QAPI program.

Based on medical record review, review of hospital records, pharmacist and staff interview, and review of medication information from Medscape, the facility failed to administer antibiotic ([MEDICATION(S)]) ear drops as prescribed by the physician to treat a resident's ear infection resulting in a significant medication error. This resulted in Actual Harm when staff failed to administer Resident #90's antibiotic ear drops as physician ordered and the resident was subsequently hospitalized for severe otitis media/otitis externa (ear infection) along with mastoiditis. This affected one (#90) out of three residents reviewed for medication administration. Facility census was 81. Findings include: Review of medical record for Resident #90 revealed admitted [DATE] and was discharged to the hospital on 05/10/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 had a Brief Interview of Mental Status (BIMS) score of 14 out of 15 indicating the resident had intact cognition. Resident #90 requires supervision for activities of daily living, except toileting. For toileting Resident #90 required total one person assistance. Review of nursing progress note for Resident #90 dated 05/07/22 at 7:52 P.M. revealed the resident went to the emergency room for ear drainage and returned with a new antibiotic prescription for an ear infection. Further review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . However, review of the nurse's notes on 05/08/22 and 05/09/22 revealed there was no documentation regarding the antibiotic ear drops. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no further documentation on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #90's nursing progress notes dated 05/10/22 at 10:43 A.M. revealed the nurse spoke to the pharmacy regarding the resident's antibiotic ear drops being misplaced and pharmacy is to send another bottle today on the first drop. Review of Resident #90's progress note for Resident #90 dated 05/10/22 revealed the social worker contacted Resident #90 on her cell phone. Resident #90 informed the social worker she was going to the bank and went to the hospital because she was not receiving her antibiotics needed for her ear. Resident #90 informed the social worker she had been admitted for an ear infection. Record review of Resident #90's nursing progress note dated 05/10/22 at 1:33 P.M. revealed the floor nurse spoke to a nurse at the hospital and was informed the resident was at the hospital and was being seen for ear pain since 10:00 A.M. Review of the hospital documentation for Resident #90 dated 05/10/22 revealed the resident was diagnosed with severe otitis media/otitis externa along with mastoiditis. The history of present illness documented Resident #90 had presented to the emergency room and complained of bloody discharge of her right ear and was seen last week in the emergency department. Resident #90 was supposed to be getting antibiotics, but it was never filled. Further review of the hospital documentation revealed Resident #90 had a Computed Tomography (CT) scan (medical imaging technique used in radiology to obtain detailed internal images of the body noninvasively for diagnostic purposes) that confirmed the resident had the severe otitis media/otitis externa along with mastoiditis diagnosis. Interview on 06/15/22 at 11:23 A.M. with Pharmacist #200 revealed the order for [MEDICATION(S)] was received by the pharmacy on 05/07/22 at 7:52 P.M. and delivered to the facility on [DATE] at 7:31 P.M. Interview on 06/15/22 at 3:08 P.M. with the Administrator verified Resident #90's [MEDICATION(S)] antibiotic ear drops were administered one time on 05/09/22 and the medication bottle was misplaced, and the pharmacy was called to replace them. The Administrator confirmed Resident #90 left prior to their arrival. Review of medication information from Medscape revealed [MEDICATION(S)] otic (ear drops) is an antibiotic used to treat chronic suppurative otitis media with perforated tympanic membranes and otitis externa (ear infections). [MEDICATION(S)] ear drops should be administered as physician ordered. This deficiency substantiates Complaint Number OH 617.