Every finding on record at North Royalton Post Acute

Based on closed record review, hospital record review, review of facility fall investigations, facility policy review and interview, the facility failed to develop and implement a comprehensive, individualized and effective fall/safety plan of care to prevent repeated falls including falls with injury for Resident #97. This affected one resident (#97) of three residents reviewed for falls. The facility census was 96.Actual Harm occurred on 12/23/25 when Resident #97, who was at high risk for falls (with four falls between 12/17/25 and 12/22/25) and who had behaviors (agitation/restlessness) sustained a fall from bed resulting in a hematoma and visible injury to her right temple without evidence of comprehensive, individualized and effective interventions being in place to prevent the fall. Actual Harm continued on 01/11/26, when the facility failed to provide adequate and necessary supervision/intervention to prevent Resident #97 from sustaining an unwitnessed fall from her wheelchair resulting in an intracranial hemorrhage (brain bleed) and a seventh cervical (C7) superior facet and pedicle vertebral neck fracture. The resident was transferred to the hospital and did not return to the facility following this incident. Findings include: Review of the closed medical record for Resident #97 revealed the resident was admitted to the facility on [DATE] with diagnoses including non-traumatic subdural hemorrhage (bleeding in the space between the brain and the outermost protective membrane), non-traumatic intracranial hemorrhage (bleeding inside the skull), non-traumatic muscle wasting, and aphasia. Prior to admission to the facility, Resident #97 was hospitalized following a cerebrovascular accident (stroke) and fall at home. An assessment included in the hospital discharge paperwork identified Resident #97 was at high risk for falls. Review of the facility's incident log dated 12/13/25 through 01/31/26 revealed Resident #97 sustained six falls at the facility on 12/17/25, 12/18/25, 12/21/25, 12/22/25, 12/23/25, and 01/11/26. Review of the care plan initiated on 12/15/25 revealed Resident #97 was at risk for activities of daily living (ADL) and mobility decline, utilized anticoagulants, and was at risk for falls related to altered balance and a history of falls. Interventions initiated on 12/15/25 included to keep call light and frequently used personal items within reach, obtain physical and occupational therapy consult as indicated and orient to new environment as indicated.Review of the plan of care revealed it was updated with new interventions on 12/18/25 to keep bed in low position with brakes locked, on 12/19/25 to provide diversionary activities during periods of restlessness and on 12/23/25 for a dump wheelchair and mattress to the floor while in bed, and move bed against the wall. An intervention included on the care plan to place Resident #97 behind the nurse's station during periods of restlessness to maintain safety was initiated on 01/12/26; however, the resident had been transferred to the hospital following a fall with injury on 01/11/26.Review of the therapy notes dated 12/15/25 through 01/10/26 revealed Precautions: falls and noted the resident was being treated by the physical and occupational therapy department. The therapy notes did not include what specific fall precautions were in place or necessary to address the resident's increased fall risk and ongoing falls sustained during this time period. The therapy notes did reflect Resident #97 was very distracted, agitated, required verbal cueing and maximal assist for activities of daily living (ADLs), had poor sitting balance due to weak core and/or trunk control throughout each session.Review of a fall investigation dated 12/17/25 at 10:35 P.M. revealed Resident #97 had a fall without injury. Resident #97 was observed lying in bed prior to her fall. Resident #97 was found sitting on the floor next to her bed and was unable to provide details of what happened. The investigation noted following the incident Resident #97's was assisted to her wheelchair and brought to the nursing station for one-on-one monitoring. Following the incident, a new intervention to keep bed in low position with brakes locked was added to the resident's plan of care. The position of the resident's bed at the time of the fall was not noted on the fall investigation.Review of the progress note dated 12/17/25 at 10:57 P.M. revealed Resident #97 was observed sitting on the floor next to the bed. Resident #97 was assessed, denied pain or discomfort, and immediate care included assisting Resident #97 to her wheelchair and bringing her to the nurse's station. Review of the facility fall investigation and corresponding nursing progress note revealed no additional information as to the circumstances of the fall, any environmental factors associated with the fall, why the fall likely occurred, whether the resident's call light was in place/activated at the time of the fall, when the resident had last been seen by staff prior to the fall, and/or if the resident was having behaviors prior to the incident. Review of a fall investigation dated 12/18/25 at 5:40 P.M. revealed Resident #97 was sitting outside of the nurse's station and attempted to get out of her chair and fell to the floor before anyone was present. Resident #97 was assisted back into her chair by 2-person assist and placed behind the nurse's station for supervision. Following the incident, the facility implemented an intervention to provide diversional activities during periods of restlessness. Review of the progress note dated 12/18/25 at 6:08 P.M. revealed Resident #97 was sitting outside the nurse's station when she attempted to get up out of her chair and fell to the floor before anyone was present. Resident #97 was assisted back into her chair with two staff and placed behind the nurse's station for supervision. Resident #97 received new orders for Hydroxyzine (an antihistamine medication that also decreases symptoms of anxiety and tension) 25 milligram as needed every eight hours after physician notification.Review of the facility fall investigation and corresponding nursing progress note revealed no evidence the facility completed a root cause analysis of the fall. There was no evidence the resident had been provided necessary supervision in the presence of restlessness to prevent this fall. In addition, there was no evidence the need for and/or use of diversional activities was individualized to meet the resident's total care needs or that the facility provided guidance to staff as to what type of diversional activities should be used following the incident.Review of the progress note dated 12/21/25 at 3:45 P.M. revealed Resident #97 was sitting at the nurse's station in her wheelchair. Resident #97 was observed to keep making gestures of trying to get up but was readjusted in her chair by staff. Resident #97 then attempted to get up again and fell to her knees, rolled over, and laid out on the floor. Resident #97 stated she was scared once back into her chair. Resident #97's family and physician were notified.Review of the fall investigation dated 12/21/25 at 3:45 P.M. revealed Resident #97 had a witnessed fall without injury at the nurse's station. Review of the fall investigation revealed Resident #97 did not have a change in her behavior; however, it was noted Resident #97 was generally extremely confused and unable to understand her lack of ability to stand and walk. Resident #97 was placed back into her chair and given something to distract her and keep her from trying to get up (following the incident). The investigation included the resident was to be placed behind the nurse's station to maintain safety. The investigation also included the resident would have a dump (seat) to the wheelchair (which would place the back of the wheelchair seat lower than the front of the wheelchair creating a sloped, bucketed effect). Review of the nursing progress note and corresponding facility fall investigation revealed no evidence a root cause analysis was completed, no evidence effective interventions/diversional interventions were in place prior to the fall and/or evidence effective interventions were in place when staff identified the resident kept making gestures to try to get up to prevent the fall from occuring.Review of a fall investigation dated 12/22/25 at 11:00 A.M. revealed Resident #97 was found lying on the floor beside her bed after stating she was trying to walk to the restroom and lost balance. Resident #97's physician and family were notified of the unwitnessed fall.Review of the progress note dated 12/22/25 at 11:36 A.M. revealed Resident #97 was found lying on the floor beside her bed. Resident #97's family was present at bedside. Resident #97 stated I was trying to walk to the restroom and lost balance. The progress note revealed Resident #97 had an immediate intervention to keep call light in place.Review of the facility fall investigation and corresponding nursing progress note revealed no additional information as to what interventions were in place at the time of the fall, any additional circumstances related to the fall, any environmental factors associated with the fall, why the fall likely occurred, when the resident had last been seen by staff prior to the fall, and/or if the resident was having behaviors prior to the incident. Review of a fall investigation dated 12/23/25 at 5:15 A.M. revealed Resident #97 had a fall with minor injury with a hematoma noted above her right eye and her nasogastric (NG) tube (a thin, flexible plastic catheter inserted through the nose, down the esophagus, and directly into the stomach) dislodged. The investigation included Resident #97 was last observed in her bed from 2:00 A.M. to 4:45 A.M., being checked every 15 to 30 minutes. After being checked on at 4:30 A.M., Resident #97 was found on the floor at the end of her bed. Resident #97 was assessed and assisted into her wheelchair. The investigation noted following the incident, Resident #97 was assisted by two staff back to her wheelchair, toileted, and placed in common area for monitoring. Resident #97 had ice applied to the hematoma and a message was left for the physician to return the call.Review of the progress note dated 12/23/25 at 2:10 P.M. revealed Resident #97 received new orders to discontinue Hydroxyzine and start Seroquel (an antipsychotic medication) 25 milligrams twice a day for agitation and restlessness. Resident #97's family was made aware. There was no additional information to explain why these changes were made at this time and/or to justify the use of the an atypical anti-psychotic medication for agitation/restlessness.Review of a progress note dated 12/23/25 at 10:09 P.M. (from the fall that occurred in the 4:00 A.M. hour) revealed Resident #97 was found on the floor on the left side of the bed on her right side with her NG tube pulled out. The note included Resident #97 was last seen and was provided with incontinence care at 4:30 A.M. Resident #97 was noted to have hematoma above her right eye. The progress note included Resident #97's call light was in reach, and the bed was in a low position. Resident #97 had ice applied to the hematoma and a message was left for her physician.Review of the facility fall investigation and nursing progress note revealed no root cause analysis of the fall was completed. In addition, there was no additional information as to any additional circumstances related to the fall, any environmental factors associated with the fall, why the fall likely occurred and/or if the resident was having any behaviors prior to the incident. Record review revealed no additional new fall/safety interviews were initiated to prevent falls from bed following this incident. Further review of Resident #97's progress notes revealed no indication of monitoring of the resident's hematoma, nor was the resident sent to the hospital for evaluation of a closed head injury sustained as a result of this fall.Review of the progress note dated 01/11/26 at 8:28 P.M. revealed Resident #97 was sitting across from the nurse's station in her wheelchair. The note included Licensed Practical Nurse (LPN) #241 had just sat down at the nurse's station a few minutes prior to chart, when she heard a loud noise. LPN #241 jumped up and observed Resident #97 lying on the floor on her left side. The note indicated LPN #241 immediately ran to Resident #97, picked her up off the ground underneath her arms, and alerted another (unnamed) LPN to help assist Resident #97 into her wheelchair. LPN #241 began brushing Resident #97 hair out of her face, when she noticed a large hematoma to the left side of the resident's forehead. Resident #97 was conscious and an ice pack was placed on the hematoma. Resident #97 was assessed and the on-call physician was made aware and gave a new order to send Resident #97 to a local emergency room (ER). Resident #97's daughter was notified of the fall, findings, and ER transfer. Emergency Medical Services (EMS) arrived and were made aware of the fall, hematoma, and vital signs and transported Resident #97 to a local hospital. Resident #97's daughter came into the facility following the incident and shouted at staff stating, It's your guy's fault.Review of a fall investigation dated 01/11/26 revealed Residet #97 sustained a fall with a major injury. Review of the fall investigation revealed Resident #97 was last seen by Certified Nurse Assistant (CNA) #359 at 7:25 P.M. and appeared confused and trying to self-ambulate. At the time of the fall, Resident #97 was sitting across from the nurse's station in her wheelchair, when LPN #241 heard a loud noise after sitting down to chart. LPN #241 jumped up and observed Resident #97 lying on the floor on her left side and immediately ran to pick her up off the ground under her arms and alerted another (unnamed) LPN to assist Resident #97 back into her wheelchair. After brushing hair out of her face, Resident #97 was noted to have a large hematoma to the left side of her forehead. Immediately following the incident, Resident #97 was placed on one-on-one supervision until EMS arrived. Resident #97 was admitted to a local hospital for trauma related to a fall.Review of the nursing progress note and facility investigation revealed no evidence comprehensive, individualized and effective fall/safety interventions, including adequate and necessary supervision were in place prior to this fall incident. Review of an encounter summary dated 01/11/26 revealed Resident #97 was admitted to a local hospital with diagnoses that included, but were not limited to, traumatic intracerebral hemorrhage with loss of consciousness, fall, acute pain due to trauma, C7 cervical fracture, and hospice care. The encounter note referenced a referral to an inpatient hospice care facility. The resident subsequently passed away in the hospital.Record review revealed Resident #97 was admitted to the facility (on 12/13/25) with a history of falls and known high fall risk requiring increased supervision and appropriate interventions. Resident #97 sustained six falls in less than 30 days following admission without evidence of a comprehensive, individualized and effective fall management program which included ongoing preventative measures to be implemented for her safety. Furthermore, Resident #97's fifth fall resulted in a head injury that she was not transferred to the hospital or sent for further medical evaluation for. Resident #97 then sustained an additional fall (sixth), that resulted in a C7 fracture and brain bleed, hospice admission, and subsequently passed away approximately 10 days after transferring to the hospital following the fall.Interview on 05/12/26 at 10:22 A.M. with Registered Nurse (RN) #357 revealed residents who had an unwitnessed fall were to be assessed, checked for range of motion, assisted back in bed, and then the falls investigated to determine the cause of the fall. RN #357 revealed following a fall, residents' families and physicians were notified, neurological checks were put in place, and interventions were to be implemented. RN #357 revealed residents with head injuries, including hematomas, were to be sent out to the hospital for further evaluation.Interview on 05/12/26 at 10:28 A.M. with RN #303 revealed unwitnessed falls required head-to-toe assessments, obtaining vital signs, checking for injuries, implementing neurological checks, notification to the physician and families, and if a resident hit their head, they were sent to the hospital for evaluation.Interview on 05/12/26 at 10:45 A.M. with the Director of Nursing (DON) revealed residents who sustained an unwitnessed fall, depending on who was present or discovered the fall, would notify the nurse immediately to assess the scene. The DON revealed staff would attempt to figure out why the fall occurred and if there were no apparent injuries, they would check range of motion and pick the resident up off the floor. The DON revealed if the fall resulted in injury or suspected head injury, the resident was to be left in place and vitals assessed with a call made to EMS for evaluation. The DON revealed if a resident had blunt head trauma, the facility would send them out via 911. The DON revealed any injury to the head required assessment, vital signs, neurological checks, and more than likely a visit to the ER. The DON stated Resident #97's case was a sad case. The resident had been driving before she was admitted to the facility after having some sort of aneurysm or stroke where she became debilitated. The DON revealed Resident #97's cognition was not there, she had poor safety awareness, and the DON stated the resident's falls were difficult to manage. The DON revealed Resident #97 was a frequent faller and had to be sent out (to the hospital) after her last fall in the facility (January 2026). The DON revealed she was not aware of what happened to Resident #97 after her fall on 01/11/26, despite facility documentation (hospital encounter) which stated Resident #97's outcome after discharge. Interviews on 05/12/26 at 4:33 P.M. and on 05/113/26 at 11:32 A.M. with the DON confirmed neither Resident #97's physician (Medical Doctor (MD) #360), or facility staff sent Resident #97 to the hospital after her 5th fall on 12/23/25 that resulted in a visible head injury, a hematoma to the forehead. The DON verified Resident #97's fall interventions were not effective due to the resident being agitated and needing to be within close distance of staff. The DON revealed staff nurses would bring Resident #97 to the nurse's station multiple times or provided one-on-one due to her being agitated or restless.Interview on 05/13/26 at 1:49 P.M. with LPN #241 revealed when residents had an unwitnessed fall, staff were to make sure they were safe, vital signs were assessed, the resident would be checked for injuries, and the family and physician would be notified. LPN #241 revealed if a resident hit their head during a fall, whether there was bleeding or not, a resident was to be sent out 911 for evaluation. LPN #241 revealed she did not work with Resident #97 a lot, but she was working at the time of her fall on 01/11/26. LPN #241 revealed Resident #97 had just finished visiting her family when they left and placed her in front of the nurse's station. LPN #241 revealed Resident #97 was seated in her wheelchair as CNAs were getting ready to put her to bed, when she turned around to sit down to chart and heard a loud noise. LPN #241 revealed she jumped up and observed Resident #97 on the floor, ran to her and picked her up off the floor with the help of CNA #359, who no longer works at the facility. LPN #241 revealed the resident's neurological assessment was not right and a call was placed to send Resident #97 out to the hospital for evaluation. LPN #241 revealed Resident #97 was to be in the common area if not in bed, had orders for a mattress on the floor in case she rolled out of bed, and was to be at the nurse's station for monitoring. LPN #241 revealed Resident #97 could not walk on her own and if she tried to get up, she was going to hit the floor. LPN #241 revealed Resident #97 sustained a hematoma to her forehead immediately after her fall.Interview on 05/13/26 at 4:27 P.M. with the DON revealed residents who were impulsive required one-on-one supervision and falls were generally reviewed in facility team meetings. The DON revealed Resident #97 was restless at times, but she did not know if she was always restless. The DON revealed Resident #97 was to be toileted, given diversional activities, and left at the nurse's station for close monitoring.Interview on 05/13/26 at 5:03 P.M. with Director of Rehab (DOR) #273 revealed Resident #97 was very impulsive and admitted to the facility in bad shape. DOR #273 revealed Resident #97 was unable to ambulate on her own, needed hands on her at all times, needed a lot of help, had poor judgment, and was a high fall risk with severe deficits. DOR #273 revealed Resident #97 had an intervention put in place of dumping the wheelchair seat, (the rehab department made the recommendation) and the maintenance department was to modify the equipment based on the recommendation. DOR #273 revealed Resident #97 had a dump wheelchair implemented between 12/21/25 to 12/24/25, but the maintenance department would have to confirm if the modification was actually completed. Interview on 05/13/26 at 5:16 P.M. with Director of Maintenance (DOM) #264 revealed his department was responsible for implementing the dump wheelchairs by request of the rehab department. DOM #264 revealed sometimes staff put in electronic work orders or told him verbally of a dump wheelchair request. During the interview, DOM #264 was unable to confirm or verify if Resident #97 had a dump wheelchair in place during her stay.Interview on 05/14/26 at 8:53 A.M. with Resident #97's family member revealed upon Resident #97's admission to the facility, the family reported to facility staff that the resident was not safe on her own and was at very high fall risk. Resident #97's family member shared Resident #97 constantly tried to get out of bed and chair and was extremely restless and needed consistent monitoring. Resident #97's family member indicated following the resident's fall on 01/11/26, the resident was admitted to hospice and passed away. Resident #97's family member stated family had requested some type of special wheelchair for the resident's safety, but none was ever implemented. Resident #97's family member revealed Resident #97 had a fall around Christmas (12/23/25) and when family arrived to the facility, Resident #97 was bruised really bad and the facility refused to send her to the hospital. Resident #97's family member stated the family took the resident to the hospital to get evaluated and were informed by hospital staff the resident had sustained a brain injury. (Review of the resident's medical record could not confirm the resident's family member took the resident to the hospital or that she was diagnosed with a brain bleed during this time period).Interview on 05/14/26 at 12:29 P.M. with LPN #358 revealed Resident #97 was confined to her bed and wheelchair and was to be placed at the nurse's station for safety due to being a high fall risk. LPN #358 revealed Resident #97 was very impulsive, had very poor trunk support, was nonverbal, and was kept in the common area for monitoring. LPN #358 revealed Resident #97 was not sent out to the hospital for the fall on 12/23/25 which resulted in a head injury and/or trauma even though LPN #358 stated residents who have falls resulting in them hitting their head were to be sent out to hospital for evaluation. LPN #358 revealed Resident #97 was sent out to the hospital for a fall one time and that was the fall that occurred on 01/11/26 when she did not return to the facility.Interview on 05/14/26 at 1:48 P.M. with MD #360 revealed Resident #97 was a high fall risk resident who was very confused. MD #360 revealed Resident #97 would attempt to get out of bed and wheelchair all the time. MD #360 revealed Resident #97 was to be kept at the nurse's station all the time to keep an eye on her, but her last fall was a big fall, and she didn't return to the facility after being sent to the hospital. MD #360 revealed that anytime a resident had a fall and hits their head, they need to be sent to the hospital for evaluation, especially residents who can't verbalize what happened during the fall or state if they hit their head or not. MD #360 also revealed if visible head trauma was noted, residents were sent to the hospital for evaluation. MD #360 revealed the facility staff informed her of all of Resident #97's falls, but she did not recall a fall with a hematoma on 12/23/25.Interview on 05/13/25 at 5:00 P.M. with the DON confirmed and verified following the fall that resulted in a head injury on 12/23/25, Resident #97 was not transferred to the hospital or provided a timely emergency medical evaluation despite evidence of injury and her known history of repeated falls. The DON verified the above findings at the time of the interview. During the onsite survey, no additional information was provided by the facility related to Resident #97's falls and/or the concerns noted above related to the lack of comprehensive, individualized and effective fall management program to prevent six falls including falls with major injury within 30 days of the resident's admission.Review of the facility document titled Fall Risk Assessment revised March 2018, revealed the facility had a policy in place to review falls and establish a resident-centered falls prevention plan based on relevant assessment information. Review of the document revealed the facility did not implement the policy.Review of the facility document titled Assessing Falls and Their Causes revised March 2018, revealed the facility had a policy in place that after a fall, if there were evidence of an injury, provide appropriate first aid and/or obtain medical treatment immediately. Review of the document revealed the facility did not implement the policy.This deficiency represents non-compliance investigated under Complaint Number 2715885.

Based on observation, interview, and facility policy review, the facility failed to properly disinfect glucometers after resident use. This affected one Resident (#33) of three residents reviewed for infection control and had the potential to affect six additional residents (#2, #20, #33, #51, #61, and #90) on the nurse's assignment that received blood glucose checks. The facility census was 96.Findings include: Record review revealed Resident#33 was admitted to the facility on [DATE] with diagnoses including osteoarthritis, dementia, type 2 diabetes, dysphagia, peripheral and vascular disease. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired and was dependent on activities of daily living. The resident received insulin.Review of the physician orders for May 2026 revealed an order for Lantus Solostar pen injector inject 5 units subcutaneously two times a day. If Libre (a blood glucose sensor) was unavailable a blood glucose device could be used [to check the resident's blood glucose level].Observation on 05/11/2026 at 8:30 A.M. of medication administration with Licensed Practical (LPN) #257 for Resident #33 revealed LPN #257 prepared to obtain Resident #33's blood glucose level and insulin administration. Continued observation revealed LPN #257 took the glucometer out of the medication cart along with supplies and entered Resident #33's room. LPN #257 washed her hands, donned gloves, wiped the resident's index finger with an alcohol pad, pricked the finger with a lancet, and applied a blood sample to the glucometer test strip to obtain a blood sugar reading of 140. LPN #257 removed her gloves, washed her hands, walked back to medication cart, cleaned the glucometer with an alcohol pad and placed the glucometer back in the medication cart.Interview 05/11/26 at 9:30 A.M. with LPN #257 revealed the process for cleaning the glucometer was to use alcohol wipes. LPN #257 verified she always cleans the glucometer with alcohol pads. Review of the facility policy titled Blood Glucose Testing undated stated to disinfect the glucometer with bleach wipes, allow drying for three to five minutes per manufacturer's instructions.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure Resident #33 was free from significant medications errors. This affected one Resident (#33) of three reviewed for medication administration. The facility census was 96. Findings include: Record review revealed Resident#33 was admitted to the facility on [DATE] with diagnoses including osteoarthritis, dementia, type two diabetes mellitus, dysphagia, and peripheral vascular disease. Review of Resident #33's active physician orders revealed the resident had orders for Lantus Solostar (a long acting insulin) inject five units subcutaneously twice day, Zyrtec (an antihistamine commonly used to treat allergy symptoms) 10 milligram (mg) daily, Gabapentin (an anticonvulsant commonly used to treat neuropathy pain) 100 mg twice daily, Miralax (a laxative) 17 grams once daily, Metoprolol Tartrate (an antihypertensive) 25 mg twice daily, Pepcid (an antacid) 20 mg twice daily, Simethicone 80 mg, give 1.5 tablets three times daily for gastric protection, Tylenol 1000 mg twice daily for pain, and Fluticasone Propionate (a nasal spray used for allergies) 50 micrograms (mcg) per actuation, give one spray in each nostril daily. Review of the Medication Administration Record (MAR) for December 2025 revealed on 12/14/25, Resident #33's evening medications, including insulin, were recorded as refused by the resident. On 12/24/25, evening medications (including Zyrtec, Gabapentin, Miralax, Metoprolol Tartrate, Pepcid, Tylenol, Simethicone, and Lantus insulin) were not documented as administered. On 12/25/25, Resident #33's morning medications (including Lantus insulin, Flonase, Gabapentin, Metoprolol Tartrate, Miralax, Tylenol, and Simethicone) were not documented as administered. On 12/30/25, Resident #33's evening medications (including Zyrtec, Gabapentin, Miralax, Metoprolol Tartrate, Pepcid, Tylenol, Simethicone, and Lantus insulin) were not documented as administered. Review of the progress notes revealed on 12/14/25 there was no documentation the physician was notified regarding the resident's refusal of medications and Lantus insulin. There was no progress note for 12/24/25, 12/25/25, and 12/30/25 regarding why scheduled insulin and medications were not administered or to indicate the physician had been notified. Continued review of the progress notes revealed a note dated 12/29/25 at 10:58 A.M. stated the physician notified of allegation from 12/14/25 that the resident did not receive scheduled insulin.Review of the MAR for March 2026 revealed on 03/24/26 the morning medications were not documented as administered including Lantus, Flonase, Gabapentin, Metoprolol Tartrate, Miralax, Tylenol, and Simethicone.Review of the progress notes revealed on 03/24/26 there was no notification to the physician regarding refusal of medications and Lantus insulin.Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired and was dependent on activities of daily living. The resident was recorded to have received insulin.Interview on 05/14/26 at 9:45 A.M. with the Registered Nurse (RN) #357 verified that there was no documentation that Resident #33 received scheduled medications including insulin on the dates above in December 2025 and in March 2026. RN #357 verified that the physician was not notified of the missed medications and insulin in December 2025 or March 2026. Review of the facility policy titled Charting and Documentation dated July 2017 all services provided to the resident, progress toward the care plan goals, or any changes int her resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.Review of the facility policy titled Medication Administration dated 06/29/2017 revealed after administration, return to the medication cart and document medication administration with initials on the MAR immediately after administering medication to each resident. The policy further noted that if the insulin dose cannot be administered at the designated time or interval, notify the prescriber as appropriate. The policy noted insulin should be immediately documented on the MAR after administration to avoid duplicate administration by another nurse. This deficiency represents non-compliance investigated under Complaint Numbers 2966927 and 2705845.

Based on record review, interview, observation, and facility policy review, the facility failed to ensure urinary catheter care was provided according to professional standards of practice, and failed to ensure urinary catheter and colostomy care were provided and in a timely manner to Resident #49. This affected one resident (#49) of three residents reviewed for bowel and bladder care. The facility census was 96. Findings include: Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, epilepsy, type 2 diabetes, chronic kidney disease, dysfunction of the bladder and Bell's Palsy.Review of Resident of the care plan dated 03/16/26 revealed the resident was at risk for complications with urinary system related to neurogenic bladder and a suprapubic catheter. The Resident was at risk of complication with gastrointestinal system due to a colotomy. The resident was care planned for enhanced barrier precaution (EBP) during high contact activities due to presence of suprapubic catheter and colostomy, Intervention included to ensure items for EBP are in place gloves, gowns, alcohol bases hand sanitizer, signage and trash receptacles. Utilize personal protective equipment (PPE) during high contact resident care activities.Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and was dependent on staff for toileting. The resident had indwelling catheter and bowel continence was recorded as not rated. Review of the physician orders for May 2026 revealed an order for colostomy care every shift and suprapubic catheter care every shift and as needed. Review of the Treatment Administration Record (TAR) for March revealed catheter care was not documented as provided on 03/20/26, 03/26/26, 03/27/26, 03/28/26, 03/29/26, and 03/31/26 on day shift. Continued review of the TAR revealed colostomy care was not documented as provided on 03/20/26, 03/26/26, 03/27/26, 03/28/26, 03/29/26, and 03/31/26 on day shift.Review of the TAR for April 2026 revealed catheter care was not documented as provided on 04/03/36, 04/06/26, 04/09/26, 04/10/26, 04/20/26, 04/24/26/ and 04/30/26. Continued review of the TAR revealed colostomy care was not documented as provided on 04/03/36, 04/06/26, 04/09/26, 04/10/26, 04/20/26, 04/24/26/ and 04/30/26.Review of the TAR for May 2025 revealed catheter care was not documented as provided on 05/01/26 on night shift and on 05/04/26 and 05/10/26 on day shift. Continued review of the TAR revealed colostomy care was not recorded as provided on the night shift of 05/01/26 and on day shift on 05/04/26 and 05/10/26.Observation on 05/12/26 at 11:56 A.M. revealed Licensed Practical Nurse (LPN) #239 perform urinary catheter care for Resident #49. Upon entering the room, signate was observed on the door that read contact precautions everyone must: clean their hands before room entry and discard gloves before room exit. Put on a gown before room entry and discard gloves before exit. LPN #239 was in the room gathering supplies for care. LPN #239 was observed wearing gloves but no gown. LPN #239 removed Resident #49's brief and cleaned around the catheter site and on each side of the catheter. LPN #239 did not clean the down the catheter. LPN #239 changed gloves, rinsed and dried around the catheter, then applied a brief.Interview on 05/12/26 at 12:09 P.M. with LPN #239 following the observation revealed LPN #239 stated she was unaware she had to wear a gown while providing catheter care. LPN #239 verified she did not clean the catheter because she did not want to dislodge the catheter. LPN #239 stated she was a new nurse and had not performed catheter care since nursing school.Interview on 05/12/25 at 3:13 P.M. with Registered Nurse (RN) #351, the Unit Manager, revealed RN #351 stated she would expect the nurses to clean the catheter during care.Interview on 05/13/26 at 11:00 A.M. with the Director of Nursing (DON) verified the catheter care and colostomy care was not documented on the above dates. The DON stated she would have to talk to the nurses to find out why care was not documented on those dates.Further observation on 05/14/26 at 10:55 A.M. with the DON of Resident #49's colostomy bag revealed it had come loose. There was loose stool over Resident #49's abdomen. Interview at the time of observation with Resident #49 revealed she had been waiting two hours for someone to clean her up and put on a new [colostomy] bag. Interview at this time with the DON stated she would get the nurse and aide to clean up the resident and change the colostomy bag. Interview on 05/14/26 at 2:30 P.M. with Certified Nursing Assistant (CNA) #325 stated she was assigned to Resident #49. CNA #325 checked on Resident #49 between 7:00 A.M. and 7:30 A.M. at the beginning of her shift and did not get back to her until 11:00 A.M. when she was told by the nurse to provide care to Resident #49. Interview on 05/14/26 at 2:35 P.M. with LPN #251 stated she was the assigned nurse to Resident #49. LPN #251 stated she was unaware that Resident 49's colostomy bag had come loose until the DON told her to change the bag and that was prior to lunch.Review of the facility's policy titled Suprapubic Catheter Care undated revealed the policy stated to clean area around catheter with soap and water, clean any crusted material from the catheter at the insertion site. Do not pull on the catheter or advance the catheter into the bladder. Rinse and dry the area well. The policy did not address to clean down the catheter.Review of the facility policy titled Charting and Documentation dated July 2017 revealed the following information was to be documented in the resident medical record: objective observations, medications administered, treatments or services performed, change in condition, events, incidents or accidents involving the resident, and progress toward or changes in the care plan goals and objectives.This deficiency represents non-compliance investigated under Complaint Numbers 2966927 and 2705845.

Based on resident record review, staff interviews, and facility policy review, the facility failed to provide a timely response to resident concerns. This affected one resident (#33) of three reviewed for resident's rights. The facility census was 96.Findings include: Review of the medical record for Resident #33 revealed she was admitted to the facility on [DATE] with diagnoses that included osteoarthritis of the left shoulder, type two diabetes mellitus, and dementia. Review of the care plan dated 03/21/25 revealed Resident #33 had a self-cere performance deficit with interventions to assist with ADLs.Review of the facility concern document dated 03/11/26 revealed Resident #33's representative reported Resident #33 was missing two pairs of pants, one black and whites stripped pair and one all white pair. Review of the document revealed Resident #33's missing items were not located in the laundry department, lost and found, and her room after a full sweep of the facility. Review of the concern document revealed a follow-up on 03/12/26 with a resolution that the facility would reimburse Resident #33 for two pairs of missing pants with receipt. Review of the receipt attached to the concern document revealed two pairs of men's active pants priced at $12.99 and $24.99.Review of the facility refund request details document dated 04/09/26 revealed a refund in the amount of $41.02 was to be paid to Resident #33 representative for two pairs of missing pants. Review of the facility document property refund dated 05/07/26 for miscellaneous payment request revealed the payment was still unpaid for Resident #33, approximately 57 days later after being made aware.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 0 that indicated she had short- and long-term cognition deficits. Review of the MDS assessment revealed Resident #33 was impaired on one side upper extremity and required assistance from staff for activities of daily living (ADLs).Interview on 05/19/26 at 10:45 A.M. with the Director of Nursing (DON) revealed when residents and/or family informed them of missing items, it was documented on a concern form and then designated departments searched for the missing item. The DON revealed that once an item cannot be found, the concern form goes to the Administrator, and he puts in place a possible reimbursement or alternative solution. The DON revealed the residents and/or family would need to produce receipts to fulfill a reimbursement. The DON revealed she was aware of Resident #33 missing items but stated she notified us a while ago and should have already been reimbursed for that. The Administrator handles the reimbursement part. The DON confirmed and verified the above findings at the time of the interview. Interview on 05/19/26 at 11:28 A.M. with the Administrator revealed the facility had already reimbursed Resident #33's representative and that was the responsibility of the facility's corporate office. The Administrator revealed he had no control over how the corporate office handled reimbursement of funds for residents and families or how long it takes. Review of the facility documents related to Resident #33's representative concerns with the Administrator confirmed and verified the facility failed to provide timely resolution to Resident #33's representative and reimbursement still was not provided.This deficiency represents non-compliance investigated under Complaint Number 2705845.

Based on record review, interview and review of the facility policy, the facility failed to notify the physician timely and monitor the resident for adverse effects after a medication error occurred. This affected one resident (Resident #44) of three residents reviewed for medication errors. The facility census was 119.Findings include:Record review for Resident #44 revealed an admission date of 11/03/21. Diagnosis included type two diabetes mellitus (DM) with diabetic neuropathy, long term use of insulin and Alzheimer's disease. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed Resident #44 was unable to complete the Brief Interview for Mental Status, had short- and long-term memory problems and had severely impaired cognitive skills. Resident #44 had diabetes mellitus and received insulin injections daily. Review of the physician orders for Resident #44 revealed on 02/14/25 Resident #44 was to receive Lantus Solostar subcutaneous solution pen injector 100 units per milliliter (ml), inject 20 units subcutaneous in the evening for DM.Record review of the Investigation Report dated 02/15/25 untimed with a date of incident of 02/14/25 completed by Director of Nursing (DON) revealed: On 02/14/25 Resident (#44) did not receive 7:00 P.M. insulin. On 02/14/25 Nurse (Licensed Practical Nurse (LPN) #213) reports she was passing medication to (Resident #44) when family requested that her comforter be changed. Nurse (LPN #213) reported that she assisted with family request and continued to pass medications. Nurse (LPN #213) reports she did not realize that she did not administer (Resident #44's) insulin until the next day when she received a call from the Unit Manager (UM) (#371). UM (#371) reports she was notified by the daughter of the resident. Review of Resident #44's medical record revealed no evidence the resident was monitored for adverse effects of missing insulin.Review of the care plan dated 03/21/25 revealed Resident #44 had a diagnosis of diabetes and was at risk for complications manifested by hyperglycemia, hypoglycemia, neuropathy, peripheral vascular disease and skin breakdown. Interventions included to administer medications per the physician orders.Review of the Investigation report dated 10/28/25 untimed completed by DON with date of incident 10/17/25 revealed on 10/17/25 (Resident #44) had a missed dose of insulin. Review of the timeline of events revealed LPN (#267) stated she was unable to take care of (Resident #44) due to (Resident #44's) daughter request. LPN #213 agreed to care for (Resident #44). (LPN #213) was also reminded to administer the insulin. (Resident #44) missed afternoon insulin and her bedtime medications. This was verified by recording review, medical record review and witness statements.Review of the physician orders and Medication Administration Record (MAR) for Resident #44 for 10/17/25 revealed Resident #44 missed the following medications and accucheck:1. Cetirizine HCL oral tablet 10 milligrams (mg) give one tablet by mouth for allergies to be administered at 5:00 P.M.2. Lantus Solorstar sq solution pen injector 100 units per ml, inject 20 units sq in the evening for DM to be administered at 5:00 P.M.3. Accucheck without coverage two times a day for DM, notify on call if blood sugar over 250 to be assessed at 7:00 P.M.4. Gabapentin capsule 100 mg give one capsule by mouth for neuropathy to be administered at 4:00 P.M.5. Glycolax powder give 17 grams by mouth for constipation to be administered at 7:00 P.M.6. Metoprolol Tartrate 25 mg give one tablet by mouth for hypertension to be administered at 4:00 P.M.7. Tylenol extra strength oral tablet 500 mg give 1000 mg by mouth for pain to be administered at 5:00 P.M.8. Pepcid oral tablet 20 mg give one tablet by mouth two times a day for gastro esophageal reflux disorder (GERD) to be administered at 6:00 P.M.9. Simethicone oral tablet 80 mg give one tablet by mouth for gas to be administered at 5:00 P.M.10. Sucralfate suspension one gram per 10 ml, give 10 ml by mouth for gastric protection to be administered at 5:00 P.M.Review of Resident #44's medical record revealed no evidence the resident's physician was notified of the medication errors on 10/17/25 or was monitored for adverse effects of missing the medications.Interview on 11/25/25 at 12:18 P.M. with Director of Nursing (DON) verified the medication errors that occurred for Resident #44 on 02/14/25 and 10/17/25. DON revealed that when there was a medication error, the resident should be monitored daily for 72 hours following the error. DON reviewed the medical record and confirmed on 02/14/25 and 10/17/25 Resident #44 was not monitored daily for 72 hours for effects related to the missed doses of medications and the physician was not notified timely of the medication errors that occurred 10/17/25.Review of the facility policy titled, Adverse Consequences and Medication Errors dated February 2023 revealed a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician orders, manufacturer specifications, or accepted professional standard and principals of the professional providing services. Example of medication errors include omission (a drug is ordered but not administered). Medication errors are managed according to facility policy. Procedures include to monitor the resident for medication -related adverse consequences when there is a medication error. Promptly notify the provider of any significant error or adverse consequences. Implement the providers orders and monitor the resident for 24 to 72 hours or as directed. Document the information in an incident report and in the resident's clinical record.The deficiency represents non-compliance investigated under Complaint Number 1348045.

Based on observation, interview, record review and review of the facility policy, the facility failed to maintain infection control practices for one Resident #91 during incontinence care and wound care. This affected one resident (Resident #91) of three residents observed for infection control. The facility census was 119. Findings include: Record review for Resident #91 revealed an admission date of 03/02/23. Diagnosis included dysphagia, polyneuropathy, and encounter for attention to gastrostomy. Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #91 was moderately cognitively impaired. Resident #91 used a wheelchair for mobility, required substantial/maximal assistants for bed mobility, dependent for chair/bed to chair transfer, and personal hygiene. Resident #91 had a feeding tube and received an antibiotic. Review of the care plan dated 11/03/25 revealed Resident #91 was at risk for complications related to peg site infection. Interventions included infection control prevention practices and to monitor for signs and symptoms of worsening infection. Review of the care plan dated 11/06/25 revealed Resident #91 had impaired skin integrity as evidence by skin tear/abrasion to the left lateral calf and was at high risk for further breakdown and or slow delayed healing. Interventions included to administer treatments as ordered and monitor for effectiveness and notify the physician if signs and symptoms of infection occur. Review of the care plan dated 05/14/25 for Resident #91 revealed Enhanced Barrier Precautions: Resident requires EBP during high contact resident care activities due to the presence of indwelling device (e.g. central lines, feeding tubes) not known to be infected or colonized with any MDRO. Interventions included to utilize PPE (gown and gloves; face shield as indicated) during high contact resident care activities (e.g. dressing, bathing/showering, transferring, hygiene, linen changes, brief changes, toileting assistant, device care, wound care). Review of the physician orders for Resident #91 for November 2025 revealed orders to: 1. Cleanse peg tube insertion site with soap and water, pat dry, apply Bactroban topically, cover with a dry sterile dressing twice a day. 2. Enhanced Barrier Precautions: Use gown and gloves for high-contact resident care including dressing, bathing, showering, transfers, hygiene care, changing linens, changing briefs, assisting with toileting, dressing changes, and care of any device (trach, central line, tube feeding, catheter). every shift for reducing the chance of spreading infection. Observation on 11/19/25 at 11:41 A.M. of incontinence care provided by Certified Nursing Assistant (CNA) #394 and #399 for Resident #91 revealed Resident #91 was lying in bed. CNA #394 and #399 entered the room, applied gloves and began repositioning Resident #91 in bed. Resident #91 had a large bowel movement. Resident #91's right leg was pressed against CNA #399's clothing while holding him to the side while CNA #394 was cleaning his backside. Neither CNA #394 nor #399 applied an isolation gown during the care. Interview on 11/19/25 at 11:52 A.M. revealed CNA #394 revealed they only need to apply an isolation gown if the resident had a foley catheter. CNA #399 revealed she was not aware they were supposed to apply a gown to provide care. Observation on 11/23/25 at 9:37 A.M. of Licensed Practical Nurse (LPN) #261 provide wound care to Resident #91's peg tube insertion site revealed LPN #261 removed the intact undated dressing at Resident #91's peg tube insertion site. The dressing had a moderate amount of thick brown drainage. The inside edges of the dressing was covered with black drainage. The peg tube site was deep red and excoriated approximately three inches surrounding the insertion site. LPN #261 applied clean gloves then cleaned the insertion site with soap and water, applied antibiotic ointment to the sterile drain sponge (using the same gloves she cleaned the soiled wound with), then applied the sterile drain sponge over the insertion site. Observation revealed LPN #261 never washed her hands or used hand sanitizer after cleaning the peg tube insertion site and before applying the sterile dressing. LPN #261 confirmed she did not wash her hands or use hand sanitizer after cleaning the soiled peg tube site area and confirmed she wore the same soiled gloves used to clean the site to apply the sterile dressing. Interview on 11/23/25 at 10:47 A.M. with Director of Nursing (DON) confirmed LPN #261 should have washed her hands with soap and water or used hand sanitizer after cleansing Resident #91's peg tube site and before applying the sterile dressing. DON confirmed the physician order was for a dry sterile dressing twice a day and according to the order, sterile technique should have been used to apply a sterile dressing. DON confirmed sterile techniques were never used (including sterile gloves) to provide the treatments to the peg tube site. DON revealed the order should not have been sterile due to wound care for peg tube sites were usually not a sterile technique but clean technique should have still been used. DON also confirmed that an isolation gown should be worn at all times when providing hands on care for Resident #91. Review of the facility policy titled, Enhanced Barrier Precautions dated December 2024 revealed Enhanced Barrier Precautions (EBP) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. EBP refer to infection prevention and control interventions designed to reduce the transmission of MDROs during high contact resident care activities. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gowns are applied prior to performing the high contact resident care activity. Examples of high contact care activities requiring the use of gown and gloves for EBPs include dressing, bathing, providing hygiene or grooming, changing briefs or assisting with toileting, providing bed mobility, and wound care. Review of the facility policy titled, Dressing Change (Clean) undated revealed the purpose was to protect the wound, prevent irritation, prevent infection and spread of infection and to promote healing. The procedure included to remove the soiled dressing and discard in a plastic bag, dispose of gloves, wash hands, put on a second pair of disposable gloves, cleanse wound with prescribed solution, dispose of gloves, wash hands, put on third pair of disposable gloves, apply prescribed medication if ordered, apply dressing and secure, remove gloves and discard, wash hands.The deficiency represents non-compliance investigated under Complaint Number 1348043 and 2661500.

Based on observation, record review and interview, the facility failed to ensure a medication error rate of less than 5%. A total of 31 medications were administered with two errors for a medication error rate of 6.45%. This affected two residents (Resident #26 and Resident #79) of five residents observed for medication administration. 1.Record review for Resident #26 revealed an admission date of 02/09/23. Diagnosis included Type one diabetes mellitus (DM) with diabetic neuropathy and hypertensive chronic kidney disease with stage one through stage four chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #26 was cognitively intact. Resident #26 had DM and required insulin injections. Review of the care plan dated 03/13/25 revealed Resident #26 had a diagnosis of diabetes and was at risk for complications manifested by hyperglycemia (high blood sugar), hypoglycemia (low blood sugar), skin breakdown and neuropathy. Interventions included administering medications per order. Review of the physician orders for Resident #26 dated 09/20/25 revealed an order for Novolog flexpen subcutaneous (sq) solution pen injector 100 units per milliliter (ml) inject seven units one time a day for DM, hold if blood sugar less than 120. Observation on 11/20/25 at 8:45 A.M. of medication administration revealed Licensed Practical Nurse (LPN) Unit Manager (UM) #401 assessed Resident #26's blood sugar. LPN UM #401 then removed Resident #26's Novolog insulin pen from the medication cart and placed a new needle on the insulin pen. LPN UM #401 then dialed the insulin pen to seven. Observation revealed LPN UM #401 did not prime the insulin pen. LPN UM #401 then administered the insulin to Resident #26 then returned to the medication cart. LPN UM #401 confirmed she did not prime Resident #26's insulin pen prior to dialing the seven units and administering the insulin. LPN UM #401 revealed she did not need to prime insulin pens.2. Record review for Resident #79 revealed an admission date of 02/11/21. Diagnosis included DM with unspecified diabetic retinopathy, chronic kidney disease, and diabetic polyneuropathy. Review of the quarterly MDS dated [DATE] revealed Resident #79 was cognitively intact. Resident #79 required assistants with activities of daily living, had a diagnosis of DM and received insulin injections. Review of the care plan dated 04/02/25 revealed Resident #79 had a diagnosis of diabetes and was at risk for complications manifested by hyperglycemia (blood sugar too high) and hypoglycemia (blood sugar too low). Interventions included to administer medications as ordered. Review of the physician orders for Resident #79 dated 10/31/25 revealed an order for Lantus Solostar solution pen injector 100 units per ml inject 20 units sq one time a day for DM. Observation on 11/20/25 at 9:10 A.M. of medication administration revealed LPN #310 removed Resident #79's Lantus Solostar solution pen injector from the medication cart and placed a new needle on the insulin pen. LPN #310 then dialed the insulin pen to 20. Observation revealed LPN #310 did not prime the insulin pen. LPN #310 then administered the insulin to Resident #79 then returned to the medication cart. LPN #310 confirmed she did not prime the insulin pen and revealed she only primes the insulin pens if she sees air bubbles. Interview on 11/20/25 at 11:08 A.M. with Director of Nursing (DON) confirmed insulin pens require the pen to be primed after placing the needle on and prior to dialing the ordered dose of insulin. DON confirmed both nurses, LPN UM #401 and LPN #310 worked at different times throughout the facility with all residents residing in the facility. Review of the insulin pen pamphlet information provided by DON titled, To use an insulin pen undated revealed Step one: Prepare the pen. Twist a new needle onto the pen. A new needle is required for every injection. Prime the pen: Dial two units on the dose selector. Point the needle up and gently tap the pen to move air bubbles to the top. Press the injection button and watch for a drop of insulin to appear on the needle tip. If you don't see a drop, repeat the priming process. Dial the correct dose prescribed by the Dr.; The instructions included to the administer the insulin per the physician orders. Review of the facility policy titled, Administering Medications revised April 2019 revealed medications are administered in a safe and timely manner, and as prescribed. The deficiency represents non-compliance investigated under Complaint Number 1348044 and 1348045.

Based on observation, interview, and record review, the facility failed to ensure #78 received the ordered amount of tube feeding daily. This affected one resident (Resident #78) of three residents reviewed for tube feeding management. The facility census was 119.Findings include:Record review for Resident #78 revealed an admission date of 08/01/25. Diagnosis included dysphagia following cerebral infarction, hemiplegia and hemiparesis, and aphasia. Review of the admission MDS dated [DATE] revealed Resident #78 was severely cognitively impaired. Resident #78 was dependent for activities of daily living including bed mobility and transfers. Resident #78 had no or unknown weight loss and weight was 188. Review of the physician orders dated 08/01/25 revealed Resident #78 was NPO. Additional orders dated 08/28/25 for Resident #78 revealed an order for enteral feed order every shift for nutrition Peptamen 1.5 continuous: Give formula at 75 cc an hour flush 300 cc every six hours ok to use Jevity 1.5 if Peptamen unavailable.Review of the care plan for Resident #78 dated 08/05/25 revealed Resident #78 had a peg tube and was at risk for enteral nutrition complications related to aspiration pneumonia, clogged tubing, excessive residual, infection, nausea or vomiting, and tubing and displacement. Interventions included to monitor weight per protocol.Review of the weight log for Resident #78 revealed on 09/04/25 Resident #78 weighed 192.3 pounds. On 10/07/25 Resident #78 weighed 192.4 pounds. On 11/07/25 Resident #78 weighed 188.6 pounds. Observation on 11/19/25 at 2:23 P.M. revealed Resident #78 was in bed with his eyes closed. Observation revealed Resident #78's tube feeding pump was beeping and revealed, clog in line downstream. The containing of tube feeding was Jevity 1.5 dated as initiated on 11/19/25 at 12:50 A.M. at 75 cc an hour. The container was a 1000 ml container. Observation revealed there was 370 ml remaining in the container and the tube feeding was not flowing.Observation on 11/19/25 at 3:09 P.M. and 4:30 P.M. revealed Resident #78' tube feeding pump was beeping, not infusing and read, clog in line downstream.Observation on 11/19/25 at 4:31 P.M. with LPN #268 confirmed Resident #78's tube feeding was not infusing. LPN #268 confirmed the tube feeding pump was beeping and revealed, clog in line downstream. The containing of tube feeding was Jevity 1.5 dated as initiated on 11/19/25 at 12:50 A.M. at 75 cc an hour. The container was a 1000 ml container. Observation confirmed there was 370 ml remaining in the container. LPN #268 revealed she started her shift at 3:00 P.M., had not visited with Resident #78 yet and was not told his tube feeding had not been infusing. The tube feeding should have been completed at approximately 1:00 P.M. LPN #268 confirmed Resident #78 did not receive the ordered amount of nutrition.This deficiency represents non-compliance investigated under Complaint Number 2661500.

Based on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident #14 received timely assistance to maintain continence. This affected one resident (Resident #14) of three residents observed for incontinence care. The facility census was 119.Findings include:Record review for Resident #14 revealed an admission date of 02/25/22. Diagnosis included Parkinson's disease and muscle wasting.Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #14 revealed a Brief Interview of Mental Status (BIMS) score of 12 (moderately cognitively impaired). Resident #14 was frequently incontinent of bowel and bladder, used a wheelchair for mobility, required partial/moderate assistants for toileting transfer and toileting hygiene. Review of the care plan dated 04/07/25 revealed Resident #14 had an activity of daily living (ADL) self-care performance deficit related to physical limitations. Interventions included Resident #14 required extensive assistance of one person for toileting. Observation on 11/19/25 at 11:17 A.M. revealed Resident #14 was sitting up in a wheelchair in the Activities room. Observation on 11/19/25 at 11:33 A.M. revealed Activities Aide #247 was pushing Resident #14's wheelchair towards her room from the Activities room. Activities Aide #250 was walking next to Activities Aide #247. Observation revealed Resident #14 requested to use the bathroom revealing she had to urinate. Activities Aide #250 instructed Activities Aide #247 that Resident #14 would have to wait at the nurses' station stating, We can't take her to her room, or she will try to go to the bathroom by herself. Observation revealed Activities Aid #247 sat Resident #14 across from the nurses' station then both Activities Aides #247 and #250 turned and walked up the hall away from Resident #214. Observation revealed neither Activity Aide notified any staff that Resident #14 requested to use the bathroom to urinate. Continued observation on 11/19/25 from 11:33 A.M. to 12:09 P.M. revealed no staff assisted Resident #14 to the bathroom. Resident #14 continued sitting across from the nurse's station. Interview on 11/19/25 at 11:52 A.M. with Certified Nursing Assistant (CNA) #394 and #399 revealed there was not enough staff to timely assist residents to the bathroom or with incontinent care timely, especially during the mealtimes residents would have to wait. Observation revealed at 12:09 P.M. Activities Director #246 approached Resident #14 and pushed her wheelchair to the Recreational Therapy room, served her lunch tray to her then left the room. Interview with Resident #14 verified no one took her to the bathroom and Resident #14 revealed she still needed to go. Interview on 11/19/25 at 12:11 P.M. with Certified Nursing Assistant (CNA) #394 confirmed she was Resident #14's primary CNA. CNA #394 confirmed that no one told her Resident #14 needed to use the bathroom to urinate. Observation with CNA #394 confirmed Resident #14 was sitting in the Recreational Therapy room by herself eating her lunch. Activities Director #246 entered the room and revealed she put Resident #14 there because they were going to have an activity after lunch. Activities Director #246 revealed she would sit with Resident #14 while she ate her meal. CNA #394 thanked Activities Director #246 and walked away without offering to take Resident #14 to the bathroom. Resident #14 then again revealed to Activities Director #246 that she needed to use the bathroom to urinate. Activities Director #246 did not leave to get assist for Resident #14 to use the bathroom. Interview on 11/19/25 at 12:20 P.M. with Activities Aides #247 and #250 revealed Activity Aid #250 was training Activity Aid #247. Both Activities Aides #247 and #250 verified neither notified any staff Resident #14 needed to use the bathroom when they sat her across from the nurses station at approximately 11:33 A.M.; Activity Aid #250 revealed, We cannot take her to her room, or she will try to go by herself, we did not see staff so we left, no one was notified. Observation on 11/19/25 at 12:30 revealed Resident #14 was still sitting in the Recreational Therapy room by herself. Resident #14 confirmed she was still waiting to use the bathroom. Observation on 11/19/25 at 12:50 P.M. revealed Resident #14 was sitting in the doorway of her room. Resident #14 verified her CNA just finished assisting her to the bathroom. Resident #14 revealed, If my bladder is full, it does hurt and I have to go a little in my pants when I can't hold no more. Resident #14 revealed it happens some days when they are too busy to take her. Interview on 11/19/25 at 12:51 P.M. with Licensed Practical Nurse (LPN) #267 confirmed she was Resident #14's primary nurse and revealed, (Resident #14) is continent of urine if we take her. Interview on 11/19/25 at 12:54 P.M. with CNA #394 revealed she took Resident #14 to the bathroom about 10 minutes ago. CNA #394 revealed Resident #14's brief was wet with urine, but she also urinated in the toilet too. CNA #394 revealed Resident #14 was usually continent of urine but sometimes also incontinent and revealed Resident #14 was last assisted to the bathroom right before breakfast (approximately 8:00 A.M.). Interview on 11/20/25 at 4:00 P.M. with Director of Nursing (DON) revealed (Activities Aides #247 and #250) should have immediately notified Resident #14's nurse or CNA of her request to go to the bathroom and Resident #14 should have been assisted to the bathroom as soon as staff found out she needed to go. Review of the facility policy titled, Activities of Daily Living dated 06/08/22 revealed the purpose is to preserve activities of daily living function, promote independence and increase self-esteem and dignity.The deficiency represents non-compliance investigated under Complaint Number 1348042 and 2661500.

Based on observation, interview and record review, the facility failed to timely assist Resident #91 to get out of bed per his request and failed to provide foot pedals per request for Resident #83. This affected two residents (Resident #91 and #83) of three residents observed for timely accommodation of needs/requests. The facility census was 119.Findings include:1. Record review for Resident #91 revealed an admission date of 03/02/23. Diagnosis included dysphagia, polyneuropathy, and encounter for attention to gastrostomy. Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #91 was moderately cognitively impaired. Resident #91 used a wheelchair for mobility, required substantial/maximal assistants for bed mobility, dependent for chair/bed to chair transfer, and personal hygiene. Review of the care plan dated 05/14/25 revealed Resident #91 had an activity of daily living self-care mobility functional ability performance deficit related to physical limitations, cognitive deficit, and cerebral infarction. Interventions included to assist with transfers with two assistants via Hoyer lift and wheelchair for mobility. Observation on 11/19/25 10:53 A.M. revealed Resident #91 was lying in bed. Resident #91 revealed he needed changed, and he wanted to get out of bed and revealed he asked his aide, but she never came back to help him up. Interview on 11/19/25 at 11:20 A.M. with Certified Nursing Assistant (CNA) #362 confirmed she was Resident #91 primary CNA. CNA #362 revealed Resident #91 was incontinent and changed earlier that day. CNA #362 stated, He asked me to get up, I just need to find his Broda chair, he asked me around 10:45 this morning but I had to go get someone else up. Observation on 11/19/25 at 11:37 A.M. revealed Resident #91 was still in bed. Resident #91 revealed he was not changed yet and requested surveyor to assist him. Resident #91 revealed he was also still waiting to get out of bed. Interview on 11/19/25 at 11:41 A.M. with CNA #394 revealed CNA #362 went on her lunch break. CNA #394 revealed she would assist to provide incontinence care for Resident #91. Interview on 11/19/25 at 1:39 P.M. with Resident #91 revealed he was still waiting to get out of bed. Interview on 11/19/25 at 1:43 P.M. with CNA #362 revealed she went in to assist Resident #91 about 15 min ago, he said he was sleepy. CNA #362 revealed she was going to get him up earlier, but she could not find a Broda chair to put him in and revealed she just found the chair. 2. Record review for Resident #83 revealed an admission date of 11/10/25, a discharge date of 11/15/25 and a readmission of 11/17/25. Diagnosis included spondylosis with radiculopathy lumbosacral region, muscle wasting and atrophy, incomplete lesion of L1 level of lumbar spinal cord subsequent encounter, post laminectomy syndrome, polyneuropathy, repeated falls, chronic pain, atherosclerotic heart disease, cervicalgia, foot drop right foot, presence of neurostimulator, muscle spasms, idiopathic chronic gout multiple sites, and transient cerebral ischemic attack. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #83 was moderately cognitively impaired. Resident #83 had impairment to one side of the lower extremities, was dependent for putting on and taking off foot wear, partial moderate assist for sit to stand, and chair/bed to chair transfer. Resident #83 used a manual wheelchair and required supervision or touch assistance for mobility. Observation on 11/20/25 at 12:15 P.M. revealed Resident #83 was in a wheelchair being pulled backwards through the entrance of the facility doors and down the hall. Resident #83's feet were dragging on the floor. Observation revealed his elderly brother was pulling the wheelchair backwards, he ran into the wall nearly falling. Resident #83 screamed in fear. Admissions #243 approached. Interview with Resident #83 revealed he was returning from a doctor appointment. Resident #83 revealed his brother went with him and was returning him to the facility. Resident #83 revealed it was too hard to hold his legs in the air to go forward, it was too painful, and he did not have the strength, so his brother had to pull him backwards. Resident #83 expressed he was frustrated, he had asked several times for several days for foot pedals for the wheelchair, but no one had got them for him. Observation revealed Resident #83's brother then continued pulling Resident #83 down the hall backwards toward his room, staff never offered assistants. Interview on 11/20/25 at 2:21 P.M. with Physical Therapy Assistant (PTA) #322 revealed she worked with Resident #83 on ambulation for a while the previous day but Resident #83 was in too much pain in his legs, knees and back. PTA #322 revealed Resident #83 was self-limited due to pain and revealed he should not be pushed in the wheelchair with no foot pedals. Interview on 11/20/25 at 2:28 P.M. with Licensed Practical Nurse (LPN) Unit Manager (UM) #401 revealed Resident #83 did not get out of bed too often and stated, He can do more than he is willing to do, he is not doing it, he would rather everyone do it for him, back pain is normal for him; he recently had a pump put in his back. LPN UM #401 revealed when a resident was admitted to the facility, the staff normally put the foot pedals on the wheelchair for transport and revealed she did not know why no one put them on Resident #83's chair other than he did not get out of bed very often. Interview on 11/20/25 at 2:39 P.M. with Housekeeping/Maintenance Director #308 revealed foot pedals are located in different places, there was no designated place so she has to go look for them, but she found some in one of the shower rooms and Resident #83 could use those. Interview on 11/20/25 at 2:53 P.M. with Certified Nursing Assistant (CNA) #805 revealed Resident #83 was normally pushed in the wheelchair by the CNA's and because he did not have footrests, he had to be pushed backwards. Interview on 11/20/25 at 256 P.M. with Director of Nursing (DON) revealed the wheelchairs do have foot pedals, if the residents are able to move around they don't need to be pushed in the wheelchair, so they don't need foot pedals. DON confirmed residents should not be pulled backwards in a wheelchair. This deficiency represents non-compliance investigated under Complaint Number 1348042.

Based on interview, closed medical record review, and facility policy review, the facility failed to ensure Resident #71, Resident #93, Resident #99 skin impairments were thoroughly assessed, monitored and treated timely. This affected three residents (#71, #93, and #99) out of three residents reviewed for skin impairments. The facility census was 95. Findings included: 1. Review of the closed medical record for Resident #99 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnosis included but not limited to displaced intertrochanteric fracture of left femur, Parkinson's disease, aneurysm of the ascending aorta, chronic vascular disorder of intestine, right bundle-branch block, intracardiac thrombosis, history of falling, history of walking, muscle wasting and atrophy, and COVID-19. Review of the Admission Minimum Data Set (MDS) assessment, dated 07/25/24, revealed the resident had intact cognition. Review of Resident #99's hospital discharge paper work dated 07/18/24 at 11:27 A.M. revealed facility admission orders to have hip dressing in place for seven (7) days. Review of the Admission assessment dated [DATE] revealed under section 10, (skin) there was a picture/diagram of a person showing front and back side and numbered. The site was numbered #34 and left front thigh and type of skin impairment was identified to be a surgical incision. There were no further description of the incision and no further documentation regarding the surgical incision or the dressing required for the incision. Review of the physician orders for July 2024 revealed there was no admission order on 07/18/24 for Resident #99's dressing to left hip to remain in place for 7 days. Review of the care plan dated 07/19/24 revealed he receives anticoagulant drug therapy related to risk for developing a blood clot. Interventions included administer medications per physician order, assess for side effects including, bleeding abnormalities and monitor skin for bruises. Review of the Treatment Administration Records (TARS) dated 07/22/24 at 11:00 P.M. revealed the facility put in an order for Resident #99's left hip to keep dressing dry and intact for 7 days and to remove after 7 days. Review of the Weekly Skin Check form for Resident #99 dated 07/25/24, 08/01/24, and 08/08/24 revealed a picture/diagram of a person showing front and back side and on the front side the left thigh area was circled and on the back side the left elbow area was circled. There was no documentation as to what the area was or any further description of the skin areas. The form was signed by the nurse. Review of the Weekly Skin Check form for Resident #99 dated 08/14/24 revealed a picture/diagram of a person showing front and back side and on the front side is circled the left thigh area and on the back side is circled the left elbow area. There was documentation on the left thigh front stating pre-existing. There was no further description of the circled areas. The form was signed by the nurse. Interview on 08/26/24 at 6:19 A.M. with Licensed Practical Nurse (LPN) #156 revealed weekly skin checks were to be completed by the nurse to include circling the area on the picture/diagram and documenting on the skin sheet the description and measurements of any skin impairments. Interview on 08/27/24 at 9:14 A.M. with Wound Registered Nurse (RN) #105 revealed there was no physician order put in place on 07/18/24 on admission for Resident #99 hip dressing change until 07/22/24 when she followed up with the resident and put the order in. Weekly skin checks were to be completed by the nurse to include circling the area on the picture/diagram and documenting on the skin sheet the description and measurements of any skin impairments Interview on 08/27/24 at 10:22 A.M. with Director of Nursing (DON) revealed skin assessments only had to list the locations by circling and no description of the skin area circled was required. Interview on 08/27/24 at 10:42 A.M. with LPN #148 revealed weekly skin checks were to be completed by the nurse to include circling the area on the picture/diagram and documenting on the skin sheet the description and measurements. Interview on 08/27/24 at 1:24 P.M. with LPN #178 revealed weekly skin checks were to be completed by a stat tested nursing assistance (STNA) circling on the skin sheet/shower sheet and nursing then documenting any skin issues in the computer to include description and measurement. Review of facility policy, Skin Management, revised 11/30/23, revealed a resident identified with skin breakdown will have a documented skin assessment weekly, wound description including measurements will be documented in point click care (computer system) and treatments as ordered. 2. Review of the closed medical record for the Resident #71 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnosis included but not limited to encounter orthopedic aftercare, ankylosis spondylitis unspecified sites in spine, collapsed vertebra, and unspecified subsequent encounter for fracture with routine healing. Review of the Medicare 5-day Minimum Data Set (MDS) assessment, dated 08/14/24 , revealed the resident had intact cognition. Review of the Admission assessment dated [DATE] revealed under section 10, (skin) there was a picture/diagram of a person showing front and back side and numbered. The site stated other (specify) lower back and type surgical incision. There were no measurements and no further documentation regarding the surgical incision or the dressing. Review of the Weekly Skin Check form for Resident #71 dated 08/14/21 revealed a picture/diagram of a person showing front and back side and on the back side was circled with no description of the skin area circled. There was no documentation as to what the area was or any further description or measurements. The form was signed by the nurse. Review of the Weekly Skin Check form for Resident #71 dated 08/21/21 revealed a picture/diagram of a person showing front and back side and on the back side was circled with the word surgical: wrote on form. There was no further documentation as to what the area was or any further description or measurements of the area. The form was signed by the nurse. Interview on 08/26/24 at 6:19 A.M. with LPN #156 revealed weekly skin checks were to be completed by the nurse to include circling the area on the picture/diagram and documenting on the skin sheet the description and measurements of any skin impairments. Interview on 08/27/24 at 9:14 A.M. with Wound RN #105 revealed revealed weekly skin checks were to be completed by the nurse to include circling the area on the picture/diagram and documenting on the skin sheet the description and measurements of any skin impairments. Interview on 08/27/24 at 10:22 A.M. with DON revealed skin assessments only had to list the locations by circling and no description of the skin area circled was required. Review of facility policy, Skin Management, revised 11/30/23, revealed a resident identified skin breakdown will have a documented skin assessment weekly, wound description including measurements will be documented in point click care (computer system) and treatments as ordered. 3. Review of the closed medical record for Resident #93 revealed an admitted ,d+[DATE]//24 and a discharge date of [DATE]. Diagnosis included but not limited to vertebrogenic low back pain, and sacrum, subsequent encounter for fracture with routine healing. Review of the Admission Medicare 5-day assessment dated [DATE] revealed Resident #93 had intact cognition. Review of the Admission assessment dated [DATE] revealed under section 10, (skin) there was a picture/diagram of a person showing front and back side and numbered and the section was blank. Review of the Weekly Skin Check form for Resident #93 dated 08/13/24 and 08/22/24 revealed a picture/diagram of a person showing front and back side and on the front side there was a circle on right elbow, a circle of left elbow and circle above left elbow. There was no description or measurements of the skin area circled. The form was signed by the nurse. Review of the Weekly Skin Check form for Resident #93 dated 08/24/24 revealed a picture/diagram of a person showing front and back side and on the front side a circle on right elbow, left elbow and above left elbow. There is writing on the document stating bruising. There was no description or measurements of the bruising. The form was signed by the nurse. Interview on 08/26/24 at 6:19 A.M. with LPN #156 revealed weekly skin checks were to be completed by the nurse to include circling the area on the picture/diagram and documenting on the skin sheet the description and measurements of any skin impairments. Interview on 08/27/24 at 9:14 A.M. with Wound RN #105 revealed revealed weekly skin checks were to be completed by the nurse to include circling the area on the picture/diagram and documenting on the skin sheet the description and measurements of any skin impairments. Interview on 08/27/24 at 10:22 A.M. with DON revealed skin assessments only had to list the locations by circling the skin impaired area and no description of the skin area circled was required. Review of facility policy, Skin Management, revised 11/30/23, revealed a resident identified skin breakdown will have a documented skin assessment weekly, wound description including measurements will be documented in point click care (computer system) and treatments as ordered.

Based on interview and record review the facility failed to ensure a comprehensive discharge care plan was in place for Resident #99. This affected one resident (Resident #99) out of three residents reviewed for comprehensive care plans. The facility census was 95. Findings include: Review of the closed medical record for the Resident #99 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnosis included but not limited to displaced intertrochanteric fracture of left femur, Parkinson's disease, aneurysm of the ascending aorta, chronic vascular disorder of intestine, right bundle-branch block, intracardiac thrombosis, history of falling, history of walking, muscle wasting and atrophy, and COVID-19. Review of the Admission Minimum Data Set (MDS) assessment, dated 07/25/24, revealed the resident had intact cognition. The resident was extensive assistance for bed mobility, substantial with maximal assistance for toileting hygiene, Review of behavior and mood revealed he had feelings of being down and trouble falling asleep. He had no behaviors. Review of the comprehensive care plan dated 07/19/24 revealed no care plan was in place for Resident #99's discharge. Interview on 08/27/24 at 7:49 A.M. with Licensed Social Worker (LSW) #167 verified there was no comprehensive discharge care plan in place for Resident #99. Review of facility policy, Care Planning-Interdisciplinary Team, revised 11/13/19, revealed the disciplinary team is responsible the development of an individualized comprehensive care plan for each resident and a comprehensive care plan for each resident is developed with in seven (7) days of completion of the resident assessment.

Based on observation, interview, and record review the facility failed to provide a clean and sanitary environment for Resident #7 and #28, and failed to ensure Resident #57 had clean bed linens. This affected three (#7, #28 and #57) of ten residents observed for environment. The facility census was 83. Findings include: 1. Observations on 01/28/24 at 10:45 A.M. revealed Resident #7 was up in a wheelchair with his bedside table in front of him. Resident #7's wheelchair had dirty debris on the foot rests and on the cushioned leg brace to the left side. Resident #7's bedside table had various areas of dried spilled debris on the top of the table and in an open drawer of the table. Further observation revealed Resident #7's roommate (Resident #28) was receiving tube feeding. The tube feeding pole had various areas of dried tube feeding formula on it. Scattered debris was observed on the floor behind Resident #28's bed. Interview with Resident #28 at time of observation revealed They come in sometimes, but they don't look back there. Observations were confirmed by Licensed Practical Nurse (LPN) #587 on 01/28/24 at 11:00 A.M. 2. Observation on 01/30/24 at 7:07 A.M. revealed Resident #57 was out of bed. Observation of Resident #57's bed linens revealed multiple areas of dried blood and a large dried yellow stain on the middle of the bed sheet. Observation of and interview with Resident #57 revealed he could not say where the blood or yellow stains had come from or how long they had been there. Resident #57 said he was continent of urine and used the bathroom. Resident #57 did not have any obvious scratches, abrasions or skin tears. Interview on 01/30/24 at 10:30 A.M. with State tested Nursing Assistant (STNA) #585 revealed Resident #57 was continent of urine and walked to the bathroom. STNA #585 had changed Residents #57's bed linens after being asked by the Administrator to change the sheets because they were soiled. STNA #585 confirmed the sheets had dried blood and a large dried yellow stain but he was unaware where the stains came from or how long they had been there. STNA #585 said Resident #57 did not have any scratches, abrasions, or skin tears that he was aware of and Resident #57 usually made his own bed in the mornings and kept his blankets pulled up over the sheets. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #57 was independent with toileting, showering and ambulation. Resident #57 was incontinent of bowel and bladder.

Based on record review and interview the facility failed to ensure the facility assessment was updated and accurate. This had the potential to affect all residents. The facility census was 83. Findings include: Review of the Facility assessment dated [DATE] revealed the paragraph listed under Resident Population included another facility's name and indicated that facility provided care and services to individuals with certain medical and cognitive disabilities. The facility assessment further indicated how the facility utilized the minimum data set (MDS) assessment in regard to the resident population and the type of residents they did not admit. Further review of the facility assessment revealed a test box under the staffing plan that listed the position of the staff and the range needed. The range did not include the numbers needed for each position; the hours per patient per day for the licensed nurses and nurse aides; the full time equivalent (FTE) per week for the nursing personnel with administrative duties; staff needed for behavioral healthcare and services and the dietitian, or the FTE per day for the food and nutrition services staff. The facility assessment also did not indicate the use of the contracted agency nursing staff under facility resources, section E, contracts/memorandums/agreements with third parties for services. Review of the facility's two nursing agency staffing contracts revealed they were effective as of 03/01/23 and 03/06/23. Interview on 01/29/24 at 11:54 A.M. with the Administrator verified the above identified findings. The Administrator stated they had used agency staffing periodically since she had been with the facility, which was about a year.

Based on observations, review of facility policy and procedures, interviews with the Communicable Disease Investigator and facility staff and review of the Centers for Disease Control and Prevention guidelines, the facility failed to implement effective infection control practices including a system to ensure the availability and appropriate use of personal protective equipment (PPE) by staff, a system to ensure staff were donning and doffing PPE when required and to ensure the local health department was properly notified of a facility COVID-19 outbreak. This resulted in Immediate Jeopardy and the potential for serious negative health outcomes and/or life-threatening harm when 43 residents (#97, #67, #80, #88, #31, #75, #93, #16, #10, #95, #43, #38, #87, #17, #34, #36, #25, #78, #44, #81, #47, #83, #49, #51, #30, #33, #82, #69, #01, #79, #74, #21, #24, #62, #14, #58, #37, #77, #06, #11, #45, #65 and #61) and 12 staff (State tested Nursing Assistant (STNA) #362, #364, #429, #384, Nurse Aid in Training #311, Registered Nurse (RN) #436 and RN #388, Admissions #386 and #312, Licensed Practical Nurse (LPN) #431 and LPN #420 and Receptionist #322) tested positive for COVID-19 without the aforementioned systems in place to prevent the transmission and spread of COVID-19 to the vulnerable residents in the facility. The lack of current effective infection control practices during a COVID-19 outbreak in the facility placed all 94 residents at potential risk for the likelihood of serious life-threatening harm, negative health complications and/or death. The facility census was 94. On 11/29/23 at 1:40 P.M., the Administrator, Director of Nursing (DON), and Clinical Service Manager #447 were notified Immediate Jeopardy began on 11/11/23 when Resident #64, #67, #80, and #88 tested positive for COVID-19 and the facility failed to implement appropriate and recommended infection control practices to prevent the additional spread of COVID-19 in the facility resulting in an outbreak. The facility staff failed to ensure the appropriate donning and doffing of PPE when entering and exiting a COVID-19 isolation room, and failed to ensure necessary PPE was readily available to staff. Upon entrance to the facility on [DATE], a total of 43 residents had tested positive with 10 positive residents within an eight-day time frame since 11/21/23. The Immediate Jeopardy was removed on 11/30/23 when the facility implemented the following corrective actions: On 11/29/23, an Ad Hoc Policy Review was held with the Administrator, Director of Nursing (DON) Registered Nurse (RN) #308, Regional Clinical Service Manager #447, and Meical Director #448 (via telephone) to review COVID-19 guidelines, Transmission Based Precaution guidelines, including assuring availability of PPE and hand hygiene. On 11/29/23, the Regional Clinical Service Manager educated the Administrator and DON on COVID-19 guidelines, Transmission Based Precautions guidelines, ensuring availability of PPE, and Hand Hygiene. On 11/29/23, the Administrator and DON educated Administrative staff Medicaid Liaison #379, Minimum Data Set (MDS) Registered Nurse (RN) #380, MDS LPN #395, Business Office Manager #346, Infection Control/Wound Nurse RN #445, Housekeeping Director #430, Licensed Social Worker (LSW) #405, Registered Dietitian #391, Director of Rehab #449, Nursing Scheduler #419, Unit Manager RN #360, Human Resources/Payroll #424, Social Service Designee (SSD) #437, Maintenance Director #399, and Food Service Director #325 on policies COVID-19 guidelines, Transmission Based Precautions guidelines, including ensuring availability of PPE, and Hand Hygiene. On 11/29/23, an Ad Hoc Resident Council meeting was held with the Activities Director, Administrator and five residents to review policies of Infection Control Practices including but not limited to handwashing and source control. On 11/29/23, Administrative Staff as listed above educated all direct care staff on policies including COVID-19 guidelines, Transmission Based Precautions guidelines, including ensuring availability of PPE, and Hand Hygiene. The training included the appropriate use of PPE, including what to wear and when to utilize it, and when to dispose or change it. Any remaining staff not educated on 11/29/23 would be removed from the schedule after 11/29/23, pending completion of mandatory education. Education/Training was completed for 33 nurses, 40 nursing assistants, six activity staff, 10 environmental services staff and 13 dietary staff. On 11/29/23, the facility Unit Managers on both East and [NAME] Units completed COVID-19 screens on all residents not in transmission-based precautions for COVID-19 with no adverse findings. On 11/29/23, the Clinical Service Manager and or DON completed audits of screening of all staff, with no adverse findings. Beginning 11/29/23, an ongoing observational audit would be completed by the Administrator/Designee daily on each shift throughout the building to ensure proper infection control practices for four weeks, then randomly thereafter. Audits would include proper hygiene, proper donning and doffing of PPE, and availability of PPE. Beginning 11/29/23, the facility would continue to test both residents and staff for 14 days following the last positive staff or resident. The facility would also test any resident or staff member who exhibited symptoms which would include fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body ache, headache, new loss of taste or smell, sore throat and cold like symptoms. Observations on 11/30/23 from 7:45 A.M. through 4:45 P.M., revealed facility staff providing care for residents were wearing correct PPE and performing hand hygiene. All halls had PPE stocked on the doors for access to correct PPE for residents with COVID-19. Interviews on 11/30/23 between 8:00 A.M. and 4:45 P.M., with RN #450, Housekeeper #375, #306, LPN #438, STNA #330, #364, #441, and Scheduler #419, verified they had been educated on COVID-19 isolation precautions, the proper PPE to wear in the room of a resident who was positive for COVID-19, donning and doffing of PPE and hand hygiene. Although the Immediate Jeopardy was removed on 11/30/23, 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 was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: On 11/28/23 between 10:00 A.M. through 4:55 P.M., observations revealed residents, including Residents #21, #24, #62, #14, #58, #37, #77, #6, #11, #45, #65, and #61 were in isolation for a diagnosis of COVID-19 were in rooms which were spread throughout the facility. The facility did not have a designated COVID-19 unit. The facility had 43 residents test positive for COVID-19 from 11/11/23 through 11/26/23. On 11/11/23, Resident #97, #67, #80, and #88 tested positive for COVID-19. On 11/12/23 Resident #31, #75, #93, #16, #10, #95, #43, #38, #87, and #17 tested positive for COVID-19. On 11/14/23 Resident #34, #36, and #25 tested positive for COVID-19. On 11/16/23 Resident #78 tested positive for COVID-19. On 11/17/23 Resident #44, #81, #47, #83, #49, #51, #30, #33, #82, #69, #1, #79, and #74 tested positive for COVID-19. On 11/19/23 Resident #21 and #24 tested positive for COVID-19. On 11/21/23 Resident #62, #14 and #58 tested positive for COVID-19. On 11/23/23 Resident #37 and #77 tested positive for COVID-19. On 11/24/23 Resident #6, #11, #45, and #65 tested positive for COVID- 19 and on 11/26/23 Resident #61 tested positive for COVID-19. The facility had 12 staff members test positive for COVID-19 from 11/11/23 through 11/25/23. On 11/11/23, STNA #362, and #364 tested positive for COVID-19. On 11/12/23, RN #436 tested positive for COVID-19. On 11/14/23, RN #388 tested positive for COVID-19. On 11/15/23, Nurse Aid in Training #311 tested positive for COVID-19. On 11/17/23, STNA #384 and Admissions #386 tested positive for COVID-19. On 11/18/23, LPN #431 tested positive for COVID-19. On 11/22/23, LPN #420 tested positive for COVID-19. On 11/24/23, STNA #429 tested positive for COVID-19. On 11/25/23, Admissions #312 and Receptionist #322 tested positive for COVID-19. Per the Administrator four additional staff had tested positive for COVID-19 but did not work more than 48 hours prior to testing. An interview with the facility Infection Preventionist #445 on 11/28/23 at 3:31 P.M., revealed the facility had completed contact tracing and were unable to determine the initial source (staff or visitor) of COVID-19 in the facility. Both staff and residents tested positive initially on 11/11/23. During the onsite investigation the following concerns were identified placing additional residents at risk for serious illness/complications from contracting COVID-19: On 11/28/23 at 12:15 P.M., State tested Nursing Assistant (STNA) #384 was observed passing trays to residents served from the meal cart. STNA #384 was observed to be wearing an N95 mask that was visibly soiled with an orange/brown dried substance. STNA #384 donned a gown, gloves and face shield and entered Resident #37's room (Resident #37 had a diagnosis of COVID-19) with a lunch tray. Upon exit, STNA #384 did not doff the soiled N95 mask or the face shield. STNA #384 went back to the food cart, obtained another food tray, and went to pass the tray to Resident #29, a resident who was not diagnosed with COVID-19. The surveyor intervened prior to the STNA entering Resident #29's room and the STNA confirmed he did not remove or change his N95 mask or clean his face shield before or after exiting Resident #37's room and prior to going to assist another resident who was not COVID-19 positive. STNA #384 verified his N95 mask was soiled. STNA #384 then took off his N95 mask and face shield and placed it on top of Resident #37's isolation cart. STNA #384 revealed he was going to leave the mask and face shield there so he could use it again when he goes back in the room (Resident #37's room) later. On 11/28/23 at 12:27 P.M., STNA #384 was observed exiting Resident #24's room (Resident #24 had tested positive for COVID-19). STNA #384 was observed hanging his N95 mask on the inside of Resident #24's door. STNA #384 revealed he was saving the PPE to reuse it later and stated this was how they did it every day, staff would hang their PPE on the door or in the bathroom to reuse. Interview on 11/28/23 between 1:45 P.M. and 2:00 P.M., with LPN #383 and LPN #431 revealed they worked with COVID-19 positive and non-COVID-19 positive residents during the same shift. LPN #383 and #431 revealed they wore the same N-95 mask throughout the day as long as they covered it with a surgical mask when entering a COVID-19 positive room. LPN #383 revealed she also wore the same face shield throughout the day as long as she cleaned it once a day. Observation on 11/28/23 at 2:10 P.M. revealed the call light was activated above the door of Resident #37's room. Observation revealed RN Unit Manager (UM)/ADON #380 was in her office located at the entrance to the hall. RN UM/ADON #380 was observed exiting her office picking up an N95 mask and face shield off her desk. The face shield had two initials marked in black marker in the corner of the face shield. The face shield was visibly smudged with multiple fingerprints. RN UM/ADON #380 donned the N95 mask and face shield retrieved from her office, donned gloves and a gown from the isolation cart and entered Resident #37's room. Observation revealed at 2:15 P.M., RN UM/ADON #380 exited the room and walked up the hall toward her office with the N95 mask still on, while wiping off her faces shield. Upon entering her office, RN UM/ADON #380 removed the N95 mask and laid it on top of her desk. RN UM/ADON #380 confirmed she did not change her N95 mask after exiting Resident #37's room and revealed she could reuse the facemask when covered by a face shield. On 11/28/23 between 3:45 and 4:05 P.M., STNA #451 was observed wearing a surgical mask and face shield while assisting residents and throughout the halls. At 4:05 P.M., STNA #451 donned a gown to enter Resident #24's room. A sign posted on Resident #24's door to his room included the required PPE to wear when entering (an N95 mask, gown, gloves, and eye protection). STNA #451 did not don an N95 mask or gloves. STNA #451 entered Resident #24's room. While entering Resident #24's room, an N95 mask fell off the door onto the floor. Observation revealed a gown, and a face shield were also hanging on the door. STNA #451 confirmed the PPE hanging on the door and stated, sometimes they do that. STNA #451 revealed she would get the gloves in the resident's room as there were none on the isolation cart and closed the door. Upon exiting the resident's room, STNA #451 confirmed she did not wear an N95 mask into the room or gloves. STNA #451 began walking up the hall, she did not remove her surgical mask or face shield she had been wearing. STNA #451 revealed she did not need to wear an N95 mask when she wore a face shield, she only needed a surgical mask, and she did not need to change the surgical mask. STNA #451 confirmed she did not clean her face shield and stated, she only needed to clean the face shield at the end of her shift. STNA #451 then entered Resident #69's room who was not on isolation for COVID-19 and observed to physically assist Resident #69. Interview on 11/28/23 at 4:15 P.M., with the DON revealed staff should be wearing an N95 mask, face shield, gown and gloves when entering a resident room with COVID-19. When doffing PPE, the staff could reuse the face shield if they cleaned it with soap and water after each use. The DON revealed all other PPE should be disposed of after each use. The DON confirmed the facility did not have a shortage of PPE and stated staff should not be saving PPE (other than the face shield after cleansed). The DON revealed the last education provided to staff regarding COVID-19 and donning and doffing PPE was completed on 10/05/23. Interview on 11/29/23 at 8:30 A.M., with the Administrator revealed she reported positive COVID-19 cases weekly via e-mail to the local Health Department. The Administrator stated the Health Department never gave advice or communicated back to her regarding the positive COVID-19 cases. During an interview with the DON on 11/29/23 at 11:16 A.M., the DON confirmed there was no education provided to staff on donning and or doffing PPE on or after the outbreak of COVID-19 on 11/11/23. The DON revealed there was no oversight to assure staff were donning or doffing PPE appropriately to prevent the spread of COVID-19 to additional residents. Interview on 11/29/23 at 3:15 P.M., with Medical Director #448 revealed he was made aware of the positive COVID-19 cases at the facility. Medical Director #448 revealed he instructed the facility to follow the protocols with donning and doffing PPE. Interview on 11/30/23 at 2:56 P.M., with the Communicable Disease Investigator (CDI) #452 representing the Local Health Department (LHD) revealed the facility contact person, CDI #453, did not work at the department anymore. The facility had been submitting their COVID-19-line list weekly. Where the facility was sending the information to, was not being monitored by the local health department due to the assigned person no longer being with the department and the information the facility was sending was going into an empty box. CDI #452 revealed the facility was not reassigned to another CDI. CDI #452 confirmed this was an oversight on their end, but the facility was still required to include the information to physicians at the County Board of Health, and they did not. Interview on 11/30/23 at 3:10 P.M., with the Administrator confirmed the facility had not been sending the COVID-19- line list to physicians at the County Board of Health. Interview on 11/30/23 at 3:20 P.M., with CDI #452 revealed if the HD was aware of the outbreak at the facility, the advice to the facility would have included outbreak testing every three to seven days, recommendations to encourage mask wearing for all staff. Visitors should also be encouraged, and education to staff on hand hygiene, including donning and doffing, should have been reviewed along with the most recent CMS guidelines. Interview on 12/01/23 at 12:45 P.M., with the DON revealed testing for residents and staff was every three to seven days and they would test anytime if a resident had symptoms of COVID-19. The DON revealed nurses were to observe signs and symptoms of COVID-19 during daily care. Review of the policy provided for donning and doffing titled, COVID-19 Infection Prevention and Control Practice Audit, updated 07/25/22, revealed Health Care Personnel wear the following PPE in all Transmission Based Precaution rooms to include gloves, gown, N95 and eye protection. Review of the CDC guidelines titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, May 8, 2023, revealed Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection Health Care Professionals (HCP) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a National Institute for Occupational Safety and Health (NIOSH) approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). This deficiency represents the non-compliance discovered during the investigation of Master Complaint OH000148588.

Based on record review, interviews, and facility policy review the facility failed to ensure accurate documentation in the medical record for respiratory care and enteral tube feeding care for Resident #93. This affected one resident (#93) of three residents reviewed for respiratory care and enteral tube feeding care. The facility census was 92. Findings include: Review of the medical record for Resident #93 revealed an admitted [DATE] with diagnoses including traumatic subdural hemorrhage, acute and chronic respiratory failure, gastrostomy, tracheostomy, and personal history of traumatic brain injury. Review of Resident #93's physician's orders revealed he had orders for staff to check the residuals of his tube feeding every shift dated 05/28/23 and discontinued 06/05/23; to administer well water only, no tap water every shift dated 05/28/23 and discontinued 06/05/23; perform tracheostomy care twice daily and as needed every day and evening shift dated 05/28/23 and discontinued 06/05/23; change the tracheostomy inner cannula daily and as needed dated 05/28/23 and discontinued 06/05/23; and to monitor his oxygen level every four hours and if any signs of distress or oxygen is less than 90 percent (%), staff were to uncap him and apply humification dated 07/05/23. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) reviewed for June 2023 and July 2023 revealed nursing staff did not document these items as being completed: Tube feeding residuals on dayshifts on 06/01/23, 06/03/23 and 06/04/23 and on evening shift on 06/02/23. Well water only, no tap water on dayshifts on 06/01/23, 06/03/23 and 06/04/23 and on evening shift on 06/02/23. Tracheostomy care on dayshifts on 06/01/23 and 06/04/23 and on evening shift on 06/02/23. Change tracheostomy inner cannula on 06/01/23 and 06/04/23. Oxygen saturation on 07/07/23 at 8:00 A.M., 12:00 P.M. and 4:00 P.M.; on 07/09/23 at 8:00 A.M. and 12:00 P.M.; on 07/11/23 at 8:00 A.M. and 12:00 P.M., and on 07/12/23 at 8:00 A.M. and 12:00 P.M. Interview on 07/27/23 at 3:49 P.M. with the Director of Nursing (DON) revealed there were times the staff did not sign off on the MAR and TAR. She stated she had been educating to ensure they were documenting when they completed a task. Interview on 07/31/23 at 8:35 A.M. with the Administrator verified staff had completed the missing documentation on the MARs and TARs for Resident #93 on 07/29/23. She provided hand signed copies of Resident #93's MARs and TARs for the months of June 2023 and July 2023. She stated the staff had completed the tasks, just failed to document in the medical record. Review of the facility policy titled Oxygen Administration, dated 06/08/22, revealed the staff were to document in the medical record after assessing the resident. Review of the facility policy titled Enteral Tube Feeding-Bolus and Continuous, dated 06/08/22, revealed the staff were to document after checking residuals and feedings.

Based on record review and interviews the facility failed to prevent misappropriation of resident funds. This affected 11 residents (Resident #1, Resident #4, Resident #12, Resident #14, Resident #19, Resident #20, Resident #90, Resident #93, Resident #100, Resident #101 and Resident #102) out of 29 residents with resident accounts. The census was 98. Findings include: Review of a Self Reported Incident (SRI) dated 10/20/22 revealed an investigation of alleged misappropriation of three former Residents (#100, #101 and #102) and eight current residents ( #1,#4,#12, #14, #19,#20, #90 and #93) was substantiated by the facility. According to the SRI, the Manager Regional Business Office Support (MRBS) #332 completed an audit of resident trust accounts from 01/01/21 through 09/13/22. The audit was started on 09/13/22 and was signed off on 10/07/22. The investigation included the resident trust account information, including discharged residents, punch details of staff who had access to resident funds and staff and resident interviews. MRBS #332 discovered 11 residents had unauthorized withdrawals from their accounts. It was suspected that the Former Business Office Manager (FBOM) #1 was withdrawing funds from the accounts. Interviews were conducted with Former Administrator (FA) #334, Receptionist (REC) #235 as well as other staff. It was discovered REC #235 kept her password in a locked drawer which FBOM #1 had access to the drawer. Residents were interviewed and denied withdrawing those amounts. A police report was filed, #220-3084. The facility replenished funds on 10/20/22. Residents and representatives were notified on 10/20/22. The medical director was notified and an ad hoc quality assurance meeting was held on 10/21/22. It was determined FBOM #1 misappropriated $18,460 from resident trust accounts. Review of employee record for FBOM #1 revealed she was terminated on 08/24/22 for a work rule violation. She had been suspended and investigated for theft, as she purchased items through her employer without submitting payroll deduction forms. Termination occurred prior to the facility knowledge of the misappropriation of resident funds. Interview on 11/08/22 at 3:48 P.M. with the Interim Administrator revealed the FBOM #1 was terminated in August related to not paying through payroll deduction as she should have. The Interim Administrator stated the FA #334 had requested the MRBS #332 do an audit when a resident started asking in September about her account and some purchases allegedly made on her behalf. He stated an SRI was started on 10/20/22. He stated there were 29 residents who had accounts and 11 were affected by the misappropriation. Interview on 11/08/22 at 5:03 P.M. with MRBS #332 verified misappropriation occurred. She revealed she was contacted by the FA #334 who had requested she audit a resident fund after a resident inquired about a clothing order FBOM #1 allegedly made on the resident's behalf. FA #334 saw some odd withdraws to raise suspicion and wanted a complete audit of resident funds. MRBS #332 said she started looking at accounts remotely on 09/13/22, the day of the request, then came to the building on 09/14/22 to continue the audit. She stated it took her several weeks to complete the audit and the misappropriation of resident funds did occur in the amount of $18,460.00. This deficiency substantiates complaint number OH 098.

Based on record reviews and interviews the facility failed to report an allegation of misappropriation to the state agency in a timely manner. This affected 11 residents (#1, #4, #12, #14, #19, #20, #90, #93, #100, #101 and #102) of 29 who had resident fund accounts. The census was 98. Findings include: Review of the Self Reported Incident (SRI) dated 10/20/22 involving a substantiated allegation of misappropriation of resident funds affecting 11 residents (#100, #101, #102, #1, #4,#12, #14, #19, #20, #90 and #93) revealed the date of discovery was listed as 10/20/22 on the SRI. According to the SRI an audit of resident funds was started on 09/13/22 and completed on 10/07/22. The audit was completed by Manager Regional Business Office Support (MRBS) #332 and it was determined a former employee, Former Business Office Manager (FBOM) #1 misappropriated $18,460.00 from resident fund accounts. Review of the facility investigation of the SRI revealed the facility began investigating misappropriation of resident funds on 09/13/22, finished the investigation on 10/07/22 but did not report it to the state agency until 10/20/22. Interview on 11/08/22 at 3:48 P.M. with the Interim Administrator, who had been at the facility as the Interim Administrator for one month, revealed the Former Administrator (FA) #334 for the facility had requested MRBS #332 do an audit of resident funds after one resident started asking questions in Septemer 2022 about her account and some purchases made from the account. The Interim Administrator verified 11 residents had been affected by misappropriation and he started an SRI on 10/20/22. Interview on 11/08/22 at 4:34 P.M. with Human Resources (HR) #240 revealed the investigation into the misappropriation of resident funds began in the middle of September 2022. HR #240 explained the FBOM #1 had been terminated in August due to other unrelated issues and was terminated prior to the facility identifying the misappropriation of resident funds in September 2022. Interview on 11/08/22 at 5:03 P.M. with MRBS #332 revealed she was contacted by the FA #334 who had requested she audit a resident fund after a resident inquired about a clothing order FBOM #1 allegedly made on the resident's behalf. FA #334 saw some odd withdraws and became suspicious. MRBS #332 started looking at accounts remotely on 09/13/22, the day of the request, then came to the building on 09/14/22 to continue the audit. She stated it took her several weeks to complete the audit because she had vacation time she had to use or lose. She stated she oversaw ten buildings, some of which she was filling in at and it was month end, a busier time for billing. MRBS #332 stated once she was done with vacation there was a conference call on 10/20/22 to discuss the investigation and then reported it the same day. She stated her time off during the investigation was 09/19/22 through 09/26/22 and 10/10/22 through 10/14/22. She was off on 10/17/22 also. Review of facility policy titled Patient Protection Abuse, Neglect, Mistreatment and Misappropriation Prevention, dated 10/2021, revealed the facility did not implemented the policy in regards to timely reporting of alleged misappropriation. This deficiency substantiates Complaint Number OH 098.

Based on observation, record review and interview, the facility failed to properly display appropriate signage outside 10 resident rooms (Residents #4, #24, #26, #32, #43, #60, #69, #73, #103 and #110) who were in airborne isolation precautions to include the type of precautions and personal protective equipment (PPE) required by staff and/or visitors and the facility failed to ensure all staff donned proper personal protective equipment (PPE) when entering rooms of residents on airborne isolation precautions. This affected 10 residents of 11 residents on airborne isolation precautions and had the potential to affect all 48 residents (Residents #4, #8, #10, #12, #13, #16, #21, #22, #24, #26, #27, #28, #32, #33, #37, #38, #41, #42, #43, #45, #47, #48, #54, #59, #60, #62, #64, #68, #69, #70, #72, #73, #76, #78, #80, #81, #82, #85, #86, #89, #90, #92, #94, #100, #103, #105, #110 and #111) residing on the West side of the facility, which included the West Wing and Medbridge rooms. The facility census was 110. Findings include: Review of Resident #4's medical record revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She resided in a West Wing room and was on airborne isolation precautions for possible COVID-19 infection since admission. Review of Resident #24's medical record revealed he was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He resided in a Medbridge room and was on airborne isolation precautions for possible COVID-19 infection since admission. Review of Resident #26's medical record revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He reside in a Medbridge room and was on airborne isolation precautions for possible COVID-19 infection since admission. Review of Resident #32's medical record revealed he was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He resided in a West Wing room was on airborne isolation precautions for possible COVID-19 infection since admission since 06/15/22 when he tested positive for COVID-19. Review of Resident #43's medical record revealed she was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She resided in a West Wing room and was on airborne isolation precautions for possible COVID-19 infection since admission. Review of Resident #60's medical record revealed he was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He resided in a Medbridge room and was on airborne isolation precautions for possible COVID-19 infection since admission. Review of Resident #69's medical record revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She resided in a West Wing room and was on airborne isolation precautions for possible COVID-19 infection since admission. Review of Resident #73's medical record revealed he was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He resided in a Medbridge room and was on airborne isolation precautions for possible COVID-19 infection since admission. Review of Resident #103's medical record revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #103 had tested positive for COVID-19 in the hospital on 06/13/22 prior to admission. When admitted she resided in a West Wing room and was on airborne isolation precautions for COVID-19 infection admission. Review of Resident #110's medical record revealed she was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She resided in a West Wing room and was on airborne isolation precautions for possible COVID-19 infection since admission. Observation on 06/21/22 at 7:01 A.M. revealed Resident #32's room had a plastic bin outside of his room with PPE inside the bin. Plastic pages with directions on what PPE to don for different types of isolation precautions were attached to the cart. There was no signage posted at or outside of Resident #32's room/door to indicate the type of isolation precautions he was in for staff/visitors to don the appropriate PPE. There was no sign to direct staff and/or visitors to see the nurse before entering the room. Observation on 06/21/22 at 7:09 A.M. revealed State tested Nursing Assistant (STNA) #805 enter Resident #24's room. She was wearing an N95 respirator mask and face shield at the time of the observation. There was a plastic PPE bin located outside of Resident #24's room but no signage was posted at or outside the door to indicate what type of isolation precautions Resident #24 was ordered, what PPE should be worn or for staff/visitors to see the nurse before entering. Interview with STNA #805 at that time revealed she was not aware Resident #24 was ordered airborne isolation precautions. STNA #805 indicated she would don a gown, gloves, N95 respirator mask and face shield when entering a room of a resident on airborne isolation. STNA #805 confirmed she did not wear an isolation gown to prevent possible cross contamination of her clothing while caring for Resident #24. Observation on 06/21/22 at 7:10 A.M. with Licensed Practical Nurse (LPN), Unit Manager #806 revealed STNA #807 entered Resident #60's room, who was on airborne isolation precautions. STNA #807 was observed wearing a surgical mask and face shield during provision of of resident care. There was a plastic bin of PPE outside Resident #60's door. There was no signage posted at or outside of Resident #60's room/door to indicate the type of isolation precautions he was in for staff/visitors to don the appropriate PPE. There was no sign to direct staff and/or visitors to see the nurse before entering the room. STNA #807 was not wearing an N95 respirator mask or an isolation gown to protect her clothing against cross contamination while in with Resident #60. Interview with STNA #807 at 7:14 A.M. revealed she was not aware she was required to don an N95 respirator mask, gown, gloves and face shield when entering Resident #60's room to answer the call light even though she confirmed she was aware he was ordered airborne isolation precautions. Observations on 06/21/22 from 7:16 A.M. to 7:22 A.M. with LPN Unit Manager #806 revealed Residents #4, #24, #26, #32, #43, #60, #73, and #103 were ordered to be on airborne isolation precautions and they all had a plastic bin with PPE outside of their rooms. LPN Unit Manager #806 confirmed none of these residents had signage posted at or outside their rooms/doors to indicate the type of isolation precautions they were in for staff/visitors to don the appropriate PPE. There were no signs to direct staff and/or visitors to see the nurse before entering these rooms. Observations and subsequent interview on 06/21/22 from 11:45 A.M. to 12:09 P.M. with the Administrator confirmed the concerns with Residents #4, #24, #26, #32, #43, #60, #69, #73 and #103 being on airborne isolation precautions and none had appropriate signage on or outside their rooms. Review of the facility form, Standard Precautions Practice Guidelines, dated 07/21, indicated standard precautions included hand hygiene before and after patient contact and after contact with the immediate patient care environment. PPE was required when exposure to blood, body fluids, excretions, secretions, mucous membranes or non-intact skin. PPE included gloves when hand contamination was anticipated, masks and eye protection when splashes may occur and gowns when soiling of clothes may occur. Review of the form, Airborne Precautions Infection Control Manual Practice Guidelines, dated 07/21, indicated in addition to standard precautions, staff must wear an N95 fit tested disposable mask when entering the room of a patient on airborne precautions. Review of the form, Signage Notice Practice Guidelines, dated 07/21, indicated to protect patient confidentially and provide a safe and healthful environment, a stop, see nurse for instructions sign was to be posted on a patient room door for any transmission-based precautions. Review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations to Prevent COVID-19 Spread in Nursing Homes dated 02/02/22 indicated empiric use of transmission-based precautions was recommended for residents who were newly admitted to the facility and for resident who have had close contact with someone with a COVID-19 infection if they were not up to date with all recommended COVID-19 vaccine doses. Health care providers (HCP) who enter a room with a patient with suspected or confirmed COVID-19 infection should adhere to standard precautions and use an N95 respirator mask, gown, gloves and eye protection. This deficiency substantiates Complaint Number OH 514.

Based on observations, staff interviews, review of the medical record, police report, emergency room documentation, accuweather.com, timeanddate.com, and the facility's Wandering And Exit Seeking policy and procedure, the facility failed to provide adequate supervision to prevent the elopement of one resident (Resident #204) who was assessed with [REDACTED]. This resulted in Immediate Jeopardy on 05/09/19 at approximately 5:45 A.M. when Resident #204 exited the facility without staff knowledge. The likelihood of actual harm that was Immediate Jeopardy occurred when Resident #204 was found on his knees in his bare feet at the bottom of a ravine with an incline of approximately 70 degrees next to a creek. The ravine contained heavy brush, weeds, downed trees, rocks, and large tree branches. When found, Resident #204 was cold and had cuts, bruises and abrasions to his face, arms and feet. This affected one of nine residents reviewed for elopement risk and wandering behaviors. The facility identified nine residents (Residents #7, #17, #25, #42, #51 #75, #78, #81 and #204) at risk for elopement. The facility census was 111. On 05/09/19 at 4:40 P.M., the Administrator, Director of Nursing (DON) and Corporate Nurse #619 were notified Immediate Jeopardy began on 05/09/19 at 5:45 A.M. when Resident #204, who was at risk for elopement and exhibited a desire to leave the facility, was identified as missing from the facility. Resident #204 was subsequently found at 6:37 A.M. at the bottom of a steep ravine next to a creek on his knees in his bare feet with cuts, bruises and abrasions. Resident #204 was transferred to the local hospital via emergency medical services (EMS). The Immediate Jeopardy was removed on 05/09/19 at 10:30 P.M. when the facility implemented the following corrective actions: · On 05/09/19 at 6:37 A.M., Resident #204 was located and transported to the local hospital at approximately 7:06 A.M. via EMS. · On 05/09/19 at 8:00 A.M., Secure Care devices (bracelets that signal a door alarm when exiting) were validated for placement and function by Scheduler #613. Eight residents (Residents #7, #17, #25, #42, #51 #75, #78, and #81) were identified with a need for Secure Care bracelets and were verified to have bracelets in place and the devices were functioning, · On 05/09/19 at 8:15 A.M., Maintenance Director (MD) #612 completed a door check on all doors with no negative findings. All exit doors were armed with the Secure Care wander management system and functioned as designed. · On 05/09/19 at 8:30 A.M., a missing resident drill was conducted by the DON with licensed practical nurses (LPNs), registered nurses (RNs), state tested nurse aides (STNAs), activity staff and housekeeping personnel currently in the building participating. Staff responded appropriately and followed all facility procedures. · On 05/09/19, at 12:30 P.M., the contracted maintenance company for the Secure Care security system conducted a maintenance and inspection check of all doors. All doors were functioning properly. · On 05/09/19 by 4:00 P.M., all residents identified with exit seeking behaviors (Residents #7, #17, #25, #42, #51 #75, #78, #81) were re-assessed and care plans were updated accordingly by Licensed Social Worker (LSW) #605. · On 05/09/19 by 5:00 P.M., all residents not previously identified as a risk for exit seeking behaviors were re-assessed for current risk and care plans were reviewed and revised as indicated by LSW #605. · On 05/09/19 at 10:30 P.M. staff had received education by the Administrator or DON regarding indicators of elopement and possible interventions, and review of the company's behavior practice guide including missing resident actions. This was confirmed by review of education sign in sheets. Any staff not in-serviced would not be allowed to work until education was provided by the respective department heads. · Beginning on 05/09/19, Maintenance Director #612 will complete audits of all door alarms weekly for four weeks. · Beginning on 05/09/19, the DON will complete an exit seeking audit (tool used for monitoring for elopement interventions and wandering status/behaviors for those identified at risk) weekly for four weeks and all results will be brought to the Quality Assurance Committee for evaluation and/or additional monitoring. · Interviews on 05/10/19 between 5:44 A.M. and 1:23 P.M. with STNAs #615, #617, #618, and LPNs #607 and #617, who represented all shifts, revealed staff were knowledgeable of facility policies and procedures regarding elopement and what to do in the event of missing persons. Although the Immediate Jeopardy was removed on 05/09/19 at 10:30 P.M., the deficiency remained at a Severity Level 2 (no actual harm with the potential for minimal harm that is not Immediate Jeopardy) as the facility was continuing with staff in-services and was in the process of monitoring staff and exit doors to ensure compliance and determine if further action required. Findings Include: Review of Resident #204's medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#204 had severe cognitive impairment with no behaviors and required limited to extensive assistance of staff for activities of daily living. Review of Resident #204's care plan dated 02/18/19 revealed he was at risk for elopement due to dementia and exit seeking behaviors. Interventions included completing a resident identity sheet due to risk factors, Secure Care device placement to left ankle, accompany to meals and activities, and engage in activities/tasks to keep occupied. Review of the medical record revealed Resident #204 was sent to a local psychiatric hospital on [DATE] for [MEDICAL CONDITION]. Resident #204 returned to the facility on [DATE]. Review of physician's orders [REDACTED]. Review of the behavioral symptom assessment completed by LSW #605 dated 05/06/19 indicated Resident #204 had exit seeking, unsafe and impulse behaviors. Observation of Resident #204 on 05/06/19 at 7:57 P.M. revealed he walked with a slow shuffling gait. Resident #204 was aware of self but confused to time, place, and situation. Resident #204 was unable to provide meaningful information when interviewed. Review of the nursing progress note written by LPN #606 dated 05/08/19 and timed 8:56 P.M. revealed the resident had exit seeking behaviors noted all day and was observed wandering in and out of other patients' rooms. Review of a facility incident report dated 05/09/19 revealed Resident #204 was unable to be located when LPN #607 entered his room to give morning medication at approximately 5:45 A.M. The report indicated Resident #204 was located in a ravine with heavy brush, weeds, downed trees and tree branches, with a steep approximately 70-degree angle with no shoes on. Observation on 05/09/19 at approximately 9:30 A.M. revealed the 200 unit where Resident #204 resided had three alarmed doors at the end of each of the three hallways. Further observation revealed all facility exit doors were alarmed. The facility was encircled by a paved lighted parking lot. Approximately 20 yards behind the rear parking lot was a heavily wooded area with an approximate 70 degree drop to a creek. The wooded area was covered with dead leaves, downed trees, tree limbs, rocks, weeds and bushes. Upon walking to the area where Resident #204 was found, the terrain was slippery and difficult to traverse. Review of daily historical temperatures on accuweather.com revealed a low temperature of 52 degrees Fahrenheit (F) on 05/09/19. Review of sunrise times on timeanddate.com revealed sunrise on 05/09/19 was 6:14 A.M. Review of LPN #607's statement dated 05/09/19 revealed Resident #204 was observed trying to get into the nurses' station restroom at approximately 5:00 A.M. Resident #204 was subsequently redirected back to his room by LPN #607, toileted and put back to bed. Upon re-entering Resident #204's room to give medication at 5:45 A.M. LPN #607 noted Resident #204 was not in his room. An immediate search was started and a Dr. Walker (missing resident) announcement was made via the overhead paging system. Review of RN #608's statement dated 05/09/19 revealed she was made aware at 5:45 A.M. that Resident #204 was missing by LPN #607 and other staff members on the unit. RN #608 assisted with the search of Resident #204 on his unit and other areas of the building. Review of STNA #609's statement dated 05/09/19 revealed she made no observations of restlessness or wandering behaviors throughout the night (by Resident #204). Review of STNA #611's statement dated 05/09/19 revealed she made observations of restless behaviors by Resident #204 between 12:15 A.M. and 12:30 A.M. STNA #611 indicated she sat with Resident #204 to calm him and assisted him back to bed after he calmed down. Review of the police report dated 05/09/19 revealed the police were dispatched to the facility at 6:26 A.M. for a report of a missing male (Resident #204). The report indicated Resident #204 was last seen at 5:30 A.M. in his bed and he was wearing a white shirt and plaid pajama pants. Resident #204 was found at 6:37 A.M. The narrative read Send squad he's cold and scraped up, he was by the creek. EMS arrived and transported Resident #204 to a local hospital at approximately 7:06 A.M. Review of the Emergency Documentation from the hospital dated 05/09/19 revealed Resident #204 was found down a 60 foot embankment in a creek. His tympanic (ear) temperature en route was 90 degrees F (normal oral temperature 98.6 degrees F and a tympanic temperature is 0.5 to 1 degree higher than an oral temperature), blood pressure 129/84 (normal less then 120 systolic and less than 80 diastolic) and heart rate 130 beats per minute (normal 60-100). Resident #204 did not remember the fall and denied pain. The resident stated the only thing that is bothering me is my cold feet! He was covered head to toe in abrasions. The physical exam revealed Resident #204's skin was warm and dry, cyanotic (bluish discoloration) left foot, head to toe abrasions, dry blood in mouth, right lateral chest wall ecchymosis (the escape of blood into the tissues from ruptured blood vessels), bilateral knee swelling and ecchymosis over right flank. Review of radiology reports revealed no fractures. The notes section of the documentation indicated Resident #204 was found to be hypothermic and treated with a Bair Hugger (convective temperature management system used to maintain core body temperature) as well as warmed intravenous fluids. He was admitted for additional evaluation and treatment. Interview with LPN #607 via telephone on 05/09/19 at 11:15 A.M. revealed Resident #204 went to bed on 05/09/19 at approximately 3:45 A.M. At approximately 5:00 A.M., Resident #204 was observed trying to enter the staff bathroom located at the nurses' station. LPN #607 redirected Resident #204 back to his room, took the resident to the bathroom and laid Resident #204 back in his bed at approximately 5:15 A.M. Upon reentering Resident #204's room to give morning medication, Resident #204 was not in his room. LPN #607 started an immediate headcount of all residents and a Dr. Walker (missing resident) page was announced over the facility loud speaker. LPN #607 indicated a local ambulance service arrived to drop off a resident from the local emergency room between 5:00 A.M. and 5:30 A.M. and set off the alarm to the main entrance of the facility twice. LPN #607 did not recall hearing any other alarms between 5:00 A.M. and 6:00 A.M. on 05/09/19. Interview with the DON on 05/09/19 at 11:49 A.M. revealed she arrived at the facility at approximately 5:00 A.M. Upon hearing the over-head page of Dr Walker over the loud speaker, the DON gathered information about what was going on and began an outside perimeter search of the building. The DON said Resident #204 was found in a ravine behind the facility near a creek by herself, the administrator and night shift supervisor (RN #614). Resident #204 was on his knees wearing flannel pajama pants, a polo shirt and no shoes. He had scratches, cuts and bruises on his arms, legs and face. The DON indicated upon Resident #204 being found, staff were instructed to call local EMS for transport to a local hospital for evaluation. Resident #204 was escorted up the ravine by the local police department, placed in an ambulance and transported to a local hospital at approximately 6:35 A.M. on 05/09/19. Interview with the Administrator on 05/09/19 at 11:55 A.M. revealed she arrived at the facility at 6:00 A.M. on 05/09/19. Upon arriving the to the facility, the Administrator was made aware of the situation and began assisting with the search process. At approximately 6:20 A.M., the Administrator contacted the local police department to assist in the search for the resident. Immediately following her phone call to the local police department, the Administrator contacted the spouse of Resident #204. The spouse of Resident #204 noted that Resident #204 enjoyed the outdoors and being in the woods and suggested to look in the wooded area behind the facility. The Administrator verified Resident #204 was found at the bottom of a ravine near a creek at approximately 6:30 A.M. After the resident was found, the Administrator tested Resident #204's Secure Care device and verified it was functioning with all facility exit doors. Interview with RN #608 on 05/09/19 at 1:57 P.M. revealed she last observed Resident #204 attempting to enter the bathroom located at the nurses' station at approximately 5:00 A.M. RN #608 was made aware Resident #204 was missing via the Dr. Walker page and assisted in the head count and search of the interior building for Resident #204. RN #608 denied hearing any door alarms go off in the building between 5:00 A.M. and 6:00 A.M. on 05/09/19. Interview with STNA #609 on 05/10/19 at 5:50 A.M. revealed she last saw Resident #204 at the nurses' station around 4:45 A.M. STNA #609 was made aware Resident #204 was missing by other staff members and the Doctor Walker overhead page. After finding Resident #204, STNA #609 was asked to bring shoes and a blanket to Resident #204 down in the ravine area. STNA #609 noted Resident #204 was wearing a polo shirt, pajama pants and no shoes and had cuts and scratches on his arms. STNA #609 denied hearing any door alarms going off from 5:00 A.M. to 6:00 A.M. on 05/10/19. Interviews on 05/10/19 between 5:55 A.M. and 6:00 A.M. with STNAs #610 and #611 revealed they noted Resident #204 being at or around the nurses' station between 4:00 A.M. and 5:00 A.M. Both STNAs, who were working on the unit where Resident #204 resided, were notified of Resident #204 missing by their coworkers and the Doctor Walker overhead page. Both STNAs denied hearing any door alarms going off between 5:00 A.M. and 6:00 A.M. Interview with Maintenance Director #612 on 05/10/19 at 1:11 P.M. revealed he was made aware of the elopement upon arrival to the facility around 7:30 A.M. on 05/09/19. Upon notification, MD #612 verified all doors were functioning properly and he contacted the company in charge of the monitoring system to come to the facility to check the system. Following inspection, the company indicated all exit door alarms were functioning as expected. Review of the facility's undated wandering and exit seeking policy revealed wandering was a behavioral symptom of special concern in the elderly and, or dementia population. Wandering was believed to be related to an individual's unmet need. The policy indicated the interdisciplinary team would evaluate the patient's history and current clinical conditions to identify patients at risks for wandering or exit seeking and develop a specific plan of care. Interventions that could be considered included structured activity program, patient room placement in relation to egress doors, personal security bracelet and safe wandering interventions. This deficiency substantiates Complaint Number OH 311.

Based on observation, interview and record review, the facility failed to ensure interventions to prevent the development of pressure ulcers were implemented, failed to ensure comprehensive pressure ulcer assessments were completed and failed to ensure treatments to heal pressure ulcers were in place for one resident, Resident #60. Actual harm occurred when Resident #60's heels were observed directly on the bed surface and pressure ulcers were found on her heels which were scabbed, red, non-blanchable, mushy and causing her pain. Additionally, Resident #60 was observed incontinent of urine and without a dressing to her Stage III sacral pressure ulcer and was found with two other pressure ulcers on her buttocks and coccyx which were not previously assessed and documented. This affected one resident (Resident #60) of three residents observed for wound treatments. Findings include: Resident #60 was readmitted to the facility on [DATE]. Review of the resident's plan of care initiated on 11/11/16 revealed the resident was at risk for alteration in skin integrity related to impaired mobility, incontinence, steroid therapy, and [MEDICAL CONDITION]. Interventions to prevent skin issues included floating heels as able (pillow or device under the ankle/lower leg to float the heel completely off the bed surface to remove all pressure to the area, pressure redistributing devices on the bed and chair, and for staff to observe her skin condition with activity of daily living care daily and to report abnormalities. Review of the resident's minimum data set 3.0 (MDS) assessment with the assessment reference date of 07/10/17 revealed the resident needed extensive assistance of two persons to move in bed and for transfers. On 07/16/17 at 10:40 A.M., Resident #60 was being observed for medication administration when she told the nurse, Licensed Practical Nurse (LPN) #301, her heels were burning. When asked if the resident had an order to float her heels, LPN #301 replied No. The resident was observed in bed on her left side wearing antiembolism stockings with anti-skid slipper socks applied to both of her lower legs and feet which were resting directly on the surface of the bed. LPN #301 removed Resident #60's sock and stocking from her right lower leg/foot to look at her right heel. The resident asked if her heel was red because it was burning like fire. The nurse indicated she did not see it as red. The surveyor asked the nurse to palpate, or examine the heel by touching or pushing on the heel. Upon palpation, the heel was red, non-blanchable and the nurse's thumb left an indentation in the heel. The left heel was observed red, non-blanchable and mushy. The resident stated again, they burn like fire. The nurse reapplied the stockings and slipper socks and placed a pillow under the resident's calves to float her heels off of the bed surface. On 07/16/17 at 12:20 P.M., Resident #60 was observed in her bed leaning to the far left attempting to eat her lunch. The resident indicated the staff brought in her tray but did not sit her up to eat. The resident's heels were resting directly on the bed surface and were not floated to relieve heel pressure. LPN #301 was obtained by the surveyor to reposition Resident #60. LPN #301 assisted Resident #60 at 12:23 P.M. LPN #301 was asked what was being done related to Resident #60's mushy, red heels. She indicated they would apply skin prep and boots. LPN #301 indicated she had not been able to measure the areas yet. At 1:23 P.M., interview with LPN #301 revealed the resident's daughter was visiting and the resident was not available for her heels to be measured. At 1:50 P.M. Resident #60 was observed sitting in the courtyard outside with her daughter. The resident continued to wear antiembolism stockings with slipper socks. Interview with Resident #60 at that time revealed her biggest care complaint was that the aides would answer the call light and tell her they were coming back in two minutes, but would not come back until one and a half hours later. She said she was wet with urine all the time. Resident #60's daughter confirmed this was a regular complaint of her mother. At 4:38 P.M. Resident #60 was observed in her room in her wheelchair with the stockings and socks still on her legs and feet. At 4:39 P.M., LPN #301 indicated the registered nurse (RN) had assessed Resident #60's new pressure ulcers on her heels. Review of a skilled nursing note dated 7/16/17 at 4:48 P.M. revealed RN #306 had assessed Resident #60's heels. Her left heel was described as red, non-tender, and non-blanchable. No open areas were noted. Her right heel was described as red, non-tender and non-blanchable. A small scabbed area measuring 0.1 centimeters (cm) by 0.3 cm was listed. The nurse practitioner was notified and treatment orders were obtained. There was no indication that RN #306 measured the mushy or soft areas of the heels, only the red areas. Review of Resident #60's physician's orders [REDACTED]. Review of a skin progress note dated 07/14/17 at 6:09 P.M. revealed the wound nurse was in to see Resident #60 that morning. The resident was incontinent of bowel and bladder, had a history of [REDACTED]. The wound to the sacrum was cleaner and around the wound was improving. There was excoriation noted to the groin, perineal area, both upper thighs and buttocks. The record indicated the resident had a sacral pressure ulcer, Stage 3, a full thickness tissue loss in which subcutaneous fat may be visible but bone, tendon or muscle is not exposed and slough (yellow/gray/tan devitalized tissue) may be present but does not obscure the depth of tissue loss and may include undermining or tunneling. This ulcer was documented as measuring 1.0 cm by 0.4 cm by 0.2 cm and had scant sero-sanguinous (bloody, serous) drainage without any foul odor. The wound margin was flat and intact. The wound bed was 26-50 % pink granulation with no slough. The skin around the ulcer was excoriated, with rash, denuded, moist and macerated. The skin color around the wound was noted as normal and improved but not resolved. There was no sign of infection. The treatment in place was to cleanse the area with wound cleanser, blot dry, apply calcium alginate, cover with foam every other day and as needed. On 07/17/17 at 10:30 A.M., Resident #60 was observed during wound care provided by RN #304 and LPN #305. When the resident was repositioned onto her right side by LPN #305 and RN #304 began to remove her brief, the resident had been incontinent of urine which had gone through the brief and to the fitted sheet of the bed. There was a foam dressing on her right buttock, but no dressing to the Stage 3 pressure ulcer on her sacrum as ordered. At 10:44 A.M., open areas were observed on Resident #60's coccyx, left buttocks and sacral areas. After removing the dressing, RN #304 went into the bathroom to wash her hands. At 10:59 A.M., Resident #60 told LPN #305 that her tailbone really hurt. At 11:00 A.M., RN #304 returned to cleanse the left buttock wound. At 11:03 A.M., the surveyor followed RN #304 into the bathroom and confirmed there was no dressing on the sacral wound and verified there was no documentation of Resident #60 having a left buttock wound or coccyx wound in her medical record. At 11:07 A.M., RN #304 measured the left buttock wound at 1 cm in length by 1 cm in width with superficial depth. Calcium alginate was applied to the buttocks and sacral wounds. A dated foam dressing was applied to the left buttocks and a larger foam dressing was applied to the sacral and coccyx wounds. RN #304 did not measure and fully assess the new coccyx wound or the existing sacral wound. This deficiency substantiates Complaint Number OH 135.

Based on observation, record review and interview, the facility failed ensure interventions to reduce the risk of falls were in place for one resident (Resident #21). This deficient practice affected one residents ( Resident #21) of four residents reviewed related to accidents. The facility census was 112. Findings include: 1. Medical record review revealed Resident #21 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A comprehensive assessment dated [DATE] revealed Resident #21 required supervision and set up help for locomotion on unit. Resident #21 was not steady and only able to stabilize with staff assistance when moving from a seated to standing position or with surface to surface transfers. Resident #21's plan of care dated 10/15/12 revealed she was at risk for falls due to amputee, hypertension, cerebral vascular accident, knee replacement, medication regimen, and inconinence of bowel and bladder. The goal of the plan of care was to minimize risk for injury related to falls. Interventions included administer medication per pharmacy order, anti-roll brakes to wheelchair, Dycem (a non slip pad) to wheelchair cushion above and below, educate and re-inforce need to call for assistance and use call light, physical therapy to evaluate and treat if indicated and therapy evaluation and treatment per orders. Fall documentation dated 02/26/13 revealed Resident #21 was found in seated positon on floor facing wheelchair with legs extended and wheelchair facing her in her room near foot of bed. Fall documentation dated 03/18/13 revealed Resident #21 had a bruise to her left temporal area. Resident #21 said she fell on [DATE] and hit head on the floor. Observation on 04/06/13 at 12:36 P.M. revealed Resident #21 was seated in a wheelchair in the dining room. An anti- roll brake was in place over the right wheel; however, the anti-roll brake on the left side was not positioned over the wheel. This observation was verified with Licensed Practical Nurse #2 who confirmed the anti -roll back brake on the left side should have been positioned over the wheel. Observation on 04/06/13 at 2:40 P.M. revealed Resident #21 moving about her room by self propelling her wheelchair with her right leg. With the assist of Registered Nurse (RN) #9, Resident #21 stood up from her wheelchair. There was not a Dycem on the cushion, there was a dycem below the cushion. RN #9 confirmed a Dycem was not in place on the cushion.

Based on observation, record review and interview, the facility failed to ensure adequate interventions were in place to prevent the developement of a pressure ulcer. This resulted in actual harm for Resident #99 who developed a Stage III pressure ulcer to her sacrum. The deficient practice affected one resident (Resident #99) of two residents reviewed related to pressure ulcers. The facility census was 112. Findings include: Resident #99 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident also had a past medical history and [DIAGNOSES REDACTED]. Review of a computerized nursing admission assessment, dated 01/14/13 revealed the resident was alert and oriented times two and dependent on staff for ambulation, bed mobility, toileting and transfers. The assessment revealed the resident was continent with episodes of incontinence at times. The assessment revealed the resident was at risk for skin breakdown. Record review revealed a plan of care, initiated on 01/24/13, related to the resident's risk for alteration in skin integrity related to impaired mobility and incontinence. The goal developed was for the resident's skin to remain intact, free from [DIAGNOSES REDACTED], breakdown, excoriation, or bruising until next review. Interventions included barrier cream to the perineal area, encourage to reposition during routine care rounds, use of assistive devices as needed, float heels as able, observe skin condition with activities of daily living care daily, report abnormalities, obtain labs as ordered and report results, pressure redistributing device on bed/chair, provide preventative skin care routinely and as needed, therapy evaluation and treatment per physician order. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment with an assessment reference date of 01/21/13 revealed the resident required extensive assistance from two staff for bed mobility, toileting, transferring and personal hygiene. The assessment revealed the resident was non-ambulatory. The assessment revealed the resident's skin was intact. Review of the MDS assessment, with an assessment reference date of 02/11/13 revealed the resident required extensive assistance from two staff for bed mobility, extensive assistance from one staff for transferring, toilet use and ambulation in the room. The assessment revealed the resident was occasionally incontinent of bladder and always continent of bowel. The assessment also revealed the resident's skin was intact at that time. Record review revealed Resident #99 sustained a fall with a right [MEDICAL CONDITION], on 02/19/13, while residing in the facility. The resident was transferred to the hospital and remained hospitalized for [REDACTED]. Additionally, a stool culture obtained on 02/19/13 prior to the resident being transferred to the emergency room revealed the resident tested positive for ,[MEDICAL CONDITION]. Difficle ([MEDICAL CONDITION]), an infection of the stool. The resident was re-admitted to the facility on [DATE] with orders for an antibiotic for treatment of [REDACTED]. Review of a computerized nursing re-assessment, dated 02/26/13 revealed the resident had a right hip incision that was intact with staples in place. No pressure ulcers were assessed, the resident's right and left buttocks were noted to be intact with no open areas noted and the resident was assessed, on 02/26/13 to be at low risk for skin breakdown. No changes were made to the resident's plan of care related to skin breakdown or skin risk at that time. Review of bowel tracking documentation revealed the resident had three episodes of bowel incontinence between 02/26/13 and 03/05/13, one on 02/26/13 at 10;40 P.M., one on 02/27/13 at 2:59 A.M. and one on 02/27/13 at 10:31 A.M. All other bowel records during this time period either noted the resident was continent or had no bowel movement. Review of bladder tracking documentation revealed entries dated 02/26/13, 02/27/13, 02/28/13 and 03/01/13 that reflected the resident was incontinent of bladder. The documentation reviewed revealed incontinence on 02/26/13 at 2:12 P.M. and 10:40 P.M., on 02/27/13 at 2:59 A.M. and 10:31 A.M. and on 02/28/13 at 2:14 P.M. On 02/28/13 at 5:25 P.M., bladder tracking documentation revealed the resident was continent of urine at that time. There was no written indication the resident was toileted or provided toileting/incontinence care related to urinary incontinence at any other times between 02/26/13 and 03/01/13. Additionally, there were extended periods of time in which there was no written documentation the resident was being checked for incontinence or that toileting was offered or provided. On 03/01/13 at 1:20 P.M. nursing progress notes revealed the resident was assessed to have a fungal rash along with some moisture incontinence skin damage. The nurse practitioner was notified and an order was obtained for an anti-fungal, [MEDICATION NAME] powder to be applied twice a day. The note indicated "will continue to monitor". Record review revealed no changes made to the resident's toileting, continence/incontinence or skin plan of care, except for the [MEDICATION NAME] powder, at that time. Review of bladder tracking computerized information, provided by the facility, revealed the resident exhibited two episodes of bladder continence and one episode of bladder incontinence on 03/01/13. On 03/02/13 at 5:35 A.M., 11:18 A.M. and 2:33 P.M. the resident was noted to be incontinent. The next entry, dated 03/02/13 at 10:53 P.M. (over eight hours later) the resident was noted to be incontinent of bladder. On 03/03/13 the resident was noted to be both continent and incontinent with toileting or care provided at 4:58 A.M., 10:58 A.M. and then again at 10:38 P.M. This again reflected extended periods of time with no documented toileting or incontinence care being provided to the resident. On 03/04/13 the resident was noted to be continent at 6:09 A.M., incontinent at 2:18 P.M. and continent at 10:43 P.M. On 03/04/13 a skin risk assessment revealed the resident was at moderate risk for skin breakdown. No changes were noted to be made to the resident's plan of care at that time. On 03/05/13 at 2:18 P.M., nursing progress notes revealed the resident was alert and oriented times one (to herself). On 03/05/13 at 7:55 P.M., nursing progress notes revealed an indwelling Foley catheter was inserted due to the resident having excoriation to the perineal and bilateral thigh areas. The note indicated this excoriation was related to [MEDICAL CONDITION] and incontinence. The note also indicated the resident was started on an oral anti-fungal medication, [MEDICATION NAME] for a fungal infection. On 03/05/13, the resident was assessed to be at high risk for skin breakdown. Again, there was no documented evidence any changes or new interventions were initiated at that time. Review of the comprehensive MDS assessment, with an assessment reference date of 03/05/13 revealed the resident required extensive assistance from two staff for bed mobility, transferring and toilet use. The resident was assessed to be non-ambulatory and also noted to have an indwelling urinary catheter in place. Review of bowel tracking documentation, from 03/05/13 through 03/08/13 revealed the resident had two episodes of bowel incontinence, on 03/07/13 at 6:34 A.M. and 9:55 A.M. All of the other documentation related to bowel revealed the resident was either continent or had no bowel movement noted. On 03/09/13 at 3:15 A.M., computerized nursing progress notes revealed "while toileting an open area was noted, measured and treatment started". Record review revealed corresponding physician orders, dated 03/09/13 for a treatment to an open area to the coccyx and a treatment to an open area to the left buttocks. The orders were to cleanse the open areas with normal saline, pat dry, cover with calcium alginate and [MEDICATION NAME] every other day and as needed. Record review and review of computerized nursing documentation revealed no written documentation of an assessment of the pressure ulcers that were noted on 03/09/13. There was no written description, staging or assessment contained in the resident's medical record. On 03/11/13 at 1:28 P.M. (two days later), the resident was seen by licensed practical nurse (LPN) #1, the facility wound nurse. The LPN documented the resident required extensive assistance from two staff for all transfers and mobility and was frequently incontinent of both bowel and bladder. The resident was assessed, by LPN #1 to have an ulcer to her sacral/gluteal cleft. The ulcer was assessed to measure 2.5 centimeters (cm) in length with one cm width and 0.1 cm depth. The wound edges were assessed to be irregular and rolled. The pressure ulcer was assessed to have 50% pale yellow tissue with a scant amount of serous exudate. The surrounding skin was assessed to be inflamed with a fungal rash due to "frequent stooling" related to [MEDICAL CONDITION], urine and stool incontinence and immobility. The LPN indicated the area presented as "moisture related skin damage". Moisture related skin damage, per review of the MDS manual, is a result of skin damage caused by moisture rather than pressure. It is caused by "sustained exposure to moisture which can be caused, for example, by incontinence, wound exudate and perspiration". On 03/15/13 at 1:40 P.M., the resident was seen by a consultant wound clinical nurse specialist. The resident was assessed to have a Stage III (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough tissue may be present and the wound may include undermining or tunneling) pressure ulcer to her sacrum, which measured 3.4 cm in length with 1.1 cm width and 0.2 cm depth noted. The note indicated due to "frequent stooling" related to [MEDICAL CONDITION], fleshy tissue with excess skin was creating a moist environment. The note also reflected the resident's immobility related to the right [MEDICAL CONDITION], confusion, urinary tract infection and fungal rash as contributing factors. The treatment order was noted to be changed at that time. On 04/07/13 at 2:22 P.M., interview with LPN #1 revealed she was the facility wound nurse. The LPN verified Resident #99 was re-admitted to the facility on [DATE] and that her skin was intact at that time. The LPN verified the resident developed a Stage III pressure ulcer while residing in the facility. The LPN indicated she felt the pressure ulcer developed due to the resident being incontinent of bowel and bladder with frequent stools from the [MEDICAL CONDITION] the resident was being treated for [REDACTED].#99 revealed a lack of written evidence the resident was exhibiting frequent bowel or bladder incontinence and after 03/05/13 the resident had a urinary catheter in place. During the interview with LPN #1, the LPN indicated that following the order for the [MEDICATION NAME] powder, on 03/01/13 it seemed as though the area got worse and indicated the resident's skin was so red and inflamed it gave the appearance of a "burn". The LPN verified the resident was found with an "open area" on 03/09/13, but was unable to provide a skin assessment or assessment, including measurements or staging of the wound at that time. The LPN indicated she was off on 03/09/13, but assessed the resident on 03/11/13 (two days later) when she returned to work. The LPN indicated she then had the wound consultant see the resident on 03/15/13, at which time the resident was assessed to have a Stage III pressure ulcer. On 04/08/13 at 3:49 P.M., interview with LPN #1 and the DON revealed staff were to document continence / incontinence for a resident at the time the care (whether toileting or incontinence) was provided. Based on the information provided and reviewed, the facility failed to ensure adequate and sufficient interventions were in place, including prompt and timely monitoring and delivery of incontinence care, to Resident #99, who required extensive assistance to total dependence on staff for activities of daily living, to prevent the resident from developing a Stage III pressure ulcer to her sacrum. On 04/08/13 at 7:35 A.M., LPN #1 was observed completing the dressing change to the resident's sacral pressure ulcer. The resident was observed to continue to have a pressure ulcer at the time of the observation. The ulcer was assessed to be irregular shaped with white edges. The ulcer did not appear to have any slough tissue or drainage at the time of the observation.

Based on record review, document review, and staff interview, the facility failed to ensure staff transferred one resident in accordance with that resident's care card, which resulted in the resident sustaining a fracture to the left femur. This affected one resident (#1) of nine resident records reviewed. The facility census was 101 residents. Findings include: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's plan of care for Activities of Daily Lining (ADL) - Self Care revealed an intervention was added on 06/10/11 for staff to use a mechanical lift for all transfers. The kardex used by the state tested nursing assistants (STNA's) for resident care needs, also documented staff were to use a mechanical lift for transferring the resident. However, review of an investigative report and an incident report revealed two STNAs improperly transferred the resident on 09/04/12, using a two person manual lift and not the required mechanical lift. An X-ray performed immediately after the incident did not show a fractured hip, but did show a fractured left ankle "which could be old." It also showed that the left knee "has a small fracture to the left distal medial femur." The general progress note dated 09/05/12 at 2:57 P.M. also contained documentation that the facility physician saw the resident in the hospital and that he agreed that since the resident was non-ambulatory, splinting " would only cause her more problems." A CT scan performed later on 09/13/12 showed a fracture of the left supracondylar distal femur. During an interview on 09/17/12 at 4:50 P.M., the administrative director of nursing services, confirmed that Resident #1 sustained a fracture as a result of an improper transfer. This deficiency substantiates Complaint Number OH 105.