Every finding on record at O'Neill Healthcare Lakewood

Based on observation, interview, review of facility temperature monitoring logs, and facility policy, the facility failed to ensure unit refrigerators used for resident foods were maintained in a safe and sanitary manner. This had the potential to affect all residents receiving food by mouth. The facility identified one resident (#7) receiving nothing by mouth (NPO). The facility census was 88.Findings include:Observation on 08/12/26 at 3:55 P.M. with Mobile Director of Nursing (MDON) #392 of the first-floor resident refrigerator located across from the nurse's station revealed the following concerns:-an eight-ounce (oz) bottle of strawberry Neocate (a dairy free nutritional supplement) with an expiration date of 05/18/26-an eight oz bottle of vanilla Neocate with an expiration date of 05/20/26-four eight oz bottles of vanilla Neocate with an expiration date of 05/13/26-an open, undated, unlabeled package of frozen Eggo waffles with an expiration date of 01/30/26-a prepared eight oz package of macaroni and cheese with an expiration date of 03/24/26.-four unlabeled, undated single popsicles that appeared to have been thawed and refrozen Observation on 08/12/26 at 4:03 P.M. with MDON #392 of the second-floor east unit resident refrigerator revealed the following concerns:-an eight-ounce container of Land O' Lakes butter with an expiration date of 05/25/25-a 15 oz container of I Can't Believe it's not Butter with an expiration date of 04/27/24-a 16 oz bottle of Bleu Cheese Dressing with an expiration date of 04/08/26-three individually packaged breakfast sandwiches were in the door of the freezer with no label, date or expiration date on package. Ice crystals were evident on each pre-packaged sandwich and appeared to be discolored. Review of the daily resident refrigerator temperature log for August 2026 for the Two East unit revealed temperatures were not recorded on 08/02/26, 08/03/26, 08/04/26, 08/07/26, 08/08/26, and 08/09/26. During an interview on 08/12/26 at 4:15 P.M., MDON #392 confirmed night shift nurses were responsible for checking unit refrigerators, recording temperatures on the monitoring logs, and discarding outdated items. MDON #392 acknowledged the temperature monitoring log for the second floor east unit was not completed daily and confirmed both observed resident refrigerators contained items that were not labeled or dated.Review of the facility policy titled Food from Outside Sources, dated 2005, revealed all food brought in must be checked by the charge nurse or dietary professional and placed in a plastic container with a tight fitting lid. The policy recommended bringing only enough food for a single visit but did not include guidelines for labeling or dating food items, temperature monitoring frequency, or ensuring foods were maintained within safe time limits for consumption.

Based on record review, interview, and review of the facility policy, the facility failed to ensure accurate and timely weights were obtained. This affected four (Residents #3, #36, #58, and #107) of four residents reviewed for nutrition. The facility census was 88.Findings include: 1. Review of the medical record revealed Resident #58 was admitted on [DATE] with diagnoses including diabetes, malnutrition, heart disease, schizophrenia, anxiety, cancer of the cecum, and acquired absence of other parts of the digestive tract. She was alert and oriented to person, place, and time (A&O x3). Recorded weights showed Resident #58 weighed 189.4 pounds on 01/29/26 and 157.2 pounds on 07/15/26, a 17% weight loss in six months. Review of physician orders revealed on 01/28/26 to monitor weekly weights for four weeks. Review of January 2026 Treatment Administration Record (TAR) revealed weight documented on 01/29/26 as 189.4 pounds and initialed by the nurse. The February 2026 TAR documented weekly weights on 02/05/26, 02/12/26, and 02/19/26 as NA, X, and NA, respectively, each initialed by nursing staff. Review of a second physician order dated 01/28/26 directed monthly weights. Entries for 02/27/26, 03/27/26, and 04/27/26 were blank. The 05/27/26 entry documented a weight of 189.4, but this was not listed in the recorded weights tab of the electronic record. The 06/27/26 entry contained an X. Review of Resident #58's medical record revealed she was hospitalized from [DATE] to 06/30/26, 07/05/25 to 07/08/26, and 07/09/26 to 07/12/26. Review of physician orders dated 07/18/26 directed weekly weights for four weeks. July 2026 TAR documented an X on 07/22/26 and a blank entry on 07/29/26. August 2026 TAR showed 08/05/26 documented as NA and 08/12/26 documented as 156.6 pounds. Durin an interview on 08/11/26 at 2:20 P.M., Registered Dietician (RD) #520 stated she did not know why Resident #58 went so long without being weighed. She reported residents are weighed weekly for four weeks after admission and then monthly. She stated nursing aides weigh residents and nurses enter weights into the electronic medical record; any discrepancies should generate an Exception Report, which will be reviewed daily. During an interview on 08/12/26 at 1:50 P.M., Licensed Practical Nurse (LPN) #376 stated there is always a list of residents needing weekly weights and monthly weights are taken the first week of the month to allow time for reweights. She reported aides gather weights and nurses enter them into the record and report changes to the provider. Review of the facility policy ONHC Weights Protocol – Obtaining and Recording, revised 02/2026, revealed weights are to be obtained upon admission, weekly for three weeks, and monthly thereafter. The unit manager or designated nurse is responsible for ensuring accurate and timely documentation. 2. Review of the medical record revealed Resident #3 was admitted on [DATE] with diagnoses including cerebral infarction, dysphagia, stage III chronic kidney disease, and gastrostomy. Review of the nutrition assessment dated [DATE] documented an admission weight of 234.6 pounds taken by Hoyer scale and indicated a loss of 10% or more in six months. Resident #3 reported his weight was 290 pounds six months prior, and the weight loss was not planned. Review of the five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 revealed a Brief Interview of Mental Status (BIMS) of 12/5 which indicated moderate cognitive impairment. Resident #3 was noted to have had significant weight loss and not be on a weight loss regimen, have a feeding tube which provided over 51% of his nutrition and required a mechanically altered diet. Review of the physician orders for Resident #3 revealed no order for weekly weights until 07/22/26 following admission on [DATE]. Review of the medical records weights tab for Resident #3 revealed the following weights:-07/09/26 of 234.6 pounds using a Hoyer (mechanical lift)-07/29/26 of 287 pounds using a wheelchair (52.4 pounds (22.3%) gain) in 20 days-07/29/26 of 287 pounds using a wheelchair-08/05/26 of 286.8 pounds using a wheelchair Review of the July 2026 Medication Administration Record (MAR) and TAR for Resident #3 revealed no weight recorded on 07/22/26 as ordered. The next weight recorded on 07/29/26 was 287 pounds using a wheelchair. During an interview on 08/11/26 at 2:00 P.M., RD #520 confirmed weekly weights should have been obtained for four weeks after admission. She stated she was unsure of the accuracy of the admission weight and a reweight should have been completed. 3. Record review showed Resident #36 was admitted on [DATE] with diagnoses including kidney calculus, hydronephrosis, lymphedema, ovarian neoplasm, and muscle wasting. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #36 revealed a BIMS score of 11/15 indicating moderate cognitive impairment. Resident #36 was noted to be dependent on staff for toileting, bathing, dressing and transfers. Review of the physician order for Resident #36 revealed a 08/01/26 order to monitor weight every month. A physician order dated 08/01/26 instructed monthly weight monitoring.Recorded weights revealed:-07/30/26: 235.6 pounds-08/07/26: 254 pounds (18.4 pound increase; 7.8% in one week) During an interview on 08/11/26 at 2:00 P.M., RD #520 confirmed there was no order for weekly weights upon admission and stated a reweight should have been requested. 4. Review of the medical record revealed Resident #107 was admitted on [DATE] with diagnoses including left below knee amputation, type II diabetes with nephropathy, and stage V chronic kidney disease. Review of the admission assessment completed on 08/10/26 Resident #107 revealed an admission weight of 08/07/26 of 181.5 pounds with a noted gain of five percent or more in the last month and a hospital weight of 170 pounds. Weight loss was anticipated due to amputation. There was no physician order for weight monitoring.Recorded weights revealed:-08/07/26: 181.5 pounds-08/11/26: 208.4 pounds (26.9 pound gain in four days)-08/11/26 (reweight): 161.8 pounds (19.7 pound loss in four days; 46.6 pound loss same day) During an interview on 08/11/26 at 2:00 P.M., RD #520 stated weights should be monitored weekly for four weeks after admission. She was unsure how often the scale is calibrated. During an interview on 08/12/26 at 1:58 P.M. with Clinical Registered Nurse (RN) #515 confirmed the resident's weights fluctuated by 20 pounds in opposite directions and stated staff may not be consistently subtracting wheelchair or foot pedal weight. Review of the policy ONHC Weights Protocol – Obtaining and Recording, revised 02/2026, revealed weights are obtained at admission, weekly for three weeks, and monthly thereafter unless otherwise directed. Significant discrepancies (+/ 5%) require a reweight under nurse supervision. The dietitian reviews significant changes and implements appropriate interventions.

Based on record review, interviews, and facility policy review, the facility failed to honor Resident #15's preferences for showers. This affected one (Resident #15) out of eighteen sample residents. The facility census was 88.Findings include:Review of the medical record for Resident #15 revealed she was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease, morbid obesity, peripheral vascular disease, hypertensive heart disease, anxiety disorder, cellulitis of right lower limb and buttock.Review of the provider orders dated 04/21/26 revealed Resident #15 was to receive showers as scheduled, and the nurse was to sign entry to verify personal care sheet was completed. Shower days were every Monday, Thursday, and Friday on day shift.Review of Medication Administration Record/Treatment Administration Record (MAR/TAR) for July and August 2026 revealed staff signed off that Resident #15 received showers on Monday, Thursday, and Friday. Review of shower sheets from June 2026 through August 2026 confirmed Resident #15 had not received shower three times weekly per preference.During an interview on 08/10/26 at 10:15 A.M., Resident #15 stated she was only receiving one shower per week. She stated she preferred three showers a week and would occasionally receive two but not per her preference.During an interview on 08/13/26 at 12:05 P.M., the Director of Nursing (DON) confirmed the discrepancy in the documentation, and verified the provider order, preference, and shower sheets.Review of the facility policy titled, ADLs (Activities of Daily Living) Protocol, revised 01/2026, revealed residents will be provided assistance in the following areas, as requested, needed or as indicated by their plan of care; eating, bathing, toileting or incontinence care, dressing, grooming, general hygiene, oral care, transfers, ambulation, and toenail care.

Based on record review and interview, the facility failed to supervise a cognitively impaired resident while at an outside appointment. This affected one (Resident #60) of three residents reviewed for outside appointments. The total census was 91. Findings include:Record review of Resident #60 revealed he was admitted to the facility 11/29/24 and had diagnoses including prostate cancer and neuromuscular bladder. His minimum data set assessment on 12/29/25 identified him to have moderate cognitive impairment. There was no documentation of him going out to an appointment on 12/31/25. Interview with Veterans Affairs (VA) Social Worker (SW) #701 on 02/17/26 at 10:40 A.M. revealed the facility sent Resident #60 to a VA appointment on 12/31/25 with no escort. The resident had limited cognitive status and could not participate in the appointment. An attempt to interview Resident #60 on 02/18/26 at 11:36 A.M. revealed he was not interviewable. Interview with Unit Manager Licensed Practical Nurse (LPN) #202 and the Director of Nursing (DON) on 02/18/26 revealed the facility did not maintain a record of assigned escorts for past appointments. Interview with VA Registered Nurse (RN) #702 on 02/17/26 at 4:09 P.M. revealed Resident #60 came for his appointment on 12/31/26 without any escort or spokesperson. He was not able to answer any questions except his name and did not know why he was there. VA staff reached out to his family but was not able to reach them. She described it as a wasted appointment due to the lack of ability to exchange any substantial information. Interview with Unit Manager LPN #801 and the DON on 02/18/26 at 10:25 A.M. revealed the facility normally sent an escort with cognitively impaired residents and could not speak for why this was not done for Resident #60. Record review of VA documentation revealed a physician note dated 12/31/25 which identified Resident #60 as having a history of dementia. Resident #60 presented unaccompanied from the nursing home, was oriented to name only, and was not able to participate in conversation. A VA social worker note dated 01/06/26 revealed Resident #60 was sent to an appointment on 12/31/25 with no escort despite his dementia and was not able to answer questions beyond his name. Interview with the Administrator on 02/17/26 at 4:40 P.M. verified Resident #60 was sent to an appointment with limited cognition and no escort. This deficiency represents noncompliance investigated under Complaint Number 2709380.

Based on observation, record review and interview, the facility failed to notify the receiving facility when a resident with Influenza A was sent to an outside appointment or reschedule the appointment as needed appropriately. The facility also failed to use enhanced barrier precautions appropriately during wound care. This affected two (Residents #17 and #60) of three residents reviewed for infection control. The total census was 91. Findings include:1. Record review of Resident #60 revealed he was admitted to the facility 11/29/24 and had diagnoses including prostate cancer and neuromuscular bladder. His minimum data set assessment on 12/29/25 identified him to have moderate cognitive impairment. A nasal swab result dated and reported 12/28/25 tested him positive for Influenza A. Review of his orders and treatment administration record revealed him to have been on droplet precautions for influenza from 12/29/25 to 01/05/26. There was no documentation of him going out to an appointment on 12/31/25. Interview with Veterans Affairs (VA) Social Worker #701 on 02/17/26 at 10:40 A.M. revealed the facility sent Resident #60 to a VA appointment on 12/31/25 without giving notice the resident was on droplet isolation for testing positive for Influenza A. An attempt to interview Resident #60 on 02/18/26 at 11:36 A.M. revealed he was not interviewable. Interview with VA Registered Nurse (RN) #702 on 02/17/26 at 4:09 P.M. revealed Resident #60 came for his appointment on 12/31/25 with no notice that he tested positive for the flu. After the appointment, his VA doctor saw that he had the flu while checking his chart. Resident #60 attends appointments on an oncology floor and so everyone including him wore masks as part of their general policy, however it was not an urgent appointment and would have been rescheduled had the VA staff known he had the flu. She said the event presented a risk to other patients on that unit, many of whom were immunocompromised. Interview with Unit Manager Licensed Practical Nurse (LPN) #801 and the Director of Nursing on 02/18/26 at 10:25 A.M. revealed the facility sent Resident #60 to his appointment with paper orders, including that he was on isolation for influenza. It was not their process to call specific report before sending residents out to appointments. Record review of VA documentation revealed a physician note dated 12/31/25 which identified Resident #60 as having a history of dementia. Resident #60 presented unaccompanied from the nursing home, was oriented to name only, and was not able to participate in conversation. A VA social worker note dated 01/06/26 revealed Resident #60 was sent to an appointment on 12/31/25 after testing positive for the flu. Per her interview with a facility representative, the resident was to have been isolated from 12/29/25 to 01/07/26. The VA was not made aware of this until after the appointment. Record review of the facility's infection control log revealed Resident #60 was identified to have Influenza A starting on 12/28/25 and resolving on 01/03/26.Record review of the facility's undated droplet isolation policy revealed staff were to wear masks when working within three feet of an isolated resident, to limit unnecessary transport of the resident, and to have them wear surgical masks when essential transportation required them to leave the room. Interview with the Administrator on 02/17/26 at 4:40 P.M. verified Resident #60 was sent to an appointment with influenza A with no advance notice given to the receiving facility. 2. Record review of Resident #17 revealed he was admitted [DATE] and had diagnoses including prostate cancer, cerebral palsy, and stage four pressure sores. He had wound care orders in place and enhanced barrier precautions (EBP) ordered as of 01/23/26. His most recent wound assessment dated [DATE] revealed he had two stage four pressure sores which were present on admission, which improved during his stay and had no documented evidence of current infection. Observation of Resident #17's room on 02/18/26 at 10:46 A.M. revealed he had an EBP sign on his door which included specific instructions to wear a gown and gloves for high contact activities including wound care. Observation of a wound care procedure for Resident #17 on 02/18/26 at 10:46 A.M. by LPN #901 revealed she did not wear a gown at any point while removing the old dressings, cleaning the wounds, or applying the new dressings. Interview with LPN #901 on 02/18/26 at 10:56 A.M. confirmed the above findings. Record review of the facility's EBP policy dated 03/2024 revealed gowns and gloves were to be used during high contact care activities with residents under EBP, including during wound care for pressure sores. This deficiency represents noncompliance investigated under Complaint Number 2723594 and Complaint Number 2709380.

Based on interview, record review, and policy review, the facility failed to provide appropriate care for an acute change in condition for Residents #116 and #123. This affected two residents (Resident #116 and Resident #123) of four residents reviewed for death. The facility census was 106.Findings Include:1. Resident #116 was admitted to the facility on [DATE] with diagnoses including pneumonia, endocarditis (an infection of the inner lining of the heart and its valves), chronic respiratory failure, diabetes, chronic obstructive pulmonary disease (COPD), chronic kidney disease, hemiplegia and hemiparesis affecting the left nondominant side following a stroke, end stage renal disease (ESRD) dependent on renal dialysis, congestive heart failure (CHF), bipolar disease, and dependence on supplemental oxygen. The resident died on [DATE].Review of the physician's orders for Resident #116 revealed an order was written on [DATE] for the resident to be a full code as well as for continuous oxygen at four liters per nasal cannula. On [DATE] orders were written for dialysis every Monday, Wednesday, and Friday at 7:00 A.M. Night shift staff were to escort the resident to the on-site dialysis center at 6:45 A.M.Review of the comprehensive Medicare five day Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed the resident was cognitively intact, required moderate assistance with eating and was dependent on staff for all other personal care, had frequent pain, became short of breath with exertion, at rest and lying float, and required continuous oxygen, and rehabilitation therapy.Review of the nurse progress notes for Resident #116 revealed the resident was admitted to the facility on [DATE] at 6:30 P.M. The resident was on two liters of oxygen, had no indicators of distress, was not short of breath and was alert and oriented to person, place and time. Review of Registered Nurse (RN) #515's progress note dated [DATE] at 7:39 A.M. revealed CNA #401 entered the room and noted the resident did not respond to voice or touch and notified RN #515. RN #515 assessed the resident and was unable to obtain a pulse. RN #515 then went to find Licensed Practical Nurse (LPN) #507 to check the resident's vital signs and again were not able to obtain a pulse or blood pressure. RN #515 then completed three rounds of chest compressions and notified the Director of Nursing (DON) and called 911. Upon arrival of Emergency Medical Services (EMS) cardiopulmonary resuscitation was not started and contacted their medical director for time of death. The note did not indicate why the nurse stopped after three rounds of chest compressions.Review of the EMS run report dated [DATE] revealed dispatch received the facility's 911 call on [DATE] at 4:24:53 A.M. EMS was enroute to the facility at [DATE] at 4:31:28 A.M. and arrived at Resident #116's bedside at 4:35 A.M. Review of the EMS documentation revealed they were dispatched to the facility for a resident who was dead on arrival. EMS found a [AGE] year old lying in bed and the last time of a well check was by CNA #401 at 2:30 A.M. Three rounds of resuscitation efforts were started them stopped prior to EMS arrival. The resident was evaluated by EMS and found the resident to be pulseless, apneic, and cold to all peripheral extremities. Rigor mortis (the temporary stiffening of muscles after death which begins in the smaller muscles of the face and then spreads to the limbs within three hours of death) had set in at the site of the mandible. No resuscitation efforts were performed by EMS. The medical director was called and provided time of death. The resident was DOA (dead on arrival). The resident's body was left at the facility and EMS returned to service. The run report listed the Call Nature as DOA/Body Found.Review of the written statement provided by RN #515 on [DATE] revealed she was called into Resident #116's room by CNA #401. The resident was unresponsive. RN #515 called out the resident's name, performed a sternal rub (a medical procedure used to assess a patient's level of consciousness and responsiveness) and the resident remained unresponsive. RN #515 indicated she assessed the resident, palpated the carotid area and radial artery for a pulse and was unable to find them. She was unable to obtain any vital signs (blood pressure, pulse, respirations, and oxygenation level). RN #515 notified LPN #507 to assess the resident. RN #515 established the resident's code status, initiated hands only CPR, called 911, and reassessed the resident the first round of compressions. No change was found and the DON was notified. EMS arrived and performed no interventions for the resident. The physician was notified as well as the family. On [DATE] the Administrator obtained a verbal statement from CNA #401 which indicated she was assigned to care for Resident #116 on the night shift of [DATE]. CNA #401 said the resident was anxious throughout the shift. When she checked on the resident she was not breathing so she called in RN #515 and RN #515 initiated chest compressions and CNA #401 then left the room. CNA #401 did not sign her statement, only the Administrator signed it.Interview with Police Officer (PO) #531 on [DATE] at 2:59 P.M. revealed she was the one dispatched to the facility call on [DATE]. PO #531 said typically the police do not respond to EMS calls but they requested an officer's presence at the scene as the call had been for a deceased body. She said the call was a bit unusual but would not elaborate. PO #531 confirmed there was no police file from the call. Interview with RN #515 on [DATE] at 10:15 A.M. revealed she always works on the first floor skilled unit. RN #515 said when a resident is found unresponsive she calls them by name, checks for a pulse, respirations, and code status. The second nurse is called to the room to verify her findings. If the second nurse confirms her findings they start cardiopulmonary resuscitation (CPR) and call 911. RN #515 said if she was unable to find a resident's code status in the chart she would contact the physician or the transferring hospital to determine code status. If they did not have one the resident would be treated as a full code (all life saving measures are to be implemented). To obtain help from the other floor she can call a direct line they have or overhead page a code. When asked when does CPR end RN #515 said she does a first round of compressions and then reassesses the resident. She does not provide rescue breathing or have the second nurse start rescue breathing as she feels compressions are more important. RN #515 said she typically does three rounds of compressions and reassesses to consider her options. Either she or the aide will call 911. When asked where she learned the method of three rounds of compressions RN #515 said she read it in a journal somewhere. The night the resident died, CNA #401 went in to start getting the resident ready for dialysis. RN #515 said she was preparing Resident #116's 6:00 A.M.'s morning medications. CNA #401 came and told her the resident did not look good. RN #515 said she went to the resident's room to assess the resident. RN #515 said the resident was not breathing and did not have a pulse. She said she did not provide any rescue breathing as she thought compressions were more important. RN #515 said she was the one who called 911 for an unresponsive resident. EMS did not do anything for Resident #116 after their arrival. RN #515 confirmed the police arrived with the squad. RN #515 confirmed she was not providing compressions when EMS arrived as she had completed her 3 cycles of compression. After each cycle she stopped and checked for a pulse. LPN #507 did not perform rescue breathing either.Interview with LPN #507 on [DATE] at 11:12 A.M. revealed she has worked for the facility for about a year and typically works on the first floor skilled unit. LPN #507 said she does not remember Resident #116 as she was not on her hallway but does remember the code on [DATE]. RN #515 was the nurse assigned to Resident #116. LPN #507 said she was on break and sitting outside when RN #515 came to her and asked her to assess Resident #116 so they could pronounce her deceased . LPN #507 confirmed the resident had no vital signs but did not remember what time that was. The only other part she had in the code was letting EMS in when they and the police arrived. LPN #507 said she pointed EMS to the room and she then went back and finished her break. LPN #507 said the code did seem unusual to her as she did not know if the resident was a full or a Do Not Resuscitate (DNR provide no life saving interventions). She did not write a statement about the code as the only thing she did was assess for vitals in order the pronounce the resident deceased and let the squad in.Interview with the Administrator, the DON, and the Regional Director of Clinical Services (RDCS) #530 on [DATE] at 12:25 P.M. revealed the statements they received regarding Resident #116's death was different from the EMS run sheet and what the staff told them. RDCS #530 confirmed CPR and rescue breathing should have been continued until EMS arrived.Review of the American Heart Association (AHA) website CPR recommendations for healthcare providers revealed conventional CPR using chest compressions and mouth-to-mouth breathing at a ratio of 30:2 compressions-to breaths.Review of the facility's Cardiopulmonary Resuscitation (CPR) policy, last revised [DATE]), revealed the resident who is unresponsive should by checked by assessing airway, breathing, and circulation (ABCs). The airway is to be opened with the head tilt/chin lift maneuver. Check the airway by placing your ear over the resident's mouth and nose then look to see if the chest is rising and falling, listen for exhalation, and feel for exhaled air. Check for signs of breathing for no more than 10 seconds. Then check for a pulse for no more than 10 seconds. If the resident is pulseless and not breathing begin CPR. The resident should be on a firm, flat surface using a back board as needed when the resident is in bed. Perform 30 compressions at a rate of 100 per minute then give two breaths for five cycles before evaluating the resident. Once CPR is started do not discontinued unless there obvious signs of life (breathing), advanced medical help/EMS arrives, another trained rescuer takes over for you, you are presented with a valid DNR order, you are too exhausted to continue, a physician pronounces the resident dead and gives orders to discontinue CPR, or an automated external defibrillator (AED) is ready for use.Review of the facility's Death of a Resident Policy, last revised [DATE], revealed pronouncement of death may be by a licensed physician or two licensed nurses with prior authorization from a physician, in accordance with applicable state laws. Documentation must be recorded in the clinical record including date and time of death, name and title of the individual pronouncing the resident deceased , and any pertinent clinical observations.2. Resident #123 was admitted to the facility on [DATE] with diagnoses including CHF, COPD, chronic respiratory failure, cirrhosis of the liver, ESRD dependent on renal dialysis, dependence on supplemental oxygen, heart disease, presence of an automatic implantable defibrillator, and atrial fibrillation. Resident #123 died on [DATE].Review of the physician's orders for Resident #123 revealed orders dated [DATE] for a full code (life saving measures are to be performed); hemodialysis every Monday, Wednesday, and Friday; and oxygen at four liters per minute via nasal cannula continuous.Review of the quarterly comprehensive MDS 3.0 assessment, dated [DATE], revealed Resident #123 was cognitively intact. She needed staff assistance to set her up for eating, oral hygiene, toileting, and personal hygiene. She required supervision for showers. The resident was short of breath lying flat, and did not have a life expectancy of less than six months. The resident received oxygen, dialysis, and participated in rehabilitative therapy.Review of Resident #123's nurses' notes revealed on [DATE] at 2:08 A.M. LPN #509 was notified by the resident she had received a call from the hospital she was transferred to the facility from advising her that they had a bed for her available so they could investigate an abnormal electrocardiogram (EKG) she had had while she was in the hospital. LPN updated the on-call nurse practitioner, arranged for transportation and the resident was transferred to the hospital at 2:10 A.M. The resident was readmitted to the facility on [DATE]. On [DATE] at 8:48 A.M. RN #460 documented Resident #123 was in pain and complained of back pain and was given an as needed order for Tramadol (a controlled medication for pain). The resident remained on her ordered oxygen of four liters oxygen per nasal cannula and had shortness of breath with exertion. Review of RN #460's documentation revealed at 12:32 P.M. CNA #409 noted Resident #123 was not breathing and notified RN #460. RN #460 assessed the resident and was not able to palpate a pulse, the resident was not breathing, and did not respond to a sternal rub. The resident had a code status of full code. An overhead page was made alerting staff to a Code Blue (an alert to staff a resident who was a full code was unresponsive and life saving measures were needed). RN #460 documented CPR was initiated, 911 was called, EMS services took over the code but were unable to revive her. EMS contacted their medical director who made the pronouncement of death. EMS left the resident's body with the facility and all notifications were made. Post-mortem care was provided by the facility.Review of the EMS run report for Resident #123, dated [DATE] revealed a call was received from the facility at 12:33:19 P.M. EMS was notified at 12:33:33 P.M. and was enroute to the facility at 12:35:33 P.M. EMS arrived at the resident's bedside at 12:39 P.M. The EMS narrative revealed they found Resident #123 in her bed and unresponsive with nurses performing CPR and had applied an AED to the resident's chest. Nursing stated the last known normal time for the resident was five minutes prior to finding her unresponsive. The resident's nurse said the resident had just been discharged from the hospital for a cardiac issue. EMS took over CPR and care of the resident. Resident #123's pupils were fixed and dilated. EMS provided ventilation through use of a Bag-Valve-Mask device (a life-saving resuscitation device that manually delivers oxygen to a patient's lungs when they cannot breathe adequately on their own which is also called an Ambu bag) and oxygen. EMS gave the resident Advanced Cardiac Life Support (an advanced medical protocol and certification for healthcare professionals to manage cardiopulmonary emergencies, building on Basic Life Support skills) and continued CPR. The resident did not respond to treatment. EMS contacted the medical director and time of death was 1:00 P.M. EMS left the resident for post-mortem care and left the facility.Review of the witness statements for Resident #123's code revealed statements were obtained from CNA #409, LPN #425, and LPN #467. CNA #409's statement was dated [DATE] revealed she was assigned to Resident #123 on day shift of [DATE]. She revealed she took Resident #123's tray in she noticed the resident was curled up with her back to her. CNA #409 called the resident's name but she did not respond. She walked over to the resident and touched her but the resident was unresponsive. CNA #409 immediately went to get the resident's nurse. RN #460 came to the room and told CNA #409 to call a code. CNA #409 left the room and called a code.LPN #425's witness statement was dated [DATE]. LPN #425 stated the code was called for Resident #123. LPN #425 brought the crash cart to the room. Upon entering the resident's room he saw another nurse providing chest compressions and the AED was being applied. After several minutes EMS arrived at the bedside.LPN # 467's witness statement was undated. LPN #467 heard a Code Blue called over the overhead page system and she went to Resident #123's room. As she rounded the corner to the east hallway where the resident resided an unnamed nurse told her to call 911 and give information to the operator. After doing that LPN #467 went to the resident's room to assist with compressions. LPN #467 was directed to get the resident's paperwork together for EMS and did so. Compressions continued, EMS arrived and took over from the staff.Interview with RDCS #530 on [DATE] at 4:50 P.M. revealed the night shift staff are responsible for keeping the crash carts fully stocked. This stopped on [DATE] when they changed it to the current system of attaching a disposable lock that has a code on it and if the code matches what is on the audit sheet then the crash cart remains fully stocked. If the numbers do not match then they have to restock it, put a new lock on the cart, and document it on the audit sheet. RDCS #530 provided a copy of the old crash carts audits from August and [DATE]. Review of the audits indicated the crash cart on the second floor was fully stocked on [DATE] when Resident #123 coded.Interview with LPN #425 on [DATE] at 2:30 P.M. revealed when the code was called for Resident #123 he took the crash cart down to the resident's room and then went back to his unit. LPN #425 said he did not participate in the code. Interview with LPN #512 on [DATE] at 2:41 P.M. revealed she had been a nurse since [DATE] and has worked for the facility since [DATE]. She works in both the nursing home and the assisted living. LPN #512 said she was working in the Assisted Living the day Resident #123 coded. When she heard the overhead page for Resident #123 coding she ran out of the Assisted Living, ran around the building and into the nursing home. LPN #512 said when she arrived at the resident's room LPN #484 was performing compressions on Resident #123. LPN #512 said LPN #425 had originally started compressions but LPN #484 took over as LPN #425 was performing compressions over the resident's left breast and not over the sternum. LPN #425 offered to take over compressions but LPN #484 declined as he performed them incorrectly. LPN #512 kept asking for the Ambu bag in order to provide oxygen to the resident but there was not one on the crash cart. LPN # 512 said LPN #467 went to find an Ambu bag without success. LPN #512 said she took over compressions from LPN #484. LPN #425 again offered to take over compressions and she, LPN #484, and CNA #505 all told him no as he had provided compressions to the wrong area. LPN #512 said CNA #505 is certified in CPR so she assisted with compressions. LPN #512 said she told Regional Registered Nurse (RRN) #532 about her concerns with the code.Interview with LPN #467 on [DATE] at 3:04 P.M. revealed she had worked for the facility for three years and has been a nurse for five years. She said she typically works on the second floor on the second floor on day shift. LPN #467 said she heard the overhead page for a code but was unable to hear the room where it was located. She left the room she was in and saw RN #460 who told her to call 911 and give report to them as well as to get the paperwork together for EMS. Once she completed her task she went to Resident #123's room where staff were performing CPR. LPN #425 and LPN #484 were doing compressions and RN #460 was setting up the AED. LPN #512 was also in the room. CPR was continued until EMS arrived and took over. LPN #467 said EMS put the compression device on the resident. Eventually EMS contacted their medical director and pronounced the resident dead. EMS did not transport the resident to the ER. LPN #467 said RN #460 notified the family and post-mortem care was provided. LPN #467 said she was unable to see who was providing care but heard LPN #512 tell LPN #425 she was taking over CPR but was unsure why. LPN #467 said the night shift staff were responsible for stocking the crash cart. There was not an Ambu bag on the cart but there was an oxygen cannister. She looked for an Ambu bag to provide ventilation to Resident #123 but was unable to locate one.Interview with CNA #505 on [DATE] at 3:23 P.M. revealed she had worked for the facility for a little over a year but has been an aide for about 20 years. CNA #505 confirmed she was CPR certified. She responded to the coded and helped LPN #425 with bringing the crash cart to the room and placing the back board under the resident. When they arrived LPN #484 was providing compressions. CNA #505 said she took over compressions from LPN #484. When LPN #425 was doing compressions she noticed he was not performing them correctly. He was compressing the left breast but not over the breast bone. CNA #505 said she, LPN #512, and LPN #484 all told LPN #425 he was performing compressions incorrectly so the three of them took over all compressions. CNA #505 did tell the Administrator about her concerns with the code.Interview with LPN #484 on [DATE] at 3:37 P.M. revealed she works on the first floor skilled unit. When she heard the overhead page for a code she got the AED off the crash cart and took it upstairs. The crash cart had just arrived when she got there so she assisted rolling Resident #123 over so the backboard could be placed under her and then started compressions. When LPN #512 arrived she took over compressions from her. LPN #484 confirmed there was not an Ambu bag on the cart so there was no one providing ventilations to the resident. LPN #484 confirmed there were issues with the CPR provided to the resident. LPN #425 was initially doing compressions but not in the correct area. LPN #484 told him he was doing compressions incorrectly as did LPN #512 and CNA #505. LPN #425 eventually moved to the correct position over the sternum after so many people told him he was performing it incorrectly. The AED kept saying no shock advised. EMS arrived and took over care of Resident #123 and eventually pronounced the resident dead. LPN # 484 said she did not tell anyone what occurred and she was not asked for a statement regarding the code.Interview with the Administrator, the DON, and RDCS #530 on [DATE] at 4:50 P.M. revealed they were unaware three staff members had told LPN #425 he was performing chest compressions incorrectly. RDCS #530 said there were some personality conflicts among staff and she thinks that is where the statements were coming from. RDCS #530 said she spoke with RN #460 who was Resident #123's nurse on [DATE] and she voiced no concerns regarding the code. They did not ask RN #460 for a written statement as her documentation in the nurses' notes was her statement. RDCS #530 said they were not aware an Ambu bag was not on the crash cart. RDCS #530 said they did recently change the crash cart checks to adding a lock to the cart with a number on it and as long as the number on the lock matches the audit sheet then the cart is fully stocked.Interview with RN #460 on [DATE] at 10:46 A.M. revealed she last saw the resident a few minutes before CNA #409 notified her she had found Resident #123 unresponsive. When CNA #409 told her the resident was unresponsive she went to the resident's room and assessed her. After assessing her she told CNA #409 to overhead page a code. RN #460 said there was a good response from the staff. LPN #425 and LPN #512 started compressions and she had LPN #467 gather the paperwork and call 911. RN #460 said she had somebody hold the elevator door open on the first floor for when the squad arrived. The first floor nurse, LPN #484 brought the AED up with her and also assisted with compressions. RN #460 had the staff stop compressions so she could place the AED on the resident which advised no shock then CPR was resumed. RN #460 did not remember if she checked the oxygenation level for Resident #123. RN #460 said the resident was on continuous oxygen at four liters per minute per nasal cannula. RN #460 said the AED would sometimes state compression were not deep enough and staff would adjust and correct it. RN #460 said she did not remember if CNA #505 provided compressions for Resident #123. She denied noticing any problems with the code. RN #460 said she felt the code went well and the staff involved were great. RN #460 confirmed no ventilation was provided during the code, just compressions. RN #460 confirmed there was not an Ambu bag on the crash cart. When EMS arrived they took over the code from the facility staff. When EMS received no response from the resident they contacted their medical director who pronounced the resident dead. EMS said they would not be taking the body as the police had to inspect the scene.Review of the facility's crash cart supply list prior to changing to the lock system revealed the crash cart should contain an ambubag. Review of the American Heart Association (AHA) website CPR recommendations for healthcare providers revealed conventional CPR using chest compressions and mouth-to-mouth breathing at a ratio of 30:2 compressions-to breaths.Review of the facility's Cardiopulmonary Resuscitation (CPR) policy, last revised [DATE]), revealed the resident who is unresponsive should by checked by assessing airway, breathing, and circulation (ABCs). The airway is to be opened with the head tilt/chin lift maneuver. Check the airway by placing your ear over the resident's mouth and nose then look to see if the chest is rising and falling, listen for exhalation, and feel for exhaled air. Check for signs of breathing for no more than 10 seconds. Then check for a pulse for no more than 10 seconds. If the resident is pulseless and not breathing begin CPR. The resident should be on a firm, flat surface using a back board as needed when the resident is in bed. Perform 30 compressions at a rate of 100 per minute then give two breaths for five cycles before evaluating the resident. Once CPR is started do not discontinued unless there obvious signs of life (breathing), advanced medical help/EMS arrives, another trained rescuer takes over for you, you are presented with a valid DNR order, you are too exhausted to continue, a physician pronounces the resident dead and gives orders to discontinue CPR, or an automated external defibrillator (AED) is ready for use.This deficiency represents noncompliance investigated under Complaint Number 2621899.

Based on observation, record review, and interview, the facility failed to ensure Resident #87 received appropriate incontinence care. This affected one resident (Resident #87) of three residents reviewed for incontinence care. The total census was 105.Findings include: Record review of Resident #87 revealed she was admitted to the facility 06/05/20 and had diagnoses including dementia, diabetes, and encounter for palliative care. Review of the minimum data set 3.0 assessment dated [DATE] revealed she had significant cognitive impairment, was always incontinent, had no listed allergies and no orders or care plan indicating specific alterations to common incontinence care practices. Observation of an incontinence care procedure for Resident #87 on 08/25/25 at 8:43 A.M. by Certified Nurse Aide (CNA) #501 revealed CNA #501 prepared for the procedure by wetting half of two towels with water. She wiped the resident’s front perineal area twice with one wetted towel, used the dry half of the same towel to dry it, then repeated the process on the resident’s backside. No soap or other peri-care area approved cleaning product was used during the process. Interview with CNA #501 on 08/25/25 at 8:56 A.M. confirmed the above observations. She said she believed Resident #87 had allergies and could not use soap. The surveyor brought up the resident’s chart on their laptop at this time and confirmed with CNA #501 the resident had no listed allergies and no orders against using soap for incontinence care. Record review of the facility’s incontinence care policy dated 01/2024 revealed staff were to give appropriate care after each incontinence episode, including washing affected areas with body wash, cleanser, or soap and water. This deficiency represents noncompliance investigated under Complaint Number 2577547.

Based on family and staff interviews, review of facility policy, and record review, the facility failed to ensure a resident's advance directives were concise and readily retrievable for staff. This affected one (Resident #100) of three residents reviewed for advance directives. The facility census was 97. Findings include: Review of the medical record for Resident #100 revealed an admitted [DATE]. Diagnoses included complication of kidney transplant, end stage kidney disease, and diabetes mellitus. Resident #100 died en route to the hospital on [DATE]. Review of the hospital paperwork revealed Resident #100 was to be Full code status on [DATE]. Review of Resident #100's advance directive form revealed DNRCCA was selected on the form and the physician signed it but did not date it. The form had a sticker on it indicating it was from the hospital. Review of the physician orders for [DATE] revealed Resident #100 was a Do Not Resuscitate Comfort Care- Arrest (DNRCCA) code status (meaning invasive or extreme life-supporting measures were allowed under any circumstance except for cardiac or respiratory arrest). An interview on [DATE] at 10:08 A.M. with Corporate Registered Nurse (CRN) #202 verified Resident #100's DNRCCA was signed by a doctor but not dated. CRN #202 confirmed the hospital discharge paperwork stated Resident #100 was a Full code and also had a undated DNRCCA signed form. An interview with the Resident #100's sister on [DATE] at 10:57 A.M. revealed Resident #100's code status was DNRCCA. Review of the facility policy titled Cardiopulmonary Resuscitation (CPR) dated ,d+[DATE] revealed it required a specific individual to check the resident's chart for DNRCC/DNRCC Arrest or full code status. This deficiency represents non-compliance investigated under Complaint Number OH00164259.

Based on observations, record review, and interview the facility failed to ensure Resident #9 had her blood drawn in a private area to maintain infection control. The affected one resident (#9) of three residents reviewed for resident rights. The facility census was 95. Findings include: Review of the medical record for Resident #9 revealed an admitted [DATE]. Diagnoses included Parkinsonism, low back pain, cognitive communication disorder, and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had moderate cognitive impairment. Residents required supervision set-up help only for bed mobility; total dependence of two-persons for transfers; and extensive one-person assistance for eating and toilet use. Review of the physician's order dated 04/15/24 revealed Resident #9 was to have a complete blood count (CBC) and basic metabolic panel (BMP) drawn every Monday for routine labs. Review of the care plan dated 05/22/24 revealed Resident #9 had impaired cognitive function with impaired thought process. Interventions included encouraging resident and family involvement and keep the resident's routine consistent and try to provide consistent caregivers. Observation on 05/28/24 at 9:40 A.M. revealed Phlebotomist #621 drawing blood from Resident #9 in the hallway in front of the nurse's station. During the blood draw Registered Nurse (RN) #563 came out of a resident's room and looked at Phlebotomist #621 and stated, What are you doing? Do you need me to help you get her to her room? Phlebotomist #621 stated you told me I could draw her blood here. RN #563 stated, no, you asked where Resident #9 was, and I simply helped you identify her. Phlebotomist #621 then finished drawing Resident #9's blood and entered another resident room. Interview after the observation with Phlebotomist #621 confirmed she did draw Resident #9's blood in the hallway. Interview on 05/28/24 at 9:45 A.M. with Resident #9 confirmed she just had her blood drawn in the hallway, but she was not sure why. Interview on 05/28/24 at 9:47 A.M. with RN #563 confirmed blood was never to be drawn outside of a resident's room. She reported she helped the phlebotomist identify Resident #9 but never told her to draw her blood right there in the hallway. This deficiency was an incidental finding identified during the complaint investigation.

Based on record review, interview, and facility policy review the facility failed to complete an accurate admission assessment for Resident #97. This affected one resident (#97) of three residents reviewed for admission assessments. The facility census was 95. Findings include: Review of the closed medical record for Resident #97 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included unspecified open wound of the abdominal wall, chronic obstructive pulmonary disorder, type two diabetes mellitus, and hypertensive chronic kidney disease with stage five end stage renal disease. Review of the admission assessment dated [DATE] for Resident #97 revealed no documentation related to Resident #97's abdominal wound. The assessment also listed absent bilateral pedal and radial pulses. Resident #97 was listed as having a colostomy with no assessment of the colostomy site. Resident #97 was listed as complaining of pain in his buttocks/coccyx area, but no skin assessment was completed. No height or weight was obtained or documented. Review of the interim care plan dated 01/12/24 revealed Resident #97 was at risk for falls and Resident #97 was at risk for skin impairment. No other information was available. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #97 was not assessed for cognition. Resident #97 required extensive two-person assistance for bed mobility, extensive one-person assistance for eating, and total dependence of one-person for toileting. Resident #97 was always incontinent of urine and had an ostomy for bowel elimination. Interview on 05/28/24 at 2:03 P.M. with Corporate Registered Nurse (RN) #623 confirmed Resident #97's admission assessments were not complete or accurate. She reported that the nurse who completed the assessment was no longer employed by the facility. Review of the undated facility policy, Admitting the Resident, revealed all resident assessment data observed during the observation should be documented. Also, the resident's height and weight should be documented. This deficiency represents noncompliance investigated under Complaint Number OH00153495.

Based on record review, interview, and facility policy review the facility failed to provide a diet order or baseline height and weight for Resident #97 during his stay at the facility. This affected one resident (#97) of three residents reviewed for nutrition. The facility census was 95. Findings include: Review of the closed medical record for Resident #97 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included unspecified open wound of the abdominal wall, chronic obstructive pulmonary disorder, type two diabetes mellitus, hypertensive chronic kidney disease in stage five end stage renal disease. Review of the discharge paperwork from the hospital for Resident #97 dated 01/12/24 revealed no diet order. Review of the physician's orders for January 2024 for Resident #97 revealed no orders for a diet. Review of the admission assessment dated [DATE] for Resident #97 revealed no height or weight. Review of the interim care plan dated 01/12/24 for Resident #97 revealed nothing related to diet. Review of the dietary communication form dated 01/12/24 for Resident #97 revealed he was a new admission. His diet order was listed as regular, with regular texture, and thin liquids. Resident #97 was allowed supplements with ordered meals if he ate less than 50% of his meal. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #97 required extensive one-person assistance for eating. Interview on 05/28/24 at 3:00 P.M. with the Administrator and Corporate Registered Nurse (RN) #623 confirmed that Resident #97 had no official diet order during his stay from a physician or a dietician. They also confirmed no height or weight was obtained on his admission. Corporate RN #623 confirmed the nurse who authored the dietary communication form with no physician order was no longer employed by the facility. Interview on 05/29/24 at 9:30 A.M. with Dietary Manager #531 reported that when a resident was admitted , a dietary communication form was completed by the nurse. Then the resident is assessed by the dietician and the speech therapist, and a final dietary order was obtained and placed into the electronic medical record system. Review of the undated facility policy, Diet Changes and Reports, revealed the charge nurse is responsible for notifying the dietary manager on duty of any changes in the resident's diet or meal service. The charge nurse will notify the dietary manager on duty when a new resident has been admitted and the type of diet the resident is to receive. Notification of the dietary manager will be through hand-written communication. Oral communication is permitted. However, all oral communication must be followed up with written communication. This deficiency represents noncompliance investigated under Complaint Number OH00153495.

Based on record review, interview, and facility policy review the facility failed to provide wound physician follow-up for a complicated abdominal wall wound for Resident #97 as ordered on admission. This affected one resident (#97) of three residents reviewed for physician services. The facility census was 95. Findings include: Review of the closed medical record for Resident #97 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included unspecified open wound of the abdominal wall, chronic obstructive pulmonary disorder, type two diabetes mellitus, and hypertensive chronic kidney disease in stage five end stage renal disease. Review of the hospital paperwork for Resident #97 revealed he was evaluated on 01/04/24 by a surgeon stating the reason for consultation was evaluation and management of infected abdominal wall surgical site ulcer. Resident #97 was at the hospital from 11/24/23 to 12/13/23 where he was found to have a large bowel obstruction and he underwent an exploratory laparotomy with loop transverse colostomy. He was discharged to an extended care facility and then returned on 12/16/23 with shortness of breath. He was in the hospital until 12/20/23 and was discharged with a wound vac to his abdominal wall surgical site. He was being managed with the wound vac at the extended care facility when the staff sent him in for foul smelling drainage from the site on 01/03/24. The site was found to be infected, and he was treated with antibiotics and the wound vac was discontinued. He was discharged to the facility on [DATE]. His discharge orders included oral antibiotics and no incision care orders. No follow-up appointments were made. Review of the admission assessment dated [DATE] revealed Resident #97 had no wound issues. Review of a separate skin assessment dated [DATE] revealed Resident #97 had an abdominal surgical incision that was to be assessed by the wound care team. No measurements were available, and it was listed as all granulation tissue, base was beefy red, it had moderate serosanguineous drainage with no odor, and the surrounding skin was normal. Review of the interim care plan dated 01/12/24 for Resident #97 revealed he was at risk for impaired skin integrity. Interventions included elevating heels when in bed and providing wound care per physician order. Review of the physician's orders revealed an order dated 01/13/24 Resident #97 was to be assessed by the wound care physician on 01/15/24. The order was cancelled on 01/16/24 with no reason for cancellation. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #97 required extensive two-person assistance for bed mobility, extensive one-person assistance for eating, and total dependence of one-person for toilet use. Resident #97 was always continent of urine and had an ostomy for bowel elimination. Interview on 05/28/24 at 3:00 P.M. with the Administrator and Corporate Registered Nurse (RN) #623 reported that Resident #97 was admitted late on a Friday night and his discharge instructions did not even list a surgeon or a follow-up appointment. They reported his order for his abdominal wound to be evaluated by the wound care team on 01/15/24 was discontinued because he was being discharged . The confirmed Resident #97 was not discharged from the facility until 01/16/24. Review of the undated facility policy, Pressure Ulcer Prevention Treatment Protocol, revealed in the event a resident is admitted with, or develops a wound interventions for wound care will be implemented per the wound care protocol and or physician orders. Referrals may be made, as needed, to the wound care specialist or therapy to aid in the treatment and healing of the wound. This deficiency represents noncompliance investigated under Complaint Number OH00153495.

Based on interview, record review, review of the facility policy the facility failed to provide Resident #98's representative proper training and education on insulin administration to ensure a safe and orderly discharge. This affected one resident (Resident #98) out of three residents reviewed for discharge planning. The facility census was 96. Findings include: Review of Resident #98's medical record revealed an admitted [DATE] and diagnoses included acute kidney failure, pancreas and kidney transplant, and type one diabetes mellitus. Resident #98 was discharged AMA (against medical advice) from the facility on [DATE]. Review of Resident #98's Fall Risk Calculation dated [DATE] revealed Resident #98 was a moderate fall risk. Review of Resident #98's care plan dated [DATE] included Resident #98 was at risk for altered nutrition, hydration status related to kidney transplant, pancreas transplant, diabetes mellitus, and dementia. Resident #98 would be free from signs and symptoms of dehydration through the next review. Interventions included administer medications as prescribed. Review of Resident #98's 5-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #98 had moderate cognitive impairment. Resident #98 had no impairment of the upper extremities, had impairment on both sides of the lower extremities, and used a walker. Resident #98 was dependent on staff for toileting, dressing and required substantial, maximal assistance for bathing. Resident #98 had an indwelling catheter and was frequently incontinent of bowel. Review of Resident #98's physician orders dated [DATE] at 7:30 A.M. revealed Insulin Lispro (one unit dial) subcutaneous solution pen-injector 100 units per milliliter, inject as per sliding scale for blood sugar, 0 to 150 give 0 units insulin, 151 to 200 give 2 units insulin, 201 to 250 give 4 units insulin, 251 to 300 give 6 units insulin, 301 to 350 give 8 units insulin, 351 to 400 give 10 units and if greater than 400 give 10 units and notify provider, subcutaneously before meals for diabetes mellitus AND inject 3 units subcutaneously before meals for diabetes mellitus. Review of Resident #98's physician orders dated [DATE] through [DATE] did not reveal orders Resident #98 left the facility AMA or orders for Resident #98's Lispro insulin pen-injector 100 units per milliliter to be sent home with him and instructions for use. Review of Resident #98's progress notes dated [DATE] at 6:05 P.M. included Resident #98 was witnessed pushing the door open and walked outside the facility with the use of a walker and was not wearing shoes or a coat. LPN #503 stayed with Resident #98 while he was outside the facility. Resident #98's family was called and able to convince Resident #98 to return to the facility, and Resident #98 walked inside. Review of Resident #98's progress notes dated [DATE] at 6:52 P.M. included Resident #98 was safely inside the facility and Nurse Practitioner (NP) #603 was called and orders to give Haldol revealed Resident #98 was refusing medications. NP #603 gave orders to send Resident #98 to the local hospital for evaluation and a psych consult. The Administrator and Director of Nursing (DON) were made aware of the situation. The DON requested to speak with Resident #98's family to assist with transportation and care at the local hospital Emergency Department. FM #602 arrived and was notified Resident #98 was to be sent to the local hospital for evaluation related to combative aggressive behaviors with exit seeking. FM #602 proceeded to walk to Resident #98's room and soon after pushed Resident #98 to the front door in a wheelchair with his belongings. Education given on AMA and Resident #98 signed the AMA paperwork with FM #602 present. The Administrator, DON and NP #603 were notified. Review of Resident #98's Medication Administration Record (MAR) dated [DATE] revealed Resident #98's Insulin Lispro (one unit dial) subcutaneous solution pen-injector 100 units per milliliter (ml) due at 5:00 P.M. was not administered as ordered due to Resident #98 was out of the facility. Interview on [DATE] at 12:01 P.M. of Family member (FM) #601 revealed nothing good happened while Resident #98 resided at the facility. FM #601 stated Licensed Practical Nurse (LPN) #503 gave FM #602 Resident #98's insulin pen when the family was taking Resident #98 out of the facility AMA (against medical advice) on Christmas Eve ([DATE]). FM #601 stated FM #602 was told by LPN #503 she was unable to show her how to use the insulin pen. FM #601 indicated she had a conversation with the Administrator and the Administrator told her LPN #503 could not show the family how to use the insulin pen because of laws. FM #601 stated Resident #98 had an insulin pump which stopped working when he was sent to the hospital before he was admitted to the facility, and he was receiving insulin per sliding scale (based on blood sugar levels). Interview on [DATE] at 2:30 P.M. of the Director of Nursing (DON) revealed Resident #98 was verbally aggressive at times and FM #601 and #602 helped calm him down. The DON stated on [DATE] Resident #98 was combative, trying to hit the nurse with a cane or walker, was in and out of other resident rooms and NP #603 was contacted for orders. The DON indicated NP #603 gave orders for Resident #98 to be sent out to the local hospital to be evaluated if he did not calm down. The DON stated LPN #503 called her on [DATE] for guidance because Resident #98 was aggressive and unable to be redirected. The DON revealed LPN #503 saw Resident #98 walk out the front door, immediately followed him and stayed with him while she tried to redirect him back into the facility. LPN #503 was unable to redirect Resident #98 back into the facility, and while keeping him in sight at all times ran back to her medication cart to get her cell phone so she could call the family for assistance. FM #602 arrived to the facility and was able to bring Resident #98 back inside the facility, but FM #602 was irritated, started packing Resident #98's belongings, put Resident #98 in a wheelchair with his belongings and went out the front door. The DON stated LPN #503 asked FM #602 if Resident #98 should go to the hospital to be evaluated and FM #602 stated she was signing him out AMA. The DON stated the facility did their best to have something set up if a resident left AMA and NP #603 was notified. The DON stated we would print out a med list and LPN #503 gave a med list to the family and she gave Resident #98's insulin pen to the family because medications could not be returned to the pharmacy. Interview on [DATE] at 1:25 P.M. of LPN #503 revealed Resident #98 was forgetful at times. LPN #503 stated on [DATE] Resident #98 using a walker came out of his room around dinnertime, was not very steady and became belligerent if staff attempted to steady him or assist in any way. LPN #503 indicated staff stayed close to Resident #98 because they were worried he was going to fall. LPN #503 indicated Resident #98 went in a resident room and started yelling at him, left that room and went in a female resident room and started walking towards her and LPN #503, trying to keep both residents safe stood between Resident #98 and the female resident. LPN #503 stated Resident #98 hit her on her arms and legs before he was redirected out of the room. LPN #503 revealed she called FM #601 and FM #601 was able to calm Resident #98 down. LPN #503 indicated NP #603 was called and an order for Haldol (antipsychotic) was obtained and FM #601 was able to talk Resident #98 into taking it. LPN #503 stated on [DATE] Resident #98 was confused and at dinnertime she prepared to check his blood sugar, he was not in his room, she went looking for him and saw him pushing the door open and attempting to exit the facility via the front entrance. LPN #503 indicated she tried talking Resident #98 into coming back inside the facility, he did not have shoes or a jacket on, but was unable to redirect him back. LPN #503 stated keeping Resident #98 in sight she ran to her medication cart to get her cell phone, then ran back to Resident #98. LPN #503 revealed she called FM #601 while she was outside the door to the facility with Resident #98 and FM #601 was able to talk Resident #98 into going back inside and once inside he sat in a chair by the front door. LPN #503 stated she called the Administrator, the DON and NP #603 and NP #603 suggested sending Resident #98 to the local hospital for a psychiatric evaluation. LPN #503 indicated the DON said to wait until the family arrived to make the situation less traumatic for Resident #98. LPN #503 stated when FM #602 arrived she said she was taking Resident #98 out of the facility AMA and LPN #503 had AMA paperwork signed. LPN #503 stated she had FM #602 give Resident #98 his blood pressure medication, and she gave her Resident #98's insulin pen because he was a type one diabetic and she thought he needed it. LPN #503 indicated she did not remember FM #602 asking for Resident #98's medication list, but if they had she would have given it to them. Interview on [DATE] at 2:01 P.M. of FM #602 revealed on [DATE] when she arrived and took Resident #98 out of the facility AMA, she asked LPN #503 about his medications and LPN #603 said she could not legally tell her anything about the medications. FM #602 indicated LPN #503 told her to make sure Resident #98 received his medications, but she would not tell her how to give the insulin. FM #602 stated she did not know how to use the insulin pen, Resident #98 had always managed his own insulin until now and if Resident #98 was given the insulin he might have died . Interview on [DATE] at 2:17 P.M. of the DON revealed Resident #98 was on insulin previous to his admission to the facility and should have his pen. The DON stated FM #602 was told to call the family physician with any questions and FM #602 was in such a hurry to leave she might not have fully understood everything. Interview on [DATE] at 3:31 P.M. of LPN #503 revealed she gave FM #602 Resident #98's Lispro insulin pen-injector, and did not send written instructions with Resident #98 explaining how to use the pen-injector. LPN #503 stated she did not call Resident #98's physician or nurse practitioner to get an order to send the pen-injector with Resident #98 when he left. LPN #503 revealed she called NP #603 after Resident #98 left the facility and told her she sent Resident #98's Lispro insulin pen-injector with him when he left and NP #603 said ok. LPN #503 stated she told FM #602 Resident #98's insulin was based on what he eats, to follow up with Resident #98's primary care physician, and the family did not tell her they did not know how to use the insulin pen. Review of the facility policy titled Discharge Against Medical Advice Policy dated ,d+[DATE] included it was the policy of the facility to assist the resident to discharge in the safest manner possible when the discharge was not recommended by the facility or the resident's physician. Orders would be requested for Home Health services and equipment needs deemed appropriate, to facilitate a safer situation in the home environment. This deficiency represents non-compliance investigated under Master Complaint Number OH00149727 and Complaint Number OH00149724.

Based on observation, interview, record review, and review of the facility policy the facility failed to transfer Resident #30 with the use of a gait belt (a belt used to prevent falls during transfers). This affected one resident (#30) of three residents reviewed for transfers. The facility census was 93. Findings include: Record review for Resident #30 revealed an admitted [DATE]. Diagnosis included heart failure, chronic pain, osteoarthritis (OA) right shoulder and knee, age related osteoporosis, difficulty in walking, muscle wasting and atrophy, and history of falls. Record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 did not have any communication issues and was cognitively intact. No behaviors or rejection of care was noted. She required extensive assistance from one staff for transfers. She required limited assistance from one staff for ambulation in her room. Balance issues were noted requiring staff assistance to stabilize. She had no falls since her prior assessment. Record review of the fall risk care plan revised 03/02/23 included the intervention dated 05/17/23, for the use of a gait belt for all ambulation and transfers. Impaired mobility care plan revised 03/02/23 also included the use of a gait belt for all transfers and ambulation. That intervention had been in place since 12/01/22. Observation on 09/28/23 at 10:17 A.M. revealed State tested Nursing Assistant (STNA) #465 transferred Resident #30 from the toilet to a standing position at the grab bar, completed dressing Resident #30 while she was standing, then transferred Resident #30 to her wheelchair. STNA #465 did not use a gait belt while assisting and transferring Resident #30. STNA #465 confirmed she did not have a gait belt with her and did not use one while transferring Resident #30. STNA #465 confirmed she was supposed to use a gait belt on Resident #30 during transfers and revealed her gait belt was in her personal bag somewhere else in the facility. Interview on 09/28/23 at 10:30 A.M. with Resident #30 revealed some STNA's wore gait belts while transferring her and some did not. Interview on 09/28/23 at 1:45 P.M. with the Director of Nursing (DON) revealed all nursing staff were given a gait belt upon hire and needed to use the gait belt on any resident anytime they need to physically lift up on a resident to assist them to stand. Record review of the facility policy titled, Nursing Transfer and Gait Belt Policy dated March 2013 revealed: Purpose: To ensure the safety of residents during transfers. The resident's transfer ability, including the number of assistants required will be communicated to staff through care plans or use of a care plan Kardex. Staff will use gait belts to transfer any resident who requires hands-on assistance. This deficiency represents non-compliance investigated under Complaint Number OH00146146.

Based on observation, staff interview, and policy review the facility failed to ensure food was labeled, dated, and stored appropriately. This had the potential to affect 91 of 91 residents who received meals from the facility kitchen. The facility identified five residents (#52, #70, #86, #87 and #202) who received no food by mouth. The facility census was 96. Findings include: The following concerns were noted during the main initial kitchen tour conducted on 08/28/23 between 8:16 A.M. and 8:42 A.M. One bag of breadcrumbs, one bag of coconut flakes, and one bag of corn flakes were open to air and not properly sealed were located in the walk-in dry storage area, one bag of sugar cookies and one bag of chocolate chip cookies were open to air and undated located in the reach-in freezer, and four containers and/or baskets of strawberries with white, fuzzy, mold were located in the walk-in refrigerator. Interview and observation on 08/28/23 at 8:25 A.M., Dietary Manager (DM) #806 verified the above findings. Review of the facility document titled Food Storage, dated 2005, revealed the facility had a policy in place that sufficient storage would be provided to keep foods safe, wholesome, and appetizing and food would be stored, prepared, and transported at an appropriate temperature and by methods designed to prevent food contamination. Review of the document revealed the facility did not implement the policy.

Based on observation and staff interview the facility failed to ensure 15 residents (#5, #14, #21, #22, #31, #36, #51, #61, #67, #68, #69, #70, #79, #84, and #87) had a clean privacy curtain and failed to maintain clean and sanitary carpeting throughout the resident rooms and hallways. This had the potential to affect all 96 residents currently residing in the facility. Findings include: 1. Observation on 08/29/23 at 7:33 A.M. with State tested Nurse Assistants (STNAs) #887 and #900 verified Residents #5, #14, #21, #22, #31, #36, #51, #61, #67, #68, #69, #70, #79, #84 and #87 had privacy curtains that were stained and dirty. Interview on 08/29/23 at 7:36 A.M. with STNA #900 revealed housekeeping and laundry staff were responsible for cleaning and maintaining the privacy curtains in resident rooms. Interview on 08/31/23 at 10:15 A.M. with Office Staff (OS) #944 revealed housekeeping staff maintained the resident rooms and common areas daily and privacy curtains were cleaned on rotation once a month unless contaminated or during isolation precautions. An environmental tour was conducted on 08/31/23 between 10:20 A.M. and 10:30 A.M. with OS #944. The following concerns were observed and verified at the time of observation. The rooms belonging to Residents #5, #14, #21, #22, #31, #36, #51, #61, #67, #68, #69, #70, #79, #84 and #87 contained privacy curtains that were stained to various degrees by unknown substances that varied from red, brown, and yellow in color and brown crusted material. Review of the facility document titled Laundry Guidelines, undated, revealed the facility had a policy in place that all personnel would handle, store, process, and transport linen to prevent the spread of infection and an adequate supply of linen would be maintained for resident care. Review of the document revealed the facility did not implement the policy. 38523 2. Observation on 08/28/23 from 8:10 A.M. through 8:35 A.M. of the hallways and each resident room revealed heavily stained, spotted, and worn carpeting. On 08/28/23 at 8:35 A.M. the Director of Nursing (DON) verified and stated the carpet was being replaced due to the stains and spots in each room and in the hallways.

Based on review of resident accounts and interview the facility failed to ensure resident funds were returned to the resident or to the resident estate in a timely manner. This affected one resident (#296) out of three resident accounts reviewed. The facility census was 96. Findings include: Record review for Resident #296 revealed an admitted [DATE] and a discharge date of [DATE]. Resident #296 discharged to another facility due to having COVID-19 and expired in [DATE]. Review of Resident #296 funds account revealed there was a balance on discharge of $2,931.95 which was not returned to the resident's estate until [DATE]. The Resident or his estate did not receive his funds for approximately 19 months. Interview on [DATE] 11:00 A.M. with the Accounts Receivable Coordinator (ARC) #914 revealed she confirmed Resident #296's funds were not returned to the resident or his estate timely.

Based on medical record review, staff interview, and policy review the facility failed to ensure advanced directives were present in the electronic chart and failed to ensure physicians orders were in place for Resident #70's advanced directives. This affected one resident (#70) of one resident reviewed for advance directives. The facility census was 96. Findings include: Review of the medical record revealed Resident #70 was admitted to the facility on [DATE]. Diagnoses included esophagitis unspecified with bleeding, gastrointestinal hemorrhage, and severe protein-calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 was alert and oriented with cognitive impairment and required one-person physical extensive assist for activities of daily living (ADL). Review of the paper medical record identified a code status of Full Code. Review of the electronic medical record, located in Point Click Care (PCC) identified no evidence of Resident #70's advanced directives request. Review of the current physician orders for August 2023 revealed no physician orders to identify the request for a code status of Full Code. Interview on 08/29/23 at 10:19 A.M. with Licensed Practical Nurse (LPN) #844 confirmed the advanced directive wishes of each resident should be in both medical records (paper and electronic), and match. LPN #844 confirmed the electronic chart should have included a physician order, which identified each residents wishes so nursing staff can quickly access the information in the event of an emergency. Review of the facility document titled Advance Directive Protocol, dated December 2014, revealed the facility had a policy in place that residents had a right to make decisions regarding the extent of resuscitation they wish to have performed was respected, honored, and discussed at the time of admission and as indicated during the course of treatment. Further review of the policy revealed a physician's order would be obtained indicating the residents code status and entered into PCC. Review of the facility document revealed the facility did not implement the policy.

Based on medical record review and interview the facility failed to ensure residents were transferred via mechanical lift without injury. This affected one (Resident #38) of three residents reviewed who required a mechanical lift for transfers. Findings Include: Review of the medical record for Resident #38 revealed an admitted [DATE]. Diagnoses included cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery, hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side and aphasia. Resident #38 was discharged on [DATE]. Review of the quarterly Minimum Data Set assessment, dated 01/04/23, revealed Resident #38 had impaired cognition, was dependent for transfers and ambulation, and had no skin alteration. Review of the nurse's note dated 03/04/23 at 5:08 P.M. revealed Resident #38's family was visiting and observed an abrasion/open area on Resident #38's left arm. The note indicated treatment would be initiated for the abrasion. Review of Resident #38's treatment administration record for February 2023 revealed an order dated 03/04/23 to cleanse left forearm with normal saline, pat dry, apply Xeroform, abdominal wound dressing (ABD) bandage and wrap with Kerlix daily for 21 days. Review of a facility self reported incident (SRI) dated 03/05/23 revealed the facility initiated an investigation related to an injury of unknown origin for Resident #38. The investigation was ongoing at the time of the survey. Observation on 03/06/23 at 8:30 A.M. revealed Resident #38 lying in bed yelling out. The left lower arm just below the elbow was covered with a Kerlix dressing. Interview on 03/06/23 at 8:30 A.M. with Licensed Practical Nurse (LPN) #154 revealed she observed a scab above the fold on Resident #38's left arm on 03/03/23; she did not observe an open area. Observation on 03/06/23 at 8:39 A.M. revealed Resident #38 being transferred via a mechanical lift by State tested Nurse Aides (STNAs) #155 and #157. Resident #38 was grabbing at the lift straps and moving about within the mechanical lift pad as she was being moved from the bed to a chair. The STNAs provided emotional support and direction to keep hands on her chest; however, Resident #38 continued to grab at the straps. Resident #38 was lowered to a chair. Resident #38 refused to allow visualization of the area beneath the Kerlix. Review of video footage provided by the family on 03/06/23 at 11:11 A.M. dated 03/04/23 revealed a darkened area approximately three inches long with a dried/pink area which was smaller than the size of a dime at the medial distal area of the darkened skin on Resident #38's left arm. The smaller area looked as if a scab had sloughed off. Interviews on 03/09/23 at 8:48 A.M. with the Administrator and Assistant Director of Quality Management (ADQM) revealed the wound to Resident #38's left arm was most likely from the mechanical lift. The Administrator stated the mechanical lift sling caused the injury, a SRI was initiated, and all staff received training on transfers and reporting injuries. Interview on 03/09/23 at 3:39 P.M. with Registered Nurse (RN) #161 revealed the family of Resident #38 was visiting and observed a wound to Resident #38's left arm. The wound looked like it was caused by shear friction. This deficiency represents non-compliance investigated under Complaint Numbers OH00140820, OH00140819, OH00140818 and OH00135604.

Based on observation, medical record review, review of electronic mail (email) communication, resident representative and staff interview and review of Roommate Authorization for Electronic Monitoring forms, the facility failed to permit Resident #50 to possess an electronic monitoring device (camera of choice) in their room unless they agree to have the facility staff install the device for a specified fee determined by the facility. This affected one of three residents reviewed for resident rights. The facility census was 84. Findings include: Review of Resident #50's medical record revealed the resident was admitted on [DATE] with diagnoses including diabetes, adjustment disorder with depressed mood and [CONDITION(S)]. Review of the face sheet in the medical record revealed Daughter #815 was Resident #50's legal guardian and first emergency contact. Review of Letters of Guardianship paperwork dated 12/31/18 indicated Resident #50 was incompetent and Daughter #815 was the guardian of person and had the power conferred by law to do and perform all the duties of the guardian as described. Resident #50's current, active care plan revealed she had the potential for impaired communication related to a hearing deficit. Interventions included for staff to be patient and provide reassurance, confirm the resident's understanding of the conversation as needed, ensure speaker's faces were not standing in front of a light source, move resident to low-noise place and remove as much background noise as possible. The Minimum Data Set assessment dated [DATE] revealed Resident #50 exhibited intact cognition. Resident #50 required extensive assistance from one staff for bed mobility, transfers, dressing, toilet use and personal hygiene. Review of an email on 05/03/22 at 1:51 P.M. from Licensed Practical Nurse, Unit Manager #804 to the Administrator indicated in a casual conversation the nurse had with Resident #50's daughter, Daughter #815 mentioned Esther's law and said she would be placing cameras in her mother's room. Daughter #815 said she got consent from Resident #81, her mother's roommate, and ordered the cameras. Daughter #815 stated they would need to be installed. Review of an email dated 05/20/22 at 10:28 A.M. from Corporate Administrator #807 to the facility Administrator revealed a conversation was conducted with Daughter #815 yesterday (05/19/22) to set up a time to review the facility's camera policy. Daughter #815 was agreeable but later requested it be emailed to her. Interview on 05/24/22 at 8:05 A.M. with the facility Administrator indicated she talked to Resident #50's daughter, Daughter #815, on multiple occasions regarding camera usage in her mother's room. The Administrator said the latest consultation was on 05/20/22. The facility Administrator indicated she talked with Daughter #815 in Resident #50's room about installing a camera. The facility Administrator said Resident #50 had a roommate, Resident #81. The facility Administrator said she called Resident #81's daughter as she was the responsible party, but not a durable power of attorney (DPOA) for healthcare or a guardian. The Administrator verified Resident #81's daughter indicated she did not have a concern with camera usage for Resident #50. Observation on 05/24/22 at 8:39 A.M. revealed Resident #50 shared a room with Resident #81. A bed curtain was provided between beds for privacy as required for care. There were no cameras observed on either side of the room. Interview on 05/24/22 at 10:43 A.M. with Corporate Administrator #807 indicated he talked to Resident #50's daughter about her concerns and use of a camera in her mother's room as well as the facility camera policy. Corporate Administrator #807 offered to move Resident #50 into a private room in order to be permitted to install an electronic camera. Corporate Administrator #807 told Daughter #815 she would be responsible for the an additional co-pay for the private room well as the actual camera fees, including installation and internet fees. Corporate Administrator #807 informed her it would be $35.00 per hour for installation of the security camera which was to be completed by facility staff. Corporate Administrator #807 stated the private room was an option as they had to wait Resident #81's daughter to obtain guardianship and send in the guardianship paperwork. Corporate Administrator #807 indicated consent from Resident #81's daughter/responsible party was not sufficient to install the camera for Resident #50 as it was a shared resident room. A second interview on 05/24/22 at 11:15 A.M. with Corporate Administrator #807 revealed the cost to move Resident #50 from a semi-private room to a private room would cost the family an additional $75.00 per day or $2,250.00 per month. Interview on 05/24/22 at 12:12 P.M. with Daughter #815 indicated she had requested cameras to be installed in her mother's room however they would not be necessary if staff were doing their jobs. Daughter #815 indicated the facility was telling her only facility staff could install the cameras and they would not accept the consent received from Resident #81's family to place the camera device. A telephone interview on 05/25/22 at 10:39 A.M. with the facility Administrator indicated Resident #50's daughter, Daughter #815, brought up camera installation on 05/03/22 to the nurses and she called the daughter that day and went over the facility policy and fees. The facility Administrator indicated Daughter #815 did not bring up the topic again until 05/20/22 and she went to Resident #50's room to talk to her. The facility Administrator stated Daughter #815 refused to talk to her and she emailed a copy of the camera policy to her email. The facility Administrator indicated Daughter #815 was going to let her know which cameras she was going to buy including a fixed position video, audio fixed position, audio only, live feed or live feed recording. A telephone interview on 05/25/22 at 1:12 P.M. with the facility Administrator and Corporate Administrator #807 confirmed Resident #50's daughter/guardian was required to use the facility staff to install a security camera in her mother's room with a charge $35.00 per hour plus pay for her own hotspot for internet usage per their policy. These facility staff verified Daughter #815 had not been permitted to install a camera device in Resident #50's room as requested as she wanted to install the cameras with the services of an outside contractor/vendor as she wished. Review of the facility's Authorization for Electronic Monitoring in Resident Room form, developed 03/22, revealed the person authorizing the electronic monitoring was responsible for all costs associated with installing, operating and maintaining the device (except electricity). Any internet or network connectivity would be provided by the resident/POA/guardian. The resident's roommate/guardian/POA must give consent before any electronic monitoring device was installed and used. The roommate may choose to place conditions on the use of the device. If the roommate does not consent, the resident wanting the electronic monitoring can be moved to another room, if one is available, and at the rate of the new room if there was a difference. A sign would be posted outside of the resident room indicating an electronic monitoring device was in use. Only the resident, their attorney in fact or guardian and law enforcement personnel were permitted to view or listen to recordings from the electronic monitoring devices, but the resident, their attorney-in-fact, their guardian can also authorize others to view the images or listen to the sound. Review of the the facility's Roommate Authorization for Electronic Monitoring form, developed 03/22, indicated proof of authority was needed if not signed by the resident. If the authorization for electronic monitoring in a resident room would be signed by an attorney in fact (DPOA for healthcare) or guardian, then the authorization would not be effective until the facility was provided a copy of the DPOA for Healthcare or letters of authority from the probate court and had verified the authority of the person signing. This deficiency substantiates Complaint Number OH 489.

Based on record review and interview, the facility failed to provide adequate supervision to prevent a fall for Resident #200. This resulted in Actual Harm when Resident #200 fell and sustained a fractured leg that required surgery. This affected one resident (Resident #200) of four residents reviewed for falls. Findings Include: Review of the closed medical record for Resident #200 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the plan of care for Resident #200 dated 02/05/15 revealed a focus that the resident was at risk for falls with interventions including to ensure the call light was within reach and encourage the resident to use for assistance as needed. Review of the Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #200 required extensive one person assist for walking in the room and in the corridor. Review of a progress note dated 02/22/15 revealed Resident #200 was found unresponsive on the floor in the hallway. The resident was assessed to have an injury to the left leg and emergency services were called. The resident was transported to the hospital. Review of a fall review progress note dated 02/22/15 revealed once Resident #200 was able to respond to staff, the resident stated that a lady had come to get her for coffee and donuts and while walking, the lady had left her to go to another room and the resident became dizzy and fell . Review of a document entitled Fall dated 02/23/15 summarized the fall incident that occurred on 02/22/15 and stated that Resident #200 was ambulating in the hallway with a wheeled walker accompanied by Activity Staff #10 to a group activity when Activity Assistant #10 was called to another room and left the resident in the hallway. Activity Assistant #10 returned to find the resident on the floor in the hallway. The document also contained an entry dated 02/26/15 that stated Resident #200 was transferred to the hospital where the resident was found to have a left proximal femur (leg) fracture requiring surgery. The document stated that Activity Assistant #10 who left the resident without assistance after starting her walking down the hall was terminated from employment at the facility since this incident. Resident #200 did not return to the facility after her hospitalization for the fracture. Interview with the Director of Nursing on 04/23/15 at 12:14 P.M. verified that Resident #200 was left in the hallway without assistance by Activity Assistant #10 and the resident fell and sustained a fractured leg.