Every finding on record at Oasis Center for Rehabilitation and Healing

Based on record review and interview, the facility failed to ensure Resident #40 was provided with timely care and services following a fall. This finding affected one (Resident #40) of three residents reviewed for falls.Findings include:Review of Resident #40's medical record revealed the resident was admitted on [DATE] with diagnoses including a nondisplaced intertrochanteric fracture of the right femur, muscle weakness and chronic obstructive pulmonary disease.Review of Resident #40's Unwitnessed Fall investigation report dated 02/02/26 at 4:20 P.M. revealed the resident was heard yelling in the hallway by staff and the resident was noted in a sitting position on the floor. The resident was leaning on the wheel of the unlocked wheelchair beside the bed. Resident #40 stated her elbow was hurting and bruising was noted along with swelling to the right elbow. Normal range of motion was noted. Upon going back to room to obtain vitals post fall, the resident told the nurse that her right hip and right upper leg area were hurting and requested that staff call her brother. The brother and Director of Nursing (DON) were notified. X-rays were ordered. The resident stated she was trying to transfer by herself from the bed to the wheelchair when her brakes were unlocked and she fell to the floor.Review of Resident #40's physician orders revealed an order dated 02/02/26 revealed an X-ray to the right elbow, right femur, and right hip; an order dated 02/03/26 (discontinued 02/06/26) for Acetaminophen extended release (ER) 650 mg (milligrams) give two tablets every 8 hours as needed for fever greater than 100; and an order dated 02/03/26 (discontinued 02/06/26) for Ibuprofen oral tablet 800 mg give one tablet every eight hours as needed for pain.The medication administration records (MARS) and treatment administration records (TARS) from 02/02/26 to 02/28/26 revealed the X-ray was completed on 02/03/26 at 8:37 A.M. The MARS revealed the resident received Acetaminophen on 02/03/26 at 9:34 A.M. and Ibuprofen on 02/03/26 at 9:37 A.M. for a pain level of 7 (1 the least pain and 10 the worst pain). Review of Resident #40's progress note dated 02/02/26 at 4:25 P.M. authored by Licensed Practical Nurse (LPN) #840 revealed the resident was found on a sitting position on the floor, leaning on the wheel of the unlocked wheelchair beside the bed. The resident stated her elbow hurt with bruising and swelling to the right elbow. The resident's range of motion was normal. The resident was assisted back to bed.Review of Resident #40's Interact Change in Condition Evaluation dated 02/02/26 at 6:27 P.M. revealed the resident had marked localized bruising, swelling or pain on the right elbow, right trochanter and right thigh. The form indicated the resident had pain.Review of Resident #40's Radiology Results Report dated 02/03/26 at 9:52 A.M. revealed the X-ray of the unilateral hips revealed the resident had an acute intertrochanteric fracture of the proximal right femur was noted. An area of sclerosis in the femoral head was noted which could represent early avascular necrosis. No other bony abnormalities were identified.Review of Resident #40's Radiology Results Report dated 02/03/26 at 9:52 A.M. revealed an X-ray of the right elbow showed an acute comminuted fracture through the olecranon process of the proximal ulna. An area of osteopenia at the fracture was noted. A two joint effusion soft tissue swelling over the elbow was noted.Review of Resident #40's progress note dated 02/03/26 at 10:05 A.M. revealed the right elbow had +4 edema and was warm to the touch. Ice was applied for 20 minutes to the right elbow, and the arm was elevated on a pillow.Review of Resident #40's progress note dated 02/03/26 at 11:00 A.M. revealed the X-ray results were reported to the physician, and the resident was to be sent to the emergency room (ER).Review of Resident #40's progress note dated 02/03/26 at 11:12 A.M. revealed the ambulance transported the resident to the ER.Review of Resident #40's hospital History and Physical form dated 02/03/26 at 5:20 P.M. revealed a right intertrochanteric hip fracture and fractures involving the right superior and inferior pubic rami with medial displacement of the medial aspect of the pubic bone. The form also indicated redemonstration of an impacted fracture involving the proximal humeral diaphysis which was similar in position with evidence of healing and a comminuted fracture involving the olecranon of the ulna. The plan was for the resident to be seen by orthopedic surgery in the emergency room (ER) with a right open reduction internal fixation (ORIF) possibly on 02/04/26 and right elbow brace with possible surgery later.Review of Resident #40's progress note dated 02/04/26 at 12:24 A.M. revealed the son reported that the resident would have surgery on the right arm on 02/05/26 in the afternoon.Review of Resident #40's Orthopedic Surgery Resident Progress Note dated 02/05/26 at 5:55 A.M. revealed the resident had a right hip ORIF.Review of Resident #40's 72-Hour Review Incidents form dated 02/06/26 at 3:43 P.M. revealed bruising to the right elbow started post-fall. X-rays revealed fractures present and the resident was sent to the hospital for surgical repair. A right hip fracture was noted as well. The resident had osteoporosis and avascular necrosis.Review of Resident #40's progress note dated 02/06/26 at 4:32 P.M. revealed the resident was readmitted to the facility.Review of Resident #40's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment.Interview on 03/26/26 at 11:25 A.M. with the DON confirmed Resident #40's X-rays were not obtained status post fall on 02/02/26 because the X-ray company could not make it to the facility on [DATE] due to inclement weather conditions. The DON confirmed the X-rays were not obtained until 02/03/26 which showed fractures and the resident was not sent to the ER on [DATE] to obtain the X-rays as an emergency measure due to the X-ray company not being able to drive to the facility in inclement weather.Interview with Resident #40 on 03/26/26 at 11:28 A.M. revealed the resident was in her room sitting in a wheelchair. She appeared alert and was able to answer questions. The resident stated she fell in the room from her wheelchair.Interview on 03/26/26 at 11:30 A.M. with Resident #40's brother revealed Resident #40 had a fall prior to admission to the facility and fell going from the wheelchair to the bed again while a resident in the facility. The brother confirmed the accident happened on 02/02/26 and the resident was not sent out to the hospital until 02/03/26 and it took almost 24 hours to find out the resident had broken bones. The brother expressed concerns with the delay in treatment.Telephone interview 03/26/26 at 12:27 P.M. with LPN #840 revealed she had heard Resident #40 yell for help and found the resident on the floor. She stated the resident complained of pain in her right elbow but did not want to go to the hospital. She stated she had assessed the resident and found bruising to her right elbow with swelling and the resident was assisted to the bed. While assisting the resident, she stated the resident then complained of right leg and thigh pain. LPN #840 confirmed the physician was notified and immediate X-rays were ordered.Telephone interview on 03/26/26 at 12:35 P.M. with Medical Director (MD) #950 revealed he was aware Resident #40 had sustained a fall and had ordered X-rays for the resident. MD #950 revealed the facility could not control the X-ray company and was aware the X-ray company did not obtain the immediate X-rays until 02/03/26 at which point fractures were identified and the resident was sent to the ER.Review of the Managing Falls and Fall Risk policy dated 03/2018 revealed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.This deficiency represents non-compliance investigated under Complaint Number 2788530.

Based on observation, interview and facility policy review, the facility failed to maintain a clean and sanitary homelike environment. This had the potential to affect all 92 residents residing in the facility. The facility census was 92.Findings include: On 01/12/26 between 9:45 A.M. and 11:00 A.M. an initial tour of the building was conducted. The following findings were observed:- room [ROOM NUMBER] was noted to have stained tiles in the room. A buildup of visible dirt and debris was noted behind the entrance door. The tiles in the bathroom were noted to be coming up. Visible dirt and debris were noted within the heating unit. Visible dirt and food were noted on the floor beneath the locked closet. The findings were verified by Certified Nurse Aide (CNA) #316 at the time of the observation.- room [ROOM NUMBER] was noted to have a buildup of visible dirt and debris behind the entrance door. Room floor tiles were noted to be stained. The bathroom was noted to have chipped floor tile. The bathroom door was noted with a hole in it. The toilet paper holder was noted to be broken. The bathroom sink was noted with visible dirt and what appeared to be beard shavings in it. Findings were verified by CNA #316 at the time of the observation.- room [ROOM NUMBER] was noted to have a buildup of visible dirt and debris behind the entrance door. Assistant Director of Nursing (ADON) #429 verified the findings at the time of the observation.- room [ROOM NUMBER] was noted with damaged tile next to A bed. ADON #316 verified the findings at the time of the observation.- The common area was noted to have a dirty floor. There was breakfast tray of food on an end table. The garbage was overflowing. ADON #316 verified the findings at the time of the observation. On 01/12/26 at 4:20 P.M. a subsequent tour of the building with Maintenance Director (MD) #409 revealed the following:- rooms [ROOM NUMBER] were noted to have a buildup of visible dirt and debris behind the entrance doors.- Rooms 404, 407, 408, and 412 were noted to have a buildup of visible dirt and debris behind the entrance doors.- room [ROOM NUMBER] was still noted to have a dirty bathroom sink with apparent beard shavings in it. The toilet paper holder was broken. Floor tiles in the bathroom were noted to be coming up. The bathroom door had a hole in it.- The common room on the 400 unit was noted to have a floor with visible dirt on it. The food tray remained on the end table.- rooms [ROOM NUMBERS] were noted to have a buildup of visible dirt and debris behind the entrance doors.- The mechanical lift on the 100 unit was noted to have visible dirt on the base of the unit.MD #409 verified the aforementioned findings at the time of the observation.A review of the facility policy titled; Homelike Environment, dated 02/2021, revealed residents were provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, home like setting. These characteristics include a clean, sanitary and orderly environment.This deficiency represents noncompliance investigated under Complaint Number 2678224.

Based on record review, observations, interviews, and facility policy review, the facility did not ensure safe smoking practices within the facility for Residents #67 and #34. This affected two residents (#67 and #34) out of two residents reviewed for smoking. The facility census was 92.Findings Include:1. Review of the medical record revealed Resident #67 was admitted to the facility on [DATE] with diagnoses of muscle weakness, chronic obstructive pulmonary disease (COPD), chronic kidney disease, disorders of bone density and structure, rheumatoid arthritis, pain in left hip, patient's noncompliance with other medical treatment and regimen due to unspecified reason, mental disorder, major depressive disorder, acquired absence of the right leg below the knee, tobacco use, anxiety disorder, and hypertension. Review of the Smokers List provided by the facility revealed as of 09/05/25, Resident #67 was on the independent smokers list.Review of the psych note dated 09/08/25 revealed the nurse practitioner observed Resident #67 lying in bed vaping. This resident has oxygen in her room. Review of the smoking assessment dated [DATE] revealed Resident #67 had no cognitive impairment, no visual deficit, and no dexterity problems. She was able to light her own cigarette, did not need adaptive equipment, and a care plan initiated to assure the resident is safe while smoking. Review of the care plan with a review start date of 11/24/25 revealed Resident #67 had a history of smoking in community/inappropriate smoking related to history of using tobacco products and cigarettes. Interventions instruct the resident residents, family members, responsible parties or visitors about smoking guidelines as necessary, instruct residents, family members, and visitors not to share lighted cigarettes, lighters or other smoking materials with other residents, instruct the resident to ask staff to provide/light smoking material, and place smoking material in designated area for storage. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #67 has a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Observation on 01/12/26 at 10:01 A.M. revealed Resident #67 had three Prime vaporizers on her bedside table.Interview on 01/12/26 at 10:05 A.M. Certified Nursing Assistant (CNA) #347 confirmed the vaporizers on the bedside table. There was a no smoking sign on Resident #67 door. Observation on 01/15/26 at 8:45 A.M. revealed an empty box of Geek vaporizers on Resident #67's bedside table. On 01/14/2026 at 10:35 A.M. interview with Activity Director #303 revealed that she does the smoking assessment on each smoker. She was the person who informed the residents if they were a supervised smoker or an independent smoker. If someone was being downgraded to a supervised smoker, she gave them an explanation why it happened. 2. Review of the medical record for Resident #34 revealed an admission date of 04/09/24 with diagnoses of chronic systolic congestive heart failure, COPD, heart failure, major depressive disorder, personal history of other mental and behavioral disorders, personality disorders, nicotine dependency, adjustment disorder, bipolar disorder, anxiety, depression, and tobacco use. Review of the Smokers List provided by the facility revealed as of 09/05/25, Resident #34 was on the independent smokers list.Review of the smoking assessment dated [DATE] revealed Resident #34 had cognitive loss, she had no visual deficits or dexterity problems. She was able to light her own cigarettes. For safety, oxygen needs to be removed before smoking. A plan of care was initiated to assure the resident is safe while smoking. Review of the care plan dated with a review start date of 12/05/25 revealed resident #34 had a history of smoking in the community. On 09/19/24, Resident #34 was educated on safe smoking policy and not smoking with oxygen on her wheelchair. Resident #34 agreed to comply with not having oxygen tank on her wheelchair when smoking. On 05/21/25, the facility educated Resident #34 about attempting to smoke in her room. Intervention included cigarettes and lighter will be held by her nurse. Review of the MDS 3.0 assessment dated [DATE] revealed Resident # 34 has a BIMS score of a 10, indicating moderate cognitive impairment. Observation on 01/12/26 at 10:23 A.M. revealed Resident #34 had a box of cigarettes on her bedside table. She also indicated she had her lighter in her jacket pocket. She showed surveyor a hard box with a disposable lighter. Interview on 01/13/26 at 1:55 P.M Licensed Practical Nurse (LPN) # 401 confirmed Resident #34's lighter and cigarettes in a hard box were in her pocket of her jacket on her bedside table. Observation on 01/15/26 at 8:37 A.M. revealed a packet of Shield cigarettes on Resident #34's bedside table. Interview on 01/14/26 at 12:05 P.M. with the Activity Director #303 regarding Resident #34 confirmed that the care plan dated 05/21/25 would still be active and she should be giving her lighter to the nurse. Review of the undated facility policy titled Smoking Policy - Residents revealed smoking is prohibited inside the building in all areas. Any smoking-related privileges, restrictions, and concerns shall be noted on the care plan. The staff shall consult the care plan to determine any restrictions on smoking privileges. Residents who have independent smoking privileges shall be permitted to keep cigarettes, pipes, tobacco, or other smoking articles in their possession. These residents will be issued lockboxes to maintain their smoking materials. Failure to secure smoking materials when not in use may result in loss of independent smoking privileges.

Based on record review, observation, interview and facility policy review, the facility failed to ensure medications were stored in a safe fashion. This affected one resident (#43) of 92 residents observed for medications at the bedside. The facility census was 92.Findings include:A review of medical records for Resident #43 revealed a date of admission of 10/08/25. Significant diagnoses included chronic congestive heart failure, acute respiratory failure with hypoxia, diabetes mellitus type II with hyperglycemia, acute pulmonary edema, gastroesophageal reflux disease, hypertension, and shortness of breath. Significant orders included, Isosorbide 10 milligrams, 1 tablet by mouth three times a day for hypertension, Atorvastatin 40 milligrams give one tablet by mouth daily for cholesterol, Nifedipine 90 milligrams, give one tablet by mouth one time daily for hypertension, hydrochlorothiazide 25 milligrams, give one tablet by mouth daily for hypertension, Magnesium 400 milligrams, give one tablet by mouth daily as a supplement, spironolactone 25 milligrams, give one tablet by mouth daily for edema, Lasix 40 milligrams, give one tablet by mouth one time daily for congestive heart failure, Klor-Con 20 milliequivalents, give one tablet two times daily for potassium supplement, Lisinopril 10 milligrams, give one tablet by mouth one time daily for hypertension, Jardiance 10 milligrams, give one tablet by mouth one time daily for diabetes, and Hydralazine 50 milligrams, give one tablet by mouth three times daily for hypertension.A care plan dated 12/17/25 for Resident #43 was reviewed. Resident #43 was not care planned for self-administration of medication.A quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating Resident #43 had moderate cognitive impairment.A review of Resident #43's assessments revealed Resident #43 was not assessed for medication self-administration.A review of the medication administration record (MAR) dated 01/01/26 through 01/31/26 revealed all oral medications were signed off as given from 01/01/26 through 01/12/26.On 01/12/26 at 10:00 A.M. an observation of Resident #43 revealed a clear medication cup with eight medications in it on the bedside table. Housekeeper #376 verified the pills in the medication cup at the time of the observation.On 01/13/26 at 11:08 A.M. an interview with Assistant Director of Nursing (ADON) #429 revealed there were no current residents in the facility who were on a medication self-administration program.A review of the policy titled Administering Medications, dated 04/2019, revealed medications are administered in a safe and timely manner, and as prescribed.A review of the policy titled Storage of Medications, dated 11/2020, revealed the facility stores all drugs and biologicals in a safe, secure and orderly manner.

Based on record review, observation, interview and facility policy review, the facility to ensure call lights were in reach. This affected two residents (#24 and #41) of 92 residents observed for call lights. The facility census was 92.Findings include:1. A review of the medical records for Resident #24 revealed the date of admission as 12/13/24. Significant diagnosis included unspecified dementia, adult failure to thrive, anxiety, unspecified other amnesia, personal history of other mental and behavioral disorders, age-related cognitive decline, and unspecified non traumatic intracerebral hemorrhage. There were no significant orders regarding the citation. A care plan dated 12/02/25 revealed Resident #24 was at risk for falls related to cognitive impairment, and gate balance problems. Interventions included to be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed.An annual Minimal Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of four out of 15, indicating Resident #24 had severe cognitive impairment. The assessment also revealed Resident #24 needed supervision or touching assistance with all activities of daily living.An observation on 01/12/26 at 9:50 A.M. revealed Resident #24 to be in bed. The call light was noted to be on the floor at the foot of the bed. Certified Nurse Aide (CNA) #316 verified the findings at the time of the observation.2. A review of medical records for Resident #41 revealed the date of admission as 10/22/15. Significant diagnosis included major depressive disorder, diabetes mellitus type II, suicidal ideations, mild cognitive impairment, personal history of other mental and behavioral disorders, Alzheimer's disease, unspecified dementia, unspecified mood disorder, legal blindness, chronic viral hepatitis B and psychosis not due to a substance or known physiological condition. There were no significant orders regarding the citation.A care plan dated 12/26/25 revealed Resident #41 required assistance with activities of daily living. Interventions included encourage the resident to use the call bell system for assistance. The care plan further revealed Resident #41 was at risk for falls related to being legally blind and anoxic brain damage. Interventions included be sure the resident's call light was within reach and encourage the resident to use the system to call for assistance as needed.An annual MDS assessment dated [DATE] revealed a BIMS score of nine out of 15, indicating moderate cognitive impairment. The assessment also revealed Resident #41 was a partial to moderate assist for all activities of daily living and had severely impaired vision.An observation on 01/12/26 at 9:55 A.M. revealed Resident #41 to be in bed. The call light was on the floor. Assistant Director of Nursing (ADON) #429 verified the findings at the time of the observation.A review of the facility policy titled; Answering the Call light, dated 03/2021, revealed when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on observation, record review and interview, the facility failed to ensure food was stored, prepared and served under sanitary conditions. This had the potential to affect all residents who received meals from the kitchen. The facility identified seven residents (#7, #25, #44, #50, #52, #61, and #85) as receiving nothing by mouth. The census was 92. Findings include: 1.Observation of the kitchen on 09/10/24 from 8:14 A.M. to 8:35 A.M. with Cook/Assistant Dietary Director (DD) #365 and DD #366 revealed the following concerns: In the walk in cooler, there was one half factory bag of shredded mozzarella cheese opened and resealed with plastic wrap with no date; four waffles wrapped in plastic wrap with no date; one hardboiled egg wrapped in plastic wrap with no date; one factory bag with four hardboiled eggs opened and resealed with plastic wrap with no date, and two opened, approximately four inch, stacks of sliced American cheese resealed with plastic wrap with no date. On a metal shelf under the exhaust hood to the left of the ovens revealed an opened bag with an unidentified product, which looked like brown sugar, which had been resealed with plastic wrap with no date or label. In the dry storage area, there was one half bag of dried penne pasta which was open to air. At the time of observation, DD#366 confirmed items opened should be resealed, labeled, and dated. Review of undated facility policy Food Storage, revealed all foods should be covered, labeled and dated. 2. Observation of the kitchen on 09/10/24 from 8:14 A.M. to 8:35 A.M. with Cook/Assistant Dietary Director (DD) #365 and DD #366 revealed the sticker on the facility exhaust hood revealed it had been last cleaned commercially in January 2024. Observation of the four square shaped vents in the hood range revealed there was an accumulation of dust and debris visible in the square vents. At the time of observation, DD #366 confirmed the areas of concern in the exhaust hood and stated the hood should be cleaned professionally every six months. Interview on 09/11/24 at 10:14 A.M. with the Administrator confirmed the exhaust hoods had not been cleaned every six months as required. He stated the facility was supposed to be on a schedule, where every January and July a commercial company was to come to the facility to clean the exhaust hoods. He stated the commercial company had reached out to the previous maintenance person's phone for a confirmation to come and clean the hoods. The company never got that confirmation since that maintenance person no longer worked for the facility, and as a result, the facility was skipped for the July cleaning. Review of undated policy Hood Cleaning revealed hood cleaning venting system shall be cleaned regularly by a system professional to reduce the potential for a grease fire. The Dining Services director or designee arranges with outside service for cleaning of hood ventilation system. Service would be performed at least every six months. Each hood will have a sticker attached that shows date of last professional cleaning. This deficiency represents non-compliance investigated under Complaint Number OH00157225.

Based on observation, interviews, and review of facility policies, facility menu, and job descriptions, the facility administration failed to ensure there was an adequate supply of emergency food and water on hand as required. This had the potential to affect all 92 residents in the facility. The facility census was 92. Findings include: Review of the administrator job description revealed the administrator was responsible for establishing systems to enforce the facility policies and procedures and to ensure compliance with all federal, state, and local regulations. Review of maintenance supervisor job description revealed the maintenance supervisor would observe all facility policies and procedures and develop and implement maintenance systems to meets residents' needs in compliance with federal, state and local requirements. Review of Food Service Director job description revealed the food service director would implement dietary and food service policies and procedures to meet residents' needs and in compliance with federal, state, and local requirements and a monitoring system for the dietary and food service department. The food service director would also make recommendations for implementation to assure compliance with federal, state, and local requirements, which included purchase or requisition of food, equipment and supplies. Review of the facility document titled HPSI Emergency Menu Plan Manual revealed the facility had a seven day emergency menu which included shelf stable milk, pop tarts, granola bars, tuna salad, chicken salad, vegetable beef stew, chili with beans, pimento cheese sandwiches, beef ravioli and various canned fruits. The manual indicated approximately two gallons of water per person per day should be stored for drinking, food preparation and hygiene. Observation of the kitchen on [DATE] from 8:46 to 8:57 A.M. with Dietary Director (DD) #366 and Cook/Assistant DD #365 revealed there were bare spots on the shelves in the dry storage area and in the walk-in coolers and freezers. Upon further review of the stock in the freezer and refrigerator and the facility emergency menu revealed an inadequate supply of food items to support the emergency menu. DD#366 confirmed the facility did not have an emergency supply of food as required. Interview on [DATE] at 3:06 P.M. and on [DATE] at 8:07 A.M. with Maintenance Director #401 revealed there was not an emergency supply of water in the building. He went on to state the facility had an emergency water supply in the past, but the facility got rid of the emergency water supply in [DATE] since the stored water bottles were exploding and the water had expired. When asked what the facility would do if there was a water line break, Maintenance Director #401 stated I don't know what I would do if there was a disaster of drinkable water. I don't know what we would do. He stated he had brought the concern to Maintenance Director #402, who did the ordering, that the facility needed to have an emergency water supply. Maintenance Director #401 stated he had lost sleep over it, all the time. Observation of the dry food storage area and the central supply area on [DATE] from 3:30 P.M. to 3:35 P.M. with Maintenance Director #401 confirmed there was no emergency supply of water in the facility. Interview on [DATE] at 9:19 A.M. with Maintenance Director #402 revealed the facility had ordered pallets of water about two years ago, and since they had been sitting so long, the containers broke and leaked and then they expired. He stated he had brought up to the Administrator the concern about not replenishing the emergency water supply. Maintenance Director #402 felt the concern had been ignored and thought maybe something had changed and the facility no longer needed a supply of emergency water. Maintenance Director #402 stated he probably should have asked if the facility still needed a supply of emergency water. Interview on [DATE] at 10:14 A.M. with the Administrator revealed he knew the facility had issues with the cases of the stored water breaking and then they expired. He stated the facility never got around to ordering more emergency water, but he knew the facility needed to have an emergency supply of water at the facility. The administrator went on to state he knew the supply of food got close on food delivery day but only having food for the day of delivery was too close. Review of facility undated policy Food and Nutrition Services Disaster Plan revealed in case the facility was unable to receive deliveries an emergency supply of food, beverages, and supplies must be available in the facility and a minimum of a three to seven day supply was recommended. In case of no water supply or water supply was shut off, the facility should have an emergency potable water supply equivalent to one half gallon per person/day minimum for drinking and one half gallon/person per day for other uses for at least seven days or per regulatory requirements. This deficiency represents noncompliance as an incidental finding during investigation of Complaint Number OH00157225.

Based on observation, record review and interview, the facility failed to follow the menu as written. This affected two residents (#5 and #89) of five residents reviewed for nutrition and had the potential to affect all residents who received meals from the kitchen excluding seven residents (#7, #25, #44, #50, #52, #61 and #85) who the facility identified as receiving nothing by mouth. The facility census was 92. Findings include: 1.Review of medical record for Resident #5 revealed an admitted [DATE]. Diagnoses included acute and chronic respiratory failure, morbid obesity due to excess calories, schizophreniform disorder, anxiety disorder, congestive diastolic heart failure, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/12/24, revealed Resident #5 was cognitively intact and was independent for eating. Review of physician orders revealed Resident #5 had a diet order dated 05/31/24 for CCHO (consistent carbohydrate)/NAS (no added salt) diet, mechanically altered chopped texture, thin liquids consistency. Observations conducted on 09/10/24 during initial facility tour from 8:14 A.M. to 8:35 A.M. revealed the posted menu in the dining room for breakfast on 09/10/24 revealed waffles, bacon, fruit cup, cream of wheat, milk and juice were to be served. Observation of Resident #5's breakfast tray revealed the resident was served two waffles, bacon, a bowl of dry cereal, milk and juice. Review of the dietary tray ticket sitting on the Resident #5's meal tray at the time of observation revealed under the dislike/do not serve section there was nothing noted indicating that fruit should not have been served and under the special instructions section it was indicated the resident wanted cold cereal instead of hot cereal. Interview with Resident #5 at the time of observation revealed she would have eaten the fruit cup if it had been served. Interview on 09/10/24 at 8:20 A.M. with Occupational Therapy Assistant #410 confirmed there was no fruit cup on Resident #5's breakfast tray. Interview on 09/10/24 at 8:45 A.M. with Dietary [NAME] #362 revealed when asked why the fruit cup had not been served for breakfast, she stated she didn't see it on the menu. Interview on 09/11/24 with Ombudsman #433 revealed the biggest concern at the building for her was dietary, which included meals not matching the posted menu. Review of Oasis Healthcare Menu Extension Tuesday 09/10/24 revealed the CCHO diets were to receive one four ounce slotted spoodle (a type of serving utensil that is a combination between a spoon and a ladle) of fruit for breakfast Review of undated facility policy Accuracy of Quality of Tray Line Service revealed the meal will be checked against therapeutic diet spread sheet to assure that foods are served as listed on the menu and each meal will be checked for accuracy of following the therapeutic diet extensions. 2. Review of medical record for Resident #89 revealed an admitted [DATE]. Diagnoses included acute kidney failure, type two diabetes, chronic kidney disease, and dysphagia. Review of the quarterly MDS 3.0 assessment, dated 06/12/24, revealed Resident #89 was moderately impaired cognitively and was independent for eating. Review of physician orders revealed a diet order dated 02/15/24 for a regular diet, mechanically altered ground texture, thin liquids consistency. Observations conducted on 09/10/24 during initial facility tour from 8:14 A.M. to 8:35 A.M. revealed the posted menu in the dining room for breakfast on 09/10/24 revealed waffles, bacon, fruit cup, cream of wheat, milk and juice were to be served. Observation of Resident #89's breakfast tray revealed the resident was served two waffles, ground sausage, a bowl of cream of wheat, milk and juice. Review of the dietary tray ticket sitting on Resident #89's tray at the time of observation revealed under the dislike/do not serve or special instructions sections, there was nothing noted indicating that fruit should not have been served. Interview on 09/10/24 at 8:23 A.M. with State tested Nursing Assistant #312 confirmed there was no fruit cup on Resident #89's breakfast tray. Interview on 09/10/24 at 8:45 A.M. with Dietary [NAME] #362 revealed when asked why a fruit cup had not been served for breakfast, she stated she didn't see it on the menu. Interview on 09/11/24 with Ombudsman #433 revealed the biggest concern at the building for her was dietary, which included meals not matching the posted menu. Review of Oasis Healthcare Menu Extension Tuesday 09/10/24 revealed mechanical soft ground texture diets were to receive one four-ounce portion of diced peaches for breakfast. Review of undated facility policy Accuracy of Quality of Tray Line Service revealed the meal will be checked against therapeutic diet spread sheet to assure that foods are served as listed on the menu and each meal will be checked for accuracy of following the therapeutic diet extensions. This deficiency represents noncompliance investigated under Complaint Number OH00157225.

Based on observation, record review and interview, the facility failed to ensure palatable food was served to all residents. This affected three residents (#36, #39 and #45) of five residents reviewed for nutrition and had the potential to affect all residents receiving meals from the kitchen. The facility identified seven residents (#7, #25, #44, #50, #52, #61, and #85) as not receiving anything by mouth. The census was 92. Findings include: 1.Review of the spread sheet for lunch on 09/10/24 revealed one three ounce chicken breast, one four ounce spoodle or one number eight scoop of parmesan creamed noodles, one four ounce slotted spoodle of French style green beans, one dinner roll, mixed fruit, milk of choice and beverage of choice was to be served. During observation of tray line on 09/10/24 between 11:45 A.M. and 1:15 P.M. revealed the noodles appeared to not have any cream sauce on them. Interview on 09/10/24 at 12:00 P.M. with Dietary [NAME] #362 confirmed there was no cream sauce on the noodles. She stated she had put butter and dried parmesan on the noodles and had no recipe for the parmesan creamed noodles. Interview on 09/10/24 at 12:01 with Dietary Director (DD) #366 revealed the recipe book had been in his office, and he was in the process of updating the recipes. Observation of the recipe book on 09/10/24 at 12:27 P.M. with DD #366 revealed there was no recipe in the book for parmesan creamed noodles, and DD#366 confirmed a recipe for parmesan creamed noodles had not been printed out until the state surveyor had asked for one on 09/10/24. DD#366 went on to say Dietary [NAME] #366 should be following recipes, and if she was unsure, she should have asked. On 09/10/24 at 1:05 P.M., a test tray was observed by the state surveyor as the last cart was beginning to be loaded. At 1:14 P.M., Dietary [NAME] #366 plated the test tray and the test tray was then loaded onto the food cart. At 1:15 P.M., the dietary cart with the test tray on it was taken to the 400 hall. By 1:21 P.M. the seventeen trays on the dietary cart had been passed and DD#366 took the test tray off the cart and took the tray to a table in the main dining room. DD #366 used a calibrated facility thermometer to take the temperatures of the items on the test tray. The temperature of the chicken was 151 degrees Fahrenheit (F), the green beans were 141 degrees F, the noodles were 151 degrees F., the canned peaches were 58 degrees F, the milk was 43.6 degrees F, and the coffee was 163.3 degrees F. As DD# 366 was taking the temperature of the items, the state surveyor was tasting the items. The chicken tasted warm, was moist and had good flavor. The noodles tasted warm but were bland and had no flavor. The green beans tasted warm but were bland and had no flavor. The fruit tasted cold and had good flavor. The milk tasted cold and did not taste spoiled. The coffee was very warm and had a good flavor. After DD #366 had taken the temperature of the items, he tasted the chicken and felt it tasted warm and had good flavor. When he tasted the green beans, he felt the green beans were bland and were over cooked. When he tasted the noodles, he felt they were undercooked and had no flavor. Review of recipe for Parmesan Cream Noodles, dated 09/10/24, confirmed the facility had not followed the recipe. According to the recipe, for 83 four-ounce servings the facility would have needed five and one half pounds of egg noodles, one quart milk, two cups butter, one and one-eighth quart of water, six and two-thirds tablespoons chicken base, one pound parmesan cheese grated, one and one-eighth teaspoons of lemon pepper, and one and one-eighth teaspoon of Italian seasoning and one half cup flour. For the sauce, milk, butter and water were to be brought to a simmer. The chicken base was then to be added, and the mixture was to be stirred well. The mixture was then to be thickened with roux to a light gravy consistency. The parmesan cheese was to be added to the mixture and the mixture was to be removed from the heat. The sauce was to be tasted and adjusted with seasonings if necessary. The sauce was then to be added to the cooked noodles. 2. Review of medical record for Resident #39 revealed an admitted [DATE]. Diagnoses included primary pulmonary hypertension, morbid obesity due to excess calories, type two diabetes without complications, heart failure and depression. Review of physician orders revealed a diet order dated 09/05/23 for CCHO (Consistent Carbohydrate) /NAS (No Added Salt) diet, mechanically altered chopped texture, thin liquid consistency. Review of quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/14/24, revealed Resident #39 was cognitively intact and was independent for eating. Interview on 09/10/24 at 2:12 P.M. with Resident #39 revealed a lot of the food was bland and for lunch on 09/10/24, the noodles tasted bland. 3. Review of medical record for Resident #45 revealed an admitted [DATE]. Diagnoses included sepsis, chronic obstructive pulmonary disease (COPD), morbid obesity with aveolar hypoventilation, multiple sclerosis, major depressive disorder, resistive to multiple antibiotics, and acute on chronic diastolic (congestive) heart failure. Review of Resident #45's physician orders revealed a diet order dated 08/06/ 24 for CCHO, Regular texture, and thin liquids consistency. Review of modification of end of the MDS assessment, dated 08/06/24, revealed Resident #45 was cognitively intact and was independent for eating. Interview on 09/10/24 at 2:13 P.M. with Resident #45 revealed the facility does not use seasoning, and the food was bland. 4. Review of Resident #36 revealed an admitted [DATE]. Diagnoses included osteomyelitis left ankle and foot, type two diabetes, unspecified chronic bronchitis, generalized anxiety disorder, chronic kidney disease stage four, acute respiratory failure with hypoxia, bipolar disorder, and depression. Review of Resident #36's physician orders revealed a diet order, dated 02/27/24, for CCHO/NAS diet, regular texture, thin liquids. Review of quarterly MDS assessment, dated 08/13/24, revealed Resident #36 was cognitively intact and was independent for eating. Interview on 09/10/24 at 2:26 P.M. with Resident #36 revealed the food was terrible and bland. Interview on 09/11/24 with Ombudsman #433 revealed the biggest concern at the building for her was dietary, which included meals not matching the posted menu. This deficiency represents non-compliance investigated under Complaint Number OH00157225.

Based on observation, interview and review of facility policy, the facility did not ensure the memory care unit environment was maintained in a clean, comfortable and homelike manner. This had the potential to affect all 22 residents (Residents #2, #3, #4, #7, #8, #12, #13, #16, #23, #32, #40, #55, #58, #62, #64, #67, #71, #72, #75, #85, #86, and # 94) living on the memory care unit out of 94 residents living in the facility. The facility census was 94. Findings include: Observation was conducted on 05/14/24 at 8:25 A.M. on the memory care unit and revealed upon entering the unit there was a strong, pervasive odor of foul smelling urine present, and the smell carried throughout the entire unit. Interview on 05/14/24 at 8:40 A.M. with Licensed Practical Nurse (LPN) #703 revealed he confirmed the memory care unit had a strong odor of foul smelling urine. LPN #703 stated housekeeping did clean on the unit, however, they did not spend much time on the memory care unit and did not remove the foul smelling urine odor. Observation was conducted on 05/14/24 at 10:30 A.M. of housekeeping on the memory care unit. The housekeeper was spraying air freshener throughout the memory care unit. A strong, pervasive odor of foul smelling urine could still be detected despite the air freshener. Review of the facility policy titled Homelike Environment last revised February 2021, revealed under section two it states The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include, under letter A. a clean, sanitary and orderly environment, under letter F. pleasant, neutral scents. Under section three the policy states The facility staff and management minimizes, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. These characteristics include, under letter B. institutional odors. This deficiency identified non-compliance as an incidental finding during the investigation of Master Complaint Number OH00153659 and Complaint Numbers OH00153284 and OH00153155.

Based on observation, interview, and review of the Hydrion Test Strip instructions the facility failed to maintain a sanitary kitchen to prepare food in a manner to prevent contamination and food borne illness. This had the potential to affect all residents (#15, #16, #18, #28 and #31) who received nothing by mouth. The facility census was 92. Findings include: Observation on [DATE] at 10:05 A.M. during a tour of the kitchen revealed a puree prep station with a buildup of grease and dirt on the bottom shelf. The top shelf of the puree prep station had a buildup of dirt on it. The white tiles around the walls in the kitchen had a buildup of black dirt on them. The microwave was dirty with dried food splatter in it. The three-sink sanitation station had a container of Hydrion strips (test strips to test the chemical levels for proper sanitization) expired [DATE]. The findings were verified by the Dietary Manager (DM) #675 at the time of the tour. On [DATE] an interview with DM #675 during the tour of the kitchen revealed food preparation stations were to be cleaned after each use. DM #675 also verified the Hydrion stips with the expiration date of [DATE] were being used to test sanitization levels. A review of the Hydrion Test Strip instructions on www.essentiallab.com revealed the test strips remain accurate until the expiration date. This deficiency represents non-compliance investigated under Master Complaint Number OH00152468.

Based on observation, interview, and facility policy review, the facility failed to provide a clean and sanitary environment. This had the potential to affect all 92 residents in the facility. Findings include: Observation on 04/11/24 at 9:35 A.M. during a tour of the facility revealed the shower room on 300-hall had broken tile around shower drain. The handwashing sink was visibly dirty. The supply cart for shower items had visible dirt on it. The paper towel dispenser had visible dirt on top of it. Hair and dirt were noted on baseboard heating unit. The tub had dirt around the drain (dirty buildup of soap scum), and the area around the tub ledge had a buildup of dirt on it. The floor was dirty. The toilet was full of a bowel movement. There were two broken tiles noted at the bottom of the doorway to that hall. The activity lounge on the 400-hall had visible dirt on the walls and chair rail. The base board heating unit had a buildup of dust on it. The windowsill had a buildup of dust and dirt. All observations were verified by Concierge #808 at the time of the tour. On 04/11/24 at 11:40 A.M. an observation of room [ROOM NUMBER] revealed a broken screen in the window. The baseboard heating units had a buildup of dirt on them. There were leaves, built-up dust clumps, food and plastic silverware noted inside baseboard heating unit. There was a buildup of dirt on the windowsill. There was a buildup of visible dirt on the blinds. There was a buildup of dust on top of the paper towel holder and a buildup of visible dust on the overbed light fixture. On 04/11/24 at 1:35 P.M. an interview with Environmental Safety and Services Director (ESSD) #759 revealed resident rooms were to be cleaned daily. Rooms were terminally cleaned when a resident discharged . ESSD #759 also verified the findings in resident room [ROOM NUMBER]. A review of the facility policy titled, Cleaning and Disinfection of Environmental Surfaces, dates August 2020, revealed environmental surfaces will be disinfected or cleaned on a regular basis (e.g. daily, three times per week) and when surfaces are visibly soiled. This deficiency represents non-compliance investigated under Master Complaint Number OH00152468.

Based on observation and interview the facility failed to provide palatable food when gelatine was served in a liquid form. This had the potential to affect all residents who received food from the kitchen. The facility identified five residents (#15, #16, #18, #28 and #31) who received nothing by mouth. The facility census was 92. Findings include: Interview on 04/11/24 at 11:30 A.M. with Resident #85 revealed no menus were provided to residents, and the food was not good. On 04/11/24 at 12:05 PM. observation of tray line in kitchen revealed a meal of pork chops, mashed potatoes, sauerkraut, and gelatine with diced pears. A test tray was requested. On 04/11/24 at 12:40 P.M. the food cart arrived to the 400-hall. At 12:50 P.M. the test tray was obtained after last the resident's tray was delivered. The gelatine was in a liquid form with diced pears in it. Interview at the time of the observation with Dietary Manager #675 verified the gelatine was not served as it should have been at the time of the test tray. Interview on 04/12/24 at 10:05 A.M. with Resident #69 revealed the food was terrible. This deficiency represents non-compliance investigated under Master Complaint Number OH00152468.

Based on record review, observation and interview, the facility failed to develop and implement an effective and individualized pressure ulcer prevention program for Resident #101 to prevent the development of a facility acquired pressure ulcer to the back of the resident's neck. Actual Harm occurred on 02/27/24 when Resident #101, who was cognitively impaired, ventilator dependent, at risk for pressure ulcer development and required total dependence on staff for bed mobility and all activities of daily living, was assessed on 02/27/24 by Wound Nurse Practitioner (NP) #703 to have a Stage IV (full thickness skin and tissue loss) facility acquired pressure ulcer with correction of the staging completed on 03/05/24 to an unstageable (full thickness loss of tissue completely covered by dead tissue) pressure ulcer to his rear neck found under his tracheostomy ties. The pressure ulcer measured 2.0 centimeters (cm) in width by 1.2 cm in length with no depth noted with the pressure ulcer having 100 percent eschar (dead tissue) to the wound bed with no undermining (tissue loss under the wound margins), tunneling, nor drainage or odor present. The facility failed to ensure adequate interventions/care including skin monitoring were provided to prevent the development of the ulcer and failed to timely identify the ulcer prior to it being a Stage IV/unstageable pressure ulcer. This affected one resident (#101) of three residents reviewed for ventilator dependence and pressure ulcers. The facility census was 96. Findings include: Review of the medical record for Resident #101 revealed an original admitted [DATE] with subsequent hospital stays dated 01/13/24 to 01/16/24, 01/20/24 to 01/25/24, 01/31/24 to 02/06/24, and 02/29/24 to 03/06/24 with diagnoses including sepsis, diabetes mellitus, acute respiratory failure with hypoxia, ventilator dependent with tracheostomy, moderate protein calorie malnutrition, hypertension, fractures of the right and left tibias, injury to thoracic spinal cord, traumatic subarachnoid hemorrhage, fracture of facial bones, right shoulder dislocation, right ulna fracture, dislocation of right humerus, multiple bilateral rib fractures, and paraplegia. The most recent hospitalization on [DATE] was due to pneumonia for which he was treated in the hospital with antibiotics. Review of the Nursing Admission Evaluation for Resident #101 dated 01/12/24, revealed Resident #101 was admitted to the facility with multiple wounds. Wounds to his scalp, face and several toes were from being struck by an automobile while crossing the street. Two wounds to his upper and lower back were surgical wounds and four wounds to his right and left buttock, right gluteal fold and occipital head were caused from pressure prior to admission to the facility. There was no wound identified to the resident's back/rear neck under tracheostomy (Trach) ties at the time of admission. Review of the Medicare five-day Minimum Data Set (MDS) 3.0 assessment, dated 02/13/24, revealed Resident #101 had severely impaired cognition, and was dependent on staff for all activities of daily living (ADLs) including bed mobility, turning, and repositioning, bowel incontinence care, and management of a suprapubic catheter. Review of the plan of care for Resident #101, initiated 01/12/24, revealed Resident #101 had potential or actual impairment to skin integrity related to fragile skin. Interventions included to supply education to the resident, family and caregivers of causative factors and measures to prevent skin injury, ensure good nutrition and hydration in order to promote healthier skin, follow facility protocols for treatment of injury, keep skin clean and dry, use lotion on dry skin, monitor and document location, size and treatment of skin injury, report abnormalities, failure to heal, signs and symptoms of infection, and maceration to the physician. In addition the plan of care included Resident #101 was ventilator dependent with interventions to include monitor, document and report as needed any pressure ulcers. Preventative measures included turning at least every two hours, use pressure relief mattress or turning bed if indicated, follow prevention of pressure ulcer plan of care and maintain nutritional needs. The disciplines responsible were listed as the licensed nurses. Review of the weekly skin and wound evaluations dated 02/07/24, 02/13/24, and 02/15/24 revealed there were no new open areas identified on Resident #101's body. Review of the Skin and Wound Evaluation V7.0 document, dated 02/27/24 and authored by Wound NP #703 revealed while completing treatment to a wound on the occipital (back of head) portion of Resident #101's head, there was a (new) pressure area found under the resident's trach ties. The wound was documented to be an in house acquired Stage IV pressure ulcer measuring 2.0 centimeters (cm) width by 1.2 cm length with no depth noted and with 100 percent eschar (dead tissue). There was no undermining or tunneling; there was no drainage or odor present. Review of a progress note dated 03/05/24 by Wound NP #703 revealed a correction in the staging of Resident #101's rear neck wound from a Stage IV to an unstageable due to wound bed having 100% eschar tissue. Review of the physician's orders dated January 2024, February 2024 and March 2024 revealed an order dated 01/19/24 for trach ties to be changed weekly on Fridays or as needed, head of bed elevated to no less than 30 degrees, low air loss mattress to bed at all times. An order for wound care, dated 02/28/24 for the wound on the resident's neck to be cleaned with normal saline, apply skin prep to the perimeter and then apply Medi honey to the wound bed and cover with a foam dressing everyday shift for wound management and as needed was also noted. At the time this order was received, it was noted that Resident #101 was also receiving daily wound treatments to a wound on the back of his head (for a pressure ulcer present on admission) that was above the new Stage IV/unstageable pressure ulcer first identified on 02/27/24. Review of the February 2024 Treatment Administration Record (TAR) for Resident #101 revealed trach ties were to be changed every Friday. The February TAR indicated the trach ties had been changed on 02/09/24, 02/16/24, and 02/23/24. Wound treatments to the rear neck pressure ulcer were completed every dayshift beginning on 02/28/24. Review of the Braden Scale risk assessment dated [DATE] revealed Resident #101 was at a high risk for developing pressure ulcers. Review of the Braden Scale risk assessment dated [DATE] revealed Resident #101 was at a moderate risk for developing pressure ulcers. Review of a typed statement dated 03/12/24, authored by Primary Care Physician (PCP) #900 and submitted via email correspondence to the surveyor on 03/12/24 revealed PCP #900 enclosed a pressure injury audit and wrote the area on his rear neck that was caused by the trach tie was in my opinion unavoidable. The physician included the wound, in the PCP's opinion was unavoidable not only due to the resident's extensive comorbidities but also due to the resident requiring a ventilator and trach ties to hold trach in place with the trach tie a medical necessity to sustain life. The head of the resident's bed elevated due to continuous tube feeding. The resident being completely immobile, sliding down in bed and requiring staff to turn him. Fecal incontinence requiring staff to frequently provide incontinence care. And the resident being bedfast with several functional limitations in range of motion. Review of the Pressure Injury Audit, dated 03/12/24, authored by PCP #900 revealed Resident #101 had a nosocomial (health care associated) existing pressure ulcer to his rear neck measuring 2.72 cm length by 1.92 cm depth and unstageable. Eschar or slough was present, and no signs of infection. Comments included: New area to rear neck found on 02/27/24. Resident was struck by an automobile, admitted with multiple wounds and multiple fractures. Resident has been to the hospital 4 times since 1/12/24. Resident has an unstageable pressure area to the rear neck from his trach tie. Trach tie is a medical necessity. Resident cannot survive without ventilator support. Curawound nurse practitioner will see on a weekly basis. Intermittent observations were conducted of Resident #101 in his room from 03/06/24 to 03/11/24 and revealed the resident was in bed lying on a low air loss mattress on his right side or back and had an enteral tube feed pump infusing enteral feeding continuously via PEG (percutaneous enterogastric) tube with the head of his bed elevate to approximately 30 degrees. Resident #101's eyes were open, but no meaningful attempts to communicate were made from him upon greetings. Interview on 03/05/24 at 1:00 P.M. with Respiratory Therapist (RT) #701 revealed NP #703 called and notified him on 02/27/24 of the new pressure ulcer found on the back of his neck and under the trach ties which was due to the trach ties being too tight. He was informed of the new orders in place. Interview on 03/05/24 at 2:00 P.M. with the Director of Nursing (DON) revealed the wound to the back of Resident #101's neck under the trach ties was found on 02/27/24 by Wound NP #703. A phone interview on 03/06/24 at 12:53 P.M. with Wound NP #703 revealed Resident #101 was found on 02/27/24 with an unstageable pressure wound to the back of his neck caused by the trach ties. Wound NP #703 then stated she was not comfortable with speaking on the phone and provided no further information about the wound. Interview on 03/06/24 at 1:25 P.M. with RT #701 revealed trach ties on any ventilator dependent resident should not cause pressure ulcers to the back of a resident's neck. RT #701 revealed Resident #101's wound was avoidable because the trach ties should be checked daily when staff provided care to ensure at least two fingers could be slipped under the ties to ensure the ties were not too tight on the resident's body. RT #701 confirmed the respiratory therapist was the only staff person who would change trach ties and the trach ties were dated when put on Resident #101 and last changed on 02/23/24. RT #701 revealed the nurses signed off the tie changes on the TAR whereas the RT documented it on the ventilator shift assessment. Observation was conducted on 03/07/24 at 11:00 A.M. of Resident #101 receiving wound care by Licensed Practical nurse (LPN) #717 and LPN #718 who was the facility wound care nurse. State tested Nursing Assistant (STNA) #709 and STNA #716 were also in the room to help position the resident. The observation revealed Resident #101 was difficult to position on his side, he was on a low air loss mattress, tube feeding was placed on hold and the head of the bed was lowered to complete treatment to the wound on the back of his neck. LPN #718 performed hand hygiene, applied gloves, loosened trach ties, and removed the old dressing dated 03/06/24. The wound dressing had no excessive drainage, the wound bed was 100% eschar with pink wound edges without undermining and no signs of infection in the wound. LPN #718 performed hand hygiene and applied new gloves, cleansed the area with normal saline, applied skin prep to the perimeter and then applied Medi honey to the wound bed and covered with a foam dressing and then retightened the trach ties placing two fingers underneath the trach ties to ensure they were not too tight causing additional pressure. The resident was repositioned in bed on his back, he was alert but not responsive to the staff speaking to him. The head of bed was again elevated to at least 30 degrees, tube feeding was turned back on and was running at the appropriate settings. LPN #718 verified these findings at the time of the observation. Interview on 03/11/24 at 1:12 P.M. with the facility wound care nurse, LPN #718 revealed resident was on a low air loss mattress and all other wound care orders were followed. She stated the wound to the back of Resident #101's neck was avoidable, could have been monitored better, and were caused by the trach ties being too tight. LPN #718 indicated Resident #101's PCP #900 does not follow the wounds because there was a physician with the wound care team if any orders were needed, and Wound NP #703 came to the building weekly to assess the wounds in the facility, to do measurements, do treatments and to write any new orders if necessary. PCP #900 verified in a written statement Resident #101, who was dependent on staff for all of his care needs, was found to have a pressure ulcer to the back/rear of his neck that was unstageable at the time of development. Although the physician expressed in writing it was his opinion the ulcer was unavoidable, interviews with RT #701 and LPN #718 identified the pressure ulcer was avoidable and caused by the resident's trach ties being too tight. In addition, the facility's identification of the resident's co-morbidities and increased care needs should have resulted in a more effective and individualized plan of care and pressure ulcer prevention program in accordance with the facility policy to prevent the development of this pressure ulcer. Review of the facility policy titled, Prevention of Pressure Injuries, last revised in April 2020 revealed the purpose of this procedure was to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. This deficiency represents noncompliance identified under Complaint Number OH00151700.

Based on observation, interviews, and review of facility policy, the facility did not ensure all residents were treated with dignity and respect at all times due to multiple staff members not wearing name badges while on duty in the facility. This had the potential to affect all 96 residents living in the facility. The facility census was 96. Findings include: Interviews were conducted intermittently beginning on 03/04/24 at 3:24 P.M. and continued on 03/05/24, 03/06/24, 03/09/24 and 03/11/24 with Residents #10, #13, #24, #35, #50, #57, #60, #62, #65, #74, #75, #84, #90, #94, #96, #97, and #99 who all revealed the staff working in the facility did not wear name tags so they did not always know who was providing care for them. Interviews conducted with the Administrator on 03/04/24 at 1:30 P.M. and on 03/05/24 at 11:00 A.M. confirmed all staff were to wear their name tags at all times while at work so residents are able to identify them. The Administrator stated he was aware the majority of his staff did not wear their name tags, and he was just happy they showed up for work so he did not push the issue with the staff. Observations made on 03/05/24 at 2:30 P.M. and on 03/06/24 form 12:46 P.M. to 2:15 P.M. of State tested Nursing Assistant (STNA) #702, STNA #707, STNA #708, STNA #709, STNA #710, STNA #711, Transportation Aide (TA) #704, and Housekeeper #712 revealed they were not wearing their name tags. Interviews conducted on 03/05/24 at 2:30 P.M. and on 03/06/24 form 12:46 P.M. to 2:15 P.M. with STNA #702, STNA #707, STNA #708, STNA #709, STNA #710, STNA #711, TA #704, and Housekeeper #712 confirmed they were not wearing their name tags. Review of the undated facility policy titled Dress Code revealed under the category Name Badges, All employees must wear a name tag so that residents can identify you. This deficiency represents noncompliance identified under Complaint Number OH00151054.

Based on record review, interview, and policy review the facility failed to ensure restorative range of motion (ROM) exercises were completed as ordered by the physician. This finding affected two residents (#8 and #76) of three residents reviewed for restorative ROM exercises. Findings include: 1. Review of Resident #76's medical record revealed the resident was admitted on [DATE], readmitted on [DATE] and discharged to the hospital on 08/08/23 with diagnoses including anoxic brain damage, muscle weakness, and tracheostomy status. Review of Resident #76's physician orders revealed an order dated 03/29/23 for restorative passive ROM exercises to all extremities for at least fifteen minutes a day every shift. Review of Resident #76's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment and required extensive two staff assist for bed mobility, dressing, and personal hygiene as well as total dependence of two staff assist for transfers, eating, and toilet use. Review of the State tested Nursing Assistant (STNA) tracking documentation from 07/07/23 to 08/15/23 revealed no evidence Resident #76 received passive ROM exercises as ordered. Interview on 08/15/23 at 12:10 P.M. with the Administrator confirmed the order was accidentally entered into Resident #76's electronic charting for staff to do passive ROM exercises as needed. He confirmed Resident #76's medical record and STNA documentation did not have evidence the passive ROM exercises were completed by the nursing staff as ordered. 2. Review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including muscle weakness, acute on chronic diastolic congestive heart failure, and unspecified dementia. Review of Resident #8's physician orders revealed an order dated 02/05/22 for active ROM exercises to all extremities at least fifteen minutes a day every night shift. Review of Resident #8's MDS 3.0 quarterly comprehensive assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of the STNA tracking documentation from 07/18/23 to 08/16/23 revealed no evidence Resident #8 received active ROM exercises as ordered on 07/19/23, 07/23/23, 07/27/23, 07/29/23, 07/30/23, 07/31/23, 08/03/23, 08/07/23, 08/11/23 and 08/14/23. Interview on 08/16/23 at 9:20 A.M. with the Director of Nursing (DON) confirmed Resident #8's medical record did not have evidence the resident received active ROM exercises for ten days from 07/18/23 to 08/16/23. Review of the Restorative Range of Motion Exercises policy, revised 10/10, revealed the purpose of the procedure was to exercise the resident's joints and muscles. This deficiency represents non-compliance investigated under Complaint Number OH00145460.

Based on record review and interview, the facility failed to ensure the accuracy of Resident #76's medical record. This finding affected one resident (#76) of three residents reviewed for the accuracy of the medical records. Findings include: Review of Resident #76's medical record revealed he was admitted on [DATE], readmitted on [DATE] and discharged to the hospital on 08/08/23 with diagnoses including anoxic brain damage, muscle weakness, and tracheostomy status. Review of Resident #76's physician orders revealed an order dated 03/08/23 to shower/bed bath the resident per the resident's father's preference every Monday, Wednesday, and Friday; an order dated 03/29/23 for restorative bilateral hand/wrist splint on for six hours and assess skin prior to application, apply at 12:00 A.M. and remove at 6:00 A.M.; an order dated 06/21/23 to cleanse the percutaneous endoscopic gastrostomy tube (PEG or G tube which was a thin, flexible tube inserted into the stomach wall for nutrition or fluids) with normal saline, apply a dry drain dressing every nightshift; an order dated 07/07/23 to cleanse the left heel with normal saline, pad and protect every night shift for wound prevention; and an order dated 07/25/23 to cleanse the left great toe with Dakins (antimicrobial wound cleanser) 0.125% (percent), apply Medihoney (wound gel with antibacterial properties) to the wound, cover with an abdominal pad and wrap with Kling gauze every night shift for wound management. Review of Resident #76's progress note dated 08/08/23 at 1:21 P.M. indicated the resident was sent out to the hospital per Physician #918. He was sent out due to having a small opening on the top of his head with metal showing and the physician stated that it looked like it may be hardware from a previous procedure. Review of Resident #76's treatment administration record (TAR) dated 08/09/23 revealed Licensed Practical Nurse (LPN) #879 documented she completed the left great toe pressure ulcer wound care dressing, left heel wound care dressing, PEG tube dressing, application of bilateral hand/wrist splints, and a shower one day after the resident was already admitted to the hospital. Interview on 08/15/23 at 2:12 P.M. with the Director of Nursing (DON) confirmed LPN #885 had documented Resident #76 received care after the resident was already admitted to the hospital and the medical record did not accurately reflect the resident's care. This deficiency represents non-compliance investigated under Complaint Number OH00145460.

Based on observation, record review and interview, the facility failed to ensure the menu was followed as written. This had the potential to affect all residents, with the exception of seven residents (#10, #11, #12, #14, #16, #27 and #73) who received no food by mouth. The facility census was 88. Findings include: Review of the menu for breakfast on 08/01/23 revealed a menu of oatmeal or cold cereal, ham, egg, and cheese breakfast omelet muffin and toast. Observation of breakfast on 08/01/23 at 8:40 A.M. revealed scrambled eggs and toast were served. Observation on 08/01/23 at 8:45 A.M. of the menu substitution log revealed no evidence of a substitution to the breakfast meal. Interview on 08/01/223 at 8:48 A.M. with Certified Dietary Manager (CDM) #204 confirmed no substitutions were made to the meal for breakfast on 08/01/23. He confirmed he was not aware scrambled eggs were served in place of the ham, egg, and cheese breakfast omelet. This deficiency represents non-compliance investigated under Complaint Number OH00144779.

Based on observation, record review, interview, and facility policy review the facility failed to ensure a variety of foods were offered and failed to honor resident preferences for meals. This affected five residents (#22, #5, #61, #62, and #78) and had the potential to affect all residents, except for seven residents (#10, #11, #12, #14, #16, #27 and #73) who received no food by mouth. The facility census was 88. Findings include: Review of the medical record for Resident #22 revealed an admitted [DATE]. Diagnoses included sepsis, diabetes, malnutrition, and kidney failure. Review of the diet orders and preferences provided by the facility revealed Resident #22 requested meat with her meal each morning. Review of the menu for the month of July 2023 revealed scrambled eggs were served 15 of 30 days. Interviews on 07/31/23 at 7:16 A.M. with Residents #5, #61, #62, and #78 revealed the same food was always served, especially eggs at breakfast. They didn't eat when they got tired of the same thing being served. Interview and observation on 07/31/23 at 9:16 A.M. revealed Resident #62 had a meal consisting of two muffins and scrambled eggs for breakfast. Observation at the time of the interview of Resident #62's tray ticket revealed he asked for meat for breakfast but did not receive any. Review of the menu for breakfast on 08/01/23 revealed a menu of oatmeal or cold cereal, ham, egg, and cheese breakfast omelet muffin and toast. Observation of breakfast on 08/01/23 at 8:40 A.M. revealed scrambled eggs and toast were served. Observation of Resident #22's breakfast revealed she did not receive meat with her meal. Interview at the time of the observation with Resident #22 confirmed the observation. Interview on 08/01/23 at 8:48 A.M. with Certified Dietary Manager (CDM) #204 confirmed no substitutions were made to the meal for breakfast on 08/01/23. He confirmed he was not aware scrambled eggs were served in place of the ham, egg, and cheese breakfast omelet. He also confirmed some residents received meat at their request but was not aware Resident #22 did not receive the meat she had requested each morning at breakfast. Review of the facility policy titled Food and Nutrition Services dated October 2017 revealed residents would be provided with a well-balanced and consider meal preferences. This deficiency represents non-compliance investigated under Complaint Number OH00144779.

Based on observation, record review, interview, and policy review the facility failed to ensure residents who required assistance with showers received them based on their preference. This affected two residents (#72 and #78) of three residents reviewed for activities of daily living (ADL). The facility census was 88. Findings include: 1. Review of the medical record for Resident #72 revealed an admitted [DATE]. Diagnoses included Multiple Sclerosis, morbid obesity, gastro-esophageal reflux disease (GERD), and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 was cognitively intact. She required total assistance of two people for transfers and toilet use, extensive assistance of two people for bed mobility and dressing and extensive assistance of one person for hygiene. It was very important for her to choose between a bed bath, tub bath, and shower. Review of the physician's orders for July 2023 revealed Resident #72 was to receive a shower based on preference, on Wednesday and Saturday, in the morning and refusals were to be documented. Review of the shower schedule revealed Resident #72 was supposed to receive a shower on Wednesdays and Saturdays on first shift. Review of the State tested Nurse's Aide (STNA) tasks dated 07/08/23 through 07/31/23 revealed Resident #72 had a shower on 07/08/23. Review of the shower sheets revealed Resident #72 had a shower on 07/12/23 and a bed bath on 07/01/23, 07/05/23, 07/19/23, 07/22/23, and 07/29/23. She refused a shower and/or bed bath on 06/28/23. Interview on 07/31/23 at 11:31 A.M. with Resident #72 revealed she would like to have a shower twice a week. She knew her shower days were Wednesday and Saturday, but she does not always get them. Observation at the time of the interview revealed Resident #72's hair was greasy and unkempt. 2. Review of the medical record for Resident #78 revealed an admitted [DATE]. Diagnoses included pulmonary embolism, pulmonary fibrosis, respiratory failure, and muscle weakness. Review of the quarterly MDS assessment dated [DATE] revealed Resident #78 was severely cognitively impaired. He required extensive assistance of one person for toilet use, limited assistance of one person for transfers, dressing and hygiene and supervision of one person for bed mobility. It was somewhat important for him to choose between a bed bath, tub bath, and shower. Review of the physician's orders for July 2023 revealed Resident #78 was supposed to receive a shower based on preference, on Monday, Wednesday, and Friday on night shift, and refusals were to be documented. Review of the shower schedule revealed Resident #78 was supposed to receive a shower on Monday, Wednesday, and Friday on night shift. Review of the STNA tasks dated 07/04/23 through 07/28/23 revealed no documented evidence Resident #78 received a shower during the time frame. Review of the shower sheets revealed Resident #78 had a shower on 07/19/23 and 07/24/23, a bed bath on 07/03/23, 07/17/23, 07/26/23, and 07/28/23. He refused on 06/30/23, 07/05/23, 07/07/23, and 07/14/23. Resident #78 was in the hospital on 07/11/23 through 07/12/23 and again on 07/19/23 through 07/23/23. Interview on 07/31/23 at 9:16 A.M. with Resident #78 revealed he does not get showers, he only got washed up and could not recall when it last occurred. He stated sometimes he would prefer a shower to a bed bath. Interview on 07/31/23 at 2:10 P.M. with STNA's #208 and #209 revealed they asked the resident if they preferred a shower or a bed bath. If a bed bath was preferred over a shower on any given day, they would document such in the medical record, as well as document any shower or bed bath refusals. STNA #208 confirmed Resident #72 preferred a shower over a bed bath. She also confirmed she knew Resident #78 had been in the hospital a few times recently, but she was unsure if she preferred a shower or a bed bath. Interview with Administrator on 08/01/23 at 9:54 A.M. verified resident preferences for type and frequency of showers was assessed on admission. He confirmed showers were not provided to Residents #72 and #78 based on preference or schedule. Review of the facility policy titled Activities of Daily Living (ADL), supporting, dated March 2018, revealed residents who were unable to carry out ADL independently would receive services necessary to maintain good hygiene. This deficiency represents non-compliance investigated under Complaint Number OH0014779.

Based on review of medical records, Facility Reported Incidents (FRIs), facility investigations, the facility's Abuse policy and procedure, and interviews with staff and residents, the facility failed to implement their abuse policy and procedure. This resulted in Immediate Jeopardy when Resident #324, who had known inappropriate sexual behavior, was found with his fingers in Resident #4's vagina and his hand on her breast on 02/23/19 at 5:15 P.M. The likelihood of actual harm occurred when the facility failed to complete a thorough investigation and substantiate the allegation of sexual abuse that had been witnessed by STNA #104. This failure prevented recognition and correction of the system to ensure the safety off all residents residing in the secured dementia unit, Residents #4, #7, #11, #18, #24, #30, #31, #33, #39, #52, #61, #64, #67 and #323. In addition the facility failed to ensure staff implemented their abuse policy regarding an allegation of sexual abuse involving Residents #123 and #72, misappropriation alleged by Resident #45, staff to resident abuse alleged by Resident #10, and resident to resident abuse affecting Residents #11, #283, and #61 which did not rise to the level of Immediate Jeopardy. This affected five of 80 facility residents and six FRIs reviewed. On 03/13/19 at 3:01 P.M. the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 02/23/19 at 6:00 P.M. when Resident #324, with known sexually inappropriate behavior, was discovered by STNA #104 with his fingers in Residents #4's vagina and his hand on resident #4's breasts while she was laying across his bed. There was no evidence statements were obtained from residents on the unit, from other staff working on the unit or the visitor who was a potential witness. There was no evidence residents were assessed for inappropriate sexual behaviors. Only one STNA was working on the unit at the time of the incident as the nurse was at lunch and the other STNA was on a break. The facility did not reassess their staffing level on the secured dementia unit following the incident. The Immediate Jeopardy was removed on 03/14/19 at 10:00 P.M. when the facility implemented the following corrective action: · On 02/23/19 at approximately 5:18 P.M. Resident #324 was placed on one-to- one supervision until he was sent to the emergency roiagnom on [DATE] at 6:55 P.M. · On 02/23/19 between 5:40 P.M. and 7:40 P.M., RN #200 assessed Residents #4, #11, #31, #30, #33, #52, #61, #64 for signs/symptoms of sexual abuse. On 03/14/19 the DON submitted late entry documentation that on 02/23/19 at 7:40 P.M. he assessed Residents #67, #3, #7, #18, #24, #3, #7, #18, #24, #323 for signs/symptoms of sexual abuse. · On 03/13/19 at 6:00 P.M., a new policy and procedures was implemented regarding sexual abuse or sexually inappropriate behaviors for a new or an unknown prior behavior and a dementia unit staffing policy was developed. · On 03/13/19 at 6:00 P.M., Regional Administrator #226 educated the Administrator and DON on the facility's abuse policies, procedures and components of a thorough investigations. · On 03/13/19 at 7:00 P.M., the facility implemented a policy that two staff were always to be present in the secured dementia unit · On 03/13/19 at 7:00 P.M. the Administrator and the DON assessed all residents for a history and/or signs of sexual inappropriateness. · On 03/13/19 at 7:00 P.M. the Administrator and DON audited STNAs #88, #89, #98, #103, #108 and #222 regarding their awareness of residents with inappropriate sexual behaviors and reporting of behaviors. Re-education was completed as necessary. · On 03/13/19 between 8:15 P.M. and 10:00 P.M., all facility staff were educated in person or via telephone regarding abuse policies and procedures, investigation procedures, supervision of residents, the new staffing requirement on the secured dementia unit, and the updated policies that were instituted. · On 03/14/18 Interviews between 8:10 A.M. and 5:22 P.M. with RN #200, STNA #107, #227, #95, and #97, Receptionist #198 and Licensed Practical Nurse (LPN) #150 confirmed they were knowledgeable regarding recognition of abuse and actions to take in the event of witnessing or having a suspicion abuse has occurred. · Interview with the DON on 03/15/19 at 3:00 P.M. confirmed all allegations of abuse, even those reported by residents with dementia would be reported, an addendum to FRI # would indicate the allegation was substantiated, and all investigations that support abuse occurred will be substantiated. Although the Immediate Jeopardy was removed on 03/14/19, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. The findings of the audits and plan of correction would be forwarded to the Quality Assurance and Performance Improvement Committee for further recommendations. Findings include: 1. Review of FRI # 2 dated 02/23/19 revealed an allegation of sexual abuse toward Resident #4 by Resident #324. The report indicated on 02/23/19 Resident #4 was observed semi-nude in Resident #324's bed. He was making physical contact with his hands to her genital area and breasts. Staff intervened before further escalation. The residents were separated and Resident #324 was sent to the emergency room for evaluation. The facility unsubstantiated the allegation due to inconclusive evidence and abuse was not suspected. Resident #324 did not return to the facility. Review of the facility's undated timeline of events revealed on 02/20/19, during a nurse to nurse report via phone before Resident #324's transfer from the hospital to the nursing home, the hospital nurse indicated Resident #324 was sexually inappropriate. Review of RN #200's statement dated 03/13/19 timed 6:45 P.M. revealed upon RN #200's return to the unit from lunch (no time) she was notified by LPN #147 Resident #234 inappropriately touched Resident #4. RN #200 indicated she kept Resident #324 across from the nurse's station and had Resident #4 stay with STNA #104 until emergency medical services (EMS) arrived (no time) to transport Resident #324 to the hospital. When EMS arrived Resident #324 began running around, screaming and became combative. Review of LPN #147's statement dated 03/13/19 timed 9:00 P.M. revealed around 6:00 P.M. STNA #104 was banging on the secured dementia unit's door to get help. After LPN #147 entered the secured dementia unit STNA #104 took Resident #4 and the other residents to the dining room while LPN #147 stayed with Resident #324 at the nurse's station. LPN #147 returned to her unit when RN #200 returned to the secured dementia unit (no time). Review of the Assistant Director of Nursing, RN #208's statement dated 03/13/19 timed 9:30 A.M. indicated on 02/25/19 (no time) she and RN #204 completed a full head to toe assessment on Resident #4 with no abnormalities noted. Interview with the DON on 03/12/19 at 10:35 A.M. revealed he was notified of the incident on 02/23/19 at 5:45 P.M. He said Resident #324 was placed on one-to-one supervision at 5:15 P.M. until EMS removed him from the facility at 6:55 P.M. He said they assessed all the residents on the unit from 5:40 P.M. to 7:40 P.M. to ensure no other residents were affected. He denied knowledge that Resident #324 had a history of [REDACTED]. Interview with the DON on 03/13/19 at 10:35 A.M. confirmed the facility investigation was not thorough as it did not include staff, visitor or resident interviews following the incident. Because the investigation was not thorough systemic problems were not identified and corrective action was not put in place. Further interview with the DON on 03/13/19 at 10:39 A.M. confirmed the facility's investigation related to the sexual abuse indicated the allegation was unsubstantiated. He did not feel abuse occurred and from this point forward he indicated he would not report allegations if he did not feel they would be substantiated. The DON also indicated he based his reporting on each resident and he would not necessarily report allegations made by a resident with dementia. Interview with STNA #104 on 03/13/19 at 2:11 P.M. revealed she worked on the secured dementia unit on 02/23/19 with RN #200 and STNA #115. When STNA #115 was on break and RN #200 was at lunch she was helping a visitor move items out of room [ROOM NUMBER]. As she was assisting the visitor to the exit door of the secured unit she saw Resident #4 on the edge of Resident #324's bed. Resident #4's feet were on the floor and she was lying back across the bed. Her pants and incontinence brief were around her ankles. Resident #324's fingers were inside Resident #4's vagina and his other hand was on her breast. STNA #104 said she screamed at the sight and immediately removed Resident #4 from the room taking her with her to let the visitor out of the secured dementia unit and called for LPN #147 who was at the adjacent nurse's station. Resident #324 was left in his room. She said LPN #147 assessed Resident #4 and informed RN #200 upon her return to the secured dementia unit. STNA #104 said Resident #4 stayed with her until Resident #324 was taken to the hospital. STNA #104 indicated Resident #324 said he did not rape the resident, he just touched her. STNA #104 felt Resident #4 did not comprehend the situation and did not appear to have a negative effect from what had occurred. Interview with LPN #147 on 03/13/19 at 2:48 P.M. revealed she was called to the secured unit by STNA #104 who informed her of what she observed. She said she was shocked at what she was told. She said all residents were kept separated from Resident #324 after the incident. 2. Review of Resident #72's medical record revealed [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #72 was able to make himself understood and he understood others. Resident #72 was assessed as being cognitively intact with no indicators of [MEDICAL CONDITION] and no behavioral symptoms. Resident #72 was dependent on staff for transfers. Resident #72 was independent for locomotion on and off the unit. Resident #72 used a wheelchair for mobility. Review of Resident #123's medical record revealed an admission date of [DATE]. A preadmission screening review (PASAR) dated 08/10/17 indicated Resident #123 received emergency mental health services twice and had two admissions to the inpatient hospital setting for psychiatric services. The PASAR indicated Resident #123 had indications of serious mental illness. [DIAGNOSES REDACTED]. review of a psychiatric progress note dated 10/30/18 indicated Resident #123 was alert and oriented to place and person but not time. No psychotic symptoms were noted. Review of the plan of care summary dated 11/14/18 indicated Resident #123 refused to participate in out of room activities and she socialized with another resident in the movie theater. A Brief Interview for Mental Status (BIMS) dated 12/21/2018 at 4:13 P.M. indicated Resident #123 had moderate cognitive impairment. Review of the quarterly MDS dated [DATE] indicated Resident #123 was able to make herself understood and understood others. No hallucinations, delusions or behavioral symptoms were documented. Resident #123 transferred and walked in the room and corridor with supervision. Resident #123 received an antipsychotic and antidepressant seven days. Review of Facility Reported Incident (FRI) # 4 revealed an allegation of sexual abuse was made on 12/27/18 by STNA #225 who reported on 12/27/18 Resident #123 was sitting on a couch in the facility's theater room with Resident #72. As STNA #225 entered the room, she discovered Resident #72 had his hand in Resident #123's pants with a blanket over it. STNA #225 immediately reported the observation. Both residents were immediately interviewed and denied any sexual relationship, stating they were very good friends. The FRI indicated Resident #123 had [DIAGNOSES REDACTED]. Resident #123 denied any sexual contact with Resident #72. Review of the FRI indicated Resident #72 had no psychiatric history and indicated he did not have his hand placed in Resident #123's pants and he was just holding her hand. The conclusion listed on the FRI indicated both residents were their own responsible parties and the psychiatrist verified both residents were competent and able to make decisions about their personal relationships. Review of the facility's Resident Abuse Investigation Report form indicated on 12/27/18 at 10:00 A.M. Activity Staff #82 walked by the theater room and saw Residents #72 and #123 watching television. Resident #123 was on the couch and Resident #72 was in his wheelchair. A blanket was over Resident #123's lap and Resident #72's hand was under the blanket. Activity staff #82 thought, but could not prove, Resident #72's hand was down Resident #123's pants. Activity Staff #82 was the only initial witness and reported the incident at 11:00 A.M. The DON indicated he immediately went to the theater room after being informed of the incident. The DON indicated he saw Residents #72 and #123 sitting next to each other with Resident #72's hand under the blanket. Resident #72's hand was observed moving at the time, but the DON was not certain he was doing anything sexual. The DON documented when he knocked on the door it was open and neither resident seemed startled. The report indicated when Resident #72 was interviewed he stated he was only holding Resident #123's hand and there was nothing sexual about it. Resident #123 stated nothing was happening. They were only holding hands. On 03/12/19 at 10:40 A.M., the DON was interviewed regarding the facility's investigation. The DON verified there was no investigation regarding the failure of Activity Staff #82 to separate the residents before she reported suspected inappropriate sexual interaction. Regarding the discrepancy of the witness information between the FRI and the investigation. The DON stated he originally thought the person who reported the incident was STNA #155 but learned it was Activity Staff #82. On 03/13/19 at 10:39 A.M., the DON was interviewed and verified when Activity Staff #82 thought inappropriate behavior might be occurring between the two residents, the residents were not separated. The DON stated after the allegation of sexual abuse was made, he went to the theater room and interviewed Residents #72 and #123 at the same time instead of interviewing them separately in case there was abuse occurring. The DON stated he was able to observe the top of Resident #123's pants above the blanket but was not sure if the pants had a zipper or other means of access. The DON was asked about the FRI indicating both residents were assessed for competence by a psychiatrist and he verified Resident #72 was not assessed by the psychiatrist because staff knew he was competent. The DON stated when he went to the theater room he could tell from the residents' expressions that Resident #72 did not have his hands down Resident #123's pants. The DON verified he did not obtain written statements according to policy and had not interviewed any additional staff or residents. While being questioned about staff actions and the investigative process, the DON responded he did not feel abuse occurred and from this point forward he would not report allegations if he did not feel they would be substantiated. The DON also indicated he based his reporting on each resident and he would not necessarily report allegations made by a resident with dementia. On 03/18/19 at 7:27 A.M., the Administrator stated he and the DON shared responsibilities for allegations of abuse, neglect and misappropriation. The DON was responsible for investigation of allegations dealing with nursing matters and the administrator dealt more with allegations regarding misappropriation or administrative nature. The Administrator stated he and the DON sometimes discussed investigations and he had not identified any concerns regarding the thoroughness of investigations. 3. Review of Resident #45's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. A modification of a quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #45 was able to make herself understood, was cognitively intact and exhibited no potential indicators of [MEDICAL CONDITION] such as hallucinations or delusions. During review of the facility's Record of Complaint forms (identified as missing item tracking by the administrator), a complaint form dated 02/20/19 indicated Resident #45 informed the administrator that on Monday (no date specified) around 1:00-2:00 P.M. one of the black aides took some of her Pepsi and drank them. The investigation part of the form indicated the administrator was to check tapes to try and verify if this took place. Under conclusion, documentation indicated administration wanted to replace a 12 pack of Pepsi. During an interview on 03/13/19 at 10:38 A.M., the DON indicated the concierge visited residents every day Monday through Friday. If there were any complaints of abuse, neglect or misappropriation, the allegation was reported to the administrator or himself. On 03/13/19 at 10:43 A.M., the administrator verified he did not report the allegation due to inconsistencies in Resident #45's details of events. The administrator reported he had never checked the video recordings. Resident #45 usually kept the Pepsi in her room. At 11:00 A.M., the administrator stated he spoke to Resident #45's responsible party who verified Resident #45 had Pepsi and did not believe she could have consumed it all herself. The administrator stated he believed the responsible party. 4. Record review revealed Resident #10 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact with no behaviors, independent for most activities of daily living (ADL), always continent of bladder and bowel with no falls and no pressure ulcers. The care plan dated 12/31/18 included care areas for self-care deficit, pain, unclear speech, [MEDICAL CONDITION] disorder, risk of falls, potential for behaviors and decline in mood. Review of the Facility Reported Incident (FRI) # 0 dated 02/25/19 revealed the resident reported to the DON on 02/22/19 at approximately 9:00 P.M. that STNA #228, on night shift, threatened him by shaking her fist and slamming the resident's door. Review of the facility investigation dated 02/25/19 revealed there were no statements from any staff or residents. On 03/12/19 at 11:00 A.M the DON provided a typed undated statement listing resident names and indicating no concerns with STNA #228 except for Resident #10. The statement did not include dates and times of interviews. 5. Review of medical record for Resident #43 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Date Set (MDS) 3.0 assessment dated [DATE] revealed the resident was severely cognitively impaired with no behaviors and required extensive assistance of two to total dependence for activities of daily living. Review of the care plan dated 02/22/19 revealed care areas included communication difficulties and impaired cognitive functioning. Review of the Facility Reported Incident (FRI) dated 11/02/19 revealed a substantiated allegation of resident to resident abuse by Resident #43 directed toward Resident #11 on the secured dementia unit. The report investigation form dated 11/02/18 indicated Resident #43 hit Resident #11's arm with his arm at 1:00 P.M. on 11/02/18. The incident was witnessed and reported on 11/02/18 by Physical Therapist Assistant (PTA) #191. The witness statement from PTA #191 did not include a time but indicated Resident #43 was grabbing the wheelchair of Resident #283 prior to hitting Resident #11. Resident #283 was calling for help and PTA #191 tried to remove Resident #43's hands from Resident #283's wheelchair. The investigation did not include an assessment of Resident #283 for injuries. Review of a FRI dated 11/15/18 revealed STNA #102 witnessed Resident #43 strike Resident #283 and Resident #61 on 11/14/18 at 1:00 P.M. STNA #102 reported the incident on 11/14/18 (no time) to the DON. Review of the facility investigation revealed there were no staff statements, including STNA #102. The DON completed the facility resident abuse investigation reporting form summarizing what was reported by STNA #102. STNA #102 did not sign the summary that was written by the DON. Interview with the DON on 03/18/19 at 10:56 A.M. verified the above incidents occurred close to each other and review of what may had led up to the incident of 11/02/19 may have prevented the incident on 11/14/19. Review of the facility's Abuse Investigations policy, dated 12/08/16, indicated all reports of alleged resident abuse, neglect, exploitation and injuries of unknown origin would be promptly and thoroughly investigated by the facility's Abuse Prohibition Coordinator. Review of the facility's Abuse, Neglect and Exploitation of Residents policy, revised 12/08/16, revealed while the investigation was being conducted, the resident would be protected, and any accused individuals would be denied unsupervised access to residents. Visits could only be made in designated areas approved by the administrator. If the alleged abuse involved another resident, the accused resident was not to be permitted to make visits to other resident rooms unattended. Investigations would be thoroughly documented including interviews with the person reporting the incident, any witnesses, the resident affected, staff members and volunteers on all shifts who had contact with the resident during the period of the alleged incident, the resident's roommate, family members and visitors and other residents. The investigated would also include review of the resident's medical record to identify events leading up to the alleged incident. Misappropriation of resident property was identified as an act or improper course of conduct, including the deliberate misplacement, exploitation or wrongful (temporary or permanent) use of a resident's belongings or funds without the resident's consent. Upon receiving an incident or suspected incident of misappropriation of resident property, the Administrator/DON/designee would conduct an investigation. Witness reports were to be in writing. Witnesses were required to sign and date such reports. A copy of such reports must be attached to the Abuse Investigation Report Form. The individual conducting the investigation was required to follow the procedure and investigation when an incident of resident misappropriation of property was alleged or suspected. All alleged suspected violations were required to be promptly reported to the appropriate State agencies and other entities or individuals as required by law. The reporting guidance indicated federal regulation required that alleged violations of misappropriation of resident property be reported immediately. The facility must report to the State agencies alleged violations of misappropriation of resident property, if and when the reasonable cause threshold had been achieved. The facility must report misappropriation of resident property within 24 hours after the reasonable cause threshold (suspicion) was concluded. If reasonable cause was not found, the facility was not required to report alleged incidents of misappropriation. This deficiency substantiates Self Reported Incident Control Number OH 888.

Based on review of medical records, Facility Reported Incidents (FRIs), facility investigations, the Abuse policy and procedure and interviews with staff and residents, the facility failed to ensure Resident #4, assessed as severely cognitively impaired and residing on a secured dementia unit, was free from sexual abuse by Resident #324, who was known to have sexually inappropriate behavior. Based on the reasonable person concept, this resulted in Immediate Jeopardy for Resident #4 who was sexually assaulted by Resident #324. Actual harm occurred when Resident #324 was found with his fingers inside Resident #4's vagina and his hand on her breast while she was laying across his bed. This affected one resident (Resident #4) and had the potential to affect 13 vulnerable residents on the secured dementia unit (Residents #7, #11, #18, #24, #30, #31, #33, #39, #52, #61, #64, #67 and #323). On 03/13/19 at 3:01 P.M. the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 02/23/19 at 5:15 P.M. when Resident #324, was discovered by State tested Nurse Aide (STNA) #104 with his fingers in Resident #4's vagina and his hand on her breast while she laid across his bed. Resident #4 was severely cognitively impaired and unable to provide consent. The residents were separated and after additional help was obtained, because STNA #104 was the only staff member present for 13 residents with dementia on the secured unit, Resident #324 was placed on one-to-one supervision until emergency medical services (EMS) arrived to transport him to the hospital. The Immediate Jeopardy was removed on 03/14/19 at 10:00 P.M. when the facility implemented the following corrective action: · On 02/23/19 at 5:18 P.M., Resident #324 was placed on one-to-one supervision until he was sent to the emergency roiagnom on [DATE] at 6:55 P.M. · On 02/23/19 between 5:40 P.M. and 7:40 P.M., RN #200 and the DON assessed Residents #4, #11, #31, #30, #33, #52, #61, #64, #67, #3, #7, #18, #24, #3, #7, #18, #24, #323 for signs/symptoms of sexual abuse. · On 03/13/19 at 6:00 P.M., a new policy and procedure was implemented regarding sexual abuse/sexually inappropriate behavior for a new or an unknown prior behavior and a dementia unit staffing policy. · On 03/13/19 at 6:00 P.M., Regional Administrator #226 educated the Administrator and DON on the facility's abuse policies, procedures and components of a thorough investigation. · On 03/13/19 at 7:00 P.M., the facility implemented a policy that two staff were always to be present in the secured dementia unit. · On 03/13/19 at 7:00 P.M., the Administrator and the DON assessed all residents for a history and/or signs of sexual inappropriateness. · On 03/13/19 at 7:00 P.M. the Administrator and DON audited STNAs #88, #89, #98, #103, #108 and #222 regarding their awareness of residents with inappropriate sexual behaviors and reporting of behaviors. Re-education was completed as necessary. · On 03/13/19 between 8:15 P.M. and 10:00 P.M., all facility staff were educated in person or via telephone regarding abuse policies and procedures, investigation procedures, supervision of residents, the new staffing requirement on the secured dementia unit, and the updated policies that were instituted. · On 03/14/18 interviews between 8:10 A.M. and 5:22 P.M. with RN #200, STNAs #107, #227, #95, and 97, Receptionist #198 and Licensed Practical Nurse (LPN) #150 confirmed they were knowledgeable regarding recognition of abuse and actions to take in the event of witnessing or having a suspicion abuse has occurred. · Interview with the DON on 03/15/19 at 3:00 P.M. confirmed all allegations of abuse, even those reported by residents with dementia would be reported. An addendum to FRI # 2 would indicate the allegation was substantiated and all investigations that support abuse occurred will be substantiated. Although the Immediate Jeopardy was removed on 03/14/19, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. The findings of the audits and plan of correction would be forwarded to the Quality Assurance and Performance Improvement Committee for further recommendations Findings include: Review of FRI # 2 dated 02/23/19 revealed an allegation of sexual abuse by Resident #324 toward Resident #4. The report indicated on 02/23/19 Resident #4 was observed semi-nude in Resident #324's bed. Resident #324 was making physical contact with his hands to Resident #4's genital area. Staff intervened before further escalation. The residents were separated and Resident #324 was sent to the emergency room for evaluation. The facility unsubstantiated the allegation due to inconclusive evidence and abuse was not suspected. Resident #324 did not return to the facility. Review of the medical record revealed Resident #324, a 71- year-old male, was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #324 had short and long-term memory problems, moderate cognitive impairment for daily decision making, no behavioral symptoms and required the limited assistance of one person for activities of daily living. Review of the facility's undated timeline of events revealed on 02/20/19, during a nurse to nurse report via phone before Resident #324's transfer from the hospital to the nursing home, the hospital nurse indicated Resident #324 was sexually inappropriate. Review of the admission plan of care dated 02/20/19 revealed Resident #324 had behavioral symptoms with a goal of having fewer episodes of being sexually inappropriate. The interventions included to re-direct the resident as needed, ask for help if resident was abusive or resistive, keep the environment calm and relaxed, remove from public area when behavior improper, encourage diversional activities, monitor internal and external factors and consult psychological services as needed. Review of a progress note dated 02/23/19 at 6:55 P.M. authored by RN #200 revealed Resident #324 was transferred to the hospital where it took three EMS attendants to put him on the gurney because he was very hostile and combative. Review of the medical record revealed Resident #4, a 59 - year-old female, was admitted on [DATE] with [DIAGNOSES REDACTED]. and dementia without behavioral disturbance. Review of physician orders [REDACTED].#4 had an indwelling urinary catheter. Review of a recreation evaluation dated 09/07/18 revealed Resident #4 was never married, had one child and her occupation was a nurse aide/therapy aide. Review of an activity assessment dated [DATE] revealed Resident #4 engaged in small group memory programs and activities. She enjoyed music and with assistance and direction she liked to do Arts and Crafts. Review of the Alzheimer's/dementia unit review dated 02/06/19 indicated Resident #4 wandered and was at risk for elopement and met the criteria for residing on the secured dementia unit. Review of the MDS 3.0 assessment dated [DATE] indicated Resident #4 was severely cognitively impaired and displayed wandering behaviors. She required the limited assistance of one staff for transfers, extensive assistance of one for dressing and toilet use. Review of a late entry progress note dated 02/23/19 and timed 6:00 P.M. authored by the DON, who was not present in the facility at the time of the incident, revealed Resident #4 was in a male resident's room. She was laying on the male resident's bed semi-nude. The male resident was sitting next to her. Staff walked into room and prevented further escalation. It was noted both residents were afflicted with dementia and were unable to give consent for sexual relations. The male resident was sent to hospital and later admitted . A complete body check was completed (for Resident #4) with no abnormalities noted. The son and physician were made aware. Observations of Resident #4 on 03/11/19 at 8:45 P.M., on 03/12/19 at 8:00 A.M. and continued intermittent observations between 03/11/19 and 03/18/19 revealed the resident wandering throughout the hallway of the unit periodically following the nurse or an STNA. At times staff redirected Resident #4 to the dining room. Attempts to contact Resident #4's family on 03/12/19 at 10:48 A.M. and 11:30 A.M. and on 03/13/19 at 3:38 P.M. were unsuccessful. Review of STNA #115's statement dated 03/13/19 timed 7:30 P.M. signed by the DON revealed Resident #324 did not display inappropriate sexual behaviors during the day on 02/23/19. Review of RN #200's statement dated 03/13/19 timed 6:45 P.M. revealed upon RN #200's return to the unit from lunch (no date or time specified) she was notified by LPN #147 that Resident #324 inappropriately touched Resident #4. RN #200 indicated she kept Resident #324 across from the nurse's station and had Resident #4 stay with STNA #104 until EMS arrived to transport Resident #324 to the hospital. When EMS arrived (no time specified) Resident #324 began running around, screaming and became combative. Review of LPN #147's statement dated 03/13/19 timed 9:00 P.M. revealed STNA #104 was banging on the secured dementia unit's door to get help (no date or time specified). After LPN #147 entered the secured dementia unit STNA #104 took Resident #4 and the other residents to the dining room while LPN #147 stayed with Resident #324 at the nurse's station. LPN #147 returned to her unit when RN #200 returned to the secured dementia unit (no time specified) Review of the Assistant Director of Nursing, RN #208's statement dated 03/13/19 timed 9:30 A.M. indicated on 02/25/19 (no time specified) she and RN #204 completed a full head to toe assessment on Resident #4 with no abnormalities noted. Interview with the DON on 03/12/19 at 10:35 A.M. revealed he was notified of the incident on 02/23/19 at 5:45 P.M. He said Resident #324 was placed on one-to-one supervision at 5:15 P.M. (the time STNA #104 found the residents) until EMS removed him from the facility at 6:55 P.M. He said they assessed all the residents on the unit from 5:40 P.M. to 7:40 P.M. to ensure no other residents were affected. He denied knowledge that Resident #324 had a history of [REDACTED]. Interview with RN #200 on 03/12/19 at 11:35 A.M. revealed she had never met Resident #324 before 02/23/19. RN #200 said on 02/23/19 Resident #324 followed Resident #4 around and she told STNA #104 to keep an eye on him because something was up. RN #200 got back from lunch to find out STNA #104 found him on top of Resident #4 ready to do it. Resident #324 had a hand on Resident #4's breast and a hand down her incontinence brief. RN #200 said Resident #324 molested Resident #4 and Resident #4 had the mind of a two year old. RN #200 called the DON and was told to keep Resident #324 on one-to-one supervision. RN #200 told the DON she was sending Resident #324 out to the hospital and kept him on one-to-one supervision until he left the facility. RN #200 said the hospital called to send him back to the facility and she refused to accept him because he put everyone at risk. RN #200 indicated she found out in the nurse to nurse report later that day that Resident #324 had a history of [REDACTED]. A follow up interview on 03/13/19 at 10:39 A.M. with the DON confirmed the facility's investigation related to the sexual abuse indicated the allegation was unsubstantiated. The DON stated he did not feel abuse occurred and from this point forward he would not report allegations if he did not feel they would be substantiated. The DON also indicated he based his reporting on each resident and he would not necessarily report allegations made by a resident with dementia. Interview with STNA #104 on 03/13/19 at 2:11 P.M. revealed she worked on the secured dementia unit on 02/23/19 with RN #200 and STNA #115. When STNA #115 was on break and RN #200 was at lunch she was helping a visitor move items out of room [ROOM NUMBER]. As she was assisting the visitor to the exit door of the secured unit she saw Resident #4 on the edge of Resident #324's bed. Resident #4's feet were on the floor and she was lying back across the bed. Her pants and incontinence brief were around her ankles. Resident #324's fingers were inside Resident #4's vagina and his other hand was on her breast. STNA #104 said she screamed at the sight and immediately removed Resident #4 from the room taking her with her to let the visitor out of the secured dementia unit and called for LPN #147 who was at the adjacent nurse's station. Resident #324 was left in his room. She said LPN #147 assessed Resident #4 and informed RN #200 upon her return from lunch. STNA #104 said Resident #4 stayed with her until Resident #324 was taken to the hospital. STNA #104 indicated Resident #324 said he did not rape the resident, he just touched her. STNA #104 felt Resident #4 did not comprehend the situation. Interview with LPN #147 on 03/13/19 at 2:48 P.M. revealed she was called to the secured unit by STNA #104 who informed her of what she observed. She said she was shocked at what she was told. She said all residents were kept separated from Resident #324 after the incident. Interview with the clinical liaison, who assessed Resident #324 for his appropriateness for admission to the facility, on 03/13/19 at 5:30 P.M. revealed she reviewed the medical record and there was no indication of sexually inappropriate behaviors. The clinical liaison gave no indication she spoke with nurses who cared for Resident #324. Interview with Social Service Designee #221 on 03/14/19 at 7:45 A.M. revealed Resident #4 was a homemaker and had no evidence of being sexually inappropriate or having promiscuous behaviors. Review of the facility's Abuse Investigations policy, dated 12/08/16, indicated while the investigation was being conducted, the resident would be protected, and any accused individuals would be denied unsupervised access to residents. Visits could only be made in designated areas approved by the administrator. If the alleged abuse involved another resident, the accused resident was not to be permitted to make visits to other resident rooms unattended. This deficiency substantiates Self Reported Incident Control Number OH 888.

Based on observation, record review, policy review and interviews, the facility failed to prevent and promptly identify a pressure ulcer for Resident #95. This resulted in harm when Resident #95 developed a facility acquired, unstageable pressure ulcer on his right heel which became infected. This affected one of 3 residents reviewed for pressure ulcers. Findings include: Resident #95 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #95 was cognitively intact and was alert and oriented based on a brief interview for mental status (BIMS). The assessment indicated the resident was at risk for the development of pressure ulcers and had no unhealed pressure ulcers at that time. The MDS assessment revealed Resident #95 required extensive assistance of two persons for bed mobility, transfers, dressing and toileting. Resident #95's potential for pressure ulcer development plan of care, initiated on 03/15/16, indicated that the facility would follow their policies for the prevention and treatment of [REDACTED]. The Treatment Administration Record (TAR) for the period of 06/01/16 to 06/30/16, indicated visual skin checks for Resident #95 were documented on 6/02/16 and 06/09/16. Nursing Progress Notes dated 6/10/16 revealed the Resident's son alerted the nurse and revealed Resident #95 had an open area on his right heel. The nurse wrote the observed heel area was 1.5 centimeters (cm) long by 1.8 cm wide by 0.1 cm deep, and appeared to be caused by pressure. A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissues. The area was described as yellow and brown in color. The note indicated the resident reported he began having pain in the area on Monday, 06/06/16. Resident #95 was educated that he needed to inform staff right away of any pain so they can take a look at it. The note revealed the resident stated the area was painful. A new order was received to elevate his heels at all times while in bed. The Weekly Wound Report dated 06/13/16 revealed that an unstageable, right heel, pressure ulcer was discovered that measured 0.9 cm by 1.2 cm by 0.2 cm in depth. The wound's appearance was documented as granulation tissue and slough with a small amount of drainage. Slough is necrotic (dead) tissue in the process of separating from the viable portions of the body. The corresponding wound consultant report dated 06/13/16, was signed by Certified Nurse Practitioner (CNP) #149. The report revealed that Resident #95 reported that his heel had been hurting him recently. The CNP's assessment indicated his capillary refill was less than two seconds, and both pedal pulses were palpable. The CNP determined the wound was an unstageable pressure ulcer that measured 0.90 cm by 1.2 cm by 0.20 cm deep. The CNP documented the wound had a moderate amount of serous exudate and the wound bed had a necrotic amount of 25 to 50% of loosely adherent yellow slough. CNP #149 wrote an order for [REDACTED].>The ultrasound report dated 06/14/16 indicated a venous duplex ultrasound was performed on both lower extremities (legs/feet) due to the resident's unspecified open wound on his right foot. The results revealed that all deep veins showed good compressibility and blood flow. The ultrasound report dated 11/10/16 indicated that an arterial duplex ultrasound was performed due to pain in the right foot. The impression was mild [MEDICAL CONDITION] with no demonstrated high-grade stenosis or occlusion. The wound culture report from 11/12/16 revealed the pressure ulcer was abscessed with heavy growth of [MEDICAL CONDITION] (MRSA). The Weekly Wound Report from 11/29/16 revealed Resident #95's right heel pressure ulcer measured 1.8 cm by 1.0 cm and 0.1 cm deep, with a wound bed described as [MEDICATION NAME] and slough. During an interview on 12/05/16 at 11:01 A.M., Resident #95 was asked about the padding noted on his right foot. Resident #95 revealed that he acquired a pressure ulcer from his bed, in June. He indicated that his family did his laundry and they noted something gooey in his sock and reported it to the nurse. He indicated that's when the staff found the hole on his right heel. On 12/07/16 at 9:33 A.M., LPN #104 was observed providing wound care for Resident #95. Resident #95 had a right heel wound that measured approximately 2.0 cm by 1.5 cm by less than 0.1 cm. There was an area of dark, black necrosis that filled approximately one-half of the wound bed, with the center of the wound red and dry. During an Interview on 12/08/16 at 3:01 P.M., the Director of Nursing (DON) verified the Nurses' Progress Note of 06/10/16 revealed Resident #95's son notified the nurse of the open area on the resident's right heel and acknowledged that the area was yellow/brown upon discovery. The DON verified that per facility documentation the Resident's skin check had been completed on 6/09/16. He indicated that the weekly skin checks were supposed to include a full body exam. The DON verified the wound on Resident #95's right heel had not been discovered until it had progressed to unstageable and only after notification by Resident #95's family member.

Based on observation, record review and interview, the facility failed to provide sufficient dental services and adequate pain management for Resident #71, who was observed to exhibit non-verbal signs of pain during oral care. The failure of not providing sufficient dental services resulted in actual harm to Resident #71 who experienced mouth pain related to a blackened, decayed tooth. This affected one resident (Resident #71) of three sampled residents reviewed for dental services of 35 residents who were observed related to oral care. The facility census was 67. Findings include: Resident #71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident received nutrition via a gastrostomy tube ([DEVICE]), which was a tube inserted through the skin into the stomach for the purpose of providing food for residents who are unable to take it by mouth due to swallowing problems. Review of a Minimum Data Set (MDS) 3.0 assessment, completed on 04/16/13, revealed the resident was severely cognitively impaired, non-verbal, and unable to make her needs known. Review of a plan of care related to risk for oral complications revealed the goal was to be complication free. Interventions included daily oral care and to provide dental exams as needed. On 06/22/13 at 3:13 P.M., interview by phone with the resident's daughter, who was her responsible party, revealed the following: When asked if Resident #71 had any dental problems the daughter responded yes. The daughter explained that she had noticed, a few months ago, maybe longer, that one of her mother's lower teeth had turned black and looked like it was rotting. The daughter expressed concern that even though her mother did not take food by mouth, she thought it caused her mother some discomfort. The daughter said she had noticed her mother would sometimes go through chewing motions and would make faces and grimace as though she had pain. Resident #71's daughter could not say specifically who she had reported this to but thought it was one of the nurses. Resident #71's daughter was told the resident would be seen by the dentist, but as far as she knew that had not happened. On 06/24/13 at 7:45 A.M., Resident #71 was observed laying in bed in her room. The resident was observed to have bottom teeth only. Observation of the resident's bottom teeth revealed there was a fair amount of tartar build up around the teeth and one tooth, the second from the right on the lower gum was black in color. Interview with a state tested nursing assistant (STNA #15), revealed she was assigned to Resident #71. Mouth care was provided at least once a shift and as needed with foam swabs per the STNA. On 06/24/13 at 10:49 A.M., Resident #71 was observed for mouth care provided by STNA #15. STNA #15 entered the room, washed her hands, applied gloves and explained the procedure to the resident. STNA #15 dipped a foam toothette into mouthwash and proceeded to swab the resident's mouth cavity, gums and teeth. The resident kept her mouth closed over the swab during care. STNA #15 then attempted to brush the resident's lower teeth with a toothbrush dipped in mouthwash. The STNA gently pulled the resident's lower lip down and coaxed the resident to keep her mouth open. There was one blackened tooth visible on the right side and the STNA brushed the teeth on the left side first. Then, as she proceeded to brush on the right side, the resident pulled her head back into the pillow, turned her head to the side and grimaced. STNA #15 finished mouth care using another foam swab and verified the resident showed signs of discomfort during upon brushing teeth on the right side where the blackened tooth was. STNA #15 explained that was why she usually used a toothette instead of a toothbrush. STNA #15 had not notified the nurse of the non-verbal indications of pain with mouth care or the blackened tooth for Resident #71. Record review revealed physician's orders [REDACTED]. There was no further evidenced follow up completed to address the cause of the pain during oral care, or any evidence an assessment was conducted and interventions implemented to alleviate the mouth pain. On 06/25/13 at 11:00 A.M., the director of nursing verified STNA #15 should have notified the nurse of the non-verbal signs of pain exhibited by Resident #71 when she brushed her teeth so that the nurse could assess the resident and provide appropriate care and pain medication.

Based on observation, record review and interview, the facility failed to provide incontinence services to Resident #90, resulting in the Actual Harm of the resident becoming frequently incontinent of bladder after her admission to the facility. The facility did not implement the planned toileting program for Resident #64. This affected two residents reviewed regarding incontinence of 39 residents identified in the facility as incontinent. Findings include: 1. Resident #90 was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident's primary language was Spanish. The admission nursing evaluation dated 03/02/12, revealed the resident was continent of bladder. The bowel and bladder assessment dated [DATE], indicated the resident was a candidate for a scheduled toileting program. The minimum data set (MDS) assessment dated [DATE], indicated the resident was not on a toileting program and was occasionally incontinent. The care plan dated 03/22/12, indicated the resident was occasionally incontinent of urine and there was not on a toileting program or scheduled toileting. The MDS assessment dated [DATE], indicated the resident was not on a toileting program and was frequently incontinent of bladder. An interview with Licensed Practical Nurse (LPN) #9 on 06/28/12 at 4:04 P.M., verified Resident #90 should be on scheduled toileting. He verified there was no scheduled toileting on the care plan and the MDS assessment dated [DATE] indicated there was no toileting program. He verified the resident was continent upon admission in March 2012, and declined to frequently incontinent by the May assessment. On 06/29/12 at 10:30 A.M., Registered Nurse (RN) #52 revealed several staff spoke and understood Spanish and communicated with Resident #90. She stated there was also a communication board that could be used to communicate with the resident. She verified there was no problem with the staff understanding the needs of the resident. 2. Resident #64 was readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Resident Care Card updated 03/26/12, revealed Resident #64 was on a scheduled every two hour toileting program to manage incontinence. Review of Bladder Assessments dated 04/06/12 and 05/15/12, revealed a three day bladder tracking was completed for each assessment. Resident #64 was placed on an every two hour toileting program using a bedpan. Review of an MDS assessment dated [DATE], revealed Resident #64 sometimes made herself understood and sometimes understood others. The MDS revealed Resident #64 was always incontinent and on a toileting program. An interview was completed with Licensed Practical Nurse (LPN) #8 on 06/27/12 at 10:15 AM. She said Resident #64 was out of bed daily for a short period of time and usually requested to return to bed. Resident #64 did not request a bedpan but was on a toileting program. The aides would assist her onto a bedpan every two hours to manage incontinence. LPN #8 revealed the state tested nurse aides (STNAs) were aware of resident needs through reviewing the Resident Care Card, daily verbal report from the nurses and consistent assignments. An interview with STNA #42 on 06/27/12 at 11:16 AM., revealed she was the STNA providing care for Resident #64. She said she frequently worked the unit and cared for the resident. STNA #42 said Resident #64 was not on a toileting program, she never offered the resident a bedpan and the resident's incontinence needs were met by checking her incontinence brief every two hours and as needed. On 06/27/12 at 11:18 A.M., Resident #64 was observed in bed positioned on her right side. An incontinence brief was visible. Resident #64 was awake and alert. She was pleasant and answered questions clearly and appropriately. She said she didn't use a bedpan and could tell when she needed to urinate. She said the aides didn't offer her a bedpan. She wasn't sure she'd want to use a bedpan because they were uncomfortable, but she couldn't physically use the toilet. On 06/28/12 at 9:00 A.M., STNA #43 was feeding and interacting with Resident #64. Following the meal, an interview with STNA #43 revealed Resident #64 was not on a toileting program, the resident did not ask for a bedpan and STNA #43 did not offer a bedpan. The STNA met the resident's incontinence needs by checking her brief every two hours and changing her as needed. An interview with the restorative nurse, LPN #9, on 06/28/12 at 9:50 A.M., verified assessments and planned interventions for Resident #64 revealed scheduled toileting with the use of a bedpan should be completed every two hours and as needed.

Based on observation, interview and record review, the facility failed to ensure splint devices were applied as ordered to maintain current function and prevent decline for one resident (Resident #13). This affected one of four residents who were reviewed relative to activities of daily living. Findings include: Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #13 was a paraplegic, was paralyzed from the waist down and had only minimal movement of arms and hands. Resident #13 was alert and oriented and able to make her needs known. Review of Resident #13's record revealed a physician's orders [REDACTED]. Review of therapy assessment documentation revealed Resident #13 was evaluated on 09/23/11 relative to muscle weakness. The resident required maximum assistance for all activities of daily living and had limited range of motion of both arms. Wrist splints were ordered to prevent wrist drop. A Minimum Set Data (MDS) assessment completed 04/03/12, revealed the resident required extensive assist with all activities of daily living and had limited range of motion of arms and legs. A plan of care relative to activities of daily living was initiated on 09/12/11, and last updated on 06/15/12. Resident #13 had impaired mobility and hand dexterity, decreased range of motion and was primarily dependent for tasks related to a [DIAGNOSES REDACTED]. Interventions included hand splints on at bedtime and off in the morning and to notify the nurse of splint refusal. On 06/26/12 at 10:32 A.M., Resident #13 was observed seated in a customized electric wheel chair in her room and was watching television. Both of the resident's hands were contracted into fists. The resident did not have hand splints in place. Interview revealed the resident had been asking for therapy for a long time. She said for approximately a year off and on but more recently, in the last couple of months she noticed her left hand was "almost completely closed up and the right one was getting worse too." The resident said she had no splint devices for her hands. On 06/26/12 at 4:41 P.M., Resident #13 was observed laying in bed with her eyes closed. There were no splints in place on either hand. The left hand was in a fisted position and the right hand was partially fisted. The resident aroused easily and she repeated it had been a long time since she had splints on her hands and finally someone came to see her that day. The resident was happy to say she would be getting hand splints and doing exercises. On 6/27/12 at 7:10 A.M., Resident #13 was in bed asleep. There were no hand splints on the resident's hands or splint devices in the resident's room. On 06/27/12 at 7:27 A.M., interview with State tested Nurse Aide (STNA) #31 revealed the nurse aides used the resident care cards as their source of information for resident care needs such as the use of hand splints. STNA #31 found Resident #13's care card which indicated the resident was alert and oriented, had hand splints on at bedtime and off in the A.M. STNA #31 had not removed hand splints for Resident #13 that morning and did not recall the resident ever having hand splints. On 06/27/12 at 7:30 A.M., interview with Licensed Practical Nurse (LPN) #32 revealed she was aware Resident #13 was to have hand splints on at bedtime and off in the morning. LPN #32 explained she vaguely recalled someone had recently talked with her about Resident #13 and the missing hand splints. She did not know where the splints were, how long they had been missing or when the resident last had them on as ordered. LPN #32 explained Resident #13 sometimes refused the hand splints and staff documented refusals on the treatment administration record (TAR). Review of the resident's TARs for May and June 2012, with LPN #32, revealed hand splints were ordered to be applied at bedtime. There was no documentation the resident had refused the splints. Nurses, including LPN #32, had documented on the TARs they had supervised the STNAs and all care had been provided for the resident per the plan of care. Review of nursing progress notes revealed no documentation the resident had refused the hand splints. LPN #32 verified there was no documentation for either the use or refusal of hand splints for Resident #13. On 06/27/12 at 9:27 A.M., interview with Physical Therapist (PT) #11 revealed Resident #13 had been evaluated on 06/27/12 by the occupational therapist for bilateral wrist drop. PT #11 explained the resident's wrist drop was due to [DIAGNOSES REDACTED] and a long-standing primary [DIAGNOSES REDACTED].#11 had just been informed the splints were missing. The resident had been re-evaluated that day and would be fitted for "cock-up" splints which she could wear during the day as well. The resident would also begin therapeutic exercises. On 06/27/12 at 12:05 P.M., interview with the director of nursing (DON) revealed Resident #13 had the resting hand splints in April 2012 when she was moved to her current room. The DON verified there was no evidence of documentation the resident's hand splints had been applied every night and removed in the morning as ordered. The DON verified hand splints had not been provided as ordered for Resident #13 for the maintenance of current function and to prevent her wrist drop from worsening.

Based on observation, record review and interviews, the facility failed to prevent the development and promptly identify two unstageable buttocks pressure ulcers for Resident #38, who was totally dependent for all care. The facility failed to ensure pressure reducing interventions were implemented to promote healing of the pressure ulcers. This affected one (Resident #38) of three residents reviewed with pressure ulcers out of three residents identified with pressure ulcers. Findings include: Resident #38 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. The 3.0 Minimum Data Set (MDS) comprehensive assessment dated [DATE] indicated Resident #38 did not speak, was rarely/never understood by others, rarely/never understands others and his vision was highly impaired. Resident #38 had both short and long term memory problems with severely impaired cognitive skills. The MDS assessment revealed Resident #38 was totally dependent on staff for all care including bed mobility. Resident #38 was incontinent of bowel and bladder. The same MDS assessment indicated Resident #38 was at risk for the development of pressure ulcers, but had no pressure ulcers at that time. The Braden Scale for predicting pressure sore risk assessment was completed on 11/15/11 and confirmed Resident #38 was at high risk for the development of pressure sores. The risk for pressure ulcer development plan of care was updated on 10/13/11 and included interventions to turn and reposition the resident every two hours and to check and change Resident #38 every two hours and as needed for incontinence. Staff were to provide prompt perineal care after incontinence. "Nurse's Notes" dated 12/07/11 at 2:30 P.M. revealed that "areas" were noted to his left and right buttocks and scrotum. The certified nurse practitioner (CNP) was notified and new orders were received. "Pressure Ulcer Record" dated 12/07/11 revealed the right buttock wound was unstageable with the proximal (closer) wound bed described with "dark" tissue and the distal (further) wound bed with yellow tissue and a small amount of serous (thin) drainage. The wound measured 4.6 centimeters (cm) by 3.5 cm. A second "Pressure Ulcer Record" also dated 12/07/11 identified a new pressure ulcer to the left buttock. The wound was also assessed as unstageable describing the wound bed as yellow tissue, with scant serous drainage. The wound measured 4.4 cm by 1.0 cm. A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). The description of yellow tissue covering the left buttock wound bed and partially covering the right buttock wound bed was consistent with slough. Slough is necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, & stringy (at times). The aforementioned description of the right buttock wound bed partially covered with dark tissue describes necrotic tissue. Necrotic (dead) or devitalized tissue presents frequently as brown or black and has lost its usual physical properties and biological activity. Since slough and necrotic tissue covered the wound beds, the pressure ulcers were classified as unstageable, as the bases of the wounds could not be visualized. A physician's orders [REDACTED].#38. A "pressure ulcer to coccyx area" plan of care was initiated on 12/07/11 that included the new order for side to side turns only while Resident #38 was in bed, and to be up in the chair for only two hours per day. The CNP's progress note was dated 12/08/11 and noted the sacral wound. The CNP indicated the wound had superficial yellow slough and a small amount of yellow drainage. The CNP wrote that Resident #38's scrotum was excoriated and red. It should be noted that the CNP's progress note only referenced one sacral pressure ulcer, not buttocks ulcers. The Treatment Administration Record (TAR) indicated wound care treatment was ordered every three days, and as needed. The TAR indicated Resident #38 had wound care provided to his bilateral buttocks wounds on 12/11/11. During an interview at 1:35 P.M., LPN #1 verified that wound treatment was not scheduled during the complaint investigation, since it had been completed the previous day; however, LPN #1 agreed to notify the surveyor should an "as needed" dressing change be required. The surveyor was not notified of such during the survey; therefore, no observation of the wound was possible. On 12/12/11 at 3:22 P.M., Resident #38 was observed lying on his bed on his back with his buttocks making direct contact with the mattress. Licensed Practical Nurse (LPN) #1 verified that Resident #38 was not supposed to be positioned on his back, but rather was to have side to side turns only. LPN #1 walked over to the top of the resident's dresser and removed a body pillow. LPN #1 indicated that staff were supposed to be using the body pillow to alternate Resident #38 from side to side every two hours. LPN #1 positioned Resident #38 on his right side by placing the body pillow behind his back. During an interview on 12/12/11 at 3:30 P.M., the administrator verified that two pressure ulcers on Resident #38's left and right buttock were not identified until they had advanced to unstageable. The administrator acknowledged Resident #38 was totally dependent on staff for all care and incontinence care was to be provided by staff every two hours. The administrator indicated it was the expectation for staff to notify the nurse of any new skin alterations. This deficiency substantiates Complaint Number OH 576.

Based on record review and interviews, the facility failed to ensure pressure relieving interventions were in place for Resident #18, (who was dependent for care) to prevent the development of a sacral pressure ulcer. The facility failed to promptly identify and provide appropriate and timely services when the sacral wound deteriorated to unstageable and became infected. This affected one of three residents reviewed with pressure ulcers out of six residents identified with pressure ulcers. Findings include: Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #18 resided on the secured dementia unit. [DIAGNOSES REDACTED]. During the complaint investigation on 10/25/11, Resident #18 was transported to the emergency room and subsequently admitted to the hospital with [REDACTED]. "Fall Investigation Summary Report" revealed Resident #18 sustained a fall on 09/11/11 at 7:00 P.M. and was sent to the hospital due to a [MEDICAL CONDITION] hip. Resident #18 was readmitted to the facility on [DATE]. The skin risk assessment dated [DATE] indicated Resident #18 was at risk for the development of pressure ulcers. The Minimum Data Set (MDS) 3.0 significant change assessment was dated 09/23/11 and indicated Resident #18 had short and long term memory impairment and severe cognitive impairment. The same MDS assessment indicated Resident #18 required extensive assistance of two-plus persons for bed mobility. The MDS assessment indicated Resident #18 had no unhealed pressure ulcers. Upon return from the hospital, there was no pressure ulcer plan of care in place for Resident #18. A potential for skin tears care plan, related to thin, fragile skin and a decline in mobility related to recent [MEDICAL CONDITION] was initiated on 09/07/11 and revised on 09/29/11. There were no pressure relieving interventions included on the skin tear plan of care. "Nurse's Notes" dated 10/01/11 at 4:00 P.M., indicated a state tested nurses aide (STNA) identified an open area with thin red drainage that measured 1.0 centimeter (cm) by 1.5 cm on her buttocks. The physician was notified and an order was received to apply antibiotic ointment and barrier cream to the area twice a day, and as needed. The aforementioned description of the wound described a stage two pressure ulcer which presents as a partial thickness skin loss involving the epidermis, dermis or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater. A Pressure Ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). "Nurse's Notes" dated 10/03/11 at 10:00 P.M., revealed the buttocks wound was yellowish in color with a clear yellow drainage noted. A new order was dated 10/05/11 to apply [MEDICATION NAME] Absorbent, and cover with a padded dressing. Acticoal Absorbent was a calcium alginate dressing which was capable of absorbing many times it's weight in exudate (drainage). The dressing forms a soft gel which can be easily lifted out of the wound in one piece or washed out with normal saline solution. "Wound Care" documentation dated 10/06/11 revealed Resident #18's wound had increased in size, measuring 3.8 cm by 4.1 cm with a depth of 1.2 cm. The wound deteriorated with the wound bed described as devitalized-slough, yellow-stringy, with moderate thin red drainage. Slough was necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, & stringy (at times). "Daily Skilled Nurses Note" dated 10/08/11 indicated the wound was yellow in the center and reddish around the border with an odor noted. "Daily Skilled Nurses Note" dated 10/11/11 revealed a strong odor was noted and the wound bed appeared to be black. The note indicated the director of nursing (DON) and the clinical manager were to assess. However, there was no indication of an assessment by the DON and/or the clinical manager. Necrotic (dead) or devitalized tissue presents frequently as brown or black and has lots its usual physical properties and biological activity. Since necrotic tissue covered the wound bed, the pressure ulcer would be classified as unstageable. Nurse's note dated 10/12/11 indicated the buttocks wound bed was black with "a small hole distal to the head." A sinus tract was a cavity or channel underlying a wound that involves an area larger than the visible surface of the wound. The note indicated the DON was notified. "Daily Skilled Nurses Note" dated 10/13/11 (not timed) revealed the buttocks wound bed was black with a small red/yellow opening in the center surrounded by yellow/white soft tissue. The drainage was described as yellow/brown and odorous. The drainage saturated the gauze dressing. The surrounding skin area was red, excoriated and tender to touch. Nurse's note timed at 5:00 P.M. indicated the wound was evaluated with the DON. The wound measured 6.0 cm by 5.0 cm, black in color with surrounding edges yellow/brown in color with a moderate amount of odorous drainage. The surrounding skin was red/inflamed, with non-blanchable and yellow areas. Resident #18 was transferred to the hospital. Nurse's note dated 10/13/11 at 11:45 P.M. indicated Resident #18 was admitted to the hospital for the coccyx wound and possible debridement. Hospital emergency department report from 10/13/11 indicated Resident #18 presented in the emergency room with a "deep, 10.0 cm by 8.0 cm decubitus ulcer overlying the sacrum." Laboratory results indicated Resident #18's white blood cell count was elevated at 20.3 with the normal range of 4.5 to 11.5. An elevated white blood cell count was an indicator of infection. "Admission/Re-Admission Nursing Eval" dated 10/18/11 at 7:40 P.M., indicated Resident #18 returned to the facility at 7:40 P.M. Re-admission [DIAGNOSES REDACTED]. Debridement was the removal of devitalized/necrotic tissue and foreign matter from a wound to improve or facilitate the healing process. Resident #18's sacral ulcer was measured at 8.0 cm by 5.0 cm with a whitish, gray wound bed with beefy red tissue around the border. Inside the center of the wound, the depth was measured at 4.5 cm, with indentations of 3.0 cm at two o'clock; 2.0 centimeters at four o'clock and 1.0 cm at ten o'clock. Resident #18 returned to the facility with a peripherally inserted central catheter (PICC) with physician's orders [REDACTED]. During an interview on 10/26/11 at 4:00 P.M., the DON verified that Resident #18 returned to the facility on [DATE] status [REDACTED]. The DON confirmed there was no pressure ulcer plan of care in place for Resident #18 upon her readmission to the facility, but rather a skin tear plan of care that was initiated on 09/07/11 and revised on 09/29/11, with no pressure relieving interventions. The DON verified Resident #18 developed a stage two pressure area on her sacrum on 10/01/11. The DON confirmed the wound deteriorated on 10/06/11 when the wound increased in size with the wound bed covered with yellow slough tissue. The DON verified Resident #18's sacral wound began to show evidence of infection (odor) on 10/10/11 and continued to worsen on 10/11 and 10/12/11, further deteriorating to unstageable with a black wound bed, increased drainage and odor. The DON acknowledged there was no evidence of physician notification when the wound declined and developed an odor on 10/10/11. The DON verified Resident #18 wad admitted to the hospital [MEDICAL CONDITION] and wound debridement on 10/13/11. She indicated Resident #18 returned to the facility on [DATE] with a PICC line for the infusion of intravenous antibiotics. The DON acknowledged Resident #18 returned to the hospital on [DATE] and remained hospitalized with a [DIAGNOSES REDACTED]. This citation substantiated Complaint Numbers OH 887, OH 773 and OH 987.

Based on observation, record review and interviews, the facility failed to prevent the development and promptly identify two unstageable buttocks pressure ulcers for Resident #38, who was totally dependent for all care. The facility failed to ensure pressure reducing interventions were implemented to promote healing of the pressure ulcers. This affected one (Resident #38) of three residents reviewed with pressure ulcers out of three residents identified with pressure ulcers. Findings include: Resident #38 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. The 3.0 Minimum Data Set (MDS) comprehensive assessment dated [DATE] indicated Resident #38 did not speak, was rarely/never understood by others, rarely/never understands others and his vision was highly impaired. Resident #38 had both short and long term memory problems with severely impaired cognitive skills. The MDS assessment revealed Resident #38 was totally dependent on staff for all care including bed mobility. Resident #38 was incontinent of bowel and bladder. The same MDS assessment indicated Resident #38 was at risk for the development of pressure ulcers, but had no pressure ulcers at that time. The Braden Scale for predicting pressure sore risk assessment was completed on 11/15/11 and confirmed Resident #38 was at high risk for the development of pressure sores. The risk for pressure ulcer development plan of care was updated on 10/13/11 and included interventions to turn and reposition the resident every two hours and to check and change Resident #38 every two hours and as needed for incontinence. Staff were to provide prompt perineal care after incontinence. "Nurse's Notes" dated 12/07/11 at 2:30 P.M. revealed that "areas" were noted to his left and right buttocks and scrotum. The certified nurse practitioner (CNP) was notified and new orders were received. "Pressure Ulcer Record" dated 12/07/11 revealed the right buttock wound was unstageable with the proximal (closer) wound bed described with "dark" tissue and the distal (further) wound bed with yellow tissue and a small amount of serous (thin) drainage. The wound measured 4.6 centimeters (cm) by 3.5 cm. A second "Pressure Ulcer Record" also dated 12/07/11 identified a new pressure ulcer to the left buttock. The wound was also assessed as unstageable describing the wound bed as yellow tissue, with scant serous drainage. The wound measured 4.4 cm by 1.0 cm. A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). The description of yellow tissue covering the left buttock wound bed and partially covering the right buttock wound bed was consistent with slough. Slough is necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, & stringy (at times). The aforementioned description of the right buttock wound bed partially covered with dark tissue describes necrotic tissue. Necrotic (dead) or devitalized tissue presents frequently as brown or black and has lost its usual physical properties and biological activity. Since slough and necrotic tissue covered the wound beds, the pressure ulcers were classified as unstageable, as the bases of the wounds could not be visualized. A physician's orders [REDACTED].#38. A "pressure ulcer to coccyx area" plan of care was initiated on 12/07/11 that included the new order for side to side turns only while Resident #38 was in bed, and to be up in the chair for only two hours per day. The CNP's progress note was dated 12/08/11 and noted the sacral wound. The CNP indicated the wound had superficial yellow slough and a small amount of yellow drainage. The CNP wrote that Resident #38's scrotum was excoriated and red. It should be noted that the CNP's progress note only referenced one sacral pressure ulcer, not buttocks ulcers. The Treatment Administration Record (TAR) indicated wound care treatment was ordered every three days, and as needed. The TAR indicated Resident #38 had wound care provided to his bilateral buttocks wounds on 12/11/11. During an interview at 1:35 P.M., LPN #1 verified that wound treatment was not scheduled during the complaint investigation, since it had been completed the previous day; however, LPN #1 agreed to notify the surveyor should an "as needed" dressing change be required. The surveyor was not notified of such during the survey; therefore, no observation of the wound was possible. On 12/12/11 at 3:22 P.M., Resident #38 was observed lying on his bed on his back with his buttocks making direct contact with the mattress. Licensed Practical Nurse (LPN) #1 verified that Resident #38 was not supposed to be positioned on his back, but rather was to have side to side turns only. LPN #1 walked over to the top of the resident's dresser and removed a body pillow. LPN #1 indicated that staff were supposed to be using the body pillow to alternate Resident #38 from side to side every two hours. LPN #1 positioned Resident #38 on his right side by placing the body pillow behind his back. During an interview on 12/12/11 at 3:30 P.M., the administrator verified that two pressure ulcers on Resident #38's left and right buttock were not identified until they had advanced to unstageable. The administrator acknowledged Resident #38 was totally dependent on staff for all care and incontinence care was to be provided by staff every two hours. The administrator indicated it was the expectation for staff to notify the nurse of any new skin alterations. This citation is a recite from the complaint investigation of 10/27/11.

Based on record review and interview, the facility failed to ensure safety interventions functioned appropriately for Resident #18 who sustained a fall with hip fracture. The facility did not ensure a safety device was in place as ordered for Resident #78 who sustained a fall. The facility did not ensure a thorough investigation was conducted following a fall for Resident #65. This affected three of four residents reviewed for falls. The facility's census was 75. Findings include: 1. Resident #18 was admitted to the facility on [DATE] and resided on the secured dementia unit. [DIAGNOSES REDACTED]. During the complaint investigation on 10/25/11, Resident #18 was transported to the emergency room and subsequently admitted to the hospital with [REDACTED].#18 were not possible. The Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] indicated Resident #18 had short and long term memory deficits with severely impaired cognition. The MDS assessment indicated that for locomotion on the unit, (if in wheelchair, self-sufficiency once in chair) the resident required extensive assistance of one person. "Fall Risk Assessment" dated 08/28/11 indicated Resident #18 was at high risk for falls. Falls and physical restraint plans of care identified Resident #18 as a risk for falling related to impaired mobility and cognitive losses with poor safety awareness. Interventions included the use of an alarming, self-release seatbelt since Resident #18 did not comprehend that she needed assistance with transfers. Resident #18 sustained falls on 05/06/11, 05/08/11, 06/03/11, 08/28/11 and 09/11/11 at 2:00 P.M. "Fall Investigation Summary Report" dated 09/11/11 indicated Resident #18 sustained a second fall on that date at 7:00 P.M. Resident #18 was observed sitting on her buttocks in an upright position on the floor in front of her wheelchair. The summary revealed the alarming self-release safety belt was not functioning at the time of the fall because the cord got tangled in her wheelchair wheels. The investigation indicated she was sent to the hospital, due to the fracture of the left hip. "Nurse's Notes" dated 09/20/11 at 1:25 P.M. was marked as a late entry for 09/11/11 at 7:00 P.M. The note indicated that Resident #18 was observed on the floor. Resident #18 was assisted by the nurse and a state tested nurses aide to the wheelchair. Resident #18 expressed no signs or symptoms of pain at that time. "Nurse's Notes" dated 09/13/11 (timed at 5:00 P.M. with a 7 written over the 5) indicated Resident #18 complained of severe left hip pain when transferred from the wheelchair to the bed. An order was received for a x-ray to rule out fracture due to the previous fall. "Nurse's Notes" dated 7:15 P.M. indicated Resident #18 was crying of pain, holding her left hip and seemed very agitated in bed. At 8:45 P.M. the mobile x-ray company arrived and completed the x-ray. On 09/13/11 at 9:45 P.M. the results of the x-ray revealed a left hip comminuted fracture of the left femoral neck with marked overriding and variable deformity. The physician was notified with orders to transport Resident #18 to the hospital emergency room . "Nurse's Notes" at 10:50 P.M. indicated the resident departed the facility via ambulance. "Nurse's Notes" dated 09/14/11 at 4:45 A.M. indicated Resident #18 was admitted with a left hip fracture. Hospital "History and Physical" dated 09/14/11 identified Resident #18's fractured left hip/femoral neck with a plan to admit the resident to the hospital and for an orthopedic consult. Orthopedic consultation dated 09/14/11 indicated Resident #18 had a flexion/adduction deformity of the left hip with significant pain. The physician wrote that it was unclear if operative intervention would be of benefit with a plan to manage with abduction pillow (wedge cushion) and pain control. Resident #18 was readmitted to the facility on [DATE] with orders for an abductor pillow at all times. Hip abduction was when the thighs were moved apart, angling the femur out to the side. An abduction pillow keeps the patient's legs at just the right angle and keeps the patient from rotating the hip too far in other directions. The pillow (wedge shaped) was placed between the patient's legs and secured at the sides of both legs with straps. Physical therapy assessment dated [DATE] revealed several bilateral hip flexion, knee flexion and left hip adduction contractures. The physical therapist (PT) indicated that Resident #18 had been treated conservatively for the left hip fracture over the past month with an abductor pillow. The PT questioned how often the abductor pillow was used as Resident #18 demonstrated a severe left hip adduction contracture which would not allow the left hip to abduct at all. The PT wrote that Resident #18 appeared to have been bed ridden and would have been dependent for any bed mobility, transfers and would not benefit from physical therapy at that time. The PT wrote the rehab potential was poor. During an interview on 10/26/11 at 4:00 P.M. the director of nursing (DON) verified that Resident #18 sustained a fall from her wheelchair on 09/11/11 at 7:00 P.M. The DON acknowledged the alarming self release safety belt did not function because the cord was tangled in the wheel of the wheelchair. The DON indicated that staff should have checked to ensure the alarm was functional and should have continued to monitor the resident while in the wheelchair. 2. Resident #78 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of a falls investigation dated 08/12/11 at 5:20 A.M., revealed Resident #78 fell from his wheelchair to the floor while attempting to reposition himself in the wheelchair. Resident #78 was sent to the emergency room (ER) for evaluation. Review of the aftercare ER instructions dated 08/12/11 revealed Resident #78 sustained a right wrist fracture. Review of a falls risk assessment (completed after the fall) dated 08/12/11 revealed Resident #78 was at a high risk for falls due to impaired mobility, impaired cognition and medications. Review of the falls investigation and care plan dated 08/12/11 revealed a wheelchair alarm was implemented to prevent further falls. Review of a falls investigation dated 10/12/11 revealed Resident #78 fell in the bathroom while attempting to transfer himself from the wheelchair to the toilet. The falls investigation revealed no alarms were in place. Resident #78 was observed on 10/26/11 at 10:30 A.M. in the hallway in his wheelchair. No wheelchair alarm was in place. At the time of the observation, Registered Nurse (RN) #3 revealed she did not know what safety devices were required for Resident #78. She stated she would check the care plan. On 10/26/11 at 1:50 P.M., Resident #78 was observed in his room with a chair alarm in place. During an interview with the director of nursing (DON) on 10/26/11 at 3:00 P.M., she verified Resident #78 did not have the care planned chair alarm in place prior to the fall from his wheelchair on 10/12/11. During the same interview, the DON verified Resident #78 did not have a chair alarm in place on 10/26/11 at 10:30 A.M. 3. Resident #65 was admitted [DATE] with [DIAGNOSES REDACTED].#65 was at a high risk for falls due to cognitive impairment, impaired mobility and balance, a history of falls and medications including Coumadin (a blood thinning medication that puts a resident at risk if injured). Review of a care plan and physician orders [REDACTED]. Review of a falls investigation dated 10/09/11 at 5:30 P.M. revealed Resident #65 was found on the floor, in front of her wheelchair, sitting on her buttocks. A second fall occurred at 7:20 P.M. Review of a falls investigation dated 10/09/11 at 7:20 P.M., revealed Resident #65 was found on the floor next to her bed. Both falls investigation verified safety interventions were in place and functional. However, both falls investigations revealed a medication review was completed. A list of medication included the Coumadin, as well as, cardiac and antibiotic medications. Review of the medication administration record (MAR) dated 10/08/11 through 10/11/11 revealed Resident #65 received nine doses of the medication, Bentyl. Bentyl is a medication to treat irritable bowel syndrome and other functional gastrointestinal disorders. Record review revealed no evidence Resident #65 had a gastrointestinal disorder. Record review revealed no evidence of a physician's orders [REDACTED]. During an interview with the DON on 10/25/11 at 5:05 P.M. and review of a medication (error) incident report dated 10/11/11 revealed Resident #65 was given Bentyl 20 milligrams by mouth without a physician order. The DON verified she completed the medication review for the falls investigation and "missed" the administration of Bentyl. Review of the Nursing 2006 Drug Handbook revealed adverse central nervous system affects were headache, insomnia, light-headedness, drowsiness, nervousness, confusion, and excitement in elderly patients. This citation substantiates Complaint Numbers OH 773, OH 833 and OH 958.

Based on observation, interview and record review, the facility failed to promptly identify pressure ulcers on the scrotum, left buttock and coccyx for Resident #21 and obtain treatment orders promptly, failed to provide pressure relieving interventions as ordered and implement pressure relieving interventions to prevent the development and aid in the healing of unstageable pressure ulcers on the heels of Resident #21 as well as a pressure ulcer on his right fifth toe. The facility failed to monitor wounds for Resident #21, Resident #65 and Resident #12 and failed to ensure pressure relieving measures were provided to prevent the development of a pressure ulcer on the left heel of Resident #12. These affected three of three residents reviewed for pressure ulcers. The facility census was 79. Findings include: 1. Resident #21 was admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. The nursing admission assessment completed on 12/15/10 indicated Resident #21 had no skin issues except for healing scars. This assessment indicated Resident #21 could transfer himself with one person to assist him and then was independently mobile in his wheelchair. The pressure ulcer sore development risk assessment completed on 12/15/10 indicated he was high risk. Resident #21 required assistance for all activities of daily living (ADL's) except for eating due to the loss of function/[MEDICAL CONDITION]. This was reflected on the ADL plan of care initiated on 12/20/10. Review of all Resident #21's care plans revealed no care plan developed related to the prevention of pressure ulcers. The Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #21 was completely alert, oriented and was his own responsible party. Resident #21 was not listed on the list of residents with pressure ulcers provided by the facility. An interview was conducted with Licensed Practical Nurse (LPN) #1 on 02/07/11 at 9:25 A.M. LPN #1 was providing care to the residents residing on the hall where Resident #21 lived. LPN #1 indicated she had one female resident who had recently been readmitted with a pressure ulcer, but she was the only one. Resident #21 was interviewed on 02/07/11 at 9:30 A.M., and he indicated a female from therapy told him several days ago or a week or so ago that he had open areas on his scrotum. Resident #21 did not know himself since he has no feeling due to his [MEDICAL CONDITION]. He gave permission to observe the nurse check his skin. At 10:20 A.M., LPN #1 examined Resident #21 and found six open areas scattered on his scrotum, one area toward the back had a small drop of bright red blood. Resident #21 was able to turn to his right side. There were linear reddened, excoriated areas extending on both sides from the inner to the central buttocks areas. There was an open area that looked like two circular areas had joined together on his left lower buttock approximately 1.0 centimeter (cm) by 0.5 cm wide. Resident #21 indicated to the nurse that someone from therapy saw the open areas on his scrotum about a week, week and a half ago. LPN #1 reviewed the nurse's notes from 02/01/11 to 02/07/11. An entry on 02/01/11 indicated the bottom of Resident #21's scrotum was red from using the slide board for transfers and a protective cream was applied. Nurse's notes on 02/02/11 and 02/06/11 indicated the scrotal area was red. The February 2011 physician orders [REDACTED]. Protective cream was ordered for his buttocks. On 02/07/11 at 10:50 A.M., LPN #1 indicated the state tested nurse aide (STNA) told her there was another open area at the top where his buttocks meet on the coccyx. Physician orders [REDACTED].#21's foot, apply triple antibiotic ointment and Allevyn, a cushioned, highly absorbent waterproof dressing, every three days until healed and a treatment started on 01/11/11 to the left heel - cleanse with normal saline, apply skin prep then Allevyn and change every five days and as needed until healed. The physical therapist (PT), a physical therapy assistant (PTA) and a certified occupational therapy assistant (COTA) were interviewed on 02/07/11 at 2:45 P.M. The COTA reviewed the documentation she wrote on 01/26/11 which indicated nursing had identified some scrotum sores but she did not see any with her care and treatment. On 01//27/11, Resident #21 had an episode of bowel incontinence and during personal care the COTA identified open areas on his scrotum. The COTA verified that she notified the nursing staff regarding the open areas. On 02/01/11 the COTA documented that nursing staff were instructed to use a Hoyer lift as needed to decrease skin issues and Resident #21 was educated on techniques for pressure reduction while up in his wheelchair. On 02/07/11 at 5:10 P.M., Registered Nurse (RN) #3 indicated the physician had not been called and treatment orders for Resident #21's open areas had not been obtained. She indicated the physician would be coming to the facility tomorrow and the wound nurse came every week. She indicated they would get treatment orders but she had taken over the second unit for LPN #1 and had not done that yet. On 02/07/11 at 5:32 P.M., the director of nursing (DON) and surveyor enter Resident #21's room. He was in bed on his back with tennis shoes on both feet. He indicated staff put the shoes on him everyday. The DON removed his shoes and socks. Resident #21's left heel had a circular area approximately 2.0 cm in diameter, a drying skin area with half of it blackish. His right foot had a circular red area about 1.0 cm in diameter on the outer fifth toe. Resident #21 indicated it had been a blister. The bottom of his right foot had a circular area approximately 2.0 centimeters in diameter which was blackish and a smaller circular area on the inner right heel approximately 1.0 to 1.5 in diameter and was faintly black. The new open area on the coccyx was observed to be about 1.0 cm in diameter without any drainage and had a red wound base. A small dark speck was seen on his right buttock and the DON was asked what it was. She wiped it with her glove and verified it was stool. Resident #21 indicated the nursing staff had not provided any personal care when they got him back to bed. Record review revealed Resident #21 was readmitted on [DATE] with a pressure ulcer to his left heel with treatment orders. There was a readmission note and an indication that the heel treatment continued but no wound monitoring was found. Entries dated 01/11/11 and 01/26/11 indicated the left heel wound was 2 cm by 2 cm without any depth. The DON indicated this was all the tracking she found. Physician orders [REDACTED].#21. Interview with Resident #21 on 02/08/11 at 9:55 A.M., revealed he had used Prafo boots at the rehabilitation hospital but had not had them since he came here. He indicated they used some soft booties at one time but not any more. The physician order [REDACTED]. There was no telephone or written physician order [REDACTED]. Each entry for the rest of the month was circled, indicating they were not applied but no documentation could be found to indicate why they were not applied. These records were verified with the DON on 02/08/11 at 4:35 P.M. 2. Resident #12 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. The Braden Scale was completed on 10/25/10 and indicated Resident #12 was at high risk for the development of pressure ulcers. This assessment indicated that his skin was often moist, that he required assistance in moving, frequently slid down in bed or needed frequent repositioning, was very limited in his ability to move his body independently and he had sensory impairments in his arms and legs. On 11/01/10 a care plan to address his risk for the development of pressure ulcers was initiated related to his decreased mobility and incontinence. Interventions listed included proper nutrition, notify the physician of any skin compromise, pressure reducing mattress and chair cushion, skin assessments quarterly and as needed, weekly skin checks by a licensed nurse and for staff to provide/assist him to turn and reposition in bed. There were no interventions for pressure relieving interventions for his feet/heels. The list of residents with pressure ulcers provided by the facility listed Resident #12 as having a Stage I (an observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperature, tissue consistency, sensation and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues) on his heel which developed on 12/01/10. Observation of Resident #12's left heel on 02/08/11 at 1:42 P.M. with LPN #5 revealed Resident #12 was in his low bed wearing his socks. There were no heel protectors or devices seen to provide pressure relief to his heels. LPN #5 removed his sock and found the dressing on his heel and then left the room to obtain supplies to change the dressing. Resident #12's room was re-entered at 1:50 P.M. and LPN #5 removed the left heel dressing. A thick, yellow crust like oval area approximately 1.5 cm in diameter, was observed on the heel and the edges were lifting. There was no drainage. LPN #5 stated that they had attempted pressure relieving measures like heel protectors and elevating his feet off of the bed but Resident #12 refused every intervention. A skin alteration care plan for the left lateral heel pressure ulcer was initiated on 12/02/10 and indicated the pressure ulcer should be assessed per policy, dressings/treatments done per orders and notify the doctor for any changes. There were no interventions implemented to provide pressure relief to his heels/feet. The medication and treatment records were reviewed for January and February 2011 and no heel/feet pressure relieving interventions were listed. The wound tracking was reviewed with the DON on 02/08/11 at 5:45 P.M. The left heel pressure ulcer developed on 12/01/10 and the tracking indicated it was 2.6 cm long by 1.5 cm wide and 0.1 cm deep. This entry indicated the left heel appeared as an open blister and the wound bed was red but there was no drainage. The physician was notified and orders were received to cleanse the wound with wound cleanser, dry area, apply Alleyvn every three days and as needed. Skin prep was ordered for the right heel. The pressure relieving interventions listed a pressure relief mattress and chair cushion and turning and repositioning every two hours. The wound tracking/assessment on 12/08/10 indicated the pressure area had improved and was 2.2 cm long by 1.6 cm wide and 0.1 cm deep. The next tracking for this pressure ulcer was on 01/11/11 and indicated it was 1.0 cm long by 1.0 cm wide with 0.1 cm deep, the wound bed was pink/red with healing tissue. The pressure ulcer assessment completed on 01/19/11 indicated the pressure ulcer declined and was 2.1 cm long by 1.6 cm wide and 0.1 cm in deep. The appearance of the wound bed was not documented. No changes in treatment were made and no documentation was found to indicate the physician was notified. The next assessment of this pressure ulcer was on 01/26/11 and the pressure ulcer was documented as improved with a length of 1.0 cm a width of 1.0 and no depth. This assessment indicated the skin was intact and was pink/red. 3. Resident #65 was admitted to the facility on [DATE] and readmitted on [DATE] and [DIAGNOSES REDACTED]. The Braden Scale was completed on 09/13/10 and indicated that Resident #65 was not at risk for pressure sores. This assessment indicated that she walked occasionally but spent most of the time in her chair or bed and but moved feebly or required minimal assistance. On 04/05/10 a care plan was initiated indicating Resident #65 was at risk for the development of pressure ulcers due to her diabetes and [MEDICAL CONDITION]. Interventions listed included proper nutrition, notify the physician of any skin compromise, pressure reducing mattress and chair cushion, elevate her heels off the mattress, skin assessments quarterly and as needed, weekly skin checks by a licensed nurse and for nurse aides to notify the nurse of any problems with skin found during daily hands on care. The list of residents with pressure ulcers provided by the facility listed Resident #65 as having a Stage I on her heel which developed on 01/07/10. Observation of Resident #65's right heel occurred on 02/08/11 at 2:20 P.M. with LPN #6. Resident #65 was sitting up in her bed and the nurse had already removed the dressing. Resident #65's right heel had an irregular area which appeared as dried red blood. It was approximately 3 cm at the longest point and 2 cm wide. LPN #6 indicated it had been a blister, had opened and was healing. Resident #65 indicated she got new diabetic shoes since this pressure area developed. The wound tracking indicated the pressure ulcer had developed on 12/08/10, and the tracking indicated it was 1.2 cm long by 0.9 cm wide with no depth. The pressure ulcer was described as a dark red to purple blister with 0.4 by 0.4 superficial brown/black eschar firmly rooted to the bottom surface. The wound tissue was described as blue, purple, dark red discoloration. On 01/11/11 the ulcer was documented as 1.5 cm long by 2.5 cm wide without any depth but with a red wound bed. The area was described as blue, purple, red discolored area. The wound had declined. There was no change in treatment and no evidence the physician was notified. The next pressure ulcer assessment/tracking dated 01/26/11 indicated the measurements were unchanged and the appearance was improved and described as a red wound bed and normal tissue appearance. There was no other tracking/assessments completed. The DON verified no change in treatment and notification to the physician. This deficiency substantiates Complaint Number OH 359.