Every finding on record at Otterbein Monclova

Based on observation, medical record review, staff interview, manufacturer representative interview, and review of a manufacturer's handbook, the facility failed to ensure a MaxiSky Lift (a ceiling mounted lift that was utilized to transfer and reposition residents) was maintained in safe working condition prior to completing a resident transfer. This affected one (#21) of five residents identified by the facility to use a MaxiSky Lift. The facility census was 54. Findings Include:Review of the medical record for Resident #21 revealed an admission date of 09/25/25 with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, dysphagia following a cerebral infarction, dysarthria following a cerebral infarction, urinary tract infection, type two diabetes mellitus, chronic bronchitis, left bundle branch block, syncope and collapse, class three obesity, hypertensive heart disease with heart failure, congestive heart failure, atherosclerotic heart disease, lumbar radiculopathy, diarrhea, angina pectoris, vitamin D deficiency, anxiety, chronic pain, dry eye syndrome, osteoarthritis, dorsalgia, palpitations, shortness of breath, heartburn, transient ischemic attack, hypercholesterolemia, weakness, and insomnia.Review of Resident #21's admission Minimum Data Set (MDS) assessment, dated 10/06/25, revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating Resident #21's cognition was intact. Further review of the MDS assessment indicated Resident #21 required substantial/maximum assistance or was dependent in all functional abilities including, but not limited to, eating, hygiene, dressing, and toileting. Observation on 12/09/25 at 1:38 P.M. of Certified Nurse Aide (CNA) #110 and CNA #203 providing incontinence care to Resident #21 revealed the safety latch on the MaxiSky Lift being used to transfer Resident #21 was broken on one side. Interview on 12/09/25 at 1:38 P.M. with CNA #110 and CNA #203 verified the safety latch on the MaxiSky Lift used to transfer Resident #21 was broken. CNA #110 and CNA #203 were unsure exactly how long the safety latch on the MaxiSky Lift had been broken, but they were both aware of it being broken. Review of the MaxiSky instructions for use, dated 03/2022, revealed all rails must be closed with end stoppers or connected to other closed rail components. Before use, make sure all end stoppers are in place and secured. A wrong installation of these items might lead to a patient fall and to injuries. Do not attempt to transfer a patient if the safety latches are not blocking the support's opening for the strap. Further review revealed the lift must be inspected for missing hardware or broken enclosure initially, before every use, and every year. Inspect the lift for any damage, and if there is any damage on the lift, or there are parts missing, DO NOT USE IT. Interview on 12/10/25 at 11:27 A.M. with Sales Representative #201 revealed the safety latch was a secondary safety feature put in place to ensure a patient does not fall when being transferred utilizing the MaxiSky Lift. This deficiency represents and incidental finding discovered during the complaint investigations.

Based on medical record review, staff interview, and policy review, the facility failed to ensure residents received medications as ordered by the physician, resulting in a significant medication error. This affected one (#7) of three residents reviewed for medication administration. The facility census was 54.Findings Include: Review of the medical record for Resident #7 revealed an admission date of 11/13/25 with diagnoses including end stage renal disease (ESRD), presence of a left artificial knee joint, hyperlipidemia, abnormalities of gait and mobility, generalized muscle weakness, osteoarthritis, anemia, renal dialysis, atherosclerotic heart disease, obesity, lumbar spinal stenosis, weakness, chronic kidney disease (CKD), and type two diabetes mellitus.Review of Resident #7's medical record revealed a physician order, dated 11/14/25, for Xphozah, generic name tenapanor (a medication used to treat CKD), 30 milligrams (mg) to be given by mouth one time per day for ESRD. Review of the November 2025 medication administrator record (MAR) for Resident #7 revealed the physician ordered 30 mg dose of Xphozah was not administered on 11/15/25, 11/16/25, 11/18/25, 11/20/25, and 11/22/25.Review of the December 2025 MAR for Resident #7 revealed the physician ordered 30 mg dose of Xphozah was not administered on 12/02/25 and 12/09/29. Interview on 12/11/25 at 12:30 P.M. with the Administrator verified the physician ordered 30 mg dose of Xphozah was not administered to Resident #7 on 11/15/25, 11/16/25, 11/18/25, 11/20/25, 11/22/25, 12/02/25, and 12/09. Further interview with the Administrator revealed the medication was not administered on these dates as it was not available in the facility to administer to Resident #7.Review of the facility policy titled, Medication Administration Procedure, dated 11/17/25, revealed medications are administered in accordance with written orders of the attending physician or physician extender. This deficiency represents non-compliance investigated under Complaint Number 2650945.

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure newly identified wounds were timely assessed and measured, and failed to ensured proper treatment timely implemented. This affected one (#20) of three residents reviewed for pressure ulcers. The facility census was 55. Findings include:Review of the medical record revealed Resident #20 was admitted on [DATE]. Diagnoses included spastic diplegic cerebral palsy, chronic kidney disease stage III, chronic respiratory failure with hypoxia, essential hypertension, mixed hyperlipidemia, hyperglycemia, and hypertensive chronic kidney disease.Review of the Minimum Data Set (MDS) assessment, dated 06/25/25, revealed Resident #20 was severely cognitively impaired and was at risk of pressure ulcers. Review of the care plan, updated 09/23/25, revealed Resident #20 had actual impaired skin integrity due to bilateral stage two pressure wounds (partial-thickness skin loss with exposed dermis) and was at potential risk for skin breakdown due to incontinence, weakness, and impaired mobility. Review of Resident #20's physician orders, dated 09/04/24, revealed an order to apply barrier cream two times a day for skin protection as needed.Review of nursing progress notes dated 09/06/25 revealed Resident #20 had a small open sore on the right buttock. The physician was notified via the communication book.Review of the weekly skin observation tool, dated 09/06/25, revealed Resident #20 had a small open sore on the right buttock. Further review revealed there was no assessment of the wound, no measurements, and no description of the wound documented. Review of nursing progress notes dated 09/12/25 revealed Resident #20 had two open sores on the bilateral upper buttocks and an order was placed for barrier cream twice a day and as needed. Review of the weekly skin observation tool dated 09/12/25 revealed Resident #20 had an open sore on bilateral upper buttocks. The wounds were described as small open sores to the upper bilateral buttocks with no further description of wound, assessment, or measurements included. Review of a wound physician evaluation and management summary dated 09/18/25 revealed Resident #20 had a stage two pressure ulcer on the left buttock measuring 1.0 centimeters (cm) long by (x) 0.5 cm wide x 0.1 cm deep. Resident #20 also had a stage two pressure wound to the right buttock measuring 0.4 cm long x 0.5 cm wide x 0.1 cm deep. Review of a physician order dated 09/18/25 revealed an order to apply triad hydrophilic wound dressing external paste to Resident #20's buttocks topically two times a day for a stage two pressure wound. Review of the wound physician evaluation and management summary dated 09/25/25 revealed Resident #20 had a stage two pressure ulcer on the left buttock measuring 0.5 cm long x 0.3 cm wide x 0.1 cm deep. The wound healing progress was described as improved with a decreased surface area. The state two wound of the right buttock was resolved. Interview on 09/26/25 at approximately 11:00 A.M. with the Director of Nursing (DON) verified there was no description or wound measurements completed of Resident #20's wounds. Interview on 09/26/25 at 1:28 P.M. with the DON verified the physician should have been called on 09/06/25 when a new open area was found.Review of a policy titled, Skin Care Management, revised 11/17/22, revealed the facility will implement, monitor, and modify if needed strategies to attain or maintain intact skin, prevent complications, promptly identify, and manage complications. This deficiency represents non-compliance investigated under Master Complaint Number 2611062.

Based on observation, staff interview, medical record review, and policy review, the facility failed to wear appropriate personal protective equipment for residents on enhanced barrier precautions and failed to maintain proper infection control measures related to hand hygiene during wound care. This affected one (#16) of three residents reviewed for wounds. The facility census was 55.Findings include:Review of Resident #16's medical record revealed an admission date of 10/02/20. Diagnoses included hemiplegia and hemiparesis following a cerebrovascular accident, epilepsy, and cellulitis of the scrotum.Review of Resident #16's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and had one surgical wound.Review of Resident #16's hospital note dated 08/15/25 revealed the resident had a large abscess in his scrotum. A scrotal exploration, incision, and drainage was completed of the abscess. The wound was irrigated and necrotic tissue was debrided. The wound was packed with wet to dry Iodoform gauze.Review of Resident #16's physician order dated 02/08/25 revealed the resident was to be under enhanced barrier precautions (EBPs) which included staff wearing gloves and gown with treatment and/or care.Review of Resident #16's physician's order dated 09/25/25 revealed an order to place gauze packing strips (Iodoform) one-half inch and apply once daily and as needed if saturated, soiled, or dislodged for 20 days. There were also instructions to pack the entire wound loosely.Observation on 09/26/25 at approximately 12:15 P.M. of the signage alerting visitors and staff to the EBPs for Resident #16 revealed a white magnetic sign was attached to the upper right side of the resident's door frame and the sign had the letters EBP at the top and contained pictures of handwashing, a gown, and gloves. Observation on 09/26/25 at 12:19 P.M. of Resident #16's wound care revealed the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #200 completed scrotal wound care wearing only protective gloves. Additional observations revealed LPN #200 assisted the DON with wound care and touched the tray tables, the resident's sheets, and bed then reached with the same gloved fingers into the bottle of Iodoform and pulled out the dressing. LPN #200 then handed the packing to the DON who placed the Iodoform in Resident #16's wound and packed it with a large cotton swab.Interview with the DON and LPN #200 on 09/26/25 at 12:33 P.M. verified they failed to wear gowns during Resident #16's wound care and confirmed proper infection control measures were not maintained when the same gloves used to touch contaminated surfaces were used to directly touch and handle clean wound dressing without cleansing hands and changing gloves. Review of the facility policy titled, Isolation Precautions Process, revised 08/01/22, revealed enhanced barrier precautions will be utilized for residents with wounds. Elements of enhanced barrier precautions included hand washing and gloves and gowns should be worn during high-contact resident care which included wound care (skin opening requiring a dressing). Signage will be posted at the entry to the resident's room to alert them of the need to consult the nurse prior to entering with the nurse providing appropriate personal protective equipment instruction.This deficiency represents non-compliance investigated under Master Complaint Number 2611062.

Based on observation, staff interview, resident interview, medical record review, and review of the Centers for Medicare and Medicaid Services (CMS) Provider History Profile document, the facility failed to have an effective quality assurance and performance improvement (QAPI) program to address repeated deficiencies identified during four consecutive comprehensive surveys. This had the potential to affected all 54 residents in the facility. The census was 54. Findings include: Review of the CMS Provider History Profile document, with Certification and Survey Provider Enhanced Reporting (CASPER) system data, last updated 03/06/25, revealed the facility was issued a deficiency for not providing services/treatments to prevent/heal pressure ulcers on the three previous comprehensive surveys in 08/2018, 09/2019, and 11/21/22 and during complaint surveys dated 07/26/23 and 11/02/23. During the current comprehensive survey, with exit date 03/27/25, the facility was cited for pressure ulcers for the fourth consecutive comprehensive survey. 1. Review of the medical record for Resident #8 revealed an admitted [DATE] with diagnoses including stage four sacral pressure ulcer, multiple sclerosis (MS), type two diabetes mellitus (DM2), paraplegia, depression, gastro-esophageal reflux disease (GERD), colostomy, neuromuscular dysfunction of bladder, insomnia, anemia, hypertension (HTN), hyperlipidemia, chronic pain syndrome, morbid obesity, non-pressure chronic ulcer of part of left lower leg with unspecified severity, non-pressure chronic ulcer of right ankle with unspecified severity, non-pressure chronic ulcer of buttock with unspecified severity, bullous pemphigoid, urinary tract infection (UTI), unspecified open wound of left ankle, and need for assistance with personal care. Review of the most Medicare Five Day Minimum Data Set (MDS) assessment, dated 03/20/25, revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating Resident #8's cognition was intact. Concurrent review of the MDS assessment revealed Resident #8 revealed she was dependent for all of her functional abilities, including rolling left and right. Observation on 03/24/25 at 11:43 A.M. revealed Resident #8 was laying on her back in her bed. Observation on 03/25/25 at 7:44 A.M. revealed Resident #8 was laying on her back in her bed. Observation on 03/25/25 at 9:53 A.M. revealed Resident #8 was laying on her back in her bed. Observation on 03/25/25 at 11:27 A.M. revealed Resident #8 was laying on her back in her bed. Observation on 03/25/25 at 1:05 P.M. revealed Resident #8 was laying on her back in her bed. Observation on 03/25/25 at 3:09 P.M. revealed Resident #8 was laying on her back in her bed. Observation on 03/26/25 at 6:58 A.M. revealed Resident #8 was laying on her back in her bed. Observation on 03/26/25 beginning at 7:00 A.M. and continuing until 9:30 A.M. revealed Resident #8 was in her room laying on her back and no staff entered her room to turn and reposition the resident. Observation on 03/26/25 at 10:04 A.M. revealed Resident #8 was laying on her back in her bed. Observation on 03/27/25 at 7:10 A.M. revealed Resident #8 was laying on her back in her bed. Interview on 03/25/25 at 3:09 P.M. with Resident #8 revealed staff does not turn and reposition her every two hours. Interview on 03/25/26 at 3:44 P.M. with Certified Nursing Assistant (CNA) #304 revealed she offers to turn and reposition Resident #8 two to three times in her eight-hour shift. Interview on 03/26/25 at 10:31 A.M. with Licensed Practical Nurse (LPN) #350 revealed no aides have reported to her that Resident #8 is refusing to be turned and repositioned. Review of Resident #8's most recent Braden Scale (a tool to evaluate a resident's risk of developing pressure ulcers) Assessment, dated 03/16/25, revealed a score of 14, indicating she was at moderate risk for developing pressure ulcers. Review of the care plan for Resident #8 revealed she has actual skim impairments/pressure ulcer and at risk for additional breakdown related to decreased mobility, a sacrum: stage IV pressure and a stage 3 pressure to right buttock and thigh. The outcome listed for this care area is pressures ulcers will show signs of healing and remain free from infection by the next review date. An intervention dated 06/07/22 revealed the resident needed monitoring, reminding, and assistance to turn and reposition at least every two hours, and more often as needed or requested. Further review of the medical record for the previous three months revealed no documentation that Resident #8 refused to be turned and repositioned. Review of the facility policy titled Skin Care Management, dated 12/09/22, revealed staff should remain alert to potential changes in the skin condition and should evaluate and document identified changes. 2. Resident #11 admitted to the facility on [DATE] with the diagnoses including, muscular dystrophy, tortcollis ([NAME] neck), scoliosis, protein calorie malnutrition, morbid obesity, major depressive disorder, anxiety disorder, chronic peripheral venous insufficiency, and anemia. According to the most current minimum data set assessment dated [DATE] assessed Resident #11 with intact cognition, no behavior indicating resistance of care, dependent on staff for the completion of activities of daily living, incontinent of bowel and bladder, at risk for pressure ulcer development with two stage 4 pressure ulcers. On 10/09/24 a nursing plan of care was revised to address Resident #11 actual skin impairment related to immobility. Interventions included the following; administer treatments as ordered and monitor for effectiveness. Follow policies/protocols for prevention and treatment of skin breakdown. If resident refuses treatment confer with resident, interdisciplinary team, and family to determine why and try alternative methods to gain compliance. Document alternative methods. According to the medical record on 10/25/24 a physician order was implemented to Resident #11 stage four (IV) pressure ulcers to his lower back and right upper back. The order directed to cleanse with house wound cleanser, then apply Hydrofera Blue (wet with normal saline if hard foam) and apply to wound bed, cover with silicone bordered foam. Complete every two days in the morning. Review of wound physician evaluation dated 03/20/25 noted Resident #11 assessed with a Stage 4 pressure wound to the right medial upper back with full thickness. Duration was greater than 1089 days, healing potential poor, cluster measurements included; 2.0 centimeters (cm) long by (x) 6.0 cm wide x 0.2 cm deep with moderate serosanguinous drainage. Additionally, a Stage 4 pressure wound to right lower back with full thickness. Duration was greater than 628 days, healing potential poor, cluster measurements included; 6.0 cm x 4.0 cm x 0.1 cm with moderate serosanguinous drainage. Observation on 03/25/25 at 11:17 A.M. noted Licensed Practical Nurse (LPN) #352 attempt to complete skin impairment dressing changes. LPN #352 completed a non-pressure wound dressing change to Resident #11 right arm. Following the dressing change Resident #11 refused to have the stage IV pressure ulcers changed due to anxiety and pain. Review of the medical record lacked documentation or attempts to re-approach Resident #11 to complete the stage IV pressure ulcer wound dressing changes. No documentation indicated the physician was notified of the wound dressing change refusal. On 03/26/25 at 9:40 A.M. interview with LPN #305 revealed she assumed care of Resident #11 at 6:30 A.M. LPN #305 indicated she was unaware Resident #11 had refused the pressure ulcer wound dressing change the previous day or if the dressing had been changed following the refusal. Review of medical record at the time verified no documentation indicating the physician was notified or the refusal or attempts to re-approach resident to change the wound dressing. Observation on 03/26/25 at 11:07 A.M. with LPN #305, Certified Nurse Aide (CNA) #274, and CNA #266 noted Resident #11 to transfer from recliner to bed. Resident #11 shirt was noted with a large amount of drainage clinging to his back. The dressings applied to Resident #11 back were dated 03/23 with yellow green drainage penetrating to dressings. LPN #305 proceeded to obtain wound cleansing solution and moistened the existing dressing, which was clinging to the wound. As LPN #305 pealed the dressing away from the wound a moderate amount of yellow/green drainage was observed on the dressings and caused fresh bleeding. LPN #305 proceeded to discard the existing dressings, cleanse the wounds and applied a new dressing. On 03/26/25 immediately following the wound dressing change LPN #305 confirmed the dressing had not been changed since 03/23/25 as documented in the medical record. Review of facility Skin Care Management Procedure dated revised 12/09/22. Staff should remain alert to potential changes in the skin condition and should evaluate and document identified changes. An evaluation of the dressing if present, is it intact, is there drainage or leakage. Determination of the need for a dressing for an ulcer is based upon the individual practitioner ' s clinical judgment and facility protocols based upon current professional standards of practice. The physician will be notified of all skin areas of concern and consulted for treatment orders. The physician will be notified of risk factors and the development of any area of concerns and consulted for treatment orders.

Based on observation, staff interview, and review of facility policy, the facility failed to follow proper sanitation and food storage practices. This had the potential to affect all residents who eat food from the facility kitchens. The facility identified that all residents receive food from the facility kitchens. The facility census is 54. Findings include: 1. Observation of the kitchen in house 5069 on 03/24/25 between 7:51 A.M. and 8:05 A.M. revealed the built-in oven under the microwave was dirty with generalized grime and dirt covering the sides and bottom of the oven, butter stored on the counter by the stove, 15 strips of cooked bacon on a plate on the stove-top on a plate, and approximately two cups of scrambled eggs in a bowl. Neither the butter, cooked bacon, or scrambled eggs were stored in a manner to ensure appropriate holding temperatures were maintained to ensure food safety, two packages of Egg-O waffles, one containing five waffles and the other containing six waffles, were both open, unsealed, and undated in the side-by-side freezer in the kitchen, a 64-ounce bag of French fries, approximately two-thirds used, was open, unsealed, and undated, the electronic freezer thermometer in the side-by-side freezer in the kitchen revealed it was not registering a temperature due to low battery, a dirty bottom shelf in the refrigerator in the storage room, one 20-ounce can of [NAME] brand apple pie filling with a dent on the top ring and a dent on the bottom ring, a foul odor was emanating from the dishwasher in the kitchen. Interview with Certified Nursing Assistant (CNA) #276 at the time of observation verified these findings. 2. Observation of the kitchen in house 5076 on 03/24/25 between 9:49 A.M. and 10:03 A.M. revealed the bottom of the in the storage area was dirty, the floor of the refrigerator in the kitchen is dirty, the built-in oven under the microwave was dirty with generalized grime and dirt covering the sides and bottom of the oven, the free-standing standard stove and oven had a dirty oven, and cabinet door faces are dirty throughout the kitchen. Interview with Licensed Practical Nurse (LPN) #221 at the time of observation verified these findings. 3. Observation of the kitchen in house 5090 on 03/24/25 between 10:13 A.M. and 10:21 A.M. revealed the bottom of the refrigerator in the storage area was dirty, bottom shelf in the stand up freezer is dirty, floor in kitchen storage room was dirty (paper and food), one 15-ounce can of beets with a dent in bottom ring, one 19-ounce can of red enchilada sauce with a dent in the side of the can, the built-in oven under the microwave was dirty with generalized grime and dirt covering the sides and bottom of the oven, the free-standing standard stove and oven had a dirty oven. Interview with CNA #298 at the time of discovery verified these findings. Review of the facility policy titled, Food Storage Policy & Procedure, dated 10/01/09 revealed all food is to be stored, labeled, and dated properly to assure stock rotation and prevent food illness.

Based on observation, staff interview, and review of facility menu, the facility failed to ensure the approved menu was followed as indicated. This affected 12 residents ( #1, #6, #9, #15, #16, #18, #21, #29, #30, #37, #47, #52) residing in home number 85. The facility census was 54. Findings include: Observation on 03/24/25 at 12:30 P.M. noted Certified Nurse Aides (CNA) #285 and CNA #351 providing the lunch meal to residents residing in the home. CNA #351 stated the previous weeks menu was posted and those meal items listed were not available. CNA #351 stated no current menu was available and the CNA's were serving residents various items available in the kitchen. CNA #351 and CNA #285 stated they were giving residents the following items; choice of one fish filet, hand full tater (potato) tots, if residents did not want tater tots residents were provided an extra fish filet. Residents were also given, some, potato salad and cut up strawberries. For residents not getting fish the were getting either turkey cold cut sandwich, or a peanut butter and jelly sandwich. Review of facility menu for 03/24/25 lunch noted the following items to be served; three ounce cheeseburger on bun with lettuce, tomato, onion, pickle, four ounces potato salad, four ounces strawberries with whipped cream. On 03/24/25 at 12:46 P.M. interview with Dietetic Technician (DT) #265 verified the home was not following a menu or dietitian calculated portion sizes. Additional interview on 03/25/25 at 09:00 A.M. interview with DT #265 identified 12 of 12 residents ( #1, #6, #9, #15, #16, #18, #21, #29, #30, #37, #47, #52) residing in the home that received meals from the facility kitchen.

Based on review of the medical record, staff interview, and policy review, the facility failed to ensure a resident's representative was notified of a change in condition. This affected one (#10) of one resident reviewed for notification of change of condition. The facility census was 54. Findings include: Review of the medical record for Resident #10 revealed an admitted [DATE]. Diagnoses included acute kidney failure, atrial fibrillation, and hypertensive heart disease. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of a nurses note dated 03/25/25 at 3:04 P.M., Resident #10 requested to transfer to the emergency room for increased pain. The resident was offered alternative measures such as pain medication, repositioning, distraction but resident was adamant on going to the emergency room for further evaluation. Review of a nurses note dated 03/26/25 at 12:17 P.M. revealed no documentation the resident's power of attorney/family member was notified of the transfer to the hospital. Interview on 03/27/25 at 8:58 A.M., the Director of Nursing (DON) revealed the resident was his own responsible party. The DON stated in the last couple of years the resident had not been speaking to his family member. The DON verified there was no documentation of attempts to reach the resident's family member and no documentation the resident had requested for his family member not to be contacted. Review of the facility policy Notification of Change of Condition, revised 11/22/21, revealed the facility would notify the resident's representative when there was a need to alter treatment significantly or a decision to transfer or discharge the resident from the facility.

Based on observation, medical record review, and staff interview, the facility failed to ensure a nursing plan of care was implemented to address a dependent resident need for assistance with activities of daily living including grooming. This affected one (#53) of 24 residents reviewed for the provision of hygiene and grooming in a facility census of 54. Findings include: Resident #53 admitted to the facility on [DATE] with the diagnoses including, cerebral infarction, type 2 diabetes mellitus, expressive language disorder, gastrostomy, and hypertension. According to the most current minimum data set assessment dated [DATE] noted Resident #53 assessed with severe cognitive impairment, limitation in range of motion to one side upper and lower extremity, dependent on staff for the completion of activities of daily living (ADL), incontinent of bowel and bladder, receives all nutrition via feeding tube, at risk for pressure ulcer development with no current skin breakdown. Observation on 03/24/25 at 9:43 A.M., and 03/25/25 at 6:08 A.M., 8:22 A.M., 11:39 A.M. 12:56 P.M. noted Resident #53 with long jagged fingernails with black/brown debris under the surface. On 03/25/25 at 2:05 P.M. interview with Certified Nurse Aide (CNA) #313 and CNA #274 verified Resident #53 was dependent for bathing and hygiene. Both CNA #313 and CNA #274 confirmed Resident #53 long jagged fingernails with black/brown debris under the surface and were unaware when his fingernails were most recently trimmed. On 03/26/25 at 2:45 P.M. interview with the Director of Nursing verified a nursing plan of care was not developed or contained in the medical record to address Resident #53 dependence on staff for the provision of ADL's.

Based on observation, medical record review, and staff interview, the facility failed to ensure dependent residents were provided with effective or sufficient assistance with activities of daily living including grooming. This affected two (#53 and #11) of 24 residents reviewed for the provision of hygiene and grooming. The facility census was 54. Findings include: 1. Resident #53 admitted to the facility on [DATE] with the diagnosis including, cerebral infarction, type 2 diabetes mellitus, expressive language disorder, gastrostomy, and hypertension. According to the most current minimum data set assessment dated [DATE] noted Resident #53 assessed with severe cognitive impairment, limitation in range of motion to one side upper and lower extremity, dependent on staff for the completion of activities of daily living, incontinent of bowel and bladder, receives all nutrition via feeding tube, at risk for pressure ulcer development with no current skin breakdown. Observation on 03/24/25 at 9:43 A.M., and 03/25/25 at 6:08 A.M., 8:22 A.M., 11:39 A.M. 12:56 P.M. noted Resident #53 with long jagged fingernails with black/brown debris under the surface. On 03/25/25 at 2:05 P.M. interview with Certified Nurse Aide (CNA) #313 and CNA #274 verified Resident #53 was dependent for bathing and hygiene. Both CNA #313 and CNA #274 confirmed Resident #53 long jagged fingernails with black/brown debris under the surface and were unaware when his fingernails were most recently trimmed. 2. Resident #11 admitted to the facility on [DATE] with the diagnoses including, muscular dystrophy, tortcollis ([NAME] neck), scoliosis, protein calorie malnutrition, morbid obesity, major depressive disorder, anxiety disorder, chronic peripheral venous insufficiency, and anemia. According to the most current minimum data set assessment dated [DATE] assessed Resident #11 with intact cognition, no behavior indicating resistance of care, dependent on staff for the completion of activities of daily living, incontinent of bowel and bladder, at risk for pressure ulcer development with two stage 4 pressure ulcers. On 07/01/22 a plan of care was revised to address Resident #11 activity of daily living self care and/or physical mobility performance deficit. Interventions included; use of medicated shampoo, requires one person assistance with bathing, total assistance with dressing, requires two staff for personal hygiene. Observation on 03/24/25 at 9:33 A.M., and on 03/25/25 at 6:11 A.M. and 11:17 A.M. noted Resident #11 with the same soiled shirt with food debris, heavy beard growth, unkept and matted hair, and long jagged finger nails. On 03/25/25 at 6:11 A.M. interview with Resident #11 revealed the resident would prefer to be clean shaven, but did not want staff to use a straight razor when shaving him. Interview on 03/25/25 at 11:45 A.M. with Licensed Practical Nurse (LPN) #352 verified Resident #11 lack of grooming, including bathing, shaving, and clean clothing.

Based on observation, resident interview, staff interview, review of medical record, and review of facility policy, the facility failed to ensure interventions were in place to promote healing of pressure ulcers. This affected two residents (#8 and #11) of four residents (#8, #10, #11, and #30) reviewed for pressure ulcers. The facility census was 54. Findings include: 1. Review of the medical record for Resident #8 revealed an admitted [DATE] with diagnoses including stage four sacral pressure ulcer, multiple sclerosis (MS), type two diabetes mellitus (DM2), paraplegia, depression, gastro-esophageal reflux disease (GERD), colostomy, neuromuscular dysfunction of bladder, insomnia, anemia, hypertension (HTN), hyperlipidemia, chronic pain syndrome, morbid obesity, non-pressure chronic ulcer of part of left lower leg with unspecified severity, non-pressure chronic ulcer of right ankle with unspecified severity, non-pressure chronic ulcer of buttock with unspecified severity, bullous pemphigoid, urinary tract infection (UTI), unspecified open wound of left ankle, and need for assistance with personal care. Review of the most Medicare Five Day Minimum Data Set (MDS) assessment, dated 03/20/25, revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating Resident #8's cognition was intact. Concurrent review of the MDS assessment revealed Resident #8 revealed she was dependent for all of her functional abilities, including rolling left and right. Observation on 03/24/25 at 11:43 A.M. revealed Resident #8 was laying on her back in her bed. Observation on 03/25/25 at 7:44 A.M. revealed Resident #8 was laying on her back in her bed. Observation on 03/25/25 at 9:53 A.M. revealed Resident #8 was laying on her back in her bed. Observation on 03/25/25 at 11:27 A.M. revealed Resident #8 was laying on her back in her bed. Observation on 03/25/25 at 1:05 P.M. revealed Resident #8 was laying on her back in her bed. Observation on 03/25/25 at 3:09 P.M. revealed Resident #8 was laying on her back in her bed. Observation on 03/26/25 at 6:58 A.M. revealed Resident #8 was laying on her back in her bed. Observation on 03/26/25 beginning at 7:00 A.M. and continuing until 9:30 A.M. revealed Resident #8 was in her room laying on her back and no staff entered her room to turn and reposition the resident. Observation on 03/26/25 at 10:04 A.M. revealed Resident #8 was laying on her back in her bed. Observation on 03/27/25 at 7:10 A.M. revealed Resident #8 was laying on her back in her bed. Interview on 03/25/25 at 3:09 P.M. with Resident #8 revealed staff does not turn and reposition her every two hours. Interview on 03/25/26 at 3:44 P.M. with Certified Nursing Assistant (CNA) #304 revealed she offers to turn and reposition Resident #8 two to three times in her eight-hour shift. Interview on 03/26/25 at 10:31 A.M. with Licensed Practical Nurse (LPN) #350 revealed no aides have reported to her that Resident #8 is refusing to be turned and repositioned. Review of Resident #8's most recent Braden Scale (a tool to evaluate a resident's risk of developing pressure ulcers) Assessment, dated 03/16/25, revealed a score of 14, indicating she was at moderate risk for developing pressure ulcers. Review of the care plan for Resident #8 revealed she has actual skim impairments/pressure ulcer and at risk for additional breakdown related to decreased mobility, a sacrum: stage IV pressure and a stage 3 pressure to right buttock and thigh. The outcome listed for this care area is pressures ulcers will show signs of healing and remain free from infection by the next review date. An intervention dated 06/07/22 revealed the resident needed monitoring, reminding, and assistance to turn and reposition at least every two hours, and more often as needed or requested. Further review of the medical record for the previous three months revealed no documentation that Resident #8 refused to be turned and repositioned. Review of the facility policy titled Skin Care Management, dated 12/09/22, revealed staff should remain alert to potential changes in the skin condition and should evaluate and document identified changes. 15816 2. Resident #11 admitted to the facility on [DATE] with the diagnoses including, muscular dystrophy, tortcollis ([NAME] neck), scoliosis, protein calorie malnutrition, morbid obesity, major depressive disorder, anxiety disorder, chronic peripheral venous insufficiency, and anemia. According to the most current minimum data set assessment dated [DATE] assessed Resident #11 with intact cognition, no behavior indicating resistance of care, dependent on staff for the completion of activities of daily living, incontinent of bowel and bladder, at risk for pressure ulcer development with two stage 4 pressure ulcers. On 10/09/24 a nursing plan of care was revised to address Resident #11 actual skin impairment related to immobility. Interventions included the following; administer treatments as ordered and monitor for effectiveness. Follow policies/protocols for prevention and treatment of skin breakdown. If resident refuses treatment confer with resident, interdisciplinary team, and family to determine why and try alternative methods to gain compliance. Document alternative methods. According to the medical record on 10/25/24 a physician order was implemented to Resident #11 stage four (IV) pressure ulcers to his lower back and right upper back. The order directed to cleanse with house wound cleanser, then apply Hydrofera Blue (wet with normal saline if hard foam) and apply to wound bed, cover with silicone bordered foam. Complete every two days in the morning. Review of wound physician evaluation dated 03/20/25 noted Resident #11 assessed with a Stage 4 pressure wound to the right medial upper back with full thickness. Duration was greater than 1089 days, healing potential poor, cluster measurements included; 2.0 centimeters (cm) long by (x) 6.0 cm wide x 0.2 cm deep with moderate serosanguinous drainage. Additionally, a Stage 4 pressure wound to right lower back with full thickness. Duration was greater than 628 days, healing potential poor, cluster measurements included; 6.0 cm x 4.0 cm x 0.1 cm with moderate serosanguinous drainage. Observation on 03/25/25 at 11:17 A.M. noted Licensed Practical Nurse (LPN) #352 attempt to complete skin impairment dressing changes. LPN #352 completed a non-pressure wound dressing change to Resident #11 right arm. Following the dressing change Resident #11 refused to have the stage IV pressure ulcers changed due to anxiety and pain. Review of the medical record lacked documentation or attempts to re-approach Resident #11 to complete the stage IV pressure ulcer wound dressing changes. No documentation indicated the physician was notified of the wound dressing change refusal. On 03/26/25 at 9:40 A.M. interview with LPN #305 revealed she assumed care of Resident #11 at 6:30 A.M. LPN #305 indicated she was unaware Resident #11 had refused the pressure ulcer wound dressing change the previous day or if the dressing had been changed following the refusal. Review of medical record at the time verified no documentation indicating the physician was notified or the refusal or attempts to re-approach resident to change the wound dressing. Observation on 03/26/25 at 11:07 A.M. with LPN #305, Certified Nurse Aide (CNA) #274, and CNA #266 noted Resident #11 to transfer from recliner to bed. Resident #11 shirt was noted with a large amount of drainage clinging to his back. The dressings applied to Resident #11 back were dated 03/23 with yellow green drainage penetrating to dressings. LPN #305 proceeded to obtain wound cleansing solution and moistened the existing dressing, which was clinging to the wound. As LPN #305 pealed the dressing away from the wound a moderate amount of yellow/green drainage was observed on the dressings and caused fresh bleeding. LPN #305 proceeded to discard the existing dressings, cleanse the wounds and applied a new dressing. On 03/26/25 immediately following the wound dressing change LPN #305 confirmed the dressing had not been changed since 03/23/25 as documented in the medical record. Review of facility Skin Care Management Procedure dated revised 12/09/22. Staff should remain alert to potential changes in the skin condition and should evaluate and document identified changes. An evaluation of the dressing if present, is it intact, is there drainage or leakage. Determination of the need for a dressing for an ulcer is based upon the individual practitioner ' s clinical judgment and facility protocols based upon current professional standards of practice. The physician will be notified of all skin areas of concern and consulted for treatment orders. The physician will be notified of risk factors and the development of any area of concerns and consulted for treatment orders. This deficiency represents non-compliance investigated under Complaint Number OH00162263.

Based on observation, medical record review, and staff interview, the facility failed to ensure devices to prevent contractures were applied in accordance with physician orders. This affected one resident (#53) reviewed for the application of range of motion interventions. The facility census was 54. Findings include: Resident #53 admitted to the facility on [DATE] with the diagnoses including, cerebral infarction, type 2 diabetes mellitus, expressive language disorder, gastrostomy, and hypertension. According to the most current minimum data set assessment dated [DATE] noted Resident #53 assessed with severe cognitive impairment, limitation in range of motion to one side upper and lower extremity, dependent on staff for the completion of activities of daily living, incontinent of bowel and bladder, receives all nutrition via feeding tube, at risk for pressure ulcer development with no current skin breakdown. On 03/02/25 a physician order was initiated for the application of a right hand splint to be on during the day and off at bed time (HS). Review of the medical record lacked documentation indicating the right hand splint was applied as ordered. Observations on 03/24/25 at 2:24 P.M., and 03/25/25 at 6:08 A.M., 8:22 A.M., 11:39 A.M., 12:56 P.M. noted Resident #53 in bed without the right hand splint applied. On 03/25/25 at 2:05 P.M. interview with Certified Nurse Aide (CNA) #313 and CNA #274 stated they were unaware of Resident #53 splint, an application schedule, or what staff was to apply the splint. CNA #274 verified the splint was not applied during the shift. Interview on 03/25/25 at 2:08 PM with Licensed Practical Nurse (LPN) #352 confirmed assigned to Resident #53 care on 03/25/25 between 6:30 A.M. and 6:30 P.M. LPN #352 verified the splint was not applied during her shift and was unaware the splint was to be applied. Observation on 03/26/25 at 6:02 A.M. noted Resident #53 in bed with the right hand splint applied. On 03/26/25 at 6:13 A.M. interview with CNA #346 revealed CNA #346 assumed care of Resident #53 between 10:30 P.M. on 03/25/25, and 6:30 A.M. on 03/26/25. CNA #346 was unaware of Resident #53's splint and that it was to be applied through the night. Review of the electronic care card with CNA #346 lacked evidence of Resident #53 having a splint or instructions regarding the application of the splint.

Based on review of the medical record, observation, staff interview, resident interview, and review of a skills procedure, the facility failed to ensure an appropriate diagnosis for the continued use of an indwelling urinary catheter and failed to ensure catheter tubing was secured. This affected one (#48) of two residents reviewed for urinary catheters. The facility identified seven residents with indwelling urinary catheters. The facility census was 54. Findings include: Review of the medical record for Resident #48 revealed an admitted [DATE]. Diagnoses included acute and chronic respiratory failure, depressive disorder, urinary tract infection, anxiety, chronic kidney disease stage three, and chronic obstructive pulmonary disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was dependent for toileting hygiene and occasionally incontinent of bowel and bladder. The resident had an indwelling urinary catheter. Review of the physician orders dated 02/14/25 revealed the resident had a 16 French urinary catheter change as needed. There were no orders for securing the urinary catheter tubing. There was no diagnosis to support the catheter use. Review of the care plan initiated 02/14/25 revealed the resident had a urinary catheter. There were no guidelines for securing the catheter tubing. Interview on 03/25/25 at 9:53 A.M., with Resident #48 and her family member revealed the resident could not stand to be wet from incontinence and needed the catheter because she frequently had to go to the bathroom and was concerned about skin breakdown. The resident revealed not wanting the catheter removed. Observation on 03/25/25 at 11:16 A.M. of Resident #48 revealed Certified Nursing Assistant (CNA) #351 and CNA #271 provided catheter care for the resident. The resident had no device to secure the catheter tubing. Interview on 03/25/25 at 11:16 A.M., CNA #351 and CNA #271 verified the resident's indwelling catheter tubing was not secured. Interview on 03/26/25 at 9:32 A.M., the Director of Nursing (DON) revealed the resident had a diagnoses of urinary retention from the hospital. The DON revealed the physician wanted the resident's catheter removed but the resident continued to refuse the removal of the catheter. The DON revealed the resident had been educated on the risks of not removing the catheter. Review of the undated facility 2025 Skills Checklist Indwelling Urinary Catheter Care and Management, revealed to ensure the catheter was secured properly.

Based on review of the medical record, staff interview, and policy review, the facility failed to ensure residents on psychotropic medication were monitored for adverse consequences, effectiveness, and behavior monitoring. This affected two (#48, and #161) of five residents reviewed for unnecessary medications. The facility identified 28 residents receiving psychotropic medications. The facility census was 54. Findings include: 1. Review of the medical record for Resident #48 revealed an admitted [DATE]. Diagnoses included acute and chronic respiratory failure, major depressive disorder, urinary tract infection, anxiety, chronic kidney disease stage three, and chronic obstructive pulmonary disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the physician orders for 03/2025 revealed an order for bupropion 75 milligrams (mg) every other day for major depressive disorder. An order for fluvoxamine 25 mg at bedtime for anxiety, buspirone 15 mg three times a day for anxiety, escitalopram 20 mg daily for antidepressant. Review of the care plan initiated 02/18/25 revealed the resident utilized antidepressant and antianxiety medications and to monitor for side effects and effectiveness and document. Review of the medication administration record (MAR) from 02/18/25 through 03/25/25 revealed no documentation of monitoring for the side effects and effectiveness of the ordered medications for depression and anxiety. Interview on 03/26/25 at 9:30 A.M., the Director of Nursing (DON) verified there were no orders in place for monitoring the side effects and effectiveness of the medications. 2. Review of the medical record for Resident #161 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, dementia, anxiety, delusional disorder, depressive disorder, and hypertension. Review of the admission MDS dated [DATE] revealed the resident had cognitive impairment. Review of the physician orders for 03/2025 revealed an order for Seroquel 100 mg at bedtime for restlessness, Seroquel 50 mg in the morning for restlessness, hydroxyzine 25 mg as needed every six hour for anxiety, trazadone 50 mg at bedtime for restlessness, and sertraline 100 mg two tablets daily for depression. Review of the care plan initiated 03/20/25 revealed the resident had a behavior of resisting care, yelling out, and restlessness. Further review of the care plan revealed the resident utilized antipsychotic, antidepressant and antianxiety medications and to monitor for side effects and effectiveness and document. Also to review behaviors/interventions and alternate therapies attempted and their effectiveness. Review of the MAR from 03/10/25 through 03/25/25 revealed no documentation of monitoring for the side effects and effectiveness of the ordered medications for depression and anxiety. Interview on 03/26/25 at 9:32 A.M., the DON verified there were no orders in place for monitoring targeted behaviors or for the side effects and effectiveness of the resident's medications. Further interview on 03/26/25 at 1:49 P.M. the DON revealed the resident had an appropriate diagnosis of major depressive disorder for the use the Seroquel but the physician order entered into the electronic medical record had not reflected the appropriate diagnosis. Review of the facility policy Psychotropic Medication Management Policy, revealed an unnecessary drug was any drug used without adequate monitoring or without adequate indication for use.

Based on review of the medical record, observation, staff interview, review of facility skills checklist and policy review, the facility failed to ensure infection control standards were in place. This affected one (#48) of two residents reviewed for indwelling catheters. The facility identified seven residents with indwelling urinary catheters. The facility census was 54. Findings include: Review of the medical record for Resident #48 revealed an admitted [DATE]. Diagnoses included acute and chronic respiratory failure, depressive disorder, urinary tract infection, anxiety, chronic kidney disease stage three, and chronic obstructive pulmonary disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was dependent for toileting hygiene and occasionally incontinent of bowel and bladder. The resident had an indwelling urinary catheter. Review of the physician orders dated 02/14/25 revealed the resident had a 16 French urinary catheter change as needed. There were no orders for placement of the drainage bag. Further review of the physician orders revealed the resident had orders for enhanced barrier precautions (EBP). Observation on 03/24/25 at 9:27 A.M. revealed the resident's catheter drainage bag was lying on the floor beneath the recliner chair. Interview on 03/24/25 at 9:29 A.M., Licensed Practical Nurse (LPN) #221 verified the resident's urinary catheter drainage bag was on the floor underneath the resident's recliner chair. Observation on 03/25/25 at 11:16 A.M. of Resident #48 revealed the resident had a enhanced barrier precaution sign on the entry door frame. Certified Nursing Assistant (CNA) #351 and CNA #271 provided catheter care for the resident wearing gloves but no other personal protective equipment including a gown. Interviews on 03/25/25 at 11:21 A.M. with CNA #351 and CNA #271 verified they were not wearing gowns while providing catheter care. Review of the undated facility 2025 Skills Checklist Indwelling Urinary Catheter Care and Management, revealed to ensure the drainage bag was below the left of the resident's bladder but off of the floor. Review of the facility policy Isolation Precautions Process, dated 12/2009 revealed enhanced barrier precautions (EBP) were used for residents with wounds and/or indwelling medical devices including catheters. EBP included the use of gloves and gowns during high-contact resident care including dressing, bathing/showering, changing linens, transferring, providing hygiene, toileting, device care, and wound care.

Based on observation, review of the facility electronic medical record (EMR), resident interview, and staff interview, the facility failed to provide a sanitary and comfortable environment. This affected two (#33 and #212) residents of five (#11, #18, #33, #35, and #212) residents reviewed for environment. The facility census was 54. Findings include: 1. Review of the EMR for resident #33 revealed an admitted [DATE] with diagnoses including congestive heart failure (CHF), type two diabetes mellitus (DM2), hypertension (HTN), hyperlipidemia, paranoid schizophrenia, atherosclerotic heart disease of native coronary arteries, gastro-esophageal reflux disease (GERD), neuromuscular dysfunction of bladder, and constipation. Review of the most recent Quarterly Minimum Data Set (MDS) assessment, dated 02/12/25, revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating Resident #33 was cognitively intact. Observation on 03/24/25 at 9:12 A.M. of Resident #33's room revealed the windowsill on the bottom of her window was missing and the wind could be heard and felt blowing in, damaged door trim, damaged paint, and an unidentified brown substance splattered and dried onto the doorframe entering the restroom as well as the waste receptacle in the resident restroom. Concurrent observation also revealed debris (hair, food crumbs, and trash) on the floor throughout Resident #33's room. Interview on 03/24/25 at 9:25 A.M. with Licensed Practical Nurse (LPN) #221 verified these findings. 2. Review of the EMR for Resident #212 revealed an admitted [DATE] with diagnoses including aftercare following joint replacement surgery, hyperlipidemia, hypertensive heart disease and chronic kidney disease (CKD), atherosclerotic heart disease, atrial fibrillation (a. fib), vitamin B deficiency, other specified disorders of bone density and structure, depression, hypertension (HTN), gastro-esophageal reflux disease (GERD). Review of the most recent Medicare Five Day Minimum Data Set (MDS) assessment, 03/17/25, revealed a Brief Interview of Mental Status (BIMS) score of 12, indicating Resident #212's cognitive was moderately impaired. Observation on 03/24/25 at 9:39 A.M. revealed damaged paint on the entryway into Resident #212's restroom. Concurrent observation revealed Resident #212's restroom was unkept, with two cups on the restroom floor, a towel on the restroom floor, a towel sitting on a shower chair in the shower, and generalized debris (paper and hair) on the restroom floor. Interview at the time of observation with Resident #212 revealed she took a shower the night prior, on 03/23/25, and the towels remained in the restroom from that time. Interview on 03/24/25 at 9:47 A.M. with Certified Nursing Assistant (CNA) #308 verified these findings. This deficiency represents non-compliance investigated under Complaint Number OH00162138.

Based on review of the medical record, observation, resident interview, staff interview, and policy review, the facility failed to ensure medications were secured and not left at the bedside. This affected one (#19) of seven residents reviewed for medications and had the potential to affect two residents the facility identified as cognitively impaired and independently mobile. The facility census was 54. Findings include: Review of the medical record for Resident #19 revealed an admitted [DATE]. Diagnoses included dysphagia following cerebrovascular disease, heart failure, chronic respiratory failure, chronic kidney disease, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident required substantial/maximal assistance with eating. Review of the malnutrition risk care plan last revised 02/14/25 revealed to provide one to one supervision with meals/snacks/fluids. Review of a physician order dated 03/24/25 revealed the resident's medication could be combined, crushed, and administered together. The resident had no orders to self-administer medications. Observation on 03/24/25 at 9:10 A.M. revealed the resident was lying in bed. On the bedside table was a medication cup with a spoon containing medications mixed in pudding. Interview on 03/24/25 at 9:10 A.M., the resident revealed the night nurse had left his medications and had not returned. Interview on 03/24/25 at 9:11 A.M., Licensed Practical Nurse (LPN) #305 revealed she had not yet administered medication to the resident this morning. LPN #305 revealed the medications were left by the previous shift nurse. Interview on 03/26/25 at 7:56 A.M., with LPN #215 verified leaving the medication unattended with the resident. LPN #215 revealed she usually left the medications with the resident and would go back later to check if the resident took the medication but on this day she forgot to go back and check. Review of the policy Medication Administration Procedure, revised 11/09/21, revealed the resident would be observed after administration to ensure the dose was completely ingested.

Based on review of the medical record, resident interview, staff interview, the facility failed to ensure resident bathing preferences were honored. This affected one (#32) of one resident reviewed for choices. The facility census was 54. Findings include: Review of the medical record for Resident #32 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus, hypertension, and depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was dependent on staff for bathing. Review of the shower schedule revealed Resident #32 was scheduled for showers on Wednesdays and Saturdays on second shift. Review of the task bathing documentation from 01/01/25 through 03/25/25 revealed the resident was not provided a bath or shower on her preferred days on 01/08/25, 01/18/25, 01/29/25, 03/08/25, and 03/15/25. Further review of the task documentation revealed the type of bathing provided on other days when received was unknown as the staff do not document if the resident received a shower or bath in tasks in the electronic medical record. Review of the nurses progress notes dated 01/01/25 through 03/25/25 revealed the resident had not refused her showers on 01/08/25, 01/18/25, 01/29/25, 03/08/25, and 03/15/25. Interview on 03/24/25 at 10:07 A.M., Resident #32 revealed she preferred showers and had not received her showers as scheduled because the aides would tell her the shower chair was not available. Interview on 03/25/25 at 10:14 A.M., Certified Nursing Assistant (CNA) #292 revealed paper shower sheets were used to document whether a resident received a shower or a bed bath. CNA #292 revealed bathing was documented in the electronic medical record but not the type of bathing provided. Interview on 03/26/25 at 12:51 P.M., the Administrator revealed she was unable to provide the paper shower forms because they were not required and were not part of the medical record. Interview on 03/26/25 at 3:04 P.M., the Director of Nursing (DON) revealed the resident's bathing preference was listed at the top of the bathing task. The DON revealed the type of bathing received was not documented in the electronic medical record. The DON revealed when the nursing assistant signed the task as completed it also meant the resident's preference was honored. Interview on 03/26/25 at 3:26 P.M., CNA #211 revealed if a resident received a bedbath instead of a shower then it would be documented on the shower sheet but not in the electronic medical record. Interview on 03/26/25 at 6:36 P.M., CNA #347 revealed in the past the shower chair was not available and the resident was provided a bed bath instead of a shower. CNA #347 revealed bathing was documented in the medical record but not the type of bathing. CNA #347 revealed bed baths and showers were documented on paper shower forms. Interview on 03/26/25 at 3:26 P.M., CNA #211 revealed if a resident received a bedbath instead of a shower then it would be documented on the shower sheet but not in the electronic medical record. Interview on 03/27/25 at 7:32 A.M., the Administrator revealed the facility had no policy regarding resident choices but followed resident rights. Interview on 03/27/25 at 8:32 A.M., Licensed Practical Nurse (LPN) #227 verified there was no documentation showers were given on 01/08/25, 01/18/25, 01/29/25, 03/08/25, and 03/15/25 and stated the resident had a bed bath or shower on other days. LPN #227 revealed it could not be determined by the bathing documentation in the electronic medical record if the resident had received a bed bath or shower.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure food was stored in a safe and sanitary manner. This had the potential to affect all 57 residents in the facility. The census was 57. Findings include: 1. Observation on [DATE] at 8:15 A.M. in House #4 revealed a refrigerator with an opened and undated carton of broccoli soup, an opened and undated carton of potato soup, and a plastic reusable bag of food without a label or date. Further observation of a second refrigerator revealed what appeared to be several paper towels lying flat underneath the bottom drawer with a pinkish/red tint to them. Interview and observation on [DATE] at approximately 8:20 A.M. with Certified Nurse Aide (CNA) #101 confirmed the food items were opened, unlabeled, and undated. CNA #101 further confirmed the item under the bottom drawer of the refrigerator appeared to be paper towels and were pink/red in color. 2. Observation on [DATE] at 8:30 A.M. in House #2 revealed a refrigerator in the kitchen area with an opened and undated container of commercial macaroni salad with a puffed-up lid, an opened container of chicken tortilla soup dated [DATE], a container of cream cheese with a green substance growing on it, and a gallon milk container with an expiration date of [DATE]. Continued observation of the refrigerator in the pantry of House #2 revealed a large reusable container of food without a label or date, and a black plastic container (similar to a restaurant take-home container) without a label or date. Additionally, the bottom drawer of the refrigerator had a dried substance that was pink in color. Interview and observation on [DATE] at 8:36 A.M. with CNA #102 confirmed the refrigerated items were unlabeled and expired, and further confirmed the dried substance in the bottom drawer appeared to have possibly been dried blood from leaking meat. 3. Observation and interview on [DATE] at 8:55 A.M. with CNA #103 in House #5 revealed a refrigerator in the kitchen area with an opened and undated bottle of apple juice, an opened container of sliced roast beef lunch meat with a tear in the seal and with a best if used by date of [DATE], a re-sealable bag containing food without a label or date, and a large undated metal bowl covered with aluminum foil containing chocolate pudding. Further observation of a refrigerator in the pantry area revealed a dried pink substance in the bottom drawer with a container of grapes, and an undated and opened container of apple juice. CNA #103 stated she just opened the apple juice in the first refrigerator for breakfast and confirmed it was undated. CNA #103 further confirmed the additional undated and expired items in both refrigerators. 4. Observation and interview on [DATE] at 9:15 A.M. with CNA #104 in House #1 revealed a refrigerator in the kitchen area containing a sipper cup containing an off-white liquid. The sipper cup was unlabeled. Further observation and interview confirmed an opened and undated container of potato soup, a bowl of ground meat covered in plastic wrap without a label or date, and an opened container of commercial potato salad dated [DATE]. CNA #104 stated she believe the sipper cup contained a nutrition supplement and confirmed it was undated and unlabeled. 5. Observation and interview on [DATE] at 9:49 A.M. with Life Enrichment Coordinator (LEC) #302 in House #3 confirmed the refrigerator in the kitchen area contained apple juice dated [DATE], and contained an opened and undated container of chicken broth. Further interview and observation with LEC #302 confirmed the refrigerator in the pantry area contained actual liquid at the bottom of the bottom drawer along with a wrapped ham. LEC #302 further confirmed the pantry contained a plastic tub of flour that was open to air, a scoop inside a container of oatmeal, and a bag of hamburger buns was open to air. Interview on [DATE] at 11:38 A.M. with Dietetic Technician (DT) #303 revealed each food item should have a delivery date and an opened date. Additionally, leftover food should be thrown out after four days and opened packaged food should be thrown out after four to seven days. Interview on [DATE] at approximately 3:00 P.M. with the Administrator revealed all 57 residents in the facility received food from the kitchen. Review of the policy titled, Food Storage Policy & Procedure, revised ,d+[DATE], revealed bulk foods, such as flour, may be stored in a clean, covered container. Further review revealed prepared food should be should be covered, labeled and dated and should be used within four to seven days after the food was prepared. This deficiency represents non-compliance investigated under Complaint Number OH00160297.

Based on observation and staff interview, the facility failed to maintain a clean and sanitary environment. This had the potential to affect all residents except 12 (#13, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, and #68) residents residing in House #5. The facility census was 57. Findings include: 1. Observation and interview on 12/24/24 at 1:36 P.M. with Maintenance Director (MD) #301 in House #1 revealed a kitchen cabinet under the sink. Further observation revealed the floor of the cabinet was collapsed and the veneer was separated from the particle board on the floor of the cabinet. The cabinet measured approximately three feet and 10 inches wide. MD #301 confirmed the back wall of the cabinet was modified to allow for plumbing and therefore the back wall did not touch the base or side walls of the cabinet. MD #301 confirmed approximately three inches of drywall were visible between the cabinet floor and the bottom of the back wall. MD #301 confirmed a black and dark brown substance was visible on the drywall across the three feet and 10 inch width of the cabinet. In some areas the substance fully coated the drywall and no white of the drywall was visible. In other areas the black and dark brown substance appeared spotted. The black and dark brown substance appeared flat to the wall and did not appear to be raised. There was a musty odor which came from the cabinet. MD #301 stated he believed the musty odor came from the collapsed base of the cabinet and stated he believed the base collapsed due to excessive weight, although MD #301 further confirmed the veneer was separated from the particle board. The cabinet contained two plungers and a bottle of dish soap. 2. Observation and interview on 12/24/24 at 2:08 P.M. with MD #301 in House #4 confirmed the cabinet under the kitchen sink was built to reveal drywall between the base and the back of the cabinet spanning the width of the cabinet and was approximately two inches high. Further observation revealed a light brown substance on the drywall covering approximately six inches wide and one inch high. Observed on the light brown substance were white, black, and gray pinpoint-sized spots. MD #301 peeled the brown off the wall, revealing white drywall beneath. MD #301 stated the brown color was the drywall discolored and peeling. 3. Observation and interview on 12/24/24 at 2:15 P.M. with MD #301 in House #3 confirmed the cabinet under the kitchen sink was built to reveal drywall between the base and the back of the cabinet spanning the width of the cabinet and was approximately two inches high. Further observation revealed an area approximately 12 inches wide and two inches high with light brown discoloration on the drywall. On the light brown areas were grey and black pinpoint spots. MD #301 confirmed the brown spotted areas and stated the drywall had been wet at some point but was dry during the current observation. Inside the cabinet were towels, scrub pads, and dishwasher soap. 4. Observation and interview on 12/24/24 at approximately 2:20 P.M. with MD #301 in House #2 confirmed the cabinet under the kitchen sink was built to reveal drywall between the base and the back of the cabinet spanning the width of the cabinet and was approximately two inches high. Further observation revealed an area approximately two feet wide and two inches high with light brown discoloration on the drywall. On the light brown areas were gray and black pinpoint spots. MD #301 confirmed the brown spotted areas on the drywall. MD #301 further confirmed pieces of drywall, approximately one to two inches in diameter, were at the back of the cabinet. The cabinet contained several bottles of dishwashing liquid. This deficiency represents non-compliance investigated under Complaint Number OH00160297.

Based on review of the medical record, staff interviews and policy review, the facility failed to timely notify the physician of signs and symptoms of a wound infection leading to a delay in treatment. This resulted in actual harm when Resident #23's toe wound began to show signs and symptoms of infection and the facility staff had not notified the physician. Resident #23 required care from the emergency room for treatment of osteomyelitis (severe wound infection). Additionally, the facility failed to correctly implement wound treatments per physician orders and timely administer antibiotics per physician orders. This affected one (Resident #23) of three residents reviewed for wound care. The facility census was 48. Findings include: Review of the medical record revealed Resident #23 had an admitted [DATE]. Diagnoses included end stage renal disease, type two diabetes mellitus, cerebral infarction, and hypertension. Review of the annual Minimum Data Set (MDS) assessment completed 10/05/23 revealed the resident had intact cognition. Review of the care plan initiated 06/07/23 for Resident #23 revealed actual skin breakdown related to diabetes. The resident had a diabetic ulcer to the left first toe. Interventions included to administer treatment as ordered; encourage to wear an open toe diabetic shoe for the left foot and closed toe diabetic shoe for right foot, may wear alternative footwear as requested or preferred, enhanced barrier precautions; monitor effectiveness of treatment and notify physician or nurse practitioner as needed if area worsens or does not respond, monitor for infection at site as evidenced by redness, edema, and a weekly skin screening of body. Review of the medical record revealed the resident had a diabetic wound of the left first toe beginning 06/07/23. The wound developed osteomyelitis and the resident was appropriately treated for the infection from 06/07/23 through 08/09/23. Review of a physician wound note dated 09/13/23 revealed the diabetic wound had improved and was scabbed over. The wound measured 0.5 centimeter (cm) in length, one cm in width with no measurable depth. There was no drainage. Review of a physician order dated 09/15/23 revealed to apply skin prep daily to the left first toe. Review of a nurse's note date 09/17/23 at 9:30 P.M. revealed the resident hit left great toe with wound on it while getting out of the shower. Wound opened slightly, and a small amount of pus and blood drained from wound. The wound was treated with betadine, triple antibiotic ointment was applied with a dry dressing, per standing physician orders. There was no documentation the physician was notified the wound had reopened. Review of a physician wound assessment dated [DATE] revealed the wound to the left first toe measured 0.3 cm by 0.4 cm 0.1 cm in depth with moderate serous drainage. The wound was noted as improved. The physician discontinued the daily skin prep and ordered alginate calcium with silver and to cover with composite dressing with border daily. Review of the Treatment Administration Record (TAR) revealed no documentation the calcium alginate with silver treatment was completed on 09/21/23, 09/22/23, 09/23/23, 09/24/23, and 09/25/23. The facility never entered the new treatment orders into the electronic medical record. Further review of the TAR revealed on 09/22/23, 09/23/23, and 09/24/23 the skin prep treatment was administered incorrectly as this treatment had been discontinued on 09/20/23. Review of a weekly skin observation tool dated 09/24/23 at 12:45 P.M. revealed the wound to the left first toe measured 0.3 cm in length, 0.4 cm in width, and 0.1 cm in depth. The wound was described as bleeding medium and mal odor. There was no documentation the physician was notified of the signs of infection. Review of a nurses note dated 09/26/23 at 5:00 P.M. revealed the resident had treatment changed on left great toe, resident had extra skin that was sloughing off with a moderate amount of purulent drainage. Discoloration was noted to the left first toe area, with swelling surround the medial foot area. Wound care to follow and treat on 09/27/23. There was no documentation the physician was notified of the purulent drainage and swelling of the foot. Review of a wound care note dated 09/27/23 revealed the resident's wound was exacerbated due to infection. The wound measured 3 cm in length, 3 cm in width, with a depth of 0.1 cm with moderate serous drainage. The wound had 30% necrotic tissue, 30% granulation tissue and 40% other tissue. The physician ordered to apply dakins solution with a gauze roll daily for 30 days. The physician recommended an intravenous (IV) antibiotic ancef 500 milligrams (mg) every eight hours for three days then when the IV antibiotic was completed start an oral antibiotic ciprofloxacin 500 mg twice a day for four weeks. Review of a nurse's note dated 09/27/23 at 1:50 P.M. revealed the resident was seen by wound care with new orders for the left great toe wound. The resident would need intravenous (IV) antibiotics. Orders were received for an osteomyelitis work up. Resident #23 originally refused IV antibiotic for infection in toe. The resident was educated it was for three days then could have oral antibiotic for four weeks and the resident then agreed. The area to the toe was debrided by the physician and an open toe boot was applied. The resident was encouraged not to wear tight socks to prevent any pressure damage. Review of a nurse's note on 09/27/23 at 7:29 P.M. noted the resident was not able to have a peripheral inserted central catheter (PICC) line inserted due to arm contraction and would need interventional radiology (IR) to get PICC line in. The wound physician was notified. Review of the x-ray dated 09/27/23 revealed the resident had subtle bone loss at the first tuft with swelling and the finding suggested osteomyelitis. Review of a physician order dated 09/28/23 revealed to apply quarter strength dakins solution to left great toe topically once daily. The order was entered incorrectly into the electronic medical record as cleanse with quarter strength dakins, apply calcium alginate and wrap with kerlix daily. Review of the TAR revealed the treatment was completed per the incorrectly entered orders until discontinued on 10/05/23. Review of a nurse's note dated 09/28/23 at 7:29 P.M. revealed the resident would receive the IV antibiotic at dialysis. Review of the Medication Administration Record (MAR) dated 09/01/23 through 09/30/23 revealed no documentation the resident received the IV antibiotic. There was no documentation in the medical record the resident was administered the antibiotic at dialysis. Review of a nurse's note dated 09/29/23 at 1:47 P.M. revealed the resident was ordered ciprofloxacin 500 milligrams by mouth twice a day for six weeks. Review of a physician order dated 09/29/23 revealed the resident was ordered ciprofloxacin 500 mg by mouth two times a day for osteomyelitis. Review of the MAR revealed the resident was administered the medication on 09/29/23. Review of a nurse's note dated 09/30/23 at 9:12 A.M. revealed the resident and Power of Attorney (POA) decided to go to the emergency room (ER). Review of nurses note dated 09/30/23 at 3:19 P.M. revealed the resident returned from the ER with new orders to discontinue the ciprofloxacin and start doxycycline 100 mg twice daily for ten days. POA stated she would make an appointment for vascular follow up. Review of an ER after visit summary note dated 09/30/23 revealed the resident was ordered doxycycline 100 mg twice a day by mouth for ten days for chronic osteomyelitis of toe of left foot. Review of a physician order dated 09/30/23 revealed the resident was ordered doxycycline 100 mg by mouth twice daily for ten days for osteomyelitis. Review of the MAR revealed the resident received the medication per physician orders until the resident was admitted to the hospital on 10/09/23. Review of a physician wound note dated 10/04/23 revealed the wound had improved. The wound measured two cm in length, three cm in width by 0.1 cm in depth, with moderate serous drainage. The wound had 30% necrotic tissue, with 30% granulation tissue and 40% other tissue. Review of a physician order dated 10/16/23 revealed to cleanse the left great toe with normal saline, apply betadine, put Neosporin/bacitracin cream on toe, apply adaptic or xeroform gauze on top, apply four by four gauze on top of adaptic, wrap with kling or kerlix then wrap with coban strip or ace wrap daily. Review of the TAR revealed no documentation the treatment was completed on 10/20/23 or 10/23/23. Review of a weekly skin observation dated 10/22/23 at 1:53 P.M. revealed the diabetic ulcer to the left great toe had pink tissue, no drainage and no odor. Interview on 10/25/23 at 1:30 P.M. with Resident #23 revealed the treatments for the left toe were not getting done. Resident #23 revealed a nursing assistant bumped her left toe and later the left toe later got infected again and she had to go to the emergency room . Observation on 10/25/23 at 1:44 P.M. of wound care with Licensed Practical Nurse (LPN) #103 revealed the resident had an undated wound dressing on the left first toe. LPN #103 removed the undated dressing. The resident had no toenail on the left great toe. The wound was 90% granulation tissue and 10% slough, red and swollen. There was no wound odor. LPN #103 completed the wound treatment and dated the wound dressing per physician orders. Interview on 10/25/23 at 1:53 P.M. with Licensed Practical Nurse (LPN) #103 verified the removed wound dressing was undated and should have been dated when applied. LPN #103 also verified there was no documentation the wound dressing was completed on 10/20/23 and 10/23/23. Interview on 10/25/23 at 4:49 P.M. with the Director of Nursing (DON) revealed a service was called to insert a PICC line to administer the resident's antibiotic. The PICC line could not be inserted due to a contracture in the resident's arm. The other arm had a fistula for dialysis. The DON revealed a recommendation was received to call Interventional Radiology but could not be completed. Then the plan was to have dialysis administer the antibiotic but they would only be able to administer once a day. The DON revealed the IV antibiotic was never administered. The DON revealed the physician was contacted and ordered the resident to start receiving the oral antibiotic. Subsequent interview with DON revealed the resident went to the emergency roiagnom on [DATE]. The ER switched to a different antibiotic for osteomyelitis. The DON revealed the resident's toe was bumped during a transfer with a sit to stand lift. The DON revealed there was no documentation the treatments on 10/20/23 and 10/23/23 were completed but the nurse stated she completed the treatments. Interview on 11/01/23 at 2:11 P.M. with the Administrator revealed there was no documentation the physician was notified on 09/17/23 of the resident bumping the first left toe. The Administrator also verified there was no documentation the physician was notified of the signs of infection to the wound on 09/24/23 when the wound had an odor, and on 09/26/23 when the wound had purulent drainage. The Administrator revealed there was no documentation the wound was monitored on 09/25/23. The Administrator verified there was no documentation wound treatments were completed as ordered by the physician. The Administrator also revealed new physician orders were once not entered into the electronic medical record and on a second occasion were entered incorrectly resulting in treatments not completed as ordered. Review of the policy, Skin Care Management Procedure, revised 12/09/22, revealed staff would monitor and remain alert to potential changes in the skin condition and evaluate and document identified changes. The physician would be notified all skin areas of concern and consulted for treatment orders. The policy had no guidelines for administering wound treatments per physician orders. This deficiency represents non-compliance investigated under Complaint Number OH00147024.

Based on medical record review, staff interview, resident interview, policy review, and review of manufacturer guidelines, the facility failed to monitor the position and inflation of a wheelchair back support cushion, resulting in avoidable skin breakdown. Additionally, the facility failed to effectively monitor and assess skin breakdown. This resulted in Actual Harm when Resident #08 developed a stage four pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) to the sacrum. This affected one (Resident #08) of three residents reviewed for wound care. The facility census was 48. Findings include: Review of the medical record for Resident #08 revealed an admitted [DATE]. Diagnoses included quadriplegia, osteoarthritis, and chronic pain syndrome. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was dependent on staff for bed mobility, transfers, toileting, and lower body dressing. Review of the care plan initiated 06/01/19 revealed potential for pressure ulcer development related to immobility due to quadriplegia and history of pressure ulcer. The resident was noted with a stage four pressure ulcer to the sacrum. Preferred position in wheelchair during day naps is reclined, causing increased pressure to sacral area. Interventions included enhanced barrier precautions; follow facility policies/protocols for the prevention/treatment of skin breakdown; report redness, open areas, bruises, skin tears, and rashes; encourage small frequent position changes, and a weekly skin assessment; monitor during routine care and bathing. Review of a skin risk assessment dated [DATE] revealed the resident was at risk for skin breakdown. Review of a weekly skin observation tool dated 09/13/23 revealed the resident had no skin impairment noted. Review of a skin/wound progress note dated 09/14/23 at 11:45 P.M., revealed the nurse was notified, after completion of a bath, the resident was noted with red and broken skin on the coccyx. The nursing assistant stated the skin was not broken when she bathed the resident two days prior and barrier cream was being applied due to redness and irritation. The nurse assessed the coccyx and determined the provider would be informed of the skin tear the following morning. Review of a late entry nursing note dated 09/15/23 at 4:58 P.M. revealed the area to the resident's coccyx was not open on observation, barrier cream would continue, wound care to observe as well during wound rounds. Review of a late entry nursing note dated 09/20/23 at 5:15 P.M. revealed wound rounds were completed, and Moisture Associated Skin Damage (MASD) was observed to Resident #08's right thigh, no open area to coccyx. Barrier cream to continue. Review of a weekly skin observation tool dated 09/20/23 revealed the resident had skin impairment, an area of redness was noted to the sacrum. Review of physician wound evaluations dated 09/20/23 and 09/27/23 revealed the physician assessed the MASD on the resident's thigh. There was no documentation the physician assessed the resident's sacrum. Review of a weekly skin observation tool dated 09/27/23 revealed Resident #08 was noted with MASD to the thigh. No other areas of skin impairment were noted. Review of a physician wound evaluation dated 10/04/23 revealed the resident refused the assessment. Review of a weekly skin observation tool dated 10/07/23 revealed Resident #08 had no documented areas of skin impairment. Review of a weekly skin observation dated 10/11/23 revealed Resident #08 was noted with a stage four pressure ulcer to the sacrum. The area measured 0.6 centimeters (cm) by 4 cm in width by 0.2 cm in depth. The area was noted as two separate wounds measured in cluster. Muscle tissue was visible. Observation on 10/25/23 at 11:04 A.M. with Licensed Practical Nurse (LPN) #100 of wound care revealed the resident had a stage four pressure ulcer to the sacrum. The area measured one centimeter (cm) in length, 4.5 cm in width, with a depth of 0.1 cm. The wound was 60% granulation tissue, 10% slough and 30% dermis and subcutaneous tissue with moderate serous exudate. Further observations revealed the horizontal shape of the wound was similar in size and shape to the horizontal row of air bubbles on the resident's back cushion on the wheelchair. Interview on 10/25/23 at 11:04 A.M. with Wound Physician (WP) #108 revealed the resident's wound was found at a stage four pressure ulcer. WP #108 revealed the wound was improving. Due to the horizontal nature of the wound, WP #108 thought something fell behind the resident's back and, due to no feeling in her back, the resident was unaware. Interview on 10/25/23 at 3:28 P.M. with Resident #08 revealed nothing fell behind her back to cause the wound. Resident #08 revealed the nursing assistants had told her for a few weeks the area was red. Resident #08 revealed the nurses were also aware. Resident #08 thought the redness would just go away. Resident #08 revealed the nurse explained she needed to see the wound physician and she was seen about a week later. Interview on 10/26/23 at 8:51 A.M. with the Director of Nursing (DON) revealed the inflation was off on the back cushion of the resident's wheelchair, the resident had the technician come out in July, and a new cushion was ordered. The DON revealed the new cushion was delivered on 09/09/23, a week or two before the resident got the area on her sacrum. The DON revealed she had no knowledge of this prior to yesterday. The DON stated she let some of the air out of the resident's back cushion today. The DON revealed she requested a visit by the service provider to check the amount of inflation and complete a pressure test. The DON revealed the nursing assistants were responsible to report to nurse if there was an observed skin condition. Interview on 10/26/23 at 10:03 A.M. with State tested Nursing Assistant (STNA) #115 revealed she first saw the area of the resident's back the first week in October. STNA #115 revealed she had a red circle by the tailbone. STNA #115 revealed the resident reported the area had not started until she got her new cushion for her chair. STNA #115 revealed not reporting the area as the resident told her everyone was aware of the area on her back. Interview on 10/26/23 at 11:26 A.M. with the DON confirmed Resident #08's stage four pressure ulcer could potentially have been caused by the back cushion on the wheelchair, especially since the resident had no pressure before the cushion was installed. The DON revealed when the pressure ulcer was first investigated, she had no knowledge of the new cushion. The DON revealed she thought the pressure was caused by the positioning of the back cushion, which could go up and down depending on the tightness of the Velcro. The DON revealed she thought the Velcro was not attached correctly and the cushion moved up and down and side to side until she looped the cushion over the headrest of the wheelchair. The DON revealed she noticed the positioning of the cushion when the resident developed the pressure ulcer. The DON confirmed there were no monitoring interventions in place for the cushion. The DON verified when the redness to the resident's back was first noticed, there was no documentation the physician was notified. The DON revealed the nurse called the physician the next morning and was told to continue the barrier cream. The DON revealed the nurse should document characteristics of skin breakdown, if applicable, and measure and describe wound, if applicable. Interview on 11/01/23 at 7:45 A.M. with Resident #08 revealed the service provider for the wheelchair cushion completed a pressure mapping test on 10/26/23 or 10/27/23 and there was only blue color, indicating no pressure points. The provider thought the cushion was over inflated and took a fair bit of air out in the lumbar (lower back) area. Interview on 11/01/23 at 10:46 A.M. with the Administrator revealed the resident made her own arrangements for the wheelchair cushion and staff would not necessarily need to inform management if a wheelchair vendor was in the building. The Administrator verified there were no prescriber recommended inflation level for the cushion as it was based on the resident's preference. Subsequent interview with the Administrator verified there was no documented wound assessment for the resident prior to 10/11/23. Interview on 11/01/23 at 4:29 P.M. with LPN #109 revealed she rounded with the wound physician on 09/20/23. LPN #109 revealed the resident's sacrum was irritated and red but there were no open areas. LPN #109 revealed the physician told her to have the nurses continue the barrier cream. Review of the manufacturer instructions for the custom back support supplement revealed a warning to check inflation. Make sure there was at least one-half inch (1.5 cm) of air supporting the individual's bony prominences. Follow the prescriber's recommended inflation levels. Review of the policy, Skin Care Management Procedure, revised 12/09/22, revealed a stage four pressure ulcer was full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. A medical device related pressure ulcer/injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system. Staff would monitor and remain alert to potential changes in the skin condition and should evaluate and document identified changes. Documentation should include the date observed, location and staging, size, drainage and amount, color, odor, pain, a description of the wound bed and type and percentage of tissue present along with a description of the wound edges. The physician would be notified of all skin areas of concern and consulted for treatment orders. This deficiency represents non-compliance investigated under Complaint Number OH00147024.

Based on medical record review, resident and staff interview, and policy review, the facility failed to ensure weights were obtained per physician order, and ongoing monitoring was provided for residents identified at nutritional risk and sustaining weight loss. This resulted in Actual Harm when Resident #39 experienced a severe weight loss of 9.33 percent from 08/18/22 to 11/15/22 and a severe weight loss of 12.76 percent from 06/06/22 to 11/15/22. There was no evidence weekly weights were obtained per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one resident (#39) out of six residents reviewed for nutrition. The facility census was 53. Findings include: Review of Resident #39's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #39 was moderately cognitively impaired, required total dependence for bed mobility, transfers, dressing, toilet use and personal hygiene and required extensive assistance with locomotion and eating. In addition, Resident #39 had significant weight loss and was not on a prescribed weight loss program. Review of a plan of care focus area initiated 04/26/21 revealed Resident #39 was at risk for altered nutrition. Interventions included activities to promote additional intake, monitor for signs and symptoms of dehydration, monitor for signs of dysphagia, encourage fluids, honor food preferences, monitor labs and diagnostics ordered, monitor skin, and wound, monitor weight as ordered. Revision of the care plan on 11/09/22 included the additional interventions for Resident #39 to provided total assistance with each meal, and the Registered Dietician (RD) was to evaluate and make recommended diet changes. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the weights revealed on 11/15/22 Resident #39 weighed 80.0 pounds (lbs.) and on 08/18/22 Resident #39 weighted 89.2 lbs., indicating a 9.43 percent severe weight loss over three months. Additional review of weights from 06/06/22 through 11/15/22 revealed a weight of 92.5 lbs. on 06/06/22, indicating a severe weight loss of 12.76 percent over six months. Review of a nutrition screen dated 5/25/22 revealed Resident #39 had a 27.3 percent significant weight loss in 30 days, which was thought to be an error. A repeat weight was requested and not completed. Review of a nutrition screen dated 06/27/22 revealed Resident #39 had a significant weight loss of 16.6 percent in 90 days. Added to weekly weight monitoring. Review of a nutritional screen dated 10/03/22 revealed Resident #39 had a significant weight loss of 11.3 percent in 90 days and 16.8 percent in 180 days. Note revealed ongoing monitoring of weekly weeks. Review of a nutritional screen dated 11/09/22 revealed Resident #39 had an 8.0 percent significant weight loss in 30 days, a 9.8 percent significant weight loss in 90 days and a 25 percent significant weight loss in 180 days. Review of a dietary progress note dated 10/25/22 revealed a significant weight loss of 7.9 percent in 30 days. Fortified milkshakes three times a day were started. Review of the electronic treatment record for Resident #39 had no documentation of weekly weights. Review of the documentation for November 2022 that Resident #39 received the fortified milkshake three times a day as ordered revealed the supplement was documented as provided once on 11/01/22, 11/02/22, 11/03/22, 11/04/22, 11/07/22, 11/10/22, 11/11/22, 11/12/22, and 11/15/22. The supplement was documented as provided twice on 11/09/22 and did not have documentation of the supplement provided on 11/05/22, 11/06/22, 11/08/22, 11/13/22, 11/14/22 and 11/16/22. Interview on 11/16/22 at 7:46 A.M., with State tested Nursing Assistant (STNA) #01 stated Resident #39 does not refuse care, adding Resident #39 does not call out but will allow staff to complete whatever care was needed. Interview on 11/17/22 at 9:08 A.M., with Household Assistant (HA) #60 revealed the supplement was provided to Resident #39 when the resident asked for it. The HA #60 verified she had not provided the fortified shake as ordered. Interview with HA #41 on 11/17/22 at 9:10 A.M., revealed no knowledge Resident #39 was to receive the supplement with each meal. Interview on 11/17/22 at 10:00 A.M., with Resident #39 revealed she has never refused to be weighed. Interview on 11/17/22 at 12:09 P.M., the Diet Technician (DT) #53 verified Resident #39 had a significant weight loss and further verified weekly weights were not ordered, obtained, or documented from 06/27/22 to 11/03/22. The DT #53 verified a weekly weight order was entered on 11/03/22 and verified weekly weights were not completed as ordered on 11/03/22 and 11/10/22. Review of the policy titled Weights, dated 04/08/21 revealed the reweighs will be requested for residents with significant weight changes. Significant weight changes were defined as a 5 percent change in 30 days and/or a 10 percent weight change in 180 days and or a fluctuation of three to five pounds. Reweighs will be completed by the tenth of the month. Additionally, if a significant weight change is noted weekly weights are to be requested and documented in the electronic treatment administration record.

Based on observations, interviews, record review, and review of the facility's infection control policies, the facility failed to place ten of ten residents in House 5085 on transmission-based precautions, to include full Personal Protective Equipment (PPE), after two staff working in the House tested positive for COVID-19. As a result of these failures, the facility had a potential risk for a COVID-19 outbreak that could affect all ten residents living in House 5085. The facility Administrator and the Assistant Clinical Vice President (ACVP) were advised on 09/17/20 at 6:05 PM of concerns rising to immediate jeopardy at F880 infection control for failure to implement transmission-based precautions and use of full PPE with residents exposed to COVID-19. The facility provided a removal plan that was accepted on 09/18/20 at 5:14 PM. The facility immediately implemented isolation carts outside the 10 resident rooms and established full PPE precautions in House 5085. The DON established full transmission-based precautions (eye protection, N95 masks, and gloves) and signs on all doors. The DON re-educated with competency training the nursing staff currently working on proper donning and doffing of PPE, transmission-based precautions, and signs and symptoms of COVID-19. The removal plan was validated by observations of staff wearing PPE, isolation carts with PPE outside of residents' rooms, and interviews with staff. Completion of staff education was verified by review of the in-service sign in sheets dated 09/17/20 and 09/18/20. The deficient practice remained at a D pattern and the severity lowered to potential for more than minimal harm following the removal of the immediate jeopardy at midnight on 09/18/20. Findings include: Review of the CDC guidance titled, Response to Newly Identified [DIAGNOSES REDACTED]-CoV-2 infected HCP (healthcare practitioner) or Residents dated 4/30/20, revealed direction: HCP who worked with symptoms consistent with COVID-19 or in the 48 hours prior to symptom onset: .Determine which residents received direct care from and which HCP had unprotected exposure to HCP who worked with symptoms consistent with COVID-19 or in the 48 hours prior to symptom onset. Residents who were cared for by these HCP should be restricted to their room and be cared for using all recommended COVID-19 PPE until results of HCP COVID-19 testing are known. If the HCP is diagnosed with [REDACTED]. Review of the CDC Guidance titled, Considerations for Use of [DIAGNOSES REDACTED]-CoV-2 [MEDICATION NAME] Testing in Nursing Homes, updated 8/27/20, revealed that A COVID-19 outbreak response in a nursing home is triggered when a resident or HCP tests positive for [DIAGNOSES REDACTED] CoV-2. The guidance further indicates that, Factors that increase the probability of infection include recent exposure to someone diagnosed with [REDACTED]. and an outbreak response should be initiated immediately when a resident or healthcare practitioner tests positive. During the entrance conference on 09/17/20 at 8:30 AM, the Administrator stated two State tested Nursing Assistants (STNA4 and STNA5) had tested positive for COVID-19 in September. Both STNA4 and STNA5 worked in House 5085, one of five houses making up the facility. During the entrance conference, the Administrator and Director of Nursing (DON) stated STNA4 called into the facility on [DATE] complaining of a sore throat and body aches. A nasopharyngeal specimen for COVID-19 was collected from STNA4 on 09/11/20 at the facility's drive-thru testing site for employees. The result of the testing came back to the facility on [DATE] as positive for COVID-19. Employee record review revealed STNA4 last worked in House 5085 on 09/09/20, during the second shift (2:30 PM to 10:30 PM). Further interview of the Administrator and DON during the entrance conference, revealed STNA5 was tested for COVID-19 during a random testing of staff on 09/15/20. STNA5's test results came back positive for COVID-19 on 09/16/20. Employee record review revealed STNA5 last worked in House 5085 on 09/15/20, on third shift (10:30 PM to 6:30 AM). Observation of House 5085 on 09/17/20 at 11:10 AM revealed there was no signage on the resident's doors to indicate that any type of transmission-based precautions were implemented for the ten residents exposed to COVID-19. Further observation revealed no PPE visible for staff to use during the care of the residents. The only PPE the staff was wearing were masks. Observation on 09/17/20 at 11:10 AM in House 5085, revealed Resident (R) 4 was self-propelling in her wheelchair, wearing a mask on her chin, with her nose and mouth exposed, trying to get out the front door of the house. Medical record review revealed the facility admitted R4 to the facility on [DATE] with a [DIAGNOSES REDACTED]. Further observation on 09/17/20 at 11:10 AM, revealed STNA14, wearing only a face mask, redirected R4, explaining to the resident she could not go outside because it was raining. The Chaplin and the Therapist, both wearing PPE consisting only of a mask, entered the front door as the resident continued to try to leave the house. The Chaplin held the resident's hand trying to calm her. The Therapist also spoke to the resident from a distance of approximately three feet. During an interview on 09/17/20 at 1:10 PM, the Director of Nursing (DON) stated, The residents in House 5085 were put in Room Restriction Isolation when we got STNA4's positive result back on 09/13/20. When asked to clarify what she meant by Room Restriction Isolation, the DON responded, Meals in their rooms. Wear masks when in common areas of the house, if not possible to keep residents in their rooms. During an interview on 09/17/20 at 1:15 PM, the Administrator stated, Our policy states (to implement transmission-based precautions and use of full PPE) when COVID-19 is suspected not (when) exposed. The Administrator indicated she thought Room Restriction Isolation was adequate. Review of the facility's policy titled, COVID-19 Policy and Procedure, revision date 09/12/20, revealed, Upon identification of a resident with known or suspected COVID-19, immediate infection prevention and control measures will be placed . Place resident in private room in designated area with contact and droplet precautions including signage on resident room .Full PPE should be worn per CDC guidance for the care of any resident with known or suspected COVID-19 (under CDC conservation guidance) . If COVID-19 transmission occurs in the facility, partners (staff) should wear full PPE for the care of all resident irrespective of COVID-19 symptoms on the affected unit. During an interview with the ACVP, who also is the active Infection Preventionist (IP) at this facility, on 09/17/20 at 1:30 PM, the ACVP/IP verified that the residents in House 5085 were exposed to COVID-19 when STNA4 and STNA5 were diagnosed with [REDACTED]. The ACVP/IP verified staff should have been using PPE, to include gloves, gowns, eye protection, and masks. The ACVP/IC stated, We have a communication problem related to the understanding of exposure vs. suspected. The ACVP/IP verified that suspected and exposed residents should be considered Persons Under Investigation (PUI) and should be in transmission- based precautions.

Based on medical record review, review of the facility's [MEDICAL CONDITION] protocol, review of manufacturer's guidelines for blood glucose monitoring, review of laboratory values, review of emergency room physician notes, review of a resident's death certificate and staff interview, the facility failed to obtain blood glucose levels as ordered by the physician for one resident (#1) with [DIAGNOSES REDACTED]. This resulted in Immediate Jeopardy for Resident #1 when the resident became symptomatic and experienced life threatening adverse consequences and subsequent death. Additionally, three residents (#13, #14 and #15) were placed at risk for more than minimal harm that is not Immediate Jeopardy due to inconsistent monitoring of their blood glucose levels. However, these residents remained asymptomatic and required no medical intervention. The facility identified a total of 14 residents who required blood glucose monitoring per physician orders. On [DATE] at 12:15 P.M., the Administrator, Director of Nursing (DON) #1, and Corporate Nurse were notified Immediate Jeopardy began on [DATE] at approximately 8:00 A.M., when the facility failed to implement a physician order [REDACTED].M. for Resident #1. On [DATE] at 10:11 A.M., Resident #1 was noted to have emesis dark brown in color. Registered Nurse (RN) #28 notified the physician. The physician gave orders for a stat complete blood count (CBC), basic metabolic panel (BMP), [MEDICATION NAME] (a medication to prevent nausea) 25 milligrams (mg), by mouth or intramuscular, and occult blood times three. The physician was not made aware the 8:00 A.M. blood glucose level had not been obtained nor was a blood glucose level obtained at this time when the resident was symptomatic. On [DATE] at 12:00 P.M., the nurses' notes indicated Resident #1 did "not look good" and was "acting different". Resident #1's blood glucose level was obtained at this time and read "HI" (a value that exceeded the highest numerical reading for the testing equipment, which was 600 milligrams/deciliter (mg/dL). The nurses note also documented Resident #1 was lethargic, but responded to a sternal rub. Resident #1 was sent out to the emergency room . Laboratory values obtained by the facility on [DATE] at 11:28 A.M. revealed Resident #1's blood glucose level was 1082 mg/dL (normal range 70 - 105 mg/dL) prior to being taken to the emergency room . Blood glucose levels obtained in the emergency room remained critically high, measuring 1164 mg/dL on [DATE] at 1:45 P.M. Resident #1 expired in the emergency roiagnom on [DATE] at 5:29 P.M., with a final [DIAGNOSES REDACTED]. The Immediate Jeopardy was removed on [DATE], when the facility implemented the following corrective actions: ? On [DATE] through [DATE], an in-service was provided by DON #1 and Minimum Data Set (MDS) Nurse #52 to 14 licensed nursing staff prior to working their next scheduled shift regarding obtaining glucose levels per physician orders, following physician orders, how to properly obtain blood glucose levels, recognizing hyper and [DIAGNOSES REDACTED] in residents, and prompt notification to physicians with resident changes. ? On [DATE] (no time documented), RN #28 was given a documented verbal counseling for failure to follow physician orders [REDACTED]. ? On [DATE] at 2:27 P.M., during interview, Licensed Practical Nurses (LPN) #22 and #34 and RN #68 at 2:33 P.M., verified they were in-serviced on following physician orders [REDACTED]. All three stated they were educated on physician notification regarding blood sugars outside normal parameters and revealed they understood the procedures. ? On [DATE] at 9:20 A.M., LPN #73 and RN #28 at 9:26 A.M. during interviews, verified they were in-serviced on following physician orders [REDACTED]. All three stated they were educated on physician notification regarding blood sugars outside normal parameters and revealed they understood the procedures. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy). Review of 13 additional resident records identified by the facility as requiring blood glucose monitoring revealed three residents (#13, #14, #15) had inconsistent blood glucose monitoring for the month of [DATE]. Residents #13, #14 and #15 were free of signs and symptoms of hyper/[DIAGNOSES REDACTED] and had daily glucose monitoring, however, their blood glucose was not monitored at the required physician ordered frequencies. Findings include: 1. Review of the closed medical record for Resident #1 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of physician orders [REDACTED].#1 was to have accu-checks (blood glucose monitoring) four times per day before meals and at bedtime, at 8:00 A.M., 12:00 P.M., 5:00 P.M., and 9:00 P.M. Additional physician orders [REDACTED].#1 was to have [MEDICATION NAME]four times per day before meals and at bedtime at 8:00 A.M., 12:00 P.M., 5:00 P.M., and 9:00 P.M. via sliding scale. The sliding scale was as follows: blood glucose level from 151 to 200 will receive two units, blood glucose level from 201 to 250 will receive four units, blood glucose level from 251 to 300 will receive six units, blood glucose level from 301 to 350 will receive eight units, and blood glucose level from 351 to 400 will receive 10 units. If blood glucose less than 60 or greater than 400, call the physician. Review of the Medication Administration Record [REDACTED]. Review of nursing progress notes dated [DATE] at 10:11 A.M., revealed Resident #1 was having emesis of dark brown color and was alert. RN #28 notified the physician and received stat orders for CBC and BMP laboratory levels, [MEDICATION NAME] 25 mg by mouth or intramuscular and occult blood levels times three. RN #28 gave Resident #1 [MEDICATION NAME] 25 mg by mouth crushed in applesauce. A progress note dated [DATE] at 12:00 P.M., revealed Resident #1 did "not look good" and was "acting different". RN #28 obtained Resident #1's blood glucose level that resulted in a reading of "HI" on the glucometer (device used to measure blood glucose levels). Resident #1's blood pressure at this time was ,[DATE] (normal ,[DATE]) and pulse was 60. Resident #1 was noted to be lethargic, but responded immediately to a sternal rub and was sent to the emergency room for evaluation. Review of undated manufacturer's instructions for Assure Platinum Test Strips (the glucometer identified by the facility as used to obtain Resident #1's blood glucose levels), revealed "if your test result is greater than 600 mg/dL the meter will show 'HI' . Review of laboratory values dated [DATE] at 11:28 P.M., obtained by the facility prior to Resident #1 being sent out to the emergency room , revealed Resident #1's blood glucose level was 1082 (normal range 70 - 105 mg/dL). Laboratory results were faxed to the facility on [DATE] at 1:35 P.M. after Resident #1 had already been sent to the emergency room . Review of the hospital emergency room documentation, revealed Resident #1 arrived via ambulance on [DATE] at 1:14 P.M. Laboratory values dated [DATE] at 1:45 P.M., revealed Resident #1 had a critically high blood glucose level of 1164. Further review of emergency room documentation, revealed Resident #1 was administered eight units of regular insulin on [DATE] at 5:21 P.M. Review of emergency room physician notes dated [DATE] at 5:36 P.M., revealed Resident #1 had no breathing and no pulse at 5:29 P.M. A final primary [DIAGNOSES REDACTED]. Review of Resident #1's death certificate filed on [DATE], revealed the immediate cause of death was identified as diabetic coma. Interview on [DATE] at 5:55 P.M. with DON #1, stated she looked through all the documentation for Resident #1 and verified no blood glucose levels were obtained on [DATE] at 8:00 A.M. as ordered by the physician. Telephone interview on [DATE] at 10:44 A.M. with RN #28, confirmed she worked the day shift (which begins at 6:30 A.M.) on [DATE] in the house where Resident #1 resided. RN #28 stated she was notified by a nursing assistant that Resident #1 was having episodes of emesis. RN #28 further verified she did not obtain Resident #1's blood glucose level at 8:00 A.M. as ordered by the physician. RN #28 was unable to explain why the [DATE] 8:00 A.M. blood glucose level was not completed for Resident #1. RN #28 further stated she did not remember notifying the physician during the call on [DATE] at 10:11 A.M., that she did not obtain Resident #1's blood glucose level at 8:00 A.M. She stated she only notified him regarding the resident's emesis. RN #28 stated on [DATE] at 12:00 P.M., Resident #1 did not look good and was not acting herself. Resident #1's blood glucose level was obtained and read 'HI' and she was sent out to the emergency room . RN #28 verified the 12:00 P.M. blood glucose level obtained on [DATE], was the only blood glucose level obtained on Resident #1 and verified she did not administer any insulin to Resident on [DATE]. Review of facility policy titled, "Hypoglycemic and Hyperglycemic Protocol" , revised [DATE], revealed elders receiving insulin injections will have glucose monitoring completed before meals and at night or as ordered by the physician. The policy further indicated if the blood sugar is 70 mg/dL or below or greater or equal to 200 mg/dL, the nurse must contact the physician for further orders. 2. Review of the medical record for Resident #13 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of physician order [REDACTED].#13 was to have blood glucose monitoring completed four times per day before meals and at bedtime at 8:00 A.M., 12:00 P.M., 5:00 P.M., and 9:00 P.M. Review of [DATE], Medication Administration Record [REDACTED].M., however, the MAR, progress notes, and vital signs reviewed indicated Resident #13's blood glucose levels were stable. This was confirmed during interview on [DATE] at 4:25 P.M. with Minimum Data Set (MDS) Nurse #52. 3. Review of the medical record for Resident #14 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of physician order [REDACTED].#14 was to have blood glucose monitoring completed at 5:00 P.M. every Sunday, Tuesday, Thursday, and Saturday. Additional physician orders [REDACTED].#14 was to have blood glucose monitoring completed every morning at 8:00 A.M. daily. Review of [DATE] Medication Administration Record [REDACTED].M. and Tuesday, [DATE] at 5:00 P.M., however, the MAR, progress notes, and vital signs reviewed indicated Resident #14's blood glucose levels were stable. This was confirmed during interview on [DATE] at 4:25 P.M. with Minimum Data Set (MDS) Nurse #52. 4. Review of the medical record for Resident #15 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of physician order [REDACTED].#15 was to have blood glucose monitoring completed two times per day before one meal and at bedtime at 8:00 A.M. and 8:00 P.M. Review of [DATE] Medication Administration Record [REDACTED].M. and 8:00 P.M.; on [DATE] at 8:00 A.M.; on [DATE] at 8:00 A.M.; on [DATE] at 8:00 P.M.; on [DATE] at 8:00 P.M.; on [DATE] 8:00 A.M. and 8:00 P.M.; on [DATE] at 8:00 P.M.; and on [DATE] at 8:00 P.M. However, the MAR, progress notes, and vital signs reviewed indicated Resident #15's blood glucose levels were stable. This was confirmed during a telephone interview on [DATE] at 5:04 P.M. with Registered Nurse #68. This deficiency substantiates Complaint Number OH 339.

Based on medical record review, review of skin care policy, observation, and interview with a resident and facility staff, the facility failed to follow their skin care policy and have a nurse perform weekly skin assessments to identify skin impairment. This resulted in actual harm for Resident #27 who was found to have a Stage III pressure ulcer in her right inner thigh/ischial area. This affected one (#27) of three residents reviewed for skin breakdown. The facility identified a total of six residents with pressure ulcers. The facility census was 47. Findings include: Review of Resident #27's medical record revealed she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent annual Minimum Data Set (MDS) assessment and care screening tool, dated 12/11/12 indicated the resident was able to express her wants and ideas and was able to understand others. She required the extensive assistance of one person for bed mobility, dressing, toileting, personal hygiene, and bathing. She was totally dependent for transfers with the assistance of two persons. She had been assessed with [REDACTED]. She was frequently incontinent of urine. She was identified at risk for pressure ulcers and was identified with one or more unhealed Stage I or higher pressure ulcers. She had one Stage II pressure ulcer and one unstageable pressure ulcer with suspected deep tissue injury in evolution. The most severe tissue type for any pressure ulcer included necrotic tissue (eschar). She had a pressure relieving mattress and chair, was on a turning and repositioning program, and was receiving ulcer care and dressing changes. She was assessed at low risk for pressure ulcers 11/20/12. Her monthly physician orders [REDACTED]. A plan of care was developed on 05/25/12 to address the resident's potential for skin breakdown due to immobility, obesity, diabetes, [MEDICAL CONDITION] of the lower extremity musculature, incontinence and spastic paralysis. The goal was to be free of redness and/or sores. Interventions included if redness appears, measurements must be taken, notify physician if redness persists, pressure reduction devices as ordered, use of creams or ointments as ordered, keeping skin clean and dry, skin assessments per policy and as needed, skin care after every incontinent episode, turning and repositioning frequently and wound care consult as needed. The plan of care from 11/21/12 revealed she was at risk for interruption in skin integrity related to decreased mobility, depression, and risk for dehydration. The goal was to receive appropriate interventions which would stabilize and minimize underlying risk factors for skin breakdown. Interventions included checking for incontinence every two hours, observing for signs and symptoms of friction, blisters, and abrasions and reporting them immediately, and providing pericare after each incontinent episode. A barrier product was to be applied to her perineal area after each cleansing. Review of Certified Nurse Practitioner (CNP) #20's notes from the Wound Management Service on 12/12/12 revealed Resident #27 had a new wound to the right inner thigh/ischial area. Nursing reported the resident was wearing a brief while up in her chair and they believed the area may be related to the brief. The resident complained of a moderate amount of pain to the area but continues to wish to wear her brief tucked into her abdominal fold tightly while in bed. She was on an antibiotic for a urinary tract infection. The date of onset for this wound was 12/05/12. There was a small amount of drainage which was serosanguinous, thin, pale, and pink. There was 75-100% granulation and the wound was beefy red. There was less than 25% [MEDICATION NAME] and was considered a Stage III wound. There was yellow slough necrotic tissue less than 25%. The wound measured 3.5 centimeters (cm) long by 5.0 cm wide by 0.20 cm deep. Observation of a dressing change for Resident #27 on 01/16/13 at 3:18 P.M. revealed the resident was lying in a bariatric bed with an air mattress. The dressing change was completed by the day shift nurse, Licensed Practical Nurse (LPN) #5. The LPN from the second shift assisted with the dressing change by pulling the resident's right leg up and out so that LPN #5 could see the resident's two right upper, inner thigh wounds. The dressing change was completed as ordered. The resident had two open areas on her right upper, inner thigh. The medial wound measured 2.2 cm wide by 1.0 cm long. The lateral wound measured 2.5 cm wide by 1.3 cm long. There was no odor or drainage. A brief was applied loosely. The resident indicated she wanted to make sure the brief was pulled up so it didn't leak. Staff educated her about keeping her brief loose. Interview with State tested Nurse Aide (STNA) #10 at 6:52 A.M. on 01/17/12 revealed that Resident #27's pressure ulcer developed about a month ago. They think that it developed from the pressure from her pulling up and tugging of her brief. She reported the resident receives education not to pull and tug at her brief. She indicated she would report any redness, warmth, pain, or new open areas to the nurse. She completes a skin assessment and give it to the nurse. During interview on 01/17/12 at 7:05 A.M., LPN #5 stated Resident #27 is non-compliant to leave her brief open to air while she is in bed because she is worried that she will be incontinent and the urine will leak from the brief. She is encouraged to turn and reposition but she refuses. During an additional interview with LPN #5 on 01/17/12 at 2:20 P.M. she indicated the electronic Treatment Administration Record (E-TAR) would alert her when a skin assessment is due. She then tells the nurse aide and the nurse aide completes the skin assessment. LPN #5 stated she would then document the results of the skin assessment. During interview on 01/17/12 at 2:30 P.M., Resident #27 expressed her dismay that she had skin breakdown. She reported the pressure ulcer on her right inner thigh used to be painful but isn't painful anymore. Additional interview with STNA #10 on 01/17/12 at 2:50 P.M. verified she completes weekly skin assessments, document the results and gives it to the nurse. She would look and document redness, abrasions, bruises, open areas, and rashes. She reported that she had not seen any redness on the resident's right upper thigh prior to finding the skin breakdown. If the nurse was in the room, she would ask how the resident's skin looked or if there was any problems we were to let her know. STNA #10 verified the nurse does not complete skin assessments. She revealed she first noticed Resident #27's right upper thigh skin breakdown when she was getting the resident up to the toilet with the lift. The lift was raising her up and she noticed there was blood dripping. The treatment nurse came in to look at the area. STNA #10 stated she has to pull the resident's legs apart so she can get to her perineal area for cleaning. She tries to make sure the resident is clean but she doesn't necessarily see the area she is cleaning when she gives her perineal care. She reported that after wiping the resident with the washcloth, she looks at the cloth to make sure it is clean, and that is how she makes sure the resident is clean when she is laying in bed. She reported she can't really see the resident's perineal area when she is laying in bed, she can only see the area if the resident is up in the hoyer lift and her legs are spread apart or if another person helps her. STNA #10 further stated the other nurse aide is usually busy with her own residents, so she usually cleans Resident #27 by herself. Review of the facility's skin assessment policy, dated 05/22/09 and revised 07/20/11, indicated a thorough head to toe skin assessment is to be completed upon admission, weekly, upon an identified significant change, and as indicated. The nurse is to complete the assessment. The skin assessment must be performed so all areas of the body can be assessed. The nurse should inspect the skin in a systematic manner from head to toe utilizing good infection control principles. A thorough elder skin check by the elder assistant will be completed during times of bathing. The elder assistant will report any skin abnormalities to the nurse immediately. The skin assessment is completed to ascertain the condition of the resident's integumentary system. Routinely inspect the skin to assure that it is intact and void of discolored, boggy, unstable underlying tissue that will result in an ulceration/break in the skin. Assess the bilateral groin area for rashes, red/irritated areas. Note if adipose tissue on skin is on wet/damp areas. Inspect the perineum for rashes, irritation, and red areas. Note if tissues are dry or urine coated. Inspect the legs from thigh to toe. Note any bruised/discolored areas, old/new incisions, varicose veins, red or excoriated areas. During interview with the Director of Nursing on 01/17/12 at 3:35 P.M., she verified that according to the facility's skin assessment policy, the nurse is to complete the skin assessments. The DON also verified Resident #27's right inner thigh/ischial area pressure ulcer was not discovered until it was already a Stage III ulcer.