Every finding on record at Otterbein Portage Valley

Based on closed medical record review and staff interview, the facility failed to ensure medications were obtained and administered in accordance with physician orders, resulting in a significant medication error. This affected one (#1) of four residents reviewed for medication administration. The facility census was 44. Findings include:Review of the closed medical record revealed Resident #1 admitted to the facility on [DATE]. Diagnoses included open wound to the right lower leg, morbid obesity, Crohn's disease of large and small intestine, pseudomonas, pressure induced deep tissue damage to the left heel and right buttock, edema, pressure ulcer to the sacral region stage II and stage III, non-pressure chronic ulcer to the right calf, coronary artery disease, anxiety disorder, peripheral vascular disease, congestive heart failure, chronic kidney disease, venous insufficiency, and urinary retention.Review of the Minimum Data Set (MDS) assessment, dated 05/19/26, revealed Resident #1 was cognitively intact. Review of the hospital discharge physician orders dated 04/30/26 revealed Resident #1 was ordered Rinvoq (used to treat chronic inflammatory and autoimmune conditions, such as Crohn's disease) 30 milligrams (mg) daily. Review of the Medication Administration Record (MAR) from 04/30/26 through 05/09/26 revealed Rinvoq was documented to refer to progress notes. Review of the nursing progress notes dated 05/02/26 at 9:14 A.M., 05/03/26 at 8:39 A.M., 05/04/26 at 10:14 A.M., 05/06/26 at 8:19 A.M., 05/07/26 at 11:05 A.M., 05/08/26 at 10:27 A.M. and 05/09/26 at 9:03 A.M. revealed an administration note for each of those dates indicating waiting for pharmacy delivery of Rinvoq. Further review revealed no evidence the physician or the resident's responsible party were notified the medication was unavailable for administration. Additional review of Resident #1's medical record revealed the resident transferred to the hospital on [DATE] and readmitted on [DATE]. Review of the hospital discharge physician orders dated 05/13/26 revealed Resident #1 was ordered Rinvoq 30 milligrams (mg) daily. Review of the MAR from 05/14/26 through 06/20/26 revealed Rinvoq was documented as refer to progress notes. Review of nursing progress notes between 05/16/26 and 06/20/26 revealed Rinvoq was not delivered by the pharmacy. Further review revealed no evidence that the physician was notified of the medication being unavailable for administration.Interview on 07/28/26 at 2:50 P.M. with the Director of Nursing (DON), during review of Resident #1's medical record, confirmed the medication Rinvoq 30 mg daily was not obtained or administered as ordered by the physician. This deficiency represents non-compliance investigated under Complaint Number 3075044.

Based on record review, staff interview, and policy review, the facility failed to ensure the physician was timely notified of a change in condition related to a fall and the facility further failed to ensure the family was notified of a resident fall. This affected one (#46) of three residents reviewed for notification of change. The facility census was 44.Findings include:Review of Resident #46's medical record revealed an admission date of 12/19/25 and a discharge date of 01/06/26. Diagnoses included unspecified intracapsular fracture of left femur, chronic obstructive pulmonary disease (COPD), protein calorie malnutrition, Alzheimer's disease, pressure ulcer of sacral region stage three, and anemia.Review of Resident #46's Medicare - five day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of three. Furthermore, Resident #46 required supervision or touching assistance for chair to bed transfers, bed to chair transfers, and required partial/moderate assistance for toilet transfers. Resident #46 had a surgical wound.Review of Resident #46's care plan dated 12/22/25 revealed Resident #46 was at risk for falls related to cognitive impairment, gait/balance problems, poor communication/comprehension and was unaware of safety needs with interventions that included to anticipate and meet resident needs, offer toileting and peri-care upon rising, before and after meals, at hours of sleep, and as needed.Review of the Incident/Accident log revealed Resident #46 suffered a fall on 12/20/25 at 1:55 A.M.Review of Resident #46's progress notes dated 12/20/25 at 1:55 A.M. revealed Resident #46 was found on the floor of her room by the exit door. Resident #46 reported hitting her head. An assessment was completed and vital signs were obtained. Resident #46 had a blood pressure of 197/106 (normal is 120/80) and her oxygen saturation was 90% (normal is greater than 87%, which is room air).Review of the undated Neurological Assessment document for Resident #46 revealed blood pressures following the fall read 191/103 at 2:10 A.M., 198/95 at 2:25 A.M., 191/97 at 2:40 A.M., and 203/108 at 3:10 A.M. Review of Resident #46's progress noted dated 12/20/25 at 11:12 A.M. revealed the physician was notified of the fall without injury that occurred at 1:55 A.M. on 12/20/25. There was no documentation regarding notification of Resident #46's blood pressure readings. Review of the medical record also contained no information of the family being notified of Resident #46's fall or elevated blood pressure.Interview on 04/13/26 at 3:13 P.M. with Licensed Practical Nurse (LPN) #51 revealed elevated blood pressures such as what Resident #46's blood pressures were following the fall need to be re-evaluated and should be reported to the physician. Furthermore, LPN #51 stated high blood pressure could indicate that the resident was in pain. LPN #51 verified family should always be notified when a resident experiences a fall or any change in condition.Interview on 04/14/26 at 9:34 A.M. with Nurse Practitioner (NP) #100 revealed if a resident had a fall during the night and had no injuries, it would be fine to be notified the next day, however if the resident sustained injuries, notification should be immediately. NP #100 verified based on the assessment and the continued elevated blood pressure for Resident #46, the provider should have been notified Interview on 04/14/26 at 2:17 P.M. with the Assistant Director of Nursing (ADON) #50 verified the physician should have been contacted after the resident was assessed. The ADON also verified family should have been notified of the fall when it occurred.Review of the facility policy with a last revision date of 12/02/25 titled Falls Management revealed in the event a fall occurs, a physical assessment of the resident for any injuries, provide immediate care to the resident as needed, and notify the resident representative and physician of the fall and findings following the immediate assessment.This deficiency represents non-compliance investigated under Master Complaint Number 2716158.

Based on observation, staff interview, and policy review, the facility failed to ensure food that was opened was properly stored and stored. This had the potential to affect all residents as the facility verified all residents received food from the kitchen. The facility census was 44. Findings include:Observation on 04/13/26 at 8:03 A.M. of walk-in freezer #1 revealed cheese pizzas, a bag of pizza dough, a bag potato wedges, dinner rolls, brown bread, and a bag of diced onions were open and undated.Interview on 04/13/26 at 8:06 A.M. with Dietary Manager (DM) #97 verified the cheese pizzas, a bag of pizza dough, a bag potato wedges, dinner rolls, brown bread, and a bag of diced onions were open and undated. DM #97 verified any time food is opened, the food item should be marked with an open date.Review of the facility policy with a revision date of May 2013 titled Food Storage Policy and Procedure revealed the purpose of the policy was to assure all food is stored, labeled, and dated properly to ensure stock rotation and prevent foodborne illnesses. Furthermore, prepared food is to covered, dated and labeled with the month and day on which it was prepared. The label also indicates the use by date which is four to seven days after the food was prepared.This deficiency represents non-compliance investigated under Complaint Number 2701756.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure monitoring of pressure ulcers. This affected one (#21) of one resident reviewed for pressure ulcers. The facility census was 45. Findings include: Review of the medical record for Resident #21 revealed an admission date of 05/26/25 with diagnoses of paraplegia, local infection of the skin and subcutaneous tissue, diabetes mellitus, anxiety, and depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #21 revealed he was cognitively intact and was admitted with wounds. Review of the admission assessment dated [DATE] revealed Resident #21 had an unstageable pressure ulcer to the sacrum (tailbone area) that measured 8.5 centimeters (cm) by 4.5 cm by 1.4 cm. Review of the current care plan revealed Resident #21 was care planned for wounds with an intervention in place for a wound vacuum (vac) as ordered. Review of the weekly skin assessments, dated 06/03/25 and 06/11/25, revealed Resident #21's wound was identified on the assessment, but no wound measurements were documented. Interview on 06/17/25 at 10:22 A.M. with the Director of Nursing (DON) revealed Resident #21 went to an outside provider for wound care per the resident's preference. The DON further stated that all residents who were followed by the in-house wound care provider had weekly wound measurements completed on Wednesday of each week. The DON verified the weekly skin assessments completed on 06/03/25 and 06/11/25 for Resident #21 did not include any measurements of the resident's pressure ulcer. The DON confirmed weekly wound measurements were not completed for Resident #21, adding the measurements were only done when the resident was seen by the outside wound care provider, which was approximately every two weeks. The DON confirmed the facility was responsible to complete the resident's wound vac treatments three times per week. Interview on 06/17/25 at 12:18 P.M. with Registered Nurse (RN) #637 revealed the nursing standard of care was to complete weekly wound measurements for monitoring and to identify potential concerns. Review of the facility policy titled, Skin Care Management, revised November 2022, revealed it was the facility policy to follow all applicable state and federal regulations regarding skin management. The facility must implement, monitor, and modify, if needed, appropriate strategies to attain or maintain intact skin and promote healing of pressure ulcers that are present.

Based on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure oxygen was administered per physician orders. This affected one resident (#147) of one resident reviewed for oxygen therapy. The facility census was 45. Findings include: Review of the medical record for Resident #147 revealed an admission date of 05/09/25 with diagnoses of chronic obstructive pulmonary disease (COPD), malignant tumor of the bronchus and lung, anxiety, and dependence on oxygen. Review of the admission Minimum Data Set (MDS) assessment, dated 05/10/25, revealed Resident #147 had mild cognitive impairment and required the use of oxygen therapy. Review of the current physician orders revealed Resident #147 was ordered humidified oxygen at a rate of four liters per minute (LPM) to maintain oxygen saturation (measurement of how much oxygen is in the body) at 90% or above. Review of the care plan, initiated May 2025, revealed Resident #147 received oxygen therapy due to ineffective gas exchange and pulmonary hypertension. Interventions included to provide oxygen therapy by way of nasal cannula (oxygen delivered by nose tubing) at four LPM continuously to maintain pulse oximeter (oxygen saturation) greater than 90% as directed by the physician. Observation on 06/16/25 at 10:06 A.M. of Resident #147 revealed she was resting in bed with oxygen running at four and one-half LPM via nasal cannula. Concurrent interview with Resident #147 revealed her oxygen was supposed to be at four LPM. Resident #147 stated she had been on oxygen for five years. Observation on 06/16/25 at 5:02 P.M. of Resident #147 revealed the resident was up and sitting in the recliner. The resident's oxygen continued to be administered at four and one-half LPM. Interview 06/16/25 at 5:21 P.M. with the Director of Nursing (DON) verified the oxygen order for Resident #147 was for oxygen to be administered at four LPM and further confirmed the resident's oxygen was running at four and one-half LPM. Interview on 06/18/25 at 8:35 A.M. with the DON and Administrator verified the facility did not have a specific policy for oxygen therapy and oxygen administration fell under medication administration. Review of the facility policy title, Medication Administration Policy, revised July 2021, revealed medications would be administered to residents/elders as prescribed and by persons lawfully authorized to do so in a manner consistent with good infection control and standards of practice.

Based on closed medical record review, hospital record review, review of the Cubex (computerized medication dispensing machine, provided and maintained by the contracted pharmacy, for frequently used medications to be available for immediate use) inventory sheet, facility policy review and interviews with staff, pharmacy and family, the facility failed to implement a timely, effective and adequate pain management plan for Resident #143 following the resident's admission to the facility. This affected one (#143) of one resident reviewed for pain management. The facility census was 45. Findings include: Review of the closed medical record for Resident #143 revealed an admission date of 06/05/25 at 1:10 P.M. and a discharge date of 06/05/25 at 10:20 P.M. Resident #143 had diagnoses including low back pain, chronic pain syndrome, intervertebral disc degeneration-thoracic region, lumbosacral intervertebral disc degeneration, radiculopathy-lumbar region, spinal stenosis-lumbosacral region, spinal stenosis-lumbar region, spondyliosis, and intervertebral disc displacement-lumbosacral region. Review of the admission assessment dated [DATE] revealed Resident #143 was alert and oriented to person, place, time, and situation. Review of the admission orders dated 06/05/25 revealed Resident #143 was prescribed gabapentin (used to treat pain) 200 milligram (mg) three times daily at 8:00 A.M., 12:00 P.M. and 8:00 P.M., Percocet (narcotic medication used to treat pain) 5-325 mg, one tablet every eight hours as needed (PRN) for pain, quetiapine fumarate (antipsychotic medication used off label to treat chronic pain) 25 mg at bedtime for chronic pain, and Tylenol 500 mg, two tablets every six hours as needed for pain. Review of the baseline care plan dated 06/05/25 revealed Resident #143 had pain due to an unstable spine. Interventions included pain medication as prescribed and to administer pain medication 30 minutes prior to any treatments. Review of a nursing progress note dated 06/05/25 at 9:15 P.M. revealed Resident #143 was administered two extra strength Tylenol per order for resident complaints of back pain. Further review revealed the resident was Requesting narcotic, writer informed resident that medication not in yet from pharmacy that should be in later this evening. Resident sitting on bed stating she needed Percocet but decided to take the Tylenol at this time. Review of the Medication Administration Record (MAR) for June 2025 revealed on 06/05/25 at 9:15 P.M., Resident #143 was administered acetaminophen (Tylenol) 500 mg, two tablets, for pain rated at a 10 on a zero to 10 scale. Further review revealed, upon reassessment, the Tylenol was not effective in managing Resident #143's pain. Additionally, the MAR revealed no doses of Percocet were administered, per resident request, and neither the quetiapine fumarate or gabapentin were administered, as physician ordered on this date. Review of a nursing progress note dated 06/05/25 at 10:03 P.M. revealed Registered Nurse (RN) #655 was in the hallway at the medication cart and heard Resident #143 on speaker phone in her room and further heard the resident state, I need help. RN #655 entered the room and the resident was still having a conversation with the person on the speaker phone, which was lying on the opposite side of the bed from the resident, who was sitting upright on her bottom on the floor. Resident #143 was asked why she was on the floor and stated, I don't know, I fell. EMS arrived and stated the resident's son called 911 to have her sent to the ER. EMS helped the resident onto the stretcher. At 10:20 P.M., the resident was transported to the ER per stretcher with EMS. Review of emergency room (ER) documentation dated 06/05/25 revealed Resident #143 arrived at the ER at 10:43 P.M. for complaints of diffuse pain. The resident stated she had been experiencing pain since being discharged from the hospital earlier that day and she was unable to receive any narcotic medications at the skilled nursing facility. Additionally, Resident #143 reported she received two doses of Tylenol while in the skilled nursing facility. Further review revealed that Resident #143 was administered morphine sulfate by way of intramuscular (IM) injection. A re-assessment was performed and Resident #143 was resting comfortably with a reported improvement in pain. Review of the Cubex machine inventory list revealed Percocet 5-325 mg, quetiapine fumarate 25 mg, and gabapentin 100 mg were on the inventory sheet as available medications in the facility's Cubex machine. Interview on 06/17/25 at 7:54 A.M. with Pharmacist #681 verified, Percocet 5-325 mg, quetiapine fumarate 25 mg, and gabapentin 100 mg were medications available in the facility's Cubex machine and were available for administration to Resident #143 following the resident's admission. Pharmacist #681 further stated the process for obtaining medication out of the Cubex machine for resident administration was for the facility to fax the orders to the pharmacy and then for pharmacy staff to enter the orders in the system. Pharmacist #681 revealed Resident #143's orders were received by the pharmacy on 06/05/25 at 2:27 P.M. and were entered into the system by the pharmacy staff on 06/05/25 at 5:50 P.M. Pharmacist #681 stated if a resident needed medication immediately, the facility nurse could call the pharmacy, and medications would be reviewed and processed immediately for administration from the Cubex machine. Pharmacist #681 further stated the process for getting a narcotic pain medication out of the Cubex machine required the facility nursing staff to call the pharmacy for an authorization number to pull the medication. Pharmacist #681 stated the pharmacy was staffed with their regular staff until midnight on weekdays and an on-call pharmacist was available after midnight to provide authorizations, as needed. Pharmacist #681 revealed there were no calls received on 06/05/25 for an authorization for Resident #143's medications to be pulled from the Cubex for administration. Interview on 06/17/25 at 4:55 P.M. with the Director of Nursing (DON) and Administrator verified pain medications were not administered as prescribed for Resident #143 and further confirmed the pain medications, Percocet, gabapentin, and quetiapine fumarate, were medications available in the Cubex for administration. Interview on 06/17/25 at 5:29 P.M. with Registered Nurse (RN) #655 revealed the facility's Cubex machine contained medications that could be administered for residents who were newly admitted or had new physician orders (prior to pharmacy delivery). RN #655 confirmed she worked with Resident #143 on 06/05/25 and further verified she had access to the Cubex machine and was aware of the process to access medications from the Cubex for administration. RN #655 stated she did not recall accessing the Cubex to obtain Resident #143's pain medications or calling the pharmacy for authorization on 06/05/25. RN #655 stated she administered what she had available, which was Tylenol, for Resident #143's pain. During the interview, RN #655 was unable to recall any specific information related to Resident #143 or her pain on 06/05/25. A telephone interview on 06/18/25 at 11:55 A.M. with Resident #143's family member revealed on 06/05/25, the resident called her from the facility because she was in pain. Resident #143's family member stated she did not reside in the area and reached out to another family member, who was closer, to check on the resident. The local family member called 911 for the resident. Review of the facility policy titled, Pain Management, revised December 2021, revealed each resident would be assessed upon identification of pain. Further review revealed after consultation with the physician and resident, medication and dosage schedules would be established based on characteristics of the resident's pain. Review of the facility policy titled, Medication Administration Policy, revised July 2021, revealed medications would be administered to residents/elders as prescribed and by persons lawfully authorized to do so in a manner consistent with good infection control and standards of practice. This deficiency represents non-compliance investigated under Complaint Number OH00166633.

Based on observation, staff interview, pharmacy staff interview, medical record review, closed medical record review, and review of the Cubex (computerized medication dispensing machine containing frequently used medications for immediate access for new admissions and/or new physician orders) machine inventory sheets, the facility failed to ensure medication doses were verified prior to administration and further failed to ensure available medications were administered per physician order. This affected two residents (#28 and #143) reviewed for medication administration. The facility census was 45. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 11/01/24 with a diagnosis of depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had mild cognitive impairment. Review of the current physician orders revealed Resident #28 was prescribed Wellbutrin XL (medication used to treat depression) oral tablet extended release (ER) 24 hour 150 milligrams (mg), one tablet in the morning. Observation on 06/17/25 at 7:23 A.M. of medication pass revealed Registered Nurse (RN) #637 pulled the medication packet for Resident #28 labeled buproprion ER XL (generic for Wellbutrin XL). Further observation revealed the medication packet did not have the dosage of the buproprion ER XL on the label. Continued observation revealed RN #637 opened the package labeled buproprion ER XL and placed the pill in the medication cup for Resident #28, along with the rest of the resident's morning medications. Concurrent interview with RN #637 confirmed the dosage of the buproprion ER XL was not on the packaging label and further stated, I know it's the right medication; I know it by the pill. Continued observation revealed RN #637 took the medication cup of pills, that included the unknown dosage of buproprion ER XL, to Resident #28 and administered the medications to the resident. Observation revealed that at no time did RN #637 verify the buproprion ER XL she removed from the package and administered to Resident #28 was the appropriate dosage ordered by the physician. Interview on 06/17/25 at 7:42 A.M. with Lead Order Entry Clerk (LOEC) #680, with the facility's contracted pharmacy, stated when a medication label did not include the dosage, facility staff would be expected to compare the description of the pill on the package and the medication number stamp to the actual pill on hand with the stamped medication number on the pill and/or the administering nurse could call the pharmacy to verify the medication to ensure the correct medication was administered. The facility nurse would be expected to notify the pharmacy of the mislabeled medication packaging to rectify the package label. 2. Review of the closed medical record for Resident #143 revealed an admission date of 06/05/25 at 1:10 P.M. and a discharge date of 06/05/25 at 10:20 P.M. Resident #143 had diagnoses including low back pain, chronic pain syndrome, intervertebral disc degeneration-thoracic region, lumbosacral intervertebral disc degeneration, radiculopathy-lumbar region, spinal stenosis-lumbosacral region, spinal stenosis-lumbar region, spondyliosis, and intervertebral disc displacement-lumbosacral region. Review of the admission assessment dated [DATE] revealed Resident #143 was alert and oriented to person, place, time, and situation. Review of the admission orders dated 06/05/25 revealed Resident #143 was prescribed Percocet (narcotic medication used to treat pain) 5-325 mg, one tablet every eight hours as needed (PRN) for pain, Tylenol 500 mg, two tablets every six hours as needed for pain, and gabapentin (used to treat pain) 200 mg three times daily at 8:00 A.M., 12:00 P.M. and 8:00 P.M., . Review of the baseline care plan dated 06/05/25 revealed Resident #143 had pain due to an unstable spine. Interventions included pain medication as prescribed and to administer pain medication 30 minutes prior to any treatments. Review of a nursing progress note dated 06/05/25 at 9:15 P.M. revealed Resident #143 was administered two extra strength Tylenol per order for (resident) complaints of back pain. Further review revealed the resident was Requesting narcotic, writer informed resident that medication not in yet from pharmacy that should be in later this evening. Resident sitting on bed stating she needed Percocet but decided to take the Tylenol at this time. Review of the Medication Administration Record (MAR) for June 2025 revealed on 06/05/25 at 9:15 P.M., Resident #143 was administered acetaminophen (Tylenol) 500 mg, two tablets, for pain rated at a 10 on a zero to 10 scale. Further review revealed, upon reassessment, the Tylenol was not effective in managing Resident #143's pain. Additionally, the MAR revealed no doses of Percocet were administered, per resident request, and the 8:00 P.M. dose of gabapentin was not administered, per physician order. Review of the Cubex machine inventory list revealed Percocet 5-325 mg and gabapentin 100 mg were on the inventory sheet as available medications in the facility's Cubex machine. Interview on 06/17/25 at 7:54 A.M. with Pharmacist #681 verified, Percocet 5-325 mg and gabapentin 100 mg were available in the facility's Cubex machine and available for administration to Resident #143 following the resident's admission. Pharmacist #681 further stated the process for obtaining medication out of the Cubex machine for resident administration was for the facility to fax the orders to the pharmacy and then for pharmacy staff to enter the orders in the system. Pharmacist #681 revealed Resident #143's orders were received by the pharmacy on 06/05/25 at 2:27 P.M. and were entered into the system by the pharmacy staff on 06/05/25 at 5:50 P.M. Pharmacist #681 stated if a resident needed medication immediately, the facility nurse could call the pharmacy, and medications would be reviewed and processed immediately for administration from the Cubex machine. Pharmacist #681 further stated the process for getting a narcotic pain medication out of the Cubex machine required the facility nursing staff to call the pharmacy for an authorization number to pull the medication. Pharmacist #681 stated the pharmacy was staffed with their regular staff until midnight on weekdays and an on-call pharmacist was available after midnight to provide authorizations, as needed. Pharmacist #681 revealed there were no calls received on 06/05/25 for an authorization for Resident #143's Percocet or gabapentin to be pulled from the Cubex for administration. Interview on 06/17/25 at 4:55 P.M. with the Director of Nursing (DON) and Administrator verified Percocet and gabapentin were not administered as prescribed for Resident #143 and further confirmed Percocet and gabapentin were available in the Cubex for administration. Interview on 06/17/25 at 5:29 P.M. with Registered Nurse (RN) #655 revealed the facility's Cubex machine contained medications that could be administered for residents who were newly admitted or had new physician orders (prior to pharmacy delivery). RN #655 confirmed she worked with Resident #143 on 06/05/25 and further verified she had access to the Cubex machine and was aware of the process to access medications from the Cubex for administration. RN #655 stated she did not recall accessing the Cubex to obtain Resident #143's Percocet or gabapentin or calling the pharmacy for authorization on 06/05/25. RN #655 stated she administered what she had available, which was Tylenol, for Resident #143's pain. Review of the facility policy titled, Pain Management, revised December 2021, revealed each resident would be assessed upon identification of pain. Further review revealed after consultation with the physician and resident, medication and dosage schedules would be established based on characteristics of the resident's pain. Review of the facility policy title, Medication Administration Policy, revised July 2021, revealed medications would be administered to residents/elders as prescribed and by persons lawfully authorized to do so in a manner consistent with good infection control and standards of practice. This deficiency represents non-compliance investigated under Complaint Number OH00166633.

Based on observation, staff interview, medical record review, and review of facility policy, the facility failed to ensure staff donned gloves prior to the administration of subcutaneous (injection of medication into the fatty tissue layer beneath the skin) medications. This affected one (#28) of one resident observed for subcutaneous medication administration. The facility census was 45. Findings include: Review of the medical record for Resident #28 revealed an admission date of 11/01/24 with a diagnosis of diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 revealed she had mild cognitive impairment. Review of the current physician orders revealed Resident #28 was prescribed liraglutide (non-insulin treatment for Type II diabetes) 18 milligrams (mg)/three milliliters (ml), inject 1.2 milligrams (mg) subcutaneously in the morning. Observation on 06/17/25 at 7:23 A.M. revealed Registered Nurse (RN) #637 prepared liraglutide for administration to Resident #28. Continued observation revealed RN #637 did not don gloves and proceeded to administer the injection to the resident. Interview on 06/17/25 at 7:36 A.M. with RN #637 verified she administered Resident #28's liraglutide injection without donning gloves. RN #637 further stated she usually wore gloves when administering injections. Review of the facility policy title, Medication Administration Policy, revised July 2021, revealed medications would be administered to residents/elders as prescribed and by persons lawfully authorized to do so in a manner consistent with good infection control and standards of practice. Review of the facility policy title, Infection Prevention and Control Program, revised November 2021, revealed it was the facility's practice to prevent, recognize, and control to the extent possible, the onset and spread of infection. Goals to prevent and control the spread of disease included prevent and control outbreaks and cross-contamination using standard and transmission based precautions.

Based on medical record review, staff interview and review of the facility incident report, the facility failed to ensure fall incidents were documented in the resident medical record. This affected one (#12) of three residents reviewed for falls. The facility census was 46. Findings include: Review of the medical record for Resident #12 revealed an admitted [DATE] with diagnoses of dementia, and muscle wasting and atrophy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/13/25, revealed Resident #12 had impaired condition, was dependent for transfers and used a wheelchair for ambulation. Further review revealed Resident #12 had a fall with a non-major injury since the previous assessment. Review of the progress notes in Resident #12's electronic medical record dated 12/14/24 through 12/16/24 revealed no documentation of a fall. Review of the neurological assessments completed in Resident #12's electronic medical record revealed one was completed on 12/14/25 at 1:35 P.M. and the next one was completed on 12/15/24. Review of a 72 Hour QShift Follow Up Assessment, dated 12/15/24 at 2:01 A.M. revealed Resident #12 was assessed by a nurse for vital signs, range of motion, level of conciousness and pain. Review of an interdisciplinary treatment team (IDT) progress note dated 12/17/24 revealed the team met to develop a fall intervention for Resident #12's fall on 12/14/24. Interview on 03/03/25 at approximately 12:30 P.M. with the Director of Nursing (DON) and concurrent review of the facility's fall investigation revealed the DON was unable to provide copies of the facility's confidential risk management documentation of falls. The DON proceeded to verbally read the document, which confirmed Resident #12 had a fall on 12/14/25 at 7:20 A.M. The DON stated Resident #12 was found lying on the floor next to the bed. The DON stated range of motion and vitals were obtained and notifications to the family and provider were completed. The DON did not identify any injuries sustained by Resident #12. Interview on 03/04/25 at 11:55 A.M. with MDS Coordinator (MDSC) #301 revealed the quarterly MDS assessment dated [DATE] indicating Resident #12 had a fall with injuries reflected an abrasion and bruising to the resident's left eyebrow as a result of the fall on 12/14/25. A follow-up interview on 03/04/25 at 12:14 P.M. with MDSC #301 and the DON confirmed the nursing progress notes in Resident #12's electronic medical record did not include documentation of the events surrounding the resident's fall on 12/14/24. The DON revealed the fall was documented in the facility's confidential risk management system. Interview on 03/04/25, beginning at 2:50 P.M., with the DON revealed she was able to share the facility's confidential risk management documentation regarding Resident #12's unwitnessed fall on 12/14/24 at 7:20 A.M. and provided an incident report. Review of the facility's incident report dated 12/14/24 at 7:20 A.M. and locked on 12/17/24 at 8:23 A.M. revealed details regarding Resident #12's fall, including the circumstances of the fall and the injuries she sustained. Further review of the document revealed the statement Privileged and Confidential - Not part of the Medical Record - Do not Copy. This was an incidental finding during the complaint survey completed 03/04/25.

Based on medical record review, staff interview, review of electronic mail (e-mail) correspondence and review of facility policy, the facility failed to implement interventions to prevent a fall for one (#13) of three residents reviewed for falls. Additionally, the facility failed to complete neurological checks following an unwitnessed fall with injury and further failed to monitor injuries resulting from a fall per physician order. This affected one (#12) of three residents reviewed for falls. The facility census was 46. Findings include: 1. Review of the medical record for Resident #13 revealed an admitted [DATE] with diagnoses of dementia and epilepsy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/28/25, revealed Resident #13 was rarely/never understood, was dependent for transfers and used a wheelchair for mobility. Review of a Fall Risk Screening, dated 09/30/24, revealed Resident #13 was at risk for falls. Review of a nursing progress note dated 12/16/24 revealed Resident #13 appeared to be sliding/moving forward in her wheelchair and therapy was to evaluate the wheelchair for proper seating. Further review of the medical record from 12/16/24 through 01/03/25 revealed no evidence Resident #13 was evaluated by therapy for proper wheelchair seating. Review of a nursing progress note dated 01/03/25 revealed Resident #13 slid from her wheelchair while seated in the dining room. Resident #13 had no injuries as a result of the fall. Review of an interdisciplinary team (IDT) note dated 01/07/25 revealed the team met to discuss Resident #13's fall and determined an intervention to evaluate Resident #13 for a new wheelchair. Review of Resident #13's current care plan revealed she was at risk for falls related to impaired mobility. A new intervention was initiated on 03/03/25 for staff to perform frequent checks on resident when in the wheelchair, and staff would boost the resident as needed. Observations of Resident #13 on 03/03/25 at 9:38 A.M., 10:26 A.M., and approximately 12:00 P.M., and on 03/04/25 at 8:37 A.M. revealed no concerns regarding Resident #13 being improperly positioned in her wheelchair. Interview on 03/03/25 at approximately 12:30 P.M. with the Director of Nursing (DON) and concurrent review of the facility's fall investigation revealed Resident #13 was observed to slide from her wheelchair in the dining room by dietary staff on 01/03/25. Resident #13 sustained no injury due to the fall. The facility determined Resident #13's wheelchair should be evaluated by therapy to determine if a new wheelchair would be more appropriate. The DON stated Resident #13 often slid her bottom to the outside edge of the wheelchair and leaned back against the backrest. Further interview revealed Resident #13 was hospitalized from 02/21/25 to 02/25/25 due to a change in condition, before any changes to her wheelchair occurred. Resident #13 returned to the facility from the hospital and continued to use her wheelchair. The DON stated the family was waiting for test results before deciding whether to pursue a new wheelchair. The DON stated the fall intervention for the fall on 01/03/25 remained an assessment of Resident #13's wheelchair, once the family followed up with the facility with their decision. Upon further inquiry, the DON stated the interim fall intervention, implemented on 03/03/25, was to monitor and reposition Resident #13 as needed. Review of an e-mail correspondence dated 03/04/24 at 1:20 P.M. from Director of Rehabilitation (DOR) #303 revealed the therapy department did not receive a consultation to assess Resident #13's wheelchair on 12/16/24. Further review revealed the therapy department was notified on 01/08/25 (23 days after the need was identified on 12/16/24 and five days after the resident's fall on 01/03/25) regarding an evaluation of Resident #13's wheelchair. An occupational therapy (OT) evaluation was completed on 01/13/25 and therapy initiated the process for Resident #13 to receive a customized wheelchair; however, this process was placed on hold by the family following the resident's hospitalization . Interview on 03/04/25 at 3:57 P.M. with DOR #303 confirmed Resident #13 remained at risk of falling from the wheelchair and confirmed some modifications to her current wheelchair could be made to decrease her fall risk. DOR #303 verified no modification had been made to Resident #13's wheelchair to decrease the fall risk. Interview on 03/04/25 at 4:22 P.M. with MDS Coordinator (MDSC) #301 confirmed Resident #13's care plan was not updated until 03/03/25 with an intervention to frequently monitor and boost Resident #13 in the wheelchair as needed. 2. Review of the medical record for Resident #12 revealed an admitted [DATE] with diagnoses of dementia, and muscle wasting and atrophy. Review of the quarterly MDS assessment dated [DATE] revealed Resident #12 had impaired cognition, was dependent for transfers and used a wheelchair for ambulation. Further review revealed Resident #12 had a fall with a non-major injury since the previous assessment. Review of the progress notes in Resident #12's electronic medical record dated 12/14/24 through 12/16/24 revealed no documentation of a fall. Review of the neurological assessments completed in Resident #12's electronic medical record revealed one was completed on 12/14/25 at 1:35 P.M. and the next one was not completed until 12/15/24. Review of a 72 Hour QShift Follow Up Assessment, dated 12/15/24 at 2:01 A.M. revealed Resident #12 was assessed by a nurse for vital signs, range of motion, level of conciousness and pain. Further review revealed a skin assessment section, including an area to document a skin tear, abrasion, bruise, laceration, or other, with no areas marked. Review of an IDT progress note dated 12/17/24 revealed the team met to develop a fall intervention for Resident #12's fall on 12/14/24. Interview on 03/03/25 at approximately 12:30 P.M. with the DON and concurrent review of the facility's fall investigations revealed the DON was unable to provide copies of the facility's confidential risk management documentation of falls. The DON proceeded to verbally read the document regarding the circumstances of Resident #12's fall and confirmed the resident had a fall on 12/14/24 at 7:20 A.M. The DON stated Resident #12 was found lying on the floor next to the bed. The DON stated range of motion and vitals were obtained and notifications to the family and provider were completed. The DON did not identify any injuries sustained by Resident #12. Interview on 03/04/25 at 11:55 A.M. with MDSC #301 revealed the quarterly MDS assessment dated [DATE], which indicated Resident #12 had a fall with injuries, reflected an abrasion and bruising to Resident #12's left eyebrow as a result of the fall on 12/14/24. Continued interview with MDSC #301, and concurrent review of Resident #12's Treatment Administration Record (TAR) dated December 2024, revealed a physician order was initiated on 12/17/24 to monitor bruising and abrasion to the left eye until healed, twice daily. Further review revealed an additional physician order initiated 12/17/24 to monitor bump on the back of the head until healed, twice daily. Further review of Resident #12's TAR for December 2024 revealed the order to monitor the bruising and abrasion and the order to monitor the bump on the back of the head were documented with an x for the morning shift on 12/17/24. The administration boxes were blank for the evening shift on 12/17/24, both shifts on 12/18/24, 12/19/24, 12/20/24, 12/21/24, and 12/22/24 and the morning shift on 12/23/24. A check mark and staff initials were documented in the evening box on 12/23/24. A follow up interview on 03/04/25 at 2:50 P.M. with MDSC #301 confirmed a check mark on a TAR indicated the treatment/assessment was completed. MDS Coordinator #301 confirmed the boxes from the evening of 12/17/24 through the morning of 12/23/24 were blank for the order to monitor Resident #12's bruising and abrasion at left eye, and were blank for the order to monitor Resident #12's bump on the back of her head. MDS Coordinator #301 was unable to verify whether the monitoring was completed. Continued interview on 03/04/25, beginning at 2:50 P.M., with the DON confirmed the first two neurological checks completed for Resident #12, in the electronic medical record, were dated 12/14/24 and 12/15/24. The DON further confirmed the facility's policy regarding neurological assessments stated an assessed was completed every 15 minutes x 4, then every 30 minutes x 2, then every hour x 2, then every 4 hours x 5, and lastly every 8 hours x 24 hours. Further interview and concurrent review of the neurological assessment completed 12/14/24 confirmed it was not completed until 1:35 P.M. (approximately six hours after the resident's fall at 7:20 A.M.). Review of the facility policy titled, Neurological Assessment, revised 03/19/21, revealed a neurological assessment should be initiated following any obvious head trauma. Further review revealed an assessment should be completed every 15 minutes x 4, every 30 minutes x 2, every hour x 2, every 4 hours x 5, and every 8 hours x 24 hours and were to be completed for a minimum of 48 hours. This deficiency represents non-compliance investigated under Complaint Number OH00162615.

Based on medical record review, staff interview and review of facility policy, the facility failed to assess a newly identified bruise and further failed to ensure neurological assessments were completed following a head injury. This affected one (#11) of three residents reviewed for injuries. The facility census was 46. Findings include: Review of the medical record for Resident #11 revealed an admitted [DATE] with diagnoses of dementia, anxiety, and osteoporosis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/10/25, revealed Resident #11 had impaired cognition. Review of the hospital discharge records, dated 02/05/25, revealed Resident #11 was assessed at the hospital after a fall on 02/05/25. The documents revealed a head computed tomography (CT) scan showed a small focus of isodense extra-axial fluid on the right side that was probably a small, subacute subdural hematoma (a collection of blood between the brain and the skull). The plan included follow up in about six weeks with a new head CT. Further review revealed Resident #11 was at risk for gradual expansion of the hemorrhage due to the prominence of the extra-axial spaces. Review of a progress note dated 02/18/25 revealed Resident #11 was observed with a new bruise on her left forehead. The progress note did not include an assessment or description of the new bruise. Review of a Weekly Skin Observation Tool, completed 02/18/25, revealed Resident #11 had a bruise to her left forehead. Further review revealed no additional description of the wound, including size, color, or any additional observable characteristics. Further review of Resident #11's medical record revealed no evidence neurological assessments were completed on 02/18/25 following the identification of the new bruise on the resident's forehead. Review of the facility's investigation revealed the facility determined Resident #11 received the bruise from lying in bed with her head pressed against the u-bar (a bar located near the head of the bed to assist residents with bed mobility). The facility's intervention was to pad the u-bars on Resident #11's bed. Interview on 03/04/25 at 12:08 P.M. with the Director of Nursing (DON) revealed the facility had no guidance or protocol for assessing a new bruise. The DON stated each nurse assessed wounds differently and it was acceptable for one nurse to provide a description of the injury, including size, location, and color, while another nurse could assess the injury by simply stating a bruise was found. Interview on 03/04/25 at 12:29 P.M. with Nurse Practitioner (NP) #302 revealed he worked in the facility five days weekly. Further interview revealed NP #302 would expect a new bruise assessment to include its location, color, and estimated measurements. Interview on 03/04/25 at 1:39 P.M. with Licensed Practical Nurse (LPN) #201 confirmed she completed a skin assessment on Resident #11's wound on 02/18/25. LPN #201 stated she did not describe the bruise, including color or size, because she believed the assessment had been completed by the previous shift's nurse. A follow-up interview on 03/04/25 at 2:50 P.M. with the DON revealed neurological assessments were not completed for Resident #11 after the bruise on her forehead was identified because the bruise was not a hematoma. The DON stated she assessed the bruise and it was purple and flat and did not have a bump. The DON confirmed no description of the bruise was in Resident #11's record. Review of the facility policy titled, Skin Care Management, revised 11/17/22, revealed it was the policy of the facility to follow all applicable state and federal regulations regarding skin care management. Further review revealed the facility would implement, monitor and modify if needed appropriate strategies to attain or maintain intact skin; prevent complications; and promptly identify and manage complications. Review of the facility policy titled, Neurological Assessment, revised 03/19/21, revealed a neurological assessment should be initiated following any obvious head trauma. This was an incidental finding during the complaint survey completed on 03/04/25.

Based on observation, medical record review, staff interview and review of the facility resident rights document, the facility failed to ensure requests made by a resident's guardian were adequately addressed. This affected one (#36) of one resident reviewed for requests made by a guardian. The facility census was 46. Findings include: Review of the medical record revealed Resident #36 admitted to the facility on [DATE]. Diagnoses included dementia, severe protein-calorie malnutrition, adult failure to thrive, and muscle weakness. Further review revealed Resident #36's daughter was appointed legal guardian on 12/04/24. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was cognitively impaired. The resident required supervision or touching assistance for chair/bed-to-chair transfers. Review of the plan of care dated 09/06/23, and revised 01/21/25, revealed Resident #36 had an activities of daily living (ADLs) self-care and/or physical mobility performance deficit related to impaired mobility. Interventions included multiple assistive signs hung in room per family request. Further review revealed no evidence of what specific care or needs were identified on the signs hung in Resident #36's room or what requests the facility implemented. Observation on 01/21/25 at 11:40 A.M. revealed Resident #36 was in bed in his room. Further observation revealed numerous signs were posted throughout the resident's room. A sign posted on the wall to the side of the resident's bed stated, Leave wheelchair next to bed as he will get out of bed when he realizes he has to go to the bathroom, not always so please check on him often. The sign also stated to contact the resident's guardian with any questions or concerns and provided a contact phone number. Resident #36's wheelchair was in the bathroom and not next to the resident's bed. Continued observations on 01/21/25 from 11:40 A.M. through 12:47 P.M. revealed Resident #36 remained in bed, with his wheelchair located in the bathroom. Interview on 01/21/25 at 12:47 P.M. with Unit Manager (UM) #386 verified Resident #36 was in bed, while his wheelchair was located in the bathroom. UM #386 confirmed the wheelchair was supposed to be next to Resident #36's bed when he was in it per his guardian's request. Interview on 01/21/25 with Resident #36's legal guardian confirmed she requested the resident's wheelchair be left next to the bed when he was in it and left a sign next to the bed as a reminder to staff. The resident's guardian stated Resident #36 would sometimes attempt to get up independently to go to the bathroom and she was concerned he would fall if the wheelchair was not accessible to him. Interview on 01/22/25 at 3:58 P.M. with the Director of Nursing (DON) confirmed Resident #36 sometimes attempted to get out of bed on his own, without staff assistance. Interview on 01/23/25 at approximately 1:00 P.M. with the Administrator confirmed Resident #36's guardian requested the resident's wheelchair be next to the bed but stated she was uncertain why the request was made. The Administrator indicated Resident #36 had no fall history that she was aware of or safety risks associated with the wheelchair being placed next to the resident's bed. The Administrator did not know if Resident #36 attempted to get out of bed on his own and she was uncertain who assessed the resident's mobility/transfer needs, adding he transferred to their facility from another facility. The Administrator reported the wheelchair next to Resident #36's bed was a guardian request, but not necessarily something the facility implemented. The Administrator confirmed there had been no further discussion with the resident's guardian related to the request. Further review of the medical record revealed no evidence the facility reviewed the guardian's request, completed any assessments related to the requests, or implemented any of the specific interventions identified on the signs hanging in Resident #36's room, including the wheelchair left at bedside. Review of the facility document titled Ohio Resident Rights & Facility Responsibilities, revised 01/22/20, revealed residents had the right to participate in decisions that affected their life, including the right to communicate with the physician and employees of the home in planning the resident's treatment or care. The document further stated a sponsor may act on a resident's behalf to assure the home did not deny the resident's rights. This deficiency represents non-compliance investigated under Master Complaint Number OH00161384.

Based on medical record review, review of staff statements, observation of a video recording, interviews, and review of the Ohio Nursing Home Residents [NAME] of Rights, the facility failed to ensure a resident was treated with dignity and respect. This affected one (#26) of three residents reviewed for dignity and respect. The facility census was 48. Findings include: Review of the medical record for Resident #26 revealed an admitted [DATE]. Diagnoses included dementia, pulmonary fibrosis, and chronic obstructive pulmonary disease. Review of the quarter Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident was always incontinent of bladder and occasionally incontinent of bowel. Review of an undated and unsigned statement by Registered Nurse (RN) #600 revealed on 08/13/24 Resident #26's daughters called and expressed after reviewing a video from their father's room, they saw and heard a nursing assistant yelling at their father and scolding him for urinating on himself. The daughter explained the nursing assistant's behavior appeared to be aggressive as she was in their fathers face yelling at him and again scolding him for urinating on himself. The daughter requested the nursing assistant to no longer be allowed in the resident's room and to no longer take care of the resident. RN #600 identified the nursing assistant and notified the Director of Nursing. RN #600 then spoke with the nursing assistant who denied yelling or scolding the resident. The nursing assistant stated the resident was hard of hearing and she had to speak loudly into his ear so he could hear her. The nursing assistant explained she was just telling the resident he should not pee on himself and he needed to call for assistance so he was not sitting in urine and for safety so he would not fall taking himself to the bathroom without assistance. RN #600 told the nursing assistant she could no longer go into the residents room or provide care for the resident. The nursing assistant was also educated on the importance of offering incontinent residents assistance to the bathroom every two hours and the proper way to approach and talk to a resident who was hard of hearing. Review of an undated and unsigned statement by State tested Nursing Assistant (STNA) #210 revealed she walked into Resident #26's room and told him he was wet. The resident put his hand to his ear and stated he could not hear. STNA #210 took her hands up and down trying to explain to the resident that he was wet. STNA #210 went to closet and got a clean pair of pants and took the resident to the bathroom. STNA #210 stated there was urine on the floor and she helped the resident change. When STNA #210 walked out of the room, the nurse stopped her and told her the resident's daughter did not want her in the room again. STNA #210 stated she was louder because the resident can't hear and was showing him pants. Observation of a video dated 08/13/24 at 11:41 A.M. revealed Resident #26 was in his room seated in his wheelchair watching television. State tested Nursing Assistant (STNA) #210 entered the room and treated the resident without dignity and respect for being incontinent of urine. STNA #210 while raising her hands in the air had spoken very loudly to the resident and stated, Why do you do this? The resident stated What? STNA #210 then pointing to the resident's pants stated This, you peed yourself, you wet yourself, while moving her right hand and then she walked away from the resident. Interview on 09/09/24 at 1:48 P.M., after reviewing the video, STNA #210 verified the interaction between herself and Resident #26. STNA #210 revealed she had not treated the resident with dignity and respect. STNA #210 revealed she should not have talked to the resident like that. Interview on 09/09/24 at 1:50 P.M., Director of Nursing (DON) reviewed the video and revealed the resident was not treated with respect and dignity. The DON revealed STNA #210 should have just cleaned up the resident and not questioned the resident why he was wet. The DON revealed if STNA #210 was frustrated she could have got someone else to help. The DON further revealed STNA #210 does not realize how she comes off to the residents. Interview on 09/09/24 at 2:28 P.M., the Administrator viewed the video then revealed there was a lack of customer service. Review of the undated, Ohio Nursing Home Residents [NAME] of Rights, revealed residents had the right to be free from physical, verbal, mental and emotional abuse and be treated at all times with courtesy, respect with full recognition of dignity and individuality. This deficiency represents non-compliance investigated under Master Complaint Number OH00156903.

Based on review of personnel records, staff interview, and policy review, the facility failed to ensure employee reference checks were completed. This had the potential to affect all residents. The facility census was 48. Findings include: Review of the personnel record for State tested Nursing Assistant (STNA) #210 revealed a hire date of 04/11/23. Further review of the personnel record revealed reference checks had not been completed. Interview on 09/10/24 at 11:56 A.M., the Administrator revealed the facility was unable to find any documentation of completed reference checks for STNA #210. Review of the policy, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, last revised 10/25/22 revealed prior to hiring a new employee the facility would attempt to obtain information from previous employers or current employers.

Based on medical record review, observation, and staff interviews, the facility failed to ensure a resident who was dependent on staff for eating was assisted with eating with her meal. This affected one (Resident #16) of one resident observed for eating and had the potential to affect eight residents (#2, #4, #14, #28, #30, #31, #42, and #43) the facility identified as requiring assistance with eating. The facility census was 49. Findings include: Review of the medical record for Resident #16 revealed she was admitted on [DATE] with diagnoses of intracerebral hemorrhage with left sided paralysis and dysphagia. Review of the care plan revised 06/2024 revealed Resident #16 was care planned for Activity of Daily Living (ADL) self-care and/or physical mobility performance deficit. Interventions included to provide extensive assistance of one staff member for eating. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively impaired and dependent on staff assistance for eating. Review of the current physician orders for 07/2024 revealed Resident #16 was ordered a regular diet, mechanical soft with thin liquids. Review of the State tested Nursing Assistant (STNA) documentation sheet dated 07/22/24 and timed 9:45 A.M. and 2:03 P.M. for Resident #16 revealed she required total dependence for those meals, indicating full staff performance. Review of the nursing progress notes for Resident #16 revealed a nursing note dated 07/22/24 at 3:00 P.M. verifying the lunch tray for Resident #16 was left in her room and appearing untouched, and the silverware was still wrapped. The nursing progress note further stated the STNA was asked to heat the food for Resident #16 and attempt to feed and her it was reported to the nurse Resident #16 ate 100% of her meal and drank 100% of her Ensure shake (a high calorie nutritional supplement). Observation on 07/22/24 at 2:45 P.M. revealed the lunch tray for Resident #16 was left in her room on the overbed table. The lunch tray was sitting with the covered dome lid in place, the silverware rolled in linen napkin and completed rolled up, a glass of juice with a straw in the glass and a glass of white milk. Further observation revealed the food under the dome lid appeared to be untouched, there were no divots or smear marks on the plate indicating the food was touched or offered to Resident #16. Interview on 07/22/24 at 2:47 P.M. with Licensed Practical Nurse (LPN) #217 verified Resident #16's lunch tray remained on the overbed table and appeared to be untouched. Interview on 07/22/24 at 2:50 P.M. with STNA #219 stated she did not get in shift change report that Resident #16 did not eat lunch. Interview on 07/22/24 at 2:51 P.M. with LPN #217 stated it was not reported to her that Resident #16 did not eat lunch. Interview on 07/22/24 at 3:15 P.M. with STNA #219 stated Resident #16 ate and drank 100% of her lunch tray and 100% of her Ensure supplement. Telephone interview on 07/22/24 at 3:57 P.M. with STNA #206 stated she attempted to feed Resident #16 and at the time she refused, so she left the tray and meant to go back and attempt again but forgot and then her shift was over. Interview on 07/23/24 at 8:30 A.M. with the Administrator stated the facility does not have any policies related to feeding residents who were dependent on staff for eating and the facility applies the interventions in the care plan. Interview on 07/23/24 at 11:39 A.M. with STNA #232 stated extensive means the resident needs extensive assistance with feeding and the by one means only one person needs to assist. STNA #232 further stated that Resident #16 will assist at times but most of the time she was fed by the staff. This was an incidental finding discovered during the course of the complaint investigation.

Based on observation, medical record review, staff interview, review of manufacturer instructions, and review of facility policy, the facility failed to ensure medications were administered as ordered by the physician, within prescribed time frames, and in accordance with manufacturer instructions for use, resulting in a medication error rate above five percent (%). A total of four medications errors were observed out of 39 opportunities for a medication administration error rate of 10.26%. This affected one (#1) of three residents observed during medication administration. The facility census was 38. Findings include: Review of Resident #1's physician orders noted the medications and prescribed times as indicated; on 05/19/24, Advair Diskus Aerosol Powder Breath Activated 250-50 micrograms (mcg) per(/) dose (Fluticasone-Salmeterol) one inhale orally every 12 hours related to chronic obstructive pulmonary disease (COPD) with acute exacerbation of shortness of breath with prescribed times 8:00 A.M. and 8:00 P.M.; on 03/08/24, Ipratropium-Albuterol Solution 0.5-2.5 milligrams (mg)/3.0 milliliter (ml) inhale orally every four hours for COPD prescribed times 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., 8:00 P.M.; on 10/17/23, Humalog KwikPen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Lispro) inject as per sliding scale: if 141 - 180 = two units; 181 - 220 = three units; 221 - 260 = four units; 261 - 300 = five units; 301 - 350 = eight units; 351 - 400 = 10 units; 401 or greater than 400 give, 12 units and call physician, subcutaneously before meals and at bedtime related to Type II Diabetes Mellitus; on 05/22/24, Polyvinyl Alcohol 1.4 % solution administer one drop in each eye three times daily for dry eyes. Observation on 05/30/24 at 9:20 A.M. noted Licensed Practical Nurse (LPN) #400 obtaining medications for Resident #1 from the medication cart outside the resident's room. Medications included the following: Advair Diskus Aerosol Powder Breath Activated 250-50 mcg, Ipratropium-Albuterol Solution 0.5-2.5 mg/3.0 ml Lispro Insulin Pen 100 unit per (/) ml. LPN #400 stated she was unable to find Polyvinyl Alcohol 1.4 % Solution eye drops and would not administer due to unavailable. On 05/30/24 at 9:21 A.M., Dietary Aide (DA) #500 exited Resident #1 room carrying Resident #1's breakfast tray. Observation with LPN #400 noted the resident had consumed 75% of the meal. On 05/30/24 at 9:27 A.M., LPN #400 entered Resident #1's room with the medications. At 9:29 A.M., LPN #400 dialed two units to the indicator window of insulin the Lispro insulin pen. No prime of the pen was initiated. LPN #400 proceeded to administer an injection of the pen to the resident's right lower abdominal quadrant. LPN #400 proceeded to administer the Advair Diskus Aerosol. At 9:32 A.M., LPN #400 placed the contents of Ipratropium-Albuterol Solution into an aerosol machine chamber and placed the aerosol mask connected to the chamber on the resident. On 05/29/24 at 9:36 A.M., an interview with LPN #400 during review of the medical record confirmed Resident #1's insulin was to be provided before meals, and the aerosol treatments were administered outside prescribed time frames. LPN #400 indicated she was unaware the Lispro Insulin Pen required priming prior to administration and verified the eye drops were not available in the facility. Review of Humalog KwikPen (insulin lispro) instructions for use revised 07/2023 revealed priming the pen which removes the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly. If pen is not primed before each injection, this may result in the patient receiving too much or too little insulin. To prime pen, turn the dose knob to select two units. Hold pen with needle pointing up. Tap cartridge holder gently to collect air bubbles at the top. Continue holding pen with needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. Insulin should be seen at tip of needle. If insulin is not seen, repeat priming no more than four times. If still no insulin is observed, change the needle and repeat priming. According to facility's Medication Administration Procedure, revised 11/09/21, revealed medications are administered in accordance with written orders of the attending physician or physician extender. Medications are administered within one hour before or one hour after scheduled time, except before or after meal orders, which are administered based on meal times. This deficiency represents non-compliance investigated under Complaint Number OH00153881.

Based on observation, medical record review, staff interview, review of the manufacturer instructions, and review of the facility policy, the facility failed to ensure a resident was free from a significant medication error when medications were not administered as ordered by the physician. This affected one (#1) of three residents observed during medication administration. The facility census was 38. Findings include: Review of Resident #1's physician orders noted the medications and prescribed times as indicated; Humalog KwikPen Subcutaneous Solution Pen-injector 100 unit per milliliter (ml) (Insulin Lispro) inject as per sliding scale: if 141 - 180 = two units; 181 - 220 = three units; 221 - 260 = four units; 261 - 300 = five units; 301 - 350 = eight units; 351 - 400 = 10 units; 401+ Greater than 400 give 12 units and call physician, subcutaneously before meals and at bedtime related to type II diabetes mellitus. Observation on 05/30/24 at 9:20 A.M. noted Licensed Practical Nurse (LPN) #400 obtaining medications for Resident #1 from the medication cart outside the resident's room. Medications included Lispro Insulin Pen 100 unit per ml. On 05/30/24 at 9:21 A.M., Dietary Aide (DA) #500 exited Resident #1's room carrying Resident #1's breakfast tray. Observation with LPN #400 noted the resident had consumed 75% of the meal. On 05/30/24 at 9:27 A.M., LPN #400 entered Resident #1's room with the medications. At 9:29 A.M., LPN #400 dialed two units to the indicator window of insulin the Lispro insulin pen. No prime of the pen was initiated. LPN #400 proceeded to administer an injection of the pen to the resident's right lower abdominal quadrant. On 05/29/24 at 9:36 A.M., an interview with LPN #400 during review of the medical record confirmed Resident #1's insulin was to be provided before meals, and the aerosol treatments were administered outside prescribed time frames. LPN #400 indicated she was unaware the Lispro Insulin Pen required priming prior to administration. Review of Humalog KwikPen (insulin lispro) instructions for use revised 07/2023 revealed priming the pen which removes the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly. If pen is not primed before each injection, this may result in the patient receiving too much or too little insulin. To prime pen, turn the dose knob to select two units. Hold pen with needle pointing up. Tap cartridge holder gently to collect air bubbles at the top. Continue holding pen with needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. Insulin should be seen at tip of needle. If insulin is not seen, repeat priming no more than four times. If still no insulin is observed, change the needle and repeat priming. According to facility policy titled Medication Administration Procedure, revised 11/09/21, revealed medications are administered in accordance with written orders of the attending physician or physician extender. Medications are administered within one hour before or one hour after scheduled time, except before or after meal orders, which are administered based on meal times. This deficiency represents non-compliance investigated under Complaint Number OH00153881.

Based on observation, medical record review, staff interview, facility policy review, and review of manufacturer instructions, the facility failed to ensure insulin was administered as ordered. This affected one (#31) of seven residents observed for medication administration. The facility census was 38. Findings include: Review of the medical record for Resident #31 revealed an admitted [DATE]. Diagnoses included type II diabetes mellitus, hypertension, hypothyroidism, chronic obstructive pulmonary disease, obstructive sleep apnea, peripheral vascular disease, encephalopathy, major depressive disorder, and insomnia. Review of the current physician orders for Resident #31 revealed an order dated 04/05/23 for blood glucose levels to be obtained prior to meals with Novolog insulin administered subcutaneously (SQ) per sliding scale via a Flex Touch pen. The order for insulin to be given per sliding scale was for blood glucose levels between 140 milligrams per deciliter (mg/dL) and 199 mg/dL, inject two units of insulin; for blood glucose levels between 200 mg/dL and 249 mg/dL, inject four units of insulin; for blood glucose levels between 250 mg/dL and 299 mg/dL, inject six units of insulin; for blood glucose levels between 300 mg/dL and 349 mg/dL, inject eight units of insulin; for blood glucose levels between 350 mg/dL and 399 mg/dL, inject 10 units of insulin; and for blood glucose levels greater than 400 mg/dL the physician was to be notified. Observation on 08/07/23 at 11:59 A.M. revealed Licensed Practical Nurse (LPN) #500 obtained Resident #31's blood glucose level and determined the level to be 171 mg/dL. Continued observation of LPN #500 revealed the nurse returned to the medication administration cart, and at 12:00 P.M., LPN #500 removed a clear plastic bag that contained the insulin pen (Novolog Flex Touch) for Resident #31 from the medication cart. LPN #500 then removed a needle and two alcohol swabs from the medication cart. The insulin pen was then removed from the bag, the cap was removed from the pen and laid on the plastic bag from which the Novolog Flex Touch pen was removed. LPN #500 proceeded to open an alcohol wipe, swabbed the top of the insulin pen, attached the needle, and dialed pen to two units of insulin. While holding the insulin pen in the left hand, LPN #500 used the right hand to return the plastic bag and the cap to the pen back into the medication cart. LPN #500 then locked the medication cart, picked up the second alcohol swab, and entered Resident #31's room. LPN #500 approached Resident #31 and injected the insulin into Resident #31's left arm. Interview with LPN #500 on 08/07/23 at 12:02 P.M. confirmed the insulin pen was not primed when the needle was applied and before administering insulin to Resident #31. LPN #500 stated insulin pens do not require priming the needle when the needle was applied, and to just dial the pen to the ordered dose and administer the insulin. Interview with the Executive Director on 08/07/23 at 2:00 P.M. verified the Novolog Flex Touch pen was required to be primed when the needle was attached to the pen. Review of a policy titled, Insulin Administration, dated 06/21/17, revealed there are several insulin devices on the market, and it is essential for the nurse to be familiar with the device prescribed and to always follow manufacturers recommendations and when using pen devices, check the manufacturer's instructions prior to use as many pens require priming or an air shot prior to administration. Review of the manufacturers instructions dated March 2023 revealed the Novolog Flex Touch pen required priming of two units of insulin to ensure insulin comes out of the needle tip to ensure the pen was working correctly, and to remove all air bubbles to ensure the correct dose of insulin was provided. This deficiency represents non-compliance investigated under Complaint Number OH00144886.

Based on observation, staff interview, review of policy, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure staff wore their masks and eye protection properly while providing care and services to residents. This affected two (#12 and #33) residents and had the potential to affect all 38 residents residing in the facility. The facility census was 38. Findings include: Review of the Centers for Disease Control and Prevention (CDC) COVID-19 Data Tracker revealed on 03/27/23 and on 03/28/23 the community transmission rate for Wood County was high. Interview on 03/27/23 at 9:30 A.M., with the Administrator revealed staff were currently required to wear a medical/surgical mask and eye protection throughout the facility. Observation on 03/28/23 at 6:40 A.M., of State tested Nurse Aide (STNA) #412 revealed the staff member was pushing Resident #12 who was in a wheelchair down a hallway and STNA #412's medical-surgical mask was around the bottom of her chin and below her nose and mouth. STNA #412 was not wearing eye protection. Interview on 03/28/23 at 6:48 A.M., with STNA #415 verified staff were required to wear a medical-surgical mask which covered the nose and mouth and eye protection. Observation on 03/28/23 at 7:18 A.M., revealed STNA #412 walking around the facility dining area wearing her mask below her nose and mouth and her eye protection on top of her head and not covering her face. Eleven unidentified residents were seated in the dining area during this time. STNA #412 verified staff were required to wear a medical-surgical mask which covered their nose and mouth and eye protection. STNA #412 reported the facility recently implemented eye protection so she must have forgotten to utilize it. STNA #412 was soon after seen pushing Resident #33 in his wheelchair while wearing her face shield on top of her head and with her medical-surgical mask below her nose and mouth. STNA #412 continued to walk throughout the dining area wearing her medical-surgical mask below her nose and mouth. Observation on 03/28/23 at 7:48 A.M., revealed STNA #408, STNA #410, and STNA #412 were standing together in the dining area. STNA #408's medical-surgical mask was below and not covering her nose. STNA #410's medical-surgical mask was below her chin and not covering her nose or mouth. STNA #410 then pushed an unidentified resident from the dining area to a sitting area while her mask remained below her nose and mouth. Interviews on 03/28/23 from 7:52 A.M. to 8:09 A.M., with STNA #408 and STNA #410 verified staff were required to wear a medical-surgical mask which covered their nose and mouth. Review of the policy titled COVID-19 Policy and Procedure, revised 03/01/23, revealed when the county was in high transmission staff would use appropriate universal source control when in an area of potential resident contact including a face mask and if in outbreak status than eye protection was to be worn along with face mask. Review of CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, revised 09/27/22, revealed Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing.

Based on observation, staff interview, review of facility resident list, and review of the policy, the facility failed to ensure medications were stored securely. This had the potential to affect seven (#4, #11, #16, #17, #23, #24, #26) of seven residents whom the facility identified as cognitively impaired and independently mobile. The facility census was 38. Findings include: Observation on 03/28/23 from 2:35 P.M. to 2:58 P.M., revealed an unlocked medication cart was located in an unsecured, open room next to the facility dining room. There were no staff observed in the area where the medication cart was located throughout this timeframe. Observation and interview on 03/28/23 at 3:02 P.M., with Licensed Practical Nurse (LPN) #454 and LPN #632 verified the unlocked medication cart containing medications for administration. LPN #454 reported she was the nurse assigned to the hallway and must have left the cart unlocked after administering an as needed medication. Review of a facility resident list revealed seven (#4, #11, #16, #17, #23, #24, #26) residents whom the facility identified as cognitively impaired and independently mobile. Review of the policy titled Medication Storage, dated 07/23/19, revealed medications and biologicals were stored safely, securely, and properly and the medication supply is only accessible to licensed nursing personnel, pharmacy personnel, or staff members authorized to administer medications.

Based on medical record review, review of hospital documentation, observation, staff interview, review of facility policy, and review of the National Pressure Injury Advisory Panel (NPIAP) guidance, the facility failed to complete accurate skin assessments, provide ongoing monitoring of pressure ulcers, failed to obtain treatment orders for pressure ulcers, and failed to provide a treatment to pressure ulcers for one resident (#39). This resulted in actual harm when Resident #39's left heel unstageable pressure ulcer had an increase in the amount of necrotic tissue present from 25% to 100% within eleven days. This affected one (#39) of one resident reviewed for pressure sores. The facility identified three residents with pressure sores. The facility census was 44. Findings include: Review of Resident #39's medical record revealed an admitted [DATE] and a readmitted [DATE]. Diagnoses included difficulty in walking, dysphagia, asthma, multiple sclerosis, cognitive communication deficit, muscle wasting and atrophy, seizures and herpes viral meningitis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively intact. Resident #39 required extensive assistance with transfers, dressing, and toilet use, and required limited assistance with personal hygiene. Resident #39 had no pressure ulcers. Review of the care plan revised 09/28/22 revealed Resident #39 had the potential to develop pressure ulcers due to impaired mobility. Interventions included float heels, Pro-Stat (supplement), and report redness, open areas, skin tears and rashes. Review of the wound care note dated 11/01/22 revealed Resident #39 had a left heel, friction wound measuring 1.5 centimeters (cm) by (x) 5.0 cm x 0.1 cm, with scant serous exudate (indicating there was moisture). Treatment orders included: cleanse with wound cleanser and apply foam two times weekly with shower days and as needed. No additional wounds were documented in the wound care note. Further review of the medical record revealed no additional wound assessments completed. Review of the physician order dated 11/03/22 revealed an order to cleanse the left heel with soap and water, pat dry, and apply foam dressing. Change every shower day, Monday, and Thursday, and as needed. Further review of current physician orders for Resident #39 revealed no additional wound care treatment orders. Further review of the medical record revealed Resident #39 went to the hospital on 11/08/22 for treatment of a urinary tract infection. Review of the hospital documentation, encounter date 11/08/22, revealed the resident was seen for a wound consultation for pressure injuries to the resident's bilateral heels. Resident #39 had erythema (reddening to the skin) to the right great toe tip, blistering to the right lateral foot measuring 12.0 cm x 2.0 cm, a dry scab to the right second toe tip (near the nail) measuring 0.2 cm x 0.2 cm, and erythema to the left medial ankle measuring 3.0 cm x 1.5 cm. All areas were noted to be blanchable, with no drainage, no tunneling, and no odor. Debridement of the right heel blister was completed, and the wound was described as a stage III pressure ulcer measuring 3.0 cm x 2.0 cm x 0.1 cm. Debridement of the left heel blister was completed, and the wound was described as an unstageable pressure ulcer measuring 3.5 cm x 4.0 cm x 0.1 cm with wound bed slough, necrotic (death of tissue), and granulation tissue. Further review revealed orders to cleanse bilateral heels with mild soap and water, apply Vaseline then Adaptic (dressing), cover with foam and change daily, bilateral waffle boots, and elevate bilateral lower extremities and float heels. Review of the re-admission screen, dated 11/10/22, revealed Resident #39 readmitted to the facility from the hospital. The assessment identified Resident #39 had right heel, left heel, and right toe blisters. There were no measurements or assessments completed of the resident's pressure ulcers upon re-admission. The hospital discharge orders contained no orders for treatments to the areas. Review of the wound care note by the Certified Nurse Practitioner (CNP), dated 11/15/22, revealed Resident #39 had four wounds. Wound #1 was located on the left posterior heel and was identified as a resolved area. Wound #2 was located on the left medial heel, identified as an unstageable pressure ulcer measuring 3.5 cm x 5.0 cm x 0.1 cm, and further described as having 25% eschar (dry, dark scab), 25% necrotic tissue, and a small amount of serous exudate (clean, thin, watery substance). The note revealed the CNP documented wound care orders for the left medial heel included: clean with wound cleanser, apply silver alginate and foam, change every other day, and as needed. Wound #3 was identified as a stage III pressure ulcer to the right medial heel measuring 4.9 cm x 2.0 x 0.1 cm and described as having 10% slough with a small amount of serosanguinous exudate (wound drainage). Wound care orders for the right medial heel included: clean with wound cleanser, apply silver alginate and foam cover dressing, change every other day, and as needed and offload. Wound #4 was identified as a stage II pressure ulcer to the left medial ankle measuring 1.0 cm x 1.0 cm x 0.1 cm and described as having 100% dermis with a scant amount of serosanguineous exudate. Wound care orders for the left medial ankle included: clean with wound cleanser, apply foam, change every other day, and as needed. The note revealed adjacent tissue of wounds #2, #3, and #4 were at risk for further breakdown. Review of physician orders revealed the orders listed in the CNP's wound care note from 11/15/22 were not listed. Review of Resident #39's Treatment Administration Record (TAR) for November 2022 and the medical record revealed no evidence of any treatments being applied to Resident #39's pressure ulcers since readmission from the hospital. The care plan was updated on 11/20/22 due to Resident #39 having actual impairment to skin integrity, including an unstageable left medial heel pressure ulcer, a stage III right medial heel pressure ulcer, and a stage II left medial ankle pressure ulcer. Interventions included pressure reducing devices as ordered, staff to encourage and assist with frequent turning and repositioning, treatment as ordered and wear slippers instead of Crocs. Review of physician orders dated 11/21/22 revealed to cleanse left medial ankle with wound cleanser and cover with foam dressing every other day; cleanse left medial heel with wound cleanser, apply silver alginate to wound bed and cover with foam dressing every other day; and cleanse right medial heel with wound cleanser, apply silver alginate to wound bed and cover with foam dressing every other day. Interview on 11/20/22 at 4:19 P.M. with Licensed Practical Nurse (LPN) #101 verified there were no wound care orders in place for Resident #39's unstageable pressure ulcer to the left medial heel, stage III pressure ulcer to the right medial heel, or stage II pressure ulcer to the left medial ankle. Interview on 11/21/22 at 7:33 A.M. with the Director of Nursing (DON) verified the wound treatment orders from the wound care visit on 11/15/22 were not included in Resident #39's orders. The DON stated she caught the discrepancy this morning and she had nursing apply dressings per physician orders. The DON claimed nursing staff were following the treatment orders in the wound care note, despite the orders no orders being written. The DON did not have an explanation on how nursing staff would know how to complete the treatments if they were not included in the resident's orders or on the TAR. Interview on 11/21/22 at 9:33 A.M. with LPN #104 (an agency staff member) verified if treatments were not included in the resident's physician's orders she would not know if a treatment was even ordered or how to complete the treatment. Interview on 11/21/22 at 1:06 P.M. with Clinical Regional Nurse (CRN) #306 revealed Resident #39 had a left heel blister, which had resolved, prior to her hospitalization on [DATE]. When Resident #39 returned from the hospital on 11/10/22, the resident had pressure ulcers on her left heel, right heel, and left medial ankle. Nursing completed the readmission screen on 11/10/22 and noted each of the pressure ulcers as blisters. CRN #306 stated the nurses were not comfortable measuring and staging wounds and noted them as blisters on the readmission screen. CRN #306 verified the wound treatment orders from the 11/15/22 wound care visit were not implemented until 11/20/22. Follow up interview on 11/21/22 at 3:27 P.M. with CRN #306 verified the treatments in the wound care notes from Resident #39's hospital admission were not ordered upon the resident's return to the facility. Resident #39 did not have any treatment orders implemented from 11/10/22 until 11/20/22 for the unstageable pressure ulcer to the left medial heel, stage III pressure ulcer to the right medial heel and the stage II pressure ulcer to the left medial ankle. Observation on 11/21/22 at 4:50 P.M. of Resident #39's wound care completed by LPN #104 revealed LPN #104 refused to complete wound measurements. The surveyor requested further assistance from CRN #306 and the observation was completed with CRN #306. Observation of Wound #2, located on the left medial heel, revealed measurements of 2.8 cm x 3.4 cm x 0.1 cm of necrotic tissue. Adjoining the area of necrotic tissue to the left of the wound, was an area measuring 2.2 cm x 2.9 cm x 0/unable to be determined, which was described as a healing deep tissue injury. The area was 100% necrotic tissue, indicating an increase of 75% necrotic tissue from the 11/09/22 hospital wound care note and the 11/15/22 wound care note. Due to the necrotic tissue, the depth of the wound was unable to be determined. Observation of Wound #3, located on the right medial heel, revealed measurements of 1.5 cm x 1.5 cm x 0 and was noted to be healing. Wound #4 was observed to measure 0.9 cm x 0.7 cm. Each of the wound treatments were completed per physician order. Review of the facility policy titled, Skin Care Assessment, revised 11/02/18 revealed all areas identified should be measured and recorded in the electronic medical record (EMR) and initiate the Skin Care Management Policy for any open areas or areas of concern due to pressure points. Review of policy titled Skin Care Management Procedure, dated 11/02/18, revealed upon admission a full skin assessment should be conducted within two to six hours of arrival and documented in the EMR. Additionally, monitoring included with each dressing change or at least weekly at a minimum, documentation should include the date observed, location and staging, size, exudates, pain, wound bed color and type of tissue/character including evidence of healing or necrosis and percentage of tissue and a description of wound edges and surrounding tissue. Dressing and treatments were determined based upon individual practitioner's clinical judgements. Review of the facility policy titled, Skin Care Assessment, revised 11/02/18 revealed all areas identified should be measured and recorded in the electronic medical record (EMR) and initiate the Skin Care Management Policy for any open areas or areas of concern due to pressure points. Review of the National Pressure Injury Advisory Panel (NPIAP) Guidance via https://npiap.com/page/PreventionPoints revealed skin should be assessed upon admission as soon as possible (but within 8 hours). Review of the NPIAP Guidance titled, NPIAP Pressure Injury Stages, revealed if necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4).

Based on medical record review, staff interview, review of facility Self-Reported Incident (SRI) investigations, and review of the mechanical lift policy, the facility failed to ensure a removable bed bolster was secured before leaving the room of one (Closed Record-CR #1) of two residents with removable bed bolsters of the total sample of six residents reviewed. This resulted in actual harm when CR #1 fell out of bed sustaining a laceration to the back of the head requiring six staples to close the injury. Additionally, the facility failed to ensure resident safety during a mechanical lift transfer for one (CR #1) of four residents reviewed for mechanical lift transfers of six sampled residents. This resulted in actual harm when CR #1 slid off the mechanical lift pad and landed on the metal base legs of the lift sustaining four fractured ribs and a punctured lung. Findings include: Review of CR #1's medical record revealed the resident was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the most recent minimum data set (MDS) assessment, dated [DATE], identified the resident with disorganized speech and periods of restlessness. She was able to recall staff names/faces and that she was in a nursing home. The resident was sometimes understood, had unclear speech, and responded adequately to simple, direct communication. She had repetitive verbalizations, sad facial expressions, repetitive physical movement and her mood was not easily altered. The resident was totally dependent on staff for transfers with a two person physical assist and extensive assistance with two person physical assistance for bed mobility. Review of the resident assessment protocol (RAP) summary dated [DATE] revealed CR #1's memory could not be determined at the time due to expressive aphasia. She was unable to answer questions or other cognitive questions. The resident had a history of [REDACTED]. She required assistance for completion of her activities of daily living (ADL's). Review of the plan of care (POC) initiated on [DATE] revealed interventions for bed bolsters while in bed and use of a mechanical lift for transfers. The at risk for falls POC initiated on [DATE] revealed a goal of no injuries should she fall. Interventions included bed bolsters to bed as ordered and a mechanical lift for transfers. A POC for potential of spontaneous fracture due to osteoporosis was initiated on [DATE]. A POC for impaired mobility related to extreme joint stiffness and multiple contractures secondary to CVA and progressive dementia was initiated on [DATE]. Review of the nurse's notes dated [DATE] at 4:00 P.M. revealed the nurse walked into the resident's room and found the resident on the floor between the bed and the wall. State tested Nurse Aide (STNA) #7 was standing next to the resident between the wall and the resident. The nurse noted CR #1 was bleeding, the bed bolster for that side of the bed was on the floor and the side rail was in the down position. The nurse applied pressure to the right side of the resident's head while a second nurse called the emergency squad. The resident was sent out to the local hospital's emergency department (ED). The nurse asked STNA #7 what happened and she stated to the nurse that "I took the bed bolster off and put the side rail down to change her. I was called away just for a second" to another resident's room. When she came back into CR #1's room, she observed the resident starting to fall out of her bed but she could not get to her in time to prevent the fall. She was already on the floor and her head was bleeding. "It's all my fault." At 6:20 P.M., facility staff were informed the resident needed to spend the night at the hospital for observations. On [DATE] at 6:36 A.M., the nurse documented that CR #1's daughter called and informed the nurse that the resident had a computed tomography (CT) scan of her head and "a spot was found on her brain". On [DATE] at 5:45 P.M., the resident returned from the hospital observation stay. She had six staples in her right posterior head. She was seen by the neurologist for a consultation regarding the results of the CT scan. Review of the facility's investigation dated [DATE] revealed a written statement from STNA #7. In the written statement, she documented that it was "all my fault". She was getting the resident dressed. She loosened the bed bolster on the left side of CR #1's bed so that she could turn her better. She turned the resident on her right side and then got a call from another STNA who needed assistance for "a minute" in another resident's room. She went to assist the STNA in another resident's room without first securing the loosened bed bolster. When she returned to CR #1's room, the resident had started to fall off the left side of the bed. She could not get to the resident before she fell on the floor. She documented that she "knew better" and that she "never dreamed she (CR #1) would ever move/fall". Review of licensed practical nurse (LPN) #8's written statement dated [DATE] at 6:45 P.M. revealed she heard the STNA on the two way radio requesting STNA #7's assistance. STNA #7 was "hysterical" after the resident fell and she could not get any information from her at the time but it was enough to know that STNA #7 walked away from CR #1. STNA #7 did tell her that the side rail was in the down position and the bed bolster was off of the bed. She explained to STNA #7 that she may be suspended until the Director of Nurse's (DON) completed her investigation. She removed the STNA from the schedule and she was sent home. STNA #7 was terminated following the results of the investigation of the fall, the resident was placed in a hi-lo electric bed which was to be kept in the lowest position and the side rail was removed from the bed. Further review of nurse's notes revealed a late entry dated [DATE] at 7:20 A.M. for [DATE] at 8:00 P.M. The notes documented LPN #8 was called to CR #1's room where she found the resident on the floor laying on the right leg of the mechanical lift. The physician, the local emergency department and the resident's daughter were notified. The resident complained of pain as the emergency personnel rolled her onto a floating flat board. The DON was notified of CR #1's fall. The local hospital emergency department called the facility to inform them that the resident was transferred to a larger hospital due to the extremely guarded condition of the resident after the fall. A second late entry note dated [DATE] at 11:58 P.M. for [DATE] at 8:00 P.M. revealed that the nurse stayed with the resident after the fall while waiting for the emergency personnel to arrive. The nurse initiated neurological checks which were normal. The resident was able to move her arms and head without signs/symptoms of pain with movement. CR #1 was comforted by keeping her still and talking to her with a low tone of voice. The resident was able to communicate and voiced signs of pain and had facial grimacing. On [DATE] at 9:10 A.M., the DON stated that after the incident, LPN #7 pulled the two STNA's off the floor. She had them wait in the nurse's station until she arrived at the facility to interview them. LPN #7 informed her that one of the lift pad loops was hanging down when she arrived in the resident's room. During the interviews, she had the two STNA's demonstrate back to her how they transferred CR #1. Following the interviews with the Administrator present the two STNA's were sent home. She stated the resident suffered four fractured ribs and a punctured lung from the fall. The family chose not to treat the punctured lung, and CR #1 was placed on Hospice services and expired four days after the fall. Review of the investigation of the fall revealed a written statement, undated, by STNA #10. She documented she was going to assist STNA #11 to transfer CR #1 via a mechanical (Hoyer) lift. She was on the resident's left side and STNA #11 was on her right side. She connected two of the loop straps on the lift pad to the lift's metal hooks. She pulled hers down to make sure they were secured. STNA #11 informed her she was ready. STNA #11 pulled the lift with the resident in the lift pad out and she pushed the wheelchair out of the way. STNA #10 saw one side of the lift pad start to come down and she ran over to it in an attempt to place herself under the resident but the resident fell before she could get to her. She called for help and grabbed a pillow to place under the resident. The nurse was in the room within seconds. Review of STNA #11's written statement revealed she and STNA #10 went in to get CR #1 ready for bed. They hooked the lift pad sling to the Hoyer hooks. The resident "was totally fine" as she got her up in the air. As she started to back the Hoyer lift up the resident started to slide. She stopped moving the Hoyer lift and attempted to get to the resident but STNA #10 got to her faster. She was "pretty sure she did a double check of the strap" loops. The resident did not hit her head but her back landed on one of the Hoyer lift's metal legs. Review of the facility's Mechanical Lift Policy with no effective date revealed it was the policy of the facility to take precautions to ensure the safety of our residents when using mechanical lifts. Staff are to examine the lift and sling to ensure they are in good working order. Ensure the straps are not frayed or worn. Apply the sling under the resident and center the resident in the sling. Push the lift over the resident close enough to connect the sling to the attachment. Lower the lift accordingly to ease the connection without putting strain on the resident or sling. Secure the connections, pull on each loop or hook to ensure they are secured. Use brakes when raising or lowering the resident. As the resident is being raised in the lift slowly, ensure each strap remains connected. One staff member is controlling the controls while the other is spotting and ensuring the resident's safety. The deficient practice which occurred with CR #1 represents an incident of past non-compliance due to the fact that the facility immediately removed STNA #10 and STNA #11 from duty following the fall, completed an investigation of the incident, immediately inserviced staff on duty and oncoming staff on Hoyer lift safety education and on [DATE] conducted a mandatory inservice to review Hoyer lifts, stand-assist lifts, alarms, transfers, ambulation, wheelchair positioning/propelling and bed bolsters. The Hoyer lift used at the time of the incident was immediately removed from the floor and checked by maintenance but still remained out of use as of [DATE]. STNA #10 and #11 were terminated following the facility's investigation. The Quality Assurance committee met on [DATE] and discussed safety regarding Hoyer lifts, educational opportunities and resident safety retraining regarding bed bolsters and alarms. This deficiency substantiates the Self-Reported Incident Investigation, Control Number OH 669.