Every finding on record at Park Vista Nursing and Rehab

Based on observation, record review, review of hospital records, review of a facility investigation, review of an emergency medical service (EMS) run report, review of the time and date weather historical data, facility policy review, and interview, the facility failed to ensure adequate supervision and monitoring to prevent hospitalization for hypothermia for Resident #66. In addition, the facility failed to ensure fall interventions were in place for Resident #48. This affected two residents (#66 and #48) of three reviewed for accidents. The facility census was 94. Actual Harm occurred on 12/30/25 when the facility failed to provide adequate supervision and implement appropriate and effective interventions to mitigate known risk for Resident #66 who was found unresponsive outdoors, after being outside for an unknown amount of time and was subsequently hospitalized and treated for hypothermia. Resident #66 had known behaviors related to staying outside for long periods of time and a prior hospitalization for hypothermia on 02/07/25 while the resident resided in the facility's attached assisted living. Despite the known behavior, Resident #66 was to receive routine every (Q) two-hour staff monitoring, the facility standard for all residents even when outside, including on 12/30/25 when the temperature was a high of 19 degrees Fahrenheit (F) and a low of 18 degrees F. Findings include:1.Review of the medical record for Resident #66 revealed an admission date of 12/04/25 with diagnoses including respiratory failure, hypertension, chronic obstructive pulmonary disease (COPD), kidney disease, arthritis and tobacco use. Review of the resident history revealed prior to admission to the skilled nursing facility, Resident #66 resided in the facility attached residential care facility. Record review revealed on 02/07/25 the resident had been hospitalized and treated for hypothermia after being outside in inclement weather for an extended period of time. Review of the care plan dated 12/05/25 revealed Resident #66 had a behavior problem of refusing treatment and oxygen and staying outside for long periods of time. Interventions included educating on the risks of using his motorized wheelchair without charging it, offering choices, providing emotional support and reassurance as needed and keeping his schedule routine and predictable. Record review revealed there was no plan of care developed with comprehensive/individualized interventions for the resident's safety risk/supervision when outside or to address safety needs related to the resident's desire to stay outside for long periods of time. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was cognitively intact. The assessment revealed the resident required (staff) supervision for eating and personal hygiene and partial to moderate assistance for oral care, toileting and showering. Review of a psychotherapy progress note dated 12/10/25 revealed Resident #66 was outside smoking a cigarette at the time of the interview. Resident #66 had minimal eye contact and denied all mental health symptoms and concerns. The note included the resident became agitated and argumentative with further attempts to explore potential symptoms of mental health related concerns. Review of a nursing progress note dated 12/30/25 at 2:59 P.M. revealed Resident #66 was assessed by the nurse. The note included neck and abdomen wounds remain resolved. Epithelial tissue present and intact. This nurse to follow- up as needed (PRN). Resident #66 was updated and aware. Nurse Practitioner (NP) #216 aware of wound resolutions. There were no further nursing progress notes until 12/30/25 at 10:34 P.M. when Resident #66 was found unresponsive in the smoke room. Review of a nursing progress note dated 12/30/25 at 10:34 P.M. revealed Resident #66 was found in the smoke room unresponsive. Oxygen was applied, and 911 was called. Upon EMS arrival, Resident #66's pupils were pinpoint and he was administered Narcan (used to reverse an opioid overdose) and was unable to communicate. The resident was taken to the local emergency department (ED). (A hospital drug screen revealed the resident only had Acetaminophen in his system). Review of weather information at https://www.timeanddate.com/weather/usa/youngstown/historic dated 12/30/25 revealed the temperature was a high of 19 degrees F and a low of 18 degrees F from 6:00 P.M. through 12:00 A.M. with light snow, mostly cloudy, humidity 82% Review of an EMS emergency response report dated 12/30/25 at 10:06 P.M. revealed Resident #66 was found slumped over in his wheelchair outside of the facility. The nurses reported he had been outside for an unknown amount of time. Upon assessment, the resident was responsive to painful stimuli and muttered sounds. His breathing was slow and shallow, and he had bradycardic peripheral pulses. His pupils were pinpoint and non-reactive. The resident was administered Narcan and became more responsive with improved breathing but remained confused and muttering words. He was able to follow commands. He was very cold to the touch and EMS records included they were unable to get an accurate temperature reading. He was warmed with blankets and heat packs, and his vitals became stable and within normal limits. Intravenous medications could not be administered because of poor blood flow, and an electronic cardiogram could not be performed because the electrodes would not stick to the resident. Resident #66 became increasingly responsive but remained confused while being transported to the local emergency room. Review of the emergency department report dated 12/30/25 at 10:44 P.M. revealed Resident #66 was brought to the facility for altered mental status. Vital signs upon arrival included blood pressure 149/88 and pulse 44. The hospital record included an entry on 12/31/25 at 2:16 A.M. of the resident's temperature being 83.3 degrees F. An entry on 12/31/25 at 6:43 A.M. included the resident's temperature was 85.1 degrees F. A central line was inserted, and the resident was admitted to the hospital. Review of the health status note dated 12/31/25 at 6:54 A.M. revealed Resident #66 was admitted to critical care on a ventilator with altered mental status, low oxygen levels and hypothermia. As of 01/15/26 the resident remained hospitalized . Review of an undated facility investigation revealed Resident #66 was seen by the wound nurse at approximately 3:00 P.M. on 12/30/25. Resident #65 was reported as seeing Resident #66 and the outdoor smoke room between 4:30 P.M. and 5:00 P.M. Resident #66 was found on 12/30/25 at 10:34 P.M. in the smoke room unable to respond, and 911 was called. The investigation further included staff working at the time of the incident were interviewed and no one reported seeing Resident #66 prior to RN #215 finding him unresponsive, when she had taken a smoke break. Resident #65 reported he had seen Resident #66 before dinner around 4:30 P.M. to 5:00 PM. He revealed he was aware Resident #66 liked to spend a lot of time in the smoke room and at times would fall asleep in the room. He reported no concerns of note when he last saw Resident #66. Camera footage of the front door was reviewed on 12/31/25. On 12/30/25 from 5:00 P.M. until 10:00 P.M. Resident #66 was not seen on the camera footage and the smoke room was not visible from the outside camera view. Review of the facility investigation revealed there were no actual written statements from staff working and/or with knowledge of the incident. In addition, the facility written investigation failed to include what the resident was wearing at the time he was found or what the temperature of the outdoor smoke area was at the time the resident was found unresponsive. Interview on 01/07/26 at 10:47 A.M. with the Administrator revealed Resident #66 had a known history of always wanting to be outside, regardless of the weather. The Administrator revealed the resident would often leave the facility in his power wheelchair which would run out of battery power. He would call the facility to pick him up. Interview on 01/07/26 at 11:42 A.M. with the Director of Nursing (DON) revealed Resident #66 would often sit outside for hours but stated he was checked on routinely. The DON revealed the resident was found on 12/30/25 not at his baseline at which point EMS was called and he was given Narcan, which was standard protocol for the area when a resident was unresponsive. The DON confirmed Resident #66 was lethargic and wouldn't speak. The DON verified it was cold outside at the time, but stated Resident #66 often chose to be outside and did not like the indoor smoking [NAME]. He revealed the resident was usually appropriately dressed for the weather, wearing a hat, gloves and appropriate footwear. Interview on 01/08/26 at 7:34 A.M. with Medical Director (MD) #206 revealed Resident #66 could make his own decisions but often did not make good choices. While at the hospital he was referred to a psychiatrist and was really not interested in services. Often when she came to see the resident, she had to look for him outside or in the lobby because he was almost never in his room. MD #206 stated she believed the resident was outside for approximately three to four hours before he was found on 12/30/25, which she stated was normal for him. Interview on 01/08/26 at 2:04 P.M. with Licensed Practical Nurse (LPN) #214 revealed on 12/30/25 she was told by Registered Nurse (RN) #215 that Resident #66 was outside and not responding. LPN #214 obtained the resident's oxygen and placed it on him, and he responded slightly while she called 911. The LPN revealed the resident was wearing gloves and a hoodie at the time of the incident but could not recall if he was wearing a jacket. Interview on 01/12/26 at 7:14 A.M. with the Administrator revealed being that staff were familiar with Resident #66 and his desire to be outside, they checked on him every one to two hours. She revealed two-hour checks were the standard of care for all residents and the facility had not considered implementing more frequent checks for Resident #66. Record review revealed there was no documentation of any checks for Resident #66 being completed. Observation on 01/13/26 at 7:43 A.M. with the DON revealed the facility had a smoke room attached to the facility which was fully enclosed and heated. The DON could not confirm whether Resident #66 was in the smoke room or outside when EMS arrived. On 01/15/26 at 4:35 P.M. information provided from the Administrator via email verified the resident's care plan did not include a frequency of monitoring/checks for safety/supervision. Review of the facility policy titled Resident Supervision, dated 10/22/25, revealed the facility would provide sufficient supervision to meet the resident's assessed needs while respecting the right to informed choices. Residents who demonstrated decision making capacity could be granted decreased supervision if the demonstrated the ability to make informed decisions, had a Brief Interview for Mental Status (BIMS) score of 12 or greater and were their own responsible party. Residents with decreased supervision would accept and acknowledge reasonable risk associated with independent decision-making including risks related to weather exposure and smoking. The facility would provide education regarding risks while honoring resident rights and levels of supervision would be included in the care plan and revised with any change in condition. 2. Review of the medical record for Resident #48 revealed an original admission date of 09/23/25 from the assisted living unit on campus due to falls. Diagnoses included dementia, cognitive communication deficit, and heart failure. Resident #48 was discharged [DATE] to an acute care hospital with return anticipated after a fall. Resident #48 returned to the facility 11/01/25. Diagnoses for hospitalization left femoral neck fracture after a fall. Review of fall risk assessment revealed that the admission fall risk assessment dated [DATE] revealed Resident #48's fall risk was low. Review of the care plan initiated on 09/24/25 and revised on 10/01/25 revealed Resident #48 was to have the call light within reach (initiated on 09/24/25), physical therapy and occupational therapy to evaluate and treat as ordered (initiated on 09/24/25), keep room free of clutter (initiated on 10/01/25), a visual reminder to call for assistance (initiated on 10/22/25), bilateral floor mats one to each side of his bed (initiated on 11/06/25), and a defined perimeter mattress (initiated on 11/10/25). Review of the admission MDS assessment dated [DATE] and the quarterly MDS assessment dated [DATE] Resident #48 was severely cognitively impaired and dependent upon staff for all activities of daily living (ADL) except for eating. Review of the fall risk assessment dated [DATE] revealed Resident #48's fall risk was high. Review of Resident #48 progress notes and fall investigations revealed Resident #48 fell on [DATE], 11/02/25, and 11/09/25. Neuro checks were completed, immediate interventions were put in place, fall risks, interventions and care plans were reviewed by the interdisciplinary team after each fall. An observation on 01/14/26 at 12:32 P.M. of Resident #48 revealed him lying in bed on his left side, and the call light was within reach. A visual cue was noted on his bulletin board; a defined perimeter mattress was on his bed; there was a floor mat to the left side of the bed, and the other floor mat was propped against a wall behind the empty bed across the room from Resident #48. Interview on 01/14/26 at the time of the observation with Certified Nursing Assistant (CNA) #218 verified the floor mat was not in place as ordered. This deficiency represents noncompliance investigated under Complaint Numbers2709253, 2667441, and 2639314.

Based on observation, record review, interview and facility policy review, the facility failed to serve palatable meals, and ensure meals were served in a manner that prevented possible contamination. This affected eight residents (Residents #22, #25, #28, #57, #63, #72, #73, #80 and #84) of eight reviewed for food quality, palatability and service, and had the potential to affect all 94 residents in the facility with the exception of Residents #19, #87 and #91, who did not receive meals by mouth.Findings include: Review of the medial record for Resident #22 revealed an admission date of 07/18/24. Diagnoses included difficulty walking, muscle weakness and protein calorie malnutrition.Review of the medial record for Resident #25 revealed an admission date of 01/17/25. Diagnoses included diabetes, high cholesterol, history of stroke and depression.Review of the medial record for Resident #28 revealed an admission date of 10/02/24. Diagnoses included heart disease, high cholesterol, diabetes and history of stroke.Review of the medial record for Resident #57 revealed an admission date of 09/27/25. Diagnoses included respiratory failure, kidney disorder, anemia, high cholesterol and alcohol abuse.Review of the medial record for Resident #63 revealed an admission date of 10/02/24. Diagnoses included Parkinson's, sleep apnea, high cholesterol and depression.Review of the medial record for Resident #72 revealed an admission date of 12/16/25. Diagnoses included heart failure, diabetes, sleep apnea, carpal tunnel and psychoactive substance abuse.Review of the medial record for Resident #73 revealed an admission date of 11/06/25. Diagnoses included high cholesterol, high blood pressure, alcohol dependence, muscle weakness and depression.Review of the medial record for Resident #80 revealed an admission date of 12/09/25 and a discharge date of 01/09/26. Diagnoses included repeated falls, diabetes, depression, muscle weakness and cellulitis,Review of the medial record for Resident #84 revealed an admission date of 10/22/25. Diagnoses included diabetes, hypertension, chronic pain, morbid obesity, depression and muscle weakness.Review of the Resident Council minutes for November and December 2025 revealed resident concerns regarding food being served cold.Interview on 01/07/26 at 9:02 A.M. with Residents #28 and #84 revealed meals were never warm when they received them, and Resident #28 revealed she had not had a hot meal in months. Resident #80 additionally reported meals were usually served in Styrofoam take-out containers.Interview on 01/07/26 at 11:38 A.M. with Stepping-Stones Counselor #207 revealed she often had to heat meals up for residents when they brought them to a group session because the food was usually served cold.Interview on 01/07/26 at 1:16 P.M. with Resident #80 revealed the food was often served cold, and he was tired of eating out of Styrofoam containers. He reported today was the first day they had received their meals on regular plates since he was admitted .Interview on 01/08/26 at 11:45 A.M. with Dietary Manager #210 revealed trays were normally passed to all residents within one hour and 15 minutes to one hour and 20 minutes. She admitted there were times the facility had to use Styrofoam containers when the dish machine needed repair. She revealed they had last been used approximately two weeks ago for two to three weeks.Interviews on 01/12/26 from 1:15 P.M. through 1:37 P.M. with Residents #22, #25, #57, #63 and #72 confirmed meals were often served cold, did not taste good and were often served in Styrofoam containers.Observation of tray line on 01/08/26 at 11:45 A.M. revealed lunch consisted of tomato soup, cold ham and cheese sandwiches and sweet potato fries. Temperatures were obtained prior to meal service, and the soup temperature was 206.9 degrees Fahrenheit (F), sweet potato fries 187 degrees F, and the ham and cheese sandwiches 44.3 degrees F. [NAME] #209 was observed using a gloved hand to retrieve hamburger buns and slices of cheese from containers. She did not change her gloves or wash her hands before resuming other tray line tasks. Interview at the time of the observation with [NAME] #209 confirmed she had not changed her gloves or practiced infection control measures when preparing sandwiches. As meal service continued, additional sweet potato fries were retrieved from the oven and appeared black on the ends. Interview with [NAME] #208 at the time of the observation confirmed the sweet potato fries had been burnt. [NAME] #208 ran out of soup bowls prior to the end of tray line for approximately five to six residents and had to wait approximately 10 minutes for the dishwasher to wash bowls in order to resume tray line. [NAME] #208 confirmed they often did not have enough dishes for each meal service and had to wash breakfast dishes in order to have enough for lunch, and there were still times they ran short. She also confirmed she had used the last of the tomato soup and the remaining five to six residents were given chicken noodle soup as a replacement. The last tray left the kitchen at 1:17 P.M. and the last resident was served at 1:22 P.M. A test tray was obtained and temperatures taken. The chicken noodle soup reached temperature of 146 degrees F, the sweet potato fries were 81 degrees F, and the sandwich was 60 degrees F. Dietary Manager #210 confirmed hot food should be at a temperature of 135 degrees F by the time the resident received it and cold temperatures should be between 40- and 55-degrees F. She confirmed the sweet potato fries were cold, soggy and burnt, and the sandwich was not an appropriate temperature for meal service.Interview on 01/14/26 at 8:11 A.M. with the Administrator confirmed the facility was aware of issues residents had regarding meals being cold upon delivery.Review of the facility policy titled Food and Nutrition Services, dated October 2017, revealed each resident would be provided with a nourishing, palatable well balanced diet ensuring meals were provided within 45 minutes of either resident request or scheduled mealtime. Food and nutrition services staff would inspect food trays to ensure the correct meal was provided to each resident, food appeared palatable and attractive and was served at a safe and appetizing temperature.This deficiency represents noncompliance investigated under Master Complaint Number 2709374 and Complaint Number 2639314.

Based on record review, interview and facility policy review, the facility failed to ensure residents were offered showers on a consistent basis. This affected two residents (Residents #48 and #59) of five residents reviewed for activities of daily living (ADL) assistance. The facility identified 75 Residents (#2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, 19, #20, #21 #22, #23, #24, #25, #26, #27, #28, #29, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55 #56, #57, #58, #59, #60, #61, #62, #63, #65, #67, #68, #69, #70, #71, #72, #73, #74 #92, #94, #95, #96 and #97) as needing assistance with showers. The facility census was 94.Findings include:1. Review of the medical record for Resident #48 revealed an admission date of 10/27/25. Diagnoses included left femur fracture, heart disease, history of falling, hypertension, kidney disease and dementia.Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was severely cognitively impaired. He required set up help for eating, supervision for oral hygiene, substantial to maximum assistance for showers and was dependent on staff for toileting.Review of the care plan dated 01/06/26 revealed Resident #48 had an ADL performance deficit due to weakness. Interventions included assisting the resident in showering or bathing with substantial or maximum assistance.Review of the facility certified nurse aid (CNA) tasks in the electronic medical record (EMR) revealed Resident #48 was to receive a shower twice a week, on Mondays and Thursdays.Review of the shower sheets for Resident #48 for November and December 2025 revealed he received a shower on 12/26/25 and a bed bath on 11/07/25, 11/13/25, 11/17/25, 11/27/25, 12/01/25, 12/11/25, 12/18/25 and 12/22/25. He refused a shower on 11/05/25, 12/15/25 and 12/29/25.2. Review of the medical record for Resident #59 revealed an admission date of 09/19/24. Diagnoses included diabetes chronic bronchitis, hyperlipidemia and sleep apnea.Review of the care plan dated 12/16/25 revealed Resident #59 had an ADL performance deficit due to weakness. Interventions included assisting the resident in showering or bathing with substantial or maximum assistance.Review of the quarterly MDS assessment dated [DATE] revealed Resident #59 was cognitively intact. He was independent in eating, required set up help for oral hygiene, substantial to maximum assistance for showers and was dependent on staff for toileting.Review of the facility CNA tasks in the EMR revealed Resident #59 was to receive a shower twice a week, on Thursdays and Saturdays.Review of the shower sheets for Resident #59 for November and December 2025 revealed he received a shower on 11/27/25 and a bed bath on 11/01/25, 11/06/25. 11/08/25, 11/15/25, 12/11/25 and 12/27/25. He refused a shower on 11/20/25, 12/04/25, 12/06/25, 12/13/25, 12/20/25, 12/23/25, and 12/25/25.Interview on 01/07/26 at 9:02 A.M. with Resident #59 revealed he is never offered a shower.Interview on 01/07/25 at 9:40 A.M. with CNA #202 revealed if a resident refused a shower a bed bath would be offered instead.Interview on 01/14/25 at 8:20 A.M. with the Administrator confirmed showers, bed baths and refusals were not consistently provided to or documented for Residents #48 and #59.Review of the facility policy titled Bathing, dated January 2020, revealed the facility would promote cleanliness and comfort to the resident by honoring bathing preferences and giving showers twice per week. If a resident refused, documentation would occur and the nurse would be notified.This deficiency represents noncompliance investigated under Complaint Numbers 2667441 and 2639314.

Based on record review, observation and interview, the facility failed to implement timely treatment for skin breakdown for Resident #59 and failed to ensure treatments were completed as ordered for Resident #90. This affected two residents (#59 and #90) of three residents reviewed for skin care. The facility census was 97.Findings include:1. A record review for Resident #59 revealed an admission date of review of the medical record for Resident #59 revealed an original admission date of 09/23/25 diagnoses included diabetes with neuropathy, hypertension, and chronic obstructive pulmonary disease.A review of Resident #59 Minimum Data Set (MDS) assessment dated [DATE] and a quarterly assessment dated [DATE] revealed that Resident #59 was alert, and oriented without memory impairment. Resident #59 required maximum assistance to total dependence on staff for performance of activities of daily living (ADL). Resident #59 required a total mechanical lift for transfer and a manual wheelchair.A review of the physician's orders for Resident #59 revealed an order dated 11/30/25 to cleanse his right flank with normal saline, apply Adaptec and a dry dressing daily and as needed. A review of the progress notes for Resident #59 revealed a note dated 01/02/26 authored by Registered Nurse (RN) #205 that stated Resident #59 had a new area of impaired skin integrity to his left flank and that the wound care nurse had been notified of the new area. There was no evidence that the physician or responsible party were notified, and no documented evidence that a treatment was implemented. An interview on 01/08/25 at 10:30 A.M. with Resident #59 revealed that he had reported discomfort to his left flank and that RN #205 had looked at it on 01/02/26, but that no one had done a dressing to that area.An observation of wound care with Wound Care Nurse #217 and Licensed Practical Nurse (LPN) #203 for Resident #59 on 01/08/25 at 1:55 P.M. revealed a new area on Resident #59 left flank. The area was red and approximately 2.0 centimeters (cm) by 2.0 cm by no depth in between skin folds. The area was assessed by Wound Care Nurse #217 and identified as a non-pressure area of moisture associated skin damage (MASD).An interview on 01/08/25 at 2:05 P.M. with Wound Care Nurse #217 revealed that it was possible that RN #205 had notified her of the new skin impairment. The usual method of communication was either a phone call or via text message. Wound Care Nurse #217 had been off the prior five days and had just returned to work that morning. Wound Care Nurse #217 verified that there was no order for Resident #59 left flank. Further it was revealed that Wound Care Nurse #217 would expect that the nurse on duty would notify the wound care nurse, the Director of Nursing (DON), the provider and the family. The nurse was expected to obtain new orders to treat any new area of skin impairment.An interview with LPN #203 on 01/13/26 at 8:58 A.M. revealed that when a new area of impaired skin integrity was identified the nurse would notify the provider to obtain new orders and that the wound care nurse was notified of all new skin issues for further assessment.2. A review of the medical record for Resident #90 revealed and admission date of 10/10/25. Diagnoses included peripheral vascular disease, and chronic ulcer of the left lower leg and ankle.A review of the facility grievance log revealed a family concern dated 10/18/25 related to wound care for Resident #90's treatments were not being completed as ordered. The concern was investigated by the Director of Nursing and an employee was disciplined. A review of the five-day MDS assessment dated [DATE] revealed that Resident #90 was alert and oriented without cognitive deficit. Resident #90 was independent for eating, required minimal staff assistance for ADL that involved the upper extremities and maximum assistance for the lower extremities.A review of the physician's orders for Resident #90 revealed an order dated 10/01/25 and discontinued 11/09/25 to cleanse the left lower leg (vascular ulcer), apply calcium alginate, and cover with a dry dressing daily; an order dated 12/05/25 and discontinued 12/17/25 to cleanse the left foot with normal saline, apply gentamicin ointment (antibiotic), calcium alginate, cover with an abdominal pad (ABD) and wrap with Kling gauze daily and as needed.A review of the treatment administration records (TAR) for Resident #90 revealed for October and November 2025 the treatment for Resident #90's left lower leg due daily at 7:00 A.M. was not completed on 10/14/25, 10/16/25, 10/17/25, 11/04/25, 11/05/25, and 11/06/25.A further review of the TAR for Resident #90 for December 2025 revealed that the treatment for Resident #90 left foot due at 7:00 A.M. daily was not completed on 12/05/25, 12/10/25, and 12/17/25A review of the progress notes from October through December 2025 for Resident #90 revealed no documented evidence to explain why wound care was not completed for October, November or December dates.An interview on 01/14/25 at 1:00 P.M. with the Director of Nursing verified that the treatments were not documented as not completed. His expectation was that wound care be completed as ordered. If a nurse was unable to complete any ordered procedure, he expected the nurse to communicate with their supervisor and to pass along any uncompleted work to the next shift to ensure that the residents received their care. It was further revealed that he had disciplined LPN #221 and had terminated her for poor work performance which included not doing wound treatments for Resident #90. LPN #221 was terminated on 10/31/25. Staff education was initiated 01/14/25 related to wound care policy and procedure.This deficiency represents noncompliance investigated under Complaint Number 2639314.

Based on observation, interview, record review and review of facility policy, the facility failed to maintain infection control procedures during wound care for Resident #61. This affected one resident (#61) of three residents reviewed for wound care. The facility census was 97.Findings include:Review of Resident #61 ' s medical record revealed an admission date of 06/23/25 with diagnoses including Charcot joint (a progressive destruction of joint related to a loss of sensation from nerve damage), heart failure, diabetes, and muscle weakness. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #61 was cognitively intact, required moderate assistance for activities of daily living, had venous or arterial ulcers, and required the application of nonsurgical dressings. Review of a wound care note for Resident #61, dated 09/11/25, revealed Resident #61 was being seen by the Advanced Practice Nurse Practitioner for treatment to venous ulcers (chronic full-thickness skin wound that is difficult to heal due to chronic venous insufficiency) to the right and left posterior lower extremities. Both ulcers were present upon admission to the facility, and were assessed as improving/healing. The individualized treatment plan included keeping the wounds clean and dry, avoiding contamination and dressing changes as ordered. Review of the physician orders for Resident #61, dated 09/11/25, revealed orders to cleanse both lower extremities with normal saline, apply alginate (a dressing that helps promote wound healing), apply an abdominal pad (an absorbent bandage), wrap with gauze, and then wrap with an elasticized bandage. The dressing changes were to be completed daily and as needed.Observation on 09/17/25 at 11:47 A.M. with Licensed Practical Nurse (LPN) #208 and Registered Nurse (RN) #210 of wound care and dressing changes for Resident #61 revealed the following: the supplies were gathered for the dressing change, a clean barrier was placed on the residents bedside table and supplies placed on the barrier following proper technique. LPN #208 and RN #210 performed hand hygiene then donned appropriate personal protective equipment (PPE) that included gloves. RN #210 picked up and held the right leg of Resident #61 with gloved hands directly touching the residents bare skin. LPN# 208 cleansed the wound, picked up the clean dressing and applied the dressing to the wound using her gloved hands. RN #210 then gently lowered the leg and assisted the resident to put a shoe and sock onto the right foot. LPN #208 then took off the gloves, did not perform hand hygiene, and put on a new pair of gloves. RN #210 then picked up the left leg without a glove change and held the left leg in direct contact with the residents skin while LPN #208 performed the wound cleansing and dressing application to the left leg with her gloved hands. RN #210 then lowered the leg and assisted the resident to put on the remaining sock and shoe. After all trash was disposed of, the barrier removed from the bedside table, and the PPE was removed, both nurses washed their hands. Interview on 09/17/25 at 12:01 P.M. with LPN #208 and RN #210 verified no hand hygiene was performed after the glove change between right and left leg dressing application by LPN #208, and that no glove change or hand hygiene was performed between holding the right and left leg by RN #210.Review of the facility policy titled Wound Care, last reviewed 04/28/25, revealed the purpose of the procedure was to provide guidelines for the care of wounds to promote healing. Steps included establishing a clean field for supplies placed on the resident's overbed table, position resident, put on exam glove, remove dressing and discard, put on gloves, use no-touch technique, apply treatments, dress wound as ordered, discard items in designated container, remove disposible gloves, wash and dry your hands thoroughly and wipe reusable supplies with alcohol as indicated. The policy did not address hand hygiene between change of gloves from soiled to clean gloves. This deficiency represents non-compliance identified under Complaint Number 2618757.

Based on observation, invoice review and interview, the facility failed to ensure the dishwasher was in good working condition. The facility has served all meals since 05/09/25 on paper products with plastic silverware when the dishwasher broke. This affected 90 of 92 residents residing in the facility. Residents #8 and #88 did not receive food from the kitchen. The facility census was 92. Findings include: Observation on 06/25/25 at 4:23 P.M. of residents eating dinner in the dining room and in residents' rooms revealed they were being served on paper plates with plastic silverware. Observation of the dishwasher on 06/26/25 at 1:00 P.M. revealed it was broken and not in working order. Interview on 06/26/25 at 1:15 P.M. with Maintenance Director (MD) #801 confirmed the dishwasher had a power surge that caused it to stop functioning. He reported the delay in getting it fixed was ordering parts and scheduling of the maintenance service. Interview on 06/26/25 at 1:18 P.M. with the Administrator revealed they confirmed the dishwasher had been broken since 05/09/25 after a power surge. The Administrator stated they had a company come out to fix it and they needed to order parts. The Administrator stated the company was to return to the facility on [DATE] to repair the dishwasher. Interview on 06/30/25 at 2:05 P.M. with the Administrator revealed the repair company did come to the facility on [DATE] but were unable to fix the dishwasher due to the additional parts needed. Interview on 06/30/25 at 2:10 P.M. with the Dietary Manager (DM) #810 revealed they confirmed residents have been served on paper plates with plastic silverware for the past six weeks. They reported that the dishwasher had a power surge, and it still was not working. DM #810 confirmed all adaptive devices were still used per order and were washed, rinsed and sanitized using the three-bay sink system in the kitchen after every meal. Review of the invoices for the dishwasher revealed that the machine went down on 05/09/25. Repairs were not made until 06/20/25, and new parts were ordered on 06/23/25. The machine was still not functional. This deficiency was an incidental finding identified during the complaint investigation.

Based on observation, interview, record review, review of the AccuWeather forecast and facility policy review, the facility failed to maintain a comfortable temperature in the facility. This affected six (Residents #3, #15, #18, #55, #64, and #84) and had the potential to affect all residents in the facility. The facility census was 92. Findings include: Review of facilities recent hospital transfers revealed Residents #3 and #18 were sent to the hospital on [DATE] due to heat exhaustion symptoms including lethargy, shortness of breath, dizziness, and weakness. 1. Review of Resident #3's medical record revealed an admission date of 01/31/25. Diagnoses included adult failure to thrive, encephalopathy, atrial fibrillation, chronic obstructive pulmonary disease, major depressive disorder, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had severely impaired cognition and required set up assistance with eating and oral hygiene, supervision or touching assistance with showers, dressing, personal hygiene and bed mobility and required partial to moderate assistance by staff for toileting hygiene. Review of Resident #3's progress notes dated 06/23/25 at 8:45 P.M. revealed the resident had gone outside for an extended period of time with another resident. Further review of Resident #3's progress notes dated 06/23/25 at 11:24 P.M. revealed the resident was sent to a local emergency room due to facility staff indicating how hot the facility was, and the resident had complaints of shortness of breath, feeling dizzy, and unable to catch his breath. Vital signs included blood pressure (BP) 115/88, pulse (P) 84, temperature (T) 98.1 degrees Fahrenheit (F), respirations (R) 20 and oxygen saturation (SpO2) 90 percent (%) on three liters per minute of oxygen. Nursing staff assessed the resident and found lungs were clear to auscultation, the resident was very lethargic with slurred speech. The resident had no complaints of pain. Further review of Resident #3's medical record revealed he returned from the hospital on [DATE] at 3:56 A.M. with no new orders. 2. Review of Resident #18's medical record revealed an admission date of 10/14/24 with diagnoses including Multiple Sclerosis, anxiety, hypertension, and protein calorie malnutrition. Review of Resident #18's quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. He was independent with eating, oral hygiene and personal hygiene. He required partial to moderate assistance with bed mobility, substantial to maximal assistance with showers, and dressing and was dependent on staff for toileting hygiene. Review of Resident #18's progress notes dated 06/23/25 at 3:00 P.M. from the social worker revealed the resident was observed sleeping soundly in the outdoor gazebo in his wheelchair. They gently woke him up to make sure he was feeling okay. The resident stated he was feeling fine. They offered him and other residents in the gazebo water. Resident #18 declined water. Review of Resident #18's progress notes dated 06/23/25 at 8:10 P.M. revealed the resident asked a Certified Nursing Assistant (CNA) to assist him in from outside stating he was dizzy and lethargic. The resident had been outside most of the day. The resident was noted to be lethargic and slow to respond and was complaining of dizziness. The nurse notified the on-call Nurse Practitioner (NP) regarding the resident and received order to send the resident to the hospital. Review of Resident #18's progress note dated 06/24/25 at 9:05 A.M. revealed the resident returned from the hospital after being assessed for fatigue and dehydration. The resident was given intravenous (IV) fluids while at the hospital and returned with no new orders. Interview on 06/25/25 at 3:45 P.M. with the Administrator revealed the air conditioning system had been broken for approximately a year and they were attempting to get it fixed. They stated there was a generator to be delivered on 06/26/25 as well as two 12-ton air conditioning units. The Administrator confirmed Residents #3 and #18 were sent to the hospital on [DATE] due to heat exhaustion symptoms including lethargy, shortness of breath, dizziness, and weakness. Observations made on 06/25/25 at various times of resident room and hallway temperatures with the Maintenance Director (MD) #801 who verified all temperatures taken revealed at: • 4:51 P.M. room [ROOM NUMBER] was 84.2 degrees Fahrenheit (F) • 4:55 P.M. room [ROOM NUMBER] was 81.5 degrees F • 5:01 P.M. room [ROOM NUMBER] was 83 degrees F • 5:03 P.M. room [ROOM NUMBER] was 86 degrees F • 5:05 P.M. room [ROOM NUMBER] was 84.6 degrees F • 5:07 P.M. room [ROOM NUMBER] was 82.4 degrees F • 5:13 P.M. room [ROOM NUMBER] was 84.4 degrees F • 5:16 P.M. room [ROOM NUMBER] was 81.2 degrees F • 5:18 P.M. Nursing 200 Hall was 81.6 degrees F • 5:23 P.M. room [ROOM NUMBER] was 85 degrees F • 5:25 P.M. room [ROOM NUMBER] was 85 degrees F • 5:29 P.M. room [ROOM NUMBER] was 82.2 degrees F • 5:35 P.M. room [ROOM NUMBER] was 85.5 degrees F • 5:38 P.M. room [ROOM NUMBER] was 83.2 degrees F Interview on 06/25/25 at 4:51 P.M. with Resident #15 revealed she was too hot and wanted to leave her room to get to some place cooler. She was sweating, and her hair was sticking to her face due to how hot she was, and she stated she was dizzy and weak. Interview on 06/25/25 at 4:52 P.M. with Licensed Practical Nurse (LPN) #802 revealed the facility was hot and humid. She stated the air conditioning was not working. LPN #802 stated it was so hot in the facility she was wearing a fan attached to her uniform to cool down. Interview on 06/25/25 at 5:01 P.M. with Resident #55's husband stated her room was entirely too hot, and the facility needed to do something to fix it. Interview on 06/25/25 at 5:03 P.M. with Resident #64 revealed she was very hot and uncomfortable. Her room was 86 degrees F. She stated she needed the two fans in their room due to how hot the facility was, and she was very unhappy about it. Interview on 06/25/25 at 5:09 P.M. with CNA #808 revealed the facility was hot and uncomfortable not just for staff but for the residents too. CNA #808 stated they were offering residents water and trying to keep them as cool as possible until the air conditioning was fixed. Interview on 06/25/25 at 5:13 P.M. with Resident #80 revealed his room was too hot and he was uncomfortable. Resident #80's room was 84.4 degrees F. Interview on 06/25/25 at 5:45 P.M. with MD #801 confirmed the facility ordered a total of 15 portable air conditioning units. He was waiting for them to arrive. He confirmed the one heating and air company comes and fixes certain units for the main system, and a third company fixes the issues they are having now. He was unable to provide the names and/or invoices of the second company. MD#801 confirmed no one was onsite to fix the air conditioning problems at the moment, but he was waiting for someone to arrive. MD #801 confirmed the residents' rooms were not at the appropriate temperatures. Review of AccuWeather.com revealed the outdoor temperatures included: • 06/21/25 was a high of 87 degrees F. • 06/22/25 was a high of 92 degrees F. • 06/23/25 was a high of 93 degrees F. • 06/24/25 was a high of 94 degrees F. • 06/25/25 was a high of 90 degrees F. Review of the facility Emergency Preparedness Policy, dated 10/10/17, revealed in the event that there is a loss of function in the cooling system or there is an area in the facility that the system has failed during hot weather, the following procedures should be implemented when the facility temperature reaches 81 degrees F and remains for greater than four hours, set up fans and portable air conditioners, draw all shades, remove residents from direct sunlight, provide ample fluids, and contact the medical director. Central air coolers are maintained at a comfortable temperature range generally between 72-78 degrees F. This deficiency represents non-compliance investigated under Master Complaint Number OH00166949.

Based on observation, interview, record review and review of facility policy, the facility failed to provide a safe, functional, sanitary and comfortable environment for all residents. This had the potential to affect all 89 residents residing in the facility. Findings include: Record review of the resident concern log dated May 2025 revealed on 05/02/25 Resident #4 had a concern about floors being sticky. On 05/15/25 there was a concern noted regarding room cleanliness by Resident #15. On 05/22/25 a concern was noted for cleanliness of the room by two residents (#90 and #91). On 05/26/25 another concern for room cleanliness was logged by Resident #90. Record review of the Resident Council meeting minutes dated 04/17/25 revealed a concern for housekeeping on the weekends. Record review of the Resident Council meeting minutes dated 05/27/25 revealed residents requesting rooms be cleaned more thoroughly. Observations were conducted on 06/04/25 between 10:45 A.M. and 12:40 P.M. with admission Director (AD) #267 of the general facility environment, resident rooms and resident common areas throughout the facility. AD #267 verified the following concerns at the time of the observations: • room [ROOM NUMBER] was noted to have a toilet with a broken handle, there was a large stain on the carpet and the curtains did not function properly due to being incorrectly hung. • Resident #79's room had curtains on the window that were not hung correctly so the curtain did not properly function. • Resident #82's room had a heavily stained carpet. • room [ROOM NUMBER], which was unoccupied at the time of the observation, had a urinal sitting on a table with approximately 300 cubic centimeters (cc) of urine in it. AD #267 stated at the time of the observation that the resident who occupied the room had been out to the hospital since 05/30/25 and verified urine was left in the urinal. • A large stain was noted in the third floor hallway in front of room [ROOM NUMBER] and the carpet inside of room [ROOM NUMBER] was heavily stained. • Resident #86's room was noted to have a stained carpet. • room [ROOM NUMBER] was noted to have a carpet that was stained and bubbled so it did not properly adhere to the floor • The hall carpet in front of room [ROOM NUMBER] was noted with a large stain and the burgundy strip that was going across the hallway was noted to be frayed causing the walking surface of the carpet to be uneven. • Resident #69's room revealed curtains that were not hung correctly so were not operable, and the paint on the top wall to the left of the window was noted with a patched area not yet repaired. • room [ROOM NUMBER] had a large stain on the carpet. • In the hallway outside of room [ROOM NUMBER], the carpet was stained. • room [ROOM NUMBER] was noted with a large stain on the carpet. Visible insulation was noted between the screen and the window. The screen was hung on the inside of the room as opposed to the outside of the window so the insulation could have been touched. • A large red stain was noted on the hall carpet in between rooms [ROOM NUMBERS]. • The room of Resident #31 and #48 had stained carpet. • Resident #55's bed had stained and dirty sheets on it and the window curtain was not properly hung so it was not operable. • The first floor carpet in both hallways was worn and stained throughout. • Resident #33's room had a brown stain resembling fecal matter smeared on the wall between the bathroom and the resident bed. The privacy curtain was noted to have brown smears on it. There was spaghetti on the floor at the foot of the bed. Certified Nurse Aide (CNA) #234 was present at the time of the observation and stated the resident had just finished lunch and had a behavior for throwing food. • room [ROOM NUMBER] had frayed carpet that caused an uneven walking surface in the room. • A large carpet stain was noted between room [ROOM NUMBER] and 164 in the hall. • There was a large water stain on the ceiling tile between rooms [ROOM NUMBERS]. An interview with Maintenance Supervisor #299 at the time of the observation verified the stained ceiling tile. On 06/04/25 at 12:50 P.M. an interview with the Administrator revealed the carpet cleaning machines had been broken since February 2025. The Administrator also stated the Housekeeping Supervisor position had been vacant since the beginning of May. The Administrator stated housekeeping had been a challenge all month. On 06/05/25 at 12:45 P.M. an interview with Housekeeper (HK) #304 revealed resident rooms should be cleaned daily. HK #304 stated any repairs that need done that are non-emergent in nature are reported via the TELS system to maintenance for repair. HK #304 stated it was housekeeping's responsibility to hang curtains and check curtains for proper hanging and operability. A review of the document titled Daily Cleaning Log, undated, revealed all surfaces, medical equipment, curtains, shower, sink, toilet, trash, and floors are to be addressed daily. A review of the policy titled Quality of Life-Homelike Environment, dated May 2017, revealed residents were provided with a safe, clean, comfortable and homelike environment. This deficiency represents non-compliance investigated under Complaint Number OH00166022 and Complaint Number OH00165979.

Based on observation, interview and facility policy review, the facility failed to store food in a manner to prevent contamination. The facility also failed to have test strips at the three-sink manual dishwash area to test for proper sanitation levels and failed to maintain clean floors in the kitchen. In addition, the facility failed to ensure refrigerator maintenance on Nursing Unit One. This had the potential to affect 99 residents receiving food from the kitchen. The facility identified two residents (#19 and #66) who received nothing by mouth. The facility census was 101. Findings include: Observation on [DATE] at 8:10 A.M. during the initial tour of the kitchen revealed the drawer with clean utensils at the puree food prep station was dirty. There was visible dirt and a dried green food substance in the drawer. Dietary Director (DD) #867 verified the findings at the time of the observation. There were no test strips to test for proper sanitation levels at the three-sink manual dishwash station. An interview with DD #867 at the time of the observation verified the lack of test strips. When asked how staff were testing the sanitation levels at the three-sink manual dishwash station, DD #867 stated she did not know. There was a heavy amount of water located on the floor between the automatic dishwasher and the three sink manual dishwash station. DD #867 verified the heavy water on the floor at the time of the observation. DD #867 stated the dishwasher was leaking. The initial tour also revealed dried foods stored improperly. There was one half of a five pound bag of ziti pasta opened and undated, a five pound bag of five minute grits one quarter full opened and undated, a 15-ounce container of brown gravy mix one quarter full opened and undated, a 1.9-pound package of instant mashed potatoes one quarter full opened and undated, a five pound package of macaroni half full opened and undated, and chicken flavoring 16-ounces one quarter full opened and undated. DD #867 verified the opened and undated aforementioned food items at the time of the observation. DD #867 stated food items should be sealed and dated after opening. Observation on [DATE] at 9:15 A.M., of the refrigerator on Nursing Unit One revealed a small carton of two percent milk with an expiration date of [DATE]. The temperature sheet on the front of the refrigerator read [DATE]. A large amount of water was on the bottom of the refrigerator with visible floating dirt. Certified Nurse Assistant (CNA) #841 verified the findings at the time of the observation. CNA #841 stated the refrigerator was to be cleaned by housekeeping. On [DATE] at 9:40 A.M. an interview with Licensed Practical Nurse (LPN)/Unit Manager (UM) #859 revealed night shift was to check the refrigerator for cleanliness and expired food items. A review of the policy titled Kitchen Sanitization Policy, dated [DATE], revealed the food service area shall be maintained in a clean and sanitary manner. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seams, cracks and chipped areas that may affect their use or proper cleaning. A review of the policy titled Food Storage, dated 2023, revealed food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Subpoint eight stated Plastic containers with tight fitting covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables and broken lots of bulk foods or opened packages. All containers or storage bags must be legible and accurately labeled and dated. A review of the policy titled Cleaning Dishes-Manual Dishwashing, dated 2023, revealed dishes and cookware will be cleaned and sanitized after each meal. Subpoint five revealed to check the sanitation sink frequently using a test strip to assure the level of sanitizing solution is appropriate. A review of the policy titled Refrigerator and Freezers, dated [DATE], revealed the facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. The policy also revealed monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. Subpoint ten stated refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a regularly scheduled basis and more often as necessary.

Based on observation, interview, laundry work order review and facility policy review, the facility failed to maintain the walk-in refrigerator, walk-in freezer and automatic dishwasher in a safe operating condition. This had the potential to affect 99 residents receiving dietary services. There were two residents (#19 and #66) identified by the facility as receiving nothing by mouth. In addition, the facility failed to ensure the laundry room, washers and dryers were maintained in clean working order. This had the potential to affect all residents residing in the facility. The facility census was 101. Findings include: 1. Observation on 02/11/25 at 8:10 A.M. during an initial tour of the kitchen the first metal panel of the floor of the walk-in refrigerator to be coming up. There was a noticeable gap between the concrete underflooring and the metal panel. The walk-in freezer had heavy ice buildup in the right upper corner of the unit. Dietary Director (DD) #867 verified the findings of the floor coming up in the refrigerator and the heavy ice buildup in the freezer at the time of the observation. The initial tour also revealed a large amount of water on the floor between the automatic dishwasher and the three-sink manual dishwashing area. DD #867 verified the large amount of water on the floor between the automatic dishwasher and the three-sink manual dishwashing area at the time of the observation. DD #867stated the dishwasher was leaking. A review of the facility policy titled Kitchen Sanitization Policy, dated October 2008, revealed the food service area shall be maintained in a clean and sanitary manner. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seams, cracks and chipped areas that may affect their use or proper cleaning. 2. Review of the dryer lint logs and work orders from 11/01/24 through 02/13/25 revealed on 02/12/25 at 12:02 P.M., dryer lint traps were being signed off as being cleaned on every shift. Observation on 02/11/25 at 1:46 P.M. revealed one large laundry room and on the right side were two industrial washers, two racks of clothing and four industrial dryers. The facility had a household dryer in between the four industrial dryers which appeared to have a screwdriver stuck inside the selection knob. Two household washers were observed by the entrance with signage stating not to use the washers. Interview on 02/11/25 at 1:48 P.M. with Laundry Staff #809 confirmed that dryer #1 and dryer #3 were not in working order. Laundry Staff #809 confirmed that two manual washers were not to be used and not in working order with signage stating they were out of order. Observation on 02/11/25 at 1:53 P.M. revealed large lint buildup behind the dryers, on the ceilings, walls, and floors. Interview on 02/11/25 at 1:55 P.M. Laundry Staff #809 confirmed that the lint was built up behind the dryers and had not been cleaned. Observation on 02/11/25 at 1:56 P.M. revealed a dirty fan covered with dust by the laundry press, not in use at the present time. Interview on 02/11/25 at 1:58 P.M. Laundry Staff #809 confirmed the dirty fan covered in dust, not in use. Observation on 02/11/25 at 2:00 P.M. revealed a metal screwdriver in place of control knob on the manual dryer in between the two commercial dryers. Interview on 02/11/25 at 2:01 P.M. Laundry Staff #986 confirmed that a screwdriver was being used as knob on the manual dryer. Observation on 02/11/25 at 2:02 P.M. a large fan hanging over the laundry table was covered with dust. Interview on 02/11/25 at 2:08 P.M. Laundry Staff #986 confirmed that the large fan hanging over laundry was covered in dust. Interview on 02/12/25 at 9:53 A.M. Regional Environmental Service Manager (RESM) #992 confirmed that the lint buildup behind the dryers could be better. He confirmed that non-working washers and dryers that were awaiting repairs should have been removed but were still present in laundry area. Observation on 02/12/25 at 10:10 A.M. revealed the screwdriver was removed from non-working dryer, and the dryer was noted to be out of service. Interview on 02/12/25 at 9:53 A.M. with RESM #992 revealed nightshift maintenance was to be performed monthly. He confirmed that several washers and dryers were out of service, waiting for repairs and should have been removed. On 02/15/25 at 1:57 P.M. review of the laundry work orders, revealed work order#16540, placed on 08/03/24, for dryer not getting hot, work order #15948, placed on 04/20/24, for need dryer fixed, and work order #14776, placed on 10/24/23, for dryers not getting hot. Review of the Maintenance Service policy, revised December 2009, revealed the maintenance director was responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment were maintained in a safe and operable manner.

Based on observation, interview, record review and review of the facility policy, the facility failed to ensure sufficient staffing to meet the needs of Resident's #34, #46, #98, and #203. This affected four residents (#34, #46, #98, and #203) and had the potential to affect 41 additional residents (#2, #7, #9, #10, #12, #14, #18, #22, #28, #30, #38, #40, #41, #42, #43, #49, #53, #55, #56, #57, #61, #64, #65, #66, #68, #70, #72, #73, #75, #76, #77, #82, #83, #88, #90, #96, #102, #103, #204, #205, and #206), residing on the nursing two and rehab two nursing units. The facility census was 101. Findings include: 1. Review of Resident #46's medical record revealed an admitted [DATE] with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, dysphagia following cerebral infarction, and anxiety disorder. Review of the Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 was cognitively intact. Resident #46 required partial to moderate assistance rolling left and right, the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, and the ability to transfer to and from a bed to a chair or wheelchair. Review of the care plan revised 12/20/24 included Resident #46 had an activities of daily living (ADL) self-care performance deficit related to weakness, chronic obstructive pulmonary disease, and endocarditis. Resident #46 will maintain ADL through the next review date. Interventions included Resident #46 required partial to moderate assistance to move between surfaces, from bed to wheelchair, from wheelchair to toilet and for showers. Review of Resident #46's Transportation Scheduling Request dated 01/08/25 included the transportation company was called on 01/16/25 and transportation was arranged for a pickup time on 02/12/25 at 8:00 A.M. for a physician appointment at 9:00 A.M. Observation on 02/12/25 at 7:45 A.M. revealed Certified Nursing Assistant (CNA) #919 and Licensed Practical Nurse (LPN) #963 were providing Resident #46's incontinence care for a bowel movement, and the incontinence care was completed at 7:48 A.M. Observation on 02/12/25 at 8:24 A.M. revealed Resident #46 was sitting in a wheelchair by the elevator with her coat on. Observation on 02/12/25 at 8:25 A.M. while standing at the medication cart with LPN #963 revealed Resident #73 was heard loudly screaming over and over. No aides were seen in the hall and were not available to check on Resident #73. LPN #963 secured the medications she was preparing for a resident and went to see why Resident #73 was screaming. A hospice aide was in the room changing Resident #73's incontinence brief and needed assistance. LPN #963 stayed in the room and assisted the hospice aide with Resident #73's care. When she was finished, LPN #963 stated Resident #73 had a fractured right hip, and it took two staff to change her incontinence brief. Observation on 02/12/25 at 8:29 A.M. while standing at the medication cart with LPN #963 revealed Resident #28 was heard loudly screaming in his room. No aides were available to check on Resident #28 and again LPN #963 secured the medication cart and went in Resident #28's room to see why he was screaming. When LPN #963 exited Resident #28's room, she stated he needed his mouth wash, and she got it for him. LPN #963 stated she did not know where the aides were. Observation on 02/12/25 at 8:35 A.M. of LPN #963 revealed she was standing at the medication cart preparing a resident's medication, several resident call lights were activated, and no aides were available to answer the call lights. LPN #963 had a stressed look on her face, slapped her hands against her legs in frustration, secured the medication cart and answered the call lights. Observation on 02/12/25 at 8:45 A.M. revealed Resident #46 was sitting in a wheelchair close to the elevator of the nursing unit she resided in. CNA #804 was talking to other staff members by the nurse's station and pushing a metal cart. After she was done talking to the staff members, CNA #804 told LPN #963 she was going to take Resident #46 downstairs to the main entrance so she would be ready for transportation to pick her up for her appointment (the pickup time was 8:00 A.M.). CNA #804 used the elevator and transported Resident #46 to the main entrance of the facility. Observation on 02/12/25 at 8:55 A.M. revealed CNA #804 returned to the nursing unit with Resident #46. CNA #804 stated the transportation driver did not take Resident #46 to her appointment. CNA #804 stated the transportation driver said she called the nursing unit to tell them she was at the facility and ready to take Resident #46 to her appointment, but no one answered the phone. LPN #963 stated she did not hear the phone ring. CNA #804 stated she was assisting residents and did not hear the phone ring. LPN #963 confirmed Resident #46's pickup time was at 8:00 A.M., and Resident #46 should have been at the main entrance at that time and ready to go to her appointment. Interview on 02/12/25 at 8:56 A.M. of CNA #919 revealed she was in Resident #46's room at 7:59 A.M. (observation at 7:48 A.M. revealed the incontinence care was completed) providing incontinence care for a bowel movement. CNA #919 stated she did not hear the phone ring at the nurse's station because she was in another resident room providing care. Interview on 02/12/25 at 8:59 A.M. of LPN #963 revealed the two aides assigned to the nursing unit have a lot of things they are responsible for, and it puts so much on the aides to also have to transport residents to the front entrance of the facility for their appointments. Interview on 02/12/25 at 9:34 A.M. revealed LPN #963 stated she helped Resident #46 with incontinence care for a bowel movement around 7:45 A.M. Review of Resident #46's progress notes dated 02/12/25 at 3:19 P.M. revealed Resident #46 missed an orthopedic appointment today, and the appointment was rescheduled for 02/26/25 at 2:40 P.M. The transport paper was sent, and Resident #46 was aware. Interview on 02/18/25 at 2:12 P.M. of Business Office Manager (BOM) #971 and Business Office Assistant (BOA) #935 revealed they scheduled transportation for the residents, and there were issues with some of the transportation companies. BOA #935 stated the drivers were only required to wait five minutes and if the residents were not ready to go, the transportation drivers leave. BOM #971 stated the drivers would leave even if they knew the resident was on the way to the transportation van. Interview on 02/19/25 at 8:07 A.M. of CNA #919 indicated that depending on the time of day a resident had an appointment, it could be hard for the aides to take residents to the transportation van because the elevators had to be used to take them downstairs to the front entrance to be picked up by the drivers, and that took time. CNA #919 stated if the aides were passing meal trays, or providing care to another resident it is hard to take everyone where they need to go at the time they need to go. CNA #919 stated there were usually only two aides assigned to the nursing unit, and it would be helpful if there was a third aide to help with things taking residents to the front entrance on time, so they did not miss their appointments. Interview on 02/19/25 at 8:35 A.M. of the Administrator revealed the nurses were responsible for telling the aides what time the residents needed to be taken to the main entrance for their pickup when they had an appointment. Review of the facility policy titled Transportation, reviewed 08/2024, included it was the policy of the facility to arrange and ensure transportation was provided for doctors and specialist appointments if the resident did not have family, a friend or responsible party available for transport. The facility staff would schedule transportation to and from the appointment as needed. The facility staff would notify staff involved of the appointment. The resident would be transported to the appointment. 2. Review of Resident #98's medical record revealed an admitted [DATE] with diagnoses including unstable burst fracture of T7-T8 thoracic vertebra, type II diabetes mellitus, morbid obesity, and chronic obstructive pulmonary disease. Review of Resident #98's physician orders dated 01/18/25 revealed oxygen therapy at four liters per minute via nasal cannula, may titrate as needed, every shift. Review of the Admission MDS 3.0 assessment dated [DATE] revealed Resident #98 was cognitively intact. Resident #98 required substantial to maximal assistance with toileting hygiene, bathing, and was dependent on staff for lower body dressing. Resident #98 required partial to moderate assistance for the ability to transfer to and from a bed to a chair or wheelchair and for the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. Resident #98 was on oxygen therapy. Review of Resident #98's Transportation Scheduling Request dated 01/21/25 included transportation was scheduled on 02/03/25 for Resident #98's appointment on 02/12/25 at 9:30 A.M. Resident #98's pickup time for his appointment was at 8:30 A.M. Review of the care plan dated 01/24/25 included Resident #98 had an ADL self-care performance deficit related to activity intolerance, disease process, impaired balance, limited mobility, pain fracture T7-T8 vertebrae, and other diagnoses. Resident #98 would improve the current level of function through the review date. Interventions included Resident #98 required supervision or touching assistance for chair-to-bed-to-chair transfers. Observation on 02/12/25 at 8:04 A.M. of Registered Nurse (RN) #815 revealed she was sitting in the back room of the nurse's station, had a concerned look on her face and stated she worked night shift, and the day shift nurse had not shown up yet. RN #815 stated she was really stressed out about it because she had to take her son to school and now, he was late. RN #815 stated she called the Director of Nursing (DON), and he assured her someone would come, but no one did. RN #815 stated she kept calling and each time she called she was told different nurses were coming to the nursing unit to relieve her. RN #815 indicated she had been waiting an hour for her relief and had not started the day shift nurse's work because she thought someone was coming to relieve her. Interview on 02/12/25 at 8:11 A.M. of the DON revealed he was not aware RN #815 had not been relieved by a day shift nurse, and he would make sure someone came to relieve her so she could go home. Review of RN #815's timecard revealed she clocked out on 02/12/25 at 8:20 A.M. Observation on 02/12/25 at 9:15 A.M. with Assistant Director of Nursing (ADON) #911 revealed Resident #98 was sitting in a wheelchair and was assisted out of the elevator and to his room by CNA #894. Interview on 02/12/25 at 9:15 A.M. of ADON #911 revealed he took over from RN #815 around 8:30 A.M. because she said she had to leave. ADON #911 stated Resident #98 missed an appointment. ADON #911 stated Resident #98's pickup time was 8:30 A.M. for his appointment, and he did not make his appointment because ADON #911 had to find an oxygen tank that would fit on a bariatric wheelchair. ADON #911 stated he did not find an oxygen tank to fit on the wheelchair but sent an oxygen tank on wheels with Resident #98. ADON #911 stated the transportation driver called and said he was at the facility, and ADON #911 indicated he told the receptionist to tell the driver to wait because he was getting him ready, but the driver did not wait. ADON #911 stated Resident #98's pick up time was 8:30 A.M. and he was downstairs by 8:55 A.M. ADON #911 indicated the transportation drivers only wait five minutes and then they leave. Observation on 02/12/25 at 9:15 A.M. revealed RN #997 arrived at the nursing unit and received report regarding the residents and counted narcotics with ADON #911. RN #997 stated she worked for a staffing agency, and she picked the shift up on 02/12/25 at 7:00 A.M. RN #997 stated the shift was just posted this morning, and she lived an hour away from the facility which was why she just arrived. Review of Resident #98's late entry progress notes dated 02/12/25 at 3:33 P.M. revealed Nurse Practitioner (NP) #1005 was updated regarding Resident #98 missing a pulmonology appointment today related to transportation. The appointment was rescheduled for 02/27/25 at 9:15 A.M. Interview on 02/13/25 at 9:43 A.M. of Staffing Coordinator (SC) #855 revealed when nurse's or aides called off for their work shift, she would check with facility staff to see if they wanted to pick a shift up. If no one picked up the shift, she would call the staffing agency. SC #855 stated the cut off for calling off was two hours before the shift started, and LPN #878 called off in plenty of time. SC #855 stated LPN #878 called off the night before around 9:00 P.M., and her shift was picked up by an agency nurse within hours. Review of the facility policy titled Transportation, reviewed 08/2024, included it was the policy of the facility to arrange and ensure transportation was provided for doctors and specialist appointments if the resident did not have family, a friend or responsible party available for transport. The facility staff would schedule transportation to and from the appointment as needed. The facility staff would notify staff involved of the appointment. The resident would be transported to the appointment. 3. Review of Resident #203's medical record revealed an admitted [DATE] with diagnoses including multiple fractures of the ribs, left side, displaced fracture of lateral condyle of right femur, displaced fracture of surgical neck of unspecified humerus, displaced articular fracture of head of left femur, and type II diabetes mellitus without complications. Review of Resident #203's Weekly Wound assessment dated [DATE] included the first observation of Resident #203's left hip revealed it was well approximated with 26 staples, light serosanguinous drainage and no signs and symptoms of infection. Measurements of the left trochanter (hip) were length 17.0 centimeters (cm), width of 0.1 cm, depth was not measured. Review of Resident #203's progress notes dated 02/03/25 through 02/12/25 did not reveal evidence Resident #203's left hip staples had reddened skin around them or her entire left buttock was reddened with white scaly open areas mixed in with the redness, or evidence that Resident #203's physician was notified of these findings. Review of the Admission MDS 3.0 assessment dated [DATE] revealed Resident #203 was cognitively intact. Resident #203 had upper extremity impairment on one side and lower extremity impairment on both sides. Resident #203 was dependent on staff for toileting hygiene and bathing. Review of the care plan revised 02/11/25 included Resident #203 had functional bladder, bowel incontinence related to multiple healing fractures, dependence on staff for toileting needs and care. Resident #203 would remain free from skin breakdown due to incontinence and brief use through the review date. Interventions included to clean peri-area with each incontinence episode; check and change as required for incontinence and wash, rinse, and dry perineum. Resident #203 had the potential for pressure ulcer development related to immobility, existing incisions to the left hip, left medial knee, left lateral knee and right lower extremity. Resident #203 would develop intact skin free of redness, blisters, or discoloration through the review date. Interventions included assessing, recording, monitoring wound healing and measuring length, width, and depth where possible, assessing and documenting status of wound perimeter, wound bed and healing progress, reporting improvements and declines to the physician; if Resident #203 refused treatment confer with the resident, interdisciplinary team and family to determine why and try alternative methods to gain compliance and document alternative methods. Observation on 02/11/25 at 9:28 A.M. of Resident #203 revealed she was lying in bed with the head of bed elevated. Resident #203 stated she wore an incontinence brief and had to clean myself up because no one comes in to do it, or I just pee in the depends which already has pee in it. Resident #203 stated the doctor said she was getting red from laying in pee. Resident #203 indicated she would activate her call light and no one answered it, or if they did answer it the aides would tell her two people were needed to change her and they did not return. Resident #203 stated the aides change me very infrequently. Observation on 02/12/25 at 10:34 A.M. of Resident #203 revealed she was lying in bed; the sheets were half off the bed, and the bare mattress could be seen. Resident #203 stated she had not been changed this morning and just now threw her incontinence brief in the trash can which was next to her bed. Observation of the trash can revealed an incontinence brief was lying on top of the other trash, and it was saturated with urine and had a pungent smell. When asked about her staples, Resident #203 rolled a little to her right side, and the staples on her left hip could be seen. Observation of Resident #203's left hip revealed a long curving line of staples, and the area around the staples was red. Resident #203's entire left buttock had reddening skin and whitish, scaly open areas mixed in with the redness. The sheet under Resident #203 was bunched up and saturated with urine and pinkish colored drainage was noted on the urine-soaked sheet. Resident #203 stated she had an appointment today. Observation on 02/12/25 at 10:35 A.M. revealed Resident #203 activated her call light and at 10:46 A.M. Certified Nursing Assistant (CNA) #872 answered the call light. CNA #872 confirmed Resident #203's staples on the left hip and left buttock had large, reddened areas around them with some whitish scaly open areas. CNA #872 stated Resident #872 told her the area hurt and when she looked, the area was red and inflamed. When asked if she told the nurse about the open, reddened areas, CNA #872 stated the nurse and other aides knew about the reddened areas because they told her about it. CNA #872 confirmed Resident #203's urine saturated incontinence brief was in the trash can. CNA #872 confirmed Resident #203's bed had the sheet half off and the sheet was bunched under Resident #203 and was saturated with urine and a pinkish colored drainage. CNA #872 stated Resident #203 used a bedpan at times, and the urine on the sheets could have been from the bedpan. Resident #203 stated she activated her call light, it was not answered timely, and by the time it was answered she had to pee so bad she asked for a bedpan. Interview on 02/12/25 at 11:01 A.M. of CNA #894 revealed she often worked on the nursing unit that Resident #203 resided on, and there was not enough staff. CNA #894 stated call lights could take a long time to be answered because the aides were in other rooms assisting residents and providing care, and the call light could not be answered until the resident's care was completed. CNA #894 indicated the nursing unit typically had one nurse and one to two aides working on the floor. Interview on 02/12/25 at 11:15 A.M. of RN/Wound Nurse (RN/WN) #861 revealed when Resident #203 was admitted to the facility her staples on the left hip looked good, were approximated and had no drainage or redness. RN/WN #861 stated she looked at Resident #203's left hip staples on 02/11/25, but did not look at the entire left hip area, and the staples had redness around them. RN/WN #861 stated today (02/12/25) the left hip area looked much worse, confirmed the left hip had open areas which were draining, and the skin was very red and inflamed. RN/WN #861 indicated Resident #203 did not ask to use the bedpan and urinated on herself. Review of Resident #203's progress notes dated 02/12/25 at 4:38 P.M. included surgeon noted maceration to left hip and prescribed Nystatin cream and a portion of staples removed. Review of the facility policy titled Incontinence Management Standard of Care, dated 01/2024, included it was the policy of the facility to promote intact skin, maintain dryness and respect the resident's standard and individualized interventions. The procedure was to implement standard interventions to promote healthy skin integrity. Interventions included routine rounding every two hours with turning and repositioning, timely response to the needs of the resident, provision of personal hygiene and skin care after each incontinent episode, barrier cream applied after each incontinent episode. 4. Review of Resident #34's medical record revealed an admitted [DATE] with diagnoses including acute respiratory failure with hypoxia, congestive heart failure, irritable bowel syndrome and chronic pain syndrome. Review of the Admission MDS 3.0 assessment dated [DATE] revealed Resident #34 was cognitively intact. Resident #34 had upper and lower extremity impairment on both sides. Resident #34 was dependent on staff for toileting hygiene, bathing, and personal hygiene. Resident #34 was dependent for the ability to roll from lying on back to left and right side and return to lying on back on the bed. Lying to sitting on the side of the bed, sit to lying, sit to stand and chair, bed to chair transfer was not attempted due to medical condition or safety concerns. Resident #34 was frequently incontinent of urine and bowel. Review of the care plan dated 01/24/25 included Resident #34 had an ADL self-care performance deficit related to her disease process, limited mobility, limited range of motion and pain. Resident #34 would improve the current level of function through the review date (it did not specify the ADL). Interventions included Resident #34 was dependent on two staff for transferring and required a mechanical lift and two staff for transfers. Observation on 02/18/25 at 10:05 A.M. revealed Resident #34 activated her call light. There were no staff available to answer the call light. LPN #878 was in the back room of the nursing station, and CNA #842 and CNA #1001 were in resident rooms providing care. Observation on 02/18/25 at 10:30 A.M. Resident #34's call light was answered by CNA #842, and Resident #34 told CNA #842 she needed changed. Observation on 02/18/25 at 10:36 A.M. revealed CNA's #842 and #1001 entered Resident #34's room to provide incontinence and morning care. CNA #842 stated after they were done providing Resident #34's care they would assist her up to a chair. Resident #34 stated okay, but she only wanted to be up for an hour because that was all she could tolerate. Observation on 02/18/25 at 10:49 A.M. revealed CNA's #842 and #1001 assisted Resident #34 to a padded chair in her room using a mechanical lift. Observation on 02/18/25 at 12:27 P.M. of Resident #34 revealed she was sitting in the padded chair in her room. Resident #34 stated her knees were really starting to hurt and wanted to go back to bed but was unable to because two aides were needed to assist her back to bed, and one of the aides was on a break. CNA #842 stated CNA #1001 was on a break, and Resident #34 had to wait until after the residents had their lunch meal to go back to bed. Resident #34 stated her pain was a 12 out of a 10 and she was really starting to hurt. Observation on 02/18/25 at 1:12 P.M. revealed CNA #842 and CNA #1001 assisted Resident #34 back to her bed. Resident #34 stated her pain in the knees was severe and was an 11 out of 10. CNA #842 stated Resident #34 always said she had a lot of pain and it was an 11 or 12. Resident #34 had tears in her eyes and stated she only wanted to be up for an hour. Review of the facility policy titled Resident Rights included federal and state laws guarantee certain basic rights to all residents of the facility and these rights included the right to self-determination.

Based on observation, record review, interview, review of the manufacturer recommendations for a glucometer and facility policy review, the facility failed to ensure Residents #1 and #95, with physician ordered isolation precautions, had the appropriate signage on the entrance door to the resident's rooms indicating the type of precautions and type of personal protective equipment (PPE) required when providing care. This finding affected two residents (#1 and #96) of four residents reviewed for isolation precautions and had the potential to affect an additional 35 residents (#5, #11, #12, #16, #24, #26, #30, #33, #34, #38, #40, #43, #47, #53, #55, #57, #58, #61, #63, #64, #65, #82, #83, #84, #89, #90, #94, #98, #99, #102, #203, #205, #206, #253, #256) residing on the 200 and 300 Rehab Units. In addition, the facility failed to ensure the glucometer blood glucose testing machine (BGT) was appropriately cleaned and sanitized after use on Resident #40 to prevent the potential for cross contamination of bloodborne pathogens. This affected one resident (#40) of two residents reviewed for BGT and had the potential to affect five additional residents (#30, #33, #64, #98 and #203) identified by the facility to receive BGT testing on the 200 Rehab Unit that used the same glucometer. The facility census was 101. Findings include: 1. Review of the medical record revealed Resident #1 was readmitted on [DATE] with diagnoses including other acute osteomyelitis, methicillin susceptible staphylococcus aureus (MSSA), and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 exhibited intact cognition. Review of Resident #1's physician orders revealed an order dated 01/12/25 for contact isolation precautions for Carbapenem-Resistant Enterobacteriaceae (CRE). (CRE is a group of bacteria that are resistant to certain antibiotics, making them difficult to treat). Review of Resident #1's care plans revealed an intervention dated 01/13/25 for staff to provide enhanced barrier precautions (EBP) and staff to gown and glove with hands on care (the resident was on contact precautions which includes wearing to gown and gloves when coming into contact with the resident or the resident's environment). Observation on 02/12/25 at 3:00 P.M. revealed Resident #1's door signage revealed the resident was in EBP and not contact isolation precautions as ordered. The care plans were not updated to reflect contact isolation precautions. Interview on 02/12/25 at 3:04 P.M. with Registered Nurse (RN) #960 confirmed the signage on Resident #1's door was not correct, and it should have been contact precautions instead of EBP. 2. Review of Resident #96's medical record revealed the resident was admitted on [DATE] with diagnoses including cutaneous abscess of the buttock, local infection of the skin, and subcutaneous tissue and resistance to vancomycin (antibiotic). Review of Resident #96's Admission MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #96's physician orders revealed an order dated 01/08/25 for contact isolation precautions every shift for vancomycin resistant enterococci (VRE). (VRE is a bacterial infection caused by a strain of enterococci bacteria that have developed resistance to the antibiotic vancomycin). Review of Resident #96's care plans revealed an intervention dated 01/15/25 for contact isolation precautions related to VRE of the coccyx wound. Observation on 02/11/25 at 3:50 P.M. of Resident #96's resident door revealed EBP signage and not contact isolation precautions. Interview on 02/11/25 at 3:56 P.M. with RN #859 confirmed the signage on Resident #96's door was not correct, and it should have been contact precautions instead of EBP. Review of the Standard Precautions policy, revised 08/2022, revealed contact isolation precautions were intended to prevent the transmission of infectious disease that were spread by direct (i.e. person-to-person) or indirect contact with the resident or the environment, and the use of appropriate PPE, including a gown and gloves upon entering (i.e. before making contact with the resident or resident's environment). Prior to leaving the resident's room, the PPE was removed and hand hygiene performed. 42013 3. Review of Resident #40's medical record revealed an admitted [DATE] with diagnoses including acute embolism and thrombosis of unspecified deep veins of lower extremity, bilateral, type II diabetes without complications and chronic obstructive pulmonary disease. Review of Resident #40's physician orders dated 09/28/24 revealed insulin Lispro subcutaneous solution pen-injector 100 units per milliliter (ml), inject per sliding scale, if blood sugar was 151 to 200 inject 2 units, if blood sugar was 201 to 250 inject 4 units, if blood sugar was 251 to 300 inject 6 units, if blood sugar was 301 to 350 inject 8 units, if blood sugar was 351 plus give 10 units and if blood sugar was over 400 contact the Nurse Practitioner or Physician. Observation on 02/12/25 at 9:47 A.M. of RN #997 revealed she checked Resident #40's blood sugar using a glucometer. After checking Resident #40's blood sugar with the glucometer, RN #997 returned to the medication cart, found an isopropyl alcohol swab and proceeded to clean the glucometer with the isopropyl alcohol swab. RN #997 confirmed she did not use an Environmental Protection Agency (EPA) approved, commercially available 1:10 quaternary/alcohol wipe or bleach wipe and thoroughly wipe down the meter. Review of the manufacturer's instructions for the glucometer included using a lint free cloth dampened with isopropyl alcohol (70 to 80 percent) or a pre-moistened isopropyl alcohol wipe to clean the outside of the blood glucose meter. To disinfect the meter, use an EPA approved, commercially available 1:10 quaternary/alcohol wipe or bleach wipe and thoroughly wipe down the meter and follow the manufacturer recommendations for contact time. This deficiency represents noncompliance investigated under Complaint Number OH00161578.

Based on record review, interview and facility policy review, the facility did not ensure a baseline care plan was completed within 48 hours for Residents #11, #92, and #257. This affected three residents (#11, #92, and #257) of the 30 resident records reviewed. The facility census was 101. Findings include: 1. Record review revealed Resident #11 was admitted [DATE] with diagnoses of acute osteomyelitis of the right ankle and foot, legal blindness, chronic diastolic (congestive) heart failure, and chronic obstructive pulmonary disease. Review of the Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11's cognition was intact as evidenced by the Brief Interview for Mental Status (BIMS) assessment score of 15 out of 15. The resident required moderate assistance for toileting, dressing, showers and transfers. Review of the care plan revealed a baseline care plan was initiated on 12/28/24. Interview on 02/18/25 at 10:24 A.M. with Unit Manager #859 confirmed a baseline care plan was not completed until 12/28/24 and not within 48 hours of admission. 2. Record review revealed Resident #257 was admitted [DATE] with diagnoses of lobar pneumonia, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and chronic diastolic (congestive) heart failure. Review of the Medicare 5-Day MDS 3.0 assessment dated [DATE] revealed Resident #257 had mild cognitive impairment as evidenced by the BIMS assessment score of 11 out of 15. Resident #257 was dependent on staff for toileting and dressing and required maximal assistance with showers. Review of the care plan revealed a baseline care plan was initiated 02/02/25. Interview on 02/18/25 at 10:35 A.M. with Unit Manager #859 confirmed a baseline care plan was not completed until 02/02/25 and not within 48 hours of admission. 3. Record review revealed Resident #92 was admitted [DATE] with diagnoses of malignant neoplasm of unspecified part of right bronchus or lung, chronic obstructive pulmonary disease, anxiety, and protein calorie malnutrition. Review of the Admission MDS 3.0 assessment dated [DATE] revealed Resident #92 had mild cognitive impairment as evidenced by the BIMS assessment score of 13 out of 15. Resident #92 required moderate assistance with showers and supervision with dressing. Review of the care plan revealed a baseline care plan was initiated on 01/05/25. Interview on 02/12/25 at 3:29 P.M. with Unit Manager #861 confirmed a baseline care plan was not completed until 01/05/25 and not within 48 hours of admission. Review of the Care Plan Policy and Procedure, dated 12/01/18, revealed as procedure, a baseline care plan be developed within 48 hours of a resident's admission and must include the minimum healthcare information necessary to properly care for a resident including, but not limited to initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, and Pre-Admission Screening and Resident Review (PASRR) recommendation, if applicable.

Based on observation, interview, record review and review of the facility policy, the facility failed to ensure Residents #57 and #90 and had a clean, sanitary and homelike environment. This affected two residents (#57 and #90) out of three residents reviewed for sanitary homelike environment. The facility census was 101. Findings include: 1. Review of Resident #57's medical record revealed an admitted [DATE] with diagnoses including bipolar disorder, major depressive disorder, and nontraumatic intracranial hemorrhage. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #57 was cognitively intact. Resident #57 had no impairment of the upper and lower extremities. Resident #57 required set-up or clean-up assistance for activity of daily living (ADL). Observation on 02/12/25 at 10:21 A.M. of Resident #57 revealed she walked up to Registered Nurse (RN) #997 and was very upset and told RN #997 her room needed cleaned. Resident #57 stated her trash can was so full that you cannot even put a Q-tip in it and her bathroom was dirty, and she cleaned it herself today. Resident #57 indicated she did not have toilet paper and had to go searching for a new roll. Resident #57 stated her room had not been cleaned for a couple of days. Observation on 02/12/25 at 10:22 A.M. of Resident #57's room with Housekeeping Aide (HA) #955 confirmed the trash receptacle was very full, and it would be hard to fit anything else in it. HA #955 confirmed Resident #57's bathroom floor and toilet needed cleaned. HA #955 confirmed the toilet paper roll was empty, and there was a new roll propped up on the towel rack. HA #955 stated Resident #57's room needed cleaned, and she would clean it right now. Interview on 02/13/25 at 2:31 P.M. of Housekeeping Director (HD) #844 revealed resident rooms should be cleaned daily which included sweeping, mopping, dusting, clean surfaces, sink, toilet, trash and floors. HD #844 reviewed Resident #57's housekeeping record, and it showed her room was cleaned daily. HD #844 stated she would educate the housekeeping staff on the correct way to clean resident rooms. 51525 2. Review of the medical record revealed that Resident #90 was admitted to the facility on [DATE] with diagnosis including alcoholic cirrhosis of the liver and a new diagnosis of alcoholic induced dementia on 11/25/24. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #90 had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment with long- and short-term memory impairments. Review of the care plan dated 01/29/25 stated Resident #90 had a behavior problem and preferred to be nude. Resident #90 often had bowel movement (BM) on the floor of his room and painted the walls and floor with feces. He often ate other people's food. The care plan also stated he refused to allow staff to put sheets and pads on his bed, refused to wear clothes or an incontinence brief, he removed his clothing and soiled linen and threw it on the floor and sometimes walked in the hallway nude. Observation of Resident #90 on 02/10/24 at 8:10 P.M. revealed him lying in bed wearing only a continence brief. He was agitated and asked the surveyor to go away. The surveyor observed kernels of corn and breadcrumbs on his floor; Resident #90 was unable to recall how the food ended up on the floor or how long it had been there. Observation on 02/11/25 3:55 P.M. revealed Resident #90 was lying in bed awake and wearing only a shirt. The floor was messy with crumbs of food and various papers. Yesterday's corn was gone. He was agitated and asked the surveyor to leave. The surveyor observed a chair in the corner of the room with a note attached that said, please clean chair: FECES! Observation on 02/12/25 at 9:00 A.M. revealed Resident #90 lying in bed without clothes wearing only a brief. He asked the surveyor to leave his room. The surveyor observed the dirty chair still in the corner. It had not been cleaned, and the sign was still on it. The surveyor also observed feces on Resident #90's toilet seat and bed linens. Interview with CNA #872 on 02/12/25 9:40 A.M. stated Resident #90 routinely took his clothing off shortly after they help him get dressed, and his room needs cleaned after every meal as he throws food everywhere. CNA #872 also stated she asks housekeeping to clean resident's room more often as he gets feces all over himself and his bed and toilet seat. Observation of Resident #90's room on 02/13/25 at 8:31 A.M. revealed the soiled chair in corner still displaying the sign asking for it to be clean as it had feces on it. Crumbs were observed on the floor. Observation on 02/13/25 at 11:07 A.M. revealed Resident #90 lying in bed wearing a hospital gown. Housekeeping was in the process of cleaning his room at the time of surveyor's observation; the room was clean and comfortable. No crumbs or papers were on the floor. The soiled chair was still sitting in the corner displaying the sign asking for it to be cleaned which was confirmed by Housekeeper #926 at the time of the observation. This deficiency represents noncompliance investigated under Master Complaint Number OH00161714.

Based on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident's #46 and #98 were transported to their scheduled appointments. This affected two residents (#46 and #98) out of three residents reviewed for transportation to appointments. The facility census was 101. Findings include: 1. Review of Resident #46's medical record revealed an admitted [DATE] with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, dysphagia following cerebral infarction, and anxiety disorder. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 was cognitively intact. Resident #46 required partial to moderate assistance rolling left and right, the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, and the ability to transfer to and from a bed to a chair or wheelchair. Review of the care plan revised 12/20/24 included Resident #46 had an activities of daily living (ADL) self-care performance deficit related to weakness, chronic obstructive pulmonary disease, and endocarditis. Resident #46 would maintain ADL through the next review date. Interventions included Resident #46 required partial to moderate assistance to move between surfaces, from bed to wheelchair, from wheelchair to toilet, and for showers. Review of Resident #46's Transportation Scheduling Request dated 01/08/25 included the transportation company was called on 01/16/25 and transportation was arranged for a pickup time on 02/12/25 at 8:00 A.M. for a physician appointment at 9:00 A.M. Observation on 02/12/25 at 7:45 A.M. revealed Resident #46 was provided incontinence care for a bowel movement at 7:48 A.M. Observation on 02/12/25 at 8:20 A.M. revealed Resident #46 was sitting in a wheelchair by the elevator with her coat on. Observation on 02/12/25 at 8:45 A.M. revealed Resident #46 was sitting in a wheelchair close to the elevator of the nursing unit she resided in. Certified Nursing Assistant (CNA) #804 was talking to other staff members by the nurse's station and pushing a metal cart. After she was done talking to the staff members, CNA #804 told Licensed Practical Nurse (LPN) #963 she was going to take Resident #46 downstairs to the main entrance so she would be ready for transportation to pick her up for her appointment (the pickup time was 8:00 A.M.). CNA #804 used the elevator and transported Resident #46 to the main entrance of the facility. Observation on 02/12/25 at 8:55 A.M. revealed CNA #804 returned to the nursing unit with Resident #46. CNA #804 stated the transportation driver did not take Resident #46 to her appointment. CNA #804 stated the transportation driver said she called the nursing unit to tell them she was at the facility and ready to take Resident #46 to her appointment, but no one answered the phone. LPN #963 stated she did not hear the phone ring. CNA #804 stated she was assisting residents and did not hear the phone ring. LPN #963 confirmed Resident #46's pick up time was at 8:00 A.M., and Resident #46 should have been at the main entrance at that time and ready to go to her appointment. Interview on 02/12/25 at 8:56 A.M. of CNA #919 revealed she was in Resident #46's room at 7:59 A.M. (observation at 7:48 A.M. revealed the incontinence care was completed) providing incontinence care for a bowel movement. CNA #919 stated she did not hear the phone ring at the nurse's station. Interview on 02/12/25 at 8:59 A.M. of LPN #963 revealed the two aides assigned to the nursing unit have a lot of things they are responsible for, and it puts so much on the aides to also have to transport residents to the front entrance of the facility for their appointments. Review of Resident #46's progress notes dated 02/12/25 at 3:19 P.M. revealed Resident #46 missed an orthopedic appointment today, and the appointment was rescheduled for 02/26/25 at 2:40 P.M. The transport paper was sent, and Resident #46 was aware. Interview on 02/18/25 at 2:12 P.M. of Business Office Manager (BOM) #971 and Business Office Assistant (BOA) #935 revealed they scheduled transportation for the residents, and there were issues with some of the transportation companies. BOA #935 stated the drivers were only required to wait five minutes, and if the residents were not ready to go, the transportation drivers leave. BOM #971 stated the drivers would leave even if they knew the resident was on the way to the transportation van. BOM #971 indicated the facility tried to get the residents transported to the main entrance before the scheduled pick-up time just to make sure they do not miss their ride, and the residents sometimes waited a long time before they were picked up. Interview on 02/19/25 at 8:07 A.M. of CNA #919 indicated that depending on the time of day a resident had an appointment, it could be hard for the aides to take residents to the transportation van because the elevators had to be used to take them downstairs to the front entrance to be picked up by the drivers. CNA #919 stated if the aides were passing meal trays, or providing care to another resident, it is hard to take everyone where they need to go at the time they need to go. Interview on 02/19/25 at 8:35 A.M. of the Administrator revealed the nurses' were responsible to tell the aides what time the residents needed to be taken to the main entrance for their pick up when they had an appointment. Review of the facility policy titled Transportation, reviewed 08/2024, included it was the policy of the facility to arrange and ensure transportation was provided for doctors and specialist appointments if the resident did not have family, a friend or responsible party available for transport. The facility staff would schedule transportation to and from the appointment as needed. The facility staff would notify staff involved of the appointment. The resident would be transported to the appointment. 2. Review of Resident #98's medical record revealed an admitted [DATE] with diagnoses including unstable burst fracture of T7-T8 thoracic vertebra, type two diabetes mellitus, morbid obesity, and chronic obstructive pulmonary disease. Review of Resident #98's physician orders dated 01/18/25 revealed an order for oxygen therapy at four liters per minute via nasal cannula, may titrate as needed, every shift. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #98 was cognitively intact. Resident #98 required substantial to maximal assistance with toileting hygiene, bathing, and was dependent on staff for lower body dressing. Resident #98 required partial to moderate assistance for the ability to transfer to and from a bed to a chair or wheelchair and for the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. Resident #98 used oxygen therapy. Review of Resident #98's Transportation Scheduling Request dated 01/21/25 included transportation was scheduled on 02/03/25 for Resident #98's appointment on 02/12/25 at 9:30 A.M. Resident #98's pick up time for his appointment was at 8:30 A.M. Review of Resident #98's care plan dated 01/24/25 included Resident #98 had an ADL self-care performance deficit related to activity intolerance, disease process, impaired balance, limited mobility, pain fracture T7-T8 vertebrae, and other diagnoses. Resident #98 would improve his current level of function through the review date. Interventions included Resident #98 required supervision or touching assistance for chair-to-bed-to-chair transfers. Observation on 02/12/25 at 8:04 A.M. of Registered Nurse (RN) #815 revealed she was sitting in the back room of the nurse's station, had a concerned look on her face and stated she worked night shift, and the day shift nurse had not shown up yet. RN #815 stated she was really stressed out about it because she had to take her son to school and now, he was late. RN #815 stated she called the Director of Nursing (DON), and he assured her someone would come, but no one did. RN #815 indicated she had been waiting an hour for her relief. Interview on 02/12/25 at 8:11 A.M. of the DON revealed he was not aware RN #815 had not been relieved by a day shift nurse, and he would make sure someone came to relieve her so she could go home. Review of RN #815's timecard revealed she clocked out on 02/12/25 at 8:20 A.M. Observation on 02/12/25 at 9:15 A.M. with Assistant Director of Nursing (ADON) #911 revealed Resident #98 was sitting in a wheelchair and was assisted out of the elevator and to his room by CNA #894. Interview on 02/12/25 at 9:15 A.M. of ADON #911 revealed he took over for RN #815 around 8:30 A.M. because she said she had to leave. ADON #911 stated Resident #98 missed an appointment. ADON #911 stated Resident #98's pick up time was 8:30 A.M., and he did not make his appointment because ADON #911 had to find an oxygen tank that would fit on a bariatric wheelchair. ADON #911 stated he did not find an oxygen tank to fit on the wheelchair but sent an oxygen tank on wheels with Resident #98. ADON #911 stated the transportation driver called and said he was at the facility, and ADON #911 indicated he told the receptionist to tell the driver to wait because he was getting him ready, but the driver did not wait. ADON #911 stated Resident #98's pick up time was 8:30 A.M. and he was downstairs by 8:55 A.M. ADON #911 indicated the transportation drivers only wait five minutes and then they leave. Review of Resident #98's late entry progress notes dated 02/12/25 at 3:33 P.M. revealed Nurse Practitioner (NP) #1005 was updated regarding Resident #98 missing a pulmonology appointment today related to transportation. The appointment was rescheduled for 02/27/25 at 9:15 A.M. Review of the facility policy titled Transportation, reviewed 08/2024, included it was the policy of the facility to arrange and ensure transportation was provided for doctors and specialist appointments if the resident did not have family, a friend or responsible party available for transport. The facility staff would schedule transportation to and from the appointment as needed. The facility staff would notify staff involved of the appointment. The resident would be transported to the appointment. This deficiency represents noncompliance investigated under Complaint Number OH00161578.

49774 Based on record review, interview and facility policy review, the facility failed to ensure an initial care conference was completed for Resident #11 and failed to ensure the quarterly care conference was completed for Resident #31. This affected two residents (#11 and #31) of the 30 resident records reviewed. The facility census was 101. Findings include: 1. Record review revealed Resident #11 was admitted [DATE] with diagnoses of acute osteomyelitis of the right ankle and foot, legal blindness, chronic diastolic (congestive) heart failure, and chronic obstructive pulmonary disease. Review of the Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11's cognition was intact as evidenced by the Brief Interview for Mental Status (BIMS) assessment score of 15 out of 15. The resident required moderate assistance for toileting, dressing, showers and transfers. Review of Resident #11's medical record revealed no documented evidence a care conference had occurred. Interview on 02/18/25 at 10:06 A.M. with Social Service Designee (SSD) #883 confirmed no care conference had been conducted since Resident #11 was admitted to the facility on [DATE]. 2. Record review revealed Resident #31 was admitted [DATE] with diagnoses of cerebral infarction, atherosclerotic heart disease of the native coronary artery without angina pectoris, chronic obstructive pulmonary disease, type II diabetes, morbid (severe) obesity due to excess calories, and psychotic disorder with delusions due to known physiological condition. Review of the Annual MDS 3.0 assessment dated [DATE] revealed Resident #31 had mild cognitive impairment as evidenced by the BIMS assessment score of 13 out of 15. Resident #31 had an impairment to one side and was dependent on staff for toileting, showers, and dressing, and required maximal assistance for personal hygiene and transfers. Review of Resident #31's medical record revealed the last quarterly care conference occurred 10/17/24. Interview on 02/18/25 at 10:06 A.M. with SSD #883 confirmed the quarterly care conference for Resident #31 was not completed in January 2025 which was when the next quarterly conference was to have been conducted. Review of the Care Conferences Policy, dated January 2024, revealed as procedure, care conferences were to be scheduled to include the resident, resident representative, and interdisciplinary team as soon as possible after admission, routinely, and with a change in condition. 51521

Based on observation, record review, interview and facility policy review, the facility failed to ensure Resident #29 was provided adequate nail care. This finding affected one resident (#29) of four residents reviewed for activities of daily living (ADL). The facility census was 101. Findings include: Review of Resident #29's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia affecting the right dominant side, dementia, and cerebral infarction. Review of Resident #29's current ADL care plan revealed an intervention dated 08/05/21 to check the nail length and trim and clean on bath days and as necessary. Report any changes to the nurse. Review of the Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #29 exhibited severe cognitive impairment and was dependent on staff for ADL care. Telephone interview on 02/11/25 at 10:02 A.M. with Resident #29's power-of-attorney (POA) revealed the POA had concerns of the resident's nail care not being provided, including cutting and cleaning the fingernails. Observation on 02/11/25 at 1:30 P.M. with Certified Nursing Assistant (CNA) #993 of Resident #29's incontinence care did not reveal concerns of infection control. The resident appeared to have brown debris under her fingernails on both the right and left hands. CNA #991 indicated the resident had some type of food items for the lunch meal that was underneath her fingernails. Observation on 02/12/25 at 12:50 P.M. with the Director of Nursing (DON) revealed Resident #29 was lying in bed, and both her right and left hands had brown debris underneath her fingernails. Interview at the time of the observation with the DON verified Resident #29's right and left hands had brown debris underneath her fingernails. Interview on 02/12/25 at 1:56 P.M. with Registered Nurse (RN) #859 confirmed staff were to clean underneath fingernails. RN #859 also verified nursing staff cut fingernails and the podiatrist cut toenails. Review of the Care of Fingernails and Toenails policy, revised 02/2018, revealed the purpose of the procedure was to clean the nail bed, to keep the nails trimmed, and to prevent infections.

Based on record review, interview and facility policy review, the facility failed to ensure Resident #49 was provided an ongoing activities program to meet the needs of the resident. This finding affected one resident (#49) of one resident reviewed for activities. The facility census was 101. Findings include: Review of the medical record revealed Resident #49 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including rheumatoid arthritis, spinal stenosis, and anxiety disorder. Review of Resident #49's current activity care plans revealed an intervention dated 11/17/23 which revealed the resident needed a variety of activity types and locations to maintain the resident's interests. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 had intact cognition. Review of Resident #49's activity logs from 01/07/25 to 02/12/25 revealed the resident received two one-to-one activity visits from the activity staff, including one on 01/07/25 and one on 02/11/25. Interview on 02/10/25 at 8:03 P.M. with Resident #49 revealed she had not received activities as she was unable to get into a wheelchair to go to the activities and was not provided with activities in her room. Interview on 02/12/25 at 11:23 A.M. with Activity Director (AD) #891 revealed Resident #49 did not have one-to-one activities in her room because two activity staff members were terminated in the prior month. AD #891 confirmed Resident #49's documentation revealed the resident was provided two one-to-one activities from 01/01/25 to 02/12/25, including one on 01/07/25 and one on 02/11/25. She confirmed the staff had not documented the activity on 02/11/25 at the time of the interview because the staff were busy with activities. Review of the Activity policy, revised 01/2020, revealed it was the policy of the facility to provide activity programming to promote the physical, mental and psychosocial well-being of each resident. Activity programs were designed to meet the interests of the residents and encourage independence and interaction in the community.

Based on observation, record review, interview and facility policy review, the facility failed to ensure orthotics/braces were applied as ordered for Resident #86. This affected one resident (#86) of five residents reviewed for limited range of motion (ROM) and had the potential to affect 13 residents (#5, #6, #7, #29, #31, #40, #42, #43, #64, 72, #81 and #86) identified by the facility as requiring application of orthotics/braces. The facility census was 101. Findings include: Review of the medical record for Resident #86 revealed an admitted [DATE] with diagnoses including cerebral infarction, vascular dementia, diabetes type two, and difficulty walking. Review of the physician's orders revealed an order dated 10/08/24 for a right ankle foot orthosis (AFO) brace when out of bed. (An AFO brace is a brace utilized for support and control the ankle and foot. An AFO is typically used to improve mobility, reduce pain, and prevent deformities). In addition, there was an order dated 11/30/24 to consult Western Reserve Orthotics for right AFO as the current AFO is broken. There was no documented evidence in the medical record on 11/30/24 that the facility called the orthotics company to have the AFO fixed. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #86 was cognitively intact. He did not reject care and had no limitation of ROM to upper and lower extremities. He required setup or clean-up help with eating and personal hygiene, partial to moderate staff assistance with upper and lower body dressing, toileting hygiene, putting on and taking off footwear, and sit to stand and chair to bed transfer, and he was dependent on staff for showers. He was able to walk ten feet with supervision or touching assistance. He was independent for wheeling a wheelchair. He was frequently incontinent of bowel and bladder. He received physical therapy (PT) and occupational therapy (OT). Review of the care plan dated 11/29/24 revealed Resident #86 had an alteration in musculoskeletal status and used a right AFO. Review of Resident #86's Medication Administration Records (MARs) dated 12/01/24 through 12/31/24 and 01/01/25 through 01/31/25 revealed the right AFO brace was signed off as applied and removed as ordered. (The right AFO was broken and unavailable from 11/30/24 to 12/30/24 when it was returned according to Director of Rehabilitation (DOR) #839; however, there was no documented evidence in the medical record that the AFO was returned until the physical therapy (PT) evaluation on 02/05/25. Review of the physical therapy (PT) evaluation dated 02/05/25 revealed Resident #86 was referred to therapy due to a functional decline as a result of bilateral lower extremity weakness and atrophy, reduced functional activity tolerance, and is at high risk for falls. The resident has received a new right AFO and requires gait training. Review of Resident #86's physician's orders revealed an order dated 02/06/25, PT eval completed. PT to treat three to five times a week for 30 days to include therapeutic exercise, therapeutic activity, neuro re-education, and gait. Observations on 02/10/25 at 8:00 P.M. and 02/12/25 at 9:30 A.M and 2:10 P.M. of Resident #86 was up in the wheelchair and was not wearing the right AFO. Interview on 02/12/25 at 9:34 A.M. with Certified Nurse Assistant (CNA) #841 revealed they had been trained on brace application. CNA #841 stated the only resident on the 100-nursing unit with leg braces was Resident #81. (Resident #86 was on the 100-hall and had an order for a brace, a right AFO brace when out of bed). Interview on 02/12/25 at 9:40 A.M. with Registered Nurse (RN) #861 verified there was no brace applied to Resident #86. RN #861 checked the orders and revealed the right AFO broke on 11/30/24. Interview on 02/12/25 at 3:22 P.M. with RN #861 revealed the orthotics company was called today regarding the broken AFO for Resident #86. RN #861 stated the company was coming Tuesday [02/18/25] to have it repaired. Review of the PT note dated 02/14/25 revealed Resident #86 was to have the right AFO brace for gait and transfers. Interview on 02/18/25 an interview with DOR #839 revealed Resident #86's right AFO brace broke in November of 2024, was repaired and returned on 12/30/24. DOR #839 stated Resident #86 was currently receiving therapy services for gait training and new right AFO brace. (The PT evaluation for the new right AFO was completed on 02/05/25). Review of the facility policy titled Resident Mobility and Range of Motion, dated July 2017, revealed residents with limited mobility will receive appropriate services, equipment (braces/splints etc.) and assistance to maintain or improve mobility unless reduction in mobility is unavoidable.

Based on record review, review of the facility incident log, interview and review of the facility post fall investigation, the facility failed to ensure Resident #47 had a comprehensive fall assessment completed after experiencing falls. This affected one resident (#47) out of three residents reviewed for falls. The facility census was 101. Findings include: Review of Resident #47's medical record revealed an admitted [DATE] with diagnoses including cerebral infarction due to unspecified occlusion or stenosis or right anterior cerebral artery, chronic obstructive pulmonary disease, and muscle weakness. Review of Resident #47's Fall Risk Evaluation dated 12/16/24 revealed she was at risk for falls. Review of the care plan dated 12/16/24 revealed Resident #47 was at risk for falls and potential injury related to debilitation, weakness, impaired balance, impaired cognition. Resident #47 was at high risk for falls due to impulsivity. Resident #47 would be free from major injury through the next review date. A fall without major injury such as a fracture or requiring transfer to the Emergency Department would not require a new intervention. Interventions included having commonly used articles within easy reach such as water, call light, remote control, monitor for side effects of psychotropic medications, and notify the physician of any irregularities. Review of the Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #47 was cognitively intact. Resident #47 required substantial to maximal assistance for toileting hygiene and lower body dressing. Resident #47 required partial to moderate assistance for the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, for toilet transfer, and the ability to transfer to and from a bed to a chair or wheelchair. Review of the facility incident log dated 12/26/24 revealed Resident #47 had unwitnessed falls at 9:00 A.M. and 2:23 P.M. Review of Resident #47's medical record including progress notes dated 12/26/24 did not reveal evidence Resident #47 experienced a fall at 9:00 A.M. Review of Resident #47's progress notes dated 12/26/24 at 2:41 P.M. included Resident #47 activated her call light. An unidentified certified nursing assistant (CNA) found Licensed Practical Nurse (LPN) #1006. Resident #47 was lying on her right side and stated she was fine and did not hit her head. The nurse obtained vital signs and assisted Resident #47 off the floor. Range of motion (ROM) was at baseline, and a call was placed to the resident's responsible party. Review of Resident #47's progress notes dated 12/26/24 at 3:06 P.M. revealed Resident #47 stated she was trying to use the bathroom and slid out of the chair. Review of Resident #47's medical record including progress notes and assessments dated 12/26/24 did not reveal evidence Resident #47's physician was notified of the falls at 9:00 A.M. or 2:23 P.M., or the family was notified of Resident #47's fall at 9:00 A.M. The medical record had no documented evidence a fall assessment or pain assessment was completed, and there was no documentation of events leading up to either fall. Interview on 02/19/25 at 8:34 A.M. of the Administrator and the Director of Nursing (DON) confirmed Resident #47 had falls documented on the incident log on 12/26/24 at 9:00 A.M. and 2:23 P.M. but there was no documentation in Resident #47's medical record including progress notes regarding a fall at 9:00 A.M. The DON and Administrator confirmed on 12/26/24 there was no evidence Resident #47 had fall assessments, a pain assessment, or the physician was notified of the falls. The DON and Administrator did not provide statements regarding the falls from the staff on duty. The DON and Administrator did not provide additional information regarding Resident #47's falls on 12/26/24 at 9:00 A.M. and 2:23 P.M. Interview on 02/18/25 at 12:46 P.M. of CNA #950 revealed she vaguely remembered working on 12/26/24 and could not remember if it was a busy day and could not remember details regarding Resident #47's falls. CNA #950 stated Resident #47 was sometimes confused and often tried to get up without assistance. CNA #950 indicated she tried to keep a close watch on Resident #47 and check on her every hour if possible. CNA #950 stated it was important to have at least two aides working on the nursing unit, and it would be really helpful if there was a float aide who floated between the two nursing rehab units. CNA #950 stated on 12/26/24, she worked with an aide who was in orientation, and he did not count in the numbers, but he was a really good aide and was helpful. CNA #950 stated there should have been a second aide not in orientation also working with both of them. Interview on 02/19/25 at 3:51 P.M. of LPN #1006 revealed she did not remember working on 12/26/24 and did not remember if it was busy that day or if Resident #47 had falls. LPN #1006 stated it was almost two months ago, and she could not remember that far back. LPN #1006 stated she tried not to stay late to finish her work, but it was often unavoidable because she could not finish everything during her shift, and she did not like to leave anything unfinished such as fall documentation or new admissions. LPN #1006 confirmed she worked until 7:50 P.M. on 12/26/24 and should have finished working at 7:30 P.M. Review of the facility Post Fall Investigation revealed when a resident had a fall the resident's name, unit, date, and time of fall should be documented. There should be physician and family notification documented in the electronic record, neuro checks if head injury or unwitnessed fall, progress notes relating to the fall with interventions and vital signs in the electronic record. There should be an order written for immediate intervention related to how the fall occurred. There should be fall assessments and pain assessments documented in the electronic record. Pass on in report to document every shift for three days. Get statements from nurses and CNAs on the unit. Complete incident report in the electronic record.

Based on observation, record review, interview and facility policy review the facility failed to ensure Resident #87, who required staff assistance for activities of daily living (ADL) care, received adequate and timely incontinence care. Actual Harm occurred on 04/10/24 when Resident #87, who was totally dependent on staff for bed mobility and toileting went from 04/10/24 at approximately 6:00 A.M. to 11:52 A.M. (almost six hours) before being provided incontinence care. Resident #87 was observed to be saturated in urine resulting in a red, bleeding, open area to her right thigh that was approximately the size of a dime. Resident #87 revealed her skin was raw, hurt, and burned from the lack of timely incontinence care. She also was observed to have her incontinence brief fastened rather than being left open as ordered by the physician. This affected one resident (#87) of three residents reviewed for incontinence care. The facility identified 49 residents (#1, #2, #5, #8, #9, #10, #12, #13, #14, #15, #16, #17, #22, #25, #26, #30, #31, #33, #34, #35, #36, #38, #39, #40, #42, #43, #44, #46, #48, #49, #51, #52, #53, #57, #62, #63, #64, #66, #67, #69, #71, #74, #75, #76, #78, #83, #84, #85, and #87) who were identified to be incontinent of bowel and/or bladder. The facility census was 87. Findings include: Review of the medical record for Resident #87 revealed an admitted [DATE] with diagnoses including atrophy (muscle wasting), urinary tract infection, morbid obesity, adult failure to thrive, and needing assistance with personal care. Review of the care plan dated 02/21/22 revealed Resident #87 had an ADL self-care performance deficit related to activities intolerance, and impaired balance. Interventions included extensive assistance with two staff for toileting, mechanical lift for transfers to move between surfaces, and skin inspection with care. Review of the care plan dated 02/21/22 revealed Resident #87 had bladder incontinence related to impaired mobility. Interventions included disposable briefs and change as needed, clean peri-area with each incontinence episode, check as required for incontinence, and apply barrier cream to protect skin. Review of the care plan dated 02/09/24 revealed Resident #87 had skin alteration (right medial thigh) related to brief use. Interventions included inspecting skin during routine care, leaving brief open to air when in bed, and treatments as ordered. Review of the care plan dated 02/14/24 revealed Resident #87 can be resistant to care as she declined to get out of bed unless her sister was present to take her for a smoke, refused medications and skin checks. Interventions included if resident resisted ADL care, reassure the resident, leave and return five to ten minutes later and try again. Review of the Braden Scale for Predicting Pressure Ulcer Risk dated 03/01/24 revealed Resident #87 was at moderate risk for developing pressure ulcers as she was slightly limited with her sensory perception, was very moist, chairfast, very limited in mobility, and she had a problem with friction and shear. Review of the readmission Bladder and Bowel Assessment completed by Registered Nurse (RN)/ Wound Nurse #550 dated 03/03/24 revealed Resident #87 was incontinent of bowel and urine. Review of the Medicare Five-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #87 had intact cognition. She was totally dependent on staff to roll left and right, with toileting, and transfers. She was always incontinent of bowel and bladder. She was at risk for pressure ulcers but had no unhealed pressure ulcers. Review of the nursing note dated 03/28/24 at 7:31 P.M. completed by RN/ Wound Nurse #550 revealed Resident #87's skin was assessed, and her right inner thigh was intact with no open wounds or discoloration. The note revealed to continue her treatment as preventative. Resident #87 was alert and oriented and updated on the status. Review of the April 2024 Physician Orders revealed Resident #87 had an order dated 12/07/23 to cleanse buttocks/ coccyx after each incontinence episode and apply thick layer of zinc cream every shift, an order dated 02/08/24 to apply zinc to her right medial thigh twice a day and with periods of incontinence every shift, and an order dated 02/08/24 to leave her incontinence brief open when in bed every shift. Interview and observation on 04/10/24 at 11:04 A.M. with Resident #87 revealed she was in bed under a sheet and blanket. She revealed she was last changed (provided incontinence care) on night shift, 04/10/24 at approximately 6:00 A.M. The resident stated no staff had been in to check and/or change her since. During the interview, the resident voiced concerns her incontinence care was not completed in a timely manner as it had been over five hours since the last time she was changed, and stated this happened often. The resident shared she had an open area on her bottom because they (staff) did not change her in a timely manner. She stated, it gets raw and hurts . burns. The resident stated some staff applied cream when they changed her, but some staff did not. Observation on 04/10/24 at 11:52 A.M. revealed State tested Nurse Aide (STNA) #551 entered Resident #87's room to provide her morning care, including incontinence care. The STNA revealed she began her shift at 7:00 A.M., and stated this was the first time she was able to get to change Resident #87. She revealed she started at the one end of her assignment and worked her way down the hall. She stated Resident #87 was one of the last residents she had to complete morning care for. The STNA verified it had been almost six hours since Resident #87 was changed. The STNA provided morning care including incontinence care, and the resident's incontinence brief was observed to be fastened, not opened as ordered by the physician. Resident #87's incontinence brief was saturated in urine, and STNA #551 verified it appeared Resident #87 had urinated multiple times in the brief as she stated, yeah probably by the time I got to her. She also verified on the resident's right thigh she had an open area that was approximately the size of a dime that was red and bleeding. STNA #551 provided incontinence care, applied peri guard protective barrier cream and antifungal powder. The STNA verified she was not using zinc as she was not aware the nurse was to apply zinc after each incontinence episode per the physician's order. She stated she had always just put the barrier cream on the resident. Interview on 04/10/24 at 2:38 P.M. with the Administrator verified residents should be provided incontinence care every two hours and/or as needed, and Resident #87's orders to keep her incontinence brief open in bed and zinc to be applied after incontinence episodes should have been completed as ordered. Review of the progress notes from 01/01/24 through 04/10/24 revealed Resident #87 occasionally refused showers, medication, and lab work; however, there was no documented evidence Resident #87 refused incontinence care. Observation on 04/11/24 at 2:37 P.M. with RN/ Wound Nurse #550 revealed the last time (date not provided) she evaluated Resident #87, her skin was intact, including her right inner thigh, and she had not heard it had re-opened. She stated this area had been an issue before, and as preventative measure, staff were to leave the resident's brief open (unfastened), and the nurse was to apply zinc after each incontinent episode. She verified Resident #87 had a new open area to her right inner thigh that measured 2.4 centimeters (cm) in length by 0.6 cm in width, with a depth of 0.1 cm. She revealed she felt the area was an abrasion caused by the friction of her incontinence brief, especially if the brief was fastened. Interview on 04/11/24 at 3:30 P.M. with the Administrator revealed the facility did not have a policy specifically for incontinence care, instead they followed the ADL policy. On 04/16/24 at 11:45 A.M. the Administrator and Director of Nursing provided a witness statement dated 04/10/24 at 8:30 A.M. completed by STNA #573 stating she went into Resident #87's room to give her breakfast tray at 8:30 A.M., and asked Resident #87 if she needed to be changed but the resident stated she did not. (This information was provided seven days after the incident was brought to the attention of the Administrator (on 04/10/24 at 2:38 P.M.)). Interview on 04/16/24 at 12:38 P.M. with STNA #573 revealed she had started working at the facility on 04/05/24 and was still on orientation the date of incident on 04/10/24. She stated she was assigned a different section on the unit than Resident #87 resided; therefore, she was not assigned to provide direct care to Resident #87. She stated, on 04/10/24 at 8:30 A.M. she assisted in passing breakfast trays and stated she always asked every resident that she passed a tray to if they needed changed before providing them their tray. She stated she did ask Resident #87, and she stated she did not need to be changed. She stated she did not see Resident #87 anymore that day, including asking her again if she needed changed. Review of the facility policy titled Activities of Daily Living (ADL), Supporting, dated August 2021, revealed residents would be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADL. The policy revealed appropriate care and services would be provided for residents who were unable to carry out ADL independently including incontinence care. The policy revealed care and services would be provided in accordance with their plan of care. This deficiency represents non-compliance investigated under Master Complaint Number OH00152380.

Based on interview, observation and record review, the facility failed to manage Resident #23's nutritional needs while accommodating the resident's allergies. This affected one of nine residents (#2, #18, #23, #24, #34, #6, #73, #35, and #53) identified with food allergies. Resident #23 experienced actual harm including emergent transfer to hospital and subsequent admission to intensive care for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: 1. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the at risk for allergic reaction plan of care initiated on 07/15/22 indicated Resident #23 had allergies to fish, nuts, shell fish, shrimp and tree nuts. The interventions included identifying the allergies and listing in the medical record, monitoring for signs and symptoms of anaphylactic reaction or sudden severe dyspnea (shortness of breath); notifying the physician immediately, notifying pharmacy of medication allergies, and notifying the dietary department of food allergies. Review of the diet orders dated 09/23/22 and 10/19/22 indicated Resident #23 was to receive a carbohydrate controlled diet, pureed texture and honey consistency liquids. Review of the allergy list in her electronic health record dated 08/04/22 revealed allergies to fish and nuts. Review of the Minimum Data Set 3.0 assessment dated [DATE] indicated Resident #23 had no [CONDITION(S)] or behavioral symptoms and required supervision for eating. Review of the nutrition note dated 08/04/22 at 1:58 P.M. indicated shrimp/shell fish allergy noted on meal ticket so staff could honor. Review of the progress note dated 09/16/22 at 11:25 P.M. revealed Resident #23 notified the nurse that she ate peanut butter and she wanted to go to the emergency room . The physician was notified and she was sent to the emergency room . The note dated 09/17/22 at 3:09 P.M. indicated when the nurse woke Resident #23 up to take her night medication at 11:49 P.M. the resident stated she needed to go to the hospital, she was allergic to nuts and she ate peanut butter. The mother was notified and wished she be sent to the hospital. She was admitted to the hospital with aspiration pneumonia. She was readmitted to the facility on [DATE]. Review of the hospital record revealed a history and physical dated 09/17/22 indicating Resident #23 ate a peanut butter sandwich and then developed itching on her arms. She was noted to be hypoxic by emergency medical services. She was seen in the emergency room and was hypoxic and agitated. Diagnostic evaluation revealed bilateral pulmonary opacifications (opaque or cloudy areas). Review of the pulmonary rehabilitation associate note dated 09/21/22 indicated they were following Resident #23 for acute [CONDITION(S)] with [CONDITION(S)] and hypercapnia CC allergic reaction. The assessment indicated she had acute on chronic [CONDITION(S)] with [CONDITION(S)] and hypercapnia requiring mechanical ventilation and was intubated on 09/17/22. Allergic reaction. Bilateral groundglass opacities (hazy opacity that does not obscure the underling [MEDICATION(S)] structures or pulmonary vessels), suspect pulmonary [CONDITION(S)]/volume overload. Review of the facility investigation revealed a statement from State tested Nurse Aide (STNA) #313 indicating Resident #23 said she was hungry and STNA #313 gave her a peanut butter and jelly sandwich. STNA #434's statement indicated Resident #23 called her over and handed the STNA an empty bag and said peanut butter. STNA #434 took the bag to notify the nurse Resident #23 was allergic to peanut butter. The nurse indicated she would handle it from there. Review of Licensed Practical Nurse (LPN) #435's statement indicated the STNA reported Resident #23 ate a sandwich. LPN #435 went to the room to give Resident #23 her medications and the resident sat up in bed. LPN #435 took Resident 23's vital signs and the resident told her she ate nuts and wanted to go to the hospital. LPN #435 notified the mother that she had a sandwich and her blood pressure was high. The mother wanted her sent out for an evaluation. Interview with Resident #34 with his family member present on 10/24/22 at 9:50 A.M. reported he was allergic to eggs but they kept serving them to him. Interview with Resident #73 on 10/24/22 at 11:00 A.M. reported she was allergic to fish and had several specified food items she would not eat. She indicated when fish was on the menu she was served the fish. Interview with LPN #433 on 10/24/22 at 11:15 A.M. reported the refrigerator on the unit had to be locked because Resident #23 went and got herself a peanut butter sandwich and was allergic to it. Interview with Resident #23's mother on 10/25/22 at 9:59 A.M. revealed an aide gave Resident #23 a peanut butter sandwich but the facility reported Resident #23 got the sandwich herself. Resident #23's mother reported receiving a call from the nurse stating her daughter ate a peanut butter and jelly sandwich and her blood pressure was 140 or 100 and asked the mother what should she do. The mother said to send her to the hospital. Interview on 10/25/22 at 11:14 A.M. with Registered Nurse (RN) #312 indicated upon admission during the skin assessment she always asked about food allergies to verify the information from the hospital transfer sheet with the resident. Interview with LPN #332 revealed she relied on the admission transfer sheet from the hospital for allergies and would confirm them with the resident. She reported Resident #22 had an allergy to fish and had been sent fish from the kitchen. Interview with Resident #2 on 10/25/22 at 11:28 A.M. revealed she was allergic to eggs and they kept sending her eggs. Interview with Resident #23 on 10/25/22 at 11:50 A.M. reported she was allergic to nuts and to fish. She reported when she lived on the first floor an aide gave her a peanut butter sandwich, she ate it and ended up going to the hospital. She also reported even though she was allergic to fish she was being sent fish. Interview with the Director of Nursing (DON) on 10/25/22 at 5:00 P.M. reported she investigated the incident and found out an aide gave Resident #23 the sandwich and did not know she had an allergy. The DON indicated it was between 7:00 P.M. and 11:00 P.M. when another aide found the sandwich bag and reported to the nurse who took it from there. That was when Resident #23 told the nurse she ate a peanut butter sandwich and had to go to the hospital. Further interview with the DON on 10/26/22 at 11:10 A.M. indicated Resident #23's diet was downgraded and she wanted regular food. The aide did not know she had an allergy to nuts. The DON indicated at the time of the incident Resident #23 had no health concerns going on and her vital signs were normal but since the mother requested she go to the hospital she was sent where she was diagnosed with aspiration pneumonia. Interview with STNA #313 on 10/26/22 at 11:55 A.M. reported there was a lot going on that night with staffing issues and issues with families. She indicated she was moving a little bit too fast. STNA #313 said Resident #23 gets hungry and they did not have big snacks to give. She checked the refrigerator and then the snack tray. STNA handed Resident #23 the peanut butter and jelly sandwich. STNA #313 said she was working with one other aide and they had 20 residents each. She reported Resident #23 was not on her assignment that night but she would get antsy and try to stand up without help. STNA #313 said she was trying to be nice and had no idea Resident #23 was allergic to nuts. STNA #313 indicated there was a new snack policy and process that had been put into place to avoid this from happening again. Further review of the facility investigation indicated a new process was initiated. The nurses must print out an allergy an diet order list for the residents at the beginning of their shift. Only nurses were to give snacks at night. The snacks would be locked in a refrigerator in the copy room. All staff had been educated on the new process. The nurses were educated regarding allergic reactions. All resident allergies would be listed in the electronic medical record and on the Kardex. Interview with the DON on 10/26/22 at 2:30 P.M. reported allergies were to be noted upon admission to the facility. Review of the facility's 46 page clinical admission assessment lacked indication allergies were assessed upon admission to the facility. Review of the facility's allergy report indicated seven residents had allergies to food items. Resident #2 was allergic to eggs, Resident #18 was allergic to seafood and shellfish, Resident #23 was allergic to fish, shellfish, shrimp and nuts, Resident #24 was allergic to bananas, Resident #34 was allergic to shellfish, Resident #56 was allergic to fish, Resident #73 was allergic to fish and shellfish, Resident #35 was allergic to tomatoes and Resident #53 was allergic to peaches. The allergy report did not have Resident #34 listed as allergic to eggs nor Resident #22 allergic to fish. On the report was an icon indicating if the resident had a prior anaphylactic reaction but no residents had the icon next to their name/allergen. This deficiency represents non-compliance investigated under Complaint Number Number OH 591 and is an example of continued noncompliance from the survey dated 10/03/22.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure appropriate care and services were provided, physician orders were followed, and care planned interventions were implemented for Resident #73 and #84's suprapubic catheters. Actual Harm occurred on 01/19/22 when Resident #84's suprapubic catheter did not drain urine properly, only had 50 cc (cubic centimeters) of urine output per day for three days from 01/16/22 through 01/19/22, resulting in pain and discomfort near the catheter site, and after being evaluated at the emergency department his catheter was found to be clogged with sediment. Resident #84's bladder was distended; the catheter was removed and immediately a large amount of urine and sediment expelled from Resident #84's bladder. This affected two residents (Resident #73 and #84) out of three residents reviewed for catheter care. Findings include: 1. Review of Resident #84's medical record revealed an initial admitted [DATE] and a re-admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #84 was transported to the hospital Emergency Department on 01/19/22 and did not return to the facility. Review of Resident #84's care plan, revised 08/17/21, revealed Resident #84 had an indwelling suprapubic catheter for [CONDITION(S)] bladder and would be or remain free from catheter-related trauma through the review date. Interventions included to check tubing for kinks each shift; to monitor and document intake and output as per facility policy; to monitor for signs and symptoms of discomfort on urination and frequency; to monitor and document for pain and discomfort due to catheter; to monitor and record, report to the physician for signs and symptoms of urinary tract infection: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp; to check urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Review of Resident #84's progress notes on 09/07/21 revealed on 08/13/21 Urology Medical Doctor (UMD) #216 wrote orders for Resident #84's suprapubic catheter to be changed at the facility, and to follow-up with UMD #216 in one year and as needed. Review of Resident #84's physician orders on 09/08/21 revealed to change suprapubic catheter every month on the eighth, every day shift. Resident #84's physician orders on 08/10/21 revealed to empty the suprapubic catheter urinary collection bag every shift and document the outputs. Review of Resident #84's Treatment Administration Record (TAR) revealed Resident #84's suprapubic catheter was changed on 09/08/21 and 10/08/21. Resident #84 was hospitalized on [DATE]. Review of Resident #84's medical record revealed he returned to the facility on [DATE] without guidance on changing the suprapubic catheter. Review of Resident #84's Clinical Admission Evaluation, dated 11/22/21, revealed the resident had a suprapubic catheter, it was patent, draining, and attached to a leg urinary collection bag. Review of Resident #84's physician orders on 11/22/21 revealed orders for suprapubic catheter care every shift and as needed. Review of Resident #84's medical record from 11/22/21 through 01/19/22 did not reveal documentation Resident #84's suprapubic catheter was changed as directed by UMD #216. Review of Resident #84's Minimum Data Set (MDS) 3.0 quarterly assessment, dated 12/29/21, revealed Resident #84 had moderate cognitive impairment and required the extensive assistance of two staff members for bed mobility, transfers, personal hygiene and toilet use. Resident #84 was always incontinent of bowel and had an indwelling catheter. Review of Resident #84's urine culture collected on 01/05/22 and reported on 01/07/22 revealed the resident had urinary tract infection and began antibiotic therapy on 01/08/22. Review of Resident #84's suprapubic catheter urinary output from 12/17/21 through 01/15/22 revealed the urine output ranged from 50 cc (cubic centimeters) to 2000 cc per day. Resident #84's urinary output from 01/16/22 through 01/18/22 revealed it was 50 cc per day, and urine output was not documented on 01/19/22. The medical record contained no evidence of follow up to the low urinary output. Review of Resident #84's progress notes on 01/15/2022 at 3:22 P.M. revealed Resident #84 was resting quietly in bed, aroused easily, alert with intermittent confusion. Oral antibiotic therapy continued with no adverse reactions, resident was afebrile, and Resident #84 continued to complain of bladder pain. Suprapubic catheter was in place, patent, draining dark amber colored urine to gravity, and catheter care was provided. Review of Resident #84's progress notes on 01/16/22 at 4:42 P.M. revealed Resident #84 was administered Tylenol for complaints of bladder and penis pain, effectiveness noted. Resident #84 continued antibiotic therapy with no adverse reactions, but Resident #84 still complaining of symptoms related to [CONDITION(S)], message left for the physician. Suprapubic catheter patent, draining dark yellow urine to gravity, and catheter care provided. Review of Resident #84's progress notes on 01/17/2022 at 1:57 A.M. revealed Resident #84 had small amount of yellow drainage coming from around his suprapubic catheter site. Catheter site was cleansed with normal saline, applied triple antibiotic ointment and dressing, notified the physician, and Resident #84 denied pain at the site. Review of Resident #84's progress notes on 01/18/22 at 2:54 P.M. revealed Resident #84's suprapubic catheter was intact and draining cloudy yellow urine. Review of Resident #84's progress notes on 01/19/22 at 3:49 P.M. revealed Resident #84 had a visitor this afternoon and after visitor left, the nurse received a call from Resident #84 ex-wife. Resident #84 was assessed after the phone call ended. Resident #84's vital signs were temperature 98.0 Fahrenheit, pulse 85, oxygen saturation 97% on room air, blood pressure 83/56. The physician was notified and new order to send Resident #84 to the local hospital Emergency Department for evaluation and treatment. The ambulance company was called to transport Resident #84, they were unable to transport Resident #84, and they stated to call 911. A 911 call was placed at 3:15 P.M. and Resident #84 was transported to the Emergency Department. Review of Resident #84's Emergency Department Visit to Hospital Admission record on 01/19/22, revealed Resident #84 had altered mental status, pneumonia of the right lower lobe due to infectious organism, and a urinary tract infection associated with cystomy catheter. The plan included to have the suprapubic catheter tube (SPT) changed per the Urology Service. Review of the Urology Service evaluation on 01/20/22 at 3:41 P.M. revealed Resident #84 had a [CONDITION(S)] bladder and had a suprapubic catheter tube placed in 05/2021. Resident #84 complained of abdominal pain and answered questions by nodding head. The Urology Service progress note revealed immediately upon removal of the SPT a large amount of urine expelled from the bladder. The end of the SPT was clogged with sediment. A new 30 French (size) SPT was inserted and the balloon inflated with 10 cc of sterile water. The Urology progress note further revealed a CT (Computerized Tomography) scan of Resident #84's abdomen and pelvis showed a distended bladder with an indwelling SPT, and when the SPT was changed the SPT was clogged with sediment. Interview on 02/08/22 at 10:55 A.M. of Family Member (FM) #200 revealed on 01/19/22 her son went to the facility to visit Resident #84, he looked lethargic, the son told an unidentified nurse something was wrong with Resident #84, waited, but the nurse did not come to to Resident #84's room. FM #200 stated her son called her to inform her Resident #84 was lethargic and he thought something was wrong, and the nurse had not come to the room yet. FM #200 stated she called the facility and spoke with a nurse and indicated Resident #84 needed to be evaluated due to lethargy. FM #200 revealed she received a call back from the facility and was told Resident #84 was really sick and needed to be transported to the Emergency Department at the local hospital. FM #200 stated Resident #84 was admitted to the hospital from the Emergency Department and was septic from his urinary catheter and had pneumonia. FM #200 indicated his suprapubic catheter was clogged and had not been irrigated or replaced. FM #200 stated on 01/17/22 Resident #84 was complaining he felt uncomfortable in the catheter area, she called the facility to have him checked, but was not able to get through to a nurse because no one answered the phone. Interview on 02/10/22 at 10:55 A.M. with DON revealed on 01/17/22 many staff were not able to travel to the facility because of the snow storm and she worked on Resident #84's nursing unit from 8:30 P.M. until 12:30 A.M. DON revealed on 01/17/22, the state tested nursing assistant (STNA) did not tell her Resident #84's catheter drained 50 cc of urine and she did not have time to check his urinary output in the medical record. DON stated there were no physician orders to monitor Resident #84's urine output. DON indicated if Resident #84's urinary output decreased substantially from what it was previously the suprapubic catheter should be checked to make sure it was patent. Interview on 02/08/22 at 2:58 P.M. with Licensed Practical Nurse (LPN) #201 revealed Resident #84 complained of pain at the suprapubic catheter insertion site area a day or two before he was transported to the Emergency Department at the local hospital, and stated he felt like he had the urge to urinate. LPN #201 stated Resident #84's suprapubic catheter was draining and Doctor of Osteopathic Medicine (DO) #202 evaluated Resident #84 around the same time and did not document any concerns. Interview on 02/08/22 at 3:14 P.M. with STNA #204 revealed she was often assigned to care for Resident #84. STNA #204 stated most of the time Resident #84's catheter drained a lot of urine, but the last time she took care of him before he went to the Emergency Department the urine had a real thick, mucousy appearance, and there wasn't very much urine in his urinary drainage bag. STNA #204 stated she told a nurse the urine was thick, had a lot of mucous in it, and there was not very much urine, but couldn't remember which nurse she told. Interview on 02/08/22 at 8:55 A.M. with DO #202 revealed she was the Medical Director for the facility, had hospital privileges and took care of Resident #84 in the hospital after he was transported to the Emergency Department on 01/19/22 and admitted as a patient. DO #202 stated Resident #84 was admitted to the hospital with pneumonia and did not have a urinary tract infection. DO #202 stated the hospital Urology physicians cared for Resident #84's suprapubic catheter while he was a patient, but were a little behind and did not evaluate the suprapubic catheter right away. DO #202 confirmed when the Urology physician's evaluated Resident #84's suprapubic catheter, it was clogged, needed replaced, it was not pretty, and there was a lot of urine and sediment that drained out of Resident #84's bladder after the catheter was removed. DO #202 stated she evaluated Resident #84 in the facility on 01/18/22 and did not find any concerns. DO #202 stated she did not remember if she checked the suprapubic catheter at the insertion site and did not check the suprapubic catheter for patency because the nurse's did not identify there was a problem with the catheter. DO #202 stated she didn't usually check the catheter unless informed by the nurse's there was a problem, then she would attempt to irrigate the suprapubic catheter to make sure it was functioning properly. DO #202 stated she did not recall being told by a nurse the suprapubic catheter only drained 50 cc of urine per shift (every 12 hours) since 01/16/22. Interview on 02/10/22 at 12:06 P.M. with STNA #205 revealed she was often assigned to care for Resident #84. STNA #205 stated about a week or so before Resident #84 was transported to the Emergency Department his suprapubic catheter was not draining urine like it had been. STNA #205 stated she knew Resident #84 and knew something wasn't right because his catheter hardly had any urine in it. STNA #205 verified even after twelve hours there was only 50 cc of urine in the collection bag, and she reported the low urine output to a nurse (could not remember which nurse), the nurse attempted to irrigate Resident #84's suprapubic catheter, was unable to irrigate the catheter, but didn't do anything else after the attempt at irrigation. STNA #205 stated she told multiple nurse's on different days there was something wrong with Resident #84's suprapubic catheter, the nurse's did not take her seriously, did not check the catheter to make sure it was functioning properly, and nothing was done about the catheter until Resident #84's family started getting angry and upset. STNA #205 stated she did not know the names of the nurse's she informed Resident #84's catheter not working correctly. Interview on 02/10/22 at 1:09 P.M. with LPN #201 revealed she did not remember any STNAs informing her Resident #84's urine output from his suprapubic catheter was low or the catheter was not draining properly. LPN #201 stated most of the time she was too busy to check urine outputs in the aide's charting and relied on the STNAs to tell her if there was a problem. LPN #201 indicated at one point Resident #84's urine was cloudy and kind of thick but she did not remember if it was close to the time he was transported to the Emergency Department. Interview on 02/13/22 at 9:52 A.M. with Registered Nurse (RN) #206 revealed she was assigned to care for Resident #84 on 01/19/22 and arranged for him to be transported via 911 to the hospital Emergency Department. RN #206 stated his mental status changed very quickly, in the morning he was talking and acting like his usual self, but had altered mental status and a low blood pressure by the afternoon. The physician ordered him sent to the Emergency Department. RN #206 stated Resident #84 was complaining of bladder pain a few days before he was transported to the Emergency Department. RN #206 stated it was hard to remember details, she could not remember how much urine was in his collection bag, the urine was dark in color, and could not remember if an STNA told her his urine output was low. Interview on 02/14/22 at 2:00 P.M. with DON confirmed Resident #84 returned to the facility on [DATE] without guidance on changing his suprapubic catheter as directed by UMD #216. Review of the facility policy titled, Catheter Care, dated 08/2021, revealed to maintain an accurate record of resident's daily output per facility policy, procedure or physician orders. If the catheter material is contributing to an obstruction, notify the physician and change the catheter if instructed to do so. Catheter irrigation may be ordered to prevent obstruction in residents at risk for obstruction. Secure catheter utilizing a leg bag if ordered. Check drainage tubing and bag to ensure that the catheter is draining properly. 2. Review of Resident #73's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #73's care plan, dated 08/11/21, revealed Resident #73 had a suprapubic catheter related to neuromuscular dysfunction of the bladder. Resident #73 would have the suprapubic catheter care managed appropriately as evidenced by no signs and symptoms of infection at the suprapubic catheter site, not exhibiting obstruction, signs of infection, dislodgment of catheter, bowel perforation, or trauma. Interventions included to assess the drainage, record the amount, type, color, odor; observe for leaks; monitor and document intake and output as per facility policy; monitor for signs and symptoms of discomfort on urination and frequency; monitor/document for pain and discomfort due to catheter; monitor/record/report to the physician for signs and symptoms of urinary tract infection: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Review of Resident #73's MDS quarterly 3.0 assessment, dated 02/04/22, revealed the resident was cognitively intact and required the extensive assistance of one staff member for bed mobility and toilet use and was totally dependent on two staff members for transfers. Resident #73 had an indwelling catheter and was always incontinent of bowel. Review of Resident #73's physician orders on 02/02/22 revealed suprapubic catheter orders to apply leg bag when up per preference, to change bag weekly, to change catheter every 30 days, flush catheter per protocol, insert catheter (18 French 30 cc balloon-size) and maintain to gravity drainage, and provide catheter care every shift. Review of Resident #73's physician orders from 02/02/22 through 02/08/22 did not reveal orders for dressing changes to Resident #73's suprapubic catheter. Review of Resident #73's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation to apply leg bag when up per preference, to change bag weekly, to change catheter every 30 days, to flush catheter per protocol, insert catheter and maintain to gravity drainage or to provide catheter care every shift. Interview on 02/08/22 at 3:26 P.M. with Resident #73 and Licensed Practical Nurse (LPN) #207 revealed he had a suprapubic catheter. Resident #73 stated he frequently had different nurse' assigned to care for him and they didn't know how to take care of his catheter. Resident #73 stated his catheter became clogged about three times a week because it wasn't care for properly, and the nurses did not clean around it every day. Observation of Resident #73's suprapubic catheter revealed there was no dressing around the catheter insertion site and greenish-brown material could be seen on the outside of the catheter tube. LPN #207 confirmed there was no dressing around the catheter insertion site and stated the night shift nurses were responsible to change the dressing every night. Observation on 02/08/22 at 3:26 P.M. with LPN #207 of Resident #73's urinary collection bag revealed it had approximately 100 cc of dark orange, cloudy urine with small pieces of whitish-brown material floating in the urine. Interview on 02/08/22 at 4:09 P.M. with LPN/Unit Manager (LPN/UM) #208 revealed Resident #73's suprapubic catheter should be irrigated every twelve hours and as needed, and should be cleaned and have the dressing changed every night shift. Interview on 02/08/22 at 4:35 P.M. with Director of Nursing (DON) revealed Resident #73 did not have physician orders written for dressing changes for the suprapubic catheter. DON confirmed Resident #73's physician orders written on 02/02/22, were not documented on Resident #73's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility policy titled, Catheter Care, dated 08/2021, revealed to maintain an accurate record of resident's daily output per facility policy, procedure or physician orders. If the catheter material is contributing to an obstruction, notify the physician and change the catheter if instructed to do so. Catheter irrigation may be ordered to prevent obstruction in residents at risk for obstruction. Secure catheter utilizing a leg bag if ordered. Check drainage tubing and bag to ensure that the catheter is draining properly. This deficiency substantiates Complaint Number OH 574.

Based on medical record review, interviews with facility staff, Laboratory Supervisor #301, Nurse Practitioner (NP) #303, and Medical Director (MD) #302, review of laboratory (lab) testing results, review of facility policies, and Medscape.com guidelines, the facility failed to ensure Resident #45's critical high International Normalized Ratio (INR) (used to monitor therapeutic levels of blood clotting), and a low hemoglobin (part of the red blood cells that carries oxygen to all the cells in the body) were immediately reported to the resident' s primary physician. Resident #45 received the oral anticoagulant (blood thinning) medication, [MEDICATION NAME] ([MEDICATION NAME]). The failure to report the critical INR lab value to the physician for three days resulted in Resident #45 continuing to receive a daily dose of [MEDICATION NAME] for those three days, resulting in Immediate Jeopardy and the potential for serious life threatening harm to Resident #45. Resident #45 was having symptoms of lightheadedness and dizziness especially when sitting up from a lying position and required transportation to the Emergency Department (ED) for evaluation and transfusion of two units of blood. Upon arrival to the ED Resident #45 had a low hemoglobin (Hgb) of 5.7 gram per deciliter (g/dL) (normal 14-17 for men) and critically high INR level of 8.1 (normal 2-3). In addition, continued non-compliance that did not rise to the level of Immediate Jeopardy occurred on 02/22/21 when the facility failed to ensure [MEDICATION NAME] was not administered to Resident #66 who had a high INR level of 3.8. This affected two (Resident #45 and Resident #66) of 10 residents who were prescribed [MEDICATION NAME] (Residents #21, #34, #41, #45, #47, #66, #70, #72, #75, and #82). The facility census was 77. On 02/25/21 at 12:32 P.M., Administrator #304 was notified Immediate Jeopardy began on 02/08/21 when the facility failed to report Resident #45's critical high INR of 5.8 and a low Hgb of 6.6 g/dL to the primary physician. Resident #45 continued to receive [MEDICATION NAME] for the next three days, 6 milligram (mg) on 02/08/21, 7 mg on 02/09/21, and 6 mg on 02/10/21. On 02/11/21 Resident #45 complained of being lightheaded and dizzy, especially when sitting up from a lying position and was unable to participate in therapy. On 02/11/21 at 1:10 P.M., NP #303 was notified Resident #45 was lightheaded, dizzy, and unable to participate therapy. NP #303 ordered stat (immediate) bloodwork including an INR. On 02/11/21 at 7:29 P.M. the lab reported an INR of 6.4 and Hgb 5.7 g/dL. Resident #45's primary physician (MD #302) was notified and gave orders to send Resident #45 to the hospital ED for evaluation and transfusion of blood. Upon arrival to the ED Resident #45's lab values were re-checked, and his INR was 8.1 and Hgb was 5.7 g/dL. Resident #45 was transfused with two units of blood on 02/12/21 between 12:19 A.M. and 6:28 A.M. and returned to the facility the morning of 02/12/21. The Immediate Jeopardy was removed on 02/26/21 when the facility implemented the following corrective action: · On 02/11/21 at 9:00 A.M., a house-wide audit was completed by Assistant Director of Nursing (ADON) #305, ADON #308, and ADON #309 with Clinical Support Associate (CSA) #312 to ensure all residents receiving [MEDICATION NAME] had [MEDICATION NAME] time (PT)/INR monitoring orders. Ten residents (Residents #21, #34, #41, #45, #47, #66, #70, #72, #75, and #82) were identified as receiving [MEDICATION NAME]. · On 02/11/21 before the 9:45 A.M. clinical auditing meeting, ADONs #305, #308, and #309 ran a labs due report for their unit, and CSA #312 ran a master report for all units to monitor and assist ADONs #305, #308 and #309 in lab management. A morning meeting template was used to audit for labs due for the day, lab results received, critical labs called to the physician upon receipt, notification to the physician on all other non-critical labs, and orders received were implemented. · Clinical auditing meetings are held Monday through Friday at 9:45 A.M. and 2:00 P.M. and will continue indefinitely. The morning meeting template will be used during every clinical auditing meeting. If one of the ADONs is not present for any reason CSA #312 will assign a designee to assist in monitoring the labs for that unit. ADONs #305, #308 and #309 will continue to manage the labs on weekends following the same process. · Starting on 02/11/21 and on-going, ADONs #305, #308 and #309 will monitor lab results before early afternoon each day. If the results are not available, the ADONs will call the lab service to request results and to find out what the barrier/issue/problem/delay is. The physician will be notified in these instances to determine if new orders are necessary or if anything needs to be done differently. · Starting on 02/11/21 and on-going Monday through Friday, the labs due report will be reviewed by the clinical team (ADONs #305, #308 and #309 and CSA #312) during the morning clinical auditing meeting at 9:45 A.M. and then again at 2:00 P.M. for any follow up. · On 02/11/21 between 10:15 A.M. and 10:20 A.M., ADONs #305, #308, and #309 educated the six Licensed Practical Nurses (LPNs) on duty that the labs for residents on [MEDICATION NAME] therapy would be managed by the ADONs to ensure results were reported timely (LPNs #325, #334, #336, #337, #338, and #339). Additionally, the LPNs were educated regarding [MEDICATION NAME] including side effects, lab monitoring (PT/INR) and critical lab values Any Licensed Nurse who did not receive this education will receive the education before their next scheduled shift by the ADONs. Any new licensed nurse will receive this same education in their orientation. · On 02/11/21 at approximately 2:38 P.M., ADON #308 was called and made aware that labs for Resident #45 included a critical INR lab value. At that time, ADON #308 notified the nurse on the floor and NP #303. New orders were received from NP #303 to hold Resident #45's [MEDICATION NAME] and recheck his INR on Saturday (02/13/21). · On 02/11/21 at approximately 2:38 P.M., a lab audit was completed by utilizing the Labs Due report to ensure ordered PT/INR labs were drawn, results obtained, reported to the physician, orders received if indicated and new orders entered. This audit was completed by ADON #305, #308, #309. · On 02/11/21 at approximately 7:53 P.M., LPN #315 received an order from Resident #45's physician to send Resident #45 to the ED due to critical lab values. LPN #315 notified Resident #45, Family Member (FM) #340 and ADON #305 of the order to send the resident to the ED for evaluation. LPN #315 called the ED and the transportation service to give report. · On 2/11/21 at approximately 10:10 P.M., Resident #45 was seen by the ED provider and received a blood transfusion for low Hgb. · On 02/12/21 at approximately 6:36 A.M., LPN #315 received a call from the ED for a nurse to nurse report and was told Resident #45 should return to the hospital if his INR went above 10. Resident #45 returned to the facility on the same day at approximately 8:02 A.M. in stable condition. Upon his return, Resident #45's labs were monitored as ordered by his provider based on the lab results. Resident #45 remained stable and had no complaints. · On 02/15/21 at 1:00 P.M., an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with MD #302 and the interdisciplinary team (IDT) to go over a [MEDICATION NAME]/lab monitoring action plan. At this time, ADONs #305, #308 and #309 gained access to E med Lab (online portal to access lab results) so they could monitor for lab results themselves as opposed to relying on a facsimile (fax). E med Lab was to be monitored frequently during the day by the ADONs. Results were to be called to the physician and any orders received would be carried out by the nurses while in close communication with the ADONs. · On 02/25/21 at 11:00 A.M. a second QAPI meeting was held with the IDT and MD #302 to go over the [MEDICATION NAME]/lab monitoring action plan. No new recommendations were given by MD #302. The QAPI team will continue to monitor the daily audits and discuss findings related to [MEDICATION NAME] therapy weekly for at least 90 days to determine if any revisions are needed. QAPI meetings are scheduled every Thursday at 11:00 A.M. · On 02/26/21 at 1:45 P.M., MD #302 gave orders to change all the [MEDICATION NAME] administration to late evening (between 8:00 P .M. and 11:00 P.M.). · The [MEDICATION NAME]/lab monitoring audits are brought to QAPI weekly on Thursday at 1100 A.M. for review to determine if any revisions are needed. · Interviews on 03/04/21 between 1:12 P.M. and 2:00 P.M. with LPN #336, LPN #346, LPN #347, and LPN #348, who worked across all shifts, revealed they were educated by ADONs #305, #308, and #309 regarding the new procedure for managing INR lab work. and [MEDICATION NAME] administration. The LPNs were knowledgeable regarding the new procedures, lab values, and correct action to take when a critical PT/INR is received. Although the Immediate Jeopardy was removed on 02/26/21 the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm) as the facility was still in the process of implementing their correction action plan to ensure ongoing compliance. Findings include: 1. Review of Resident #45's medical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated , 02/09/21 revealed Resident #45 had moderate cognitive impairment. Review of Resident #45's lab record, reported on 02/08/21 at 5:12 P.M. revealed Resident #45's INR was 5.8 and his Hgb was 6.6. Review of Resident #45's Medication Administration Record (MAR) revealed Resident #45 was administered [MEDICATION NAME] 6 mg on 02/08/21 at 6:00 P.M., [MEDICATION NAME] 7 mg on 02/09/21 between 4:00 P.M. and 7:00 P.M., and [MEDICATION NAME] 6 mg on 02/10/21 between 4:00 P.M. and 7:00 P.M. Review of Resident #45's progress note dated 02/11/21 at 1:00 P.M. revealed Resident #45 continued to complain of dizziness that was worse now than previously. NP #303 was notified of worsening dizziness. Review of Resident #45's progress note dated 02/11/21 at 2:38 P.M. revealed ADON #308 received a call from the lab with a critical INR of 6.1 for Resident #45. ADON #308 notified NP #303 and LPN #339 of the results. Review of Resident #45's progress notes dated 02/11/21 at 7:53 P.M. revealed LPN #315 received a call from the lab for a critical INR level of 6.4 and a Hgb of 5.7 g/dL. MD #302 was notified of the lab results and ordered to send Resident #45 to the hospital ED. Review of Resident #45's hospital lab results revealed on 02/11/21 at 11:47 P.M. an INR of 8.1 and Hgb of 5.7 g/dL were documented. Review of Resident #45's progress note dated 02/12/21 at 6:36 A.M. revealed Resident #45 received two units of blood at the hospital and his INR was 8.1. Interview on 02/17/21 at 2:25 P.M. with Administrator #304 revealed the facility did not have a Director of Nursing but had three ADONs. The three ADONs had been in their positions approximately one month. Administrator #304 stated the facility employed a consultant (CSA #312) to assist the ADONs. Interview on 02/18/21 at 7:34 A.M. with Lab Supervisor (LS) #301 revealed when a resident's blood was drawn for lab tests, the time of the blood collection was documented by the technician drawing the blood, and when the results were obtained a fax was automatically sent to the facility. If there were abnormal lab values the facility was called with the results. LS #301 stated on 02/08/21 at 6:31 P.M. a phone call was made to the facility and LPN #306 was notified of a critical INR of 5.8 and low Hgb of 6.6 g/dL for Resident #45. Observation on 02/18/21 at 12:17 P.M. revealed Resident #45 was not in his room and unable to be interviewed. ADON #308 stated Resident #45 had been transported to the hospital and she was not sure when he would return. Interview on 02/18/21 at 2:00 P.M. with ADON #305 revealed the ADONs were responsible for checking PT/INR and all lab results. ADON #305 stated a list of residents and lab tests needed for each resident was printed every day, and the ADONs were responsible to check the results and notify the physician. Interview on 02/21/21 at 7:39 P.M. with LPN #306 revealed on 02/08/21 she was assigned to the nursing unit Resident #45 resided on. LPN #306 stated she was very busy on 02/08/21 and did not remember taking a phone call from the lab for critical lab values for Resident #45, and she did not contact NP #303 or MD #302 regarding lab results. Interview on 02/24/21 at 12:10 P.M. with NP #303 revealed Resident #45 had blood drawn on 02/08/21 and she was not notified of the critical INR of 5.8 or low Hgb of 6.6 g/dL until 02/11/21. NP #303 stated there needed to be a reliable system in the facility for notification of abnormal lab results. NP #303 stated therapeutic levels of INR were 2-3. Interview on 02/24/21 at 2:48 P.M. with MD #302 revealed MD #302 was not notified of Resident #45's critical INR value of 5.8 and Hgb of 6.6 g/dL for three days. MD #302 stated he was furious the facility did not notify him or NP #303 regarding critical lab values for Resident #45 until 02/11/21. MD #302 stated he could not trust the facility to take care of the residents and he had a hard time sleeping at night because he was worried about the residents ' welfare. Interview on 02/24/21 at 3:35 P.M. with CSA #312 revealed the facility started an action plan involving the Quality Assurance Committee on 02/11/21 or 02/12/21 following the situation involving Resident #45 when the critical lab results were not reported to the physician for three days. A Lab Due Report was printed daily for each resident needing blood drawn. The lab was supposed to have the results available to the facility by 12:00 P.M. each day, the ADONs checked the results and if they were not back by noon the lab was called to find out why the results were not available. Interview on 02/25/21 at 9:00 A.M. with MD #302 revealed he would send a resident to the ED if the Hgb was below 6 g/dL or was dropping quickly and the resident was actively bleeding; MD #302 would arrange for a transfusion at an infusion center if the Hgb was 7 g/dL. Interview on 03/04/21 at 4:12 P.M. with Registered Nurse (RN) #339 revealed Resident #45's INR of 6.1 drawn 02/11/21 at 2:33 A.M. was reported around 2:30 P.M. on 02/11/21 by ADON #308. After the results were reported NP #303 asked about the INR and Hgb results from 02/08/21. Upon notification of the 02/08/21 labs NP #303 ordered a stat INR and Hgb for Resident #45. Interview on 03/06/21 at 3:05 P.M. with ADON #308 revealed she took the phone call from the lab on 02/11/21 at 2:38 P.M. regarding Resident #45's INR of 6.1. Resident #45 did not reside on her nursing unit so she called RN #339 and NP #303 to notify them of the critical INR level. ADON #308 did not recall calling for lab results from 02/08/21 or calling LPN #306 to find out why she did not report the results to the resident's physician on 02/08/21. 2. Review of Resident #66's medical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] revealed facility was unable to complete a Brief Interview for Mental Status (BIMS) due to severe cognitive impairment and Resident #66 needed extensive assistance with activities of daily living. Review of Resident #66's lab record reported to the facility on [DATE] at 1:42 P.M. revealed a high INR of 3.8. Review of Resident #66's MAR revealed on 02/22/21 [MEDICATION NAME] 5 mg was administered between 4:00 P.M. and 7:00 P.M. by LPN #300. Review of Resident #66's progress notes on 02/23/21 at 8:25 A.M. revealed ADON #308 called NP #303 with Resident #66's INR of 3.8 and received an order to hold the [MEDICATION NAME] on 02/23/21 and 02/24/21 and re-check the INR level on 02/25/21. Interview on 02/24/21 at 6:02 P.M. with ADON #308 confirmed Resident #66 was administered [MEDICATION NAME] 5 mg on 02/22/21 after the lab reported Resident #66's INR was 3.8 on 02/22/21. ADON #308 stated she checked the INR results from her home on 02/22/21 around 4:00 P.M., was unable to contact the nurse on the unit, checked the MAR and the [MEDICATION NAME] had already been administered. On 02/26/21 at 1:45 P.M., MD #302 gave orders to change all the [MEDICATION NAME] administration to late evening (between 8:00 P.M. and 11:00 P.M.) to ensure sufficient time for notification to the nurse administering medications. Interview on 03/09/21 at 9:57 A.M. with Lab Representative (LR) #345 revealed Resident #66's INR of 3.8 was available in the online portal on 02/22/21 at 1:42 P.M. and was faxed to the facility on [DATE] at 1:49 P.M. LR #345 stated as soon as the results were released off the instrument, they were available in the online portal. Review of the facility's undated [MEDICATION NAME] ([MEDICATION NAME]) policy revealed [MEDICATION NAME] is monitored by [MEDICATION NAME] time (PT) and the International Normalized Ratio (INR). The PT/INR is performed per practitioner order to manage the dosage of [MEDICATION NAME]. Review of the facility's undated policy titled Lab and Diagnostic Test Results-Clinical Protocol revealed a nurse will review all results. If the staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. The person who is to communicate results to a physician will review and be prepared to discuss the following (to the extent that such information is available): The individual's current condition and any recent changes in status, including vital signs and mental status; Major diagnoses, allergies [REDACTED]. status, treatments, or medications; and Any concerns or issues the physician will be expected to address upon receiving the results. Before contacting the physician, the nurse will gather and organize the information listed above and coordinate any telephone communications with others who may also need to speak with the physician. Review of information from Medscape titled, [MEDICATION NAME] Time, dated 11/21/19 revealed the reference range for INR is 0.8 to 1.1, and possible critical values are an INR greater than 5.5. A cause of prolonged [MEDICATION NAME] time included [MEDICATION NAME] use. Review of Medscape medication information titled, [MEDICATION NAME] (Rx), undated included a black box warning indicating [MEDICATION NAME] sodium ([MEDICATION NAME]) can cause major or fatal bleeding; bleeding is more likely to occur during the starting period and with a higher dose (resulting in a higher INR). Risk factors for bleeding include high intensity of anticoagulation (INR greater than 4), age [AGE] years or older, highly variable INRs, history of [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION] disease, serious [MEDICAL CONDITIONS], malignancy, trauma, [MEDICAL CONDITION], concomitant drugs, and long duration of [MEDICATION NAME] therapy. Regular monitoring of INR should be performed on all treated patients; those at high risk of bleeding may benefit from more frequent INR monitoring, careful dose adjustment to desired INR, and a shorter duration of therapy. Review of Medscape information titled, Transfusion and Autotransfusion, dated 04/16/16 revealed the guidelines for recommendations from 2016 American Association of Blood Banks include a restrictive Red Blood Cell transfusion threshold of a Hgb concentration of 7 g/dL or less should be considered for hospitalized adult patients who are hemodynamically stable. Also consider transfusion for Hgb concentrations of 8 g/dL or less in hospitalized patients who are hemodynamically stable with pre-existing cardiovascular disease. Review of Medscape information titled Hemoglobin Concentration (Hb), dated 11/27/19 revealed the reference range for adult males was 14-18. This deficiency substantiates Complaint Number OH 048.

Based on medical record review, interviews with staff, Ombudsman (OMB) #600, Resident #109 ' s family and police officer (PO) #500, review of the facility incident report, elopement policy, police call report and police incident report, and ambulance report, the facility failed to provide adequate supervision for Resident #109, who was identified at risk for elopement, when the resident was observed outside of the facility on 10/11/14 at 2:55 A.M. without a coat and with a hematoma to the head. Resident #109 eloped from the Rehabilitation Unit to the outside of the facility, attempted to re-enter the building at the main entrance and at the nursing entrance, and was refused re-entry by maintenance security staff (MSS) #211. Licensed practical nurse (LPN) #403 notified the police of a male who refused to leave facility property and appeared beaten up and intoxicated. Police responded to the facility and assisted with transfer of this male, whom facility staff failed to identify as Resident #109, to a local hospital. This resulted in Immediate Jeopardy for one resident (Resident #109) of 7 residents who resided on the Rehabilitation Unit and were assessed to be at risk for elopement. The facility identified 11 residents at risk for elopement. The facility census was 108. On 10/15/14 at 3:30 P.M., the Executive Director (ED), Director of Nursing (DON) and Assistant Director of Nursing (ADON) #401 were notified that Immediate Jeopardy began on 10/11/14 at 2:55 A.M. when Resident #109 was viewed on the facility ' s security camera outside the facility and was refused re-entry by MSS #211. The Immediate Jeopardy remained on-going until 10/17/14 when the facility implemented the following corrective measures: ? On 10/11/14, licensed nursing staff began reassessment of all 24 residents residing on the Rehabilitation Unit for elopement risk. The reassessments were completed by 10/14/14. The facility initiated a system to ensure all new admissions would be assessed for elopement risk at the time of admission. Review of five new admissions, Residents #111, #112 and #113, admitted on [DATE] and Residents #114 and #115, admitted on [DATE], had completed elopement risk assessments. ? On 10/11/14, RN #407 began staff re-education regarding elopement risk. Changes and additional education were conducted by the DON on 10/12/14 and 10/13/14. On 10/16/14 training for the 37 nursing staff working on this date, was completed by ADON #401 regarding a new system that included documenting every 15 minute checks including a description of what the resident was doing at the time the check was completed. ? On 10/13/14 the Maintenance and Security Director (MSD #200) issued a ' Memo to Maintenance and Security Staff ' of an updated resident and visitor event or emergency protocol for security personnel to follow. The memo provided updated information related to responding to an unknown person on the property which included contacting nursing or another security personnel via radio before encountering the unknown person; and contacting Nursing 1 to have them contact all floors to check for missing residents. ? On 10/14/14, State-tested nurse aide (STNA) #300 received disciplinary action for not punching in/out when leaving the facility for a lunch break and also for not completing every 15 minute checks for Resident #109 on 10/11/14 as ordered. ? On 10/15/14, new interventions were added to Resident #109 ' s Risk for Elopement plan of care including to post a picture of the resident on all units. ? On 10/16/14, security changes included the installation of delayed egress (key pads with codes) to the second floor dining room Rehabilitation Unit door, installation of a Wanderguard (a system that will sound an audible alarm when a resident wearing an activation device gets near an exit that is equipped with an alarm box) alert system on the Rehabilitation Unit elevator and the removal of the magnetic hold for open doors on nursing units 1 and 2 dining room service entrances. The facility also changed the key pad door codes throughout the facility and removed the posted codes that were visible from the exits. ? On 10/16/14, the DON implemented a new Elopement Policy and Procedure. The new policy and procedure was reviewed during the all staff in-service training on 10/17/14. ? On 10/17/14, the DON conducted education for all staff, which included 257 of 265 licensed and unlicensed personnel related to building changes for increased security measures for residents at risk for elopement. Additional nursing education was provided on this date to 123 of 129 nursing staff (licensed and unlicensed) related to elopement risk assessments, new admissions, new 15 minute check protocol and identification of residents at risk for elopement via the implementation of a resident picture system on all units. All staff not in attendance at the training would be required to receive training prior to their next shift worked. ? From 10/17/14 through 10/21/14, interviews conducted with the administrator, DON, Licensed Social Worker (LSW) #410, Registered Nurses (RN) #402, #405, #406, #407, #408, STNAs #302, #303, #304, #305, #306, #307, #308, LPNs #404 and #409, Speech Pathologist (SLP) #411, Housekeeper (HSK) #412, the MSD#200 and MSS #211 revealed all staff interviewed were knowledgeable regarding the facility elopement policy and procedures including responding to Wanderguard alarms and the facility missing person procedure. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was implementing an on-going system for monitoring the corrective measures and all staff had not received training. Findings include: Review of Resident #109's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed the resident was admitted to the facility ' s unsecured Rehabilitation Unit with no Wanderguard alerting system in place. Review of a physician order, dated 10/09/14 revealed staff were to conduct every 15 minute checks, every shift. An admission plan of care for fall and safety risks dated 10/09/14, included interventions for the use of an alarm in the chair and in the bed with a goal to keep the resident safe and uninjured. In addition to the physician ordered 15 minute checks, record review revealed on 10/09/14 RN #405 initiated a nursing intervention for the resident to have one on one staff supervision. An education memo was provided to staff working the Rehabilitation Unit that explained the intent of the one on one supervision and staff responsibilities of the one on one supervision. The education program referred to Guidelines which stated Resident #109 and a second resident, Resident #110 "must be supervised at all times with a person sitting with him. There must be a handoff to another person that is present if you are the one assigned " and " leave his side." "This is a 1:1 supervision at all times." A plan of care, initiated on 10/10/14 revealed the resident experienced wandering and was at risk for elopement. Interventions included ensuring Resident #109 had an identification band in place and to encourage him to be in a supervised area when out of bed. Review of a nursing progress note dated 10/10/14 at 2:50 A.M. as a late entry for 10/09/14 at 9:46 P.M., revealed Resident #109 remained with one on one (1:1) staff supervision. The note described the resident as impulsive, getting up unassisted frequently with poor safety awareness. On 10/10/14 at 10:16 A.M. a nurse ' s note revealed the resident was alert with confused mentation; remained with 1:1 staff supervision; continued to be impulsive and got up unassisted frequently with poor safety awareness. He was easily redirected. The resident denied pain or discomfort; bed and chair alarms were in place and functioning properly. Review of a nursing progress note, entered as a late entry on 10/11/14 at 4:23 A.M. for 10/10/14 at 8:20 P.M., revealed Resident #109 denied any pain or distress. The resident remained with 1:1 staff supervision related to decreased safety awareness. No signs or symptoms of bleeding were noted. Review of a nursing progress note, dated 10/11/2014 at 4:45 A.M. revealed STNA #300 informed RN #402 that Resident #109 was not in his room when she went to complete a 15 minute check. The Rehabilitation Unit was searched thoroughly without locating the resident ' s whereabouts. The note indicated an attempt to notify Nursing 1 and Nursing 2 Units of a possible elopement. When there was no answer via phone, RN #402 walked to the Nursing 2 unit and asked LPN #404 if she had seen the resident anywhere on her unit. She stated that she had not. MSS #211 was notified related to a possible elopement and was provided a picture of Resident #109. MSS #211 then confirmed the resident had been observed outside the facility knocking on the door to gain access earlier in the night. Per MSS#211, Resident #109 appeared confused and appeared to have sustained a head injury. The nursing progress note indicated MSS #211 had called police to assist with the situation and that MSS #211 was unaware the man was a resident of the facility. A nursing progress noted dated 10/11/14 at 5:08 A.M. revealed a local hospital was notified to determine if they had admitted a resident fitting Resident#109 ' s description. The hospital confirmed Resident #109 was admitted with a hematoma (a localized collection of blood outside the blood vessels, usually in liquid form within the tissue) to the head. On 10/11/14 at 5:23 A.M., RN #402 documented Resident #109's daughter was notified of the resident's elopement and admission to a local hospital with a hematoma injury to the head. Review of a 15 minute check documentation sheet, dated 10/11/14 for Resident #109 revealed STNA #300 documented she completed every 15 minutes from 12:00 A.M. until 3:00 A.M. On 10/15/14 at 9:25 A.M., interview with the DON confirmed Resident #109 did not have the physician ordered 15 minutes checks completed after 3:00 A.M. Additionally, the DON verified a discrepancy in facility documentation, as STNA #300 documented she observed the resident at 3:00 A.M. but security camera footage showed Resident #109 was outside the facility at the main entrance at 2:55 A.M. The DON indicated staff were not sure how the resident got outside the facility, but it was likely he exited the facility via a stairwell. Record review revealed the facility completed an incident summary following the incident. The summary indicated on 10/11/14 at approximately 3:20 A.M., an adult male buzzed in to Nursing 1 in an attempt to enter the building from the outside. LPN #404 spoke to the male, but did not recall the male giving his name. The male at the door told LPN #404 he was a teacher and had lost his car. The summary indicated the male appeared to be holding something like a notebook. At approximately 3:23 A.M., LPN #404 notified MSS #211 of a man wanting to enter the building and having slurred speech. MSS #211 arrived at the entrance at approximately 3:24 A.M. According to a corresponding video security camera timeline, at 3:25 A.M. MSS #211 responded to the breezeway entrance. Resident #109 was seen opening the folder he was carrying to show MSS #221 and there appeared to be a conversation between the two. At 3:32 A.M., Resident #109 was visualized at the Healthcare doorway and then went out of the sight of the security camera with MSS #211 towards the smoke room, reappeared and sat on the ground. MSS #211's witness statement indicated he noticed the man had a " big welt beside his right eye similar to someone being punched " . MSS #211 instructed LPN #404 to call the police. MSS #211 had the man, who was later identified as Resident #109, sit in the smoke room and wait for the police. The incident summary revealed STNA #300, who was the STNA assigned to care for Resident #109 on 10/11/14 during the night shift (11:00 P.M. to 7:00 A.M.) left the facility and went to lunch at 3:30 A.M. The summary indicated, prior to leaving the unit, the STNA spoke with RN #402, who was the charge nurse on the unit. RN #402 had been sitting at the desk by the elevator, just in front of the nursing area per the facility incident summary. STNA #301, the second STNA assigned to the Rehabilitation Unit, was sitting in the common area with another resident at that time. No alarms were noted to sound nor did RN #402 or STNA #301 hear any doors closing per the incident summary. The incident summary revealed STNA #300 was seen, via the facility video surveillance leaving the facility Portico entrance at 3:33 A.M. The incident summary indicated, upon returning from lunch at 4:00 A.M., STNA #300 went to assist another resident, Resident #110 who was attempting to get out of bed. Continued review of the facility incident summary and timeline revealed on 10/11/14 at 4:01 A.M. police arrived at the facility at the same time STNA #300 was observed re-entering the building via security camera. At 4:02 A.M., the male who was outside (still unknown to facility staff to be Resident #109) was escorted to an ambulance by police and MSS #211. The incident summary indicated on 10/11/14 at 4:30 A.M., STNA #300 entered Resident #109 ' s room and determined the resident was not in his room. STNA #300 notified RN #402 the resident was missing. However the witness statement completed by RN #402 revealed he was not notified of the missing resident until 4:45 A.M. at which time, RN #402 initiated a thorough check of the unit by having STNAs #300 and#301 check each room on the unit. RN #402 checked the stairwell from the Rehabilitation Unit all the way to the Chapel without locating the resident. RN #402 proceeded to walk from the Rehabilitation Unit to the Nursing 2 Unit and asked LPN #404 if she had seen anyone. RN #402 showed LPN #404 a picture of Resident #109 from his medication administration record (MAR) and LPN #404 told him there had been a man outside Nursing 1 earlier, but MSS #211 had handled that incident. RN #402 then called MSS #211 and showed him the picture, which MSS #211 verified was Resident #109. Resident #109, who had been outside the facility at 2:55 A.M., had been transported to the hospital at 4:01 A.M. RN #402 did not know Resident #109 was missing until after 4:45 A.M. The facility did not know the missing resident was the same man sent to the hospital by police until 5:30 A.M. when the witness statement of MSS #211 identified Resident #109. In addition to the above incident summary, review of a security timeline and incident summary completed by the facility regarding the elopement of Resident #109 on 10/11/14 revealed at 2:15 A.M., Resident #109 had locked himself in his room and RN #402 was able to talk him into unlocking and opening the door. As the resident was a high fall risk, RN #402 placed tape over the locking mechanism on the door. On 10/11/14 at approximately 2:30-2:35 A.M. STNA #300 observed Resident #109 get out of bed and ambulate to the bathroom in his room. The security camera timeline indicated on 10/11/14 at 2:55 A.M. Resident #109 came from the parking lot to the South Portico entrance and sat in a chair. At 2:57 A.M. the resident was attempting to get in through the Park Vista South entrance, and at 2:58 A.M., the resident was seen on camera sitting down reading from a booklet he had with him. However, the incident summary indicated STNA #300 stated she observed Resident #109 ' s door closed at 3:00 A.M., so she cracked the door open and visualized his legs and feet in the bed on top of the linens. He had pajama bottoms and nonskid socks at that time. On 10/11/14 at 3:04 A.M. the security camera timeline indicated Resident #109 left the Portico camera range and was seen again on the camera at the nursing entrance 50 seconds later when he tried to enter through the employee entrance and Health Care entrance. (These three entrances were all different entrances of the facility). At 3:06 A.M. the resident left security camera range and seven minutes later at 3:13 A.M. was visualized at the Portico and was looking in the door. The security camera timeline indicated at 3:15 A.M. the resident left camera range and at 3:18 A.M. the resident was visualized at the Portico. Then at 3:21 A.M. he left security camera range and was visualized again at 3:21 A.M. at the employee/healthcare entrance and tried the employee entrance first. At 3:22 A.M., Resident #109 was seen at the healthcare entrance inside the breezeway and may have rung the bell. It was at that time that LPN#404 spoke with the resident. However, LPN #404 failed to identify the man as Resident #109. Review of the ambulance " Patient Care Report " dated 10/11/14, revealed a call was received from the local police department 10/11/14 at 3:45 A.M., for an immediate response for an injured person at the facility. The ambulance arrived at 3:55 A.M. and at 4:17 A.M. transported a male (later identified as Resident #109) to the hospital. The ambulance Patient Care Report revealed the ambulance arrived at the hospital at 4:21 A.M. The chief complaint identified on the report was " other " and indicated " falls " . The report indicated the resident did not remember how he got to the area and thought he was living at the facility for rehabilitation. The assessment portion of the report revealed the resident had a hematoma to the head and his speech was clear with normal tone. The narrative further revealed Resident #109 was found by facility staff trying to get in the building and they called police who responded and while talking to the male and noticed he was missing a few days of memory of how he got back here and where he came from. The report was signed by ambulance crew member (CM #1). Review of hospital records revealed Resident #109 was admitted to the emergency department on 10/11/14 at 4:25 A.M. A hospital nursing note at 5:17 A.M. revealed hospital personnel were able to identify the resident ' s family and the previous facility he had been discharged from on 10/09/14. Two attempts were made to call the resident ' s daughter. At 5:34 A.M., the physician progress notes [REDACTED]. The physical exam revealed the resident exhibited edema and tenderness of the right facial bone. The skin was warm and dry with diffuse abrasions. At the time of the progress note, radiology results were pending. The plan was to admit the resident to the telemetry unit with a [DIAGNOSES REDACTED]. A hospital nursing progress note, dated 10/11/14 at 5:43 A.M. revealed a call was received from the resident ' s daughter. The daughter notified the hospital the resident was residing at the facility prior to his arrival to the emergency room . A physician ' s progress note, completed at 7:37 A.M. revealed the presence of possibly a new subdural hematoma; neurosurgery and medicine had been consulted and the resident would be admitted . The axial computer tomography without contrast (CT scan) signed on 10/11/14 at 7:33 A.M. indicated a possible subdural hematoma on the right side of the resident ' s head. Review of Police Incident Report #14- 8.1 dated 10/11/14 revealed the police were dispatched to the emergency room for a possible assault involving Resident #109. Upon arrival, the officer spoke with Resident #109 ' s daughter who indicated she received a call from the hospital on [DATE] at approximately 5:20 A.M. that her father was in the emergency room after he was found wandering around the city with facial injuries. This shocked her as she knew her father was a resident at the nursing facility. The police report indicated at approximately 5:39 A.M. the resident ' s daughter had received a call from a male employee at the facility explaining Resident #109 had gotten out of the facility. The caller also mentioned that a male was knocking on the door the night before and he thought it may have been Resident #109. The police officer checked with dispatch and was able to verify that police units were sent to the facility on [DATE] at 3:32 A.M. for the male with facial injuries talking with security. The caller (LPN #403) stated the male appeared intoxicated and refused to leave facility grounds. The report reflected apparently staff did not realize that Resident #109 was a resident that got out of the facility. On 10/15/14 at 10:39 A.M. interview with the DON revealed she had interviewed STNA #300, following the incident. The DON stated the STNA was very clear she had seen the bottom of Resident #109 ' s legs and his pajama bottoms and non-skid socks on 10/11/14 at 3:00 A.M. The DON verified the facility security camera showed Resident #109 outside the main entrance at 2:55 A.M. On 10/15/14 from 12:13 P.M. to 12:44 P.M., interview with OMB #600 revealed she had been in the facility on 10/14/14 and spoke with the administrator who had indicated Resident #109 had a bed alarm that did not sound on the night he went missing. OMB #600 stated she went to the hospital to visit Resident #109 on 10/14/14 and he " had a shiner. " " He looked like somebody knocked him out. " Her interview with the resident revealed he thought he had fallen and he remembered leaving and looking for his car in the parking lot. Her observations of the resident revealed the " shiner " on the right side of his face with cuts and scrapes on his right arm and his right leg. On 10/15/14 from 6:27 P.M. until 6:53 P.M., an interview was conducted with MSS #211 in the presence of MSD #200. MSS #211 confirmed his witness statement as noted in the above incident summary. When asked what the resident was wearing, MSS #211 indicated the resident was wearing a short sleeve dark colored polo shirt, dark colored pants and shoes, but no coat. MSS #211 indicated it was cold outside and stated the resident was always moving as if he was losing his balance. The resident was slurring his words and it got to the point where MSS #211 thought the resident was from one of the " group homes " located around the park across the street from the facility. MSS #211 stated many times he found people in the parking lots and sleeping on the bench in the front Portico. It was not uncommon to get a strange person at the facility because of " all the group homes " in the area. MSS #211 indicated he would have never thought the person was a resident from the facility and verified he made no attempt to check with staff to ensure all residents in the facility were accounted for. MSS #211 indicated when he first started talking to the resident, he took him to the smoke room and offered him a cigarette. Further interview with MSS #211 on 10/16/14 at 5:27 P.M. revealed Resident #109 was carrying a folder/papers with him and would open the folder, but would not let MSS #211 physically take the folder or look in it. On 10/16/14 from 7:58 A.M. to 8:17 A.M. interview with LPN #403 confirmed the above information contained in the facility incident summary. When asked what she told the police, she stated she told them they had a gentleman on the property that would not leave and she was instructed by security to have him escorted off the property. LPN #403 thought at some time the police dispatcher asked her if the " gentleman " belonged at the facility, and she told them no. At that time, she was unaware the gentleman did belong in the facility. Even after being asked this, LPN #403 made no attempt to ensure all facility residents were accounted for on all units. When Resident #109 was observed on the security camera monitor, his speech was slurred and he was rambling on about things. She assumed he had been drinking alcohol as he was not making any sense of anything. Prior to him being observed on the monitor, LPN #403 indicated she was not aware of any resident missing and she did not call the other units. LPN #403 indicated she was notified by MSS #221 on 10/11/14 at approximately 5:25 A.M., that the gentleman outside was Resident #109. On 10/16/14 at 8:20 A.M., interview with STNA #301 revealed she had not been asked to complete 15 minute checks on Resident #109 while STNA #300 left the facility to go to lunch at approximately 3:30 A.M. On 10/16/14 from 9:27 A.M. through 9:46 A.M. interview with Resident #109 ' s daughter revealed she had visited her dad during the evening of 10/10/14 and he was upset because staff had pushed him into the common room, would not allow him to move from the common room and he " reeked " of urine. The daughter stated she asked the nurse if she could take him to his room and acknowledged he had a bed and a chair alarm in place. The daughter indicated when the emergency room staff called shortly after 5:00 A.M. on 10/11/14 to inform her of Resident #109 ' s admission, the facility staff had not yet informed her that her dad was missing. When he was admitted to the hospital, he had his teeth in and had his memory book, a book that contained his name and social security number in it. She stated she took pictures of his injuries. He had a new subdural bleed, his right shoulder, right eye and cheek had bruising and swelling. Both hands and his right knee had scrapes. The daughter stated Resident #109 did not have a facility identification band/wrist band in place with his name or the name of the facility on it. He was freezing cold when the police found him. On 10/16/14 between 11:12 A.M. and 12:25 P.M. interview with STNA #300 revealed she was assigned to care for Resident #109 during the night shift on 10/11/14. During the interview, the STNA indicated as part of her job responsibilities on this night, she was to provide one on one supervision to both Resident #109 and Resident #110. The STNA indicated in addition to the one on one supervision, she was required to document every 15 minute checks being completed for Resident #109. The STNA verified she documented she had observed Resident #109 at 3:00 A.M. The STNA stated the resident was in his room in bed at that time. STNA #300 revealed she did not complete the 15 minute checks as ordered at 3:15 A.M. or at 3:30 A.M. and then at 3:30 A.M. indicated she left the facility to go to the store for lunch. There was no explanation as to why the one on one supervision or 15 minute checks were not being completed. Review of STNA #300 ' s time card and interview with STNA #300, revealed she did not punch out when she left the facility for her lunch meal and therefore it could not be verified the actual times she was gone from the facility. Interview with the STNA revealed she returned to the facility at 4:00 A.M. However, she did not return to check on Resident #109 until 4:30 A.M. at which time she determined the resident was not in his room. On 10/16/14 between 12:57 P.M. and 1:21 P.M. interview with the Director of the Rehabilitation unit (RN) #405 revealed she had instructed staff on the Rehabilitation Unit via a memo dated 10/09/14 to provide one on one supervision to Resident #109 and also a second resident, Resident #110. RN #405 revealed this one on one supervision was in addition to the every 15 minute checks that were ordered by the physician for Resident #109. During the interview, reviewed of the education memo, dated 10/09/14 with RN #405 revealed STNA #300 had signed the education sheet to verify her attendance. The education program referred to Guidelines which stated Resident #109 and Resident 110 " must be supervised at all times with a person sitting with him. There must be a handoff to another person that is present if you are the one assigned " and " leave his side. " " This is 1:1 supervision at all times. " Although RN #405 confirmed the content of the education, she indicated her intention was that when the residents were in a supervised area that one person was to have eyes on them. " I was just trying to be emphatic to staff that the residents needed to be supervised. " On 10/16/14 from 2:39 P.M. to 3:35 P.M., interview with RN #402, who was assigned to care for Resident #109 the night of the incident, confirmed his nurse ' s notes and witness statement as noted above regarding the elopement incident on 10/11/14. RN #402 confirmed STNA #300 was the staff assigned to both Resident #109 and Resident #110 for 15 minute checks and for 1:1 staff supervision. RN #402 explained STNA #300 had a desk positioned in between the rooms of the two residents (Resident #109 and #110) that she was sitting at to provide the supervision. He also explained when STNA #300 was in other rooms caring for the other residents she was assigned, STNA #301 was supposed to be watching Resident #109 and Resident #110. However, further review of the one on one supervision education revealed STNA #301 did not attend the education program. On 10/21/14 from 9:08 A.M. through 9:23 A.M., PO #500 was interviewed. PO #500 confirmed his police report and indicated he briefly interacted with the resident in the emergency roiagnom on [DATE]. He indicated the resident denied he was assaulted, and his injuries seemed more consistent with a fall. However, as the resident could not recall a fall either, PO #500 saw that he was confused and did not question him further. He identified he was very surprised that this could have happened to this man and stated the call had come in as a " drunk injured man knocking at the door and would not leave " . PO #500 stated the nursing home was in an area of town that was not a good area to be wandering in at night. On 10/21/14 from 10:49 A.M. through 10:54 A.M., interview with the DON confirmed Resident #109 eloped from the facility without staff knowledge and attempts made by the resident to re-enter the facility were not permitted. The DON confirmed Resident #109 did not have an identification bracelet in accordance with his plan of care and indicated she could not explain why this was part of his care plan as the facility stopped using identification bands " some time ago " as the residents frequently took them off. When this incident occurred, the resident ' s picture was available to nursing staff via the medication administration record and the STNA " point of care " system, but not available to security or maintenance staff. Further interview with the DON on 10/21/14 from 11:25 A.M. to 11:29 A.M. revealed prior to the incident, the facility ' s elopement policy was to have social services complete an elopement assessment for all newly admitted residents. There was no scoring or follow through with the old assessments. The new elopement policy, effective 10/16/14 ensured the elopement assessment was completed by nursing staff. If a resident was identified at risk for elopement, nursing staff would be responsible to notify all departments of the at risk residents and ensure interventions were in place to prevent at risk residents from eloping. This deficiency substantiates Complaint Number OH 667.

Based on staff and physician interviews, clinical record reviews, and review of the facility's policy and procedure regarding cardiopulmonary resuscitation (CPR), the facility failed to ensure CPR was initiated on Residents #104, #105 and #106, who were assessed as a full code status and when they were discovered without a pulse or respirations by staff. This resulted in Immediate Jeopardy for three of five full code status residents reviewed who expired in the facility. The facility census was 103. On [DATE] at 12:00 P.M. the administrator and director of nursing (DON) were notified that Immediate Jeopardy began on [DATE] at 5:15 P.M., when Licensed Practical Nurse (LPN) #18 entered Resident #106's room, found the resident without a pulse or respirations, and LPN #18 did not initiate CPR. Immediate Jeopardy continued on [DATE] at 12:10 A.M., when LPN #15 entered Resident #104's room, found the resident without a pulse or respirations, and LPN #15 failed to initiate CPR. The Immediate Jeopardy continued on [DATE] at 5:30 P.M., when LPN #2 was called to Resident #105's room, found the resident sitting up in his wheelchair with his head back, with no pulse or respirations, and LPN #2 failed to initiate CPR. All three residents had been assessed and designated as a full code status residents. Full code status means that all life saving measures were taken in order to treat a patient after/during a respiratory or [MEDICAL CONDITION]. The Immediate Jeopardy remained ongoing from [DATE] to [DATE] , as there were residents with full code status in the facility, and staff verified CPR would not have been initiated during that time frame for a resident who was found without vital signs. The Immediate Jeopardy was removed on [DATE], when the facility implemented the following corrective actions: ? On [DATE], the facility implemented a new policy entitled 'When to Initiate CPR', for all residents with full code status and for residents not specifying a code status. ? All current nursing staff, which consisted of six Registered Nurses (RNs) and 24 LPNs, were in- serviced on [DATE], on the proper procedures to follow when a resident who was a full code status was found with no pulse or respirations. ? On [DATE], the new policy was placed in all the residents' medication administration records. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm). There was insufficient evidence to determine if quality assurance systems were in place and monitoring was being implemented on an ongoing basis. The new policy was implemented and the inservice training was completed on [DATE]. Nursing staff were interviewed on [DATE], and were knowledgable of the new policy regarding 'When to Initiate CPR'. Findings include: 1. Resident #106 was admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident was admitted to the facility for therapy services. The resident was a full code status. Resident #106's nurses' note dated [DATE] at 6:52 P.M., revealed LPN #18 had entered the resident's room at approximately 5:15 P.M., and found the resident without a pulse or respirations. LPN #18 notified Physician #1 and received orders not to start CPR per the physician's request. There was no indication in the nurses' notes on [DATE], of the amount of time that had elapsed between the resident being found without pulse and respirations and Physician #1 returning LPN #18's phone call to tell her not to initiate CPR. LPN #18 was interviewed on [DATE] at 10:27 A.M. LPN #18 stated she did not remember the exact details of that day, but she did remember what happened with Resident #106. LPN #18 stated she walked into the resident's room to give the resident her medications. LPN #18 stated she gave the resident oral medications and a breathing treatment. LPN #18 stated she put the aerosol mask on the resident and returned to the room ,[DATE] minutes later when the treatment was complete. LPN #18 stated the resident's head was elevated and she asked the resident if there was anything else she needed. When the resident said no she went back to the medication cart to continue medication pass. Per LPN #18 this occurred at approximately 4:00 P.M., and the resident had no complaints at that time. LPN #18 stated she continued with medication pass and "a little while later" the State-tested nurse aide (STNA) approached her and told her to come and check on the resident. LPN #18 stated she went into the resident's room with a stethoscope to check the resident. LPN #18 said she called the resident's name, and when Resident #106 did not respond, she checked her and did not hear any heartbeat. LPN #18 stated she left the resident's room, went to the computer to check the resident's code status and called Physician #1. The resident's code status was full code. LPN #18 did not start CPR. LPN #18 stated it was the first time she was in that situation, so she asked another nurse what to do, but, by the time the other nurse answered her Physician #1 called back. LPN #18 stated she told Physician #1 the resident was a full code and Physician #1 told her the resident had already passed and not to start CPR. 2. Resident #104 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident had no cognitive impairments. The resident was admitted to the facility for therapy and received physical, occupational and speech therapies. The resident was a full code status. According to a nurses' note dated [DATE] at 12:15 A.M., Resident #104 had been up in his wheelchair and requested to be put to bed at 11:55 P.M. The staff assisted him to bed and the resident requested a pain pill. When LPN #15 entered the resident's room to administer the medication at 12:10 A.M., the resident was found to have no vital signs. The nurse wrote that the resident's pupils were fixed and unresponsive, and Physician # 1 was paged. The next nurses' note written by LPN #15 on [DATE] at 12:20 A.M. stated Physician #1 returned the call and gave an order not to start CPR and release the body to the funeral home of the family's choice. LPN #15 was interviewed on [DATE] at 2:56 P.M. LPN #15 stated on the day Resident #104 passed, the resident requested to be put to bed because he was sitting up in his wheelchair. LPN #15 stated she had just started the medication pass on the 11:00 P.M. to 7:00 A.M. shift, and STNA #28 put the resident to bed. When STNA #28 came out of the resident's room, he told the nurse Resident #104 had requested pain medication. LPN #15 stated she did not know the resident's source of pain. LPN #15 stated she was doing her midnight medication pass and she told STNA #28 she would bring the medication in about five minutes. LPN #15 stated when she went into the resident's room at approximately 12:05 A.M. to give him the pain medication, Resident #104 did not look at her when she called his name. She touched the resident's arm to gently wake him and he did not respond to the touch. When she turned on the lights to look at him closer, she stated she saw, "He was gone, or I believed he was without checking for vital signs." LPN #15 stated she then got a blood pressure cuff and stethoscope and verified the resident did not have any vital signs. LPN #15 then checked the resident's code status and found out he was a full code. LPN #15 stated she immediately called Physician #1, because she knew once you start CPR you could not stop. LPN #15 stated she had found other residents without vitals and Physician #1 told her when you find them without vital signs you do not start CPR even if they are a full code. LPN #15 stated when Physician #1 called her back at 12:20 A.M., she told LPN #15 not to start CPR, but to call the funeral home and take care of it. 3. Resident #105 was originally admitted to the facility on [DATE] and readmitted on [DATE], after a hospital stay. The resident's [DIAGNOSES REDACTED]. The resident's MDS 3.0 assessment dated [DATE], indicated the resident had moderate cognitive impairment. The resident was a full code status. According to a social services note dated [DATE], Resident #105 was alert and oriented to three spheres and was in the facility for long term care. The note indicated the resident's code status was currently full code status, with no changes at that time. The nurses' note dated [DATE] at 5:30 P.M., revealed LPN #2 was called into the room by STNA #27 because the resident was unresponsive. LPN #2 wrote that she entered the room and the resident was up in his wheelchair with his head back and no vital signs present. LPN #2 called Physician #1 to inform her of the resident's status. CPR was not initiated on the resident. LPN #2 was interviewed on [DATE] at 2:43 P.M. LPN #2 stated she was called to Resident #105's room by STNA #27. The resident was sitting in his wheelchair and no vital signs were present. LPN #2 stated she checked the resident's carotid pulse and respirations, and there were none. LPN #2 stated she called Physician #1 and told her what had happened, and Physician #1 said to 'pronounce him' , that he was gone. LPN #2 stated she told Physician #1 the resident was a full code but the physician said he was gone already, so no CPR was needed. LPN #2 was asked what the facility's policy was when a resident was found with no pulse and no respirations and was a full code status. LPN #2 stated the nurse was to notify the doctor and inform them of resident's status to see if they should initiate CPR. LPN #2 stated if the resident did have vital signs present you were to start CPR immediately. The facility's current policy titled Cardiopulmonary Resuscitation, effective [DATE], was reviewed on [DATE]. The policy revealed the signs and symptoms that indicated CPR would be needed included absent pulse, absent breathing and loss of consciousness. The policy included a general procedure on how to initiate CPR. It did not address a resident's code status and how to respond if the resident had a designated code status. Physician #1 who was also the medical director, was interviewed on [DATE] at 3:13 P.M. The physician was asked what the staff were to do if they found a resident who was a full code without pulse or respirations. Physician #1 stated if the resident was a full code and was found with no pulse and respirations, the staff should call emergency medical services. The physician stated she told the staff if it was obvious, like the resident had been gone for hours, the staff should not start CPR. Physician #1 stated she was not informed Resident #104 was a full code and that staff told her the resident had been without vital signs at least ,[DATE] minutes. Physician #1 also stated she was informed by staff that Resident #105 was without vital signs for more than an hour. This deficiency substantiates Complaint Number OH 536 and is an example of continued non-compliance from the complaint survey of [DATE].

Based on observation, record review and interview, the facility failed to ensure interventions were implemented after the decline in a right heel pressure ulcer. This affected one resident (Resident #93) of two residents reviewed related to pressure ulcer development and treatment. The facility census was 105 residents. Findings include: Resident #93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of admission nursing assessment documentation revealed the resident was admitted with an unstageable area to her right hip. The resident was also admitted with a Stage I pressure ulcer (an observable, pressure-related alteration of intact skin) to her right heel. The area was assessed on 01/02/10 to be six centimeters (cm) long by five cm wide with no depth and was described to be non-blanchable and red. Review of physician orders [REDACTED]. On 01/31/11 at 11:46 A.M., Resident #93 was observed sitting in a geriatric chair with her legs elevated. The resident wore non-skid slipper socks and her heels rested directly on geriatric chair. The resident did not have heel protectors in place. Observations were made of the resident on 01/31/11 at 12:44 P.M., 3:48 P.M. and 5:07 P.M., sitting in the geriatric chair with her heels directly on the chair without any heel protectors in place. The resident was observed on 02/01/11 at 11:08 A.M. and 2:55 P.M., sitting in the geriatric chair with her heels directly on the chair without any heel protectors in place. On 02/02/11 at 8:30 A.M. the resident was observed in her room in bed. Licensed Practical Nurse (LPN) #14 administered medications to the resident. During the medication administration, the resident complained of her feet hurting. The LPN administered the resident Tylenol for complaints of pain. The LPN did not observe or assess the resident's feet at that time. Observations on 02/02/11 at 12:03 P.M. and 3:05 P.M., revealed the resident sitting in the geriatric chair with her legs elevated without any type of heel protectors in place. On 02/02/11 at 3:35 P.M., Resident #93 was observed being transferred from the geriatric chair to bed via Hoyer lift by State tested Nurse Aide (STNA) #4 and STNA #5. After transferring the resident to bed, no heel protectors were applied and the resident's heels were observed directly on the mattress. The STNA's verified the resident was only wearing slipper socks. At 3:39 P.M., STNA #4 changed the resident's clothes. The STNA did not apply heel protectors and the resident's heels were directly on the mattress. The STNA then obtained an extra pillow and indicated she was going to place it under the resident's heels. As the STNA attempted to raise the resident's legs, the resident called out, "ouch ouch" and indicated that her right foot hurt, especially when someone was trying to touch it. The STNA was unable to place the pillow under the resident's legs. On 02/02/11 at 4:00 P.M., interview with LPN #6 and STNA #4 verified Resident #93 did not have nor did she use heel protectors. STNA #4 stated the resident had moved from a different room and possibly the heel protectors didn't come with her. The resident had a dressing in place to her right heel, but minimal touch by LPN #6 resulted in the resident complaining of pain. Once the foot/heel was untouched, the resident no longer voiced complaints of pain.