Every finding on record at Pleasantview Care Center

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, interview, and facility policy review, the facility failed to ensure medications were given as ordered for Resident #210. This affected one resident (#210) of three residents reviewed for administration of medications. The facility census was 160. Findings include:Review of the closed medical record for Resident #210 revealed she was admitted to the facility on [DATE] and had diagnoses including bladder cancer, dysphagia, and other disorders of electrolyte and fluid imbalance. She expired in the facility on [DATE]. Review of Resident #210's physician's orders revealed an order for Phos-NaK oral packet (an electrolyte supplement) to be given four times per day starting [DATE]. Review of Resident #210's [DATE] Medication Administration Record (MAR) revealed all doses of the Phos-Nak, with the exception of the evening dose on [DATE], were marked ‘other' on the MAR.Review of Resident #210's progress notes revealed notes on [DATE] and from [DATE] to [DATE] indicating the medication was ‘on order' or the facility was waiting for pharmacy to fill it. Multiple notes indicated the facility's nurse practitioner was aware. A note on [DATE] revealed the pharmacy informed nursing that the medication was over-the-counter and should be provided by the facility.Interview on [DATE] from 10:52 A.M. to 10:59 A.M. with two Certified Nurse Practitioners (CNP) #748 and #739 revealed both provided care for Resident #210 during her stay at the facility. Both CNPs denied knowledge of Resident #210 lacking her ordered medications. Interview on [DATE] at 1:02 P.M. with the Director of Nursing revealed the facility investigation revealed the concern with Resident #210's Phos-NaK. The DON reported they re-educated staff on coordinating with the pharmacy and being aware the facility provided Phos-NaK for residents. She confirmed Resident #210 missed several days of ordered Phos-NaK doses.Review of the policy Medication Administration dated 12/2019 revealed medications were to be given according to orders. If three consecutive doses were unavailable, the nurse was to notify the physician and was to document both the notification and physician response.The deficient practice was corrected on [DATE] when the facility implemented the following corrective actions: -Resident #210 expired on [DATE].-On [DATE], the Director of Nursing completed a whole house audit of medication availability and proper communication with the pharmacy. -On [DATE], the DON provided an in-service to nursing staff on medication availability and what to do if a medication is unavailable.-On [DATE], the facility initiated Medication Administration Record (MAR) audits five days a week for two weeks then two days a week for 10 weeks to ensure proper follow-through if medication is unavailable.This deficiency represents noncompliance investigated under Complaint Number 2593423.

Based on closed record review, review of a facility self-reported incident (SRI), and interviews with staff and the coroner, the facility failed to ensure Resident #145 was provided adequate and necessary care and services during the provision of personal care to prevent an accident/injury. Actual harm occurred on [DATE] when Resident #145, who had right hemiplegia/hemiparesis and was dependent on staff for bed mobility and personal care sustained a significantly displaced acute proximal right humeral neck fracture with medial angulation during care provided by staff. The resident displayed increased pain as a result of the incident and required orthopedic surgical follow-up. This affected one resident (#145) of three residents reviewed for accident hazards. The facility census was 75. Findings include: Review of the closed medical record for Resident #145 revealed an admitted [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction (stroke) affecting the right dominant side, osteopenia, atrial fibrillation, chronic pain, and convulsions. Review of the plan of care dated [DATE] revealed Resident #145 was at risk for impaired functional range of motion related to inability to move extremities independently, potential for contractures, and weakness due to history of stroke. Interventions included if the resident refused offer again later in the day and administer medications as ordered for pain. An activities of daily living (ADL) care plan related to activity intolerance, fatigue, pain and history of stroke revealed interventions including providing care based on the residents' usual performance. The care plan revealed the resident was dependent on staff for toileting, personal hygiene, rolling left to right, and transferring. Resident #145 was to always wear a gown per family. The care plan included to instruct Resident #145 to use grab bars on the bed to assist with bed mobility. Staff to assist with the completion of activities of daily living (ADLs), two people assist for all care and encourage Resident #145 to fully participate. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #145 had impaired cognition. The assessment revealed Resident #145 was dependent on staff for transfers, bed mobility (rolling left and right) and toileting. Resident #145 had impairment on one side of both lower and upper extremities. Review of a facility SRI tracking number 258571 revealed on [DATE], Resident #145 had redness and swelling on the right upper extremity. An x-ray results showed a proximal right humerus neck fracture. The SRI revealed staff were unaware of any falls or other injuries. Staff stated Resident #145 was able to roll to the right and hold the grab bar with her left hand for assistance. Following this incident, the facility initiated a new intervention for two-persons assistance with care to be provided to Resident #145. Review of the radiology report dated [DATE] at 9:30 P.M. of right shoulder revealed a significantly displaced acute proximal right humeral neck fracture with medial angulation. Greater than one shaft width displacement. The right humeral head remains in articulation with the glenoid with advanced degenerative changes of the joint space. Moderate degenerative change of the acromioclavicular joint. Reactive soft tissue swelling. Review of the physician orders dated [DATE] revealed an order for Tramadol (narcotic pain medication to treat moderate to severe pain) 50 milligrams (mg) one tablet every six hours as needed to treat the resident's pain. On [DATE], an additional order for routine pain medication was added (Tramadol 50 mg two times daily; then discontinued on [DATE]) On [DATE], Oxycodone (narcotic pain medication to treat moderate to severe pain) five mg one tablet every six hours for pain was ordered. Review of an orthopedic surgery note dated [DATE] revealed Resident #145 was seen by the physician for acute pain of right shoulder and displaced fracture of proximal end of right humerus. Review of hospital records revealed Resident #145 was transferred to the hospital on [DATE] related to hypoxia (body does not receive enough oxygen) and was treated for pneumonia. Resident #145 received comfort measures in the hospital and expired on [DATE]. Interviews on [DATE] at 10:14 A.M. with Registered Nurse (RN) #300; at 10:38 A.M. with RN #301, at 11:10 A.M. with Licensed Practical Nurse (LPN) #302; at 11:15 A.M. with Certified Nursing Assistant (CNA) #303; at 3:12 P.M. with CNA #304; at 3:16 P.M. with #305; and at 3:27 P.M. with CNA #306 revealed Resident #145 had a contracture to her right arm/shoulder and was unable to move her arm more than a few inches. Interview on [DATE] at 3:36 P.M. with RN #307 revealed she was Resident #145's nurse the weekend of [DATE], and she worked day shift. RN #307 denied knowledge of any swelling of redness to Resident#145's right arm/shoulder. The RN revealed she did not know of any injury until she came back in to work on Sunday morning. She was told the resident had a fracture of her humerus and her arm was in a sling. The resident had an order for pain medications and needed an orthro appointment made. Interview on [DATE] at 10:38 A.M. with RN #301 revealed she worked on [DATE] from 7:00 A.M. to 7:00 P.M. as the nursing supervisor. The floor nurse notified her on the evening of [DATE] that Resident #145 had redness and swelling of the right upper arm and it was warm not hot. RN #301 stated she did not see anything else out of the ordinary. Interview on [DATE] at 2:29 P.M. with the Director of Nursing (DON) revealed Resident #145 right humerus fracture must have been sustained during care (as the resident was dependent on staff for care and had an inability to move her right arm/shoulder more than a few inches). However, the DON revealed she was unable to determine how Resident #145 sustained the fracture. Interview on [DATE] at 9:50 A.M. with CNA #318 revealed he was the CNA assigned to care for Resident #145 on [DATE]. He stated during the shift on [DATE], he did not believe Resident #145 acted any different than her normal. During the interview, CNA #318 denied knowledge of any swelling in Resident #145's hand or arm, and no bruising or discoloration noted. Interview on [DATE] at 10:03 A.M. with Coroner #402 revealed the preliminary findings for cause of Resident #145's death was contributed to heart disease, pneumonia, and a right arm fracture. Coroner #402 stated there was a bruise on the arm where the fracture was, and a small bruise on the back of the resident's hand. The coroner revealed resident had osteopenia prominently and it would not have taken much to break her arm. The coroner revealed the break likely could have occurred when staff were providing care. This deficiency represents non-compliance investigated under Control Number OH00164638 and Complaint Number OH00164284.

Based on interviews, record review, review of the facilities self-reported incident (SRI), and policy review, the facility failed to ensure all injuries of unknown origin were timely reported to management and the State Survey Agency, Ohio Department of Health (ODH). This affected one (Resident #145) of one resident reviewed for abuse reporting. The facility census was 142. Findings include: Review of the closed medical record for Resident #145 revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, osteopenia, atrial fibrillation, chronic pain, and convulsions. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #145 had impaired cognition. Resident #145 was dependent on staff for transfers, bed mobility (rolling left and right) and toileting. Resident #145 had impairment on one side of both lower and upper extremities. Review of the facilities SRI tracking number 258571 revealed the facility reported an injury of unknown origin to ODH on 03/24/25 at 11:46 A.M. The incident details included on 03/22/25, Resident #145 had redness and swelling on the right upper extremity. The x-ray results showed a proximal right humerus neck fracture. Staff were unaware of any falls or other injuries. Staff stated Resident #145 was able to roll to the right and hold the grab bar with her left hand for assistance. Review of the radiology report dated 03/22/25 at 9:30 P.M. of right shoulder revealed a significantly displaced acute proximal right humeral neck fracture with medial angulation. Greater than one shaft width displacement. The right humeral head remains in articulation with the glenoid with advanced degenerative changes of the joint space. Moderate degenerative change of the acromioclavicular joint. Reactive soft tissue swelling. Interview on 04/16/25 at 10:38 A.M. with Registered Nurse (RN) #301 stated she worked at the facility on 03/22/25 from 7 A.M. to 7 P.M. as the nursing supervisor. The floor nurse notified her of Resident #145's redness and swelling of the right upper arm. The nurse notified the Nurse Practitioner on call and got orders for an ultrasound and an x-ray. She worked the next morning and was told in the morning report that Resident #145 had a humerus fracture. RN #301 stated she did not do anything else related to the incident and did not notify the Director of Nursing (DON) or Administrator of the incident. Interview on 04/17/25 at 8:15 A.M. with the DON verified she was not notified of Resident #145's arm fracture until 03/24/25 at 8:00 A.M., when she returned to the facility. The verified the SRI was not reported to ODH until 03/24/25 at 11:46 A.M. The DON verified an injury of unknown origin were to be reported to her and the Administrator immediately and should be reported to ODH within two hours of identifying an injury of unknown origin. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 01/06/25 revealed all injuries of unknown source must be reported immediately to the Administrator or designee. The Administrator/designee should be notified by informing him/her in person, calling via telephone, or sending and email or text message. If abuse is alleged or a serious bodily injury, the Administrator or his/her designee will notify ODH immediately, but not later than two hours after the allegation is made or the serious bodily injury identified. This deficiency represents non-compliance investigated under Control Number OH00164638 and Complaint Number OH00164284.

Based on observation, staff interview, and medication storage policy, the facility failed to ensure accurate labeling and storage of resident medication for medication cart #1 located on the Ridgeview unit and proper storage of medication in a locked box for Resident #408. This had the potential to affect 26 residents (6, 7, 8, 19, 23, 24, 26, 33, 36, 40, 48, 51, 55, 60, 63, 64, 81, 82, 90, 91, 98,107, 110, 118, 128, 144) who resided on Ridgeview unit. The census was 154. Findings include: 1. Observation on 06/12/24 at 9:20 A.M. of the medication cart #1 on Ridgeview unit with Licensed Practical Nurse (LPN) #534, revealed four loose white pills at the bottom of the medication cart drawer located between the medication cards. The four loose pills were observed to be without a medication label or resident identifier. Interview on 06/12/24 at 9:34 A.M., LPN #534 verified the four white pills were unable to be identified and confirmed the loose pills were without a medication label or resident identifier. 2. Record review of Resident #408 revealed an admitted [DATE]. Diagnoses included atrial fibrillation, nonrheumatic aortic valve stenosis, bradycardia, and arteriovenous malformation. Review of the Brief Interview for Mental Status (BIMS) score revealed no cognitive impairment. An Assessment for Self-Administration of Medications was completed on 05/31/24 and it was determined that Resident #408 was capable of self-administering her medications and granted approval. Review of the Physician Orders revealed Resident #408 had an order allowing her to self-administer Tikosyn 125 micrograms (mcg) twice daily unsupervised. The record did not include an order for Resident $408 to self-administer Preservision. Observation on 06/10/24 at 3:54 P.M. revealed two pill bottles sitting on the bedside tray table of Resident #408 that were identified as Preservision and Tikosyn and were not secured in a locked compartment. Interview with Resident #408 at the time revealed her husband brought the medications from home for her to self-administer. Resident confirmed she self-administers the two medications as ordered. Interview with Registered Nurse (RN) #583 on 06/11/24 at 2:39 P.M. confirmed she was unaware Resident #408 had and was self-administering Preservision and the medications were not secured in a locked drawer in the resident's nightstand. RN #583 revealed that Resident #408 never disclosed that her husband gave her Preservision to self-administer. Review of the facility policy titled Medication Storage in the Facility revised 01/2018 revealed all medications dispensed by the pharmacy are stored in the container with the pharmacy label.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure residents had access to a non-flammable ashtray and properly disposed of used cigarettes. This affected 19 residents (#3, #7, #10, #12, #15, #22, #27, #38, #55, #71, #72, #76, #96, #109, #112, #132, #137, #147, and #416), whom the facility identified as smokers, and had the potential to affect all 154 residents residing in the facility. Findings include: Observation on 06/11/24 at 2:31 P.M. with the Administrator revealed many cigarette butts in the plastic trash receptacle mixed with three empty combustible cigarette boxes, paper napkins, and plastic candy wrappers. No metal ashtray was available in the resident smoking area at the time of observation. Interview at the time of observation with the Administrator verified the above findings. Review of the facility policy titled Resident Smoking, dated 11/30/23, indicated smoking areas would have non-flammable ashtrays and non-flammable trash cans.

Based on observation, interviews, policy review, and surveyor taste test, the facility failed to serve food at a hot and palatable temperature. This had the potential to affect 145 residents that received meals from the kitchen with the exception of nine other residents (Residents #8, #19, #48, #72, #124, #135, #150, #310, #411) who were ordered nothing by mouth (NPO). The facility census was 154. Findings include: Interview with Resident #103 on 06/10/24 at 9:28 A.M. revealed the facility's food comes cold and so does the tea. Interview with Resident #408 on 06/10/24 at 3:49 P.M. revealed the resident was served eggs and cereal and does not eat them. Resident #408 also reported an incident on 06/09/24 in which she did not receive meat with her dinner. Interview with Resident #121 on 06/11/24 at 7:27 A.M. revealed the facility's food, specifically meat, is hard to cut and chew. Interview with Resident #21 on 06/11/24 at 9:55 A.M. revealed the resident was allergic to strawberries and was served strawberry jam desserts. Resident #21 also reported an incident in which he did not receive meat with his meal. Observation of lunch meal occurred on 06/12/24. Tray service began at 11:01 A.M. Observation revealed food temperatures were taken and logged prior to the start of the observation. Food temperatures were listed as followed: beef 161 degrees Fahrenheit (F); pork 158 degrees F; soup 176 degrees F; mixed vegetables 170 degrees F, baked potatoes 185 degrees F. Staff utilized plates out of the plate warmer with heated bottom and dome lid. Staff that plated food were attentive and communicated with tray line staff. Trays were plated and placed in a meal cart immediately. A test tray had been requested and was the last tray plated at 12:24 P.M. The meal cart arrived on the unit at 12:24 P.M. The staff passed out lunch food trays to residents in a disorganized manor which caused staff to transport the meal cart from one end of the unit to the other end a total of three times before all trays were passed. Once the trays were passed, the test tray was sampled at 12:41 P.M. by two surveyors with Dietary Manager #504 present. Temperatures of the foods sampled were as followed: beef 120 degrees F; mixed vegetables 120 degrees F; baked potato 130 degrees F. Dietary Manager #504 was made aware during the test tray observation that the beef, mixed vegetables, and baked potato were not palatable at the temperatures they were served. Review of the Food Temperatures at Point of Service Policy dated 06/08/22 revealed the holding temperatures for hot food should be at or above 135 degrees F.

Based on interview and medical record review, the facility failed to ensure a preadmission screening and resident review (PASRR) Identification Screen was completed for a new diagnosis of a serious mental illness. This affected one Resident (#32) of five residents reviewed for PASRR. The facility census was 154. Findings include: Review of the medical record for Resident #32 revealed admitted [DATE] and diagnoses including bipolar disorder, recurrent major depressive disorder, anxiety disorder, post traumatic stress disorder, and depressive type schizoaffective disorder. Review of the PASRR screen dated 03/30/23 revealed no evidence of schizoaffective disorder diagnosis was included on the screen. Review of Psychiatric Note dated 04/23/24 Resident #32 endorsed auditory hallucinations and delusions which supported diagnosis of schizophrenia. Additionally Resident #32's history revealed a consistent pattern of erratic behavior and challenges maintaining employment. It was recommended to add a new diagnosis of schizoaffective disorder. Review of the medical record revealed the diagnosis of depressive type schizoaffective disorder was added to Resident #32's diagnosis list on 04/23/24. Review of the medical record revealed there was no evidence of additional PASRR screening for Resident #32's newly added schizoaffective disorder diagnosis identified. There was no evidence of additional PASRR screens since 03/30/23. Interview on 06/11/24 at 10:30 A.M. with Director of Nursing (DON) and Social Service Designee (SSD) #581 confirmed a new diagnosis of schizoaffective disorder had been added for Resident #32 on 04/23/24. Interview on 06/11/24 at 11:00 A.M. with SSD #581 confirmed there had not been a PASRR screen completed for the 04/23/24 diagnosis. SSD #581 indicated she completed a PASRR screen on 06/11/24 to reflect the schizoaffective diagnosis. Review of the PASRR Result Notice dated 06/11/24 revealed Resident #32 did not require a level two evaluation and had no indications of serious mental illness and/or developmental disability.

Based on closed medical record review, hospital record review, policy and procedure review and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent and timely identify bilateral heel pressure ulcers for Resident #165. Actual harm occurred on 01/31/23 when Resident #165, who was cognitively impaired required extensive/dependence on staff for bed mobility and activities of daily living (ADL) care, was found to have an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) pressure ulcer to the right heel and a suspected deep tissue injury (SDTI) (a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear) pressure ulcer to the left heel. The ulcers deteriorated and on 05/23/23 the resident's daughter requested the resident be sent to the emergency room related to the condition of the heel ulcers, the ulcers had moderate amounts of copious drainage with a foul odor noted. The resident was subsequently admitted to the hospital and diagnosed and treated for heel ulcer wound infection. This affected one resident (#165) of three residents reviewed for pressure ulcers. Findings include: Review of Resident #165's closed medical record revealed the resident was admitted to the facility on [DATE], discharged to the hospital on 12/21/22, readmitted on [DATE] and discharged to the hospital on 05/31/23. Resident #165 had diagnoses including essential hypertension, muscle weakness and adult failure to thrive. A plan of care dated 12/20/22 revealed the resident had the potential for altercation in skin integrity due to a diagnosis of failure to thrive (FTT), easily bruising, history of a skin tear due to fragile skin condition, abnormal labs, decreased circulation/oxygenation, vitamin deficiency, mood/behavior status and being at risk for malnutrition and incontinence. Interventions included to administer medications as ordered, administer treatments as ordered, Braden score quarterly and as needed, diet per recommendations, monitor for bruising, monitor labs, offload heels as tolerated, pressure redistribution cushion to chair. An intervention dated 01/04/23 indicated to implement a low air loss mattress to the bed. Review of Resident #165's admission assessment and baseline care plans form dated 12/30/22 revealed Resident #165 was at high risk for skin breakdown and no skin concerns or pressure areas were identified on the document. Review of Resident #165's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderate cognitive impairment and required extensive two person assist for bed mobility and toilet use. The assessment also revealed the resident required total dependence with two-person assist for transfers and toilet use as well as total dependence one person assist for dressing, personal hygiene, and bathing. Review of Resident #165's medication administration records (MAR) and treatment administration records (TAR) from 01/01/23 to 01/31/23 revealed the low air loss mattress was implemented on 01/03/23. Review of Resident #165's Shower Sheet Forms dated 01/16/23, 01/19/23 and 01/23/23 did not reveal skin concerns or evidence of pressure ulcers. Review of Resident #165's progress note dated 01/25/23 at 2:26 P.M. revealed no new skin issues identified. Review of Resident #165's Shower Sheet Form dated 01/26/23 revealed her right and left heels were dry, and her shower sheet form dated 01/30/23 revealed nothing new was documented on the form. Review of Resident #165's progress note authored by Registered Nurse (RN) Wound Nurse #817 dated 01/30/23 at 11:15 A.M. revealed the resident was alert and responsive. Resident #165 required extensive assistance from one person for bed mobility and extensive assist from one person for transfers and toilet use. The note documented the resident's skin was within normal limits (WNL) and a treatment was in place. However, the progress note did not identify the type of treatment or the location of the treatment. Review of Resident #165's shower sheet form dated 01/31/23 revealed no skin issues were noted on the form. Review of Resident #165's progress note dated 01/31/23 at 7:39 A.M. revealed the resident had a SDTI (a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear) to the left heel and the wound bed was not visible with no drainage noted. The note also reflected the resident had a right heel pressure ulcer with the wound bed partially visible, 50% granulation tissue and scant drainage. (The right heel pressure ulcer was not staged by the facility per this note and the facility did not document wound measurements at this time). Review of Resident #165's Skin Alteration Incident Report Dated 01/31/23 at 11:02 A.M. indicated the son was notified on 02/01/23 at 1:05 P.M. and Certified Nurse Practitioner (CNP) #601 was notified on 01/31/23 at 1:05 P.M. of the new pressure ulcers. Review of Resident #165's facility Weekly Ulcer/Wound Documentation form dated 02/01/23 revealed a left heel SDTI measuring 5.1 centimeters (cm) length by 7.1 cm width with no cm depth which was a dark colored, non-blanching area. Resident #165 also had a right heel unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) which measured 2.3 cm by 6.1 cm by 0.1 cm depth. Resident #165 was noted to have 50% granulation tissue and 50% dark discolored area with a treatment in place. Review of the treatment administration records for February 2023 revealed no evidence the treatments were provided as ordered for the left heel on 02/06/23 or for the right heel on 02/06/23, 02/10/23, 02/14/23 or 02/28/23. Prior to the development of the pressure ulcers, there was no documented evidence of offloading for the resident's bilateral heels or turning and repositioning. Following the development of the bilateral heel pressure ulcers, the facility implemented the use of heel lift suspension boots to be used at all times. The use of the heel boots was reflected on the administration records. Record review revealed the facility completed weekly wound measurements from 02/01/23 through 05/23/23. Review of Resident #165's wound Certified Nurse Practitioner (CNP) #601's Wound Note form dated 02/14/23 revealed a left heel SDTI and a right heel unstageable pressure ulcer. The Weekly Wound Note, dated 03/28/23 at 11:27 A.M. revealed the resident had a left heel unstageable pressure ulcer which measured 5.0 cm length by 5.5 cm width with no depth and a right heel unstageable pressure ulcer which measured 2.6 cm length by 3.8 cm width with no depth which had 90% slough/necrosis present and a scant amount of thin, straw-colored drainage. Review of Resident #165's facility Weekly Ulcer/Wound Documentation form dated 05/23/23 revealed the CNP was in to assess and treat. The left heel was noted to have an unstageable pressure ulcer which measured 2.5 cm by 4.4 cm by 0.3 cm depth. Resident #165 also had a right heel unstageable pressure ulcer which measured 2.2 cm by 2.8 cm by 0.4 cm. Both heels were debrided at that time. Review of Resident #165's CNP #601's Weekly Wound Note dated 05/23/23 at 2:49 P.M. indicated the resident had an unstageable pressure ulcer to the left heel which measured 2.5 cm by 4.4 cm by 0.3 cm with a wound base of 50% granulation tissue and 50% slough/necrotic tissue with a scant amount of thin, straw-colored drainage and a debridement (a procedure to remove debris or infected/dead tissue from a wound) was completed. Resident #165 also had an unstageable right heel pressure ulcer which measured 2.0 cm by 2.8 cm by 0.4 cm with a wound base which was 100% slough/necrosis with a moderate amount of thin, straw-colored drainage and a debridement was completed. Review of Resident #165's progress note dated 05/23/23 at 10:08 P.M. indicated the resident's daughter requested the resident to be sent to the emergency room due to the ulcers to her heels. Wound care was provided, and moderate amounts of copious drainage was noted with a foul odor. Review of Resident #165's progress note dated 05/24/23 at 7:19 A.M. indicated the resident was admitted to the hospital for an infection. Review of Resident #165's emergency room visit note dated 05/24/23 at 1:46 A.M. indicated during an exam, Resident #165 was noted to have approximately grade three ulcerations of her bilateral heels, with the left worse than the right. There was foul smelling, purulent discharge with antibiotics initiated. No systemic symptoms or evidence of sepsis and radiographs showed no evidence of osteomyelitis or other deep space infection. Interview on 06/16/23 at 10:07 A.M. with CNP #601 indicated Resident #165's bilateral heels did have an odor but she did not feel it was an infectious odor but rather the odor of necrotic tissue. There was no evidence the resident's heel ulcers had ever been cultured while the wounds were being treated in the facility. Interview on 06/28/23 at 1:29 P.M. with the Director of Nursing (DON) revealed she believed Resident #165's bilateral heels were offloaded and the resident was being turned and repositioned prior to the development of the left heel SDTI heel pressure ulcer as well as the right heel unstageable pressure ulcer, although staff were not required to document the offloading or turning and repositioning in the resident's medical record. The DON confirmed Resident #165's hospital paperwork reflected the resident, upon admission to the hospital had purulent, foul-smelling drainage to her bilateral heels and she was hospitalized with a diagnosis of infection. Interview on 06/29/23 at 9:54 A.M. with Registered Nurse (RN) Wound Nurse #817 revealed the treatment in place that she documented in the progress note on 01/30/23 was barrier cream used to the resident's buttocks associated with incontinence. Interview on 06/29/23 at 11:46 A.M. with Resident #165's power of attorney (POA) for care revealed wound care concerns. The POA revealed there were multiple times the family would visit the resident and her heels would be directly on the bed and multiple times the dressings were not changed as ordered. He stated Emergency Contact #2 had visited Resident #165 prior to her discharge from the facility (on 05/24/23), and the resident's bilateral feet had a foul odor. The POA indicated the facility neglect was the reason why the resident did not return following her most recent hospitalization . Interview on 06/29/23 at 12:31 P.M. with the DON confirmed the facility did not obtain a culture of Resident #165's bilateral heel pressure wounds at any point following the development of the ulcers. Review of the facility policy titled Pressure Ulcer Prevention Protocols/Risk Assessment, dated 06/08/22, revealed a resident's level of risk for pressure ulcer development would initially be determined at the time of admission or readmission taking into consideration the nature of risk to include underlying causes. Residents were considered HIGH risk when admitted with any pressure ulcers, any history of pressure ulcers, any pressure ulcer wounds which the resident has physician order(s) addressing treatment(s), or a Braden Scale score less than or equal to 12. Pressure ulcer preventative/supportive precautions would be implemented including to offloading the resident's heels. This deficiency represents non-compliance investigated under Complaint Numbers OH00144100 and OH00143241.

Based on observation, interview, and facility policy review the facility failed to ensure food was stored and prepared appropriately to prevent potential foodborne illness. This had the potential to affect 139 residents who received meals in the facility. The facility identified 10 residents (Residents #14, #30, #56, #69, #87, #95, #122, #241, #378 and #429) as receiving no food by mouth. The facility census was 149. Findings include: Observation on 03/14/22 at 8:03 A.M. while completing the initial kitchen tour with Dietary Cook #661 revealed two tray carts with debris in the bottom of the carts, a straw on the floor of one cart, a food lid and debris in the bottom of a second cart, and two kitchen mixers had encrusted food materials behind the mixing bowls of the industrial mixer. While in the walk-in freezer ice buildup was observed on food items underneath the condenser, and two moldy oranges were found in the bin of oranges in the walk-in refrigerator. At the time of the observation, Dietary Cook #661 confirmed the findings. Observation on 03/15/22 at 9:10 A.M. of pureed food preparation with Dietary Cook #661 revealed she removed the robot coupe bowl and washed it in the sink with soapy water and replaced it on the robot coupe to complete second item. Dietary #661 confirmed she did not run the bowl through the dish machine for sanitation. Review of the facility policy titled, Cleaning Instructions: Food Preparation Appliances, dated 2017, revealed small appliances will be cleaned and sanitized after each use. Review of the facility policy titled, Cleaning and Sanitation of Dining and Food Service Areas, dated 2017, revealed the nutrition and food services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive schedule. Review of the facility policy titled, Cleaning Instructions: Food Carts, dated 2017, revealed food carts will be cleaned and sanitized immediately after each use.

Based on observation, interview, record review, and review of the facility policy the facility failed to ensure Resident #232 implemented safe smoking practices while residing in the facility. This affected one resident (Resident #232) of three residents reviewed for safe smoking practices. The facility census was 149. Findings include: Review of Resident #232's medical record revealed an admitted [DATE] with diagnoses including [CONDITION(S)], cutaneous abscess of right upper limb, and [CONDITION(S)]. Review of Resident #232's medical record and progress notes from 03/08/22 through 03/14/22 did not reveal documentation Resident #232 used tobacco and was educated on the smoking policy and risks of smoking. Review of Resident #232's Admission Assessment and Baseline Care Plan dated 03/08/22 did not reveal documentation Resident #232 used tobacco and was educated on the smoking policy and risks of smoking. Observation on 03/14/22 at 11:40 A.M. revealed Resident #232 walked out of his room with his surgical mask on. Resident #232 walked outside to the smoking area, pulled a lighter and cigarettes out of his pocket and began to smoke a cigarette. There were no facility staff present while Resident #232 smoked his cigarette. Interview on 03/14/22 at 11:52 A.M. with Resident #232 stated he walked outside and smoked whenever he wanted to. Resident #232 stated he kept his cigarettes and lighter in his pocket, and as he was talking, he pulled the cigarettes and lighter out of his right pocket to show the surveyor. Resident #232 stated facility staff was not always outside with him when he was smoking. Interview on 03/14/22 at 12:32 P.M. of Licensed Practical Nurse (LPN) #771 confirmed she was not aware Resident #232 smoked and verified he had his cigarettes and lighter in his pocket. Interview on 03/15/22 at 3:55 P.M. with Assistant Director of Nursing/Registered Nurse (ADON/RN) #790 revealed she did not know Resident #232 was a smoker and explained the smoking policy to him and made sure he was aware of supervised smoking times. ADON/RN #790 stated she did not know why smoking was not documented on Resident #232's admission assessment and told Resident #232 to make sure the nurse had his cigarettes and lighter. ADON/RN #790 stated residents needed supervised during smoke breaks. Review of the facility list of residents that smoke on 03/14/22 did not include Resident #232. Review of the undated facility policy titled Smoking Rules and Responsibilities included no residents were permitted to keep cigarettes, cigars, lighters or any other smoking materials on their person. All residents must be supervised by staff during designated smoking times only. All residents who choose to smoke are evaluated by the facility upon admission, quarterly, and as needed to determine if the resident needs any assistive devices to ensure their safety.

Based on observation, interview, record review, and review of the facility policy the facility failed to ensure physician orders were followed and care planned interventions were implemented for Resident #230. This affected one (Resident #230) of three residents reviewed for pressure ulcers. The facility census was 149. Findings include: Review of Resident #230's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged from the facility on 03/14/22. Review of Resident #230's Weekly Ulcer and Wound Documentation dated 02/22/22 revealed Resident #230 had an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) to the sacrum measuring 15.9 centimeters (cm) in length by 11.6 cm width and a depth of 0.1 cm. Review of Resident #230's admission assessment dated [DATE] included Resident #230 was at a high risk for skin breakdown. Review of Resident #230's physician orders on 02/24/22 revealed a low air loss mattress to the bed, check function every shift. Review of Resident #230's Treatment Administration Record (TAR) from 03/01/22 through 03/14/22 revealed there was documentation every shift Resident #230 had a low air loss mattress on the bed, and the function was checked every shift. Review of Resident #230's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #230 was cognitively intact and required the extensive assistance of two staff for bed mobility, transfers, and toilet use. Resident #230 was frequently incontinent of urine, always incontinent of bowel, and admitted with a pressure ulcer, but location and stage were not documented. Review of Resident #230's care plan revised 03/11/22 included Resident #230 had the potential for alteration in skin integrity related to bruises easily, history of skin tears due to fragile skin condition, abnormal labs, decreased circulation, oxygenation, vitamin deficiency, mood/behavior status, at risk for malnutrition, [CONDITION(S)], congestive heart failure, diabetes mellitus, obstructive sleep apnea, [CONDITION(S)]. [CONDITION(S)] with poor prognosis. Resident #230 would not develop skin breakdown through review date. Interventions included low air loss pressure redistribution mattress to bed. Observation on 03/14/22 at 9:24 A.M. of Resident #230 revealed she was lying in her bed and her son was at the bedside. Further observation of Resident #230 revealed she was lying on a pressure reducing mattress, not a low air loss mattress as ordered by the physician. Interview on 03/14/22 at 9:24 A.M. with Resident #230's son revealed Resident #230 had a sore on her bottom and there had been zero improvement since Resident #230 was admitted to the facility three weeks ago. When asked why Resident #230 was not on a low air loss mattress, Resident #230's son stated he did not know what that was and as far as he knew Resident #230 was on the same mattress her entire admission. Interview on 03/14/22 at 2:51 P.M. with the Director of Nursing (DON) confirmed Resident #230's mattress was not a low air loss mattress as ordered by the physician. The DON stated it was a pressure reducing mattress, not a low air loss mattress. The DON stated if it was a low air loss mattress it would have a pump hanging at the foot of the bed, and the bed did not have a pump. The DON confirmed nurses were documenting in the TAR Resident #230 had a low air loss mattress. Interview on 03/15/22 at 8:53 A.M. with Licensed Practical Nurse (LPN) #771 confirmed she documented Resident #230 had a low air loss mattress in the TAR and did not verify Resident #230 had a low air mattress when she documented it. LPN #771 stated she did not remember if Resident #230 had a low air loss mattress. Interview on 03/17/22 at 10:00 A.M. with the DON revealed Resident #230 had a low air loss mattress, the mattress malfunctioned either on 03/12/22 or 03/13/22, Registered Nurse (RN) #663 replaced the malfunctioning mattress with a pressure reducing mattress but did not document any problems with the low air loss mattress or place a maintenance work order to have it repaired. The DON stated there was no documented evidence regarding the malfunctioning mattress in Resident #230's medical record or for a maintenance work order. Interview on 03/17/22 at 2:32 P.M. of Maintenance Director (MD) #711 revealed he did not receive a work order through the electronic system for Resident #230's malfunctioning mattress. MD #711 stated if a low air loss mattress was not functioning properly for a resident the staff could replace it with another low air loss mattress, because there were low air loss mattresses available for use located in the facility. Review of the electronic maintenance work orders with MD #711 from 03/05/22 through 03/17/22 confirmed there were no work orders initiated for Resident #230's air loss mattress malfunction. Review of Resident #230's progress notes from 03/04/22 through 03/14/22 revealed no documented evidence Resident #230's low air loss mattress was not functioning properly. Review of the facility policy titled Pressure Ulcer Prevention Protocols/Risk Assessment, dated 11/30/18, included the policy was to provide guidelines for the prediction and prevention of pressure ulcers utilizing a systemic approach and monitoring skin integrity by implementing preventative and supportive precautions appropriate for the resident's identified level of risk. Residents were considered high risk when admitted with any pressure ulcers. Pressure ulcers supportive preventative precautions would be implemented.

Based on observation, interview, record review and policy review, the facility failed to maintain infection control standards when providing care for Resident #7 who was on isolation to prevent the potential spread of Covid-19. This affected one (Resident #7) of five residents reviewed for infection control and one of one resident receiving physical therapy services. The census was 137. Findings Include: Review of Resident #7's medical record revealed the resident was readmitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical record indicated Resident #7 was in quarantine due to readmit per facility policy. Transmission Based Precautions was put in place on 07/16/21. Observations on 07/17/21 at 9:47 A.M. revealed Physical Therapist (PT) #205 providing care for Resident #7. PT #205 was not wearing a gown. Further observation revealed the doorway leading to Resident #7's room had signage regarding the isolation with clear direction regarding what personal protective equipment (PPE) to don prior to entering the room and a storage pouch containing PPE. An interview was completed with PT #205 on 07/17/21 at 9:50 A.M. regarding the PPE required when entering the isolation room. After reading the signage on the door, PT #205 stated she should have been wearing a gown while in Resident #7's room. PT #205 confirmed she was not wearing a gown while in Resident 7's room providing care to the resident. Review of the facility policy titled COVID-19 Transmission Based Precautions- Droplet , dated 2021, revealed staff would utilize personal protective equipment (PPE) when providing care for a resident suspected of or diagnosed with COVID-19 which included a N95 mask, eye protection , gowns and gloves.

Based on, observations, interviews and record review, the facility failed to ensure all health care personnel (HCP) utilized personal protective equipment (PPE) properly to attempt to prevent and/or contain the spread of infection related to the global pandemic of [CONDITION(S)]-CoV-2 infection (COVID-19). This had the potential to affect all 133 residents residing at the facility. Findings include: Interview on 02/07/21 at 4:38 P.M. with State tested Nurse Aide (STNA) #350 who was wearing an N-95 mask. STNA #350 stated, I wear one mask for the week, I either take my mask home and leave it in my car or I just leave it in the locker room. They gave us five masks so I wear one a week then change it. Observation on 02/07/21 at 4:51 P.M. revealed STNA #350 exited Resident #107's room. Resident #107 had an isolation cart next to the entrance door and a sign on the door stating please see nurse. STNA #350 did not clean her face shield after exiting the isolation room. Interview on 02/07/21 at 4:52 P.M. with STNA #350 confirmed she did not clean her faceshield after exiting the isolation room. STNA#350 stated, Resident #107, is on isolation because two staff members tested positive, that's why all the residents on the hall are on isolation. STNA #350 revealed she cleaned her face shield after every three residents rooms. STNA #350 confirmed she worked the hall, where all residents were on isolation, the full shift and would assist where she was needed in the other areas of the facility. Interview on 02/07/21 at 4:52 P.M. with STNA #388 revealed she also assisted residents on the hall with STNA #350. STNA #388 confirmed she also cleaned her face shield every three rooms and stated,But I think we only have to do it at the end of our shift. STNA #388 confirmed she would wear her mask for the week then put a new one on. STNA #388 also confirmed she would store her mask in the back seat of her car or in the trunk in a bag. Interview on 02/07/21 at 5:09 P.M. with Licensed Practical Nurse (LPN) #351 revealed she only worked weekends and she would wear her N-95 mask, one mask for both days. LPN #351 confirmed she worked with residents on isolation for COVID 19 exposure and she would clean her faceshield, one time a day which was at the end of every shift. Interview on 02/07/21 at 5:27 P.M. with the Director of Nursing (DON) revealed all the staff were given five masks and five brown paper bags. At the end of the shift, the staff were to place their used mask that they wore the entire shift, back into the brown bag. The next shift, the staff were to use bag #2. The used mask was to rest 72 hours to four days between each use, then can be reused up to 5 days as long as they have the rest period. Guidance from the Centers for Disease Control updated 10/19/20, NIOSH-certified N95 FFRs are designed to filter 95% of particles when appropriately fitted to the wearer's face. This means that an N95 that is not properly fitted to the face will likely give the wearer less protection. N95 FFRs are designed to be single-use devices but may be used multiple times under crisis capacity strategies. N95 FFR performance will decrease as the number of hours and number of donnings and doffings increase. The number of times that an FFR can be reused will likely be limited by its fit because the tethering straps can become weaker or stretched after each donning. Each time an N95 FFR is donned or doffed, the integrity of the straps may be impacted. Repeated donning and doffing will result in the straps no longer being able to generate enough force to create a tight seal with the face. The resulting poor seal will allow unfiltered air to enter the N95 FFR and into the wearer's breathing zone. CDC recommends limiting the number of donnings for an N95 FFR to no more than five per device. This deficiency is an incidental finding.

Based on interview and record review, the facility failed to record and periodically update the address (mailing and email) and phone number of the resident representative(s) and facility failed to timely notify residents responsible party/representative of resident's death. This affected one resident, Resident #138, of three residents reviewed, Residents #137, Resident #138, and Resident #139. The facility census was 133. Findings include: Record review for Resident #138 revealed an admitted [DATE] and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the care plan dated [DATE] for Resident #138, who was listed as deceased on [DATE], which was completed by Licensed Practical Nurse (LPN) #323 revealed that Resident #138 had impaired cognition, thought process related to dementia, difficulty in making decisions, [CONDITION(S)] drug use and short-term memory loss. Record review of the upload dated [DATE] into the electronic medical system revealed the state of Ohio Living Will Declaration for Resident #138 dated [DATE] included a Health Care Power of Attorney (POA). The POA was listed as the niece. Record review of the facility contact list revealed Resident #138 had been named her own Responsible Party. Resident #138's sister had been titled Emergency Contact #1. Interview on [DATE] at 2:00 P.M. with Resident #138 ' s sister (Emergency contact on file) revealed the phone number the facility had was incorrect. Resident #138 ' s sister revealed after Resident #138 was admitted to the facility, she called the facility and spoke with the receptionist but was unable to recall the name. She gave the receptionist the phone number she could be reached at and requested to have the head nurse call her. She revealed a few days later when she did not receive a return call, she called back and left a voice message on the Social Workers answering machine with the number to reach her at and to return her call. Resident #138 ' s sister indicated there was no return call. She called again and spoke with a nurse, she was unable to unable to recall the nurses name, who told her that her sister was not eating. Resident #138 ' s sister stated she again left the correct number and requested an update. No one returned her call the following day, so she called again around 2:00 P.M. She was told her sister expired at 6:30 A.M. and was sent to a funeral home which was not the funeral home chosen by Resident #138. Resident #138 ' s sister indicated she checked her mail daily and received no mail from the facility. She indicated that neither she nor the POA had been contacted with any updates since admission on [DATE]. Resident #138's sister confirmed she had made multiple attempts to update the facility regarding her accurate phone number. Interview on [DATE] at 4:53 P.M. with Social Worker (SW) #332 revealed she was made aware Resident #138 had a POA after she passed. SW #332 confirmed she did not discuss with Resident #138 or her Emergency Contact if there was a POA or if they had set funeral arrangements. SW #332 revealed she would discuss those things during care conference, but she was unable to contact Resident #138 ' s Emergency Contact by phone to invite her to the care conference and Resident #138 declined the invitation to attend her care conference. SW #332 confirmed she did not mail an invitation to the care plan meeting or any information to attempt contact with Resident #138 ' s Emergency Contact. Interview on [DATE] at 12:37 P.M. with Receptionist #341 revealed she received about 300 phone calls a day. Receptionist #341 stated she received several calls in the past with families leaving phone numbers; she writes it down and gives the information to Social Services to update. Interview on [DATE] at 1:57 P.M. with Resident #138 ' s son revealed he called the facility on [DATE] at approximately 12:00 P.M. to get an update on Resident #138 ' s condition. Resident #138 ' s son expressed his concern the facility had not been returning calls to his Aunt, Resident #138 ' s sister/emergency contact. Resident #138 ' s son stated he spoke with the receptionist who took his phone number and stated the Nursing Director would return his call. Resident #138 ' s son stated, A few hours later, around 4:00 P.M. someone returned my call, I don ' t remember her name, she said the DON had called and asked her to call me, she said her shift started at 3:00 P.M. and she gave me an update on my mom. Resident #138 ' s son confirmed at that point, the facility had his number to contact him and his aunt's number. Interview on [DATE] at 3:00 P.M. with the DON revealed she initially recall receiving the message to call Resident #138 ' s son. DON revealed after speaking with Receptionist #341, she recalled receiving the message and phone number from Resident #138 ' s son on [DATE]. The DON sent an e-mail, with phone number, to RN Supervisor #337 on [DATE] to return a call Resident #138 ' s son. RN Supervisor #337 had LPN #335 call him to give him an update on Resident #138 ' s condition. LPN #335 was no longer employed at the facility and could not be interviewed. Record review revealed no documentation, including during the admission process, where the facility was able to contact the Emergency Contact by phone. Record review and interview revealed no attempts were made by the facility to contact the Emergency contact by mail or email. Record review and interview revealed the facility had the contact information for Resident #138's son prior to her death. This deficiency substantiates Complaint Number OHOO 2

Based on observations, interview, review of the facility's Coronavirus (COVID-19) policy, review of the Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS) Memo QSO-20-38-NH, updated 08/26/20, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure hand hygiene was consistently implemented to potentially prevent the spread of COVID-19 infections and failed to place a resident exposed to COVID-19 on transmission based precautions. This had the potential to affect all 145 residents residing in the facility. The facility census was 145. Findings include: Observation on 12/06/20 between 8:20 A.M. and 8:46 A.M. with State tested Nursing Assistants (STNA)'s #509 and #520 revealed N95 respirators were not covering their nose, mouth and chin. STNA #509 and #520 had their N95 respirators pulled down from their nose and only covering their mouth. STNA #509 and #520 confirmed the N95 respirators were not covering their noses and reached up two to three times during the interview to adjust their mask and did not use hand sanitizer after touching their mask. STNA #520 answered a call light during the interview and did not use hand sanitizer before entering Resident #7's room. STNA #520 confirmed she did not used hand sanitizer after touching her mask and entering Resident #7's room. STNA #509 confirmed she touched her mask and did not use hand sanitizer before continuing with her work. STNA #509 and #520 both stated they work different units in the facility depending on the need for a particular day. Review of Resident #131's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #131 had severe cognitive impairment and required extensive assistance with activities of daily living. Observation on 12/08/20 at 10:48 A.M. of Resident #131 sitting in the dining room wearing a surgical mask and sitting at least six feet away from six other residents (Residents #12, #13, #28, #41, #67 and #77). Review of the facility list of residents testing positive for COVID-19 revealed Resident #111 was tested on [DATE] and the positive results were obtained 11/30/20. Resident #111 was transferred from resident room [ROOM NUMBER] to the facility COVID-19 unit on 11/30/20. Review of the facility resident roster revealed Resident #111 had a roommate, and the roommate was Resident #131. Observation on 12/08/20 at 10:45 A.M. of Resident #131's room did not reveal resident was placed on transmission based precautions for exposure to COVID-19. There was no sign on the door stating Resident #131 was placed on transmission based precautions, and there was no Personal Protective Equipment (PPE) outside of the resident room. Interview on 12/08/20 at 11:50 A.M. with Infection Preventionist (IP) #519 and Administrator #501 confirmed Resident #131 was not placed on transmission based precautions after being exposed to COVID-19. Administrator #501 stated all the residents were monitored for COVID-19 symptoms, wore masks when out of their rooms, stayed at least six feet apart when they were in the common areas, and did not think Resident #131 had to be quarantined to her room. Review of CDC Coronavirus Disease 2019 (COVID 19), Using PPE, updated August 19,2020 states don't touch or adjust your face mask without cleaning your hands before and after. Review of the CDC, Coronavirus Disease 2019 (Covid-19), Interim Infection Prevention and Control recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic Infection Control Guidance, updated July 15, 2020 stated Healthcare Personnel (HCP) should wear a face mask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers. Further review stated HCP who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator (or face mask if respirator not available), and gown, gloves and eye protection. HCP working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with [DIAGNOSES REDACTED]-CoV-2 infection. If [DIAGNOSES REDACTED]-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP should follow Standard Precautions (and Transmission-Based Precautions if required based on the suspected diagnosis). Review of the Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS) Memo QSO-20-38-NH, updated 08/26/20, stated if a resident has symptoms consistent with COVID-19 or has been exposed to COVID-19, or if there is a facility outbreak and the resident declines testing, he or she should be placed on or remain on TBP until he or she meets the symptom-based criteria for discontinuation.

Based on observation, interview and record review, the facility failed to ensure residents fingernails were trimmed and cleaned, failed to ensure incontinence care was provided from clean to dirty areas of the body per recommended guidelines, and the facility failed to ensure physicians orders were followed to provide a resident with a condom catheter. This affected one resident (Resident #34) of three residents reviewed for trimmed and clean fingernails, one resident (Resident #47) of one resident reviewed for incontinence care, and one resident (Resident #61) of one resident reviewed for physician orders for condom catheters. The facility census was 145. Findings include: 1. Review of Resident #34's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #34 was cognitively intact and required extensive assistance with activities of daily living. Observations on 12/01/20 at 4:11 P.M. and 12/06/20 at 8:28 A.M. of Resident #34 lying in bed with the head of the bed elevated forty five degrees revealed long, approximately one half inch to three quarter inch in length fingernails with brown material under them. Resident #34 stated she never got out of bed and would like to. Resident #34 further stated she had only been out of bed one time since she came to live at the facility on 06/15/20. Interview on 12/06/20 at 7:46 A.M. with State tested Nursing Assistant (STNA) #517 revealed Resident #34 was never out of her bed. STNA #517 further stated she did not cut Resident #34's fingernails because she was afraid to and would tell the nurses they needed trimmed. The nurses did not trim the fingernails after she informed them this needed done. STNA #517 did not identify which nurses did not trim Resident #34's fingernails. Interview on 12/06/20 with Licensed Practical Nurse (LPN) #518 confirmed Resident #34 had long fingernails with a brownish substance seen underneath them. LPN #518 revealed she was not aware Resident #34 did not get out of bed. Interview on 12/06/20 at 10:47 A.M. with the Director of Nursing (DON) stated she was aware Resident #34 did not get out of bed and this was because Resident #34 refused to get out of bed. The DON further stated we encourage residents to get out of bed, but we cannot force them to. Review of Resident #34's care plan did not reveal interventions for Resident #34's refusal to get out of bed until 12/06/20. Review of Resident #34's progress notes did not reveal documented evidence that Resident #34 refused to get out of bed from 10/04/20 through 12/06/20. Further review of the progress notes did not reveal documentation staff members had provided activities and worked with Resident #34 on a one to one basis. 2. Review of Resident #47's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #47 was cognitively intact and required one person physical assist for activities of daily living. Observation with STNA #517 on 12/06/20 at 7:45 A.M. of Resident #47 revealed a saturated incontinence brief with urine on the sheets covering approximately a twelve inch circular area. STNA #517 filled a basin with warm water, gathered wash cloths and liquid soap. STNA #517 rolled Resident #47 onto his side, removed his incontinence brief, put the wash cloths in the water, lifted one out, applied soap and proceeded to wash the rectal area. She returned the cloth to the basin, took another cloth from the water and rinsed the rectal area, and returned the cloth to the basin. Next she dried the rectal area with a towel and rolled Resident #47 onto his back. STNA #517 reached in the basin took a cloth out, applied soap, washed Resident #47's genital area, put the cloth back in the water, took a cloth from the water, and rinsed the area, put the cloth back in the water, took the towel and dried the perineal area. STNA #517 assisted Resident #47 to sit on the edge of the bed, reached in the basin, took a cloth out, applied soap and washed under Resident #47's arms and his chest area, put the cloth back in the water, took a cloth out of the water, and rinsed under Resident #47's arms and his chest, put the cloth back in the water, took the towel, dried Resident #47 and put his shirt on. At no time during the care was the water changed or new wash cloths used. STNA #517 confirmed this was the way she provided incontinence care and washed Resident #47. Review of Resident #47's care plan revealed an intervention to check and change resident at least every two hours when in bed/nights and as needed and provide incontinence care as needed. Review of the facility policy titled, Incontinence Care, reviewed 11/13/19, included the purpose was to prevent infection. 3. Review of Resident #61's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #61 was cognitively intact and required two-person assistance for transfers and extensive assistance for mobility while in bed. Observation and interview on 12/06/20 at 7:46 A.M. of Resident #61 revealed the resident lying in bed with his gown on and covered with a sheet. Resident #61 was upset because he stated the STNA's refused to take him to the bathroom during the night. Resident #61 stated they won't give me my catheter, they won't take me to the bathroom, they expect me to sit up at the bedside and use a urinal, but I have a hard time sitting without falling backwards. There was no observation of a catheter for Resident #61. Interview on 12/06/20 at 8:46 A.M. with STNA #509 stated Resident #61 kept putting his call light on to go to the bathroom during the night, and also wanted his condom catheter. STNA #509 stated she kept telling Nurse #515 that Resident #61 wanted his catheter during the night shift. Nurse #515 was passing medications and went in Resident #61's room, but she did not put the catheter on him. STNA #509 confirmed she did not take Resident #61 to the bathroom but had him sit on the edge of the bed to use the urinal. Resident #61 stated he felt like he was going to fall, fell back a little, the mattress slipped away from the frame of the bed, and STNA #509 had to get STNA #516 to assist Resident #61 into the lying down position in bed. Phone interview on 12/06/20 at 12:30 P.M. with Nurse #515 stated she had not been told Resident #61 wanted a condom catheter and did not apply it. Nurse #515 stated this was the first she heard he wanted a condom catheter during the night. Interview on 12/07/20 at 4:39 P.M. with the Director of Nursing (DON) revealed she talked to STNA #509 and Nurse #515. The DON stated Nurse #515 now remembered she had been told Resident #61 wanted a condom catheter around 6:45 A.M. Review of physician's orders revealed an order 10/01/20 for a condom catheter every evening shift per resident request, apply in the evening. Review of Resident #61's progress notes did not reveal a condom catheter was provided for Resident #61 during the night shift on 12/06/20. This deficiency substantiates Complaint Number OH 228.

Based on interview and the Center for Disease Control Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings dated 03/27/20 the facility failed to ensure staff properly stored N95 masks prior to re-use in the facility. This had the potential to affect 95 residents who did not reside on the Covid positive unit. The census was 128 residents. Findings include: An interview with Registered Nurse (RN) #130 on 08/11/20 at 9:20 A.M. indicated she was educated on the storage of the N95 respirator type mask between uses. RN #130 indicated at the end of her shift she placed the used N95 mask in a paper bag and then placed the paper bag with the N95 used respirator mask in a grocery type plastic bag to carry out of the facility. RN #130 indicated prior to entering the building on her next scheduled working day she donned the N95 respirator type mask before entering the building at the start of her eight hour shift. RN #130 did not work in the Covid positive unit; the Covid positive unit had dedicated staff. An interview with State tested Nursing Assistant (STNA) #131 on 08/11/20 at 9:25 A.M. indicated he was educated on the storage of the N95 respirator type mask between uses. STNA #131 stated he placed his used N95 respirator mask in a paper bag and then sealed the paper bag with the used N95 respirator type mask in a sealed Ziploc bag at the end of his shift and carried the sealed Ziploc bag out of the facility to store until his next shift. STNA #131 indicated he re-used the N95 mask during his next scheduled shift in the facility. STNA #131 did not work in the Covid positive unit. An interview with the Infection Control Preventionist (ICP) on 08/11/20 at 10:00 A.M. indicated she was aware the staff were using the paper bags provided by the facility to store their N95 respirator mask. ICP indicated the staff could take their used N95 respirator type mask in the paper bag out of the facility to store in their car or other area until their next scheduled shift. The Center for Disease Control (CDC) Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings dated 03/27/20 indicated guidance for re-use of the N95 respirator type filtering mask. The recommendation indicated there is no way of determining the maximum possible number of safe reuses for an N95 respirator as a generic number to be applied in all cases. Safe N95 reuse is affected by a number of variables that impact respirator function and contamination over time. However, manufacturers of N95 respirators may have specific guidance regarding reuse of their product. The recommendations are designed to provide practical advice so that N95 respirators are discarded before they become a significant risk for contact transmission or their functionality is reduced. The recommendation included to hang used respirators in a designated storage area or keep them in a clean, breathable container such as a paper bag between uses. To minimize potential cross-contamination, store respirators so that they do not touch each other and the person using the respirator is clearly identified. Storage containers should be disposed of or cleaned regularly. The facility policy and procedure titled COVID 19 Crisis Strategies for Face Mask Quick Guide Per CDC Guidelines dated 03/18/20 did not give clear guidance to the staff to determine if the paper bag and N95 mask could be stored outside the facility or in a plastic bag prior to the re-use of the N95 mask. The guidance indicated for extended use of face masks for multiple resident encounters without removal will be utilized during crisis times. The guidance included when removing the face mask, carefully fold so that the outer surfaces are touching to reduce contact with the storage container. Face masks should be stored in a paper bag or breathable container labeled with the staff name and stored in a non-resident area.

Based on record review, observation, and interview, the facility failed to ensure staff did not falsely record the removal of [MEDICATION NAME]es for Resident #105. This affected one of seven residents reviewed for medication administration (Resident #105, #447, #62, #64, #98, #67, and #110). the facility census was 150. Findings include: Observation of a medication administration pass for Resident #105 on 04/02/19 at 8:25 A.M. by Licensed Practical Nurse #201 revealed the resident to have two [MEDICATION NAME] 4% patches dated 04/01/19 already on their knees. The nurse removed the old patches then applied new patches on each knee. Record review of Resident #105 revealed orders for their [MEDICATION NAME]es to be applied at 9:00 A.M. each morning and removed at 5:00 P.M. each evening. Review of their Medication Administration Record [REDACTED].M. No evidence could be found indicating a different set was applied in between that time and Licensed Practical Nurse #201's removal of the old patches on 04/02/19. This finding was confirmed with the Director of Nursing on 04/02/19 at 4:12 P.M.

Based on interview, observation and record review, the facility failed to ensure the care plans were updated timely for residents with catheters. This affected two residents (Resident #44 and Resident #88) out of two residents reviewed for catheters. The facility census was 148. Findings Include 1. Resident #44 was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. According to Resident #44's Minimum Data Set 3.0 (MDS) assessment, dated 01/24/19, this resident had moderate cognitive impairment. She needed extensive assistance of staff for bed mobility, transfers, dressing, toilet use and personal hygiene. Review of the bowel and bladder assessment of this MDS showed that the resident did have an indwelling urinary catheter. Review of Resident #44's physician orders [REDACTED]. The foley catheter is to be secured with the foley leg strap. Review of this resident's plan of care dated 01/21/19 revealed the resident was at risk for infection and/or trauma related to use of a foley catheter for a [MEDICAL CONDITION] bladder. Review of the interventions for this plan of care showed to: Check foley catheter for patency, and/or kinks in tubing every shift; foley catheter care every shift, assess resident for pain/discomfort every shift and to monitor for signs/symptoms of urinary tract infection. There was no intervention listed to secure the foley with a foley leg strap. Interview with the Director of Nursing (DON) on 04/03/19 at 12:35 P.M. revealed that the resident did not have the intervention to secure the resident's catheter with foley leg strap. 2. Resident #88 was admitted to this facility on 01/09/18. His admitting [DIAGNOSES REDACTED]. Resident #88's Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed this resident was cognitively intact. Resident #88 needed extensive assistance of staff for bed mobility, transfers, toilet use and personal hygiene. The bowel and bladder assessment of this MDS stated the resident did have a foley catheter (a urinary catheter inserted into the bladder) to drain his urine. Review of the physician's orders [REDACTED]. Secure the foley catheter with a leg strap. Review of the care plan dated 03/01/19 revealed the resident was at risk for infection related to the use of a foley catheter. Interventions for this care plan included Checking the foley catheter for patency, kinks in tubing every shift; and to provide foley catheter care every shift. It did not include that the foley catheter was to be secured with a foley catheter leg strap. Observation of catheter care being provided to this resident by State tested Nurse Aide (STNA) #500 on 04/03/19 at 11:00 A.M. revealed that the resident did not have his foley catheter secured with a leg strap per the physician's orders [REDACTED].>STNA #500 verified that the resident did not have a leg strap in place on 04/03/19 at 11:25 A.M. Interview with the DON on 04/04/19 at 12:35 P.M. verified that the resident did not have an intervention in his care plan instructing staff to secure the foley catheter with a leg bag. .

Based on observation, record review and interview the facility failed to ensure housekeeping staff followed infection control protocols when cleaning Resident #51's room to prevent the spread of infection. This affected one resident (Resident #51) of two residents who were in isolation precautions. Findings include: During the initial tour on 08/20/18 beginning at 10:50 A.M. there were two observations of Stop See Nurse signs (reflective of isolation precautions), one on the door of Resident #132 who had [MEDICAL CONDITION] (bacterial infection) and one on the door of Resident #51 who had an itchy skin rash with small pustules. The rooms both contained personal protective equipment and a pink trash can. Review of the Resident #51's medical record revealed a current dietary note, dated 08/17/18 that indicated the resident had a rash On 08/20/18 at 11:11 A.M. Housekeeper #235 was observed in Resident #51's room. The housekeeper was sweeping a pile of trash in the room near bed A. During an interview with the housekeeper at the time of the observation, the housekeeper was asked what the protocol was for housekeeping staff to be in and clean the rooms of residents who were in isolation. Housekeeper #235 hesitantly replied that a gown, gloves and sometimes mask were to be used. She stated she was to clean the surfaces with bleach and disinfectant. This surveyor observed a sign on the upper left door frame of the resident's room that indicated to Stop See Nurse, and PPE supplies were observed in the room. During an interview on 08/20/18 at 11:25 A.M. with the assistant director of nursing (ADON)/infection control registered nurse (RN) #275 the above observation of Housekeeper #235 in Resident #51's room was shared. RN #275 was informed the housekeeper was observed in the resident's room without wearing a gown or gloves. RN #275 indicated PPE should have been utilized by the housekeeper. RN #275 also indicated Resident #51 had been placed in isolation earlier that morning until the physician could see the resident. Review of the undated Policy and Procedure for Infection Control revealed to wear a gown when entering resident area if you anticipate that you will have substantial contact with the resident, resident items or environmental surfaces or if the resident is incontinent. This deficiency substantiates Complaint Number OH 509.

Based on review of hospital records, medical record review, review of facility investigative reports, staff interview, review of disciplinary records, and review of the policy and procedure on the use of gait belts, the facility failed to ensure Resident #141 was properly transferred resulting in a dislocation of the left shoulder. Actual harm occurred when staff failed to use a gait belt to properly transfer the resident and the resident's left shoulder became dislocated causing subsequent severe pain and hospitalization . This affected one (Resident #141) out of four residents reviewed for accidents. Findings include: Resident #140 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Review of the facility admission assessment revealed Resident #140 was admitted to the facility on [DATE] at 4:30 P.M. She was alert and oriented and stated she experienced pain quite often, and was especially sore from the transport from hospital. She was only able to partially lift her right hand/arm due to a torn rotator cuff. Resident #140 wore an air cast on her right ankle, and a brace on the left knee for support when ambulating. The resident was able to ambulate with a walker and the assistance of one person and able to make major and frequent changes in position without assistance. The resident was allowed 100% weight bearing. The resident had a history of [REDACTED]. Review of physician's orders [REDACTED].M., revealed the resident was to have the assistance of one person for transfers and walking. An admission care plan for falls included placing items in reach, verbal cues for safety, assistive devices, a clutter free environment and non skid socks/shoes. Review of the nursing notes dated 06/01/17 at 10:04 P.M., revealed Registered Nurse (RN) #5 was called to Resident #140's room after verbalizing complaints of left shoulder /upper arm pain. Resident #140 stated that her injury occurred upon transfer from the wheelchair to her bed. Resident #140 stated State tested Nurse Aide (STNA) #2 put her arm under Resident #140's armpit during a transfer, Resident #140 heard something pop and felt pain in her left arm and shoulder. Assessment revealed no bruising, however, she was unable to lift her arm. Resident #140 was transferred to the hospital per the family's request. Review of the facility investigation and staff witness statements revealed on 06/01/17, STNA #2 notified the supervisor that Resident #140 was complaining of pain in her left shoulder after being transferred from her wheelchair to the bed. Resident #140 was assessed by RN #5 and no bruising or swelling of the left shoulder was found . Resident #140 stated she heard her left shoulder pop. The physician was notified and ordered an X-ray of the left shoulder and humerus. Resident #140's son and daughter were present and requested Resident #140 be transferred to the hospital. Resident #140's daughter requested pain medication for the resident prior to the transfer. The emergency squad started an intravenous line and administered pain medication prior to the transfer. Review of STNA #2's witness statement (no date) revealed she and RN #5 assisted Resident #140 to the bathroom. They transferred Resident #140 from the wheelchair to the toilet with two assist. After finishing in the bathroom, STNA #2 wheeled Resident #140 from the bathroom to the bedside and transferred her. Resident #140 stood up on her own power, and STNA #2 placed her hands on either side of the rib cage area and guided her to the bed. Upon sitting on the bed, Resident #140 stated she was experiencing pain in her left shoulder. STNA #2 immediately notified the nurse. Review of RN #5's witness statement (no date) revealed he and STNA #2 assisted Resident #140 from the bed to the wheelchair, then onto the toilet. RN #5 left Resident #140 in STNA #2's care after they transferred the resident back into her wheelchair from the toilet. RN #5 returned when STNA #2 reported the resident was having pain in her left arm and shoulder. Resident #140 stated she was injured while being transferred to the bed from the wheelchair and had pain in her left shoulder/left arm. The arm was assessed and no bruising appeared to be present at the time. Resident #140 was unable to lift her left arm. Resident #140's family requested a transfer to the hospital. Review of the hospital notes dated 06/02/17 at 12:12 A.M., revealed Resident #140 presented with left shoulder pain after being transferred to her bed. The resident heard a pop which was immediately followed by severe pain. Resident #140 complained of severe pain with range of motion but denied any other injuries. Physical examination and X-ray revealed dislocation of the left shoulder. A reduction of the dislocated shoulder (manual manipulation of the shoulder back into proper position) was successfully completed under local anesthetic. Interview with STNA #2 on 06/20/17 at 11:40 A.M. with the Director of Nursing (DON) present revealed STNA #2 and RN #5 went together to assist Resident #140 to the bathroom. STNA #2 did not recall how she got into her wheelchair, but they wheeled her into the bathroom. The resident stood up very slowly on her own, turned and sat down on the toilet. RN #5 stayed outside the door. After completing her toileting STNA #2 was on the resident's right side, the hand rail was on her left side. STNA #2 placed her arm under the resident's right armpit and RN #5 helped lift with his left arm. Resident #140 stood up, very slowly and held onto the grab bar with both hands while she was cleaned. The wheelchair was positioned behind the resident and she sat down. RN #5 left the room and STNA #8, who was an orientee, came in and stayed. Resident #140 was wheeled to the bedside facing the head of the bed. STNA #2 stood in front of the resident and STNA #8 was on the other side of the bed. STNA #2 put both arms on Resident #140's upper rib cage and helped stand her up and slowly turn and sit on the bed. When she sat down she yelled out, 'oh my shoulder, you popped my arm. STNA #2 notified the nurse immediately. STNA #2 did not use a gait belt during the transfer. Interview with Physical therapy assistant #14 on 06/20/17 at 12:25 P.M. revealed staff should always use a gait belt to transfer a resident. They should never put their arms under a resident's arm/armpit as it could result in shoulder injury. Interview with Licensed physical therapist/doctor of physical therapy #18 on 06/20/17 at 12:30 P.M. revealed a gait belt should be used for all transfers. Attempting to assist by placing one's arms under the armpit could result in shoulder injury. Interview with RN #5 on 06/20/17 at 1:02 P.M. revealed Resident #140 put her call light on for bathroom assistance. STNA #2 and RN #5 both reached around and grabbed the back of her pants to help her to stand her up from the bed and sit in the wheelchair. The resident was assisted to the toilet and RN #5 returned to the room, after Resident #140 was finished. Resident #140 used her left arm to help pull herself up and STNA #2 assisted. She was cleaned and put her back into the wheelchair. STNA #2 moved her to the sink and RN #5 left the room. RN #5 said they did not use a gait belt. On 06/2017 at 1:31 P.M. the DON both RN #5 and STNA #2 received disciplinary action for not using a gait belt during Resident #140's transfer which ultimately resulted in a dislocated left shoulder with severe pain. Review of the gait belt policy dated 07/13/16 revealed a gait belt was to be used unless contraindicated by the residents' condition, for all standing pivot transfers and when ambulating a resident who required contact guard or physical assist. Indications included standing pivot transfer with assist of one or two staff, and ambulation assistance. Review of the disciplinary reports dated 06/01/17 revealed STNA #2 and RN #5 received a written disciplinary action regarding the use of gait belts during a resident transfer. This deficiency substantiates Complaint Number OH 680.

Based on observation, record review and interview, the facility failed to ensure a complete assessment and treatment was provided to a new open pressure ulcer. This deficient practice resulted in harm to one resident (Resident #41) who developed an avoidable, unstagable pressure ulcer to the left buttock. This affected one of two residents reviewed for pressure ulcers. The facility census was 147. Findings include: Review of the medical record revealed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Health Documentation Note dated 05/05/14 revealed the discovery of a new skin issue, an open area to the left lower buttock. The nurse was made aware of the area and the wound was covered with a dressing on 05/04/14. Documentation revealed the nurse practitioner, physician and family were not notified. No documentation of wound size, wound description, or treatment orders was found. Review of Skin Care Administration for May 2014 verified no treatment for [REDACTED]. Review of the Nurses Notes dated 05/07/2014 revealed an unstageable pressure ulcer to the left buttock with measurement of 2.2 centimeters (cm) x 3.5 cm x 0.2 cm. The wound base was not visible, was covered with 100% slough and had a scant amount of thin clear drainage with no odor. Review of the National Pressure Ulcer Advisory Panel's updated pressure ulcer staging system revealed an unstagable pressure ulcer is a "Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Interview on 07/30/14 at 12:25 P.M. with Nursing Supervisor #202 revealed when a floor nurse identifies a wound, the nurse should measure and document the wound, notify the physician for orders and notify the family of the changes. During an interview on 07/30/14 at 12:40 P.M., Nursing Supervisor #202 verified the physician and family were not notified when the new wound was identified. Nursing Supervisor #202 further verified he initiated a wound treatment order dated 05/08/14. On 07/31/14 at 12:15 P.M. observation of the left lower buttock pressure ulcer revealed the wound measured 3.5 cm X 3.5 cm X 2.2 cm. The peri wound area was irregular in shape and pink in color. The eschar (dead tissue that sheds) was moist and tissue was coming away from the wound bed. On 07/31/14 at 12:15 P.M. interview with the primary care physician verified the resident's debilitated condition could have impacted a superficial pressure ulcer to deteriorate into a more severe pressure ulcer in a few days.

Based on observations, review of a self-reported incident (SRI) investigation, clinical record review, resident and staff interviews and review of the facility's abuse policy, the facility failed to ensure a cognitively impaired resident (#51) was free from physical abuse from State tested Nurse Aide (STNA) #202, when STNA #202 pulled the resident's hair and kicked her in the right leg twice. This resulted in Immediate Jeopardy with the likelihood to cause serious injury/harm to 21 residents and actual harm to one of three sampled residents (#51) who were all cognitively-impaired and resided on the Crystal Hall Unit in a total census of 160. On 12/17/10 at 11:50 A.M., the Administrator was notified Immediate Jeopardy began on 11/23/10 at 9:00 A.M. when STNA #200 witnessed STNA #202 pull Resident #51's hair. STNA #200 failed to report the incident of hair pulling to the Crystal Hall Unit supervisor, Licensed Practical Nurse (LPN) #204, or any other supervisor. During lunch at approximately 12:30 P.M. on 11/23/10, STNA #200 and STNA #201 witnessed STNA #202 kick Resident #51 in her right leg twice. Resident #51 sustained an abrasion on the shin area of the right leg. STNA #200 and STNA #201 again failed to immediately report the incident of kicking to LPN #204, or any other nurse, director of nursing or administrator. STNAs #200 and #201 waited until 2:30 P.M. on 11/23/10, after STNA #202 left the facility at the end of her shift, to report the abuse incidents to the nursing supervisor, LPN #203. The Immediate Jeopardy was removed on 11/23/10 when STNA #202 was terminated from employment at approximately 5:00 P.M. The deficiency remained at a Severity Level 2 (no actual harm with potential for more that minimal harm that is not immediate jeopardy) until it was corrected on 11/24/2010 when the facility implemented the following corrective actions: ? On 11/23/10, when made aware of the abuse, Nursing Supervisor LPN #203 assessed Resident #51 for injuries and provided first aide for the abrasion on the shin area of the right leg. Resident #51's plan of care was reviewed to ensure appropriateness for care needs, including management of behaviors. ? On 11/23/10, the physician and responsible party were notified regarding the abuse incident and the injury to Resident #51. ? On 11/23/10, a Self Reporting Incident Form was submitted to the Ohio Department of Health and finalized on 11/24/10. ? On 11/23/10, the local police department was notified regarding the witnessed abuse of Resident #51 by STNA #202. The police officer arrived at the facility on 11/23/10 and completed a police report. ? On 11/23/10, STNA #200 and STNA #201 were given verbal discipline for failing to report abuse immediately to supervisor as required by the facility's Abuse, Neglect, and/or Misappropriation of Resident Funds or Property Policy revised 11/01/10. ? On 11/24/10, Nursing Supervisor LPN #203 provided inservice to 170 of 205 staff, reviewing the facility's Abuse, Neglect, and/or Misappropriation of Resident Funds or Property Policy, revised 11/01/10, that required immediate reporting of physical abuse to the Administrator, Director of Nursing , or if unavailable to the nursing supervisor. ? On 11/26/10, 11/29/10 and 11/30/10, observations of staff to resident interactions did not identify any mistreatment, neglect or abuse on Crystal Hall Unit. ? On 11/29/10 and 11/30/10, LPN #204, STNA #200 and STNA #201, were interviewed regarding the abuse protocol and procedures. All three employees were knowledgeable on the abuse protocol with special emphasis on timely reporting of abuse. ? On 12/17/10, 12/18/10 and 12/19/10, Registered Nurse (RN) #230 provided inservice to 19 of the remaining 45 staff, reviewing the facility's Abuse, Neglect, and/or Misappropriation of Resident Funds or Property policy, revised 11/01/10, that required immediate reporting of physical abuse to the Administrator, Director of Nursing, or if unavailable, to the nursing supervisor. Findings include: Review of the medical record of Resident #51 revealed she had [DIAGNOSES REDACTED]. Review of the Minimum Data Set 3.0 assessment dated [DATE] revealed the resident had impaired short and long term memory and moderately impaired decision making. She displayed inattention and was short tempered and easily annoyed. The resident's care plan was revised on 08/04/10 to address annoyance with staff particularly when they redirected her. Staff was to intervene by always approaching the resident in a calm, soothing and non-judgmental manner, attempt to identify and resolve basis for voiced/demonstrated anger at care received and encourage participation in enjoyed activities. Review of the facility's Self Reported Incident Form dated 11/23/10 revealed on 11/23/10 two STNAs (#200 and #201) working on the Crystal Hall Unit alleged they witnessed STNA #202 kick and pull the hair of Resident #51. The report indicated the incident occurred around 12:00 Noon on 11/23/10 on the Crystal Hall Unit dining room. Review of STNA #200's witness statement revealed on 11/23/2010 around 9:00 A.M. she was walking in the hall past Resident #51's room when she saw STNA #202 pull Resident #51's hair. Then during lunch, while the nurse was on break, STNA #200 saw STNA #202 kicked Resident #51 in the right leg. Review of STNA #201's witness statement indicated she saw STNA #202 kick Resident #51's leg twice when Resident #51 was trying to leave the dining room. Review of Nursing Secretary #205's written statement indicated on 11/23/2010 she called STNA #202 at 5:00 P.M. and left a voice mail. At 5:30 P.M., STNA #202 returned the telephone call. Nursing Secretary #205 informed STNA #202 she was terminated and she should not to return to the facility. Review of Nursing Supervisor's (LPN #203) witness summary statement dated 11/23/10 at 2:30 P.M. indicated STNA #200 reported she and STNA #201 witnessed STNA #202 abuse Resident #51 at lunch in the dining room. STNA #200 said STNA #202 kicked Resident #51 in her right lower leg and pulled her hair. STNA #202 was already gone for the day. Nursing Supervisor LPN #203 examined Resident #51 and found a 1.0 centimeter (cm) skin tear on the front of her right lower leg with a small amount of bleeding. The area was raised and tender to touch. The resident was unable to give accurate information of the incident. No other injuries were noted. The Administrator and Director of Nursing were then notified and an investigation was started. Resident #51 was observed on 11/26/10 at 11:25 A.M. sitting in the wheelchair in her room. A small surface abrasion (approximately 0.1 cm long) was observed on the shin area of the right leg. There was no drainage or redness. There was minimal bruising to the inner right ankle. Resident #51 indicated no pain and did not know what happened. Interview with STNA #201 on 11/26/10 at 11:40 A.M. indicated she was feeding a resident in the dining room. She heard another resident state "they're fighting". She turned and saw STNA #202 kick the leg of Resident #51 two times. Interview with STNA #201 on 11/29/10 at 2:00 P.M. indicated she did not report the allegation at the time of occurrence to the charge nurse because she was unsure of what STNA #202 would do. Interview with STNA #200 on 11/30/10 at 11:30 A.M. indicated at about 9:00 A.M. in the morning on 11/23/10 she was walking past Resident #51's room. She observed STNA #202 pull Resident #51's hair. STNA #200 said she did not report the incident to the nurse or supervisor at the time of occurrence. At approximately 12:30 P.M., STNA #200 was collecting trays in the dining room. She heard Resident #110 yell out "they're fighting". She turned around and saw STNA #202 kick Resident #51 two times in the right leg. She did not see any injury at that time. She indicated she did not report this to the nurse or supervisor at the time of occurrence because she thought it would cause "a big problem" and was unsure what would happen. She indicated she reported the incident after STNA #202 left for the day, about 2:30 P.M. On 11/30/10 at 9:50 A.M., Resident #51 was observed with a circular area on the right lower mid leg that measured 1.0 cm. The area around the wound was reddened. The right inner ankle was bruised and there was [MEDICAL CONDITION] (swelling) in the lower leg and ankle. Review of the facility's Abuse, Neglect, and/or Misappropriation of Resident Funds or Property Policy, revised 11/01/10, revealed under the area of Training, staff was to report their knowledge related to allegations without fear of reprisal. Under the area of Protection, staff was to render immediate assistance when witnessing an incident. Staff was not to move the resident until he/she had been assessed by a nurse supervisor for possible injuries. Staff was to report all incidents immediately to their direct supervisors. Staff was not to leave a victim unattended unless absolutely necessary to summon assistance. This substantiates Self-Reported Incident Number OH 576 and Complaint Number OH 924.