Every finding on record at Providence Care Center

Based on medical record review, staff interviews, hospital record review, and review of facility policy, the facility failed to accurately and timely assess an acute change in condition (lack of assessments), failed to collaborate with the surgeon and failed to timely recognize significant changes in condition for a post-surgical resident resulting in delayed interventions. This resulted in Immediate Jeopardy and serious physical harm, injuries, and/or negative health outcomes on 06/04/26 at 12:02 P.M. when Resident #100 was seen by Vascular Surgeon #250 and the left lower extremity was assessed to have palpable femoral pulses bilaterally with no appreciable flow detected in the distal left lower extremity with no distal pulses palpable, absent sensation over the left foot with preserved sensation at a more proximal level, and clammy skin with mottled discoloration. Resident #100 was diagnosed with a distal superficial femoral artery occlusion (a blockage in the lower third of the thigh's main artery) requiring an urgent hospital admission for intravenous (IV) heparin therapy (a fast-acting blood thinner used to treat and prevent harmful blood clots) and underwent an endovascular intervention (wire-catheter based approach) on 06/06/26 to restore perfusion (the delivery of blood and its vital nutrients and oxygen to the body's tissues) to the left lower extremity. This affected one (#100) of three residents reviewed for appropriate care and services. The facility census was 97.On 06/11/26 at 3:10 P.M., the Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy which began on 06/04/26 at 12:02 P.M. when Resident #100 required urgent hospitalization and intervention to restore perfusion to the left lower extremity when staff failed to timely and accurately assess Resident #100 after the resident verbalized pain to the left lower extremity, failed to timely recognize significant changes in condition and failed to collaborate with the vascular surgeon for a post-surgical resident after Resident #100 continued to verbalize ongoing pain along with added complaints of numbness and tingling in the left lower extremity. The Immediate Jeopardy was removed on 06/15/26 at 1:00 P.M., when the facility implemented the following corrective actions:- On 06/11/26, the DON/designee completed pain assessments and vitals on all residents to determine whether unrecognized changes in condition or unmet pain management needs existed. No additional concerns were identified.- On 06/11/26, the Director of Risk Management (#405) reviewed the facility's Pain Assessment and Management and Notification of Change policies to ensure regulatory compliance and consistency with facility practice.- On 06/11/26, the [NAME] President of Clinical Services #406, Director of Risk Management #405, and [NAME] President of Operations #407 educated the Administrator and DON regarding facility expectations, regulatory requirements, and policy compliance related to pain assessment, change in condition recognition, and physician notification. - On 06/11/26 and 06/12/26, the DON/designee educated all licensed nursing staff and the Interdisciplinary Team (IDT) which included the Administrator, Medical Director #500, DON, Staff Development Coordinator (SDC) #200, Unit Manager #410, and Director of Social Services #270) that the vascular physician is the physician responsible for anticoagulant orders. - Between 06/11/26 and 06/14/26, the DON and SDC #200 educated all nursing staff on peripheral vascular disease, neglect, pain assessment and management, conducting an accurate and timely resident assessment, medication administration, notification of change in condition, guidelines for notifying physicians of clinical problems, and medical record documentation policies and procedures. - Between 06/11/26 and 06/14/26, the DON/designee educated all nursing staff on the need to complete pain assessments on all residents every shift and to follow the change in condition policy to ensure timely physician notification. - Between 06/11/26 and 06/14/26, the DON/designee educated all nursing assistants on recognizing and reporting changes in resident condition and the use of eInteract (Stop and Watch Tool) within Point Click Care (electronic medical record) to facilitate timely communication with licensed nursing staff. - On 06/12/26, the Quality Assurance and Performance Improvement (QAPI) committee met and implemented a plan of action/correction.- On 06/13/26 at 3:20 P.M., Resident #100 returned to the facility. The DON reviewed Resident #100's medications and care plan, clarified the new coumadin (blood thinning medication) order, reviewed plans for laboratory testing, completed and documented a full head to toe assessment including a pain assessment. The DON viewed the resident's condition with the resident's primary nurse and Unit Manager #251.- On 06/15/26, the DON/designee reviewed the 24-hour report for any resident change in condition, timely assessments, physician notification and follow-up. The DON/designee will continue to review the 24-hour report daily during clinical huddles. - Starting the week of 06/15/26, the DON/designee will audit all pain assessments, change in condition documentation, physician notifications, responsible party notifications, and clinical follow-up documentation records. - Starting the week of 06/15/26, the DON/designee will audit the medication administration records (MAR) of nine random residents three times a week for 52 weeks. Any issues will be addressed immediately by the DON/designee.- The DON/designee will present audit results and corrective actions weekly to the QAPI Committee for a minimum of three months and thereafter as determined by the QAPI Committee until the facility demonstrates sustained substantial compliance.- On 06/15/26, between 10:00 A.M. and 11:00 A.M., interviews with Unit Manger #251, Licensed Practical Nurse (LPN) #266, LPN #301, and Registered Nurse (RN) #252 revealed education had been received over the last couple of days regarding peripheral vascular disease, neglect, pain assessment and management, conducting an accurate and timely resident assessment, medication administration, notification of change in condition, guidelines for notifying physicians of clinical problems, and medical record documentation policies and procedures.- On 06/15/26, between 10:00 A.M. and 11:00 A.M., interviews with Certified Nursing Assistant (CNA) #233, and CNA #302 verified education was received on the Stop and Watch Tool and the need to facilitate timely communication with licensed nursing staff when a resident has a change in condition.Although the Immediate Jeopardy was removed on 06/15/26, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include:Review of Resident #100's medical record revealed an admission date of 01/29/26 after a hospitalization. Diagnoses included cerebral vascular accident, peripheral artery disease (PAD), anemia, and hypertension. Review of the hospital discharge record dated 01/29/26 revealed on 01/18/26, Resident #100 underwent a left lower extremity angiogram which revealed a left superficial femoral artery (SFA) and popliteal occlusion requiring mechanical thrombectomy and stenting of the SFA and popliteal arteries along with balloon angioplasty of the left popliteal artery. Resident #100 was seen by the vascular surgeon (Vascular Surgeon #250) in February and was doing pretty well overall with normal vascular waveforms and no ongoing ischemic pain. Orders included for the nursing facility to perform vascular assessments and administer Eliquis (an oral anticoagulant used to prevent and treat blood clots) 5 milligrams (mg) twice a day. Review of the post-operative visit note dated 02/16/26 written by Vascular Surgeon #250 revealed no post-operative concerns.Review of Resident #100's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately intact cognition. The resident was prescribed diabetic, opioid, and anticonvulsant medications. The MDS assessment did not indicate that Resident #100 was prescribed or receiving anticoagulant medications.Review of Resident #100's most recent care plan dated 05/11/26 revealed the resident was identified as having peripheral vascular disease (PVD). The goal was to remain free of complications related to PVD through the review date. Interventions included compression stockings, which were ace wraps applied daily to bilateral lower extremities, elevate legs when sitting or sleeping, and encourage good nutrition and hydration. The care plan was absent for Resident #100 being prescribed an anticoagulant medication.Review of Resident #100's physician orders revealed an order dated 01/29/26 for Eliquis 5 mg to be administered twice daily. Further review of the physician orders revealed on 03/24/26 Facility Physician #200 discontinued the Eliquis 5 mg, and a new order was written for Eliquis 2.5 mg twice daily, to start on 03/25/26 due to a pharmacy recommendation related to the resident having an elevated creatinine level. Review of Resident #100's progress notes and facility physician notes dated 03/24/26 revealed Vascular Surgeon #250 was not consulted regarding lowering the dose of Eliquis.Review of Resident #100's progress note dated 05/04/26 revealed documentation that the resident failed to receive the evening dose of Eliquis 2.5 mg due to the medication not being available and on order.Review of nursing progress note dated 05/11/26 timed 10:27 A.M. revealed Resident #100 had left lower leg pain. One tablet of Oxycodone (opioid pain medication) 5 mg was administered as it was ordered as needed for pain. At 2:36 P.M., Resident #100 requested and received another dose of Oxycodone. Review of Resident #100's nursing progress note dated 05/12/26 at 5:20 P.M. revealed Resident #100 requested Oxycodone due to left lower leg pain. Review of the nursing progress note dated 05/12/26 at 5:41 P.M. revealed Facility Physician #200 was notified of Resident #100's left lower leg pain and orders were received to increase the resident's dose of Gabapentin (nerve pain medication) from 100 mg three times a day to 200 mg three times a day and to complete a venous doppler to assess for a venous blood clot. The venous doppler was completed on 05/13/26 at 11:00 A.M. and the results were negative. Review of the MAR for 05/14/26 revealed Resident #100 was administered Oxycodone 5 mg at 4:12 P.M.Review of the MAR for 05/15/26 revealed Resident #100 received Oxycodone 5 mg at 3:46 A.M. Review of the nursing progress note on 05/15/26 at 12:42 P.M., revealed Resident #100 was complaining of burning pain in the left leg and requested pain medication. Oxycodone 5 mg was administered at 12:31 P.M. Facility Physician #200 was notified of the residents' pain, and an order was received to increase Gabapentin to 300 mg three times a day.Review of the nursing progress note for 05/15/26 at 3:32 P.M. documented by LPN #265 indicated Resident #100 had a normal skin assessment.Further review of the MAR for 05/15/26, revealed Resident #100 received Oxycodone 5 mg again at 4:40 P.M.Review of a nursing progress note on 05/17/26 at 8:59 A.M. revealed Resident #100 complained of severe left leg pain and requested as needed pain medication. Review of the MAR for 05/17/26 revealed Resident #100 received Oxycodone 5 mg at 8:59 A.M. and at 4:49 P.M.Review of Resident #100's progress note dated 05/18/26 revealed the resident complained of burning pain in the left leg. Oxycodone was administered at 12:42 P.M. Review of Facility Physician #200's progress note dated 05/19/26 revealed the physician found Resident #100 to have left lower leg pain and suspected a neurogenic or sciatic issue. Facility Physician #200 documented that Resident #100 had a history of PAD and the next plan will be to have the resident see neurosurgery or pain management. Facility Physician #200 ordered a second venous doppler ultrasound. The venous doppler results were negative. Review of the MAR for 05/20/26 revealed Oxycodone 5 mg was administered at 9:40 A.M.Review of the MAR for 05/22/26 revealed Oxycodone 5 mg was administered at 9:15 P.M.Review of the MAR for 05/26/26 revealed Oxycodone 5 mg was administered at 8:18 P.M.Review of a nursing progress note dated 05/27/26 at 1:06 P.M. revealed the resident's family (niece) contacted Facility Physician #200 due to Resident #100's ongoing left lower leg pain. Gabapentin was increased to 600 mg twice daily.Review of the MAR for 05/27/26 revealed both Oxycodone 5 mg and an as needed dose of Tylenol 1000 mg were administered at 1:18 P.M. Review of the nursing progress note on 05/28/26 at 4:32 P.M. revealed Eliquis 2.5 mg unavailable and on order. Review of the MAR for 05/28/26 revealed neither dose of Eliquis was administered as ordered.Review of Facility Physician #200's progress note dated 05/29/26 and timed 12:58 P.M. revealed Resident #100 was examined and had pain that was tender to touch from the knee down to the ankle and around the leg with some red discoloration noted. Facility Physician #200 charted that it did not appear to be a blood flow problem or fracture but suspected radicular-type (radiating) pain from a pinched nerve in the resident's back. Facility Physician #200 noted that the resident had a follow up appointment scheduled with a vascular surgeon (on 06/04/26) regarding past blockages and stents. Facility Physician #200 ordered Doxycycline (antibiotic) 100 mg twice a day for cellulitis. Review of the nursing progress note on 05/31/26 at 7:40 P.M. revealed Eliquis 2.5 mg was not administered as it was unavailable, requested from the pharmacy but not yet delivered.Review of Resident #100's progress note dated 06/02/26 at 10:25 A.M. revealed the resident was having pain in her left lower leg, and she refused to have the physician ordered ace wraps applied. On 06/04/26, Resident #100 was accompanied by the niece to the vascular surgeon's appointment.Review of Vascular Surgeon #250's office note dated 06/04/26 and timed 12:02 P.M. revealed the resident and family informed the vascular surgeon that for the past five weeks the resident suffered from left lower extremity pain, tingling and mottled discoloration. On examination Vascular Surgeon #250 found that Resident #100 had palpable femoral pulses bilaterally with no appreciable flow detected in the distal left lower extremity with no distal pulses palpable, absent sensation over the left foot and preserved sensation at a more proximal level. The skin was clammy and had a mottled discoloration. Resident #100 was diagnosed with a distal superficial femoral artery occlusion and required an urgent hospital admission.Review of the hospital note dated 06/04/26 revealed Resident #100 had been a resident at a long-term care facility after having a re-cannulization of the left superior femoral artery in January 2026 and was admitted to the hospital directly from the vascular surgeon's office with a chief complaint of a left cold leg and edema. The resident had been stable on Eliquis and on examination at the vascular surgeon's office the resident was noted to have absent pulses in the left leg. The resident reports intermittent pain, cold sensation and worsening edema. The plan was to initiate a heparin (fast acting anticoagulant) infusion at high intensity with surgery the next day.Interview with Vascular Surgeon Nurse #210 on 06/09/26 at 10:53 A.M. revealed Resident #100 had an appointment on 06/04/26 and was found to have an occluded femoral artery. Vascular Surgeon Nurse #210 stated Vascular Surgeon #250 phoned the facility, and it was verified that the resident had missed some Eliquis doses due to the facility being out of stock. Vascular Surgeon Nurse #210 stated Vascular Surgeon #250 was upset regarding not being notified of the resident's leg pain and missed anticoagulant doses. Interview with the DON on 06/10/26 at 10:32 A.M. stated the facility nursing staff completed the vascular assessments but failed to document them. The DON also verified Resident #100's care plan was incomplete, and that the facility failed to recognize the resident's change in condition, complete and document skin assessments when Resident #100 complained of left lower leg pain and therefore failed to collaborate/coordinate care with Resident #100's vascular surgeon.Interview with Resident #100's niece on 06/10/26 at 12:10 P.M. revealed she had informed the facility staff on multiple occasions of the concerns regarding Resident #100's increased pain and skin discoloration and they trusted the facility physician and staff to care for her properly. The niece stated Vascular Surgeon #250 was very upset regarding the situation and informed the resident he was unsure if he could save her leg. The niece said surgery was completed on 06/06/26 and fortunately the leg was able to be saved. Telephone interview with Vascular Surgeon Certified Nurse Practitioner (CNP) #300 on 06/16/26 at 4:20 P.M. revealed when Resident #100 was examined at the office on 06/04/26 the resident's left lower extremity was found to be cold and clammy. CNP #300 stated the resident's niece was concerned and shared that the resident had been having issues with pain for several weeks and had been informed by the facility that they had been in contact with the vascular surgeon's office. CNP #300 stated she and Vascular Surgeon #250 spoke with all of their office staff and reviewed phone messages and found nothing regarding the facility contacting the office regarding Resident #100. CNP #300 said she called the facility DON and was informed that Resident #100 had missed doses of Eliquis. CNP #300 also stated the facility physician ordered venous doppler testing but failed to check for arterial blood flow. CNP #300 denied the facility informing them of Facility Physician #200 lowering Resident #100's Eliquis dose from 5 mg twice daily to 2.5 mg twice daily, adding if they had been consulted or had known an additional blood thinning agent would have been added and they would have seen the resident in the office sooner. Interview with Resident #100 on 06/15/26 at 11:02 A.M. revealed she was tearful regarding the lack of care but was thankful Vascular Surgeon #250 was able to save her leg. Following rehabilitation, Resident #100 plans to return home.Review of the facility policy titled Conducting an Accurate Resident Assessment, dated 05/12/26 revealed all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. Qualified staff who are knowledgeable about the residents will conduct an accurate assessment addressing each resident's status, needs, strengths, and areas of decline. The assessment will be documented in the medical record.Review of the facility policy titled Notification of Changes, dated 08/05/26 revealed the purpose of the policy was to ensure the facility promptly informs the resident, consults with the resident's physician and notified, consistent with his or her authority, the resident's representative when there is a change requiring notification.This deficiency represents non-compliance investigated under Master Complaint Number 3035044 and Complaint Number 3034892.

Based on medical record review, staff interviews, hospital record review and review of facility policy, the facility failed to ensure Eliquis (an oral anticoagulant medication used to prevent and treat blood clots) was administered as ordered by the physician. This resulted in Immediate Jeopardy and serious physical harm, injuries, and/or negative health outcomes on 06/04/26 at 12:02 P.M. when Resident #100 was seen by Vascular Surgeon #250 and the left lower extremity was assessed to have palpable femoral pulses bilaterally with no appreciable flow detected in the distal left lower extremity with no distal pulses palpable, absent sensation over the left foot with preserved sensation at a more proximal level, and clammy skin with mottled discoloration. Resident #100 was diagnosed with a distal superficial femoral artery occlusion (a blockage in the lower third of the thigh's main artery) requiring an urgent hospital admission for intravenous (IV) heparin therapy (a fast-acting blood thinner used to treat and prevent harmful blood clots) and underwent an endovascular intervention (wire-catheter based approach) on 06/06/26 to restore perfusion (the delivery of blood and its vital nutrients and oxygen to the body's tissues) to the left lower extremity. Resident #100 started to complain of left lower leg pain and upon review of the medication administration record (MAR) Resident #100 did not receive the prescribed dose of Eliquis on 05/04/26, 05/28/26, 05/29/26, 05/31/26 and 06/02/26. This affected one (#100) of three residents reviewed for medication administration. The facility census was 97. On 06/11/26 at 3:10 P.M., the Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy which began on 06/04/26 at 12:02 P.M. when Resident #100 required an urgent hospitalization and intervention to restore perfusion to the left lower extremity after staff failed to accurately and timely administer the resident's ordered anticoagulant therapy and failed to collaborate with the vascular surgeon for a known post-surgical resident to prevent a reoccurrence of an arterial thrombosis. The Immediate Jeopardy was removed on 06/15/26 at 1:00 P.M., when the facility implemented the following corrective actions:- On 06/11/26, the DON completed an order listing report from the electronic medical record for all residents on anticoagulants and identified 26 residents. - On 06/11/26, the DON/designee completed physical and pain assessments on all residents on anticoagulant therapy. - On 06/11/26, the Administrator and DON were educated by the Director of Clinical Risk Management (#405) regarding the policies of pain management, medication orders, and notification of change. - On 06/11/26 and 06/12/26, the DON/designee audited the Medication Administration Records (MARs) for the 26 residents on anticoagulants. No other resident were identified to have missed a dose of anticoagulant medication. - On 06/11/26 and 06/12/26, the DON/designee educated all licensed nursing staff and the Interdisciplinary Team (IDT) which included the Administrator, Medical Director #500, DON, Staff Development Coordinator (SDC) #200, Unit Manager #410, and Director of Social Services #270 that the vascular physician is the physician responsible for anticoagulant orders. - On 06/12/26, the Quality Assurance and Performance Improvement (QAPI) committee met and implemented a plan of action. - On 06/12/26, the DON/designee educated all licensed nursing staff on the Medication Procurement Policy regarding any missing or out of stock medicines, including medications available from the continency box. - On 06/12/26, the DON/designee posted instructions on medication procurement in the medication room and on the medication cart regarding what to do if a medication for a resident is unavailable. - On 06/13/26 at 3:20 P.M., Resident #100 returned to the facility. The DON reviewed Resident #100's medications and care plan, clarified the new coumadin (blood thinning medication) order, reviewed plans for laboratory testing, completed and documented a full head to toe assessment including a pain assessment. The DON reviewed the resident's condition with the resident's primary nurse and Unit Manager #251. - On 06/15/26, the DON/designee reviewed the 24-hour report for any resident change in condition, timely assessments, physician notification and follow-up. The DON/designee will review the 24-hour report daily during clinical huddles. - Starting the week of 06/15/26, the DON/designee will audit the MARs of nine random residents three times a week for 52 weeks for any medication not administered as ordered. Any issues will be addressed immediately by the DON/designee. - The DON/designee will present audit results and corrective actions weekly to the QAPI Committee for a minimum of three months and thereafter as determined by the QAPI Committee until the facility demonstrates sustained substantial compliance.- On 06/15/26, between 10:00 A.M. and 11:00 A.M., interviews with Unit Manger #251, Licensed Practical Nurse (LPN) #266, LPN #301, Registered Nurse (RN) #252 revealed education had been received over the last couple of days regarding medication administration, what to do if a medication is unavailable, medications available in the continency box, the guidelines for notifying physicians of clinical problems, and medical record documentation. Although the Immediate Jeopardy was removed on 06/15/26, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for minimum harm that is not Immediate Jeopardy) as the facility was continuing to educate staff and was in the process of completing and reviewing audits to determine if further action is required and monitoring to ensure ongoing compliance.Findings include:Review of Resident #100's medical record revealed an admission date of 01/29/26 after a hospitalization. Diagnoses included cerebral vascular accident, peripheral artery disease (PAD), anemia, and hypertension.Review of the hospital discharge record dated 01/29/26 revealed on 01/18/26, Resident #100 underwent a left lower extremity angiogram which revealed a left superficial femoral artery (SFA) and popliteal occlusion requiring mechanical thrombectomy and stenting of the SFA and popliteal arteries along with balloon angioplasty of the left popliteal artery. Orders included to administer Eliquis 5 milligrams (mg) twice daily. Review of the post-operative visit note dated 02/16/26 written by Vascular Surgeon #250 revealed Resident #100 was doing pretty well overall and had normal vascular waveforms with no ongoing ischemic pain. Review of Resident #100's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately intact cognition. The resident was prescribed diabetic, opioid, and anticonvulsant medications. The MDS assessment did not indicate that Resident #100 was prescribed or receiving anticoagulant medications. Review of Resident #100's most recent care plan dated 05/11/26 revealed the resident was identified as having peripheral vascular disease (PVD). The goal was to remain free of complications related to PVD. Interventions included compression stockings which were ace wraps applied daily to bilateral lower extremities, elevate legs when sitting or sleeping, and encourage good nutrition and hydration. The care plan was absent for Resident #100 being prescribed anticoagulant medication.Review of Resident #100's physician orders revealed an order dated 01/29/26 for Eliquis 5 mg to be administered twice daily. Further review of the physician orders revealed on 03/24/26 the Eliquis dose was lowered to 2.5 mg twice daily, to start on 03/25/26. The order was written by Facility Physician #200 based off of a pharmacy recommendation due to the resident having an elevated creatinine level. Review of Resident #100's progress notes and facility physician notes dated 03/24/26 revealed Vascular Surgeon #250 was not consulted regarding lowering the dose of Eliquis.Review of Resident #100's medical record revealed a progress note dated 05/04/26 stating that the resident failed to receive the evening dose of Eliquis 2.5 mg due to the medication not being available and on order.Review of the nursing progress note on 05/28/26 at 4:32 P.M. Eliquis 2.5 mg was unavailable and on order. Review of the MAR for 05/28/26 revealed neither dose of Eliquis 2.5 mg was administered as ordered. Review of Resident #100's MAR dated May 2026 revealed on 05/04/26 the evening dose of Eliquis 2.5 mg was not administered as the medication was unavailable and on order. Further review of the MAR revealed on 05/28/26 both doses of Eliquis 2.5 mg failed to be administered due to the medication being on order, on 05/29/26 the evening dose was documented as refused and on 05/31/26 the evening dose was missed due to the medication was yet to be delivered. Review of Resident #100's progress note dated 06/02/26 at 10:25 A.M. revealed the resident was having so much pain in her left lower leg that she refused to have the physician ordered ace wraps applied. Review of the MAR for June 2026 revealed on 06/02/26 the evening dose of Eliquis 2.5 mg was not administered as the dose was on order.On 06/04/26, Resident #100 was accompanied by the niece to the vascular surgeon's appointment.Review of Vascular Surgeon #250's office note dated 06/04/26 and timed 12:02 P.M. revealed the resident and family informed the vascular surgeon that for the past five weeks the resident had suffered left lower extremity pain, tingling and mottled discoloration. On examination Vascular Surgeon #250 found that Resident #100 had palpable femoral pulses bilaterally with no appreciable flow detected in the distal left lower extremity and no distal pulses palpable, absent sensation over the left foot and preserved sensation at a more proximal level, the skin was clammy and had a mottled discoloration. Resident #100 was diagnosed with a distal superficial femoral artery occlusion and required an urgent hospital admission.Review of the hospital note dated 06/04/26 revealed Resident #100 had been a resident at a long-term care facility after having a re-cannulization of the left superior femoral artery in January 2026 and was admitted to the hospital directly from the vascular surgeon's office with a chief complaint of a left cold leg and edema. The resident had been on Eliquis and on examination at the vascular surgeon's office the resident was noted to have absent pulses in the left leg. The resident reports intermittent pain, cold sensation, and worsening edema in the left leg. A heparin (fast acting anticoagulant) infusion at high intensity was initiated with a plan for surgery the next day.Interview with Vascular Surgeon Nurse #210 on 06/09/26 at 10:53 A.M. revealed Resident #100 had an appointment on 06/04/26 and was found to have an occluded femoral artery. Vascular Surgeon #250 phoned the facility, and it was verified that the resident had missed some Eliquis doses due to the facility being out of stock. Vascular Surgeon Nurse #210 stated Vascular Surgeon #250 was upset regarding the resident missing the anticoagulant doses. Interview with LPN #262 on 06/10/26 at 5:52 A.M. confirmed Eliquis was supplied in the contingency box, but she was unaware of that fact when caring for Resident #100. Interview with the DON on 06/10/26 at 10:32 A.M. verified LPN #262 and other nurses caring for the resident were unaware that Eliquis was one of medications available in the contingency box. The DON confirmed Resident #100 missed doses of Eliquis 2.5 mg on 05/04/26, 05/28/26, 05/29/26, 05/31/26 and 06/02/26. The DON also confirmed the facility failed to collaborate/coordinate care with Resident #100's vascular surgeon and did not communicate the dose reduction of the Eliquis. Telephone interview with Physician #200 on 06/10/26 at 12:01 P.M. revealed he did not recall if the facility staff notified him regarding the missing doses of Eliquis. Physician #200 verified he approved the pharmacy recommendation of reducing Resident #100's Eliquis dose from 5 mg twice a day to 2.5 mg twice a day without consulting with Vascular Surgeon #250. Physician #200 stated he knew Resident #100 had severe vascular disease.Interview with Resident #100's niece on 06/10/26 at 12:10 P.M. revealed she had informed the facility staff on multiple occasions of their concern regarding Resident #100's increased pain and skin discoloration and they trusted the facility physician and staff to care for her properly. The niece stated Vascular Surgeon #250 was very upset regarding the situation and informed the resident he was unsure if he could save her leg. Surgery was completed on 06/06/26 and fortunately the leg was able to be saved. Interview with Resident #100 on 06/15/26 at 11:02 A.M. revealed she was tearful regarding the lack of care but was thankful Vascular Surgeon #250 was able to save her leg. Following rehabilitation, Resident #100 stated she plans to return home.Telephone interview with Vascular Surgeon Certified Nurse Practitioner (CNP) #300 on 06/16/26 at 4:20 P.M. revealed when Resident #100 was examined at the office on 06/04/26 the resident's left lower extremity was found to be cold and clammy. CNP #300 stated the resident's niece was concerned and shared the resident had been having issues with pain for several weeks and that she had been informed by the facility that they had been in contact with the vascular surgeon's office. CNP #300 stated she and Vascular Surgeon #250 spoke with all of their office staff and reviewed phone messages and found nothing regarding the facility contacting the office regarding Resident #100. CNP #300 said she called the facility DON and was informed that Resident #100 had missed doses of Eliquis. CNP #300 also stated the facility physician ordered venous doppler testing but failed to check for arterial blood flow. CNP #300 denied the facility informing them of the facility physician lowering Resident #100's Eliquis dose from 5 mg twice daily to 2.5 mg twice daily, adding if they had been consulted or had known an additional blood thinning agent would have been added and they would have seen the resident in the office sooner.Review of the facility policy titled Medication Administration dated 11/05/25 revealed to report any discrepancies to the nurse manager. Review of the facility policy titled Medication and Treatment Orders dated 05/12/26 revealed drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available. This deficiency represents non-compliance investigated under Complaint Number 3035044.

Based on observation, medical record review, resident interview, staff review, and review of facility policy, the facility failed to ensure therapy ordered positioning equipment was utilized. This affected one (#39) of three residents reviewed for positioning and position equipment. The facility census was 97.Findings include:Review of Resident #39's medical record revealed an admission date of 08/09/24. Diagnoses included morbid obesity, diabetes mellitus, bladder cancer, and chronic kidney disease.Review of Resident #39's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a mild cognition decline. The resident had no rejection of care and required substantial assistance for all activities of daily living except eating.Review of Resident #39's most recent care plan revealed it was silent regarding positioning.Review of Resident #39's physician orders found no order pertaining to positioning equipment.Review of Resident #39's Physical Therapy Treatment encounter note dated 04/21/26 signed at 2:16 P.M. revealed the resident was dependent for repositioning to ensure a straight alignment while in bed. Staff were educated on bolster placement to keep the resident centered in bed and to prevent a left lateral lean.Review of Resident #39's Physical Therapy Treatment encounter note dated 04/22/26 and signed 6:38 P.M. revealed the resident was seen regarding being discharged from therapy due to resident reaching maximal potential. The patient was provided a different wedge cushion due to the resident reporting discomfort with the previous wedge cushion provided. Resident #39 reported improved comfort. Staff training was provided on supine positioning and the use of the wedge cushion. Interview with Resident #39 on 06/09/26 at 9:22 A.M. revealed the facility staff failed to place the wedge or the bolster in her bed. The resident stated she had to ask to have the equipment positioned in her bed.Observations throughout the survey on 06/09/26 and 06/10/26 revealed when Resident #39 was bed the wedge cushion was sitting in the resident's wheelchair and the bolster was laying in her recliner. Two signs observed on Resident #39's wall above the bed contained instructions for staff regarding the placement of the wedge cushion and the bolster.Interview with Certified Nursing Assistant (CNA) #225 on 06/09/26 at 12:22 P.M. verified Resident #39 failed to have the positioning equipment in her bed. CNA #225 verified the instructions above the resident's bed and further verified when Resident #39 ins in bed the wedge cushion and bolster should be used. CNA #225 further stated the resident could ask for them if she wanted them in place.Interview with Therapy Program Manager #312 on 06/10/26 at 7:55 A.M. revealed Resident #39 was provided a wedge cushion and a bolster due to her inability to hold herself in a straight position stating Resident #39 tends to lean to the left. The pillows were fitted specifically for the resident to ensure proper body alignment. Therapy Program Director #312 stated all staff on the floor at the time were educated on the use of the wedge cushion and bolster and the signs were placed above the residents' bed to educate all staff missed. Therapy Program Director #312 confirmed the equipment was failed to being utilized.Review of the facility policy titled Medication and Treatment Orders revised 01/03/22 revealed orders for treatments will be consistent with principles of safe and effective order writing.This deficiency represents non-compliance investigated under Complaint Number 3034892.

Based on observation, staff interviews, resident interviews, and policy review revealed the facility failed to ensure required respiratory treatments were implemented as ordered. This affected one (#39) of two residents identified for requiring continuous positive airway pressure (CPAP) devices. The facility census was 97.Findings include:Review of Resident #39's medical record revealed an admission date of 08/09/24. Diagnoses included obstructive sleep apnea, morbid obesity, diabetes mellitus, bladder cancer, and chronic kidney disease.Review of Resident #39's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a mild cognition decline. The resident had no rejection of care and required substantial assistance for all activities of daily living except eating. The resident was documented as not requiring a non-invasive mechanical ventilator.Review of Resident #39's most recent care plan revealed it was silent regarding the need for a CPAP.Review of Resident #39's physician orders dated 01/12/26 stated the resident was to be assisted with putting on CPAP at bedtime for sleep apnea.Review of Resident #39's Treatment Administration Record (TAR) dated 05/26 and 06/26 revealed it was absent of documentation regarding the physician's order to assist the resident with applying the CPAP.Review of Resident #39's CPAP Report provided by the resident's family dated 06/01/26 through 06/08/26 revealed the machine was worn on 06/02/26 and 06/05/26. Interview with Resident #39 on 06/09/26 at 11:01 A.M. revealed her care in the facility was lacking. The staff failed to put her CPAP on nightly, and she was unable to complete the task herself. This left her lethargic and tired in the daytime. Resident #39 verified requesting assistance from facility staff for the application of the CPAP, but the assistance was not always provided. Observation on 06/10/26 at 5:42 A.M. revealed resident #36 was sleeping in bed on her back. The CPAP was sitting on her nightstand and not applied to the resident.Interview with Certified Nursing Assistant (CNA) 225 on 06/10/26 at 5:45 A.M. verified the night staff failed to assist Resident #39 with putting on her CPAP.Review of the facility policy titled Respiratory Services dated 12/29/25 revealed to place the mask interface loosely on the resident's face. Adjust the headgear straps so that the mask has a comfortable fit but seals appropriately. Ensure resident safety and comfort.This deficiency represents non-compliance investigated under Complaint Number 3034892.

Based on review of the medical record, staff interview, review of a Self-Reported Incident (SRI) investigation, review of staff schedules and timekeeping records, and policy review, the facility failed to complete a thorough investigation into a resident's allegation of verbal and physical abuse. This affected one (Resident #53) of three residents reviewed for abuse. The facility census was 93. Findings include:Review of the medical record for Resident #53 revealed an admission date of 11/15/24 with diagnoses including cerebral infarction, restless leg syndrome, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/20/26, revealed Resident #53's cognition was moderately impaired.Review of SRI 271580, submitted on 03/02/26, revealed Resident #53 revealed an allegation of a staff member speaking unkindly to him to an Ohio Department of Health (ODH) surveyor, who subsequently reported it to Licensed Social Worker (LSW) #231. Resident #53 would not share the staff member's name to the ODH surveyor. LSW #231 spoke to Resident #53 immediately.The facility's investigation of SRI #271580 revealed they had only one statement in their investigation from LSW # 231. LSW #231 revealed an ODH surveyor stopped by her office on 03/02/26 and reported Resident #53 had shared with her that a staff member spoke to him abusively Saturday (02/28/26). LSW #231 spoke to Resident #53 who stated Certified Nursing Assistant (CNA) #240 was very rough with cleaning him and she was very strong. Resident #53 stated that he feels that CNA #240 does not like her job or him. There was no statement from CNA #240 and Resident #53. The facility did not complete a physical assessment after Resident #53 alleged CNA #240 was very rough with cleaning him. The facility did not interview like residents. The facility did not suspend CNA #240 while completing their investigating. The facilicy concluded on 03/06/26 the allegation was unsubstantiated and CNA #240 received education on patient handling.Review of the staff schedules and timekeeping records revealed CNA #240 did not work on 03/02/26, and worked the following night shifts on 03/03/26 from 6:48 P.M. to 8:20 A.M., 03/04/26 from 6:52 P.M. to 9:08 A.M., and on 03/05/26 from 6:50 P.M. to 12:53 A.M. CNA #240 worked all of these shifts where Resident #53 resided on.Interview on 05/28/26 at 3:10 P.M. with LSW #231 revealed she interviewed Resident #53 and submitted her signed statement of the conversation to the Director of Nursing (DON) and the Administrator. LSW #231 stated it was not facility practice for her to investigate SRIs.Interviews on 05/28/26 beginning at 3:12 P.M. with the DON and Administrator verified they only obtained one statement from LSW #231 and did not complete any further investigation into Resident #53's allegation of abuse. The DON and Administrator verified CNA #240 was not suspended during the investigation and continued to work with Resident #53. The DON and Administrator verified they never obtained CNA #240 nor Resident #53's statements. here was no further documentation of an investigation regarding this alleged incident. The DON and Administrator verified there was no investigatory documentation for this allegation of abuse by Resident #53 regarding CNA #240. Review of the facility policy titled Abuse, Neglect, and Exploitation, dated 05/22/25, revealed the facility will develop and implement written policies and procedures that investigate allegations of abuse, neglect, and exploitation. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. Written procedures for investigations include: identifying staff responsible for the investigation, identifying and interviewing all involved persons, including the alleged victim, perpetrator, witnesses, and others who might have knowledge of the allegations, focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause and providing complete and thorough documentation of the investigation. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Including: responding immediately to protect the alleged victim and the integrity of the investigation, examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed, increased supervision of the alleged victim and residents, room or staffing changes to protect the residents from the alleged perpetrator, protection from retaliation, and providing emotional support and counseling to the resident during and after the investigation as needed.This was an incidental finding discovered during the complaint investigation.

Based on staff interview and medical record review, the facility failed to ensure the resident's medical record was accurate when documenting incontinence care being provided to the residents. This affected three (#33, #52, and #90) of three residents reviewed for medical record accuracy. The facility census was 93.Findings include:1. Review of the medical record for Resident #33 revealed an admission date of 07/20/22. Diagnoses included stage three chronic kidney disease, morbid obesity, neuromuscular dysfunction of the bladder, polyneuropathy, and adult failure to thrive. The annual Minimum Data Set (MDS) assessment, dated 04/20/26, revealed Resident #33's cognition was intact. Resident #33 was dependent on staff for toileting, and was frequently incontinent of both bowel and bladder.Review of incontinence care documentation for Resident #33 for March 2026 revealed there was no documentation of incontinence care was provided on 03/03/26, 03/07/26, 03/13/26, 03/14/26, 03/21/26, 03/26/26, and 03/31/26.The incontinence care documentation for Resident #33 for April 2026 revealed there was no documentation of incontinence care was provided on 04/04/26, 04/06/26, 04/09/26, 04/12/26, 04/14/26, 04/16/26, 04/17/26, 04/18/26, 04/19/26, 04/20/26, 04/21/26, 04/22/26, 04/23/26, and 04/25/26.The incontinence care documentation for Resident #33 for 05/01/26 through 05/27/26 revealed there was no documentation of incontinence care was provided on 05/01/26, 05/04/26, 05/05/26, 05/08/26, 05/10/26, 05/12/26, and 05/16/26.Interview on 05/28/26 at 3:30 P.M. with the Administrator verified there was no documentation of incontinence care being performed for Resident #33 on 03/03/26, 03/07/26, 03/13/26, 03/14/26, 03/21/26, 03/26/26, 03/31/26, 04/04/26, 04/06/26, 04/09/26, 04/12/26, 04/14/26, 04/16/26, 04/17/26, 04/18/26, 04/19/26, 04/20/26, 04/21/26, 04/22/26, 04/23/26, 04/25/26, 05/01/26, 05/04/26, 05/05/26, 05/08/26, 05/10/26, 05/12/26, and 05/16/26. The Administrator revealed that if a care task is not documented as being completed, it cannot be verified as being complete.2. Review of the medical record for Resident #52 revealed an admission date of 06/01/24. Diagnoses included benign prostatic hyperplasia with lower urinary tract symptoms and dementia. The quarterly Minimum Data Set (MDS) assessment, dated 03/31/26, revealed Resident #52's cognition was moderately impaired. Resident #52 required moderate assistance from staff with toileting, and was always incontinent of both bowel and bladder.Review of the incontinence care documentation for Resident #52 for March 2026 revealed there was no documentation of incontinence care was provided on 03/01/26, 03/13/26, 03/15/26, 03/17/26, 03/18/26, and 03/19/26. The incontinence care documentation for Resident #52 for April 2026 revealed there was no documentation of incontinence care provided on 04/04/26, 04/06/26, 04/07/26, 04/11/26, 04/12/26, 04/14/26, 04/16/26, 04/22/26, 04/23/26, 04/27/26, and 04/28/26.The incontinence care documentation for Resident #52 for 05/01/26 through 05/28/26 revealed there was no documentation of incontinence care provided on 05/06/26, 05/10/26, 05/16/26, 05/18/26, 05/25/26, 05/27/26, and 05/28/26.Interview on 05/28/26 at 3:30 P.M. with the Administrator verified there was no documentation of incontinence care being performed for Resident #52 on 03/01/26, 03/13/26, 03/15/26, 03/17/26, 03/18/26, 03/19/26, 04/04/26, 04/06/26, 04/07/26, 04/11/26, 04/12/26, 04/14/26, 04/16/26, 04/22/26, 04/23/26, 04/27/26, 04/28/26, 05/06/26, 05/10/26, 05/16/26, 05/18/26, 05/25/26, 05/27/26, and 05/28/26. The Administrator revealed that if a care task is not documented as being completed, it cannot be verified as being complete.3. Review of the medical record for Resident #90 revealed an admission date of 01/13/23. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affection right dominant side and memory deficit following cerebral infarction, frontal lobe and executive deficit following cerebral infarction. The quarterly Minimum Data Set (MDS) assessment, dated 04/20/26, revealed Resident #90's cognition was severely impaired. Resident #90 required assistance from staff with toileting, and was occasionally incontinent of bladder and always incontinent of bowel. Review of incontinence care documentation for Resident #90 for March 2026 revealed there was no documentation of incontinence care was provided on 03/01/23, 03/02/26, 03/06/26, 03/07/26, 03/08/26, 03/09/26, 03/13/26, 03/15/26, 03/17/26, 03/20/26, 03/23/26, 03/25/26, 03/26/26, 03/27/26, and 03/28/26. The incontinence care documentation for Resident #90 for April 2026 revealed there was no documentation of incontinence care was provided on 04/02/25, 04/03/26, 04/04/26, 04/06/26, 04/07/26, 04/09/26, 04/10/26, 04/12/26, 04/14/26, 04/17/26, 04/19/26, 04/20/26, 04/22/26, 04/23/26, 04/24/26, and 04/26/26.The incontinence care documentation for Resident #90 for 05/12/26 through 05/28/26 revealed there was no documentation of incontinence care was provided on 05/03/26, 05/04/26, 05/08/26, 05/16/26, 05/20/26, and 05/22/26.Interview on 05/28/26 at 3:30 P.M. with the Administrator verified there was no documentation of incontinence care being performed for Resident #90 on 03/01/23, 03/02/26, 03/06/26, 03/07/26, 03/08/26, 03/09/26, 03/13/26, 03/15/26, 03/17/26, 03/20/26, 03/23/26, 03/25/26, 03/26/26, 03/27/26, 03/28/26, 04/02/25, 04/03/26, 04/04/26, 04/06/26, 04/07/26, 04/09/26, 04/10/26, 04/12/26, 04/14/26, 04/17/26, 04/19/26, 04/20/26, 04/22/26, 04/23/26, 04/24/26, 04/26/26, 05/03/26, 05/04/26, 05/08/26, 05/16/26, 05/20/26, and 05/22/26. The Administrator revealed that if a care task is not documented as being completed, it cannot be verified as being complete.This was an incidental finding discovered during the complaint investigation.

Based on medical record review, staff interview, resident interview, and facility policy, the facility failed to complete wound treatments and failed to complete wound treatments as prescribed by the provider. This affected one resident (#84) of three for wound care completion. The facility census was 98.Findings include: Review of the medical record for Resident #84 revealed an admission date of 03/23/18. Diagnoses include diabetes mellitus, acute hematogenous osteomyelitis (fast bacterial infection of the bone usually caused by a blood stream bacteria lasting less than four weeks), chronic obstructive pulmonary disease (COPD), and need for assistance for personal care. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] for Resident #84 revealed he was cognitively impaired and had unhealed pressure ulcers. Review of the current physician orders from 02/26 for Resident #84 revealed wound to right ischium, cleanse with vashe cleanser, pat dry, apply honey gel or sheet, alginate, apply skin prep to around the wound and then apply silicone border foam dressing daily, wound to sacrum cleanse with vashe cleanser, apply skin prep to around the wound prior to placing the adhesive, apply transparent dressing around the wound and to hip area to protect the skin, apply green foam to wound bed and bridge to hip area with track pad, cover with green foam with transparent dressing, and cut a small list in the top of the dressing in the hip area, apply the negative-pressure wound therapy (NPWT, or wound-vac) (a type of treatment used to close wounds using soft, mild, constant suction), set the wound vac to 125 millimeters per Mercury (mmHg), change the dressing every Monday, Wednesday, and Friday, and finally a wound order for the sacrum in the event the negative pressure treatment is not able to be maintained, sacrum wet to dry normal saline dressing may be applied to the sacral wound if the NPWT is held. Review of the care plan revised 02/26 for Resident #84 revealed he was care planned for skin break down and pressure ulcers with interventions in place for treatments per order, monitor effectiveness, repositioning side to side when in bed, tilt-in-space wheelchair when out of bed and utilize for repositioning, and facility protocols for wound prevention. Review of the January 2026 Treatment Administration Record (TAR) for Resident #84 revealed the wound-vac was not applied on 01/08/26. Review of the February 2026 TAR for Resident #84 revealed the wound treatment to the right ischium was not completed on the following days: 02/04/26, 02/19/26, and 02/26/26. Further review of the February 2026 TAR revealed the wound-vac dressing was not completed on 02/25/26 and 02/27/26. Interview on 03/02/26 at 2:25 P.M. with Registered Nurse (RN) #420 verified the missing initials on the TAR for January 2026 and February 2026 for Resident #84. RN #420 stated the expectation is for the nurse to and sign out the TAR as the treatments are completed and blank initials indicate the wound care or treatment was not completed. Observation of wound care on 03/02/26 at 10:01 A.M. for Resident #84 revealed the wound-vac machine was sitting in a chair in the resident's room. Further observation revealed the dressing removed was an abdominal pad (ABD pad) (thicker, more absorbent than just gauze) with a piece of gauze and was dated 03/02/26 at 3:30 A.M. Concurrent interview with Resident #84 stated the wound-vac should be in place, and it was not and he was not able to recall the last time it was in place. Interview with Licensed Practical Nurse (LPN) #440 verified the dressing in place was not the wound-vac. Continued interview with LPN #440 stated she applied the wound-vac on 02/23/26, the last time she worked. Interview on 03/02/26 at 4:13 P.M. with Nurse Practitioner (NP) #401 stated there has been identified concerns of some wound care not being completed and this had been shared with the leadership at the facility. NP #401 further stated the ideal treatment for Resident #84 is the wound-vac and the wet to dry dressing is only there for an alternative if the equipment is not functioning correctly. NP #401 stated there has been no notifications that the wound-vac is not functioning correctly. NP #401 further stated the wound has improved despite the staff not using the wound-vac and does not feel there is harm considering the condition of the wound at the current time. Review of the facility policy titled, Pressure Injury Prevention and Management, revised 11/25 revealed the facility is committed to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Evidence based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present.

Based on observation, staff interview, and review of facility policy, the facility failed to wear appropriate Personal Protective Equipment (PPE) while providing wound care. This affected one resident (#84) observed for wound care. The facility census was 98.Findings include: Review of the medical record for Resident #84 revealed an admission date of 03/23/18. Diagnoses include diabetes mellitus, acute hematogenous osteomyelitis (fast bacterial infection of the bone usually caused by a blood stream bacteria lasting less than four weeks), chronic obstructive pulmonary disease (COPD), and need for assistance for personal care. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] for Resident #84 revealed he was cognitively impaired and had unhealed pressure ulcers. Observation on 03/02/26 at 10:01 A.M. revealed a sign on the outside of the door of Resident #84's room that alerted all staff to Enhanced Barrier Precautions (EBP). The signage indicated for all staff and providers that a gown and gloves must be worn in all high-contact resident care activities to include wound care and catheter care and a PPE cart (cart holding all PPE easily accessible for staff and providers) was available. Observation of Resident #84 revealed he had a suprapubic catheter and a wound. Continued observation revealed Licensed Practical Nurse (LPN) #440 washed her hands and donned clean gloves, then positioned Resident #84 on his right side and proceeded to remove the old wound dressing to the sacrum and throw it into the garbage. LPN #440 then cleaned her hands and continued to cleanse the sacral wound. At 10:13 A.M. Certified Nursing Assistant (CNA) #410 entered the room, donned clean gloves and assisted LPN #440 with positioning of Resident #84 to help hold him on his side for better access to the wound. Follow up interview on 03/02/26 at 10:32 A.M. LPN #440 completed the wound dressing and verified Resident #84 was in EBP for wounds and urinary catheter. LPN #440 further verified she nor CNA #410 donned the appropriate PPE when they provided wound care to Resident #84. Review of the facility policy titled, Enhance Barrier Precautions, revised 09/25 revealed it is the policy of the facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. An order for enhance barrier precautions will be obtained for residents with any of the following: wounds-chronic such as pressure ulcers, and indwelling medical devices such as urinary catheter devices. High-contact resident care activities include: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care, and wound care.

Based on review of the medical record, staff interview, review of a Self-Reported Incident (SRI) investigation, review of staff schedules and timekeeping records, and policy review, the facility failed to prevent further potential abuse during the investigation of an allegation of sexual abuse when the alleged perpetrator was allowed to continue to work on the same unit while an investigation was in progress. This had the potential to affect 36 residents (#75, #27, #88, #15, #11, #95, #63, #9, #82, #16, #47, #64, #53, #42, #39, #61, #74, #23, #46, #85, #24, #68, #69, #89, #87, #41, #20, #19, #10, #66, #58, #8, #31, #67, #96, #36) residing the Cedarview unit. The facility census was 97. Review of the medical record for Resident #69 revealed an admission date of 06/07/21. Diagnoses included dementia with behavioral disturbance, osteoarthritis, depression, anxiety, visual hallucinations, and bilateral hearing loss. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #69 had severe cognitive impairment.Review of the medical record for Resident #68 revealed an admission date of 02/23/21. Diagnoses included hemiplegia and hemiparesis, hypertension, atrial fibrillation, and type two diabetes mellitus.Review of the quarterly MDS dated [DATE] revealed Resident #68 had intact cognition. Review of a SRI submitted on 07/08/25 at 8:41 A.M. revealed on 07/04/25 at 6:00 A.M., Resident #68 indicated Resident #69 stated Licensed Practical Nurse (LPN) #202 had touched her chest while trying to wake her up to give her medications. Resident #68 stated he had not seen LPN #2-2 touch Resident #69's chest but he wanted to believe her so he had. Resident #68 stated he just did not want LPN #202 back in the room. Resident #68 stated Resident #69 had issues with other male caregivers when on another unit but had not known why.Review of statements dated 07/05/25 by the Administrator revealed she had received a call from LPN #410 stating Resident #68's Power of Attorney (POA) had called to say the resident no longer wanted LPN #202 in their room. The POA reported Resident #68 stated the nurse had rubbed Resident #69's chest. The Administrator called the POA who reported he no longer wanted LPN #202 in the room due to Resident #68 reporting LPN #202 had rubbed Resident #69's chest when passing medications. The Administrator informed the POA the incident would be investigated. The Administrator called LPN #202 who explained he rocked Resident #69's shoulder while calling her name several times to wake her up. LPN #202 stated he had only touched Resident #69's shoulder when trying to wake her up. The Administrator spoke with Resident #68 who reported he had not seen the incident. Resident #68 then told Resident #69 to show the Administrator where the nurse touched her on the chest. Resident #69 appeared confused then after further prompting, Resident #69 rubbed the area above her chest mirroring where Resident #68 was rubbing his chest. Interviews beginning on 07/10/25 at 10:54 A.M. the Administrator revealed LPN #202 had worked a 12-hour night shift on 07/03/25 into 07/04/25. The Administrator revealed on 07/04/25 the day shift nurse LPN #410 called and told her Resident #69 told Resident #68 that LPN #202 had touched her chest. The Administrator revealed she called LPN #202 and Resident #69's family. The Administrator verified she had not reported the incident to the state agency until 07/08/25. The Administrator revealed alert and oriented residents on the unit were interviewed with no concerns. The Administrator verified the facility was still in the process of completing skin assessments for the cognitively impaired residents on the unit and the investigation had not yet been completed. The Administrator verified LPN #202 was not suspended and had worked 12-hour night shifts on 07/07/25 and 07/08/25 while the investigation continued. Interview on 07/10/25 at 11:06 A.M. LPN #202 revealed a resident had made an allegation of sexual abuse when he worked night shift from 07/03/25 into 07/04/25. LPN #202 revealed the Administrator called him to discuss the incident six days ago. LPN #202 revealed he was not suspended during the investigation and had worked on 07/07/25 into 07/08/25 and 07/08/25 into 07/09/25. Review of staffing schedules from 07/03/25 through 07/10/25 revealed LPN #202 was scheduled three shifts on the Cedarview unit, on 07/03/25 from 6:30 P.M. to 7:00 A.M., on 07/07/25 from 6:30 P.M. to 7:00 A.M., and on 07/08/25 from 6:30 P.M. to 7:00 A.M. Review of LPN #202's employee timecard revealed the nurse worked on the Cedarview unit on 07/03/25 from 6:30 P.M. through 6:36 A.M. on 07/04/25, On 07/07/25 from 6:31 P.M. through 6:53 A.M. on 07/08/25, and on 07/08/25 from 6:32 P.M. through 6:40 A.M. on 07/09/25. Review of the facility policy Abuse, Neglect and Exploitation, revised 12/2024, revealed the facility would make efforts to ensure all residents were protected from physical and psychosocial harms, as well as additional abuse, during and after the investigation. Including responding immediately to protect the alleged victim and integrity of the investigation and room or staffing changes, if necessary to protect the residents from the alleged perpetrator.This deficiency represents non-compliance investigated under Complaint Number 1373153.

Based on review of the medical record, staff interview, policy review, and review of a Self-Reported Incident (SRI) investigation, the facility failed to notify the physician of a resident change in condition. This affected one (#69) of three residents reviewed for change in condition. The facility census was 97. Review of the medical record for Resident #69 revealed an admission date of 06/07/21. Diagnoses included dementia with behavioral disturbance, osteoarthritis, depression, anxiety, visual hallucinations, and bilateral hearing loss. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #69 had severe cognitive impairment.Review of the SRI submitted on 07/08/25 at 8:41 A.M. revealed on 07/04/25 at 6:00 A.M., Resident #68 indicated Resident #69 stated Licensed Practical Nurse (LPN) #202 had touched her chest while trying to wake her up to give her medications. Resident #68 stated he had not seen LPN #202 touch Resident #69's chest but he wanted to believe her so he had. Resident #68 stated he had not wanted LPN #202 back in the room. Resident #68 stated Resident #69 had issues with other male caregivers when on another unit but had not known why. Review of statements dated 07/05/25 by the Administrator revealed she had received a call from LPN #410 stating Resident #68's Power of Attorney (POA) had called to say the resident no longer wanted LPN #202 in their room. The POA reported Resident #68 stated the nurse had rubbed Resident #69's chest. The Administrator called the POA who reported he no longer wanted LPN #202 in the room due to Resident #68 reporting LPN #202 had rubbed Resident #69's chest when passing medications. The Administrator informed the POA the incident would be investigated. The Administrator called LPN #202 who explained he rocked Resident #69's shoulder while calling her name several times to wake her up. LPN #202 stated he had only touched Resident #69's shoulder when trying to wake her up. The Administrator spoke with Resident #68 who reported he had not seen the incident. Resident #68 then told Resident #69 to show the Administrator where the nurse touched her on the chest. Resident #69 appeared confused then after further prompting, Resident #69 rubbed the area above her chest mirroring where Resident #68 was rubbing his chest. Review of the nurse's notes dated 07/04/25 through 07/10/25 revealed no documentation the physician was notified of an allegation of sexual abuse for Resident #69. Interview on 07/10/25 at 10:54 A.M., the Administrator verified there was no documentation of the allegation of sexual abuse allegedly occurring on 07/04/25 at 6:00 A.M. in Resident #69's medical record and no documentation the physician was notified. The Administrator revealed the nurse should have documented the incident and notification in the medical record. The Administrator revealed she had notified the physician on 07/05/25 but the notification had not been documented in the medical record. Interview on 07/14/25 at 11:38 A.M., Licensed Practical Nurse (LPN) #410 revealed around lunch time on 07/04/25, Resident #68 alleged Resident #69 had stated a male nurse had touched her chest. LPN #410 revealed she had notified the Administrator on 07/04/25 at 1:30 P.M. LPN #410 revealed she had not notified the physician and was unsure if she was supposed to notify the physician. Review of the facility policy Notification of Changes, dated 10/02/22, revealed the resident's physician would be notified when there was a change requiring notification including accidents, significant changes in physical, mental or psychosocial condition, and circumstances requiring a need to alter treatment.

Based on review of the medical record, review of a Self-Reported Incident (SRI) investigation, staff interview, and review of facility policy, the facility failed to timely report an allegation of sexual abuse. This affected one (#69) of three residents reviewed for abuse and one of one SRIs submitted since the annual comprehensive survey. The facility census was 97. Review of the medical record for Resident #69 revealed an admission date of 06/07/21. Diagnoses included dementia with behavioral disturbance, osteoarthritis, depression, anxiety, visual hallucinations, and bilateral hearing loss. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #69 had severe cognitive impairment.Review of the medical record for Resident #68 revealed an admission date of 02/23/21. Diagnoses included hemiplegia and hemiparesis, hypertension, atrial fibrillation, and type two diabetes mellitus.Review of the quarterly MDS dated [DATE] revealed Resident #68 had intact cognition. Review of an SRI submitted on 07/08/25 at 8:41 A.M. revealed on 07/04/25 at 6:00 A.M., Resident #68 indicated Resident #69 had stated Licensed Practical Nurse (LPN) #202 had touched her chest while trying to wake her up to give her medications. Resident #68 stated he had not seen LPN #202 touch Resident #69's chest but he wanted to believe her, so he had. Resident #68 stated he just had not wanted LPN #202 back in the room. Resident #68 stated Resident #69 had issues with other male caregivers when on another unit but had not known why. Review of statements dated 07/05/25 by the Administrator revealed she had received a call from LPN #410 stating Resident #68's Power of Attorney (POA) had called to say the resident no longer wanted LPN #202 in their room. The POA reported Resident #68 stated LPN #202 had rubbed Resident #69's chest. The Administrator called the POA who reported he no longer wanted LPN #202 in the room due to Resident #68 reporting LPN #202 had rubbed Resident #69's chest when passing medications. The Administrator informed the POA the incident would be investigated. The Administrator called LPN #202 who explained he rocked Resident #69's shoulder while calling her name several times to wake her up. LPN #202 stated he had only touched Resident #69's shoulder when trying to wake her up. The Administrator spoke with Resident #68 who reported he had not seen the incident. Resident #68 then told Resident #69 to show the Administrator where the nurse touched her on the chest. Resident #69 appeared confused then after further prompting, Resident #69 rubbed the area above her chest mirroring where Resident #68 was rubbing his chest. Review of the nurse's notes from 07/04/25 through 07/10/25 revealed no documentation of the incident dated 07/04/25 in the residents' medical records. Interview on 07/10/25 at 10:15 A.M., Certified Nursing Assistant (CNA) #316 revealed Resident #68 reported Resident #69 had stated LPN #202 had touched her chest. CNA #316 revealed Resident #68 had reported the incident about a week and half ago, sometime during the week before 07/04/25. CNA #316 revealed she had reported the incident to the nurse but was unable to recall which nurse. CNA #316 revealed the nurse told her she had spoken with Resident #68 and Resident #69. CNA #316 revealed she had not been interviewed regarding the allegation and had not been asked to write a statement. Interviews on 07/10/25 beginning at 10:54 A.M., the Administrator revealed LPN #202 had worked a 12-hour night shift on 07/03/25 into 07/04/25. The Administrator revealed on 07/04/25 the day shift nurse LPN #410 called her around 1:30 P.M. and stated Resident #69 told Resident #68 that LPN #202 had touched her chest. The Administrator revealed she called LPN #202 and Resident #69's family. The Administrator verified she had not reported the incident occurring on 07/04/25 to the state agency until 07/08/25. Interview on 07/10/25 at 11:06 A.M., LPN #202 revealed he was notified a resident had made an allegation of sexual abuse when he worked night shift from 07/03/25 into 07/04/25. LPN #202 revealed the Administrator called him to discuss the incident six days ago. LPN #202 denied the allegation and stated he had touched the resident's shoulder when trying to wake her up to give her medications. Interview on 07/14/25 at 11:38 A.M., LPN #410 revealed on 07/04/25 around lunch time a nursing assistant had notified her Resident #68 wanted to speak with her. LPN #410 stated Resident #68 told her his spouse was not comfortable with male nurses and had not wanted male nurses in the room anymore. LPN #410 revealed after several minutes of conversation, Resident #68 reported Resident #69 told him a male nurse had touched her chest, but he had not witnessed the incident. LPN #410 revealed Resident #68 and Resident #69's Power of Attorney (POA) had called the facility stating they no longer wanted male staff providing care for Resident #69. LPN #410 revealed she then notified the Administrator on 07/04/25 around 1:30 P.M. LPN #410 revealed she had not documented the incident in the medical record. LPN #410 also revealed she had not notified the physician because she was not sure if she was supposed to. LPN #410 also verified she had not assessed Resident #69 after Resident #68's allegation of abuse. LPN #410 revealed Resident #68 had previously told her a week or two prior to the incident on 07/04/25 that he had not wanted male caregivers for Resident #69. LPN #410 told him at that time he would need to speak with the Administrator. LPN #410 revealed she had not documented or reported Resident #68's original request for no male staff for Resident #69 to the Administrator. Review of the facility policy Abuse, Neglect, and Exploitation, revised 12/2024, revealed the facility would report all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes: immediately, but not later than two hours after the allegation was made, if the event causing the allegation involved abuse or result in seriously bodily injury or not later than 24 hours if the events causing the allegation do not involve abuse and do not result in serious bodily injury. This deficiency represents non-compliance investigated under Complaint Number 1373153.

Based on observation, staff interview and maintenance record review, the facility failed to ensure ice machines were maintained in a clean and sanitary condition. This had the potential to affect all residents. The facility census was 96. Findings include: Observation on 05/19/25 at 10:05 A.M. of the large industrial ice machine on the Rosewood unit, with Director of Maintenance (DOM) #600, revealed the inside of the machine had noticeable mold-like built up on the bottom of the machine and other areas throughout the machine. Multiple areas of the machine had large orange, rust-like areas. Concurrent interview with DOM #600 confirmed the findings and stated the ice machine was often used by staff and residents for various uses, such as filling water pitchers. Review of the ice machine maintenance records revealed the machine was last serviced on 02/14/24 and had no upcoming maintenance scheduled.

Based on observation and staff interview, the facility failed to maintain the dumpster area in a clean and sanitary manner. This had the potential to affect all residents. The facility census was 96. Findings include: Observation on 05/20/25 at 8:30 A.M. of the outside dumpster area revealed numerous cardboard boxes, gloves, food scraps and six alcoholic beverage cans on the ground, outside of the dumpster. Interview on 05/18/25 at 8:45 A.M. with [NAME] (CK) #257 verified the debris located on the ground, around the dumpster.

Based on medical record review, staff interview and review of facility policy, the facility failed to maintain complete documentation of care provided for residents. This affected four (#14, #95, #301, and #35) of four residents reviewed for activities of daily living (ADLs). The facility census was 96. Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 01/05/18. Diagnoses included atherosclerotic heart disease of native coronary artery, atrial fibrillation (a. fib), unspecified thoracic, thoracolumbar and lumbosacral intervertebral disc disorder, spinal stenosis, hypertension (HTN), major depressive disorder, anxiety, history of falling, unsteadiness on feet, generalized muscle weakness, and respiratory disorder. Review of the most recent quarterly Minimum Data Set (MDS) assessment revealed Resident #14 had a Brief Interview of Mental Status (BIMS) score of 11, indicating the resident was moderately cognitively impaired. The resident required assistance with hygiene. Review of the facility shower schedule revealed Resident #14 was scheduled to receive showers twice a week, every Tuesday and Saturday. Review of the shower sheets from February 2025 through 05/21/25 revealed no documentation of showers provided for Resident #14 on 02/04/25, 02/08/25, 02/11/25, 02/18/25, 02/22/25, 03/04/25, 03/08/25, 03/11/25, 03/22/25, 04/05/25, 04/08/25, 04/12/25, 04/15/25, 04/19/25, 04/29/25, 05/09/25, 05/10/25, 05/13/25, and 05/17/25. Interview on 05/21/25 at 11:17 A.M. with the Director of Nursing (DON) verified Resident #14's showers were not documented as completed. 2. Review of the medical record for Resident #95 revealed an admission date of 03/03/25. Diagnoses included chronic obstructive pulmonary disease (COPD), type two diabetes mellitus (DM2), generalized muscle weakness, dysphagia, hemiplegia and hemiparesis, acute and chronic respiratory failure, mild cognitive impairment, lack of coordination, unsteadiness on feet, HTN, aphasia, and obstructive and reflux uropathy. Review of the Medicare 5-Day MDS assessment, dated 03/06/25, revealed a BIMS score of 03, indicating Resident #9 was severely cognitively impaired. The resident required substantial/maximal (staff) assistance with personal hygiene. Review of the facility shower schedule revealed Resident #95 was scheduled to receive showers twice a week, on Tuesdays and Fridays. Review of the shower sheets from March 2025 through 05/20/25 revealed no documentation of showers provided for Resident #95 on 03/04/25, 03/07/25, 03/11/25, 03/14/25, 03/18/25, 03/21/25, 03/25/25, 03/28/25, 04/01/25, 04/08/25, 04/15/25, 04/18/25, 04/22/25, 04/25/25, 04/29/25, 05/02/25, 05/06/25, 05/09/25, 05/13/25, 05/16/25, and 05/20/25. Interview on 05/21/25 at 11:17 A.M. with the DON verified Resident #95's showers were not documented as completed. 3. Review of the medical record for Resident #301 revealed an admission date of 03/03/23. Diagnoses included obesity, DM2, HTN, anemia, major depressive disorder, fibromyalgia, anxiety, respiratory disorders, muscle weakness, need for assistance with personal care, and spina bifida. Review of the most recent quarterly MDS assessment, dated 04/08/25, revealed a BIMS score of 14, indicating Resident #301 was cognitively intact. The resident required assistance with personal hygiene. Review of the facility shower schedule revealed Resident #301 was scheduled to receive showers twice a week, on Mondays and Thursdays. Review of the shower sheets from February 2025 through April 2025 revealed no documentation for showers completed for Resident #301 on 02/17/25, 02/20/25, 03/10/25, 03/13/25, 03/17/25, 03/27/25, 03/31/25, 04/03/25, 04/14/25, 04/24/25, and 04/28/25. Interview on 05/21/25 at 11:17 A.M. with the DON verified Resident #301's showers were not documented as completed. 4. Review of the medical record for Resident #35 revealed an admission date of 06/13/23. Diagnoses included metabolic encephalopathy, type two diabetes mellitus (DM2), hepatic encephalopathy, dysphagia, need for assistance with personal care, respiratory disorders, hypertension (HTN), depression, obstructive sleep apnea (OSA), and osteoarthritis. Review of the MDS assessment, dated 03/09/25, revealed a Brief Interview of Mental Status (BIMS) score of 11, indicating Resident #35 was moderately cognitively impaired. Review of the Activities of Daily Living (ADL) Incontinence Care documentation from February 2025 through 05/01/25 revealed no documentation for incontinence care provided for Resident #35 on 02/02/25, 02/04/25, 02/06/25, 02/10/25, 02/11/25, 02/14/25, 02/15/25, 02/17/25, 02/19/25, 02/20/25, 03/01/25, 03/05/25, 03/08/25, 03/09/25, 03/11/25, 03/14/25, 03/16/25, 03/18/25, 03/19/25, 03/20/25, 03/22/25, 03/22/25, 03/24/25, 03/25/25, 03/26/25, 03/27/25, 03/29/25, 03/30/25, 04/02/25, 04/03/25, 04/04/25, 04/07/25, 04/08/25, 04/09/25, 04/11/25, 04/12/25, 04/13/25, 04/14/25, 04/15/25, 04/16/25, 04/17/25, 04/18/25, 04/19/25, 04/20/25, 04/21/25, 04/22/25, 04/23/25, 04/24/25, 04/25/25, 04/27/25, 04/30/25, 05/01/25, 05/02/25, 05/03/25, 05/04/25, 05/05/25, 05/06/25, 05/07/25, 05/08/25, 05/09/25, 05/10/25, 05/11/25, 05/13/25, 05/14/25, 05/15/25, 05/16/25, 05/18/25, 05/20/25, and 05/21/25. Interview on 05/21/25 at 11:17 A.M. with the DON verified the incontinence care provided for Resident #35 was not documented in the resident's medical record. Review of the facility policy titled, Documentation in Medical Record, dated 04/03/25, revealed each resident's medical record shall contain an accurate representation of the resident and include enough information to provide a picture of the resident's progress through completed, accurate, and timely documentation.

Based on review of the facility infection tracking records, staff interview and review of the facility policy, the facility failed to ensure residents met infection criteria prior to the initiation of antibiotics. This affected 27 (#10, #11, #12, #18, #19, #24, #25, #26, #27, #30, #37, #40, #48, #50, #56, #62, #63, #64, #66, #69, #71, #75, #82, #88, #89, #102, and #301) of 27 residents reviewed for antibiotic stewardship. The facility census was 96. Findings include: Review of the facility infection tracking records from 12/01/25 through 01/31/25 revealed the facility utilized McGeer's (set of clinical and laboratory findings used to assist in identifying infections requiring antibiotic treatment) criteria to determine appropriate antibiotic usage. Further review revealed the following residents were ordered antibiotics without being reviewed to determine whether the McGeer's criteria for antibiotic use was met: • Resident #66, with an admission date of 09/12/23, was ordered ceftriaxone for a bladder infection on 12/02/24. • Resident #10, with an admission date of 10/10/24, was ordered levofloxacin for a bladder infection on 12/02/24. Resident #10 was also ordered Bactrim for a bladder infection on 01/20/25. • Resident #19, with an admission date of 05/15/24, was ordered doxycycline for a skin infection on 12/02/24. • Resident #25, with an admission date of 02/09/23, was ordered Maxipime for a bladder infection on 12/04/24. • Resident #56, with an admission date of 09/21/18, was ordered Bactrim for a bladder infection and cephalexin for a surgical wound on 12/07/24. Resident #56 was also ordered doxycycline for skin and surgical infections on 12/12/24, and was ordered doxycycline for an elbow infection on 01/16/25. • Resident #75, with an admission date of 06/23/22, was ordered doxycycline for a wound infection on 12/10/24. • Resident #37, with an admission date of 02/07/24, was ordered cefdinir for a bladder infection on 12/12/24, and was ordered Invanz for a bladder infection on 01/08/25. Resident #37 was also ordered levofloxacin for a bladder infection on 01/09/25. • Resident #88, with an admission date of 10/01/24, was ordered cephalexin for a bladder infection on 12/14/24. • Resident #102, with an admission date of 04/06/23, was ordered cefuroxime for a bladder infection on 12/18/24. • Resident #40, with an admission date of 05/27/18, was ordered doxycycline for a skin infection on 12/21/24. • Resident #27, with an admission date of 12/23/24, was ordered Bactrim for a post-surgical intervention on 12/26/24. Resident #27 was also ordered clindamycin for a post-surgical intervention on 01/03/25. • Resident #26, with an admission date of 03/31/23, was ordered cephalexin for a bladder infection on 01/02/25. • Resident #64, with an admission date of 09/01/21, was ordered doxycycline on 01/03/25 for an infection of the leg, and was ordered Invanz for a bladder infection on 01/22/25. • Resident #71, with an admission date of 06/07/21, was ordered cefdinir for a bladder infection on 01/03/25. • Resident #69, with an admission date of 05/21/22, was ordered cephalexin for a skin infection on 01/06/25. • Resident #62, with an admission date of 12/17/24, was ordered amoxicillin for a bladder infection on 01/11/25. Resident #62 was also ordered Invanz for a bladder infection on 01/30/25. • Resident #63, with an admission date of 08/28/24, was ordered cefadroxil for a bladder infection on 01/14/25. • Resident #301, with an admission date of 03/03/23, was ordered doxycycline for a lung infection on 01/15/25. • Resident #24, with an admission date of 11/22/23, was ordered doxycycline for a lung infection on 01/21/25. • Resident #48, with an admission date of 07/21/23, was ordered cephalexin for a bladder infection on 01/27/25. • Resident #89, with an admission date of 10/18/24, was ordered doxycycline for a skin infection on 01/28/25. • Resident #12, with an admission date of 01/26/22, was ordered Macrobid for a bladder infection on 01/29/25. • Resident #82, with an admission date of 09/23/23, was ordered doxycycline for blisters on their back on 01/29/25. • Resident #11, with an admission date of 07/03/19, was ordered doxycycline for a lung infection on 01/30/25. • Resident #30, with an admission date of 02/27/21, was ordered doxycycline for a lung infection on 01/30/25. • Resident #50, with an admission date of 12/05/24, was ordered Rocephin for a bladder infection on 01/31/25. • Resident #18, with an admission date of 10/10/21, was ordered doxycycline for methicillin-resistant staphylococcus aureus of an unknown origin on an unknown date in January 2025. Interview on 05/21/25 at 8:12 A.M. with Registered Nurse (RN) #590, identified as the facility's infection preventionist, confirmed the facility utilized McGeer's criteria as part of their antibiotic surveillance program and further verified the above residents were ordered antibiotics without the facility determining whether residents met McGeer's infection criteria for antibiotic usage. RN #590 reported the facility was supposed to ensure all residents who were prescribed antibiotics met McGeer's criteria but she did not have time to complete the process for any residents in the months of December 2024 or January 2025. Review of the facility policy titled, Antibiotic Prescribing Practices, dated 03/01/23, revealed antibiotic use protocols were implemented as a part of the facility's antibiotic stewardship program for the purpose of optimizing the treatment of infections and reducing adverse events associated with antibiotic use.

Based on observation, record review, staff interview, and review of the facility policy, the facility failed to ensure the physician was notified when a medication was unavailable for administration. This affected one (#57) of three residents reviewed for physician notification. The facility census was 96. Findings include: Review of Resident #57's medical record revealed an admission date of 10/07/24 with diagnoses including Parkinson's disease, hypertension (HTN), hyperlipidemia, hypothyroidism, major depressive disorder, anemia, and neuromuscular dysfunction of the bladder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/27/25, revealed a Brief Interview of Mental Status (BIMS) score of 13, indicating Resident #57 was cognitively intact. Review of a physician order, dated 10/07/24, revealed Resident #57 had an order for trihexyphenidyl hydrochloride (HCl) (used to treat movement problems caused by Parkinson's disease), two milligrams (mg) to be administered orally (PO) two times per day. Observation on 05/19/25 at 7:00 A.M. of medication administration with Licensed Practical Nurse (LPN) #527 revealed trihexyphenidyl HCl was not administered to Resident #57. Concurrent interview with LPN #527 verified trihexyphenidyl HCI was not administered to Resident #57 due to the medication being unavailable. LPN #527 stated she would request the medication from the pharmacy and would administer it if it came in. Review of the Medication Administration Record (MAR) revealed Resident #57 was not administered either of the two ordered doses of trihexyphenidyl HCl on 05/19/25. Further review of Resident #57's medication record revealed no evidence the physician was notified that trihexyphenidyl HCl was unavailable for administration on 05/19/25. Interview on 05/21/25 at 9:10 A.M. with the Director of Nursing (DON) verified the prescribing physician was not notified that trihexyphenidyl HCl was unavailable for administration to Resident #57 on 05/19/25. Review of the facility policy titled, Notification of Changes, dated 10/02/22, revealed the facility promptly informed the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.

Based on observation, staff interview, resident interview, and review of the facility policy the facility failed to ensure bedding was maintained in a clean and sanitary manner. This affected one (#16) resident reviewed for soiled bedding. The facility census was 96. Findings include: Review of the medical record for Resident #16 revealed an admission date of 06/01/23. Diagnoses included Parkinson's disease, chronic kidney disease, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/21/25, revealed Resident #16 was mildly cognitively impaired and required supervision for bathing. Observation on 05/18/25 at 10:30 A.M. of Resident #16's bedding revealed several light brown streaks on the fitted sheet of the bed and a dark brown spot on the bed pad. Concurrent interview with Resident #16 revealed her sheets had not been changed in a while and stated they were dirty. Observation on 05/19/25 at 9:40 A.M. of Resident #16's bedding revealed the sheets remained with the same brown streaks on the fitted sheet. Concurrent interview with Resident #16 confirmed her sheets had not been changed. Observation on 05/20/25 at 9:29 A.M. of Resident #16's bedding revealed the bedding remained dirty and unchanged. Interview on 05/20/25 at 10:07 A.M. with Registered Nurse (RN) #509 verified the light brown streaks on the fitted sheet and the dark brown spot on the bed pad on Resident #16's bedding. Review of the facility policy titled, Homelike Environment, revised February 2021, revealed residents were provided a safe, clean, comfortable and homelike environment. The facility staff and management maximized, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting, to include a clean bed and bath linens that are in good condition.

Based on medical record review, observation, staff interview and review of the facility policy, the facility failed to ensure valid indications for the use of mobility restricting devices. This affected two (#3 and #56) of two residents reviewed for elopement. The facility census was 96. 1. Review of Resident #3's medical record revealed an admission date of 06/01/22. Diagnoses included Alzheimer's disease, dementia, hypothyroidism and congestive heart failure. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/04/25, revealed Resident #3 was severely cognitively impaired, required supervision for completing activities of daily living (ADLs) and exhibited no wandering behaviors. Further review of the MDS assessments since Resident #3's admission to the facility revealed the resident was never identified as having any wandering behaviors. Review of the Elopement Risk Assessment, dated 04/04/25, revealed Resident #3 had no history of elopement in the last six months and was identified as not being an elopement risk. Review of the care plan, dated 06/01/22, revealed Resident #3 was risk for wandering/elopement, with no specific diagnosis or reasoning for the wandering/elopement risk was identified. Interventions included WanderGuard to the left ankle and check its placement every shift. Review of the physicians orders revealed an order dated 02/05/24 to check placement of the WanderGuard (a medical device to help prevent residents, especially those at risk of wandering, from leaving secure areas within a facility) every shift daily and an order dated 03/08/24 to check WanderGuard function daily. Further review of the medical record revealed no documentation to support the use of a WanderGuard for Resident #3. Observation of Resident #3 on 05/20/25 at 9:45 A.M. revealed Resident #3 was sitting in her room watching television. Resident #3 presented with no observable restlessness or any indications that she was exit seeking. 2. Review of Resident #56's medical record revealed an admission date of 09/21/18. Diagnoses included Alzheimer's disease, schizophrenia, dementia, and major depressive disorder. Review of the MDS 3.0 assessment, dated 02/06/25, revealed Resident #56 was severely cognitively impaired, required one person assistance for completing ADLs, and exhibited no wandering behaviors. Further review of the MDS assessments since Resident #56's admission to the facility revealed the facility had never identified the resident as having wandering behaviors. Review of the Elopement Risk Assessment, dated 04/17/25, revealed Resident #56 had no history of elopement in the last six months and was identified as not being an elopement risk. Further review of previous Elopement Risk Assessments revealed Resident #56 had not been identified as being at risk for elopement since 11/16/23. Review of the physician orders revealed an order initiated on 02/05/24 to check placement of the WanderGuard every shift daily and an order dated 09/01/23 to check WanderGuard function daily. Observation on 05/20/25 at 10:15 A.M. of Resident #56, with the Director of Nursing (DON) present, revealed Resident #56 was laying back in her tilt-n-space wheelchair (reclining wheelchair) looking around in a common area. Resident #56 presented with no distress or repetitive movements/phrases that would indicate possible exit seeking behaviors. Interview with the DON on 05/20/25 at 11:00 A.M. confirmed the medical records for both Resident #3 and Resident #56 lacked indications for the use of the WanderGuard device. Review of the facility policy titled, Restraint Free Environment, dated 05/20/25, revealed it was the policy of the facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibited the use of physical or chemical restraints for discipline or convenience and limited restraint use to circumstances in which the resident had medical symptoms that warrant the use of such restraints. This deficiency represents non-compliance investigated under Complaint Number OH00163154.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure residents who received psychotropic medications were monitored for behaviors, adverse effects, and efficacy. This affected one (#15) of five residents reviewed for unnecessary medications. The facility census was 96. Findings include: Review of the medical record revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included anxiety, depression, psychotic disorder, and schizophrenia. Review of the Minimum Data Set (MDS) assessment, dated 04/21/25, revealed Resident #15 was cognitively intact. Review of the plan of care, revised 03/08/24, revealed Resident #15 used psychotropic medications. Interventions included administering medications as ordered and monitoring for side effects and effectiveness, and monitoring and reporting as needed side effects and adverse reactions of medication. Review of Resident #15's active physician orders for May 2025 revealed an order for buspirone (anti-anxiety medication) 7.5 milligram (mg) oral tablet, give one tablet by mouth two times per day for major depressive disorder; lorazepam (benzodiazepine medication used to treat anxiety) 0.5 mg oral tablet, give one tablet by mouth two times per day related to anxiety disorder; lorazepam 0.5 mg oral tablet, give 0.25 mg one time per day for anxiety disorder; and sertraline (anti-depressant medication) 50 mg oral tablet, give one tablet by mouth one time per day for major depressive disorder. Review of the Medication Administration Records (MAR) from 03/01/25 through 05/20/25 revealed Resident #15 received sertraline once daily from 03/01/25 through 04/14/25 and 04/18/25 through 05/20/25. The resident received buspirone twice per day from 03/01/25 through 04/14/25 and 04/14/25 through 05/19/25. Resident #15 also received lorazepam twice per day from 03/01/25 through 04/14/25 and 04/18/25 through 05/19/25. Further review of the medical record revealed no evidence Resident #15 was monitored for any specified behaviors or for efficacy related to the three medications from 03/01/25 through 05/20/25. In addition, there was no evidence the resident was monitored for adverse effects from the medications from 05/01/25 through 05/20/25. Interview on 05/20/25 at 5:45 P.M. with the Director of Nursing (DON) verified there was no evidence Resident #15 was monitored on a regular basis for behaviors, efficacy, and adverse effects for psychotropic medication use. Review of the facility policy titled, Use of Psychotropic Medication, undated, revealed the resident's response to psychotropic medications, including the presence/absence of adverse consequences, would be documented in the resident's record, and the resident's symptoms would be clearly identified and documented. Review of the facility policy titled, Behavioral Assessment, Intervention and Monitoring, revised March 2019, revealed when medications were prescribed for behavioral symptoms, documentation would include potential underlying causes of the behavior, specific target behaviors and expected outcomes, monitoring for efficacy and consequences.

Based on medical record review and staff interview, the facility failed to complete timely Minimum Data Set (MDS) assessments following a significant change. This affected one (#91) of one resident reviewed for hospice services. The facility identified five residents receiving hospice services. The facility census was 96 Findings include: Review of Resident #91's medical record revealed an admission date of 11/11/24. Diagnoses included dementia, insomnia and neck fracture. Review of the most recent Minimum Data Set (MDS) 3.0 assessment, dated 02/13/25, revealed Resident #91 was severely cognitively impaired and required extensive assistance from staff for activities of daily living (ADLs). The MDS did not indicate Resident #91 received hospice services. Review of the physician orders revealed an order dated 04/29/25 to consult a local hospice provider for potential admission for Resident #91. Further review of the medical record revealed Resident #91 elected hospice services on 05/01/25, with a diagnosis of senile degeneration of the brain. Additional review of the MDS assessments from 05/01/25 through 05/19/25 revealed no evidence that a significant change MDS was completed upon Resident #91's election of hospice services. Interview on 05/19/25 at 1:30 P.M. with the Director of Nursing (DON) verified a significant change MDS was not completed within 14 days of Resident #91 electing hospice services.

Based on medical record review, staff interviews, review of the facility investigation, review of the facility's policy for Emergency Procedure - Cardiopulmonary Resuscitation, review of the American Heart Association Journal, review of a job description for Licensed Practical Nurses (LPN), and review of cardiopulmonary resuscitation (CPR) certifications, the facility failed to timely initiate CPR or contact emergency medical services (EMS) for one resident (Resident #03) found unresponsive, without a pulse or blood pressure, and who was identified as a Full Code status. This resulted in Immediate Jeopardy, serious life-threatening harm, and ultimate death when Resident #03 did not receive CPR after she was discovered with no pulse and no blood pressure and EMS was not contacted for assistance. This affected one (#03) of three residents (#03, #06, and #07) who expired unexpectedly at the facility. Additionally, the facility failed to ensure four nurses employed by the facility (Licensed Practical Nurse (LPN) #206, LPN #210, LPN #211, and LPN #222) of ten nurses had a current CPR certification for Healthcare Providers. This had the potential to affect 27 residents (#05, #09, #20, #25, #28, #38, #46, #47, #51, #53, #58, #65, #68, #73, #77, #78, #79, #81, #82, #84, #86, #91, #95, #98, #99, #102, and #104) designated with a Full Code resuscitation status. The facility census was 90. On [DATE] at 12:15 P.M., the Executive Director and Administrator #501 were notified Immediate Jeopardy began on [DATE] at approximately 1:00 A.M. when Resident #03, who was a Full Code resuscitation status, was found unresponsive by State tested Nurse Aide (STNA) #104. STNA #104 notified LPN #205 of Resident #03 being unresponsive. Prior to responding to the room, LPN #205 checked Resident #03's chart for her resuscitation status and discovered the resident was a full code. LPN #205 assessed Resident #03 with no pulse or blood pressure, and Resident #03 was cold to the touch. LPN #205 chose to not initiate CPR or call EMS. LPN #205 called Resident #03's physician, Physician #800, and was unable to reach him. Two agency registered nurses (RN), RN #202 and RN #203, assessed Resident #03 and found no pulse or blood pressure. RN #202 suggested CPR be initiated for Resident #03 and LPN #205 responded with the decision to not initiate CPR or call EMS. LPN #205 notified the family of the resident's death by 1:44 A.M., and notified the funeral home, who picked up Resident #03 on [DATE] at 3:50 A.M. The facility received return contact from Physician #800 on [DATE] at approximately 6:45 A.M. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE], the Executive Director notified the Medical Director of the incident. On [DATE], the Director of Social Services reviewed all residents' advance directive paperwork with the electronic medical record order for accuracy. On [DATE], the Executive Director completed Code Education with all staff through a virtual platform. The Code Education defined the proper response when finding an unresponsive individual at the facility. On [DATE] at 9:40 A.M., LPN #205 was suspended pending investigation. On [DATE] LPN #205 was terminated. On [DATE], the Executive Director and the Director of Nursing (DON) completed a Root Cause Analysis of the incident. On [DATE], the Executive Director educated RN #202 and RN #203 on the facility's proper protocol and procedure for responding to residents with a Full Code resuscitation status. Beginning [DATE], the DON/designee audited new admissions to compare the resident's advance directives to the physician orders for accuracy. This audit was done weekly for seven weeks from [DATE] through [DATE]. Findings were reviewed at the monthly Quality Assessment and Assurance (QAA) Committee meeting. On [DATE], an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting reviewed the plan of correction, including education and audits. On [DATE], the DON or designee performed a Code Blue drill with licensed n ursing staff. Code Blue drills will be held quarterly with findings reviewed at the monthly QAA Committee meeting. On [DATE] the Executive Director educated Physician #800 on the importance of timely responses to communications from the facility. On [DATE] the medical record for Resident #06 and Resident #07, who expired unexpectedly at the facility, were reviewed and found staff responded appropriately. Although the Immediate Jeopardy was removed [DATE], the facility remains out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and non-compliance due to four nurses working at the facility had expired CPR certification. Findings include: 1.Review of the medical record for Resident #03 revealed a readmitted [DATE] and a discharge date of [DATE]. Medical diagnoses included chronic obstructive pulmonary disease, hear t failure, and legal blindness. Review of a physician order dated [DATE] revealed Resident #03 had a Full Code resuscitation status. Review of a progress note dated [DATE] revealed Resident #03's code status was reviewed during a care conference and Resident #03 wished to remain a Full Code at that time. Review of a progress note dated [DATE] at 1:44 A.M. revealed Resident #03 was found unresponsive, without a pulse, with no readable blood pressure, and cold to the touch. Resident #03 was last noted to be responsive at 10:00 P.M. on [DATE]. The family was notified and coming in and Physician #800 was notified. Review of the facility investigation related to Resident #03's death, initiated on [DATE], revealed the Executive Director obtained statements via an interview from staff working the night Resident #03 expired. STNA #104's statement obtained during an interview, revealed she spoke with Resident #03 on [DATE] at approximately 12:30 A.M. STNA #104 returned to provide care at approximately 1:30 A.M. and found Resident #03 unresponsive to verbal and physical prompts. STNA #104 then notified LPN #205 that Resident #03 was unresponsive. Continued review of STNA #104's statement revealed LPN #205 checked Resident #03's pulse and vitals. STNA #104 heard LPN #205 say Resident #03 was gone. STNA #104 did not hear LPN #205 call a Code Blue, or give any further direction to the aides after saying Resident #03 was gone. Review of the documented interview statement from LPN #205 revealed she was notified by STNA #104 to check on Resident #03. LPN #205 assessed Resident #03 and found no vital signs were present and Resident #03 was not breathing. LPN #205 statement revealed she knew Resident #03 was a Full Code. RN #202 and RN #203, both agency staff, were in Resident #03's room with LPN #205 and LPN #205 informed them Resident #03 was a Full Code. Both RNs asked LPN #205 about starting CPR. LPN #205 did not initiate CPR. LPN #205 stated she called Physician #800 about Resident #03's death but did not receive a response. Interview on [DATE] at 2:18 P.M. with the Executive Director and the DON confirmed LPN #205 should have initiated CPR on Resident #03, who had a Full Code status and was found unresponsive on [DATE]. Further interview revealed LPN #205 no longer worked at the facility. The Executive Director revealed LPN #205's employment was terminated for multiple reasons, and ultimately for failure to follow physician orders. Further, the facility did not report LPN #205 to the Board of Nursing and did not file a self-reported incident regarding this event. Interview on [DATE] at 3:07 P.M. with STNA #104 revealed she spoke with Resident #03 on [DATE] at approximately 12:30 A.M. and Resident #03 was responsive at that time. STNA #104 returned to Resident #03's room at approximately 1:30 A.M. to check her for continence care. The light was off at that time. STNA #104 called Resident #03's name and gently tapped her on the shoulder/collar bone to elicit a response. STNA #104 stated Resident #03's skin was still warm, but she did not respond. STNA #104 then sought the help of the nearest nurse, LPN #205. STNA #104 stated LPN #205 checked on Resident #03 and did not initiate CPR or call EMS. A telephone interview on [DATE] at 3:27 P.M. with LPN #205 revealed she was not assigned to Resident #03 on [DATE] but was familiar with her. LPN #205 stated she was charting at the nurses' station when STNA #104 called for help with Resident #03. LPN #205 looked in Resident #03's chart at that time and found Resident #03 had a Full Code status. LPN #205 found Resident #03 unresponsive, without a pulse or blood pressure, and her arms and hands were cold to the touch. LPN #205 stated two agency nurses came into the room and also assessed Resident #03. The crash cart was brought to the room by aides. LPN #205 stated she used her nursing judgment to determine Resident #03 had passed and LPN #205 decided not to initiate CPR or call EMS. LPN #205 stated both agency RNs questioned whether CPR should be initiated. Again, LPN #205 stated she had decided not to initiate CPR. A follow up telephone interview with LPN #205 on [DATE] at 11:49 A.M. revealed she notified Physician #800 of Resident #03 being found unresponsive without a blood pressure and pulse via a phone call and a text message. She was unable to recall the time of the attempted telephone call. LPN #205 stated she heard back from Physician #800 on [DATE] between approximately 7:00 A.M. to 7:30 A.M. A telephone interview on [DATE] at 9:40 A.M. with agency RN #202 revealed she was not assigned to Resident #03 on [DATE]. RN #202 stated she received a call for assistance from an aide. When RN #202 approached Resident #03's room several people were standing outside the room. LPN #205 was in the room with Resident #03 and told RN #202 that Resident #03 Was gone. RN #202 stated LPN #205 informed her Resident #03 had a Full Code status. RN #202 indicated they should begin CPR on Resident #03 at that time. RN #202 stated LPN #205 told her LPN #205 had spoken with the doctor and he had Called it. RN #202 assessed Resident #03 and found no vital signs. Resident #03's coloring was dusky, and she felt cold. RN #202 stated she deferred to LPN #205 because she was facility staff and LPN #205 stated she had spoken with the physician. A telephone interview on [DATE] at 12:18 P.M. with Physician #800 revealed he was the previous medical director in the facility. Physician #800 verified he received a telephone call the day Resident #03 died in the facility at approximately 1:00 A.M. but did not hear his telephone ring during the night to answer the call. Physician #800 stated he was almost always up in the morning by 6:00 A.M. and that was the approximate time he saw he missed a call from the facility. Physician #800 stated it was after Resident #03 died that he talked to the nurse who had responded, as she was still on duty. Physician #800 stated when he called the facility, he was notified of Resident #03's death and recalled the nurse telling him Resident #03 was absent of vital signs and cold to the touch when discovered. Physician #800 could not recall what Resident #03's code status was, and upon being informed Resident #03 was a Full Code, Physician #800 stated the decision to begin resuscitation efforts would be based on nursing judgement in Resident #03's situation. Physician #800 stated since Resident #03 had an unwitnessed apparent arrest that occurred at least 15 minutes, or probably more, before being discovered by staff to have no vital signs, and she was cold to the touch, he would not have recommended the staff perform resuscitation efforts. Physician #800 stated Resident #03 would have had little to no hope of resuscitation given the situation. Review of the facility policy titled Emergency Procedure - Cardiopulmonary Resuscitation, revised February 2018, revealed if an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR, Basic Life Support (BLS) shall initiate CPR unless: a. it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. there are obvious signs of irreversible death (e.g., rigor mortis). Review of the American Heart Association Journal, Vol. 122, No.18, found at https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.110.970905, revealed the goals of resuscitation are to preserve life. Criteria for not starting CPR would include: Situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril; Obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition); or a valid, signed, and dated advance directive indicating that resuscitation is not desired, or a valid, signed, and dated do not resuscitate order. 2. Review of the documentation provided by the facility revealed ten nurses were currently employed. Of those ten nurses, four LPNs (#206, #210, #211, and #222) had expired CPR certification for Healthcare Providers. Interview on [DATE] at 12:37 P.M. with Human Resource (HR) Director #302 confirmed four facility-employed nurses had expired CPR certification. Review of the facility's job description for Licensed Practical Nurses, revised [DATE], revealed LPNs must be currently certified in CPR. The deficiency represents noncompliance under Master Complaint Number OH00137743.

Based on medical record review, staff interview, review of the Self-Reported Incident (SRI), review of the facility investigation, review of the manufacturers recommendations, and policy review, the facility failed to ensure mechanical lift equipment was maintained in a safe working condition and failed to ensure residents received appropriate supervision during mechanical lift transfers from the wheelchair to the bed. This resulted in Actual Harm when State tested Nursing Assistant (STNA) #100 failed to ensure there were two staff members present for the transfer using the mechanical lift when the lift suffered mechanical failure resulting in Resident #01 descending three feet to the floor and subsequently suffered a left sacral fracture. This affected one resident (#01) of three residents reviewed for mechanical lift transfers. The facility census was 116. Findings Include: Review of the medical record revealed Resident #01 was admitted to the facility on [DATE]. Diagnoses included [CONDITION(S)], diabetes, and [CONDITION(S)]. Review of the most recent Minimum Data Set assessment dated [DATE] revealed Resident #01 required two staff person assistance for activities of daily living including transfers. Resident #01 was discharged to a local hospital on 05/28/21. Review of the plan of care revealed the resident required two staff person assistance for transfer and the use of a mechanical lift during transfers. Review of the SRI revealed on 05/26/21 STNA #100 was assisting Resident #01 into bed. Resident #01 utilized a mechanical lift for the transfer and during the resident's transfer from his wheelchair to the bed, the mechanical lift malfunctioned which in turn caused Resident #01 to descend from roughly three feet in the air to the ground. The mechanical lift was noted to have had a bolt/screw in the swing arm that came loose and caused the arm to giveaway. Resident #01 refused to go to the local emergency room for evaluation. An X-ray was completed with no findings. Resident #01 stated his pain was manageable at the time of the incident. After a few days Resident #01 complained of hip pain and agreed to go to the emergency room (ER) on 05/28/21 for further evaluation. The ER completed a Computed Tomography scan (CT) of Resident #01's lower back which revealed a left sacral fracture. Review of the facility investigation dated 05/27/21 revealed STNA #100 was attempting to transfer Resident #01 in the mechanical lift by herself with no other staff present. Review of the undated witness statement revealed STNA #100 placed Resident #01 on the lift and when she lifted him up in the air the lift began to lean, and the resident landed on the floor. STNA #100 noticed the lift was bent and showed the nurse on duty. Interview on 06/13/21 at 8:33 A.M., and again at 10:40 A.M., STNA #100 was unable to be reached and no return contact had been made. Interview on 06/13/21 at 10:00 A.M., the Administrator verified the bolt/screw came loose and caused the arm to lean. The Administrator further verified STNA #100 had used the mechanical lift alone. Review of the manufacturer's instructions for use of the mechanical (Hoyer) lift revealed two persons are needed to operate the lift. Review of the facility policy titled Safe Lifting and Movement of Residents revised July 2017 revealed the lifting and transferring needs will be documented in the plan of care. To protect the safety and well-being of the residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents.

Based on medical record review, staff interview, review of the police report, review of the facility policy for missing residents, and review of the facility investigation, the facility failed to provide adequate supervision to prevent a cognitively impaired resident from eloping from the facility. This resulted in Immediate Jeopardy and the potential for serious injury when Resident #04, who had history of exit seeking behaviors and dementia, left the facility unknown to staff and was found one tenth of a mile from the facility by a civilian when Resident #04 walked into a local business and the employees notified emergency services. A facility staff entered the front entrance by accessing the digital keypad which in turn disarmed the Wanderguard alarm system. Resident #04 walked out of the facility as the employee returned to the building. This affected one (#04) of three (#04, #07, and #11) residents reviewed who were assessed with [REDACTED]. The facility census was 113. On 03/15/21 at 4:44 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 03/04/21 at approximately 12:47 P.M., when Resident #04 who had a documented history of exit seeking behaviors had eloped from the facility unknown to staff. Receptionist #100 was returning to the facility after lunch and entered a digital code that opened the front door entrance doors and disarmed the Wanderguard alarm system which then failed to alert staff of an elopement. That was Receptionist #100's first day of employment and he was to be supervised by Receptionist #200. As Receptionist #100 entered the building, Resident #04 walked out of the doors while Receptionist #200 was assisting visitors. The facility staff were unaware Resident #04 was missing until emergency medical services returned her to the facility. The Immediate Jeopardy was removed on 03/16/21 at 3:42 P.M. when the facility implemented the following corrective actions: · On 03/04/21 at 1:15 P.M., a total facility head count was completed to ensure no other residents were missing. · On 03/04/21 at 1:15 P.M., interviews were conducted with all scheduled staff at that time. · On 03/04/21 at 1:15 P.M., safety checks for 24 hours were initiated on Resident #04. · On 03/04/21 at 1:20 P.M., an assessment was completed on Resident #04 to ensure no harm and rechecked the Wanderguard for functionality. The Wanderguard was in place and functioning properly. · On 03/04/21 at 1:25 P.M., Receptionist #100 was educated on elopements and given the task of reviewing the elopement book during his shift that day (book provided at education) and the directive to review all residents ' profiles in Point Click Care. · On 03/04/21 at 1:30 P.M., the facility conducted a series of tests on the Wanderguard system at the front entrance to determine how Resident #04 got through the door. · On 03/04/21 at 1:30 P.M., the facility immediately started educating scheduled staff on the front door protocol and signage that is now posted above the keypads at the front main entrance indicating not to utilize the door code during unlocked door hours. This education was completed on 03/16/21 at 3:42 P.M. · On 03/04/21 at 2:00 P.M., Resident #04's Medication Administration Record [REDACTED]. · On 03/04/21 at 2:05 P.M., the family of Resident #04 and physician were notified of the incident. · On 03/04/21 at 2:05 P.M., a [MEDICATION NAME] care visit was set up with Resident #04's daughter for 03/06/21. A Facetime visit was completed with activities staff assistance between Resident #04 and her daughter after the incident. · On 03/04/21 at 2:30 P.M., Wanderguard checks for functionality and placement were completed on the remaining 20 residents with Wanderguards. · On 03/15/21 from 10:00 A.M. to 5:00 P.M. and on 03/16/21 from 7:20 A.M. to 3:50 P.M. observations revealed no exit doors were alarming and residents were not observed exit seeking. · Interviews on 03/16/21 at 3:28 P.M. with Receptionist #100 revealed he had been educated on the fact that using the keypad code on the front door would deactivate the Wanderguard system. The receptionist also stated he was educated on orientation regarding the elopement policy and reeducated by management on identifying residents at risk for elopement. · Review of the medical record for Resident #07 and Resident #11, who were identified to be at risk for eloping from the facility, revealed no occurrences of either resident leaving the facility unattended. · Interviews on 03/31/21 between 10:45 A.M. and 10:55 A.M. with Registered Nurse (RN) #255, RN #700, and STNA #701 revealed they were educated on the elopement procedures and the new keypad protocol for the front entrance. · Interview on 03/31/21 at 10:45A.M. with the DON revealed no further residents have left the building unsupervised. Although the Immediate Jeopardy was removed on 03/16/21, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until the deficient practice was corrected on 03/31/21. Findings Include: Review of the medical record revealed Resident #04 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #04 had severe cognitive deficits and exhibited wandering behavior. Review of Resident #04's care plan revealed the resident was an elopement risk/wanderer and had cognitive deficits. Interventions included to check placement and function of elopement alarm bracelet each shift and redirect the resident from exit doors. Review of the quarterly Elopement Risk assessment dated [DATE] revealed Resident #04 was disoriented, did not understand her surroundings, had sundowners, stated she wanted to leave the facility and packed her belongings. The resident had a history of [REDACTED]. Resident #04 was ambulatory and at a high risk for elopement. Review of the physician progress notes [REDACTED].#04's nursing staff denied any recent behaviors. The resident was ambulatory around the facility. [DIAGNOSES REDACTED]. Review of the nurses' notes dated 03/04/21 at 1:58 P.M. revealed the nurse had checked the position of the alarm bracelet at morning medication pass and it was present on her left ankle and functioning. At 11:30 A.M. Resident #04 was observed eating lunch. At 1:15 P.M. the resident was returned by emergency services to staff and was informed the resident had been found walking down the street. The police were notified, and the resident was identified and returned to the facility. A full body assessment was performed and there were no signs or symptoms of injury. The secure bracelet was present to the left ankle; however, it was pushed down to the top of her shoe. Resident #04 denied any injury, pain or discomfort. Review of the police report dated 03/04/21 revealed a call was received at 12:54 P.M. The caller stated an elderly female was wondering the area without a coat. The police assisted the local fire department with identification of the female and found she was a resident of Providence Care Center and in early stages of dementia. The fire department transported the resident back to the facility. The report revealed the call was cleared at 1:29 P.M. Review of the witness statement dated 03/04/21 from Receptionist #100 revealed he came back from lunch. The door was locked, he punched in the code and Resident #04 was standing in front of him. There were a few others in the lobby as well. Resident #04 said that I didn't have to hold the door, she would catch it. She walked past me and went outside. Review of the witness statement dated 03/04/21 from Receptionist #200 revealed Resident #04 was around 10:30 A.M. standing in the front lobby by a brown leather chair. The alarm was on because a red light was on above the door. I had to let someone in and I put in the code. Resident #04 was still there when I let the person in. Receptionist #200 stated she did not see the resident again until 1:05 P.M. when the police and rescue squad guys brought her back on a stretcher. Review of the witness statement dated 03/04/21 from Dietitian #800 revealed she saw Resident #04 at 12:45 P.M. when she passed the resident in Cedarview hall heading towards the front of the building. Review of the facility policy titled Missing Person Elopement Search and Rescue Plan dated 02/01/18 revealed residents considered at risk for elopement are any resident who has been assessed and deemed to be cognitively impaired and who would leave the building unescorted, be unable to care for him/herself and would be at risk for harm. This deficiency substantiates allegations in Complaint Number OH 649.

Based on medical record review, staff interview and review of hospital documentation, the facility failed to monitor therapeutic blood levels for one resident on oral anticoagulation (blood thinning) therapy. This resulted in actual harm for one resident (#1) receiving oral anticoagulation therapy who was hospitalized for [REDACTED]. This affected one (#1) of three sampled residents receiving oral anticoagulation therapy of a total of 17 residents on oral anticoagulation therapy. Findings include: Review of Resident #1's closed medical record revealed an admission date of [DATE] for rehabilitation and intravenous antibiotic therapy following surgery to place a temporary spacer in the right hip due to infection. [DIAGNOSES REDACTED]. In addition, the resident had a history of [REDACTED]. The resident also had a peripherally inserted central catheter (PICC) located in the right upper arm for intravenous antibiotic therapy. Review of physician orders [REDACTED]. Review of laboratory (lab) results from 01/17/13, indicated Resident #1 had a [MEDICATION NAME] Time and International Normalized Ratio (PT/INR) lab test obtained to determine his blood clotting time. The PT level was elevated at 49 (normal is 9.0-12.9) and the INR level was elevated at 4.5 (normal is 2.0-3.0). The physician was made aware of the lab results on 01/17/13 and ordered Resident #1's [MEDICATION NAME] to be held for three days and repeat the PT/INR lab test on 01/21/13. The results of the 01/21/13 PT/INR lab test revealed a PT of 17.7 and an INR of 1.6, a sub-therapeutic level. Review of nurses' notes revealed from 01/21/13 at 10:43 A.M. revealed the nurse had faxed Resident #1's PT/INR lab results to the physician and was awaiting new orders. However, further review of nurses' notes from 01/21/13 at 10:43 A.M. through 01/28/13 at 6:05 P.M. revealed no documented evidence of follow-up with Resident #1's physician regarding the subtherapeutic PT/INR levels that were obtained on 01/21/13. Further review of nurses' notes revealed an entry dated 01/28/13 at 2:20 P.M. which indicated the resident's right lower arm and hand were [MEDICAL CONDITION]. The nurse documented she notified the charge nurse. The next nurse's note dated 01/28/13 at 6:05 P.M. indicated a family member of Resident #1 was visiting and voiced concerns about the [MEDICAL CONDITION] in his right arm. The nurse documented she notified the physician and was awaiting a response. On 01/28/13 at 7:15 P.M. the nurse noted she attempted to contact the physician but was informed the physician was not on call and there was no one covering. The nurse then called another physician for an order to send Resident #1 to the emergency room for evaluation. The last nurse's note dated 01/28/13 at 8:00 P.M. indicated the resident's right arm was swollen, red, and warm to touch. The nurse documented she received an order to send the resident to the emergency room (ER). The nurse also noted Resident #1 was admitted to the hospital on [DATE] at 2:00 A.M. for multiple blood clots in the right arm. During interview with Registered Nurse (RN) #1 on 04/04/13 at 11:00 A.M., she indicated she called the physician's office and spoke to the office manager asking that she let the physician know that she had faxed Resident #1's PT/INR results. RN #1 stated the physician failed to call back so she called the office again around 3:00 P.M. on 01/21/13 and left another message. She verified the physician never called back with orders regarding the resident's [MEDICATION NAME] medication. RN #1 also verified the medical record contained no evidence of physician follow-up after the two attempts she made on 01/21/13 until 01/28/13, when Resident #1's right lower arm and hand were noted to be [MEDICAL CONDITION]. Review of hospital documentation revealed Resident #1 has a history of chronic [MEDICATION NAME] ([MEDICATION NAME]) therapy for a heart valve. The son indicated the resident has a "St. Jude" valve and is not supposed to ever come off his [MEDICATION NAME] but for some reason the nursing home had stopped his [MEDICATION NAME] on 01/17/13. The resident's PT/INR lab test was obtained and revealed an INR level of 1.2 (subtherapeutic). In the ER, the resident was found to have a right upper extremity [MEDICAL CONDITION] (blood clot) affecting the cephalic and axillary vein. The resident was immediately started on [MEDICATION NAME] (a blood thinning injection medication) and [MEDICATION NAME] to get him to a therapeutic range of 2 to 3. Resident #1 was admitted to the hospital and also found to have bilateral acute [MEDICAL CONDITION]. Further review of hospital documentation revealed Resident #1 and the resident's family refused to go back to the nursing home. The resident was discharged from the hospital on [DATE] with home health services. "This deficiency substantiates Complaint Number OH 706."

Based on medical record review, surveyor observations, review of facility policy and staff interview, it was determined the facility failed to provide interventions to prevent the development and/or worsening of pressure ulcers for two (#101 and #133) of nine residents reviewed for pressure ulcers of a total of 21 residents currently identified with pressure ulcers in the facility. This resulted in actual harm for Resident #101 who developed three, Stage 3 pressure ulcers to the right lower leg and ankle. Findings include: 1) Review of the closed record for Resident #101 revealed the resident was admitted to the facility on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment, dated 04/30/11, revealed the resident required extensive assist of two staff for bed mobility and transfer and toileting. On 04/23/11, a Braden Scale form was completed to assess the risk for pressure ulcer development. A score of 12 or less indicated high risk. Resident #101 scored a 14 indicating moderate risk for development of a pressure ulcer. Review of the initial skin inspection completed on admission (04/23/11) revealed the resident had multiple bruises, but no open areas. Review of the admission nurses notes dated 04/23/11 at 4:43 P.M., noted Resident #101 had a new [DIAGNOSES REDACTED]. The notes revealed the resident was wearing a custom fitted leg brace which was to be worn at all times. Physician orders dated 05/05/11, revealed the resident was to wear the brace continuously. Review of the plan of care "Risk for pressure area development" dated 04/23/11, identified the resident to be at risk due to immobility, the use of the long leg brace on her right leg and her need for extensive assistance of staff to turn, reposition, and toilet. The goal was for the resident to be free of pressure areas. Interventions included assisting her to turn and reposition every two hours when in bed or chair, encouraging meal and fluid intake, monitoring pressure points under the brace to ensure that no rubbing or red, sore areas were present, offloading the heels when in bed, utilizing a pressure reduction mattress to the bed, and performing skin inspections with care interventions daily. Review of the documentation revealed the licensed nursing staff completed a body inspection weekly. Interviews between 2:20 P.M. and 3:15 P.M. on 08/24/11 with State tested Nursing Assistants (STNA's) #25, #27, #29, #31, #33, #35 and #32 who work the first and second shifts all verified they inspect the skin, especially pressure points, at least once a shift and each time care is rendered for all of their residents. They further stated Resident #101 had never complained of pain in the area of her ankle or heel, nor had there been any redness observed. Review of the medical record revealed the resident had an appointment with the surgeon on 05/26/11 and the brace was adjusted to flex the knee slightly. Interview with STNA #31 on 08/24/11 at 3:15 P.M. revealed another STNA had gone in to reposition the resident on 05/30/11 and noted the presence of drainage on the pillow case that was supporting the resident's foot. Interview with the Director of Nursing (DON) on 08/25/11 at 9:30 A.M. verified the drainage was immediately reported to the nurse who alerted the Administrator. Observation and inspection revealed the presence of a pressure wound under the strap of the brace. Both STNA #31 and the Director of Nursing verified the area was not visible until the brace strap was moved. Review of the nurse's notes and skin grids failed to document the inspection of pressure points under the brace/strap as per the plan of care, until after the presence of the drainage was noted. Further review of the nurse's notes on 05/31/11, revealed the resident was seen by the surgeon on this date and informed/educated the family regarding the wound development under the brace. He stated he wanted to continue the brace and allow it to be removed for bathing and skin inspections. Review of the x-ray report dated 06/16/11 of the fractured area (which was approximately two months after the fracture), revealed there was still no significant callus formation (a band of new cell growth around the fracture indicative of healing). Review of the wound care center physician's history and physical revealed the resident showed decreased pedal pulses to the right lower extremity but demonstrated apparent intact sensation. The documentation also noted there was no redness, no swelling, no purulent (pus) drainage, no gangrene, no odor and no abscesses. The physician determined there were three, Stage III pressure ulcers to the right lower leg and ankle. 2) Review of the medical record for Resident #133 revealed the resident was admitted to the facility on [DATE] and admitted to Hospice services on 05/27/11 with a [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) assessment dated 06/09/11, revealed the resident had short and long-term memory loss with severely impaired decision-making skills. The resident was identified as being dependent on one staff for bed mobility, dressing, eating, toilet use, hygiene and bathing and dependent on two staff for transfers. The resident was assessed as being incontinent of bowel and bladder. Review of the Braden Scale assessment completed 01/31/11, revealed the resident had a score of ten and identified the resident as being at high risk for pressure sore development. Interview with Licensed Practical Nurse (LPN) #13 on 08/07/11 at 4:04 P.M., verified the resident had a pressure ulcer and was not sure what it was staged at. She stated the Registered Nurses (RN's) take care of that. Review of the plan of care for "Skin Breakdown," initiated 12/29/08, identified the resident was at risk, and had a Stage II pressure area to her buttocks on admission which in now healed. An additional care plan provided by the facility entitled, "Resident Care Plan," dated 03/05/11, identified a new problem of a pressure ulcer on the coccyx. Interventions included having the resident sit in her chair for meals only using an anti-pressure device while up in chair, turning the resident when in bed, and not to position her on the ulcer. Interview with STNA #7 on 08/09/11 at 1:35 P.M. and STNA #10 at 3:10 P.M. revealed both STNA's were aware of the presence of the pressure ulcer and stated she was to be turned every two hours. They further stated she has a body pillow to her back when in bed, wears foam boots to her feet, has a special mattress and has a cushion to her chair when up. STNA #10 also stated that Resident #133 was not supposed to be positioned on her back. Neither STNA was aware of limiting the resident's time up in the chair to meal times or of the new physician order of the previous day to discontinue use of the body pillow. Observations revealed the resident to be up in her reclined chair with her weight on the coccyx area for lengthy periods of time, as well as being positioned on her back in bed. On 08/07/11 at 2:41 P.M., the resident was noted to be in bed and turned onto her right side. At 4:30 P.M., she was observed up in her reclining geri-chair on her back in the reclined position. Observation revealed the resident to be up in her chair at the bedside and visiting with her daughter on 08/08/11 at 3:30 P.M. At 6:00 P.M. she remained up in her chair in the lounge area. At 7:00 P.M., she was noted to be in bed and positioned on her right side with a body pillow to her back for support. A low air loss mattress was on and functioning. A pressure relieving cushion was noted in the seat of her reclining geri-chair. On 08/09/11 at 9:15 A.M., she was observed to be turned onto her right side with the body pillow to her back for positioning. At 11:20 A.M. she was seated in the lounge area in her reclined chair. At 12:30 P.M., the resident was returned to bed and positioned on her left side. At 3:00 P.M., she was observed resting on her back and at 5:30 P.M. she was up in her chair in the dining room for supper. On 08/10/11 at 7:15 A.M., the resident was observed in bed lying on her left side and at 9:00 A.M., was noted to be positioned on her back. Review of the wound sheets revealed the pressure area to the coccyx was initially noted on 03/05/11 with the wound measuring 2 centimeters (cm) by 0.5 cm by less than 0.1 cm. There was light bloody drainage present in a moderate amount. Observation of the coccyx pressure ulcer during assessment by the Hospice wound nurse at 10:00 A.M. on 8/10/11, revealed the wound measured 1.0 cm by 0.8 cm by 0.1 cm. Interview with the Hospice nurse at this time stated the wound remained a Stage III. Observation of the right ear revealed the presence of an open area with no active drainage on the outer rim (pinna) of the ear measuring 0.6 by 0.4 by less than 0.1 cm and documented as a stage II pressure area by the wound consultant. Review of the facility policy entitled "Skin Care Management", revised 05/31/11, revealed the purpose of the policy was to provide a systematic way to monitor skin integrity and to identify residents as a risk for pressure ulcer formation, to prevent pressure ulcer formation and to promote healing residents with pressure ulcer formation. The policy also revealed if an area of concern is noted, the area will be reviewed by the charge nurse. The results will be documented in the resident's record. Recommended interventions will be obtained. If necessary, the physician will be notified and appropriate treatment will be obtained. The nursing supervisor will be notified of any adverse findings.