Every finding on record at Ridgewood Manor

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on medical record review, staff interview, coroner interview, and policy review, the facility failed to ensure resident supervision through purposeful rounding every two hours per the facility's standard of care. This affected one (#01) of three residents reviewed for death. The facility census was 67. Findings include:Review of Resident #01's medical record revealed an admission date of [DATE] and a discharge date of [DATE]. Diagnoses included schizoaffective disorder, alcohol dependence with withdrawal delirium, narcolepsy without cataplexy, depression, type II diabetes mellitus, and attention-deficit hyperactivity disorder.Review of Resident #01's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident required supervision or touch assistance for toileting, moving to a standing position from a sitting position and transfers. The resident had no negative behaviors.Review of Resident #01's care plan dated [DATE] revealed the resident was a full code and had the potential for a psychosocial well-being problem related to current health status.Review of Resident #01's current physician orders revealed a physician order dated [DATE] stating that the resident was a full code. Review of Resident #01's vital signs report revealed vitals were last acquired on [DATE] at 9:06 P.M. and found to be within normal limits.Review of Resident #01's nursing progress note dated [DATE] at 11:45 A.M. revealed Registered Nurse (RN) #300 was at the resident's bedside with Licensed Practical Nurse (LPN) #400 and the resident was found to be absent of vital signs.Review of Resident #01's medication administration note dated [DATE] at 12:12 P.M. revealed RN #300 attempted to wake the resident for morning medication and the resident failed to respond. RN #300 inquired other staff if that was Resident #01's normal activity, RN #300's note stated she was told the resident preferred to sleep in, usually until around 10:30 A.M., and often skipped breakfast. Review of the facility investigation report dated [DATE] revealed Resident #01 did not receive the required purposeful rounding consistent with the facility's standard of care, for approximately 11.5 hours.Interview with the Director of Nursing (DON) at 8:20 A.M. on [DATE] revealed staff contacted her on [DATE] at approximately 11:45 A.M. and stated Resident #01 was deceased and was cold to the touch. The staff contacted emergency medical services (EMS) and the physician. The DON stated when EMS arrived, the paramedics did not initiate cardiopulmonary resuscitation as the resident was obviously decreased. The coroner was notified. An autopsy was scheduled for [DATE]. Telephone interview with RN #300 on [DATE] at 10:50 A.M. revealed she was an agency nurse, and it was her first time working at this facility. She arrived for her [DATE] shift at 7:00 A.M. claiming she found the facility to be unorganized. RN #300 verified a shift report was received from the night nurse who was also an agency nurse. Due to computer issues, she began working the floor at 8:30 A.M. RN #300 stated she entered Resident #01's room at approximately 9:45 A.M. to administer morning medications and found the resident lying on her side facing the wall, covered with a black shawl and there was no response to verbal stimuli, so she assumed the resident was sleeping. RN #300 she inquired about Resident #01 with facility staff she was told the resident's routine was to not wake up until 10:30 A.M. most days. RN #300 stated she did not think anything more about it, discarded the medications she pulled and went on to take care of another resident. RN #300 stated around lunch she entered Resident #01's room to complete blood sugar testing at which time the aide was in the room passing lunch trays and informed the nurse that the resident was not moving and was cold to the touch. RN #300 stated she assessed the resident and it was obvious that the resident had been dead awhile and therefore no cardiopulmonary resuscitation (CPR) was initiated. RN #300 stated EMS was called and when EMS arrived they also did not start CPR due the residents' condition. The police were contacted and came to the facility and remained in the facility until Resident #01's son arrived.Interview with the DON and the Regional Director of Clinical Services on [DATE] at 2:27 P.M. revealed the facility conducted their investigation on [DATE] it was determined the last time Resident #01 was checked was at 11:30 P.M. on [DATE] after visitors (one woman and two men) who were thought to be family members left the facility. The DON stated per staff interviews the resident and family members ordered pizza, ate in the resident's room with the visitors leaving around 10:30 P.M. The DON stated Resident #01 had visitors often so there was nothing unusual about the evening. The Regional Director of Clinical Services verified Resident #01 had not been checked on for approximately 11.5 hours which she confirmed was not consistent with the facility's standard of care for resident supervision, stating residents should be checked every two hours. Telephone interview with the County Deputy Coroner on [DATE] at 3:22 P.M. revealed Resident #01's autopsy was completed on [DATE]. The Coroner stated that he was able to rule out sepsis and diabetic ketoacidosis, adding that the resident did have a fatty liver, pulmonary edema, and atrophy of the pancreas. The Coroner stated toxicology results were pending, adding that the pulmonary edema could have been caused by a drug overdose but stated that cannot be confirmed until the toxicology results are received.Review of the facility policy titled Accidents and Supervision, dated [DATE] revealed each resident will receive adequate supervision to prevent accidents and ensure the resident's environment is free of hazards. The facility shall establish and utilize a systematic approach to assess resident risk and environmental hazards. The facility will provide adequate supervision to prevent accidents.The deficient practice was corrected on [DATE] when the facility implemented the following corrective actions: -On [DATE] the DON notified the Medical Director of Resident 01's death.-On [DATE] the DON instructed nursing staff to call EMS and the sheriffs department of the incident.-On [DATE] the DON/designee contacted Resident 01's son and requested he come to the facility as soon as possible.-On [DATE] the DON instructed nursing staff to call the county coroner. -On [DATE] an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with the DON, Medical Director, Administrator, Activity Director, Human Resources and the Scheduler to discuss purposeful rounding and the failure of the facility to conduct safety checks of the resident population every two hours. An abatement plan was outlined. -On [DATE] at 1:59 P.M. the DON completed observational audits on all residents.-On [DATE] the Administrator reviewed the facility's policy on accidents and supervision. No revisions were needed. Quick reference guides for rounding were created.-On [DATE] the DON/designee educated all staff on the facility's purposeful rounding policy and documentation requirements, resident supervision responsibilities and expectations for notifications immediately if assigned rounds cannot be completed. Quick Reference guides were provided.-The DON/designee educated all licensed nurses on the facility's policy on accidents and supervision. Quick reference guides were provided. Ongoing monitoring will include:-Starting [DATE] the DON/designee will complete random observational audits daily for two weeks then weekly for two weeks then randomly thereafter for continued compliance. Audits will be reviewed at QAPI.-Starting [DATE] Unit Managers will monitor compliance for purposeful rounding. Any non-compliance identified will be met immediately with disciplinary action.-Starting [DATE] the DON/designee will audit purposefully rounding documentation daily for four weeks. Audits will be reviewed at QAPI. This deficiency represents non-compliance investigated under Master Complaint Number 3090948.

Based on review of the medical record, resident interview, staff interview, and policy review, the facility failed to ensure residents were free of significant medication errors. This affected two (#31, #19) of three residents reviewed for medication administration. The facility census was 55.Findings include:1. Review of the medical record for Resident #31 revealed an admission date of 02/08/26. Diagnoses included hypertension, type two diabetes mellitus, osteoarthritis, heart failure, generalized anxiety disorder, and chronic obstructive pulmonary disease.Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident had moderate cognitive impairment. The resident required substantial/maximal assistance from staff for activities of daily living. Review of the hospital discharge physician medication orders revealed orders for furosemide 40 milligrams (mg) by mouth twice daily, gabapentin 100 mg three times per day, guaifenesin 600 mg 12-hour tablet twice daily, metformin 500 mg twice daily, oxycodone 5 mg as needed every eight hours for severe pain, and zolpidem 10 mg as needed at bedtime. Further review of the orders revealed six medications including buspirone 30 mg, dapagliflozin propanediol 10 mg, lorazepam 0.5 mg every eight hours as needed, polyethylene glycol 17 grams, sennosides 8.6 mg, and tramadol 50 mg were paused with orders to wait to take the medications until a physician or other care provider instructed to start the medications again. Review of the physician orders dated 02/09/26 revealed the resident was ordered furosemide 40 mg twice daily for edema, gabapentin 100 mg three times a day for neuropathy, guaifenesin 12 hour 600 mg twice daily, lorazepam 0.5 mg every eight hours as needed for anxiety, metformin 500 mg twice daily for diabetes mellitus, oxycodone 5 mg every eight hours as needed for post-surgical pain for three days, tramadol 50 mg every eight hours as needed for pain, and senna plus 8.6/50 mg four times a day for constipation.Review of the facility contingent medication supply document revealed medications available on hand included gabapentin 100 mg, furosemide 40 mg, guaifenesin 600 mg, metformin 500 mg, lorazepam 0.5 mg, oxycodone 5 mg, and zolpidem 5 mg tablets. Review of the medication administration record (MAR) for 02/08/26 revealed the resident was administered no medications per physician orders on 02/08/26. Interview on 03/16/26 at 9:14 A.M., Resident #31 revealed he had not received any evening medications on 02/08/26 including his anxiety medication which was really needed. Interview on 03/16/26 at 1:24 P.M., Unit Manager Licensed Practical Nurse (UMLPN) #222 revealed the floor nurse was responsible for reviewing medication orders with the physician and entering the orders. UMLPN #222 revealed for new admissions the nurse should first address the medication orders. UMLPN #222 verified Resident #31 had not received medications per physician orders on 02/08/26. UMLPN #222 verified the nurse should have pulled the medications available from the facility contingent supply. UMLPN #222 verified the resident could have received the gabapentin, furosemide, guaifenesin, metformin, oxycodone, and zolpidem as the medications were available. UMLPN #222 revealed the resident could have also received the lorazepam for anxiety had the nurse clarified the paused medication orders with the physician. UMLPN #222 further revealed Resident #31 had voiced concerns about not receiving all his medications and she later clarified the orders with the physician.2. Review of the medical record for Resident #19 revealed an admission date of 01/23/26. Diagnoses included schizoaffective disorder, dementia, chronic pain, anxiety, chronic obstructive pulmonary disease, hypothyroidism, gastroesophageal reflux disease (GERD), and epilepsy.Review of the admission MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of the 02/2026 physician orders revealed orders revealed the resident had orders for lacosamide 100 mg at bedtime for seizures, levothyroxine 50 micrograms (mcg) daily for thyroid, pantoprazole 20 mg daily for GERD, trazodone 100 mg at bedtime, lamotrigine 100 mg give with 25 mg to equal 125 mg twice daily for epilepsy, buspirone 10 mg three times a day for anxiety, acetaminophen 500 mg three times a day for pain, and rosuvastatin 10 mg by mouth at bedtime for cholesterol. Review of the MAR dated 02/01/26 through 02/28/26 revealed the resident was not administered the lacosamide 100 mg on 02/05/26 and 02/10/26, the levothyroxine 50 mcg on 02/02/26, 02/05/26, 02/10/26, and 02/11/26, the pantoprazole 20 mg on 02/02/26, the 02/05/26, 02/10/26, 02/11/26, and 02/27/26, the rosuvastatin 10 mg on 02/04/26, 02/10/26, the trazodone 100 mg on 02/04/26 and 02/10/26, the lamotrigine 100 mg with an additional 25 mg at 4:00 A.M. on 02/02/26, 02/05/26, 02/10/26, 02/11/26, and 02/27/26, the acetaminophen 500 mg at 7:00 P.M. on 02/04/26 and 02/10/26, and the buspirone 10 mg at 7:00 P.M. on 02/04/26 and 02/10/26.Review of the nursing notes dated 02/01/26 through 02/28/26 revealed no documentation the resident had refused the medications.Interview on 03/17/26 at 7:46 A.M., Resident #19 revealed the nurse was not waking her up to give her medications. Resident #19 further revealed some nurses just do not give me my medications.Interview on 03/17/26 at 2:03 P.M., the Regional Director of Clinical Services (RDCS) #700 verified Resident #19 was not administered medications per physician orders. RDCS #700 revealed the resident had no changes in condition since admission. RDCS #700 revealed she could not find any documentation the resident had refused the medications. Review of the facility policy Administering Medications, revised 04/2019, revealed medication would be administered per physician orders, including any required time frame.This deficiency represents non-compliance investigated under Complaint Number 2796620.

Based on review of the medical record, resident interview, staff interview, and policy review, the facility failed to ensure resident medications were administered per physician orders. This affected two (#31, #19) of three residents reviewed for medications administration. The facility census was 55.Findings include:1. Review of the medical record for Resident #31 revealed an admission date of 02/08/26. Diagnoses included hypertension, type two diabetes mellitus, osteoarthritis, heart failure, generalized anxiety disorder, and chronic obstructive pulmonary disease.Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident had moderate cognitive impairment. The resident required substantial/maximal assistance from staff for activities of daily living. Review of the hospital discharge physician medication orders revealed orders for furosemide 40 milligrams (mg) by mouth twice daily, gabapentin 100 mg three times per day, guaifenesin 600 mg 12-hour tablet twice daily, metformin 500 mg twice daily, oxycodone 5 mg as needed every eight hours for severe pain, and zolpidem 10 mg as needed at bedtime. Further review of the orders revealed six medications including buspirone 30 mg, dapagliflozin propanediol 10 mg, lorazepam 0.5 mg every eight hours as needed, polyethylene glycol 17 grams, sennosides 8.6 mg, and tramadol 50 mg were paused with orders to wait to take the medications until a physician or other care provider instructed to start the medications again. Review of the physician orders dated 02/09/26 revealed the resident was ordered furosemide 40 mg twice daily for edema, gabapentin 100 mg three times a day for neuropathy, guaifenesin 12 hour 600 mg twice daily, lorazepam 0.5 mg every eight hours as needed for anxiety, metformin 500 mg twice daily for diabetes mellitus, oxycodone 5 mg every eight hours as needed for post-surgical pain for three days, tramadol 50 mg every eight hours as needed for pain, and senna plus 8.6/50 mg four times a day for constipation.Review of the facility contingent medication supply document revealed medications available on hand included gabapentin 100 mg, furosemide 40 mg, guaifenesin 600 mg, metformin 500 mg, lorazepam 0.5 mg, oxycodone 5 mg, and zolpidem 5 mg tablets. Review of the medication administration record (MAR) for 02/08/26 revealed the resident was administered no medications per physician orders on 02/08/26. Interview on 03/16/26 at 9:14 A.M., Resident #31 revealed he had not received any evening medications on 02/08/26 including his anxiety medication which was really needed. Interview on 03/16/26 at 1:24 P.M., Unit Manager Licensed Practical Nurse (UMLPN) #222 revealed the floor nurse was responsible for reviewing medication orders with the physician and entering the orders. UMLPN #222 revealed for new admissions the nurse should first address the medication orders. UMLPN #222 verified Resident #31 had not received medications per physician orders on 02/08/26. UMLPN #222 verified the nurse should have pulled the medications available from the facility contingent supply. UMLPN #222 verified the resident could have received the gabapentin, furosemide, guaifenesin, metformin, oxycodone, and zolpidem as the medications were available. UMLPN #222 revealed the resident could have also received the lorazepam for anxiety had the nurse clarified the paused medication orders with the physician. UMLPN #222 further revealed Resident #31 had voiced concerns about not receiving all his medications and she later clarified the orders with the physician.2. Review of the medical record for Resident #19 revealed an admission date of 01/23/26. Diagnoses included schizoaffective disorder, dementia, chronic pain, anxiety, chronic obstructive pulmonary disease, hypothyroidism, gastroesophageal reflux disease (GERD), and epilepsy.Review of the admission MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of the 02/2026 physician orders revealed orders revealed the resident had orders for lacosamide 100 mg at bedtime for seizures, levothyroxine 50 micrograms (mcg) daily for thyroid, pantoprazole 20 mg daily for GERD, trazodone 100 mg at bedtime, lamotrigine 100 mg give with 25 mg to equal 125 mg twice daily for epilepsy, buspirone 10 mg three times a day for anxiety, acetaminophen 500 mg three times a day for pain, and rosuvastatin 10 mg by mouth at bedtime for cholesterol. Review of the MAR dated 02/01/26 through 02/28/26 revealed the resident was not administered the lacosamide 100 mg on 02/05/26 and 02/10/26, the levothyroxine 50 mcg on 02/02/26, 02/05/26, 02/10/26, and 02/11/26, the pantoprazole 20 mg on 02/02/26, the 02/05/26, 02/10/26, 02/11/26, and 02/27/26, the rosuvastatin 10 mg on 02/04/26, 02/10/26, the trazodone 100 mg on 02/04/26 and 02/10/26, the lamotrigine 100 mg with an additional 25 mg at 4:00 A.M. on 02/02/26, 02/05/26, 02/10/26, 02/11/26, and 02/27/26, the acetaminophen 500 mg at 7:00 P.M. on 02/04/26 and 02/10/26, and the buspirone 10 mg at 7:00 P.M. on 02/04/26 and 02/10/26.Review of the nursing notes dated 02/01/26 through 02/28/26 revealed no documentation the resident had refused the medications.Interview on 03/17/26 at 7:46 A.M., Resident #19 revealed the nurse was not waking her up to give her medications. Resident #19 further revealed some nurses just do not give me my medications.Interview on 03/17/26 at 2:03 P.M., the Regional Director of Clinical Services (RDCS) #700 verified Resident #19 was not administered medications per physician orders. RDCS #700 revealed the resident had no changes in condition since admission. RDCS #700 revealed she could not find any documentation the resident had refused the medications. Review of the facility policy Administering Medications, revised 04/2019, revealed medication would be administered per physician orders, including any required time frame.This deficiency represents non-compliance investigated under Complaint Number 2796620.

Based on observation, resident and staff interview, medical record review, and review of the facility policy, the facility failed to ensure resident privacy was maintained during personal care and treatments. This affected two (#35 and #31) of 17 residents observed for privacy. The facility census was 45.Findings include: Review of Resident #35's medical record revealed an admission date of 09/22/25. Diagnoses included type I diabetes; traumatic amputation of one lesser toe, subsequent encounter; obesity; generalized anxiety disorder; major depressive disorder; cannabis use; and pancreatitis.Review of Resident #35's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #35 was cognitively intact. Resident #35 was independent with bed mobility, transfer, and dressing. Resident #35 required set up assistance with bathing and toilet use. Resident #35 displayed no behaviors at the time of the review. Review of Resident #35's care plan revised 10/02/25 revealed supports and interventions for enhanced barrier precautions related to a recent toe amputation, self-care deficit, personal care preferences included it was very important for Resident #35 to have privacy when using the telephone, alteration in comfort related to amputation of the left fifth toe and infected wounds on the left foot, and risk for impaired skin integrity. Review of Resident #31's medical record revealed an admission date of 09/19/25. Diagnoses included anoxic brain damage, abnormalities of gait, major depressive disorder, abuse of other non-psychoactive substances, nicotine dependence, and cognitive communication deficit. Review of Resident #31's MDS assessment dated [DATE] revealed a BIMS score of 11 indicating Resident #31 was moderately cognitively impaired. Resident #31 was independent with the majority of activities of daily living and required setup with bathing and personal hygiene. Resident #31 displayed rejection of care behaviors four to six days during the review period. Review of Resident #31's care plan revised 10/02/25 revealed supports and interventions for risk for falls, tobacco use, potential for psychosocial well-being problem related to being homeless, impaired cognitive function, resistive to care, and risk for development of self-care deficit. Observation on 12/01/25 at 11:52 A.M. of Resident #31 and Resident #35 in their shared room found the privacy curtain was tied in a knot, up against the window, and unable to be pulled between the beds for privacy. Continue observation revealed Resident #35 was having wound vacuum (vac) care provided while Resident #31 was eating his lunch seated on the side of his bed facing Resident #35. Interview on 12/01/25 at 11:54 A.M. with Certified Nurse Aide (CNA) #630 verified the privacy curtain was tied in a knot and was unable to be closed for resident privacy. CNA #630 also verified Resident #35 was receiving wound vac care in the line of sight of Resident #31 while he was eating. Further observations on 12/02/25 at 8:32 A.M., 12/02/25 at 11:08 A.M., 12/03/25 at 9:04 A.M., and 12/03/25 at 1:41 P.M. found the privacy curtain between Resident #31 and Resident #35's beds continued to be tied in a knot and unable to be used. Interview on 12/03/25 at 1:43 P.M. with Resident #31 revealed he had not tied the privacy curtain, he was unable to untie the curtain, and verified the privacy curtain was not able to be used for him or his roommate (Resident #35). Resident #31 reported when he wanted privacy he would go into the bathroom. Review of the undated facility policy titled, Resident Rights, revealed each resident had the right to personal privacy including during accommodations, medical treatments, and personal care.

Based on observation, resident and staff interview, medical record review, review of shower sheets, review of designated smoking times, and review of facility policies, the facility failed to maintain a resident's choice for bathing and smoking when the facility failed to ensure these activities were provided as scheduled. This affected one (#19) of two residents reviewed for activities of daily living and two (#29 and #51) of four residents reviewed for smoking. The facility census was 45.Findings include: 1. Review of Resident #19's medical record revealed an admission date of 11/01/22. Diagnoses included traumatic brain injury, hypertension, and legal blindness. Review of Resident #19's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Resident #19 required set up with showering and bathing. Resident #19 displayed rejection of care behaviors four to six days during the review period. Review of Resident #19's care plan revised 11/20/25 revealed supports and interventions for impaired visual function, potential for falls, and self-care deficit. Self-care deficit supports included providing assistance with bathing/showering. Review of Resident #19's shower sheets for the last 30 days revealed on 12/01/25 Resident #19 shower was documented as not applicable. Observation on 12/01/25 at 9:03 A.M. of Resident #19 found her hair appeared unwashed and uncombed. Interview on 12/01/25 at 9:07 A.M. with Resident #19 found her to be alert and aware. Resident #19 reported her shower days were Mondays and Thursdays on first shift. Resident #19 stated she had not gotten a shower yet and with it being after 9:00 A.M. she most likely would not be getting one that day. Resident #19 stated when she was showered it was earlier in the day. Resident #19 stated she was not able to shower without assistance. Observation on 12/02/25 at 8:08 A.M. of Resident #19 found her to be seated in her chair in her room. Resident #19 was wearing the same clothes as the previous day and her hair continued to be unwashed. Interview on 12/02/25 at 8:09 A.M. with Resident #19 verified she did not get her shower yesterday as scheduled. Resident #19 reported she wanted a shower but no one ever came in to get her for her scheduled shower. Resident #19 stated she would have to wait until Thursday now since that was her scheduled shower day. Resident #19 stated she washed herself up in the sink but did not get the shower she wanted. Interview on 12/02/25 at 8:32 A.M. with Certified Nurse Aide (CNA) #644 verified with Resident #19 she had not been showered as scheduled yesterday. CNA #644 asked Resident #19 if she would want to have a shower today and Resident #19 stated she would. Resident #19 stated she would put her call light on after she ate to let them know she was ready for her shower. Review of the facility policy titled, Activities of Daily Living (ADL), Supporting, revised April 2025, revealed residents who were unable to carry out activities of daily living independently received services necessary to maintain good grooming and personal hygiene. Review of the undated policy titled, Resident Rights Policy and Procedure, revealed each resident had the right to make choices about aspects of their lift in the facility. 2. Review of the medical record for Resident #51 revealed an admission date of 11/25/25 with diagnoses of acute versus chronic respiratory failure, chronic obstructive pulmonary disease (COPD), and dependence on oxygen. Review of the admission assessment dated [DATE] for Resident #51 revealed the resident was alert and oriented with no confusion. Review of the initial care plan dated 11/25/25 for Resident #51 revealed she was care planned for tobacco use with interventions for smoking cessation if warranted by the resident, education for facility the smoking policy, and orient the resident to smoking times and procedures. Review of a facility document titled, Smoking Contract, dated and signed on 11/25/25 for Resident #51 revealed residents shall be informed of the facility smoking policy to include approved smoking location, and smoking times for their choice of smoking time. Further review of revealed designated smoking times were not listed in the contract; however, the smoking times were listed near the smoking area, and smoking sessions were for 15 minutes in length. Interview on 12/02/25 at 11:35 A.M. with Resident #51 stated there were no cigarettes left out last night (12/01/25) so no one was able to have a smoke break for the 7:00 P.M., 9:00 P.M., or the 6:00 A.M. smoke time. Resident #51 further stated she went to bed last night at 7:30 P.M. because she did not have access to her cigarettes and could not go out to smoke. Interview on 12/02/25 at 11:37 A.M. with Licensed Practical Nurse (LPN) #634 stated she was aware last night (12/01/25) prior to the end of her shift at 7:00 P.M. that the 7:00 P.M. smoke break for the residents could not be taken. LPN #634 further stated the cigarettes were not available for the smokers due to missing lockbox keys where the cigarettes and lighters are kept. LPN #634 further stated she attempted to find the keys and get the cigarettes dispensed and could not find the key or the cigarettes for the residents. LPN #634 stated the 7:00 P.M. smoke break was not given to the smokers. Interview on 12/03/25 at 10:51 A.M. with Resident #29, who was a smoker, stated he was not able to smoke for the 7:00 P.M. and 9:00 P.M. on 12/01/25 smoke break due to no access to smoking supplies. Resident #29 stated the resident's smoking materials were locked and no one was able to get them. Interview on 12/02/25 at 11:50 A.M. with Activities Director (AD) #668 stated the activities department was responsible for smoking during the normal business hours and once the 4:00 P.M. smoking time commenced, the activity staff will stock the lockbox with enough cigarettes for each resident to smoke at 7:00 P.M., 9:00 P.M., and 6:00 A.M. AD #668 stated the CNAs are then responsible to give the smoke break during the off hours. Observation at the time of the interview with AD #668 on 12/02/25 revealed two lock boxes for smoking items, one that was kept in the activity room that contained the cartons or multi-packs of cigarettes for the residents and the second lock box was stored in the secured pantry that when stocked contained only the cigarette usage for use during off hours. AD #668 stated both lock boxes had a key lock and confirmed she was not aware the key was not able to be found until it was mentioned in the interview. Review of the facility posted smoking times revealed smoking times were 6:00 A.M., 10:00 A.M., 1:00 P.M., 4:00 P.M., 7:00 P.M., and 9:00 P.M. Review of the facility policy titled, Resident Smoking Policy and Procedure, dated 2025, revealed it is the facility's responsibility to respect a resident's choice to smoke and is balanced by the potential impact on the resident's well-being.

Based on review of the medical record, observation, staff and resident interview, and policy review, the facility failed to ensure physician orders for wound treatments were clarified, accurately documented and completed per physician orders. This affected two (#11, #37) of three residents reviewed for wound care. The facility identified six residents with non-pressure related wounds. The facility census was 38. Findings include: Review of the medical record for Resident #11 revealed an admission date of 10/18/23. Diagnoses included hypertension, chronic obstructive pulmonary disease, and peripheral vascular disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of a nurse's note dated 05/24/25 at 1:39 P.M. revealed the resident had a skin tear to the left shin measuring 2.5 centimeters (cm) in length by 1.5 cm in width. The wound was cleansed and treated with a border form dressing. The wound care provider was notified of the new area. Review of the physician orders from 05/24/25 through 05/27/25 revealed there were no wound care treatment orders for the skin tear to the left shin. Review of the treatment administration record revealed there was no documentation the resident received wound treatments for the skin tear from 05/25/25 through 05/27/25. Review of a nurse practitioner skin wound note dated 05/28/25 revealed Resident #11 had a left shin skin tear/laceration with orders to cleanse with wound cleanser, apply oil emulsion to base of wound, secure with bordered gauze and change daily. There were no wounds noted to the left foot or ankle and no wound treatment orders for the left foot and ankle. Review of the physician orders from 05/28/25 through 06/02/25 revealed there were no wound treatment orders for the skin tear to the left shin and no wound treatment orders for the left foot/ankle. Review of the treatment administration record from 05/29/25 through 06/01/25 revealed no documentation of completed wound treatments for the left shin. Interview on 06/02/25 at 8:42 A.M., Resident #11 revealed the staff were not completing wound care dressings daily. Observation on 06/02/25 at 10:24 A.M. with Licensed Practical Nurse (LPN) #435 revealed Resident #11 had gauze dressing wrapped around the left foot/ankle and covered with an elastic bandage. LPN #435 removed an undated wound dressing to the left foot/ankle and the resident had no wounds on the left foot or ankle. Further observation revealed the resident had a border dressing on the left lower shin dated 05/28/25. Interview on 06/02/25 at 10:36 A.M., LPN #435 verified the resident had a wound dressing on the left lower shin dated 05/28/25. LPN #435 verified physician orders for the wound were not entered into the treatment administration record and the daily wound treatments had not been completed. LPN #435 also verified the resident had no wounds on his left foot/ankle and no physician orders for treatment. 2. Review of the medical record for Resident #37 revealed an admission date of 08/04/16. Diagnoses included cerebral infarction, spinal stenosis, and dementia. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of a nurse practitioner skin and wound note dated 05/14/25 at 1:18 P.M. revealed the resident had a skin tear to the left knee from a recent fall. The area measured two centimeters (cm) by 1.6 cm in width with no depth. Treatment recommendations included to cleanse with wound cleanser, apply bacitracin ointment to base of the wound and leave open to air. Review of a nurses note dated 05/20/25 at 3:02 P.M. revealed the resident had a skin tear on his right leg. The wound was cleansed and measured seven cm in length and four cm width. An abdominal pad was placed and wrapped with a gauze dressing. Wound care notified of the skin tear. Review of a wound nurse practitioner skin and wound note dated 05/21/25 at 11:42 A.M. revealed the resident had a skin tear improving to the left knee and a new skin tear to the right lateral lower leg. The wound to the left knee measured 1.7 cm in length by 1.5 cm in width by zero cm in depth. The wound to the right lateral lower leg measured 7.5 cm in length by 4.2 cm in width x 0.1 cm in depth. The wound NP treatment orders included to cleanse the skin tear to the left knee with wound cleanser, apply bacitracin and leave open to air. The treatment order for the right lateral lower leg skin tear was to cleanse with wound cleanser, apply non-adhering dressing to base of wound, secure with abdominal pad and rolled gauze, and change daily and as needed. Review of physician orders dated 05/21/25 revealed to cleanse the left knee with soap and water, pat dry, apply bacitracin ointment to wound bed and leave open to air every day shift. Also to cleanse the right lower extremity with wound cleanser, pat dry, apply oil emulsion non-adhering dressing to wound bed, cover with abdominal padding, then wrap with rolled dry gauze daily. Review of a nurse practitioner skin and wound note dated 05/28/25 at 7:07 P.M. revealed the skin tears to the right lower leg and left knee were healed and to continue preventative recommendations for daily emollients and prevent use of adherent tape directly to skin. The physician orders for the wound treatment for the skin tear to the left knee and right lower extremity skin tear had not been discontinued. Review of the Treatment Administration Record (TAR) from 05/22/25 through 06/01/25 revealed the wound treatments were documented as completed per physician orders. Observation on 06/02/25 at 2:06 P.M. revealed Resident #37 had an exposed scabbed area on the left knee. Further observation revealed the resident had an undated loosely wrapped gauze dressing around the lower left leg near the ankle. Further observation revealed the resident had an exposed scabbed area on the right lateral lower extremity and a loosely wrapped gauze wound dressing dated 05/31/25 around the right ankle. Interview on 06/02/25 at 2:06 P.M., LPN #435 revealed the resident's wounds were healed but the physician orders had not been discontinued. LPN #435 verified the treatment to the left knee was to cleanse wound, apply bacitracin and leave open to air. LPN #435 verified there were no physician orders for a wound dressing to the left knee and should not have been wrapped with gauze. LPN #435 verified the dressing on the resident's right lower extremity skin tear had slid down and was not in place over the wound. LPN #435 also verified the wound dressing for the right lower extremity skin tear was dated 05/31/25 and wound care had not been completed as documented on 06/01/25. Interview on 06/04/25 at 10:30 A.M., the Director of Nursing (DON) revealed after a wound was healed, the wound nurse practitioner wanted healed wounds to be padded and protected for an additional week. The DON verified there were no physician orders to pad and protect Resident #37's skin tear wounds. Interview on 06/04/25 at 11:15 A.M., Certified Wound Nurse Practitioner (CWNP) #700 revealed wound orders were continued for one additional week after a wound had healed. CWNP #700 verified she should have clarified with the facility when to discontinue Resident #37's wound care orders. Review of the facility policy Wound Care, dated 10/2010, revealed to verify a physician order for wound care. Also record in the medical record the type of wound care given, the date and time the wound care was given, and assessment data obtained when inspecting the wound. This deficiency represents non-compliance investigated under Complaint Number OH00165739.

Based on observation, staff interview, and review of a facility policy, the facility failed to store and label food and drink items in a manner to prevent spoilage and failed to maintain the floor in the nursing unit pantry in a sanitary manner. This had the potential to affect all 39 residents who receive food from the facility. The facility census was 39. Findings include: Observation on [DATE] at 9:16 A.M. in the pantry located at the nurse's station revealed one opened and undated 0.42 ounce packet of thickened tea with a use by date of [DATE]. Further observation of the pantry revealed two single serve bowls covered with plastic lids containing dried cereal that was multicolored and round with no date or label, one plastic mug with a lid that had condensation and no label or date, one 16.9-ounce clear plastic bottle labeled water that was opened and three-quarters full with no date, one opened can of kiwi guava flavored energy drink with no date, and one uncovered gray metal travel mug with a red straw half-full of liquid with no date. Continued observation of the pantry revealed the floor behind the trash can had one empty single-serve container of cranberry juice, two balled up paper towels, and a sticky dried red substance on the floor. Interview on [DATE] at 9:32 A.M. with Certified Nurse Aide (CNA) #423 confirmed the aforementioned observations in the pantry located at the nurse's station of opened, undated, unlabeled, and expired food and drink items, and the observation of the used paper towels and the sticky dried red substance on the floor. Observation on [DATE] at 10:33 A.M. in the pantry located at the nurse's station revealed the floor had not been cleaned. Concurrent interview with the Administrator confirmed the floor behind the trash can in the pantry had one empty single-serve container of cranberry juice, two balled up paper towels, and a sticky dried red substance on the floor. Review of an undated facility policy titled, Food Storage, revealed food would be stored in a clean and sanitary manner to minimize contamination. The policy also indicated the food storage areas would be clean. Further review of the policy indicated food not stored in the original container would be labeled and dated.

Based on observation, staff interview, and facility policy review, the facility failed to potential hazards were secured in a safe manner. This had the potential to affected six (#1, #6, #7, #19, #27, and #34) of six residents who the facility identified as cognitively impaired and independently ambulatory. The facility census was 39. Findings include: Observation on 05/05/25 at 9:16 A.M. of the pantry located at the nurse's station revealed one sharp kitchen knife with a blade approximately four inches long, and one sharp kitchen knife with a blade approximately eight inches long located in the left-most drawer. Further observation revealed the door to the pantry was not locked. Interview on 05/05/25 at 9:32 A.M. with Certified Nurse Aide (CNA) #423 confirmed the pantry at the nurse's station was unlocked and there were two sharp kitchen knives in the left-most drawer. Interview on 05/06/25 at 10:33 A.M. with the Administrator revealed the door to the pantry at the nurse's station should be locked to prevent unauthorized access. Review of an undated facility policy titled, Safe and Homelike Environment, revealed the facility would provide a safe environment for residents.

Based on medical record review, hospital discharge document review, resident interview, and staff interview, the facility failed to ensure resident blood glucose levels were monitored as ordered by the physician. This affected one (#141) of four residents reviewed as new admissions to the facility in a census of 39. Findings include: Review of the medical record revealed Resident #141 admitted to the facility on [DATE] with the diagnoses including acute kidney failure, chronic kidney disease stage five (5), myocardial infarction, type II diabetes mellitus, hypertension, vitreous hemorrhage right eye, glaucoma, and anemia. Review of an admission assessment dated [DATE] assessed Resident #141 as alert and able to make needs known, received hemodialysis, and had small amount of edema in the legs. Review of Resident #141's hospital discharge community referral form (CRF) dated 05/03/25 revealed the discharge physician orders included the use of a glucometer and glucose blood test strips, and glucose blood test strips were directed to be used three times daily and as needed to monitor the resident's blood sugar levels. Review of a nursing plan of care dated 05/04/25 revealed it was developed to address Resident #141's diagnosis of diabetes mellitus. Interventions included for diabetes medication to be provided as ordered by physician, monitor and document for side effects and effectiveness, and monitor blood sugars as ordered by physician. Review of the medical record lacked documented evidence indicating Resident #141 blood sugar had been obtained or monitored. On 05/07/25 at 8:27 A.M., interview with Resident #141 stated he had a history of monitoring his blood sugar daily and administering insulin according to the a sliding scale based on the blood sugar result (level). Interview with Licensed Practical Nurse (LPN) #456 on 05/07/25 at 8:31 A.M., during review of Resident #141's medical record, verified no evidence of daily blood glucose monitoring or related insulin coverage was documented in the medical record. At 8:40 A.M., LPN #456 obtained a blood sugar from Resident #141 with a level of 166 milligrams per deciliter (mg/dL) obtained. On 05/07/25 at 9:06 A.M., interview with the Director of Nursing (DON), during medical record review, confirmed Resident #141 had a diagnosis of type II diabetes mellitus with a history of blood sugar monitoring and related insulin administration. The DON verified physician orders for daily blood sugar monitoring was listed on the resident's hospital discharge CRF; however, no daily blood glucose monitoring had occurred since admission on 05/03/25.

Based on observation, medical record review, staff interview, review of an equipment manual, and review of a facility policy, the facility failed to initiate orders and plans of care to ensure bilevel positive airway pressure (BiPAP) therapy was correctly utilized and staff responded timely to BiPAP machine alarms. This affected one (#14) of two residents reviewed for respiratory care. The facility census was 39. Findings include: Review of the medical record for Resident #14 revealed an admitted [DATE] with diagnoses including type two diabetes mellitus, heart disease, lymphocytic leukemia of B-cell type, depression, anxiety, mild intermittent asthma, chronic obstructive pulmonary disease, and obstructive sleep apnea. Review of the admission Minimum Data Set 3.0 assessment dated [DATE] for Resident #14 revealed she was cognitively intact and experienced shortness of breath with exertion and when lying flat. Observation on 05/06/25 at 7:17 A.M. in Resident #14's room revealed the resident was resting in bed with her eyes closed under a blanket with her BiPAP machine on and alarming. Interview on 05/06/25 at 7:30 A.M. with Licensed Practical Nurse (LPN) #420 at the nurse's station confirmed the BiPAP machine alarm coming from Resident #14's room was not audible at the nurse's station and LPN #420 did not know how long the BiPAP machine had been alarming. Observation on 05/06/25 at 8:19 A.M. in the doorway to Resident #14's room revealed the resident was resting with her eyes closed under a blanker in bed and her BiPAP machine was alarming. Interview on 05/06/25 at 8:20 A.M. with Registered Nurse (RN) #457 at the nurse's station confirmed the BiPAP machine alarm coming from Resident #14's room was not audible at the nurse's station. Interview on 05/06/25 at 12:39 P.M. with the Administrator confirmed there were no orders nor care plans for Resident #14's oxygen or BiPAP machine. Review of Resident #14's physician orders for oxygen and BiPAP machine revealed these orders were not entered until 05/06/25. Observation on 05/07/25 at 7:10 A.M. in Resident #14's room revealed she was resting in bed with her eyes closed wearing pajamas and her BiPAP machine was not running. Observation on 05/07/25 at 7:23 A.M. in Resident #14's room with Certified Nurse Aide (CNA) #423 revealed the resident stated she did not know why her BiPAP machine was not on. Interview on 05/07/25 at 9:45 A.M. with LPN #456 revealed she was not aware Resident #14's BiPAP machine was not running. Additionally, LPN #456 indicated she had not been informed of any issues or refusal of care regarding Resident #14's BiPAP machine. Review of the manual for Resident #14's BiPAP machine indicated alarms must be responded to, and corrective actions implemented, promptly. Review of an undated facility policy titled, Noninvasive Ventilation, indicated noninvasive ventilation would be provided per physician orders. Procedures included the facility would obtain physician orders for use and settings, the facility would follow manufacturers instructions regarding proper use of the machine, and there would be documentation regarding the use of the machine.

Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure medications were provided as ordered by the physician and without error. This result in nine (9) medication errors out of 25 medications being administered for an error rate of 36 percent (%). This affected two (#24 and #141) of three residents observed for medication administration in a facility census of 39. Findings include: 1. Review of Resident #24's medical record noted physician orders including the narcotic pain medication oxycodone five (5) milligrams (mg) two times daily for pain, scheduled for 9:00 A.M. and 9:00 P.M. and ordered on 02/27/25; the antianxiety medication Ativan 0.25 mg every morning and at bedtime, scheduled for 7:00 A.M. and 7:00 P.M. and ordered on 04/07/25; the blood pressure and heart failure medication Coreg 6.25 mg every morning and at bedtime, scheduled for 7:00 A.M. and 7:00 P.M. and ordered on 05/07/24; the nerve pain medication gabapentin 600 mg three times daily, scheduled for 7:00 A.M., 2:00 P.M., 7:00 P.M. and ordered on 04/21/25; and glargine insulin with instructions to inject 30 units subcutaneously every morning and at bedtime for diabetes, scheduled for 7:00 A.M. and 7:00 P.M. and ordered on 01/16/25. Observation and interview on 05/06/25 at 8:21 A.M. noted Licensed Practical Nurse (LPN) #420 obtaining and preparing Resident #24 medications for administration. These medications included, Ativan 0.25 mg, Coreg 6.25 mg, gabapentin 600 mg, and glargine insulin 30 units via insulin syringe. LPN #420 stated Resident #24 was to receive oxycodone 5 mg for pain; however, the medication was not available. Further observation revealed at 8:34 P.M., LPN #420 provided the medications to Resident #24. On 05/06/25 at 8:38 A.M., interview with LPN #420 verified medications were not administered within the prescribed timeframes for Resident #24 and oxycodone 5 mg was omitted. 2. Review of the medical record for Resident #141 revealed physician orders including Coreg 25 mg two times a day, scheduled for 8:00 A.M. and 4:00 P.M. and ordered on 05/04/25; the anti-hypertensive medication clonidine 0.2 mg three times daily, scheduled for 7:00 A.M., 2:00 P.M., and 7:00 P.M. and ordered on 05/04/25; erythromycin ophthalmic ointment 5 milligrams per gram (mg/gm) with instructions to instill 1.25 centimeters in the left eye four times a day for keratitis (inflammation of the cornea) of the left eye, scheduled four times daily at 7:00 A.M., 11:00 A.M., 3:00 P.M., and 7:00 P.M. and ordered on 05/04/25; and prednisolone acetic ophthalmic suspension 1% with instructions to instill one drop in the left eye four times daily for neurotropic keratitis of the left eye at 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M. and ordered on 05/04/25. Observation on 05/06/25 at 9:22 A.M. noted LPN #420 gathered Resident #141's medications for administration from the medication cart. The medications included prednisolone acetic ophthalmic suspension 1%, erythromycin ophthalmic ointment 5 mg/gm, Coreg 25 mg, and clonidine 0.2 mg. Continued observation revealed at 9:25 A.M., LPN #420 administered the Coreg 25 mg and clonidine 0.2 mg to Resident #141 with a cup of water. At 9:27 A.M., LPN #420 administered prednisolone acetic ophthalmic suspension 1% one drop into the resident's left eye and at 9:44 A.M., LPN #420 returned to Resident #141, and placed erythromycin ophthalmic ointment 5 mg/gm to the left eye. Interview on 05/06/25 at 9:48 A.M. with LPN #420 verified Resident #141's medications were administered outside prescribed time frames per the physician orders. Review of facility administering medications policy, revised December 2012, revealed medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified.

Based on observation, medical record review, staff interview, and facility policy, the facility failed to ensure medications were administered as ordered by the physician, and within prescribed time frames, to prevent significant medication errors. This affected three (#16, #24, and #141) for four residents reviewed for the administration of medications in a facility census of 39. Findings include: 1. Review of Resident #24's medical record noted physician orders including the narcotic pain medication oxycodone five (5) milligrams (mg) two times daily for pain, scheduled for 9:00 A.M. and 9:00 P.M. and ordered on 02/27/25; the antianxiety medication Ativan 0.25 mg every morning and at bedtime, scheduled for 7:00 A.M. and 7:00 P.M. and ordered on 04/07/25; the blood pressure and heart failure medication Coreg 6.25 mg every morning and at bedtime, scheduled for 7:00 A.M. and 7:00 P.M. and ordered on 05/07/24; the nerve pain medication gabapentin 600 mg three times daily, scheduled for 7:00 A.M., 2:00 P.M., 7:00 P.M. and ordered on 04/21/25; and glargine insulin with instructions to inject 30 units subcutaneously every morning and at bedtime for diabetes, scheduled for 7:00 A.M. and 7:00 P.M. and ordered on 01/16/25. Observation and interview on 05/06/25 at 8:21 A.M. noted Licensed Practical Nurse (LPN) #420 obtaining and preparing Resident #24 medications for administration. These medications included, Ativan 0.25 mg, Coreg 6.25 mg, gabapentin 600 mg, and glargine insulin 30 units via insulin syringe. LPN #420 stated Resident #24 was to receive oxycodone 5 mg for pain; however, the medication was not available. Further observation revealed at 8:34 P.M., LPN #420 provided the medications to Resident #24. On 05/06/25 at 8:38 A.M., interview with LPN #420 verified medications were not administered within the prescribed timeframes for Resident #24 and oxycodone 5 mg was omitted. 2. Review of the medical record for Resident #141 revealed physician orders including Coreg 25 mg two times a day, scheduled for 8:00 A.M. and 4:00 P.M. and ordered on 05/04/25; the anti-hypertensive medication clonidine 0.2 mg three times daily, scheduled for 7:00 A.M., 2:00 P.M., and 7:00 P.M. and ordered on 05/04/25; erythromycin ophthalmic ointment 5 milligrams per gram (mg/gm) with instructions to instill 1.25 centimeters in the left eye four times a day for keratitis (inflammation of the cornea) of the left eye, scheduled four times daily at 7:00 A.M., 11:00 A.M., 3:00 P.M., and 7:00 P.M. and ordered on 05/04/25; and prednisolone acetic ophthalmic suspension 1% with instructions to instill one drop in the left eye four times daily for neurotropic keratitis of the left eye at 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M. and ordered on 05/04/25. Observation on 05/06/25 at 9:22 A.M. noted LPN #420 gathered Resident #141's medications for administration from the medication cart. The medications included prednisolone acetic ophthalmic suspension 1%, erythromycin ophthalmic ointment 5 mg/gm, Coreg 25 mg, and clonidine 0.2 mg. Continued observation revealed at 9:25 A.M., LPN #420 administered the Coreg 25 mg and clonidine 0.2 mg to Resident #141 with a cup of water. At 9:27 A.M., LPN #420 administered prednisolone acetic ophthalmic suspension 1% one drop into the resident's left eye and at 9:44 A.M., LPN #420 returned to Resident #141, and placed erythromycin ophthalmic ointment 5 mg/gm to the left eye. Interview on 05/06/25 at 9:48 A.M. with LPN #420 verified Resident #141's medications were administered outside prescribed time frames per the physician orders. 51513 3. Review of the medical record for Resident #16 revealed an admitted [DATE] with diagnoses including unspecified focal traumatic brain injury without loss of consciousness, unspecified glaucoma, and legal blindness. Review of Resident #16's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact and had severely impaired vision. Review of Resident #16's physician's orders revealed an order dated 10/23/24 to administer the medication used to lower intraocular pressure Rocklatan ophthalmic solution one drop in both eyes at bedtime. Further review revealed an additional physician's order dated 01/23/25 for Resident #16 to receive the pain and anti-inflammatory medication ketorolac tromethamine ophthalmic solution with instructions to instill one drop in both eyes every morning and at bedtime. Review of Resident #16's medication administration record (MAR) for February and March 2025 revealed Rocklatan ophthalmic solution was not administered on 02/09/25, 03/12/25, 03/14/25, 03/16/25, 03/17/25, 03/18/25, 03/27/25, and 03/31/25 as prescribed. Further review revealed ketorolac tromethamine ophthalmic solution was not administered on 03/01/25 at bedtime, 03/02/25 in the morning, 03/03/25 at bedtime, 03/04/25 in the morning and at bedtime, 03/16/25 at bedtime, and 03/17/25 at bedtime as prescribed. Review of the progress notes for February and March 2025 revealed nurses entries indicating Resident #16's Rocklatan ophthalmic solution was on order on 02/09/25, 03/13/25, 03/15/25, 03/16/25, 03/17/25, and 03/31/25. Review of the progress notes for March 2025 revealed nurses entries indicating Resident #16's ketorolac tromethamine ophthalmic solution was on order on 03/02/25, 03/03/25, 03/04/25, and 03/17/25. The medication was unavailable on 03/01/25 and 03/04/25 per entries on those dates. On 03/05/25 an entry revealed late administration due to not being able to locate eye drops. Interview on 05/07/25 at 3:10 P.M. with Registered Nurse (RN) #457 confirmed there was no documentation in Resident #16's medical record to verify the resident received Rocklatan ophthalmic solution and ketorolac tromethamine ophthalmic solution on the aforementioned dates in February and March 2025. Review of facility administering medications policy, revised December 2012, revealed medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified.

Based on review of the medical record, staff interview, resident interview, and policy review, the facility failed to ensure wound care treatments were completed per physician orders. This affected one resident (#18) of three residents reviewed for wound care. The facility identified five residents with wounds. The facility census was 44. Findings include: Review of the medical record for Resident #18 revealed an admitted [DATE]. Diagnoses included paraplegia, chronic obstructive pulmonary disease, pressure ulcer of sacral region stage four, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had intact cognition. The resident was at risk for pressure ulcers and had a stage four pressure ulcer present on admission. Review of the skin risk assessment dated [DATE] revealed the resident was at moderate risk for skin breakdown. Review of a physician order dated 01/29/25 revealed to cleanse sacral wound with wound cleanser, apply calcium alginate to wound bed, pack remaining space with normal saline gauze and cover with border gauze every Monday, Wednesday, Friday and as needed. Review of a nurse practitioner (NP) wound note dated 02/05/25 revealed the resident had a stage four pressure ulcer to the sacrum. The NP noted the wound dressing was removed but there was no primary dressing present on the wound at this time. The wound measured two centimeters (cm) in length, 7.5 cm in width, and 1.5 cm in depth. The wound was 30 percent epithelial tissue, 40 percent granulation tissue, 20 percent slough and zero percent eschar. The wound edges were unattached. There was a moderate amount of serosanguineous drainage. The surrounding skin was fragile, had scarring, was red, and macerated. The NP ordered a new wound treatment to cleanse wound with wound cleanser, apply collagen, calcium alginate to base of wound, secure with bordered gauze, change daily and as needed. Review of a nurses note by Licensed Practical Nurse (LPN) #386 dated 02/09/25 at 6:12 P.M., revealed the resident's wound dressing change was done as needed due to being soiled. Review of a physician order dated 02/09/25 at 10:53 P.M. revealed to cleanse the sacral wound with wound cleanser, place collagen to immediate wound bed, then pack remaining wound space with calcium alginate and secure with border gauze every dayshift and as needed for wound care. Review of the Treatment Administration Record (TAR) dated 02/01/25 through 02/09/25 revealed the treatment ordered by the NP on 02/05/25 was not entered into the electronic medical record until 02/09/25 at 10:53 P.M. and not completed for the resident until 02/10/25. Interview on 02/10/25 at 8:52 A.M., Resident #18 revealed she had a stage four pressure ulcer since her admission to the facility. Resident #18 revealed her treatments were ordered on Mondays, Wednesdays, Fridays, and as needed or when soiled. Resident #18 stated to LPN #620 she was soiled yesterday and the nurse had not completed her wound dressing the right way. Resident #18 stated staff had removed the old dressing and a brown dressing was applied with no treatment to the wound. Interview on 02/10/25 at 12:51 P.M., Resident #18 revealed LPN #620 had still not fixed her wound dressing. Observation on 02/10/25 at 3:54 P.M. of wound care for Resident #18 with Unit Manager (UM) #320 revealed the resident had a brown foam dressing in place to the sacral wound. The dressing was dated 02/09/24 and initialed by LPN #386. UM #320 removed the brown foam dressing. There was no wound treatment in place to the wound bed and no packing in the wound space as ordered. The wound was a stage four pressure ulcer measuring approximately two cm in length, seven cm in width, and less than two cm in depth. The wound bed was 20 percent slough, 30 percent epithelial tissue, and 50 percent granulation tissue. The wound had a slight odor. The surrounding skin was red. There was moderate serosanguinous drainage. Interview on 02/10/25 at 3:54 P.M., UM #320 verified Resident #18's wound was covered with a foam dressing instead of bordered gauze. UM #320 verified there was no treatment in place to the wound bed and the wound space had no packing. Review of the facility policy Wound Care, revised 10/2010, revealed to verify physician orders for wound care and complete treatments as ordered. This deficiency represents non-compliance investigated under Complaint Number OH00162257.

Based on review of the medical record, observation, interview, and policy review, the facility failed to clarify and implement physician orders for the care of a tracheostomy and further failed to provide tracheostomy care. This affected one resident (#19) of two residents reviewed for respiratory care. The facility identified 19 residents receiving respiratory care. The facility census was 44. Findings include: Review of the medical record for Resident #19 revealed an admitted [DATE]. Diagnoses included acute respiratory failure, epilepsy, pneumonia, hemiplegia, and hypertension. Review of the hospital discharge orders dated 02/06/25 revealed orders for tracheostomy care twice a day and tracheostomy suction as needed. Review of the baseline care plan dated 02/06/25 revealed tracheostomy cannula size six, suction, oxygen. There were no interventions to provide tracheostomy care and no instructions regarding the frequency of suctioning. Review of the admission physician orders for 02/06/25 revealed the resident had no orders in place for tracheostomy care or tracheostomy suctioning. There were no orders for a spare tracheostomy, inner cannula, or Ambu bag (bag valve mask) at bedside. Review of the treatment administration record (TAR) from 02/06/25 through 02/09/25 revealed no documented treatments were completed for care of the resident's tracheostomy. Observation on 02/10/24 at 8:07 A.M. of Resident #19 revealed there was no spare tracheostomy or Ambu bag, or inner cannula available at the bedside. Interview on 02/10/24 at 8:07 A.M., Licensed Practical Nurse (LPN) #602 looked through the drawers in the residents bedside stand and verified there was no spare tracheostomy, Ambu bag, or inner cannula in the bedside stand with the other tracheostomy supplies. Observation on 02/10/24 at 9:08 A.M., revealed Resident #19 had no spare tracheostomy, Ambu bag, or inner cannula available at the bedside. Interview on 02/10/24 at 9:08 A.M., LPN #385 also searched the resident's room and verified the resident had no spare tracheostomy, Ambu bag or inner cannula at the bedside. Interview on 02/10/25 at 11:21 A.M., the Director of Nursing (DON) verified Resident #19 should have a spare tracheostomy and inner cannulas available at the bedside. The DON revealed the resident had moved out of her previous room on 02/07/25 and some tracheostomy supplies must have been left in her previous room. Further interview on 02/10/25 at 2:11 P.M., the DON verified Resident #19 had no orders in place for tracheostomy care and for a spare tracheostomy, Ambu bag and inner cannulas to be available at bedside. The DON verified there was no documentation tracheostomy care or suctioning had been completed for the resident. The DON verified the physician orders for the resident's tracheostomy care were not entered into the treatment administration record until 02/10/25. Further interview on 02/11/25 at 1:16 P.M., the DON stated she saw staff providing tracheostomy care and was not sure why the nurses had not entered the physician orders regarding the tracheostomy into the electronic medical record. Observation on 02/10/24 at 1:04 P.M., of tracheostomy care for Resident #19 with LPN #385. and Unit Manager (UM) #320 revealed UM #320 provided tracheostomy care for Resident #19 per physician orders. Review of the facility policy Tracheostomy Care, revised 10/2023, revealed a replacement tracheostomy tube must be available at the bedside at all times. Tracheostomy care should be provided as often as needed, at least once daily for an established tracheostomy, and at least every eight hours for residents with an unhealed tracheostomy. This deficiency represents non-compliance investigated under Master Complaint Number OH00162375.

Based on observation, staff interview, medical record review, and review of the Centers for Medicare and Medicaid Services (CMS) Provider History Profile document, the facility failed to have an effective quality assurance and performance improvement (QAPI) program to address repeated deficiencies identified during four consecutive comprehensive surveys. This had the potential to affected all 44 residents in the facility. The census was 44. Findings include: Review of the CMS Provider History Profile document, with Certification and Survey Provider Enhanced Reporting (CASPER) system data, last updated 12/10/24, revealed the facility was issued a deficiency for not administering medications as ordered resulting in significant medication errors on the three previous comprehensive surveys in August 2023, January 2024, and 07/18/24. During the current comprehensive survey, with exit date 12/19/24, the facility was cited for significant medication errors for the four consecutive comprehensive survey. Review of Resident #13's medical record revealed an admitted [DATE]. Diagnoses included epilepsy, iron deficiency anemia, heart failure, primary osteoarthritis, insomnia, hyperlipidemia, hypertension, atrial fibrillation, type two diabetes mellitus, post-traumatic stress disorder, and major depressive disorder. Review of Resident #13's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #13's current physician orders as of 12/18/24 revealed the resident was to receive Novolog insulin eight (8) units subcutaneously (SQ) before meals for blood sugar control. Review of an additional order for Novolog insulin per sliding scale was to be administered SQ with meals and at bed time. Observation and interview on 12/18/24 at 8:14 A.M. of Licensed Practical Nurse (LPN) #701 administering medication for Resident #13 revealed the nurse obtained a blood glucose level for Resident #13 of 224 milligrams per deciliter (mg/dL), which required four (4) units of Novolog insulin from the sliding scale order. LPN #701 stated she would be administering 12 units total of Novolog insulin to Resident #13. LPN #701 then was observed to attach an administration needle to the insulin administration pen, turned the dose selector dial to 12 units, and proceed to administer the insulin to Resident #13 without first priming the Novolog insulin administration pen. Interview on 12/18/24 at 8:37 A.M. with LPN #701 confirmed she administered the ordered 12 units of Novolog insulin to Resident #13, but did not prime the pen needle prior to administration. Review of the Novolog FlexPen package insert, dated 2023, revealed before each injection, to avoid injecting air and ensure proper dosing, turn the dose selector to two (2), hold the Novolog FlexPen with the needle pointing up, and press the push button all the way in until the dose selector returns to zero (0). A drop of insulin should be seen at the tip of the needle. The dose selector then can be dialed to the correct dose of insulin for administration. Review of the facility policy titled, Administering Medications, revised 2012, revealed medications will be administered in a safe and timely manner, and as prescribed.

Based on observation, staff interview, medical record review, review of a medication package insert, and review of facility policies, the facility failed to ensure water temperature testing was completed as part of the facility Legionella prevention program. In addition, the facility failed to ensure staff wore proper personal protective equipment during resident care for a resident (#13) on enhanced barrier precautions and failed to cleanse a resident's (#24) insulin dispensing pen prior to affixing a needle for administration. This deficient practice had the potential to affect all 44 residents residing in the facility. The facility census was 44. Findings Include: 1. Review of the facility water temperature logs on 12/19/24 at 8:35 A.M. revealed water temperature testing was absent from 10/01/24 through 12/19/24. Interview with Maintenance Supervisor #631 on 12/19/24 at 8:40 A.M. revealed he had been employed at the facility for a short time and was unaware of the Legionella policy. Interview with Regional Director of Operations #703 on 12/19/24 at 9:10 P.M. verified the facility failed to complete Legionella water temperature testing timely. Review of the facility policy titled, Legionella Surveillance and Detection, revised September 2022, revealed the facility is committed to the prevention, detection and control of water-borne contaminates, including Legionella. Legionnaire's disease is included as part of our infection surveillance activities. 44815 2. Review of the medical record for Resident #24 revealed an admitted [DATE] with diagnoses of a pressure ulcer and colostomy status. Review of the admission comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 had intact cognition. Additional review reviewed Resident #24 had an indwelling catheter and an ostomy (an artificial opening into an organ of the body). Review of the physician order dated 09/19/24 revealed Resident #24 was in enhanced barrier precautions (EBP) for wounds and an indwelling catheter. Observation on 12/16/24 at approximately 2:40 P.M. revealed Resident #24 had a sign next to her doorframe indicating the resident was on EBP. The sign advised staff to wear a gown and gloves when changing briefs or assisting with toileting. Under the sign was a plastic set of drawers with personal protective equipment (PPE), including blue disposable gowns and disposable gloves. Interview on 12/17/24 at approximately 7:40 A.M. with Licensed Practical Nurse (LPN) #702 revealed staff were in Resident #24's room providing care. Observation on 12/17/24 at 7:44 A.M. revealed Certified Nurse Aide (CNA) #591 exiting Resident #24's room carrying bags of soiled items. No blue items were observed in the bags. Concurrent interview with CNA #591 revealed she just finished providing colostomy care to Resident #24. CNA #591 stated she only wore gloves while providing the care. CNA #591 confirmed Resident #24 was in EBP and CNA #591 should have worn a disposable gown while providing colostomy care to Resident #24. Review of the policy, Policy on Disease-Specific Isolation/Precautions, dated 04/01/24, revealed enhanced barrier precautions include the use of personal protective equipment, gowns and gloves, during high contact resident care activities. 49742 3. Review of the facility electronic medical record for Resident #13 revealed an admitted [DATE] with diagnoses including epilepsy, iron deficiency anemia, heart failure, primary osteoarthritis, insomnia, hyperlipidemia, hypertension atrial fibrillation, type two diabetes mellitus post-traumatic stress disorder, and major depressive disorder. Review of Resident #13's most recent quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact. Observation and interview on 12/18/24 at 8:14 A.M. of Licensed Practical Nurse (LPN) #701 administering medication for Resident #13 revealed the nurse obtained a blood glucose level for Resident #13 of 224 milligrams per deciliter (mg/dL). LPN #701 stated she would be administering 12 units of Novolog insulin to Resident #13. At this time, LPN #701 was observed to attach a needled to the end of the Novolog insulin administration pen without first wiping the rubber stopper at the tip with an alcohol swab and administered the insulin to Resident #13. Interview on 12/18/24 at 8:37 A.M. with LPN #701 confirmed she did not wipe the rubber stopper of the Novolog insulin pen with an alcohol swab prior to attaching a needle. Review of the Novolog FlexPen package insert, dated 2023, revealed when preparing the Novolog FlexPen for administration, first wipe the rubber stopper with an alcohol swab prior to attaching the needle. Review of the facility policy titled, Administering Medications, revised December 2012, revealed staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolations, etc.) for the administration of medications.

Based on observation, resident and staff interview, review of medical records, review of a behavior contract, review of facility equipment logs, and review of facility policies, the facility failed to ensure emergency crash carts were completely stocked per facility policy. This had the potential to affect 33 (#1, #3, #4, #5, #10, #12, #13, #14, #16, #17, #18, #19, #20, #21, #23, #24, #27, #28, #29, #30, #31, #32, #33, #35, #38, #39, #40, #41, #44, #45, #46, #48, and #50) residents identified by the facility as being full code (the resident wishes to receive resuscitation and all live saving measures in the event of a cardiac or respiratory arrest). In addition, the facility failed to ensure smoking materials were stored safely for one (#28) of one residents reviewed for smoking and failed to ensure one (#43) of one residents reviewed for accidents and hazards was transferred with the appropriate level of assistance to prevent falls. The facility census was 44. Findings Include: 1. Interview and observation on 12/18/24 at 2:21 P.M. of the emergency crash cart at the North nurse's station with Licensed Practical Nurse (LPN) #702 revealed no oxygen tubing and no oxygen mask were available in the cart. Additionally, LPN #702 confirmed the oxygen tank was empty, but stated the regulator needed to be adjusted to show if there was oxygen available. Continued observation on 12/18/24 at 2:27 P.M. revealed LPN #702 and Registered Nurse (RN) #515 attempting to adjust the regulator and determine if oxygen was in the tank. Interview on 12/18/24 at 2:29 P.M. with RN #515 confirmed they could not determine if the oxygen tank located with the crash cart contained oxygen. RN #515 stated if she needed oxygen she would go to the closet located inside the dining room to get another tank. Interview and observation on 12/18/24 at 2:33 P.M. with RN #515 of the crash cart at the South nurse's station revealed no oxygen tank was with the cart. RN #515 confirmed no oxygen tank was with the cart. Continued observation on 12/18/24 at 2:33 P.M. revealed RN #515 could not unlock or open the crash cart. Corporate Risk Management Nurse (CRMN) #700 approached the cart and attempted to open it. After several attempts, CRMN #700 was able to turn the key and successfully open the cart. CRMN #700 noted something was jammed against the inside lock causing the delay in accessing the cart. CRMN #700 demonstrated hidden levers on every drawer required sliding before the drawers would open. Observation and interview on 12/18/24 at 3:53 P.M. with LPN #701 revealed she could not open the crash cart at the South nurse's station. LPN #701 turned the key but was unable to open the drawers of the cart. LPN #701 further confirmed she could not find the crash cart checklist. LPN #701 stated she previously worked in the facility on night shift and stated the night shift nurse was responsible for conducting a nightly inventory on the crash cart. Interview on 12/19/24 at 9:02 A.M. with the Director of Nursing (DON) confirmed she could not find the crash cart book for the South nurse's station crash cart. Review of the document titled, Crash Cart Equipment, revealed a list of all items to be included in the crash cart. Review of the Crash Cart Equipment form from the notebook with the North nurse's station crash cart revealed all items were present in the crash cart on 12/16/24, including an oxygen mask and a full oxygen tank. Review of the policy titled, Emergency Crash Cart, copyright 2024, revealed the emergency crash cart is checked every 24 hours and after every use. Additionally, equipment/supplies used from the emergency crash cart are noted and replaced promptly. 2. Review of the medical record for Resident #28 revealed an admitted [DATE] with diagnoses of heart disease, congestive heart failure, and depression. Review of the comprehensive admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had intact cognition and used tobacco. Review of the current care plan revealed Resident #28 was a smoker. Interventions included storing Resident #28's smoking supplies at the nursing station. Review of a progress note dated 10/11/24 at 4:27 P.M. revealed Resident #28 was educated on the smoking policy. Further review revealed Resident #28's cigarettes and lighter were confiscated and placed in the smoke box. Review of a progress note dated 10/11/24 at 5:39 P.M. revealed Resident #28 was educated to smoke only in designated areas and smoking materials were not to be kept in his room. Further review revealed Resident #28 stated understanding and agreed to give cigarettes to the nurse to be locked up. Interview on 12/16/24 at 9:26 A.M. with Resident #28 revealed he kept his cigarettes and lighter in his pocket. Concurrent observation revealed a cigarette pack in Resident #28's left pocket. Further observation revealed a cigarette burn in his jacket and another on his pants. Observation on 12/17/24 at 10:08 A.M. revealed Resident #28 lying in bed watching television. A cigarette pack was on his bedside table. Concurrent interview with Resident #28 stated he was allowed to keep his cigarettes and lighter in his room because he was allowed to smoke independently. Interview on 12/19/24 at 11:25 P.M. with Social Services Director (SSD) #643 revealed she was familiar with Resident #28. SSD #643 stated Resident #28 should not have cigarettes or lighters in his room. Interview on 12/19/24 at 11:29 A.M. with SSD #643 and Resident #28 revealed Resident #28 confirmed he had cigarettes and lighters in his room. Resident #28 gave permission to look in a shopping bag hanging from the arm of his wheelchair. Observation with SSD #643 confirmed two packs of cigarettes were in the bag. Continued observation revealed Resident #28 removing two lighters from his jacket pockets and handing them to SSD #643. Review of the Behavior Contract for Resident #28, signed 12/11/24, revealed Resident #28 understood cigarettes and smoking materials (i.e., lighters) may not be kept on his person. 49742 3. Review of the medical record for Resident #43 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, hypothyroidism, anxiety disorder, dysphagia, cachexia, and dementia. Review of the most quarterly recent MDS assessment dated [DATE] revealed the resident was rarely/never understood. Further review of the MDS assessment revealed the resident was dependent for all functional care areas. Review of the most recent care plan for Resident #43 revealed she required a mechanical lift with two staff assistance for transfers. Observation on 12/18/24 at 1:09 P.M. revealed one staff member, Certified Nurse Aide (CNA) #601, was transferring Resident #43 from her Broda chair (a chair that provides comfort, support, positioning, and mobility) to her bed unassisted by another staff member and without a mechanical lift. An interview on 12/18/24 at 1:11 P.M. with CNA #601 confirmed she transferred Resident #43 from her Broda chair to her bed unassisted from another staff member and without a Mechanical Lift. An interview on 12/18/24 at 1:19 P.M. with MDS RN #517 confirmed Resident #43's plan of care revealed the resident required a mechanical lift with two staff assistance for transfers. This deficiency represents non-compliance investigated under Complaint Number OH00160151.

Based on medical record review and staff interview, the facility failed to ensure residents who were being discharged from Medicare Part A services received timely notification. This affected three (#25, #49, and #104) of three residents reviewed for beneficiary notices. The facility census was 44. Findings include: 1. Review of the medical record for Resident #25 revealed an admitted [DATE]. Review of the Notice of Medicare Non-Coverage (NOMNC) for Resident #25 revealed his services would end on 11/23/24. Further review revealed Resident #25 was notified his services were ending via a telephone call on 11/22/24. 2. Review of the medical record for Resident #49 revealed an admitted [DATE] and a discharge date of [DATE]. Review of the NOMNC for Resident #49 revealed her services ended on 12/11/24. Further review revealed Resident #49 was notified on 12/10/24 regarding the end of her services. 3. Review of the medical record for Resident #104 revealed an admitted [DATE] and a discharge date of [DATE]. Review of the NOMNC for Resident #104 revealed her services ended on 09/14/24. Further review revealed Resident #104 was notified on 09/13/24 regarding the end of her services. Interview on 12/18/24 at 10:15 A.M. with Business Office Manager (BOM) #706 confirmed Resident #25, Resident #49, and Resident #104's NOMNCs for were given 24 hours in advance of the end of services rather than the required 48 hour notification. BOM #706 stated she worked in two buildings and was not always able to provide NOMNC documents timely.

Based on medical record review, review of self-reported incidents (SRIs) and facility investigation, review of a witness statement, and staff interview, the facility failed to ensure residents were free from abuse. This affected two (#7 and #23) of three residents reviewed for abuse. The facility census was 44. Findings include: 1. Review of the medical record revealed Resident #7 was admitted on [DATE]. Diagnoses included cerebral infarction due to unspecified occlusion or stenosis of an unspecified cerebral artery, unspecified dementia, schizoaffective disorder bipolar type, essential hypertension, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was moderately cognitively impaired. 2. Review of the medical record revealed Resident #39 was admitted on [DATE]. Diagnoses included dislocation of the C1/C2 cervical vertebrae, atherosclerotic heart disease of native coronary, Parkinson's disease, chronic viral hepatitis C, schizoaffective disorder bipolar type, and asymptomatic human immunodeficiency virus (HIV) infection status. Review of the MDS assessment dated [DATE] revealed Resident #39 was cognitively intact. Review of an SRI dated 11/07/24 revealed Resident #7 and Resident #39 were involved in an altercation in their shared bedroom. Licensed Practical Nurse (LPN) #702 was the only witness to the incident stating Resident #39 was in the doorway of the resident room and Resident #7 was behind him waiting to get out. LPN #702 asked Resident #39 to move out of the doorway so Resident #7 could get out of the room. Resident #39 became upset and yelled, You stinky mother (expletive), you could have asked me to move, at Resident #7. Resident #7 responded, (expletive) you mother (expletive). Resident #39 then stood from the wheelchair, walked over to Resident #7, and began to hit him in the head and chest in addition to kicking him in the legs. Both residents were immediately separated from each other and assessed. There were no injuries noted to either resident, vital signs were within normal limits, and both residents denied pain or discomfort. Both residents were interviewed immediately following the incident. Resident #7 stated Resident #39 was always mean to him and he just used him as a punching bag. Resident #39 stated he does not like Resident #7 adding that he smells and was glad he hit him. Review of a witness statement dated 11/07/24, written by LPN #702, revealed during the morning medication pass, the writer witnessed two residents (#7 and #39) have a verbal and physical altercation. Resident #39 was sitting in the doorway of his bedroom and Resident #7 was behind him waiting to get out. LPN #702 asked Resident #39 to move aside so Resident #7 could get out of the room. Resident #39 then yelled at Resident #7, calling him an expletive name and telling him he could have asked him to move. Resident #7 then cursed at Resident #39. Resident #39 then got out of his wheelchair and walked to Resident #7 and began hitting him in the head and chest and kicking him in his legs. Resident #7 did not hit back and attempted to wheel back from Resident #39. LPN #702 verbally encouraged the residents to stop and Resident #39 was assisted back into his wheelchair. Review of the physical aggression received documentation dated 11/07/24 revealed Resident #7 was hit in the face and chest multiple times and kicked in the legs by another resident (#39). Review of the physical aggressive initiated documentation dated 11/07/24 revealed Resident #39 was in the doorway of his room when LPN #702 asked the resident to move aside so his roommate (#7) could get through to exit the room. Resident #39 then began yelling at his roommate, got out of his wheelchair, and began hitting his roommate in the chest and face and kicking the roommate in the legs. The roommate attempted to back away from the resident. LPN #702 verbally intervened and assisted the resident back into his wheelchair and separating the two residents. Resident #39 continued to verbally attack Resident #7 as he was leaving the room. Resident #39 stated he did not like his roommate and he stunk, adding he does not care that he verbally and physically attacked his roommate. Interview on 12/17/24 at 11:58 A.M. with the Director of Nursing (DON) verified resident-to-resident abuse occur between Resident #7 and Resident #39 on 11/07/24.

Based on medical record review, resident interview, staff interview, and facility policy review, the facility failed implement ordered interventions to aid in producing a bowel movement. This affected one (#15) of one residents reviewed for bowel and bladder. The facility census was 44. Findings include: Review of the medical record revealed Resident #15 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease, muscle wasting and atrophy, chronic pulmonary edema, heart failure, dyspnea, hypotension, polyneuropathy, essential hypertensive, chronic systolic heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was moderately cognitively impaired, was always incontinent of bowel, and received hospice services. Review of the care plan dated 07/15/24 revealed Resident #15 was at risk for pain due to disease process and interventions included to monitor for side effects of pain medication including to observe for constipation. Review of a physician order dated 09/11/24 revealed an order for the laxative Glycolax powder with instructions to give 17 grams by mouth as needed for constipation. Observation and interview on 12/16/24 at 3:09 P.M. revealed Resident #15 was laying in bed and stated he was constipated. Review of the bowel function tracking dated 12/06/24 to 12/13/24 revealed Resident #15 did not have a bowel movement documented during that time frame. Review of the December 2024 medication administration record revealed from 12/06/24 to 12/13/24 Resident #15 was not provided any as needed medication for constipation. Interview on 12/17/24 at 11:57 A.M. with the Director of Nursing (DON) verified Resident #15 had an eight (8)consecutive day time frame with no documented bowel movement. The DON stated when Resident #15 began hospice services all routine orders ended and the medical record system did not provide notification for intervention. Interview on 12/17/24 at 1:46 P.M. with Hospice Registered Nurse (RN) #704 verified no knowledge of Resident #15's lack of bowel movements for 8 days. Hospice RN #704 stated the facility would have needed to call the hospice provider so the physician could have given orders for treatment. Review of the policy bowel disorders clinical protocol, dated September 2017, revealed the staff and physician will help identify individuals with previously identified lower gastrointestinal tract conditions and symptoms which may include an alteration in bowel movements. The physician will identify and order pertinent cause-specific and symptomatic interventions.

Based on medical record review, review of hospital documentation, staff and resident interviews and policy review, the facility failed to ensure Resident #17, who had an indwelling suprapubic catheter, received timely treatment for a symptomatic urinary tract infection (UTI). This resulted in Actual Harm on 10/05/24 when Resident #17's symptomatic UTI was not treated at the facility and the resident was subsequently transported to the hospital and admitted . Resident #17 required intravenous (IV) antibiotic at the hospital to treat the UTI and sepsis. Additionally, the facility failed to provide indwelling urinary catheter care for Resident #52 for a period of eight days, from admission on 09/16/24 to 09/24/24, placing the resident at risk for the potential for more than minimal harm, at which time the urinary catheter was removed. This affected two (#17 and #52) of three residents reviewed for urinary catheters. The facility census was 51. Findings include: 1) Review of the medical record for Resident #17 revealed an admitted [DATE]. Diagnoses included quadriplegia, neuromuscular dysfunction of bladder, pressure ulcer stage four of the sacral region, chronic pain, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had intact cognition. Resident #17 had an indwelling catheter and ostomy. Resident #17 was dependent on staff for toileting hygiene. Review of the plan of care initiated on 06/14/20 and last revised on 01/24/23 revealed Resident #17 had a suprapubic catheter related to a neurogenic bladder and was at risk for infection. Interventions included to check tubing for kinks throughout each shift, monitor for signs and symptoms of discomfort on urination and frequency, monitor and document for pain/discomfort due to catheter, and monitor/record/report to physician for signs and symptoms of a UTI including pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increase temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. Review of the medical record revealed Resident #17 had a history of UTI and sepsis. Resident #17 was treated for a UTI with IV antibiotics from 09/02/24 through 09/09/24. Review of a physician progress note dated 09/27/24 revealed Resident #17 had dysuria with a plan to obtain a urinalysis with culture and sensitivity. The physician noted Resident #17 had a history of UTI's with multidrug-resistant organisms and if the urinalysis was positive then the physician would consider broad-spectrum antibiotic therapy. Further review of the progress note revealed Resident #17 complained of urinary symptoms such as mild burning and increased urine sediment over the past several days. Resident #17 denied fever and chills but admits to some mild intermittent fatigue. The physician noted Resident #17 would like to have a urinalysis along with culture and sensitivity. Review of a physician order dated 09/29/24 revealed Resident #17 was ordered a urinalysis with culture and sensitivity. Review of a preliminary laboratory result report dated 10/01/24 revealed Resident #17 had dark yellow turbid urine with leukocytes, white blood cells and bacteria present. The physician was notified and awaiting the culture results. Review of the final laboratory result report dated 10/03/24 revealed Resident #17 had a UTI with greater than 100,000 colony forming unit (cfu) per milliliter (ml) of the bacteria Providencia stuartii. There was no documentation the physician was notified of the results and no new orders were received to treat Resident #17's UTI. Review of the nurse's notes from 09/27/24 through 10/04/24 revealed no documentation of Resident #17's signs and symptoms of a UTI. Review of nurse's note dated 10/05/24 at 6:13 A.M. revealed Resident #17 was screaming and yelling out in pain. Resident #17 was requesting to go out to the hospital. Emergency Medical Services (EMS) transported Resident #17 to the hospital. The physician was notified. Resident #17's blood pressure was 145/76, with a pulse of 100 beats per minute and a temperature of 100.3 degrees Fahrenheit (F). Review of a change in condition evaluation dated 10/05/24 at 4:54 P.M. revealed Resident #17 had abdominal pain, uncontrolled pain that started in the afternoon on 10/04/24. Resident #17 complained of lower abdominal/back pain related to a UTI. Resident #17 was also noted with groin pain. Resident #17 was sent to the emergency room for evaluation. Review of the treatment administration record (TAR) from 09/01/24 through 10/09/24 revealed Resident #17 had received suprapubic catheter care twice daily with no refusals noted. Review of hospital documentation dated 10/05/24 at 6:13 A.M. revealed Resident #17 was treated in the emergency room and admitted to the hospital for principal problem of sepsis due to gram negative UTI. Further review of the hospital documentation revealed Resident #17 had a history of drug-resistant infections and potential for colonization. A urinalysis with culture and sensitivity and blood cultures were ordered. Continued review of the hospital documentation revealed Resident #17 had an abnormal urinalysis. Blood cultures were negative on day four. No urine culture and sensitivity results were documented with several documented notes stating, culture not sent. Resident #17 was treated with the IV antibiotic Zosyn for three days. Resident #17 returned to the facility on [DATE] with new orders for oxycodone extended release 20 milligrams every six hours for pain related to sepsis due to gram-negative UTI. Resident #17 also received orders for pregabalin 150 milligram capsule by mouth three times daily for sepsis due to unspecified organism. Interview on 10/09/24 at 10:57 A.M., Resident #17 revealed on 10/04/24 he was having abdominal pain and signs of a UTI and told the Director of Nursing (DON). Resident #17 revealed the facility had not notified the physician and the following day he had to go to the hospital. Resident #17 revealed he had a UTI and was septic. Resident #17 revealed he was treated with IV antibiotics in the hospital and then returned to the facility. Interview on 10/09/24 at 11:04 A.M., the DON revealed Resident #17 had reported abdominal pain on 10/04/24. The DON revealed she told Resident #17's nurse to have the physician see the resident when he came into the building. The DON revealed the physician never came to the building. The DON revealed there was no documentation that the resident's nurse had contacted the physician about the resident's abdominal pain on 10/04/24. Interview on 10/10/24 at 8:06 A.M., the DON revealed there was no documentation Resident #17's physician was notified of the resident's urinalysis culture and sensitivity results on 10/03/24 and no new orders had been received. The DON revealed an agency nurse was working when the results would have been received and was not returning calls to the facility. The DON confirmed Resident #17 was admitted to the hospital on 10/05/24 for UTI and sepsis. Interview on 10/10/24 at 9:45 A.M., Licensed Practical Nurse (LPN) #200 revealed on 10/04/24 the day shift nurse had not reported Resident #17 was having abdominal pain. LPN #200 revealed Resident #17 had not reported pain until the following morning 10/05/24 and was sent to the hospital. LPN #200 revealed Resident #17 had a urinalysis with culture and sensitivity previously ordered on 09/28/24 and she sent it to the laboratory on 09/30/24. LPN #200 revealed Resident #17 had complained of urine odor and sediment in his suprapubic catheter. Interview on 10/10/24 at 12:30 P.M., Regional Director of Clinical Services (RDCS) #400 revealed Resident #17 had been sent out to the hospital five times this year for UTI and had been treated monthly for chronic UTI's. RDCS #400 revealed Resident #17 was noncompliant with suprapubic catheter care and wound care. RDCS #400 revealed Resident #17 had stage four pressure ulcers and stays up in his chair for up to 22 hours per day. RDCS #400 also revealed Resident #17 had refused suprapubic catheter care and wound care in the hospital. Further interview with RDCS #400 revealed the hospital had a history of not completing urine cultures on Resident #17 and just treating him for sepsis. 2) Review of the medical record for Resident #52 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included malignant neoplasm of the bladder, hematuria, chronic kidney disease, acute kidney failure, diabetes mellitus type two, end stage renal disease and chronic obstructive pulmonary disease. Review of the admission MDS dated [DATE] revealed Resident #52 had intact cognition. The resident had an indwelling urinary catheter and required partial moderate assistance with toileting hygiene. Review of the admission nursing assessment dated [DATE] revealed Resident #52 had an indwelling urinary catheter. Review of the admission physician orders dated 09/16/24 revealed no orders for an indwelling urinary catheter or catheter care. Review of the treatment administration record from 09/16/24 through 09/24/24 revealed no documentation Resident #52 had received catheter care. Interview on 10/01/24 at 1:09 P.M., Corporate Compliance Registered Nurse (CCRN) #500 revealed Resident #52 had no orders for catheter care. CCRN #500 revealed she had some statements from some staff stating they had completed catheter care for Resident #52 but there was no documentation in the medical record that catheter care had been completed. CCRN #500 revealed Resident #52's catheter had been removed on 09/24/24 with no signs of infection. Review of the policy Change in a Resident's Condition or Status, revised 02/2021, revealed the nurse would notify the resident's attending physician or physician on call when there was a significant change in the resident's condition. Review of the policy Urinary Continence and Incontinence - Assessment and Management, revised 08/2022, revealed the physician and staff would provide appropriate services and treatment to prevent UTI to the extent possible. If an indwelling catheter was needed, staff would monitor for and report complications such as evidence of a symptomatic infection. Review of the policy Prevention and Screening - Clinical Protocol, revised 03/2018, revealed the physician would order laboratory screening tests relevant to monitoring the individual's treatment regimen or identifying modifiable risks and complications. Further review of the policy revealed no guidelines for reporting laboratory results to the physician. Review of the policy Catheter Care, Urinary revised 08/2022, revealed to observe the resident for complications associated with urinary catheters. Report unusual findings to the physician or supervisor immediately including signs and symptoms of UTI. Further review of the policy revealed catheter care would be documented in the resident's medical record. This deficiency represents non-compliance investigated under Complaint Number OH00158444.

Based on review of the medical records, observations, and staff interviews, the facility failed to ensure a resident's wound was timely assessed and treatments were initiated. This resulted in Actual Harm for Resident #213 when the resident's left heel wound deteriorated from a stage one pressure ulcer upon admission, to a deep tissue injury on 01/22/24. Additionally, the facility failed to timely assess and complete treatments per physician orders. This affected three (#213, #27, #22) of four residents reviewed for pressure ulcers. The facility census was 70. Findings include: 1. Review of the medical record for Resident #213 revealed an admitted [DATE]. Diagnoses included encephalopathy, acute kidney failure, protein calorie malnutrition, cystitis, hypertension, hyperlipidemia, atrial fibrillation, dementia, and sepsis. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident was dependent on staff for bed mobility, transfers, and locomotion. Review of hospital documentation dated 12/31/23 revealed the resident had a history of a stage one pressure ulcer to the left heal that healed on 12/31/23. Review of an undated handwritten hospital to facility nurse report at 4:45 P.M. revealed the resident had stage one pressure ulcers (intact skin with non-blanchable redness of a localized area usually over a bony prominence) to the bilateral heels. Review of a skin risk assessment completed 01/17/24 revealed the resident was at risk for skin breakdown. Review of the admission skin assessment dated [DATE] at 12:16 A.M. revealed no documented skin breakdown. Review of a skin monitoring/shower review sheet dated 01/18/24 revealed the the resident had a discolored area to the right heel with intact skin. The resident's left heel was described as soft. Review of the physician orders from 01/17/24 through 01/25/24 revealed there were physician orders dated 01/17/24 to apply skin prep to the right heel daily at bedtime for a deep tissue injury. On 01/20/24 an order was implemented to apply a heel protector to the right lower extremity while in bed. There were no orders for treatments to the left heel. Review of the Nurse Practitioner (NP) wound assessment report dated 01/22/24 revealed the stage one pressure ulcer to the resident's left heel had worsened to a Deep Tissue Injury (DTI) (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue). The wound measured 1.6 centimeters (cm) in length by 2.2 cm in width by zero cm in depth. The wound was 50-74% epithelial tissues and 25-49% eschar with attached wound edges. The wound had no drainage and the surrounding skin was described as fragile. A treatment was initiated to apply skin prep twice daily to the DTI and leave area open to air. The NP recommended an air/low air loss mattress, and ongoing pressure reduction and turning/repositioning precautions including pressure reduction to the heels and all bony prominence's. All prevention measures were discussed with the staff at the time of the visit. Observation on 01/24/24 at 9:45 A.M. revealed Resident #213 was in bed. The resident had a heel protector on the right heel. The left heel with the DTI was resting directly on the bed. Interview on 01/24/24 at 12:53 P.M., Quality Assurance Registered Nurse (QARN) #605 and Assistant Director of Nursing (ADON) #510 revealed there was no documented wound assessment of the resident's heel wounds upon admission. ADON #510 revealed the admitting nurse was responsible for documenting and assessing a resident's wounds. QARN #605 revealed the clinical team should follow up the following day to ensure a new resident's skin condition was documented and treatments were in place if needed. Interview on 01/24/24 at 1:18 P.M., Nurse Practitioner (NP) #604 revealed the resident had a DTI to the left heel. NP #604 revealed she was not aware of what wounds were present upon admission. Observation on 01/24/24 at 1:23 P.M. revealed the resident was in a geriatric chair. The residents heels were resting directly on the foot rest of the chair. Observation on 01/24/24 at 1:53 P.M. of wound care with Licensed Practical Nurse (LPN) #528 revealed the resident had a DTI to the bottom of the left heel. The quarter size area was deep purple in color. The surrounding skin was intact. The wound had no drainage. LPN #528 applied skin prep to the area per physician orders. Observation on 01/24/24 at 4:15 P.M. revealed the resident was in bed. The right heel protector was not in place and the residents right heel and left heel were resting directly on a blanket. Interview on 01/24/24 at 4:18 P.M., Licensed Practical Nurse (LPN) #528 verified the resident's heel protector was not in place to the right heel. LPN #528 also verified the resident's left heel with the DTI was resting directly on the bed. LPN #528 revealed the resident's heels should not be resting directly on the bed. Interview on 01/24/24 at 4:30 P.M. with ADON #510 revealed the resident was admitted to the facility with a soft mushy left heel and discoloration to the right heel. ADON #510 further revealed the hospital reported to the resident's admission nurse the resident had stage one pressure ulcers to the bilateral heels. ADON #510 verified there were no treatments in place for the left heel until the resident was assessed with a DTI on 01/22/24. Interview on 01/24/24 at 4:53 P.M. with Regional Clinical Service Director (RCSD) #603 verified while reviewing the physician orders the resident had a treatment in place to the right heel upon admission but no treatment was initiated for the left heel until 01/22/24. Review of the facility policy, Pressure Ulcers/Skin Breakdown--Clinical Protocol, last revised 03/2014 revealed staff would examine the skin of a new admission for ulceration or alteration in skin. The nurse would describe and document/report a full assessment of pressure sore including location, stage, length, width and depth, presence of exudate or necrotic tissue. The physician would authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressing and application of topical agents if indicated for type of skin alteration. 15816 2. Review of the medical record revealed Resident #27 admitted to the facility on [DATE] with diagnoses including, quadriplegia, myocardial infarction, abnormal posture, neuromuscular dysfunction of bladder, protein calorie malnutrition, hypertension, stage four sacral pressure ulcer, major depression, colostomy and suprapubic catheter. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #27 was assessed with intact cognition, ability to make needs known, dependent on staff for activities of daily living including bed mobility and transfer, utilized an indwelling catheter and ostomy for elimination, at risk for pressure ulcer development with two stage three pressure ulcers, and received antianxiety, antidepressant, anticoagulant, and opioid medications. On 09/11/23, a nursing plan of care was developed due to Resident #27's resistance to care related to refuses eye drops, refuses to take prostat at times, refuses to take prescribed medications at times, and refuses wound treatments at times. Interventions included the following: Allow the resident to make decisions about treatment regime, to provide sense of control. Educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care. Encourage as much participation/interaction by the resident as possible during care activities. Give clear explanation of all care activities prior to and as they occur during each contact. Praise the resident when behavior is appropriate. On 12/27/23, a nursing plan of care was revised to address Resident #27's pressure ulcer to left posterior thigh due to immobility and right posterior thigh pressure ulcer related to disease process quadriplegia, and immobility. Interventions included the following: Administer treatments as ordered and monitor for effectiveness. Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Measure wound weekly. On 01/08/24, Certified Nurse Practitioner (CNP) #1 Wound Specialist's assessment report documented Resident #27's right posterior thigh wound as stage three pressure with measurement 0.80 centimeters (cm) length by (x) 1.90 cm wide x 1.0 cm deep. Wound drainage was described as moderate amount of serosanguineous. Assessment of the left posterior thigh wound stage three pressure measured 2.0 cm x 2.20 cm x 2.0 cm with moderate amount of serosanguineous. According to nurses notes between 01/17/24 at 10:16 A.M. and 01/21/24 at 5:00 P.M. Resident #27 was hospitalized . Review of hospital documentation indicated Resident #27 was assessed with pressure wounds to the right and left posterior thigh. However, no wound measurements were recorded. Review of nursing admission assessment dated [DATE] signed as complete at 6:11 P.M. documented Resident #27 with pressure wounds to right and left buttock. No wound descriptions or measurements were noted. On 01/23/24, a weekly skin assessment signed at 3:40 P.M. indicated Resident #27 was assessed with pressure wounds to left and right posterior thighs. No wound descriptions or measurements were noted. Review of physician orders noted on 01/21/24 revealed treatment applications were ordered to the right buttock pressure wound to cleanse with wound cleanser, apply calcium alginate and border gauze twice daily (BID) and as needed (PRN) and pressure wound to left thigh treatment to include, cleanse with wound cleanser, apply calcium alginate and border gauze BID and PRN. On 01/22/24, the treatments were revised to include pressure stage three wound to left thigh, cleanse with wound cleanser, apply silver alginate and border foam every day (QD) and PRN. The right posterior thigh was also revised on 01/22/24 to include, pressure stage three to right posterior thigh, cleanse with wound cleanser, apply silver alginate and border foam QD and PRN. On 01/23/24 at 2:35 P.M. observation with Licensed Practical Nurse (LPN) #601 noted Resident #27 in bed. LPN #601 assembled wound treatment dressings and placed them at the bedside. State tested Nurse Aide (STNA) #525 assisted LPN #601 with positioning Resident #27 to the right side and removed an adult brief. Located to the resident's coccyx and posterior bilateral thighs discovered a pink dressing dated 01/20/24 at 5:00 A.M. LPN #601 was unaware the dressing to the bilateral posterior thighs had not been completed since return from the hospital on 01/21/24. LPN #601 removed the dressing and exposed a small soft bowel movement contained under the dressing. Both wounds were covered with same dressing. LPN #601 proceeded to cleanse the wounds and apply the treatment including silver alginate to wound bed, and cover with border dressing. Followed by placing date and time on each dressing. No wound measurement or description was obtained. On 01/24/24 at 6:40 A.M. interview with Assistant Director of Nursing Registered Nurse (RN) #509, during review of the medical record, confirmed no current wound measurements had been obtained since 01/21/24 when Resident #27 was returned from the hospital. RN #509 indicated Resident #27 refused. However, no documentation contained in the record indicated the resident was re-approached to obtain wound measurements and descriptions or that the wound dressing had not been changed since the resident was in the hospital (dated 01/20/24). On 01/24/24 at 12:45 P.M. Wound Specialist CNP #604 evaluated the bilateral posterior thigh wounds. Right posterior thigh was identified as a stage three pressure wound measuring 1.20 cm long x 5.60 cm wide x 0.70 deep with moderate amount of serosanguineous. Left posterior thigh was identified as a stage three pressure wound measuring 2.90 cm long x 2.80 cm wide x 2.00 deep with moderate amount of serosanguineous. Dressing treatments remained the same. On 01/24/24 at 12:55 P.M. interview with Wound Specialist CNP #604 revealed debridement of the left posterior thigh wound was completed. However, the bilateral wound depth had improved. According to Pressure Ulcers/Skin Breakdown Clinical Protocol Revised March 2014 noted staff will examine the skin of a new admission for ulcerations or alterations in skin. The nursing staff and attending physician will assess and document an individuals significant risk factors for developing pressure sores. In addition, the nurse shall describe and document the following: full assessment of the pressure sore including location, stage, length, width and depth and the presence of exudate or necrotic tissue, pain assessment, mobility status, current treatments, including support surfaces and all active diagnoses. The physician will authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressings, and application of topical agents if indicated. 45445 3. Review of the medical record for Resident #22 revealed an admitted [DATE]. Diagnoses included paraplegia, traumatic subdural hemorrhage with loss of consciousness, traumatic subarachnoid with hemorrhage with loss of consciousness, hypertension, full incontinence of feces, seizures, adjustment disorder with anxiety, and a dissection of thoracoabdominal aorta. Review of the admission MDS dated [DATE] revealed Resident #22 was cognitively intact, had functional impairment of bilateral lower extremities and used a motorized wheelchair. Resident #22 required partial assistance with bathing and personal hygiene and was dependent for toilet use, lower body dressing, bed mobility, and transfers. Resident #22 was incontinent of bowel and bladder and had two stage four pressure ulcers that required dressing changes and the application of medications and ointments. Review of the care plan dated 12/03/23 revealed Resident #22 had actual skin impairment to the right posterior thigh and coccyx with interventions that included for staff to check placement and function of air mattress every shift, educate resident/family on causative factors, and to follow facility protocols for treatment of injury. Review of the care plan updated 12/06/23 revealed Resident #22 had a pressure ulcer to the coccyx and interventions included for medications and treatments to be administered as ordered, for staff to monitor for effectiveness of treatments and document side effects. Review of the current physician orders revealed an order written on 12/07/23 for the pressure injury to the coccyx to be cleansed with soap and water, patted dry, followed by silver alginate to be applied to the wound bed and covered with an abdominal dressing and fix with tape everyday and as needed. An order was written on 01/16/24 for the pressure injury of the right posterior thigh to be cleansed with wound cleaner, with a dakins moistened gauze applied to the wound bed, covered with silver alginate and border foam every day and as needed. Interview on 01/22/24 at 2:20 P.M. with Resident #22 revealed concerns related to the care of his wounds with the correct treatments not being provided and soiled dressings not being changed timely. Observation on 01/23/24 at 9:00 A.M. of incontinence care for Resident #22 performed by State tested Nursing Assistant (STNA) #527 revealed the dressing to the right posterior thigh was soiled and loose. STNA #527 removed the dressing to the right posterior thigh and after completing incontinence care notified the nurse of the need for the dressing to be replaced. The dressing to the coccyx was noted to be tan in color with an adhesive border, was clean and dry, and undated. Continuous observation of Resident #22 occurred from 9:00 A.M. until 9:50 A.M. of Resident #22 laying on his right side with a towel covering the residents buttocks and the right posterior thigh wound. Observation on 01/23/24 at 9:50 A.M. of wound care completed by Licensed Practical Nurse (LPN) #600 revealed the tan coccyx wound dressing was removed, the wound was cleaned with warm and soapy water, patted dry, and silver alginate was cut to fit onto the wound bed, covered with silver alginate and covered with an abdominal dressing and fixed with tape. Interview with LPN #600 at the time of the observation verified the dressing that was removed from Resident #22's coccyx was the incorrect dressing. Review of the facility policy titled, Pressure Ulcers/Skin Breakdown Clinical Protocol, Revised March 2014 the physician will authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressings, and application of topical agents if indicated. Review of the undated facility policy titled Medication and Treatment Orders, revealed medications and treatments shall be administered as ordered.

Based on observation, medical record review, hospital record review, review of the emergency services report, resident and staff interviews, review of witness statements, and policies Administering Medications, Obtaining a Fingerstick Glucose Level Insulin Administration and Nursing Care of the Resident with Diabetes Mellitus, the facility failed to have comprehensive systems in place to prevent significant medication errors for Resident #25, #37 and #57 related to the monitoring of diabetes mellitus and administration of insulin. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, complications and/or death beginning on 06/10/23 when the facility failed to accurately document blood glucose results and contact the physician, as ordered when Resident #25 ' s blood glucose level was over 400 milligram /deciliter (mg/dL). Between 06/10/23 and 08/03/23 nursing staff continued to inaccurately document blood sugar results, failed to contact the physician for elevated blood glucose levels outside sliding scale parameters and/or failed to administer insulin as ordered for Resident #25, Resident #37 and Resident #37 resulting in ongoing incidents of hyperglycemia and inadequate diabetes mellitus management. Additional complications as a result of this facility practice occurred when the facility failed to facilitate an appointment for Resident #25 for an endocrinologist (physician who specializes in diabetes management) and on 08/03/23 for Resident #57, who was hospitalized for a change in condition which included an episode of hyperglycemia not properly identified and managed by facility staff. This affected three residents (#25, #37 and #57) of four residents reviewed for significant medication errors. The facility identified 15 residents (#04, #10, #15, #16, #17, #21, #25, #30, #37, #40, #41, #46, #55, #57 and #261) currently requiring insulin. The facility census was 59. On 08/07/23 at 3:05 P.M., Interim Director of Nursing (IDON) #250 and [NAME] President of Nursing of Clinical Operations (VPCO) #255, were notified Immediate Jeopardy began on 06/10/23 when an identified lack of comprehensive systems resulted in the inadequate management/monitoring and care for residents, including Resident #25, #37 and #57 who had a diagnosis of diabetes mellitus. Between 06/10/23 and 08/03/23 facility nursing staff failed to accurately document resident blood glucose levels, failed to notify the physician of elevated blood glucose levels as required and/or failed to administer insulin as ordered resulting in medical complications. The Immediate Jeopardy was removed on 08/07/23 when the facility implemented the following corrective actions: the facility implemented the following corrective actions: On 08/02/23 at approximately 6:25 P.M., the surveyor notified Director of Nursing (DON) #252 and the Medical Director of an observation of a licensed nurse (Licensed Practical Nurse (LPN) #260) not documenting an actual blood sugar result for Resident #25. On 08/02/23 at approximately 6:35 P.M. the surveyor notified IDON #250 and VPCO #255 of an observation of LPN #260 not documenting an actual blood sugar result for Resident #25. On 08/02/23 at approximately 6:45 P.M., the facility removed LPN #260 from patient care. On 08/02/23 at 7:00 P.M., LPN #260 was interviewed by IDON # 250 regarding the incident. LPN #260 admitted to not documenting the actual blood sugar of Resident #25 on the Electronic Medication Administration Record (EMAR). LPN #260 admitted to not calling the physician when the blood sugar was elevated but stated she would calculate how much insulin she should administer. LPN #260 stated she did not understand she was working beyond her scope of practice based on the Ohio Nurse Practice Act. LPN #260 was immediately terminated from her employment with Ridgewood Manor after the interview. On 08/02/23 at 8:00 P.M., IDON #250 began to interview/educate nurses on the following: Their understanding of documenting blood sugar in the EMAR. Their understanding of requirements for notification to the physician when an FSBS is above or below the identified parameters. Their understanding of documentation of new orders and the requirements of documentation Each nurse was asked if they had administered insulin without an order. All interviews were completed by 08/06/23 at 6:00 P.M. Nurses who were not interviewed during this time period were removed from the schedule until an interview and education were completed. On 08/02/23, beginning at 8:00 P.M. and concluding on 08/06/23 at 6:00 P.M., all nurses were educated on the following by IDON #250: Insulin Administration Policy and Procedure. Nursing Care of the Resident with Diabetes Mellitus. Obtaining a Fingerstick Glucose (Blood) Level Policy and Procedure. Demonstration on documenting insulin administration on the EMAR when a blood sugar is above or below the insulin sliding scale parameter. On 08/03/23 at 4:20 P.M., an Ad Hoc Quality Assurance Performance meeting was held with the interdisciplinary team to discuss the inaccurate recording of resident ' s blood sugar and residents receiving the correct amount of insulin, to formulate the corrective plan of correction the center would implement. On 08/04/23 at 3:00 P.M., IDON #250 reviewed all current patients diagnosed with diabetes with the Medical Director, and clarification orders were obtained as applicable. New orders were also obtained as applicable. This was completed by 08/06/23 at 6:00 P.M. On 08/04/23 at 4:00 P.M., with completion on 08/07/23 at 6:00 P.M., IDON #250 reviewed and corrected all patients with diabetes clinical records for the following: Appropriate diagnoses. Appropriate diets. Blood sugar parameters to notify the physician. Accurate transcription of orders. Appropriate laboratory tests were ordered and would be obtained on Monday, 08/07/23. Laboratory results would be reviewed with the Medical Director by IDON #250, and additional orders would be obtained as needed. Diabetic care plans were reviewed and revised as applicable. Effective 08/06/23, IDON #250 and/or Director of Nurses, would review new admissions with a diagnosis of diabetes for accuracy daily for 14 days, then three times a week for 30 days, then within 24 hours of the resident being admitted to the facility. Effective 08/06/23, IDON #250 and/or Director of Nurses, would review new physician orders for diabetic patients for accuracy daily for 14 days, then three times a week for 30 days, then within 24 hours of the order being written. Effective 08/06/23, IDON #250, VPCO #255 and/or Director of Nursing would review all residents with insulin sliding scales daily for accuracy of documentation, notification to the Medical Director as applicable, and follow-up transcription of orders daily for 14 days, then three times a week for 30 days then Monday through Friday in the morning clinical meeting. Any areas of concern would be addressed to the licensed nurse as applicable. Effective 08/06/23, all new hires and agency staff assigned to work at the facility would receive the above education before resident care by IDON #250 and/or the Director of Nursing. On 08/08/23, review of the in-service records revealed all licensed nursing staff received education about obtaining blood sugars, administering insulin per orders, calling physician and facility policies. On 08/08/23 from 9:22 A.M. to 9:53 A.M. interviews with LPN #229, LPN #232, and LPN #239 verified they had received facility training and were knowledgeable on insulin administration, obtaining a fingerstick glucose (blood sugar) level, documentation of medication administration, and physician notification. Although the Immediate Jeopardy was removed on 08/07/23, the facility remained 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 is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of Resident #25 ' s medical record revealed an admitted [DATE], with diagnoses included type II diabetes mellitus, morbid obesity, hyperlipidemia, and gastro-esophageal reflux disease. Review of Resident #25 ' s quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/15/23 revealed Resident #25 was cognitively intact, required limited assistance of one staff member for transfers, dressing, and toileting and received insulin injections daily during the look back period of the MDS assessment. Review of Resident #25 ' s care plan, revised 06/21/23 revealed the resident was at risk for complications related to diabetes mellitus and had the potential for nutritional problems related to inconsistent carbohydrate intake, the need for a therapeutic diet, and diabetes medication for glucose control. Listed interventions included to educate Resident #25 on importance of ordered diet, encourage resident to comply with ordered diet. The care plan also noted to administer medications as ordered and indicated Resident #25 refused medications at times. Review of Resident #25 ' s physician ' s orders revealed an order dated 06/15/23 for insulin Lispro (short acting insulin), measured in units, to be injected four times daily before meals and at bedtime per a sliding scale, with the number of units to be given based on blood sugar results. The sliding scale stated to inject two units for a blood sugar of 151-200, four units for a blood glucose level of 201-250, 6 units for a blood glucose level of 251-300, 8 units for a blood glucose level of 301-350, and inject 10 units for a blood glucose level of 351-400. The order further specified to contact the medical doctor if the resident ' s blood sugar was less than 70 or greater than 400. Review of physician ' s orders revealed an order dated 06/15/23 for six units of insulin Lispro to be given before meals in addition to the sliding scale amount. Review of Resident #25 ' s Medication Administration Record (MAR) for June 2023 revealed beginning on 06/10/23 there were 36 instances out of 91 opportunities where Resident #25 ' s blood glucose level was documented as being exactly 400. Review of the MAR for June 2023 revealed with each instance of the blood glucose documented as 400, Resident #25 was administered 10 units of insulin coverage. Review of Resident #25 ' s interdisciplinary progress notes for June 2023 revealed zero instances where the physician or nurse practitioner were notified of an elevated blood glucose level, or a refusal for a blood glucose check or medication to treat an elevated blood glucose level. Review of physician ' s orders dated 07/28/23 revealed an order for Humulin 70/30 (intermediate-acting insulin) 50 units (by subcutaneous injection) twice daily and 40 units (by subcutaneous injection) at bedtime. Review of physician ' s progress notes revealed Nurse Practitioner (NP) #284 saw Resident #25 for hyperglycemia on 07/20/23, 07/26/23, and 08/01/23. Each note written by NP #284 contained an order for Resident #25 to be referred to an endocrinology specialist. Review of Resident #25 ' s MAR for July 2023 revealed 88 instances out of 191 opportunities where Resident #25 ' s blood glucose level was documented as exactly 400. Resident #25 ' s MAR listed 13 times where his blood glucose level was entered as a result of 1. There was no code identified as a 1 in the key code of the MAR to indicate an abnormal result. Review of the MAR for July 2023 revealed with each instance of the blood glucose documented as 400, Resident #25 was administered 10 units of insulin coverage. Review of Resident #25 ' s interdisciplinary progress notes for July 2023 revealed on two instances (07/10/23 and 07/23/23), the physician was contacted about elevated blood glucose levels and new orders were received. On one date, 07/31/23, the physician was notified of Resident #25 refusing early morning blood glucose checks. Review of a nursing progress note dated 07/26/23 at 6:18 P.M., revealed LPN #270 documented Resident #25 was sent to the emergency room due to the resident feeling unwell. Resident #25 experienced dizziness and shortness of breath, with a pulse oximetry (oxygen) level of 83% (normal level 95-100%) on room air. Resident #25 was instructed to go back to his room and put his supplemental oxygen back on and take deep breaths. Resident #25 was evaluated by the Medical Director (also Resident #25 ' s primary physician) who ordered Resident #25 to be sent to the emergency room (ER). The progress note stated report was given to ambulance staff and the patient was sent out by ambulance on 07/26/23 at 6:00 P.M. Review of a nursing progress note dated 07/26/23 at 8:03 P.M., revealed Director of Nursing (DON) #252 documented Resident #25 returned to the facility from theER on [DATE] at 10:30 P.M. While at the ER, Resident #25 was given additional insulin due to an elevated blood sugar level and then Resident #25 returned to the facility. The nursing progress note further stated Resident #25 was educated on anxiety, diabetes mellitus, and diet. The progress notes further explained ER staff phoned the facility and provided an update on what was completed at the ER and that laboratory test and x-rays were negative. DON #252 concluded the progress note by stating she would continue to monitor Resident #25. Review of Resident #25 ' s medical record did not contain any information related to an emergency room visit on 07/26/23. Review of the local Emergency Medical Services (EMS) report, dated 07/26/23 and timed 5:50 P.M., revealed (unnamed) ambulance staff arrived at the facility and met Resident #25 at the nurse ' s station. The EMS staff checked Resident #25 ' s blood glucose level with the result of 313. Resident #25 stated he was unaware the nursing staff called EMS. Resident #25 was noted as alert, oriented, and complained of hyperglycemia. The EMS report noted Resident #25 ' s nurse updated EMS staff that prior to their arrival, Resident #25 ' s blood glucose level was in the 400 ' s, and he had received 50 units of insulin ten minutes prior to squad arrival. Resident #25 was assessed by the EMS squad and after discussion with the nurse, chief complaint was being addressed by the facility doctor. Resident #25 signed a form that he refused transport to the local hospital, and care was returned to facility staff. Observation on 08/02/23 at 6:17 P.M., revealed LPN #260 entered Resident #25 ' s room to check his pre-meal blood glucose (sugar) level. LPN #260 obtained a result of 510 mg/dL. LPN #260 proceeded back to the medication cart stationed outside of Resident #25 ' s room. LPN #260 proceeded to type 400 in Resident #25 ' s electronic MAR to indicate his blood glucose level at that time. LPN #260 verified that the result of 400 was not the result she obtained immediately prior but stated that was the maximum Resident #25 ' s sliding scale coverage for his insulin Lispro went up to, so that was the maximum amount she could document. LPN #260 verified that entering 400 did not reflect the result she obtained, and she backspaced the erroneous 400 reading and entered 510. LPN #260 stated it was her practice to document a result of 400 if she checked a blood sugar and obtained a result of 400 or greater. LPN #260 verified that when she documented a result of 400 in Resident #25 ' s record, it meant the result was somewhere above 400, but she was unsure of exactly how high. LPN #260 stated it was not her practice to notify Resident #25 ' s physician or nurse practitioner of the elevated blood glucose levels. During an interview on 08/02/23 at 6:25 P.M., with DON #254 and the Medical Director a discussion of LPN #260 ' s practice immediately prior was conducted. The Medical Director stated Resident #25 was always non-compliant with his diet, ordering and eating excessive food and non-compliant with treatment regimen, with multiple refusals of blood glucose level checks and refusals of ordered insulin. The Medical Director stated it frustrated him to get notified about high readings knowing Resident #25 ' s non-compliance. However, DON #254 and the Medical Director stated they were both unaware that Resident #25 ' s record did not reflect accurate blood glucose readings. Interview on 08/03/23 at 8:43 A.M., with DON #252, Interim Director of Nursing (IDON) #250, and VPCO #255 revealed they could not locate emergency room records for Resident #25. DON #252 stated they would contact the hospital medical record department and have the hospital fax over the ER records from 07/26/23. Interview on 08/03/23 at 3:11 P.M., with Resident #25 and IDON #250, revealed Resident #25 stated he did not go to the emergency room or hospital on 07/26/23. Resident #25 stated the squad was called, they checked him over, stated he was stable and did not take him to the hospital. IDON #250 stated she would follow up with the nurse who wrote the progress note indicating the resident went to the hospital. Interview on 08/03/23 at 4:19 P.M., with DON #252 verified she falsely documented a progress note about Resident #25 returning from theER on [DATE]. DON #252 stated she had no firsthand knowledge of the event, but rather documented the note as a follow up based on information she had been told by another nurse. During the interview, DON #252 denied knowledge Resident #25 needed a referral to an endocrinology specialist. Interview on 08/07/23 at 9:01 A.M., with LPN #265 revealed she had no knowledge of any recent laboratory test or x-rays completed for Resident #25. LPN #265 reported no x-rays were on order for Resident #25. Interview on 08/07/23 at 9:23 A.M., with LPN #265 revealed Resident #25 ' s blood glucose levels run high. LPN #265 verified she had documented a result of exactly 400 in Resident #25 ' s record on multiple occasions. When LPN #265 documented the 400 results, she stated the actual and accurate result was higher than the recorded 400. LPN #265 stated she documented the value of 400, as that was the practice demonstrated by other nurses at the facility. Interview on 08/07/23 at 9:42 A.M., with IDON #250 revealed Resident #25 did not have an appointment scheduled with an endocrinology specialist. IDON #250 stated the specialist referral was pending and stated the Medical Director would be able to get Resident #25 in more quickly with another health system. Interview on 08/09/23 at 8:30 A.M., with IDON #250 verified an appointment with an endocrinology specialist referral had still not been completed for the resident. Interview on 08/09/23 at 11:12 A.M., with Nurse Practitioner (NP) #284 revealed she had seen Resident #25 multiple weeks in a row for elevated blood glucose levels and had increased the resident ' s ordered insulin dosage multiple times. NP #284 stated prior to seeing Resident #25, she would touch base with the floor nurse to get an update on the resident. NP #284 stated Resident #25 ' s blood glucose levels trend high, in the 400-500 range. NP #284 denied knowledge of inaccurate blood sugar results being recorded in the electronic MAR and had heard of no issues relating to diabetic care at the facility. NP #284 reviewed Resident #25 ' s blood sugar trend in the electronic record and stated the nurses probably did not want to call the Medical Director as he never responds. NP #284 further stated the Medical Director was hard to get ahold of, he would communicate with his office manager, but she had never met or talked with the Medical Director personally. Review of a witness statement from Registered Nurse (RN) #222, recorded and cosigned by IDON #250, dated 08/03/23, revealed RN #222 documented a result of 400 if a residents fasting blood sugar (FSBS) was greater than 400, as she did not know how to advance in the electronic MAR if she put anything higher than the sliding scale. RN #222 ' s witness statement further revealed she entered a result of 1 in the electronic MAR if the patient refused their blood sugar check, for the same reason, she was unsure how to record the resident refused. The statement further noted that due to the seriousness of RN #222 ' s documentation, she was suspended pending investigation. Review of a witness statement for LPN #239, recorded and signed by IDON #250, revealed documentation of a phone interview that took place on 08/06/23. LPN #239 had worked at the facility for four weeks, and upon hire was trained by Agency LPN #280. LPN #239 reported she was trained by Agency LPN #280 to document 400 on the electronic MAR when a resident ' s blood glucose result was greater than the maximum amount specified in the sliding scale insulin order. Agency LPN #280 further informed LPN #239 that the Medical Director does not like to be bothered, and to administer an additional ten units of insulin, as that was what the Medical Director always ordered. LPN #239 further stated Agency LPN #280 also stated it was okay to use a tuberculin syringe (measured in milliliters) instead of an insulin syringe (measured in units) to administer insulin. Review of a witness statement for LPN #260, dated 08/03/23, recorded and cosigned by IDON #250, revealed LPN #260 checked Resident #25 ' s blood sugar on 08/03/23 and obtained a result in the 500 ' s. LPN #260 admitted she returned to the electronic MAR and began to enter a result of 400. LPN #260 stated she was entering 400 as that was how she always does it. LPN #260 further stated it was per practice to calculate how much additional insulin she felt the patient needed and would administer such insulin without calling the physician. LPN #260 stated this had been her practice for months. The statement further identified that LPN #260 did not identify that she had done anything incorrectly, nor worked beyond the nurse practice act. The witness statement concluded that LPN #260 ' s employment was terminated with the facility, and she was escorted out of the facility. 47990 2. Review of the medical record revealed Resident #57 was admitted on [DATE] and discharged to the hospital on 08/03/23. Resident #57 had diagnoses including other cerebral infarction due to occlusion or stenosis of small artery, cerebral palsy, type two diabetes mellitus without complications, dysphagia (swallowing disorder) with recent percutaneous endoscopic gastrostomy (PEG) feeding tube, dysarthria (motor speech disorder controlling muscles for speech) , anarthria (speech disorder of understanding words), essential (primary) hypertension, obesity, pressure ulcer of left buttock Stage 3, and unspecified urinary incontinence. Review of Resident #57 ' s Minimum Data Set (MDS) 3.0 assessment, dated 06/29/23, revealed Resident #57 was severely cognitively impaired. Resident #57 was totally dependent on staff for activities of daily living including bed mobility, dressing, eating, toilet use, and personal hygiene. Resident #57 received insulin injections daily during the look back period of the MDS assessment. Review of a physician ' s order, dated 06/23/23, revealed an order for insulin Aspart injection solution 100 unit/milliliters (ml), inject per sliding scale. If the resident ' s blood sugar was 51 to 200 administer two units; if 201-250 administer 4 units; if 251 to 300 administer 6 units; if 301 to 350 administer eights units; if 351 to 400 administer 10 units, and over 400 notify the physician. The order indicated to administer subcutaneously before meals and at bedtime for diabetes mellitus type two. Record review revealed a plan of care was initiated on 07/09/23 related to diabetes mellitus. Interventions included diabetes medication as ordered by doctor, monitor/document for side effects and effectiveness. The care plan was updated on 08/03/23, to include interventions of monitor/document/report as needed any signs or symptoms of hyperglycemia/ hypoglycemia, obtain fasting blood sugars as ordered by the doctor and refer to a podiatrist for foot care. Review of a physician ' s order, dated 07/31/23, revealed an order for insulin Basaglar KwikPen Subcutaneous Solution Pen-Injector 100 unit/ml (insulin glargine), inject 10 unit subcutaneously at bedtime for type two diabetes. Review of the Medication Administration Record (MAR), dated July 2023, revealed there were twelve instances Resident #57 ' s blood sugar was noted above 400. On 07/12/23, the blood sugar was 465; on 07/14/23, the blood sugar was 501 and 527; on 07/17/23, the blood sugar was 426; on 07/23/23, the blood sugar was 481; on 07/26/23, the blood sugar was 480; on 07/27/23 blood sugar was 434 and 500; on 07/28/23 blood sugar was 503 and 504; and on 07/31/23, the blood sugar was 558 and 445. In all instances, Resident #57 ' s insulin was documented as chart code 11 which was defined as held per parameters. The MAR reflected six instances when Resident #57 ' s blood sugar was documented exactly as 400 with 10 units of insulin administered. The MAR also reflected three instances of the resident ' s blood sugar not being checked, and no insulin provided. Review of the MAR, dated July 2023, revealed on 07/31/23 Resident #57 received Basaglar 10 units. Review of a physician ' s order, dated 07/31/23 to 08/10/23, revealed an order for Basaglar KwikPen Subcutaneous Solution Pen-Injector 100 unit/ml, inject 10 unit subcutaneously at bedtime for type two diabetes. Review of a physician ' s progress note, dated 08/01/23 at 2:03 P.M., revealed Resident #57 was seen today due to hyperglycemia with blood sugar currently documented at 573. Resident #57 was on a feeding tube and blood sugars had ranged from 277-573 with no signs of hypo/hyperglycemia. Recommendations to increase insulin Basaglar to 20 units nightly. Given 16 units insulin Aspart times one now for 573 blood sugar. Review of the physician ' s orders and MAR, dated 08/01/23, revealed no documented evidence Resident #57 had received the Aspart 16 units on this date. Further review of the MAR for 08/01/23, revealed the morning blood sugar was not obtained and marked as NA. Ten units of Basagler insulin was administered in the morning. The lunch blood sugar was 397, and 10 units of Basagler insulin was given. The supper and bedtime blood sugar documented to be 400 with 10 units of Basagler insulin given. Review of the August 2023 MAR revealed on 08/03/23 no A.M. blood sugar was obtained. At 2:17 P.M. the resident ' s blood sugar was documented to be 558 with no documentation of insulin being administered. Review of laboratory results, collected and resulted on 08/03/23, revealed Resident #57 had critical laboratory results including an elevated glucose (sugar) level of 486 milligrams per deciliter (mg/dl) (reference range 70-100 mg/dL). The resident was subsequently transferred to the emergency room for additional changes in condition but also with the elevated blood sugar (hyperglycemia). Review of hospital notes, dated 08/06/23, revealed Resident #57 was admitted to the hospital on 08/03/23. The emergency department noted Resident #57 to be ill-appearing, dehydrated, tachycardic (with some rhonchi (adventitious lung sounds)), and with a large decubitus ulcer with foul smelling gray-brown yellow and purulent drainage. Interview on 08/07/23 at 9:07 A.M., with IDON #250 verified the medical record from July 2023 reflecting twelve instances of holding insulin due to outside parameters and three instances of the resident ' s blood sugar not being checked, and no insulin provided. Interview on 08/10/23 at 9:28 A.M. with IDON #250 verified the 08/01/23 physician visit, physician ' s orders, and medication administration did not align. IDON #250 verified Nurse Practitioner (NP) #284 completed progress notes prior to leaving the facility on 08/01/23. IDON #250 verified the 07/31/23 order was not received until 08/01/23 and was not accurate in the record. During the investigation, licensed staff involved with the above concerns for Resident #57, which potentially included but were not limited to LPN #260, LPN #239 and RN #222 were unavailable for discussion/interview specific to Resident #57. 35033 3. Review of Resident #37 ' s medical record revealed an admitted [DATE], with diagnoses including type two diabetes mellitus, morbid obesity, cerebral palsy, and chronic obstructive pulmonary disease. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed the resident had intact cognition. The resident was dependent on two staff for transfers, and bed mobility. The resident was dependent on one staff for toileting. Review of a physician ' s order dated 06/26/23 revealed the resident was ordered insulin Lispro via a sliding scale for blood sugar checks before meals and at bedtime for diabetes mellitus. The sliding scale include for blood sugars between 180-205 administer 15 units; 206-230 administer 28 units; 231-245 administer 30 units; 246-270 administer 33 units; 271-306 administer 35 units; and 307-327 administer 38 units. The order did not specify or direct staff to call the physician if the resident ' s blood sugar was 328 or greater. Review of the medication administration record (MAR) dated 07/01/23 through 07/31/23 revealed the resident ' s insulin was held on 07/12/23 at 8:00 P.M., for a blood sugar reading of 400. The resident ' s insulin was held on 07/13/23 at 8:00 P.M., for a blood sugar reading of 367. On 07/26/23 at 4:00 P.M., the resident ' s insulin was held for a blood sugar reading of 400. The resident ' s blood sugar was not checked on 07/08/23 at 5:00 A.M., on 07/13/23 at 8:00 A.M. and on 07/22/23 at 8:00 P.M. and no insulin was documented as administered. Review of the nurse ' s notes dated 07/01/23 through 07/31/23 revealed no documentation of why the insulin was not given on or blood sugar was checked for the dates above. Interview on 08/07/23 at 9:05 A.M., with IDON #250 verified there was no documentation the resident received insulin for his elevated blood sugar readings on 07/12/23, 07/13/23 or 07/26/23. IDON #250 also verified there was no documentation the resident ' s blood sugar was checked on 07/08/23 at 5:00 A.M.; on 07/13/23 at 5:00 A.M.; or on 07/22/23 at 8:00 P.M.; and no insulin was administered. Continued interview with IDON #250 revealed staff should have called the physician when the resident ' s blood sugar was outside of the sliding scale parameters. Interview on 08/07/23 at 10:04 A.M., with Resident #37 revealed LPN #260 would sometimes give him a partial dose of insulin when his blood sugar was over the high ends of the sliding scale, but she did not want to give him the full ordered dose because she thought it would be too much. During the investigation and following the interview with Resident #37, LPN #260 was not available to interview as the LPN had been terminated and was not available via telephone. During the investigation, licensed staff involved with the above concerns for Resident #37, which potentially included but were not limited to LPN #260, LPN #239 and RN #222 revealed these staff were unavailable for discussion/interview specific to Resident #37. Review of the policy titled Administering Medications, revised December 2012, revealed medications shall be administered in a safe and timely manner, and as prescribed. The policy further stated medications must be administered in accordance with the orders, which included any required time frame. Review of the policy titled Obtaining a Fingerstick Glucose Level, revised October 2011, revealed the documentation of blood glucose levels should include all assessment data obtained during the procedure, including the blood sugar results. The policy further stated that information should be reported in accordance with facility policy and professional standards of practice. Review of the policy titled Nursing Care of the Resident with Diabetes Mellitus, revised December 2012, revealed documentation should reflect the carefully assessed diabetic resident[TRUNCATED]

Based on observation, medical record review, hospital record review, resident and staff interviews, policy review for Clinical Protocol Pressure Ulcers/Skin Breakdown and review of the facility pressure ulcer staging guide, the facility failed to implement comprehensive and individualized pressure ulcer care and treatment for Resident #57, including the timely completion of physician orders for laboratory and radiology testing resulting in hospitalization for pressure ulcer treatment. This resulted in Immediate Jeopardy and serious life-threatening harm on 07/31/23 when Resident #57's physician ordered laboratory and radiology testing was not completed to rule out osteomyelitis of a Stage III (wound caused by pressure with full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed) pressure ulcer to the resident's left buttock. Laboratory testing, completed on 08/03/23, which was following surveyor intervention revealed the resident's potassium, blood glucose and hemoglobin were all critical and the resident's white blood cell count was elevated (indicative of infection). The physician was notified, and the resident was transferred to the hospital and admitted for immediate treatment of severe anemia with critical hemoglobin, hyperkalemia (elevated potassium level), hyperglycemia (critical blood glucose level), septic shock, and an infected Stage IV (deep wound where the skin is severely damaged, and the surrounding tissue begins to die (tissue necrosis). Muscles, tendons, cartilage, and bone are exposed and may be damaged and risk of infection) sacrococcygeal ulceration with extended spectrum beta-lactamase (ESB) and Escherichia coli (E. Coli) infection requiring surgical debridement and a wound vacuum placement. In addition, a concern that did not rise to the level of Immediate Jeopardy was identified related to the facility's failure to appropriately complete pressure ulcer treatments as ordered by the physician, failure to complete timely and accurate assessments of wounds, and failure to implement pressure relieving devices ordered by the physician for Resident #21 and #48. This affected three residents (#57, #21 and #48) of three residents reviewed for pressure ulcers. The facility census was 59. On 08/07/23 at 3:05 P.M., Interim Director of Nursing (IDON) #250 and [NAME] President of Nursing of Clinical Operations (VPCO) #255, were notified Immediate Jeopardy began on 07/31/23, when Resident #57's physician orders for laboratory and radiology testing to rule out osteomyelitis of the worsening of the resident's Stage III pressure ulcer to an unstageable pressure ulcer to the left buttock were not completed timely. The delay in testing placed Resident #57 at risk for additional complications and lack of timely treatment. On 08/03/23, following the review of laboratory testing results, Resident #57 was transferred and admitted to the hospital for necessary wound care including surgical debridement of an infected Stage IV pressure ulcer and treatment with a wound vacuum. The resident also required medical/hospital intervention for the treatment of critical laboratory results. As of 08/10/23, the resident remains hospitalized . The Immediate Jeopardy was removed on 08/07/23 when the facility implemented the following corrective actions: On 08/03/23, Resident #57 was sent to the hospital for treatment. As of 08/10/23 the resident remained hospitalized . On 08/07/23 from 11:00 A.M. to 7:30 P.M., Regional Minimum Data Set (MDS) Coordinator #285 and facility MDS Coordinator #237, initiated a facility skin sweep for all residents. On 08/07/23 at 3:58 P.M., IDON #250 notified the facility Medical Director via telephone of the pressure ulcer concerns and Immediate Jeopardy identified by the State Agency. On 08/07/23 at 4:00 P.M., an Ad Hoc Quality Assurance and Performance Improvement meeting was held with the interdisciplinary team to discuss the findings of the Immediate Jeopardy related to Data Tag F686 Pressure Sores and formulate plan of correction. On 08/07/23 from 4:55 P.M. to 10:54 P.M. IDON #250, initiated education with all licensed nurses and nursing assistants on the policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol. On 08/07/23 from 5:19 P.M. to 7:16 P.M. VPCO #255 and MDS Coordinator #237, completed a Braden Scale (skin risk assessment) on all facility residents and placed the assessments in each resident ' s medical record. On 08/07/23 at 7:30 P.M., Weekly Skin Assessments were entered into all residents' electronic records. New skin areas identified were reviewed with the attending physician, with new orders obtained as applicable. On 08/07/23 at 10:45 P.M., the facility implemented a plan for all licensed nurses and nursing assistants who did not receive education to be removed from resident care until they had been educated on the pressure sore policy by IDON #250, and/or the Director of Nursing. On 08/07/23 at 10:45 P.M., the facility implemented a plan for IDON #250, or the Director of Nursing to educate new hires and agency staff on the above during orientation before initiating resident care. Effective on 08/07/23 at 10:45 P.M., to ensure the deficit practice does not recur, the facility implemented a plan to for staff to round with the Wound Nurse Practitioner. Orders would then be processed timely by the licensed nurse participating in wound rounds. Effective on 08/07/23, IDON #250, and/or the Director of Nursing, would print the physician order summary report daily for 14 days, then three times a week for 30 days, then Monday through Friday, to ensure orders had been processed. Areas of concern would be addressed immediately. On 08/08/23 from 9:22 A.M. to 9:53 A.M. during interviews with State tested Nursing Assistant (STNA) #247, STNA #282, STNA #283, Licensed Practical Nurse (LPN) #229, LPN #232, and LPN #239 each staff member verified receiving education regarding clinical protocol for wound management and skin breakdown and was able to verbalize the education provided on pressure sores. Although the Immediate Jeopardy was removed on 08/07/23, the deficiency remained at a Severity Level 2 (no actual harm with potential for minimal 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 on-going compliance. Findings include: 1. Review of the medical record for Resident #57 revealed the resident was admitted to the facility on [DATE] and discharged to the hospital on 08/03/23. Resident 357 had diagnoses including other cerebral infarction due to occlusion or stenosis of small artery, cerebral palsy, type two diabetes mellitus without complications, dysphagia (swallowing disorder) with recent percutaneous endoscopic gastrostomy (PEG) feeding tube, dysarthria (motor speech disorder controlling muscles for speech), anarthria (speech disorder of understanding words), essential (primary) hypertension, obesity, pressure ulcer of left buttock Stage III, and unspecified urinary incontinence. Review of the form titled Admission Nursing Observation, dated 06/23/23, revealed Resident #57 presented with a Stage II (a wound with partial thickness loss of skin presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising) left buttock pressure ulcer measuring 2.6 centimeters (cm) in length by 3.5 cm width with 0.1 cm depth and a right buttock pressure ulcer measuring 1.8 cm in length by 2.4 cm width with 0.1 cm in depth. No drainage was observed, the areas were cleaned, dry dressing applied, and resident was repositioned. Review of Resident #57's admission physician's orders dated 06/23/23 revealed no orders for wound treatments for the pressure sores present on admission. Review of the wound assessment and wound assessment report, dated 06/26/23, revealed Resident #57 had a Stage III left buttock pressure ulcer measuring 3 cm length by 1.2 cm width with 0.4 cm depth. Moderate exudate serosanguineous in color, 1-24 % epithelial, 50-74% granulation, 1-24% slough, and 0% necrotic tissue. The report revealed current treatment noted to include cleanse wound with wound cleanser, apply silver alginate to base of the wound, secure with border gauze and change daily. Review of the physician's orders, dated 06/26/23 to 07/05/23 revealed an order to cleanse left buttock with wound cleanser/normal saline, apply silver alginate and cover with foam dressing until heeled every dayshift. Review of the wound assessment, dated 06/28/23, revealed Resident #57 had a Stage III left buttock pressure ulcer measuring 3 cm length by 1.2 cm in width with 0.4 cm in depth. Moderate exudate serosanguineous in color and watery, 1-24 % epithelial, 50-74% granulation, 1-24% slough, and 0% necrotic tissue. Status of wound was marked as improved. Current treatment noted to include cleanse wound with wound cleanser, apply silver alginate to base of the wound, secure with border gauze and change daily. Review of Resident #57's Minimum Data Set (MDS) 3.0 assessment, dated 06/29/23, revealed Resident #57 was severely cognitively impaired. Resident #57 was totally dependent on staff for activities of daily living including bed mobility, dressing, eating, toilet use, and personal hygiene. Upon admission, Resident #57 was assessed to have one Stage III pressure ulcer. Review of the care plan, revised on 07/09/23 revealed Resident #57 was at risk of skin breakdown due to cerebral palsy, decreased mobility, incontinent, and risk of malnutrition. Interventions on the plan of care included air mattress, dietary consult as needed, encourage good nutrition and hydration in order to promote healthier skin, keep skin clean and dry, monitor and document, Roho cushion to Broda (specialized) chair, draw sheet or lifting device to move resident, use caution during transfers, weekly skin checks, and weekly treatment documentation to include measurement of each area of the skin breakdown ' s width, length, depth, type of tissue, and exudate and any other notable changes or observations. Review of Resident #57's Braden Scale for Predicting Pressure Sore Risk Assessments dated 06/23/23, 07/01/23, 07/19/23, and 07/27/23, revealed Resident #57 was assessed to be at high risk for pressure ulcer development. Review of the Treatment Administration Record (TAR) for June 2023, for Resident #57, revealed no documented evidence of wound treatments being provided on 06/23/23, 06/24/23, 06/25/23, or 06/28/23. Review of the wound assessment, dated 07/03/23, revealed Resident #57 had a Stage III left buttock pressure ulcer measuring 6.5 cm length by 8.5 cm width with 0.4 cm depth. Moderate exudate serosanguineous in color, 1-24 % epithelial, 50-74% granulation, 1-24% slough, and 0% necrotic tissue. Status of wound was marked as declined. Current treatment noted to include cleanse wound with wound cleanser, apply silver alginate to base of the wound, secure with border gauze, and change daily. Review of the physician's orders, dated 07/06/23 to 07/19/23 revealed an order to cleanse left buttock with wound cleanser/normal saline and cover with foam dressing until healed one time a day. Review of would assessment report, dated 07/10/23, revealed Resident #57 had a Stage III left buttock pressure ulcer measuring 6 cm length by 9.5 cm width with 0.4 cm depth. Moderate exudate serosanguineous in color, 1-24 % epithelial, 25-49% granulation, 25-49% slough, and 1-24% eschar. Status of wound was described as worsening. Current treatment noted to include to cleanse daily with wound cleanser, apply silver alginate, and apply bordered gauze. Review of the wound assessment, dated 07/17/23, revealed Resident #57 had a Stage III left buttock pressure ulcer measuring 6 cm length by 9.9 cm width with 0.4 cm in depth. Moderate exudate serosanguineous in color, 1-24 % epithelial, 25-49% granulation, 25-49% slough, and 1-24% necrotic tissue. Status of wound was marked as declined. Current treatment noted to include cleanse wound with wound cleanser, apply silver alginate to base of the wound, secure with border gauze and change daily. Review of physician's orders, dated 07/20/23 to 07/25/23 revealed an order to cleanse left buttock with wound cleanser/normal saline, silver alginate and cover with bordered gauze dressing until healed. Review of the wound assessment, dated 07/24/23, revealed Resident #57 had a Stage III left buttock pressure ulcer measuring 6 cm length by 10.3 cm width with 0.4 cm in depth. Moderate exudate serosanguineous in color, 1-24 % epithelial, 25-49% granulation, 25-49% slough, and 1-24% necrotic tissue. Status of wound was marked as no change. Current treatment noted to include cleanse wound with wound cleanser, apply Silver Alginate to base of the wound, secure with border gauze and change daily. Review of a physician's order, dated 07/26/23 revealed an order to cleanse wound cleaner, apply Santyl to necrotic tissue only and apply calcium alginate to base of the wound, secure with border gauze. Change daily until heeled. Review of the Treatment Administration Record (TAR) for July 2023, for Resident #57, revealed no documented evidence of the wound treatment being completed on 07/08/23, 07/09/23, 07/23/23, 07/25/23, 07/26/23, or 07/27/23. Review of the Skin Assessment Weekly, dated 07/30/23, revealed Resident #57 had a Stage III sacrum pressure ulcer measuring 6 cm length by 10.3 cm in width with 0.4 cm depth. Review of the wound assessment, dated 07/31/23, revealed Resident #57 had an unstageable left buttock pressure ulcer measuring 7.3 cm length by 10.3 cm width with 0.2 cm depth. Moderate exudate serosanguineous in color, 1-24 % epithelial, 25-49% granulation, 25-49% slough, and 1-24% necrotic tissue. Status of wound had declined. Medical Director notified calcium alginate, Santyl to necrotic tissue only, calcium alginate to remaining area, bordered foam, and superabsorbent. Review of a nurse practitioner skin and wound note, dated 07/31/23, revealed Resident #57 was seen for unstageable pressure ulcer to left buttock. The wound was noted to be worsening with pre-debridement size measuring 7.3 cm length by 10.3 cm width with 0.2 cm depth. The exposed tissues were subcutaneous, wound edges were unattached, peri wound was fragile, and moderate amount of serosanguineous exudate. Surgical wound debridement for tissue removal including but not limited to biofilm to keep the wound in an active state of healing. Treatment recommendations included to cleanse with wound cleanser, apply calcium alginate, Santyl to necrotic tissue only, calcium alginate to remaining area to base of wound, secure with bordered foam, change daily and as needed. New recommendations included education provided to the staff regarding the resident ' s wound, dressing care, and general treatment recommendations for left buttock dressing, continue to recommend resident was in wheelchair for no more than two hours at a time for promotion of healing, recommend osteomyelitis workup due to softening of eschar and worsening necrosis but still to fibrous to debride. Continue Santyl to area, area crosshatched. Pelvic x-ray, culture, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and complete blood count (CBC) recommended. On 08/02/23 at 2:49 P.M., LPN #280 was observed to provide wound care to Resident #57. Resident #57's tube feeding was placed on hold by LPN #280, and Resident #57 was positioned on her left side by LPN #280 and STNA #254. The wound to Resident #57's left buttock/sacrum area appeared as a circular/round wound, 50% black and necrotic appearing, with the other 50% of the wound appearing pink and red in color. LPN #280 applied Santyl ointment (a topical medication used for removing damaged tissue to allow for growth of healthy skin) to the necrotic areas of the wound, calcium alginate, and secured with border gauze. Appropriate infection control practices were followed during wound care observation. Upon completion of wound care Resident #57 was repositioned, the head of bed elevated, and the tube feeding restarted by LPN #280. Following the observed pressure ulcer treatment observation, interview on 08/02/23 at 3:31 P.M. with LPN #280 revealed the LPN had no knowledge of Resident #57's physician orders for x-ray and laboratory recommendations. Interview on 08/02/23 at 3:55 P.M., with Director of Nursing (DON) #252 verified x-ray and laboratory recommendations noted in the wound progress note dated 07/31/23 were not ordered or completed as recommended as of this time. The laboratory testing was subsequently obtained following the surveyor's interview/intervention. Interview on 08/03/23 at approximately 11:00 A.M., with IDON #250 verified no wound treatments were documented as completed for Resident #57 on 06/24/23, 06/25/23, 06/28/23, 07/08/23, 07/09/23, 07/23/23, 07/25/23, 07/26/23, or 07/27/23. Review of laboratory results, collected and resulted on 08/03/23, revealed Resident #57's the resident's Complete Blood Count and Automated Differential County (WBC AUTO) was elevated at 19.22 ten-point three microliter (10.3/ul) (reference range 4.0 to 10.6), the resident ' s potassium level was critical at 6.1 millimoles per liter (mmol/L) (reference range 3.5 to 5.1), the resident ' s glucose level was critical at 486 milligrams per deciliter (mg/dl) (reference range 70-100 mg/dL), and the resident ' s hemoglobin was critical 6.3 grams per deciliter (g/dl) (reference range 12.0 to 15.0 g/dL). Review of a nursing progress note, dated 08/03/23 at 12:59 P.M., revealed Resident #57's former physician prior to facility placement, called the facility after receiving and reviewing laboratory results. Resident #57 had critical potassium, glucose, and hemoglobin and ordered the resident to be sent to the hospital. Review of a nursing progress note, dated 08/03/23 at 1:57 P.M., revealed Resident #57 was transferred via 911 (to the hospital) for critical laboratory results. The resident ' s responsible party was notified, and staff called report to emergency department. Review of hospital notes, dated 08/06/23, revealed Resident #57 was admitted (to the hospital) on 08/03/23. The emergency department noted Resident #57 to be ill-appearing, dehydrated, tachycardic had some rhonchi (adventitious lung sounds), and had a large decubitus ulcer with foul smelling gray-brown yellow and purulent drainage. A Computerized Axial Tomography (CAT) scan of the abdomen and pelvis were completed, reflecting extensive subcutaneous emphysema overlying the sacrum and coccyx extending to the cortical surface of the underlying osseous structures with no definitive findings of osteomyelitis. Resident #57 was admitted and seen by the general surgery team and on 08/03/23. Resident #57 had a sacral wound excision/debridement using a scalpel and cautery down to but not including the bone. On 08/03/23, Resident #57 was documented to have an infected sacrococcygeal ulceration Stage IV status post-surgical debridement with wound vac placement. The wound was found to be positive for proteus extended spectrum beta-lactamase (ESBL) and e-coli infection to the area. Interview on 08/07/23 at 8:30 A.M., with IDON #250 and [NAME] President of Nursing #255 verified Resident #57 was admitted to the hospital on 08/03/23. IDON #250 revealed recommendations for the x-ray and laboratory testing had been emailed to her within the nurse practitioner ' s progress note on 07/31/23, in the evening but stated that was not the proper protocol for receiving and processing physician ordered recommendations. Interview on 08/07/23 at 11:09 A.M., with Wound Nurse Practitioner (WNP) #281 verified Resident #57's pressure ulcer had deteriorated and developed necrosis following admission. WNP #281 stated the week prior she had scored/cross hatched (a wound debridement technique to increase medication absorption) the necrotic area, with the hope to soften the area and be able to debride it. WNP #281 verified recommendations were made on 07/31/23 to the nurse rounding who should have also relayed the information. Interview on 08/08/23 at 2:00 P.M., with IDON #250 verified no wound care/treatment orders were in place for Resident #57 from admission (06/23/23) until 06/26/23, three days later. 35033 2. Review of Resident #21's medical record revealed Resident #21 had an original admitted [DATE]. The resident was discharged from the facility on 03/25/23 and returned on 04/06/23. The resident was then discharged on [DATE] and returned on 04/29/23. The resident discharged again on 05/08/23 and returned on 05/11/23. Diagnoses for Resident #21 included chronic obstructive pulmonary disease, hypertension, acute and chronic respiratory failure with hypoxia, and type two diabetes mellitus with polyneuropathy. Review of the medical record from 03/20/23 through 05/23/23 revealed the resident had a history of readmission to the facility and a history of moisture associated skin damage and pressure ulcer to the sacrum. Review of the five-day MDS 3.0 assessment dated [DATE] revealed the resident had mild cognitive impairment, required the extensive assistance of two staff for bed mobility, and transfers and was dependent on two staff for toileting. The resident was frequently incontinent of bowel and occasionally incontinent of bladder. The resident was assessed with no current unhealed pressure ulcers. Review of the plan of care, initiated 05/30/23, revealed to complete sacral wound treatments per physician orders and weekly skin checks and report adverse finding to physician as indicated. On 07/28/23, the plan of care was revised to include weekly treatment documentation; include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate; and any other notable changes or observations. Review of a wound assessment report dated 05/23/23 revealed an area to the sacrum was resolved but noted staff could not rule out a deep tissue injury to the sacrum. Review of a physician's order dated 06/03/23 revealed an order to cleanse sacral area with soap and water and pat dry. Apply Triad cream and leave open to air every shift to rule out deep tissue injury to sacrum. Review of the treatment administration record (TAR) dated 06/03/23 through 06/30/23 revealed the Triad treatment to the sacrum was not documented as being completed during nine shifts which included on 06/12/23, 06/13/23, 06/17/23, 06/21/23, 06/22/23, 06/25/23, 06/26/23, 06/29/23, and 06/30/23. Review of the TAR dated 07/01/23 through 07/30/23 revealed the Triad treatment to the sacrum was not documented as being completed during 11 shifts including on 07/04/23, 07/06/23, 07/14/23, 07/23/23, two shifts on 07/25/23, 07/26/23, two shifts on 07/27/23, and two shifts on 07/28/23. Review of a weekly skin assessment dated [DATE] revealed the resident had a pressure ulcer to the sacrum. There was no wound description, staging and no wound measurements. The wound was cleansed with wound wash, patted dry and Triad cream was applied and left open to air per treatment order. Review of a weekly skin assessment dated [DATE] revealed the resident had a pressure ulcer to the sacrum. There was no wound description, staging and no wound measurements. The assessment noted an order for Triad was in place. Review of a wound assessment dated [DATE] revealed the resident had a Stage II pressure ulcer to the sacrum. The area measured 3.3 cm length by 1.2 cm width with 0.3 cm in depth. The wound had no tunneling, no undermining and was described as not a reoccurring wound. The wound had light serosanguineous exudate with no odor. The wound tissue was 50% epithelial, 25% granulation and 25% slough. The wound had declined and reopened. A new treatment for calcium alginate with silver and cover with dry dressing was ordered. Review of a physician's order dated 07/19/23 revealed a treatment order to cleanse sacrum, pat dry, apply calcium silver and cover with dry dressing. Review of the TAR dated 07/19/23 through 07/30/23 revealed the treatment of calcium silver was not completed on 07/23/23, 07/25/23, 07/26/23 or 07/27/23. Review of a wound assessment report dated 07/24/23 revealed the resident's sacral wound was new. The wound was a Stage III pressure ulcer measuring 3 cm length by 1.20 cm width with 0.8 cm depth. The wound had moderate serosanguineous exudate without an odor. The wound tissue was 1-24% epithelial, 50-74% granulation, and 1-24% slough. Subcutaneous tissue was exposed. The peri-wound was fragile, macerated, with erythema and scarring. A new treatment was ordered daily to cleanse the wound with wound cleanser, apply silver alginate and Calmoseptine to the surrounding tissue and cover with an ABD (abdominal) pad. Review of the TAR dated 07/01/23 through 07/31/23 revealed the order given on 07/24/23 for silver alginate and Calmoseptine was not implemented until 07/31/23. Review of a physician's order dated 07/30/23 revealed a treatment order to cleanse the sacrum, pat dry, apply silver alginate, apply triad to peri-wound to base of the wound, secure with ABD, no adhesive, change daily. The order indicated to use Triad until Calmoseptine was available every dayshift. Further, review of the physician's orders dated 07/30/23 revealed the resident was ordered an air mattress, check placement and function every shift. Review of the TAR from 08/01/23 through 08/07/23 revealed the treatment was not completed as ordered on 08/03/23. On 08/08/23 at 1:29 P.M. LPN #229 was observed completed wound care/dressing change for Resident #21. At the time of the observation, there was no dressing in place. Resident #21 was observed to have a Stage III long vertical wound to the sacrum. The wound measured 4 cm length by 1.2 cm width with 0.2 cm in depth. The wound was 100% granulation tissue. The surrounding skin was red. There was no exudate and no odor. LPN #21 cleansed the wound to the sacrum and patted dry. LPN #229 applied the silver alginate to the base of the wound. LPN #229 then applied Triad cream over the silver alginate in the base of the wound. LPN #229 covered the wound with an ABD pad. Further observation revealed there was no air mattress in place. On 08/08/23 at 1:33 P.M. interview with Resident #21 stated he had a bowel movement earlier and the nursing assistants had removed his dressing. Interview on 08/08/23 at 1:33 P.M., with LPN #229 revealed the STNA staff had not reported to her the removal of the resident's dressing at the time it had been removed. During the interview, LPN #229 also verified she placed the Triad cream over top of the silver alginate in the wound base not to the peri-wound. Interview on 08/08/23 beginning at 1:50 P.M., with VPCO #255 verified the treatments to the resident ' s sacrum were not completed as ordered in June on, 06/12/23, 06/13/23, 06/17/23, 06/21/23, 06/22/23, 06/25/23, 06/26/23, 06/29/23, or 06/30/23. VPCO #255 verified the treatment to the resident's sacrum was not completed as ordered in July on, 07/04/23, 07/06/23, 07/14/23, 07/23/23, two shifts on 07/25/23, 07/26/23, two shifts on 07/27/23, and two shifts on 07/28/23. VPCO #255 verified there were no wound measurements, no staging of the wound and no wound description for the 07/13/23 and 07/14/23 weekly skin assessments. VPCO #255 verified the wound assessment completed on 07/18/23 was most likely inaccurately staged at a Stage II pressure ulcer as the ulcer had 25% slough in the wound. During further interview, VPCO #255 verified the calcium silver treatment was not completed on 07/23/23, 07/25/23, 07/26/23 and 07/27/23. Continued interview with VPCO #255 revealed the 07/24/23 order for silver alginate with Calmoseptine was not completed from 07/24/23 through 07/30/23 and the order was not entered for the treatment until 07/31/23. VPCO #255 also verified the silver alginate treatment was also not completed on 08/03/23. VPCO verified the Triad cream should not have been placed in the base of the wound over the silver alginate. Interview on 08/08/23 at 2:03 P.M., with DON #250 verified the nursing assistants should have notified the nurse timey when the the resident's dressing had been removed. Observation on 08/09/23 at 2:17 P.M., revealed there was no air mattress on the resident's bed. Interview on 08/09/23 at 2:17 P.M., with VPCO #255 verified the resident had no air mattress in place on his bed. Further interview with VPCO #255 revealed staff had been documenting the air mattress was in place. 44815 3. Review of the medical record for Resident #48 revealed an admitted [DATE] with a diagnosis of history of pressure-induced deep tissue damage. The resident has remained at the facility without any discharges. Review of the Admission Nursing Observation dated 03/21/23, and completed on 03/27/23, by DON #302 revealed Resident #48 had a suspected deep tissue injury (DTI) to the top of his left arm, a Stage 1 pressure ulcer to his right buttock, and a suspected DTI to his right toe. Review of the Wound Assessment completed by DON #302 on 03/24/23 revealed Resident #48 had a Stage 1 pressure ulcer to his right heel and suspected DTI to his right toe. Review of the comprehensive admission MDS 3.0 assessment dated [DATE] revealed Resident #48 had no pressure ulcers upon admission. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #48 had impaired cognition and had two unhealed Stage II pressure ulcers. Review of the medical record revealed no further reference to or treatment orders for a right buttock pressure ulcer or the resident having an area on the buttock. Review of a NP wound care progress note, dated 04/01/23, revealed Resident #48 was admitted with a DTI to the distal right lateral foot and a Stage 1 pressure ulcer to the right heel. The note was silent of pressure wound to the right great toe. Treatment orders for the right heel and the distal right lateral foot were initiated in the medical record on 04/13/23. Review of a Skin Assessment Weekly dated 04/20/23 revealed Resident #48 had a pressure ulcer. No description of the wound was included, no location, and/or no stage. Review of the wound evaluation dated 04/25/23 revealed Resident #48 had a worsening pressure ulcer- suspected DTI to the right great toe. Measurements were 1.13 cm length by 1.47 cm width with 0.0 cm depth. Treatments included: normal saline wound cleanser, interventions included ensure compliance with turning protocol, float heels, softening offloading heel boots. Recommended foot cradle and soft offloading heel boots. Review of a Skin Assessment Weekly dated 04/27/23 revealed Resident #48 had a pressure ulcer. No description of the wound was included, no location, and/or no stage. Treatment orders for the right toe began on 04/27/23 which included to cleanse with wound cleanser, pat dry, skin prep daily and leave open to air. Review of the TAR, dated April 2023, revealed Resident #48 did not received two out of eighteen treatments of the wound care on the right distal lateral foot. The right toe treatments revealed all were documented as completed. The right heel treatments were not completed two out of eighteen treatments of the wound care on the right heel. Review of the wound evaluation dated 05/02/23 revealed Resident #48 had a pressure ulcer - suspected DTI to his right great toe, acquired in-house 04/18/23, measuring 1.18 cm in length by 0.81 cm width and no depth. Treatment recommendations included skin prep (skin protectant), foot cradle, and soft offloading heel boots. Review of the wound evaluation dated 05/09/23 revealed Resident #48 had a stable pressure ulcer - suspected DTI to his distal right great toe, measuring 1.30 cm length by 1.50 cm width and no depth. Treatment recommendations included cleanse with wound cleanser, leave open to air, float heels and utilize for cradle. Review of a physician's order dated 05/18/23 revealed Resident #48 [TRUNCATED]

Based on medical record review, staff interviews, community member interviews, review of an infection control log, review of an autopsy report, review of a coroner ' s case summary document, and review of facility policies for neglect, pressure ulcer prevention and treatment, and medication administration, the facility failed to perform timely and adequate skin assessments, failed to initiate pressure wound treatments and interventions, and failed to administer an antibiotic medication as ordered for one resident (#97). This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death when Resident #97 was assessed at admission with no pressure ulcers and was assessed at risk for pressure ulcer development. Resident #97 ' s skin was not assessed timely and there was no documentation of interventions implemented to prevent pressure ulcer development until [DATE] when Wound Nurse Practitioner (WNP) #810 assessed Resident #97 and discovered an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough (non-viable yellow, tan, gray, green or brown tissue) or eschar (dead or devitalized tissue) on the sacrum. WNP #810 implemented wound treatments, a low air loss mattress to Resident #97 ' s bed, and an antibiotic medication which were not administered and provided to Resident #97 as ordered. Resident #97 was transferred to the hospital and subsequently died from bacterial sepsis due to a sacral pressure ulcer as a result of medical neglect. Resident #97 ' s death occurred by failure of caregiver(s) to provide adequate and timely medical care for a sacral pressure wound and the manner of death was ruled a homicide by the coroner. This affected one (#97) of six (#21, #23, #47, #51, #60, and #97) residents reviewed for pressure ulcers and medications. The facility identified five (#21, #23, #47, #51, and #60) residents currently residing in the facility with pressure ulcers. The census was 52. On [DATE] at 3:57 P.M., Administrator #545, [NAME] President of Clinical Services (VPCS) #750, and Regional Director of Operations (RDO) #770 were notified Immediate Jeopardy began on [DATE] when Resident #97 was assessed with an unstageable pressure ulcer to the sacrum which did not exist upon admission. Resident #97 was assessed at risk for pressure ulcer development on admission and throughout the stay in the facility. The facility did not complete skin assessments as ordered, and there was no documentation of pressure-reducing interventions in place prior to the discovery of the pressure ulcer on [DATE]. WNP #810 ordered a wound treatment, a low air loss mattress, and an antibiotic medication on [DATE] which were not administered as ordered or implemented in a timely manner. Resident #97 was sent to the hospital on [DATE] due to the condition of the pressure ulcer on the sacrum and ultimately died on [DATE] at 8:15 P.M. Resident #97 died from bacterial sepsis of the sacral pressure ulcer due to medical neglect. Resident #97 ' s death was ruled a homicide by the coroner from the failure of caregiver(s) to provide timely and adequate care for the sacral wound. The Immediate Jeopardy was removed on [DATE] at 1:50 P.M. when the facility implemented the following corrective actions: On [DATE], the facility held a Quality Assurance and Performance Improvement (QAPI) meeting with Medical Director #890 to discuss the incident about Resident #97 and develop a plan of correction. On [DATE], Director of Nursing (DON) #518, Assistant Director of Nursing (ADON) #515, and regional nurses (Regional Director of Clinical Services (RDCS) Registered Nurse (RN) #700, Regional Director of Minimum Data Set (MDS) RN #710, Regional Director of MDS RN #720, RDCS RN #730, and RN Travel Nurse #740) began full skin assessments and ensured assessments for pressure ulcer development risk were in place for all 52 residents residing in the facility. All assessments were completed by [DATE]. On [DATE], DON #518, ADON #515, and regional nurses began assessments to validate the presence of unaddressed skin impairment, ensure appropriate interventions were in place, and care plan interventions were updated of all 52 residents in the facility. A visual check was performed of all 52 residents to ensure appropriate pressure-reducing interventions were in place and was completed on [DATE]. On [DATE], regional nurses began education to all facility staff on neglect with all facility staff members educated by [DATE]. On [DATE], DON #518 began education to all facility nurses and nurse aides on pressure reducing interventions, identifying residents at risk for pressure ulcer development, following physician orders, and completing skin assessments. The education was completed on [DATE]. On [DATE], Administrator #545 initiated a self-reported incident (SRI) related to the allegation of neglect in Resident #97 ' s care. On [DATE], new admissions to the facility were voluntarily stopped until an unknown date to be determined by the QAPI committee. On [DATE], DON #518 began audits of residents assessed at high risk for pressure ulcer development to ensure treatments and interventions were ordered and were observed in place. DON #518 or designee will continue with these audits three times weekly for six weeks. On [DATE], DON #518 began review of all new admissions by completing a second skin assessment, evaluating the resident ' s risk for pressure ulcer development, and ensuring interventions were ordered and observed in place. DON #518 or designee will continue with these reviews three times weekly for six weeks. On [DATE], RN Travel Nurse #740 reviewed antibiotic medication orders for all three (#11, #17, and #21) residents currently prescribed antibiotic medications. The medical record was reviewed to ensure orders were current, the antibiotic was given as ordered, the medication administration record (MAR) reflected administration of the medication, and there were no missed doses. DON #518 or designee will monitor antibiotic medication orders and administration of the antibiotic five times weekly for six weeks to ensure compliance. On [DATE], review of the medical records for Resident #21, Resident #23, Resident #47, Resident #51, and Resident #60, who all were assessed with pressure ulcers currently in the facility, revealed no concerns related to treatments completed as ordered, interventions in place as ordered, skin assessments completed timely, medications administered as ordered, and care plan interventions in place. On [DATE], between 12:58 P.M. and 1:50 A.M., ADON #515, Licensed Practical Nurse (LPN) #555, LPN #522, State tested Nurse Aide (STNA) #502, STNA #503, and STNA #560 verified they were educated on resident neglect, pressure reducing interventions, identifying residents at risk for pressure ulcer development, following physician orders, and completing skin assessments. All staff members interviewed were knowledgeable of the content of each education provided by the facility. Although the Immediate Jeopardy was removed on [DATE], 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 #97 ' s medical record revealed an admitted [DATE]. Diagnoses included metabolic encephalopathy, muscle weakness, morbid (severe) obesity, major depressive disorder, anxiety disorder, atrial fibrillation, acute kidney failure, altered mental status, essential hypertension, and lymphedema. Resident #97 was discharged from the facility on [DATE]. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #97 was assessed with severely impaired cognition, required extensive two-plus persons physical assistance for bed mobility, was at risk for developing pressure ulcers and injuries, with no pressure ulcer present on admission, and interventions of a pressure reducing device for a chair and a pressure reducing device for a bed. Review of the Care Area Assessment (CAA) Summary revealed the care area of pressure ulcers was triggered and noted Resident #97 had a left inner ankle wound on admission and had potential for further skin deficits from cognitive loss, decreased mobility, weakness, and incontinence. Results of the pressure ulcer CAA indicated a care plan for pressure ulcers would be initiated. Review of an admission nursing assessment dated [DATE] at 4:22 P.M. revealed Resident #97 was admitted to the facility from another nursing home with an admitting diagnoses of acute kidney failure and need for long term care. Resident #97 required extensive assistance with bed mobility, was alert and oriented to person only, and was assessed with no pressure ulcers or wounds on admission. Review of an admission assessment used to predict pressure ulcer development risk dated [DATE] revealed Resident #97 was assessed at risk. Subsequent assessments completed on [DATE], [DATE], and [DATE] revealed Resident #97 was assessed at high risk for pressure ulcer development. Review of a late entry nurse practitioner progress note dated [DATE] revealed Resident #97 was a new admission to the facility from another nursing home, and was supposed to go home with her husband, but became too hard to care for on his own. Resident #97 was alert and oriented with an ongoing wound to the left ankle that was wrapped in a clean bandage. Resident #97 ' s skin was documented as pink, warm, and dry with a wound to the left ankle and no other skin impairments noted. Review of a physician order dated [DATE] revealed Resident #97 was ordered weekly skin assessments at bedtime every Saturday. Review of the [DATE] Treatment Administration Record (TAR) revealed Resident #97 ' s skin assessments were scheduled for [DATE] and [DATE] at 9:00 P.M. Further review of the [DATE] TAR revealed the skin assessment scheduled for [DATE] was not completed and the skin assessment on [DATE] was documented as completed with no impairments noted. Review of weekly skin assessments dated [DATE] and [DATE] revealed Resident #97 had a non-pressure ulcer to the left inner ankle with no other skin impairments identified. There were no further skin assessments completed in the medical record for Resident #97 between [DATE] and [DATE]. Review of a physician assistant progress note dated [DATE] at 7:09 P.M. revealed Resident #97 was seen for a readmission pain management evaluation and was noted to have been seen by the physician assistant at another skilled nursing facility over a year ago. Resident #97 was noted to have a bandage on the left foot and ankle but Resident #97 denied any wound, however, Resident #97 did indicate she had a wound on her buttocks. The physician assistant recommended proper repositioning and indicated the facility physician or nurse practitioner would need to address that. The physician assistant ' s physical examination of Resident #97 ' s skin included notation of lesions with no location specified and no other skin impairments noted. Review of a shower sheet dated [DATE] revealed Resident #97 was identified with no skin impairments. This was the only documented shower Resident #97 received between [DATE] and [DATE] in the medical record. Review of the [DATE] infection control log revealed Resident #97 tested positive for COVID-19 on [DATE] and was placed in isolation until [DATE]. Review of a late entry nurse practitioner progress note dated [DATE] at 2:09 P.M. revealed Resident #97 received wound care for the left ankle wound with no new issues or complaints and no indication of any other skin impairments. Resident #97 ' s skin was assessed as pink, warm, and dry with a notation to continue wound care management of the left ankle. Review of the [DATE] TAR revealed Resident #97 ' s skin assessments were scheduled for [DATE], [DATE], [DATE], and [DATE] at 9:00 P.M. Further review of the [DATE] TAR revealed the skin assessments scheduled for [DATE], [DATE], and [DATE] were not completed and the assessment dated [DATE] indicated Resident #97 was in the hospital. Review of a care plan dated [DATE] revealed Resident #97 had an activities of daily living (ADLs) self-care performance deficit related to generalized weakness and abnormality of gait and mobility. Care plan interventions included Resident #97 required extensive assistance by one to two staff members to turn and reposition in bed as necessary and Resident #97 required a skin inspection with staff instructed to observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. Review of a care plan dated [DATE] revealed Resident #97 had potential or actual skin impairments to the skin related to lymphedema and subcutaneous tissues with a noted non-pressure chronic ulcer of the left ankle and fungal redness under the breasts. Care plan interventions included for Resident #97 to have weekly treatment documentation to include measurements of each area of skin breakdown and any other notable changes or observations, Resident #97 needed a pressure relieving/reducing cushion to protect the skin when up in a chair, Resident #97 needed a pressure relieving/reducing mattress to protect the skin when in bed, and the staff should follow facility protocols for treatment of injury. Review of physician orders dated between [DATE] and [DATE] revealed no orders were created for pressure relieving devices to be implemented to Resident #97 ' s bed or chair as care planned. Review of nursing progress notes dated between [DATE] and [DATE] revealed no documented evidence of any interventions utilized to relieve pressure for Resident #97 when in bed or in a chair. Review of a wound practitioner visit progress note dated [DATE] revealed Resident #97 was seen by WNP #810 for an initial evaluation and treatment of a wound. WNP #810 noted an unstageable, full thickness pressure ulcer to Resident #97 ' s sacrum with a surrounding area of eschar as well as a nearby deep tissue pressure ulcer. WNP #810 indicated the pressure ulcer had copious amounts of putrid, seropurulent (wound fluid drainage that appears as light green, brown, yellow, or tan) drainage with a large amount of wet, non-viable tissue partially obscuring the deep sacral wound. WNP #810 debrided the overlaying wet necrotic tissue to remove the seropurulent drainage and reveal the extent of the wound depth and removed loose tan necrotic tissue from the wound bed. Further assessment of Resident #97 ' s sacral pressure ulcer once WNP #810 removed the obstructing non-viable tissue revealed measurements of 13.5 centimeters (cm) long by 15.2 cm wide with no measurable depth. The pressure ulcer had tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) noted at the 7:00 o ' clock position with a maximum distance of 8.4 cm with no sinus tract noted and undermining (the destruction of tissue or ulceration extending under the skin edges (margins) so that the pressure ulcer is larger at its base than at the skin surface) was noted at the 6:00 o ' clock position and ended at the 12:00 o'clock position with a maximum distance of 2.0 cm. The wound bed at between one (1) percent (%) and 25% eschar and between 76% and 100% slough with no healthy tissue noted. The pressure ulcer was cleaned with copious amounts of saline to obtain a wound culture. Further review of the wound practitioner visit progress note dated [DATE] revealed WNP #810 ordered for Resident #97 ' s wound to be cleansed with wound wash and Dakin ' s one-fourth (,d+[DATE]) strength (a solution used to cleanse wounds and prevent infection) moistened gauze applied, then Kerlix gauze packed into the wound tunneling and undermining, covered with a four-inch by four-inch gauze then an absorbent pad, and secured with tape. The dressing was to be changed twice daily and as needed for soiling, saturation, or accidental removal. WNP #810 noted Resident #97 had large amounts of drainage and may need dressing changes completed three to four times daily for the next few days and for staff to not allow excess drainage to lie on the surrounding skin. WNP #810 requested a low air loss mattress be obtained for Resident #97 and recommended bedrest only until Resident #97 ' s sacral wound was more stable. WNP #810 also recommended starting a broad-spectrum antibiotic such as doxycycline 100 milligrams (mg) by mouth for 10 days until wound culture results were available. WNP #810 documented an addendum that Resident #97 ' s power of attorney (POA) was contacted on [DATE] and discussed Resident #97 ' s wound status and treatment plan. Resident #97 ' s POA expressed the desire to treat the pressure ulcer as needed to prevent any further discomfort or preventable complications such as sepsis, and Resident #97 ' s POA agreed to serial debridement as needed and agreed that should Resident #97 ' s wound significantly deteriorate or cause increased or further discomfort she would want Resident #97 to be sent to the hospital. WNP #810 noted the information was conveyed to Former DON #850 on the morning of [DATE]. Review of a laboratory document revealed Resident #97 had a wound culture collected on [DATE] at 2:40 P.M. Results of the wound culture were received on [DATE] at 9:32 A.M. and revealed many neutrophils (a type of white blood cell that helps the body fight infection), many Gram-negative rods (bacteria), many Gram-positive cocci (bacteria) in clusters, with heavy growth of proteus mirabilis (a Gram-negative bacterium) and light growth of Escherichia coli (E. coli, a Gram-negative bacterium). Review of a physician order dated [DATE] revealed Resident #97 was ordered to have the sacral wound cleansed with normal saline, patted dry, have collagen applied, then a calcium alginate dressing, and covered with an island dressing every shift. The order was scheduled to start on [DATE]. Review of a physician order dated [DATE] revealed Resident #97 was ordered the antibiotic doxycycline hyclate 100 mg by mouth twice daily for infection for 10 days per wound care nurse practitioner. Further review of the physician orders between [DATE] and [DATE] revealed there was no order for a low air loss mattress for Resident #97 ' s wound healing as recommended by WNP #810 on [DATE]. Review of the [DATE] TAR revealed Resident #97 ' s wound treatment was not completed on the evening shift on [DATE] nor the morning or evening shift on [DATE]. Review of the [DATE] Medication Administration Record (MAR) revealed Resident #97 did not receive ordered doses of doxycycline hyclate 100 mg on [DATE] and [DATE] in the evening and on [DATE] in the morning. Review of a nurse practitioner progress note dated [DATE] at 6:48 P.M. revealed Resident #97 was visited to follow up monthly on chronic issues. The nurse practitioner documented Resident #97 was doing well at this time and was currently in her bed resting. There was no indication of the type of mattress applied to Resident #97 ' s bed during the nurse practitioner ' s visit. The nurse practitioner noted ongoing treatment of Resident #97 ' s left ankle wound with no plan or treatment documented for Resident #97 ' s sacral pressure ulcer. The nurse practitioner ' s documentation of Resident #97 ' s skin during the visit was the skin was pink, warm, and dry with a wound to the left ankle. Review of a nursing progress note dated [DATE] at 11:57 A.M. revealed Resident #97 ' s low air loss mattress came to the facility on [DATE] and was placed on the bed. Review of a nursing progress note dated [DATE] at 11:00 A.M. revealed Resident #97 was transported to the hospital as Resident #97 ' s POA insisted she be sent out due to deteriorating wound and mental status. Review of a transfer form dated [DATE] at 11:00 A.M. revealed Resident #97 had an unplanned transfer due to a skin wound or ulcer and proper notifications were made. Review of a nursing progress note dated [DATE] at 5:23 P.M. revealed Resident #97 ' s POA was at the facility with family to gather Resident #97 ' s belongings and stated Resident #97 was actively dying. Review of a report from the county coroner ' s office revealed an autopsy was completed on [DATE] at 8:30 A.M. for Resident #97 by Deputy Coroner (DC) #950. Resident #97 ' s noted date of death was [DATE] at 8:15 P.M. DC #950 noted Resident #97 had evidence of wounds or trauma with a large stage four (full-thickness skin and tissue loss) pressure ulcer over the lower back measuring 4 ,d+[DATE] inches long by 7 ,d+[DATE] inches wide which included the surrounding green-black eschar. DC #950 indicated the center of the wound had a 2 ,d+[DATE] inches long by 3.0 inches wide area defect down to the sacral spine. The soft tissue in the wound was dark tan and red to green-gray, macerated (a white appearance with very soft texture), and extended through the deep tissue surrounding the sacral bone. Resident #97 ' s sacral bone was tan-pink and friable (easily crumbled). There was purulent (fluid containing pus) tan-pink exudate (any fluid that has been forced out of the tissues or its capillaries because of inflammation or injury) in the soft tissue and no involvement of the pelvic organs. DC #950 performed a microscopic examination of Resident #97 ' s sacral ulcer deep tissue and it was significant for sheets of neutrophils dissecting through degenerating skeletal muscle and connective tissue. Review of a documented case summary of Resident #97 ' s death from DC #950 revealed the date of Resident #97 ' s examination was [DATE]. Resident #97 ' s autopsy findings included a large stage four pressure ulcer over the sacrum with necrosis extending through the deep tissue surrounding the sacral bone, necrotizing fasciitis (inflammation of the fasciae of muscles or other organs results in rapid destruction of overlying tissues) and myositis (a group of rare conditions with symptoms of weak, painful, or aching muscles) by microscopic examination, purulent tan-pink exudate, friable sacral bone, and gangrenous (dead tissue) skin surrounding deep tissues in the wound. Resident #97 had blood and sacral wound cultures obtained during the autopsy and were positive for proteus mirabilis and Escherichia coli. DC #950 documented, it was his opinion, Resident #97 ' s cause of death was bacterial sepsis (proteus mirabilis and E. coli) due to a sacral pressure ulcer due to medical neglect. Resident #97 ' s injury occurred by failure of caregiver(s) to provide adequate or timely medical care for a sacral pressure ulcer and the manner of death was documented as homicide. A telephone interview was completed on [DATE] at 8:28 A.M. with Long-Term Care Ombudsman Program Director (LTCOPD) #800 who stated he went to the facility on [DATE] to see Resident #97 and observed her in her room lying in bed. LTCOPD #800 stated there was a foul odor in the room and Resident #97 was completely curled up with her head against the wall and appeared uncared for. LTCOPD #800 stated he could see Resident #97 ' s foot sticking out from the blanket and could see it had a treatment on it, and the fitted sheet was partially off the mattress and noted a regular mattress on Resident #97 ' s bed. LTCOPD #800 stated he asked Resident #97 if she needed repositioned and Resident #97 indicated she did, so he went to tell the director of nursing. LTCOPD #800 stated he talked to the director of nursing about Resident #97 ' s condition and the director of nursing showed him a few documents from Resident #97 ' s medical record which included review of Resident #97 ' s admission nursing assessment which showed no skin impairments. LTCOPD #800 stated he knew something was not right, so he and the director of nursing walked down to Resident #97 ' s bedroom to address the issues and noted Resident #97 now had a low air loss mattress on her bed, she was changed, and repositioned. Interview on [DATE] at 11:22 A.M. with VPCS #750 verified there was no documentation of a pressure ulcer to Resident #97 ' s sacrum on admission, no documentation of interventions utilized to prevent pressure ulcer development, no consistent assessments of Resident #97 ' s skin completed, and once wound treatments and antibiotics were ordered for Resident #97, the facility did not complete the treatments or administer the medications as ordered. VPCS #750 stated there were no administrative staff still working in the facility who would have been employed during the time Resident #97 was in the facility. VPCS #750 stated ADON #515 was still employed by the facility but was on a leave of absence while Resident #97 resided in the facility. VPCS #750 stated the majority of direct care staff at that time were agency staff and she was not aware of any direct care staff currently employed by the facility who took care of Resident #97. A telephone interview was completed on [DATE] at 1:28 P.M. with DC #950 who verified he was the individual that completed Resident #97 ' s autopsy and case summary of Resident #97 ' s death. DC #950 stated all the information about Resident #97 ' s autopsy findings was in the two reports and confirmed, after reviewing Resident #97 ' s case again, he continued to rule Resident #97 ' s death a homicide as a result of medical neglect. A telephone interview was completed on [DATE] at 2:20 P.M. with WNP #810 who verified she saw Resident #97 once while she was a resident in the facility on [DATE]. WNP #810 stated Former Director of Nursing (FDON) #850 contacted her and stated she needed her to see Resident #97. WNP #810 stated FDON #850 told her they found a wound on Resident #97 the past couple days but thought the wound was there longer. WNP #810 stated when she saw Resident #97 on [DATE] her wound had a dressing on it, but she did not know where the dressing came from or who ordered it. WNP #810 stated Resident #97 ' s sacral pressure ulcer had dead tissue hanging in flaps over it and when WNP #810 touched it with her hands, it would just fall off. WNP #810 stated the severity and odor from Resident #97 ' s wound was very bad. WNP #810 stated she spoke to Resident #97 ' s family and they did not know how long the wound had been there either. WNP #810 stated she took some of the dead tissue off the wound, cleaned it, and applied a dressing before ordering scheduled treatments, an antibiotic, and a low air loss mattress for Resident #97 ' s bed. WNP #810 stated she looked at Resident #97 ' s medical record and saw the antibiotic she ordered was not initiated, and when WNP #810 informed FDON #850, she indicated she thought the antibiotic was initiated but it was for another resident, so it was started that day. WNP #810 stated she told FDON #850 many times to monitor Resident #97 ' s wound condition and if it got any worse to send her to the hospital. WNP #810 stated a few days later Resident #97 ' s POA contacted her and told her the wound was getting worse. WNP #810 stated the facility never contacted her about the wound getting worse and they never sent Resident #97 to the hospital until Resident #97 ' s POA had concerns. WNP #810 stated she talked to FDON #850 after Resident #97 was sent to the hospital and FDON #850 told her she never looked at Resident #97 ' s wound after WNP #810 saw her on [DATE] and FDON #850 told her Resident #97 was now in hospice care, so the facility no longer had to worry about the wound. WNP #810 stated she no longer provided services for residents in the facility. Interview on [DATE] at 12:58 P.M. with ADON #515 verified she was on a leave of absence from the facility while Resident #97 was in the facility. ADON #515 stated she had no knowledge about Resident #97 but confirmed she found the one and only shower sheet documented in Resident #97 ' s medical record dated [DATE]. A telephone interview was completed on [DATE] at 2:51 P.M. with Medical Director (MD) #890 who stated he began his role as medical director for the facility at the start of [DATE]. MD #890 stated he had no knowledge of Resident #97, until the facility asked him to review her medical record. MD #890 verified he never saw Resident #890 while she was in the facility and stated he had no record of the facility ever contacting him about Resident #97. MD #890 stated he had problems with the facility getting him information and, when he first started, there was no leadership as all the administrative staff were transitioning out of the facility. MD #890 stated the facility had a lot of systems collapse on them at the same time which contributed to Resident #97 ' s condition. A telephone interview was completed on [DATE] at 3:51 P.M. with FDON #850 who stated she was director of nursing at the facility for around eight weeks and stated she was new to the facility when Resident #97 was admitted . FDON #850 stated she remembered Resident #97 was admitted to the facility with no wounds and one day the direct care staff came to her and told her Resident #97 had a bad wound on her buttocks. FDON #850 stated she contacted WNP #810 to look at the wound, but FDON #850 stated she did not personally see Resident #97 ' s pressure ulcer. FDON #850 verified she never observed Resident #97 ' s pressure ulcer while she was in the facility before she was sent out to the hospital. FDON #850 stated she was not aware if Resident #97 received wound treatments or received her ordered antibiotic and could not give specific dates or details about Resident #97 ' s care. FDON #850 stated she thought Resident #97 ' s wound happened very fast but could not give a timeline. FDON #850 stated most of the nurses during that time were through agency and could not recall any nurses or nurse aides who worked with Resident #97 that were still employed by the facility. Review of a facility policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised [DATE], revealed the nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers. In addition, the nurse shall describe and document/report a full assessment of pressure sore, pain assessment, mobility status, current treatments, including support surfaces, and all active diagnoses. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. The physician will assist the staff to identify the type of ulcer and will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings, and application of topical agents. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wounds. Review of a facility policy titled, Prevention of Pressure Injuries, revised [DATE], revealed residents will be assessed on admission (within eight hours) for existing pressure injury risk factors. The risk assessment will be completed weekly and upon any changes in condition. Staff will conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge. The skin should be inspected on a daily basis when performing or assisting with personal care or ADLs. Appropriate surfaces should be selected based on the resident's risk factors and in accordance with current clinical practice. Review of a facility policy titled, Administering Medications, revised [DATE], revealed medications are administered in a safe and timely manner, and as prescribed. Review of a facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised [DATE], re[TRUNCATED]

Based on medical record review, observation, staff interview, review of hospital records, review of a facility statement, and review of facility policies, the facility failed to ensure a thorough skin assessment was completed when one resident (#03) returned from the hospital. This resulted in Immediate Jeopardy and serious life-threatening harm and/or injury when Resident #03 returned from the hospital with a surgical pressure compression dressing in place to his penis, which was not identified by the facility to be present until removal 13 days after admission, with no documented assessment of the skin breakdown present under the compression dressing documented for three days after the dressing was removed. At the time the dressing was removed, Certified Nurse Practitioner (CNP) #01 documented the glans of Resident #03's penis with necrotic, hard tissue present. Resident #03 required hospitalization for surgical interventions of debridement of the necrotic tissue and removal of the tip of the penis. This affected one (#03) of three (#03, #12, and #13) residents reviewed for pressure ulcers. Additionally, the facility failed to ensure wound treatments were administered as ordered by the physician which placed a second resident (#12) at risk for the potential for more than minimal harm that is not Immediate Jeopardy. This affected one (#12) of three (#03, #12, and #13) residents reviewed for pressure ulcers. The facility identified three residents residing in the facility with pressure ulcers. The facility census was 50. On 11/17/22 at 4:56 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 10/24/22 at 11:07 P.M. when Resident #03 returned from the hospital following suprapubic catheter surgical replacement with a pressure/compression dressing, an ACE bandage, wrapped around his penis. Documentation in the medical record from readmission on 10/24/22 through 11/09/22 failed to mention the presence of any dressings to Resident #03's penis. On 11/06/22 at 4:05 A.M., Registered Nurse (RN) #200 removed the Ace bandage from Resident #03's penis, only documenting the presence of a Stage 2 pressure area of excoriation to the upper scrotum. On 11/09/22 at 2:37 P.M., CNP #01 documented Resident #03 had an ACE bandage wrapped around his penis. On examination, the head of the penis was necrotic and hard, with the area surrounding the necrotic are to be slightly excoriated. Resident #03 was subsequently admitted to the hospital and underwent extensive debridement of the penile shaft due to necrosis of the glans penis and partial necrosis to the penis shaft. The Immediate Jeopardy was removed on 11/09/22 at 6:30 P.M. when the facility implemented the following corrective actions: On 11/08/22, the DON informed Resident #03's attending physician of the skin breakdown on the resident's penis and obtained a treatment. On 11/08/22, the DON and Assistant DON (ADON) completed audits of all new admissions, including skin sweeps, to assess for the presence of unidentified dressings or areas of skin breakdown. On 11/08/22, the facility initiated a Quality Assurance Performance Improvement (QAPI) meeting with the Medical Director and CNP #01 addressing resident needs and plan of action. On 11/09/22, the DON and ADON assessed the skin of all residents in the facility. Treatments and splints were verified. On 11/09/22, the DON educated all nurses on admission/readmission assessments; comprehensive skin checks; reporting assessment findings; obtaining orders for treatments and admission responsibilities shift to shift. The education was completed on 11/09/22 at 6:30 P.M. On 11/09/22, the DON initiated weekend admission audits to be completed by the on-call nurse. On 11/09/22, the DON initiated daily wound and admission audits, including QAPI, every Friday at 3:00 P.M. These will be completed by either the DON or the ADON. On 11/11/22 at 3:34 P.M., the facility had a QAPI Ad Hoc meeting with the Medical Director to review the incident with Resident #03 and develop a plan of correction. Review of the medical record for one additional resident in the facility with a pressure ulcer (Resident #13) revealed no concerns with pressure ulcer care. Although the Immediate Jeopardy was removed on 11/09/22, the facility remains out of compliance at a Severity Level 2 (no actual harm with potential for more than minimum harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1) Review of the medical record revealed Resident #03 admitted to the facility on [DATE]. Diagnoses included quadriplegia, neuromuscular dysfunction of the bladder, supra-pubic urinary catheter, colostomy, moderate protein-calorie malnutrition, pressure ulcer to sacral region and heel, anxiety disorder, hypertension, fracture of left tibia and fibula, spinal fusion, and history of pulmonary embolism. Review of the Minimum Data Set (MDS) assessment, dated 09/01/22, revealed Resident #03 was identified with intact cognition, was dependent on staff for the completion of all activities of daily living, had an indwelling urinary catheter and colostomy, and had a Stage 4 pressure ulcer. Review of Nurses' Notes dated 10/24/22 at 11:07 A.M. revealed RN #200 documented Resident #03 readmitted to the facility. There was no documentation regarding a skin assessment. Review of the hospital discharge orders dated 10/24/22, revealed Resident #03 had undergone a surgical procedure for replacement of the suprapubic catheter. Orders included to irrigate the bladder with gentamycin solution every 48 hours for 30 days. The hospital discharge documents did not identify a dressing to Resident #03's penis was in place. Review of the record revealed on 10/25/22 at 6:21 A.M., RN #200 documented an assessment identifying Resident #03 was alert and oriented, makes needs known to staff, and was dependent on staff for care. There was no assessment of the resident's perineum. Review of the record revealed no assessment of Resident #03's skin was documented which revealed a pressure dressing was present on the resident's penis from admission until 11/06/22. Review of the weekly skin assessment dated [DATE] at 4:05 A.M. by RN #200 documented a Stage 2 pressure area of excoriation was present to Resident #03's upper scrotum. There was no documentation of a dressing being in place. Review of the physician orders on 11/06/22 at 8:05 A.M. revealed the physician provided an order for barrier cream to the excoriated area to the scrotum. Review of the physician orders on 11/08/22 at 4:24 P.M. revealed the DON obtained a physician order for treatment to the excoriated area to the scrotum, shaft of penis and eschar to glans. The treatment order was to cleanse with in-house wound cleanser, pat dry, paint all areas with betadine, keep open to air, and to complete each shift. There was no documentation of Resident #03's skin to the penis documented in the medical record. Review of Nurses' Notes dated 11/09/22 at 11:52 A.M. revealed CNP #01 is to be into see Resident #03's necrotic tissue to the penis. CNP #01 recommended follow up with the urologist. Urologist office contacted with return call pending per the nurse. Review of Nurses' Notes on 11/09/22 at 12:58 P.M. revealed the ADON called and spoke to the nurse at the urologist office. The ADON informed the urology office nurse there were no orders sent with this resident from the hospital regarding the dressing on the resident's penis. The urology office nurse reported the Urologist applied the dressing due to bleeding and instructed the staff at the hospital to remove the dressing in two hours after application. The ADON reported Resident #03 stated he woke up from surgery with the dressing on and was informed it was due to excess bleeding during surgery. Review of Nurses' Notes on 11/09/22 at 2:09 P.M. revealed the urology office returned a call and requested the resident to be sent to the hospital emergency room for evaluation and treatment. Review of the progress note dated 11/09/22 at 2:37 P.M., CNP #01 documented Resident #03 was recently admitted to the hospital and an ACE bandage had been wrapped around his penis due to bleeding from a procedure. However, the wrap was not removed for over seven days. On examination the head of the penis was necrotic with hard tissue. The area surrounding the necrotic area was slightly excoriated. CNP #01 recommended Resident #03 see the urologist to discuss options and debridement was not likely possible. Review of Nurses' Notes on 11/09/22 at 2:40 P.M. revealed eschar tissue was found on peritoneal area of resident per the DON. Resident #03 was sent to the emergency room for evaluation. Review of hospital documentation dated 11/09/22 at 7:08 P.M. noted Resident #03 presented with black discoloration of the penis. The note revealed a bandage was taken off the penis today and there was a black discoloration of the glans penis. Review of the hospital urology consultation notes on 11/10/22 at 9:37 A.M. documented a phone call to the physician's office questioning the need for an ACE bandage and revealed the bandage was placed to Resident #03's penis for urethral bleeding at the time of his cystoscopy and suprapubic tube placement. Review of hospital surgical report documentation dated 11/11/22, revealed Resident #03 had extensive debridement of the penile shaft due to necrosis of the glans penis and partial necrosis to the penis shaft. Review of hospital documentation dated 11/13/22, revealed Resident #03 was status post debridement of the penis for necrotic tissue. The RN reported Resident #03 was very upset regarding surgical debridement and loss of tip of penis. The area of debridement shows a questionable area of further necrosis. A note on 11/15/22 documented the penis wound was assessed to have a dark scab on top. The scrotal area had a small moist ulcer. Review of an undated, untitled facility prepared statement written by the DON revealed Resident #03 went to the hospital 10/17/22 for surgical replacement of suprapubic catheter. A surgical/compression dressing was applied to the penis during the procedure due to bleeding. The physician had told hospital staff who transported Resident #03 back up to his hospital room to relay to nursing staff to remove the bandage after two hours. Resident #03 returned from the hospital 10/24/22. There were no orders for the bandage when he returned and no mention of it on the re-admission assessment completed by the facility. On 11/06/22 the night nurse and night aide noticed changes of skin condition to Resident #03's scrotum. The nurse removed the bandage and called the physician for new orders. A note and incident report were completed at this time. The next day the DON was called to Resident #03's room by the resident to inspect the penis. The DON immediately reached out to the primary care physician for follow up and obtained new treatment orders. When CNP #01 assessed Resident #03's skin she recommended urology assess the resident. After several calls to obtain a urology consult the facility was able to send Resident #03 to the hospital to be assessed by the urologist the resident had seen on his last stay. Resident #03 was currently at the hospital and has undergone an incision and drainage for the necrotic penial tissue. The resident was also given medication to aide in restoring blood flow to the penis. Interview via telephone on 11/17/22 at 1:05 P.M., CNP #01 stated she was called in to evaluate Resident #03's penis. The resident was in his room and no dressing was applied to the penis. CNP #01 stated the penis was assessed as described in the progress note. CNP #01 was not aware of the resident having any orders to wrap the penis and had not evaluated prior to 11/09/22. Interview on 11/17/22 at 2:20 P.M. with the DON revealed on 11/06/22 RN #200 discovered Resident #03 with a gauze dressing and an ACE bandage wrapped around his penis. RN #200 removed both dressings and contacted the physician for a treatment to the excoriation on the resident's scrotum. The DON confirmed no documentation identified skin breakdown to the penis on 11/06/22. The DON stated on 11/08/22 at approximately 8:30 A.M., Resident #03 requested the DON to speak with him. Resident #03 requested the DON to look at his penis. The resident's penis was observed to be open to air under an adult incontinence brief. No dressing was in place. The glans of the penis was hard and necrotic. The penial shaft was excoriated with pink/shearing tissue. The DON was informed by Resident #03 of a dressing having been applied to the penis since his hospital stay. The DON spoke with CNP #02 and described Resident #03's skin breakdown to the penis. The DON requested CNP #02 to evaluate the resident's skin. It was not until 11/09/22 when CNP #01 was in the area of the facility that Resident #03's skin was assessed. CNP #01ordered the resident to be evaluated by a urologist. The DON confirmed the physician did not assess the wound. Interview via telephone on 11/17/22 at 4:06 P.M., Physician #01 revealed he was contacted on 10/25/22 to confirmed admission orders for Resident #03. The physician was not informed of a dressing, or an Ace bandage being applied to the resident's penis. On 11/06/22 the physician was notified Resident #03 had an excoriated area of tissue to the scrotum. The physician stated the nurse did not report the resident had a gauze dressing and an ACE bandage wrapped around the penis. The physician was unaware the resident was assessed with necrotic tissue to the glans of the penis. Review of the facility policy titled Admission Notes, revised September 2012, revealed when a resident is admitted to the nursing unit, the admitting nurse must document in the nurses' notes, on the admission form, or other appropriate place as designated by facility protocol the presence of a dressing. Review of the facility policy titled Admission Assessment and Follow Up: Role of the Nurse, revised September 2012, revealed an admission assessment included a physical assessment including the following systems: eyes, ears, nose, throat, neurological, musculoskeletal, gastrointestinal, genitourinary, and skin. Information should be recorded in the record including all relevant assessment data obtained during the assessment. 2. Review of the medical record revealed Resident #12 admitted to the facility on [DATE]. Diagnoses included paraplegia, chronic obstructive pulmonary disease, major depression, unstageable pressure ulcer to sacral region, Stage 4 pressure ulcer to bilateral buttocks, acute kidney failure, anemia, hypertension, urogenital implants, colostomy, and hydronephrosis with renal and ureteral calculus obstruction. Review of the MDS assessment, dated 10/13/22, revealed Resident #12 had intact cognition, was dependent on staff for the completion of activities of daily living, and had three Stage 4 pressure ulcers. Review of the plan of care initiated on 08/25/22 and revised on 11/15/22 revealed Resident #12 had pressure ulcers and potential for further pressure ulcer development. The interventions included to administer treatments as ordered and monitor for effectiveness. Review of Nurses' Notes on 11/03/22 at 7:58 A.M. revealed Resident #12 returned to the facility following a brief hospitalization from [DATE]. No new wounds were discovered. Review of wound documentation dated 11/04/22 revealed the resident had a Stage IV sacral pressure ulcer measuring 6.5 centimeters (cm) long by 8.2 cm wide by 1.0 cm deep. The right buttocks had a Stage IV pressure ulcer measuring 5.8 cm long by 4.8 cm wide by 1.2 cm deep. The left buttock had a Stage IV pressure ulcer measuring 3.5 cm long by 2.5 cm wide by 3.0 cm deep. Review of the physician orders, dated 11/04/22, revealed the treatment orders included cleanse sacral/left buttocks/right buttocks wounds with in-house wound cleanser, pat dry, cover exposed bone area with Adaptic, pack with alginate, and fill with Kerlix. Change daily and as needed every evening shift for wound care. Review of wound documentation dated 11/11/22 revealed the Stage IV sacral pressure ulcer measured 4.7 cm long by 8.5 cm wide by 1.3 cm deep. The right buttocks Stage IV pressure ulcer measured 4.7 cm long by 4.2 cm wide by 1.5 deep. The left buttock Stage IV pressure ulcer measured 3.2 cm long by 2.7 cm wide by 2.7 cm deep. Review of the physician orders revealed on 11/11/22 the treatment orders were changed to cleanse sacral/left buttocks/right buttocks wounds with in-house wound cleanser, pat dry, pack with dry calcium alginate, cover with foam dressing, and change twice daily and as needed. Review of the November 2022 Treatment Administration Record (TAR) revealed no documentation the pressure ulcer treatments were completed on the evening shift of 11/14/22 and 11/15/22. Observation on 11/16/22 at 6:40 A.M. revealed Licensed Practical Nurse (LPN) #203 obtained wound dressing supplies to complete Resident #12's pressure ulcer dressing changes. The supplies included dry calcium alginate and a silicone foam border dressing. LPN #203 then proceeded to Resident #12's room. Resident #12 was positioned to the left side and the existing dressing was exposed. LPN #203 removed two large abdominal (ABD) dressings followed by Kerlix gauze, which was packed into the three pressure ulcer wounds. LPN #203 cleansed the wound with wound cleanser and packed the wounds with dry calcium alginate followed by covering with a silicone foam bordered dressing. Interview on 11/16/22 at 6:56 A.M., LPN #203 confirmed the treatment removed from Resident #12's pressure ulcers was not the current treatment ordered on 11/11/22. Interview on 11/16/22 at 7:14 A.M., Regional Director of Clinical Services #01 confirmed the dressing removed from Resident #12's pressure ulcer wounds was not the current dressing order originating on 11/11/22. Interview on 11/16/22 at 8:35 A.M., with Regional Registered Nurse (RRN) #01 confirmed Resident #12 was not provided with the current wound treatment which included the application of calcium alginate and cover with silicone border dressing. Review of the facility policy titled Wound Care, revised October 2010, revealed the physician order for the treatment was to be verified prior to application of the procedure. This deficiency represents non-compliance investigated under Master Complaint Number OH00137571, Complaint Number OH00137544 and Complaint Number OH00137456 and is an example of continued noncompliance from the survey dated 10/19/22.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of the Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memos, observations, staff interviews, review of the facility policies and procedures, review of the staff screening for COVID-19 documentation, medical record reviews, review of the Centers for Disease Control and Prevention (CDC) COVID Data Tracker and guidance, review of staff schedules, review of staff testing for COVID-19, review of staff training check list, and review of posted COVID-19 signage regarding Personal Protective Equipment (PPE), the facility failed to implement effective and recommended infection control practices, including a system to ensure all staff and residents were tested for COVID-19 according to CMS guidelines, a system to ensure all staff were self-screening for symptoms of COVID-19 prior to each shift of work, a system to ensure staff did not work with symptoms consistent with COVID-19, ensure the appropriate use of PPE by staff to prevent the potential spread of COVID-19 within the facility and ensure residents who tested positive for COVID-19 remained in their rooms with the door closed. This resulted in Immediate Jeopardy and the potential for serious negative health outcomes and/or life-threatening harm when 26 residents (#05, #04, #19, #20, #21, #08, #07, #10, #22, #15, #23, #06, #09, #14, #16, #17, #18, #52, #64, #02, #13, #34, #41, #73, #74, and #24) and 10 staff (State tested Nurse Assistant [STNA] #107, STNA #108, STNA #106, STNA #113, STNA #114, Laundry Assistant #501, Licensed Practical Nurse [LPN] #201, LPN #205, LPN #209, and Housekeeping Supervisor #506) tested positive for COVID-19 without systems in place to ensure all staff and residents were tested according to CMS guidelines and to ensure staff were self-screening for symptoms of COVID-19 prior to working to prevent the spread of COVID-19 to the vulnerable residents within the facility. The facility was not ensuring staff were using PPE effectively and positive residents remained in quarantine. The lack of current effective infection control practices during a COVID-19 outbreak in the facility placed all 61 residents at potential risk for the likelihood of harm, negative health complications and/or death. The facility census was 61 residents. On 09/13/22 at 3:53 P.M., the Administrator (#02) and Director of Nursing (DON)/Infection Control Preventionist (IP), were notified that Immediate Jeopardy began on 08/16/22 when the facility failed to have evidence of systems in place to ensure all staff and residents were tested for COVID-19 according to CMS guidelines, a system to ensure all staff were self-screening for symptoms of COVID-19 prior to each shift of work, a system to ensure staff did not work with symptoms consistent with COVID-19, ensure the appropriate utilization of PPE by staff, and ensure residents who tested positive for COVID-19 remained in their rooms with the door closed. The Immediate Jeopardy was removed on 09/14/22 at 8:00 P.M., when the facility implemented the following corrective actions: · On 09/13/22 beginning at 5:30 P.M., the DON and Administrator #02 met with administrative staff to formulate a removal plan. · On 09/13/22 beginning at 5:30 P.M., the DON and Administrator #02 applied a plastic barrier to the door of COVID positive residents. · On 09/13/22 beginning at 5:30 P.M., COVID positive residents were educated on COVID isolation requirements by the DON and/or designee. · On 09/13/22 beginning at 5:30 P.M., the building back door was locked and one screening station implemented at the front of the facility. · On 09/13/22, beginning at 5:30 P.M., new Testing Logs for staff and residents were developed and implemented by the DON. · On 09/13/22, beginning at 5:30 P.M., all current staff in the facility were confirmed that they were screened in, and no symptoms were present by the DON and/or designee. Staff will be screened prior to their shift and validation will be completed by the DON and/or designee. The DON and/or designee will audit this process every day for 14 days starting on 09/15/22. · On 09/13/22 beginning at 5:30 P.M., the DON validated that all current staff were utilizing an N95 mask, eye protection and that they were being worn appropriately. · On 09/13/22 at 7:00 P.M., the DON and Administrator #02 met with Medical Director (MD) #01 and discussed the Immediate Jeopardy removal plan and reviewed infection control and COVID policies. All policies were pulled for review and no updated changes were required. MD #01 agreed with the plan, the policies, and the need for staff education. · On 09/14/22 beginning at 9:00 A.M., all residents were assessed for signs and symptoms of COVID along with testing being completed. New resident Testing Logs were implemented. The DON and/or designee will audit this process every day for 14 days starting on 09/15/22. · On 09/14/22 beginning at 9:00 A.M., the DON validated proper PPE usage by staff in the facility. The DON and/or designee will audit this process every day for 14 days starting on 09/15/22. · On 09/14/22 beginning at 11:00 A.M. and concluding at 6:00 P.M., all staff education was completed on infection control policies including proper donning and doffing of PPE, screening, and documenting of staff screening, designated screening area, testing and documenting of staff and residents and maintaining isolation of COVID positive residents by the DON and/or designee. · On 09/14/22, all staff will provide return demonstration of donning and doffing an N95 mask, and goggle/face shield protection and the wearing of appropriate PPE, conducted by the DON and/or designee. · On 09/14/22, all staff will complete a post-test to validate education on the difference between KN95 and N95 masks, proper PPE requirements and changes when caring for COVID positive and Isolation patients, and when to wear eye protection, and were reviewed by the DON and/or designee. · On 09/14/22, all nurses will be educated on proper PPE to wear during COVID testing, complete a post-test to validate understanding of the process and be reviewed by the DON and/or designee. · On 09/14/22 beginning at 11:00 A.M. and concluding by 6:00 P.M., all staff will be tested for COVID-19 by the DON and/or designee. The DON and/or designee will audit this process every day for 14 days starting on 09/15/22. · On 09/14/22 at 11:00 A.M., a new staff screening form was implemented by the DON. · On 09/14/22, updated screening and PPE requirements were sent to all staffing agencies utilized by the facility to inform their staff prior to entrance to the facility. · On 09/14/22 from 5:00 P.M. to 7:00 P.M., a Quality Assurance and Performance Improvement (QAPI) meeting was held with Medical Director #01, Administrator #02, the DON, and Regional Nurse #503 to review progress of the removal plan. · On 09/14/22 at 8:00 P.M., the facility alleged the removal plan was completed and auditing to begin on 09/15/22. · On 09/15/22, the DON and/or designee will begin random audits for residents remaining in the correct isolation. · On 09/15/22, random interviews between 2:37 P.M. and 2:57 P.M., with LPN #210, STNA #115, Dietary Manager #510 and Regional Nurse #503 revealed they were educated on infection control related to how to don and doff PPE, screening prior to work, new forms, COVID-19 testing, and residents in isolation. No concerns were identified, and staff were knowledgeable regarding the in-service provided by the facility. All staff were observed to be utilizing the appropriate PPE correctly. · On 09/15/22, review of the screening logs revealed staff were screened prior to their shift with temperature and signs and symptoms being absent. Although the Immediate Jeopardy was removed on 09/14/22 at 8:00 P.M., the facility remains 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 is still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: 1) Interview on 08/30/22 at 9:35 A.M. with Administrator #01 revealed Resident #05 tested positive for COVID-19 on 08/16/22, which began the current outbreak. While testing residents per outbreak protocol: Resident #04, Resident #19, and Resident #20 also tested positive on 08/16/22. Continued interview with Administrator #01 verified the following dates and positive results of COVID-19 testing: On 08/17/22, Resident #21 tested positive. On 08/21/22, Resident #08 and STNA #107 tested positive. On 08/22/22, Resident #07, Resident #10, Resident #22, Laundry Assistant #501, LPN #201, and LPN #205 tested positive. On 08/25/22, STNA #108 tested positive. On 08/26/22, Resident #15 and Resident #23 tested positive. On 08/28/22, Resident #06, Resident #09, Resident #14, and STNA #106 tested positive. On 08/29/22, Resident #16, Resident #17, Resident #18, Resident #52, Resident #64, and Housekeeping Supervisor #506 tested positive. Further interview with Administrator #01 confirmed Resident #02 and Resident #13 tested positive for COVID-19 on 08/29/22 but were not updated on the line listing at that time. Interview on 09/12/22 at 9:15 A.M., the DON revealed STNA #113 tested positive on 09/02/22 and STNA #114 tested positive on 09/06/22. Interview on 09/13/22 at 1:28 P.M., the DON revealed LPN #209 tested positive on 09/01/22. Further interview revealed Resident #34, Resident #41, and Resident #73 tested positive on 09/02/22, and Resident #74 and Resident #24 tested positive on 09/06/22. Interview on 09/14/22 at approximately 9:00 A.M. with Regional Nurse #503 revealed she reviewed the community transmission levels weekly and [NAME] County ' s transmission level had been red (high) for at least six months. A total of 26 residents and 10 staff tested positive for COVID-19 in the facility between 08/16/22 and 09/06/22. Review of the Centers for Disease Control and Prevention (CDC) COVID Data Tracker (https://covid.cdc.gov/covid-data-tracker/#county-view|Ohio| |Risk|community_transmission_level), revealed the COVID-19 Integrated County view, dated on 08/18/22, 08/25/22, 09/01/22, 09/08/22, 09/15/22, indicated the facility's county community transmission level was color coded red indicating it was at a high level. 2) Review of the staffing schedules and employee COVID-19 screening logs dated 08/16/22 through 09/13/22, revealed staff failed to fully complete the COVID-19 screening. The screening included obtaining and documenting temperature and/or recording any signs or symptoms of COVID-19 as follows: On 08/16/22, 45 staff worked and 37 did not fully complete the screening log. On 08/17/22, 46 staff worked and 32 did not fully complete the screening log. On 08/18/22, 47 staff worked and 35 did not fully complete the screening log. On 08/19/22, 41 staff worked and 33 did not fully complete the screening log. On 08/20/22, 31 staff worked and 31 did not fully complete the screening log. On 08/21/22, 32 staff worked and 30 did not fully complete the screening log. On 08/22/22, 44 staff worked and 28 did not fully complete the screening log. On 08/23/22, 46 staff worked and 34 did not fully complete the screening log. On 08/24/22, 52 staff worked and 42 did not fully complete the screening log. On 08/25/22, 50 staff worked and 39 did not fully complete the screening log. On 08/26/22, 44 staff worked and 30 did not fully complete the screening log. On 08/27/22, 31 staff worked and 24 did not fully complete the screening log. On 08/28/22, 29 staff worked and 23 did not fully complete the screening log. On 08/29/22, 38 staff worked and 09 did not fully complete the screening log. On 08/30/22, 38 staff worked and 23 did not fully complete the screening log. On 08/31/22, 42 staff worked and 28 did not fully complete the screening log. On 09/01/22, 40 staff worked and 31 did not fully complete the screening log. On 09/02/22, 36 staff worked and 27 did not fully complete the screening log. On 09/03/22, 26 staff worked and 24 did not fully complete the screening log. On 09/04/22, 26 staff worked and 26 did not fully complete the screening log. On 09/05/22, 34 staff worked and 24 did not fully complete the screening log. On 09/06/22, 45 staff worked and 29 did not fully complete the screening log. On 09/07/22, 44 staff worked and 31 did not fully complete the screening log. On 09/08/22, 44 staff worked and 31 did not fully complete the screening log. On 09/09/22, 40 staff worked and 30 did not fully complete the screening log. On 09/10/22, 29 staff worked and 27 did not fully complete the screening log. On 09/11/22, 30 staff worked and 25 did not fully complete the screening log. On 09/12/22, 44 staff worked and 23 did not fully complete the screening log. On 09/13/22, 39 staff worked and 19 did not fully complete the screening log. Review of the staff schedules revealed LPN #201 worked on 08/16/22, 08/18/22 and 08/19/22. Interview on 09/12/22 at 3:50 P.M. with LPN #201 verified she did not complete the employee COVID-19 screening log between 08/15/22 and 08/21/22. LPN #201 stated she is not vaccinated and screens herself every day but does not always have time to complete the form. Review of the staff schedule from 08/16/22 through 09/13/22 revealed STNA #106 worked 08/16/22, 08/17/22, 08/20/22, 08/21/22, 08/23/22, 08/25/22, and 08/26/22. Review of the staff COVID-19 testing records revealed STNA #106 testing positive for COVID-19 on 08/28/22. Interview on 09/13/22 at 8:10 A.M. with STNA #106 revealed she is not vaccinated and did not complete the employee COVID-19 screening logs between 08/16/22 and 09/13/22. Further interview revealed she comes in through the back entrance to the facility and went directly to work with residents without screening for COVID-19. Interview on 09/15/22 at 3:16 P.M., Regional Nurse #503 verified the employee COVID-19 screening logs dated 08/16/22 through 09/13/22, included staff who did not fully complete the screening logs accurately. Review of the policy titled Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, updated May 2020, revealed anyone entering the facility, including staff, should be screened for signs and symptoms of and exposure to others with COVID-19 infection. 3) Observation and interview on 08/29/22 at 10:45 A.M. with Housekeeper #301 verified he was wearing a KN95 mask with ear loops. Observation on 08/29/22 at 11:08 A.M., revealed Regional Nurse #503 wearing an N95 mask with both straps around the nape of her neck. Interview at the time of the observation, verified she was not wearing the mask correctly. Observation on 08/29/22 at 12:21 P.M., revealed Unit Manger (UM) #202 instructing a visitor to don PPE prior to entering a quarantine room. The visitor did not don eye protection and was not instructed to by UM #202. Observation and interview on 08/29/22 at 12:31 P.M. with LPN #203, verified she was wearing an N95 mask with both straps around the nape of her neck. Observation on 08/29/22 at 12:34 P.M., of the Minimum Data Set (MDS) Nurse #507 revealed he was wearing a KN95 mask with ear loops. Interview at that time of the observation, verified he was not wearing an N95 mask. MDS Nurse #507 stated his understanding was the KN95 and N95 masks could be used interchangeably. Interview on 08/29/22 at 12:51 P.M., with UM #202 verified she did not instruct the visitor to wear eye protection, when applying PPE. Observation and interview on 08/29/22 at 3:06 P.M. with STNA #105, verified she was wearing a KN95 with ear loops. Interview and observation on 08/29/22 at 3:12 P.M. with the UM #202, verified an unidentified staff member was observed sitting at the nurses ' station and had an N95 strap dangling below her chin. Interview on 08/29/22 at 3:32 P.M. with the DON, revealed she felt it was appropriate for staff to wear a KN95 when entering COVID-19 isolation and quarantine rooms. The DON stated she believed the KN95 and N95 masks were interchangeable. Interview on 08/29/22 at 3:53 P.M. with the Administrator #01, revealed all staff should always be wearing an N95 and goggles/eye coverings in the facility due to outbreak status. Observation on 08/30/22 at 7:40 A.M., revealed STNA #105 wearing a cloth mask. Interview at that time verified she wore a cloth mask, that was not a surgical mask. Observation on 08/30/22 at 8:28 A.M., revealed Activities Assistant #500 wearing an N95 mask with both straps around the nape of her neck. Interview at the time of the observation, verified she was wearing the N95 straps incorrectly. Observation on 08/30/22 at 8:45 A.M., revealed Housekeeper #302 cleaning a COVID-19 room wearing a surgical mask under an N95 mask. After cleaning the room and exiting into the hallway, Housekeeper #302 was observed not to change or clean her goggles and did not change her mask. Interview at the time of the observation, verified she did not clean or change her goggles and wore a surgical mask under the N95, which she also did not change. She did not clean any additional rooms and entered the employee hallway with her cleaning cart. Interview and observation on 08/30/22 at 2:37 P.M. with STNA #102, verified she was wearing a KN95 mask with ear loops, while working on the COVID unit. Further interview revealed she entered a COVID-19 isolation room earlier that day wearing a KN95 mask. Observation on 08/30/22 at 4:05 P.M., revealed Laundry Assistant #501 walked through the COVID-19 isolation unit wearing a KN95 mask held on with ear loops covered by a surgical mask, a pair of gloves, with no goggles and no isolation gown. Laundry Assistant #501 walked into the soiled linen room beyond the plastic wall barrier. Further observation of the Laundry Assistant #501 revealed she picked up a bag of soiled linens and held them against her jeans. Interview at the time of the observation, verified she was not wearing a gown, or eye protection, was wearing a KN95 mask with ear loops covered by a surgical mask, and held the laundry bag against her jeans. Observation on 08/30/22 at 4:40 P.M., revealed LPN #502 entered the COVID-19 isolation unit wearing a KN95 mask with ear loops, goggles, an untied gown, and gloves. She then proceeded to tie the gown behind her back. Interview at the time of the observation, verified she was wearing a KN95 mask with ear loops on the COVID unit. Continued interview revealed she was assigned to care for all residents on the 200-hall, including residents who did not have COVID-19. Observation on 08/30/22 at 4:45 P.M., revealed LPN #502 entered Resident #06's room while wearing the KN95 mask with ear loops, goggles, a tied gown, and gloves, and proceeded to provide care to Resident #06. Resident #06 was on the COVID-19 isolation unit due to positive COVID-19 status. LPN #502 exited Resident #06 ' s room and removed her gown in the hallway of the COVID-19 unit and was unable to find a trash receptacle in which to dispose her soiled PPE. LPN #502 began to leave the COVID-19 unit, with her soiled gown in her arms, into the interior of the facility when the Administrator #01 entered the unit and instructed LPN #502 to exit the COVID-19 unit through the back door leading outside, walk around the exterior of the facility, and re-enter through the front door. LPN #502 walked through the COVID-19 unit without wearing a gown, though she was still wearing a KN95 with ear loops and goggles, walked through the plastic barrier wall at the end of the COVID-19 unit and disposed of her soiled PPE in the soiled room, and was observed wearing a KN95 mask with ear loops coming out of the soiled room, and walking into the clean room, then coming back out of the clean room before exiting through the exterior door. LPN #502 was not observed removing or changing her KN95 with ear loops prior to exiting the COVID-19 unit. Observations on 09/12/22 at 8:04 A.M., revealed Housekeeper #303 approached the surveyor to ask if she was wearing her N95 appropriately. Observation at that time revealed Housekeeper #303 wearing an N95 mask with the straps cut off. Housekeeper #303 wore a surgical mask atop the N95 to hold the N95 mask in place. Interview at the time of the observation, Housekeeper #303 revealed she was told to wear an N95 and chose to cut the straps and hold it to her face with a surgical mask. She again asked the surveyor if it was the correct way to wear an N95. The surveyor advised her to ask her supervisor. Observation on 09/12/22 at 8:06 A.M., revealed Housekeeper #303 donning an N95 mask with the top strap around the crown of her head and the bottom strap around the nape of her neck. Observation and interview on 09/12/22 at 9:02 A.M., verified LPN #206 wearing an N95 with the loops behind her ears. Further interview revealed she cut the straps from the N95 and tied them so they could stay behind her ears. Observation and interview on 09/12/22 at 9:13 A.M., verified Registered Nurse (RN) #207 and LPN #208 were wearing N95 masks with both straps around the napes of their necks. Observation and interview on 09/12/22 at 9:16 A.M. with STNA #106, verified her N95 mask had only one strap and it was around the nape of her neck. Observation on 09/12/22 at 9:23 A.M. of Social Services Director #504, revealed she was wearing an N95 mask while at the nurse ' s station with the top strap around the nape of her neck and the bottom strap was under her chin. Interview at the time of the observation, Social Services Director #504 verified she was not wearing her N95 correctly. Observation on 09/12/22 at 9:44 A.M., revealed STNA #105 donned a gown and gloves to enter a COVID-19 isolation room. STNA #105 was wearing regular eyeglasses (without goggles or a face shield) and an N95 mask with the straps placed appropriately at the crown of head and nape of neck. Continued observation revealed STNA #105 doffed the gown and gloves before exiting the room. She did not change her mask or clean her glasses. She walked to the pantry and washed her hands. Upon exit from the pantry, she sanitized her hands and proceeded to collect a breakfast tray from room [ROOM NUMBER] (a non-COVID-19 room). Interview with STNA #105 verified Resident #24 was in a COVID-19 isolation room, and STNA #105 verified she did not change her mask upon exit from the COVID-19 isolation room, did not don goggles or a face shield, or wash her regular glasses upon exit. Further interview verified she entered room [ROOM NUMBER] (a non-COVID-19 room) to collect a breakfast tray. Continued observation revealed she continued to entered Rooms #123, #125, and #126 (all non-COVID-19 rooms) to collect breakfast trays. Interview on 09/12/22 at 9:55 A.M. with STNA #105, verified she knew she should change her N95 mask upon exiting a COVID-19 isolation room. Observation on 09/12/22 at 10:01 A.M., revealed STNA #105 changing her N95 mask to a fresh N95. Observation on 09/12/22 at 10:05 A.M., revealed a visiting contracted Nurse Practitioner (NP) #505 exited a COVID-19 isolation room without changing her N95 mask and goggles. Interview with NP #505 verified she did not change her mask or goggles and she was unaware if that was the expected process. Continued observation revealed NP #505 then proceeded to change her N95 mask at that time. Observation on 09/12/22 at 1:51 P.M. of LPN #206, revealed she wore an N95 mask with both straps around the nape of her neck. During an interview she verified she had worn her mask earlier in the day with the loops behind her ears, and now was wearing the mask with both straps around the nape of her neck. Observation on 09/12/22 at 2:02 P.M., revealed Activities Assistant #500 in the dining room with three residents providing an activity with her N95 mask below her nose. When eye contact was made, Activities Assistant #500 then placed her N95 back in the proper position. The three unidentified residents were socially distanced from Activities Assistant #500. Interview on 09/13/22 at 10:02 A.M. with the DON and Regional Nurse #503 revealed all staff should wear N95 masks and goggles or eye protection throughout the facility due to the high community transmission level. Further interview with the DON revealed the facility had an adequate supply of PPE available. Observation on 09/13/22 at 11:13 A.M., revealed Activities Assistant #500 in the South Hallway providing a bingo activity for the residents while wearing her N95 mask below her nose. When eye contact was made, Activities Assistant #500 was observed to reposition her mask correctly. Residents were socially distanced at that time. Observation on 09/14/22 at approximately 7:10 A.M., revealed three STNAs (#110, #111, and #112) standing at the nurses ' station without goggles. Further observation revealed STNA #112 wore a surgical mask and was holding STNA #111 ' s rapid COVID-19 test, awaiting results. No residents were in the hallway or at the nurses ' station at that time. Interview at that time, verified all three staff were not wearing goggles, and STNA #112 was holding a completed COVID-19 test. STNA #110 revealed she left her goggles in her car. STNA #111 stated she did not know where to find goggles. Interview on 09/14/22 at 7:15 A.M. with STNA #112, revealed he had worn an N95 during his shift but was leaving and changed into a surgical mask which he was wearing at the nurses ' station. He verified he did not wear goggles but was wearing eyeglasses. Observation on 09/14/22 at 9:15 A.M. with STNA #111, revealed she wore an N95 mask with both straps at the nape of her neck. Interview at that time revealed STNA #111 was unsure whether a strap should be around the crown of her head. Review of the COVID-19 signage posted on all COVID-19 quarantine and isolation rooms revealed a mask should be worn with one strap around the crown of the head and one strap around the nape of the neck. Review of the COVID-19 signage posted outside the COVID-19 isolation unit revealed all staff should don a gown, mask, goggles, and gloves before entering the COVID-19 unit. Review of the policy titled Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, updated May 2020, revealed staff should wear gloves, an isolation gown, eye protection and an N95 or higher-level respirator for residents with known or suspected COVID-19. 4) Interview on 08/29/22 at 3:32 P.M. with the DON revealed UM #202 was trained to perform rapid COVID-19 tests in the facility. Observation on 08/29/22 at 5:18 P.M., revealed UM #202 testing residents for COVID-19 on the 200-hall due to outbreak status in the facility. Observation revealed UM #202 wearing an N95 mask and face shield. Interview with UM #202 revealed she had previously tested Resident #02 a few minutes earlier with a rapid COVID-19 test. Observation of the test showed a faint pink line suggesting Resident #02 was positive for COVID-19. Further interview revealed UM #202 planned to retest Resident #02 to confirm the test results. Continued observation revealed UM #202 donned gloves, entered Resident #02's room, performed the nasal swab, and returned to the medication cart to place the swab into the testing card. UM #202 did not change her face shield or mask upon exiting Resident #02's room, nor did she clean her face shield. Continued observation revealed UM #202 standing at the nurses' cart watching Resident #02's test result for several minutes until a faint pink line appeared, indicating Resident #02 was COVID-19 positive. At that time, UM #202 stated Resident #02 would isolate in place, did not have a roommate, and UM #202 would notify maintenance to hang a plastic cover over Resident #02's door with PPE signage and a PPE cart outside the room door. UM #202 verified Resident #02 and Resident #13 tested positive for COVID-19 on 08/29/22. Interview on 08/29/22 at 6:02 P.M. with UM #202 verified she did not wear a gown when testing Resident #02 for COVID-19, and further verified she did not change her face shield or N95 mask after performing testing on Resident #02. Review of the form titled Training Checklist for performing rapid COVID-19 tests, dated September 2020, revealed staff should perform hand hygiene and don gloves, N95, gown and face shield prior to collecting a specimen. Review of UM #202's completed Training Checklist for performing rapid COVID-19 tests revealed UM #202 was trained on 01/25/22. 5) Review of the medical record for Resident #10 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a progress note dated 08/17/22 revealed the facility had a case of COVID-19 in the facility. Continued review revealed no documentation of COVID-19 testing from 08/17/22 through 08/18/22. A review of a progress note dated 08/22/22 revealed Resident #10 tested positive for COVID-19 during facility outbreak testing. Review of the medical record for Resident #13 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a progress note dated 08/16/22 revealed the facility had a case of COVID-19 in the facility. Continued review revealed no documentation of COVID-19 testing from 08/16/22 through 08/26/22. Observation on 08/29/22 at 5:18 P.M., revealed UM #202 testing residents for COVID-19 on the 200-hall due to outbreak status in the facility. Interview and observation at that time, revealed she used the bed board (census sheet) for the day to highlight the residents she tested and marked residents who tested positive with a plus sign. Further interview revealed her process after completing COVID-19 testing on residents included notifying the DON about any residents who tested positive, then discarding the highlighted bed board sheet. Interview on 08/30/22 at 9:25 A.M. with the DON, revealed staff self-tested upon entry to work on Mondays and Thursdays. Staff left their tests in the front office and the DON would document the date, staff name, and results of the tests on individual sheets of paper for each test and each staff. Further interview revealed she is unaware if the facility is verifying all staff were testing twice weekly for COVID-19. Interview on 08/30/22 at 9:35 A.M. with Administrator #01 revealed she could not provide documentation to show staff and residents were being tested for COVID-19 twice weekly per the outbreak protocol of QSO Memorandum 20-38-NH. Interview on 08/30/22 at 9:35 A.M. with Administrator #01, revealed she could not provide documentation to show staff and residents were being tested for COVID-19 twice weekly per the outbreak protocol. Observation at that time, revealed a stack of papers, one for each staff for each test, piled in a box in the front office. The papers were not in any type of chronological order or by staff. Interview on 08/30/22 at 11:40 A.M. with the Administrator #01, verified no COVID-19 outbreak testing was documented for Resident #10 for the outbreak on 08/16/22. Interview on 08/30/22 at 1:58 P.M. with the DON, verified no COVID-19 outbreak testing was documented for Resident #13 for the outbreak on 08/16/22. The DON stated the facility used the QSO Memorandum 20-38 NH to conduct testing and provided a copy to the surveyor. Review of the policy titled QSO Memorandum QSO-20-38-NH, revised 03/10/22, revealed the facility shall document in the resident records that testing was offered, completed (as appropriate t [TRUNCATED]

Based on medical record review, review of hospital documentation, review of emergency medical services (EMS) run report, staff interview, observations, and review of facility policy on [MEDICAL CONDITION] care, the facility failed to follow physician orders for oxygen administration via a [MEDICAL CONDITION] and failed to provide interventions to prevent a resident from repeatedly removing her [MEDICAL CONDITION]. This resulted in Immediate Jeopardy for one resident (#78) who did not receive oxygen as ordered by the physician and did not receive adequate supervision to prevent her from repeatedly removing her [MEDICAL CONDITION], which led to the resident being found with her [MEDICAL CONDITION] removed, without a pulse or respirations, and unable to be resuscitated. This affected one (#78) resident out of three (#78, #32, and #46) residents identified by the facility to have tracheostomies. Additionally, the facility failed to follow their policy to provide a spare [MEDICAL CONDITION] at the bedside for emergencies for one (#46) out of three residents reviewed for tracheostomies. The facility census was 77. On [DATE] at 1:49 P.M., the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 10:15 P.M. when Resident #78 had dislodged her [MEDICAL CONDITION] for the second time since her admission at 7:00 P.M. The facility did not implement any interventions. The resident pulled out the [MEDICAL CONDITION] out again at 11:30 P.M. and was sent to the emergency room . Resident #78 returned to the facility on [DATE] at 3:00 A.M. with no new interventions implemented. She again pulled the [MEDICAL CONDITION] out at 3:30 A.M., at which time Licensed Practical Nurse (LPN) #110 identified the resident to be cyanotic and with a pulse oximetry (SPO2) level of 85% (measure of oxygen in the blood with normal above 90%). On [DATE] at 8:03 A.M. Resident #78 was found unresponsive, without pulse or respirations, and with the [MEDICAL CONDITION] removed and lying beside the resident. Cardiopulmonary resuscitation (CPR) was started, and the emergency squad was called. The emergency squad pronounced Resident #78's death on [DATE] at 8:56 A.M. Additionally, the hospital discharge orders indicated Resident #78 was to receive oxygen at five liters per minute (LPM) via a [MEDICAL CONDITION] mask. There was no evidence any oxygen was implemented for Resident #78 until [DATE] at 3:30 P.M., when LPN #110 applied oxygen at three LPM via a nasal cannula. The Immediate Jeopardy was removed on [DATE] at 11:45 P.M. when all nurses had been educated on [MEDICAL CONDITION] care and transcribing new admission orders [REDACTED]. Additionally the facility implemented the following corrective actions: · On [DATE] at 4:00 P.M. the DON and Unit Managers began educating all licensed nurses on [MEDICAL CONDITION] care and reconciling admission physician orders. Education also began for all staff on the process to manage potentially harmful resident behaviors. The education was completed for all staff members on [DATE] at 11:45 P.M. · On [DATE] the Unit Managers audited the medical records of new admission since [DATE] to ensure hospital discharge physician orders were implemented. · On [DATE] the Minimum Data Set (MDS) Nurse #133 completed an audit of the medical records for all residents in the facility and no residents were identified with behaviors that would affect the status of their health by self removal of devices such as: [MEDICAL CONDITION], gastric feeding tubes, indwelling urinary catheters, [MEDICAL TREATMENT] catheters, and oxygen. · On [DATE] a subcommittee of Quality Assurance and Performance Improvement (QAPI) committee which included the Administrator, DON, Medical Director, MDS Nurse #133, Unit Managers, and the Assistant Director of Nursing (ADON), developed a plan which included: The Infection Control Preventionist, or designee, and a respiratory therapist will develop a protocol for emergency dislodgement of [MEDICAL CONDITION], Unit Managers will begin auditing the records of new admissions, DON, or designee, will audit two random admissions twice a week, and audits will be submitted weekly to the subcommittee for review. · Review of the medical records for Resident #32 and Resident #46, who had tracheostomies, revealed no concerns with the residents attempting to remove their [MEDICAL CONDITION]. Although the Immediate Jeopardy was removed on [DATE], the facility remains 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 is still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: 1. Review of the medical record revealed Resident #78 admitted to the facility on [DATE] at 7:00 P.M. [DIAGNOSES REDACTED]. Review of the hospital records revealed the Advanced Practice Registered Nurse-Certified Nurse Practitioner (APRN/CNP) notes, dated [DATE] at 5:51 P.M. indicated Resident #78 was utilizing a cuffed [MEDICAL CONDITION] (with balloon on the end to secure in place) and supplies included a [MEDICAL CONDITION] mask with humidification at five liters (L). Review of the hospital discharge orders, with a print date of [DATE] at 5:53 P.M., revealed an entry for oxygen via [MEDICAL CONDITION] mask with humidification at five LPM. Review of the facility admission physician orders revealed orders for [MEDICAL CONDITION] care every shift. The oxygen order was not written on the facility admitting orders. There was also an order for [REDACTED]. Review of the Clinical Health Status form, revealed Resident #78 admitted to the facility from a local hospital on [DATE] at 7:00 P.M. The form indicates the resident appeared anxious, was cognitively impaired with poor decision making skills, was to have oxygen at five LPM via [MEDICAL CONDITION], and had behaviors of pulling tubes out. Review of the undated facility form titled Nurse Tech Information Kardex for Resident #78 revealed the resident was to receive oxygen at five liters per minute via [MEDICAL CONDITION]. A notation under the Behavior Interventions section documented Frequent monitoring, resident pulls [MEDICAL CONDITION] out. Review of the nurses' notes on [DATE] at 7:00 P.M., revealed LPN #125 documented revealed she entered Resident #78's room to discover resident was sitting on the side of the bed pulling off electrocardiogram stickers. Resident #78 had removed her hospital gown and had dislodged the [MEDICAL CONDITION]. LPN #125 repositioned the [MEDICAL CONDITION] and refastened the straps to hold the [MEDICAL CONDITION] in place. LPN #125 then assisted Resident #78 to redress and helped to back bed. Review of a nurses' note dated [DATE] at 10:15 P.M., revealed LPN #135 an unidentified State tested Nurse Aide (STNA) had went to check on Resident #78 and the resident had pulled her [MEDICAL CONDITION] out. The [MEDICAL CONDITION] was reinserted with no problems. There was no evidence any new interventions had been implemented at this time to prevent Resident #78 from pulling out her [MEDICAL CONDITION]. Review of a nurses' note dated [DATE] at 11:30 P.M. revealed LPN #135 had checked on Resident #78 and discovered the [MEDICAL CONDITION] had been pulled out again. Resident #78 was breathing normally with SPO2 levels between 94 and 95%. The [MEDICAL CONDITION] was reinserted and Resident #78 was sent to the emergency room for evaluation. Review of the nurses' note dated [DATE] at 3:00 A.M., by LPN #110, Resident #78 returned to the facility and the [MEDICAL CONDITION] was in place. There was no evidence of any new interventions being put into place. A nurses' note at 3:30 A.M. revealed Resident #78 was again discovered with the [MEDICAL CONDITION] removed. LPN #110 documented oxygen was applied at three LPM via nasal cannula to bring the resident's SPO2 level up to 93%. There was no documentation of a respiratory assessment or of the resident's SPO2 level prior to the application of oxygen. Nurses' notes documented at 4:00 A.M., 4:30 A.M., 5:00 A.M., 5:30 A.M., 6:00 A.M. and 6:30 A.M. revealed Resident #78 was observed resting comfortable with SPO2 levels of 90% to 94% with oxygen at three LPM via nasal cannula. On [DATE] at 7:00 A.M. LPN #110 documented an observation with the oncoming nurse. Resident #78 was able to blink in response to questions and her SPO2 level was at 94% on three liters oxygen via nasal cannula. Review of the physician orders revealed no order for the oxygen at three LPM until [DATE], when LPN #110 wrote a physician's order, which was back dated to [DATE], for oxygen prn for oxygen saturations less then 90% on room air, not to exceed five LPM. The physician signed this order on [DATE]. Review the nurses' note dated [DATE] by LPN #120 revealed she had observed Resident #78 at 7:10 A.M. with the previous nurse. At 7:30 A.M. LPN #120 was in the room with Resident #78 and the [MEDICAL CONDITION] was in place. At 8:05 A.M., LPN #120 was called into Resident #78's room by an unidentified staff. Resident #78 noted to have no pulse and the [MEDICAL CONDITION] was removed and next to the resident. LPN #120 confirmed code status and began chest compressions. The EMS was called and arrived at 8:20 A.M. and assumed care of Resident #78. Review of the local EMS run report, dated [DATE], revealed the squad was at the facility at 8:20 A.M. Staff reported to the EMS the resident had been pulling the [MEDICAL CONDITION] out with the balloon inflated. Documentation revealed [MEDICAL CONDITION] suctioning removed a large clot from the end of the [MEDICAL CONDITION] with ventilation of the resident being easier. At 8:53 A.M. the resuscitative efforts were ceased and the resident was pronounced expired at 8:56 A.M. Interview on [DATE] at 12:48 P.M., LPN #110 revealed Resident #78 had pulled out the [MEDICAL CONDITION] twice prior to his shift start on [DATE] at 11:00 P.M. LPN #110 stated Resident #78 had pulled out the [MEDICAL CONDITION] around 11:30 P.M. and it was able to be replaced in the facility. Emergency squad had already been called and transported Resident #78 to the emergency room . The resident returned to the facility at approximately 3:00 A.M. After return to the facility, Resident #78 pulled the [MEDICAL CONDITION] out once again and LPN #110 was able to replace it without difficulty. At that time Resident #78 was placed on half hour visual checks related to having pulled out the [MEDICAL CONDITION], which LPN #110 completed throughout the remaining shift. LPN #110 stated an oxygen concentrator was in Resident #78's room when his shift began. There was nasal cannula tubing available, but there were no [MEDICAL CONDITION] masks in the facility. An additional interview with LPN #110 on [DATE] at 3:35 P.M. revealed he had applied oxygen to Resident #78 at 3:30 A.M., after she was observed with the [MEDICAL CONDITION] out, for the fourth time, and was cyanotic with a SPO2 level of 85 %. He applied the oxygen, via nasal cannula, while reinserting the [MEDICAL CONDITION]. LPN #110 could not explain why he had not applied the oxygen to the [MEDICAL CONDITION]. Telephone interview on [DATE] at 7:10 P.M., LPN #120 revealed she was the nurse on duty on [DATE] at 7:00 A.M. She reported she had observed Resident #78 at approximately 7:10 A.M. with the off-going nurse and Resident #78 was noted to be resting comfortably, with the [MEDICAL CONDITION] in place and secure and she blinked her eyes when spoken to. LPN #120 stated she observed Resident #78 again at 7:35 A.M. and no changes were noted. She was alerted to Resident #78 needing care at approximately 8:00 A.M. Upon entering the room, Resident #78 was noted to be unresponsive and pulseless, with [MEDICAL CONDITION] lying beside her on the bed. LPN #120 ensured code status and immediately began chest compressions. LPN #155 and LPN #160 arrived to the room and assisted with cardiopulmonary resuscitation (CPR) and replacing the [MEDICAL CONDITION]. When the EMS arrived they assumed care of Resident #78. Interview on [DATE] at 9:09 A.M., the DON verified verified the written orders from the hospital included oxygen via [MEDICAL CONDITION] mask at five liters per minute and there was no documentation of Resident #78 ever having oxygen delivered via [MEDICAL CONDITION] mask. Interview on [DATE] at 10:12 A.M., LPN #125 revealed she had been on duty when Resident #78 arrived at the facility. LPN #125 stated she had received a verbal report from the hospital and was told Resident #78 was on room air. When Resident #78 arrived at the facility, via transport, she did not have any oxygen equipment. LPN #125 stated she had obtained [MEDICAL CONDITION] care supplies, an oxygen concentrator, nasal cannula tubing, and an emergency inner cannula. Upon LPN #125's return to the room, less than ten minutes later, Resident #78 was noted to be sitting on the side of the bed, pulling electrocardiogram stickers off her chest. Resident #78's gown was askew and the [MEDICAL CONDITION] ties were loose. LPN #125 assisted Resident #78 back into bed and retied the [MEDICAL CONDITION] ties. LPN #78 stated Resident #78 was non-verbal and confused. LPN #125 stated she had not reviewed the hospital orders as she was going off-shift. Interview on [DATE] at 10:57 A.M., with LPN #155 revealed she had participated in performing CPR for Resident #78 on [DATE]. Upon her entrance into the room she observed the [MEDICAL CONDITION] was lying on the bed beside Resident #78. LPN #155 stated she had reinserted the [MEDICAL CONDITION] and held it in place as the ties were not found until the EMS arrived and took over care. Interview on [DATE] at 11:10 A.M., LPN #135 revealed she had been the nurse on duty from 7:00 P.M. to 11:30 P.M. on [DATE]. She stated she had received a verbal report from LPN #125 stating Resident #78 was on room air and had dislodged the [MEDICAL CONDITION] while pulling stickers off her chest. LPN #135 stated she had transcribed the hospital admission orders [REDACTED].M. with the [MEDICAL CONDITION] found on the bed. LPN #135 stated she had called the DON and was instructed to send the resident to the emergency room if was removed again. Resident #78 had pulled the [MEDICAL CONDITION] out again at 11:15 P.M. and the on-coming nurse, LPN #110, sent her to the emergency room for an assessment. Interview on [DATE] at 4:11 P.M. with the Administrator revealed the facility had not provided adequate supervision to prevent Resident #78 from pulling her [MEDICAL CONDITION] out. Interview on [DATE] at 10:16 A.M., Respiratory Therapist #400 stated a resident with a [MEDICAL CONDITION] should receive supplemental oxygen through the [MEDICAL CONDITION] and administering it through the nasal cavity was not beneficial. 2. Review of the medical record of Resident #46 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Observation on [DATE] at 10:54 A.M. of Resident #46's bedside supplies revealed there was no extra [MEDICAL CONDITION] with an obturator at the resident's bedside. Interview and observation on [DATE] at 11:08 A.M. with Assistant Director of Nursing (ADON) #105 verified the lack of an extra [MEDICAL CONDITION] with obturator available at the bedside for Resident #46. Interview on [DATE] at 12:20 P.M. with LPN #105 confirmed there should be an extra [MEDICAL CONDITION] at the bedside available in case of emergencies. LPN #105 stated he would normally check this every shift but had not checked to make sure one was available that day. Review of the facility policy titled [MEDICAL CONDITION] Care, last revised ,[DATE], revealed a replacement [MEDICAL CONDITION] must always be available at the bedside. This deficiency substantiates Complaint Number OH 417.

Based on observations, review of medical records, review of a police report, review of the facility Self-Reported Incident (SRI), review of the facility policy titled Resident Abuse, review of in-service records, and interviews with residents and staff, the facility failed to implement the facility abuse policy of reporting an allegation of threat to cause bodily harm and to protect a resident form the threat, when Resident #20's verbal threat to cause bodily harm to Resident #10 was made and then acted upon. This resulted in Immediate Jeopardy when Resident #20 acted upon his threat by punching Resident #10 repeatedly in the face with a closed fist causing serious injuries to Resident #10 who sustained multiple fractures of the nose, a laceration of the lip, a chipped tooth and contusions to the right eye. Resident #10 was subsequently hospitalized for [REDACTED]. This affected one (#10) of three residents reviewed for abuse. The facility census was 78. On 08/15/18 at 2:19 P.M., the Interim Administrator, Corporate Clinical Support (CCS) #05, and the Director of Nursing (DON) were notified Immediate Jeopardy began on 07/13/18 at 7:00 A.M. when Resident #20 threatened bodily harm to his roommate (Resident #10) and the facility staff failed to act upon the threat made and provide interventions to protect Resident #10. On 07/28/18 at 8:30 A.M., a commotion was heard coming from the room of Resident #20 and Resident #10 when staff entered the room, Resident #20 was observed repeatedly punching Resident #10 in the face with a closed fist which resulted in a fractured nose, laceration of the lip, a chipped tooth, and contusions to the right eye. Resident #10 was subsequently hospitalized for [REDACTED]. The Immediate Jeopardy was removed on 08/15/18 at 7:00 P.M., when the facility implemented the following corrective actions: On 07/28/18 at 8:30 A.M., Resident #20 was immediately separated from Resident #10, placed in a private resident room, until the resident was transported to the hospital for a psychiatric evaluation. · On 07/28/18 at approximately 8:35 A.M., the facility sent Resident #10 to the local emergency room for treatment of [REDACTED]. · On 07/28/18 at 3:30 P.M., Resident #20 was sent to the hospital for a psychiatric evaluation. · On 07/30/18, both Resident #20 and #10 were seen for a psychological evaluation. · On 07/30/18, the Quality Assessment and Assurance (QAA) team met, including the Interdisciplinary Team, to review monitoring resident behavior and interventions. · On 08/15/18, the facility completed the SRI for the 07/13/18 incident where Resident #20 made the verbal threat of bodily harm to Resident #10. · On 08/15/18, the facility began monitoring for potential abuse by randomly interviewing five staff members three times a week for four weeks and randomly thereafter for alleged incidents of abuse. The facility will complete random interviews with five cognitively intact residents three times a week for four weeks. The interviews will be completed by the DON or designee. · On 08/15/18, the facility began auditing nurse's notes, one time a day, for three days a week for four weeks. The audits will be conducted by the DON or designee. · On 08/15/18, beginning at 3:00 P.M. to 5:00 P.M., interviews were conducted with all residents that were assessed as being moderately impaired to cognitively intact to screen for threats made against them, knowledge of abuse occurring, reports of any allegations or if they felt safe in the facility. These interviews were conducted by the Administrative staff, DON or designee. Residents who were severely cognitively impaired were assessed for physical signs of abuse by the DON of floor staff nurse. · On 08/15/18, beginning at 3:00 P.M. to 7:00 P.M., all facility staff were educated on the Abuse Policy and Procedure, behavior management, abuse reporting and the chain of command for reporting and how to report allegations. Review of the in-service sheets verified all nursing staff and ancillary staff were in-serviced by facility administration or DON. Although the Immediate Jeopardy was removed on 08/15/18 at 7:00 P.M., when Resident #20 was removed from the same room as Resident #10 and placed in a private room until transport to the hospital, and Resident #10 was sent to the emergency room for treatment and the facility in-serviced staff, the facility remained 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 in the process of implementing their corrective action of auditing and monitoring to ensure on-going compliance. Findings include: Review of Resident #20's medical record revealed an admission date of [DATE] at 2:30 P.M. The resident had [DIAGNOSES REDACTED]. Review of the behavior care plan for Resident #20 dated 07/13/18 revealed Resident #20 displayed behavior problems such as swearing and being combative towards staff. Resident #20 is a new admission and needs time to adjust. The goal indicated Resident #20 would have no evidence of behavior problems of being combative/swearing by review date. Interventions on 07/13/18 included the following: anticipate and meet the resident's needs; caregivers to provide opportunity for positive interaction, attention, stop and talk with him as passing by; if reasonable, discuss the resident's behavior; explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; intervene as necessary to protect the rights and safety of others; approach/speak in a calm manner, divert attention, remove from situation and take to alternate location as needed; and praise any indication of the resident's progress/improvement in behavior. Review of Resident #20's Nurses Notes dated 07/13/18 at 7:00 A.M., documented by Registered Nurse (RN) #520, revealed the resident was very hostile, cursing, throwing room items, and lunging at staff. The resident was angry because his roommate had the television on and was snoring. Resident #20 was heard threatening to do bodily harm to roommate. RN #520 talked to the resident and he began to calm down. RN #520 documented she will pass the information on to Social Services, that resident wants to leave. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed as being cognitively intact and having had no behavior symptoms or rejection of care in the assessment period. There was no [MEDICAL CONDITION] noted. The functional status revealed Resident #20 was independent with set up only with bed mobility, transfers, walking in the room and corridor, locomotion on and off the unit, and independent with one assist with toileting. The resident was extensive assistance with one assist with hygiene and dressing. Resident #20 had not received any antidepressant, antianxiety, antipsychotic, hypnotic, opioid, diuretic, antibiotic, or anticoagulants in the assessment period. Review of Resident #20's behavior charting revealed no episodes of cursing or throwing things since 07/13/18 until 07/28/18. Review of the SRI dated 07/28/18 at 8:30 A.M. revealed Resident #20 and Resident #10 got into a verbal altercation. Staff heard a commotion and upon entering the room, Resident #20 was striking Resident #10 with a closed fist. The residents were separated with one-to-one therapeutic communication provided. The police were called. Resident #10 was sent to the emergency room to be evaluated. Resident #20 was sent to the hospital for psychiatric evaluation and returned to the facility after the physician cleared him as not being an imminent danger to himself or others or needing hospitalization . Review of the hospital record dated 07/28/18 at 4:06 P.M. revealed Resident #20 was evaluated after punching another resident at the nursing home. The resident was remorseful and apologetic. The plan documented the resident was being discharged back to the nursing home as he did not meet the criteria for inpatient hospitalization . The resident is not an imminent danger to himself or others. Review of the behavior care plan for Resident #20 revealed the care plan was updated on 07/28/18 and revealed new interventions to include psychiatric evaluation, room change due to behavior and [MEDICATION NAME] medication added. Review of the nurse's note dated 07/29/18 at 12:45 A.M. revealed Resident #20 was returned to the facility and placed in a private room. Review of the physician notes of a psychological evaluation dated 07/30/18 revealed Resident #20 had [MEDICAL CONDITION] disorder, current episode depressed, mild (new) and the plan on 07/30/18 was to start Resident #20 on [MEDICATION NAME] 20 milligrams daily, due to Resident #20 had been easily excitable repeatedly as reported by staff and has been reported to lash out at others. Resident #20 also had assaulted another resident over the weekend on 07/28/18. Observation on 08/14/18 at 9:10 A.M. of Resident #20 revealed he was well groomed and dressed appropriately. He was using a cane to ambulate and had a visible contracture of the elbow on the left side. Interview on 08/14/18 at 9:11 A.M. with Resident #20 revealed he changed rooms because he didn't get along with the roommate, Resident #10. Resident #20 stated Resident #10 wanted to fight and Resident #20 broke Resident #10's nose. Resident #20 stated he wasn't going to back down and wasn't afraid of anything. Resident #20 stated he threw the first punch and Resident #10 wanted to fight, and he wasn't going to pass it up. Resident #20 stated Resident #10 didn't call him any names, it is over and done with, and he doesn't want to talk about it anymore. Resident #20 stated he had no injuries from the incident. Review of the Resident #10's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #10's MDS assessment dated [DATE] revealed the resident was assessed as being severely cognitively impaired. Resident #10 required extensive assistance with one assist for bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #10 was independent with set up help only. Review of the behavior care plan for Resident #10 revealed an initiation date of 04/20/17. The care plan revealed the resident had impaired/inappropriate behaviors and moods. The plan identified Resident #10 as having the behaviors of yelling and racial remarks related to cognitive loss, [MEDICAL CONDITION] diagnosis, ineffective coping skills, ineffective impulse control, [MEDICAL CONDITION] and medication use. Review of Resident #10's Nurses Notes dated 07/28/18 at 8:30 A.M. revealed a nurse was called to room [ROOM NUMBER] by State tested Nurse Aide (STNA) ID # 400. STNA #400 informed the nurse that the residents were verbally fighting. When the LPN #500 entered the room, Resident #20 was on Resident #10's side of the room. Blood was around Resident #10's mouth and he had swelling above his right eye. A call was placed to Unit Manager RN #250 and to Resident #10's sister and they were informed of the incident. A call was placed to the police and the police advised the nurse to send Resident #10 to the local emergency room for evaluation. Resident #10 was sent to the local emergency room . Review of the police report dated 07/28/18, documented the police were dispatched to the facility to address a report of assault. Upon our arrival, Licensed Practical Nurse (LPN) #500 stated two patients (Residents #10 and #20) began arguing and Resident #20 punched Resident #10 in the face. LPN #500 further stated that both men have severe mental and physical disabilities. Resident #10 was transported to the local hospital for extreme minor injuries to the face. LPN #500 also stated Resident #20 was rehoused to a different room in the facility. Review of Resident #10's nurses note dated 07/28/18 at 1:00 P.M. revealed the facility received a call from the local emergency room and was informed Resident #10 had a fractured nose and they would call back later to inform the facility if Resident #10 would be admitted . A nurse's note dated 07/28/18 at 9:00 P.M. revealed a facility nurse called the local hospital to check on the status of Resident #10 and was informed he was admitted with numerous nasal fractures, contusions, laceration of the lip, and dental issues. Review of the nurses notes from 07/30/18 at 12:40 P.M. revealed Resident #10 returned to the facility via stretcher at 12:30 P.M. Bruising around the right eye was noted. Resident #10 verbally denied pain and his nonverbal pain score was zero. The call light was within reach, and all safety precautions were in place. Review Resident #10's hospital discharge records dated 07/30/18 revealed Resident #10 had fractured nasal bones, laceration of the lip, dental injury (chipped tooth), and contusion of the right eye. Review of the physician note for a psychological evaluation dated 07/30/18 revealed Resident #10 verified he called his roommate (Resident #20) a vulgar name because Resident #20 gets on his nerves. Resident #10 stated he felt safe in the facility. Observation on 08/14/18 at 8:55 A.M. of Resident #10 revealed he was lying in bed and was unable to move his left arm. The resident had a light yellowish discoloration above his right eye. Interview on 08/14/18 at 8:55 A.M. with Resident #10 revealed on 07/28/18 around 8:30 A.M., he was lying in bed and stated he called Resident #20 a derogatory name because he was tired of him and how he acted. Resident #10 stated he didn't have to put up with it. Resident #10 stated Resident #20 took advantage of him, since he was unable to defend himself, and he came over to his side of the room and started hitting him in the face. Resident #10 stated all the aides came running in the room when they heard a commotion. Resident #10 stated couldn't remember exactly what happened after the aides came into the room and he was sent to the hospital for a couple days and had a broken nose, and a bruised right eye. Resident #10 stated the facility moved Resident #20 out of his room right away and has not been in his room since. Interview on 08/14/18 at 10:27 A.M. with STNA #400 revealed she was a witness to the incident on 07/28/18 between Residents #10 and #20. STNA #400 stated she was in the dining room and heard Residents #20 and #10 yelling and arguing in their room. STNA #400 went down the hall to investigate and when she got to room [ROOM NUMBER], she could hear a punching noise, like something getting hit. Another STNA #410, arrived at room [ROOM NUMBER] first, and STNA #400 observed STNA #410 pull Resident #20 off Resident #10. STNA #400 stated Resident #10 has paralysis on his left side and was unable to protect to himself and looked stunned after the incident happened. STNA #400 stated Resident #10's mouth was bleeding and his right eye was swollen. STNA #400 stated they had Resident #20 leave the room. STNA #400 stated they informed LPN #500 of the incident and then she went to get a cold compress for Resident #10. STNA #400 stated Residents #10 and #20 had never had an incident like that before and there has not been another incident since 07/28/18 with Residents #10 and #20. Interview on 08/14/18 at 10:50 A.M. with Social Services Director (SSD) #320 revealed she was not here the day of the altercation between Residents #10 and #20 on 07/28/18. SSD #320 stated she spoke to Residents #10 and #20 the following Monday and they were both back to themselves. Further interview on 08/14/18 at 3:13 P.M. revealed SSD #320 stated she was never notified of the incident on 07/13/18 of Resident #20 threatening to do bodily harm to Resident #10. On 07/16/18, SSD #320 stated she was stopped in the hallway by STNA #400 and was told she needed to talk with Resident #20 because he was not nice to the aides. SSD #320 stated she told STNA #400 that Resident #20 had been homeless, to just walk away and let him calm down and go back in fifteen minutes and try again. SSD #320 stated a second STNA #430, told her Resident #20 was swearing at the aides and she told her to walk away and wait fifteen minutes and then go back. SSD #320 again verified that no one had reported to her of the threat made by Resident #20, or she would have had moved the resident's rooms right away. SSD #320 did not recall speaking to RN #520 about Resident #20 making a threat. Interview on 08/14/18 at 11:04 A.M. with LPN #500 revealed one of the STNAs #400 came down the hall and stated Resident #20 was threatening to hit Resident #10. LPN #500 stated by the time she got to the room, Resident #20 had already hit Resident #10. LPN #500 stated she called the physician, the on-call supervisor, family, and the police. Resident #10 was sent to the local emergency room , and she was later notified that Resident #10 had a broken nose and was admitted to the hospital. Resident #20 was removed from the incident and was put in another room by himself, that same day, until he was sent out for a psychiatric evaluation and had medications adjusted. Interview on 08/14/18 at 3:20 P.M. with RN #520 revealed she had thought Resident #20 had wanted to cause bodily harm to STNA #420, not the roommate on 07/13/18. RN #520 stated she had caught SSD #320 walking in the hallway, the morning after her shift, and started to tell her of the incident with Resident #20. RN #520 stated SSD #320 cut her off and stated STNA #420 had already told her. Interview on 08/15/18 at 7:43 A.M. with STNA #420 revealed she worked on the night shift of 07/13/18 and stated Resident #20 was being very hostile and she called RN #520 to come down to the room. Resident #20 stood very fast and lunged toward STNA #420, but he was talking about harming his roommate, who is Resident #10. STNA #420 stated Resident #20 shouted I am going to hit him (Resident #10) and hurt him. STNA #420 stated she spoke to SSD #320 in passing in the hall, but STNA #420 was headed out the door as she was off the clock. STNA #420 stated Residents #20 and #10 would argue for a few minutes about something brief and STNA #420 would tell them to quiet down and they would. STNA #420 verified she told her supervisor RN #520 that night that he threatened bodily harm to his roommate. She just wanted to talk to SSD #320 about Resident #20 being nasty to the staff. Interview on 08/15/18 at 1:30 P.M. with the Regional Corporate Nurse #40 revealed she completed the abuse investigation from the incident on 07/28/18. Regional Corporate Nurse #40 revealed a Self-Reported Incident (SRI) was filed on 07/28/18, the same day of the event, for resident to resident physical abuse. She stated it was unsubstantiated because after talking with Resident #20, she thought he wasn't willful in his intent. Regional Corporate Nurse #40 stated Resident #20 had a history of [REDACTED].#20. She also verified no facility staff had reported the threat made by Resident #20 on 07/13/18 to management, so there was no investigation or SRI completed. Regional Corporate Nurse #40 verified the facility staff did not follow the policy. Review of the facility policy titled Resident Abuse, revised 02/01/17, revealed Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Psychological/Emotional Abuse is defined as humiliation, harassment, malicious teasing, threats of punishment or deprivation. Procedure: acts of abuse directed against residents are absolutely prohibited. Such acts are cause for disciplinary action, including and possible criminal prosecution. Prevention: The company is committed to the prevention of abuse, neglect, or misappropriation of property. Sufficient numbers of staff to meet the needs of the residents. Department heads that monitor staff to identify inappropriate behavior. Monitoring of residents who may be at risk is the responsibility of all facility staff. This includes monitoring residents who are at risk or vulnerable for abuse, for indications of changes in behavior, changes in condition or other non-verbal indication of abuse. Procedures for Reporting Abuse: Any employee, who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and to other officials in accordance with State law. In the absence of the Executive Director, the Director of Clinical Services is the designated abuse coordinator. Once an allegation of abuse is reported, the abuse coordinator is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulation, including notification of law enforcement if a reasonable suspicion of crime has occurred. In all cases, the Executive Director or Director of Clinical Services will ensure notification to the residents' legal guardian, family member, responsible party or significant other of the alleged, suspected or observed abuse, neglect or mistreatment, and the residents attending physician. Investigation: The abuse coordinator shall investigate all reports or allegations of abuse. A social service representative may be offered the role of resident advocate during any questioning of or interviewing of residents. Preliminary Investigation: Immediately upon an allegation of abuse or neglect, the suspect shall be segregated from residents pending the investigation resident of the allegation. Investigation: The abuse coordinator shall take statements from the victim, the suspect and all possible witnesses including all other employees near the alleged abuse. The abuse coordinator shall secure all physical evidence. Upon completion of the investigation, a detailed report shall be prepared. Review of the Report: report the results of all investigations to the Executive Director or their designated representative and to other officials in accordance with state law, including to the state survey agency within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This deficiency substantiates the allegations contained in Compliant Number OH 412.

Based on observations, review of medical records, review of a police report, review of the facility Self-Reported Incident (SRI), review of the facility policy titled Resident Abuse, review of in-service records, and interviews with residents and staff, the facility failed to report a verbal threat made by a resident against another resident to cause bodily harm, to the Administrator and the State Agency. This resulted in Immediate Jeopardy when Resident #20 acted upon his threat by punching Resident #10 repeatedly in the face with a closed fist causing serious injuries to Resident #10 who sustained multiple fractures of the nose, a laceration of the lip, a chipped tooth and contusions to the right eye. Resident #10 was subsequently hospitalized for [REDACTED]. This affected one (#10) of three residents reviewed for abuse. The facility census was 78. On 08/15/18 at 2:19 P.M., the Interim Administrator, Corporate Clinical Support (CCS) #05, and the Director of Nursing (DON) were notified Immediate Jeopardy began on 07/13/18 at 7:00 A.M. when Resident #20 threatened bodily harm to his roommate (Resident #10) and the facility staff failed to act upon the threat made and provide interventions to protect Resident #10. On 07/28/18 at 8:30 A.M., a commotion was heard coming from the room of Resident #20 and Resident #10 when staff entered the room, Resident #20 was observed repeatedly punching Resident #10 in the face with a closed fist which resulted in a fractured nose, laceration of the lip, a chipped tooth, and contusions to the right eye. Resident #10 was subsequently hospitalized for [REDACTED]. The Immediate Jeopardy was removed on 08/15/18 at 7:00 P.M., when the facility implemented the following corrective actions: · On 07/28/18 at 8:30 A.M., Resident #20 was immediately separated from Resident #10, placed in a private resident room, until the resident was transported to the hospital for a psychiatric evaluation. · On 07/28/18 at approximately 8:35 A.M., the facility sent Resident #10 to the local emergency room for treatment of [REDACTED]. · On 07/28/18 at 3:30 P.M., Resident #20 was sent to the hospital for a psychiatric evaluation. · On 07/30/18, both Resident #20 and #10 were seen for a psychological evaluation. · On 07/30/18, the Quality Assessment and Assurance (QAA) team met, including the Interdisciplinary Team, to review monitoring resident behavior and interventions. · On 08/15/18, the facility completed the SRI for the 07/13/18 incident where Resident #20 made the verbal threat of bodily harm to Resident #10. · On 08/15/18, the facility began monitoring for potential abuse by randomly interviewing five staff members three times a week for four weeks and randomly thereafter for alleged incidents of abuse. The facility will complete random interviews with five cognitively intact residents three times a week for four weeks. The interviews will be completed by the DON or designee. · On 08/15/18, the facility began auditing nurse's notes, one time a day, for three days a week for four weeks. The audits will be conducted by the DON or designee. · On 08/15/18, beginning at 3:00 P.M. to 5:00 P.M., interviews were conducted with all residents that were assessed as being moderately impaired to cognitively intact to screen for threats made against them, knowledge of abuse occurring, reports of any allegations or if they felt safe in the facility. These interviews were conducted by the Administrative staff, DON or designee. Residents who were severely cognitively impaired were assessed for physical signs of abuse by the DON of floor staff nurse. · On 08/15/18, beginning at 3:00 P.M. to 7:00 P.M., all facility staff were educated on the Abuse Policy and Procedure, behavior management, abuse reporting and the chain of command for reporting and how to report allegations. Review of the in-service sheets verified all nursing staff and ancillary staff were in-serviced by facility administration or DON. Although the Immediate Jeopardy was removed on 08/15/18 at 7:00 P.M., when Resident #20 was removed from the same room as Resident #10 and placed in a private room until transport to the hospital, and Resident #10 was sent to the emergency room for treatment and the facility in-serviced staff, the facility remained 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 in the process of implementing their corrective action of auditing and monitoring to ensure on-going compliance. Findings include: Review of Resident #20's medical record revealed an admission date of [DATE] at 2:30 P.M. The resident had [DIAGNOSES REDACTED]. Review of the behavior care plan for Resident #20 dated 07/13/18 revealed Resident #20 displayed behavior problems such as swearing and being combative towards staff. Resident #20 is a new admission and needs time to adjust. The goal indicated Resident #20 would have no evidence of behavior problems of being combative/swearing by review date. Interventions on 07/13/18 included the following: anticipate and meet the resident's needs; caregivers to provide opportunity for positive interaction, attention, stop and talk with him as passing by; if reasonable, discuss the resident's behavior; explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; intervene as necessary to protect the rights and safety of others; approach/speak in a calm manner, divert attention, remove from situation and take to alternate location as needed; and praise any indication of the resident's progress/improvement in behavior. Review of Resident #20's Nurses Notes dated 07/13/18 at 7:00 A.M., documented by Registered Nurse (RN) #520, revealed the resident was very hostile, cursing, throwing room items, and lunging at staff. The resident was angry because his roommate had the television on and was snoring. Resident #20 was heard threatening to do bodily harm to roommate. RN #520 talked to the resident and he began to calm down. RN #520 documented she will pass the information on to Social Services, that resident wants to leave. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed as being cognitively intact and having had no behavior symptoms or rejection of care in the assessment period. There was no [MEDICAL CONDITION] noted. The functional status revealed Resident #20 was independent with set up only with bed mobility, transfers, walking in the room and corridor, locomotion on and off the unit, and independent with one assist with toileting. The resident was extensive assistance with one assist with hygiene and dressing. Resident #20 had not received any antidepressant, antianxiety, antipsychotic, hypnotic, opioid, diuretic, antibiotic, or anticoagulants in the assessment period. Review of Resident #20's behavior charting revealed no episodes of cursing or throwing things since 07/13/18 until 07/28/18. Review of the SRI dated 07/28/18 at 8:30 A.M. revealed Resident #20 and Resident #10 got into a verbal altercation. Staff heard a commotion and upon entering the room, Resident #20 was striking Resident #10 with a closed fist. The residents were separated with one-to-one therapeutic communication provided. The police were called. Resident #10 was sent to the emergency room to be evaluated. Resident #20 was sent to the hospital for psychiatric evaluation and returned to the facility after the physician cleared him as not being an imminent danger to himself or others or needing hospitalization . Review of the hospital record dated 07/28/18 at 4:06 P.M. revealed Resident #20 was evaluated after punching another resident at the nursing home. The resident was remorseful and apologetic. The plan documented the resident was being discharged back to the nursing home as he did not meet the criteria for inpatient hospitalization . The resident is not an imminent danger to himself or others. Review of the behavior care plan for Resident #20 revealed the care plan was updated on 07/28/18 and revealed new interventions to include psychiatric evaluation, room change due to behavior and [MEDICATION NAME] medication added. Review of the nurse's note dated 07/29/18 at 12:45 A.M. revealed Resident #20 was returned to the facility and placed in a private room. Review of the physician notes of a psychological evaluation dated 07/30/18 revealed Resident #20 had [MEDICAL CONDITION] disorder, current episode depressed, mild (new) and the plan on 07/30/18 was to start Resident #20 on [MEDICATION NAME] 20 milligrams daily, due to Resident #20 had been easily excitable repeatedly as reported by staff and has been reported to lash out at others. Resident #20 also had assaulted another resident over the weekend on 07/28/18. Observation on 08/14/18 at 9:10 A.M. of Resident #20 revealed he was well groomed and dressed appropriately. He was using a cane to ambulate and had a visible contracture of the elbow on the left side. Interview on 08/14/18 at 9:11 A.M. with Resident #20 revealed he changed rooms because he didn't get along with the roommate, Resident #10. Resident #20 stated Resident #10 wanted to fight and Resident #20 broke Resident #10's nose. Resident #20 stated he wasn't going to back down and wasn't afraid of anything. Resident #20 stated he threw the first punch and Resident #10 wanted to fight, and he wasn't going to pass it up. Resident #20 stated Resident #10 didn't call him any names, it is over and done with, and he doesn't want to talk about it anymore. Resident #20 stated he had no injuries from the incident. Review of the Resident #10's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #10's MDS assessment dated [DATE] revealed the resident was assessed as being severely cognitively impaired. Resident #10 required extensive assistance with one assist for bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #10 was independent with set up help only. Review of the behavior care plan for Resident #10 revealed an initiation date of 04/20/17. The care plan revealed the resident had impaired/inappropriate behaviors and moods. The plan identified Resident #10 as having the behaviors of yelling and racial remarks related to cognitive loss, [MEDICAL CONDITION] diagnosis, ineffective coping skills, ineffective impulse control, [MEDICAL CONDITION] and medication use. Review of Resident #10's Nurses Notes dated 07/28/18 at 8:30 A.M. revealed a nurse was called to room [ROOM NUMBER] by State tested Nurse Aide (STNA) ID # 400. STNA #400 informed the nurse that the residents were verbally fighting. When the LPN #500 entered the room, Resident #20 was on Resident #10's side of the room. Blood was around Resident #10's mouth and he had swelling above his right eye. A call was placed to Unit Manager RN #250 and to Resident #10's sister and they were informed of the incident. A call was placed to the police and the police advised the nurse to send Resident #10 to the local emergency room for evaluation. Resident #10 was sent to the local emergency room . Review of the police report dated 07/28/18, documented the police were dispatched to the facility to address a report of assault. Upon our arrival, Licensed Practical Nurse (LPN) #500 stated two patients (Residents #10 and #20) began arguing and Resident #20 punched Resident #10 in the face. LPN #500 further stated that both men have severe mental and physical disabilities. Resident #10 was transported to the local hospital for extreme minor injuries to the face. LPN #500 also stated Resident #20 was rehoused to a different room in the facility. Review of Resident #10's nurses note dated 07/28/18 at 1:00 P.M. revealed the facility received a call from the local emergency room and was informed Resident #10 had a fractured nose and they would call back later to inform the facility if Resident #10 would be admitted . A nurse's note dated 07/28/18 at 9:00 P.M. revealed a facility nurse called the local hospital to check on the status of Resident #10 and was informed he was admitted with numerous nasal fractures, contusions, laceration of the lip, and dental issues. Review of the nurses notes from 07/30/18 at 12:40 P.M. revealed Resident #10 returned to the facility via stretcher at 12:30 P.M. Bruising around the right eye was noted. Resident #10 verbally denied pain and his nonverbal pain score was zero. The call light was within reach, and all safety precautions were in place. Review Resident #10's hospital discharge records dated 07/30/18 revealed Resident #10 had fractured nasal bones, laceration of the lip, dental injury (chipped tooth), and contusion of the right eye. Review of the physician note for a psychological evaluation dated 07/30/18 revealed Resident #10 verified he called his roommate (Resident #20) a vulgar name because Resident #20 gets on his nerves. Resident #10 stated he felt safe in the facility. Observation on 08/14/18 at 8:55 A.M. of Resident #10 revealed he was lying in bed and was unable to move his left arm. The resident had a light yellowish discoloration above his right eye. Interview on 08/14/18 at 8:55 A.M. with Resident #10 revealed on 07/28/18 around 8:30 A.M., he was lying in bed and stated he called Resident #20 a derogatory name because he was tired of him and how he acted. Resident #10 stated he didn't have to put up with it. Resident #10 stated Resident #20 took advantage of him, since he was unable to defend himself, and he came over to his side of the room and started hitting him in the face. Resident #10 stated all the aides came running in the room when they heard a commotion. Resident #10 stated couldn't remember exactly what happened after the aides came into the room and he was sent to the hospital for a couple days and had a broken nose, and a bruised right eye. Resident #10 stated the facility moved Resident #20 out of his room right away and has not been in his room since. Interview on 08/14/18 at 10:27 A.M. with STNA #400 revealed she was a witness to the incident on 07/28/18 between Residents #10 and #20. STNA #400 stated she was in the dining room and heard Residents #20 and #10 yelling and arguing in their room. STNA #400 went down the hall to investigate and when she got to room [ROOM NUMBER], she could hear a punching noise, like something getting hit. Another STNA #410, arrived at room [ROOM NUMBER] first, and STNA #400 observed STNA #410 pull Resident #20 off Resident #10. STNA #400 stated Resident #10 has paralysis on his left side and was unable to protect to himself and looked stunned after the incident happened. STNA #400 stated Resident #10's mouth was bleeding and his right eye was swollen. STNA #400 stated they had Resident #20 leave the room. STNA #400 stated they informed LPN #500 of the incident and then she went to get a cold compress for Resident #10. STNA #400 stated Residents #10 and #20 had never had an incident like that before and there has not been another incident since 07/28/18 with Residents #10 and #20. Interview on 08/14/18 at 10:50 A.M. with Social Services Director (SSD) #320 revealed she was not here the day of the altercation between Residents #10 and #20 on 07/28/18. SSD #320 stated she spoke to Residents #10 and #20 the following Monday and they were both back to themselves. Further interview on 08/14/18 at 3:13 P.M. revealed SSD #320 stated she was never notified of the incident on 07/13/18 of Resident #20 threatening to do bodily harm to Resident #10. On 07/16/18, SSD #320 stated she was stopped in the hallway by STNA #400 and was told she needed to talk with Resident #20 because he was not nice to the aides. SSD #320 stated she told STNA #400 that Resident #20 had been homeless, to just walk away and let him calm down and go back in fifteen minutes and try again. SSD #320 stated a second STNA #430, told her Resident #20 was swearing at the aides and she told her to walk away and wait fifteen minutes and then go back. SSD #320 again verified that no one had reported to her of the threat made by Resident #20, or she would have had moved the resident's rooms right away. SSD #320 did not recall speaking to RN #520 about Resident #20 making a threat. Interview on 08/14/18 at 11:04 A.M. with LPN #500 revealed one of the STNAs #400 came down the hall and stated Resident #20 was threatening to hit Resident #10. LPN #500 stated by the time she got to the room, Resident #20 had already hit Resident #10. LPN #500 stated she called the physician, the on-call supervisor, family, and the police. Resident #10 was sent to the local emergency room , and she was later notified that Resident #10 had a broken nose and was admitted to the hospital. Resident #20 was removed from the incident and was put in another room by himself, that same day, until he was sent out for a psychiatric evaluation and had medications adjusted. Interview on 08/14/18 at 3:20 P.M. with RN #520 revealed she had thought Resident #20 had wanted to cause bodily harm to STNA #420, not the roommate on 07/13/18. RN #520 stated she had caught SSD #320 walking in the hallway, the morning after her shift, and started to tell her of the incident with Resident #20. RN #520 stated SSD #320 cut her off and stated STNA #420 had already told her. Interview on 08/15/18 at 7:43 A.M. with STNA #420 revealed she worked on the night shift of 07/13/18 and stated Resident #20 was being very hostile and she called RN #520 to come down to the room. Resident #20 stood very fast and lunged toward STNA #420, but he was talking about harming his roommate, who is Resident #10. STNA #420 stated Resident #20 shouted I am going to hit him (Resident #10) and hurt him. STNA #420 stated she spoke to SSD #320 in passing in the hall, but STNA #420 was headed out the door as she was off the clock. STNA #420 stated Residents #20 and #10 would argue for a few minutes about something brief and STNA #420 would tell them to quiet down and they would. STNA #420 verified she told her supervisor RN #520 that night that he threatened bodily harm to his roommate. She just wanted to talk to SSD #320 about Resident #20 being nasty to the staff. Interview on 08/15/18 at 1:30 P.M. with the Regional Corporate Nurse #40 revealed she completed the abuse investigation from the incident on 07/28/18. Regional Corporate Nurse #40 revealed a Self-Reported Incident (SRI) was filed on 07/28/18, the same day of the event, for resident to resident physical abuse. She stated it was unsubstantiated because after talking with Resident #20, she thought he wasn't willful in his intent. Regional Corporate Nurse #40 stated Resident #20 had a history of [REDACTED].#20. She also verified no facility staff had reported the threat made by Resident #20 on 07/13/18 to management, so there was no investigation or SRI completed. Regional Corporate Nurse #40 verified the facility staff did not follow the policy. Review of the facility policy titled Resident Abuse, revised 02/01/17, revealed Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Psychological/Emotional Abuse is defined as humiliation, harassment, malicious teasing, threats of punishment or deprivation. Procedure: acts of abuse directed against residents are absolutely prohibited. Such acts are cause for disciplinary action, including and possible criminal prosecution. Prevention: The company is committed to the prevention of abuse, neglect, or misappropriation of property. Sufficient numbers of staff to meet the needs of the residents. Department heads that monitor staff to identify inappropriate behavior. Monitoring of residents who may be at risk is the responsibility of all facility staff. This includes monitoring residents who are at risk or vulnerable for abuse, for indications of changes in behavior, changes in condition or other non-verbal indication of abuse. Procedures for Reporting Abuse: Any employee, who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and to other officials in accordance with State law. In the absence of the Executive Director, the Director of Clinical Services is the designated abuse coordinator. Once an allegation of abuse is reported, the abuse coordinator is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulation, including notification of law enforcement if a reasonable suspicion of crime has occurred. In all cases, the Executive Director or Director of Clinical Services will ensure notification to the residents' legal guardian, family member, responsible party or significant other of the alleged, suspected or observed abuse, neglect or mistreatment, and the residents attending physician. Investigation: The abuse coordinator shall investigate all reports or allegations of abuse. A social service representative may be offered the role of resident advocate during any questioning of or interviewing of residents. Preliminary Investigation: Immediately upon an allegation of abuse or neglect, the suspect shall be segregated from residents pending the investigation resident of the allegation. Investigation: The abuse coordinator shall take statements from the victim, the suspect and all possible witnesses including all other employees near the alleged abuse. The abuse coordinator shall secure all physical evidence. Upon completion of the investigation, a detailed report shall be prepared. Review of the Report: report the results of all investigations to the Executive Director or their designated representative and to other officials in accordance with state law, including to the state survey agency within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This deficiency substantiates the allegations contained in Compliant Number OH 412.

Based on observations, review of medical records, review of a police report, review of the facility Self-Reported Incident (SRI), review of the facility policy titled Resident Abuse, review of in-service records, and interviews with residents and staff, the facility failed to take precautionary measures to protect the health and safety of a resident when the facility failed to act upon Resident #20's verbal threat to cause bodily harm to Resident #10. This resulted in Immediate Jeopardy when Resident #20 acted upon his threat by punching Resident #10 repeatedly in the face with a closed fist causing serious injuries to Resident #10 who sustained multiple fractures of the nose, a laceration of the lip, a chipped tooth and contusions to the right eye. Resident #10 was subsequently hospitalized for [REDACTED]. This affected one (#10) of three residents reviewed for abuse. The facility census was 78. On 08/15/18 at 2:19 P.M., the Interim Administrator, Corporate Clinical Support (CCS) #05, and the Director of Nursing (DON) were notified Immediate Jeopardy began on 07/13/18 at 7:00 A.M. when Resident #20 threatened bodily harm to his roommate (Resident #10) and the facility staff failed to act upon the threat made and provide interventions to protect Resident #10. On 07/28/18 at 8:30 A.M., a commotion was heard coming from the room of Resident #20 and Resident #10 when staff entered the room, Resident #20 was observed repeatedly punching Resident #10 in the face with a closed fist which resulted in a fractured nose, laceration of the lip, a chipped tooth, and contusions to the right eye. Resident #10 was subsequently hospitalized for [REDACTED]. The Immediate Jeopardy was removed on 08/15/18 at 7:00 P.M., when the facility implemented the following corrective actions: · On 07/28/18 at 8:30 A.M., Resident #20 was immediately separated from Resident #10, placed in a private resident room, until the resident was transported to the hospital for a psychiatric evaluation. · On 07/28/18 at approximately 8:35 A.M., the facility sent Resident #10 to the local emergency room for treatment of [REDACTED]. · On 07/28/18 at 3:30 P.M., Resident #20 was sent to the hospital for a psychiatric evaluation. · On 07/30/18, both Resident #20 and #10 were seen for a psychological evaluation. · On 07/30/18, the Quality Assessment and Assurance (QAA) team met, including the Interdisciplinary Team, to review monitoring resident behavior and interventions. · On 08/15/18, the facility completed the SRI for the 07/13/18 incident where Resident #20 made the verbal threat of bodily harm to Resident #10. · On 08/15/18, the facility began monitoring for potential abuse by randomly interviewing five staff members three times a week for four weeks and randomly thereafter for alleged incidents of abuse. The facility will complete random interviews with five cognitively intact residents three times a week for four weeks. The interviews will be completed by the DON or designee. · On 08/15/18, the facility began auditing nurse's notes, one time a day, for three days a week for four weeks. The audits will be conducted by the DON or designee. · On 08/15/18, beginning at 3:00 P.M. to 5:00 P.M., interviews were conducted with all residents that were assessed as being moderately impaired to cognitively intact to screen for threats made against them, knowledge of abuse occurring, reports of any allegations or if they felt safe in the facility. These interviews were conducted by the Administrative staff, DON or designee. Residents who were severely cognitively impaired were assessed for physical signs of abuse by the DON of floor staff nurse. · On 08/15/18, beginning at 3:00 P.M. to 7:00 P.M., all facility staff were educated on the Abuse Policy and Procedure, behavior management, abuse reporting and the chain of command for reporting and how to report allegations. Review of the in-service sheets verified all nursing staff and ancillary staff were in-serviced by facility administration or DON. Although the Immediate Jeopardy was removed on 08/15/18 at 7:00 P.M., when Resident #20 was removed from the same room as Resident #10 and placed in a private room until transport to the hospital, and Resident #10 was sent to the emergency room for treatment and the facility in-serviced staff, the facility remained 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 in the process of implementing their corrective action of auditing and monitoring to ensure on-going compliance. Findings include: Review of Resident #20's medical record revealed an admission date of [DATE] at 2:30 P.M. The resident had [DIAGNOSES REDACTED]. Review of the behavior care plan for Resident #20 dated 07/13/18 revealed Resident #20 displayed behavior problems such as swearing and being combative towards staff. Resident #20 is a new admission and needs time to adjust. The goal indicated Resident #20 would have no evidence of behavior problems of being combative/swearing by review date. Interventions on 07/13/18 included the following: anticipate and meet the resident's needs; caregivers to provide opportunity for positive interaction, attention, stop and talk with him as passing by; if reasonable, discuss the resident's behavior; explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; intervene as necessary to protect the rights and safety of others; approach/speak in a calm manner, divert attention, remove from situation and take to alternate location as needed; and praise any indication of the resident's progress/improvement in behavior. Review of Resident #20's Nurses Notes dated 07/13/18 at 7:00 A.M., documented by Registered Nurse (RN) #520, revealed the resident was very hostile, cursing, throwing room items, and lunging at staff. The resident was angry because his roommate had the television on and was snoring. Resident #20 was heard threatening to do bodily harm to roommate. RN #520 talked to the resident and he began to calm down. RN #520 documented she will pass the information on to Social Services, that resident wants to leave. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed as being cognitively intact and having had no behavior symptoms or rejection of care in the assessment period. There was no [MEDICAL CONDITION] noted. The functional status revealed Resident #20 was independent with set up only with bed mobility, transfers, walking in the room and corridor, locomotion on and off the unit, and independent with one assist with toileting. The resident was extensive assistance with one assist with hygiene and dressing. Resident #20 had not received any antidepressant, antianxiety, antipsychotic, hypnotic, opioid, diuretic, antibiotic, or anticoagulants in the assessment period. Review of Resident #20's behavior charting revealed no episodes of cursing or throwing things since 07/13/18 until 07/28/18. Review of the SRI dated 07/28/18 at 8:30 A.M. revealed Resident #20 and Resident #10 got into a verbal altercation. Staff heard a commotion and upon entering the room, Resident #20 was striking Resident #10 with a closed fist. The residents were separated with one-to-one therapeutic communication provided. The police were called. Resident #10 was sent to the emergency room to be evaluated. Resident #20 was sent to the hospital for psychiatric evaluation and returned to the facility after the physician cleared him as not being an imminent danger to himself or others or needing hospitalization . Review of the hospital record dated 07/28/18 at 4:06 P.M. revealed Resident #20 was evaluated after punching another resident at the nursing home. The resident was remorseful and apologetic. The plan documented the resident was being discharged back to the nursing home as he did not meet the criteria for inpatient hospitalization . The resident is not an imminent danger to himself or others. Review of the behavior care plan for Resident #20 revealed the care plan was updated on 07/28/18 and revealed new interventions to include psychiatric evaluation, room change due to behavior and [MEDICATION NAME] medication added. Review of the nurse's note dated 07/29/18 at 12:45 A.M. revealed Resident #20 was returned to the facility and placed in a private room. Review of the physician notes of a psychological evaluation dated 07/30/18 revealed Resident #20 had [MEDICAL CONDITION] disorder, current episode depressed, mild (new) and the plan on 07/30/18 was to start Resident #20 on [MEDICATION NAME] 20 milligrams daily, due to Resident #20 had been easily excitable repeatedly as reported by staff and has been reported to lash out at others. Resident #20 also had assaulted another resident over the weekend on 07/28/18. Observation on 08/14/18 at 9:10 A.M. of Resident #20 revealed he was well groomed and dressed appropriately. He was using a cane to ambulate and had a visible contracture of the elbow on the left side. Interview on 08/14/18 at 9:11 A.M. with Resident #20 revealed he changed rooms because he didn't get along with the roommate, Resident #10. Resident #20 stated Resident #10 wanted to fight and Resident #20 broke Resident #10's nose. Resident #20 stated he wasn't going to back down and wasn't afraid of anything. Resident #20 stated he threw the first punch and Resident #10 wanted to fight, and he wasn't going to pass it up. Resident #20 stated Resident #10 didn't call him any names, it is over and done with, and he doesn't want to talk about it anymore. Resident #20 stated he had no injuries from the incident. Review of the Resident #10's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #10's MDS assessment dated [DATE] revealed the resident was assessed as being severely cognitively impaired. Resident #10 required extensive assistance with one assist for bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #10 was independent with set up help only. Review of the behavior care plan for Resident #10 revealed an initiation date of 04/20/17. The care plan revealed the resident had impaired/inappropriate behaviors and moods. The plan identified Resident #10 as having the behaviors of yelling and racial remarks related to cognitive loss, [MEDICAL CONDITION] diagnosis, ineffective coping skills, ineffective impulse control, [MEDICAL CONDITION] and medication use. Review of Resident #10's Nurses Notes dated 07/28/18 at 8:30 A.M. revealed a nurse was called to room [ROOM NUMBER] by State tested Nurse Aide (STNA) ID # 400. STNA #400 informed the nurse that the residents were verbally fighting. When the LPN #500 entered the room, Resident #20 was on Resident #10's side of the room. Blood was around Resident #10's mouth and he had swelling above his right eye. A call was placed to Unit Manager RN #250 and to Resident #10's sister and they were informed of the incident. A call was placed to the police and the police advised the nurse to send Resident #10 to the local emergency room for evaluation. Resident #10 was sent to the local emergency room . Review of the police report dated 07/28/18, documented the police were dispatched to the facility to address a report of assault. Upon our arrival, Licensed Practical Nurse (LPN) #500 stated two patients (Residents #10 and #20) began arguing and Resident #20 punched Resident #10 in the face. LPN #500 further stated that both men have severe mental and physical disabilities. Resident #10 was transported to the local hospital for extreme minor injuries to the face. LPN #500 also stated Resident #20 was rehoused to a different room in the facility. Review of Resident #10's nurses note dated 07/28/18 at 1:00 P.M. revealed the facility received a call from the local emergency room and was informed Resident #10 had a fractured nose and they would call back later to inform the facility if Resident #10 would be admitted . A nurse's note dated 07/28/18 at 9:00 P.M. revealed a facility nurse called the local hospital to check on the status of Resident #10 and was informed he was admitted with numerous nasal fractures, contusions, laceration of the lip, and dental issues. Review of the nurses notes from 07/30/18 at 12:40 P.M. revealed Resident #10 returned to the facility via stretcher at 12:30 P.M. Bruising around the right eye was noted. Resident #10 verbally denied pain and his nonverbal pain score was zero. The call light was within reach, and all safety precautions were in place. Review Resident #10's hospital discharge records dated 07/30/18 revealed Resident #10 had fractured nasal bones, laceration of the lip, dental injury (chipped tooth), and contusion of the right eye. Review of the physician note for a psychological evaluation dated 07/30/18 revealed Resident #10 verified he called his roommate (Resident #20) a vulgar name because Resident #20 gets on his nerves. Resident #10 stated he felt safe in the facility. Observation on 08/14/18 at 8:55 A.M. of Resident #10 revealed he was lying in bed and was unable to move his left arm. The resident had a light yellowish discoloration above his right eye. Interview on 08/14/18 at 8:55 A.M. with Resident #10 revealed on 07/28/18 around 8:30 A.M., he was lying in bed and stated he called Resident #20 a derogatory name because he was tired of him and how he acted. Resident #10 stated he didn't have to put up with it. Resident #10 stated Resident #20 took advantage of him, since he was unable to defend himself, and he came over to his side of the room and started hitting him in the face. Resident #10 stated all the aides came running in the room when they heard a commotion. Resident #10 stated couldn't remember exactly what happened after the aides came into the room and he was sent to the hospital for a couple days and had a broken nose, and a bruised right eye. Resident #10 stated the facility moved Resident #20 out of his room right away and has not been in his room since. Interview on 08/14/18 at 10:27 A.M. with STNA #400 revealed she was a witness to the incident on 07/28/18 between Residents #10 and #20. STNA #400 stated she was in the dining room and heard Residents #20 and #10 yelling and arguing in their room. STNA #400 went down the hall to investigate and when she got to room [ROOM NUMBER], she could hear a punching noise, like something getting hit. Another STNA #410, arrived at room [ROOM NUMBER] first, and STNA #400 observed STNA #410 pull Resident #20 off Resident #10. STNA #400 stated Resident #10 has paralysis on his left side and was unable to protect to himself and looked stunned after the incident happened. STNA #400 stated Resident #10's mouth was bleeding and his right eye was swollen. STNA #400 stated they had Resident #20 leave the room. STNA #400 stated they informed LPN #500 of the incident and then she went to get a cold compress for Resident #10. STNA #400 stated Residents #10 and #20 had never had an incident like that before and there has not been another incident since 07/28/18 with Residents #10 and #20. Interview on 08/14/18 at 10:50 A.M. with Social Services Director (SSD) #320 revealed she was not here the day of the altercation between Residents #10 and #20 on 07/28/18. SSD #320 stated she spoke to Residents #10 and #20 the following Monday and they were both back to themselves. Further interview on 08/14/18 at 3:13 P.M. revealed SSD #320 stated she was never notified of the incident on 07/13/18 of Resident #20 threatening to do bodily harm to Resident #10. On 07/16/18, SSD #320 stated she was stopped in the hallway by STNA #400 and was told she needed to talk with Resident #20 because he was not nice to the aides. SSD #320 stated she told STNA #400 that Resident #20 had been homeless, to just walk away and let him calm down and go back in fifteen minutes and try again. SSD #320 stated a second STNA #430, told her Resident #20 was swearing at the aides and she told her to walk away and wait fifteen minutes and then go back. SSD #320 again verified that no one had reported to her of the threat made by Resident #20, or she would have had moved the resident's rooms right away. SSD #320 did not recall speaking to RN #520 about Resident #20 making a threat. Interview on 08/14/18 at 11:04 A.M. with LPN #500 revealed one of the STNAs #400 came down the hall and stated Resident #20 was threatening to hit Resident #10. LPN #500 stated by the time she got to the room, Resident #20 had already hit Resident #10. LPN #500 stated she called the physician, the on-call supervisor, family, and the police. Resident #10 was sent to the local emergency room , and she was later notified that Resident #10 had a broken nose and was admitted to the hospital. Resident #20 was removed from the incident and was put in another room by himself, that same day, until he was sent out for a psychiatric evaluation and had medications adjusted. Interview on 08/14/18 at 3:20 P.M. with RN #520 revealed she had thought Resident #20 had wanted to cause bodily harm to STNA #420, not the roommate on 07/13/18. RN #520 stated she had caught SSD #320 walking in the hallway, the morning after her shift, and started to tell her of the incident with Resident #20. RN #520 stated SSD #320 cut her off and stated STNA #420 had already told her. Interview on 08/15/18 at 7:43 A.M. with STNA #420 revealed she worked on the night shift of 07/13/18 and stated Resident #20 was being very hostile and she called RN #520 to come down to the room. Resident #20 stood very fast and lunged toward STNA #420, but he was talking about harming his roommate, who is Resident #10. STNA #420 stated Resident #20 shouted I am going to hit him (Resident #10) and hurt him. STNA #420 stated she spoke to SSD #320 in passing in the hall, but STNA #420 was headed out the door as she was off the clock. STNA #420 stated Residents #20 and #10 would argue for a few minutes about something brief and STNA #420 would tell them to quiet down and they would. STNA #420 verified she told her supervisor RN #520 that night that he threatened bodily harm to his roommate. She just wanted to talk to SSD #320 about Resident #20 being nasty to the staff. Interview on 08/15/18 at 1:30 P.M. with the Regional Corporate Nurse #40 revealed she completed the abuse investigation from the incident on 07/28/18. Regional Corporate Nurse #40 revealed a Self-Reported Incident (SRI) was filed on 07/28/18, the same day of the event, for resident to resident physical abuse. She stated it was unsubstantiated because after talking with Resident #20, she thought he wasn't willful in his intent. Regional Corporate Nurse #40 stated Resident #20 had a history of [REDACTED].#20. She also verified no facility staff had reported the threat made by Resident #20 on 07/13/18 to management, so there was no investigation or SRI completed. Regional Corporate Nurse #40 verified the facility staff did not follow the policy. Review of the facility policy titled Resident Abuse, revised 02/01/17, revealed Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Psychological/Emotional Abuse is defined as humiliation, harassment, malicious teasing, threats of punishment or deprivation. Procedure: acts of abuse directed against residents are absolutely prohibited. Such acts are cause for disciplinary action, including and possible criminal prosecution. Prevention: The company is committed to the prevention of abuse, neglect, or misappropriation of property. Sufficient numbers of staff to meet the needs of the residents. Department heads that monitor staff to identify inappropriate behavior. Monitoring of residents who may be at risk is the responsibility of all facility staff. This includes monitoring residents who are at risk or vulnerable for abuse, for indications of changes in behavior, changes in condition or other non-verbal indication of abuse. Procedures for Reporting Abuse: Any employee, who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and to other officials in accordance with State law. In the absence of the Executive Director, the Director of Clinical Services is the designated abuse coordinator. Once an allegation of abuse is reported, the abuse coordinator is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulation, including notification of law enforcement if a reasonable suspicion of crime has occurred. In all cases, the Executive Director or Director of Clinical Services will ensure notification to the residents' legal guardian, family member, responsible party or significant other of the alleged, suspected or observed abuse, neglect or mistreatment, and the residents attending physician. Investigation: The abuse coordinator shall investigate all reports or allegations of abuse. A social service representative may be offered the role of resident advocate during any questioning of or interviewing of residents. Preliminary Investigation: Immediately upon an allegation of abuse or neglect, the suspect shall be segregated from residents pending the investigation resident of the allegation. Investigation: The abuse coordinator shall take statements from the victim, the suspect and all possible witnesses including all other employees near the alleged abuse. The abuse coordinator shall secure all physical evidence. Upon completion of the investigation, a detailed report shall be prepared. Review of the Report: report the results of all investigations to the Executive Director or their designated representative and to other officials in accordance with state law, including to the state survey agency within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This deficiency substantiates the allegations contained in Compliant Number OH 412.

Based on medical record review, observations, interviews with staff and a family member, review of the Elopement Assessment Guidelines, and review of the facility's policy titled Elopement Risk, the facility failed to ensure adequate supervision was provided to prevent the elopement of Resident #1. This resulted in Immediate Jeopardy when Resident #1 left the facility, without staff knowledge, and was found unattended in her wheelchair in the middle of the two lane highway, near the front of the facility, by a concerned citizen driving by on the highway placing the resident at risk for serious injury and/or death. This affected one (#1) of three residents (#1, #3 and #4) reviewed for being at risk for elopement. The facility identified a total of eight residents assessed as being at risk for elopement. On 03/09/17 at 3:35 P.M., the Director of Nursing (DON), Assistant Director of Nursing #100, and North Unit Manager #101 were notified Immediate Jeopardy began on 03/03/17 at 3:00 A.M., when documentation in the nurses notes by Registered Nurse (RN) #10 revealed Resident #1 was out of bed in her wheelchair banging on the front door yelling, I'm going home. She was asking where her sister was and continued to bang on the door and shake the railing. RN #10 documented she made three attempts to redirect Resident #1 which were unsuccessful. Resident #1 continued to yell, I'm going home. After the incident, there was no evidence of an elopement assessment being completed or any interventions implemented to prevent Resident #1 from eloping. Consequently, on 03/05/17 at 12:15 P.M., the facility received a call from a concerned citizen (#201) stating Resident #1 was in her wheelchair in the middle of the highway. The facility was unaware Resident #1 was missing until concerned citizen #201 called the facility. Resident #1 independently propelled her wheelchair out the front door approximately 200 feet from the facility into the middle of the highway, into an intersection down the street from the front of the facility. Resident #1 was removed from the highway by concerned citizen #201 and placed on the sidewalk in front of the facility until staff arrived to return the resident to the facility. The resident was assessed by nursing staff and no injury was discovered. The Immediate Jeopardy was removed on 03/07/17 at 5:20 A.M. when the facility completed all in-servicing, including elopement drills on all shifts, and the facility implemented the following corrective actions: · On 03/05/17 at approximately 12:45 P.M., an elopement assessment was completed for Resident #1 and a Wander Guard/Secure Care Device was placed on her right ankle upon the resident's return to the facility. · On 03/05/17 at 2:00 P.M., mandatory in-service training on elopement for all facility staff was conducted on all shifts by the DON. · On 03/05/17 by 4:00 P.M., all residents were assessed for risk of elopement and personalized elopement interventions were in place by nursing staff and the DON when indicated by the elopement risk assessment. · On 03/06/17 at 12:00 P.M. and 3:30 P.M. and on 03/07/17 as of 5:20 A.M., all facility staff had been educated and participated in an elopement drill conducted by the DON. · On 03/09/17, random interviews with State tested Nurse Aides (STNA) #11, #13, #14 and #15, Licensed Practical Nurses (LPN) #12 and #16, and Registered Nurse (RN) #10 verified attendance and content of the provided elopement in-service. · On 03/09/17, monitoring for on-going compliance was initiated and will continue for four weeks by the clinical management team and be reported to the Quality Assurance program. The Quality Assurance program review will provide additional education and monitoring for any identified non-compliance. · On 03/10/17, review of two (#3 and #4) additional residents' medical records and observations revealed no concerns with elopement assessments and interventions were observed in place to prevent elopement. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of monitoring their corrective action plan to ensure on-going compliance as of 03/09/17. Findings include: Review of Resident #1's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] indicated the resident scored a 12 on the Brief Interview for Mental Status (BIMS), identifying Resident #1 with moderate cognitive impairment. She was independent with locomotion off the unit using a wheelchair. Review of the Elopement Risk Evaluation dated 01/17/17 indicated Resident #1 was assessed as not being at risk for elopement. Review of the plan of care implemented on 01/31/17 revealed the resident exhibited wandering behavior. There were no goals or interventions addressing the wandering behavior. Review of the quarterly MDS assessment dated [DATE] revealed the resident scored an 11 on the BIMS, again indicating Resident #1 has a moderate cognitive impairment. She was independent with locomotion off the unit using a wheelchair. Review of the nurse's note dated 03/03/17 at 3:00 A.M. documented Resident #1 was out of bed in her wheelchair banging on the front door yelling, I'm going home. Resident #1 was asking where her sister was and continued to bang on the door and shake the railing. RN #10 documented she made three attempts to redirect Resident #1 which were unsuccessful. Resident #1 continued to yell, I'm going home. After the incident, there was no evidence of an elopement assessment being completed or any interventions implemented to prevent Resident #1 from eloping. Review of the nurse's notes dated 03/05/17 at 12:15 P.M., documented the facility received a call from concerned citizen #201 stating Resident #1 was in her wheelchair in the middle of the highway. The facility was unaware Resident #1 was missing. Resident #1 independently propelled her wheelchair out the front door approximately 200 feet from the facility into the middle of a highway, into an intersection down the street from the front of the facility. Resident #1 was removed from the highway and placed on the sidewalk in front of the facility until staff arrived to return the resident to the facility. The resident was assessed by nursing staff and no injury was discovered. Observations on 03/09/17 at 9:15 A.M. revealed Resident #1 wearing a Wander Guard on her right ankle. When the resident was asked if she had left the faciity on Sunday, 03/05/17, she smiled and said she didn't think so. Interview on 03/09/17 at 9:20 A.M. with Resident #1's family member revealed on 03/05/17, when she arrived at the facility at 1:00 P.M., she was informed by staff that Resident #1 had been found in the middle of the intersection on the highway near the facility. The family member stated when she visited with Resident #1 she was very confused. Resident #1 told her she was trying to get to her sister's house. Resident #1's family member verified Resident #1 did not have a wander guard on until after she was found in the highway. Interview on 03/09/17 at 11:30 A.M. with the DON verified she had not read the nurse's note dated 03/03/17 at 3:00 A.M. She verified she was not aware of the incident as stated in the documentation prior to the elopement of Resident #1 on 03/05/17. She stated residents observed to be exit seeking should be reassessed for elopement and the plan of care updated with interventions put into place to prevent elopement. The DON stated she had posted an, Elopement Assessment Guideline, at each nurse's station to assist nurses in implementation of elopement assessments and interventions. The DON verified the Elopement Assessment Guidelines were posted at each nurse's station prior to 03/03/17. Review of the undated Elopement Assessment Guideline, documented the charge nurse is to complete an elopement assessment on admission, quarterly, and/or at the time the resident is noted to be exit seeking. Following an elopement assessment indicating the resident is an elopement risk, a physician order is to be written for a wander guard placement. On 03/09/17 at 3:45 P.M. during an interview with RN #10, she verified she had documented the nurse's note dated 03/03/17 at 3:00 A.M., and had not completed an elopement assessment. Observation on 03/09/17 at 4:30 P.M. of the highway to the right front of the facility, where the resident was found, revealed a posted 45 mile per hour speed limit. Review of the facility policy titled Elopement Risk, dated 11/30/14, documented if the resident is identified as an elopement risk based on the assessment, the care plan will reflect the interventions (i.e., Wander Guard or Code Alert) and desired outcome. The care plan will be reviewed and/or revised following attempts to leave the facility. This deficiency substantiates Complaint Number OH 022.

Based on observations, medical record review, resident interviews, family interviews, staff interviews, and review of facility policy, the facility failed to provide monitoring and treatments as ordered to pressure ulcers for three (#13, #17, and #114) of three residents reviewed for pressure ulcers. This resulted in actual harm when Resident #13's pressure ulcers increased in size and worsened from two Stage II pressure ulcers to one unstageable pressure ulcer. The facility identified eight residents in the facility with pressure ulcers. The census was 84. Findings include: 1. Review of medical record revealed Resident #13 was admitted on [DATE]. [DIAGNOSES REDACTED]. The plan of care dated 06/04/14 identified the resident to be at risk to develop pressure ulcers due to fragile skin and [MEDICAL CONDITION]. Review of the Pressure Ulcer Record dated 01/11/15 revealed the resident had developed two Stage II pressure ulcers on her coccyx. Wound #1 was located on the coccyx and measured 2.6 cm length by 0.6 cm width and less than 0.1 cm deep. The tissue was granulated and red in color. The wound edges were firm without redness. There was a small amount of serous drainage and no odor. There was no further evaluation of Wound #1 in the medical record. Wound #2 was also located on the coccyx and measured 2 cm length by 3 cm width and no depth was indicated. The tissue was granulated and red in color. The wound edges were firm without redness. There was a small amount of serous drainage and no odor. Documentation on 01/19/15 revealed the wound had increased in size and measured 3.5 cm length by 3.5 cm width by 0.1 cm deep. The remainder of the assessment was unchanged. Review of the 01/12/15 physician orders [REDACTED]. Review of the treatment administration record (TAR) documented the treatments to both pressure ulcers were only completed on 01/12/15 and 01/18/15. Observation on 01/21/15 at 2:00 P.M. of the dressing change completed by Licensed Practical Nurse (LPN) #9 revealed the two areas appeared much larger. One of the wounds was directly over the coccyx, opened with the center yellow in color with slough tissue present. The surrounding peri-wound was bright red and opened. The second wound was opened and bright red. The areas appeared to be merging together into one wound. LPN #9 completed the dressing change without measuring the wounds. Interview immediately following the dressing change with LPN #9 verified she did not do any wound measurements. She stated the measurements had to be done by Thursday, but she does not do them because she only works one day a week. She did not know who would do the measurements. She stated she was finished with everything she needed to do and she was going home now. LPN #9 then left the unit without documenting the completion of the dressing change in the TAR. She did not document the wound bed, drainage, color, odor or peri-wound appearance on the Pressure Ulcer Record. She did not report the appearance of the wound or the changes of the size or color to anyone. Interview with the Director of Nursing (DON) on 01/22/15 at 9:21 A.M. verified LPN #9 did not give report to anyone regarding the assessment or condition of the wound. She did not tell anyone the wound had worsened. She verified the LPN should report changes so the wound could be reevaluated. Observation of dressing change on 01/22/15 at 10:22 A.M. with Assistant Director of Nursing (ADON) #4 revealed the two wounds were merged together as one. ADON #4 measured the opened area as 4 cm length by 11.2 cm width by 0.3 cm depth. Interview with ADON #4 following the dressing change stated the two wounds were all one area. She stated she needed to call the doctor for new orders because the wound had increased significantly in size and was now an unstageable pressure wound based on the slough area at the center. ADON #4 verified the staff nurses are to document on the wounds and report negative findings. Review of undated facility policy titled "Wound Care Prevention and Treatment Objectives" revealed the facility was to complete skin assessments, identify skin alterations, document findings, discuss skin alterations in weekly meetings, notify interdisciplinary team members, and provide treatment to skin wounds as ordered by the physician. 2. Review of Resident #114's medical record revealed Resident #114 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #114's community referral form dated 01/14/15 revealed a sacral wound with treatment orders which included Dakins solution to the wound and a wet to dry dressing twice a day, turn every two hours, keep heels off of the bed, and provide a pressure relief overlay to bed. Review of Resident #114's admission nursing assessment dated [DATE] revealed Resident #114 had a pressure ulcer on the coccyx. Review of pressure ulcer record dated 01/14/15 and 01/16/15 revealed Resident #114 had a stage 4 pressure ulcer measuring 8.3 centimeters (cm) in length by 8.3 cm in width and 3.4 cm deep. The ulcer was described as yellow in color with slough, granulation, and a large amount of pink sero-sanguinous drainage present. Review of Resident #114's physician orders [REDACTED].#114 was to receive a dressing change to the coccyx of Dakin's one-fourth strength, wet to dry dressing, twice a day. Nurses notes on 01/18/15 documented Resident #114 refused a dressing change to the coccyx. The nurses note on 01/18/15 and 01/19/15 documented Resident #114 continued to refuse to have the coccyx wound dressing change. Nurses note dated 01/20/15, six days after admission, was the first note indicating the dressing change was completed. Review of Resident #114's treatment administration record (TAR) dated January 2015 revealed an order for [REDACTED].#114 did not get her dressing changed as ordered. The TAR revealed three occasions where nurse's did not leave the boxes blank, but had initialed the dressing as refused by circling their initials in the box. There were eight occasions when Resident #114 received the dressing change as ordered. Observation on 01/23/15 at 2:15 P.M. with Licensed Practical Nurse (LPN) #18 and Registered Nurse (RN) #19 and Certified Nurse Practitioner (CNP) #20 for a dressing change to Resident #114 revealed the wound measured approximately 8.0 cm by 6.0 cm by 3.1 cm. The dressing removed was covered in green drainage and the wound had a medium amount of pink sero-sanguineous drainage which was dried in a large circle on the bed pad. The wound had a slight odor. The dressing change was completed as ordered. Interview on 01/21/15 at 12:45 P.M. with Resident #114 and spouse revealed Resident #114 had been in an accident in the past, had [MEDICAL CONDITION], and had developed a pressure ulcer on her coccyx. They stated the dressing changes are not completed as ordered. Resident #114 stated the dressing was supposed to be changed twice a day, and it has not always been changed once a day. She explained there have been times she has refused at the time the staff ask, but then they never come back and do it later. Interview with the Director of Nursing (DON) on 01/23/15 at 11:40 A.M. verified Resident #114's TAR revealed the treatment was not completed as ordered. 3. Review of Resident #17's medical record revealed Resident #17 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #17's admission nursing assessment dated [DATE] revealed a notation indicating "ulcer" written and pointing to a photo of a foot in the pain assessment area of the nursing assessment. The skin assessment within the admission nursing nursing assessment indicated skin was intact, and no notes were written in the body graph in the skin assessment. Review of Resident #17's undated pressure ulcer risk assessments revealed skin was intact. assessment dated [DATE] revealed a blank sheet with nothing marked. Review of Resident #17's skin integrity assessments dated 09/18/14 revealed a blank sheet. Review of Resident #17's undated pressure ulcer record revealed Resident #17 had an unstageable pressure ulcer on left foot. It did not reveal any measurements or description. Review of Resident #17's physician orders [REDACTED]. Review of Resident #17's wound clinic records dated 09/19/14 and 10/03/14 revealed Resident #17 had an unstageable wound to the left foot. The wound clinic had provided orders to clean left foot wound with normal saline, pat dry, cover with ABD dressing, secure with Kerlix, change daily and as needed. Review of Resident #17's nurses notes from admission on 09/18/14 through 10/18/14 revealed no indication in the skilled nursing skin assessment checklist and no indication in the narrative nursing notes of any wound on the left foot. There was no assessment or description of the left heel wound anywhere in the medical record. Review of Resident #17's treatment administration record (TAR) dated September and October 2014 revealed an order to clean left foot wound with normal saline, pat dry, cover with ABD, secure with Kerlix, change daily and as needed. The order was blank with no initials indicating the dressing had ever been completed. Interview with the DON on 01/23/15 at 3:40 P.M. verified Resident #17 did have an unstageable foot wound. The DON verified Resident #17's medical record revealed no indication of the foot wound in any way except physician orders [REDACTED]. Review of undated facility policy titled "Wound Care Prevention and Treatment Objectives" revealed the facility was to complete skin assessments, identify skin alterations, document findings, discuss skin alterations in weekly meetings, notify interdisciplinary team members, and provide treatment to skin wounds as ordered by the physician.