Every finding on record at Riverview

Based on observation, staff interview, and review of facility policy, the facility failed to ensure that medications were stored securely. This had the potential to affect 74 residents, #1, #2, #3, #4, #7, #8, #10, #12, #13, #14, #15, #17, #20, #25, #28, #29, #32, #33, #34, #36, #37, #40, #41, #42, #43, #44, #45, #50, #51, #52, #58, #61, #62, #76, #77, #78, #79, #84, #85, #86, #88, #89, #90, #92, #93, #94, #95, #102, #103, #104, #107, #110, #112, #116, #117, #120, #121, #122, #138, #175, #178, #179, #180, #226, #227, #229, #231, and #232 The facility also failed to ensure that medications, including three cups containing various types of pills, were stored appropriately. The facility census was 120. Findings include: 1. Continuous observation on 04/30/25 from 8:44 A.M. until 8:47 A.M. revealed an unattended and unlocked medication cart on Unit #4. Registered Nurse (RN) #201 exited a room across the hall and to the left of the unlocked medication cart at 8:47 A.M. and returned to the medication cart. Interview with RN #201 on 04/30/25 at 8:47 A.M. confirmed that she had left the medication cart unlocked and further verified the medication cart was out of her line of sight. 2. Observation on 04/30/25 at 9:28 A.M. during medication administration with RN #201, revealed three illegible labeled medication cups with an assortment of pills in the top drawer of the medication cart for unit #4. Interview at the time of the observation with RN #201 confirmed she had prepared the medications for the residents and when she went to administer them, the Residents were not their rooms so RN #201 placed the cups in the top drawer to be able to administer them later when she found the residents. RN #201 explained that she did not have time to re-prepare the medications as she was already behind. RN #201 was unable to identify what the medications were in the each of the medication cups and was unable to denitrify the resident for which the medications were prepared for and not administered. Interview on 05/01/25 at 10:49 A.M. with the Director of Nursing and Regional Clinical Manager #400 confirmed that medication cups should not be left in the nurse ' s cart. Residents should receive medications as they are prepared. Review of the facility policy titled Medication Administration, dated 08/07/23 stated medications are to be administered according to physician order and professional standards of practice. Medications are to prepared, and administered one resident at a time and the medication administrated is to be documented directly after administration. Additionally, the policy stated when when a nurse is administering medications the nurse is to lock the medication cart when not it is not in direct view. Review of the facility policy titled Medication and Treatment Storage, dated 08/07/23 stated medications, treatments, biologicals, and supplies should be maintained per manufacturer guidelines. Additionally, the facility is required to ensure accurate labeling and dating of medications and treatments for safe administration, as well as secure storage. 50008

Based on observation, staff interview, and policy review the facility failed to distribute and serve food under sanitary conditions. This had the potential to affect all residents residing in the facility who receive food from the kitchen except for residents #68 and #114 who did not eat or drink food from the kitchen. The census was 120. Findings include: Observation and tour on 04/28/25 from 9:30 A.M. to 10:00 A.M of the kitchen with Regional Dietary Manager #400 and Dietary Manager (DM) #216 revealed the following: -One large empty plate warmer unit sitting in the service line area revealed the spring loaded plate dispenser was covered with orange and black particles and dust like substance. When wiped with a white paper towel the brown orange colored substance could be wiped off and what appeared to be rusted areas remained, and unable to be removed. The observation was confirmed by DM #216. -One full dome cover dispenser, sitting in the service line area next to the plate warmer revealed multiple food crumbs, dried food and dried liquid marks on both the inside and outside of the unit and on the domes contained in the unit. The observation was confirmed by DM #216. -A plastic crate used in the dishwasher housed several eight ounce hard plastic cups. Six of the cups were covered in a hard white dried powder substance that could be removed with a fork. Regional Dietary Manager #400 verified the white dried powder substance on the plastic cups was lime stains. -The clean area of the kitchen where the utensils and silverware were stored revealed four tray line metal bin dividers sitting on a crate full of clean utensils, The metal dividers had black, white, brown specs of crumbs and dust on them. Hanging off the shelf above the utensils was one pair of large serving tongs with a dried white food substance. This observation was also confirmed by DM #216. Interview with DM #216 at 10:00 A.M. after the kitchen tour, DM #216 verfiied he was not wearing the proper hair restraints. DM #216 was wearing a baseball cap and had no beard cover. An additional observations on 04/29/25 at 10:45 A.M. revealed outside food Sales Representative #500 was observed entering the kitchen, walked through the kitchen and into the clean area of stored dishes and preparation station to meet with DM #216. Sales Representative #500 did not wear a hair cover in place. Regional Dietary Manager # 400 verified the observation. Review of the facility's policy titled Food Service Employee Hygiene/Uniform Policy, dated 12/31/24 revealed food and nutrition service employees will practice good personal hygiene and safe handling procedures. Food Service employees should wear hair restraints that cover the entirety of their hair, including beards grated than a quarter of an inch. Bald employees do not have to wear restraints.

Based on observations, resident interview, staff interview, and review of facility policy, the facility failed to provide food and drink at a palatable, attractive, and at a safe and appetizing temperature. This affected one resident (Resident #75) and had the potential to affect all 65 of the residents on units #2 and #4 except for Resident #68 and Resident #114, who did not eat or drink food from the kitchen. The facility census was 120 residents. Findings include: 1. Review of the medical record for Resident #75 revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus, and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #75, dated 04/11/25, revealed that her short term and long term memories were assessed as being okay. Review of physician orders for Resident #75 dated 08/23/24 revealed the resident was on a regular diet with regular textures. Review of the plan of care dated 04/11/24 for Resident #75 revealed that she was at risk for malnutrition with a goal to maintain adequate nutritional status by consuming at least 75% of at least two meals daily. Interventions included honoring her food preferences and providing her diet as ordered. Observation on 04/30/25 at 8:40 A.M. were delivered to Unit 4. Meal trays were delivered to residents from 8:40 A.M. to 9:17 A.M. Observation on 04/03/25 at 9:14 A.M. of Resident #75's meal plate revealed that it did not appear to be warm. The egg on the breakfast sandwich was visualized to be dry. Holding the surveyor's hand near the plate revealed that no warmth was felt from the proximity of the meal plate. Interviews on 04/28/25 at 10:53 A.M. and on 04/30/25 at 9:14 A.M. with Resident #75 confirmed that food and beverages were not served in a timely manner and at satisfactory temperatures on Unit 4. Resident #75 stated meals are not palatable or attractive. 36648 2. Observation on 04/29/25 from 12:55 P.M. to 1:40 P.M. of food trays being delivered in an enclosed metal cart with doors to the 200 Unit residents revealed on top of the cart there were beverages of milk, juices and water in two plastic bins with ice. A coffee craft and beverage cups. The distribution of the trays when arrived to the unit took and took 55 minutes to pass. A test tray was included on the cart. The test tray temperature was checked by Dietary Manager (DM) #406 using a facility thermometer and revealed the barbecued chicken was 21 degrees Fahrenheit (F), the carrots were 100 degrees F, and the O'Brien potatoes were 100 degrees F. DM #406 verified the temperatures were not acceptable per guidelines and for residents to enjoy a warm and palatable meal . Review of facility policy titled Food Palatability, dated 04/04/2025, revealed cart delivery times should be followed and updated as needed. Designated staff should deliver all the trays in the cart within 20 minutes of arrival to the unit. Review of facility policy titled Tray line Food Temperatures, dated 08/01/2024 revealed the facility will hold and serve food at acceptable temperatures that deter bacterial growth. The internal temperature of potentially hazardous foods (Time/Temperature for Safety Food) must be 41 degrees Fahrenheit or below for cold foods and 135 degrees Fahrenheit or above for hot at all times.

Based on record review, interview and policy review, the facility failed to ensure accurate physician order reconciliation was conducted following a hospital admission for one (Resident #82) of two residents reviewed for hospitalization s. The facility census was 120. Findings include: Review of the medical record for Resident #82 revealed an admitted [DATE] with diagnoses of end-stage renal disease, type II diabetes mellitus, occlusion and stenosis of an unspecified carotid artery, hypotension, and diastolic heart failure. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/04/25, revealed Resident #82 was cognitively intact and received dialysis. Review of the care plan dated 11/13/23 revealed Resident #82 had altered cardiovascular status related to atrial fibrillation, cerebrovascular accident (stroke), chronic kidney disease (CKD), hypotension, chronic heart failure, and peripheral vascular disease. Review of physician orders dated 11/27/24 revealed Resident #82 had an order for midodrine five milligram (mg) oral tablet every 12 hours as needed for low blood pressure if the mean arterial pressure (MAP - average blood pressure throughout a cardiac cycle) is under 65. Review of a hospital after visit summary dated 03/24/25 revealed Resident #82 was admitted to the hospital for hypotension, end-stage renal disease, acute hypoxic on chronic respiratory failure, chronic congestive heart failure, and tachypnea (rapid breathing). The hospital discharge summary included a medication change: midodrine 5 mg tablet to be taken by mouth twice daily as needed for a MAP less than 65, and on Mondays, Wednesdays, and Fridays prior to each scheduled hemodialysis. Further review of the physician orders revealed no updated midodrine orders after 03/24/25, following Resident #82's hospitalization . Review of the Medication Administration Record (MAR) for March 2025 and April 2025 revealed no documentation that midodrine was administered to Resident #82 prior to dialysis on Mondays, Wednesdays, and Fridays. Review of dialysis communication form revealed that midodrine was not identified as administered to Resident #82 on the following dates: 03/24/25, 03/28/25, 03/31/25, 04/02/25, 04/04/25, 04/07/25, 04/09/25, 04/11/25, 04/14/25, and 04/16/25. On 04/18/25, midodrine was listed as administered. Further review of Resident #82's record revealed the dialysis communication form for 04/21/25 and 04/23/25 were not available in the record. Review of dialysis report revealed that on 04/25/25 and 04/30/25, Resident #82 received midodrine prior to dialysis. Interview on 05/01/25 at 10:49 A.M. with the Director of Nursing (DON) and Regional Clinical Manager (RCM) #400 revealed they could not confirm or deny whether midodrine had been administered to Resident #82 prior to hemodialysis at the off-site dialysis center. They stated they would follow up with the dialysis provider, as the facility did not have access to the full administration record at the dialysis clinic. The DON and RCM #400 confirmed midodrine was only listed on the facility's orders as an as-needed medication but not specifically ordered for administration before each dialysis session. The DON verified the hospital after-visit summary documented a change in the midodrine order, specifying that midodrine should be administered prior to each scheduled hemodialysis treatment on Monday, Wednesday, and Friday. She further acknowledged that the instruction to administer midodrine before each dialysis session, as indicated in the hospital summary, had been overlooked and was not entered into the facility ' s physician orders. Review of the facility's medication, treatment, and physician order transcription policy dated 11/03/23 revealed orders are transcribed then noted by the licensed nurse, the licensed nurse noting an order is responsible for accurate transcription and initiation of orders.

Based on medical record review, staff interview, review of the Electronic Information Dissemination and Collection (EIDC) system, and review of the facility policy, the facility failed to report an injury of unknown origin to the State Survey Agency (SSA). This affected one resident (Resident #7) of two residents reviewed for abuse. The facility census was 120. Findings include: Review of Resident #7's medical record revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting the left non-dominant side, chronic kidney disease (CKD), epilepsy, chronic atrial fibrillation, mild cognitive impairment, and chronic pulmonary embolism. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/12/25, revealed Resident #7's cognition was unable to be assessed due to the resident being rarely/never understood. Further review revealed Resident #7 had impaired range of motion (ROM) on one side, utilized a wheelchair for mobility, was dependent on staff for personal hygiene and lower body dressing, and required substantial/maximum staff assistance for upper body dressing. Review of the plan of care, revised 03/25/24, revealed Resident #7 had a potential for impairment to skin integrity related to fragile skin, history of malignant neoplasm of the skin, impaired mobility, left hemiplegia, and anticoagulant use. Interventions included encourage long sleeves, follow facility protocols for treatment of injury, identify/document potential causative factors and eliminate/resolve where possible, and monitor for signs of bleeding. Review of a nursing progress note, dated 03/01/25 at 8:47 P.M., revealed that during medication pass, a big hematoma with bruise, painful to touch, was identified on Resident #7's right forearm. The facility assessed the resident and Resident #7 was sent to the emergency department (ED) for evaluation at the physician's direction. Review of the physician orders dated 03/10/2025 revealed an order to observe bruising to the right arm for worsening/improvement until resolved, observe hematoma to the right forearm on every shift until resolved, and monitor for signs and symptoms of bleeding related to use of anticoagulant medication. Review of the EIDC system revealed no evidence of a facility submitted Self-Reported Incident (SRI) related to Resident #7's injury of unknown source, identified on 03/01/25, had been reported to the SSA. Interview on 04/30/35 at 2:50 P.M. with the Director of Nursing (DON) verified the hematoma discovered on Resident #7's forearm on 03/01/25 was not reported to the SSA as an injury of unknown origin. Review of the facility policy titled, Abuse, dated 04/13/23, revealed the facility would ensure that all allegations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property, and crimes were reported immediately to the SSA, but no later than 24 hours if the allegation did not involve abuse and did not result in serious bodily injury.

Based on medical record review, resident interview, staff interview and review of the facility policy, the facility failed to thoroughly investigate an injury of unknown origin. This affected one (#7) of two residents reviewed for abuse. The facility census was 120. Findings include: Review of Resident #7's medical record revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting the left non-dominant side, chronic kidney disease (CKD), epilepsy, chronic atrial fibrillation, mild cognitive impairment, and chronic pulmonary embolism. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/12/25, revealed Resident #7's cognition was unable to be assessed due to the resident being rarely/never understood. Further review revealed Resident #7 had impaired range of motion (ROM) on one side, utilized a wheelchair for mobility, was dependent on staff for personal hygiene and lower body dressing, and required substantial/maximum staff assistance for upper body dressing. Review of the plan of care, revised 03/25/24, revealed Resident #7 had a potential for impairment to skin integrity related to fragile skin, history of malignant neoplasm of the skin, impaired mobility, left hemiplegia, and anticoagulant use. Interventions included encourage long sleeves, follow facility protocols for treatment of injury, identify/document potential causative factors and eliminate/resolve where possible, and monitor for signs of bleeding. Review of a nursing progress note, dated 03/01/25 at 8:47 P.M., revealed that during medication pass, a big hematoma with bruise, painful to touch, was identified on Resident #7's right forearm. The facility assessed the resident and Resident #7 was sent to the emergency department (ED) for evaluation at the physician's direction. Interview on 04/30/25 at 11:41 A.M. with Nurse Manager (NM) #238 revealed that the ED after visit summary indicated Resident #7's hematoma was the result of a fall; however, NM #238 stated the resident's roommate verbalized Resident #7 got the hematoma from playing with her overbed table that evening. Interview on 05/01/25 at 10:18 A.M. with the Director of Nursing (DON) revealed the facility did not have evidence a facility investigation was conducted related to the injury of unknown source identified on Resident #7's right forearm, including staff interviews, witness statements, or assessments or interviews with like residents. The DON verified she did not conduct any staff or resident interviews and further confirmed no staff education was completed related to the incident. Interview on 05/01/25 at 11:26 A.M. with Resident #106, Resident #7's roommate, revealed on the night the injury was identified on Resident #7's forearm, staff did not ask her any questions related to the injury. Resident #106 revealed when staff came into the room to provide care for the resident, she informed staff that Resident #7 had been trying to get out of bed with the assistance of her bedside table. Resident #106 revealed that she did not see the injury occur. Review of the facility policy titled, Abuse, dated 04/13/23, revealed the facility conducted a timely, thorough, and objective investigation of any allegation of abuse. The facility's policy was to investigate all allegations involving abuse, neglect, misappropriation of resident property, exploitation or mistreatment, including injuries of unknown source. The investigation process included: identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations (such as other residents, family members, staff who worked closely with the alleged perpetrator and/or alleged victim) and providing complete and thorough documentation of the investigation. The results of the investigation were reported to the Administrator and a final report would be submitted to the State Survey Agency (SSA) no later than five working days after the discovery of the incident.

Based on record review, staff interview, and policy review the facility failed to ensure residents receive care consistent with professional standards of practice when they failed to timely transcribe a new physician order for a pressure ulcer dressing change for Resident #105. This affected one (Resident #105) of four Residents reviewed for pressure ulcers. The facility census was 120. Findings include: Record review of Resident #105 revealed an admitted [DATE] with pertinent diagnoses of: sepsis, aphasia, type one diabetes mellitus, encephalopathy, cerebral infarction, chronic respiratory failure with hypoxia, hypertension, altered mental status, and personal history of other venous thrombosis and embolism. Review of the 02/17/25 quarterly Minimum Data Set (MDS) revealed Resident #105 is rarely or never understood and currently has a pressure ulcer. Review of the 04/23/25 wound assessment and care plan revealed the wound doctor came in and saw Resident #105 on the weekly wound rounds and wrote to change the order. The new order for left ischial tuberosity was to cleanse with normal saline, pat dry, apply collagen powder to wound bed, apply calcium alginate, and apply dry clean dressing every one day and as needed. Review of the physician order dated 04/23/25 revealed wound care order site left ischial tuberosity 1) cleanse with normal saline, 2) pat dry with gauze 3) apply collagen sheet to wound bed, then saline moistened gauze 4) cover with foam dressing every day shift for wound care. Review of the physician order dated 04/23/25 and timed at 10:15 A.M. revealed wound care order site: left ischial tuberosity: 1) cleanse wound with normal saline 2) pat dry with gauze 3) apply collagen sheet to wound bed, then calcium alginate to wound bed 4) cover with foam dressing every day shift for wound care and as needed for loosening or soilage. Interview with Licensed Practical Nurse (LPN) #335 on 04/30/25 at 11:25 A.M. verified she did not put the order in correctly on 04/23/25 to include applying the calcium alginate to the wound. LPN #335 verified the order was not corrected until 04/30/25. The wound area did not increase due to the order not being transcribed correctly. Review of the facility Medication, Treatment, and Physician Order Transcription policy dated 11/03/23 revealed orders are transcribed then noted by the licensed nurse. The licensed nurse noting the order is responsible for accurate transcription and initiation of orders.

Based on record review, interviews, and facility policy review, the facility failed to timely respond to monthly medication regimen reviews (MRR) for two Residents (#51 and #76) out of five residents (#10, #51, #57, #76 and #89) reviewed for unnecessary medications. The facility census was 120. Findings include: 1. Review of the medical record revealed Resident #51 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, pneumonia, insomnia, bipolar and hypoxia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was severely cognitively impaired. Required one person assistance with activities of daily living and transport with a wheelchair. Review of the medication administration record (MAR) for November 2024 and December 2024 revealed Resident # 51 was receiving Trazadone 50 milligrams (mg) at bedtime. Review of the monthly medication regimen reviews revealed on 11/29/24 the pharmacist documented Resident #51 had been using Trazadone 50 mg at bedtime and a trial dose reduction was recommended and instructions were provided to document in the progress notes if the therapy is required to prevent future depressive episodes. The response, dated 01/06/25 from Certified Nurse Practitioner (CNP) #402 confirmed Resident #51 had good response to current treatment and remains at a functional baseline, therefore a dose reduction was not approved due to a reduction was likely to impair the resident's function or cause psychiatric instability. 52012 2. Review of the medical record for Resident #76 revealed an admitted [DATE], diagnoses included chronic obstructive pulmonary disease, type II diabetes mellitus, sick sinus syndrome, bipolar disorder, major depressive disorder, emphysema, and anxiety. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #76 was receiving scheduled antidepressant medications. Resident #76 also received antipsychotic and antianxiety medications with indications present. Review of the medication administration record (MAR) from December 2024 through January 6, 2025 revealed Duloxetine 60 milligrams (mg) was administered daily as ordered. Side effects of the medications, and side effects of the antipsychotic and antianxiety medications were also monitored every shift. Review of the monthly pharmacy medication regimen review conducted on 11/29/2024 the pharmacist recommended a trial dose reduction of the Duloxetine as Resident #76 had been receiving the medication since 04/09/24 after an acute manic episode. The pharmacy recommendation was reviewed and signed by the Nurse Practitioner (NP) #402 on 01/06/2025. The trial dose reduction was not accepted due to the resident having a good response to the current treatment and the benefits of the current treatment outweigh the risks of a change in treatment. Interview on 04/30/25 with the Director of Nursing (DON) at 4:00 P.M. confirmed the pharmacy reviews are conducted monthly. When recommendations are made a copy of the consultant pharmacist recommendation is given to the physician who ordered the medication. The DON verified their contract psychiatric services CNP #402 did not respond to the November recommendations until 01/06/25. The DON confirmed the December 2024 recommendations were reviewed on 12/29/24. Review of facility policy titled Medication Regimen Review, revised 07/22/2024 stated the physician will document in the medical record that any irregularities or recommendations identified by the pharmacist have been reviewed and what action was taken to address it by their next mandatory visit.

Based on record review, observation, staff interview, and review of facility policy, the facility failed to ensure hand hygiene was performed prior to medication administration and failed to ensure proper sanitary practices were followed when preparing medications for administration. This failure affected one resident (Resident #82) out of the six residents observed during medication administration. The facility census was 120. Findings include: Review of the medical record for Resident #82 revealed an admitted [DATE], with diagnoses including dysphagia, squamous cell carcinoma, and malignant neoplasm of the head, face, and neck. Review of the current physician orders identified the following medications were prescribed on 02/18/25: folic acid, 1 milligram (mg) tablet by mouth once a day, one multivitamin tablet by mouth, once daily, thiamine mononitrate 100 mg by mouth once daily, and Fluticasone propionate nasal suspension, 50 micrograms per activation twice daily. Observation of medication administration on 04/30/25 at 9:22 A.M. with Registered Nurse (RN) #201 revealed while preparing Resident #82's medications, RN #201 opened the medication drawer, touched multiple potentially contaminated surfaces, including the drawer handles, numerous medication cards in the second drawer, and the computer mouse. RN #201 then grabbed a medication cup, removed a bottle of multivitamins, opened it, and dispensed a pill directly into her hand, then placed the pill into the medication cup, closed the bottle and placed it back into the drawer. RN #201 then identified the folic acid bottle, opened it, and transferred a pill into her hand before placing it into the medication cup, closed the folic acid bottle and returned the bottle to the medication cart. Next, RN #201 removed thiamine B-1 from package, directly into her hand, and then transferred it into the medication cup. RN #201 then identified and removed the Fluticasone propionate from its box, prepared a cup of water, locked the medication cart, and turned off the computer screen, and headed to Resident #82's room. Upon entering the room and finding the resident absent, RN #201 exited the room and went to search for Resident #82. After locating the resident in the hallway, RN #201 re-entered the resident's room with the resident. RN #201 then handed Resident #82 the cup of water and the medication cup of pills. Resident #82 was observed taking the medication without issue. RN #201 then removed the cap from the Fluticasone propionate and handed it directly to the resident, who took it without concern. Upon completion of medication administration, RN #201 exited the room, returned to the medication cart, signed off the medication administration using the computer, and proceeded to prepare the next resident's medication. Interview on 05/30/25 at 9:28 A.M. with RN #201 acknowledged that the medications were dispensed directly into her unwashed hands. RN #201 also confirmed hand hygiene was not conducted before or after administering the medication to Resident #82. Interview on 05/01/25 at 10:49 A.M. with the Director of Nursing and Regional Clinical Manager #400 confirmed is it unacceptable for the nurses to dispense medications directly into their hands when preparing medications, and further verfiied hand hygiene should be conducted before and after medication administration. Review of the facility policy titled Medication Administration, dated 08/07/23 revealed hand hygiene is to be preformed prior to medication administration. Nurses are not to touch the medication or the the inside of the medication cup when preparing or administering medications for a resident.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure resident dignity was maintained during medication administration. This affected one (Resident #93) of nine residents observed for dining. The facility census was 136 residents. Findings include: Review of the medical record for Resident #93 revealed an admitted [DATE] with diagnoses including type two diabetes mellitus, dementia without behavioral disturbance, and anxiety. Review of the physician's orders for Resident #93 revealed an order dated 12/16/24 for Lispro insulin inject subcutaneously before meals for diabetes mellitus per sliding scale. Review of the Minimum Data Set (MDS) assessment for Resident #93 dated 01/16/25 revealed the resident was cognitively impaired. Observation of the lunch meal in the main dining room on 03/10/25 at 12:14 P.M. revealed Registered Nurse (RN) #164 checked Resident #93's blood sugar while the resident was eating lunch and without asking for the resident's consent. RN #93 then left the dining room and returned with an insulin syringe, lifted up Resident #93's shirt and administered the injection into the resident's abdomen without asking for the resident's consent. Interview on 03/10/25 at 12:35 P.M. with RN #164 confirmed the facility allowed medication administration in the dining room during lunch if the resident was okay with it. RN #164 confirmed since Resident #93 had dementia she did not ask for his consent to check his blood sugar and give him an injection in his abdomen during mealtime. RN #164 confirmed her actions towards Resident #93 were a violation of Resident #93's rights. Interview on 03/10/25 at 4:15 P.M. with the Director of Nursing (DON) confirmed RN #164's actions of conducting blood sugar checks, lifting a resident's shirt, and giving injections in a resident's abdomen in the dining room during lunch was a violation of Resident #93's rights, was against the facility's medication administration policy, and was prohibited. Review of the facility policy titled Medication Administration dated 08/07/23 revealed the nurses should administer medication according to professional standards of practice and resident needs. This deficiency represents noncompliance investigated under Complaint Number OH00162973.

Based on medical record review, review of hospital records, observation, staff interviews, interview with the Local County Health Department (LCHD), interview with the physician, review of a death certificate, review of the facility's Legionella bacteria prevention plan, review of email communications with the LCHD, review of facility policy and procedures, review of the Legionella risk assessment, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to follow their water management plan to ensure all shower heads were descaled semi-annually and flushes were completed weekly which resulted in elevated risk levels of Legionella bacteria in the facility's water system and exposure to the residents. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, negative health outcomes, and/or death when on [DATE] one resident (#100) was found to have increased effort of breathing, fatigue and generalized weakness, was sent to the emergency room (ER) for evaluation, tested positive for Legionella pneumonia in the hospital, and subsequently died on [DATE]. In addition, Resident #118 tested positive for the Legionella urine antigen on [DATE]. The facility's failure to have an effective water management program in place to monitor control measures to prevent the growth of potential Legionella in the water system affected two (#100 and #118) of four residents reviewed for Legionella and placed an additional 131 current residents at potential risk for Legionella bacteria exposure. The facility census was 133. On [DATE] at 11:13 A.M., the Administrator, Director of Nursing (DON) and Regional Clinical Director #111 were notified that Immediate Jeopardy began on [DATE] when Resident #100 exhibited a change in condition and was hospitalized on [DATE] due to labored breathing, fatigue, and generalized weakness and subsequently passed away on [DATE]. Admitting hospital diagnoses included sepsis, anemia, Legionella infection, pneumonia, acute kidney injury and possible chronic heart failure exacerbation. Review of the death certificate dated [DATE] revealed Resident #100 died on [DATE] at 3:06 A.M. with an immediate cause of death as acute renal failure, septic shock, and bacteremia. Review of the facility's Legionella preventative measures and interview with Maintenance Supervisor #221 revealed the facility was not completing weekly dead-end flushes (a length of water pipework closed at one end through which no water passes) and semi-annually descaling per facility policy. On [DATE] at 4:44 P.M., the LCHD communicated to the facility, that a resident who previously resided in the facility had tested positive for the Legionella urine antigen and passed away. The facility failed to implement immediate action to protect further residents from Legionella infection when public health made recommendations, which included restricting water usage or installing point-of-use filters, and to follow the current CDC guidance or current water management plan if already developed. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE], Resident #100 was transferred to the hospital. On [DATE], upon notification of the positive urine antigen test regarding Resident #100, facility staff followed LCHD guidance in reviewing all resident's medical records who were diagnosed with pneumonia for the past three months. Residents #44, #48, #99, #118, #250, #251, #252, #253, #254, and #301 were identified to have been diagnosed with pneumonia in the past three months. On [DATE], the DON was made aware an additional resident (Resident #118) tested positive for the Legionella urine antigen. The facility's Certified Nurse Practitioner (CNP) #900 reviewed the urine analysis results and determined no other treatment was warranted. On [DATE], water filters on ice machines and water fountains were serviced and cleaned by Service Company #500 according to manufacturer guidelines and preventative maintenance agreement. On [DATE], Maintenance Supervisor #221 and Maintenance Staff #166 descaled faucets and shower heads and completed dead leg flushes. On [DATE] and [DATE], the LCHD collected data points for water temperatures, PH levels and chlorine levels. On [DATE], the DON/designee reviewed all current residents with a respiratory assessment with no new respiratory concerns identified. On [DATE], an additional seven water samples were obtained for Legionella testing by a third party (Water Treatment Company #600) initiated by the Administrator. Water Treatment Company #600 will provide the facility with their results of the seven water samples in eight to 11 days. On [DATE], Maintenance Supervisor #221, Maintenance Staff #166 and Maintenance Staff #311 were provided education by the Administrator regarding descaling and flushing dead legs (a length of water pipework leading to a fitting through which water only passes infrequently where there is draw off from the fitting, providing the potential for stagnation) per the facilities water management policy. The Administrator will monitor the maintenance staff to ensure they are following the facility's Legionella prevention plan. Beginning on [DATE], Maintenance Supervisor #221/designee will audit water temperatures, chlorine levels and flush all dead legs two times a week for two months. Any concerns will immediately be reported to the Administrator and follow up with the Quality Assurance and Performance Improvement (QAPI) committee as needed. On [DATE], the Water Management Committee (WMC) met to review the proposed issues and concerns from the Ohio Department of Health Survey. The WMC (including the Administrator, DON, Maintenance Supervisor #221, and Medical Director #112) reviewed the facility's Legionella Risk Assessment and Control Measures, proposed Plan of Correction (POC) and root cause analysis (RCA). The WMC will meet twice a month for two months to review on-going Legionella testing, interim measures, audits completed, RCA corrective action items and POC status. Thereafter, the DON and Infection Control Preventionist (ICP) will report to the Quality Assurance Committee to assure that issues identified at the time of the survey are corrected. On [DATE] and [DATE], the DON/designee provided in-services to all staff, residents, and residents responsible parties regarding the water management program, Legionella screening symptoms, facility remediation measures, and the plan for continued water management. Beginning on [DATE], the DON/designee will complete daily respiratory monitoring assessments until the results of the water testing are received. The findings of the respiratory monitoring will be reviewed with the attending physicians and medical director as needed. On [DATE], the facility began utilizing bottled water. Residents #2 and #119, who resided in the former Residents #100 and #118's rooms (who tested positive for the Legionella urine antigen) were moved out of their rooms and were relocated in the facility. All ice in the ice machine was disposed of and the facility utilized bagged ice. Showers and baths were put out of service until the installation of point of use filters. No-rinse wipes (a pre-moistened, disposable wipe designed to clean and sanitize a surface without the need to rinse it with water afterwards) were provided to the residents for hygiene needs at that time. On [DATE], the facility engaged with Legionella Consultant #650 who reviewed the facility water management plan with the team and will provide 90-day point of use filters that will be installed facility wide by [DATE]. Beginning on [DATE], the DON/designee will complete audits three times a week regarding employee call-offs for four weeks for signs and any symptoms related to Legionella illness. Any concerns will immediately be reported to the Administrator and followed up on with the QAPI committee as needed. On [DATE], 20 additional water samples were obtained by Legionella Consultant #650. On [DATE], maintenance staff installed point of use filters on all water outlets (showers, sinks) in the facility. These filters were rated for 90-day efficacy from the date of installment. All water filters were inspected and then all sinks and showers were put back into service. Although the Immediate Jeopardy was removed on [DATE], the deficiency remained 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 action plan and monitoring to ensure on-going compliance. Findings include: 1) Review of the closed medical record for Resident #100 revealed the resident was admitted to the facility on [DATE] and discharged on [DATE] to the local hospital. The resident had diagnoses including kidney and ureter disorder, paroxysmal atrial fibrillation, chronic kidney disease, and chronic diastolic (congestive) heart failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 was cognitively intact as evidence by a Brief Interview for Mental Status (BIMS) assessment score of 15. The resident was assessed to require supervision or touching assistance with bed mobility, transfers, toileting, and eating. Review of Resident #100's change in condition evaluation dated [DATE] revealed the resident was documented to have increased confusion, weakness, disorientation, and abnormal vital signs. The CNP #900 was notified with an order to send Resident #100 to the local hospital for evaluation. Review of Resident #100's hospital discharge summary dated [DATE] at 6:29 A.M. revealed active hospital problems of rectal bleeding, Legionella infection, volume overload, acute kidney injury superimposed by chronic kidney disease, bacteremia, and electrolyte disorder. The hospital course included evaluation of the worsening shortness of breath, cough, and lower extremity edema. Laboratory results at that time were notable for leukocytosis, positive urine Legionella antigen, and x-ray with pulmonary edema with dense right upper lobe airspace opacity. Resident #100 started on oxygen to maintain adequate supply of oxygen, but in the morning of [DATE], he was seen to have recurrent hypoxia (inadequate supply of oxygen) requiring escalation to Bilevel Positive Airway Pressure (BIPAP) and transferred to the Intensive Care Unit (ICU). The residents' antibiotics were adjusted for Legionella coverage; however, overnight from [DATE] to [DATE], Resident #100 decompensated quickly resulting in passing on [DATE] at 3:06 A.M. Review of Resident #100's death certificate revealed the resident died on [DATE] at 3:06 A.M. with an immediate cause of death as acute renal failure, septic shock, and bacteremia. 2) Review of the medical record for Resident #118 revealed re-admitted [DATE]. The resident had diagnoses including hemiplegia, muscle weakness, chronic kidney disease, chronic pulmonary embolism, mild cognitive impairment, altered mental status and essential hypertension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #118 was severely cognitively impairment. Resident #118 required setup or clean-up assistance with eating. Review of the progress notes revealed on [DATE] at 3:42 P.M., Resident #118 seemed congested with crackle sound and coughing, no fever, and oxygen low at 90 percent saturation. The progress note dated [DATE] at 7:12 P.M. revealed the nurse received a new order for chest x-ray for congestion. Review of physician orders dated [DATE] revealed chest x-ray: 2 views for chest congestion. The progress note dated [DATE] at 8:47 A.M. revealed the chest x-ray results were received with left perihilar atelectasis/infiltrates noted and CNP #900 was notified. New orders for Levaquin (antibiotic) 750 milligrams (mg), ipratropium-albuterol inhalation solution (used to help open airways and reduce inflammation in the lungs to help you breathe), and Mucinex (help symptom relief for cold, flu, sinuses and sore throat). Review of Resident #118's physician orders dated [DATE] revealed an order to obtain urine specimen for Legionella antigen. Review of Resident #118's strep pneumonia and Legionella pneumonia AG result dated [DATE] revealed Legionella antigen had a positive result. The progress note dated [DATE] revealed Resident #118's results of urine antigen discussed with provider, residents' treatment appropriate at this time, and no further treatment required. Review of the LCHD email dated [DATE] at 4:44 P.M. revealed a resident (#100) who previously resided in the facility had tested positive for Legionella urine antigen and passed away. The email communication included guidance as listed, perform a retrospective review of cases, develop a line list of possible and definite cases, work with health care facility staff to identify all new and recent patients with health care associated pneumonia and test them for Legionella, consider recommendations for restricting water exposures in the facility or other immediate control measures, and facilitate an environmental assessment and sampling. The email from Environmental County Health Division (ECHD) dated [DATE] at 3:38 P.M. revealed the typical steps in a full investigation are to protect current residents by restricting water usage or installing point-of-use filters and follow the current CDC guidance or current water management plan if already developed. The Administrator's email was incorrectly entered. The following email was resent to the correct Administrator's email address on [DATE] at 8:43 A.M., with an email response from the Administrator on [DATE] at 4:31 P.M. The email communication dated [DATE] at 12:34 P.M. from ECHD Supervisor #999 to the Administrator revealed guidance stating, we again advise you to protect current residents by restricting water usage or installing point-of-use filters. Review of Semi-Annual Faucet and Showerhead Scale Inspection documentation as part of the facility's Legionella bacteria prevention plan revealed the only record available for review was on [DATE]. There were no records available prior to [DATE]. Observations on [DATE] from 8:02 A.M. to 8:24 A.M. revealed the resident rooms' sinks did not have water filters in place and they were in working order. Shower rooms were in working order and no filters were in place on the shower heads. Interview on [DATE] at 2:00 P.M. with Maintenance Supervisor #221 denied issues with the water system in the facility, stating he regularly conducts temperature checks, flushes, and monitors chlorine levels in accordance with facility policy. He stated that most of the residents' showers in their rooms were shut off and were considered dead ends, as they do not receive water flow through them, often resulting in stagnant water sitting in the lines. Maintenance Supervisor #221 denied flushing all dead ends, specifically shower heads, on a weekly basis, which is the standard procedure according to the facility's policy. He confirmed descaling of faucets and shower heads should occur semi-annually. Additionally, he confirmed the most recent descaling was performed on [DATE]. However, the facility had no other available records regarding past descaling maintenance. Interview on [DATE] at 2:03 P.M. with Maintenance Supervisor #221 and the Administrator confirmed no additional records were available for Semi-Annual Faucet and Showerhead Scale Inspection. Interview via telephone on [DATE] at 9:27 A.M. with ECHD Program Coordinator #113 confirmed he visited the building on [DATE] and [DATE]. During his visits, he discussed potential causes of increased Legionella growth, including the need for routine flushing of dead legs, descaling of faucets, monitoring water temperatures and chlorine levels, and interventions to prevent further spread (filters and water restrictions) with Maintenance Supervisor #221. The goal of the [DATE] visit was to limit potential exposure to other residents in the facility. ECHD Program Coordinator #113 stated the Administrator was concerned about placing filters on the water outlets. The Administrator felt if he placed filters on the water outlets, then the Legionella testing may not show accurate results. However, ECHD Program Coordinator #113 told the Administrator the filters could be placed on the water outlets, and he could remove the filter to test the water and then put the filter back on. ECHD Program Coordinator #113 confirmed he had sent guidance to the Administrator on [DATE], was notified of the email error, and resent it on [DATE] at 8:43 A.M. without issues. Interview on [DATE] at 11:32 A.M. with the DON and Regional Clinical Director #111 confirmed Resident #118 had a diagnosis of pneumonia, and confirmed Legionella is caused by aspiration of contaminated water. The DON confirmed Resident #118 has a history of aspiration. Interview on [DATE] at 3:00 P.M. with Physician #114, who completed Resident #100's death certificate, confirmed the diagnoses listed on Resident #100's death certificate could have been caused by Legionella bacterium. He also verified the resident was admitted with pneumonia, which could have contributed to the development of sepsis. Review of the undated Potable Water Systems Operation and Maintenance document as part of the facility's Legionella bacteria prevention plan revealed the task was to flush to drain all outlets that are used less than once per week. Purging one to three minutes, based on pipe supply length. Review of the Legionella environmental policy dated [DATE] revealed a confirmed case is one where the patient/resident has had a continuous inpatient stay of 10 or more days prior to illness onset. The facility's mission is to maintain policies ensuring actions are taken to identify infected patients/residents and reduce Legionella risk. Control measures include routine chlorine level testing, water temperature monitoring, flushing unused pipes, and monitoring conditions like water main breaks or equipment failures. Interim measures may include supplying bottled water, installing point-of-use filters, and relocating residents. Review of the Legionella clinical policy/procedure dated [DATE] revealed the facility's mission is to maintain policies ensuring actions are taken to identify infected residents and reduce Legionella infection risk. The DON or designee will collaborate with the local board of health on further actions, which could include using bottled water, discontinuing the ice machine, and utilizing filters on sinks and showers, as recommended by an outside consultant. Review of the Legionella risk assessment dated [DATE] revealed potential low use points, such as dead legs will increase stagnation and risk of bacterial growth. Recommendations made were to flush low use points and vacant units weekly to remove the volume of stagnant water to the connection point and draw water containing disinfectants into the line. Also, a recommendation is made to institute a procedure for routine flushing in vacant units and other hot water outlets deemed low use. Additionally, it is recommended to clean the showerhead and aerators on a semi-annual basis. Review of the CDC website at, https://www.cdc.gov/legionella/wmp/healthcare-facilities/water-mgmt-validation.html, revealed according to the CDC/Healthcare Infection Control Practices Advisory Committee (HICPAC), healthcare facilities have two options for confirming that their water management program is working as intended including performing environmental sampling for Legionella and performing active clinical surveillance for infections due to Legionella. This deficiency represents non-compliance investigated under Complaint Number OH00161885.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure the milk served during meal service remained in a safe and palatable temperature for serving. This had the potential to affect 56 residents (Residents #1, #2, #3, #5, #6, #8, #9, #10, #12, #13, #14, #15, #18, #19, #20, #21, #22, #23, #25, #27, #28, #32, #34, #35, #36, #37, #40, #41, #42, #43, #47, #48, #49, #51, #52, #54, #59, #60, #63, #69, #74, #75, #76, #81, #82, #84, #89, #93, #101, #102, #103, #113, #116, #120, #130 and #238) who regularly consume milk. The facility census was 133. Findings include: Observation of breakfast meal service on 01/28/25 at 8:29 A.M. revealed multiple residents trays had various types of milk on them, those milks included low fat milk, 2% milk and whole milk. Direct care staff removed a 2% milk from the cart to complete a test tray. The milk temperature was 60 degrees Fahrenheit (F). Interview on 01/28/25 at 8:31 A.M. with Certified Nursing Assistant (CNA) #350 confirmed the 2% milk was at 60 degrees F. CNA #350 stated she was unsure of the safe serving temperature for milk. Interview on 01/28/25 at 12:12 P.M. with Regional Culinary Director #500 and Food Services Director #170 denied the kitchen staff placed milk on trays. Facility policy stated the milk cartons should be placed in a bucket of ice on top of the serving carts to ensure they remain cold. Observation of tray arriving on the unit on 01/28/25 at 12:19 P.M. revealed low-fat, 2%, and whole milk were again placed on residents' trays. This observation was conducted with Food Services Director #170, who confirmed that dietary staff did not follow facility policy. Upon removal of the final tray, Food Services Director #170 and surveyor began temperature checks. The milk was measured at 60 degrees F. Food Services Director #170 requested a temperature re-check. Upon returning at 12:36 P.M. with a digital thermometer, his probe read 57.6 degrees F, while the surveyor's probe read 62 degrees F. Food Services Director #170 confirmed the milk was not within safe serving temperatures. Review of trayline food temperatures dated 08/01/24 revealed the facility will hold and serve food at acceptable temperatures to deter bacterial growth. The internal temperatures of potentially hazardous foods must be 41 degrees F or below for cold food. Additionally, the policy states that cold food shall remain under refrigeration or on ice during meal service to ensure that cold foods are served at no greater than 41 degrees F. This deficiency represents non-compliance investigated under Complaint Number OH00161708.

Based on medical record review, resident and staff interview, and review of a self-reported incident, the facility failed to ensure residents received proper assistance with transfers and toileting per the plan of care. This affected one (#1) of three residents reviewed for accidents. The facility census was 132. Findings include: Review of Resident #1's medical record revealed an admitted [DATE] with diagnoses included encounter for orthopedic aftercare (fractured right ankle), foot drop of the left foot, unsteadiness on feet, weakness, cerebral infarction, morbid obesity, chronic kidney disease, chronic pain syndrome, and chronic respiratory failure. The resident was discharged on [DATE]. Review of Resident #1's admission Minimum Data Set (MDS) assessment, dated 03/12/24, revealed the resident had intact cognition. The assessment indicated the resident had no behaviors, including rejection of care. The resident required physical assistance and was dependent for sit-to-stand, chair/bed-to-chair transfers, and toilet transfers. The MDS assessment indicated the resident had impairment of both lower extremities and her mobility device was a wheelchair. Review of an activities of daily living (ADLs) self-care performance deficit care plan dated 03/09/24 revealed Resident #1 had an intervention for a two-person assist to the bedside commode for toileting and transfers using a wheeled walker and gait belt. Review of a self-reported incident (SRI) dated 04/01/24 at 7:22 A.M. revealed State tested Nurse Aide (STNA) #202 assisted and transferred Resident #1 to the bedside commode without the assistance of another staff member. Interview on 04/01/24 at 1:20 P.M., with Regional Director of Nursing #205 confirmed Resident #1 was at risk for falls and required assistance of two staff for transfers and toileting per her care plan. Regional Director of Nursing #205 also confirmed the information in the SRI dated 04/01/24 indicating STNA #202 assisted Resident #1 to the bedside commode without proper assistance. Telephone interview on 04/04/24 at 2:43 P.M., with Resident #1 stated STNA #202 always transferred her to the bedside commode without the assistance of a second staff member. Interview on 04/05/24 at 2:20 P.M., the Director of Nursing confirmed Resident #1's care plan indicated she required assistance from two staff for transfers.

Based on record review, resident and staff interview, and review of the facility policy, the facility failed to ensure a resident received the physician ordered catheter care. This affected one (Resident #200) of two residents reviewed for urinary catheter care. The facility census was 135. Findings include: Review of the medical record for Resident #200 revealed an admitted [DATE]. Diagnoses included muscle weakness, urinary tract infection, neuromuscular dysfunction of bladder with urinary stoma, and ileostomy. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #200 had intact cognition. Review of Resident #200's physician orders revealed an order dated 02/16/24 for straight catheter kits for self-catheterization every shift. Review of Resident #200's Treatment Administration Record (TAR) from 02/16/24 to 02/29/24 revealed straight catheter kits for self-catheterization every shift was not documented as provided on the following five days: 02/20/24, 02/21/24, 02/22/24, 02/23/24 and 02/29/24 for the 12-hour shift. Interview with Resident #200 on 03/05/24 at 10:00 A.M. revealed she had not received straight catheter kits the previous week, resulting in Resident #200 calling family to obtain personal supplies from home after Resident #100 had to utilize a used catheter to urinate. Interview on 03/06/24 at 2:16 P.M. with the Director of Nursing (DON) verified Resident #200's physician ordered colostomy care was not documented as being provided on 02/20/24, 02/21/24, 02/22/24, 02/23/24 and 02/29/2024 for the 12-hour shift. Review of the facility policy titled Catheter- Intermittent Catheterization, dated 08/24/23, revealed a sterile field and sterile catheter is to be utilized for intermittent catheterization. This deficiency represents non-compliance investigated under Complaint Number OH00151619.

Based on record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #200) of one resident reviewed for significant medication errors. The facility census was 135. Findings include: Review of the medical record for Resident #200 revealed an admitted [DATE]. Diagnoses included urinary tract infection. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #200 had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. Review of Resident #200's physician orders revealed an order dated 02/26/24 for Ceftriaxone sodium (antibiotic) injection two gram intramuscularly one time only for pneumonia. A physician order dated 02/27/24 for Ceftriaxone sodium (antibiotic) injection one gram intramuscularly one time a day for pneumonia for six days. Review of Resident #200's Medication Administration Record (MAR) for February 2024 revealed the Ceftriaxone sodium injection one gram was not documented as administered on 02/26/24 and Ceftriaxone sodium injection one gram was not documented as administered on 02/27/24 and 02/28/24. Resident #200 had three missed doses of her antibiotic Ceftriaxone sodium injection. Interview with Resident #200 on 03/05/24 at 10:00 A.M. revealed she had not correctly received an antibiotic medication as ordered by her physician for her pneumonia. Interview on 03/06/24 at 2:16 P.M. with the Director of Nursing, (DON) verified Resident #200 did not receive her scheduled dose of Ceftriaxone sodium injection two gram on 02/26/24 as scheduled and ordered by the physician, nor did she receive her scheduled dose of Ceftriaxone sodium injection one gram on 02/27/24 and 02/28/24. Review of the facility policy titled Administering Medications, dated 08/07/23, revealed medications must be administered in accordance with frequency prescribed by physician and standards of practice. This deficiency represents non-compliance investigated under Complaint Number OH00151280 and Complaint Number OH00151026.

Based on record review, resident and staff interview, observation, and review of the facility policy, the facility failed to ensure residents received care and services for their intravenous catheter (IV). This affected one (Resident #200) of two residents reviewed for IV care. The facility census was 135. Findings include: Review of the medical record for Resident #200 revealed an admitted [DATE]. Diagnoses included hypotension, urinary tract infection, severe protein calorie malnutrition, depression, nd acute kidney failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #200 had intact cognition. Review of Resident #200's physician orders revealed an order dated 02/23/24, ok to put in peripheral IV one time only for one day. Resident #200 physician orders was silent for care of the peripheral IV, including maintaining patience and function and dressing changes. Review of Resident #200's Medication Administration Record (MAR) for February 2024, revealed documentation of a peripheral IV had been placed on 02/23/24. Review of Resident #200 progress notes from 02/24/24 though 03/05/24 was silent for assessment, or care provided for peripheral IV place on 02/23/24. Interview and subsequent observation of Resident #200 on 03/05/24 at 10:00 A.M. revealed the appearance of an IV catheter tubing hanging down from left upper arm with a clear non-dated dressing over insertion cite. Resident #200 stated they put the IV in a week and a half ago, gave her some fluids for a day, and the nurses had not provided any care or even looked at it since. Resident #200 stated she had brought the IV to the nurse's attention several times with no avail. Interview with Director of Nursing (DON) on 03/06/24 at 2:16 P.M. revealed the facility had no policy for peripheral IV care. The DON stated the staff would refer to the center for disease infection control standards for the prevention of intravascular catheter related infections dated (2011), which stated to evaluate the catheter insertion site daily. The DON verified there was no documentation of daily evaluations of Resident #200's peripheral IV per standard of IV care, documented assessments including maintaining patency, site care and assessment were part of standard nursing care. This deficiency represents non-compliance investigated under Complaint Number OH00151280.

Based on record review, resident and staff interview, and review of the facility policy, the facility failed to ensure residents received the physician ordered care of their ostomy. This affected one (Resident #200) of two residents reviewed for ostomy care. The facility census was 135. Findings include: Review of the medical record for Resident #200 revealed an admitted [DATE]. Diagnoses included neuromuscular dysfunction of bladder with urinary stoma and ileostomy. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #200 had intact cognition. Review of Resident #200's physician orders revealed an order dated 02/16/24 to empty colostomy bag as needed every shift for colostomy care. Review of Resident #200's Treatment Administration Record (TAR) from 02/16/24 to 02/29/24 revealed empty colostomy bag as needed every shift for colostomy care was not documented as provided on the following four days: 02/20/24, 02/21/24, 02/22/24 and 02/23/24 for the 12-hour shift. Interview with Resident #200 on 03/05/24 at 10:00 A.M. revealed she had not received ostomy care including having supplies for the ostomy care the previous week, resulting in the stool overflowing out of the bag. Interview on 03/06/24 at 2:16 P.M. with the Director of Nursing (DON) verified Resident #200's physician ordered colostomy care was not documented as being provided on 02/20/24, 02/21/24, 02/22/24 and 02/23/24 for the 12-hour shift. Review of the facility policy titled Colostomy-Ileostomy Care, revision date 06/03/19 revealed the registered nurse or licensed practical nurse will manage the colostomy and ileostomy care appropriately. This deficiency represents non-compliance investigated under Complaint Number OH00151619.

Based on medical record review, staff interviews, and review of the facility policy, the facility failed to ensure a resident's pressure ulcer was assessed and monitored and the treatment to the pressure ulcer was administered as physician ordered. This affected one (Resident #100) of three residents reviewed for pressure ulcer care. The facility census was 135 Findings include: Review of the closed medical record for Resident #100 revealed an admitted [DATE]. Diagnoses included encephalopathy, lack of coordination, muscle weakness, dementia, chronic kidney disease, and sacrococcygeal Deep Tissue Injury (DTI) (Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue). The resident was discharged on [DATE] to the hospital. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 had severe cognitive impairment. Resident #100 was dependent on staff for toileting, upper and lower body dressing, and personal hygiene. Review of resident's initial nursing assessment dated [DATE] revealed there was no assessment of Resident #100's DTI on the sacrococcygeal. There was no description or measurements of the wound during Resident #100's stay at the facility. Review of Resident #100's care plan dated 02/22/24 revealed support and interventions for self-care deficit and actual and potential for impaired skin integrity related to fragile skin and DTI. Interventions for potential and actual skin impairment included to follow facility protocols for treatment of injury, monitor, document location size, and treatment of skin injury. Review of Resident #100's physician orders dated 02/16/24 revealed an order for the sacrococcygeal DTI blister: paint with betadine-soaked gauze over blistered/open area then apply zinc-based barrier ointment to general area four times daily and as needed (PRN) and an order for lower thoracic- lumbar spine: hydrocolloid dressings to protect prominent spinal bones every shift for protection. Review of Resident #100's Treatment Administration Record (TAR) from 02/17/24 to 02/23/24, revealed the physician ordered treatment to the sacrococcygeal DTI blister was not documented as being completed (blank signatures) ten times out of 28 opportunities on 02/20/24 at 9:00 A.M., 1:00 P.M., 5:00 P.M., and 9:00 P.M.; on 02/21/24 at 9:00 A.M., 1:00 P.M., and 5:00 P.M. and 02/22/24 at 9:00 A.M., 1:00 P.M., and 5:00 P.M Further The physician ordered treatment to the lower thoracic-lumbar spine was not documented as being completed (blank signatures) three times out of seven opportunities on 02/20/24, 02/21/24, and 02/22/24. Interview on 03/06/24 at 2:16 P.M. with the Director of Nursing, (DON) verified that blank signatures in the treatment administration record indicated a physician order was not completed per order. Interview with Registered Nurse (RN) #3 on 03/07/24 at 3:10 P.M. verified Resident #100's medical record did not contain an admission skin assessment with measurements of skin areas and a weekly measurements of each skin issue. Review of the facility policy titled Skin Care Program, dated 01/24/23, revealed upon admission, resident will have their skin assessed from head to tie by a professional nurse. Each area will be documented by the professional nurse on the illustration of documentation and measurements of skin area form. Weekly, a professional nurse needs to measure each skin issue and enter into Point Click Care (electronic medical record). This deficiency represents non-compliance investigated under Master Complaint Number OH00151682 and Complaint Number OH00150932. This is an example of continued non-compliance from the survey dated 02/08/24.

Based on observation, record review, staff interviews, review of wound notes, and facility policy review, the facility failed to accurately assess, timely notify the physician of an identified pressure area, and implement interventions to prevent a middle lumbar pressure ulcer from worsening for Resident #16. Additionally, the facility failed to comprehensively assess, notify the physician, and implement a treatment plan timely for Resident #9 and Resident #67 who were admitted to the facility with pressure ulcers/injuries. Actual Harm occurred on 10/22/23 when Resident #16, who required extensive assistance from two staff and was incontinent, had a middle lumbar wound that was not accurately assessed as a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open/ ruptured blister.) pressure ulcer which worsened to an unstageable (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound.) pressure ulcer without evidence of timely physician notification, implementation of appropriate prevention interventions, and treatment or adequate assessments of the wound area. This affected three residents (#9, #16, and #67) of three residents reviewed for pressure ulcers. The facility identified 13 residents having pressure ulcers. The facility census was 130. Findings Include: 1. Review of the medical record for Resident #16 revealed an initial admitted [DATE] with diagnoses including severe degeneration of the brain, protein calorie malnutrition, vitamin D deficiency, dementia, hypertension, anemia, cerebrovascular accident, osteoarthritis, and pressure ulcer of the back. Review of the plan of care dated 01/19/23 revealed the resident had the potential for impairment to skin integrity related to decreased mobility, use of assistive devices, assist of staff, cerebral vascular accident, osteoarthritis, impaired decision making and safety awareness, dementia, anemia and incontinence. Interventions included keep skin clean and dry, use lotion on dry skin, low air loss mattress, monitor the status of resident's toenails as needed, obtain blood work as physician ordered, pressure relieving cushion to wheelchair, reposition resident for comfort as needed, turn/reposition resident regularly to relieve pressure points, use a draw sheet or lifting device to move resident and use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface. Review of the progress note dated 10/22/23 at 8:15 P.M. revealed the resident was found to have a reddened area with two blisters on his back. The nurse documented moisturizing cream was applied to the reddened area. Review of the resident's medical record revealed no documented evidence that the resident's primary care physician (PCP) was notified of the reddened area with two blisters on the resident's back or a treatment was initiated. Review of the primary care physician (PCP) #238 progress note dated 10/25/23 revealed no documented evidence the physician was aware of the reddened area with two blisters to the resident's back. Review of the resident's physician's orders revealed an order dated 10/30/23 to cleanse wound to back with normal saline (NS), apply calcium alginate and cover with a foam dressing every Monday, Wednesday, and Friday with the special instructions to be changed by hospice nurse or staff nurse per order and as needed for wound care. Review of the resident's medical record revealed no documented evidence that the physician ordered treatment to the resident mid lumbar spine was provided. Review of the weekly skin & wound assessment dated [DATE] revealed Resident #16 was found to have an unstageable pressure ulcer to the mid lumbar spine measuring 3.9 centimeters (cm) by 0.8 cm. The wound was described as 40% epithelial, 10% granulation and 50% slough. The wound was noted to have a light amount of serous exudate. The facility implemented the intervention to cleanse with NS, apply calcium alginate and cover with foam dressing. Review of the weekly skin and wound assessment dated [DATE] revealed the unstageable pressure ulcer to the resident's mid lumbar spine measured 3.7 cm by 1.3 cm. The wound was described as 20% epithelial tissue, 10% granulation and 70% slough. The wound had a light amount of serous exudate with a faint odor. The surrounding tissue was macerated (wet, white, waterlogged tissue). The facility determined the wound had deteriorated. The facility changed the treatment to cleanse with NS, pat dry, apply Medi honey, apply calcium alginate to fit the wound bed and cover with a foam dressing. Review of the medical record revealed no documented evidence that the resident's power of attorney (POA) was notified of the deterioration of the unstageable pressure ulcer to the resident's mid lumbar spine. Review of the weekly skin and wound assessment dated [DATE] revealed the unstageable pressure ulcer to the resident's mid lumbar spine measured 4.8 cm by 2.0 cm. The wound was described as 30% epithelial tissue, 10% granulation and 60% slough. The wound had a moderate amount of serosanguineous exudate with a moderate odor. The facility determined the wound was stable and made no changes to the treatment. Review of the weekly skin and wound assessment dated [DATE] revealed the unstageable pressure ulcer to the resident's mid lumbar spine measured 4.2 cm by 1.5 cm. The wound was described as 20% epithelial tissue and 80% slough. The wound had a light amount of serous exudate with no odor. The facility determined the wound was stable and made no changes to the treatment. Review of the weekly skin and wound assessment dated [DATE] revealed the unstageable pressure ulcer to the resident's mid lumbar spine measured 1.7 cm by 0.8 cm. The wound was described as 60% granulation tissue and 40% slough. The wound had a light amount of serous exudate with no odor. The facility determined the wound was stable and made no changes to the treatment. Review of the resident's November 2023 Treatment Administration Record (TAR) revealed no documented evidence the physician ordered treatment to the resident's mid lumbar spine was provided on 11/10/23, 11/13/23, and 11/27/23. Review of the weekly skin and wound assessment dated [DATE] revealed the unstageable pressure ulcer to the resident's mid lumbar spine measured 1.8 cm by 1.4 cm. The wound was described as 30% granulation tissue and 70% slough. The wound had no exudate. The facility determined the wound was stable and made no changes to the treatment. Review of the weekly skin and wound assessment dated [DATE] revealed the unstageable pressure ulcer to the resident's mid lumbar spine measured 5.7 cm by 2.4 cm by 0.2 cm. The wound was described as 100% slough. The wound had a light amount of serosanguineous exudate with no odor. The facility determined the wound had had improved despite the increased size, depth and the wound being 100% slough. The facility made no changes to the treatment. Review of the medical record revealed no documented evidence that the resident's POA was notified of the deterioration of the wound. Review of the weekly skin and wound assessment dated [DATE] revealed the unstageable pressure ulcer to the resident's mid lumbar spine measured 3.6 cm by 2.0 cm. The wound was described as 90% granulation tissue and 10% slough. The wound had a light amount of serosanguineous exudate with no odor. The facility determined the wound was stable and made no changes to the treatment. Review of the weekly skin and wound assessment dated [DATE] revealed the unstageable pressure ulcer to the resident's mid lumbar spine measured 4.1 cm by 1.6 cm by 0.2 cm. The wound was described as 70% granulation tissue and 30% slough. The wound had a moderate amount of serosanguineous exudate with no odor. The facility determined the wound was stable and made no changes to the treatment. Review of the resident's December 2023 TAR revealed no documented evidence the physician ordered treatment to the resident's mid lumbar spine was provided on 12/10/23. Review of the weekly skin and wound assessment dated [DATE] revealed the unstageable pressure ulcer to the resident's mid lumbar spine measured 2.5 cm by 1.8 cm by 0.2 cm. The wound was described as 70% granulation tissue and 30% slough. The wound had a moderate amount of serosanguineous exudate with no odor. The facility determined the wound was stable and made no changes to the treatment. Review of the weekly skin and wound assessment dated [DATE] revealed the unstageable pressure ulcer to the resident's mid lumbar spine measured 2.6 cm by 2.1 cm by 0.2 cm. The wound was described as 70% granulation tissue and 30% slough. The wound had a moderate amount of serosanguineous exudate with no odor. The facility determined the wound was stable and made no changes to the treatment. Review of the weekly skin and wound assessment dated [DATE] revealed the unstageable pressure ulcer to the resident's mid lumbar spine measured 1.9 cm by 1.5 cm by 0.2 cm. The wound was described as 80% granulation tissue and 20% slough. The wound had a light amount of serosanguineous exudate with a faint odor. The facility determined the wound was stable and the treatment was changed to cleanse with Dakin's solution, apply calcium alginate and cover with a foam dressing. Review of the medical record revealed no documented evidence the resident's POA was notified of the change in treatment. Review of the plan of care dated 01/18/24 revealed the resident was at risk for pressure injury formation related to generalized debility and weakness as evidenced by decreased mobility in bed and wheelchair, incontinence of bowel and bladder, requires assistance from staff with incontinence care, turning and repositioning, Braden score less than 17 and pressure ulcer to lumbar and right lateral mid foot. Interventions included Braden scale to be completed per facility protocol, cushion to wheelchair daily, encourage and assist as needed to turn and reposition per policy, use assistive devices as needed, encourage intake of 75 to 100% of diet and fluids daily, Registered Dietician (RD) to assess dietary needs quarterly and with significant changes, encourage resident to float heels and/or wear heel boots, monitor skin daily during care and for redness, excoriation or breakdown, skin evaluation weekly, weekly nursing skin evaluations with shower, notify primary care physician and wound care nurse of any skin changes. Review of the weekly skin and wound assessment dated [DATE] revealed the unstageable pressure ulcer to the resident's mid lumbar spine measured 2.5 cm by 1.6 cm by 0.2 cm. The wound was described as 80% granulation tissue and 20% slough. The wound had a moderate amount of serosanguineous exudate with no odor. The facility determined the wound was stable and made no changes to the treatment. Review of the weekly skin and wound assessment dated [DATE] revealed the unstageable pressure ulcer to the resident's mid lumbar spine measured 2.7 cm by 2.0 cm by 0.2 cm. The wound was described as 80% granulation tissue and 20% slough. The wound had a moderate amount of serosanguineous exudate with no odor. The facility determined the wound was improving and made no changes to the treatment. Review of the resident's January 2024 TAR revealed no documented evidence the physician ordered treatment to the resident's mid lumbar spine was provided as ordered on 01/22/24 on the day shift and on 01/25/24 on the day shift. Review of the resident's February 2024 TAR revealed no documented evidence the physician ordered treatment to the resident's mid lumbar spine was provided as ordered on 02/02/24 on the night shift. Review of the monthly physician orders for February 2024 identified orders (initiated 03/16/23) for barrier cream to peri-area and buttocks every shift, cushion to wheelchair, check and change frequently, encourage lotion to all dry areas, encourage to clip and file nails every shift, ammonium lactate lotion 12% to bilateral lower extremities every shift; on 07/10/23 house med pass supplement 240 milliliters (ml) three times a day; on 10/20/23 house liquid protein 30 ml twice daily for wound healing, encourage resident to float bilateral heels while in bed, skin evaluation weekly; on 01/17/24 cleanse wound to mid lumbar spine with Dakin's solution, pat dry, apply calcium alginate (cut to fit wound bed), and cover with foam dressing twice daily and as needed; on 01/18/24 cleanse right lateral foot with Dakin's solution soaked gauze, pat dry, apply calcium alginate (cut to fit wound bed), then cover with foam dressing daily and as needed; on 01/24/24 apply betadine to right first digit and leave open to air and on 01/25/24 apply foam to left posterior knee for protection every two days. Observation on 02/05/24 at 11:40 A.M. of the physician ordered treatment to mid lumbar spine by the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #268 revealed upon entry to the room the required supplies were set-up on a disposable barrier on the resident's bedside table. The staff washed their hands. The resident was then positioned on his left side and the LPN removed the soiled dressing to his back. The LPN then cleansed the wound with Dakin's soaked 4 X 4 and changed her gloves. The wound was quarter size with a pink wound bed. The wound also had slough present around the edges of the wound. The LPN then applied a 2 X 2 piece of calcium alginate without cutting to fit the wound bed and applied a foam dressing. Interview on 02/05/24 at 4:02 P.M. with the DON verified the wound to the mid lumbar spine was not accurately assessed, there was no timely notification to the physician of the identified pressure area or evidence comprehensive, effective and individualized interventions were implemented to prevent the ulcer from deteriorating to an unstageable pressure ulcer on 11/01/23. Review of the facility policy titled, Skin Care Program, last revised 01/14/23 revealed a Stage II pressure ulcer was defined a partial thickness skin loss involving epidermis, dermis, or both. The ulcer was superficial and presents clinically as an abrasion, blister, or shallow crater. Upon admission the residents would have their skin assessed from head to toe by a professional nurse. Each area would be documented by the professional nurse on the illustrations of documentation and measurements of skin area form. This information would be entered as appropriate into the electronic medical record (EMR). Notify the physician for orders and notify the authorized representative of the skin condition and orders accordingly. Weekly a professional nurse needs to measure each skin issue and enter the resident's EMR. Update the residents' plan of care as needed. When a new skin issue was noted, the nurse would measure the area initially and then every seven days until healed. All information would be entered into the EMR. Notify the physician for orders and notify the authorized representative of the new skin condition and orders accordingly. Weekly measurements need to be entered into the resident's EMR. Update the plan of care as needed. 2. Review of the medical record for Resident #67 revealed an initial admitted [DATE] with the latest readmission of 01/20/24 with diagnoses including metabolic encephalopathy, pseudomonas, sepsis due to pseudomonas, acute and chronic respiratory failure, hydronephrosis, chronic obstructive pulmonary disease (COPD), paraplegia, neuromuscular dysfunction of bladder, paralytic syndromes, spinal stenosis of cervical region, hypertension, insomnia, benign prostatic hyperplasia, depression, chronic pain syndrome and neurogenic bowel. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was not assessed. Review of the mood and behavior revealed the resident had not rejected any care. The assessment indicated the resident required substantial/maximal assistance for toileting, dressing, personal hygiene, and dependent for bathing. The resident required moderate assistance for bed mobility and was dependent with transfers. The assessment indicated the resident had an indwelling urinary catheter and was frequently incontinent of bowel. The assessment indicated the resident was at risk for pressure ulcers and had no unhealed pressure ulcers. However, the resident had moisture associated skin damage (MASD). The facility implemented the interventions pressure reducing device to bed/chair and applications of ointments/medications other than to feet. Review of the state optional MDS assessment dated [DATE] revealed the resident's cognition was not assessed. Review of the mood and behavior revealed the resident rejected no care. The resident required extensive assistance of two staff for bed mobility, transfers, eating and toilet use. The assessment indicated the resident had no unhealed pressure ulcers. Review of the readmission assessment dated [DATE] revealed the resident's bilateral buttocks/coccyx was reddened with dark red areas and superficial open areas. The resident also had a dark skin scab like area to the back of his heel. Review of the progress note dated 11/22/23 at 10:00 P.M., authored by Registered Nurse (RN) #338 revealed the resident was readmitted back to the facility with coccyx/buttocks reddened with dark red area scattered on buttocks and coccyx. Scabbed areas noted to bilateral shins and posterior left calf. Right heel with darkened red areas. The facility implemented the treatment of hydrogen peroxide and povidone iodine. The facility implemented the interventions of heel suspension/protection device, mattress with pump, moisture barrier, moisture control and turning and repositioning program. Review of the medical record revealed no documented evidence the described areas to the coccyx/bilateral buttocks were assessed, physician notified, or a treatment put in place to prevent a decline of the areas. Review of the skin and wound evaluation dated 11/24/23 revealed the resident had a Stage II pressure ulcer to his coccyx measuring 3.8 cm by 1.7 cm and was described as 100% epithelial tissue. The wound had no exudate. The facility implemented the following interventions, heel protectors, incontinence management, mattress with pump, moisture barrier, moisture control, repositioning devices and turning/repositioning program. The assessment indicated the resident was notified despite the resident having a severe cognitive impairment and a power of attorney (POA) on file. Review of the plan of care dated 11/29/23 revealed the resident was at risk for further alteration in skin integrity related to actual skin impairment, weakness, decreased mobility, multiple wounds present, COPD with head of bed elevated, use of Bi-pap and oxygen, overall decline in condition, anemia, functional quadriplegia, abnormal labs, variable by mouth intakes, bowel incontinence, use of indwelling urinary catheter, chronic sacral wound (suspected Kennedy ulcer) with status post debridement, pressure injuries to left heel times two, right heel, right lateral foot, right ankle, left lateral foot, arterial ulcers to right and left shin. Interventions included administer treatment per physician orders, air mattress to bed, barrier cream to peri area/buttocks as needed, coordinate wound care and treatments with wound care provider, diet and supplements per physician order, elevate heels as able, encourage and assist as needed to turn and reposition, use assistive devices as needed, encourage fluids, float heels while in bed, observe skin condition with activities of daily living (ADL) care daily and report abnormalities, obtain labs as ordered and report results to physician, podiatric care as needed, pressure redistributing device bed/chair, provide preventative skin care routinely and as needed and use pillows/position devices as needed. Review of the weekly skin and wound evaluation dated 12/01/23 revealed the Stage II pressure ulcer to the resident's coccyx had no measurements and the wound was described as 90% epithelial tissue and 10% granulation tissue. The wound had a light amount to serous exudate, the surrounding skin was dry and flaky. The treatment remained to cleanse with normal saline (NS), apply calcium alginate and cover with a foam dressing. The facility determined the wound was stable. Review of the weekly skin and wound evaluation dated 12/06/23 revealed the Stage II pressure ulcer to the resident's coccyx measured 5.0 cm by 1.0 cm and described as 80% epithelial tissue and 20% granulation tissue. The wound had no exudate. The facility determined the wound had improved. Review of the weekly skin and wound evaluation dated 12/13/23 revealed the Certified Nurse Practitioner (CNP) #345 classified the wound as moisture associated skin dermatitis (MASD) to the resident's coccyx measuring 11.6 cm by 7.6 cm and described as 20% epithelial tissue and 80% granulation tissue. The surrounding tissue was described as fragile and at risk for skin breakdown and macerated. The wound had no exudate. The facility determined the wound had improved. Review of the weekly skin and wound evaluation dated 12/20/23 revealed CNP #345 continued to classify the wound as MASD to the resident's coccyx measuring 8.4 cm by 4.1 cm and described as 20% epithelial tissue and 80% granulation tissue. The surrounding tissue was macerated. The wound had no exudate. The facility determined the wound was stable. Review of the weekly skin and wound evaluation dated 12/27/23 revealed the MASD was now unstageable measuring 8.4 cm by 4.1 cm. The wound was described as 80% granulation tissue and 20% slough. The wound had a light amount of serosanguineous exudate. The surrounding tissue was fragile and at risk of skin breakdown. The assessment documented CNP #345 resolved the MASD to an unstageable area with redden, darken areas. The area was not resolved and to see new assessment labeled pressure, [NAME]-sacrum. The assessment indicated the resident's POA was notified of the decline in the wound. Review of the weekly skin and wound evaluation dated 01/03/24 revealed CNP #345 classified the wound as a Kennedy terminal ulcer and measured 9.4 cm by 6.8 cm. The wound was described as 20% granulation tissue, 40% slough and 40% eschar. The wound had light serosanguineous exudate. The surrounding skin was fragile and at risk of breakdown. CNP #345 recommended hospice services at that time. Review of the weekly skin and wound evaluation dated 01/10/24 revealed the Kennedy terminal ulcer measured 12.4 cm by 11.6 cm. The wound was 90% eschar with serosanguineous odorous exudate. The facility determined the wound had deteriorated. Review of the medical record revealed the resident was discharged from the facility to an acute care hospital from 01/11/24 to 01/20/24 where he was treated for an infection to the ulcer which was assessed to be a Kennedy terminal ulcer. Review of the admission/re-admission evaluation dated 01/20/24 revealed the resident was readmitted to the facility with a pressure wound to the coccyx, pressure wounds to bilateral heels and left and right shin wounds. The assessment failed to indicate the staging of the pressure wounds, measurements, and description of the wounds. The wound was described as 40% granulation and 60% slough. The wound had bone exposed and had a moderate amount of serosanguineous odorous exudate. Review of the medical record revealed the first comprehensive assessment of the wound to the coccyx was on 01/24/24. The Kennedy terminal ulcer was classified as unstageable and measured 19.1 cm by 16.2 cm by 1.0 cm with undermining. The assessment failed to indicate where the undermining was located within the wound. The facility implemented the treatment to cleanse with Dakin's solution, pat dry, apply Santyl to wound bed and cover with Dakin's moisten gauze and foam dressing every shift and as needed. Review of the weekly skin & wound assessment dated [DATE] revealed the Kennedy terminal ulcer was now classified as a Stage IV (full thickness tissue loss with exposed bone,tendon,or muscle)pressure ulcer measuring 14.6 cm by 10.0 cm by 1.0 cm. The wound was described as 60% granulation tissue, 20% slough, and 20% eschar with serosanguineous exudate. The facility determined the wound had deteriorated. Review of the resident's monthly physician orders for February 2024 identified orders (initiated on 11/23/23) for a regular mechanical soft diet, resident is to be fed for meals, house liquid protein 30 ml by mouth twice daily, weekly skin evaluation; on 12/30/23 barrier cream to buttocks every shift and as needed; on 01/24/24 cleanse sacrum wound with Dakin's solution, pat dry, apply Santyl to wound bed and cover with Dakin's moistened gauze and cover with foam dressing every shift and as needed; and on 01/26/24 house nutritional juice drink twice daily for additional calories, Review of the resident's progress notes revealed the resident was admitted to the local acute care hospital on 02/02/24 for confusion. Interview on 02/05/24 at 1:26 P.M. with the DON revealed the resident had MASD that was resolved in October 2023. The DON revealed the MASD weekly skin and wound assessment was supposed to be closed as resolved in October 2023 but was not. She revealed CNP #345 documented the assessment on the MASD instead of the Stage II assessment. She revealed the MASD was closed, and the assessments were combined. The DON verified the lack of a comprehensive assessment of the wounds detailed on the 11/22/23 and 01/20/24 admission/re-admission evaluation. Review of the facility policy titled, Skin Care Program, last revised 01/14/23 revealed a Stage II pressure ulcer was defined a partial thickness skin loss involving epidermis, dermis, or both. The ulcer was superficial and presents clinically as an abrasion, blister, or shallow crater. Upon admission the residents would have their skin assessed from head to toe by a professional nurse. Each area would be documented by the professional nurse on the illustrations of documentation and measurements of skin area form. This information would be entered as appropriate into the electronic medical record (EMR). Notify the physician for orders and notify the authorized representative of the skin condition and orders accordingly. Weekly a professional nurse needs to measure each skin issue and enter the resident's EMR. Update the residents' plan of care as needed. When a new skin issue was noted, the nurse would measure the area initially and then every seven days until healed. All information would be entered into the EMR. Notify the physician for orders and notify the authorized representative of the new skin condition and orders accordingly. Weekly measurements need to be entered into the resident's EMR. Update the plan of care as needed. 3. Review of the medical record for Resident #9 revealed an initial admitted [DATE] with diagnoses including pressure ulcer to the left heel, convulsions, asthma, chronic kidney disease, hypothyroidism, disorder of thyroid, dementia, obesity, diabetes mellitus, hypertension, and depression. Review of the baseline admission evaluation dated 08/23/23 revealed the resident was admitted with deep tissue injury (DTI) (purple or maroon localized area of discolored intact skin or blood filled blister) to right outer ankle and left heel. The assessment contained no description of the wound. The assessment also indicated the resident had a sore on the left and right buttocks. Review of the plan of care dated 08/24/23 revealed the resident had potential/actual impairment of skin integrity of the left leg and knee related to pressure of left heel, history of left femur fracture and incontinence of bowel and bladder. Interventions included pressure relieving/reducing mattress, complete Braden scale per facility protocol, encourage good nutrition and hydration in order to promote healthier skin, encourage resident to not scratch and keep hands and body parts from excessive moisture, keep fingernails short, encourage resident to turn and reposition regularly, encourage skin to be clean and dry, use lotion to dry skin, encourage to float heels from bed, encourage to use a draw sheet for lifting device to move resident, monitor/document location size and treatment of skin injury, report abnormalities, obtain blood work as ordered by physician, weekly treatment documentation to include measurement of each area of skin breakdown, width, length, depth, type of tissue, exudate and any other notable changes of observations. Review of the weekly skin & wound assessment dated [DATE] revealed the resident had a deep tissue injury to her left heel measuring 2.1 cm by 0.7 cm and was purple in color. The facility implemented the treatment of cleanse with normal saline and paint with betadine and cover with a foam dressing. Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The assessment indicated the resident was always incontinent of both bowel and bladder. The assessment indicated the resident was at risk for skin breakdown and had an unhealed unstageable pressure ulcer present on admission. The facility implemented pressure reducing device for bed, nutrition, or hydration intervention to manage skin problems, pressure ulcer/injury care and application of dressing to feet. Review of the state optional MDS assessment dated [DATE] revealed the resident had a moderate cognitive impairment. The resident required extensive assistance of two staff for bed mobility, transfers, and toileting. The assessment indicated the resident was at risk for skin breakdown and had an unhealed unstageable pressure ulcer. The facility implemented pressure reducing device for bed, nutrition, or hydration intervention to manage skin problems, pressure ulcer/injury care and application of dressing to feet. Review of the most recent weekly skin and wound assessment dated [DATE] revealed the resident's wound was a Stage III (full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle is not exposed, slough may be present) pressure ulcer measuring 1.5 cm by 1.1 cm by 0.2 cm. The wound was described as 70% granulation and 30% slough and had a light amount of serosanguineous drainage. The treatment implemented was cleanse with normal saline, apply calcium alginate, Medi honey and cover with a foam dressing. The facility determined the wound had improved. Review of the resident's monthly physician orders for February 2024 identified orders (initiated on 09/22/23) for house nutritional drink six ounces daily, house med pass supplement 237 milliliters (ml); on 10/05/23 skin evaluation weekly; on 01/03/24 cleanse left heel with NS, pat dry, apply Medi honey to wound bed, cover with calcium alginate, cut to fit wound bed and secure with bordered foam dressing daily and as needed; and on 01/17/24 apply barrier cream to left and right buttocks after each incontinence episodes. Interview on 02/05/24 at 4:02 P.M. with the DON verified Resident #9's left heel wounds were not comprehensively assessed on admission to the facility. Review of the facility policy titled, Skin Care Program, last revised 01/14/23 revealed a Stage II pressure ulcer was defined a partial thickness skin loss involving epidermis, dermis, or both. The ulcer was superficial and presents clinically as an abrasion, blister, or shallow crater. Upon admission the residents would have their skin assessed from head to toe by a professional nurse. Each area would be documented by the professional nurse on the illustrati [TRUNCATED]

Based on observation, record review, interview and facility policy review, the facility failed to ensure two residents (#9 and #67), who were dependent on staff for personal hygiene was shaved. This affected two (Resident #9 and #67) of three residents reviewed for personal hygiene. The facility census was 130. Findings Include: 1. Review of the medical record for Resident #67 revealed an initial admitted [DATE] with the latest readmission of 01/20/24 with the diagnoses including metabolic encephalopathy, pseudomonas, sepsis due to pseudomonas, acute and chronic respiratory failure, hydronephrosis, chronic obstructive pulmonary disease (COPD), paraplegia, neuromuscular dysfunction of bladder, paralytic syndromes, spinal stenosis of cervical region, hypertension, insomnia, benign prostatic hyperplasia, depression, chronic pain syndrome and neurogenic bowel. Review of the plan of care dated 11/29/23 revealed the resident had a self-care deficit related to weakness, decreased mobility, paralytic syndrome, spinal stenosis, chronic pain and requires electric wheelchair for mobility. Interventions included assist to bathe/shower as needed, assist with daily hygiene, grooming, dressing, oral care and eating as needed, encourage and assist to reposition frequently, therapy evaluation and treatment per physician orders, splint wear and transfer with full mechanical lift with Hoyer and two staff assist. Review of the discharge minimum data set (MDS) assessment dated [DATE] revealed the resident's cognition was not assessed. Review of the mood and behavior revealed the resident displayed verbal behaviors directed towards others, however the resident rejected no care. The resident's functional abilities were not assessed. The assessment indicated the resident had an indwelling urinary catheter and was always incontinent of bowel. Review of monthly physician orders for February 2024 identified no orders related personal hygiene. Observation on 02/01/24 at 9:53 A.M. of Resident #67 revealed his shirt had crumbs on the front and had several days of facial hair growth. Interview on 02/01/24 at 11:47 A.M. with State tested Nursing Assistant (STNA) #289 verified the resident had several days of facial hair growth. 2. Review of the medical record for Resident #9 revealed an initial admitted [DATE] with the diagnoses including severe degeneration of the brain, protein calorie malnutrition, vitamin D deficiency, dementia, hypertension, anemia, cerebrovascular accident (CVA), osteoarthritis, and pressure ulcer of the back. Review of the plan of care dated 01/19/23 revealed the resident had a self-care deficit related to decreased mobility, use of assistive devices, assist of staff, history of CVA, osteoarthritis, impaired decision making and safety awareness, dementia, incontinence as well as effects of medications as ordered. Interventions included bed mobility with one assist, transfers with Hoyer lift and two assist, activity as tolerated, bathing/shower as ordered and as needed per one assist, ensure call light is available to the resident on the unaffected side and assist with activities of daily living (ADL): eating, toileting, personal hygiene, bathing, bed mobility and wheelchair mobility every shift and as needed, check nail length and trim and clean on bath day and as needed. Review of the state optional MDS assessment dated [DATE] revealed the resident's cognition was not assessed. Review of the mood and behavior revealed the resident rejected no care. The resident required extensive assistance of two staff for bed mobility, transfers, eating and toilet use. The assessment indicated the resident had no unhealed pressure ulcers. Review of the resident's monthly physician orders for February 2024 identified no physician's orders related to personal hygiene. Observation on 02/01/24 at 12: 36 P.M. of Resident #9 revealed he had several days of facial hair growth. Observation on 02/05/24 at 11:40 A.M. of Resident #9 revealed the resident continued to have several days of facial hair growth. Interview on 02/05/24 at 1:26 P.M. with the Director of Nursing (DON) verified the resident has several days of facial hair growth. Review of a policy titled, Hygiene and Grooming, last revised 01/10/23 revealed it is the facility's policy to make sure the resident's needs are met regarding hygiene and grooming while addressing the resident's personal hygiene preferences and daily routine. This deficiency represents non-compliance investigated under Complaint Number OH00150547.

Based on medical record review, hospital record review, staff interviews, and review of the facility policy the facility failed to provide Resident #20 with adequate assistance and devices to prevent accidents. This resulted in actual harm when Resident #20 was improperly transferred during a therapy session when the therapist did not utilize a gait belt during transfer resulting in Resident #20 being lowered to the floor after her knees buckled resulting in pain and hospitalization with multiple fractures. This affected one (#20) of three residents reviewed for falls. The facility census was 89. Findings include: Review of the medical record for Resident #20 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. She was discharged from the facility to the hospital on [DATE]. Review of the physician telephone orders dated 06/30/20 revealed an order for [REDACTED]. Review of the fall risk assessment dated [DATE] revealed Resident #20 was at risk for falls. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 had no cognitive deficits, required extensive assistance with bed mobility, transfers, and toileting. She did not walk any during the assessment window for the MDS. She has had had one fall since admission with no injury. Review of the restorative program note dated 07/13/20 revealed Resident #20 received restorative care 15 minutes every day. The restorative aide was to provide verbal prompts, hands on support, the use of a gait belt, shoes on securely, and task segmentation. The goal was for Resident #20 to be able to move to and from the bed, move sit to stand, move to and from the wheelchair, with transfer of physical assistance of one person. Review of the physical therapy evaluation dated 07/29/20 revealed Resident #20 was receiving therapy services to address transfers, ambulation, functional activities in sitting and standing. These functional deficits were a result of Resident #20's impaired strength, impaired balance, and pain. Resident #20 was at risk for falls and decreased participation in functional tasks. Resident #20 had a history of [REDACTED]. Resident #20 had physical therapy prior and was discharged a month ago using independent slide board transfers. She required maximum assistance for sit to stand and she had been non-ambulatory for past two years. Review of the occupational therapy evaluation dated 07/29/20 revealed Resident #20 was received therapy to address deficits with bilateral upper extremity strength, dynamic standing balance, and functional activity tolerance, which limits her independence and safety with ADL's and functional transfers. She required maximum assistance with transfers and staff was utilizing stand lift for Resident #20. Review of the occupational therapy visit note dated 07/31/20 revealed during treatment session with Certified Occupation Therapy Assistant (COTA) #89 was working with the resident on static stand using an assist bar from wheelchair level with moderate assistance from a sit to stand transition when Resident #20's knees buckled and she was lowered to the floor by COTA #89 and Occupation Therapist (OT) #90 after COTA #89 called out for OT #90's assistance. OT #90 had a wheelchair behind Resident #20 but Resident #20 refused to be assisted back into chair and asked to be put on the floor and then she was lowered to the ground. Resident #20 complained of bilateral ankle pain and nursing staff was notified. Review of the nurses note dated 07/31/20 at 1:50 P.M. revealed Resident #20 was in the therapy room at the time of the fall as reported by the therapist, Resident #20 was standing at transfer pole when her kneed buckled and with the help of other therapist attempting to put her back into wheel chair and the resident shouted no she wanted lowered to the floor and she was lowered to the floor. She complained of bilateral ankle pain and insisted she on being sent to the emergency room . She refused any physical assessment to be done and did not want to be touched. Review of the facilities summary of incident dated 07/31/20 revealed Resident #20 was having therapy and her knees buckled due to leg weakness and lost her balance, she was sent to emergency room for evaluation. Immediate safety approaches were to have resident be assisted by two therapy staff during treatment. Review of the facilities fall investigative report dated 07/31/20 revealed the time of incident was 11:15 A.M., and the incident occurred in therapy room. Prior to the fall, Resident #20 was sitting in a wheelchair. The physician and family were notified, and she was sent to emergency room for evaluation. Review of the witness statement dated 07/31/20 at 12:30 P.M. written by OT #90 revealed the therapist was sitting at her desk with her back to COTA #89 when COTA #89 requested immediate assistance from OT#90. Resident #20 knees had buckled while standing at the transfer pole in the gym. OT #90 tried to get Resident #20 in the wheelchair, and she refused and stated she wanted down on the floor and they lowered her to floor. Resident #20 complained of ankle pain and OT#90 notified the unit manager. Review of the witness statement dated 07/31/20 at 12:50 P.M. written by COTA #89 revealed she was having Resident #20 stand at transfer pole when her knees buckled. COTA #89 called for assistance from OT #90 and OT #90 tried to assist her back into the wheelchair and she yelled no that she wanted to go to the floor. Resident #20 complained of ankle pain and nursing staff was notified. Review of Resident #20's plan of care revealed alteration in comfort related to arthritis. Resident #20 was at risk for falls due to medications, pain, decreased mobility, lack of safety awareness, history of left hip dislocation and interventions included to anticipate needs, assess for fall risk, call light within reach, monitor for pain, keep items in reach, remind to use call light to assist with transfers, and therapy. Resident #20 refused care and to accept treatment, take medications, and comply with safety measures. Resident #20 had self-care deficit due to impaired vision, decreased mobility and weakness. Interventions included to use stand lift for transfers and pivot transfers as able. Review of the hospital emergency room note dated 07/31/20 at 4:28 P.M. revealed Resident #20 presented with back and bilateral ankle pain. She was at the extended care facility doing therapy when they were getting her up from a chair to a standing position, she was holding a pole when her knees gave out. She was helped to the ground and did not actually fall. Resident #20 stated they twisted her ankle awkwardly and complained of bilateral ankle pain. Resident #20 rated her pain eight out ten. Her right and left ankle had decreased range of motion, swelling, and lateral malleolus tenderness. Final X-ray results were minimally displaced lateral malleolar fracture (a broken ankle which usually occurs when the fibula just above the ankle bone fractures) extending to ankle mortise, non-displaced medial malleolar fracture, and diffuse demineralization. Review of hospital consult report dated 07/31/20 revealed displaced Maisonneuve fracture (a spiral [MEDICAL CONDITION] third of the fibula (the smaller bone in the lower leg)) to the right lower extremity. Imaging revealed right ankle fracture, proximal fibula fracture, and chronic anterior cruciate ligament (ACL) tear. Order for strict non weight bearing to right lower extremity with ice and elevation. Closed extra-articular fracture of right distal tibia with plan for nonoperative treatment, strict ice and elevation, and pain control. Interview on 08/05/20 at 3:05 P.M. with OT #90 stated she was sitting at her desk in therapy room with her back to COTA #89 and Resident #20. She stated COTA #89 yelled for help and when OT turned around COTA #89 had Resident #20 at transfer pole and her knees were buckled. She stated she tried to place Resident #20 back into the wheelchair that was right behind her and she refused so they lowered her to the floor. She stated COTA #89 did not have a gait belt around Resident #20 and verified she should have had one in place. OT #90 stated gait belts should be used with all transfers. She stated the facility had enough gait belts and denied any trouble getting them. Interview on 08/05/20 at 3:35 P.M. with the DON stated they had no policies on transfers and the use of gait belts. Phone interview on 08/06/20 at 10:39 A.M. with COTA #89 stated she was working with Resident #20 on 07/31/20 with sit to stand transfers with the transfer pole in therapy gym. She stated she had Resident #20's wheelchair locked and right behind her but Resident #20's knees buckled while she was still holding onto the pole. She stated this was the first time she had tried transfers at this pole with Resident #20. She stated it was only her second time working with Resident #20. She stated Resident #20 would not sit back into the wheelchair and she then yelled for OT #90's assistance and they lowered her to the floor. COTA #89 verified she did not use a gait belt with Resident #20 and stated she should have. Interview 08/06/20 at 1:00 P.M. with the DON verified COTA #89 did not use a gait belt with Resident #20 and COTA #89 was no longer at the facility. Review of facility policy titled Accident and Incident Prevention and Fall Risk undated revealed the policy is to provide guidance regarding assessment of a resident's fall risk and to provide a safe, secure environment regarding all incidents and accidents. This deficiency substantiated allegations in Complaint Master Control Number OH 624.

Based on medical record review, observations, review of video recordings, staff interviews, and review of facility policies and procedures, the facility failed to ensure a resident was free from neglect over a five day period when multiple staff members failed to provide necessary care, services and treatments for one (#130) of 21 residents reviewed for neglect. This resulted in Immediate Jeopardy and serious harm when Resident #130 was left for hours over a five day period positioned on a Stage IV (full thickness of skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structure) pressure ulcer to her coccyx, ordered treatments to the pressure ulcer were not completed or not completed as ordered, incontinence care was not provided, medications were not administered, and Activities of Daily Living (ADLs) and Range of Motion (ROM) were not completed as ordered. Additionally, this placed the other 122 residents in the facility at risk for the likelihood of serious impairment or harm as the facility had established practices of failing to provide the care, services, and treatments as required and as prescribed by the physician representing a systemic failure and oversite to avoid physical harm and mental anguish of residents residing in the facility. On 03/29/17 at 12:34 P.M., the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) were notified Immediate Jeopardy began on 02/21/17 at 7:47 P.M. when Resident #130 was video recorded being neglected by multiple facility staff members on all three shifts, over a five day period of time. Facility staff were observed failing to provide the necessary care, services, treatments and medications as required and in accordance with physician orders [REDACTED]. provide ADLs and ROM. The Immediate Jeopardy was removed on 03/30/17 when the facility established systems to ensure residents received ordered services and/or treatments and medications, and the facility implemented the following corrective actions: · On 03/29/17, the facility suspended the following employees identified on the video recordings who were involved in the neglect of Resident #130: Licensed Practical Nurses (LPNs) #06, #122, #132, and #159, State tested Nursing Assistants (STNAs) #108, #153, and #172. · On 03/29/17, the Staff Development Coordinator and/or designee began educating the facility staff nurses on treatments, appropriate techniques, barrier use, infection control, following physician's orders [REDACTED]. By 03/30/17, 16 LPNs and 10 Registered Nurses (RNs) were educated. All remaining nurses and ancillary staff, as appropriate, were to be educated prior to being given an assignment. · On 03/29/17, the Staff Development Coordinator and/or designee began educating the facility staff on bathing, perineal care, incontinence care, and infection control. By 03/30/17, nine (09) RNs, 17 LPNs and 35 STNAs were educated. All remaining nursing staff were to be educated prior to being given an assignment. · On 03/29/17, the Staff Development Coordinator and/or designee began educating the facility staff on proper positioning. By 03/30/17, nine (09) RNs, 18 LPNs and 36 STNAs were educated. All remaining nursing staff were to be educated prior to being given an assignment. · On 03/30/17, education was provided by the Staff Development Coordinator and/or designee to 21 LPNs and 10 RNs regarding facility medication administration practices. All remaining nursing staff were to be educated prior to being given an assignment. · On 03/30/17, the Staff Development Coordinator and/or designee began educating the facility staff on resident rights. Ten (10) RNs, 17 LPNs and 38 STNAs had been educated on resident rights. All remaining nursing staff and ancillary staff were to be educated prior to being given an assignment. · On 03/30/17, the facility staff was re-educated on the facility's cell phone policy. Eight (08) RNs, 13 LPNs and 28 STNAs were educated and all remaining staff were to be re-educated prior to being given an assignment. · On 03/30/17, the Staff Development Coordinator and/or designee began educating the facility staff on pain. Nine (09) RNs, 16 LPNs and 36 STNAs had been educated. All remaining nursing staff were to be educated prior to being given an assignment. · On 03/30/17, the Staff Development Coordinator and/or designee began educating the facility staff on ROM. Ten (10) RNs, 17 LPNs and 38 STNAs were educated. All remaining nursing staff were to be educated prior to being given an assignment. · On 03/30/17 at 5:00 P.M., a head to toe assessment was conducted on Resident #130 by the DON to establish a baseline assessment of the resident's current overall condition. Additionally, all residents identified with a Stage II pressure ulcer or higher were re-assessed. · On 03/30/17, the facility assigned a nursing management team member or corporate team member to each shift to conduct audits and monitor care practices involving staff to resident interactions. · Interviews on 03/30/17 between 9:57 A.M. and 3:46 P.M. with Housekeeper (HK) #56 confirmed she had been educated on infection control and the use of personal protective equipment (PPE). In addition, STNAs #96, #192, LPN #207 and RN #86, confirmed they had been educated on infection control, use of PPE, turning and repositioning, incontinence care, false documentation, and the use of cell phones in resident rooms. LPN #210 and RN #96 further confirmed they had been educated on appropriate medication pass as well. · Beginning on 04/02/17, five residents will be interviewed and/or observed weekly, for six weeks, to ensure appropriate care and services are being provided. Although the Immediate Jeopardy was removed, the facility remains out of compliance at Severity Level 2 (no actual harm with the 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: Review of Resident #130's medical record revealed an original admission date of [DATE] with the latest readmission on 02/11/17. Resident #130's admitting [DIAGNOSES REDACTED]. Review of Resident #130's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech, sometimes understood, rarely/never made herself understood, had both short and long term memory loss and had a severe cognitive deficit. The MDS revealed the resident had not rejected any care, was dependent on staff for ADLs, had a functional limitation in ROM to both upper and lower extremities, had an indwelling urinary catheter and was always incontinent of bowel. The MDS revealed the resident received a pain regimen, as needed pain medication, the resident was noted to have verbal complaints of pain, non-verbal sounds of pain and displayed facial expressions of pain. The MDS further indicated the resident was at risk for skin breakdown, had two venous and arterial ulcers on both heels, and had an unhealed Stage IV pressure ulcer on her coccyx measuring 16.0 centimeters (cm) by 15 cm by 3.0 cm with slough being the most severe tissue type. Review of the skin and ulcer treatment section of the MDS indicated the facility implemented pressure reduction devices to the resident's bed and chair, nutrition/hydration intervention, pressure ulcer care, application of non-surgical dressings and application of ointments or medications. Review of the monthly physician's orders [REDACTED].M., 11:00 A.M., 5:00 P.M. and 9:00 P.M. based on the blood glucose (BG) results with the following parameters: if BG was 140 to 180 give four units; if BG was 181 to 220 give eight units; if BG was 221 to 260 give ten units; if BG was 261-300 give ten units; if BG was 301 to 340 give 12 units; if BG was 341 to 380 give 14 units; and if BG was above 381 give 16 units. Sodium Phosphorus (electrolyte) 250 milligrams (mg) was to be administered via enteral tube four times a day at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M. Additional medications ordered included [MEDICATION NAME] 10 mg (chest pain) to be administered via enteral tube three times a day at 6:00 A.M., 2:00 P.M. and 10:00 P.M., Phoslo (for [MEDICAL CONDITION]) 667 mg, give two capsules via enteral tube three times a day, at 6:00 A.M., 2:00 P.M. and 10:00 P.M., Balanced B complex with Vitamin C extended release 15-10-50-300 mg via enteral tube daily at 9:00 A.M., [MEDICATION NAME] (heart) 25 mg via enteral tube twice a day at 9:00 A.M. and 9:00 P.M., [MEDICATION NAME] (anti-convulsant) 500 mg via enteral tube twice a day at 9:00 A.M. and 9:00 P.M., [MEDICATION NAME] (nerve pain) 200 mg via enteral tube every twelve hours at 9:00 A.M. and 9:00 P.M., [MEDICATION NAME] (cholesterol) 40 mg via enteral tube daily at 9:00 P.M., [MEDICATION NAME] (blood thinner) 75 mg via enteral tube daily at 9:00 P.M., [MEDICATION NAME] (antibiotic) 500 mg via enteral tube three times a day at 6:00 A.M., 2:00 P.M., and 10:00 P.M., [MEDICATION NAME] ([MEDICAL CONDITION]) 150 mg via enteral tube twice daily at 9:00 A.M. and 9:00 P.M., [MEDICATION NAME] 100 mg via enteral tube every Monday, Wednesday and Friday at 6:00 P.M. In addition, physician orders [REDACTED]. Wound orders included to cleanse the coccyx wound with normal saline (NS), moisten [MEDICATION NAME] with one fourth strength Dakin's solution and pack wound, cover with an ABD pad and foam dressing, twice a day and as needed, cleanse the wound to the right heel with NS, moisten gauze with one fourth strength Dakin's solution and cover wound with ABD and wrap with kerlix and cleanse the wound to the left heel wound with NS, apply skin prep and pad and protect. Change daily and as needed. Review of a continuous video recording of Resident #130 beginning on 02/21/17 at 7:47 P.M. revealed LPN #132 began providing wound care to the resident. LPN #132 raised the resident's bed, and roughly removed the pillow out from under the right side of the resident's back and buttocks causing shearing. The resident displayed facial grimacing when LPN #132 removed the pillow. LPN #132 removed the [MEDICATION NAME] packing from the packaging, shook it, and placed the clean dressing on the resident's bedside table with no barrier between the dressing and the table. LPN #132 then opened a clean foam dressing, removed the [DEVICE] dressing and utilized the draw sheet to pull the resident over to the left side and then rolled the resident onto her right side with no staff assistance. Resident #130 again displayed non-verbal indicators of pain with facial grimacing during the repositioning. LPN #132 tore off the soiled dressing and the packing to the coccyx wound. Between the handling of the soiled [DEVICE] dressing and removing the coccyx dressing, LPN #132 did not wash her hands or change her soiled gloves. LPN #132 proceeded to put on a new dressing with packing and covered the wound, however, did not cleanse the wound prior to applying a new dressing. LPN #132 also did not moisten the dressing with one fourth strength Dakin's solution when placing it in the coccyx wound. LPN #132 then pushed the resident back over onto her back without regard to the resident's comfort. When LPN #132 placed the pillow under the residents left side, the pillow was not positioned adequately to allow for offloading of the Stage IV pressure ulcer to Resident #130's coccyx. Resident #130 had facial grimacing observed throughout the dressing change. LPN #130 was further noted to not have PPE on while providing care to the resident who was on contact isolation. On 02/23/17 beginning at 3:33 P.M., review of the continuous video recording revealed Resident #130 lying in bed with a pillow positioned under her right hip. There were no staff members observed to enter the resident's room until 4:23 P.M. at which time STNA #187 entered the room. STNA #187 was on her personal cell phone while standing at the resident's bedside. STNA #187 was observed on her phone in the resident's room from 4:23 P.M. until 4:27 P.M. and was not interacting with Resident #130. At 4:28 P.M., STNA #187 applied Chap Stick to Resident #130's lips. STNA #187 left the room at 4:28 P.M. and did not provide any additional resident care or services to the resident. Resident #130 was left in the same position as when STNA #187 entered the room. No additional staff entered Resident #130's room until 4:58 P.M. at which time LPN #122 entered the room. At that time, LPN #122 gave an insulin injection to Resident #130's upper right arm. LPN #122 was not observed obtaining the resident's blood glucose level prior to giving the insulin. LPN #122 left the room at 4:59 P.M. and did not provide any turning or repositioning as prescribed by the physician. Further observation of the continuous video recording revealed on 02/23/17 from 5:00 P.M. through 6:08 P.M., Resident #130 remained in the same position in her bed, with a pillow wedged under her right hip. At 6:08 P.M., STNA #187 entered the resident's room and was again on her personal cell phone as she placed an earpiece in her right ear. STNA #187 dropped a glove on the floor, picked it up, and placed it back on her hand, now having double gloves on. STNA #187 remained on her cell phone and was not interacting with the resident. At this time, LPN #122 entered the resident's room to provide a treatment to the resident's coccyx wound. STNA #187 provided incontinence care and assisted with the coccyx dressing change. STNA #187 cleansed Resident #130's buttocks which had visible signs of feces. STNA #187 removed the soiled coccyx dressing and wound packing with the dirty wash cloth she had just used to clean the resident's buttocks. LPN #122 then cleansed the wound and packed the coccyx wound while STNA #187 held the resident to her side. STNA #187 continued to wear the same dirty gloves throughout all of the resident's care. LPN #122 began working on the wounds to Resident #130's heels. LPN #122 removed Resident #130's Prevalon boots (heel protectors that float the heels off the surface of the mattress), cut part of the dressing off, then took a new piece of tape and placed it on the resident's right heel without providing any treatment to the wound. LPN #122 then put the Prevalon boot back on the resident's right foot. LPN #122 cut a piece of dressing off the left heel, obtained a new piece of tape and placed it on the left heel dressing. No wound care was observed to the left heel, just a new piece of tape applied to the old dressing that was still in place. STNA #187 then placed a pillow under the resident's left hip which was not positioned to adequately provide off-loading to the Stage IV pressure ulcer to her coccyx. LPN #122 looked at the resident's tube feeding (TF) pump, put her hands up in the air, and walked out. The TF was not noted to be turned off throughout the wound care. No medications were given when the nurse was in the room. The video recording ended at 7:38 P.M. No medications were observed to be given throughout the entire video on 02/23/17 from 3:33 P.M through 7:38 P.M. Observation of the continuous video revealed STNA #187 and LPN #122 not wearing any PPE while providing care to Resident #130. Review of the continuous video recording from 02/24/17 beginning at 5:59 A.M. through 7:38 P.M. revealed, from 5:59 A.M. through 8:12 A.M., no staff members entered Resident #130's room to provide any care or services to the resident. During the entire observation, Resident #130 was lying in bed, on her back, directly on the Stage IV pressure ulcer to her coccyx. At 8:12 A.M., STNA #153 entered the resident's room and placed her personal cell phone on the resident's bedside table and was talking on the phone. No care was provided. At 8:19 A.M., STNA #153 turned off the resident's TF and raised the head of the bed (HOB) while still holding her personal phone in one hand. STNA #153 put in an earpiece so she could continue to talk on the phone, and then took a sip of a drink. STNA #153 continued on the phone, placed gloves on, and uncovered the resident. Resident #130 was noted to be lying in bed with her pants pulled down. STNA #153 began washing the resident's face while still on the phone. Resident #130 was noted to be incontinent of stool. STNA #153 had gloves on, washed the resident's perineal area, and then dried the resident off with a towel. STNA #153 then pulled the resident to the left side of the bed using the draw sheet and the resident had visible facial grimacing. The STNA disconnected the resident from the TF and placed it on top of the pole at the resident's bedside. STNA #153 turned the resident to the right side and began cleaning the stool from the resident using a wet washcloth with no soap. STNA #153 placed a clean disposable brief under the resident. STNA #153 finished dressing the resident, rolling the resident on to her right side once again, with facial grimacing observed. She then took a towel off the floor, which was used during incontinence care, and placed it over the resident's chest. STNA #153 began providing oral care and a water mouth rinse. STNA #153 wiped the resident's mouth with the same towel that she picked up off the floor and used during incontinence care and left the room at 8:47 A.M. The STNA had not placed a cushion under the resident or repositioned her. The resident continued to be lying on her back on the Stage IV pressure ulcer with no off-loading since the video started at 5:59 A.M. At 8:49 A.M., Resident #130 still had the water rinse in her mouth, and it was drooling down her chin. No staff were observed in the room again until 9:38 A.M., when two male ambulance attendants arrived to transport the resident to her [MEDICAL TREATMENT] appointment. There was no cushion placed under the resident to go with her to [MEDICAL TREATMENT]. On 02/24/17 at 2:58 P.M., Resident #130 was observed on the video recording to be returned to her room from [MEDICAL TREATMENT]. At 3:05 P.M., STNA #143 and STNA #107 came into the resident's room and put gloves on. STNA #107 lowered the HOB and the resident had facial grimacing with an open mouth. STNA #107 removed a few wipes from a container and placed them on the resident's bed. STNA #107 and STNA #143 then pulled the resident's pants down and she again displayed facial grimacing. STNA #107 put on double gloves and pulled the residents brief down. STNA #107 wiped Resident #130's perineal area with a rag and then placed the dirty rag on the clean incontinence brief. STNA #143 and STNA #107 turned the resident to her right side to clean her buttocks area and stool. STNA #107 took another wipe and wiped the resident's face off, still wearing the soiled gloves she used to provide incontinence care, and wiped the stool from the resident. STNA #107 lowered the residents HOB, and the resident was again observed with facial grimacing. STNA #143 covered the resident with a blanket and both STNAs walked out of the room at 3:21 P.M. with no repositioning or off-loading observed. Neither STNA #107 nor STNA #143 wore any PPE when providing incontinence care to Resident #130. There were no staff observed in Resident #130's room again until 5:02 P.M. on 02/24/17 when LPN #6 entered the room. LPN #6 hooked up the resident's TF, which had been off since 8:19 A.M. LPN #6 proceeded to put on gloves and raised the resident's HOB, and the resident was noted with facial grimacing. LPN #6 gave Resident #130 a thumbs up and left the room. No medications were observed to be given, the resident's blood glucose was not checked, and no insulin was given. Resident #130 continued to lay on her back with no off-loading to the Stage IV pressure ulcer to her coccyx. Resident #130 had not been changed since 3:12 P.M. when she first returned from [MEDICAL TREATMENT]. At 7:26 P.M., STNA #203 entered the room to provide incontinence care, put on gloves, and did not place on any PPE. STNA #203 lowered the resident's HOB, however, did not turn off the TF and left the room. STNA #203 returned to the room and put on new gloves, dropped one on the floor, picked it up, and put it on her left hand. STNA #203 turned the resident on her right side with the resident displaying facial grimacing. STNA #203 wiped the stool off of Resident #130 and removed the dirty incontinence brief. STNA #203 rolled the resident back on her back and the resident again was observed with facial grimacing. STNA #203 did not wash her hands during the entire provision of care. STNA #203 picked up her phone and started talking on it while still providing resident care. The STNA did not position any pillows under the resident after providing care. Resident #130 had not been turned nor had off-loading to the coccyx during the entire observation on 02/24/17 (for 24 hours). The resident was not observed to be provided wound care to the coccyx, left heel, or right heel any time during the 7:00 A.M. through 7:00 P.M. shift on 02/24/17, with continuous video recordings observed from 5:59 A.M. through 7:39 P.M. No ROM or restorative care was observed during the entire observation of video as prescribed by the physician. Observation of the video recording of Resident #130 on 02/25/17 beginning at 6:23 A.M. through 8:23 P.M. and then from 10:41 P.M. through 11:59 P.M. revealed no staff entered Resident #130's room on 02/25/17 until 7:19 A.M. when STNA #203 entered the room and left without providing any care or repositioning. At 7:33 A.M., STNA #204 entered the room and put gloves on and was eating toast and watching television, while standing at the resident's bedside. STNA #204 began providing care, including removing Resident #130's hospital gown, cleaning the resident's face, and wiping the resident down. STNA #204 pulled down the resident' incontinence brief, washed the resident's perineal area which had visible feces, and then continued washing the resident's body with the same towel used to wash the perineal area, including her legs. STNA #204 rolled the resident to her other side and the resident was barely hanging on the left side of the bed. STNA #204 took off her gloves and put a new brief on Resident #130. STNA #204 continued to wipe feces off the resident with a towel, all while wearing no gloves and no PPE. STNA #204 put on new gloves and began brushing the resident's teeth, dressed the resident and left the room. STNA #204 came back in the room at 8:08 A.M., was watching television and was observed to be folding sheets. At 8:55 A.M., STNA #204 returned to Resident #130's room and picked up a clean pair of gloves. STNA #204 and Resident #130 were speaking to each other and STNA #204 exited the room at 8:56 A.M. without providing any care to the resident. At 11:51 A.M., STNA #204 returned to Resident #130's room and was leaning on the resident's wheelchair while on her personal cell phone. STNA #204 exited the room at 12:01 P.M. and did not deliver any care to the resident. There were no additional staff observed in Resident #130's room on 02/25/17 until 12:35 P.M. when STNA #204 entered the room again and was drinking from a cup, watching television. At 12:38 P.M., the STNA exited the resident's room without providing any care. No observations were viewed of the nurse giving the resident's 12:00 P.M. medication or obtaining the 11:00 A.M. blood glucose level. At 1:28 P.M., STNA #204 entered Resident #130's room and was observed walking in the resident's bathroom after picking up a roll of toilet paper off Resident #130's bedside table. The STNA was seen coming out of the bathroom and set the roll of toilet paper back onto the resident's bedside table and leaned back onto the resident's wheelchair. At 1:50 P.M., STNA #204 remained leaning on the resident's wheelchair watching television. At 2:00 P.M., STNA #204 exited the resident's room without providing care. Again, no observations were made of the resident receiving her scheduled 2:00 P.M. medications or obtaining the 5:00 P.M. blood glucose check. There were no additional staff members observed in Resident #130's room on 02/25/17 until 6:38 P.M. when LPN #132 entered the resident's room with STNA #203. They both exited a few seconds after entering the room providing no care and services or treatments. At 8:23 P.M., LPN #59 entered the room with medication, and the video ended. The video began again on 02/25/17 at 10:41 P.M. There were no staff members observed in the resident's room the rest of the day, through 12:00 A.M. on 02/26/17. There was no repositioning, offloading, or restorative ROM observed being provided to Resident #130 on 02/25/17. Review of the February 2017 Treatment Administration Record (TAR) revealed LPN #122 documented on 02/23/17 as providing the treatment change to the left and right heel for the day shift on 02/23/17, however, the video revealed the treatments were not completed. Review of the February 2017 Medication Administration Record [REDACTED].M. Also documented was 125 mg of [MEDICATION NAME] (an antibiotic used to treat [MEDICAL CONDITION]) was given at 6:00 P.M. However, the video revealed the blood glucose level and medications were not completed per physician's orders [REDACTED]. Further review of the February 2017 MAR indicated [REDACTED].M. did not administer the following medications: [REDACTED]., [MEDICATION NAME] at 9:00 A.M., B-Complex with Vitamin C, [MEDICATION NAME], and [MEDICATION NAME] at the scheduled time of 9:00 A.M. Additionally, on 02/24/17, LPN #6 documented the following 6:00 P.M. medications were administered: Humalog insulin subcutaneous, [MEDICATION NAME], and [MEDICATION NAME]. However, the video revealed the medications were not administered per physician's orders [REDACTED]. Review of the March 2017 TAR revealed the physician ordered treatment to the Stage IV pressure ulcer to Resident #130's coccyx was not provided on 03/06/17 during the day shift, on 03/12/17 on the day or night shifts, on 03/15/17 on the night shift, on 03/17/17 on the day shift, on 03/18/17 on the day or night shifts, and on 03/19/17 on the day shift. Further review of the TAR revealed the physician ordered treatment to the arterial ulcer on the resident's right heel was not provided on 03/06/17 during the day shift, 03/08/17 during the day shift, on 03/12/17 during the day or night shifts, 03/15/17 on the night shift, on 03/17/17 on the day shift, on 03/18/17 on the day or night shifts, and on 03/19/17 on the day shift. Additional review revealed the physician ordered treatment to the Stage II pressure ulcer to the resident's left heel was not provided on 03/06/17, 03/08/17 and 03/12/17. Observation on 03/20/17 at 9:11 A.M. revealed Resident #130 was lying in bed on her back with a pillow under her left side with no off-loading from the Stage IV pressure ulcer on her buttocks. At 3:15 P.M., observation of Resident #130 revealed the resident was in the same position as observed at 9:11 A.M. Observation on 03/21/17 at 9:26 A.M. revealed Resident #130 was lying in bed on her back with no off-loading from the Stage IV pressure ulcer on her buttocks. At 1:49 P.M. observation of Resident #130 revealed the resident was lying in bed on her back with a pillow tilting her right hip to the left. The positioning did not achieve off-loading from the Stage IV pressure ulcer on her buttocks. At 4:22 P.M., Resident #130 remained positioned on her back with a pillow tilting her right hip to the left with no off-loading from the coccyx achieved. Observation on 03/22/17 at 7:30 A.M. revealed Resident #130 was lying in bed on her back with no off-loading from the coccyx achieved. At 4:10 P.M., observation of Resident #130 revealed the resident was lying on her back with a pillow under her right hip, not achieving off-loading from the Stage IV pressure ulcer to her coccyx. Interview with the DON at the time of the observation confirmed the pillow was not positioned correctly and caused pressure to remain on Resident #130's Stage IV pressure ulcer. Interview with the [MEDICAL TREATMENT] RN on 03/22/17 at 10:15 A.M. revealed she was aware the resident had a Stage IV pressure ulcer to her coccyx. She stated the only intervention the [MEDICAL TREATMENT] staff could provide was to turn her side to side in the chair they used. The [MEDICAL TREATMENT] RN stated the center was not equipped to provide incontinence care. The [MEDICAL TREATMENT] RN further stated the facility did not send a cushion to provide off-loading while the resident was receiving [MEDICAL TREATMENT] at the center. On 03/22/17 at 1:40 P.M., observation and interview with STNA #153 revealed she was assigned to the care of Resident #130. She stated the resident was to be turned every two hours. The resident was noted to be lying on her back with no pillow under her right or left hip. Observation of STNA #153 revealed the STNA lifted the right side of the cloth incontinence pad and pulled the resident towards the left side of the bed and placed a pillow under the resident's right hip and buttocks and placed the resident back down onto the pillow. The pillow placement revealed the pillow placed pressure against the Stage IV pressure ulcer to the coccyx. The STNA stated she had not received any education on turning and repositioning the resident. The STNA stated that was how she positioned all the residents. Observations of Resident #130 on 03/23/17 at 7:50 A.M. through 1:40 P.M. revealed the resident was positioned on her back with no off-loading from her Stage IV pressure ulcer. Continued observations on 03/23/17 at 3:00 P.M. revealed Resident #130 was tilted to the right using a pillow behind her back and left shoulder with no off-loading achieved to the Stage IV pressure ulcer. Observation on 03/24/17 at 7:45 A.M. revealed Resident #130 was positioned on her left side with pillows behind her back and right shoulder with no off-loading from the Stage IV pressure ulcer being achieved. At 9:30 A.M., observation of the resident revealed the resident was being transferred onto a stretcher to be transported to [MEDICAL TREATMENT]. No cushion was observed under the resident. The LNHA, DON, Corporate Nurse, Chief Corporate Administrator and the facility's Chief Executive Officer (CEO) observed the video recordings of Resident #130 on 03/29/17 at 10:00 A.M. The CEO confirmed the video revealed Resident #130 was neglected to be provided with the care and services ordered for five days between 02/21/17 and 02/26/17 by multiple staff members assigned to her care. Interview with STNA #187 on 03/29/17 at 3:17 P.M. confirmed she was assigned to the care of Resident #130 at times. The STNA stated she was to provide incontinence care every two hours, because she had loose stools all the time. STNA #187 confirmed she was not permitted to talk on the cell phone while in a resident's room. STNA #187 confirmed she was the STNA in the video on 02/23/17 at 4:23 P.M., confirmed she was on her personal cell phone, and confirmed Resident #130 was not positioned at that time to provide offloading to the Stage IV pressure ulcer on her coccyx. STNA #187 further stated she did ROM when she moved the resident's hands up and washed her. However, she was unaware of the ROM the resident was to receive. On 03/29/17 at 4:03 P.M., LPN #132 was shown the video recording of 02/21/17 beginning

Based on medical record review, observations, review of video recordings, staff interviews, and review of facility abuse policy and procedures, the facility failed to implement their abuse policy to ensure a resident was free from neglect over a five day period when multiple staff members failed to provide necessary care, services and treatments for one (#130) of 21 residents reviewed for neglect. This resulted in Immediate Jeopardy and serious harm when Resident #130 was left for hours over a five day period positioned on a Stage IV (full thickness of skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structure) pressure ulcer to her coccyx, ordered treatments to the pressure ulcer were not completed or not completed as ordered, incontinence care was not provided, medications were not administered, and Activities of Daily Living (ADLs) and Range of Motion (ROM) were not completed as ordered. Additionally, this placed the other 122 residents in the facility at risk for the likelihood of serious impairment or harm as the facility had established practices of failing to provide the care, services, and treatments as required and as prescribed by the physician representing a systemic failure and oversite to avoid physical harm and mental anguish of residents residing in the facility. On 03/29/17 at 12:34 P.M., the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) were notified Immediate Jeopardy began on 02/21/17 at 7:47 P.M. when Resident #130 was video recorded being neglected by multiple facility staff members on all three shifts, over a five day period of time. Facility staff were observed failing to provide the necessary care, services, treatments and medications as required and in accordance with physician orders [REDACTED]. provide ADLs and ROM. The Immediate Jeopardy was removed on 03/30/17 when the facility established systems to ensure residents received ordered services and/or treatments and medications, and the facility implemented the following corrective actions: · On 03/29/17, the facility suspended the following employees identified on the video recordings who were involved in the neglect of Resident #130: Licensed Practical Nurses (LPNs) #06, #122, #132, and #159, State tested Nursing Assistants (STNAs) #108, #153, and #172. · On 03/29/17, the Staff Development Coordinator and/or designee began educating the facility staff nurses on treatments, appropriate techniques, barrier use, infection control, following physician's orders [REDACTED]. By 03/30/17, 16 LPNs and 10 Registered Nurses (RNs) were educated. All remaining nurses and ancillary staff, as appropriate, were to be educated prior to being given an assignment. · On 03/29/17, the Staff Development Coordinator and/or designee began educating the facility staff on bathing, perineal care, incontinence care, and infection control. By 03/30/17, nine (09) RNs, 17 LPNs and 35 STNAs were educated. All remaining nursing staff were to be educated prior to being given an assignment. · On 03/29/17, the Staff Development Coordinator and/or designee began educating the facility staff on proper positioning. By 03/30/17, nine (09) RNs, 18 LPNs and 36 STNAs were educated. All remaining nursing staff were to be educated prior to being given an assignment. · On 03/30/17, education was provided by the Staff Development Coordinator and/or designee to 21 LPNs and 10 RNs regarding facility medication administration practices. All remaining nursing staff were to be educated prior to being given an assignment. · On 03/30/17, the Staff Development Coordinator and/or designee began educating the facility staff on resident rights. Ten (10) RNs, 17 LPNs and 38 STNAs had been educated on resident rights. All remaining nursing staff and ancillary staff were to be educated prior to being given an assignment. · On 03/30/17, the facility staff was re-educated on the facility's cell phone policy. Eight (08) RNs, 13 LPNs and 28 STNAs were educated and all remaining staff were to be re-educated prior to being given an assignment. · On 03/30/17, the Staff Development Coordinator and/or designee began educating the facility staff on pain. Nine (09) RNs, 16 LPNs and 36 STNAs had been educated. All remaining nursing staff were to be educated prior to being given an assignment. · On 03/30/17, the Staff Development Coordinator and/or designee began educating the facility staff on ROM. Ten (10) RNs, 17 LPNs and 38 STNAs were educated. All remaining nursing staff were to be educated prior to being given an assignment. · On 03/30/17 at 5:00 P.M., a head to toe assessment was conducted on Resident #130 by the DON to establish a baseline assessment of the resident's current overall condition. Additionally, all residents identified with a Stage II pressure ulcer or higher were re-assessed. · On 03/30/17, the facility assigned a nursing management team member or corporate team member to each shift to conduct audits and monitor care practices involving staff to resident interactions. · Interviews on 03/30/17 between 9:57 A.M. and 3:46 P.M. with Housekeeper (HK) #56 confirmed she had been educated on infection control and the use of personal protective equipment (PPE). In addition, STNAs #96, #192, LPN #207 and RN #86, confirmed they had been educated on infection control, use of PPE, turning and repositioning, incontinence care, false documentation, and the use of cell phones in resident rooms. LPN #210 and RN #96 further confirmed they had been educated on appropriate medication pass as well. · Beginning on 04/02/17, five residents will be interviewed and/or observed weekly, for six weeks, to ensure appropriate care and services are being provided. Although the Immediate Jeopardy was removed, the facility remains out of compliance at Severity Level 2 (no actual harm with the 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: Review of Resident #130's medical record revealed an original admission date of [DATE] with the latest readmission on 02/11/17. Resident #130's admitting [DIAGNOSES REDACTED]. Review of Resident #130's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech, sometimes understood, rarely/never made herself understood, had both short and long term memory loss and had a severe cognitive deficit. The MDS revealed the resident had not rejected any care, was dependent on staff for ADLs, had a functional limitation in ROM to both upper and lower extremities, had an indwelling urinary catheter and was always incontinent of bowel. The MDS revealed the resident received a pain regimen, as needed pain medication, the resident was noted to have verbal complaints of pain, non-verbal sounds of pain and displayed facial expressions of pain. The MDS further indicated the resident was at risk for skin breakdown, had two venous and arterial ulcers on both heels, and had an unhealed Stage IV pressure ulcer on her coccyx measuring 16.0 centimeters (cm) by 15 cm by 3.0 cm with slough being the most severe tissue type. Review of the skin and ulcer treatment section of the MDS indicated the facility implemented pressure reduction devices to the resident's bed and chair, nutrition/hydration intervention, pressure ulcer care, application of non-surgical dressings and application of ointments or medications. Review of the monthly physician's orders [REDACTED].M., 11:00 A.M., 5:00 P.M. and 9:00 P.M. based on the blood glucose (BG) results with the following parameters: if BG was 140 to 180 give four units; if BG was 181 to 220 give eight units; if BG was 221 to 260 give ten units; if BG was 261-300 give ten units; if BG was 301 to 340 give 12 units; if BG was 341 to 380 give 14 units; and if BG was above 381 give 16 units. Sodium Phosphorus (electrolyte) 250 milligrams (mg) was to be administered via enteral tube four times a day at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M. Additional medications ordered included [MEDICATION NAME] 10 mg (chest pain) to be administered via enteral tube three times a day at 6:00 A.M., 2:00 P.M. and 10:00 P.M., Phoslo (for [MEDICAL CONDITION]) 667 mg, give two capsules via enteral tube three times a day, at 6:00 A.M., 2:00 P.M. and 10:00 P.M., Balanced B complex with Vitamin C extended release 15-10-50-300 mg via enteral tube daily at 9:00 A.M., [MEDICATION NAME] (heart) 25 mg via enteral tube twice a day at 9:00 A.M. and 9:00 P.M., [MEDICATION NAME] (anti-convulsant) 500 mg via enteral tube twice a day at 9:00 A.M. and 9:00 P.M., [MEDICATION NAME] (nerve pain) 200 mg via enteral tube every twelve hours at 9:00 A.M. and 9:00 P.M., [MEDICATION NAME] (cholesterol) 40 mg via enteral tube daily at 9:00 P.M., [MEDICATION NAME] (blood thinner) 75 mg via enteral tube daily at 9:00 P.M., [MEDICATION NAME] (antibiotic) 500 mg via enteral tube three times a day at 6:00 A.M., 2:00 P.M., and 10:00 P.M., [MEDICATION NAME] ([MEDICAL CONDITION]) 150 mg via enteral tube twice daily at 9:00 A.M. and 9:00 P.M., [MEDICATION NAME] 100 mg via enteral tube every Monday, Wednesday and Friday at 6:00 P.M. In addition, physician orders [REDACTED]. Wound orders included to cleanse the coccyx wound with normal saline (NS), moisten [MEDICATION NAME] with one fourth strength Dakin's solution and pack wound, cover with an ABD pad and foam dressing, twice a day and as needed, cleanse the wound to the right heel with NS, moisten gauze with one fourth strength Dakin's solution and cover wound with ABD and wrap with kerlix and cleanse the wound to the left heel wound with NS, apply skin prep and pad and protect. Change daily and as needed. Review of a continuous video recording of Resident #130 beginning on 02/21/17 at 7:47 P.M. revealed LPN #132 began providing wound care to the resident. LPN #132 raised the resident's bed, and roughly removed the pillow out from under the right side of the resident's back and buttocks causing shearing. The resident displayed facial grimacing when LPN #132 removed the pillow. LPN #132 removed the [MEDICATION NAME] packing from the packaging, shook it, and placed the clean dressing on the resident's bedside table with no barrier between the dressing and the table. LPN #132 then opened a clean foam dressing, removed the [DEVICE] dressing and utilized the draw sheet to pull the resident over to the left side and then rolled the resident onto her right side with no staff assistance. Resident #130 again displayed non-verbal indicators of pain with facial grimacing during the repositioning. LPN #132 tore off the soiled dressing and the packing to the coccyx wound. Between the handling of the soiled [DEVICE] dressing and removing the coccyx dressing, LPN #132 did not wash her hands or change her soiled gloves. LPN #132 proceeded to put on a new dressing with packing and covered the wound, however, did not cleanse the wound prior to applying a new dressing. LPN #132 also did not moisten the dressing with one fourth strength Dakin's solution when placing it in the coccyx wound. LPN #132 then pushed the resident back over onto her back without regard to the resident's comfort. When LPN #132 placed the pillow under the residents left side, the pillow was not positioned adequately to allow for offloading of the Stage IV pressure ulcer to Resident #130's coccyx. Resident #130 had facial grimacing observed throughout the dressing change. LPN #130 was further noted to not have PPE on while providing care to the resident who was on contact isolation. On 02/23/17 beginning at 3:33 P.M., review of the continuous video recording revealed Resident #130 lying in bed with a pillow positioned under her right hip. There were no staff members observed to enter the resident's room until 4:23 P.M. at which time STNA #187 entered the room. STNA #187 was on her personal cell phone while standing at the resident's bedside. STNA #187 was observed on her phone in the resident's room from 4:23 P.M. until 4:27 P.M. and was not interacting with Resident #130. At 4:28 P.M., STNA #187 applied Chap Stick to Resident #130's lips. STNA #187 left the room at 4:28 P.M. and did not provide any additional resident care or services to the resident. Resident #130 was left in the same position as when STNA #187 entered the room. No additional staff entered Resident #130's room until 4:58 P.M. at which time LPN #122 entered the room. At that time, LPN #122 gave an insulin injection to Resident #130's upper right arm. LPN #122 was not observed obtaining the resident's blood glucose level prior to giving the insulin. LPN #122 left the room at 4:59 P.M. and did not provide any turning or repositioning as prescribed by the physician. Further observation of the continuous video recording revealed on 02/23/17 from 5:00 P.M. through 6:08 P.M., Resident #130 remained in the same position in her bed, with a pillow wedged under her right hip. At 6:08 P.M., STNA #187 entered the resident's room and was again on her personal cell phone as she placed an earpiece in her right ear. STNA #187 dropped a glove on the floor, picked it up, and placed it back on her hand, now having double gloves on. STNA #187 remained on her cell phone and was not interacting with the resident. At this time, LPN #122 entered the resident's room to provide a treatment to the resident's coccyx wound. STNA #187 provided incontinence care and assisted with the coccyx dressing change. STNA #187 cleansed Resident #130's buttocks which had visible signs of feces. STNA #187 removed the soiled coccyx dressing and wound packing with the dirty wash cloth she had just used to clean the resident's buttocks. LPN #122 then cleansed the wound and packed the coccyx wound while STNA #187 held the resident to her side. STNA #187 continued to wear the same dirty gloves throughout all of the resident's care. LPN #122 began working on the wounds to Resident #130's heels. LPN #122 removed Resident #130's Prevalon boots (heel protectors that float the heels off the surface of the mattress), cut part of the dressing off, then took a new piece of tape and placed it on the resident's right heel without providing any treatment to the wound. LPN #122 then put the Prevalon boot back on the resident's right foot. LPN #122 cut a piece of dressing off the left heel, obtained a new piece of tape and placed it on the left heel dressing. No wound care was observed to the left heel, just a new piece of tape applied to the old dressing that was still in place. STNA #187 then placed a pillow under the resident's left hip which was not positioned to adequately provide off-loading to the Stage IV pressure ulcer to her coccyx. LPN #122 looked at the resident's tube feeding (TF) pump, put her hands up in the air, and walked out. The TF was not noted to be turned off throughout the wound care. No medications were given when the nurse was in the room. The video recording ended at 7:38 P.M. No medications were observed to be given throughout the entire video on 02/23/17 from 3:33 P.M through 7:38 P.M. Observation of the continuous video revealed STNA #187 and LPN #122 not wearing any PPE while providing care to Resident #130. Review of the continuous video recording from 02/24/17 beginning at 5:59 A.M. through 7:38 P.M. revealed, from 5:59 A.M. through 8:12 A.M., no staff members entered Resident #130's room to provide any care or services to the resident. During the entire observation, Resident #130 was lying in bed, on her back, directly on the Stage IV pressure ulcer to her coccyx. At 8:12 A.M., STNA #153 entered the resident's room and placed her personal cell phone on the resident's bedside table and was talking on the phone. No care was provided. At 8:19 A.M., STNA #153 turned off the resident's TF and raised the head of the bed (HOB) while still holding her personal phone in one hand. STNA #153 put in an earpiece so she could continue to talk on the phone, and then took a sip of a drink. STNA #153 continued on the phone, placed gloves on, and uncovered the resident. Resident #130 was noted to be lying in bed with her pants pulled down. STNA #153 began washing the resident's face while still on the phone. Resident #130 was noted to be incontinent of stool. STNA #153 had gloves on, washed the resident's perineal area, and then dried the resident off with a towel. STNA #153 then pulled the resident to the left side of the bed using the draw sheet and the resident had visible facial grimacing. The STNA disconnected the resident from the TF and placed it on top of the pole at the resident's bedside. STNA #153 turned the resident to the right side and began cleaning the stool from the resident using a wet washcloth with no soap. STNA #153 placed a clean disposable brief under the resident. STNA #153 finished dressing the resident, rolling the resident on to her right side once again, with facial grimacing observed. She then took a towel off the floor, which was used during incontinence care, and placed it over the resident's chest. STNA #153 began providing oral care and a water mouth rinse. STNA #153 wiped the resident's mouth with the same towel that she picked up off the floor and used during incontinence care and left the room at 8:47 A.M. The STNA had not placed a cushion under the resident or repositioned her. The resident continued to be lying on her back on the Stage IV pressure ulcer with no off-loading since the video started at 5:59 A.M. At 8:49 A.M., Resident #130 still had the water rinse in her mouth, and it was drooling down her chin. No staff were observed in the room again until 9:38 A.M., when two male ambulance attendants arrived to transport the resident to her [MEDICAL TREATMENT] appointment. There was no cushion placed under the resident to go with her to [MEDICAL TREATMENT]. On 02/24/17 at 2:58 P.M., Resident #130 was observed on the video recording to be returned to her room from [MEDICAL TREATMENT]. At 3:05 P.M., STNA #143 and STNA #107 came into the resident's room and put gloves on. STNA #107 lowered the HOB and the resident had facial grimacing with an open mouth. STNA #107 removed a few wipes from a container and placed them on the resident's bed. STNA #107 and STNA #143 then pulled the resident's pants down and she again displayed facial grimacing. STNA #107 put on double gloves and pulled the residents brief down. STNA #107 wiped Resident #130's perineal area with a rag and then placed the dirty rag on the clean incontinence brief. STNA #143 and STNA #107 turned the resident to her right side to clean her buttocks area and stool. STNA #107 took another wipe and wiped the residents face off, still wearing the soiled gloves she used to provide incontinence care, and wiped the stool from the resident. STNA #107 lowered the residents HOB, and the resident was again observed with facial grimacing. STNA #143 covered the resident with a blanket and both STNAs walked out of the room at 3:21 P.M. with no repositioning or off-loading observed. Neither STNA #107 nor STNA #143 wore any PPE when providing incontinence care to Resident #130. There were no staff observed in Resident #130's room again until 5:02 P.M. on 02/24/17 when LPN #6 entered the room. LPN #6 hooked up the resident's TF, which had been off since 8:19 A.M. LPN #6 proceeded to put on gloves and raised the resident's HOB, and the resident was noted with facial grimacing. LPN #6 gave Resident #130 a thumbs up and left the room. No medications were observed to be given, the resident's blood glucose was not checked, and no insulin was given. Resident #130 continued to lay on her back with no off-loading to the Stage IV pressure ulcer to her coccyx. Resident #130 had not been changed since 3:12 P.M. when she first returned from [MEDICAL TREATMENT]. At 7:26 P.M., STNA #203 entered the room to provide incontinence care, put on gloves, and did not place on any PPE. STNA #203 lowered the residents HOB, however, did not turn off the TF and left the room. STNA #203 returned to the room and put on new gloves, dropped one on the floor, picked it up, and put it on her left hand. STNA #203 turned the resident on her right side with the resident displaying facial grimacing. STNA #203 wiped the stool off of Resident #130 and removed the dirty incontinence brief. STNA #203 rolled the resident back on her back and the resident again was observed with facial grimacing. STNA #203 did not wash her hands during the entire provision of care. STNA #203 picked up her phone and started talking on it while still providing resident care. The STNA did not position any pillows under the resident after providing care. Resident #130 had not been turned nor had off-loading to the coccyx during the entire observation on 02/24/17 (for 24 hours). The resident was not observed to be provided wound care to the coccyx, left heel, or right heel any time during the 7:00 A.M. through 7:00 P.M. shift on 02/24/17, with continuous video recordings observed from 5:59 A.M. through 7:39 P.M. No ROM or restorative care was observed during the entire observation of video as prescribed by the physician. Observation of the video recording of Resident #130 on 02/25/17 beginning at 6:23 A.M. through 8:23 P.M. and then from 10:41 P.M. through 11:59 P.M. revealed no staff entered Resident #130's room on 02/25/17 until 7:19 A.M. when STNA #203 entered the room and left without providing any care or repositioning. At 7:33 A.M., STNA #204 entered the room and put gloves on and was eating toast and watching television, while standing at the resident's bedside. STNA #204 began providing care, including removing Resident #130's hospital gown, cleaning the residents face, and wiping the resident down. STNA #204 pulled down the resident' incontinence brief, washed the residents perineal area which had visible feces, and then continued washing the residents body with the same towel used to wash the perineal area, including her legs. STNA #204 rolled the resident to her other side and the resident was barely hanging on the left side of the bed. STNA #204 took off her gloves and put a new brief on Resident #130. STNA #204 continued to wipe feces off the resident with a towel, all while wearing no gloves and no PPE. STNA #204 put on new gloves and began brushing the resident's teeth, dressed the resident and left the room. STNA #204 came back in the room at 8:08 A.M., was watching television and was observed to be folding sheets. At 8:55 A.M., STNA #204 returned to Resident #130's room and picked up a clean pair of gloves. STNA #204 and Resident #130 were speaking to each other and STNA #204 exited the room at 8:56 A.M. without providing any care to the resident. At 11:51 A.M., STNA #204 returned to Resident #130's room and was leaning on the resident's wheelchair while on her personal cell phone. STNA #204 exited the room at 12:01 P.M. and did not deliver any care to the resident. There were no additional staff observed in Resident #130's room on 02/25/17 until 12:35 P.M. when STNA #204 entered the room again and was drinking from a cup, watching television. At 12:38 P.M., the STNA exited the resident's room without providing any care. No observations were viewed of the nurse giving the resident's 12:00 P.M. medication or obtaining the 11:00 A.M. blood glucose level. At 1:28 P.M., STNA #204 entered Resident #130's room and was observed walking in the resident's bathroom after picking up a roll of toilet paper off Resident #130's bedside table. The STNA was seen coming out of the bathroom and set the roll of toilet paper back onto the resident's bedside table and leaned back onto the resident's wheelchair. At 1:50 P.M., STNA #204 remained leaning on the resident's wheelchair watching television. At 2:00 P.M., STNA #204 exited the resident's room without providing care. Again, no observations were made of the resident receiving her scheduled 2:00 P.M. medications or obtaining the 5:00 P.M. blood glucose check. There were no additional staff members observed in Resident #130's room on 02/25/17 until 6:38 P.M. when LPN #132 entered the resident's room with STNA #203. They both exited a few seconds after entering the room providing no care and services or treatments. At 8:23 P.M., LPN #59 entered the room with medication, and the video ended. The video began again on 02/25/17 at 10:41 P.M. There were no staff members observed in the resident's room the rest of the day, through 12:00 A.M. on 02/26/17. There was no repositioning, offloading, or restorative ROM observed being provided to Resident #130 on 02/25/17. Review of the February 2017 Treatment Administration Record (TAR) revealed LPN #122 documented on 02/23/17 as providing the treatment change to the left and right heel for the day shift on 02/23/17, however, the video revealed the treatments were not completed. Review of the February 2017 Medication Administration Record [REDACTED].M. Also documented was 125 mg of [MEDICATION NAME] (an antibiotic used to treat [MEDICAL CONDITION]) was given at 6:00 P.M. However, the video revealed the blood glucose level and medications were not completed per physician's orders [REDACTED]. Further review of the February 2017 MAR indicated [REDACTED].M. did not administer the following medications: [REDACTED]., [MEDICATION NAME] at 9:00 A.M., B-Complex with Vitamin C, [MEDICATION NAME], and [MEDICATION NAME] at the scheduled time of 9:00 A.M. Additionally, on 02/24/17, LPN #6 documented the following 6:00 P.M. medications were administered: Humalog insulin subcutaneous, [MEDICATION NAME], and [MEDICATION NAME]. However, the video revealed the medications were not administered per physician's orders [REDACTED]. Review of the March 2017 TAR revealed the physician ordered treatment to the Stage IV pressure ulcer to Resident #130's coccyx was not provided on 03/06/17 during the day shift, on 03/12/17 on the day or night shifts, on 03/15/17 on the night shift, on 03/17/17 on the day shift, on 03/18/17 on the day or night shifts, and on 03/19/17 on the day shift. Further review of the TAR revealed the physician ordered treatment to the arterial ulcer on the resident's right heel was not provided on 03/06/17 during the day shift, 03/08/17 during the day shift, on 03/12/17 during the day or night shifts, 03/15/17 on the night shift, on 03/17/17 on the day shift, on 03/18/17 on the day or night shifts, and on 03/19/17 on the day shift. Additional review revealed the physician ordered treatment to the Stage II pressure ulcer to the resident's left heel was not provided on 03/06/17, 03/08/17 and 03/12/17. Observation on 03/20/17 at 9:11 A.M. revealed Resident #130 was lying in bed on her back with a pillow under her left side with no off-loading from the Stage IV pressure ulcer on her buttocks. At 3:15 P.M., observation of Resident #130 revealed the resident was in the same position as observed at 9:11 A.M. Observation on 03/21/17 at 9:26 A.M. revealed Resident #130 was lying in bed on her back with no off-loading from the Stage IV pressure ulcer on her buttocks. At 1:49 P.M. observation of Resident #130 revealed the resident was lying in bed on her back with a pillow tilting her right hip to the left. The positioning did not achieve off-loading from the Stage IV pressure ulcer on her buttocks. At 4:22 P.M., Resident #130 remained positioned on her back with a pillow tilting her right hip to the left with no off-loading from the coccyx achieved. Observation on 03/22/17 at 7:30 A.M. revealed Resident #130 was lying in bed on her back with no off-loading from the coccyx achieved. At 4:10 P.M., observation of Resident #130 revealed the resident was lying on her back with a pillow under her right hip, not achieving off-loading from the Stage IV pressure ulcer to her coccyx. Interview with the DON at the time of the observation confirmed the pillow was not positioned correctly and caused pressure to remain on Resident #130's Stage IV pressure ulcer. Interview with the [MEDICAL TREATMENT] RN on 03/22/17 at 10:15 A.M. revealed she was aware the resident had a Stage IV pressure ulcer to her coccyx. She stated the only intervention the [MEDICAL TREATMENT] staff could provide was to turn her side to side in the chair they used. The [MEDICAL TREATMENT] RN stated the center was not equipped to provide incontinence care. The [MEDICAL TREATMENT] RN further stated the facility did not send a cushion to provide off-loading while the resident was receiving [MEDICAL TREATMENT] at the center. On 03/22/17 at 1:40 P.M., observation and interview with STNA #153 revealed she was assigned to the care of Resident #130. She stated the resident was to be turned every two hours. The resident was noted to be lying on her back with no pillow under her right or left hip. Observation of STNA #153 revealed the STNA lifted the right side of the cloth incontinence pad and pulled the resident towards the left side of the bed and placed a pillow under the resident's right hip and buttocks and placed the resident back down onto the pillow. The pillow placement revealed the pillow placed pressure against the Stage IV pressure ulcer to the coccyx. The STNA stated she had not received any education on turning and repositioning the resident. The STNA stated that was how she positioned all the residents. Observations of Resident #130 on 03/23/17 at 7:50 A.M. through 1:40 P.M. revealed the resident was positioned on her back with no off-loading from her Stage IV pressure ulcer. Continued observations on 03/23/17 at 3:00 P.M. revealed Resident #130 was tilted to the right using a pillow behind her back and left shoulder with no off-loading achieved to the Stage IV pressure ulcer. Observation on 03/24/17 at 7:45 A.M. revealed Resident #130 was positioned on her left side with pillows behind her back and right shoulder with no off-loading from the Stage IV pressure ulcer being achieved. At 9:30 A.M., observation of the resident revealed the resident was being transferred onto a stretcher to be transported to [MEDICAL TREATMENT]. No cushion was observed under the resident. The LNHA, DON, Corporate Nurse, Chief Corporate Administrator and the facility's Chief Executive Officer (CEO) observed the video recordings of Resident #130 on 03/29/17 at 10:00 A.M. The CEO confirmed the video revealed Resident #130 was neglected to be provided with the care and services ordered for five days between 02/21/17 and 02/26/17 by multiple staff members assigned to her care. Interview with STNA #187 on 03/29/17 at 3:17 P.M. confirmed she was assigned to the care of Resident #130 at times. The STNA stated she was to provide incontinence care every two hours, because she had loose stools all the time. STNA #187 confirmed she was not permitted to talk on the cell phone while in a resident's room. STNA #187 confirmed she was the STNA in the video on 02/23/17 at 4:23 P.M., confirmed she was on her personal cell phone, and confirmed Resident #130 was not positioned at that time to provide offloading to the Stage IV pressure ulcer on her coccyx. STNA #187 further stated she did ROM when she moved the resident's hands up and washed her. However, was unaware of the ROM the resident was to receive. On 03/29/17 at 4:03 P.M., LPN #132 was shown the video record

Based on medical record review, review of video recordings, facility infection control policies and procedures and staff interviews, the facility failed to maintain acceptable infection control practices in the areas of isolation, handwashing, wound care, personal care and soiled laundry handling for one resident, (#130). This resulted in Immediate Jeopardy when multiple staff members over a five day period provided personal care and medical treatment to Resident #130, who was on contact isolation, without appropriate hand washing and without wearing personal protective equipment (PPE). This had the harmful potential for the spread of infection to all 123 residents residing in the facility. The Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) were notified on 03/29/17 at 12:34 P.M. Immediate Jeopardy began on 02/21/17 at 7:47 P.M. when Resident #130, who was on contact isolation for Clostridium Difficile (c-diff/infectious diarrhea), was provided incontinence care, pressure ulcer treatments, activities of daily living, medication administration, and oral care without the facility staff donning PPE or completing handwashing over a five day period. The facility staff were also observed eating and drinking in Resident #130's room during care. The Immediate Jeopardy was removed on 03/30/17 when the facility established systems to ensure proper infection control measures were maintained, and the facility implemented the following corrective actions: · On 03/29/17 the facility suspended the following employees identified on the video providing care without PPE to Resident #130: Licensed Practical Nurses (LPNs) #6, #122, #132 and #159, State tested Nursing Assistants (STNAs) #108, #153 and #172. · On 03/29/17 the Staff Development Coordinator and/or designee re-educated Registered Nurse (RN) #36, Housekeeper #56, STNA #143 and RN #167 on proper infection control practices. By 03/30/17, 16 LPNs and 10 RNs were educated on treatments, appropriate techniques, barrier use, and infection control practices. All remaining staff were to be educated prior to being given an assignment. · On 03/29/17 the Staff Development Coordinator and/or designee began educating the facility staff on bathing, perineal care, incontinence care and infection control. By 03/30/17 Nine RNs, 17 LPNs and 35 STNAs were educated. All remaining staff were to be educated prior to being given an assignment. · On 03/29/17 the Staff Development Coordinator and/or designee began educating the facility staff on no eating or drinking in resident rooms, resident care areas, nurse's station or hallways. By 03/30/17 nine RNs, 17 LPNs and 35 STNAs were educated. All remaining staff were to be educated prior to begin given an assignment. · On 03/29/17 the Staff Development Coordinator and/or designee began educating the facility staff on the facility handwashing policy and proper soiled linen handling. By 03/30/17 nine RNs, 17 LPNs and 35 STNAs were educated. All remaining staff were to be educated prior to being given an assignment. · By 03/30/17 all residents with orders for isolation were assessed by the Nurse Manager Team to ensure all measures were in place. · Beginning 03/30/17 proper use of PPE will be monitored by the Staff Development Coordinator and/or designee five times a week for six weeks. · Beginning 03/30/17 incontinence care will be observed and audited by the Staff Development Coordinator and/or designee five times a week for six weeks. · On 03/30/17 the facility assigned a nursing management team member or corporate team member to each shift to observe care practices, monitor staff/resident interactions with residents and complete audits. · Interviews on 03/30/17 between 9:57 A.M. and 3:46 P.M., with Housekeeper (HK) #56 confirmed she had been educated on infection control and the use of personal protective equipment (PPE). In addition, STNAs #96, #192, LPN #207 and RN #86, confirmed they had been educated on infection control, and for the use of personal protective equipment (PPE). Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their correction action plan and monitoring to ensure on-going compliance and not all staff had been re-educated on infection control procedures Findings include: Review of Resident #130's medical record revealed an original admission date of [DATE] with the latest readmission on 02/11/17. Resident #130's admitting [DIAGNOSES REDACTED]. Review of Resident #130's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech, sometimes understood, rarely/never made herself understood, had both short and long term memory loss and had a severe cognitive deficit. The MDS revealed the resident had not rejected any care, was dependent on staff for ADLs, had a functional limitation in ROM to both upper and lower extremities, had an indwelling urinary catheter and was always incontinent of bowel. The MDS revealed the resident received a pain regimen, as needed pain medication, the resident was noted to have verbal complaints of pain, non-verbal sounds of pain and displayed facial expressions of pain. The MDS further indicated the resident was at risk for skin breakdown, had two venous and arterial ulcers on both heels, and had an unhealed Stage IV pressure ulcer (full thickness of skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structure) on her coccyx, measuring 16.0 centimeters (cm) by 15 cm by 3.0 cm with slough being the most severe tissue type. Review of the skin and ulcer treatment section of the MDS indicated the facility implemented pressure reduction devices to the resident's bed and chair, nutrition/hydration intervention, pressure ulcer care, application of non-surgical dressings and application of ointments or medications. Review of the monthly physician's orders [REDACTED].#130 was ordered contact isolation for[DIAGNOSES REDACTED] beginning 01/25/17. Review of the video recordings from the room of Resident #130 from 02/21/17 at 7:47 P.M. revealed LPN #132 began providing wound care to the resident's Stage IV pressure ulcer to her coccyx. LPN #132 removed dry [MEDICATION NAME] packing from a package, shook it and laid it on the resident's bedside table with no barrier between the clean dressing and table. The nurse then ripped the soiled dressing off of the wound and removed packing from the coccyx wound. Between the handling of the soiled [DEVICE] dressing and removing the coccyx dressing, LPN #132 did not wash her hands or change her soiled gloves. LPN #132 then put on a new dressing with packing and covered the wound; however, she did not cleanse the wound. LPN #132 also did not moisten the dressing with the physician ordered one fourth strength Dakins solution when placing packing in the coccyx wound. The LPN failed to change gloves or wash her hands during the procedure and did not have PPE on while providing care. Review of the video from the room of Resident #130 from 02/23/17 at 4:23 P.M., revealed STNA #187 entered the room without PPE and was talking on her personal cell phone. STNA #187 applied Chap Stick on the resident's lips. LPN #122 then entered the resident's room without PPE, dialed insulin and gave the insulin in the resident's upper right arm. At 6:08 P.M., STNA #187 entered the resident's room, again without PPE, and was again on her phone as she placed an earpiece in her right ear and was talking while delivering care to Resident #130. STNA #187 dropped a glove on the floor, picked it up, and placed it on her hand, now wearing two gloves on her hand. LPN #122 then entered the resident's room without PPE on. STNA #187 provided incontinence care and cleansed Resident #130's buttocks which had visible stool present. STNA #187 and LPN #122 began the dressing change. STNA #187 removed the soiled coccyx dressing and packing from the wound with the dirty wash cloth she had just used to clean the resident's stool. LPN #122 then cleansed the wound while STNA #187 held the resident on her side. LPN #122 moistened the dressing and packed it in the coccyx wound. STNA #187 continued to wear the same soiled gloves throughout the resident's care. LPN #122 put on new gloves and placed a second and third border dressing on the resident's Stage IV pressure ulcer. LPN #122 then began changing the dressings to Resident #130's heels without washing her hands or donning clean gloves. Review of the video from 02/24/17 of Resident #130 beginning at 5:59 A.M. and going through 7:38 P.M. revealed STNA #153 entered the resident's room without PPE, put in an earpiece to talk on her personal cell phone and took a sip of a drink. STNA #153 remained on the phone, donned gloves and uncovered the resident. Resident #130 was lying in bed with her pants pulled down. STNA #153 began washing the resident's face while still on the phone. STNA #153 began providing incontinence care and Resident #130 was noted to be incontinent of stool. STNA #153 had gloves on, washed the perineal area, and then dried the resident off with a towel. STNA #153 then turned the resident to the right side, and began cleaning the stool from the resident, using a wet washcloth with no soap. STNA #153 put on new gloves without washing her hands and picked up a towel off the floor, which was used during incontinence care and placed it over the resident's chest. STNA #153 began providing oral care and a water mouth rinse. STNA #153 wiped the resident's mouth with the same towel that she picked up off the floor and used during incontinence care, and left the room at 8:47 A.M. At 2:58 P.M., Resident #130 returned to her room from her dialysis appointment. At 3:05 P.M., STNA #143 came into the resident's room, donned gloves and no other PPE. STNA #107 also came into the room and donned gloves. STNA #107 removed a few cleaning wipes and placed them on the resident's bed. STNA #107 pulled the resident's brief down and wiped Resident #130's perineal area with a washcloth, and then placed the dirty rag on the clean incontinence brief. STNA #143 and STNA #107 then turned the resident to her right side to clean stool from her buttocks area. STNA #107 took another wipe and wiped the resident's face off, still wearing the soiled gloves she used to wipe the stool off the resident during incontinence care. Neither STNA #107 nor STNA #143 donned PPE when providing incontinence care of the resident's stool. At 7:26 P.M., STNA #203 entered the room to provide incontinence care, donned gloves, and did not place on any PPE. STNA #203 lowered the head of the resident's bed, however did not turn off the tube feeding (TF). STNA #203 dropped one glove on the floor, picked it up, and put it on her left hand. The STNA removed Resident #130's brief and wiped stool off of her buttocks. STNA #203 did not wash her hands at any time during care. Review of the video from 02/25/17 beginning at 6:23 A.M. and going through 8:23 P.M., and again picking back up again from 10:41 P.M. through 11:59 P.M. of Resident #130's room revealed at 7:33 A.M., STNA #204 entered the room and placed gloves on her hands and no other PPE. STNA #204 was observed eating toast and watching television, while standing at the resident's bedside. STNA #204 began providing care, including removing Resident #130's hospital gown, cleaning the resident's face, and wiping the resident down. STNA #204 then pulled down the resident's brief, washed the resident's stool off of her perineal area and continued washing the resident's body with the same washcloth used to wash the perineal area, including her legs. STNA #204 then took off her gloves and put a clean incontinence brief on the resident. While applying the clean brief, STNA #204 wiped off stool with a washcloth using her bare, ungloved hands and no PPE. The LNHA, DON, Corporate Nurse, Chief Corporate Administrator and the facility's Chief Executive Officer (CEO) were shown the video on 03/29/17 at 10:00 A.M. The CEO confirmed the video revealed infection control practices were not implemented while multiple staff members provided personal care to Resident #130 for five days between 02/21/17 and 02/26/17, placing other residents at risk for infection. On 03/29/17 at 3:17 P.M. interview with STNA #187 verified she was the STNA in the video of 02/23/17 at 4:23 P.M. The STNA verified she did not utilize the PPE, and knew Resident #130 was on contact isolation. The STNA also verified she removed the dressing and packing from the Stage IV pressure ulcer with the same gloves she used to provide incontinence care. Interview on 03/29/17 at 6:47 P.M. with LPN #159 revealed she did know Resident #130 was on contact isolation for Cl-diff and verified she did not wear PPE while she provided care to the resident. Interview with STNA #153 on 03/29/17 at 5:52 P.M. revealed she knew Resident #130 was in isolation. The STNA had no knowledge of why the resident was on isolation. STNA #153 verified she put other residents at risk for transmitting the infection[DIAGNOSES REDACTED] to other residents she provided care to. Interview on 03/30/17 at 8:28 A.M., with LPN #6 verified after reviewing the video dated 02/24/16 she was not wearing PPE and stated she should have been wearing PPE. Interview on 03/30/17 at 8:51 A.M. with STNA #107 verified she knew Resident #130 was in isolation for[DIAGNOSES REDACTED] and she did not utilize the PPE when working with the resident. The STNA verified she should change gloves when moving to different parts of the body, and when you provide incontinence care and move to the face. The STNA stated she usually wore two pair of gloves, and would take a pair off when one became soiled. The STNA verified it was not the facility's practice to double glove. The STNA also verified she should have washed her hands prior to applying Resident #130's Chap Stick. On 03/29/17 at 9:07 A.M., the Corporate Nurse (CP) #200 confirmed the clean dressing was placed on Resident #130's bedside table on 02/23/17 by LPN #122 without a barrier. CP#200 said she would expect there to be a barrier. CP #200 also confirmed the LPN did not change her gloves or wash her hands. Review of the facility's infection control policy and procedure, dated 03/18/13 revealed the infection control program is to ensure the prevention and control of health care associated infections (HAI) for the protection of our residents, families and employees. The infection control process strives to improve the trends and patterns of significant infections. The facility will use a coordinated process, which includes guidelines from the Centers for Disease Control (CDC) two tier isolation precautions, as follows, standard precautions and transmission based precautions, contact, droplet and airborne. The infection control program will be presented to all new employees during orientation and annually. The facility staff will follow standard precautions as observed daily during clinical rounds by the DON and/or designee. Compliance with infection control practices is measured and documented by staff evaluation utilizing clinical competences, observation of practices by the DON and/or designee. Review of the CDC recommendation for the prevention and spread of[DIAGNOSES REDACTED] revealed the elderly population is at the most at risk for contracting the infection[DIAGNOSES REDACTED]. C-diif is shed in feces and can be transmitted on any surface, device, or material (e.g., commodes, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the[DIAGNOSES REDACTED] spores.[DIAGNOSES REDACTED] spores are transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item. The CDC recommends any patient with known or suspected[DIAGNOSES REDACTED] infection be placed in contact isolation, in a private room and, if a private room was not available, these patients could be placed in rooms with other patients with the[DIAGNOSES REDACTED] infection. The use of gloves when entering patient's rooms and during care is recommended. Vigorous handwashing after removing gloves. Preventing contamination of the hands via glove use remains the cornerstone for preventing[DIAGNOSES REDACTED] transmission via the hands of healthcare workers. Use gowns when entering patients' rooms and during patient care. Dedicate or perform cleaning of any shared medical equipment. Continue these precautions until diarrhea ceases. Because[DIAGNOSES REDACTED] infected patients continue to shed organism for a number of days following cessation of diarrhea, some institutions routinely continue isolation for either several days beyond symptom resolution or until discharge, depending upon the type of setting and average length of stay. Implement an environmental cleaning and disinfection strategy, ensure adequate cleaning and disinfection of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently.

Based on medical record review, observations, review of video recordings, staff interviews, review of the National Pressure Ulcer Advisory Committee (NPUAC) information related to pressure ulcers, and review of facility policies and procedures, the facility staff failed to ensure appropriate care to promote healing was provided and physician ordered treatments were completed for one (#130) of three residents reviewed for pressure ulcers. This resulted in Immediate Jeopardy and serious harm when Resident #130 was not provided with the physician ordered treatments to a Stage IV (full thickness of skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structure) pressure ulcer to the coccyx. Additionally, facility staff failed to provide proper positioning to off-load pressure to the area on the coccyx resulting in a decline in the pressure ulcer. The facility identified 13 residents with pressure ulcers. The facility census was 123. On 03/29/17 at 12:34 P.M., the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) were notified Immediate Jeopardy began on 02/21/17 at 7:47 P.M. when video recordings of Resident #130 revealed facility staff failed to provide ordered treatments and appropriate care for the resident's Stage IV pressure ulcer as prescribed by the physician to prevent decline of the ulcer on the resident's coccyx. The Immediate Jeopardy was removed on 03/30/17 when the facility established systems to ensure residents received ordered services and/or treatments of pressure ulcers, and the facility implemented the following corrective actions: · On 03/29/17 the facility suspended the following employees identified on the video recordings who failed to provide treatments as ordered for Resident #130, Licensed Practical Nurses (LPNs) #06, #122, #132, and #159, State tested Nursing Assistants (STNAs) #108, #153, and #172. · On 03/29/17, the Staff Development Coordinator and/or designee began educating the facility staff nurses on treatments, appropriate techniques, barrier use, infection control, following physician's orders [REDACTED]. By 03/30/17, 16 LPNs and 10 Registered Nurses (RNs) were educated. All remaining nurses were to be educated prior to being given an assignment. · On 03/29/17, the Staff Development Coordinator and/or designee began educating the facility staff on perineal care, incontinence care and infection control. By 03/30/17, Nine RNs, 17 LPNs and 35 STNAs were educated. All remaining nursing staff were to be educated prior to being given an assignment. · On 03/29/17, the Staff Development Coordinator and/or designee began educating the facility staff on proper positioning. By 03/30/17, Nine RNs, 18 LPNs and 36 STNAs were educated. All remaining nursing staff were to bed educated prior to being given an assignment. · On 03/30/17 at 5:00 P.M., a head to toe assessment was conducted on Resident #130 by the DON to establish a baseline assessment of the resident's current overall condition. · On 03/30/17, skin sweeps were completed by the Nurse Management Team for all residents with a Stage II (partial thickness skin loss involving epidermis, dermis or both, the ulcer is superficial and presents clinically as an abrasion, blister or shallow crater) pressure ulcer or greater. The facility identified 13 residents with pressure ulcers. A list of high risk residents will be completed by 03/30/17 by the Nurse Management Team. These residents will be reviewed for pressure relief interventions in place, nursing orders, for turning and repositioning, nurse aide task list updated and care plans by the Nurse Management Team on 03/30/17. · Weekly skin rounds will be started on 03/30/17 and continue for six weeks to evaluate progress or necessary treatment changes by the Staff Development Coordinator and/or designee. · Continued staff education on positioning and turning will be completed by the Staff Development and/or designee by 03/30/17. Audits will be completed by the Staff Development Coordinator and/or designee five times a week for six weeks beginning 03/30/17. · Interviews on 03/30/17 between 9:57 A.M. and 3:46 P.M. with STNA #96 and #192, LPN #207 and RN #86 confirmed they had been educated on turning and repositioning, incontinence care, false documentation and administering physician ordered treatments. Although the Immediate Jeopardy was removed, the facility remains out of compliance at Severity Level 2 (no actual harm with the 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: Review of Resident #130's medical record revealed an original admission date of [DATE] with the latest readmission on 02/11/17. Resident #130's admitting [DIAGNOSES REDACTED]. Review of the resident's wound tracking grid dated 07/10/15 revealed the resident was admitted to the facility with a Stage III (full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia) pressure ulcer to the coccyx. The ulcer was noted to be a deep crater with or without undermining of adjacent tissue, measuring 6.3 centimeters (cm) by 7.0 cm by 0.8 cm. Review of the actual skin integrity impairment document dated 12/31/15 revealed Resident #130 had an open area to the coccyx, right heel and left heel with the goal for the resident to have no incident of impaired skin integrity and would show signs and symptoms of healing. The facility implemented the following interventions, off-loading air mattress to bed, attempt to keep heels off mattress, treatment to ulcers as ordered, cushion to wheelchair, incontinence care as needed, weekly skin assessments, and coccyx/sacrum treatment per physician's orders [REDACTED].>Further review of the wound tracking grid dated 09/26/16 revealed the wound declined to a Stage IV pressure ulcer, measuring 5.5 cm by 6 cm by 1.0 cm with 50 percent of the wound bed being slough. On 10/03/16 the Stage IV pressure continued to decline and measured 10 cm by 6.0 cm by 2.0 cm and remained 50 percent slough. Review of Resident #130's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech, sometimes understood, rarely/never made herself understood, had both short and long term memory loss and had a severe cognitive deficit. The MDS revealed the resident had not rejected any care, was dependent on staff for ADLs, had a functional limitation in Range of Motion (ROM) to both upper and lower extremities, had an indwelling urinary catheter and was always incontinent of bowel. The MDS revealed the resident received a pain regimen, as needed pain medication, the resident was noted to have verbal complaints of pain, non-verbal sounds of pain and displayed facial expressions of pain. The MDS further indicated the resident was at risk for skin breakdown, had two venous and arterial ulcers on both heels, and had an unhealed Stage IV pressure ulcer on her coccyx, measuring 16.0 cm by 15 cm by 3.0 cm with slough being the most severe tissue type. Review of the skin and ulcer treatment section of the MDS indicated the facility implemented pressure reduction devices to the resident's bed and chair, nutrition/hydration intervention, pressure ulcer care, application of non-surgical dressings and application of ointments or medications. Review of the wound tracking grid dated 01/10/17 revealed the Stage IV pressure ulcer declined and measured 18 cm by 15 cm by 4.0 cm and was 10 percent slough. Review of the resident's March 2017 monthly physician's orders [REDACTED].¼ strength Dakins, cover with an ABD pad and wrap with kerlix twice a day and as needed and cleanse the Stage II pressure ulcer to the left heel with NS, apply skin prep and pad and protect, change daily and as needed. Review of a continuous video recording of Resident #130 beginning on 02/21/17 at 7:47 P.M. revealed LPN #132 came into the resident's room and roughly removed the pillow out from under the right side of the resident's back and buttocks causing shearing. The pillow was not positioned correctly under the resident to achieve off-loading as physician ordered. LPN #132 removed the dry [MEDICATION NAME] packing from the package and placed it on the resident's bedside table with no barrier between the clean dressing and the table. LPN #132 then removed the soiled [DEVICE] dressing from the resident. The nurse then ripped off the soiled dressing and removed the packing from the coccyx wound. Between the handling of the soiled [DEVICE] dressing and removing the coccyx dressing, LPN #132 did not wash her hands or change her soiled gloves. LPN #132 then put on a new dressing with packing and covered the wound, however did not cleanse the wound. LPN #132 also did not moisten the dressing with the physician ordered 1/4 strength Dakins solution before placing it in the coccyx wound. When LPN #132 placed the pillow under the residents left side, the pillow was not positioned adequately to allow for off-loading. Resident #130 had facial grimacing observed throughout the dressing change. It was further observed LPN #132 did not have PPE on while completing the dressing change to the resident's coccyx. On 02/23/17 beginning at 3:33 P.M., review of the continuous video recording revealed Resident #130 lying in bed with a pillow positioned under her right hip with no off-loading being provided to the Stage IV pressure ulcer to her coccyx. Further review of the video revealed no staff members entered the resident's room until 4:23 P.M. at which time STNA #187 entered the room and was observed on her personal cell phone while standing at the resident's bedside. At 4:28 P.M., STNA #187 left the resident in the same position as when she entered, with the pillow under the resident's hip and no care had been provided. Further observation of the continuous video recording revealed on 02/23/17 from 5:00 P.M. through 6:08 P.M., Resident #130 remained in the same position in her bed, with a pillow wedged under her right hip without providing off-loading to the Stage IV pressure ulcer to her coccyx. At 6:08 P.M., STNA #187 entered the resident's room and was again on her personal cell phone as she placed an earpiece in her right ear while providing incontinence care to Resident #130. STNA #187 cleansed the stool off Resident #130's buttocks. LPN #122 entered the room and began to complete the dressing change to Resident #130's Stage IV coccyx wound. STNA #187 removed the soiled coccyx dressing and removed the wound packing with the dirty wash cloth she just used to cleanse the resident's stool. LPN #122 then cleansed the wound while STNA #187 held the resident to her side. LPN #122 moistened the dressing and packed it in the coccyx wound. STNA #187 continued to wear the same dirty gloves worn throughout all resident care. LPN #122 then began the treatment to Resident #130's feet. LPN #122 removed the left and right Prevalon boots (heel protectors that float the heels off the surface of the mattress), cut part of the dressing off, then took a new piece of tape and placed it on the resident's right heel and put the Prevalon boot back on the resident's right foot. No wound care was observed to be completed to the right foot. LPN #122 then cut a piece of dressing off the left heel wound dressing, threw that piece of dressing in the trash, continued to cut at the dressing, obtained a new piece of tape and placed it on the left heel's old dressing. No wound care was observed to the left heel. Neither STNA #187 nor LPN #122 were observed to be wearing PPE. Review of the video recording from 02/24/17 beginning at 5:59 A.M. through 7:38 P.M. revealed from 5:59 A.M. through 8:12 A.M., no staff members entered Resident #130's room to provide any type of care or services to the resident. During the entire observation, Resident #130 was lying in bed on her back directly on the Stage IV pressure ulcer to her coccyx. At 8:12 A.M., STNA #153 entered the resident's room, and was observed looking at her personal cell phone. The STNA did not provide any care and had not placed a cushion under the resident or repositioned her, so the resident continued to be lying on her back on the Stage IV pressure ulcer with no off-loading since the video started at 5:59 A.M. At 9:40 A.M., transport employees transferred Resident #130 from her bed to the stretcher for transport to her [MEDICAL TREATMENT] appointment. Resident #130 returned from [MEDICAL TREATMENT] at 2:58 P.M. and was transferred back into her bed and placed on her back with pressure being placed on the Stage IV pressure ulcer to her coccyx. At 3:05 P.M., STNA #143 and STNA #107 came into the resident's room and put gloves on. After providing incontinence care, the STNAs walked out of the room at 3:21 P.M. with no repositioning or off-loading observed. Neither staff member was observed wearing PPE. There was no staff observed in Resident #130's room again until 5:02 P.M. on 02/24/17, when LPN #06 entered the room. LPN #06 hooked up the resident's Tube Feeding, which had been off since 8:19 A.M. when STNA #153 was providing care. LPN #06 gave Resident #130 a thumbs up and left the room. The resident's position was not changed and the resident remained on her back with no off-loading being achieved to the Stage IV pressure ulcer to her coccyx. There was no staff observed in Resident #130's room until 7:26 P.M. on 02/24/17 and Resident #130 continued to lay on her back with no off-loading to the Stage IV pressure ulcer to her coccyx. The resident had not been changed since 3:12 P.M. when she first returned from [MEDICAL TREATMENT]. STNA #203 entered the room to provide incontinence care. Following incontinence care, the STNA did not position any off-loading to the Stage IV pressure ulcer to the resident's coccyx, nor did she have PPE on while providing the care. In total, Resident #130 had not been turned nor had off-loading to the Stage IV coccyx wound during the entire observation on 02/24/17. The resident was not observed to be provided wound care to the coccyx, left heel, or right heel any time during the 7:00 A.M. through 7:00 P.M. shift on 02/24/17 with continuous video watched from 5:59 A.M. through 7:39 P.M. Observation of the video recording of Resident #130 on 02/25/17 beginning at 6:23 A.M. through 8:23 P.M. and again from 10:41 P.M. through 11:59 P.M. revealed no staff entered Resident #130's room on 02/25/17 until 7:19 A.M. when STNA #203 entered Resident #130's room and immediately left without providing any care or offloading to the Stage IV pressure ulcer to her coccyx. At 7:33 A.M., STNA #204 entered the room and placed gloves on her hands and was observed to be eating toast and watching television while standing at the resident's bedside. The STNA provided no positioning or off-loading and left the room. At 8:55 A.M. STNA #204 returned to Resident #130's room and picked up a clean pair of gloves. STNA #204 and Resident #130 were speaking to each other and STNA #204 exited the room at 8:56 A.M. without providing any care or positioning to the resident. At 11:51 A.M., STNA #204 again entered Resident #130's room and was leaning on the resident's wheelchair and was on her personal cell phone. At 11:55 A.M., the STNA moved in front of the television and continued to have her cell phone out. STNA #204 exited the room at 12:01 P.M. and did not deliver any care to the resident. There were no additional staff in Resident #130's room again until 12:35 P.M. when STNA #204 entered the room and was drinking from a cup and watching television. At 12:36 P.M., STNA #204 again leaned against the resident's wheelchair and was on her personal cell phone. At 12:38 P.M., the STNA exited the resident's room without providing any care. At 1:28 P.M., STNA #204 returned to Resident #130's room and walked into the bathroom. The STNA exited the bathroom and again leaned against the resident's wheelchair. At 1:35 P.M., STNA #204 picked up a roll of toilet paper and walked into the resident's bathroom. STNA #204 exited the bathroom and set the roll of toilet paper back onto the resident's bedside table and leaned back onto the resident's wheelchair. STNA #204 remained leaning on the resident's wheelchair watching television. At 2:00 P.M., STNA #204 exited the resident's room without providing care to the resident. There were no additional staff members in Resident #130's room on 02/25/17 until 6:38 P.M. when LPN #132 entered the resident's room with STNA #203. No care or treatments were observed being provided. At 8:23 P.M., LPN #59 entered the room with medication and the video recording ended. The video recording began again on 02/25/17 at 10:41 P.M. There were no staff members observed in the resident's room the rest of the day through 12:00 A.M. on 02/26/17. No repositioning or off-loading to Resident #130's Stage IV coccyx wound was observed on 02/25/17 or 02/26/17. Review of the February 2017 Treatment Administration Record (TAR) revealed LPN #122 documented the treatment to Resident #130's heels were completed on 02/23/17. However, the video recording revealed the treatments were not completed as ordered. Review of the February 2017 TAR also revealed LPN #06 documented providing the physician ordered treatments to Resident #130's Stage IV pressure ulcer to her coccyx, the arterial wound to the resident's right heel and the Stage II pressure ulcer to the left heel. However, the video recordings revealed the treatments were not completed as ordered. Review of the March 2017 TAR revealed the physician ordered treatment to Resident #130's Stage IV pressure ulcer to her coccyx was not provided on 03/06/17 during the day shift, on 03/12/17 on the day or night shifts, on 03/15/17 on the night shift, on 03/17/17 on the day shift, on 03/18/17 on the day or night shifts, and on 03/19/17 on the day shift. Further review revealed the physician ordered treatment to the arterial ulcer on the resident's right heel was not provided on 03/06/17 during the day shift, 03/08/17 during the day shift, on 03/12/17 during the day or night shifts, 03/15/17 on the night shift, on 03/17/17 on the day shift, on 03/18/17 on the day or night shifts, and on 03/19/17 on the day shift. Additional review revealed the physician ordered treatment to the Stage II pressure ulcer to the resident's left heel was not provided on 03/06/17, 03/08/17 and 03/12/17. Observations of Resident #130 on 03/20/17 from 9:11 A.M. through 4:15 P.M. revealed the resident was lying in bed on her back with no off-loading from the Stage IV pressure ulcer on her buttocks. Observation of Resident #130 on 03/21/17 at 9:26 A.M. revealed the resident was lying in bed on her back with no off-loading from the Stage IV pressure ulcer on her buttocks. Observations of Resident #130 on 03/22/17 from 7:30 A.M. through 4:10 P.M. revealed the resident was lying in bed, on her back with no off-loading to her Stage IV coccyx wound. On 03/22/17 at 10:15 A.M., interview with the [MEDICAL TREATMENT] RN revealed she was aware Resident #130 had a Stage IV pressure ulcer to her coccyx. She stated the only intervention the [MEDICAL TREATMENT] staff could provide was to turn her side to side in their chair they used. The RN stated they did not provide incontinence care and was not equipped to provide that type of care. She further stated the facility had not sent a cushion with the resident to help provide off-loading to the Stage IV coccyx wound during her [MEDICAL TREATMENT] treatments. On 03/22/17 at 1:40 P.M., observation and interview with STNA #153 revealed she was assigned to the care of Resident #130. She stated the resident was to be turned every two hours. Observation of STNA #153 revealed the STNA lifted Resident #130's right side of the incontinence pad and pulled the resident towards the left side of the bed and placed a pillow under the resident's right hip and buttocks. The pillow placement revealed the pillow placed pressure against the Stage IV pressure ulcer to the coccyx. The STNA stated she had not received any education on turning and repositioning the resident. The STNA stated that was how she positioned everyone. Observations of Resident #130 on 03/23/17 from 7:50 A.M. through 10:30 A.M. revealed the resident was positioned on her back with no off-loading to her Stage IV coccyx wound. Observation of the physician's orders [REDACTED].#130's Stage IV coccyx wound on 03/23/17 at 10:35 A.M. completed by LPN #122, RN #67 and RN #164 was completed per the physician's orders [REDACTED]. RN #67 measured the wound at 9.0 cm by 16.0 cm by 4.0 cm with 2.8 cm of undermining (a closed passageway under the skin that is open only at the skin surface, generally, it appears as an area of skin ulceration at the margins of the ulcer with skin overlying the area.) at 10 o'clock and 1.6 cm undermining at 2 o'clock. The wound bed was pinkish red with scattered yellow slough. The edges were tan in color and boggy. The upper edges running from 9 o'clock to 3 o'clock had a 1 cm wide darkened area. Observations of Resident #130 after the dressing change to her Stage IV coccyx wound on 03/23/17 beginning at 11:30 A.M. through 3:00 P.M. revealed the resident continued to be positioned on her back with no off-loading to the wound. Observation on 03/24/17 from 7:45 A.M. through 9:30 A.M. revealed Resident #130 was positioned on her left side with pillows behind her back and right shoulder with no off-loading being achieved. At 9:30 A.M., the resident was being transferred onto a stretcher to be transported to [MEDICAL TREATMENT]. No cushion was observed under the resident. On 03/29/17 at 10:00 A.M., the LNHA, Corporate Nurse (CN) #200, the Chief Corporate Administrator and the facility's Chief Executive Officer (CEO) were shown the video recordings. The CEO confirmed the video revealed Resident #130 was neglected to be provided with the care and services ordered for her Stage IV pressure ulcer for five days between 02/21/17 and 02/26/17 by multiple staff members assigned to her care. On 03/29/17 at 3:17 P.M., interview with STNA #187 confirmed she provided care to Resident #130 and was supposed to provide incontinence care every two hours because she had loose stools all the time. STNA #187 further confirmed she was the STNA in the video from 02/23/17 at 4:23 P.M. and confirmed Resident #130 was not positioned to provide off-loading to the Stage IV pressure ulcer to her coccyx. On 03/29/17 at 4:03 P.M., an attempt was made to interview LPN #132. LPN #132 was shown the video of her providing care to Resident #130. LPN #132 became uncooperative and refused to answer any questions and left the room. However, the DON confirmed the LPN in the video was LPN #132 on 02/21/17. Interview on 03/29/17 at 6:47 P.M. with LPN #159 revealed she felt the STNAs were providing the appropriate care for Resident #130. She stated she was unaware Resident #130 was not being provide with incontinence care or being turned and repositioned every two hours. Interview with STNA #153 on 03/29/17 at 5:52 P.M. revealed the STNA was aware Resident #130 needed to have care every two hours. The STNA stated she provided care as close as possible to every two hours. STNA #153 then watched the video from 02/24/17 and confirmed incontinence care or positioning every two hours had not been provided. The STNA stated Resident #130 had been neglected. Interview on 03/30/17 at 8:28 A.M. with LPN #06 revealed she was the assigned nurse for Resident #130 on 02/24/17. Upon review of the video, LPN #06 agreed there was no evidence the resident's physician ordered treatments to the resident's Stage IV pressure ulcer, right heel and left heel, incontinence care and turning and repositioning had been completed. Interview on 03/30/17 at 8:51 A.M. with STNA #107 verified she did not provide turning and repositioning, incontinence care, morning Activities of Daily Living care and ROM during the 7:00 A.M. to 7:00 P.M. shift on 02/26/16. Review of information from the National Pressure Ulcer Advisory Panel (NPUAP) 2014, defined pressure ulcers as a localized injury to the skin and/or underlying tissue over a bony prominence, as a result of pressure, or pressure in combination with shear. The NPUAP recommends turning and repositioning all individuals at risk for pressure injury, unless contraindicated due to medical condition or medical treatments. Turn the individual into a 30-degree side lying position, and use your hand to determine if the sacrum is off the bed. Avoid positioning the individual on body areas with pressure injury. Continue to reposition an individual when placed on any support surface. Use a pressure redistributing chair cushion for individuals sitting in chairs or wheelchairs. Reposition weak or immobile individuals in chairs hourly. Cleanse the skin promptly after episodes of incontinence. Review of the facility's perineal care policy, last revised 04/16/13, indicated it was the facility's policy and procedure to provide cleanliness and comfort to residents, to prevent infection, skin irritation and to observe the resident's skin condition. This deficiency substantiates Complaint Number OH 215.

Based on medical record review, recorded video review, observations, and staff interview, the facility failed to implement restorative nursing Range Of Motion (ROM) services to one (#130) of one resident reviewed for ROM. This resulted in harm when Resident #130 did not receive physician ordered restorative ROM and had a decline in ROM to her right hand. The facility census was 123. Findings include: Review of Resident #130's medical record revealed an original admission date of [DATE] with the latest readmission on 02/11/17 with [DIAGNOSES REDACTED]. Review of the Occupational Therapy (OT) evaluation and plan of treatment dated 01/28/16 revealed Resident #130's goal was to improve the use of the right upper extremity to allow for participation during self feeding tasks. The evaluation indicated the resident had impairment to the right fingers and had minimal active range of motion (AROM). Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident had a severe cognitive deficit. The MDS indicated the resident was dependent on staff or activities of daily living, and had a functional limitation in ROM to both upper and lower extremities. Review of special treatment and procedure section of the MDS indicated the resident had three days of passive ROM. Review of Resident #130's physician's orders [REDACTED]. Review of the video from 02/24/17 from 5:50 A.M. through 7:38 P.M. revealed Resident #130 was not observed to have been provided ROM any time during the 7:00 A.M. through 7:00 P.M. shift on 02/24/17. Review of the video from 02/25/17 from 6:23 A.M. through 8:23 P.M. revealed Resident #130 was not observed to have been provided ROM any time during the 7:00 A.M. through 7:00 P.M. Review of the video from 02/26/17 beginning at 1:31 A.M. and going through 02/27/16 through 12:09 A.M. revealed Resident #130 was not observed to have been provided any ROM. On 03/29/17 at 3:17 P.M. interview with State tested Nursing Assistant (STNA) #187 confirmed she did not provide ROM services to Resident #130 on 02/23/17. Interview with STNA #153 on 03/29/17 at 5:52 P.M. confirmed she did not provide ROM services to Resident #130 on 02/24/17. Interview on 03/30/17 at 8:51 P.M. with STNA #107 confirmed she did not provide ROM to Resident #130 on 02/26/16. Review of the interdisciplinary therapy screen dated 03/30/17 revealed Resident #130 had a decrease in ROM to the right hand and wrist, and was coded as a decline in ROM. On 03/30/17 at 2:00 P.M. observation and interview with Physical Therapist (PT) #208 revealed Resident #130's fingers to her right hand were observed frozen, in a semi-curled position during the screen for positioning. PT #208 stated Resident #130's ROM in the right hand had declined and a splint would be required to prevent any further decline. Review of the facility's Restorative Nursing Care policy and procedure, (undated) revealed it was the facility's policy that restorative nursing care was provided for each resident admitted . Nursing personnel were trained in restorative nursing care. The facility had an active program of restorative nursing which was developed and coordinated through the resident's care plan. The facility's restorative care program was designed to assist each resident to achieve and maintain an optimal level of self-care and independence. Restorative nursing care is performed daily for those residents who require such service. The restorative programs will be delivered five to seven days per week. This deficiency substantiates complaint number OH 215.

Based on medical record review and interview the facility failed to ensure a resident was free from pain. This affected one (#5) of three reviewed for pain medications. This resulted in actual harm to Resident #5 who had to wait twelve hours for pain medication. The resident was not able to lie down or straighten out her legs due to the level of pain. The census was 131. Findings include: Review of the medical record revealed Resident #5 was admitted on [DATE] at 3:15 P.M. with [DIAGNOSES REDACTED]. An undated care plan revealed an immediate plan of care for acute pain due to pancreatic [MEDICAL CONDITION]. Interventions included to assess pain for intensity, location, and type of pain and to medicate resident for pain as ordered. Review of a progress note dated 07/15/16 at 3:15 P.M. revealed Resident #5 arrived at the facility with a prescription for [MEDICATION NAME] (pain medication) but no continuity of care. Review of the physician orders [REDACTED].M. Review of the Medication Administration Records (MAR) revealed [MEDICATION NAME] was not administered at 10:00 P.M. as ordered. Review of the controlled disposition/audit record from the emergency drug kit (EDK) revealed Licensed Practical Nurse (LPN) #13 signed out four [MEDICATION NAME] 5-325 mg on 07/16/16 at 2:25 A.M. Review of the controlled disposition form revealed Resident #5 received [MEDICATION NAME] on 07/16/16 at 3:00 A.M. LPN #13 did not document where Resident #5 was having pain or the severity of the pain On 07/27/16 at 10:27 A.M. an interview with Assistant Director of Nursing (ADON) #18 revealed the physician order [REDACTED]. On 07/27/16 at 10:48 A.M., ADON #18 provided documentation a doctor called the facility and verified the orders on 07/16/16 at 12:15 A.M. On 07/27/16 at 11:16 A.M. Resident #5 was interviewed and provided a text message she had sent to a friend dated 07/16/16 at 2:46 A.M. that indicated she had not received any medication including pain medication. Resident #5 stated she was crying and her pain was a nine on a scale of one to ten. Resident #5 further revealed when she asked for pain medication on 07/15/16 around 9:00 P.M., LPN #13 said the orders were at the facility but the medication would not be delivered from the pharmacy until after midnight. Resident #5 stated the nurse brought in pain medication around 3:00 A.M. and her pain was a ten on a scale of one to ten with pain radiating to her back. Resident #5 stated she could not lie down or straighten out her legs because of the pain. On 07/27/16 at 12:16 P.M. an interview with Corporate Director of Nursing Services #20 revealed the pharmacy would not allow medications to be pulled from the EDK until the doctor verified the orders. Corporate Director of Nursing Services #20 stated the on call doctor worked at another facility and the doctor was often busy and could not take phone calls. On 07/27/16 at 1:10 P.M. during a follow up interview with Corporate Director of Nursing Services #20 and Registered Nurse (RN) #24 revealed they felt it was not the facility's fault they did not receive the continuity of care. If the continuity of care had been provided, the doctor would have verified the orders when Resident #5 was admitted . Corporate Director of Nursing Services #20 and RN #24 also indicated they felt it was not the facility's fault the on call doctor was busy and did not verify orders until 12:15 A.M. Corporate Director of Nursing Services #20 and RN #24 further stated there was no documentation in Resident #5's medical record of her having pain. Corporate Director of Nursing Services #20 verified LPN #13 did not document anything on 07/15/16 during her shift from 7:00 P.M. to 7:00 A.M. including administering [MEDICATION NAME] on 07/16/16 at 3:00 A.M. On 07/27/16 at 3:00 P.M. a follow up was conducted with Corporate Director of Nursing Services #20 and RN #24. At the time of the interview a review of the MAR from the hospital revealed Resident #5 was given the last dose of [MEDICATION NAME] by mouth on 07/14/16 at 9:56 A.M. for pain rated nine out of ten and the last dose of [MEDICATION NAME] (pain medication) 0.5 milliliter was given intravenously on 07/14/16 at 10:03 P.M. for pain rated a seven out of ten. Corporate Director of Nursing Services #20 and RN #24 further stated they did not believe Resident #5 would have rated her pain ten out of ten on 07/15/16 or 07/16/16. RN #24 stated Resident #5 would have still had [MEDICATION NAME] in her system from the dose she received on 07/14/16 and Resident #5 did not request any pain medication at the hospital on [DATE]; therefore, it was not believable Resident #5 had severe pain before the pain medication was available at the facility. Corporate Director of Nursing Services #20 and RN #24 again confirmed LPN #13 did not document anything from 7:00 P.M. on 07/15/16 to 7:00 A.M. on 07/16/16. Corporate Director of Nursing Services #20 and RN #24 also confirmed Resident #5 was at the facility for over nine and a half hours before any medication was verified and Resident #5 did not receive pain medication for 12 hours after being admitted . This deficiency substantiates Complaint Number OH 620.

Based on observation, record review and staff interview, the facility failed to provide supervision and assistive devices to prevent falls. This resulted in actual harm to Resident #199 when she fell from the bed and sustained a head injury and laceration that required treatment at the emergency department and 19 sutures to the forehead. The facility also failed to have fall interventions in place for one of three residents reviewed for falls ( Resident #270). The facility also failed to maintain patient care equipment in safe operating condition for one resident (#95) of 40 residents reviewed in stage one for safe equipment. The facility census was 131. Findings include: 1. Review of the clinical record revealed Resident #199 was admitted on [DATE] with [DIAGNOSES REDACTED]. The plan of care dated 09/11/13 revealed the resident was at risk for falls with a goal for the resident to be free of injury through 03/31/14. Interventions included low bed, perimeter mattress, fall matt to bedside. Review of the quarterly assessment dated [DATE] revealed the resident was severely cognitively impaired and needed extensive assistance for bed mobility, transfers, dressing and personal hygiene. The fall risk assessment completed on 12/04/13 revealed the resident was scored at a 24; a score of 9 or more indicated the resident was at risk for falls. Review of the progress notes dated 01/04/14 at 8:45 A.M. documented the nurse was notified by a State tested Nursing Assistant (STNA) the resident had fallen on the floor. The resident was found sitting on the floor and stated "I was sitting on the side of my bed and reached to grab something, next thing I knew I was on the floor". The resident was alert and oriented and had a large laceration to middle of forehead vertically, bleeding, no inward or outward rotation of limbs. Range of motion was done of all extremities. The laceration was cleaned, pressure was applied to stop the bleeding and a clean dry dressing was applied. The resident was assisted back to bed. Vital signs were blood pressure 155/75, pulse 75 beats per minute, respirations 20 breaths per minute and temperature 97.6 degrees Fahrenheit (F). The supervisor, physician, and resident's responsible party were notified. The physician ordered the resident sent to the hospital for sutures. The intervention added to the care plan after this fall was to place floor mats next to the bed. Review of the Treatment Administration Record for January 2014 revealed the nurses signed off the fall mats to the bedside were in place from the time they were ordered after her fall on 01/04/14 to 01/08/14. Observation on 01/07/14 at 10:05 A.M. and again at 2:18 P.M. revealed Resident #199 was lying in bed. The resident had multiple sutures to the forehead from her hairline down to her eyebrow. The area was open to air and the surrounding skin was reddish/purplish in color. There were no floor mats at the bedside and the bed was not in lowest position on either of the observations. Observation on 01/08/13 at 7:53 A.M. revealed the resident did not have any floor mats on either side of the bed. Licensed Practical Nurse (LPN) #22 confirmed the above findings on 01/08/13 at 10:25 A.M. Interview on 01/08/14 at 11:25 A.M., with Registered Nurse (RN) #70 revealed the resident used to walk but has not lately. She confirmed there was only one STNA with the resident at the time of the fall. She stated the resident was sitting on the side of the bed with the aide dressing her and the resident ask for a sweater and the aide left her sitting on the side of the bed to retrieve the sweater from the closet. She confirmed the resident was a two person assist and if there were two STNA's with her, she wouldn't have fallen. She stated the resident reached for something and lost her balance and fell to the floor from the bed. She stated that one aide does the personal care and then and goes to get another aide to help get her up after she is ready and dressed and she should have laid her back in the bed and went and got the second staff before getting the sweater/jacket from the closet. She confirmed a physician's telephone order was written on 01/04/14 for a floor matt as a new intervention after the fall. She also confirmed the nurses were signing off the treatment administration record that the matt was in place when it was not. Interview with the Director of Nursing (DON) on 01/08/13 at 2:40 P.M., revealed the aide assignment sheets are not part of the plan of care. She confirmed the plan of care did not include specific information of the residents needs for activities of daily living such as how many staff it took to transfer the resident. 2. Review of the clinical record revealed Resident #270 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had two separate falls with the first on 11/20/13 at 1:30 P.M. when the resident was observed by the nurse to be on the floor, on mat beside bed. Bed was in low position, sensor alarm was sounding. The resident was confused and stated her cell phone does not work, I am fine. The incident summary written by the DON revealed the resident had attempted to self transfer and did not remember to use the call light and ask for assistance. There was no injury. On 12/22/13 at 10:00 A.M. the progress notes revealed a visitor seen the resident sitting on her buttocks as he walked by her room and notified this nurse. The resident was sitting on her buttocks in the doorway of her room. Resident was dressed in gown with non skid socks, floor was clean and dry. When this nurse asked what she was trying to do, resident stated, I don't know. Resident has confusion per her usual. resident noted with small abrasion to her right knee, scant amount of bleeding. Resident was able to move all joints freely as possible, no shortening or rotation noted. Resident denied pain and was able to stand with assist from this nurse and another nurse and ambulate to her bed, all safety precautions in place. Physician and family were notified. New intervention to lock wheels on bed. Knee cleansed with normal saline and triple antibiotic ointment and Band-Aid applied. The Nurse Aide Task List Assignment revealed the resident was to have a low bed, floor mats to bedside, alarm to bed, alarm to chair and a perimeter defined mattress as interventions to prevent falls. The Plan of Care dated 11/27/13 identified the resident at risk for falls. The goal was for the resident to be free of injury related to falls through next review of 02/28/14. The interventions included a bed alarm, call light in reach, chair alarm, fall matt and low bed. Observation on 01/03/13 at 2:00 P.M. resident was lying in bed with her sister present, standing in room. Bed was observed in low position, alarm in place. There were no floor mats in place at bedside and and perimeter mattress was not in place. A regular mattress was on the bed. This was confirmed with STNA #39. She stated the floor mats were in the bathroom. Interview on 01/09/13 at 2:00 PM with STNA #37 stated she didn't know if she had the mats on the floor or not. She went to the room and confirmed they were not there. She also looked in the Kiosk (care tracker) and the resident stated the resident was supposed to have a perimeter mattress on bed and mat to the floor, chair alarm and bed alarm. She confirmed the perimeter mattress was not in place either. She states the supply person puts on the mattresses and they really don't have anything to do with that. Interview with the Director of Nursing on 01/09/13 at 3:00 P.M. revealed the resident had moved from another unit in December and apparently the perimeter mattress she had on her bed did not get moved to the resident's new room with her. 3. Observation on 01/08/13 at 2:00 PM revealed Resident #95's motor scooter in resident's room with the arm rests and head rest cracked and peeling. The left armrest had white tape on it. Interview on 01/08/13 at 2:00 PM with Resident #95 revealed that the motor scooter has been cracked and peeling for "awhile now." Interview on 01/09/13 at 10:43 AM with Maintenance Staff #102 he verifies that Resident #95's chair needs fixed because of the peeling arm and headrests. He says that maintenance is responsible for fixing these things although they rely on nursing and housekeeping to inform them when the have an issue that needs repaired.