Every finding on record at Scarlet Oaks Nursing and Rehabilitation Center

Based on observation, staff interview, and policy review, the facility failed to ensure food was stored and served in accordance with professional standards for food safety. This deficient practice had the potential to affect all 65 residents who received food from the kitchen. The facility census was 65. Findings included: Observations, during initial tour of the kitchen, on 01/20/25 from 8:50 A.M. to 9:10 A.M., with the facility's Dietary Manager (DM) revealed the following: one 5-pound bag of frozen tater tots that was not in the original packaging and not labeled or dated with a use-by date in the walk-in freezer; one 16-ounce bag of broccoli that was not in the original package and was not labeled or dated with a use-by date in the walk-in freezer; one 5-pound container of peanut butter that was opened but not labeled with a date that was opened on the counter; and four 18-ounce containers of spices (one paprika, one garlic powder, one Italian seasoning, and one seasoned salt) that were opened but not labeled with a use-by date or the date they were opened that were noted on the shelf above the sink in the food preparation area. Observations in the kitchen on 01/21/25 at 10:45 A.M. with the DM revealed the following: four plastic bins of serving utensils that were uncovered with food crumbs and debris noted in the container with the utensils. Observations on 01/21/25 at 11:35 A.M., during observations of tray line/meal service, there were two male employees noted with facial hair that were not wearing beard restraints, and they were preparing plates of food for the residents. An interview with the DM, at the time of the observation, revealed he was unaware that staff needed to wear beard restraints because it had never been brought to his attention before. Interview on 01/22/25 at 10:04 A.M., with the DM stated he had been working at the facility for six years. He stated his role/responsibilities included managing the staff, ordering food, and ensuring staff knew what to do to avoid cross-contamination. He stated the facility policy was to label and date all food items with expiration dates but was unaware that items should be labeled with an opened date. Interview on 01/23/25 at 3:52 P.M., with the Administrator stated that she made weekly rounds in the kitchen. She stated the health department was at the facility about two months ago and they made them clean. She stated she expected the kitchen to be clean and policies to be followed to ensure food was served in a sanitary manner. Review of the policy titled, Food Receiving and Storage, revised October 2017, revealed Foods shall be received and stored in a manner that complies with safe food handling practices. The policy revealed 1. Food Services, or other designated staff, will maintain clean food storage areas at all times. The policy revealed, 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated ('use by' date). Review of the policy titled, Food Preparation and Service, revised October 2017, revealed, Food and nutrition services employees shall prepare and serve food in a manner that complies with safe food handling practices. The policy revealed, 7. Food and nutrition services staff shall wear hair restraints (hair net, hat, beard restraint, etc. [et cetera; and so forth]) so that hair does not contact food.

Based on record review, staff interview, provider interview, email communication reviews and policy reviews, the facility failed to implement the policy to ensure a nurse practitioner (NP) immediately reported an allegation of abuse to facility management when made aware of the allegation, resulting in late reporting to the state agency by the facility. This affected one (#59) of three residents reviewed for abuse. The facility census was 65. Findings included: Review of the admission record revealed Resident #59 was admitted on [DATE]. Resident #59 had a medical history including diagnoses of chronic respiratory failure with hypoxia, epilepsy, tracheostomy status, gastrostomy status, dependence on respiratory (ventilator) status, and dependence on supplemental oxygen. Review of the quarterly Minimum Data Set assessment (MDS), with an Assessment Reference Date (ARD) of 12/04/24, revealed Resident #59 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident had no behaviors during the assessment period. The MDS revealed the resident had two or more falls with no injury since the prior assessment or reentry. Review of Resident #59's care plan included a focus area, initiated 06/06/24, indicated the resident was dependent on staff for meeting emotional, intellectual, physical and social needs related to cognitive deficits, disease process (ventilator dependency, tracheostomy status, aphasia, pulmonary fibrosis, chronic obstructive pulmonary disease, and pneumonia), and immobility and physical limits. The care plan also included a focus area, initiated on 07/29/24, that indicated the resident had a behavior problem and was at risk for falls and injuries related to overt behaviors. The focus area revealed the resident pulled at the ventilator circuit and held their breath at times, causing the ventilator alarm to sound. Review of an email dated 01/06/25 at 1:35 P.M., addressed from Nurse Practitioner (NP) #11 to the Assistant Director of Nursing (ADON), revealed, last week [Resident #59] complained to me about a night shift nurse being abusive. Per the email, Resident #59 reported when they fell out of bed, the nurse was verbally abusive to them, and had kicked them while they were on the floor and also pinched them. Per the email, the resident was unable to remember the nurse's name, but identified them as a male night shift nurse and reported that the nurse had been verbally abusive on several occasions and had also pinched them on several occasions. Review of the Self Reported Incident Form, dated 01/03/25, revealed the facility became aware of the abuse allegation on 01/03/25. Per the form, the date, time, and location of the occurrence was 01/03/25 at 12:00 P.M. in the resident's room. Interview on 01/23/25 at 1:41 P.M., via telephone, with NP #11 stated she was informed of the allegation of abuse reported by Resident #59 against a nurse on 12/31/24. She stated she did not believe that reporting the allegation was urgent at that moment because the resident said it occurred a couple weeks prior, and it had not happened since. NP #11 stated it was also a holiday, so there was no one around to whom to report the allegation. NP #11 stated, on 01/03/25, the resident remembered the name of the nurse (alleged perpetrator), and she reported the allegation to Registered Nurse #16 at that time. Review of an email confirmation titled, Immediate (24 Hour) Facility Reported Incident #255730, indicated the facility notified the state survey agency of the abuse allegation on 01/03/25 at 3:16 P.M., which was not in compliance with the required reporting timeframe for an abuse allegation received on 12/31/24. An email confirmation titled, Final Facility Reported Incident #255730 revealed the facility submitted the required 5-day investigation report to the state agency on 01/08/25, which was not compliant with the required timeframe for an abuse allegation received on 12/31/24. Interview on 01/23/25 at 3:50 P.M., with the Administrator stated she expected staff to report allegations of abuse immediately. The Administrator stated if the allegation involved physical abuse, the allegation should be reported to the state agency within two hours. The Administrator said she thought she had reported the allegation within two hours. The Administrator stated she was unaware Resident #59 had reported an allegation of abuse to NP #11 on 12/31/24. Review of the policy titled, Abuse, Neglect, Exploitation and Misappropriation - Reporting and Investigating, revised in 09/2022, revealed, If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown or source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The policy revealed, Immediately is defined as: Within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Review of the policy titled, Abuse and Neglect Protocol, dated 09/18/24, revealed, Employees, facility consultants and/or Attending Physicians must immediately report any suspected abuse or incidents of abuse to the Director of Nursing Services. In the absence of the Director of Nursing Services such reports may be made to the Nurse Supervisor on duty. This deficiency represents the non compliance investigated under Complaint Number OH00161750.

Based on record review, staff interview and policy review, the facility failed to inform and provide written information regarding the resident's right to formulate an advance directive. This affected three (#16, #51, and #63) of three residents reviewed for advanced directives. The facility census was 65. Findings included: 1. Review of the admission record revealed Resident #51 was admitted on [DATE]. Resident #51 had a medical history that included diagnoses of chronic respiratory failure, atrial fibrillation, tracheostomy status, malignant neoplasm of the prostate, and type 2 diabetes mellitus. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #51 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident was dependent on staff for all activities of daily living (ADLs). Review of Resident #51's care plan included a focus area revised on [DATE], indicating the resident was at risk for alteration in code status and was a DO NOT RESUSCITATE, DNR-CC, [do not resuscitate - comfort care]. Interventions directed staff to advocate for the resident's end-of-life preferences to ensure advanced directives were implemented in accordance with the resident's wishes (revised on [DATE]); to allow extra time for the resident to discuss feelings regarding advanced directives (revised on [DATE]); arrange visits from clergy and social services at the resident's request (revised on [DATE]); check for vital signs (revised on [DATE]); effectively communicate DNR wishes by placing it in the front of the chart or when the resident must be transferred outside of the facility (revised on [DATE]); if the DNR decision poses an ethical conflict for staff, reassign duties as needed and assign caregivers who are capable of advocating on behalf of the resident's wishes (revised on [DATE]); and provide comfort measure and symptom palliation to allow the dying process to occur as comfortably as possible (revised on [DATE]). Review of Resident #51's Order Summary Report with active physician orders as of [DATE] contained an order dated [DATE] for DNR-CC. Review of the DNR Order Form, dated [DATE], revealed Resident #51 had chosen the code status option of DNR Comfort Care to be effective immediately. Continued review of Resident #51's medical record revealed there was no advanced directive available for review or an acknowledgment that information had been provided to the resident regarding their right to formulate an advanced directive if they wished. Interview on [DATE] at 1:27 P.M., with the Director of Nursing (DON) stated she believed advanced directives were discussed in the initial care conference, and Social Services was the person to speak to. Interview on [DATE] at 1:39 P.M., with the Social Services Director (SSD) stated no form was provided to families to fill out regarding information about advanced directives. She stated she did not discuss that information with the residents or their families. SSD stated she asked the resident or family what they wanted their code status to be while they were there, then the facility would get an order and complete the DNR form if needed. She stated she documented the information regarding their choice to be a full code or DNR in the progress notes. Interview on [DATE] at 9:37 A.M., with the SSD stated she did not offer information to the residents or families about advanced directives, only code status. Interview on [DATE] at 12:35 P.M., with the Admissions Director (AD) stated the facility did not offer to assist residents or their families with creating advanced directives if they did not have them nor explain what they were. The AD stated there was no documentation of the resident's choice to have or not have advanced directives. The AD stated she somewhat knew the difference between advanced directives and code status and that it was a clinical thing, like social services. Interview on [DATE] at 2:44 P.M., with the DON stated, I don't know the difference between code status and advanced directives. DON stated the facility had gone through multiple social service personnel recently, and there were areas of the program that were lacking. Interview on [DATE] at 4:08 P.M., with the Administrator stated her expectation was for staff to discuss code status with the residents and families initially, and information regarding advanced directives would be provided at their 72-hour care conference going forward, as well as the offer to assist them as needed. 2. Review of the admission record revealed Resident #63 was admitted on [DATE]. Resident #63 had a medical history including diagnoses of acute respiratory failure with hypoxia, convulsions, and a personal history of traumatic brain injury. Review of the Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #63 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was dependent on staff for all activities of daily living (ADLs). Review of Resident #63's care plan included a focus area revised on [DATE] that indicated the resident was at risk for alteration in code status, and the resident was a FULL CODE. Interventions directed staff to allow extra time for the resident to discuss their feelings regarding the Full Code Status (initiated on [DATE]); call 911 immediately (initiated on [DATE]); effectively communicate FULL CODE STATUS wishes by placing in the front of the chart and/or when resident must be transferred outside the facility (initiated on [DATE]); intercede rapidly and begin immediate resuscitative efforts utilizing all life-sustaining measure available if the resident's heart stops beating or the resident stops breathing, such as CPR (cardio-pulmonary resuscitation), oxygen administration, and defibrillation (initiated on [DATE]); notify family or guardian of the resident's condition promptly (initiated on [DATE]); and obtain vital signs and notify the physician promptly (initiated on [DATE]). Review of Resident #63's Order Summary report with active physician orders as of [DATE] contained an order dated [DATE] for Full Code (CPR). Continued review of Resident #63's medical record revealed there was no advanced directive available for review or an acknowledgment that information had been provided to the resident regarding their right to formulate an advanced directive if they wished. Interview on [DATE] at 1:27 P.M., with the Director of Nursing (DON) stated she believed advanced directives were discussed in the initial care conference, and Social Services was the person to speak to. Interview on [DATE] at 1:39 P.M., with the Social Services Director (SSD) stated no form was provided to families to fill out regarding information about advanced directives. She stated she did not discuss that information with the residents or their families. SSD stated she asked the resident or family what they wanted their code status to be while they were there, then the facility would get an order and complete the DNR form if needed. She stated she documented the information regarding their choice to be a full code or DNR in the progress notes. Interview on [DATE] at 9:37 A.M., with the SSD stated she did not offer information to the residents or families about advanced directives, only code status. Interview on [DATE] at 12:35 P.M., with the Admissions Director (AD) stated the facility did not offer to assist residents or their families with creating advanced directives if they did not have them nor explain what they were. The AD stated there was no documentation of the resident's choice to have or not have advanced directives. The AD stated she somewhat knew the difference between advanced directives and code status and that it was a clinical thing, like social services. Interview on [DATE] at 2:44 P.M., with the DON stated, I don't know the difference between code status and advanced directives. DON stated the facility had gone through multiple social service personnel recently, and there were areas of the program that were lacking. Interview on [DATE] at 4:08 P.M., with the Administrator stated her expectation was for staff to discuss code status with the residents and families initially, and information regarding advanced directives would be provided at their 72-hour care conference going forward, as well as the offer to assist them as needed. 49044 3. Review of the admission record revealed Resident #16 admitted on [DATE]. Resident #16 had a medical history including diagnoses of nontraumatic intracranial hemorrhage, type 2 diabetes mellitus without complications, morbid (severe) obesity due to excess calories, aphasia following cerebral infarction, tracheostomy status, gastrostomy status, and dependence on respiratory ventilator status. Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #16 had severe impairment in cognitive skills for daily decision making and had short-term and long-term memory problems per a Staff Assessment of Mental Status (SAMS). Review of Resident #16's care plans revealed a focus area initiated on [DATE], indicating the resident was at risk of alteration in code status and was a FULL CODE. Review of the Order Summary Report, with active physician orders as of [DATE], revealed Resident #16 had an order for Full Code (CPR [cardio-pulmonary resuscitation]) dated [DATE]. Review of the Progress Note dated [DATE] at 4:32 P.M., revealed the Social Service Director (SSD) wrote, resident code status was verified, resident is full code. Resident's chart, orders, and care plans all coincide. The Progress Note did not indicate that the SSD discussed with the resident or family if the resident had an advance directive. Interview on [DATE] at 1:39 P.M., with the Social Services Director (SSD) stated no form was provided to families to fill out regarding information about advanced directives. She stated she did not discuss that information with the residents or their families. She stated she asked the resident or family what they wanted their code status to be while they were there, then the facility would get an order and complete the DNR form if needed. She stated she documented the information regarding their choice to be a full code or DNR in the progress notes. Interview on [DATE] at 12:34 P.M.,with the Admissions Director (AD) stated she did not offer to help the new admissions with advanced directives; that was more social work. AD stated she somewhat understood the difference between code status and advanced directives, but that was why she did not do it; it was more clinical. Interview on [DATE] at 3:50 P.M., with the Administrator stated when they had a new admission, social services should be asking if they had an advance directive or if they wanted one. The Administrator stated staff should have a care conference to determine if the resident had advance directives or if they wanted one. The Administrator stated staff should be asking the residents quarterly after that. The Administrator stated they were supposed to have a 72-hour care conference and that should be when the residents were offered the advance directive. Review of the policy titled, Advance Directives, dated [DATE], revealed, the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. The policy revealed, Determining Existence of Advance Directive 1. Prior to or upon admission of the resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 2. The resident or representative is provided with written information concerning the right to refuse medical or surgical treatment, and to formulate an advance directive if he or she chooses to do so. 3. Written information about the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive is provided in a manner that is easily understood by the resident of representative. The policy revealed, If the Resident Does not have an Advance Directive: 1. If the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. a. The resident or representative is given the option to accept or decline assistance, and care will not be contingent on either decision. b. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance.

Based on record review, staff interviews, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual review, and policy review, the facility failed to identify and complete a Significant Change in Status Assessment (SCSA) when a resident was discharged from Hospice care. This affected one (#48) of 20 sampled residents reviewed. The facility census was 65. Findings included: Review of the admission record revealed Resident #48 was on 03/20/23. Resident #48 had a medication history including diagnoses of unspecified sequelae of nontraumatic intracerebral hemorrhage, vascular dementia with other behavioral disturbance, hemiplegia (partial paralysis) affecting the left nondominant side, dysarthria (difficulty speaking) following cerebral infarction (stroke), acute respiratory failure with hypoxia, tracheostomy status, and gastrostomy status. Review of the quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 10/23/24, revealed Resident #48 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was receiving hospice care within the last 14 days from the ARD. Review of Resident #48's care plan revealed a focus area initiated 06/03/24, that indicated the resident had the potential for/or decline in condition; receiving hospice services, met criteria with an admitting diagnosis of unspecified sequelae of nontraumatic intracerebral hemorrhage. The focus area listed the hospice service provider who was providing care to the resident. The focus area was revised on 01/20/25 and was marked as resolved. Review of Resident #48's clinical census revealed the resident had been receiving hospice services from 06/04/24 through 11/26/24. Review of Resident #48's Order Recap [Recapitulation] Report, for the timeframe from 01/01/24 through 01/23/25, revealed a physician order for May utilize services of hospice care to evaluate resident one time only for Hospice evaluation for 1 Day, with an order date of 04/25/24 and discontinuation date of 04/27/24. The Order Recap Report revealed a physician order for May utilize services of [Hospice Provider Name] hospice care for evaluation and care/treatment, with an order date of 05/10/24 and discontinuation date of 12/23/24. Review of a Resident #48's Progress Notes revealed a skin and wound note dated 11/25/24 at 5:12 P.M., that indicated the resident was under hospice care but was going to transition out of hospice care. The note revealed once Resident #48 was no longer under hospice, they recommended an appointment with a gastro-intestinal physician to evaluate the wound around the gastrostomy tube and discussed the plan of care with the wound nurse. Review of Resident #48's Progress Notes revealed Psychiatry Progress Note dated 11/27/24 at 12:59 A.M., indicated the resident did not respond when spoken to and staff said Resident #48 was no longer on hospice services as they felt the resident's current state was chronic. Review of Resident #48's Progress Notes revealed a skin and wound note, dated 12/04/24 at 3:15 P.M., indicated the resident was under hospice care but was now transitioned out of hospice care. Review of Resident #48's electronic health record revealed staff had not completed a SCSA within 14 days of the resident being discharged from hospice care. Interview on 01/23/25 at 11:58 AM, MDS Coordinator (MDSC) #7 stated she completed the MDS assessments and some of the care plans. MDSC #7 stated when identifying a SCSA, they would look at changes in ADLs, diagnoses that would impact functional abilities, being admitted to or discharged from hospice, and two areas of change under functional abilities. MDSC #7 stated she would complete an SCSA if a resident was discharged from hospice. MDSC #7 stated typically, it would be announced if a resident were being discharged from hospice in clinical meetings, or it would go out in an email to the interdisciplinary team. MDSC #7 stated the staff person who was notified of the discharge from hospice would send the email. MDSC #7 stated she was familiar with Resident #48. MDSC #7 stated the resident was discharged from hospice on 11/26/24, and she was not notified. MDSC #7 stated she was notified this week the resident was discharged from hospice after the survey team brought it to the facility's attention. Interview on 01/23/25 at 2:45 P.M., with the Director of Nursing (DON) stated she expected the MDS assessments to be completed and completed on time. The DON stated MDSC #7 needed to communicate with everyone to make sure everyone was completing MDS assessments like they should. The DON stated the MDS should reflect whatever was going on with the resident. She stated she expected a SCSA to be completed when a resident was discharged from hospice. Interview on 01/23/25 at 3:50 P.M., with the Administrator stated she expected staff to follow the policy, complete the MDS timely and she expected them to be accurate. She stated she expected a SCSA to be completed if a resident had a change in condition. Review of the policy titled, Resident Assessments, revised October 2023, revealed 1. OBRA [Omnibus Budget Reconciliation Act] -Required Assessments are federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes. OBRA assessments include: d Significant Change in Status Assessment (SCSA). The policy revealed, 5. The RAI [Resident Assessment Instrument] User's Manual (Chapter 2) provides detailed information on timing and submission of assessments. 6. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely appropriate resident assessments. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.19.1 October 2024, revealed, An SCSA is required to be performed when a resident is receiving hospice services and then decides to discontinue those services (known as revoking of hospice care). The ARD [Assessment Reference Date] must be within 14 days from one of the following: 1) the effective date of the hospice election revocation (which can be the same or later than the date of the hospice election revocation statement, but not earlier than); 2) the expiration date of the certification of terminal illness; or 3) the date of the physician's or medical director's order stating the resident is no longer terminally ill.

Based on staff interview, record review, and policy review, the facility failed to ensure resident's who were at nutritional risk had weights completed per policy. This affected two (#60 and #63) of three residents reviewed for nutrition. The facility census was 65. Findings included: 1. Review of the admission record revealed Resident #60 was admitted on [DATE]. Resident #60 had a medical history including diagnoses of a nontraumatic subarachnoid hemorrhage (brain bleed), dysphagia (difficulty swallowing), and gastrostomy status. Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/07/24, revealed Resident #60 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was dependent on staff for all activities of daily living (ADLs). The MDS revealed and a (-) dash was placed where the resident's height and weight were to be recorded, as there was no admission height or weight obtained. Review of Resident #60's care plan included a focus area initiated 11/11/24, that indicated the resident required a tube feeding related to dysphagia. Interventions directed staff to keep the head of the bed elevated at 45 degrees and to look for signs and symptoms of aspiration. The care plan revealed no interventions related to obtaining the resident's weight. Review of Resident #60's census list revealed the resident was admitted to the facility on [DATE], was discharged to the hospital on 11/26/24, and was readmitted to the facility on [DATE]. Review of Resident #60's Order Recap [Recapitulation] Report for the timeframe from 10/01/24 through 01/20/25 revealed there was no order for an admission weight or weekly weights for four weeks placed in the computer for Resident #60's initial admission on 10/31/24 or an order for a weight upon the resident's readmission on 12/01/24. Further review of the Order Recap Report revealed an order for weekly weights one time a day, every Friday, with a start date of 12/13/24 and an end date of 12/17/24, and an order for weekly weights one time a day, every Friday, for four weeks, with a start date of 12/20/24 and an end date of 1/17/25. Review of Resident #60's Weight Summary revealed a weight of 175.5 pounds on 11/22/24, 174.8 pounds on 12/20/24, and 144.7 pounds on 01/10/25. Review of Resident #60's Medication Administration Record [MAR], for December 24 revealed a transcription of an order for weekly weights one time a day, every Friday, with a start date of 12/13/24 and a discontinuation date of 12/17/24. The MAR revealed staff had initialed the box dated 12/13/24 as completed; however, there was no weight present on the MAR. The MAR revealed a transcription of an order for weekly weights one time a day, every Friday for four weeks, with a start date of 12/20/24. The MAR revealed that staff documented that on 12/20/24 the resident weighted 174.8 and on 12/27/24 the resident weighted 174.8. Review of Resident #60's MAR for January 25 revealed a transcription of an order for weekly weights one time a day, every Friday for four weeks, with a start date of 12/20/24. The MAR revealed the box for 01/03/25 was not initialed as complete and no weight was recorded on the MAR. The MAR revealed staff initialed the box for 01/10/25 as completed, and a weight of 144.7 was recorded. Interview on 01/22/25 at 1:47 P.M., with the Director of Nursing (DON) stated the process was for a weight to be obtained on admission and weekly for four weeks after that. DON stated that however, she was constantly on them (the certified nursing assistants) to do the weights, and they did not always do them. She stated the weights were to be recorded in the weight/vitals section of the computer, and the staff had missed weighing Resident #60 on admission and for almost a month after admission. The DON stated Resident #60 was readmitted and again did not receive an admission weight or consistent weekly weights for four weeks. She was not made aware of the potential 30.1-pound weight loss recorded for the resident. Interview on 01/22/25 at 1:59 P.M., with the Assistant Director of Nursing (ADON) stated she did not know why Resident #60 had not had an admission weight, weekly weights, or a readmission weight completed. She stated that she had not been made aware of a potential 30.1-pound weight loss. She stated there had been issues getting weights at times, and she had to stay after the CNAs to get them done. Interview on 01/22/25 at 12:20 P.M., via telephone, with the Registered Dietician (RD) pulled up Resident #60's weight and said, Oh wow, [he/she] has lost a lot of weight since I last saw [him/her] and no one has let me know about this. The RD stated the facility was not good about getting weights on residents on admission or the following four weeks, which made her job more difficult. Interview on 01/23/25 at 10:25 A.M., with Licensed Practical Nurse (LPN) #14 stated she had put in the weight of 144.7-pounds for Resident #60 that was given to her by the CNA. She stated the CNAs obtained the weights and wrote them down for the nurses to enter into the computer. She stated she was just data inputting numbers and did not recognize the potential 30-pound weight loss, so she did not notify anyone. Interview on 01/23/25 at 1:46 P.M., with LPN #10 stated she had initialed the box for the weight on 12/13/24 to acknowledge it needed to be done, Like an FYI [for your information], but the CNAs were the ones that got the weights and put them in the computer. 2. Review of the admission record revealed Resident #63 was admitted on [DATE]. Resident #63 had a medical history including diagnoses of acute respiratory failure with hypoxia, stage 3 pressure ulcer of the sacrum, convulsions, and a personal history of traumatic brain injury. Review of the admission MDS, with an ARD of 12/20/24, revealed Resident #63 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was dependent on staff for all activities of daily living (ADLs) and had an admission weight of 107 pounds. Review of Resident #63's care plan included a focus area initiated on 12/18/24, that indicated the resident was at risk for a nutritional/fluid imbalance due to taking nothing by mouth, difficulty swallowing, having a feeding tube, multiple areas of altered skin integrity, a BMI (Basic Metabolic Index) that reflects an underweight status, altered labs, and poly pharmacy and the use of IV (intravenous) ATB (antibiotic therapy). Interventions directed staff to monitor, record, and report to the doctor as needed signs and symptoms of malnutrition, emaciation (cachexia), muscle wasting, significant weight loss: >(greater than) 5% in one month, >7.5% in three months, >10% in six months (initiated 12/19/24); monitor intake, weight, skin, labs, medication, diet tolerance and hydration status (initiated 12/19/24); inform POA (power of attorney) of significant weight changes (initiated 12/19/24); and to weigh at the same time of the day and record weekly weight for four weeks (initiated 12/19/24). Review of Resident #63's Order Recap [Recapitulation] Report for the timeframe from 12/01/24 through 01/21/25 revealed an order for weekly weights for four weeks, every Friday on dayshift, with a start date of 12/20/24 and end date of 01/17/25. Review of Resident #63's Weight Summary revealed a weight obtained by a Hoyer lift scale on 12/13/24 of 107 pounds. The Weight Summary revealed there were no other weights available for review. Review of Resident #63's Medication Administration Record [MAR], for December 24 revealed a transcription of an order for weekly weights for four weeks, every Friday on dayshift, with a start date of 12/20/24. The MAR revealed the box for 12/20/24 was left blank with no initial of completion and no weight recorded. The MAR revealed the staff had initialed the box for 12/27/24 as completed; however, there was no weight documented on the MAR. Review of Resident #63's Medication Administration Record for January 25 revealed a transcription of an order for weekly weights for four weeks, every Friday on dayshift, with a start date of 12/20/24. The MAR revealed staff initialed the boxes for 01/03/25 and 01/10/25 as completed; however, there were no weights documented on the MAR for either date. Interview on 01/23/25 at 10:45 A.M., with Licensed Practical Nurse (LPN) #9 stated that when she signed the MAR on 12/27/24, she was acknowledging there was supposed to be a weight done that day, and there was not a place to document the weight on the MAR. She stated the CNAs obtained the weights and put them into the facility's electronic health record themselves. Interview on 01/22/25 at 12:20 P.M., via telephone, with the Registered Dietician (RD) reviewed Resident #63's medical record and stated there had been no weight obtained since admission. She stated that she had reviewed her notes and had asked the facility to obtain weekly weights for four weeks more, and it had not occurred. The RD stated this was not a new occurrence, as she had to send emails to the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Diet Technician frequently to obtain weights and reweighs. She stated the facility was not good at following a standard practice for weight loss and reweighs. She stated that a diet technician usually sent her an email with weight losses for her to review on her next visit; however, without them weighing Resident #63 at all, the resident would not have shown up on the report for her to address. The RD stated that the facility not obtaining weights was an ongoing issue, and it had made her job difficult to do when not given the necessary information to make decisions regarding the resident's nutritional health. Interview on 01/22/25 at 1:59 P.M., with the ADON acknowledged Resident #63 had not been weighed since admission, and she was not aware why. She verified the resident's MAR was missing initials of completion for one date and had initials of completion for the other days; however, none of the designated days had weights recorded. Interview on 01/22/25 at 1:48 P.M., with the DON stated she was not familiar with Resident #63, as she had been away from work recently. She reviewed Resident #63's chart and stated no weekly weights had been obtained for the resident since admission, and the facility had been having problems getting the CNAs to put the weights into the computer. The DON stated there was not a weight variance meeting held weekly; however, a diet technician came in weekly to review weights and would address concerns. Interview on 01/23/25 at 3:02 P.M., with the DON stated her expectation was for all admissions to have admission weights completed and to follow the policy going forward for weekly weights for four weeks and then monthly after that. She stated that when the facility failed to weigh residents, there was the opportunity to miss a symptom like weight loss, which could be a sign of a larger underlying issue or a significant weight change. Review of the policy titled, Weight Assessment and Intervention, dated 9/30/24, revealed, Resident weights are monitored for undesirable or unintended weight loss or gain. The policy revealed, Weight Assessment 1. Residents are weighted upon admission and at intervals established by the Interdisciplinary team. 2. Weights are recorded in each unit's weight record chart and in the individual's medical record. 3. Any weight change of 5% [percent] or more since the last weight assessment is retaken the next day for confirmation. a. if the weight is verified, nursing will notify the dietician. The policy revealed, 5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight - actual weight)/ (usual weight) x 100]: a. 1 month - 5% weight loss is significant; greater than 5% is severe. b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months - 10% weight loss is significant; greater than 10% is severe.

Based on observation, staff interview, record review, and policy review, the facility failed to ensure staff obtained physician's orders for the use of supplemental oxygen. This affected one (#6) of two residents reviewed for oxygen therapy. The facility census was 65. Findings included: Review of the admission record revealed Resident #6 was admitted on [DATE]. Resident #6 had a medical history including diagnosis of Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/10/24, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. The MDS indicated the resident required partial to moderate assistance with all activities of daily living (ADLs). Review of Resident #6's care plan revealed no evidence of a focus, goal, or interventions related to the administration of oxygen therapy. Review of Resident #6's Order Summary Report, with active orders as of 01/20/25, revealed no evidence of a physician's order for supplemental oxygen administration. Observation on 01/20/25 at 12:39 P.M., revealed Resident #6 was receiving supplemental oxygen via nasal cannula, and the concentrator was set at 2 liters per minute (L/M). Observation on 01/21/25 at 12:37 P.M. revealed Resident #6 lying in bed and appearing to watch television. Resident #6's eyes were open, but the resident did not respond to verbal stimuli. Resident #6 was receiving supplemental oxygen, and the concentrator was set at 2 L/M. Interview on 01/21/25 at 12:58 P.M., with Licensed Practical Nurse (LPN) #2 confirmed Resident #6 was receiving oxygen therapy and had been on supplemental oxygen for a while. LPN #2 checked the resident's physician's orders and said she was unable to confirm when the oxygen therapy started. LPN #2 stated that when someone required supplemental oxygen, the process was to contact the physician and get an order. LPN #2 stated unless it was an emergency, supplemental oxygen should have a physician's order before it was administered to a resident. Interview on 01/23/25 at 2:24 P.M., with the Director of Nursing (DON) stated the process for supplemental oxygen administration was for the nurse to get an order from the physician before administering supplemental oxygen to a resident. The DON stated it was her expectation that residents receiving supplemental oxygen should have a physician's order documented in the record. Interview on 01/23/25 at 3:50 P.M., with the Administrator stated it was her expectation that residents receiving supplemental oxygen had an active physician's order. Review of the policy titled, Oxygen Administration, revised October 2010, revealed The purpose of this procedure is to provide guidelines for safe oxygen administration. The policy revealed, Preparation 1. Verify that there is a physician's order for this procedure. Review of the policy titled, Medication Orders, revised November 2014, revealed The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. The policy revealed 3. Oxygen Orders - When recording orders for oxygen, specify the flow, route, and rationale.

Based on observation, staff interview, and record review, the facility failed to maintain appropriate infection control practices while providing tracheostomy care. This affected one (#51) of one resident observed for tracheostomy care. The facility census was 65. Findings included: Review of the admission record revealed Resident #51 was admitted on [DATE]. Resident #51 had a medical history including diagnoses of chronic respiratory failure and tracheostomy status. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/20/24, revealed Resident #51 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident was dependent on staff for all activities of daily living (ADLs) and received tracheostomy care while at the facility and within the last 14 days of the assessment period of the MDS. Review of Resident #51's care plan included a focus area initiated on 10/26/24, that indicated the resident had a tracheostomy related to impaired breathing mechanics. Interventions directed staff to ensure that tracheostomy ties were secured at all times (initiated 10/26/24), to monitor/document respiratory rate, depth, and quality (initiated 10/26/24), to suction as necessary (initiated 10/26/24), and to use universal precautions as appropriate (initiated 10/26/24). Review of Resident #51's Order Summary Report contained a physician order dated 11/29/24 for tracheostomy care every shift and as needed. Observation of tracheostomy care on 01/21/25 at 12:20 P.M., revealed Respiratory Therapist (RT) #19 was observed entering Resident #51's room. RT #19 put on a gown, mask, and gloves and gathered supplies to include: four vials of normal saline, a tracheostomy kit, multiple individually packaged 4 x 4 gauze pads, and a prepackaged #6 Shiley inner cannula and placed these items on the resident's bedside table. RT #19 did not clean the bedside table or place a barrier down on the bedside table prior to placing the items on the table. RT #19 then opened the sterile tracheostomy kit and placed the provided sterile barrier from inside the kit onto the bedside table as his sterile field. RT #19 then picked up the normal saline, 4 x 4 gauze pads, and prepackaged inner cannula from the contaminated bedside table and placed them onto the sterile barrier, contaminating his sterile field. RT #19 then removed the remaining contents of the tracheostomy kit and placed them onto the contaminated sterile field and filled one of the sections of the kit with normal saline from the vials. RT #19 then realized he had not secured a trash container, so he grabbed a nearby box of normal saline vials, opened Resident #51's two-drawer bedside stand, and poured the remaining vials into the drawer, and used the empty box (a non-absorbent and non-leak proof container) as his trashcan for the remainder of the care. RT #19 then donned sterile gloves, and with his left hand he removed Resident #51's tracheostomy cap, placed the cap on the sterile field, and removed the soiled split gauze dressing from around Resident #51's tracheostomy, throwing it away in the empty box. This made RT #19's left hand no longer sterile. RT #19 removed the disposable inner cannula from Resident #51's tracheostomy with his right hand and placed it in the empty box, making his right hand no longer sterile. While the inner cannula remained out, RT #19 used multiple 4 x 4 gauze pads and normal saline to clean around Resident #51's stoma, then dried around the stoma with a 4 x 4 gauze pad. Without performing hand hygiene or changing gloves, RT #19 opened the new, sterile inner cannula, and with dirty gloves, placed it in Resident #51's tracheostomy. RT #19 then placed a clean split gauze around the tracheostomy and replaced the cap from on the bedside table back over the tracheostomy. RT #19 then gathered up the remaining supplies and the trash box, threw them away, took off his personal protective equipment, and washed his hands to exit the room. Interview on 01/22/25 at 2:35 P.M., with RT #19 about the issue with infection control during tracheostomy care, RT #19 stated I do this every day, all day long, sometimes it all runs together. Interview on 01/23/25 at 3:10 P.M., with the Director of Nursing (DON) stated her expectation was that she wanted the respiratory therapists to perform tracheostomy care correctly. DON stated she wanted infection control to be done correctly, wanted clean and dirty to be kept separate, wanted gloves changed and hands washed between clean and dirty tasks and for staff to follow facility policy for tracheostomy care to prevent infection.

Based on observations, staff interviews, record reviews, and policy reviews, the facility failed to ensure comprehensive person-centered care plans were developed and implemented. This affected four (#6, #11, #60, and #63) of 20 sampled residents reviewed. The facility census was 65. Findings included: 1. Review of the admission record revealed Resident #6 was admitted on [DATE]. Resident #6 had a medical history including diagnosis of Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/10/24, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. The MDS indicated the resident required partial to moderate assistance with all activities of daily living (ADLs). Review of Resident #6's care plan revealed no evidence of a focus, goal, or interventions related to the administration of oxygen therapy. Review of Resident #6's Order Summary Report, with active orders as of 01/20/25, revealed no evidence of a physician's order for supplemental oxygen administration. Observation on 01/20/25 at 12:39 P.M., revealed Resident #6 was receiving supplemental oxygen via nasal cannula, and the concentrator was set at 2 liters per minute (L/M). Observation on 01/21/25 at 12:37 P.M. revealed Resident #6 lying in bed and appearing to watch television. Resident #6's eyes were open, but the resident did not respond to verbal stimuli. Resident #6 was receiving supplemental oxygen, and the concentrator was set at 2 L/M. Interview on 01/21/25 at 12:58 P.M., with Licensed Practical Nurse (LPN) #2 confirmed Resident #6 was receiving oxygen therapy and had been on supplemental oxygen for a while. LPN #2 checked the resident's physician's orders and said she was unable to confirm when the oxygen therapy started. LPN #2 confirmed the use of supplemental oxygen should be reflected on the resident's care plan. Interview on 01/23/25 at 11:58 A.M., with MDS Coordinator (MDSC) #7 confirmed she was responsible for the development and revision of care plans. MDSC #7 stated care plan focus areas and interventions were based on the MDS and data retrieved from a facility checklist. MDSC #7 stated the facility checklist contained data such as diagnoses, behaviors, and medications that would also be added to the care plan. MDSC #7 confirmed care plans were reviewed in the daily IDT meeting and during the weekly utilization meeting; care plans were revised and updated at that time if needed. MDSC #7 stated focus areas were added to the care plan based on new orders. MDSC #7 stated she would expect a resident receiving supplemental to have interventions on the care plan that would direct care activities. Interview on 01/23/25 at 2:24 P.M., with the Director of Nursing (DON) stated her expectation was that the use of supplemental oxygen should be reflected on the resident's care plan. Interview on 01/23/25 at 3:50 P.M., with the Administrator confirmed it was her expectation that oxygen therapy be reflected on the resident's care plan. 2. Review of the admission record revealed Resident #11 was admitted on [DATE]. Resident #11 had a medical history including diagnosis of post-traumatic stress disorder (PTSD). Review of the quarterly MDS assessment, with an ARD of 11/29/24, revealed Resident #11 had a BIMS score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required supervision to moderate assistance with all activities of daily living (ADLs). The MDS revealed the resident had a diagnosis of PTSD. Review of Resident #11's care plan revealed no evidence of a focus, goal, or interventions related to their PTSD diagnosis. Review of Resident #11's Psychiatry Progress Note, dated 01/10/25, revealed the Chief Complaint/Reason for this Visit included a follow-up for PTSD. Observation on 01/21/25 at 12:34 P.M., Resident #11 was observed seated in their room and watching television, dressed, and groomed. An interview was attempted with the resident; however, the resident declined. Interview on 01/21/25 at 12:38 P.M., with Certified Nursing Assistant (CNA) #3 stated there were no issues with Resident #11's behavior. CNA #3 stated the resident was cooperative and mostly understood what was being asked. CNA #3 stated the resident liked to stay in their room but would occasionally come out to the day room and watch television. CNA #3 stated she was unaware the resident had a diagnosis of PTSD. Review of Resident #11's Brief Trauma Questionnaire, dated 03/06/24, revealed the resident was involved in a transportation accident, had been physically punished or beaten, assaulted with a weapon, pressured into unwanted sexual contact, experienced a life-threatening illness or injury, and witnessed someone being seriously injured or killed. Interview on 01/23/25 at 9:24 A.M., with the Social Service Director (SSD) confirmed she completed the trauma questionnaire and entered the data into the medical record. The SSD stated the trauma questionnaire was initiated when someone identified a need to her, such as a family trauma or an incident that had happened at the facility. The SSD stated the information gathered from the trauma questionnaire was discussed at the Interdisciplinary Team Meeting (IDT), which met every morning. The SSD stated she does not do care plans; and that Minimum Data Set Coordinator (MDSC), who also attended the morning IDT meeting, was responsible for the care plans. Interview on 01/23/25 at 11:58 A.M., with MDSC #7 confirmed she was responsible for the development and revision of care plans. MDSC #7 stated care plan focus areas and interventions were based on the MDS and data retrieved from a facility checklist. MDSC #7 stated the facility checklist contained data such as diagnoses, behaviors, and medications, which would also be added to the care plan. MDSC #7 confirmed that care plans were reviewed in the daily IDT meeting and during the weekly utilization meeting; care plans were revised and updated at that time if needed. MDSC #7 stated she was unfamiliar with PTSD and interventions, such as potential triggers; however, she would expect an active diagnosis of PTSD to be reflected on the care plan. Interview on 01/23/25 at 2:24 P.M., with the Director of Nursing (DON) stated her expectation was that residents with a diagnosis of PTSD should have that addressed on their care plan with interventions that are specific to the care the resident needs, such as what may trigger behaviors. Interview on 01/23/25 at 3:50 P.M., with the Administrator confirmed it was her expectation that the care plan reflects the needs of the resident. 28193 3. Review of the admission record revealed Resident #60 was admitted on [DATE]. Resident #60 had a medical history including diagnoses of a nontraumatic subarachnoid hemorrhage and cognitive communication deficit. Review of the admission MDS, with an ARD of 11/07/2024, revealed Resident #60 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident was dependent on staff for all activities of daily living (ADLs). The MDS revealed the resident's preferred language was not English. Review of Resident #60's Progress Notes revealed an Admission Summary dated 10/31/24 at 2:59 P.M., indicated Resident #60 was unable to comprehend or speak English. The notes revealed family members had to answer all questions and provide the information needed for admission. Review of Resident #60's Progress Notes revealed a Psychiatry Progress Note dated 11/06/24 at 5:21 P.M., indicated it was hard for the physician to get a good medical history due to the resident's English being very broken and speech seems disrupted. Review of Resident #60's Progress Notes revealed a Psychiatry Initial Consult dated 11/13/24 at 12:59 A.M., that indicated the resident was only oriented to self and did not speak English. The notes revealed a family member had to call a translator to assist. Review of Resident #60's Progress Notes revealed a Psychiatry Progress Note dated 11/13/24 at 12:01 P.M., indicated Resident #60 had endorsed some abdominal discomfort, but due to the language barrier it was difficult to assess other symptoms. The note revealed the resident's speech patterns were not able to be determined due to the language barrier, broken English, and difficulty with speech. Review of Resident #60's Progress Notes revealed a Psychiatry Progress Note dated 11/20/24 at 7:28 P.M., indicated Communication remains difficult with [him/her] due to the language barrier. Review of Resident #60's care revealed no focus area addressing the language barrier identified upon admission or interventions provided to assist the staff and resident in communicating effectively. Interview on 01/23/25 at 2:53 P.M., with the Director of Nursing (DON) stated the care plan process was driven from the MDS. The DON stated difficulty communicating related to a language barrier should be care planned, and care plans should be updated frequently in the daily clinical meeting or at least quarterly with the MDS. Interview on 01/23/25 at 11:59 A.M., with MDS Coordinator (MDSC) #7 stated she created resident care plans through the MDS process. She stated care plans were reviewed quarterly with the MDS, at a daily clinical meeting, and at the weekly utilization review meeting, in which new orders and items that were discontinued were added or removed from resident care plans. MDSC #7 stated communication issues regarding language barriers should be care planned but she thinks they were not. She stated that if she did not do a thorough review of the care plans, they did not get revised; and if they were not revised, residents could potentially not receive accurate care. 4. Review of admission record revealed Resident #63 was admitted on [DATE]. Resident #63 had a medical history that included acute respiratory failure with hypoxia, a stage 3 pressure ulcer of the sacral region, convulsions, and a personal history of traumatic brain injury. Review of the admission MDS, with an ARD of 12/20/24, revealed Resident #63 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was dependent on staff for all activities of daily living (ADLs). The MDS revealed the resident had three stage 3 pressure ulcers, two unstageable pressure ulcers, and two deep tissue injuries (DTIs) upon admission. Review of Resident #63's Order Summary Report with active physician orders as of 01/21/25 revealed the following orders: Apply betadine to open area on left ankle, leave open to air every shift (start date 01/02/25); Cleanse darkened area, deep tissue injury (DTI) on left heel with normal saline, pat dry, apply betadine to the site, and leave open to air every shift (start date 12/26/24); Cleanse open site located on right elbow with normal saline, pat dry, apply Xerofoam (a non-adherent, occlusive dressing) to the wound bed as the primary dressing and secure in place with border gauze every shift (start date 12/19/24); Cleanse open site located on sacrum with normal saline, pat dry, apply medical grade honey as the primary dressing followed by calcium alginate, secure in place with a border gauze every day shift (start date 01/09/25); Cleanse open site on right lateral foot with normal saline, pat dry, apply Xerofoam to the wound bed as the primary dressing and secure in place with a border gauze every day shift (start date 12/19/24); and Cleanse open site on right scapula with normal saline, pat dry, apply Xerofoam gauze to the wound bed as the primary dressing and secure in place with border gauze (start date 12/27/2024). Review of Resident #63's Progress Notes revealed a skin and wound note dated 01/08/25 indicated the resident had a stage 3 pressure ulcer to their left lateral ankle, a DTI to their left heel, a stage 3 pressure ulcer to their right lateral foot, a stage 3 pressure ulcer to their right elbow, an unstageable pressure ulcer to their sacrum, and a stage 3 pressure ulcer to their right scapula (shoulder blade). Review of Resident #63's care plan included a focus area revised on 12/13/24 that indicated the resident had a pressure ulcer on their sacrum. Interventions directed staff to administer medications as ordered (initiated 12/13/24); administer treatments as ordered and monitor effectiveness (initiated 12/13/24); educate the resident/family/caregivers on the causes of skin breakdown (initiated 12/13/24); encourage small frequent position changes (initiated 12/13/24); and to follow facility policies and protocols for the prevention and treatment of skin breakdown (initiated 12/13/24). Further review revealed the care plan did not address Resident #63's stage 3 pressure ulcer to their left lateral ankle, a DTI to their left heel, a stage 3 pressure ulcer to their right lateral foot, a stage 3 pressure ulcer to their right elbow, and a stage 3 pressure ulcer to their right scapula. Interview on 01/23/25 at 11:59 A.M., MDSC #7 stated she created resident care plans through the MDS process. MDSC #7 stated care plans were reviewed quarterly with the MDS at a daily clinical meeting and at the weekly utilization review meeting, in which new orders and items that were discontinued were added or removed from resident care plans. MDSC #7 stated care plans were removed from a resident's chart during the clinical meetings and quarterly. MDSC #7 stated wound care plans were supposed to have wound locations individually spelled out on the care plan. MDSC #7 stated that if she did not do a thorough review of the care plans, they did not get revised; and if they were not revised, residents could potentially not receive accurate care. Interview on 01/23/25 at 2:57 P.M., with the Director of Nursing (DON) stated each wound should be listed individually on the care plan due to having individual treatment orders for each wound. She stated a clinical meeting was held every morning, in which they read all the nurses' notes from the previous 24 hours. She stated that if they were aware of changes, they fixed the care plans in that meeting. She stated her expectation was for the nurses to communicate with the management staff so that the care plans could be kept up to date and current. Review of the policy titled, Care Planning - Interdisciplinary Team, dated 10/10/22, revealed, 2. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). Review of the undated facility policy titled, Care Plans, Comprehensive Person-Centered, revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. The policy revealed, 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The policy revealed, 8. The comprehensive, person-center care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; g. Incorporate identified problem areas; o. Reflect currently recognized standards of practice for problem areas and conditions. Review of the policy titled, Oxygen Administration, revised October 2010, revealed The purpose of this procedure is to provide guidelines for safe oxygen administration. The policy revealed, Review the resident's care plan to assess for any special needs of the resident. Review of an undated facility policy titled, Trauma Informed Care, revealed Social service and nursing staff are trained on trauma screening tool/assessment and how to identify triggers associated with re-traumatization. The policy revealed Trauma-informed care is culturally sensitive and person-sensitive.

Based on observation, staff interviews and record review, the facility failed to ensure a handwashing sink with flowing water had a filter in place to prevent the spread of Legionella. This affected all 34 residents (#34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54. #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66 and #67) on the third floor but had the potential to affect all 62 residents who resided in the facility. The facility also failed to ensure there were handwashing stations in resident rooms who were in Enhanced Barrier Precautions (EBPs). This affected 24 residents (01, #02, #03, #04, #05, #06, #07, #08, #09, #10, #11, #12, #13, #14, #16, #19, #22, #23, #27, #29, #32, #33, #48, and #66) of the 24 residents who the facility identified as being in EBPs, but had the potential to affect all 62 residents who resided in the facility. The facility also failed to ensure outside a Laboratory Phlebotomist wore the appropriate personal protective equipment (PPE) when caring for a resident in EBPs related to Candida Auris (C. Auris) to prevent the spread of C. Auris. This affected one (#67) of the 24 residents reviewed for infection control. The facility census was 62. Findings include: 1) Review of Resident #11's medical record revealed the resident admitted to the facility on [DATE]. Diagnoses included respiratory failure with hypoxia, chronic embolism and thrombosis of unspecified vein, mild protein calorie malnutrition, anxiety disorder, other seizures, paraplegia, major depressive disorder, personal history of traumatic brain injury, tracheostomy status and chronic obstructive pulmonary disease. Review of Resident #11 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 was severely cognitively impaired. Review of Resident #11's progress note dated 10/19/24 revealed the resident was ordered a midline catheter (a thin, flexible tube inserted in a vein in the upper arm and ends near the shoulder to administer fluids or medications) be placed for intravenous (IV) antibiotics to treat C. Auris. A midline catheter could not be placed in house and the on-call nurse practitioner (NP) ordered Resident 11 to be sent to the hospital to receive treatment. Resident #11's responsible party was contacted. Resident #11 left the facility with no skin issues. Review of Resident #11's hospital records dated 10/28/24 revealed Resident #11 was admitted to the facility on [DATE]. Resident #11 tested positive for Legionella (type of serious pneumonia caused by a type of bacteria) on 10/20/24 and negative for Legionella five hours later on 10/21/24. The significance of the discordant serial Legionella urinary antigenic testing was listed as uncertain. Review of Resident #11's progress note dated 10/29/24 revealed Resident #11 returned to the facility at 2:55 P.M. by ambulance. Review of the facility's water sampling dated 10/30/24 revealed there was one positive Legionella water sample collected from Resident #02's room. The sample resulted on 11/11/24 and the positive water sample was on the same floor, but a different wing of Resident #11's room. The facility completed a second water sampling for Legionella on 11/11/24 and there were no new cases identified when the sampling was reported on 11/21/24. Review of an email correspondence from the Local Health Department (LHD) #600 to the Director of Nursing (DON), Administrator, Licensed Practical Nurse (LPN) #96 and Maintenance Director #55 on 11/05/24, revealed LHD #600 was in contact with the facility regarding a presumptive Legionella healthcare associated case in the facility. LHD #600 requested the facility follow steps including implementing water use restrictions throughout the facility or by using point of use filters. The filters should be installed within two to three days after the receipt of the email. The facility should communicate to staff and residents about the water restrictions and post signage near each fixture with a filter for people to contact maintenance if a filter is damaged or removed. Observation of the facility on 11/18/24 at 8:48 A.M., revealed there was a handwashing sink in the third-floor shower room without a filter in place. Further observation of the handwashing sink revealed the handwashing sink had running, unfiltered water with no sign indicating the water should not be used due to the Legionella case. Interview with Maintenance Assistant #79 on 11/18/24 at 8:48 A.M., verified the handwashing sink in the third-floor shower room was turned on, did not have a filter in place and did not have a sign indicating the water should not be used. Maintenance Assistant #79 stated the water to the handwashing sink in the third-floor shower room should have been turned off or had the appropriate filter for Legionella installed on it. Telephone interview with State Health Department Environmental Specialist (SHDES) #700 on 11/18/24 at 2:46 P.M., revealed the facility had a presumptive positive healthcare associated case of Legionella and the facility was informed that they should restrict water or use filters on the water sources. SHDES #700 stated he was not aware the facility had a handwashing sink with running water that did not have a filter on it in the third-floor shower room. 2) Review of the facility's undated list of 24 residents (01, #02, #03, #04, #05, #06, #07, #08, #09, #10, #11, #12, #13, #14, #16, #19, #22, #23, #27, #29, #32, #33, #48, and #66) who were in EBPs. Review of the facility's undated list of 12 residents (#01, #02, #03, #04, #05, #08, #11, #12, #14, #15, #19 and #13) with C. Auris and in EBPs located on the second floor of the facility. Observation of the facility on 11/18/24 at 8:48 A.M. revealed the water supply to the handwashing sinks in all of the resident's rooms were turned off. There was a gallon jug of water located on each of the resident's sink. Further observation of the facility revealed the all of the resident's toilets had running water to them. There was a filter for Legionella on a handwashing sink in the employee bathroom located on the second floor. There was a filter for Legionella on a handwashing sink in the employee bathroom located on the third floor and a handwashing sink with running water that did not have a filter located in the shower room. Interview with Maintenance Assistant #79 on 11/18/24 at 8:48 A.M., verified the facility had disconnected the water supply to all of the resident's handwashing sinks in rooms due to a Legionella case. Maintenance Assistant #79 stated the facility provided a gallon jug of water in each resident's room. Maintenance Assistant #79 stated the handwashing sink in the third-floor shower room was not supposed to be turned on because it did not have a filter on it. Maintenance Assistant #79 reported the facility only had one approved handwashing station on the second and third floors, which was located in the employee bathrooms on each floor. Interview with Regional Director of Operations (RDO) #800 on 11/18/24 at 11:04 A.M. revealed the facility only had two handwashing sinks with filters in place that were available for use for all residents and staff because the facility was told to restrict water or put filters on water sources by the local Health Department after the facility had a presumptive positive Legionella case. Telephone interview with LHD #650 on 11/18/24 at 2:24 P.M. revealed LHD #650 became involved with the facility after the facility had a positive C. Auris case on 09/21/24. LHD #650 stated the facility had four additional residents test positive for C. Auris on 10/09/24 and one additional resident test positive for C. Auris on 10/31/24 during point prevalence screening. LHD #650 reported she was aware of the presumptive positive Legionella case but stated that she believed the facility had installed point of use filters on all faucets. LHD #650 stated she was not aware that the facility had only one filtered handwashing station located in the employee bathroom on second floor and one filtered handwashing station located in the employee bathroom on the third floor. LHD #650 reported it was not appropriate for the facility to only have two handwashing stations with running water especially with the increased C. Auris cases. LHD #650 reported that gallon jugs of water being used in resident rooms would also not be appropriate for handwashing after caring for residents with C. Auris and it was not appropriate to only have one handwashing station on the same floor as 12 residents that were positive for C. Auris and in EBPs. Review of email correspondence from LHD #650 to LPN #96 dated 10/01/24, revealed LHD #650 sent documentation regarding implementation of personal protective equipment use in the nursing home to prevent the spread of Multi Drug Resistant Organisms (MDROs). LHD #650 also recommended the facility review their handwashing for the containment of C. Auris. Review of the Centers for Disease Control and Prevention (CDC) article titled preventing the spread of C Auris (https://www.cdc.gov/candidaauris/prevention/index.html#:~:text=auris%20can%20spread%20easily%20from,or%20ABHS%20is%20not%20available) dated 04/24/24 revealed C. Auris can spread easily from patients who are colonized or infected. Healthcare providers can help stop it from spreading with frequent hand cleaning with alcohol-based hand sanitizer and the use of soap and water if hands are soiled or alcohol-based hand sanitizer is not available. 3) Review of Resident #67's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included vascular dementia, major depressive disorder, epilepsy, chronic kidney disease, type two diabetes mellitus without complications, aphasia, insomnia. The resident was moderately cognitively impaired. Review of Resident #67's medical chart from 09/19/23 to 11/09/24 revealed no documented evidence that the resident was positive for C. Auris or on EBP. Review of Resident #02's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses including anoxic brain damage, non-pressure chronic ulcer of right heel and midfoot with other specified severity, resistance to multiple antibiotics, acute respiratory failure, anxiety disorder and epilepsy. Resident #02 was severely cognitively impaired. Review of Resident #02's hospital records dated 02/29/24, revealed Resident #02 had a diagnosis of C. Auris with an onset date of 02/14/24. Review of Resident #02's physician order dated 11/06/24 revealed Resident #02 was ordered EBP related to C. Auris of the skin. Observation of Resident #02's room on 11/19/24 at 12:07 P.M. revealed Phlebotomist #500 was in Resident #02's room leaning over Resident #02 without a gown in place and drawing blood. Phlebotomist #500 was wearing gloves, but Phlebotomist #500's clothing was making direct contact with Resident #02, the resident's linen and bed as she was leaning over him. Resident #02's door had signs indicating EBP precautions and to see the nurse before entering. Further observation of Phlebotomist #500 revealed Phlebotomist #500 finished drawing Resident #02's blood, exited the room, removed her gloves and placed them in her bag. Phlebotomist #500 then put Resident #500's vial of blood in a plastic bag and placed it in the side of her bag. Phlebotomist #500 did not complete any hand hygiene. Phlebotomist #500 proceeded to the elevator, pressed the call button, and once inside, she entered the code to the elevator and pressed the third-floor button. Phlebotomist #500 got off on the third floor where there were no cases of C. Auris. Phlebotomist #500 walked to Resident # 67's room, donned gloves, leaned over Resident #67 to draw her blood while making contact with Resident #67, her linens and the bed. Interview with Phlebotomist #500 on 11/19/24 at 12:10 P.M. verified she saw the signage on Resident #02's door about being in EBP. Phlebotomist #500 verified she entered Resident 02's room, completed her lab procedure without wearing a gown. Phlebotomist #500 verified she then went to Resident #67's room and completed a lab procedure and without completing any hand hygiene after leaving Resident #02's room. Phlebotomist #500 stated she was aware that Resident #02 was in EBP but thought it would be fine to not wear a gown since she was only drawing the resident's blood. Review of the facility's enhanced barrier precautions policy dated August 2022 revealed Enhanced Barrier Precautions were utilized to prevent the spread of MDROs to residents. Enhanced barrier precautions employ targeted gown and glove use during home contact resident care activities. Gloves and a gown are applied prior to performing the high contact resident care activity. The PPE is changed before caring for another resident. Face protection may be used if there is also a risk of splashes or sprays. Examples of high contact resident care activities requiring gown and glove use for EBPs include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use which includes care of central lines, feeding tubes, tracheostomy and ventilator and wound care or any skin opening requiring a dressing. EBPs may be indicated for residents infected or colonized with C. Auris. Signs are posted on the door or wall outside the resident's room indicating the type of precautions and PPE required and PPE is available outside of the resident's room. This deficiency represents non-compliance investigated under Complaint Number OH00159925, OH00159910 and OH00159811.

Based on observation, staff interviews and record review, the facility failed to ensure water temperatures were maintained within an appropriate range. This affected all 62 residents who resided in the facility. Findings include: Observation of the facility on 11/18/24 at 8:48 A.M., revealed the water temperature of the only operational handwashing sink located in the third floor shower room was 84 degrees Fahrenheit. The water temperature of the only operational handwashing sink located in the second floor shower room was 91.6 degrees Fahrenheit. Interview with Maintenance Assistant #79 on 11/18/24 at 8:48 A.M. verified the water temperature of the handwashing sink in the third floor shower room was 84 degrees Fahrenheit and the water temperature of the handwashing sink in the second floor shower room was 91.6 degrees Fahrenheit. Review of the facility's safety of water temperatures policy dated December 2009 revealed water heaters that service resident rooms, bathrooms, common areas and shower areas shall be set to temperatures between 105 and 120 degrees Fahrenheit.

Based on observation, staff interviews and record review, the facility failed to ensure dependent residents were provided assistance with eating in a timely manner. This affected five (#35, #42 #47, #48, and #67) of the nine residents identified by the facility who required assistance with eating. The facility census was 62. Findings include: Review of Resident #42's medical record revealed Resident #42 was admitted to the facility on [DATE]. Diagnoses included cachexia, mass and lump in the neck, chronic obstructive pulmonary disease, heart failure, insomnia, male erectile dysfunction, hypertensive heart disease with heart and diverticulosis of large intestine without perforation or abscess without bleeding. Review of Resident #42 admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was severely cognitively impaired and dependent on staff for eating. Observation of the third floor on 11/18/24 at 11:59 A.M. revealed the meal trays arrived on the floor. Certified Nursing Assistant (CNA) #47 and CNA #57 started to pass trays. Observation of the third floor on 11/18/24 at 12:34 P.M. revealed five residents (#35, #42 #47, #48, and #67) had not received their room meal trays. Interview with CNA #47 on 11/18/24 at 12:34 P.M. revealed the third floor had seven Residents (#35, #42 #47, #48, #55, #56, and #67) who were dependent on staff for assistance with eating and reported that the facility had two CNAs on the third floor to assist with feeding the seven residents. CNA #47 reported the scheduler, medical records staff member and two nurses were supposed to assist with feeding residents on the third floor. Observation of the third floor on 11/18/24 at 12:51 P.M. revealed Resident #42's meal tray was still sitting on the meal cart. Interview with Licensed Practical Nurse (LPN) #37 and LPN #501 on 11/18/24 at 12:51 P.M. revealed both LPN #37 and LPN #501 had not assisted any residents with eating on 11/18/24. Both LPN #37 and LPN #501 reported that they were busy with medication pass and other nurse duties and were not able to feed the residents. LPN #501 reported the scheduler and medical records staff member were also unavailable to feed residents. LPN #501 verified Resident #42 had not received his meal or assistance with eating because the facility only had two CNAs to feed eight residents. Review of the facility's undated assistance with meals policy revealed residents shall receive assistance with meals in a manner that meets the individual needs of each resident. This deficiency represents non-compliance investigated under Complaint Number OH00159910.

Based on observation, staff interviews and record review, the facility failed to maintain adequate staff levels to ensure the residents who required feeding assistance were timely provided with meals. This affected five (#35, #42 #47, #48, and #67) of the nine residents identified by the facility who required assistance with eating. The facility census was 62. Findings include: Review of Resident #42's medical record revealed Resident #42 was admitted to the facility on [DATE]. Diagnoses included cachexia, mass and lump in the neck, chronic obstructive pulmonary disease, heart failure, insomnia, male erectile dysfunction, hypertensive heart disease with heart and diverticulosis of large intestine without perforation or abscess without bleeding. Review of Resident #42 admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was severely cognitively impaired and dependent on staff for eating. Observation of the third floor on 11/18/24 at 11:59 A.M. revealed the meal trays arrived on the floor. Certified Nursing Assistant (CNA) #47 and CNA #57 started to pass trays. Observation of the third floor on 11/18/24 at 12:34 P.M. revealed five residents (#35, #42 #47, #48, and #67) had not received their room meal trays. Interview with CNA #47 on 11/18/24 at 12:34 P.M. revealed the third floor had seven Residents (#35, #42 #47, #48, #55, #56, and #67) who were dependent on staff for assistance with eating and reported that the facility had two CNAs on the third floor to assist with feeding the seven residents. CNA #47 reported the scheduler, medical records staff member and two nurses were supposed to assist with feeding residents on the third floor. Observation of the third floor on 11/18/24 at 12:51 P.M. revealed Resident #42's meal tray was still sitting on the meal cart. Interview with Licensed Practical Nurse (LPN) #37 and LPN #501 on 11/18/24 at 12:51 P.M. verified CAN #47 and CAN #57 were assigned to the floor. LPN #37 and LPN #501 stated they had not assisted any residents with eating. Both LPN #37 and LPN #501 reported that they were busy with medication administration and other nursing duties and were not able to feed the residents. LPN #501 reported the scheduler and medical records staff member were also unavailable to feed residents. LPN #501 verified Resident #42 had not received his meal or assistance with eating because the facility only had two CNAs to feed eight residents. Review of the daily staffing for 11/24/24, revealed CNA #47 and CNA #57 were the only CNAs assigned to the third floor. Review of the facility's undated assistance with meals policy revealed residents shall receive assistance with meals in a manner that meets the individual needs of each resident. This deficiency represents non-compliance investigated under Complaint Number OH00159910.

Based on record review, observation, staff interview, review of the facility investigation, and review of the facility policy, the facility failed to ensure residents who were dependent on staff for bathing received adequate bathing to promote proper hygiene. This affected one (Resident #15) of three residents reviewed for activities of daily living (ADLs.) The facility census was 68. Findings include: Review of the medical record for Resident #15 revealed the resident was admitted on [DATE]. Diagnoses included hemiplegia/hemiparesis, tracheostomy, gastrostomy, encephalopathy, and acute and chronic respiratory failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 required total dependence with all ADLs. Review of the care plan dated 02/23/23 revealed Resident #15 had an ADL self-care performance deficit related to disease process. Resident #15 required staff assist to complete ADL tasks daily. Fluctuations were expected related to diagnosis. At risk for decline in physical function, activity intolerance, confusion, disease process, hemiplegia, and limited mobility due to stroke. Review of a nursing note dated 08/14/23 for Resident #15, revealed the Administrator, Assistant Director of Nursing (ADON) #30, and the nurse were notified that during care, Resident #15 was noted to have what appeared to be a maggot underneath her on the mattress. The Administrator instructed for Resident #15 to be bathed and have the mattress cleaned. The nurse and ADON #30 assessed Resident #15 and the resident was noted to have increased oral secretions with moist tracheostomy (trach) ties. Upon rolling Resident #15 over, what appeared to be maggots, were on the back of Resident #15's head in her hairline. There were no wounds noted to the back of the resident's head or the back of the neck. Staff assisted Resident #15 up to a chair and gave Resident #15 a shower and washed her hair. The nurse and ADON #30 assessed Resident #15 again with no signs and symptoms of maggots or open areas to back of head or neck. The nurse practitioner (NP) was notified of the situation and ordered the resident Atropine drops to decrease the oral secretions and assist with cutting down on the moisture. The resident's family was informed of the findings and the new orders. Review of the facility's timeline dated 08/15/23, revealed on 08/10/23 a bed bath was given to Resident #15 with no abnormalities noted. On 08/11/23, a skin assessment was completed on Resident #15 with no abnormalities noted. On 08/13/23, Resident #15 was given a bed bath with no abnormalities. On 08/14/23, the night shift nurse discovered a maggot on Resident #15's mattress and noted maggots to be on the right side of the resident's hair line. A skin assessment was completed, and a new area to right inner thigh was noted related to brief and no other skin issues noted. On 08/14/23, after the resident's shower, the trach ties were changed, and trach care was administered. On 08/14/23, a new order was obtained for Resident #15 to have atropine to assist with the increased oral secretions. On 08/14/23, a whole house audit and skin assessments were completed with no abnormalities noted. On 08/15/23, new orders were obtained to have trach ties changed to every shift instead of every three days. Review of a witness statement dated 08/15/23 and authored by State tested Nursing Assistant (STNA) #32, revealed STNA #32 was the aide for Resident #15 on 08/13/23 from 7:00 A.M. to 7:00 P.M. STNA #32 gave Resident #15 a bed bath and there were no bugs were noted on Resident #15. Review of the witness statement dated 08/15/23 and authored by ADON #30, revealed she received a message from Licensed Practical Nurse (LPN) #33 on 08/14/23 which indicated as the staff rolled Resident #15 and maggots were found on the mattress. Review of a work order dated 08/15/23, revealed Resident #15's room was treated for flies. Review of the witness statement dated 08/16/23 and authored by LPN #31, revealed on Sunday 08/13/23, LPN #31 cared for Resident #15. Resident #15 appeared to be in the same condition that she typically was in, and the vital signs were within normal limits. LPN #31 reported that she had often seen small flies in the resident's room. All efforts to protect Resident #15 from the small flies had been made including a bed bath (according to the aide) and frequently drying the excessive saliva and mucus that Resident #15 tends to produce. Throughout the shift, LPN #31 did not notice any flies in her hair line or abnormalities in regards to her trach site. LPN #31 witnessed the aide provide care and a linen change to Resident #15's bed. Review of the physician order dated 08/17/23 for Resident #15, revealed the resident was ordered to receive a scopolamine transdermal patch every 72 hours one milligram (mg) for excessive secretions and remove per schedule. An interview with the Director of Nursing (DON) on 08/23/23 at 7:40 A.M. revealed she got a call on 08/14/23 around 6:30 A.M. from LPN #33, and reported the STNAs indicated when they were turning Resident #15, they found what appeared to be a maggot on the resident's mattress. The DON stated that she came into the facility to assess Resident #15 and found maggots in the resident's hairline. The DON stated they got Resident #15 into a chair and while waiting for the shower to be clear, they were removing the maggots from Resident #15's hair. The DON stated there were a fair number of maggots. The DON indicated after Resident #15 got her shower, she was re-assessed and there were no more maggots observed on Resident #15. Random observations of the facility on 08/23/23 and 08/24/23, revealed only one fly was noted in the stairwell, and no flies were noted on the resident's halls. Interview with STNA #35 on 08/24/23 at 6:33 A.M., revealed she was training an orientee on 08/13/23 during the night shift (7:00 P.M. to 7:00 A.M.) and they cared for Resident #15. STNA #35 stated they checked and changed Resident #15 every two hours along with repositioning Resident #15 and never seen any maggots all night, then on the last rounds at approximately 6:30 A.M. when they rolled the resident, they noticed maggots on the mattress and informed the nurse. Interview with LPN #33 on 08/24/23 at 6:37 A.M. revealed STNA #35 called her in to the resident's room and she saw approximately three maggots on the resident's mattress, so she reported it to the DON. LPN #33 stated she did not see any maggots during the 7:00 P.M. to 7:00 A.M. shift on 08/13/23 through 08/14/23. Interview with Maintenance Director #39 on 08/24/23 at 12:06 P.M., revealed the facility gets treated for pest control weekly; however, if there were identified issues, then they would be treated more often. Interview with STNA #38 on 08/24/23 at 1:08 P.M. revealed while they were waiting on the shower to be cleared, she was helping the DON remove the maggots from Resident #15's hairline and by the time they could get Resident #15 into the shower, there were just a couple of maggots left and they were removed when Resident #15's hair was washed. STNA #38 stated the maggots in the resident's hair could have been prevented by providing more thorough care. STNA #38 stated that house flies come in through a door downstairs, but their main pest problem were the gnats that were everywhere. Review of the facility policy titled Giving a Bed Bath (dated 10/2010), revealed staff were to wash the back from the hairline to the waist and to comb/brush resident's hair if he/she cannot do it. This deficiency represents non-compliance investigated under Complaint Number OH00145672 and Complaint Number OH00145287.

Based on record review, staff interview, and policy review, the facility failed to have a comprehensive care plan in place for residents receiving tracheostomy care. This affected one (Resident #15) of three residents reviewed for care plans. The in-house facility census was 65. Findings include: Record review for Resident #15 revealed Resident #15 was admitted on [DATE] with diagnoses including hemiplegia/hemiparesis, tracheostomy, and acute and chronic respiratory failure. Resident #15 required total dependence with activities of daily living. Review of the care plan dated 08/24/23 revealed Resident #15 has a tracheostomy related to impaired breathing mechanics. Intervention dated 08/24/23 was to suction as necessary. There was no care plan for tracheostomy care prior to 08/24/23 and there were no other interventions for tracheostomy care. Interview on 08/24/23 at 3:40 P.M. with Regional Clinical Director #40 verified there was no care plan for tracheostomy care indicating Resident #15 needed to have excessive salivation cleaned more frequently and a care plan was created on 08/24/23. Review of the facility's Respiratory Therapy-Prevention of Infection policy (not dated) revealed to review the resident's care plan to assess for any special circumstances or precautions related to the resident. This deficiency represents non-compliance investigated under Complaint Number OH00145672 and Complaint Number OH00145287.

Based on record review, observation, staff interview, review of facility policy, and review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess the resident's skin and failed to timely identify a resident's pressure ulcer until it reached an advanced stage which resulted in actual harm to Resident #37 who was admitted to the facility without pressure ulcers and developed an unstageable pressure ulcer to the right heel. The facility also failed to ensure pressure ulcer treatments were administered per the physician's order which placed the resident at risk for more than potential harm that was not actual harm. This affected two (Residents #04 and #37) of three residents reviewed for pressure ulcers. The facility census was 67. Findings include: 1. Review of the medical record for Resident #37 revealed an admitted [DATE] with diagnoses including unspecified dementia with mood disturbance, chronic kidney disease, diabetes mellitus (DM), and cardiomyopathy. Review of the pressure ulcer risk assessment date 04/18/23 for Resident #37, revealed resident was at risk for the development of pressure ulcers. Review of the Minimum Data Set (MDS) assessment date 04/28/23 for Resident #37, revealed the resident was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADLs.) Resident was coded negative for the presence of pressure ulcers. Review of the weekly skin checks dated 05/05/23 and 05/13/23 for Resident #37, revealed there were no skin issues noted. Review of the care plan for Resident #37 updated 05/08/23, revealed the resident was at risk for impairment to skin integrity related to decline in mobility, dementia, muscle weakness, difficulty walking, cognitive communication deficit, and need for assistance with personal care. Interventions included the following: Braden scale assessment per protocol, educate resident/family/caregivers of causative factors and measures to prevent skin injury, encourage and assist the resident to turn and reposition every two hours or as tolerated, encourage good nutrition and hydration in order to promote healthier skin, follow facility protocols for treatment of injury, peri-care provided after each incontinent episode, and pressure redistributing mattress to bed. Review of the care plan for Resident #37 dated 05/17/23, revealed the resident had an unstageable pressure ulcer to the right heel. Interventions included the following: administer treatments as ordered and monitor for effectiveness, assist resident to reposition and/or turn at frequent intervals to provide pressure relief, educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, heel boots as tolerated, inform the resident/family/caregivers of any new area of skin breakdown, keep shoe off right foot until the area is resolved, monitor nutritional status, serve diet as ordered, monitor intake and record, provide incontinence care after each incontinent episode, or per established toileting plan, resident requires a pressure reducing mattress to bed, and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Review of a nurse progress note date 05/17/23 for Resident #37 and authored by the Assistant Director of Nursing (ADON) /Licensed Practical Nurse (LPN) #125, revealed the nurse on the unit notified LPN #125 that the resident had an area to his right heel. LPN #125 assessed the resident and noted the resident was lying in bed with his legs crossed and his heel on the mattress. An area to the right heel was noted measuring 2.5 centimeters (cm) in length by 2.4 cm in width by 0.1 cm in depth. The wound bed was noted with eschar (necrotic tissue that develops over wounds) with peri wound pink in color. Surrounding skin was pink and tender to touch. No drainage or odor noted. Wound Nurse Practitioner (NP) #575 was notified and gave treatment orders for the resident's wound to be treated with Medihoney fluffed gauze to the wound bed and cover with foam border gauze. An order was also given to apply heel boots to the resident's bilateral feet as tolerated. Review of the wound assessment dated [DATE] for Resident #37, completed by LPN #125 revealed the resident had a facility- acquired unstageable right heel pressure which measured 2.5 cm in length by 2.4 cm in width by 0.1 cm in depth. The wound bed was 100 percent (%) eschar. Treatment orders included Medihoney fluffed gauze to wound bed and cover with foam border gauze and heel boots as tolerated. Review of the NP #575 visit note dated 05/23/23 for Resident #37, revealed the resident had a facility-acquired unstageable pressure ulcer first identified on 05/17/23 to the right heel which measured 2.5 cm in length by 2.5 cm in width by 0.1 cm in depth. The wound bed was 100% covered with slough. Review of the NP #575 visit note dated 07/06/23 for Resident #37, revealed the resident's right heel pressure ulcer now presented as a stage III pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed) which measured 1.5 cm in length by 1.0 cm in width by 0.1 cm in depth. The wound bed was 25-49% slough. Observation of wound care on 07/11/23 at 1:03 P.M. for Resident #37, with LPN #580, revealed the resident was resting on a pressure reduction mattress and was compliant with wearing heel protectors. Observation revealed the resident had a dime-sized pressure ulcer to his right heel with the wound bed partially covered with slough tissue. Interview with NP #575 on 07/12/23 at 9:32 A.M., confirmed Resident #37 had no prior pressure ulcers on the right heel prior to 05/17/23. NP #575 confirmed facility notified her on 05/17/23 of a pressure ulcer to the resident's right heel which she first assessed on 05/23/23 and determined it was an avoidable facility-acquired pressure ulcer which was unstageable due to the wound bed was 100% obscured by slough/eschar tissue. NP #575 confirmed the etiology of the ulcer to the right heel was due to pressure from being in bed and she had ordered heel protectors on 05/17/23 after staff had notified her of the pressure ulcer. NP #575 confirmed with thorough assessment the facility could have identified the pressure ulcer before it had reached an advanced stage and possibly could have prevented it from developing into an unstageable pressure ulcer. Interview on 07/12/23 at 10:19 A.M. with the Director of Nursing (DON), LPN #125, and Regional Nurse (RN) #585, confirmed Resident #37 had a skin check on 05/13/23 which showed no skin abnormalities. LPN #125 confirmed she observed the pressure ulcer to Resident #37's right heel on 05/17/23 and determined it was an unstageable pressure ulcer which was covered 100% in slough/eschar. Review of the facility policy titled Prevention of Pressure Ulcers Injuries dated July 2017 revealed nurses would assess skin weekly and would inspect the skin on a daily basis when performing and assisting with personal care and ADLs and would identify any signs of developing pressure injuries such as nonblanchable erythema and for darkly pigment individual signs such as changes in skin tone, temperature, and consistency. Skin inspection should include inspection of pressure points including the heels. Review of the NPUAP guidelines dated 2014 pages 70-71 at (https://npiap.com/general/custom.asp?page=2014Guidelines) revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. 2. Review of the medical record for Resident #04 revealed an admitted [DATE] with diagnoses including acute respiratory failure with hypoxia, neuromuscular dysfunction of bladder, anxiety disorder, DM, and tracheostomy status. Review of the MDS assessment dated [DATE] for Resident #04, revealed the resident was cognitively impaired and required extensive assistance of one to two staff with ADLs. Review of the physician orders dated 06/13/23 for Resident #04, revealed the resident was ordered to have the left heel cleansed with wound cleanser, patted dry, calcium alginate applied to wound bed, then covered with an abdominal (ABD) pad and wrapped with Kerlix gauze every shift (twice daily). Review of the NP #575's wound visit note dated 07/06/23 for Resident #04, revealed the resident had a healing stage III pressure ulcer to the left heel which measured 1.0 cm in length by 1.8 cm in width by 1.0 cm in depth. Review of the nurse progress notes dated 07/09/23 for Resident #04, revealed the notes did not include any documentation of resident's refusal of treatment or any rationale for treatment to left heel not being completed as ordered. Review of the July 2023 Treatment Administration Record (TAR) for Resident #04 revealed the dayshift and nightshift treatments for 07/09/23 were not signed off as being completed. Observation of Resident #04 on 07/10/23 at 12:26 P.M. with RN #415, revealed the resident had a dressing to her left foot which was dated 07/08/23 and had a nurse's initials written on the dressing. Interview on 07/10/23 at 12:26 P.M. with RN #415, confirmed Resident #04 had a stage III pressure ulcer to her left heel and the treatment was ordered every shift. RN #415 confirmed the dressing on resident's left foot was dated 07/08/23 and had the initials of RN #410. RN #415 confirmed she was orienting RN #410 and had observed the nurse apply the dressing to Resident #04's left heel on 07/08/23. Interview on 07/12/23 at 10:19 A.M. with the DON, LPN #125, and RN #580, confirmed RN #415 had brought it to their attention on 07/10/23 that the Surveyor had observed an outdated dressing on Resident #04's foot. Interview confirmed the facility had investigated and determined the treatment for resident was not completed as ordered on 07/09/23. Review of the facility policy titled Wound Care dated October 2010 revealed the facility would ensure nurses provided wound care per physician's order. This deficiency represents non-compliance investigated under Complaint Number OH00143918.

Based on record review, staff interview, review of the facility fall investigation and review of the facility's policy, the facility failed to ensure care was provided per the president's plan of care in order to prevent falls with injury. This affected one resident (#32) of three residents reviewed for falls. The facility census was 67. Findings include: Review of the medical record for Resident #32 revealed an admitted [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, chronic kidney disease, coronary artery disease, diabetes mellitus, and acute and chronic respiratory failure with hypoxia. Review of the care plan for Resident #32 dated 02/22/23 revealed the resident had an activities of daily living (ADL) self-care deficit related to disease process. Resident required staff assistance to complete ADL tasks daily. Resident was at risk for a decline in function related to activity intolerance, confusion, disease process, hemiplegia, limited mobility, and stroke. Interventions included the following: resident was totally dependence on the assistance of two staff with toileting, resident required a mechanical lift for transfers with assistance of two staff for transfers. the resident was totally dependent on staff for repositioning and turning in bed every two hours, and as necessary. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #32, revealed the resident was cognitively impaired and was totally dependent on the assistance of two staff with bed mobility, transfer, and toilet use. Review of the fall risk assessment dated [DATE] for Resident #32, revealed the resident was at high risk for falls. Review of the nurse progress note dated 06/23/23 for Resident #32, revealed an State tested Nursing Assistant (STNA) reported while providing peri-care to resident, the resident's leg slid off mattress resulting in the resident falling from the bed to the floor. The STNA (identified as STNA #455) reported he called for assistance, and the nurse assessed the resident, and the staff assisted the resident back into bed. There was swelling noted to the left eye and active bleeding above the eye. The nurse applied pressure to the bleeding area, 911 was called and the resident was transferred to the hospital for an evaluation. Review of the hospital notes dated 06/23/23 for Resident #32, revealed the resident had a computerized tomography (CT) scan of her head to rule out injury and neurosurgery was consulted to evaluate the resident. Resident #32 underwent laceration repair and returned to the facility. Review of the facility post fall investigation for Resident #32 dated 06/23/23, revealed the resident had a witnessed fall out of bed on 06/23/23 resulting in swelling and bleeding above the left eye. An aide reported he was providing peri-care to the resident by himself, and the resident fell off of low air loss mattress onto the floor. Contributing factor to fall included staff not having a second person for assistance and root cause of the fall was only having one person to assist with ADLs. Interventions to prevent recurrence was staff education. Review of facility form titled Teachable Moment dated 06/26/23, completed per Assistant Director of Nursing (ADON)/Licensed Practical Nurse (LPN) #125 to State tested Nursing Assistant (STNA) #455 revealed the STNA was educated on asking for assistance for any resident that required a two-person assist. All residents with air mattresses or who have tracheostomies (trachs), or ventilators (vents) should be a two-person assist for all care. Review of the wound evaluation dated 06/28/23 for Resident #32, revealed the resident had a laceration to left eyebrow with steri-strips intact. Review of the wound nurse visit note dated 06/28/23 for Resident #32, revealed the resident had a laceration to the left eyebrow which measured 1.6 centimeters (cm.) The laceration was secured with steri-strips and staff were to leave laceration open to air and to monitor steri-strips until they fell off. Interview on 07/12/23 at 10:19 A.M. with the Director of Nursing (DON), LPN #125, and Regional Nurse (RN) #585, confirmed STNA #455 provided peri-care to Resident #32 by himself on 06/23/23 when resident fell out of bed sustaining a laceration to her left eyebrow. Interview confirmed Resident #32 was a two-person assist for toileting and bed mobility and the facility's investigation had determined the root cause of resident's fall was that the resident's care plan was not followed and only one staff (STNA #455) was assisting the resident when she fell out of bed. Interview confirmed Resident #32 was evaluated at the hospital following the fall and the CT scan to her head was negative for any injuries. Resident #32 sustained a laceration above her left eyebrow which was able to be secured with steri-strips. STNA #455 was provided with verbal education on following the resident's care plan regarding level of ADL assistance needed and also received written education on a Teachable Moment form regarding need for two-person assistance with care. Review of the facility policy titled Fall Risk assessment dated [DATE], revealed the facility would assess residents for fall risk on admission, quarterly, and upon significant change. The facility would identify and address modifiable fall risk factors and interventions to minimize the consequences of risk factors that were not modifiable. Review of the facility policy titled Perineal Care dated October 2010, revealed prior to providing care staff should review the care plan to assess for any special needs of the resident. This deficiency represents non-compliance investigated under Complaint Numbers OH00144181, OH00143880, and OH00143792.

Based on staff interview, record review, policy review, and review of medical terminology definition, the facility failed to respond timely to a change of condition. This affected one (Resident #21) of three residents reviewed for tracheostomy care. The facility census was 64. Findings include: Review of the medical record for Resident #21 revealed an admitted [DATE]. Diagnoses included COVID-19 (12/15/22), dependence on ventilator, heart failure, and anoxic brain damage. Review of the care plan dated 06/29/22 revealed Resident #21 was at risk for developing complications secondary to Tracheostomy related to impaired breathing mechanics. Interventions included to elevate the head of the bed/avoid lying flat, give humidified oxygen a prescribed, provide good oral care daily, and monitor/report signs of respiratory distress. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #21 had severely impaired cognition, had self-directed behaviors, did not reject care, and did not wander. Review of the progress note dated 12/28/22 at 9:01 A.M. revealed Respiratory Therapist (RT) #83 found Resident #21 flat in the bed and she appeared to have aspirated small amount of tube feed. The tube feed was noted coming out of her trach. There was no additional follow up noted in the medical record until the following day on 12/29/22. Subsequent review of the progress note dated 12/29/22 at 8:29 A.M. revealed Licensed Practical Nurse (LPN) #71 received a verbal order for a stat chest x-ray. During an interview conducted on 12/29/22 at 11:53 A.M., RT #83 stated she told LPN #120 her suspicions that Resident #21 had aspirated tube feeding on 12/28/22, and it was the nurse's responsibility to notify the family and physician of the resident's changes in condition. During an interview on 12/29/22 at 12:01 P.M., LPN #120 stated RT #83 told her on 12/28/22 she had suctioned and repositioned Resident #21, but there was no mention of concerns for aspiration. LPN #120 stated she did not know if STAT x-ray had been scheduled as ordered. During an interview on 12/29/22 at 12:06 P.M., LPN #71 state she had reviewed progress notes before morning meeting on 12/29/22 and saw the note written on 12/28/22 at 9:01 A.M. about Resident #21 and a possible aspiration concerns. LPN #71 notified the Director of Nursing (DON) and Nurse Practitioner (who was in the building at that time), and got order for a stat chest x-ray, and reported the order to LPN #120 to schedule. LPN #71 verified the STAT x-ray had not been scheduled yet - four hours after the order had been received. Review of the policy titled Acute Changes In Condition - Clinical Protocol, dated March 2018, revealed direct-care staff were trained to recognize and report subtle but significant changes in the resident to the nurse. Nursing staff contacted the physician, the physician responded in a timely manner to order diagnostic tests and authorize appropriate treatments. Review of the Medical-Dictionary.thefreedisctionary.com defined STAT as referring to a diagnostic or therapeutic procedure that is to be performed immediately; Latin for statim, which means immediately. This was an incidental finding during the course of the complaint investigation.

Based on staff interview and record review, the facility failed to notify families of COVID-19 status in the building during an outbreak of COVID-19. This affected three (Residents #9, #16 and #21) of three residents reviewed for COVID-19 notification. The facility census was 64. Findings include: 1. Review of the medical record for Resident #9 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 had severely impaired cognition. Review of the progress notes revealed the Social Worker notified Resident #9's Power of Attorney (POA) that Resident #9 had tested positive for COVID-19 on 12/08/22, but there was no other documentation related to notification of facility COVID-19 outbreak status when the outbreak started on 12/06/22 with staff testing positive for COVID-19 or subsequent notifications as additional staff and residents tested positive. 2. Review of the medical record for Resident #16 revealed an admitted [DATE]. Diagnoses included schizoaffective disorder bipolar type. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #16 had severely impaired cognition. Review of the medical record revealed Resident #16 had no documentation related to notification of facility COVID-19 outbreak status when the outbreak started on 12/06/22 with staff testing positive for COVID-19 or subsequent notifications as additional staff and residents tested positive. 3. Review of the medical record for Resident #21 revealed an admitted [DATE]. Diagnoses included COVID-19 (12/15/22) and anoxic brain damage. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #21 had severely impaired cognition. Review of the medical record revealed Resident #21 had no documentation related to notification of facility COVID-19 outbreak status when the outbreak started on 12/06/22 with staff testing positive for COVID-19 or subsequent notifications as additional staff and residents tested positive. Review of the facility's timeline for COVID-19 outbreak revealed the outbreak started on 12/06/22 when Respiratory Therapist #83 and Cook #10 tested positive for COVID-19. The following timeline is when staff and residents tested positive for COVID-19: On 12/07/22, Business Office Manager #70 tested positive; On 12/08/22, Licensed Practical Nurse (LPN) #120 and Residents #9, #50, #51, #52, and #60 tested positive; On 12/11/22, Assistant Director of Nursing #75 tested positive; On 12/12/22, Residents #5, #13, #20, #22, #35, #59, and #63 tested positive. On 12/14/22, Residents #21, #39, and #54 tested positive; On 12/15/22, Resident #49 tested positive; and on 12/20/22, Registered Nurse #73 tested positive. During an interview on 12/29/22 at 12:52 P.M., the Administrator stated the facility notified all families at the beginning of an outbreak and did not provide additional general notification during the outbreak as additional staff and residents tested positive for COVID-19. Family members were notified as individual residents tested positive for COVID-19. The Administrator stated she was unaware she had to notify families of the COVID-19 status of the building with each subsequent positive test identified during outbreak. The facility did not provide a policy related to COVID-19 notification. This deficiency represents non-compliance investigated under Complaint Number OH00138659.

Based on staff interview, record review, and policy review, the facility failed to timely notify resident representatives of new physician orders. This affected one (Resident #21) of three residents reviewed for notification of change. The facility census was 64. Findings include: Review of the medical record for the Resident #21 revealed an admitted [DATE]. Diagnoses included COVID-19 (12/15/22), dependence on ventilator, stage III chronic kidney disease, and anoxic brain damage. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #21 had severely impaired cognition. Review of the physician orders dated 12/17/22 revealed Resident #21 had a new order for intravenous (IV) antibiotic Zosyn 3.375 gram (gm) use 100 milliliter (ml) intravenously every eight hours for five days related to pseudomonas and streptococcus. The medical record was silent for the resident's representative being notified of the new order. During an interview on 12/29/22 at 10:27 A.M., the Director of Nursing (DON) verified there was no documentation in the medical record related to family notification of the new orders for the IV antibiotics on 12/17/22 . Review of the facility policy titled Change in a Resident's Condition or Status, dated May 2017, revealed a nurse would notify the resident representative if there was a change in room assignment or a change in mental, physical, or psychosocial status. This deficiency represents non-compliance investigated under Complaint Number OH00138659.

Based on observation, resident interview, and staff interview, the facility failed to ensure resident equipment was maintained in a clean and sanitary manner. This affected one (#63) of three residents reviewed for physical environment. The facility census was 63. Findings include: Observation on 11/21/22 at 1:44 P.M. revealed Resident #63 laying in bed with a fan sitting on a chair directly next to the bed, in the on position and facing Resident #63. The front and back of the fan were caked in a thick fuzzy grey material. Interview on 11/21/22 at 1:44 P.M., Resident #63 stated the fan runs all the time and, Yeah, it's really dirty. Resident #63 could not recall the last time the fan was cleaned. Interview on 11/21/22 at 1:52 P.M., Registered Nurse (RN) #325 verified the front and back of the fan was caked in a thick fuzzy grey material. RN #325 further affirmed the fan needed to be cleaned. RN #325 stated she was unsure of how often fans should be cleaned. Observation on 11/22/22 at 11:58 A.M., the fan remained caked in a thick fuzzy grey material, in the on position, and facing directly on Resident #63. The deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, observation, staff interview, resident interview, and review of the facility smoking policy, the facility failed to ensure Resident #29 exhibited safe smoking practices, stored his smoking materials appropriately, and did not smoke while near oxygen. This resulted in Immediate Jeopardy and the potential for serious injury, harm, impairment, and/or death, on 08/10/22 when Resident #29, who utilized oxygen therapy, was found outside the building, in the facility's designated smoking area, smoking with his oxygen on. This affected one (Resident #29) out of three residents reviewed for smoking. The facility identified 18 residents (#02, #06, #11, #12, #13, #20, #24, #26, #29, #32, #33, #40, #41, #48, #51, #58, #59, and #67) who currently reside in the facility and smoke. The facility census was 67. On 08/11/22 at 5:12 P.M., the Administrator and Regional Clinical Director #650 were notified Immediate Jeopardy began on 08/10/22 at 4:46 P.M. when Resident #29, who utilized oxygen therapy, was found outside the building, in the facility ' s designated smoking area, smoking with his oxygen on. The Immediate Jeopardy was removed on 08/11/22 when the facility implemented the following corrective actions: · On 08/11/22, Resident #29 was issued a 30-Day Notice of Discharge by the Administrator and Director of Nursing (DON) related to unsafe smoking practices. · On 08/11/22, Resident #29 gave smoking materials that he had in his room to the Administrator and DON and was re-educated by the Administrator on the dangers of smoking with oxygen on, up to and including death. · On 08/11/22, Department Managers completed a 100% audit of all rooms for smoking materials, collected any items found, and secured them at the nurse ' s station. · On 08/11/22, families of residents that smoke were educated by Activity Director #10 regarding the smoking policy, not giving cigarettes to residents directly, and that cigarettes need to be given to staff at the nurse ' s station. · On 08/11/22, Business Office Manager #25 and Marketing Director #28 educated all family members of non-smoking residents regarding the smoking policy and not to give smoking paraphernalia directly to any residents. Smoking paraphernalia must be given to staff at the nurse ' s station. · On 08/11/22, a Resident Council meeting was held by the Administrator and DON to discuss the smoking policy, supervised smoke times, and offered information on smoking cessation. This information was reviewed with all residents that smoke tobacco products. · On 08/11/22, all smokers were educated by management staff on the smoking policy and Smoking Behavior Agreements were reviewed with all smokers and signed by the residents. · On 08/11/22, smoking assessments were completed by the DON/designee, on all residents in the facility. · On 08/11/22, the smoking care plans of all residents that smoke tobacco products were reviewed for accuracy and updated by Minimum Data Set (MDS) Coordinator #32. · On 08/11/22, a staff member was assigned to monitor the smoking area 24/7 by Staffing Coordinator #48. · On 08/11/22, the DON/Designee in-serviced all staff on the smoking policy, appropriate supervision of smokers during smoke times, and oxygen safety. Agency staff that were present on 08/11/22 and going forward received/will receive education on the smoking policy by the DON/designee. · On 08/12/22, the Administrator conducted random audits of smoking to ensure measures were in place per the plan of correction. Audits will be completed by the DON/designee daily for two weeks, then three times a week for two weeks, and then weekly for four weeks. Audits will be taken to Quality Assurance and Performance Improvement (QAPI) committee for review and to determine the need for continuation. · On 08/12/22, the Administrator conducted random audits of smoking assessments to ensure accuracy and implementation of interventions. Audits will be completed by the DON/designee daily for two weeks, then three times a week for two weeks, and then weekly for four weeks. Audits will be taken to QAPI committee for review and to determine the need for continuation. · On 08/12/22, the Administrator conducted random audits of smoking care plans to ensure accuracy and implementation of interventions. Audits will be completed by the DON/designee daily for two weeks, then three times a week for two weeks, and then weekly for four weeks. Audits will be taken to QAPI committee for review and to determine the need for continuation. · The smoking policy and oxygen safety will be discussed in new hire orientation by the DON/designee. Agency staff will be educated on the smoking policy and oxygen safety upon arrival to the facility. · Observation on 08/15/22 at 9:39 A.M. of the scheduled smoke break revealed staff were outside supervising the residents. Resident #29 was observed sitting in a patio chair and smoking with his wheelchair and oxygen tank inside the facility. No oxygen tanks or other unsafe smoking practices were observed. · Observation on 08/15/22 at 10:44 A.M. revealed staff were outside monitoring residents in the designated smoking area. No residents were observed smoking. · Interviews on 08/15/22 from 10:49 A.M. through 1:44 P.M. with Licensed Practical Nurse (LPN) #350, LPN #14, Floor Technician #100, LPN #08, Activity Staff #05, State tested Nursing Assistant (STNA) #102, LPN #400, STNA #450, and Respiratory Therapist #34, revealed they had all been educated on the smoking policy and were able to verbalize key elements regarding smoking at the facility. Agency staff (LPN #400 and STNA #450) were also interviewed and reported they had been educated upon arrival to the facility for their shift and signed acknowledgement of the policy. · Interviews on 08/15/22 from 10:59 A.M. through 1:48 P.M. with Residents #02, #20, #22, #29, #32, #51, and #58, revealed the residents had been educated regarding the smoking policy, the facility was storing their smoking materials, and room audits had been completed. · Observation on 08/15/22 from 1:18 P.M. through 1:53 P.M. revealed staff were outside the facility in the designated smoking area with residents in preparation for the scheduled smoke break. Staff were observed obtaining the box with resident smoking materials from inside the facility before passing out cigarettes and lighting them for residents. The container holding the smoking materials was observed to be a clear plastic box with separate compartments, and there were individual plastic bags that contained cigarettes and lighters with resident names on the outside of the bags. Resident #29 was observed sitting in a patio chair and smoking a cigarette with his wheelchair and oxygen tank located inside the facility. Staff were observed supervising residents with no unsafe smoking practices observed. · Observation on 08/15/22 at 2:53 P.M. with LPN #400 revealed resident smoking materials were secured in a clear plastic box with separate compartments. · Although the Immediate Jeopardy was removed on 08/11/22, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action and monitoring to ensure ongoing compliance. Findings include: Review of the medical record for Resident #29 revealed he was admitted to the facility on [DATE]. Resident #29 ' s diagnoses included but were not limited to dependence on supplemental oxygen, acute and chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, other seizures, malignant neoplasm of unspecified part of unspecified bronchus or lung, secondary malignant neoplasm of liver and intrahepatic bile duct, and secondary neoplasm of brain. Review of the facility assessment titled Smoking Safety Evaluation, dated 05/10/22, revealed Resident #29 smoked, had issues with his short-term memory, removed oxygen tubing and did not bring it into smoking area, followed smoking guidelines per policy, and returned smoking materials for storage. Review of Resident #29 ' s quarterly Minimum Data Set (MDS) assessment, dated 05/20/22, revealed Resident #29 had intact cognition. Resident #29 was assessed to require supervision for bed mobility, transfer, dressing, eating, toileting, and personal hygiene. Resident #29 was identified as receiving oxygen. Review of Resident #29 ' s physician order dated 06/23/22 revealed an order for oxygen at four liters via nasal cannula. Review of the facility form titled Behavior Agreement, dated 07/19/22 and signed by the resident on 07/22/22, revealed Resident #29 was not following the smoking policy and smoking materials were found in his room. The agreement indicated Resident #29 had been educated and verbalized understanding of the smoking policy at the facility. Further review of the agreement revealed Resident #29 would have his smoking materials stored by nursing staff, would not smoke unsupervised, would not have marijuana anywhere in the facility or property, and was aware that his room could be searched any time there was suspicion of smoking materials being stored in his room due to safety concerns for Resident #29 and other residents at the facility. Review of Resident #29 ' s plan of care, dated 08/10/22, revealed Resident #29 smoked. Interventions included assess for changes in mental status that would affect Resident #29 ' s ability to smoke safely as necessary, care conference as necessary to address unsafe smoking practice, educate Resident #29 on facility smoking policies and protocols, monitor clothing for holes and burn marks as necessary, monitor/document/report any instances of non-compliance, one to one assistance/supervision as necessary to prevent injury, provide smoking cessation as necessary, educated Resident #29 on the risks of smoking with oxygen up to and including death, leave oxygen tank in the facility during smoke break, and smoking assessment quarterly and as necessary. Observation on 08/10/22 at 4:46 P.M. revealed Resident #29 was smoking in the designated smoking area at the main entrance of the facility with his oxygen tank hanging on the back of his wheelchair. A cloud of smoke was observed rising in front of his head. LPN #300 was observed speaking with Resident #29 before LPN #300 proceeded to enter the facility. Interview on 08/10/22 at 4:46 P.M. with LPN #300 revealed Resident #29 was out there smoking with his oxygen on. LPN #300 then stated he, the LPN, had turned Resident #29 ' s oxygen off. Interview on 08/10/22 at 5:08 P.M. with STNA #84 revealed smoking materials are stored behind the nursing station on the second floor. She reported Resident #29 had gone outside to smoke with his oxygen tank before and refused to let staff intervene. STNA #84 stated she had reported the issue to the charge nurse on duty in the past. Interview on 08/10/22 at 5:19 P.M. with LPN #14 revealed Resident #29 often went to smoke breaks with his portable oxygen tank but was to leave the oxygen tank in the entrance way. LPN #14 reported Resident #29 had been found outside smoking with his oxygen tank several times. She stated smoking materials are stored at the nursing station, but she believed Resident #29 had his smoking materials in his possession. Interview on 08/11/22 at 9:58 A.M. with Resident #29 revealed he would exit the facility to smoke, turn off his oxygen, smoke about half a cigarette, and then turn his oxygen back on when he was finished. During the interview, a pack of cigarettes was observed on Resident #29's side table. Resident #29 confirmed he stored his cigarettes and lighter in his room. Resident #29 reported the facility had smoke breaks identified on the activity calendar but Resident #29 stated he would go outside to smoke when he desired. Resident #29 reported he had been informed he could smoke with his oxygen on the back of his wheelchair as long as it was turned off. Resident #29 stated last night on 08/10/22 and again early in the morning on 08/11/22, he was told that he would need to leave his oxygen inside the building during smoke breaks. Interview on 08/11/22 at 11:06 A.M. with the Administrator revealed she just obtained the pack of cigarettes from Resident #29's room. The Administrator opened the top of the pack of cigarettes and a lighter as well as several cigarettes were observed. Review of the facility policy titled Smoking Policy - Residents, revised 07/2017, revealed the policy statement was to establish and maintain safe resident smoking practices. Further review of the policy revealed the use of oxygen is prohibited in smoking areas and residents are not permitted to keep cigarettes, e-cigarettes, pipes, tobacco, lighters, matches, and other smoking materials in their possession.

Based on closed and open medical record review, hospital record review, Self-Reported Incident (SRI) review, staff interview, review of staff statements, review of a personnel file, and facility policy review the facility failed to ensure medications were transcribed correctly upon admission/readmission from the hospital. This resulted in actual harm to Resident #149 when Licensed Practical Nurse (LPN) #150 did not transcribe anticonvulsant medications correctly upon the residents return from the hospital for [MEDICAL CONDITION] activity. Resident #149 experienced convulsions within three days of readmission and was readmitted to the hospital's neurology unit. The facility also failed to transcribe orders correctly for Resident #36 and the resident missed a hypertensive medication for two and a half months. This affected two (#36 and #149) of three residents reviewed for medications. The facility census was 62. Findings include: 1. Review of Resident #149's closed medical record revealed the resident was originally admitted on [DATE]. The resident was sent to the hospital on [DATE] for [MEDICAL CONDITION] activity, readmitted on [DATE] and discharged to the hospital on [DATE] for [MEDICAL CONDITION] activity. [DIAGNOSES REDACTED]. Review of the modification of discharge return anticipated dated 02/05/21 revealed Resident #149 had severe cognitive deficits, required extensive assistance to total dependence for activities of daily living, and was always incontinent of bowel and bladder. Review of the undated care plan revealed Resident #149 had a [MEDICAL CONDITION] disorder. Interventions included give medications as ordered, monitor and document for effectiveness and side effects. Review of the hospital paperwork dated 02/02/21 revealed the resident was admitted on [DATE] for breakthrough [MEDICAL CONDITION] activity. Review of health status note dated 02/02/21 at 6:20 P.M. revealed during a phone report from the hospital the nurse indicated that Resident #149 should be getting [MEDICATION NAME] (anticonvulsant) through [DEVICE] ([DEVICE]) not orally. Although staff was told previously that the medication should be administered by mouth. A new order was submitted to increase the [MEDICATION NAME] from 50 milligrams (mg) to 175 mg. Review of the continuation of care (COC) form from the hospital dated 02/02/21 revealed [MEDICATION NAME] (generic form of [MEDICATION NAME]) 175 mg give three and half 50 mg tablets to equal 175 mg per [DEVICE] two times a day, DO NOT EVER CHANGE TO SUSPENSION, hold tube feeds one hour before and two hours after [MEDICATION NAME] administration, clobazam (anticonvulsant) 10 mg, take half a 10 mg tablet equaling 5 mg by mouth in morning and at bedtime for 30 days, lacosamide (anticonvulsant) 200 mg one tablet per [DEVICE] two times a day, and [MEDICATION NAME] sodium (stool softener) take 100 mg by mouth in morning and a bedtime. Review of physician orders [REDACTED]. The physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. There was no evidence that the clobazam, lacosamide or [MEDICATION NAME] sodium were given. Review of skilled note dated 02/05/21 revealed Resident #149 was heard yelling at 6:40 P.M., the nurse went to check on Resident #149 and noticed the resident was having a [MEDICAL CONDITION] behavior. The nurse assessed Resident #149 to make sure the resident was safe and clear of any objects. The nurse stayed at the bedside with Resident #149 for safety. Resident #149 seized for seven minutes. The Medical Director (MD) was notified and gave a new order to send Resident #149 to the hospital via emergency nine-one-one (911) due to prolonged [MEDICAL CONDITION] activity. Resident #149 was safe in the bed at this time. Vital signs were blood pressure 137/91, temperature 100.4, and pulse 152. Review of skilled note dated 02/06/21 revealed the nurse received a telephone call from the local hospital emergency room that Resident #149 was admitted to neurology for observation. The Director of Nursing (DON) was notified. Review of an SRI dated 02/07/21 revealed Resident #149 was sent out to the hospital on [DATE]. The Administrator was notified by the hospital admissions of a concern that Resident #149 was not receiving her prescribed medications from her 02/02/21 hospitalization . An investigation was initiated. Resident #149's readmission on 02/02/21 from the recent hospitalization was reviewed by the DON and Regional Director of Clinical Services. After reviewing the COC from the hospital, it was identified that there was a transcription error when Resident #149 was readmitted from the hospital. The MD was notified about the transcription error. The DON spoke with LPN #150 who was on duty when Resident #149 was readmitted . LPN #150 stated she didn't see any new medications from the hospital and she had called to verify the orders with the MD. The allegation of neglect was unsubstantiated due to this was a transcription error rather than an intent to not administer medications. Resident #149 was transferred to another facility from the hospital. Review of verbal statement from LPN #150 via phone dated 02/08/21 revealed when Resident #149 arrived at the facility, LPN#150 looked at all of her medications to make sure they were correct. LPN #150 stated she did not see anything different for Resident #149's [MEDICAL CONDITION] medications. LPN #150 did indicate during report from the nurse from the hospital, she was told that the facility needed to give the [MEDICATION NAME] through her [DEVICE] and not orally and LPN #150 wrote that order. LPN #150 stated if she had saw something different, she would have written it. LPN #150 called and verified all of the orders with the doctor. LPN #150 reported there were no changes from what she had transcribed per the MD. LPN #150 refused to give a written statement. Review of LPN #150's personnel file revealed her date of hire was 10/12/20, her license was verified with no board action taken, and her background/abuse registry for abuse was verified. LPN #150 was terminated on 02/09/21 due to Group IV violation meaning insubordination. Review of hospital record dated 02/09/21 revealed the resident presented with breakthrough [MEDICAL CONDITION] activity from the nursing home. [MEDICAL CONDITION] from 02/02/21 was due to failure of facility to administer anit-epileptic drugs (AEDs). The resident was at the hospital because she reportedly did not her prescribed [MEDICATION NAME] (lacosamide) and Onfi (clobazem) on her med list at the skilled nursing facility. [MEDICATION NAME] dose listed as 150 mg twice a day (BID) instead of 175 mg BID as ordered on last discharge. She supposedly was getting [MEDICATION NAME] as prescribed. [MEDICATION NAME] level low again on admission at 3.6. In addition, both lacosamide and leviteracitam ([MEDICATION NAME]) labs from last admission are undetectable. Etiology for [MEDICAL CONDITION]ly improper administration of AEDs at nursing home. Further review revealed it is believed that the bulk of her [MEDICAL CONDITION] are due to facility not administering her medications appropriately. Review of the Administrator statement dated 02/17/21 revealed Resident #149 returned to the facility on [DATE]. LPN #150 was instructed by the hospital Registered Nurse (RN) that Resident #149's [MEDICATION NAME] (anticonvulsant) was to be increased to 175 mg twice daily, in tablet form, and to be administered via [DEVICE] and no longer by mouth. This was due to absorption issues. On 02/05/21, Resident #149 was noted with [MEDICAL CONDITION] activity and was sent to the hospital. Upon investigation, LPN #150 stated that she had verified orders with the MD to resume prior orders and change the [MEDICATION NAME], per hospital instructions. It was noted the LPN #150 wrote the order for three tablets of 50 mg rather than three and a half tablets, which would equal 175 mg. LPN #150 stated that she not receive any other changes and verified this with the hospital RN and MD. During the investigation, it was noted that the COC also had orders for clobazam 5 mg twice daily, lacosamide 200 mg twice daily, and [MEDICATION NAME] sodium 100 mg twice daily. None of these orders were transcribed. LPN #150 reported that she did not see these orders and verified the orders that were written, with the MD. A phone interview on 03/08/21 at 3:36 P.M. with the Administrator and the DON verified Resident #149 did not receive the correct dose of [MEDICATION NAME] 175 mg and only received 150 mg for six doses. The resident also did not receive clobazam 5 mg twice daily, lacosamide 200 mg twice daily, and [MEDICATION NAME] sodium 100 mg twice daily on 02/03/21, 02/04/21, and 02/05/21. 2. Review of the medical record revealed Resident #36 was originally admitted on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed Resident #36 had moderate to severe cognitive deficits, required extensive assistance with activities of daily living, and was always incontinent of bowel and bladder. Review of the undated care plan revealed Resident #36 had hypertension. Interventions included to give anti-hypertensive medications as ordered and monitor for [MEDICAL CONDITION] , increased heart rate ([MEDICAL CONDITION] and effectiveness. Review of hospital COC dated 12/31/20 revealed an order to start [MEDICATION NAME] (anit-hypertensive) 25 mg, commonly known as [MEDICATION NAME]-XL, take one tablet by mouth daily. Review of physician orders [REDACTED]. Review of the MAR indicated [REDACTED]. A phone interview on 03/09/21 at 4:17 P.M. with Regional Clinical Director #143 verified the order for [MEDICATION NAME] 25 mg was never transcribe from the COC and Resident #36 never received the medication from 12/31/20 through 03/09/21. Review of the facilities undated policy entitled Reconciliation of Medications on Admission revealed the purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes, and dosages upon admission or readmission to the facility. Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. Review of the facilities undated policy entitled Administration of Medication/Medication Errors Policy revealed examples of a medication error are as follows: omission, unauthorized medication, wrong dose, wrong route, wrong form, wrong drug, wrong time, wrong documentation, and anytime that manufacturer instruction/professional standards are not followed related to the medication. This deficiency substantiates Complaint Number OH 927.

Based on record review, observation, interview, policy review and review of the National Pressure Injury Advisory Panel (NPIAP) recommendations, the facility failed to ensure two residents (Residents #61 and #155) received adequate care, monitoring, and treatment to prevent the development and decline in pressure ulcers. This resulted in actual harm when Resident #61 was found to have an avoidable unstageable wound to the right heel, a deep tissue injury (DTI) to the left heel and a sacral wound that had increased in size. In addition Resident #155 had a a stage two pressure ulcer on admission that declined to an unstageable pressure ulcer. This affected two of three residents reviewed for pressure ulcers. The facility identified two pressure ulcers in the facility. The facility census was 62. Findings included: 1. Medical record review revealed Resident #61 was admitted on [DATE]. Medical [DIAGNOSES REDACTED]. Review of the admission wound assessment, dated 03/10/20, revealed Resident #61 was admitted with pressure ulcers including a right buttock pressure ulcer that measured 5.5 centimeters (cm) by 8 cm by 1.5 cm., left buttock pressure ulcer measuring 6.5 cm by 3 cm by 0.5 cm. and a coccyx ulcer measuring 2.5 cm by 3 cm by 0.5 cm. Review of admission dietary assessment dated [DATE] revealed Resource 2.0, a supplement drink, 120 milliliters (ml) once a day; Prostat, a protein supplement, 30 ml once per day; and a vitamin, stress tablet with zinc, once per day. The resident's [MEDICATION NAME], or protein stores, was 3.2 grams per deciliter (normal 3.4 to 5.4) and Body Mass Index (BMI) was 33.8, obese. Review of the care plan dated 04/06/20 for Resident #61 revealed she had a Stage IV pressure ulcer related to disease process related to stroke and [MEDICAL CONDITION] and [MEDICAL CONDITION] following a cerebral infarction affecting the right dominate side and immobility. Interventions included to monitor, remind, and assist resident to turn and reposition every two hours and more as often as needed. The resident required a pressure reducing cushion to chair, pressure reducing mattress to bed. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. There were no interventions listed specific to the resident's heels. Review of a receipt dated 08/18/20 revealed Resident #61 received a low air loss mattress. Review of wound notes dated 11/26/20 revealed Resident #61 developed a closed blister to the right foot that measured 3.0 cm by 2.0 cm with depth unable to be determined. It was classified as a Stage II ulcer. There was no odor and no drainage. The left heel had a closed area that measured 6.0 cm by 3.0 cm with depth unable to be determined. It was classified as a Stage II ulcer. Treatment was to apply skin prep to the heels every shift. Current preventative interventions in place were a low air loss mattress and turn and reposition every two hours. The wounds were to be measured weekly. The medical record contained no documentation about the wounds on 12/03/20 or 12/10/20. Review of physician wound notes dated 12/17/20 revealed the ulcer to the sacrum was aSstage IV full thickness exposed underlying structure that measured 1.0 cm by 1.4 cm by 0.5 cm with 100 percent granulation tissue. Undermining was 0.9 cm from 10 o'clock to 2 o'clock with moderate exudate. The treatment order was to cleanse daily with normal saline and apply calcium alginate to the wound bed and cover with a dry dressing. Granulation remained poor. The right heel ulcer had declined. It was now unstageable and measured 5.0 cm by 5.4 cm with no depth with 40 percent granulation tissue, 30 percent slough, and 30 percent eschar. The left heel was determined to be a deep tissue injury that measured 2.4 cm by 5.6 cm and unable to determine the depth. The wound was to be measured weekly. The record contained no measurements or wound notes for 12/24/20. Review of wound notes dated 12/31/20 revealed the ulcer to the sacrum had declined related to moisture. The wound measurement was 11 cm by 5.0 cm with 97 percent granulation tissue and 3 percent slough. The undermining was 10 0 clock to 2 o'clock at 0.9 cm with a moderate amount of exudate and no odor. The treatment was not changed. Review of the Treatment Administration Record (TAR) from 11/01/20 through 01/31/21 revealed the dressing to the sacral wound was not documented as being completed on 11/10/20, 11/14/20, 11/20/20, 12/17/20, 12/18/20, 12/21/20, 12/22/20, 12/27/20, 01/04/20, 01/08/20, 01/10/20, and 01/14/20. Review of the TAR from 11/26/20 through 01/31/21 revealed the dressings to the right and left heels were not documented as being completed on 12/21/20, 12/24/20, 12/25/20, 01/06/21, 01/08/21, 01/10/21, 01/15/21, 01/18/21, 01/24/21, and 01/29/21. Review of progress notes dated 01/06/21 revealed Resident #61 tested positive for COVID-19 and was moved to the COVID unit. Review of the annual MDS assessment, dated 01/19/21, revealed Resident #61 was severely cognitively impaired and was rarely or never understood. Her functional status was extensive assistance for bed mobility, toilet use, and eating. Transfers did not occur. She was always incontinent for bladder and bowel. She had one sSage IV pressure ulcer and two unstageable pressure ulcers. The dietary assessment dated [DATE] revealed a 10 percent weight gain and to increase the Resource 2.0 supplement to 120 ml twice a day. The skin condition of right heel was a Stage III and a coccyx alteration was documented in the note. She was on a vitamin of a stress tablet and Vitamin C to aid in healing of the skin conditions. Observation of wound care for Resident #61 on 03/03/21 at 10:14 A.M. revealed she was lying on an air mattress on her left side. Her heels were elevated on pillows. The dressing had the date of 03/03/21 and the [MEDICATION NAME] was removed and there was gauze covering the wound. The gauze was removed and had a small amount of blood on it and the wound was wrinkled inside, reddened and there was about one inch around the edges that curved down into the wound. The wound was cleaned with normal saline. A moistened gauze (wet to dry dressing) was applied and covered with a dry dressing. Observation of the right and left heels revealed 100 percent eschar. Review of Wound Physician (WP) #200 notes dated 03/04/21 revealed Resident #61's wound on her sacrum now measured 20.5 cm by 19.5 cm by 3.0 cm deep. The wound was 60 percent granulation, 40 percent slough, large amount of exudate and purulent odor. During an interview on 03/09/21 at 3:46 P.M., WP #200 stated the resident's heel ulcers were avoidable. He stated there would be no reason to acquire pressure ulcers on the heels unless they were not floated off of the bed. During an interview on 03/10/21 at 9:45 A.M., the Director of Nursing (DON) stated she wasn't aware WP #200 did not see the resident on 12/24/20. She confirmed there was no documentation of the wound on this date. She verified there was no specific interventions to prevent pressure ulcers to the heels prior to the development of the ulcers. She stated WP #200 visited weekly. If WP #200 does not come, it is the responsibility of the staff to measure and document the wound appearance. She verified there was no wound documentation for 12/03/20, 12/10/20 or 12/24/20. Interview with State tested Nursing Assistant (STNA) #87 on 03/10/21 at 10:48 A.M. revealed Resident #61 was on an air loss mattress since she came into the facility. She stated her heels were not being floated until after the ulcers developed. She stated the resident had a significant decline after she acquired COVID-19. 2. Closed record review for Resident #155 revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of physician orders dated 01/20/21 revealed to apply a Dermafoam dressing to the sacrum area every three days and as needed for treatment Review of the admission wound assessment dated [DATE] revealed a pressure ulcer to the sacrum that measured 0.5 cm by 0.5 cm and the depth was unable to be determined. This was an open area with no drainage, odor or bleeding. Review of weekly skin assessments for Resident #155 revealed on 01/22/21 and 01/26/21, there were not any new skin abnormalities. Review of the Braden Scale for skin risk assessment, dated 01/26/21, revealed the resident was at risk for a pressure ulcer development. Review of the admission MDS assessment, dated 01/27/21, revealed Resident #155 was severely cognitively impaired. His functional status was extensive assistance for mobility, transfers, supervision for eating and total dependence for toilet use. He was coded for an indwelling catheter and occasionally was incontinent for bowel. Review of the care plan dated 01/28/21 revealed Resident #155 had a pressure ulcer to the sacrum and had potential for pressure ulcer development related to history of ulcers and immobility. Interventions were to administer medications and treatments as ordered. Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition, and frequent repositioning. Encourage small frequent position changes. Review of the TAR revealed the Dermafoam dressing was changed on 01/23/21, but there was no documentation of the appearance or measurement of the wound. The dressing was not documented as being changed on 01/27/21. Review of physician wound notes dated 01/28/21 for the resident revealed the sacral wound was now unstageable. It measured 6.5 cm by 6.6 cm with 25 percent granulation tissue, 15 percent slough and 60 percent eschar. Periwound was within normal limits and exudate was minimal. New order was issued to cleanse the wound with normal saline, apply a nickel think layer of Santyl and cover with moist gauze and change every day and as needed. In addition place a low air loss mattress to the bed. On 02/04/21, the Braden scale revealed the resident was at high risk for a pressure ulcer development. Interview with Dietician #148 on 03/04/21 at 4:43 P.M. revealed she did an initial assessment on the resident and didn't find any concerns for dehydration or malnourishment. She stated his BMI was within normal limits, he consumed 50 to 75 percent of his meals and supplements. During an interview on 03/08/21 at 11:26 A.M., the DON stated there was a referral for WP #200 to visit the resident, but since the resident arrived on 01/20/21 and the physician came into do wound rounds the next day, the referral was not completed. She said the order for the Dermafoam was ordered upon admission and the staff were to be applying this treatment to his wound until the physician came into see the resident on 01/28/21. During a follow up interview on 03/10/21 at 9:30 A.M., the DON stated she wasn't aware WP #200 didn't come into the facility on [DATE] to see the resident. She confirmed the wound got bigger and the care plan didn't include interventions of turning and repositioning to promote wound healing. She said the resident was refusing to turn and reposition, but stated there was no care plan for the resident's non-compliance. She confirmed there wasn't any measurements of the wound on 01/23/21 and no further documentation about the wound until the physician saw the resident on 01/28/21. During an interview on 03/09/21 at 1:46 P.M., WP #200 stated he did not come into the facility on [DATE]. He did not see Resident #155 until 01/28/21. He stated the facility didn't call him to inquire about the Dermafoam dressing and if they did, he would have not ordered that for a treatment for [REDACTED]. Review of the facility policy titled Pressure Ulcers, dated 03/01/14, revealed the nursing staff and attending physician will assess and document pressure sore including location, stage, length, width and depth, presence of exudate or necrotic tissue. Review of NPIAP website (https://npiap.com/) revealed an unstageable pressure injury is defined as and obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. A deep tissue pressure injury (DTPI) is defined as persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury. Further review revealed to ensure that the residents heels are free from the bed. Recommended using heel offloading devices or [MEDICATION NAME] foam dressings on individuals at high-risk for heel ulcers. This deficiency substantiated Complaint Number OH 963.

Based on medical record review, observations, staff interviews, review of facility policy and review of documentation from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to complete assessments, implement interventions and provide treatments to promote healing for Resident #92's stage two pressure ulcer which was present upon admission. This resulted in actual harm for Resident #92 who was admitted with a stage two pressure ulcer which was not timely treated and was not assessed for 18 days following admission and later progressed to an area that was described to contain slough (yellow, tan, gray, green or brown dead tissue). This affected one (#92) of three Residents reviewed for pressure ulcers. The facility identified three residents with pressure ulcers. Facility census was 69. Findings include: Medical record review revealed Resident #92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of five day minimum data set (MDS) comprehensive assessment dated [DATE] revealed the presence of one stage two pressure ulcer that was present upon admission. Resident #92 required extensive assistance with bed mobility, eating, toileting, and personal hygiene. His mental status wasn't assessed. Review of admission MDS dated [DATE] revealed one stage two pressure ulcer was present upon admission. Resident #92 had moderately impaired cognitive skills for daily decision making and functioning level remained consistent with assessment completed on 12/14/16. Review of hospital discharge paperwork dated 12/12/16 revealed Resident #92 had a stage two pressure ulcer to the coccyx. Review of nursing progress note dated 12/12/16 at 7:00 P.M. revealed Resident #92 was admitted from the hospital. Excoriation was noted to the coccyx, the nurse practitioner was notified, and a [MEDICATION NAME] dressing was applied. Review of nursing admission assessment dated [DATE] revealed excoriated coccyx. Review of Braden Scale for Predicting Pressure Sore Risk dated 12/12/16 revealed a score of 11 which indicated Resident #92 was at high risk. Review of advanced level provider health history and physical dated 12/13/16 revealed Resident #92 had a stage two pressure ulcer to the coccyx and a [MEDICATION NAME] dressing was in place. Review of skilled nursing assessments dated 12/13/15, 12/20/15, 12/21/15, 12/22/15, 12/23/15, 12/24/15, 12/26/15, 12/27/15, 12/28/15 and 12/29/15 revealed the skin was warm and dry without noted abnormalities. Review of wound evaluation flow sheet dated 12/30/16 documented the presence of a stage two pressure ulcer to the sacrum, large triangular bone at the base of the spine which was noted to be present upon admission on 12/12/16. The area measured 11 centimeters (cm) long by eight cm wide and 0.15 cm deep. Slough was noted throughout the wound bed with slight pink noted on outer portion of wound bed. Current preventative interventions included to turn and reposition every two hours and as tolerated. The physician and family were notified and current treatment included to wash with normal saline, pat dry, apply calcium alginate, cover with [MEDICATION NAME] dressing every other day and as needed. The current treatment was initiated on 12/30/16. This was the only documented assessment of Resident #92's pressure ulcer since his admission on 12/12/16. Further review of wound evaluation flow sheet revealed a stage two pressure ulcer was partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. Review of Resident #92's care plan initiated 12/28/16 revealed Resident #92 was admitted with a stage two pressure area on the coccyx and was at risk for further skin declines. Interventions included to avoid scratching and keep body from excessive moisture. Keep fingernails short. Educate family and caregivers about skin injury. Encourage good nutrition and hydration, use of side rails for turning in bed, and follow facility protocols for treatment of [REDACTED]. Review of treatment administration record (TAR) for December 2016 revealed a physician order [REDACTED]. This was the first ordered and documented treatment to the coccyx pressure ulcer since Resident #92 was admitted . This treatment was documented as completed once on 12/21/16, 12/22/16, and 12/24/16, and twice on 12/23/16, 12/25/16, 12/26/16, and 12/2716. This order was discontinued on 12/28/16 and [MEDICATION NAME] to coccyx area for each incontinent episode was ordered every day and night shift. Review of hospital paperwork revealed Resident #92 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. Review of summary of hospital stay revealed the resident was discharged with a stage four sacral decubitus ulcer with penetration to bone. Magnetic resonance imaging (MRI) was completed to look for a bone infection and results were unremarkable. An observation on 01/18/17 at 5:37 P.M. revealed Resident #92 was in bed on a low air loss mattress. The Resident was unable to be interviewed due to a confused mental status and altered thought process. Observation on 01/19/17 at 10:28 A.M. of wound treatment to Resident #92 by the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #380 revealed the presence of a stage four pressure ulcer to the coccyx measuring 11 cm by 8.4 cm by 4.5 cm depth with minimal sanguineous drainage (containing blood mixed with other fluids) and without odor. The wound bed was 90 percent (5) tan slough without visible bone and the edges were curled. The resident was cooperative throughout the procedure without signs of discomfort. A Santyl dressing was applied according to physician order. An interview on 01/19/17 at 1:31 P.M. with Regional Clinical Director #400 reported the nurse practitioner (NP) whom completed the residents history and physical on 12/13/16 upon admission never visualized the stage two pressure ulcer to the coccyx but documented this based upon the nurses report. No treatment was ordered the pressure ulcer. The wound evaluation flow sheet completed on 12/30/16 was the only documented assessment of Resident #92's pressure ulcer. According to the description of the wound bed on this assessment, it did not meet the guidelines for a stage two pressure ulcer. An interview on 01/19/17 at 3:09 P.M. with LPN #384 reported she was unable to recall the reason she obtained the treatment orders for Resident #92 on 12/21/16 and 12/28/16. LPN #384 further denied visualizing the residents pressure ulcer. An interview on 01/19/17 at 3:17 P.M. with LPN #380 reported she completed Resident #92's skin assessment upon admission to the facility on [DATE]. LPN #380 reported the resident had three superficial areas to the coccyx approximately two to three centimeters long. The NP was notified, the areas were cleansed, and a [MEDICATION NAME] dressing was applied. LPN #380 reported she notified the oncoming nurse but did not put a treatment order into place. An interview on 01/19/17 at 5:03 P.M. with the DON reported Resident #92 was admitted to the facility from the hospital on [DATE] with a stage two pressure ulcer to the coccyx as noted on his transfer hospital paperwork. LPN #380 reported excoriation to the residents coccyx upon admission, consulted with the NP, cleansed the area, and applied a [MEDICATION NAME] dressing. The NP diagnosed the pressure ulcer as a stage two based upon information she obtained from the nurse as she had never visualized the wound. A treatment wasn't ordered. Resident #92 went back out to the hospital on [DATE] to 12/16/16. He returned to the facility with a stage two pressure ulcer to his coccyx as noted on his MDS assessment. A skin/ wound assessment wasn't documented upon return to the facility. Upon return to the facility on [DATE]/16, the staff reported they began applying [MEDICATION NAME] to the buttocks however this wasn't documented, there wasn't any documented assessment of the area, and there wasn't an order for [REDACTED]. On 12/23/16, the five day MDS assessment indicated a stage two pressure ulcer with slough. There wasn't any documented assessment of the pressure ulcer during this time. On 12/28/16, the treatment order was changed to [MEDICATION NAME] as the resident was having frequent loose stools and the dressing wouldn't stay intact. On 12/30/16, the former treatment nurse LPN #505 completed an initial assessment of the wound. An interview on 01/19/17 at 5:08 P.M. with NP #490 reported she never visualized Resident #92's pressure ulcer and orders were provided based upon request of nursing. An interview on 01/19/17 at 5:10 P.M. with LPN #412 reported she completed the MDS assessments for Resident #92. LPN #412 reported she never visualized his pressure ulcer but obtained the MDS skin information from the former treatment nurse. According to the NPUAP, a stage two pressure ulcer was a partial-thickness loss of skin with exposed dermis. The wound bed was viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Granulation tissue, slough and eschar are not present in stage two pressure ulcers. A stage three pressure ulcer was full-thickness loss of skin, in which adipose (fat) was visible in the ulcer and granulation tissue and rolled wound edges were often present. Slough and/ or eschar may be visible with stage three pressure ulcers. If slough or eschar obscures the extent of tissue loss this was an unstageable pressure ulcer. An unstageable pressure ulcer was a full thickness tissue loss in which actual depth of the ulcer was completely obscured by slough (yellow, tan, gray, green or brown dead tissue) and/ or eschar (tan, brown or black dead tissue) in the wound bed. Until enough slough and/ or eschar are removed to expose the base of the wound, the true depth cannot be determine but it will be either a stage three or four. Review of facility Pressure Ulcers/ Skin Breakdown - Clinical Protocol revised February 2014 revealed the nurse would describe and document/ report a full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. The physician would authorize pertinent orders related to wound treatments and identify medical interventions related to wound management. During resident visits, the physician will evaluate and document the progress of wound healing.

Based on medical record review, observation and interviews the facility failed to prevent an avoidable injury. This affected one resident of three reviewed. This resulted in harm Resident #10 who sustained a fracture during an improper transfer. The facility identified eight residents who required a mechanical lift device for transfer. Findings include: Review of Resident #10's medical record revealed she was admitted to the facility from an area acute care hospital with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #10 was cognitively intact with no delirium, non-ambulatory, and dependent upon two persons for transfer. Resident #10 required extensive assistance of one person for bed mobility, locomotion on or off the unit, dressing, toilet use and personal hygiene. Review of the Nurse's Aide Information Sheet for Resident #10, undated, revealed the resident required the assistance of two persons with a mechanical (Hoyer) lift for transfers. Review of the Plan of Care for Activities of Daily Living (ADL), dated 02/25/15, also revealed Resident #10 required the participation of two persons and a mechanical lift for safe transfer. Review of the Progress Notes dated 04/15/15 at 2:07 P.M., revealed a large bruise to Resident #10's right shin was discovered by an unnamed nurse aide. The nurse aide reported the bruise to Licensed Practical Nurse (LPN) #32 who had an x-ray performed to the right lower leg. At the time, Resident #10 was unable to explain the cause of the bruise; therefore, the facility initiated an investigation into the cause of the injury of unknown origin. The x-ray dated 04/15/15 at 4:49 P.M., revealed an avulsion fracture to the right proximal tibia. Review of the facility's self reported incident # dated 04/15/15, revealed State tested Nurse Aide (STNA) #33 and a patient transport driver had physically lifted Resident #10 without a mechanical lift device, and transferred her from her bed to a wheelchair on the morning of 04/15/15. During the transfer, Resident #10 complained of pain to her right lower leg. Resident #10 was transported out of the facility for a planned out-patient appointment. The investigation determined Resident #10's right tibia avulsion fracture was caused during the transfer by STNA#33 and the transportation driver. On 05/05/15 at 2:20 P.M. and 3:55 P.M. respectively, the Director of Nursing (DON) and LPN #32 corroborated the investigation findings that Resident #10's injury was accidentally caused during the improper transfer of Resident #10 by STNA#33 and the transportation company driver on 04/15/15 morning. However, they were not able to determine exactly how the injury occurred. The DON also corroborated the injury could have been avoided, had Resident #10 been transferred with a mechanical lift on the morning of 04/15/15 as instructed in the Care Plan and the Nursing Aide's Information Sheet. During observation and interview on 05/06/15 at 11:15 A.M., Resident #10 denied any staff had physically abused her. This deficiency substantiates Complaint Number OH 827.

Based on medical record review, staff interviews, review of the policy for Wandering/Elopement Risk, and review of the hospital records, the facility failed to provide adequate supervision to prevent a resident who was assessed at risk for elopement from leaving the unit without staff knowledge. This resulted in Immediate Jeopardy for one (#57) of six sampled residents on the 300 unit, when she left the unit through the corridor door in a wheelchair, and was found lying at the bottom of nine steps in a cement stairwell. The facility identified six residents as being at risk for elopement. The resident census was 57. On [DATE] at 11:30 A.M., the Corporate Vice President of Operations #12 and the Corporate Clinical Consultant #16 were notified Immediate Jeopardy began on [DATE] at 5:40 P.M. when Resident #57 was found by State tested Nurse Aide (STNA) #5 outside the unit on the stairwell landing after she fell down nine steps. As a result of the fall, Resident #57 suffered numerous cervical spine fractures, a hematoma over her right eye and multiple skin tears. The resident expired four days later at the hospital. The Immediate Jeopardy was removed on [DATE] at 8:15 A.M. when the facility initiated continuous monitoring of the corridor door and implemented the following actions: ? On [DATE] at 5:00 P.M., the Director of Nursing (DON) initiated continuous monitoring of the corridor door. A staff member was scheduled to sit at the door which ensured no resident at risk for elopement could leave the unit unobserved. There was ,[DATE] coverage of the door; this was observed by the surveyors and the monitoring sheets reviewed. ? On [DATE], the DON began in-service training of all staff regarding the door alarms and staff responsibility. ? On [DATE] at 4:00 P.M., the maintenance staff placed additional alarms on each exit door on the 300 unit (two fire doors and the corridor door). When the doors are opened a very loud, piercing alarm will sound. Staff must punch in a code to turn off the alarm. ? On [DATE] at 8:15 A.M., the facility's door company implemented changes to the corridor door alarm system. The actual alarm box was moved from the door to the nurse's station in the middle of the unit. The alarm will sound when a resident wearing a monitoring device is within eight to nine feet of the door. The actual alarm sound was increased to a higher decibel level to ensure all staff can hear the alarm. Although the Immediate Jeopardy was removed on [DATE] when the facility initiated the above interventions, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility had not completed education of all staff and had not started audits to verify the corrective action taken was effective and being monitored for on-going compliance. Findings include: Review of the medical record revealed Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan initiated on [DATE] revealed Resident #57 was an elopement risk/wanderer as evidenced by impaired safety awareness and disorientation to place. The goal of the care plan revealed the resident was not to leave the facility unattended and to maintain her safety. Interventions included assisting the resident to another location, gaining the input of family/guardian for best approaches, involving the resident in leisure activities of choice, providing structured activities including toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes, and redirecting to appropriate surroundings/room setting as needed. Review of the wandering risk assessment dated [DATE] revealed the resident was at moderate risk. Resident #57 was also documented on the Fall Risk assessment dated [DATE] as at risk for falls. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated she had a short/long term memory problem, delusions were present, and she had verbal behaviors directed towards others. The MDS indicated the resident wandered daily and required extensive assistance of staff with bed mobility, transfers, dressing, toilet use, bathing, and hygiene tasks. She did not walk and used a wheelchair for mobility. Review of the physician orders [REDACTED].#57 had a signaling device (wander guard) bracelet placed on her left ankle. When Resident #57 attempted to go through the corridor door leading from the nursing unit to the assisted living unit, an alarm would sound to alert staff of her whereabouts. Review of the nurse's note dated [DATE] written at 7:12 P.M. revealed Licensed Practical Nurse (LPN) #2 was notified by STNA #5 that the resident was on the floor. LPN #2 observed Resident #57 on the landing at the bottom of the stairs and the wheelchair was on top of the resident. Resident #57 was assessed and had a head injury to her left side. A small amount of bleeding was noted on left forehead. Resident #57's right eye had a hematoma about golf ball size and multiple skin tears were noted on bilateral lower extremities. Her temperature was 97.6 degrees, pulse 68, respirations 22, blood pressure ,[DATE], and oxygen saturation level was assessed at 94%. LPN #2 called 911 and notified the physician and Resident #57's daughter of the incident. Staff were still in the stairwell assessing the resident when the emergency squad arrived at the facility. The emergency squad transported the resident to hospital. On [DATE] at 2:37 A.M. the nurse's note documented the hospital was contacted to follow-up on the resident. The hospital nurse reported the resident was admitted at 6:30 P.M. on [DATE] with a [DIAGNOSES REDACTED]. Review of the hospital's discharge notes dated [DATE] revealed the resident was found at the bottom of nine steps at the nursing home. The discharge notes revealed Resident #57 had multiple C-spine fractures including comminuted fracture of C-1 (cervical spine), comminuted fracture of C-2 with traumatic anterior subluxation which was highly unstable, and mildly displaced C-3 spinous process fracture. Resident #57 had some superficial injuries as well but there were no severe thoracoabdominal injuries. Regarding the resident's C-spine fractures, orthopedist discussed case with family and team and given overall picture; felt the resident was non-operational for fractures and she was kept in a collar. The discharge notes revealed Resident #57 began to develop increasing oxygen requirement and a heart rate variability with periods of bradycardia. Given the overall picture and in discussion with family, she was made a do not resuscitate comfort care with a plan for evaluation by Hospice/palliative care on the evening of [DATE]. On [DATE], Resident #57's respiratory status became more tenuous and the physician was called to the bedside at 12:30 P.M. for cessation of spontaneous respiration. The resident was pronounced expired at 12:46 P.M. The discharge note further revealed the immediate cause of death was A) cardiopulmonary arrest from respiratory failure due to B) fall down stairs with several C-spine fractures due to C) overall state of poor health and age. Review of the written statement (no date) from STNA #5 revealed at approximately 5:43 P.M. STNA #5 walked out of a resident room from picking up dinner trays and heard the wander guard (signaling device) alarm going off. She went up the hall past the nurses' station where the nurse was sitting. She looked down the hall and saw the hall was empty and as she walked by Room #302, she heard the water running and saw that the fire alarm box had been tampered with. STNA #5 opened the hall door and looked down the steps and saw Resident #57 lying at the bottom of the steps with the wheel chair on top of her. STNA #5 then notified LPN #2 who instructed STNA #5 to notify Registered Nurse (RN) #4. STNA #5 ran down to the second floor and notified RN #4 and LPN #6. Review of the written statement from STNA #7 dated [DATE] revealed STNA #7 was attending to a resident in Room #319 and when she came out of the room, STNA #5 stated that Resident #57 fell down the steps. The statement further revealed STNA #7 ran down the hall to the stairwell where she saw Resident #57 lying on a small landing at the base of nine steps and the nurse standing there. A review of LPN #2's statement (no date) revealed she was on the hallway doing medication pass and was putting the carts back at the nurses' station. She had just arrived at the nurses' station when STNA #5 informed her Resident #57 was on the stairs. She rushed to the stairs and found Resident #57 on the floor with the wheelchair on top of her. She moved the wheelchair and assessed the resident. Resident #57 was bleeding on her left forehead. Her left eye was swollen shut. STNA #5 had walked back to where STNA #7 was and when they came back, LPN #2 asked her to get the other nurse (RN #4). LPN #2 called 911 at 5:50 PM. After calling 911, LPN #2 called the family member to inform her of the fall. Review of RN #4's statement (no date) revealed STNA #5 came to the second floor at 5:50 P.M. and notified her Resident #57 was on the floor in the hallway at the bottom of the stairwell. When RN #4 arrived at the stairwell the resident was yelling "get me up" . Resident #57 had a gown, non-skid socks, and a wander guard on. Resident #57's chair alarm was also sounding. The resident was lying on her left side with her left arm and leg underneath her. Resident #57's head was bleeding. Resident's right eye had a golf ball size hematoma above it. Resident # 57 was alert when RN #4 arrived with confusion which was normal for the resident. The emergency squad arrived at 6:02 P.M. and they (the squad) took over at that time. On [DATE] at 10:00 A.M., the corridor door the resident eloped from prior to her fall was observed. The corridor door led from the nursing home 300 unit into the Assisted Living unit into a large library. This corridor door was used by Assisted Living residents who were walking to the designated smoke area. The corridor door also opened to a hallway that led to various management staff offices. When the corridor door was opened from the nursing unit, there was a stairway located immediately to the right with two flights of steps leading to the second floor which was at ground level. Resident #57 who was in a wheelchair, opened this corridor door, exited through the door, then fell down nine cement steps to an approximate 4.0 by 8.5 foot cement landing. During an interview with the DON on [DATE] at 3:10 P.M. he stated the incident occurred the day after Thanksgiving ([DATE]) and he was not present at the facility. At 5:40 P.M., the alarm to the corridor exit door went off. STNA #5 responded. She had been picking up supper trays in the dining room around the corner from the corridor door. She stated she responded at approximately 5:43 P.M. She stated she heard water running full blast in the room by the exit door and she stopped there first. She turned off the water. She noticed the fire alarm box by the corridor exit door was tampered with. She went through the door and saw Resident #57 lying on the landing. The DON stated the Administrator was contacted regarding the fall and was at the facility 15 minutes later. He stated the Administrator had been suspended on Friday [DATE] by the facility's corporate staff. He stated a sign to close the corridor door tightly was placed on the corridor door on [DATE]. He further stated on [DATE] at 5:00 P.M. a staff member was placed at a desk in front of the door to monitor the door continuously. He stated he had not completed any in-servicing of the staff regarding residents who were elopement risks and how to keep them safe. He stated he would start in-servicing immediately. He confirmed no monitoring of the residents at risk for elopement had been completed and he did not notify the medical director of the incident and the resident's injuries. On [DATE] at 10:50 A.M., interview with RN #4 revealed on [DATE] she was working on a new admission on the second floor. An STNA came and got her at about 5:50 P.M. but she could not remember which STNA it was for sure because it happened so fast. She ran to the stairwell and found Resident # 57 lying on her left side. The resident was trying to get up and stated "help me up." Her wheelchair was moved off the resident and put to the side. It was still alarming. Her right eye was closing and had a large hematoma. RN #4 stated she brought LPN #6, the second floor nurse, with her. LPN #6 used towels to apply pressure on the head wound while RN #4 assessed her and took her vitals. She stated she was not finished with her assessment when the squad came and took over. During a telephone interview with STNA #5 on [DATE] at 11:15 A.M. she stated on [DATE] at the end of dinner, she and STNA #7 were working the 300 unit along with LPN #2. The other nurse, RN #4, had been pulled to the second floor to do an admission. She stated they were picking up trays at the dining room around the corner and also in rooms. She stated she had helped STNA #7 in Room #319. She stated STNA #7 stated that it sounded like a wander alarm was going off. STNA #5 went down the hall to check. LPN #2 was standing by the medication room. The alarm was sounding through the call box on the desk. STNA #5 stated she walked past the nurses' station, then the elevator. She stated she knew no one with a wander guard was on the elevator because the doors would not have been closed. The wander guards prevent the elevator door from closing. She stated she heard water running in Room #302. She went into the room and turned off the water and did not see anyone in there but right outside Room #302 is the corridor door. The fire alarm box next to the door had been tampered with. When STNA #5 opened the door, which was still alarming, she saw Resident #57 on the first landing and the wheel chair was on top of her. She stated she yelled for the nurse and stated Resident #57 had fallen. LPN #2 came down the hall and then she (STNA #5) went to get STNA #7 and RN #4. She stated she found the resident less than a minute or two after the alarm went off. During a telephone interview with STNA #7, on [DATE] at 11:24 A.M., she stated she was doing dinner with the other aide (STNA #5). She stated Resident #57 must have left the dining room and was roaming the hall as usual. STNA #7 stated she went into a resident's room to take care of her. The alarm went off while she was in the room taking care of a resident who was yelling. STNA #7 stated she didn't hear the alarm. It was then the other aide approached her and told her to come down to the stairs. STNA #7 ran down to the steps and saw Resident #57 on the landing. Again, STNA #7 stated she did not hear the alarm go off. On [DATE] at 12:30 P.M., the corridor door alarm was tested with the use of an activated wander guard device. The DON walked up to the corridor door on the 300 unit (the door Resident #57 wandered out of) holding the activated device. Approximately one foot from the door, a low tone beeping sound was heard, and at this distance the alarm panel at the nursing station did not sound or show any warning. The DON stated the low tone would be hard to hear. When he opened the corridor door holding the device and crossed the door's threshold, a louder alarm was heard. The alarm was activated and also the call box located at the nurses' station was activated at this time. The DON confirmed the louder alarm was not activated until he was already out of the door. During a telephone interview with LPN #2 on [DATE] at 3:09 P.M., she stated she was instructed by her attorney not to speak to the surveyor. On [DATE] at 3:35 P.M. an interview with the Assistant Director of Nursing (ADON) #18 revealed she checks the residents' wander guard bracelets daily using a scanner. The scanner reads the codes on the bracelets and indicates that it is functioning correctly or not. She then records the checks on a wander guard function and alarm sheet daily. The wander guard function and alarm sheets were reviewed and indicated that the wander guard bracelets were checked daily. On [DATE] at 3:54 P.M., Environmental Facility Director (EFD) #10 stated her department checks the door alarms monthly. When asked why the alarm did not go off until the door was opened, she stated the bracelet probably was not activated correctly. She stated it has to be activated or it does not work correctly. She then went to the corridor door and used an activated bracelet to cause the alarm to go off. Again, the alarm did not start alarming until approximately one foot in front of the door with a faint beeping sound and when the door was opened and she crossed the threshold it began to alarm loudly. EFD #10 stated the alarm was initially used with individual annunciators, which nursing staff would carry, and that is why the sound at first is so low. She stated she did not know why the alarm did not sound fully until the person crossed the threshold. EFD #10 stated she checked the door alarms monthly by activating the alarm with a wander guard bracelet and documented the checks on a doors, locks, gate, and alarm test operation monitoring log. She verified that when she checked the doors monthly the system was still set up to function with the individual annunciators that were no longer used by nursing staff and the door alarm did not activate fully until the person crossed the threshold. The monitoring logs were reviewed and showed the door alarm was checked monthly. Review of the facility's policy for Wandering/Elopement Risk revealed the following: 7) A resident will be considered at high risk and will require a secure care wandering device if a score of 10 or higher is noted on the Wandering/Elopement Risk Assessment and they meet at least 1 or more of the following criteria a) verbalizes desire to leave facility b) is observed looking for exits c) witnessed attempts to leave facility d) is observed banging on door/windows 8) any resident wearing a secure care wandering device will require supervision when off the nursing unit. 9) Any resident wearing a secure care wandering device will have placement of device checked every shift and, 10) each, secure care wandering device will be tested daily to ensure proper functioning. Any device noted to be malfunctioning will be replaced immediately. This citation substantiates Complaint Number OH 175.

Based on observation, staff interview and record review, the facility failed to ensure residents assessed at high risk for falls had care planned fall interventions in place. This affected one (#43) of four sampled residents reviewed for falls when the resident's walker was not in left in reach and the resident fell and sustained a subdural hematoma. The facility census was 64. Findings include: Review of the medical record of Resident #43 revealed [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of Fall Risk Assessments dated 09/11/12, 12/04/12 and 03/03/13 revealed Resident #43 was assessed at high risk for falls due to disorientation, medications used, diagnoses, a history of falls, balance problems, gait pattern changes while walking, and use of an assistive device while walking. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #43 was not steady in terms of mobility, had a history of [REDACTED]. Nurse's Notes dated 09/12/12 revealed the resident was having difficulty with incontinence at night and the State tested Nurse Aide (STNA) was to check on the resident every two hours throughout the night. Review of the resident's fall care plan dated 09/30/12 revealed the resident was at risk for falls related to poor vision, incontinence, medication and medical factors. The care planned interventions included ensuring the call light was within reach, toileting the resident after awakening, prior to meals and after, and before bed and as needed, anticipating the resident's needs, and encouraging the use of assistive devices. The resident's incontinence care plan dated 09/30/12 revealed the resident was incontinent of bladder related to cognitive impairment. The care planned interventions included ensuring the call light was within reach. No toileting schedule or time period to check the resident for incontinence was included at that time. Nurse's notes dated 10/02/12 stated Resident #43 fell in her room and was found facing the bathroom door with no injury. Review of the Post Fall Investigation/Summary regarding the 10/02/12 fall revealed Resident #43 was attempting to toilet herself without the use of her walker. A fall prevention intervention to toilet the resident upon awakening, prior to meals and after, and before bed and as needed was again implemented. A care plan decision was added to toilet the resident with assistance on schedule and to encourage the resident to maintain her walker within her reach at all times. Nurse's Notes dated 10/06/12 at 2:35 A.M. revealed Resident #43 fell and sustained an injury to the right elbow. The notes stated the resident's walker and call light were in place and she did not use them. The resident was attempting to change her soiled clothes. Review of the Post Fall Investigation/Summary for 10/6/2012 fall revealed Resident #43 was attempting to change and toilet herself without utilizing her walker. An intervention to toilet the resident every two hours was implemented. A care plan decision was added to check to ensure the resident's walker was within reach at all times and if not, to place the walker within the resident's reach. There was no nurse's notes entries in the resident's record from 10/07/12 at 4:00 P.M. through 10/09/13 at 6:00 A.M. Nurse's Notes dated 10/09/12 at 6:00 A.M. stated the STNA told Licensed Practical Nurse (LPN) #2 that upon entering the resident's room she saw blood coming underneath the doorway. The STNA found Resident #43 on the floor facing away from the doorway. The documentation indicated the resident was alert and oriented times two and had a laceration to the back of head. 911 was called. Review of the Post Fall Investigation/Summary from the 10/09/12 fall revealed Resident #43 was ambulating in a dark room without her walker and fell and hit her head. An order was received to send Resident #43 to the emergency room for treatment and evaluation. The care plan decision included to toilet the resident at 2:00 A.M. and to leave the resident's door open and the bathroom light on during the night. Review of emergency room documentation from 10/09/12 revealed Resident #43 had an acute subdural hematoma and a small amount of subdural hemorrhage, and an eight centimeter scalp laceration. The resident had a low hematocrit and hemoglobin count as well. The scalp laceration required 18 staples to close. Review of the resident's re-admission assessment dated [DATE] at 3:45 P.M. revealed a [DIAGNOSES REDACTED]. The assessment revealed the resident required one person assistance to transfer and was to use a wheelchair only upon admission instead of her walker. The resident was assessed as incontinent of bladder and was to be assisted with toileting every hour. Observation on 04/22/13 at 11:50 A.M. revealed Resident #43 was in the dining area on the third floor using a rolling walker with a steady gait. On 04/23/13 at 2:15 P.M., Resident #43 was observed in her room seated in a chair with a walker next to her chair. On 04/23/13 at 4:42 P.M. and on 04/24/13 at 10:15 A.M., Resident #43 was observed ambulating with a walker in the hallway with a steady gait. During interview on 04/24/13 at 12:10 P.M., the Administrator stated STNA #5 did not do proper checks of Resident #43 on 10/09/12. The Administrator stated the resident's call light was within reach at the time of the fall but her walker was not next to her bed as care planned. During interview on 04/24/13 at 1:54 P.M., LPN #20 stated Resident #43 was able to transfer from the bed and walk independently with a walker. LPN #20 stated Resident #43 was not always compliant with using the call light or her walker in her room. She stated however when the walker was accessible the resident would use it. Interview with Assistant Director of Nursing (ADON) #1 on 04/25/13 at 11:55 A.M., revealed on 10/09/12 the staff did not place Resident #43's walker in the appropriate place. ADON #1 stated the resident would not have been able to reach the walker to get to the bathroom where it was placed. ADON #1 stated fall prevention interventions were care planned but not put into place at the time of Resident #43's fall on 10/09/12. Further interview with ADON #1 on 04/25/13 at 3:35 P.M. revealed the facility's policy was to document on post-fall documentation. ADON #1 stated documentation of interventions in place at the time of the resident's falls on 10/02/12 and 10/06/12 was not available. ADON #1 further confirmed there was no nurse's notes from 10/07/12 at 4:00 P.M. until 10/09/13 at 6:00 A.M. Review of the staff disciplinary action related to Resident #43's 10/09/12 fall, revealed Licensed Practical Nurse (LPN) #2 was off the unit for an unspecified amount of time at the time of the resident's fall and STNA #5 failed to follow Resident #43's care plan.