Every finding on record at Shawnee Manor

Based on record review, family interview, and staff interview, the facility failed to ensure a resident's Bilevel Positive Airway Pressure (BiPAP)/Continuous Positive Airway Pressure (CPAP) Continuous Positive Airway Pressure (CPAP) machine was being implemented per physician recommendations and care plan. This affected one (Resident #1 )of three residents reviewed for the use of CPAP machines. The facility census was 129.Findings include:Review of the medical record for Resident #1 revealed the resident was admitted to the facility on [DATE] and discharged to another facility on 10/14/25. Diagnoses included congestive heart failure, obstructive sleep apnea, bronchiectasis, and chronic respiratory failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition and was receiving non-invasive oxygen therapy.The care plan dated 05/18/22 revealed Resident #1 was at risk for altered respiratory status. Interventions include assist Resident #1 ensuring the BiPAP)/CPAP mask was in place per order nightly.Review of Resident #1's physician orders dated 08/11/22 to 10/14/25, including discharge orders, revealed there was no physician order for the BiPAP/CPAP therapy machine. Per the order dated 05/04/24 the staff were ordered to cleanse the BiPAP mask weekly every Sunday.Resident #1's medical record including Treatment Administration Records (TAR), task worksheets, and nursing progress notes did not have evidence the BiPAP/CPAP was administered to Resident #1 every night as noted in the care plan.Interview on 02/26/26 at 11:50 A.M. with Resident #1's family representative revealed the resident did have an order upon admission to the facility for a CPAP machine. Per the family representative, the facility failed to ensure the resident was using the CPAP machine the physician's order. The family representative stated she was informed the resident was not always using the CPAP machine but was not told when the resident was refusing the therapy.Interview on 02/26/26 at 2:15 P.M. with the Administrator and the Director of Nursing (DON) verified Resident #1's medical records were lacking in documentation regarding the administration of the BiPAP/CPAP machine and verified there were no physician orders to administer it nightly but there should have been. This deficiency represents non-compliance under Complaint Number 2705837.

Based on observation, staff interview, and policy review, the facility failed to ensure food products were not stored in medication carts near biologicals, ensure medication was stored in the original packaging and labeled with resident identification, failed to ensure all prepackaged medication remained in their resident labeled box, and failed to ensure insulin and medications were dated upon opening. This affected three of six medication carts and two of two medication rooms. This had the potential to affect 23 residents who received medications from the D-hall medication cart, 24 residents who received medications from the A-hall cart, one resident receiving ear drops from the F-Hall cart, and five resident receiving insulin from insulin pens from the A-hall cart. The facility census was 119. Findings include: 1. Observation and interview on 02/12/25 at 9:03 A.M of the F-hall medication cart revealed one opened bottle of a generic ear drops, for wax build-up, with no open date in the third drawer. Interview with Licensed Practical Nurse (LPN) #533 verified the ear drops had no open date. 2. Observation and interview on 02/12/25 at 9:20 A.M. of the A-hall medication cart revealed an unmarked, clear, plastic medication cup with nine various tablets and/or capsules located in the top drawer. There was Resident #84's Basaglar Insulin pen, opened, without an open date. Interview with LPN #424 at 9:25 A.M. stated medications should be stored in their original package until they were ready to be administered to the resident and confirmed the Resident #84's insulin pen did not have an open date. 3. Observation and interview on 02/12/25 at 9:25 A.M. of the medication room in the memory care unit revealed one opened vial of tuberculin derivative dated 01/07/25. Interview with Staff Developer #411 verified the opened vial of tuberculin derivative was dated 01/07/25 and should be disposed of because it has been greater than 30 days. 4. Observation on 02/12/25 at 9:45 A.M. revealed bananas, bags of hot flaming onion chips, potato chips, cookies, Cheese-Its, Cheese-O's, and different types of crackers were noted in the bottom, left drawer of the D-hall medication cart along with opened containers of biologicals, including hemorrhoidal cream. Also there were 11 unopened, individual packages of Cymbalta (antidepressant) 20 milligram, with no resident's name, found in the back of the fourth drawer, behind boxes of resident medication. Two open bottles of artificial tears eye drops, undated, were located in the top drawer. Interview with License Practiced Nurse (LPN) #440 at 9:50 A.M. verified food was stored with biologicals, 11 packages of Cymbalta, and artificial eye drops were undated. Review of the policy titled Medication Storage in the Facility dated 12/19/24 revealed medications are stored in containers that meet legal requirements. Outdated medications are immediately removed.

Based on observation, staff interview, and record review, the facility failed to ensure call lights were within reach for the residents. This affected three residents (#31, #104, and #235). The facility census was 119. Findings include: 1. Record review revealed Resident #31 was admitted on [DATE]. Diagnoses included spastic hemiplegia affecting left nondominant side, abnormal posture, contracture on left elbow, and convulsions. Review of the care plan dated 11/29/24 revealed Resident #31 was at risk to make basic needs known on a daily basis with goal to monitor effectiveness of communication strategies and assistive devices. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was cognitively impaired. Observation on 02/10/25 at 7:21 P.M. revealed Resident #31 was laying on her left side in bed. Call light was on the right side of the bed wrapped around the handrail and stuck tightly between the mattress and handrail. Resident #31 was not able to see or reach the call light for assistance. Interview on 2/10/25 at 7:22 P.M. with Certified Nursing Assistant (CNA) #509 verified call light was stuck in between mattress and handrail and was out of Resident #31's reach. 2. Review of the medical record for Resident #235 revealed an admitted [DATE]. Diagnoses included displaced fracture of base of neck of left femur, cerebral palsy and intellectual disabilities. Review of the plan of care revealed Resident #235 was at risk for falls which included the intervention for a reachable call light. Observation on 02/11/25 at 4:44 P.M. revealed Resident #235 was lying in her bed with her touch call light on the night stand out of reach. Interview with Registered Nurse #437 verified the call light was not within reach of the resident and placed the touch call light by her hand. 3. Review of medical record for Resident #104 revealed an admitted [DATE]. Diagnoses included cognitive communication deficit, unsteadiness on feet, major depressive disorder, and mood disorder. Review of the care plan dated 11/19/24 revealed Resident #104 was at risk for falls which included the intervention of visually stimulating call light to remind and encourage use and be sure call light was within reach. Observation on 02/12/25 at 3:42 P.M. revealed Resident #104 lying in bed with call light at the foot of the bed on the floor out of the residents reach. Interview on 02/12/25 at 3:46 P.M. with Certified Nursing Assistant (CNA) #450 verified the call light was not in reach of Resident #104. CNA #450 picked the call light up from the floor and placed it in reach of the resident.

Based on medical record review, observation, and staff interview, the facility failed to ensure a resident who was dependent on staff for bathing received the necessary services to maintain good hygiene. This affected one (Resident #97) of one resident reviewed for activities of daily living (ADL). The facility census was 119. Findings include: Review of the medical record for Resident #97 revealed an admitted [DATE]. Diagnoses included infection of the skin, diabetes mellitus (DM), pressure ulcer of left and right buttocks, and spinal stenosis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #97 was cognitively intact. Resident #97 was impaired bilateral lower extremity and required assistance from staff with bathing and had three pressure ulcers. Review of the plan of care revealed Resident #97 was at risk for decline of ADL related to cellulitis, injury to right knee, morbid obesity, noncompliance, spinal stenosis, gait and or balance problems, incontinence, unaware of safety needs. Interventions included being totally dependent on staff for toileting and required one to two staff for bathing. Observation on 02/12/25 at 10:30 A.M. revealed Certified Nursing Assistant (CNA) #404 and #623 were performing bathing on Resident #97. CNA #623 washed her hands, filled a tub of warm water and placed five washcloths in the water. CNA #623 placed gloves on then retrieved a washcloth from the basin, placed liquid soap on it and washed the back and legs of Resident #97, which had blood on it due to open wounds. CNA #623 placed the blood-soiled washcloth into the basin and retrieved another washcloth to rinse soap off the resident. This was repeated to wash the buttocks of the resident. CNA #404 was helping to hold Resident #97 on his left side during the bathing. CNA #623 took the basin to the bathroom and cleaned out replaced with warm water. CNA #404 performed the perineal care on Resident #97 with clean wash cloths and put soiled washcloths in a plastic bag after using. Interview on 02/12/25 at 11:00 A. M. with CNAs #404 and #623 verified during bathing of Resident #97, CNA #623 did place soiled washcloths back into the basin of warm water during this bathing. CNAs #404 and #623 verified the washcloths should have not been placed back into the basin of warm water and should have been placed in a plastic bag so it would contaminate the water and would ensure infection control measures were followed. Review of the facility's undated policy titled Quality of Care Policy/ADL revealed each resident will receive and the manner will provide the necessary care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. In the area of ADL; a resident's abilities in ADL will not diminish unless circumstances of the individual's clinical condition demonstrate the diminution was unavoidable.

Based on medical record review, observation, and staff interview, the facility failed to ensure a resident's treatment for a skin tear was completed as physician ordered. This affected one (#12) of three residents reviewed for non-pressure related skin concerns. The facility census was 119. Findings include: Review of Resident #12's medical record revealed an admitted [DATE]. Diagnoses included carpal tunnel syndrome, type two diabetes mellitus, cognitive heart failure, and major depressive disorder. Review of a quarterly Minimum Data Set (MDS) assessment revealed Resident #12 was cognitively intact. Review of a skin issue assessment dated [DATE] revealed Resident #12 was noted with skin tear measuring 2.5 centimeters (cm) in length by 1.5 cm wide to the left forearm. Review of the physician orders dated 01/24/25 revealed an order to cleanse skin tear on left forearm with normal saline (NS), apply triple-antibiotic ointment (TAO), and covered with bordered gauze every day shift. Review of the treatment administration record (TAR) revealed Resident #12's left forearm dressing was documented as being completed on 02/09/25, 02/10/25, and 02/11/25. Observation of Resident #12's left forearm on 02/11/25 at 8:48 A.M. revealed the dressing was dated 01/08/25. Interview with Licensed Practical Nurse (LPN) #605 on 02/11/25 at 8:53 A.M. confirmed the dressing on Resident #12's left forearm was dated 01/08/25. LPN #605 confirmed the treatment was documented as being completed on 02/11/25. LPN #605 confirmed she had documented the treatment as being completed, but had not yet completed the treatment. LPN #605 stated the dressing was probably incorrectly dated 01/08/25 instead of 02/08/25. LPN #605 confirmed Resident #12's dressing was not changed as ordered.

Based on record review, observation, staff interview, and policy review, the facility failed to ensure hand and foot splints were applied per physician order. This affected one (Resident #1) of two residents reviewed for splints. The facility census was 119. Findings include: Review of the medical record for Resident #1 revealed an admitted [DATE]. Diagnoses included dementia, schizoaffective disorder, type two diabetes mellitus, extrapyramidal and movement disorder, osteoarthritis, intellectual disabilities, contracture of right shoulder and right elbow, and contracture of muscle right hand. Review of the care plan dated 01/09/25 revealed Resident #1 used a left wrist hand finger orthosis (WHFO), right c-splint elbow brace, PRAFO boots (a custom-fitted ankle foot orthosis that helps support the foot and ankle), palm protectors due to muscle weakness, contractures, and pain. Interventions included braces as ordered with no signs and symptoms of skin irritation and pain and no further decline through next review. Provide passive range of motion to affected were before and after application. Certified Nursing Assistants (CNAs) to apply braces per plan of care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had severe cognitive impairment. Resident #1 was dependent on staff for activities of daily living and had impairment on both upper and lower extremities. Review of the current physician orders revealed bilateral hand splints on in the morning and off in the afternoon as tolerated, right elbow brace on in the afternoon and off in the evening. Review of CNA tasks in the electronic medical record revealed there was no documentation regarding bilateral hand splints on in the morning and off in the afternoon (bilateral hand rolls to be in place when splints were not being worn) for the past 30 days. Review of the treatment administration record from 02/01/25 to 02/11/25 revealed braces were signed off for 02/11/25. Review of the progress notes for February 2025 revealed no documentation of resident refusing braces on 02/11/25. Observations on 02/11/25 at 7:11 A.M. and 9:00 A.M. of Resident #1 revealed the resident up in the wheelchair in the hallway. No braces or splints noted on hands, elbows, or lower extremities. Interview on 02/11/25 at 9:10 A.M. with Business Office Manager (BOM) #635 verified Resident #1 did not have any splints or braces on hands or elbows at this time. Review of the policy titled Range of Motion Policy revised 04/2016 revealed a resident with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Residents will be monitored for decline in range of motion on admission and quarterly thereafter.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure a fall intervention was in place when a resident fell . This affected one (Resident #335) of four residents reviewed of accidents. The facility census was 119. Findings include: Review of Resident #335's closed medical record revealed an admitted [DATE]. Diagnoses included depression, chronic kidney disease, malnutrition, atrial fibrillation, and seizures. Resident #335 was discharged from the facility on 01/20/25. Review of a five-day [NAME] Data Set (MDS) assessment dated [DATE] revealed Resident #335 was severely cognitively impaired and has had repeated falls. Review of a care plan dated 10/24/24 revealed Resident #335 was at risk for falls related to deconditioning, gait/balance problems, incontinence, cerebrovascular accident (CVA), and history of repeated falls. Interventions included to encourage the resident to rest after lunch as tolerated was added on 01/14/25 and wheel resident uses has her name name on it for identification was added on 01/20/25. Review of progress notes dated 01/12/25 at 11:56 P.M. revealed Resident #335 was found observed lying on the floor in front of a chair in her room. No injuries were noted. Review of an interdisciplinary team (IDT) note dated 01/14/25 at 7:35 P.M. revealed a root cause analysis of determined Resident #335's fall was caused from her being tired after lunch. The IDT discussed and determined the appropriate intervention was changing Resident #335's wheelchair to assist in comfort and security along with encouraging Resident #335 to rest after lunch. The progress notes dated 01/18/25 at 11:13 A.M. revealed Resident #335 was found by a nurse laying on the floor in the dining room underneath a table. Resident #335 was noted with a small abrasion and bleeding to the corner of her right eye. Resident #335 was sent to the emergency room (ER) for evaluation per request of family. The progress notes dated 01/18/25 at 5:30 P.M. revealed Resident #335 returned to the facility with no new orders. Review of the IDT noted dated 01/20/25 at 9:36 A.M. revealed a root cause analysis of determined Resident #335's fall was caused from not being in a tilt and space wheelchair. Further discussion with the IDT team determined the appropriate intervention to be labeling the correct wheelchair with her name. Interview with the Director of Nursing (DON) on 02/13/24 at 1:07 P.M. stated after Resident #335 slid out of her wheelchair on 01/12/25, it was determined she needed a tilted wheelchair. On 01/18/25, when Resident #335 fell in the dining room she was not in a tilt wheelchair. Staff had put her in the wrong wheelchair. It was believed the wheelchair had been sat at in the hallway. Interview with the DON, Administrator, and Therapy Director (TD) #306 on 02/13/25 at 2:20 P.M. confirmed Resident #335 was not in the correct wheelchair when she fell in the dining room on 01/18/25. Review of the facility's Fall Reduction Policy revealed it is the facility's policy to identify residents at risk for falls and to implement a fall reduction program to reduce the risk of falls and possible injury. A fall risk reduction plan will be incorporated into the resident's plan of care. This deficiency represents non-compliance investigated under Complaint Number OH00162227 and Complaint Number OH00161841.

Based on medical record review, observation, and staff interview, the facility failed to ensure a resident's respiratory equipment was changed as physician ordered. This affected one (#12) of three residents reviewed for respiratory care. The facility census was 119. Findings include: Review of Resident #12's medical record revealed an admitted [DATE]. Diagnoses included cognitive heart failure and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment revealed Resident #12 was cognitively intact. Review of the physician orders dated 04/07/24 revealed an order for oxygen maintenance, change oxygen (O2) tubing and supply bag weekly. Wipe down the concentrator and clean filter weekly. Change water jug weekly. Observation of Resident #12's oxygen concentrator humidification bottle on 02/11/25 at 8:48 A.M. revealed it was dated 12/29/24. Interview with Licensed Practical Nurse (LPN) #605 on 02/11/25 at 8:53 A.M. confirmed the dressing on Resident #12's O2 humidification bottle was dated 12/29/24. Review of the facility's policy titled Respiratory Service Disposable Supply Changes dated 05/01/24 revealed disposable supplies need to be dated when changed. O2 humidifier bottles needed to be changed weekly or as needed (PRN).

Based on medical review review, observations, resident interview, staff interviews, and review of facility's policy's, the facility failed to ensure staff implemented enhanced barrier precautions (EBP) during catheter and ostomy care. This affected one (Resident #79) of residents reviewed for catheter care. The facility census was 119. Findings include: Review of the medical record for Resident #79 revealed admitted [DATE]. The resident was admitted with diagnoses including urinary tract infection, multiple sclerosis, neuromuscular dysfunction of bladder, pressure ulcer to left hip, stage three, colostomy status, pressure ulcer to left buttock and dementia. Review of the physician's orders revealed an order dated 01/08/25 for changing ostomy appliance every three days and as needed (PRN). An oder dated 02/12/25 for indwelling Foley catheter 16 french with catheter care every shift. The Minimum Data set (MDS) assessment dated [DATE] revealed Resident #79 was cognitively intact and required extensive assistance for bed mobility, and totally dependent on staff for toileting. Resident #79 had an indwelling catheter and ostomy. A care plan relative to catheter and having multidrug - resistant organisms (MDRO) infection revealed the interventions included Resident #79 may be in EBP while residing at the facility. Resident #79 will understand that staff may be wearing appropriate Personal Protective Equipment (PPE) when they are completing high contact resident care activities. Interview and observation with Resident #79 on 02/12/25 at 9:00 A.M. stated the nurses and certified nursing aides wear gowns when performing his wound care but never wear a gown when changing the ostomy or catheter. The resident explained they only need to wear gowns for the wound due to the risk of infection. Observation of the sign above Resident #79's bed revealed EBP precautions and PPE included gowns and gloves to be used when performing any care during high contact resident care activities which included infection or colonized with an MDRO infection and for indwelling medical devices which included examples such as urinary catheter regardless of MDRO colonization status. Observation on 02/12/25 at 11:12 A.M. revealed Registered Nurse (RN) #402 was preparing to perform ostomy replacement on Resident #79. The nurse gathered all equipment needed, cleaned tray and washed her hands. The nurse placed gloves on and took off old ostomy bag and placed new ostomy by following physician's orders. The nurse gathered soiled ostomy bag and placed in garbage bag. The nurse did not put on a gown (PPE) during this procedure. Interview with RN #402 on 02/12/25 at 11:33 A.M. verified there was no other PPE (gown) used during the care for the ostomy due to Resident #79 was no longer on any kind of precaution. Observation and interview on 02/12/25 at 3:15 P.M. revealed CNA #520 was performing catheter care on Resident #79. CNA #520 gathered basin of warm water, wash cloths and garbage bag. CNA #520 washed her hands and put on gloves then proceeded to perform the catheter care per physician's orders. CNA #520 did not place a gown on at any time during this care. CNA #520 verified gloves were on but did not put on a gown to perform the catheter care. Review of the facility's undated policy titled Standard Precautions revealed it is the intention of this facility to use EBP in addition to standard precautions to prevent transmission of MDRO in our community. An impervious gown should be worn when high-contact resident care activities are being performed. EBP may be considered for the following situations which included infection or colonized with an MDRO when contact precautions do not apply and for indwelling medical devices such as urinary catheter regardless of MDRO colonization status. High contact resident care activities included device care or use wound care or any skin opening.

Based on observation, medical record review, staff interview, and review of the facility policy, the facility failed to provide two residents, #25 and #40, of five (#25, #40, #63, #67, and #80) reviewed for showers, with showers twice weekly. The facility census was 126. Findings include: 1. Review of the medical record of Resident #25 revealed an admitted [DATE]. Diagnoses include disorders of bladder, repeated falls, dementia, and diabetes mellitus type II. Review of the quarterly minimum data set assessment dated [DATE] revealed Residents #25 was cognitively impaired and was dependent for personal hygiene. Review of the Certified Nursing Assistant (CNA) documentation revealed Resident #25 received a shower on 11/29/24, 12/02/24, and 12/13/24 for the past 30 days with one refusal on 12/16/24. 2. Review of the medical record of Resident #40 revealed an admitted [DATE]. Diagnoses include dementia. Review of the quarterly minimum data set assessment dated [DATE] revealed Residents #40 was severely cognitively impaired and was dependent for all activities of daily living. Review of the CNA documentation revealed Resident #25 received a shower on 11/26/24, 12/17/24 for the past 30 days. Interview on 12/19/24 at 8:00 A.M. with Director of Nursing provided verification the showers were not documented as having been provided to the two residents. Review of the facility policy titled Activities of Daily Living, dated 04/29/16 stated the facility will provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and the plan of care. A resident who is unable to carryout activities of daily living will receive the necessary services to maintain good nutrition, grooming, personal and oral hygiene. This deficiency represents non-compliance investigated under Complaint Number OH00159551.

Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure clean and sanitary incontinence care was provided to two residents, #25 and #63, observed for incontinence care. The facility census was 126. Findings include: 1. Review of the medical record of Resident #25 revealed an admitted [DATE]. Diagnoses include disorders of bladder, repeated falls, dementia, diabetes mellitus type II, Review of the quarterly minimum data set assessment dated [DATE] revealed Residents #25 was cognitively impaired and was dependent for transfers and toileting. The assessment revealed Resident #25 was always incontinent of bladder. Observation on 12/19/24 at 7:05 A.M. revealed Certified Nursing Assistant (CNA) #221 completing incontinence care for Resident #25. CNA #221 did not remove the soiled gloves or perform hand hygiene prior to adjusting bed linens and numerous personal items on the overbed table. Resident #25's perineal area was free of any redness or open areas. 2. Review of the medical record of Resident #63 revealed an admitted [DATE]. Diagnoses include chronic respiratory failure, metabolic encephalopathy, traumatic subdural hemorrhage, diabetes mellitus type II, depression, and polyarthritis. Review of the admission minimum data set assessment dated [DATE] revealed Residents #63 was cognitively intact and was dependent for toileting hygiene. The assessment revealed Resident #63 was frequently incontinent of bladder. Observation on 12/19/24 at 10:10 A.M. revealed Certified Nursing Assistant (CNA) #227 providing morning and incontinence care for Resident #63. CNA #227 allowed Resident #63 to wash her own face. CNA #227 washed the chest, abdomen, and axilla areas of Resident #63 and dried them. CNA #227 assisted Resident #63 with donning her shirt using the same gloves. CNA #227 then washed the perineal and anal areas and dried them, and then placed a clean incontinent brief and pants on Resident #63, all while wearing the same soiled gloves. CNA #227 proceeded to touch Resident #63's personal blankets, and even CNA's personal shirt, all while still wearing her soiled gloves. CNA #227 removed her gloves at this point but did not perform hand hygiene. Interview on 12/19/24 at 10:35 A.M. with CNA #227 provided verification of the lack of removing soiled gloves and performing hand hygiene prior to touching clean clothing/objects. Review of the policy titled Use of Gloves, dated 07/2003, revealed hands should be cleaned after removing gloves. This deficiency represents non-compliance investigated under Master Complaint Number OH00160575, and Complaint Number OH00159551.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure a follow-up vision appointment was scheduled for a resident. This affected one (#54) of three reviewed for ancillary medical appointments. The census was 122. Findings include: Review of Resident #54's medical record revealed an admitted [DATE]. Diagnoses listed included protein calorie malnutrition, dementia, cognitive communications deficit, anxiety disorder, and hydrocephalus. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 had severed cognitive impairment and required limited assistance, required limited assistance with personal hygiene, and had corrective lenses for vision. Review of a optometry office appointment noted date 06/04/22 revealed Resident #54 should return to the office within six months for a dilated eye exam to monitor the health of the back of her eyes. Further review of Resident #54's medical record revealed no documentation of a follow-up optometry appointment within six months of 06/04/22. There was not documentation of any optometry office visits or in-facility optometrist visits. During an interview on 09/05/23 at 3:51 P.M. the Administrator confirmed Resident #54 had not had an optometry appointment since 06/04/22. The Administrator stated if a resident family does not follow-up the facility's social worker was responsible for making follow-up appointments. During an interview on 09/06/23 at 2:50 P.M. Resident Services Coordinator (RSC) #120 confirmed Resident #54 had not seen an optometrist since 06/04/22. Review of the facility's policy titled Quality of Care Policy/Activities of Daily Living dated 04/29/16 revealed to ensure that residents received proper treatment and assistive devices to maintain vision and hearing abilities, the facility will, if necessary, assist the resident in making appointments and by arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing devices. This deficiency represents non-compliance with Complaint Number OH00145958.

Based on medical record review, review of a medication error report/investigation and staff and resident interviews, the facility failed to ensure a resident received medications as ordered resulting in a significant medication error. This resulted in Actual Harm when Resident #45 was given another resident's (#01) medications on 01/05/23 and was subsequently admitted to the hospital with encephalopathy (altered brain function) due to the medication administration error. This affected one (#45) out of four residents reviewed for medications. Facility census was 126. Findings include: Review of the medical record for Resident #45 revealed an admitted [DATE] with medical diagnoses of metabolic encephalopathy, morbid obesity, insomnia, hypothyroidism, and hypertension. Review of the medical record for Resident #45 revealed a Minimum Data Set (MDS) assessment dated [DATE] which indicated Resident #45 was cognitively intact. The MDS documented Resident #45 required extensive staff assistance for bed mobility and bathing and required supervision with transfers and dressing. Review of the medical record for Resident #45 revealed a nurse's note dated 01/05/23 at 7:18 A.M. which documented Resident #45 was accidentally given Resident #01's medications. The note indicated the physician was notified and new orders were received to monitor Resident #45's vital signs. Further review of Resident #45's medical record revealed a nurses note dated 01/05/23 at 10:40 P.M. which indicated Resident #45 was sent to the emergency department due to complaints of feeling dizzy and loopy. Review of the medical record for Resident #45 revealed a hospital history and physical, dated 01/05/23, which documented Resident #45 was seen in the emergency department due to altered mental status. Further review of the history and physical revealed Resident #45 was diagnosed with mental status alteration toxic cause, altered mental status, and medication reaction. Review of the medical record for Resident #45 revealed a hospital physician progress note, dated 01/08/23, which indicated Resident #45 had acute encephalopathy due to a medication administration error. The physician note stated the encephalopathy had resolved. Review of the medical record for Resident #45 revealed a nurse's note dated 01/09/23 at 3:00 P.M. which documented Resident #45 had returned to the facility from the hospital. Review of the facility medication error reports from November 2022 to January 2023 revealed an incident on 01/05/23 in which a resident was given another resident's medications. The report did not include resident names. Review of the medication error investigation report for Resident #45 revealed on 01/05/23 Resident #45 was administered Resident #01's medications by Licensed Practical Nurse (LPN) #38. The investigation report indicated LPN #38 notified the physician and new orders were received. The investigation report revealed Resident #45 remained drowsy throughout the day and was sent to the emergency department and admitted to the hospital for observation. Further review of the medication error investigation report revealed Resident #45 received the following wrong medications: aspirin 81 milligram (mg) one tablet, FiberCon 625 mg two tablets, fluoxetine (antidepressant) 40 mg one capsule, Januvia (lowers blood sugar levels) 50 mg one tablet, lactobacillus (laxative agent) one tablet, Lipitor 20 mg one tablet, multivitamin one tablet, Nebivolol HCL (antihypertensive) 20 mg one tablet, potassium chloride extended release 20 milliequivalent's (mEq) one tablet, senna 8.6 mg one tablet, tamsulosin HCL (used to treat lower urinary tract symptoms) 0.4 mg one tablet, Tiptropium Bromide-olodaterol inhalation aerosol two puff inhale orally, famotidine (for acid reflux) 20 mg one tablet, Hiprex (prevent urinary tract infections) one gram one tablet, iron 325 mg one tablet, Lyrica (pain control) 300 mg one tablet, and Vitamin C 500 mg one tablet. Interview on 01/20/23 at 11:30 A.M. with the Director of Nursing (DON) stated the facility did not have a specific policy regarding accurate medication administration. The DON stated the nursing staff are to follow the Five Rights of medication administration when administering medications. The DON confirmed the Five Rights which included the right patient, right medication, right dose, right route, and right time. Interview on 01/20/23 at 11:40 A.M. with the Administrator and DON confirmed LPN #38 administered Resident #01's medications to Resident #45 on 01/05/23. The DON stated education was provided to LPN #38 on 01/05/23 and the rest of the nursing staff on 01/06/23. Interview on 01/20/23 at 1:09 P.M. with Resident #45 stated she was sent to the hospital due to the nurse gave her another residents medications. Resident #45 stated after receiving the wrong medications she became sick and was admitted to the hospital for several days. Resident #45 denied any issues with medications since that incident. Interview on 01/20/23 at 1:12 P.M. with the Administrator confirmed the facility had not conducted medication audits or monitoring of medication administration after the medication error incident on 01/05/23. The Administrator stated the audits on medication administration were started 01/20/23 and would be conducted on each shift three times per week for four weeks. This deficiency represents non-compliance investigated under Complaint Number OH00139120.

Based on medical record review, observation, staff and resident interviews, and policy review, the facility failed to ensure a resident consumed their medications at the time of administration resulting in unattended medications at a residents bedside. This affected one (#43) resident out of the three reviewed for medication administration. Facility census was 143. Findings include: Review of the medical record for Resident #43 revealed an admitted [DATE] with medication diagnoses of chronic respiratory failure with hypoxia, morbid obesity, epilepsy, and obstructive sleep apnea (OSA). Review of the medical record for Resident #43 revealed a quarterly Minimum Data Set (MDS) dated [DATE] which indicated Resident #43 was cognitively intact. The MDS documented Resident #43 required supervision with bed mobility, transfers, ambulation, and toileting. Review of the medical record for Resident #43 from 09/01/22 to 01/20/23 revealed no documentation to support the facility completed a medication self-administration evaluation. Observation with interview on 01/20/23 at 8:55 A.M. revealed Resident #43 lying in bed with bi-level positive airway pressure (Bipap) machine in place. Observation revealed a medication cup full of medications sitting on Resident #43's bedside table. Resident #43 stated the nurse brought his medications in his room and set the medication cup on his bedside table and left the room. Resident #43 stated he dozed off after the nurse left the room and did not take his medications. Resident #43 stated the nurses leave medication cups full of medications on his bedside table and leave the room at times. Interview on 01/20/23 at 8:57 A.M. with Licensed Practical Nurse (LPN) #130 confirmed she entered Resident #43's room and left the medication cup full of medications on Resident #43's bedside table and did not observe Resident #43 consume his medications. Review of facility policy titled Oral Medication Administration, dated 03/30/22, revealed the facility staff are to administer the medications and to remain with the resident while medication is swallowed. This deficiency represents non-compliance investigated under Complaint Number OH00139120.

Based on review of Quality Assessment and Assurance (QAA) sign-in documents and staff interview, the facility failed to ensure all required members attended a QAA meeting quarterly. This had the potential to affected all 82 residents. The facility census was 82. Findings include: Review of the QAA sign-in documents for July 2022 revealed the medical director did not attending the QAA meeting on 07/28/22. The last meeting the medical director attended was on 04/29/22. Interview on 08/18/22 at 2:50 P.M. with the Administrator verified the medical director did not attend QAA meeting on 07/28/22.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure residents were treated with dignity. This affected three (Residents #7, #17, and #27) of three observed for dignity. The facility census was 82. Findings include: Observations on 08/16/22 at 11:55 A.M. revealed Resident #17 was wearing slippers with the resident's first and last name typed in black letters across the top, visible to the public. Continued observation revealed Resident #7 was wearing non-skid socks with a white label with the resident's first and last name typed in black letters, visible to the public. Resident #27 was wearing athletic shoes with the resident's first and last name written in black ink. Interview on 08/16/22 at 2:37 P.M. with State tested Nursing Assistant (STNA) #16 verified the residents had their names labeled in an obvious area of their clothing, including footwear, visible to the public. Review of the facility's Resident Rights policy dated 11/08/16 revealed the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.

Based on record review, observation, and interview, the facility failed to ensure Resident #78's baseline care plan addressed Activities of Daily Living (ADL) care needs. This affected one (Resident #78) of five residents reviewed for care plans. The facility census was 82. Findings include: Review of medical record for Resident #78 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #78 required limited assistance of two staff members for ambulation and extensive assistance of one staff member for locomotion, dressing, eating, and bathing. Review of Resident #78's care plan dated 08/05/22 revealed no goals or interventions in place for ADLs. Observation on 08/17/22 at 9:29 A.M. of Resident #78 during morning care, revealed the resident required limited assistance for upper body bathing. Resident #78 was able to wash the front of their upper body. State tested Nursing Assistant (STNA) #105 washed, rinsed, and dried Resident #78's lower body, peri area, and back. STNA #105 dressed Resident #78 while in bed. Resident #78 required extensive assistance from STNA #105 to turn in bed. Interview on 08/17/22 at 12:38 P.M. with MDS Nurse #97 verified Resident #78's care plan did not address ADL care needs. MDS Nurse #97 reported Resident #78's care plan would be updated to reflect ADL care needs.

Based on medical record review, staff interview, review of Self-Reported Incidents (SRIs), and review of facility policy, the facility failed to ensure care plans were updated to reflect residents' current status. This affected two (Residents #10 and #28) of two reviewed for care plan revisions. The facility census was 84. Findings include: 1. Review of the medical record for Resident #10 revealed admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident required extensive assistance of two people for bed mobility and extensive assistance of one person for transfers. The resident had no falls since admission/re-entry. Review of the Nursing Fall Review dated 07/10/22 revealed Resident #10 had a recent fall while getting out of her bed and into her wheelchair. Immediate intervention included to put gripper socks on the resident. The resident was considered to be at moderate risk for falls. Review of Resident #10's care plan dated 06/15/22 revealed the resident was at moderate risk for falls related to de-conditioning and gait/balance problems. Interventions included to anticipate and meet the resident's need, ensure call light is within reach and encourage the resident to use it for assistance, respond to the resident's needs promptly, educate on the importance of calling for assistance prior to transferring, ensure PRAFO (a device that is worn on the calf and foot, similar to a boot) on while in bed as tolerated, ensure ankle foot orthosis (AFO) bracing orthotic therapy for mild to moderate joint stiffness, contracture, or [CONDITION(S)] of the ankle and foot) while up during day as tolerated, monitor skin/pain, perimeter mattress to assist with spatial recognition, physical therapy evaluation and treat as ordered and needed, and room modification to allow for optimum space for the resident to move about. Further review of the care plan revealed no intervention in place for proper footwear. Interview on 08/18/22 at 10:59 A.M. with Restorative Nurse #36 verified Resident #10's care plan did not address proper footwear and stated proper footwear was usually one of the first interventions implemented. Restorative Nurse #36 updated the resident's care plan on 08/18/22 at 11:05 A.M. 2. Review of the medical record revealed Resident #28 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was severely cognitively impaired. Review of the Self-Reported Incidents (SRI) dated 07/14/22 revealed Resident #28 was observed in bed with another resident. The local police department was notified, residents were separated, skin checks and body assessments were completed with no injury, and notifications were completed. Review of the SRI dated 08/01/22 revealed Resident #28 had a cane in the air and another resident reported Resident #28 had hit him on the arm. The residents were separated and assessed. Review of the SRI dated 08/12/22 revealed Resident #28 pushed another resident to the floor. Assessments were completed, no injury occurred, notifications were made, and fifteen minute check in place. Review of Resident #28's undated care plan revealed interventions in place for elopement including redirect exit seeking behaviors as needed, secure unit per physician order, staff will be aware of resident's location at all times, assess for fall risk, and distract resident from wandering by offering pleasant diversion activities, food, conversation, television and books. Further review of the care plan revealed no documentation addressing Resident #28 having other behaviors, including inappropriate and aggressive interactions towards others. Interview on 08/18/22 at 10:18 A.M. with the Administrator verified Resident #28's care plan did not include goals and interventions in place to address Resident #28's behaviors. Review of the facility policy titled, Resident Assessment, revised 11/02/16, revealed the facility will develop a comprehensive person centered care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must periodically reviewed and revised by a team of qualified persons after each assessment.

Based on medical record review, observation of Snapchat video, resident interview, family interview, staff interview, review of the facility's Self-Reported Incidents (SRIs), review of facility handbook, and review of facility policy, the facility failed to ensure residents were protected from mental abuse by staff. This affected one (#11) of three residents reviewed for abuse and exploitation. This resulted in actual harm for Resident #11 when a staff member posted a video on the social media platform Snapchat in which Resident #11 could be identified sitting on the toilet with feces on her leg, including a statement that the situation made the staff member pissed. Resident #11 suffered psychosocial harm when she reported the situation had caused her increased anxiety and depression and stated she could no longer trust the staff. The facility census was 84. Findings Include: Review of Resident #11's medical record revealed an admitted [DATE] and a readmitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's Minimum Data Set (MDS) dated [DATE] revealed Resident #11 was cognitively intact. Resident #11 required limited assistance with transfer, dressing, toilet use, and personal hygiene. Review of Resident #11's progress notes dated 01/21/22 revealed Psychiatric Certified Nurse Practitioner (PCNR) #591 documented Resident #11 was seen by psychiatric services for her scheduled 30 day follow up visit. Resident #11 reported her mood hadn't been real good. She stated an aide took pictures of her when she was getting ready for the day and Resident #11 was told the aide posted them. Resident #11 reported she had trust issues anyway and reported increased depression and anxiety following the incident. Resident #11 reported the increase in anxiety because she didn't know what she did or said to the aide. It was noted Resident #11 had increased depression due to an incident that occurred with an aid at the facility. Review of a the facility investigation and SRI # 9 revealed on 01/15/22 the Director of Nursing (DON) was made aware of a video that was put on State tested Nurse Aide (STNA) #568's Snapchat social media of Resident #11 in which her face was not visible, but her lower body and feet were visible. The video was sent to the facility by the daughter of Resident #11 to Licensed Practical Nurse (LPN) #473 who reported it immediately to the DON. An investigation was started, and the SRI was filed. During interviews Resident #11's daughter reported Resident #11's brother was sent the video and recognized Resident #11 because of the rainbow tie-dyed colored Crocs she was wearing on her feet. Resident #11's brother did not know who took the video, but indicated he received it on 01/15/22 from STNA #507. STNA #507 reported she had not opened the Snapchat video from STNA #568 until 01/15/22. When she saw the video she immediately let Resident #11's family know as she was friends with Resident #11's brother. The facility identified STNA #568 had not worked with Resident #11 since 01/11/22. STNA #568 was terminated prior to the 01/15/22 allegation for attendance issues. STNA #568 was not able to be reached by the facility for an interview until 01/19/22. During the interview STNA #568 admitted to taking a photo of Resident #11 and herself but deleted it because she was told it was illegal. STNA #568 denied taking a video and denied having any of Resident #11's family connected to her Snapchat account on social media. STNA #507 was interviewed and reported she it was STNA #568's Snapchat account on social media because they were connected through the platform as friends. STNA #430 was interviewed and reported she had not heard of the video until 01/17/22 and she viewed it then. STNA #430 reported STNA #568 admitted to her she was the one who sent the video and she thought it was ok because she covered Resident #11's face. Resident #11 was interviewed and reported she was not aware of anyone taking her picture. Resident #11 was interviewed again on 01/19/22 and stated she did not understand why someone would do that to her. The facility's conclusion after investigation of the incident was mental abuse was unsubstantiated. The incident did not meet the definition because Resident #11 was unaware the photo was taken, and the resident's face was not visible in the photo. Resident #11 also had no negative psychosocial affects related to the incident, and will continue to be monitored. Interview on 01/24/22 at 12:03 P.M. with the Administrator revealed the video of Resident #11 was sent to the DON on the 01/15/22 and the facility immediately began their investigation as soon as they were aware. It was determined STNA #568 was friends with some of Resident #11's family members and they were connected via social media on Snapchat. A family member of Resident #11 saw the video and shared it with other members of the family. The family identified the person in the video was Resident #11 by her unique shoes. STNA #568 was interviewed when she returned to the facility to get her final paycheck. She denied she took the video, but other staff members were interviewed and reported she had confessed to them she had taken the video, saying she was not aware it was illegal. The Administrator reported STNA #568 had actually been terminated prior to the facility learning of the video for attendance issues. The Administrator verified the video existed and it was a STNA #568 who had taken the video. The Administrator during interview Resident #11 did not see the video but was told what was in it. Resident #11 was assessed and no ill affects were noted by the facility and they continued to monitor her. Observation on 01/25/22 at 9:37 A.M. of the Snapchat social media video on the Administrator's computer revealed a one second video of an african american female seated on the toilet with feces running down her left leg. The woman was not identified and her face was not visible. A square cartoon character image (Bit Emoji) of STNA #568 was placed over the woman's face and upper torso. The woman was wearing rainbow tie-dyed Croc brand shoes. A typed statement was across the bottom of the photo read, Bruh, now I am pissed and ready to f-ing go. Coinciding interview with the Administrator revealed they were not able to identify the resident but the family was able to based on the woman's rainbow colored shoes. The Administrator reported as far as he was aware there were no other residents in the facility with those shoes. Interview on 01/25/22 at 11:27 A.M. with Resident #11's daughter verified Resident #11 was the person in the video. Resident #11's daughter reported they were able to identify Resident #11 by her body shape and her shoes. Resident #11's daughter reported she had bought her mom the rainbow tie-dye Croc shoes she was wearing in the video. Resident #11's daughter reported she spoke with Resident #11 every day and Resident #11 had reported to her she did not feel she could trust anyone at the facility after the incident and wanted to go home. Interview on 01/25/22 at 12:03 P.M., Resident #11 reported she felt safe in the facility but since her privacy was invaded she did not feel she could trust the staff. Resident #11 stated she did not know why someone would do that to her. Review of the undated facility handbook section titled Social Media, revealed the facility expected staff to exercise good judgement when using social media platforms and the facility would not tolerate unlawful or inappropriate communications on social media sites. Any conduct that would be grounds for disciplinary action if performed at work will be grounds for disciplinary action if performed online when interacting other employees or relating to work. Accessing, posting or using social media sites during work hours was prohibited. Posting false and/or defamatory information about it's customers, employees or affiliates was also prohibited. Misuse of social media was subject to disciplinary action up to and including termination. Review of the facility policy titled Abuse, Neglect, and/or Misappropriation of Resident Property Policy, revised 04/22/21. revealed exploitation was taking advantage of a resident regardless of whether the action was for personal gain, whether the resident knew of the action or whether the resident was harmed. The facility would not tolerate abuse or neglect of it's residents. This deficiency substantiates Complaint Number OH 395.

Based on observation, staff interview, review of facility policy, and review of the Center for Disease Control and Prevention (CDC) guidance, the facility failed to ensure staff who tested positive for COVID-19 did not return to the resident unit, wore N95 respirator's properly, and performed hand hygiene when handling the N95 respirator. This had the potential to affect all residents in the facility. The facility census was 84. Findings include: Observation on 01/24/22 at 9:50 A.M. found Administrative Assistant (AA) #546 interviewing State tested Nursing Assistant (STNA) #542 regarding contact tracing and her contact and interactions with residents. While the questionnaire was being completed STNA #542 was observed to have her N95 respirator on with both straps low on her neck. STNA #542 had difficulty keeping the N95 up over her mouth and nose. It was observed rolling and twisting with STNA #546 using her right hand to untwist and pull the N95 back up over her nose. STNA #546 did not perform hand hygiene before or after touching her N95. No hand sanitizer was observed to be available in the area. Upon completion of the contact tracing questionnaire AA #546 directed STNA #542 to go back on the floor and let her coworkers know she would be leaving for the day. STNA #542 responded by adjusting her mask and stating What? AA #546 repeated her instructions for STNA #542 to go back on the floor and tell her coworkers and the nurse she would be leaving for the day. STNA #542 adjusted her N95 again and walked down the hallway. No hand hygiene was performed. Interview on 01/24/22 at 10:00 A.M. with AA #546 verified STNA #542 tested positive for COVID-19 and she had sent her back on the floor to notify her coworkers she would be leaving for the day. AA #546 also verified there was no hand sanitizer available in the area for STNA #542 to use before or after she repeatedly adjusted her N95 respirator and no hand hygiene was completed. Interview on 01/24/22 at 10:54 A.M. with Infection Preventionist, Licensed Practical Nurse (IPLPN) #536 verified STNA #542 should not have been directed by AA #546 to go back on the floor. She reported the facility protocol was for the positive staff person to leave the facility immediately, their possessions would be gathered for them if there were items in the facility, and the staff would notify the scheduler and coworkers of the staff being off for the day. Review of the facility policy titled COVID-19 Protocol COVID-19 Confirmed Positive Within the Care Community, revised 11/16/21, revealed if a staff member tested positive with COVID-19 they would be immediately removed from the facility and notifications would be made. Review of the CDC guidance titled How to Use Your N95 Respirator, revised 01/25/22, revealed N95s must form a seal to the face to work properly. Wash your hands prior to application. Pull the top strap over your head, placing it near the crown. Then, pull the bottom strap over and place it at the back of your neck, below your ears. Do not crisscross the straps. Make sure the straps lay flat and are not twisted. After you adjust or remove your N95, wash your hands with soap and water, or hand sanitizer containing at least 60% alcohol if soap is not available. This deficiency substantiates Master Complaint Number OH 610 and Complaint Number OH 461.

Based on medical record review, observations, staff and physician interviews, review of the facility policy/skills checklist for transferring a resident with a mechanical lift (Hoyer), review of hospital documentation and reports, review of the facility investigation including witness statements and review of the death certificate, the facility failed to ensure a resident requiring transfers with a mechanical lift was transferred safely. This resulted in Immediate Jeopardy when Resident #02 sustained serious life-threatening injuries during an avoidable fall from a mechanical lift, resulting in an acute fracture of cervical (C) 2 and C3, a left occipital acute hemorrhage and subarachnoid hemorrhage of the left temporal lobe and subsequently expired at the hospital. This affected one (#02) of three residents reviewed for utilization of a mechanical lift for transfers. The facility identified 38 residents requiring the use of a mechanical lift for transfers. The facility census was 104. On [DATE] at 4:10 P.M., the Administrator and Regional Registered Nurse (RN) #201 were notified Immediate Jeopardy began on [DATE] at 9:30 A.M. when State tested Nursing Assistant (STNA) #302 transferred Resident #02 from her bed to the wheelchair using a mechanical lift without another staff member present. STNA #302 reported the top left corner of the lift pad gave way and the resident slid from her torso down to the ground and landed on her left side. The facility policy required two staff members present when completing a mechanical lift transfer. Resident #02 was sent to the emergency room via Emergency Medical Services (EMS) where she was diagnosed with [REDACTED]. The death certificate listed the cause of death as [MEDICAL CONDITION] due to a fall from the Hoyer lift. The Immediate Jeopardy was removed on [DATE] at 1:00 P.M. when the facility completed all staff in-service training regarding appropriate mechanical lift techniques and implemented the following corrective actions: · On [DATE] at approximately 9:30 A.M., Resident #02 was immediately assessed and sent to the emergency room (ER) for evaluation and treatment. The resident ' s family and physician were immediately notified of the incident. · On [DATE] at approximately 9:30 A.M., STNA #302 who performed the mechanical lift transfer of Resident #02 was immediately removed from the floor and interviewed by the Administrator. · On [DATE], the Administrator reviewed the personnel file for STNA #302 who completed the mechanical lift transfer. STNA #302 had been trained on the use of the mechanical device upon hire on [DATE]. No performance issues related to mechanical lift transfers were identified. At approximately 2:00 P.M., STNA #302 was terminated per progressive discipline that was unrelated to specific care issues. · On [DATE] at 10:00 A.M., Maintenance Director #600 took the mechanical lift used for the transfer of Resident #02 out of service and inspected the lift prior to returning it to service. Maintenance Director #600 initiated audits of all mechanical lifts and was completed on [DATE] at 12:00 P.M., with no concerns identified. · On [DATE] at 8:00 P.M., the Administrator completed an audit of maintenance records of the mechanical lift inspections and no concerns were noted. · On [DATE] and [DATE], the Restorative Nurse/or designee provided in-service education to all nursing staff on the proper use of the mechanical lift. · On [DATE] at 4:00 P.M., the Administrator and Regional Nurse #201 audited all mechanical lift pads in the building to ensure they were free of any damage (frays, tears, rips, etc.) and no concerns were identified. · On [DATE] at 1:00 P.M., Regional Nurse #201 and Registered Nurse (RN) #205 conducted care plan audits to ensure all residents that use mechanical lifts had care plans in place that addressed the use of mechanical lifts. · On [DATE], the Director of Nursing (DON) and/or designee, initiated audits for the proper use of lifts during a resident transfer. The audits were to be completed four times a week for four weeks, with all results reviewed at the Quality Assurance Performance Improvement (QAPI) committee meeting. Audits were completed on [DATE], [DATE] and [DATE], with no concerns identified. · Interviews on [DATE] at 12:40 P.M. with STNAs #306 and #308 and at 3:55 P.M. with LPN #413, all verified they received in-service training on mechanical lift transfers and had no concerns. Although the Immediate Jeopardy was removed, the deficiency remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #02 ' s medical record revealed an admission date of [DATE] and a discharge date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #02's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had severe cognitive impairment. Further review of the MDS revealed Resident #02 required total dependence of two or more staff for physical assistance for transfers. Review of the most recent plan of care revealed Resident #02 was at risk for falls related to dementia, muscle weakness, limited mobility, altered mental status, impaired safety awareness and incontinence. The care plan listed interventions including the use of a full mechanical lift as needed. Review of Resident #02 ' s physician order dated [DATE], revealed an order for [REDACTED].>Review of Resident #02 ' s nurses notes, dated [DATE] at 9:30 A.M., revealed STNA #304 notified Licensed Practical Nurse (LPN) #411, the resident had fallen during a transfer. The resident was on the floor on her left side by the bed and bleeding was noted from a laceration on her head. Emergency Medical Services (911) were notified, and the resident was transported to the ER for evaluation. On [DATE] at 9:55 A.M., Resident #02 ' s son and Certified Nurse Practitioner (CNP) #700 were notified of the incident and transfer to the ER. Review of the facility ' s investigation dated [DATE] revealed Resident #02 had been in bed when STNA #302 went to get the resident up with a mechanical lift. STNA #302 stated she had checked the connections before lifting the resident from the bed to the chair. STNA #302 stated the top left corner of the connection gave way and the resident slid from her top torso down to the ground. The resident landed on her left side. When STNA #302 was questioned about having two staff to transfer the resident, the STNA had stated nobody ever helps. STNA #302 did not ask for assistance with the transfer. STNA #302 stated she knew it was the facility ' s policy to have two persons to complete the transfer. The STNA was placed on leave following the investigation. Upon completion of the investigation, it was determined STNA #302 had transferred Resident #02 using only one person. It is a requirement at the facility that all residents transferred via mechanical lift were to have two staff members present during the transfer for safety. Review of STNA #304 ' s statement of incident, dated [DATE], revealed after the resident had fallen, STNA #302 came to STNA #304 and asked for help. STNA #304 observed the resident on the floor and the sling was hanging from the mechanical lift. STNA #304 stated STNA #302 did not ask her for assistance with the transfer of the resident. Review of LPN #411 ' s statement of incident, dated [DATE], revealed STNA #304 approached the LPN to inform her Resident #02 was lying on the floor. LPN #411 reported the resident was bleeding from her left forehead. Emergency services were notified, and the resident was transported to the hospital. Review of the hospital emergency room department notes for Resident #02 revealed the cervical spine Computerized Tomography (CT) results were acute fracture of C2 and C3 of the spine. CT results from of the head revealed left occipital acute extra-axial hemorrhage and associated subarachnoid hemorrhage left temporal lobe. Review of the Neurosurgical Consultation note for Resident #02 revealed a suboccipital extra-axial hemorrhage and left temporal lobe subarachnoid hemorrhage. Review of Resident #02 ' s death certificate dated [DATE] revealed the resident expired on [DATE] at 9:05 P.M. The cause of death was listed as [MEDICAL CONDITION] due to a fall from the Hoyer lift. During an interview on [DATE] at 10:15 A.M. with STNA #304, she stated she had been working on [DATE] on Buckeye hall. STNA #304 stated STNA #302 had transferred Resident #02 by herself and did not ask for help with transferring the resident with the mechanical lift. STNA #304 stated STNA #302 came and got her after the resident had fallen from the mechanical lift. STNA #304 stated she did not know why STNA #302 did not ask for assistance when transferring the resident. Interview on [DATE] at 11:00 A.M. with the Administrator and Regional Nurse #201 revealed on [DATE] there were two STNA ' s (#302 and #304) and LPN #411 working on the Buckeye Hall. The Administrator stated the hall was fully staffed. The Administrator stated it was the facility policy that two persons were required when transferring a resident with a mechanical lift. The Administrator verified only STNA #302 had transferred Resident #02 from her bed to the wheelchair. The Administrator stated during mid transfer of the resident, the lift pad gave way and the resident landed on the floor on her left side. STNA #302 notified STNA #304, then notified LPN #411 of the residents fall. Resident #02 was sent to the emergency room for evaluation. The Administrator stated all lift pads were inspected and found no concerns with the lift pads. Regional Nurse #201 stated the facility policy/skills checklist was in place that indicated two staff must be present when transferring a resident utilizing a mechanical lift. Telephone interview on [DATE] at 12:05 P.M. with Medical Director #520 revealed he had signed a death certificate for Resident #02 and had listed the cause of death as [MEDICAL CONDITION] due to a fall. Telephone interview on [DATE] at 1:30 P.M. with LPN #411, revealed STNA #302 transferred Resident #02 with a mechanical lift by herself and the resident fell to the floor. LPN #411 stated when she entered the resident ' s room, the resident was lying on her left side and her forehead was bleeding and she put compression on the resident ' s head and called for an ambulance. LPN #411 did not see how the lift pad was positioned on the mechanical lift. Telephone interview on [DATE] at 2:45 P.M. with STNA #302, revealed on [DATE] she had been transferring Resident #02 by herself with a mechanical lift from her bed to the wheelchair. STNA #302 stated the resident became agitated and started to grab the lift, the hooks came undone from the mechanical lift and the resident fell to the floor landing on her left side. STNA #302 stated she was aware the mechanical lift should have two staff present when completing the transfer. Observation on [DATE] at 12:40 P.M. of STNAs #306 and #308 completing a mechanical lift transfer for Resident #04 without any concerns. Both STNAs stated they were in-serviced on the facility policy requiring two staff to be present for mechanical lift transfers. Observation on [DATE] between 10:30 A.M. and 11:00 A.M. of two mechanical lifts and lift pads, revealed no concerns regarding the operation or the condition of the lift pads. There was also signage on the mechanical lifts that indicated a minimum of two people were required to operate the lift. Review of the facility policy titled, Skill Checklist-Transferring a Resident from Bed to Chair-Mechanical Lift, dated [DATE], revealed two people were always required when operating a mechanical lift. This deficiency substantiates Complaint Number OH 566.

Based on medical record review, staff interview, and review of facility policy, the facility failed to identify a potential pressure ulcer risk area and provide appropriate preventative measures to prevent the development of a pressure ulcer. This resulted in actual harm for Resident #200 who developed an avoidable Stage II pressure ulcer to the back of the left ankle that deteriorated to an unstageable pressure ulcer. This deficient practice affected one (#200) of three residents reviewed for pressure ulcers. The facility identified a total of three current residents with pressure ulcers. The facility census was 120. Findings include: Review of the closed medical review for Resident #200 revealed he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the admission minimum data set ((MDS) dated [DATE], revealed he was alert and oriented. The MDS coded him for extensive assist of two staff in most activities of daily living, secondary to the need for a long leg splint and non-weight bearing on the left leg. Further review of the MDS documented he was admitted without any pressure ulcers and was assessed to be at risk of developing pressure ulcers. The only intervention documented on the MDS was the use of a pressure relieving mattress to the bed. Review of the initial nursing assessment dated [DATE], identified there were no pressure ulcers and the resident utilized a left leg splint. Review of the facility's assessment tool entitled, "Pressure Ulcer Protocol", dated 02/20/13, identified Resident #200 was at high risk for development of a pressure ulcer. The instructional guide for this tool stated the resident would be monitored every week for four weeks after admission and changes documented in the medical record. Review of the assessment tool for Resident #200, revealed he was assessed on admission, 03/10/13 and 03/18/13. Review of the nurses notes on 03/09/13, documented a pressure area to the back of the left ankle. The weekly skin grid also dated 03/09/13, revealed this area to be a Stage II pressure area and measured one inch in length, one inch in width and one inch in depth. On 03/14/13, the weekly skin grid documented this area measured 3.5 centimeters(cm) by 4.6 cm by 0.2 cm. On 03/22/13, the weekly skin grid documented the would measured 6.0 cm by 6.7 cm by 0.1 cm. On 03/28/13, the weekly skin grid revealed the wound measured 7.0 cm by 7.5 cm and depth was unstageable. Review of the admission care plan dated 02/20/13, revealed he was at risk for potential of skin breakdown with interventions in place that included monitoring skin, turning and reposition, keep skin clean and dry, waffle cushion as ordered, elevate heel as ordered, provide pressure relief mattress and incontinent care as needed. Further review of the revised care plan dated 03/01/13, revealed he was at risk for skin breakdown. The interventions included a pressure reduction mattress and to provide incontinent care as needed. The other interventions were crossed out, including elevating the heels and turning and repositioning. On 03/09/13, the at risk for skin breakdown care plan was updated to include interventions of a multi-vitamin with minerals, to off the load heels while in bed and to provide a treatment as ordered by the physician. Review of physician orders [REDACTED]. On 03/14/13, the physician ordered ace wraps to bilateral lower legs due to pedal [MEDICAL CONDITION]. Review of the treatment administration records dated March 2013, revealed the facility was to off load the heels while in bed. There was no documentation to ensure the off-loading was being completed. Review of the nurses notes dated 03/18/13, revealed Resident #200 was found to have an additional open area to the right heel measuring 6 cm by 7.4 cm and less than 0.1 cm. On 03/26/13, the physician ordered wound cultures to be completed and ordered a wound consult. The wounds were cultured and contained bacteria and an antibiotic was ordered. On 04/02/13, the resident was seen at the wound clinic and was a direct admit to the hospital. Interview with the Director of Nursing on 04/13/13 at 2:30 P.M., revealed at admission when he was assessed as a high risk, the standard procedure would be to elevate the heels. She verified the care plan only addressed a pressure reduction mattress and did not include elevating the heels. She further verified the off-loading/elevating the heels was not added until after the development of the pressure ulcer on 03/09/13. Review of facility policy entitled, "Pressure Policy", dated as revised on 11/2010, revealed a resident who enters without a pressure ulcer will not develop one unless that the individual's clinical condition demonstrates that it is unavoidable. The policy indicated all residents will be assessed for pressure ulcer risk on admission, monitored weekly and reviewed quarterly and as needed. The policy further indicated all residents are placed on a pressure reduction mattress and other appropriate preventative interventions will be implemented (i.e. wheel chair cushion, offloading heels, etc). This deficiency substantiates Complaint Number OH 767.