Every finding on record at St Catherine's C C of Fostoria

Based on medical record review, staff interview, observation, review of staff written statements, review of the facility investigation, review of hospital records, review of emergency medical service (EMS) records, review of facility guidance for emergency medical codes, review of the facility's policy for cardiopulmonary resuscitation (CPR), and review of the American Heart Association guidance, the facility failed to timely respond and appropriately perform CPR for one resident (Resident #49) found unresponsive, without a pulse or respirations, and who was identified as a full code status. This resulted in Immediate Jeopardy, serious life-threatening harm, and ultimate death when Resident #49 was discovered by staff in bed with a change in condition approximately 48 minutes after his call light had been activated. Resident #49, who had a tracheostomy, remained in bed on a standard pressure reduction mattress while staff performed chest compressions without use of a backboard, with no rescue breaths (ventilation) administered, and without staff utilizing the emergency crash carts available in the facility. Resident #49 was taken to the hospital by EMS where it was discovered the resident had a blockage in his tracheostomy and was placed on a ventilator and transported to a second hospital for a higher level of care. While at the second hospital, Resident #49 continued on the ventilator and was diagnosed with a severe anoxic brain injury. Resident #49 died on [DATE] when life support measures were withdrawn. This affected one (#49) of three residents who died in the facility. This had the potential to affect 18 (#10, #11, #12, #13, #14, #15, #16, #17, #19, #20, #22, #25, #27, #40, #41, #43, #47, and #48) residents designated with a full code resuscitation status. The facility census was 39.On 08/24/26 at 1:54 P.M., the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on 08/14/26 at approximately 10:20 P.M. when Resident #49, who was a full code resuscitation status (full life saving measures are implemented in the event of cardiac and respiratory arrest), was found unresponsive by Certified Nurse Aide (CNA) #704. CNA #704 notified Licensed Practical Nurse (LPN) #707 of Resident #49 being unresponsive. LPN #707 assessed Resident #49 with no pulse or respirations and began performing chest compressions while the resident remained in bed. LPN #891 arrived at Resident #49's room and took over performing chest compressions on the resident. The crash cart was never obtained, there was no backboard used, and no rescue breaths were administered during CPR. EMS personnel arrived at the facility and moved Resident #49 to the floor, took over chest compressions, began using a bag-valve-mask and took Resident #49 to the hospital. While in the hospital, Resident #49 was diagnosed with an anoxic brain injury following cardiac arrest, and the resident ultimately expired in the hospital on [DATE], when life-sustaining measures were ceased.The Immediate Jeopardy was removed on 08/25/26 when the facility implemented the following corrective actions:- On 08/14/26 at 11:40 P.M., the Medical Director was notified of the incident.- On 08/17/26, the DON reviewed all residents' medical records for code statuses.- On 08/17/26, the DON audited all crash carts to ensure they contained the required equipment.- On 08/17/26 and 08/18/26, the DON and Minimum Data Set (MDS) Coordinator #710 completed mock code drills with all shifts to ensure the crash cart was obtained.- On 08/17/26 and 08/19/26, the DON provided education to all nurses regarding the facility's CPR protocol.- Beginning on 08/17/26, the DON or designee began code status audits of three residents per week for four weeks and then monthly for two months.- Beginning on 08/17/26, the DON or designee began crash cart audits for equipment three times per week for four weeks and then monthly for two months.- Beginning on 08/17/26, any concerns identified from the random audits were addressed immediately and reviewed by the quality assessment and performance improvement (QAPI) committee monthly to determine if current interventions were adequate or whether additional action needed implemented to ensure compliance.- As of 08/24/26, the facility had no other residents with tracheostomy tubes.- On 08/24/26, the Administrator, the DON, Scheduler #728, Human Resources Director/ Business Office Manager #730, Therapy Director #894, Activities Director #555, MDS Coordinator #710, and Medical Records Clerk #856 reviewed the policy related to CPR. Ongoing audits of all CPR events were added to the policy.- On 08/24/26, the DON educated all staff on staff responsible for obtaining crash carts.- On 08/24/26, the DON educated Respiratory Nurse #712 on ensuring an artificial manual breathing unit (Ambu bag), also called a bag-valve-mask or manual resuscitator, is kept at the bedside for all residents with tracheostomies.- Beginning on 08/24/26, Respiratory Therapist #550 educated nurses on one and two responder CPR with ventilations for advanced airways prior to applicable resident admissions.- On 08/24/26, the Administrator, the DON, Scheduler #728, Human Resources Director/Business Office Manager #730, Therapy Director #894, Activities Director #555, MDS Coordinator #710, Food Services Director #721, and Medical Records Clerk #856 conducted an ad-hoc quality assurance meeting and discussed the incident and corrective actions.- Beginning on 08/24/26, the DON will conduct audits of all CPR events that occur, to ensure appropriate equipment, ventilation, and surface are utilized and maintained. Audits will be ongoing.- On 08/24/26, the DON performed a root-cause analysis and identified an opportunity to enhance processes related to emergency equipment readiness and accessibility at the point of care.- On 08/25/26, the DON began educating all staff regarding the use of backboards and/or ensuring an appropriate surface during CPR.- On 08/25/26, the DON began educating all nurses on emergency response for residents with tracheostomy tubes.- On 08/25/26, three (#52, #53, and #55) additional resident medical records were reviewed for care and services in preventing death with no concerns noted.Although the Immediate Jeopardy was removed on 08/25/26, the facility remains out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include:Review of the medical record revealed Resident #49 was admitted to the facility from the hospital on [DATE]. Medical diagnoses included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, encounter for attention to tracheostomy, malignant neoplasm of the larynx, other diseases of the larynx, dysphagia, alcohol use, and nicotine dependence. Review of the care plan dated 06/29/26 revealed Resident #49 was at risk for alteration in code status and was a full code. Interventions included interceding rapidly and immediately beginning resuscitative efforts utilizing all life-sustaining measures available if the resident's heart stops beating or the resident stops breathing (such as CPR, oxygen administration, and defibrillation).Review of the care plan dated 06/29/26 revealed Resident #49 was at risk for skin breakdown. Interventions included a pressure redistribution surface to his bed. Review of the Medicare five-day MDS assessment dated [DATE] revealed Resident #49 was assessed to be cognitively intact and required tracheostomy care and oxygen. Review of Resident #49's active physician orders for August 2026 revealed the resident had a full code resuscitation status order dated 06/11/26 (prior to admission).Review of the CPR risk tool dated 08/14/26 revealed the Administrator and DON were notified immediately that staff performed CPR on Resident #49. An investigation and timeline were initiated. Staff marked not applicable for what would be done to prevent the situation from recurring, what systemic changes would be made, and for an ad-hoc quality assurance meeting.Review of the nursing progress notes dated 08/14/26 and timed 10:32 P.M. revealed the DON received a call from the nurse on duty that a CPR event had occurred. A timeline was initiated. At 9:35 P.M., LPN #707 began receiving report. After report, LPN #707 gathered supplies for medication administration (pass). At 10:00 P.M., LPN #707 began medication pass on the B-hall and then went to the A-hall (where Resident #49 resided) to begin preparing for medication pass. While at the cart, CNA #704 approached LPN #707 to discuss another resident. During the discussion, CNA #704 noted Resident #49's call light was on and went to answer the call light. LPN #707 went into the medication room and heard CNA #704 yell. LPN #707 arrived at Resident #49's room at approximately 10:20 P.M. Resident #49 was unresponsive with no pulse and CPR was initiated at that time. LPN #707 sent CNA #704 to retrieve LPN #891 for assistance. LPN #891 called emergency medical services (EMS) at 10:32 P.M. while LPN #707 continued CPR. Nurses switched compressions when LPN #891 arrived back to the resident's room. CPR continued until EMS arrived and took over CPR. Additional information included Resident #49 had a tracheostomy and was non-compliant with tracheostomy care. The resident had also recently made the decision to transition to hospice care, but his code status remained a full code at the time of the CPR event, with a plan to meet with a hospice provider on 08/17/26. An investigation was completed into the CPR event, and CPR was initiated appropriately at the time of the code. Staff CPR certifications were current for those involved in the code. All areas of care were appropriately documented.Review of the nursing progress notes dated 08/14/26 and timed 11:40 P.M. revealed a CNA found Resident #49 lying in bed unresponsive and called for help. When the nurse entered the room, Resident #49 was lying on his back horizontally over the bed with his eyes open. Resident #49 was unresponsive to verbal and tactile stimulation with no pulse noted. CPR was initiated immediately and the CNA was sent to get the other nurse while the present nurse performed CPR. The other nurse called EMS. EMS was enroute while the two nurses then took turns performing CPR. CPR was provided until EMS arrived to take over. The DON and Resident #49's brother were notified of the incident.Review of the nursing progress notes dated 08/15/26 and timed 3:55 A.M. revealed the nurse contacted the local hospital for an update and received that Resident #49 had a normal heart rhythm with a stable oxygen level. The resident was placed on a ventilator and had a blood clot in his tracheostomy.Review of the written statement provided by CNA #704 revealed on 08/14/26, CNA #704 checked on Resident #49 while passing snacks on the A-hall and the resident was okay. CNA #704 continued to pass snacks to the other two halls. CNA #704 then took the snack cart back to the kitchen and returned to find LPN #707 to discuss an issue that another resident was having. LPN #707 was at the medication cart preparing medications. While CNA #704 and LPN #707 were discussing the issue, CNA #704 looked down the hall and noticed Resident #49's call light was on. CNA #704 told LPN #707 she was going to see what the resident wanted. When CNA #704 walked into the resident's room, the resident was sitting on the bed. CNA #704 asked what Resident #49 needed and Resident #49 did not look right at all and was not responding. CNA #704 ran out of Resident #49's room, yelling for LPN #707. LPN #707 entered as CNA #704 was screaming Resident #49's name and immediately started CPR. LPN #707 directed CNA #704 to get LPN #891. CNA #704 ran out of the room and yelled for LPN #891 to hurry and come to Resident #49's room. LPN #707 continued CPR. LPN #891 came to the room and said she was calling EMS. LPN #891 then came back and took over CPR. CNA #704 went to let the paramedics in, and they went into Resident #49's room and took the resident out of the facility. Review of the written statement provided by LPN #707 revealed she clocked in for work on 08/14/26 at 9:17 P.M. LPN #707 received report, counted narcotics, and passed some medications. At approximately 10:00 P.M., LPN #707 went to the B-hall to pass medications and was informed by LPN #891 that she would pass medications on B-hall. LPN #707 then went to the A-hall to pass medications. The CNA working at the time (CNA #704) approached LPN #707 to discuss an unrelated resident's report of pain and noticed that Resident #49's call light was on during the conversation. CNA #704 went to answer the call light while LPN #707 went to the medication room to obtain an antibiotic. LPN #707 heard CNA #704 begin to yell LPN #707's name. LPN #707 rushed out of the medication room and entered Resident #49's room at 10:30 P.M. Resident #49 was unresponsive, lying in bed with no pulse, with his eyes and mouth open. LPN #707 instantly started chest compressions and told CNA #704 to get the other nurse (LPN #891). After LPN #891 called EMS, the two nurses switched and LPN #891 began performing chest compressions. CPR continued until EMS arrived and took over. Once Resident #49 left the facility, the nurses charted and informed the necessary parties of what occurred.Review of the written statement provided by CNA #708 revealed she worked second shift on 08/14/26. CNA #708 and CNA #842 completed rounds together on C-hall and then on B-hall. CNA #708 noticed a resident needed linens and went to the linen closet located on the A-hall. When going to the linen closet, CNA #708 noticed Resident #49's call light was on. CNA #708 retrieved the linen and went back to assist CNA #842 with caring for a resident. After caring for the resident, CNA #708 noticed Resident #49's call light was still on. CNA #708 and CNA #842 then went to assist another resident whose call light was on. CNA #842 went to retrieve a bed pad and said Resident #49's call light was still on. Once finished, CNA #708 took the trash out and returned. Resident #49's call light was still unanswered. CNA #708 continued working and then saw firetrucks pulling into the driveway. CNA #708 asked CNA #842 what happened and she did not know. CNA #708 walked to the front and asked CNA #704 what happened and CNA #704 grunted. CNA #708 did not know Resident #49 was found unresponsive without a pulse until after EMS left. No emergency medical code was called and there was no crash cart.Review of the EMS run report, dated 08/14/26, revealed EMS arrived at the facility on 08/14/26 at 10:37:07 P.M., arrived at Resident #49's room at 10:38:00 P.M., and found the resident lying on his bed with two nursing home staff performing CPR. Resident #49 was pulled off his bed and placed onto the ground and manual CPR was performed. A bag valve mask was used through Resident #49's tracheostomy and epinephrine one (1) milligram (mg) was administered via intravenous route. EMS staff were able to obtain a pulse, lifted and moved Resident #49 to the stretcher, and left the facility at 10:50:56 P.M. enroute to the hospital. Review of the hospital records dated 08/14/26 revealed Resident #49 arrived at the hospital in cardiopulmonary arrest. Resident #49 had a history of malignant laryngeal cancer status post-tracheostomy and presented to the hospital after being found unresponsive and cyanotic with CPR initiation and EMS contact. Upon EMS arrival at the nursing home, Resident #49 was in pulseless electrical activity. CPR was continued and the resident received epinephrine as well as bag via tracheostomy. Resident #49 ended up having a return of spontaneous circulation and was brought to the hospital for further evaluation. Resident #49 was placed on a ventilator. Due to cardiopulmonary arrest with return of spontaneous circulation as well as a tracheostomy with an apparent blockage, Resident #49's tracheostomy tube was replaced. The old tracheostomy was clogged with dried, thick mucus. The decision was made for Resident #49 to be transferred to another hospital for a higher level of care on 08/15/26 at 1:03 A.M.Review of the hospital records dated 08/15/26 through 08/16/26 revealed Resident #49 remained on a ventilator. Resident #49 had a severe anoxic brain injury, would not improve, and the chances of survival were dismal. Resident #49 passed away on 08/16/26 at 5:35 P.M. when life support measures were withdrawn.Interview on 08/19/26 at 6:24 A.M. with LPN #707 revealed Resident #49 had a tracheostomy tube and needed suctioned multiple times a day. LPN #707 reported Resident #49 would activate his call light to let staff know when he needed suctioned. On 08/14/26, CNA #704 and LPN #707 had been discussing another resident and CNA #704 went to check on Resident #49 because his call light was activated. CNA #704 yelled and came running out of the room. LPN #707 went to Resident #49's room and found the resident unresponsive at approximately 10:20 P.M. LPN #707 began performing chest compressions while CNA #704 went to get LPN #891. LPN #891 arrived at the room after contacting EMS and took over chest compressions. LPN #707 reported that during CPR, both nurses performed chest compressions on Resident #49 while the resident was lying in his bed and the staff did not use a backboard, move the resident to the floor, or provide any rescue breaths. LPN #707 stated the bag valve mask was located on the crash cart, which was not present. EMS arrived, took over CPR, and then took the resident to the hospital. LPN #707 contacted the hospital for an update, and the hospital reported there was a blood clot in Resident #49's tracheostomy tube. LPN #707 did not know how long the call light may have been activated prior to staff response, as she had been busy passing medications.Interview on 08/19/26 at 6:55 A.M. with CNA #704 revealed she was assigned to care for Resident #49 on 08/14/26 from 5:00 P.M. until the resident left to go to the hospital. CNA #704 reported that she did not have a pager during her shift, which was how staff are notified of when a call light was activated. CNA #704 reported she began passing snacks on the A-hall (where Resident #49 resided) and saw the resident sometime between 9:00 P.M. and 9:15 P.M. and the resident was okay at that time. CNA #704 proceeded to pass snacks to the rest of the A-hall, then to B-hall, and then to C-hall. CNA #704 finished passing snacks, took the snack cart to the kitchen, and returned to the A-hall to speak with LPN #707 about another resident. While speaking with LPN #707, CNA #704 looked down the hallway at approximately 10:20 P.M. and saw Resident #49's call light was activated, so she went to check on the resident. CNA #704 stated upon entering the room, Resident #49 was lying across the width of his bed, as if he had been sitting up and fallen back or leaned back and was not responding. CNA #704 ran into the hallway and yelled for LPN #707. LPN #707 arrived at the room, checked the resident, and began performing CPR while directing CNA #704 to go and get LPN #891. CNA #704 ran to get LPN #891. LPN #891 called EMS and then went to Resident #49's room and took over chest compressions. CNA #704 then went to the front of the building to wait for EMS to arrive. Once EMS arrived, they took over performing CPR and took Resident #49 to the hospital. CNA #704 reported she had no idea how long Resident #49's call light could have been activated prior to when he was found unresponsive, since she did not have a pager.Interview on 08/19/26 at 7:31 A.M. with Respiratory Nurse #712 revealed Resident #49 communicated with staff to let them know when he needed to be suctioned.Interview on 08/19/26 at 8:12 A.M. with the DON revealed Resident #49 would activate his call light to let staff know when he needed his tracheostomy tube suctioned. The DON confirmed Resident #49's call light was activated at the time when the resident was found unresponsive.Observation on 08/20/26 at 10:34 A.M. with the DON revealed the facility had two crash carts, both of which contained a bag valve mask and a backboard that was attached. One of the crash carts was located on the A-hall, which was diagonal and slightly down the hall from Resident #49's room at the time of the incident on 08/14/26.Interview on 08/20/26 at 12:04 P.M. with Respiratory Therapist (RT) #550 revealed if a resident such as Resident #49, with a tracheostomy tube was found unresponsive, staff should absolutely provide rescue breaths via a bag valve mask. RT #550 reported residents with tracheostomy tubes should receive a breath every six seconds with continuous chest compressions. RT #550 stated, if there was only one responder, staff should then perform 30 compressions followed by two breaths repeatedly.Interview on 08/20/26 at 1:06 P.M. with Nurse Practitioner (NP) #554 revealed if a resident was found unresponsive in bed and was a full code resuscitation status, staff should utilize a backboard or pull the resident to the floor.Interview on 08/20/26 at approximately 5:45 P.M. with the DON verified she was aware that staff had performed chest compressions while Resident #49 remained in bed and there was no backboard used. The DON also confirmed she knew staff had not administered rescue breaths to Resident #49. The DON reported that when CPR was administered by one responder, it was supposed to consist of all chest compressions and no rescue breaths.Interview on 08/25/26 at 1:45 P.M. with the DON revealed nurses employed by the facility had not received any education, aside from what they would have received in their regular CPR trainings, regarding emergency response for a resident with a tracheostomy tube. The DON verified that regular CPR training included guidance on providing continuous compressions without pausing for ventilation and ventilation every six seconds and had no guidance for when there was only one staff member providing CPR.Interview on 08/25/26 at 4:40 P.M. with CNA #708 revealed she was working on 08/14/26 and did not know that Resident #49 had coded until the resident was leaving with EMS. CNA #708 reported she was concerned because Resident #49's call light had been on for a long time prior to when staff found the resident unresponsive. CNA #708 could not specify how long Resident #49's call light had been activated but reported she had extensively cared for two different residents during the time.Interview on 08/25/26 at 6:14 P.M. with CNA #842 revealed she was working on 08/14/26, and she was concerned about how long Resident #49's call light had been activated prior to the resident being found unresponsive. CNA #842 reported this to the DON on 08/14/26, and the DON informed her she would pull the call light report for that night.Observation and interview with the DON on 08/25/26 at 6:25 P.M. revealed there was a monitoring system located in the MDS office that contained information on call light response times. Review of Resident #49's call light response times revealed the resident's call light was activated on 08/14/26 at 9:42 P.M. and was cleared on 08/14/26 at 10:30 P.M. Interview at the time of observation with the DON confirmed Resident #49's call light had been activated for 48 minutes on 08/14/26.Review of the facility document titled, Step-by-Step Guide to Running a Code Blue, dated 08/17/26, included beginning CPR immediately, placing a backboard under the patient if available, and ensuring the crash cart and defibrillator were at the bedside. High-quality CPR included a ratio of 30 compressions to two breaths until an advanced airway was placed.Review of the facility policy titled, Emergency Response for Cardiac Arrest, dated 01/10/19, revealed one of the elements of providing CPR was provision of respiratory assistance.Review of the American Heart Association Basic Life Support manual, dated October 2025, revealed the person receiving CPR should be faceup on a firm, flat surface, such as the floor or a backboard. This will help ensure that the chest compressions are as effective as possible. If the person is on a soft surface, such as a mattress, the force from the chest compressions will simply push the person's body into the soft surface. A firm surface allows compression of the chest and the heart to create adequate blood flow. This deficiency represents non-compliance investigated under Complaint Master Number 3166855 and Complaint Number 3039188.

Based on review of the Facility Assessment, medical record review, review of job descriptions, and staff interview, the facility failed to ensure the facility developed a comprehensive facility assessment to include active involvement from direct care staff, residents, resident representatives and family members within the facility assessment, and failed to address the education needs of staff caring for residents with tracheostomy tubes. This had the potential to affect all 39 residents residing in the facility. The facility census was 39. Findings include:1. Review of the Facility assessment dated [DATE], which was reviewed on 08/25/26, revealed no documentation to support the facility included active involvement from direct care staff, residents, resident representatives, or family members.Interview on 08/25/26 at 1:45 P.M. with the Director of Nursing (DON) verified there was no mention the facility had incorporated involvement from direct care staff, residents, resident representatives, or family members within the assessment.2. Review of the medical record revealed Resident #49 was admitted to the facility from the hospital on [DATE]. Medical diagnoses included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, encounter for attention to tracheostomy, malignant neoplasm of the larynx, other diseases of the larynx, dysphagia, alcohol use, and nicotine dependence. The resident discharged from the facility on 08/14/26.Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was assessed to be cognitively intact and required tracheostomy care and oxygen.Review of the Facility assessment dated [DATE], which was reviewed on 08/25/26 revealed services and care provided included tracheostomy care and staff education regarding specialized care would be provided in accordance with employee job descriptions.Review of the facility's nursing job descriptions revealed no inclusion of specific training regarding education related to emergency response for residents with tracheostomy tubes.Review of the facility training records for 2026 revealed the only tracheostomy education provided for nurses employed by the facility was for regular care and suctioning.Interview on 08/25/26 at 1:45 P.M. with the DON revealed nurses employed by the facility had not received any education, aside from what they would have received in their regular cardiopulmonary resuscitation training, regarding emergency response for a resident with a tracheostomy tube. The DON verified that this was not something the facility had identified as needed.This deficiency was an incidental finding discovered during the course of this complaint investigation.

Based on observation, medical record review, staff interview, review of call light records, review of written statements, and review of a facility policy, the facility failed to maintain an adequately equipped call system which relayed the call directly to a staff member or centralized staff work area from each resident's bedside toilet, and bathing facility. This deficient practice had the potential to affect all 39 residents residing in the facility. The facility census was 39.Findings include:Review of the medical record revealed Resident #49 was admitted to the facility from the hospital on [DATE]. Medical diagnoses included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, encounter for attention to tracheostomy, malignant neoplasm of the larynx, other diseases of the larynx, dysphagia, alcohol use, and nicotine dependence. The resident discharged from the facility on 08/14/26.Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was assessed to be cognitively intact and required tracheostomy care and oxygen.Review of the plan of care dated 06/29/26 revealed Resident #49 had a tracheostomy. Interventions included providing means of communication and reassuring that help was available immediately.Review of the call light records for 08/14/26 revealed Resident #49's call light was activated at 9:42 P.M. and cleared at 10:30 P.M. (48 minutes).Interview with the Director of Nursing (DON) on 08/25/26 at 6:25 P.M. confirmed Resident #49's call light had been activated for 48 minutes on 08/14/26.Review of the written statement provided by Certified Nurse Aide (CNA) #704 revealed that on 08/14/26, she did not have a pager from 5:00 P.M. through at least 10:30 P.M. CNA #704 reported this was due to there only being two pagers in the building and that CNA #708 and CNA #842 had the only pagers.Review of the written statement provided by CNA #708 revealed she worked second shift on 08/14/26. CNA #708 and CNA #842 were completing rounds together on C-hall and then on B-hall. CNA #708 noticed she needed linens for a resident and went to the linen closet located on the A-hall. When going to the linen closet, CNA #708 noticed Resident #49's call light was on. CNA #708 retrieved the linen and went back to assist CNA #842 with caring for a resident. After caring for the resident, CNA #708 noticed Resident #49's call light was still on. CNA #708 and CNA #842 then went to assist another resident whose call light was on. CNA #842 went to retrieve a bed pad and indicated Resident #49's call light was still on. Once finished, CNA #708 took her trash out and returned. Resident #49's call light was still unanswered. CNA #708 did not know how long Resident #49's call light was on because neither CNA #708 or CNA #842 had pagers.Interview on 08/19/26 at 6:19 A.M. with Licensed Practical Nurse (LPN) #707 revealed Resident #49 had a tracheostomy tube and needed suctioned multiple times a day. LPN #707 reported Resident #49 would activate his call light to let staff know when he needed suctioned. LPN #707 also reported Resident #707 was unable to talk or yell due to his tracheostomy and would point and write to communicate.Interview on 08/19/26 at 6:55 A.M. with CNA #704 revealed when a resident activated their call light, a light illuminated near the door of their room and a notification went to pagers that were carried by staff. CNA #704 reported there was no other audible sound or visual way of seeing that a call light was activated. CNA #704 reported there were only two pagers in the building, so staff often worked without pagers and did not know when call lights were activated when they were not in view of the light near resident doors. CNA #704 was assigned to care for Resident #49 on 08/14/26 from 5:00 P.M. until at least 10:50 P.M. CNA #704 reported she did not have a pager during her shift, which was how staff are notified when a call light was activated. CNA #704 reported she began passing snacks on the A-hall (where Resident #49 resided) and saw the resident sometime between 9:00 P.M. and 9:15 P.M. CNA #704 proceeded to pass snacks to the rest of the A-hall, then to B-hall, and then to C-hall. CNA #704 finished passing snacks, took the snack cart to the kitchen, and returned to the A-hall to speak with the nurse about another resident. While speaking with the nurse, CNA #704 looked down the hallway at approximately 10:20 P.M. and saw Resident #49's call light was activated, so she went to check on the resident. CNA #704 reported she had no idea how long Resident #49's call light could have been activated prior to when she saw it, since she did not have a pager.Interview on 08/19/26 at 7:31 A.M. with Respiratory Nurse #712 revealed Resident #49 communicated with staff to let them know when he needed to be suctioned.Interview on 08/19/26 at 8:12 A.M. with the DON revealed Resident #49 would activate his call light to let staff know of when he needed his tracheostomy tube suctioned. The DON reported Resident #49 could not speak but would mouth words, point, and use a dry-erase board to communicate.Interview on 08/20/26 at 8:00 A.M. with LPN #891 revealed the facility was having an issue with not having enough pagers for staff because staff kept taking them home. LPN #891 reported there was maybe one pager in the building. LPN #891 reported the only way to know if a call light was activated was by seeing the light near the door of each resident's room. LPN #891 verified there was no other sound, light, panel, or centralized staff location for staff to know when a call light was activated.Interview on 08/25/26 at 4:40 P.M. with CNA #708 revealed she worked the afternoon shift 08/14/26. CNA #708 reported there were three CNAs working between 5:00 P.M. and 10:50 P.M. and none of them had pagers to know when call lights were activated. CNA #708 reported she and CNA #842 were assigned to the B-hall and the C-hall during that time and had been completing rounds together. CNA #842 saw Resident #49's call light was activated for a long period of time, but was not sure of how long since she did not have a pager. CNA #708 reported there were never enough pagers because staff would take them home and there was not a process to sign them in or out. CNA #842 confirmed there was no other audible sound or visual way to see a call light was activated in a centralized staff work area.Observation and interview on 08/25/26 at 6:14 P.M. with CNA #842 revealed she worked the afternoon shift on 08/14/26 and did not have a pager that day. CNA #842 reported she often worked without a pager and observation revealed she did not have a pager at the time of the interview. CNA #842 reported there was no other direction provided to staff, such as completing increased rounds due to a lack of pagers.Observation and interview on 08/25/26 at 6:14 P.M. with Registered Nurse (RN) #439 verified there was no centralized staff location where staff could see that call lights were activated.Review of the facility policy titled, Answering the Call Light, revised September 2022, revealed the purpose of the procedure was to ensure timely response to resident requests and needs. Steps included answering the call system immediately. When answering an auditory request for assistance, staff were to identify themselves and respond to the resident by their name. The policy also directed staff to indicate the approximate time it will take to respond when a resident needed assistance. If the resident's request was something the staff member answering could fulfill, staff were to complete the task within five minutes if possible.This deficiency was an incidental finding discovered during the course of this complaint investigation.

Based on review of staffing schedules and staff interview, the facility failed to ensure a Registered Nurse (RN) was present in the facility for eight consecutive hours per day as required. This had the potential to affect all 39 residents residing in the facility. The facility census was 39.Findings include:Review of the staffing schedules for 07/19/26 through 08/19/26 revealed there was no RN present in the facility for eight consecutive hours on 07/19/26, 07/25/26, 08/01/26, 08/02/26, 08/08/26, 08/09/26, 08/15/26, 08/16/26, and 08/17/26.Interview on 08/19/26 at 11:51 A.M. with the Director of Nursing (DON) verified there was no RN present and working in the building for eight consecutive hours on the aforementioned dates.Interview on 08/19/26 at 12:05 P.M. with Staffing and Scheduling Coordinator #728 also verified there was no RN present and working in the building for eight consecutive hours on the aforementioned dates. Staffing and Scheduling Coordinator #728 reported she knew this was going to be an issue as she had been telling management.This deficiency represents non-compliance investigated under Complaint Number 3039188.

Based on medical record review, staff interview, observation, review of emergency medical service (EMS) records, review of hospital records, review of facility guidance, review of the facility's policy for cardiopulmonary resuscitation (CPR), and review of American Heart Association (AHA) guidance, the facility failed to be administered in a manner that utilized its resources effectively and efficiently to ensure resident safety. This deficient practice affected one (#49) of one residents found unresponsive in the facility with CPR initiated. This had the potential to affect 18 (#10, #11, #12, #13, #14, #15, #16, #17, #19, #20, #22, #25, #27, #40, #41, #43, #47, and #48) designated with a full code resuscitation status. The facility census was 39.Findings include:Review of the medical record revealed Resident #49 was admitted to the facility from the hospital on [DATE]. Medical diagnoses included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, encounter for attention to tracheostomy, malignant neoplasm of the larynx, other diseases of the larynx, dysphagia, alcohol use, and nicotine dependence. The resident discharged from the facility on [DATE].Review of the care plan dated [DATE] revealed Resident #49 was at risk for alteration in code status and was a full code (full life saving measures are to be implemented in the event of cardiac or respiratory arrest). Interventions included interceding rapidly and immediately beginning resuscitative efforts utilizing all life-sustaining measures available if the resident's heart stops beating or the resident stops breathing (such as cardiopulmonary resuscitation (CPR), oxygen administration, and defibrillation).Review of the care plan dated [DATE] revealed Resident #49 was at risk for skin breakdown. Interventions included a pressure redistribution surface to his bed.Review of Resident #49's active physician orders for [DATE] revealed the resident had a full code resuscitation status order dated [DATE] (prior to admission).Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was assessed to be cognitively intact and required tracheostomy care and oxygen.Review of the nursing progress notes dated [DATE] and timed 10:32 P.M. revealed the Director of Nursing (DON) received a call from the nurse on duty that a CPR event had occurred. A timeline was initiated. At 9:35 P.M., Licensed Practical Nurse (LPN) #707 began receiving report. After report, LPN #707 gathered supplies for medication administration (pass). At 10:00 P.M., LPN #707 began medication pass on the B-hall and then went to the A-hall (where Resident #49 resided) to begin preparing for medication pass. While at the cart, Certified Nurse Aide (CNA) #704 approached LPN #707 to discuss another resident. During the discussion, CNA #704 noted Resident #49's call light was on and went to answer the call light. LPN #707 went into the medication room and heard CNA #704 yell. LPN #707 arrived at Resident #49's room at approximately 10:20 P.M. Resident #49 was unresponsive with no pulse and CPR was initiated at that time. LPN #707 sent CNA #704 to retrieve LPN #891 for assistance. LPN #891 called emergency medical services (EMS) at 10:32 P.M. while LPN #707 continued CPR. Nurses switched compressions when LPN #891 arrived back to the resident's room. CPR continued until emergency medical services (EMS) arrived and took over CPR. Additional information included Resident #49 had a tracheostomy and was non-compliant with tracheostomy care. The resident had also recently made the decision to transition to hospice care, but his code status remained a full code at the time of the CPR event, with a plan to meet with a hospice provider on [DATE]. An investigation was completed into the CPR event, and CPR was initiated appropriately at the time of the code. Staff CPR certifications were current for those involved in the code. All areas of care were appropriately documented.Review of the EMS run report, dated [DATE], revealed EMS arrived at the facility on [DATE] at 10:37:07 P.M., arrived at Resident #49's room at 10:38:00 P.M., and found the resident lying on his bed with two nursing home staff performing CPR. Resident #49 was pulled off his bed and placed onto the ground and manual CPR was performed. A bag valve mask was used through Resident #49's tracheostomy and epinephrine one (1) milligram (mg) was administered via intravenous route. EMS staff were able to obtain a pulse, lifted and moved Resident #49 to the stretcher, and left the facility at 10:50:56 P.M. enroute to the hospital.Review of the hospital records dated [DATE] through [DATE] revealed Resident #49 was placed on a ventilator. Resident #49 had a severe anoxic brain injury, would not improve, and the chances of survival were dismal. Resident #49 passed away on [DATE] at 5:35 P.M. when life support measures were withdrawn.Review of the CPR risk tool dated [DATE] revealed staff marked, not applicable, for what would be done to prevent the situation from recurring, what systemic changes would be made, and for an ad-hoc quality assurance meeting.Interview on [DATE] with LPN #707 revealed Resident #49 had a tracheostomy tube and needed suctioned multiple times a day. Resident #49 was found unresponsive on [DATE] at approximately 10:20 P.M. and had a full code resuscitation status. LPN #707 and LPN #891 performed CPR on Resident #49 while the resident remained in bed with no backboard used or rescue breaths administered.Interview on [DATE] at 8:12 A.M. with the DON revealed Resident #49 would activate his call light to let staff know of when he needed his tracheostomy tube to be suctioned. The DON confirmed Resident #49's call light was activated when the resident was found unresponsive but stated the facility did not have the ability or a report to see how long the call light had been on. The DON reported she believed facility staff performed CPR correctly and with no concerns.Interview on [DATE] at 12:04 P.M. with Respiratory Therapist (RT) #550 revealed that if a resident, such as Resident #49, with a tracheostomy tube was found unresponsive, staff should absolutely provide rescue breaths via a bag-valve mask.Interview on [DATE] at 1:06 P.M. with Nurse Practitioner #554 revealed that if a resident was found unresponsive in bed and was a full code resuscitation status, staff should utilize a backboard or pull the resident to the floor to perform CPR.Interview on [DATE] at 5:07 P.M. revealed the DON continued to state staff responded appropriately during the CPR incident with Resident #49. The DON reported the facility had not provided any recent education regarding CPR surfaces or rescue breaths during CPR.Interview on [DATE] at 7:54 A.M. with the DON revealed she had sent American Heart Association (AHA) guidance to the surveyor via electronic mail (e-mail), which read residents should not be moved from their mattress for CPR and that performing compressions only (no ventilation/breaths) was appropriate. The DON reported she had sent guidance to staff that included the use of a backboard if available and included information on compressions but was going to re-educate staff that they should not use a backboard or attempt to move the resident when initiating/performing CPR. During this interview, the DON reported the process for calling a code at nighttime was to speak over a telephone system that staff could not hear very well, or to send a runner as they did during the recent CPR event. The DON reported it would not have been necessary for the other two nurse aides working at the time of the incident to know there was a code because they were not CPR certified, while also maintaining that a backboard was not expected to be used, the crash cart retrieved, or ventilation/breaths provided due to a lack of time for the staff who were responding to the emergency.Observation on [DATE] at 10:14 A.M. with the DON revealed she utilized her computer to show the documents that she had referred to as AHA guidance. The DON reported she had used artificial intelligence to create the AHA guides. The listed sources for information contained within the guides included a source from the Canadian government. The DON also presented an AHA article that had been written in the year 2010.Interview on [DATE] at 1:45 P.M. with the DON revealed nurses employed by the facility had not received any education, aside from what they would have received in their regular CPR trainings, regarding emergency response for a resident with a tracheostomy tube. The DON verified that regular CPR training included guidance on providing continuous compressions without pausing for ventilation and ventilation every six seconds and had no guidance for when there was only one staff member providing CPR. The DON maintained that it was not the facility's responsibility to provide education to nurses regarding emergency response for residents with advanced airways.Interview on [DATE] at 4:40 P.M. with CNA #708 revealed she was working on [DATE] and did not know that Resident #49 had coded until the resident was leaving with EMS. CNA #708 reported she was concerned because Resident #49's call light had been on for a long time prior to when staff found the resident unresponsive.Interview on [DATE] at 6:14 P.M. with CNA #842 revealed that she was working on [DATE], and she was concerned about how long Resident #49's call light had been activated prior to the resident being found unresponsive. CNA #842 reported this to the DON on [DATE], and the DON stated she would pull the call light report for that night. CNA #842 reported she had no idea there was an emergency until after it was over.Observation and interview with the DON on [DATE] at 6:25 P.M. revealed there was a call light monitoring system located in the MDS office that contained information on call light response times. Resident #49's call light had been activated on [DATE] at 9:42 P.M. and was cleared on [DATE] at 10:30 P.M. Interview with the DON at the time of observation confirmed Resident #49's call light had been activated for 48 minutes. Review of the e-mail notification received from the DON on [DATE] at 7:25 P.M. revealed the facility had not completed any recent education or audits regarding call lights.Review of the facility document titled, Step-by-Step Guide to Running a Code Blue, dated [DATE], included beginning CPR immediately, placing a backboard under the patient if available, and ensuring the crash cart and defibrillator were at the bedside. High-quality CPR included a ratio of 30 compressions to two breaths until an advanced airway was placed.Review of the facility policy titled, Emergency Response for Cardiac Arrest, dated [DATE], revealed one of the elements of providing CPR was provision of respiratory assistance.Review of the American Heart Association (AHA) Basic Life Support manual, dated [DATE], revealed the person receiving CPR should be faceup on a firm, flat surface, such as the floor or a backboard. This will help ensure that the chest compressions are as effective as possible. If the person is on a soft surface, such as a mattress, the force from the chest compressions will simply push the person's body into the soft surface. A firm surface allows compression of the chest and the heart to create adequate blood flow.This deficiency was an incidental finding discovered during the course of this complaint investigation.

Based on staff interview, review of personnel files and training records, and review of a facility policy, the facility failed to ensure nurse aides completed required training for dementia care. This affected two (#447 and #720) of five certified nurse aide personnel files reviewed. The facility census was 39.Findings include:Review of the personnel file and staff training records for Certified Nurse Aide (CNA) #447 revealed a hire date of 03/11/15 and no documentation of training for dementia management had been completed.Review of the personnel file and staff training records for CNA #720 revealed a hire date of 02/08/24 and no documentation of training for dementia management had been completed.Interview on 08/24/26 at 9:48 A.M. with Human Resources Director and Business Office Manager #730 verified there was no evidence CNA #447 or CNA #720 received dementia management training as required.Review of the facility policy titled, In-Service Training, All Staff, revised August 2022, revealed all staff were required to participate in annual in-service training. Required training topics included dementia management training.This deficiency represents non-compliance investigated under Complaint Number 3039188.

Based on observation, interview, and record review, the facility failed to store, label, date, and maintain food in a manner to prevent contamination and spoilage in accordance with acceptable food safety practices. This deficient practice had the potential to affect all residents, as all facility residents received food prepared and distributed from the facility kitchen. The facility census was 52. Findings include: During a tour of the facility kitchen on 03/23/26 at 8:05 A.M., 10 four-ounce containers of cucumber and tomato salad were observed in the kitchen's free-standing refrigerator that were unlabeled and undated with the date of preparation. An approximately one-half full, three-quart container of ketchup was also observed to be unlabeled and undated with the date opened.Interview on 03/23/26 at 8:06 A.M. with Nutrition Services Assistant (NSA) #210 verified the 10 four-ounce containers of cucumber and tomato salad were unlabeled and undated. NSA #210 stated the items were prepared on 03/20/26. NSA #210 also verified the three-quart container of ketchup was one-half full and unlabeled and undated with the date opened.Observation on 03/23/26 at 8:16 A.M. revealed an approximately one-half full, six-quart container of salad mix in the refrigerator that was brown, discolored, and contained an unidentified liquid. The container was labeled with a preparation date of 03/17/26.Interview on 03/23/26 at 8:25 A.M. with NSA #238 verified the above findings and confirmed the items should have been labeled and dated according to facility policy. NSA #238 verified the condition of the salad mix. NSA #238 stated facility policy requires all prepared food items to be labeled with the name of the item, preparation date, and discard date, and to be discarded three days after preparation.Observation on 03/23/26 at 8:20 A.M. of the dry storage area revealed the following dented canned goods: two 50-ounce cans of Swedish-Style Meatballs with large dents in the sides, one 108-ounce can of Corned Beef Hash with a dent in the bottom rim, and one six-pound, seven-ounce can of stewed tomatoes with a dent in the bottom rim.Interview on 03/23/26 at 8:22 A.M. with NSA #210 verified the presence of the dented cans and stated uncertainty regarding the facility process for handling dented cans.Interview on 03/23/26 at 8:23 A.M. with NSA #238 revealed dented cans are to be removed from use, placed aside, and returned to the distributor.Review of an attestation statement dated 03/25/26 from the Administrator revealed the facility procedure is to photograph dented cans and submit the image to the vendor for refund.Review of the facility policy titled Storage of Perishable Foods, dated March 2025, revealed the policy's purpose is to protect food from contamination and spoilage and to preserve nutritive value. The policy further indicated prepared or leftover foods are to be stored covered, clearly labeled, dated, and used within three days or discarded.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure personal protective equipment (PPE) was applied during resident care as required and enhanced barrier precautions were in place. This affected two (#4,and #8) of three residents reviewed for enhanced barrier precautions. The facility census was 52. Findings include: 1. Review of Resident #4's medical record revealed an admission date of 01/07/26. Diagnoses included nontraumatic intracranial hemorrhage, hypertensive heart disease with heart failure, neuromuscular dysfunction of the bladder, benign prostatic hyperplasia with lower urinary tract symptoms, and peripheral vascular disease. Review of Resident #4's Modification of admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident #4 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 12. Further review revealed Resident #4 had an indwelling urinary catheter. Review of Resident #4's care plan dated 01/07/26 revealed Resident #4 was on Enhanced Barrier Precautions (EBP) related to the urinary catheter with interventions that included the direct care staff and visitors would follow EBP, direct care staff to utilize gowns and gloves for all personal care, and to educate resident, responsible party, and direct care staff on EBP. Review of Resident #4's physician's orders revealed an order with a start date of 02/03/26 that read indwelling catheter care every shift related to other retention of urine. Observation on 03/25/26 at 2:13 P.M. of catheter care for Resident #4 revealed when completing catheter care, CNA #224 did not wear a gown as required for residents on Enhance Barrier Precautions (EBP). Interview on 03/25/26 at 2:29 P.M. with CNA #224 verified she did not wear a gown when completing catheter care. CNA #224 stated she forgot to wear one. 2. Review of Resident #8's medical record revealed an initial admission date of 07/25/25 and a re-entry date of 08/07/25. Diagnoses included metabolic encephalopathy, Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation, acute respiratory failure with hypercapnia, hypertensive chronic kidney disease, and a pressure ulcer of the sacral region stage four. Review of Resident #8's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15. Furthermore, Resident #8 had a stage four pressure ulcer with treatments that included a pressure reducing device for the chair, a pressure reducing device for the bed, pressure ulcer care, the application of nonsurgical dressings other than to feet, and the application of ointments/medications other than to feet. Review of Resident #8's care plan dated 01/28/26 revealed Resident #8 required wound management for a pressure ulcer on his coccyx with interventions that included to notify the provider if there were no signs of improvement on the current wound regimen, provide wound care per the treatment orders, and to utilize wound care provider. Review of Resident #8's physician orders revealed an order with a start date of 02/27/26 that read wound care for the coccyx, negative pressure wound vac set at 125 millimeters of mercury (mmHg) at all times with instructions that stated every shift for wound care. The wound vac was to be changed three times weekly on Mondays, Wednesdays, and Fridays. If the wound vac was unable to be applied or remain intact, apply calcium alginate into the wound, then cover with a gauze bordered dressing and change every day and as needed only if the wound vac was not intact. Observation on 03/25/26 at 10:08 A.M. of wound care completed by the Infection Control Registered Nurse (ICRN) #248 and Wound Nurse Practitioner (WNP) #368 revealed ICRN #248 and WNP #368 did not wear a gown during the wound care. Interview on 03/25/26 at 10:27 A.M. with ICRN #248 and WNP #368 verified they were not wearing gowns as required for Resident #8 who required EBP. Review of policy, Infection Control Plan, dated August 2022, verified enhanced barrier precautions was an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) involving residents know to be colonized or infected with a MDRO as well as those increased at risk of MDRO acquisitions (e.g. resident with wounds or indwelling medical devices).

Based on medical record review, observation, and staff interview, the facility failed to ensure a catheter securement device was utilized for one resident (#4) of three residents reviewed for catheter securement devices. The facility census was 52. Findings include:Review of Resident #4's medical record revealed an admission date of 01/07/26. Diagnoses included nontraumatic intracranial hemorrhage, hypertensive heart disease with heart failure, neuromuscular dysfunction of the bladder, benign prostatic hyperplasia with lower urinary tract symptoms, and peripheral vascular disease. Review of Resident #4's Modification of admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident #4 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 12. Resident #4 was coded to have an indwelling urinary catheter. Review of Resident #4's physician's orders revealed an order with a start date of 02/03/26 for indwelling catheter care every shift related to other retention of urine. Observation on 03/25/26 at 2:13 P.M. of catheter care revealed Resident #4 did not have a catheter securement device present. Interview on 03/25/26 at 2:20 P.M. with Certified Nursing Assistant (CNA) #224 verified Resident #4 did not have a catheter securement device.

Based on record review, staff interview, observation of wound care, and policy review, the facility failed to timely assess and treat a pressure ulcer. This affected one resident (#8) of three residents reviewed for pressure ulcers. The facility census was 52. Findings include:Review of Resident #8's medical record revealed an initial admission date of 07/25/25 and a re-entry date of 08/07/25. Diagnoses included metabolic encephalopathy, Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation, acute respiratory failure with hypercapnia, hypertensive chronic kidney disease, and a pressure ulcer of the sacral region stage four (full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling). Review of Resident #8's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15. Furthermore, Resident #8 had a stage four pressure ulcer with treatments that included a pressure reducing device for the chair, a pressure reducing device for the bed, pressure ulcer care, the application of nonsurgical dressings other than to feet, and the application of ointments/medications other than to feet. Review of Resident #8's care plan dated 01/28/26 revealed Resident #8 required wound management for a pressure ulcer on his coccyx with interventions that included to notify the provider if there were no signs of improvement on the current wound regimen, provide wound care per the treatment orders, and utilize facility contracted wound care provider. Review of Resident #8's physician orders revealed an order with a start date of 02/27/26 that read wound care for the coccyx, negative pressure wound vac set at 125 millimeters of mercury (mmHg) at all times with instructions that stated every shift for wound care. The wound vac was to be changed three times weekly on Mondays, Wednesdays, and Fridays. If the wound vac was unable to be applied or remain intact, apply calcium alginate into the wound, then cover with a gauze bordered dressing and change every day and as needed only if the wound vac was not intact. Review of Resident #8's hospital documentation dated 07/17/25 revealed Resident #8 had a sacral wound with an unknown wound age on 07/12/25. Review of Resident #8's admission assessment dated [DATE] revealed Resident #8's skin was warm and dry, skin color was Within Normal Limits (WNL), skin turgor was normal, and no skin issues were noted. Review of Resident #8's skilled evaluation progress notes dated 08/09/25 and 08/10/25 revealed Resident #8's skin was warm and dry, skin color was WNL, and skin turgor was normal. Review of Resident #8's post fall evaluation progress notes dated 08/08/25, 08/09/25, and 08/10/25 revealed skin was warm and dry, skin color was WNL, and skin turgor was normal.Review of Resident #8's skilled evaluation progress note dated 08/11/25 written by Registered Nurse (RN) #265 revealed a new skin issue #001 that was a stage two pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising. May also present as an intact or open/ruptured blister. ) on Resident #8's coccyx. Skin loss with exposed dermis was noted and it is noted the wound was present on admission. A measurement of the wound was not taken at this time as the dressing on the wound was intact. Review of Resident #8's wound provider's initial wound evaluation management summary dated 08/13/25 revealed the wound was an unstageable Deep Tissue Injury (DTI) (Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler than adjacent tissue.) within and around the wound. Measurements of the wound were 4.4 centimeters (cm) in length, 4.6 cm in width, and 0.1cm in depth. The wound had heavy Sero-sanguinous exudate and no signs of infection were noted. Review of Resident #8's Treatment Administration Record (TAR) for the month of August 2025 revealed the first wound treatment documented was on 08/13/25. The wound treatment order read to the open area to the coccyx/left buttock: cleanse with soap and water, apply Opti foam, change every three days every evening shift for wound care. Interview on 03/24/26 at 2:54 P.M. with the Director of Nursing (DON) and Regional Nurse #367 verified the admission assessment was inaccurate as Resident #8 had the wound on admission to the facility. The DON verified Resident #8 was admitted from the hospital to the facility on [DATE] and the dressing to his coccyx was dated 08/06/25. The dressing remained on Resident #8 until 08/12/25 when the wound was assessed and new measurements were taken. Measurements of the wound on 08/12/25 were 4.5 cm in length , 5 cm in width, and 0 cm in depth. Review of the facility policy with a last revision date of 11/2015 titled Resident Assessment Policy revealed regarding accuracy of assessment: the assessment will accurately reflect the resident's status.

Based on observation, staff interview, medical record review, and review of facility policy, the facility failed to provide necessary assistance with personal hygiene to maintain grooming and cleanliness for one resident (#41) of three residents (#30, #41, and #44) reviewed for activities of daily living (ADLs). The facility census was 52. Findings Include: Review of the medical record for Resident #41 revealed an admission date of 05/06/20 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting non-dominant side, chronic obstructive pulmonary disease (COPD), Type Two Diabetes Mellitus (DM2), vascular dementia, aphasia following cerebral infarction, hypertensive heart and chronic kidney disease with heart failure, congestive heart failure (CHF), epilepsy, atrial fibrillation, stage three chronic kidney disease (CKD3), osteoporosis, major depressive disorder, hyperlipidemia, anemia, diverticulitis, ventral hernia, constipation, atopic dermatitis, other long-term (current) drug therapy, allergic rhinitis, long-term use of anticoagulants, and long-term use of insulin. Review of the most recent annual Minimum Data Set (MDS) assessment, dated 02/26/26, revealed a Brief Interview of Mental Status (BIMS) was unable to be determined due to the residents cognition. Further review of this MDS assessment revealed Resident #41 had unilateral impairment in both upper and lower extremities and was dependent for all functional abilities including, but not limited to, eating, hygiene, bathing, dressing, repositioning, transfers, and propelling in her wheelchair. Observation on 03/25/25 at 7:24 A.M. revealed Resident #41 in seated in her wheelchair in the common area of the nursing unit the resident's nails were long and unkept. Further observation of Resident #41's nails revealed the nails on her thumb, index finger, and middle finger on her right hand were caked with an unidentified dark brown substance. Interview on 03/25/26 at 7:27 A.M. with Registered Nurse (RN) #300 verified Resident #41's nails were long and unkept. RN #300 also verified the nails on Resident #41's thumb, index finger, and middle finger on her right hand were caked with an unidentified dark brown substance. Review of the facility policy titled, Quality of Care Policy/Activities of Daily Living, dated 04/29/16, revealed each resident will receive and the Manor 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 plan of care. A resident who is unable to carryout activities of daily living receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene.

Based on observation, interview, review of facility shower schedule, and medical record review, the facility failed to ensure a resident who was not dependent on staff for activities of daily living received bathing services as scheduled. This affected one resident (#44) of three residents (#30, #41, and #44) reviewed for Activities of Daily Living (ADLs). The facility census was 52. Findings Include: Review of the medical record for Resident #44 revealed an admission date of 01/29/26 with diagnoses including atrial fibrillation, hypokalemia, hypertension (HTN), anxiety, depression, other idiopathic peripheral autonomic neuropathy, post-traumatic stress disorder (PTSD), cervical spinal stenosis, obstructive sleep apnea, abnormal weight loss, solitary pulmonary nodule, attention and concentration deficit, frontal lobe and executive function deficit, palpitations, personal history of transient ischemic attack (TIA), and cerebral infarction.Review of the admission Minimum Data Set (MDS) assessment, dated 02/10/26, revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating Resident #15's cognition was intact. Further review of this MDS assessment revealed Resident #44 required partial or moderate assistance with all functional abilities including, but not limited to, eating, hygiene, toileting, showering/bathing, dressing, repositioning, and transferring. During an interview on 03/23/26 at 10:38 A.M. Resident #44 stated she does not receive showers as she should, specifically on Fridays.Review of the facility provided shower schedule revealed Resident #44 was scheduled to receive showers on Tuesday and Friday during the 7:00 A.M. to 3:00 P.M. shift. Review of Resident #44's facility-provided shower documentation for February 2026 revealed there were eight opportunities for Resident #44 to receive a shower and no documentation that she received a shower on the scheduled days.Review of Resident #44's facility-provided shower documentation for 03/01/26 through 03/25/26 revealed there were seven opportunities for Resident #44 to receive a shower and one shower was documented to be provided during this review period on 03/06/26. Interview on 03/25/26 at 2:18 P.M. with the Director of Nursing verified the only shower documentation for the review period of 01/29/26 through 03/25/26 was on 03/06/26.Review of the facility policy titled, Quality of Care Policy/Activities of Daily Living, dated 04/29/16, revealed each resident will receive and the Manor 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 plan of care.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interview, and facility policy review, the facility failed to adequately monitor a resident's (Former Resident #52) wound on admission the throughout her stay. The facility census was 42. Findings included: Review of Former Resident (FR) #52's medical record revealed an admission date of 02/24/25 and discharged on 03/03/25. Diagnosis included Stage IV sacral pressure ulcer (Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.), acute kidney failure, acute respiratory distress syndrome, bacteremia, congestive heart failure, and atrial fibrillation. Review of FR #52's discharge Minimum Data Set (MDS) dated [DATE] revealed the resident had an intact cognition. She was dependent for all activities of daily living. Review of FR #52's medical record revealed the record was absent of wound evaluations or measurements. Interview with Corporate Nurse #170 on 05/19/25 at 2:43 P.M. verified the facility failed to measure or assess FR #52's Stage IV sacral pressure ulcer during her respite stay. Interview with FR #52's home health nurse on 05/15/25 revealed the wound worsened during the resident's stay and required a wound vac. The nurse stated the wound was within one month of healing, but the condition of the wound declined during her admission to the facility. The nurse failed to provide the requested documentation for surveyor review. Review of the facility policy titled Pressure Ulcer Policy revised 04/16 revealed should a pressure area present either upon admission or in house, the wound will be monitored at least weekly and should have documentation including location and staging, size (perpendicular measurements of the greatest extend of length and width of the ulceration), depth; and the presence, location and extent of any undermining or tunneling/sinus tract, drainage; the amount and characteristics, pain if present and characteristics, and wound bed and surrounding tissue. As a result of the incident, the facility took the following actions to correct the deficient practice by 05/16/25: • On 04/24/25 the DON/Designee completed skin sweeps of all residents. • On 04/24/25 education was provided to nurse leadership team to ensure that a skin check was completed for all new admission within 72 hours of admission by the DON/Designee. • By 04/25/25 all nurses were educated by the DON/Designee on the pressure ulcer policy. • On 04/25/25 all nurse aides were educated by the DON/Designee on how frequently skin checks were to be completed. They were also educated on notifying the nurse if/when a dressing comes off of the wound. • By 04/25/25 all nurses were educated on following physician orders and policy by DON/Designee. They were educated on not signing an order of application or administration until after completion. • Audits will be completed five times per week for four weeks by the DON/Designee on all new admission to have a thorough skin evaluation and that documentation supported the evaluation including identifying any skin issues, type, description and measurements if applicable through 05/24/25. • Audits were completed three times a week by interviewing nurse aides on knowledge of the frequency of skin checks and what to do if a dressing is off or comes off a wound by the DON/Designee through 05/19/25. • On 05/12/25 three aseptic dressing technique competencies per week were completed with all nurses by the DON/Designee. • On 05/12/25 three catheter irrigation competencies per week were completed with all nurses by the DON/Designee. • On 05/16/25 special QAPI meeting was held and on 05/28/25 a regular QAPI meeting is scheduled. This deficiency represents non-compliance investigated under Complaint Number OH00165070.

Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident was supervised for eating. Resident #19 obtained and ate whole food when ordered a pureed diet, choked, received the Heimlich maneuver, and was admitted to the hospital. This deficient practice affected one resident (#19) of three reviewed (#11 and #24) for choking. In addition, two residents (#19, #53) of four reviewed (#11 and #24) failed to have fall precautions in place which resulted in falls. The facility census was 42. Findings included: 1 - Review of Resident #19's medical record revealed an admission date of 01/18/15. Diagnosis included cerebral vascular accident, schizoaffective disorder, epilepsy, mild intellectual disabilities, and congestive heart failure. Review of Resident #19's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a moderately intact cognition. The resident had coughing or choking during meals or when swallowing medications along with complaints of difficulty or pain with swallowing. Review of Resident #19's care plan revealed the resident had a history of cerebral vascular accident, dysphasia, and teeth in disrepair when affected his chewing ability. Notify the physician for signs of dysphasia, pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, or concerns noted during meals. Review of Resident #19's medical record revealed a physician's order dated 04/08/25 through 05/10/25 for a consistent carbohydrate diet, pureed texture, and regular consistency. Review of Resident #19's medical record revealed on 04/08/25 the resident had a choking episode in the dining room during lunch. The resident choked on hamburger. The Heimlich maneuver was performed without success. The resident was lowered to the floor and placed on his side and the airway was able to be cleared. The physician and family were notified. Further orders were received for a chest x-ray due to shortness of breath and to rule out aspiration. Review of Resident #19's speech therapy note dated 04/10/25 revealed the patient was educated on compensatory strategies to use during meals to increase safety. The therapist trained the Certified Nursing Assistants (CNA) to use compensatory strategies with the resident during meals to decrease the risk of aspiration. The diet assessment was completed in order to determine the resident's ability to tolerate diet textures and liquid viscosity at meals. Review of Resident #19's speech therapy note dated 04/23/25 revealed the speech therapist implemented a plan for necessary environmental modifications and cueing to maintain attention to meal task for intake. Speech therapy educated the resident on compensatory strategies to use during meals to increase safety. Speech therapy instructed the resident to utilize lingual sweep and/or alternate bite/sip to clear residue from the oral cavity. Review of Resident #19's progress note dated 05/08/25 revealed the nurse was called to the dining room by a CNA and found the resident having respiratory difficulty with cyanosis. A faint cough was noted. The resident had a history of seizures and dysphasia, and his airway was found to be occluded. Upon reaching Resident #19 the nurse performed the Heimlich maneuver which was unsuccessful. Emergency Medical Services (EMS) had been called. The resident was lowered to the ground and abdominal thrust was initiated. The resident coughed with copious amounts of sputum released. Cyanosis persisted after respirations became regular. Pulses were strong to the extremities. Oxygen was placed on the resident at 8 liters per minute via a nonrebreather mask. The resident was placed on his side to maximize breathing. Resident #19 was transported to the hospital. Review of the hospital emergency room note dated 05/08/25 revealed according to the bedside report taken for EMS upon arrival Resident #19 was eating in the common area non-solid foods, when he was thought to have been choking. There was also a description that he might have had a seizure although staff members are not certain what his seizures look like. EMS reported that when they arrived on scene the patient had spontaneous pulses and respiration. He was not following commands. They checked a blood sugar in route that was greater than 100. They attempted IV access in transport. Upon arrival to the emergency department setting the patient would acknowledge his name. His eyes opened spontaneously. He was not speaking or answering questions. He would follow simple commands such as holding his right or left arm up. Based upon this evaluation he had a Glasgow Coma Score (GCS) score of 11. The physician did not hear any course breath sounds bilaterally. The physician proceeded with an altered mental status workup also evaluated for the possibility of aspiration. Diagnosis included alerted mental status, aspiration, seizure, postictal state, arrhythmia, electrolyte abnormality, liver failure, urinary tract infection, and encephalopathy. Interview with the Administrator on 05/15/25 at 12:10 P.M. revealed Resident #19 choked on fruit during dinner on 05/08/25. The resident had been served the proper pureed meal and CNA's were at the table observed the resident eating. The aides left the table to assist with cleaning the dining room when another resident placed his regular texture fruit cup in front of Resident #19. This resulted in Resident #19 eating the fruit and choking. Telephone interview with Speech Therapist #175 on 05/20/25 at 11:02 A.M. revealed Resident #19 should not eat in his room alone. He should eat in the dining room with staff present due to his high risk of choking. The resident should be in an upright position and eating utensils should be within reach. Review of the facility policy titled Regular Pureed Diet revised 05/2020 revealed the diet is designed for the resident who has some difficulty in chewing or swallowing or who has poor coordination of the lips or tongue. Foods should be of little or no chewing and be easy to swallow. 2. Review of Resident #19's medical record revealed an admission date of 01/18/15. Diagnosis included cerebral vascular accident, schizoaffective disorder, epilepsy, mild intellectual disabilities, and congestive heart failure. Review of Resident #19's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a moderately intact cognition. The resident was independent with ambulation and used a walker. Review of Resident #19's care plan revealed the resident was at risk for falls related to seizure disorder, history of a cerebral vascular accident with a mild right foot drop, mild developmental disability and history of falls. Interventions included Dycem to the recliner. Review of the post fall evaluation dated 04/21/25 revealed on 04/20/25 Resident #19 suffered an unwitnessed fall which occurred in the resident's room. The resident was getting out of bed and into his recliner. The root cause was determined to be that Dycem was not in his recliner per his care plan. No injuries were noted. Interview with the Director of Nursing (DON) on 05/19/25 at 9:10 A.M. verified Resident #19's Dycem pad failed to placed in his recliner causing him to slide out of the recliner. Review of the facility policy titled Fall Reduction Policy revised 04/29/16 revealed it was the policy of the Manor to identify residents at risk for falls and to implement a fall reduction program to reduce the risk of falls and possible injury. 3. Review of Former Resident (FR) #53's medical record revealed an admission date of 02/26/25 with a discharge date of 03/05/25. Diagnosis included rhabdomyolysis, acute kidney failure, dementia, epilepsy, and femur fracture. Review of FR #53's discharge Minimum Data Set (MDS) dated [DATE] revealed the resident had a moderately intact cognition. Bed to chair transfer required supervision or touching assistance. Review of FR #53's care plan revealed he was at risk for falls related to his current diagnosis, recent change in environment, and admission to a care community. Interventions included a safe environment and staff to anticipate his needs and keeping items within reach, and assisting with toileting. Review of FR #53's Fall Risk Evaluation dated 02/26/25 revealed he was a high risk for falls. Review of FR #53's progress note dated 03/04/25 revealed a CNA was walking down the hall when she noticed the resident was sitting on the floor with his back up against the lower end of the bed. His legs were stretched out in front of him. The resident was wearing grippy socks but the bed was not in a locked position and was moving about freely. FR #53 was unable to fully explain what happened. No injuries were noted. Staff were educated regarding the fact the need for the bed to be in the lowest locked position. Interview with the Director of Nursing (DON) on 05/19/25 at 9:10 A.M. verified FR #53's bed failed to be locked causing the bed to move while the resident was attempting to get out of bed. Review of the interdisciplinary team progress note dated 03/04/25 revealed the cause of the fall was that the bed was in the lowest position causing wheels to unlock. The new intervention was to put bed in lowest position that can be with wheels locked. The care plan was updated, and the family, physician and Director of Nursing were updated. Review of the facility policy titled Fall Reduction Policy revised 04/29/16 revealed it was the policy of the Manor to identify residents at risk for falls and to implement a fall reduction program to reduce the risk of falls and possible injury. This deficiency represents non-compliance investigated under Complaint Number OH00165646.

Based on record review, staff interview, and facility policy review the facility failed to ensure prescribed medications were with the resident on discharge. This affected one Former Resident ( #52) of three former residents (#52, #53, #54) reviewed for discharge. The facility census was 42. Summary of findings: Review of Former Resident (FR) #52's medical record revealed an admission date of 02/24/25 and discharged on 03/03/25. Diagnosis included acute kidney failure, acute respiratory distress syndrome, bacteremia, sacral pressure ulcer, congestive heart failure, and atrial fibrillation. Review of FR #52's discharge Minimum Data Set (MDS) dated [DATE] revealed the resident had an intact cognition. She was dependent for all activities of daily living. Review of FR #52's care plan revealed she wished to return home with family after respite stay. Review of FR #52's medical record revealed she required Acetaminophen (pain), Albuterol nebulizer solution (shortness of breath), Colace (constipation), Eliquis (blood thinner), Famotidine (indigestion), Gabapentin (nerve pain), Guaifenesin (chest congestion), Lactobacillus (probiotic), Levothyroxine (hypothyroidism), Losartan (hypertension), Magnesium Oxide (supplement), Methocarbamol (muscle relaxant), Midodrine (hypotension), Occuvite vitamins, Potassium Chloride (supplement), Pulmicort inhaler (shortness of breath), Sennosides (laxative), Sertraline (antidepressant), and a Ventolin inhaler (bronchospasms) as prescribed by the physician. Review of the Interdisciplinary Discharge Summary and Plan of Care revealed the FR #52 was admitted [DATE] and discharged [DATE]. The reason for admission was respite care. There was a hand written list of medications and the area titled Sent With Resident and Prescriptions Called To Pick Up were left blank. The form failed to be signed or dated. Interview with the Director of Nursing on 05/19/25 at 1:10 P.M. verified that the nursing staff failed to complete a complete discharge assessment and verified medications were not sent home with the resident. Review of the facility policy titled Discharge Summary revised 11/2016 revealed when the manor anticipates discharge a resident must have a discharge summary that included a recapitulation of the resident's stay, a final summary of the resident's status at the time of the discharge that is available for release to authorized persons, agencies, with the consent of the resident representative, reconciliation of all pre-discharged medications with the resident's post-discharge medications, and a post-discharge plan of care that is developed with the participation of the resident and his or her family, which will assist the resident to adjust to his or her new living environment. This deficiency represents non-compliance investigated under Complaint Number OH00165070.

Based on observation, staff interview, and facility policy review, the facility failed to ensure foods and cooking equipment were maintained in a clean and sanitary manner. This had the potential to affect all 36 residents receiving food from the kitchen as the the facility identified no residents who received nothing by mouth. The facility census was 36. Findings include: Observation on 04/01/24 between 8:15 A.M. and 8:30 A.M. during the initial tour of the kitchen revealed the walk-in freezer contained greater than 10 boxes of frozen food sitting on the floor of the freezer. Further review revealed a food cart with two trays of left over, uncovered, undated cherry pies. Interview on 04/01/24 at 8:25 A.M. with Dietary Manager (DM) #277 verified the greater than 10 boxes of frozen food on the floor in the walk-in freezer and the left over pies on the cart that were left unattended. Further interview with DM #277 stated the items on the floor of the walk-in freezer were from the product delivery on Friday, 03/29/24. Follow-up observation on 04/03/24 at 10:15 A.M. in the kitchen revealed the bottom plates on the front of oven were caked with a dark brown substance, the handles and front of the oven doors had a light brown substance that was sticky to touch, and the top of the stove was caked with dried food. Interview on 04/03/24 at 10:15 A.M. with Cook #246 verified the findings of the kitchen stove. Review of the facility policy titled, Inventory-Storage, revised 07/03, revealed dry or stapled food items shall be stored off the floor and shelving height should be six to twelve inches off the floor. Review of the facility policy titled, Sanitation, revised 11/03, revealed all equipment will be kept clean and maintained in good repair.

Based on medical record review, observation, resident and staff interview, and policy review, the facility failed to maintain the facility environment in a clean, safe, and functional manner. This affected five (#4, #17, #22, #32, and #86) of six residents reviewed for environment. The facility census was 36. Findings include 1. Review of the medical record revealed Resident #86 had an admitted [DATE]. Diagnoses included dementia, chronic obstructive pulmonary disease, and hypertension. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #86 had impaired cognition. Observation on 04/01/24 at 9:37 A.M. revealed there were four red circular stains on Resident #86's ceiling, multiple stains on the privacy curtain, and the window ledge was loose. Interview on 04/03/24 at 10:30 A.M., with Environmental Services Supervisor (ESS) #222 verified the stains on the resident's ceiling and privacy curtain. ESS #222 also verified the loose window ledge in the resident's room. 2. Review of the medical record for Resident #4 revealed an admitted [DATE] and a readmitted [DATE]. Diagnoses included schizophrenia and heart failure. Review of a significant change MDS assessment dated [DATE] revealed Resident #4 had impaired cognition. Observation on 04/01/24 at 11:18 A.M. revealed there were multiple stains on Resident #4's privacy curtain. Interview on 04/03/24 at 10:31 A.M., with ESS #222 verified the stains on the Resident #4's privacy curtain. 3. Review of the medical record for Resident #17 revealed an admitted [DATE] and a readmitted [DATE]. Diagnoses included atrial fibrillation and chronic obstructive pulmonary disease. Review of the quarterly MDS assessment dated [DATE] revealed Resident #17 had intact cognition. Observation on 04/01/24 at 11:18 A.M. revealed there were several stains on Resident #17's privacy curtain. Interview on 04/03/24 at 10:31 A.M., with ESS #222 verified the stains on Resident #17's privacy curtain. Interview on 04/03/24 at 2:04 P.M., Resident #17 was not aware of staff ever cleaning or replacing her privacy curtain. 4. Review of the medical record revealed Resident #32 had an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease and hypertension. Review of the quarterly MDS assessment dated [DATE] revealed Resident #32 had intact cognition. Observation on 04/01/24 at 10:24 A.M. revealed Resident #32's privacy curtain was covered with several large stained areas. Interview on 04/01/24 at 10:24 A.M., with Resident #32 revealed the curtain was never cleaned. Interview on 04/03/24 at 10:40 A.M., with ESS #222 verified the stained areas on Resident #32's privacy curtain. 5. Review of the medical record revealed Resident #22 had an admitted [DATE]. Diagnoses included type two diabetes mellitus, atrial fibrillation, and congestive heart failure. Review of the quarterly MDS assessment dated [DATE] revealed Resident #32 had intact cognition. Observation on 04/01/24 from 9:54 A.M. to 10:00 A.M. revealed the water in Resident #32's bathroom sink was still cold after running the water for six minutes. Further observation revealed the resident had multiple stains on the privacy curtain. Interview on 04/01/24 at 10:00 A.M., with Resident #22 revealed the water was too slow to warm up and staff were aware. Resident #22 also revealed the facility never washed the privacy curtain. Observation on 04/03/24 at 10:43 A.M. with ESS #222 revealed the water temperature in Resident #22's bathroom sink was 59 degrees Fahrenheit. Interview with ESS #222 revealed she was unsure why the temperature was so cold as the water in the rooms on each side of the resident's room had warm water. ESS #222 also verified the stains in the resident's privacy curtain. ESS #222 revealed she was not aware when the five (#4, #17, #22, #32, and #86) resident's privacy curtains were last cleaned. Review of the policy titled, Hot/Cold Water Temperatures, dated 06/2017, revealed the facility's standard for water temperature in resident areas would be 110 to 117 degrees Fahrenheit. Review of the undated policy titled, How to Routine Clean Resident Rooms, revealed privacy curtains would be laundered monthly.

Based on observation, resident and staff interview, and medical record review, the facility failed to maintain resident dignity of by not covering a urinary catheter collection bag. This affected one (#8) of one residents reviewed for dignity. The facility census was 36. Findings include: Review of the medical record for Resident #8 revealed an admitted [DATE] with diagnoses of obstructive uropathy and reflux uropathy, hematuria (blood in the urine), and urinary retention. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #8 revealed the resident required an indwelling catheter. Review of the physician orders for April 2024 for Resident #8 revealed the resident was ordered an indwelling urinary (Foley) catheter with instructions to change as needed to maintain patency and catheter care every shift and as needed. Review of the care plan revised January 2024 for Resident #8 revealed the resident was care planned for an indwelling urinary catheter with an intervention to position the catheter bag and tubing below the level of the bladder and away from entrance room door. Observation on 04/01/24 at 11:41 A.M. and 2:36 P.M. of Resident #8 revealed her Foley catheter was not covered and was visible from the hallway. Interview on 04/02/24 at 9:23 A.M. with Resident #8 stated it bothered her if someone saw the urinary catheter bag. Interview on 04/02/24 at 9:53 A.M. with State tested Nurse Aide (STNA) #236 stated the policy for residents with urinary catheters was to turn the collection bag backwards toward the door. Observation on 04/03/24 at 7:38 A.M. of Resident #8 revealed her Foley catheter was not covered and visible from the hallway. Interview on 04/03/24 at 7:40 A.M. with Registered Nurse (RN) #260 verified the Foley catheter for Resident #8 was visible from the hallway and the facility's policy was to cover Foley catheters.

Based on observation, medical record review, and resident and staff interview, the facility failed to ensure hearing aids were offered to maintain adequate hearing. This affected one (#16) of one residents reviewed for hearing. The facility census was 36. Findings include: Review of the medical record revealed Resident #16 had an admitted d of 05/06/20. Diagnoses included type two diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction, chronic kidney disease, and atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had impaired cognition and the resident was assessed as not having hearing aids. Review of an audiology consultation report dated 08/22/22 revealed Resident #16 had bilateral moderate to moderately severe sensorineural hearing loss. Review of the care plan dated 09/01/22 revealed to encourage Resident #16 to wear hearing aids, although she refused to wear bilateral hearing aids. Review of Resident #16's current monthly physician orders revealed no orders for bilateral hearing aids. Review of the nursing progress notes dated 01/01/24 through 04/02/24 revealed no documentation Resident #16 was offered or refused her hearing aids. Observations on 04/01/24 from 1:00 P.M. through 5:30 P.M. revealed Resident #16 was not wearing hearing aids. Interview on 04/01/24 at 2:00 P.M., with Resident #16's family member stated the facility could not find the resident's hearing aids and the resident had not been wearing the hearing aids. Interview on 04/02/24 at 9:41 A.M., with Licensed Practical Nurse (LPN) #230 stated she was not aware of Resident #16 having hearing aids in the past year. Interview on 04/02/24 at 9:46 A.M., with LPN #231 revealed Resident #16 had not wanted her hearing aids and threw them away about a year and a half ago. Interview on 04/02/24 at 2:08 P.M. with Social Service Designee (SSD) #242 revealed Resident #16 had hearing aids. SSD #242 revealed no one informed her the resident's hearing aids were missing. Further interview with SSD #242 revealed the resident's hearing aids had been found. Interview on 04/02/24 at 2:44 P.M., LPN #230 stated she was not aware Resident #16 had hearing aids and stated the resident's hearing aids were found in the bottom of the medication cart. LPN #230 stated now that the resident had hearing aids she would offer to put the resident's hearing aids in. Observation on 04/02/24 at 2:52 P.M. revealed Resident #16 was not wearing hearing aids. Observation and interview on 04/03/24 at 2:02 P.M. revealed Resident #16 was not wearing hearing aids. Resident #16 stated she could use her hearing aids. Interview on 04/03/24 at 2:27 P.M., the Director of Nursing (DON) revealed Resident #16 had no physician order for hearing aids. The DON revealed the resident used to refuse the hearing aids. The DON revealed she would go ask the resident if she wanted her hearing aids. The DON had no information on how the staff would know the resident had hearing aids or to offer to put the hearing aids in for the resident. Further interview on 04/03/24 at 3:17 P.M., the DON revealed she administered the resident's hearing aids and she wore them for approximately 40 minutes before removing them.

Based on medical record review, resident and staff interview, review of shower schedules, and policy review, the facility failed to honor a resident's preference for bathing on scheduled days. This affected one (#26) of one resident reviewed for choices. The facility census was 36. Findings include: Review of Resident #26's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, hyperlipidemia, hypertension, and morbid obesity. Review of Resident #26's quarterly Minimum Data Set assessment, dated 02/21/24, revealed the resident was assessed as cognitively intact and with no exhibited behaviors such as rejection of care. The resident was dependent on staff for bathing and personal hygiene. Review of the facility's shower schedule revealed Resident #26 was scheduled to be showered on the evening shift every Tuesday and Saturday. Review of Resident #26's electronic medical record and shower sheets revealed the resident did not receive showers on 03/12/24, 03/31/24, and 04/02/24. Review of Resident #26's nursing progress notes did not reveal any evidence of the resident refusing to be showered on their scheduled shower days on 03/12/24, 03/31/24, and 04/02/24 to explain why a shower had not been provided. During an interview on 04/01/24 at 11:12 A.M., Resident #26 reported showers were supposed to be completed on Sunday and Tuesday evenings and often the resident did not receive them. Resident #26 reported being scheduled for a shower on 04/02/24 and would likely not receive one. During a follow up interview on 04/03/24 at 7:35 A.M., Resident #26 reported a shower was not received on 04/02/24 as scheduled. Resident #26 reported she preferred to shower in her regular wheelchair rather than in a shower chair, and staff normally honored that preference when offering the resident a shower. Resident #26 reported on 04/02/24, staff stated they could not shower Resident #26 in her wheelchair because the Ohio Department of Health (ODH) was in the building and staff would get in trouble for showering the resident in a wheelchair. During an interview on 04/04/24 at 2:15 P.M., Regional Nurse #280 verified there was no additional evidence to support Resident #26 was provided showers per their preference on the aforementioned dates. Review of the facility policy titled, Quality of Care Policy/Activities of Daily Living, revised April 2016, each resident will receive and the manor will provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being.

Based on medical record review, review of a facility incident report, review of a staff statement, review of hospital reports, review of a weather report, interviews with staff and Family Member #240, and review of the policy on elopement, the facility failed to provide adequate supervision to prevent Resident #01, who had mild cognitive impairment with recent increased confusion due to a urinary tract infection, from leaving the facility unsupervised and unknown to staff. Additionally, the facility failed to complete a thorough investigation into the elopement incident. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm and/or negative health outcomes when on 01/17/24, sometime after 10:45 P.M., Resident #01 eloped from the facility unsupervised and unknown to staff and was discovered by chance when a pharmacy delivery driver who arrived at the facility around 10:55 P.M. found the resident locked outside the facility and bleeding from the hand while standing on the porch. The resident had been locked outside the facility for approximately ten minutes exposed to temperatures below 22 degrees Fahrenheit (F) without a winter coat. Resident #01 was assessed and treated by Licensed Practical Nurse (LPN) #100 then taken to the emergency room by family the following day and diagnosed with a urinary tract infection and pneumonia. This affected one resident (#01) of four residents (#01, #17, #18, #30) reviewed for accident hazards/elopement. The facility identified 11 current residents (#01, #04, #06, #07, #12, #17, #18, #19, #23, #24, #27) at moderate or high risk for elopement. The facility census was 36. On 01/30/24 at 9:43 A.M., the Administrator, Director of Nursing (DON), Regional Director of Operations (RDO) #305, and Registered Nurse Clinical Education Specialist (RNCES) #180 were notified Immediate Jeopardy began on 01/17/24, sometime after 10:45 P.M., when Resident #01 eloped from the facility and was not noticed missing by facility staff until Pharmacy Delivery Driver (PDD) #50 arrived at the facility at 10:55 P.M. and discovered Resident #01 locked outside the facility in temperatures below 22 degrees F without a winter coat. PDD #50 revealed the resident told him she was waiting by the pillar on the porch for someone. PDD #50 revealed the facility doors were locked. PDD #50 called the facility nurse at 10:55 P.M. and she came to the door. PDD #50 revealed he pointed at the resident so the nurse would know the resident was outside. PDD #50 revealed he held the door while the nurse got the resident back in the building. The resident was assessed and treated by LPN #100 then later taken to the emergency room by family and diagnosed with a urinary tract infection and pneumonia. The Immediate Jeopardy was removed on 01/31/24 when the facility implemented the following corrective actions: On 01/17/24 at approximately 11:00 P.M., Resident #01 was found to be standing outside the door on the patio by the pharmacy delivery driver. The resident was immediately assessed by LPN #100 and was noted to have a small skin tear to her right fifth digit at the knuckle. It appeared the skin tear was from the wheelchair. LPN #100 applied a secure care ankle bracelet (monitoring device), treated the skin tear, redirected resident to her room and initiated 15-minute checks. On 01/18/24, Resident #01 ' s care plan was reviewed by Registered Nurse (RN) #200 and was revised to include the resident was at risk for elopement as a result of the incident and interventions for the secure care ankle bracelet. On 01/29/24 at approximately 3:30 P.M., a thorough investigation was completed by the DON. The investigation included interviews with staff working 01/17/24 during the time frame, review of the medical record, and verification the doors were working properly. On 01/29/24, 35 residents had a wandering evaluation completed by RN #200 and RN #201. Eleven residents were identified at risk for wandering/elopement (#01, #04, #06, #07, #12, #17, #18, #19, #23, #24, #27). On 01/29/24, 62 staff were educated on elopement and the missing persons policy and identifying hazards and risk and modifying interventions as appropriate by the DON, Activity Director (AD) #202, Environmental Services Supervisor (ESS) #203, and the Administrator. Any staff member not educated by 01/29/24 would not be permitted to work until education was completed. On 01/29/24 at approximately 2:30 P.M., the DON and the Administrator were educated on elopement, missing persons policy and on completing a thorough investigation by the RNCES #180. On 01/30/24, an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held which included Medical Director (MD) #210 (via phone), the Administrator, DON, Minimum Data Set (MDS) Coordinator RN #200, Infection Prevention Licensed Practical Nurse (IPLPN) #205, Case Manager RN #201, ESS #203, Resident Services Coordinator (RCS) #202, and Business Office Manager (BOM) #206 to discuss elopement procedures and the incident. Interviews on 01/30/24 from 7:57 A.M. through 8:49 A.M. revealed LPN #120, RN #121, and State tested Nursing Assistant (STNA) #123 had been educated on the elopement policy, hazards and risks, and identifying resident interventions as appropriate. On 01/30/24 at 10:40 A.M., an Elopement Drill was completed and there were no concerns were identified with the drill. Staff followed the elopement policies and procedures as directed. Interviews on 01/30/24 from 4:18 P.M. to 4:21 P.M. revealed LPN #112 and RN #113 had been educated on the elopement policy, hazards and risks, and identifying resident interventions as appropriate. Beginning on 01/31/24, the DON or designee will randomly audit/observe five residents who exhibit wandering behavior three times a week for four weeks to ensure the behavior is care planned, the care plan includes appropriate interventions to address elopement risk, and staff are implementing the interventions in accordance with the plan of care. Review of the medical records on 01/31/24 for Resident #6, Resident #12, and Resident #18 identified as an elopement risk revealed their care plans and elopement risk assessments were updated. Although the Immediate Jeopardy was removed on 01/31/24, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record revealed Resident #01 had an admitted [DATE]. Diagnoses included urinary tract infection, chronic kidney disease, insomnia, chronic pain, spinal stenosis, and radiculopathy of the lumbar region. Review of the quarterly MDS assessment dated [DATE] revealed Resident #01 had mild cognitive impairment. The resident required the supervision/touching assistance of one staff for bed mobility, transfers, and ambulation. The resident used a walker and a wheelchair. The resident exhibited no wandering behavior. Review of a wandering risk assessment dated [DATE] revealed the resident was at low risk for wandering. Review of the plan of care initiated 10/14/23 revealed no interventions for wandering or elopement risk until the care plan was revised on 01/18/24 after the resident eloped from the facility. Interventions included an elopement prevention device per physician ' s orders, check function of elopement device every shift and as needed, check placement of elopement prevention device every shift, redirect exit seeking behaviors as needed, and staff to be aware of resident ' s location at all times. Review of a nurse ' s note dated 1/15/24 at 2:37 P.M. revealed the resident returned from the hospital and continued to appear confused. The resident stated people were trying to kill her, take her to the basement, and throw her in the furnace. The nurse and the resident ' s family were unable to redirect the resident ' s behavior. The resident was noted to have a urinary tract infection and had a prescribed antibiotic. Review of a wandering risk assessment dated [DATE] revealed the resident was at moderate risk for wandering and identified a recent change in condition due to a urinary tract infection. There were no interventions added for the increased wandering risk. Review of a nurse ' s note dated 01/17/24 at 2:36 P.M. revealed the resident ' s confusion getting better and the nurse would continue to monitor. Review of an incident report dated 01/17/24 at 11:00 P.M. revealed Resident #01 was confused and wandered to the porch of the facility. Resident #01 stood up from her wheelchair attempting to open the door and cut her right pinky finger at the knuckle from the wheelchair lock. The laceration was bleeding and left a trail. When redirected and asked what she was doing the resident stated, I am waiting on my folks to get here. Resident #01 repeated the statement three times. The resident was redirected in the facility to her room. Vitals were taken as a precaution, which were within normal limits. The laceration was washed with soap and water, and a bandage gauze was placed on it. A wanderguard (monitoring device) was placed on the resident as intervention for her confusion. Resident #01 was also placed on 15-minute checks. Further review of the incident report revealed no witnesses were identified. Review of a change in condition progress note dated 01/18/24 at 2:05 A.M. revealed the resident was confused and had wandered to the porch of the facility. While attempting to stand and open the door, the resident cut her right fifth finger on the wheelchair creating a laceration. The resident recently returned from the hospital with diagnosis of urinary tract infection and remained confused upon her return to the facility. The resident stated she was waiting on her folks to get her. The resident ' s vital signs were within normal limits and the resident was treated for bleeding from the finger laceration. The resident ' s family and facility administrator were notified. An SBAR (situation, background, assessment, recommendation) form was completed for the physician. The resident was redirected to her room and a wanderguard was placed on the resident ' s ankle. Review of a nurse ' s note dated 01/18/24 at 9:30 A.M. revealed Nurse Practitioner #400 was notified of Resident #01 ' s wandering and skin tear. Review of a nurse ' s note dated 01/18/24 at 11:39 A.M. revealed the family was going to transport the resident to the emergency room due to increased paranoia and refusal to eat and drink. Review of hospital documentation dated 01/18/24 at 2:09 P.M. revealed the resident was treated for a urinary tract infection and pneumonia. Review of the weather report from wunderground.com revealed on 01/17/24 at 10:52 P.M. the air temperature was 22 degrees Fahrenheit. Review of a statement dated 01/18/24 from the Administrator revealed she had received a call from LPN #100 stating Resident #01 had wandered onto the porch with the pharmacy delivery man. The pharmacy delivery driver (#50) called the facility to let the nurse know he was here and when LPN #100 went to the front door, Resident #01 was standing outside with him next to the first pillar. LPN #100 noted the resident ' s fifth finger was bleeding from a skin tear. The resident told LPN #100 she was waiting for her folks to come get her. The resident was easily redirected and returned inside with the nurse and PPD #50. Resident #01 had parked her wheelchair between the set of doors. LPN #100 stated she felt the resident had just gone outside because she was not cold, specifically stating her ears and neck were warm. LPN #100 applied a wanderguard to the resident and was completing notifications. Interview on 01/29/24 at 8:57 A.M., Resident #01 revealed she went outside to the parking lot a couple of weeks ago. Resident #01 stated she was outside for around seven or more minutes. Resident #01 revealed she was not wearing a winter coat and was cold. Resident #01 thought it was daylight outside. Resident #01 revealed she was not walking well so she stayed in the parking lot. Resident #01 stated she just wanted to go outside. Resident #01 revealed a guy was delivering stuff to the building and asked if I needed help to open the door and I did. Interview on 01/29/24 at 9:05 A.M., RN #102 revealed Resident #01 was treated for a urinary tract infection at the hospital and came back confused. RN #102 revealed the resident went outside and was locked out until the pharmacy driver found her. RN #102 revealed the resident was evaluated the following day in the emergency room and treated for a urinary tract infection and pneumonia. Interview on 01/29/24 at 9:11 A.M., the Administrator revealed LPN #100 notified her around 11:40 P.M. on 01/17/24 that Resident #01 had walked outside, and the pharmacy delivery driver was outside. The Administrator was unaware how long the resident was outside. The Administrator revealed the doors were not locked to go outside but the doors were locked to get back into building. The Administrator revealed the doors were locked around 9:00 P.M. until around 7:00 A.M. The Administrator revealed Resident #01 had never tried to leave the facility before. The Administrator stated the immediate intervention was to place a wanderguard on the resident. Interview on 01/29/24 at 12:00 P.M., the DON revealed she had not completed an investigation of Resident #01 ' s elopement. The DON revealed she had not considered the incident an elopement because the resident had not left the property, was not outside long and was attended to by the pharmacy delivery driver (#50). The DON also verified there was no documentation staff had completed the nurse ' s intervention for 15-minute checks on the resident after she was back inside the facility. Interview on 01/29/24 at 1:39 P.M. with Resident #01 ' s Family Member #240 revealed someone from the facility called and notified her Resident #01 got out, cut her finger, was found by a driver outside, and was brought back into the building. Family Member #240 revealed she thought she was notified around 11:30 P.M. Interview on 01/29/24 at 2:05 P.M., PDD #50 revealed on 01/17/24 as he was pulling up to the facility, he saw an older lady outside the facility. PDD #50 revealed the resident was not wearing a winter coat. PDD #50 revealed the temperature was in the teens that night. PDD #50 revealed the resident was bleeding from her hand and everything she touched had blood on it. PDD #50 revealed he asked the resident if she needed assistance, and she denied needing assistance. PDD #50 revealed he touched the resident ' s arm to make sure she knew he was talking to her because she was acting confused. PDD #50 revealed the resident ' s arm was still warm. PDD #50 revealed the resident told him she was waiting by the pillar on the porch for someone. PDD #50 revealed the facility doors were locked. PDD #50 checked his call log and revealed he called the facility nurse at 10:55 P.M. and she came to the door less than a minute later. PDD #50 revealed he pointed at the resident so the nurse would know the resident was outside. PDD #50 revealed he held the door while the nurse got the resident back in the building. Interview on 01/29/24 at 2:26 P.M., LPN #100 revealed on 01/17/24 she received during report that Resident #01 had recently returned from the hospital with a urinary tract infection and was still confused. LPN #100 revealed she began her medication pass and Resident #01 had refused her medications including antibiotics at approximately 9:30 P.M. and again at 10:15 P.M. LPN #100 revealed she completed her medication pass around 10:45 P.M., later than normal. LPN #100 revealed it was a busy night with a heavy medication pass. LPN #100 revealed the smokers were upset they could not go outside because it was less than 10 degrees Fahrenheit outside. LPN #100 revealed she took a break after her medication pass was completed. LPN #100 revealed the phone rang just before 11:00 P.M. and it was the pharmacy driver saying he was here. LPN #100 revealed she rounded the corner on her way to let the driver in and noticed a phone on the floor. LPN #100 revealed she next noticed a wheelchair inside the front entrance double doors. LPN #100 revealed she went to move the wheelchair to open the door and noticed blood where you would lock the wheelchair and more blood on the door where you would push it open. LPN #100 revealed she then saw Resident #01 outside by the pillar holding onto the pillar. LPN #100 revealed the resident was wearing light colored sweatpants, a shirt, grippy slipper socks, and a pink fleece jacket. LPN #100 revealed the resident was also wearing a gait belt. LPN #100 revealed the aides said they were just in her room and were going to get her ready for bed, but the resident had not wanted to go to bed. LPN #100 revealed she assessed the resident and found the location of the bleeding on her fifth finger. LPN #100 revealed the resident ' s fingertips were cold but everything else was warm. LPN #100 revealed she took the resident to her room and wrapped up her finger, placed a wanderguard on the resident, then told the aides to begin 15-minute checks on the resident. LPN #100 revealed she then called the Administrator and resident ' s family. Interview on 01/29/24 at 3:03 P.M., STNA #120 revealed on 01/17/24 she was assigned to care for Resident #01. STNA #120 revealed the resident was confused and she had checked on the resident multiple times that evening. STNA #120 revealed she assisted the resident to the bathroom and was going to put her in bed, but the resident stated she was not ready for bed. STNA #120 revealed she left the resident around 10:45 P.M., took the trash outside and went to assist another resident. STNA #120 revealed she had left the resident ' s gait belt on her so she could assist the resident to bed later. STNA #120 revealed when she exited another resident ' s room around 11:00 P.M., Resident #01 was with LPN #100 who was applying pressure to the resident ' s finger. STNA #120 revealed it was cold outside but could not recall how cold it was. STNA #120 revealed the resident had blue and pink on and thought she might have had a pink fleece jacket on and may have had shoes on. STNA #120 revealed she heard LPN #100 tell the oncoming third shift staff to complete 15-minute checks on Resident #01. Interview on 01/30/24 at 8:42 A.M., Registered Nurse Clinical Education Specialist (RNCES) #180 revealed elopement assessments were completed on residents upon admission and quarterly. RNCES #180 revealed the facility had no policy on elopement assessments. RNCES #180 revealed there were no new interventions put in place for Resident #01 due to her increased confusion. RNCES #180 revealed if the resident had a change in condition, the clinical team would review the individual resident, determine why there was a change, and the expectation would be to put something different in place if warranted. RNCES #180 revealed she believed the clinical team had not had a chance to review the resident. RNCES #180 revealed she educated the Administrator and DON regarding the definition of an elopement and completing an investigation. RNCES #180 revealed anytime there was an incident, an investigation should be completed. In a follow-up interview, RNCES #180 revealed Resident #01 ' s Physician #210 and Nurse Practitioner #400 were not notified of the incident until the following day. Review of the policy, Missing Resident Policy, approved 05/09/17, revealed no guidelines for preventing or investigating a resident elopement. This deficiency represents non-compliance investigated under Complaint Number OH00150439.

Based on medical record review, staff interview, and policy review, the facility failed to timely assess and treat a resident who was at a high nutrition risk and admitted with a nasogastric (NG) tube with poor oral intake. Actual harm occurred to Resident #01, when the resident was treated in the hospital with intravenous fluids and the resident experienced a severe weight loss of 7.0 percent in two weeks. This affected one (#01) of three residents reviewed for nutritional status. The facility identified no current resident with enteral nutrition and one resident who had significant weight loss in the last month. The facility census was 43. Findings include: Review of the medical record for Resident #01 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #01 was discharged to the hospital on 03/10/22. Review of the hospital after visit summary, dated 02/17/22, revealed Resident #01 had severe protein-calorie malnutrition and a NG tube and tube feeding was initiated while Resident #01 was to encephalopathic (damage or disease that affects the brain and can alter the brain function) to safely eat. [CONDITION(S)] drastically improved with vitamin and nutritional supplementation. Resident #01 was now able eat and swallow safely but was still malnourished. The recommendation was for one more week of tube feeding, but if taking adequate oral nutrition and the diarrhea was overly burdensome, this could be stopped sooner. Resident #01 had a waxing/waning mental status in the evening, so NG tube was left in place at discharge to ensure the skilled nursing facility had access for vitamin administration if needed. Further review of the discharge instructions revealed there was no order for enteral nutrition via NG tube and no order for NG tube care and no order for an oral diet. There was an undated hospital weight of 175 pounds. Review of the progress notes revealed Resident #01 was admitted to the facility on [DATE] at 2:04 P.M. Review of the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the baseline care plan revealed there was no care plan developed to address the resident's high nutrition risk or NG tube. Review of the meal intake documentation, from 02/17/22 to 02/20/22, revealed there was lack of documentation of Resident #01 being offered a meal, the resident refusing to eat a meal, and/or offering a substitute. There was no evidence of Resident #01 being offered or provided an evening meal on 02/17/22. The meal intake documentation, dated 02/18/22, revealed there was no evidence of breakfast or lunch being offered or provided and Resident #01 consumed 29 percent for dinner. The meal intake documentation dated 02/19/22, revealed the meal intakes were 29 percent, 15 percent, and 29 percent. The meal intake documentation, dated 02/20/22, revealed the medical record contained no evidence of Resident #01 being offered or provided breakfast or the afternoon meal and Resident #01 consumed 29 percent of the evening meal. Review of the progress notes dated 02/17/22 through 02/19/22 for Resident #01, revealed no evidence of physician notification of the decreased oral meal intakes. Review of the weight documentation revealed Resident #01's weight dated 02/18/22 was 169 pounds, and the weight dated 03/01/22 was 157.2 pounds. This was a 11.8-pound weight loss and a 7.0 percent severe weight loss. Resident #01's weight dated 03/09/22 was 154.7 pounds. Review of the medical record for Resident #01 revealed no evidence of care and services provided for the NG tube. Review of a progress note dated 02/20/22 at 6:03 A.M. revealed Resident #01 was very confused and aggressive. Resident #01 ripped out the NG tube that morning. The NG tube was not being utilized and Resident #01 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The progress note revealed Resident #01 was administered medication and had some difficult swallowing. The physician was made aware. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The family voiced concerns related to Resident #01's nutritional status being poor. Resident #01 presented to the facility with a NG tube, but no feedings were given via NG tube. Over the past few days, Resident #01 had pulled out the NG tube, was irritable, agitated, and combative with staff. The progress note reported the family was clearly frustrated. The physician advised the family that Resident #01 needed to be in a hospital setting or subacute setting and should go to the hospital for hydration. Review of a progress note dated 02/21/22 at 9:00 A.M. revealed Resident #01 was sent to the hospital for evaluation and treatment. Review of the hospital after visit summary dated 02/21/22, revealed Resident #01 was sent to the hospital for evaluation and treatment. The chief complaint was dehydration. A complete blood count and basic metabolic panel was completed with abnormal results. The resident was administered sodium chloride 0.9 percent 1,000 milliliter (ml) bolus and the antipsychotic medication [MEDICATION(S)] 5.0 milligram (mg) intravenous (IV). Resident #01 was discharged in stable condition. Review of the medical record for Resident #01 revealed the resident return to the facility on [DATE]. The time of arrival was not documented. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #01 had severe impaired cognition. Resident #01 required extensive assistance of one person for eating, personal hygiene, and dressing. Review of the medical record for Resident #01 revealed the medical record contained no evidence of the resident being assessed by the registered dietician or the dietician technician until 03/02/22. Resident #01 was nutritionally assessed 13 days after Resident #01 admitted to the facility. Interview on 03/23/22 at 10:55 A.M. with Registered Dietitian (RD) #500 revealed residents who were admitted to the facility with a high risk for nutrition would normally be assessed by the RD on the next visit. The RD was in the building one to two times a month. RD #500 reported the facility employed a dietary technician who was at the facility once a week. RD #500 reported as the RD, she was responsible to review any residents that were referred as a high nutritional risk. RD #500 stated all residents were to have a nutrition assessment and the expectation was that nutrition assessments be completed within seven days of admission. RD #500 verified Resident #01 was a high nutritional risk and verified the nutrition assessment for Resident #01 was completed on 03/02/22. RD #500 verified Resident #01 was not nutritionally assessed timely and was missed as a new admission. RD #500 verified the facility did not notify her of Resident #01's new admission with a NG tube. RD #500 verified Resident #01 had a significant weight loss from 02/17/22 to 03/02/22 with no nutritional interventions. Interview on 03/23/22 at 1:46 P.M. with the Director of Nursing (DON) verified Resident #01 was admitted to the facility with a NG tube and verified Resident #01 was not provided care and services to maintain a NG tube. The DON verified Resident #01 had poor oral intakes on 02/17/22, 02/18/22, and 02/19/22. The DON further verified the medical record contained no evidence of the physician being made aware of the resident's poor oral intake until 02/20/22, when the physician was notified of the resident pulling out the NG tube. The DON verified on 02/21/22, Resident #01 was sent to the hospital for hydration and possible replacement of the NG tube. The DON reported Resident #01 was administered IV fluids while at the hospital, but a NG tube was not inserted. Review of a policy titled Nutritional Assessments, revised 01/2018, revealed upon arrival, the nutrition service supervisor, dietetic technician, nutrition associate, and or registered dietitian will identify information needed to plan for the individual's resident's nutritional care. The information will be documented using the medical nutrition therapy review, nutrition progress notes, and the plan of care. The information will be analyzed to determine potential problems and or need for increased nutrients. This deficiency substantiates Complaint Number OH 904.

Based on medical record review, review of the wound care initial evaluation, policy review, and physician and staff interviews, the facility failed to ensure accuracy of wound assessment was completed and implemented treatments to promote healing. This resulted in actual harm when Resident #18 had a pimple like area to the right posterior thigh/hip that worsened and turned into an unstageable pressure ulcer (full thickness skin and tissue loss in which the extent of the tissue damage within the ulcer cannot be confirmed because it is covered by slough (yellow devitalized tissue, that can be stringy or thick and adherent on the tissue bed) or eschar (a piece of dead skin). This affected one (#18) of three residents reviewed for pressure ulcers. The facility census was 68. Findings include: Review of Resident #18's medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the annual minimum data set (MDS) assessment dated [DATE], identified the resident as being rarely/never understood and being severely impaired for cognitive skills for daily decision making. The MDS identified the resident as being total dependent of two-person physical assist with bed mobility, transfers, dressing, toilet use and personal hygiene. The resident required total dependence of one person assistance with eating. The resident was assessed as always being incontinent of bowel and bladder and having a Stage 3 and 4 pressure ulcer. Review of the nurse's notes revealed on 09/25/17 at 1:41 P.M., Resident #18 had an area on his right posterior thigh, slightly reddened with hard area in the center of the red area under the skin. Review of the nurse ' s note dated 09/25/17 at 9:26 P.M. and on 09/26/17 at 9:26 P.M., revealed the resident has a pimple like red dot intact to right posterior thigh. Review of the physician orders and the physician notifications revealed on 09/25/17, the physician was notified about Resident #18 having an area on his right posterior thigh that looks like a pimple festering under the skin. The area is red, measures 0.5 centimeters (cm) by 0.8 cm and can feel something in the center. The nurse recommended for warm compresses four times a day for five days and the physician agreed and signed the order on 09/26/17. Review of the skin/wound note dated 09/27/17 at 2:30 P.M., revealed an area on right posterior thigh with increased redness from 09/25/17. The assessment revealed the area of redness was now 3.5 cm by 3.0 cm and was hard under the entire redden area. The assessment documented the center was now open and dark colored with scant amount of bloody drainage, and the physician was faxed regarding this area. Review of the physician notification with physician orders dated 09/27/17, revealed the area on the right posterior thigh was now open and draining with a scant amount of bloody drainage. It revealed the area has increased in size, the redness was now 3.5 cm by 3.0 cm and it was hard to the touch under the whole redden area. The center that was open was now with a black area. The Licensed Practical Nurse (LPN) recommended to discontinue the warm compresses and to start treatment of [REDACTED]. The physician signed this order on 09/28/17. Review of the physician notification with physician orders revealed on 09/28/17, the nurse informed the physician of the area to the back of Resident #18's right posterior thigh draining, with new orders for a wound culture of open area to the back of the right thigh. Review of the nurse's notes on 09/28/17 at 10:29 P.M., revealed a new order for a wound culture of right posterior thigh and the wound culture was obtained at 11:00 P.M. Review of the nurse's notes dated 10/01/17 at 8:00 P.M., revealed the physician was notified of wound culture results and new order for Bactrim DS (antibiotic) two times a day for ten days. Review of the skin/wound note dated 10/07/17 at 2:37 P.M., revealed the area on the residents right posterior thigh reddened around with black eschar in the center of the wound, and treatment as ordered. Review of the skin/wound note dated 10/08/17 at 6:34 A.M., revealed the dressing was changed to the right thigh with moderate amount of blood drainage noted, odor also noted and the area had eschar present. Review of the physician notification with physician orders dated 10/08/17, revealed the resident's area on the right upper posterior thigh with black eschar tissue and a culture was obtained and positive for [MEDICAL CONDITION]-Resistant Staphylococcus Aureus (MRSA) and was started on antibiotics. This note indicated the area needed debridement. Review of the (MONTH) (YEAR), Treatment Administration Record (TAR), indicated there was an order to cleanse open area to the back of the right thigh with saline, pay dry, apply [MEDICATION NAME] and dry dressing twice daily until resolved on the day shift and evening shift, this was ordered 10/08/17 and discontinued on 10/10/17. Further review of the (MONTH) TAR, indicated this treatment was signed off as being completed from 10/08/17 on the 3:00 P.M. to 11:00 P.M. shift until 10/10/17 on the 7:00 A.M. to 3:00 P.M. shift. Review of a physician order dated 10/09/17, was for Santyl and cover with moistened gauze and change two times a day until healed. Review of the nurse's note dated 10/10/17 at 5:40 P.M., revealed there was a new order obtained for Santyl ([MEDICATION NAME] agent) Ointment 250 unit/gram, apply to right upper posterior thigh topically every day and evening shift for wound. Review of the (MONTH) TAR, indicated an entry dated 10/10/17, for Santyl Ointment apply to right upper posterior thigh topically every day and evening shift for wound debridement. Further review of the (MONTH) TAR, indicated the first treatment was not completed until 10/11/17 on the 7-3 shift. Review of the Nursing Wound Documentation Record indicated the first time the wound nurse assessed the area to the right buttock/hip area was on 10/11/17, and the area was identified as being an unstageable pressure ulcer measuring 3 cm x 3.5 cm. The assessment documented the right buttock/hip area was also written as the thigh area and started as a pimple [MEDICAL CONDITION] and has changed to an unstageable with eschar. Review of the Wound Care Specialist Initial Evaluation dated 10/13/17, indicated Resident #18 had a Stage 4 pressure ulcer to the right lateral hip measuring 2.9 cm x 3.0 cm x 0 cm. The note documented the duration was less than 15 days, the peri-wound radius was surrounded by a deep tissue injury (DTI) and the wound was 100% thick adherent black necrotic tissue. This note indicated surgical excisional debridement was completed. There was a recommendation for a tighter diabetic control. Review of the Nursing Wound Documentation Record dated 10/13/17, revealed the right hip area was now a Stage 4 pressure ulcer measuring 2.9 cm x 3.0 cm x 2.2 cm. The wound physician completed a debridement of the area to the right hip that started as a pimple and became pressure. Review of the skin/wound note dated 10/13/17 at 11:30 A.M., revealed the wound doctor was in for the right hip wound and the coccyx. It revealed debridement was performed to the right hip wound. Interview via telephone with Physician #300 on 01/11/18 at 3:25 P.M., revealed he was not notified by phone and was notified by facsimile (fax) regarding the residents pressure area to his right hip having a black area on it. He voiced typically if he was notified by fax and something was unclear, he would stop out and take a look at it himself, however, he voiced that he does not have a note around that time so he didn't stop in and look at it. He voiced that typically when there is a black area, that means its narcotic and there should have been something better than [MEDICATION NAME] ordered. He voiced the [MEDICATION NAME] would have kept that area moist. Again, he voiced there would have been a better option, something like Santyl or other [MEDICATION NAME] agent, to debride that area. He confirmed since the nurse was the one physically assessing the pressure area, she should have implemented a more appropriate treatment. Interview with Regional Nurse #200 on 01/11/18 at 4:42 P.M., confirmed the LPN assessed Resident #18 and faxed the physician regarding the resident's area on the right posterior thigh. The area was initially getting warm compresses and then the area opened and was draining a scant amount of blood drainage. The area had increased in size and was open and with a black area. Regional Nurse #200, confirmed the LPN recommended [MEDICATION NAME] ointment and dry dressing two times a day until resolved and the physician agreed with this order. Regional Nurse #200, confirmed they were applying [MEDICATION NAME] to an area that was assessed to have a black area. Regional Nurse #200 confirmed the physician was faxed on 10/08/17 regarding the resident ' s area to the right upper posterior thigh with eschar tissue and needed debridement. However, confirmed the staff were still continuing the treatment of [REDACTED]. She confirmed on 10/09/17, the physician wrote an order for [REDACTED]. Review of the facility policy titled, Pressure Ulcer Policy, dated 04/29/16, revealed a resident with a pressure ulcer will receive interventions and monitoring to promote healing, prevent infection and prevent new ulcers from developing. This deficiency substantiates Complaint Number OH 401.