Every finding on record at St Francis Senior Ministries

Based observation and staff interview the facility failed to ensure the facility was adequately maintained. This had the potential to affect all 52 residents residing in the facility. The facility census was 52. Findings include: Observation on 04/10/25 from 8:09 A.M. through 9:05 A.M., during an environmental tour with the Administrator, revealed the following: Outside the main elevator on the first floor, and continued down the hallway and into the dining room, were damaged and improperly fitted ceiling tiles. Multiple ceiling tiles in the first floor dining hall, near the solarium opening, had dried water stains. On the second floor, outside the main elevator and down the south hall (200-220 unit), and continued down the west hall (221-239 unit), were multiple water stained, damaged, and improperly fitted ceiling tiles. On the first-floor memory care unit, fluorescent light ballast covers contained dirt and debris, including perished bugs and flies, and several covers were cracked with partially broken covers throughout both south and east halls. Concurrent interview with the Administrator verified the above findings.

Based on medical record review, review of the facility Self-Reported Incidents (SRIs), staff interview and review of facility policy, the facility failed to ensure staff implemented the facility's abuse policy related to immediate reporting of allegations of abuse to the Administrator. This affected one (#32) of one resident reviewed for abuse. The facility census was 52. Findings include: Review of Resident #32's medical record revealed an admitted [DATE]. Diagnoses including phantom limb syndrome with pain, chronic respiratory failure, and acquired absence of left leg above the knee. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/21/25, revealed a Brief Interview of Mental Status (BIMS) score of 14, indicating Resident #32 was cognitively intact. Review of the facility submitted SRI, created 01/26/25, revealed on 01/25/25, Resident #32 reported to Certified Nursing Assistant (CNA) #310 and Licensed Practical Nurse (LPN) #315 that at approximately 1:30 A.M., an unidentified staff member used force while applying cream to his left lower extremity (LLE) stump and, while providing incontinence care, it felt like the staff inserted a digit into his rectum. Further review of the SRI revealed LPN #315 did not report the alleged abuse to the facility administration until 01/26/25. At the time LPN #315 reported the alleged abuse, the facility immediately began an investigation, made appropriate notifications, and suspended the possible staff members pending the results of the facility investigation. Interview on 04/10/25 at 2:02 P.M. with the Director of Nursing (DON) confirmed Resident #32 initially reported an allegation of abuse to LPN #315 on 01/25/25, but LPN #315 did not report it to administration until the resident made the allegation a second time on 01/26/24. Review of the facility policy titled, Abuse, Neglect, and Exploitation, dated 11/21/24, revealed all alleged violations would be reported to the Administrator immediately, but not later than two hours after the allegation was made.

Based on staff interview and review of facility documentation, the facility failed to ensure facility daily staffing included a Registered Nurse (RN) for eight hours during a 24-hour period. This had the potential to affect all 79 residents residing in the facility. Findings include: Review of the facility's staffing schedules between 03/06/23 and 03/12/23 revealed the facility did not have a RN for eight hours in the 24-hour period on Sunday 03/12/23. Interview on 03/13/23 at 2:56 P.M. with the Administrator revealed the facility's staffing schedules were reviewed and the Administrator confirmed the facility lacked RN coverage for the entire day on 03/12/23 during a 24-hour period. This deficiency represents non-compliance investigated under Complaint Number OH00140552.

Based on resident and staff interview, record review, observation of meal service, review of the facility menu, recipe review, and review of facility policy, the facility failed to ensure residents who received pureed meals from the second floor kitchen received the correct serving sizes. This affected five (#20, #24, #33, #36, and #177) of five residents who received pureed meals on the second floor. In addition, the facility failed to follow the approved menu and recipe during meal service. This affected all residents except 14 (#5, #12, #15, #20, #24, #33, #36, #59, #60, #64, #68, #177, #179, and #180) identified by the facility as not having the food items for which the recipe was not followed. The facility census was 79. Findings include: 1. Review of a facility document titled 2022 Fall/Winter Menus, undated, revealed the pureed lunch meal consisted of a number eight scoop of beef burgundy, a number eight scoop of egg noodles, and a number twelve scoop of key west vegetable blend for 03/13/23. Observation on 03/13/23 at 11:30 A.M. of meal service in the second floor dining room revealed Dietary Aide (DA) #351 plated the lunch meal, consisting of beef burgundy, egg noodles, and key west vegetable blend. DA #351 provided two number eight scoops of food into divided dishes for residents on a pureed diet. Three residents (#20, #33, and #36) were served a pureed meal in the dining room, while two (#24 and #177) residents received pureed meal trays delivered to their rooms on the second floor. Interview on 03/13/23 at 11:56 A.M. with DA #351 confirmed residents who received pureed meals were served two items during the lunch meal. DA #351 stated the beef burgundy and egg noodles were pureed together and the vegetables were a separate item. DA #351 confirmed she plated a number eight scoop of the pureed beef and noodles and a number eight scoop of the key west vegetable blend for each of the pureed meals. DA #351 verified she did not provide two number eight scoops of the beef and egg noodle puree to accommodate the serving size of a number eight scoop of each food item. DA #351 confirmed Residents #20, #24, #33, #36, and #177 received pureed meals from the second floor dining room. Interview on 03/13/23 at 12:20 P.M. with Registered Dietitian (RD) #417 confirmed the lunch menu for pureed meals consisted of a number eight scoop of beef burgundy, a number eight scoop of egg noodles, and a number twelve scoop of the key west vegetable blend. RD #417 verified residents on pureed diets should have been served two number eight scoops of the beef and noodle puree since the food items were pureed together. RD #417 stated the facility did not typically puree foods together and it probably confused DA #351. RD #417 verified the number eight scoop equaled approximately a one-half cup, or about four to five ounces, of food. In addition, RD #417 also confirmed the serving size of a number eight scoop was not accurate based on the menu and should have been a number twelve scoop for the key west vegetable blend, which equaled approximately a one-third cup, or two and one-half to three ounces. Lastly, RD #417 stated the facility had a new cook and Food Service Director (FSD) #319 was off on leave. RD #417 stated she would mention to the kitchen staff serving sizes needed to be adjusted if foods were pureed together. Review of the facility policy titled Puree Food Preparation, dated 04/27/22, revealed residents receiving puree diets should always receive portions equivalent to those serviced on the regular or therapeutic diet ordered. 35033 2. Review of the menu for 03/13/23 revealed dinner included pepperoni pizza, tossed salad with choice of dressing, cheese garlic bread, cottage cheese and peaches. Review of the recipe for the tossed salad revealed ingredients included fresh whole iceberg lettuce, fresh tomato diced, cucumber peeled and sliced, and fresh mushrooms sliced. Interview on 03/13/23 at 9:59 A.M. with Resident #54 revealed the residents don't always get what's on the menu. Observation of meal plating on 03/13/23 at 4:40 P.M., revealed the residents were served regular garlic bread and not cheese garlic bread. Further observation revealed the tossed salad contained lettuce and shredded cheese and contained no tomato, no cucumber and no mushrooms. Interview on 03/13/23 at 4:40 P. M. with Cook #349 revealed the resident were supposed to receive cheesy garlic bread but she could not find it anywhere. Further interview with Cook #349 revealed there were no cucumbers or mushrooms for the tossed salad. Cook #349 also revealed the facility does not put tomatoes in salads because not everyone likes tomatoes. Cook #349 revealed she was trained to serve a tossed salad with lettuce and cheese. Review of the facility's list of resident's food preferences for the dinner meal on 03/13/23 revealed Resident #5, #12, #15, #20, #24, #33, #36, #59, #60, #64, #68, #177, #179, and #18 did not order the salad or the garlic cheese bread. Review of the facility policy titled Menus and Adequate Nutrition, dated 04/27/22, revealed menus will be followed as posted. Notification of any deviations from the menu shall be made as soon as practicable. Substitution shall comprise of foods with comparable nutritive value.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure resident medications were kept secured and out of reach of cognitively impaired and independently mobile residents. This affected one resident (#327) and had the potential to affect four additional residents who were cognitively impaired and independently mobile (#29, #49, #68, and #177) on the two-east hall. The facility census was 79. Findings Include: Observation on 03/15/23 at 4:07 P.M. revealed a medication cart located on two east was unlocked and unattended with loose pills in a clear plastic medication cup on top of the medication cart. Licensed Practical Nurse (LPN) #373 was approximately eight feet from the medication cart with his back turned toward the medication cart talking and joking with a resident and their family. Observation at this time, also revealed a cognitively impaired, independently mobile resident, Resident #177, seated in a recliner approximately four feet from the unlocked, unattended medication cart with loose pills in a medication cup on the top of the medication cart. Interview on 03/15/23 4:11 P.M. with LPN #373 revealed LPN #373 verified his back was turned away from the medication cart and he was talking to a resident and family members, approximately eight feet away. LPN #373 verified the unlocked medication cart and the loose pills in the clear plastic medication cup on top of medication cart were medications for Resident #327. Review of the facility policy titled Medication Storage, dated 05/2022, revealed the facility was to ensure all medications housed on their premises would be stored in pharmacy and/or medication rooms according to the manufacturers recommendation and sufficient to ensure proper sanitation, temperature, light, moisture control, segregation, and security. The guidelines revealed during medication pass, medications must be under the direct observation of the person administering medications or locked in the mediation storage area/cart.

Based on observation, resident and staff interview, and policy review, the facility failed to ensure residents were served meals palatable to taste and temperature. This had the potential to affect all residents except nine residents (#20, #24, #33, #36, #59, #60, #64, #68, and #177) who received alternative meals or were on a pureed diet. The facility census was 79. Findings include Interview on 03/13/23 at 9:59 A.M. with Resident #54 revealed the facility food was served cold. Interview on 03/13/23 at 12:36 P.M. with Resident #1 stated the food was cold sometimes. Resident #1 further stated staff would put hot food on cold plates. Observation on 03/13/23 at 4:25 P.M. revealed Cook #349 took the temperature of the pizza and the garlic bread. The pizza was 167 degrees Fahrenheit (F) and the garlic bread was 187 degrees F. Observation and interview on 03/13/23 at 4:40 P.M. of dinner service revealed Cook #349 was plating meals. Further observation revealed the plate warmer was not on. Cook #349 verified the plate warmer was not on. Cook #349 then flipped the plate warmer switch to on. Further observation on 03/13/23 at 5:20 P.M. of a test tray with Cook #349 revealed the pizza was barely warm at 98 degrees F and the garlic bread was barely warm at 89 degrees F. The salad was bland containing just lettuce and shredded cheese. Interview on 03/13/23 at 5:20 P.M. with Cook #349 verified the pizza and garlic bread were not warm enough and not palatable to temperature. Cook #349 verified the salad was bland to taste. Review of the facility's list of residents food preferences and diets revealed Residents 20, #24, #33, #36, #59, #60, #64, #68, and #177 either requested an alternate meal or was on a pureed diet for the dinner meal on 03/13/23. Review of the facility policy titled Record of Food Temperatures, dated 04/27/22, revealed hot foods would be held at 135 degrees F or greater.

Based on observations, medical record review, and staff interview, the facility failed to ensure residents were assessed and provided care and treatment to maintain normal bladder function, including timely incontinence care. This affected two (Residents #24 and #38) of two residents reviewed for bowel and bladder continence. The facility census was 79. Findings include: 1. Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, left side hemiplegia, paranoid schizophrenia, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 had moderately impaired cognition, dependent on staff for the completion of activities of daily living including toileting, incontinent of bladder, continent of bowel, and was at risk for pressure ulcer development with no skin breakdown. Review of the nursing plan of care dated 08/29/19 revealed it was initiated to address Resident #38's incontinence of bowel and bladder with staff providing peri-care as needed putting her at risk for skin breakdown. Interventions included to monitor skin for breakdown with each incontinent episode and staff to provide peri care as needed. On 04/16/20, an additional plan of care was implemented to address the resident having occasional bladder incontinence related to impaired mobility, extensive assistance with toileting, and multi-medication use. Interventions included to clean the peri-area with each incontinence episode. Monitor/document/report as needed (PRN) any possible causes of incontinence: bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, stroke, and medication side effects. Review of the physician order dated 02/22/23 revealed an order to apply barrier cream after each incontinence episode and as needed. Review of the medical record lacked documentation indicating the type of urinary incontinence, interventions to promote urinary continence including a plan of care or assessment of the resident's urinary habits. Review of the state tested nurse aide (STNA) task documentation between 11/14/22 and 03/14/23 revealed Resident #38 was continent of bowel. Between 02/13/23 and 03/14/23, Resident #38 was documented as continent of bladder fourteen time and had 20 bladder incontinent episodes. Observation on 03/13/23 at 9:38 A.M. revealed there was a bedside commode inside Resident #38's bathroom. Interview on 03/15/23 at 10:19 A.M. with STNA #311 confirmed caring for Resident #38 frequently. STNA #311 stated Resident #38 calls out to use commode and verified no specific bladder schedule or continence maintenance plan was in place. STNA #311 indicated Resident #38 has incidents of bladder incontinence. Interview on 03/15/23 at 11:30 A.M. with the Director of Nursing (DON) verified Resident #38's medical record did not contain information of the type of the residents incontinence or the promotion of urinary continence interventions. Subsequent interview on 03/16/23 at 8:10 A.M. with the DON confirmed no interventions were listed on the plan of care to address promoting Resident #38's bladder continence. 2. Review of Resident #24's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease and anxiety disorder. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 had intact cognition, required the extensive assistance of one staff for toileting and was incontinent of bladder. Review of the nursing plan of care, dated 01/11/23, revealed it was implemented to address the resident's activities of daily living self-care performance deficit related to fatigue and recent COVID-19 infection. Interventions included the following; Resident #24 required extensive assist by one staff for toileting. Review of the pressure sore development risk assessment dated [DATE] revealed Resident #24 was at risk for skin breakdown. The resident's skin was exposed to moisture and was very moist and the skin was often, but not always moist. The resident's bed linen must be changed at least once a shift. Review of the state tested nursing assistant (STNA) task documentation between 02/03/23 to 03/15/23 revealed Resident #24's bladder status was recorded as incontinent between 02/03/23 and 03/15/23. No interventions contained in the medical record indicated the frequency for the resident to be provided incontinence care or related interventions. Observation on 03/14/23 at 9:10 A.M. with Registered (RN) #393 and State tested Nurse Aide (STNA) #405 noted Resident #24 positioned to the right in bed. An air alternating air mattress was in place and adjusted to 230 pounds. Resident #24 appeared to be totally dependent on staff for positioning and required RN #393 and STNA #405 to position for the administration of a wound treatment to the coccyx. The staff removed the front of the resident's adult brief and noted Resident #24 was incontinent of urine and bowel. The adult brief was removed and the adult brief was noted with a heavy amount of urine contained in the brief with an existing dressing to the coccyx soiled with fecal matter. Interview with RN #393 and STNA #405 stated Resident #24 was to be repositioned every two hours. STNA #405 stated the last shift staff that left at 6:00 A.M. were the last staff to provide Resident #24 with a change in position which included checking for incontinence. STNA #405 confirmed being assigned to the resident's care and was not aware of the time the last shift staff repositioned or checked the resident for incontinence. RN #393 proceeded to remove and replace the dressing to the coccyx. Immediately following the dressing change, Resident #24 was repositioned in the bed. STNA #405 stated to Resident #24 she would be back in two hours to reposition him. Resident #24 verbalized two hours was too long and expressed this would result in the resident being uncomfortable. Interview on 03/16/23 at 9:36 A.M. with RN #393 confirmed no personalized incontinence schedule had been established for Resident #24. Interview on 03/14/23 at 10:09 A.M. with the Director of Nursing (DON) and Administrator confirmed Resident #24 was to be checked for incontinence every two hours.

Based on observation, medical record review, staff interview, review of the facility policy, and review of the manufacturer user manual, the facility failed to ensure skin pressure relieving interventions were implemented timely and in accordance with device instructions for use. This affected one (Resident #24) of three residents reviewed for the prevention and healing of skin breakdown. The facility identified two residents with pressure ulcers and 74 residents receiving preventative skin care. The facility census was 79. Findings include: Review of Resident #24's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, anxiety disorder, congestive heart failure, and bone density disorder. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 had intact cognition, required the extensive assistance of one staff for activities of daily living, incontinent of bladder, and was at risk for pressure ulcer development with no skin breakdown. Resident #24 was receiving hospice services. Review of the nursing plan of care, dated 01/11/23, revealed it was implemented to address the resident's activities of daily living self-care performance deficit related to fatigue and recent COVID-19 infection. Interventions included the following; Resident #24 required extensive assist by one staff to turn and reposition in bed and for toileting. Resident #24 also had potential for pressure ulcer development related to recent COVID-19 infection with deconditioning. Interventions included the following: Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Teach the resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. There was no documentation was contained in the care plan and associated medical record indicating the frequency for position changes or monitoring of pressure relief interventions for proper function. Review of the pressure sore development risk assessment dated [DATE] revealed Resident #24 was at risk for skin breakdown. The resident's skin was exposed to moisture and was very moist and the skin was often, but not always moist. The resident's bed linen must be changed at least once a shift. Review of Resident #24's weight history revealed the following weights were recorded: 134.2 pounds (lbs) on 02/03/23, 148.0 lbs on 01/04/23, 150.8 lbs on 01/01/23, and 154.7 lbs on 12/20/22. Review of the skin and wound evaluation documentation dated 02/21/23 revealed Resident #24 was discovered with a stage II pressure wound (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough) to the coccyx. Interventions at the time of discovery included incontinence management, mattress with pump, moisture control, and turning/repositioning program. An additional intervention was to contact hospice to obtain a low air loss mattress. On 03/14/23 at 9:23 A.M., the skin and wound evaluation documentation recorded the pressure wound to be a deteriorating unstageable pressure ulcer (Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar) measuring 2.4 centimeters (cm) long by 2.1 cm wide by 0.3 cm deep. Observation on 03/14/23 at 9:10 A.M. with Registered (RN) #393 and State tested Nurse Aide (STNA) #405 noted Resident #24 positioned to the right in bed. An air alternating air mattress was in place and adjusted to 230 pounds. Resident #24 appeared to be totally dependent on staff for positioning and required RN #393 and STNA #405 to position for the administration of a wound treatment to the coccyx. The staff removed the front of the resident's adult brief and noted Resident #24 was incontinent of urine and bowel. The adult brief was removed and the adult brief was noted with a heavy amount of urine contained in the brief with an existing dressing to the coccyx soiled with fecal matter. Interview with RN #393 and STNA #405 stated Resident #24 was to be repositioned every two hours. STNA #405 stated the last shift staff that left at 6:00 A.M. were the last staff to provide Resident #24 with a change in position which included checking for incontinence. STNA #405 confirmed being assigned to the resident's care and was not aware of the time the last shift staff repositioned or checked the resident for incontinence. RN #393 proceeded to remove and replace the dressing to the coccyx. Immediately following the dressing change, Resident #24 was repositioned in the bed. STNA #405 stated to Resident #24 she would be back in two hours to reposition him. Resident #24 verbalized two hours was too long and expressed this would result in the resident being uncomfortable. Interview and observation on 03/16/23 at 9:36 A.M. with RN #393 confirmed the low air loss mattress settings was set for 230 pounds. RN #393 stated hospice set up the mattress. RN #393 immediately obtained the resident's weight from the medical record and adjusted the mattress to 134 pounds. RN #393 verified the facility did not obtain a resident weight at the time the air mattress was put into use and no weights had been obtained since it was implemented. Additionally, no personalized repositioning schedule had been established for the resident other than facility repositioning guidelines of every two hours and indicated no mechanism was instituted to monitor the operation of the alternating air mattress for appropriate use. Interview on 03/14/23 at 10:09 A.M. with the Director of Nursing (DON) and Administrator confirmed Resident #24 was to be checked for incontinence and repositioned every two hours. Additional observation on 03/15/23 at 7:56 A.M. revealed STNA #405 was seated next to Resident #24's bed assisting the resident with the breakfast meal while in bed. Resident #24's alternating air mattress was deflated. STNA #344 entered the room and was aware the mattress was not inflated. STNA #244 proceeded to re-energize the air mattress by plugging the compressor into the electrical outlet. Both STNAs verified they started the shift at 6:00 A.M. and were unaware the alternating air mattress was unplugged. Interview on 03/16/23 at 8:10 A.M. with the DON revealed the air mattress was delivered to the facility on [DATE] and placed in use the same day. No further information was contained in the medical record indicating the operation of the air mattress was monitored and maintained in accordance with manufacturer user manual instructions. Review of the facility's skin integrity-skin impairments policy dated 11/23/22 revealed the facility will utilize a systematic approach for the prevention and management of skin impairments, including impairments, assessment, care planning, monitoring, and modification of interventions as appropriate. When a skin impairment is discovered, the nurse shall complete and incident report and interventions will be implemented for prevention and to promote healing. Review of the alternating pressure mattress replacement system with low air loss user manual instructions, last revised 11/2017, revealed the product is not a substitute for a turning schedule and procedures for turning should be adhered to at all times. Adjust the pressure level of the air mattress to the desired firmness based on personal comfort or weight setting. Maintenance includes; checking the power cord and plug to see if there are abrasions or excessive wear. Check mattress cover for signs of wear or damage. Endure the mattress cover and tubes are connected correctly. Plug the control unit and check air flow from the hose connection port. The air flow should alternate between ports every half-cycle time. Check air hoses for kinks or breaks. Make sure mattress tube is well connected. Check the control unit and make sure both power indicators are off when the switch is turned off. This deficiency represents non-compliance investigated under Complaint Number OH00140552.

Based on observation, medical record review, staff interview, and review of the facility's guideline and policy, the facility failed to ensure interventions were implemented timely to promote wound healing and prevent further skin injury. This affected one (Resident #7) of one resident for non-pressure related skin issues. The facility census was 79. Findings include: Review of Resident #7's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease stage, lymphedema, type II diabetes mellitus, peripheral vascular disease (PVD), non-pressure chronic ulcer lower extremities, edema, morbid obesity, neuropathy, chronic embolism and thrombosis right popliteal vein. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had intact cognition, independent with activities of daily living, utilized a walker and wheelchair for locomotion, was at risk for pressure ulcer development, and had four venous and arterial ulcers involving infection of the foot. Review of the skin breakdown risk assessment dated [DATE] revealed Resident #7 was at minimal risk for the development of skin breakdown. Review of the nursing plan of care dated 09/17/19 and revised 02/09/22, revealed a plan of care was developed to address Resident #7's diagnoses of PVD related to edema, diabetes mellitus with neuropathy, and history of arterial ulcers. Interventions included to monitor/document/report as needed any signs or symptoms of skin problems related to PVD (redness, edema, blistering, itching, burning, bruises, cuts, other skin lesions). On 03/01/21, another nursing plan of care was developed to address the resident's history of ulcers to bilateral lower extremities, PVD, diabetes mellitus neuropathy related to the presence of inflammation and weeping edema to the bilateral lower extremities. Interventions included to avoid mechanical trauma, notify the physician as indicated, and refer to the treatment administration record (TAR) for physician wound dressing orders. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Further review of the medical record revealed there was no wound noted to Resident #7's left lateral hip on 02/16/23 to 02/20/23. There was no treatment order in place during this time of 02/16/23 to 02/20/23. Review of the skin and wound evaluation documentation dated 02/21/23 at 9:12 A.M. noted Registered Nurse (RN) #393 had an abrasion to Resident #7's left lateral hip. The abrasion was recorded as in-house acquired on the exact date of 02/16/23 and measurements were as follows: 3.8 centimeters (cm) long by (x) 0.8 cm wide x 0.2 cm deep. The wound characteristics noted 100% granulation tissue to the wound, bleeding, with a light amount of serosanguineous exudate, wound edges were non-attached: edge appeared as a cliff, surrounding tissue had erythema and was fragile. The wound was cleansed and a hydrocolloid dressing was applied. RN #393 stated the date of 02/16/23 was a typing error and the wound was found on 02/21/23 on 03/14/23 at 10:10 A.M. Review of the skin and wound evaluation documentation dated 03/14/23 at 10:35 A.M. revealed the wound was described as in-house acquired abrasion and noted measurements as follows: 3.0 cm long x 1.2 cm wide x 0.3 cm deep. The wound characteristics noted 100% granulation tissue to the wound with a light amount of serosanguineous exudate, wound edges were non-attached: edge appeared as a cliff, discoloration black and blue surrounding tissue and intact unbroken skin. Progress was recorded as deteriorating. Further review of the medical record from 02/21/23 to 03/14/23 revealed there was no documentation the physician was notified of the wound to the left hip area and there was no physician order for treatment of the left hip. There was no documentation indicating the origin of the wound had been determined with preventative interventions. Observation and interview on 03/14/23 at 10:10 A.M. with Wound Nurse RN #393 revealed there were treatments applied to Resident #7's bilateral legs. RN #393 verbally prompted Resident #7 to reposition to expose a left hip wound. Resident #7 stated the left hip wound was an abrasion caused by his wheelchair. RN #393 cleansed the wound and applied a moisture barrier cream. Interview with RN #393 immediately following the treatment observation stated the left hip wound (abrasion) was caused by the resident's wheelchair and documented as occurring on 02/21/23. Interview on 03/15/23 at 11:58 A.M. with Wound Nurse RN #393 revealed she was first made aware of the resident's abrasion to the left lateral hip on 02/21/23 and assessed as a new wound. RN #393 stated Resident #7 had sustained an abrasion approximately a year ago which healed. Review of the medical at the time of interview verified the record lacked documentation regarding the physician being notified of the skin injury, a physician ordered treatment to the wound, documentation of the wound upon discovery of 02/21/23, or investigation into the origin of the wound. RN #393 confirmed when the wound was assessed on 03/14/23 and the wound had deteriorated. RN #393 stated multiple non-physician ordered treatments were attempted and not documented. However, the dressing treatments would consistently fall off and not adhere. No order for those treatments were obtained due to not being able to establish a treatment that would stay in place. Interview on 03/16/23 at 8:10 A.M. with the Administrator and Director of Nursing (DON) verified no additional information was available indicating Resident #7's left hip wound (abrasion) was reported to the physician, consistently treated with a wound application, or the origin of the injury from the residents wheelchair evaluated in an attempt to prevent further tissue injury. Review of the facility's wound treatment guidelines last revised 06/01/21 revealed wound treatments will be provided in accordance with physician orders, including the cleansing method, dressing type, and frequency of dressing change. In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. Dressings will be applied in accordance with manufacturer recommendations. Treatments will be documented in the TAR. Review of the facility's skin integrity-skin impairments policy dated 11/23/22 revealed the facility will utilize a systematic approach for the prevention and management of skin impairments, including impairments, assessment, care planning, monitoring, and modification of interventions as appropriate. When a skin impairment is discovered, the nurse shall complete and incident report and interventions will be implemented for prevention and to promote healing.

Based on observation, medical record review, resident and staff interview, and review of the facility policy, the facility failed to ensure residents who were dependent on staff for assistance received assistance with shaving and nail care. This affected one (#60) of one residents reviewed for activities of daily living (ADLs). The facility identified 73 residents who required assistance from staff with bathing and 70 residents who required assistance with dressing. The facility census was 79. Findings include: Review of Resident #60's medical record revealed a re-admitted [DATE]. Diagnoses included congestive heart failure (CHF), acquired absence of left leg above the knee, morbid obesity, and chronic obstructive pulmonary disease (COPD). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was cognitively intact and required extensive assistance from staff with dressing, and personal hygiene. Resident #60 had no refusals of care during the review period. Review of the plan of care initiated 05/09/22 revealed Resident #60 had an ADLs self-care performance deficit. Interventions included to provide extensive one person assistance with personal hygiene and dressing. Review of the State tested Nurse Aide (STNA) documentation for showers and personal hygiene from 02/13/23 through 03/14/23 revealed no documentation Resident #60 refused care. Observation and interview on 03/13/23 at 11:14 A.M. of Resident #60 revealed the resident was sitting up in his wheelchair. Resident #60 was observed to have full beard and long, jagged fingernails with debris under the nails. Resident #60 stated he preferred to be clean shaven and have his nails clipped short. Resident #60 stated he was typically shaved and had his fingernails clipped on shower days but the staff had not assisted with those tasks the past couple of showers. Resident #60 stated he looked like expletive. Resident #60 stated he did not know why staff had not been providing assistance with shaving and nail care. Subsequent observations on 03/14/23 at 9:51 A.M. revealed Resident #60 sitting in his wheelchair in his room. Resident #60 had a full beard and the resident's fingernails were long and jagged with a brown substance noted under the fingernails. Interview on 03/14/23 at 9:57 A.M. with STNA #405 revealed Resident #60 required extensive one person assistance with all ADLs, including shaving and nail care. STNA #405 stated Resident #405 tried to toilet himself, but frequently needed assistance with cleaning up spills from the urinal. STNA #405 explained shaving and showers were typically done on shower days, but it could be done anytime it was needed. Observation and interview on 03/14/23 at 10:05 A.M. with STNA #405 verified Resident #60's beard and fingernails were jagged with a brown substance under the fingernails. STNA #405 stated today was Resident #60's shower day. Interview on 03/14/23 at 1:48 P.M. with the Administrator confirmed Resident #60's medical record from 02/13/23 through 03/14/23 revealed no documentation the resident refused care related to showers or personal hygiene. Observation on 03/15/23 at 9:03 A.M. of Resident #60 revealed the resident had been shaved and fingernails were clipped and clean. Interview of Resident #60 at the time of the observation confirmed he received assistance yesterday with a shower, shaving, and nail care. Resident #60 stated he felt better and did not know why his beard had been let go for so long and was uncertain if staff just did not want to mess with it or what. Review of the facility policy titled Activities of Daily Living, dated 03/01/18, revealed a resident who was unable to carry out ADLs would receive the necessary services to maintain incontinence, good nutrition, grooming, and personal and oral hygiene.

Based on observations, medical record review, and staff interview, the facility failed to ensure the resident's care plans were revised and updated with current interventions to address their care needs. This affected two (Residents #35 and #71) of 19 residents reviewed for care plan revisions. The facility census was 79. Findings include: 1. Review of Resident #71's medical record revealed an admitted [DATE]. Diagnoses included Alzheimer's disease. Review of Resident #71's physician orders revealed an order dated 12/06/22 for a silent alarm to be in place at all times on day and night shift. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 was rarely or never understood. Resident #71 had a bed alarm and chair alarm that were used daily. Review of Resident #71's care plan revised 02/15/23 revealed supports and interventions for self-care deficit, impaired cognitive function, and risk for falls. Fall interventions included anticipate needs and call light in reach. The care plan did not reflect the fall intervention of using a cushion alarm or checking placement or functionality. Review of Resident #71's progress notes revealed on 03/11/23, Resident #71 had a witnessed fall in the dining room. It was noted Resident #71 got up from his seat and his pad alarm did not sound. Resident #71 lost his balance before staff could reach him and he fell backward, bonked his head on the table, and landed on his bottom. Observation on 03/13/23 at 11:06 A.M. and at 12:01 P.M. revealed Resident #71 was seated in a chair in the common area of the secured unit. A white pad was observed to be in place under him. Interview on 03/14/23 at 10:18 A.M. with Licensed Practical Nurse (LPN) #372 verified Resident #71 had a current order for a silent alarm at all times and there was no current tracking in place in the treatment administration record (TAR) for monitoring placement or functionality. Further review of Resident #71's care plan on 03/14/23 at 2:18 P.M. a care plan support was added to check the function and placement of silent alarm every shift. Prior to 03/14/23 there was not a care plan support or intervention to check placement and function of Resident #71's silent alarm. Interview on 03/15/23 at 8:49 A.M. with the Director of Nursing (DON) verified Resident #71's care plan did not have the fall intervention to check the placement and function of Resident #71's silent alarm prior to 03/14/23. 47057 2. Review of Resident #35's medical record revealed Resident #35 was admitted on [DATE] with diagnoses including dementia and atrial fibrillation (a heart condition where the heart beats abnormally). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 had severe cognitive impairment. Review of Resident #35's Order Summary Report (a list of the medications ordered by the physician) dated March 2023 revealed Resident #35 was prescribed anticoagulation therapy, apixaban 2.5 milligrams twice daily for atrial fibrillation Review of Resident #35's care plan dated 12/13/22 revealed Resident #35 was not care planned for anticoagulant therapy. Interview on 03/14/23 at 3:27 P.M. with Corporate Registered Nurse (CRN) #419 and the Director of Nursing (DON) verified the care plan for Resident #35 did not address anticoagulation therapy.

Based on medical record review, staff interview, and review of the facility guideline, the facility failed to notify the physician when a resident tested positive for COVID-19 and when a resident sustained an abrasion. This affected two residents (#6 and #7) of two residents reviewed for notification of change. The facility census was 79. Findings include: 1. Review of Resident #6's medical record revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease, and congestive heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively intact. Review of a nursing progress note dated 02/04/23 revealed Resident #6 requested a COVID-19 test due to symptoms of cough, dry eyes, and congestion. The COVID-19 swab was positive. Further review Resident #6's progress notes and medical record from 02/04/23 through 02/06/23 revealed no documentation of physician notification of Resident #6's positive COVID-19 positive test result. Interview on 03/15/23 at 10:00 A.M. with Assistant Director of Nursing (ADON) #377 revealed the facility typically sent a fax to the physician notifying of any change in condition and the fax confirmation was kept in the resident's medical record. ADON #377 verified Resident #6's medical record contained no evidence the physician was notified of Resident #6's positive COVID-19 test result but stated Nurse Practitioner (NP) #418 was aware Resident #6 had COVID-19. Interview on 03/15/23 at 11:43 A.M. with NP #418 verified the facility did not notify her Resident #6 tested positive for COVID-19 on 02/04/23. NP #418 stated she became aware Resident #6 had COVID-19 when was at the facility on 02/10/23 for scheduled rounds. NP #418 stated Resident #6 was still on isolation on 02/10/23. NP #418 stated faxed notifications from the facility were scanned into their records at the physician office. NP #418 verified she reviewed faxes that had been received from the facility and the physician's office did not receive faxed notification of Resident #6's positive COVID-19 test result. Review of the facility policy titled Notification of Changes, dated 11/29/22, revealed the facility must inform the resident, consult with the resident's physician, and notify the resident's family member or legal representative when there is a change requiring such notification. 15816 2. Review of Resident #7's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease stage, lymphedema, peripheral vascular disease (PVD), non-pressure chronic ulcer lower extremities, edema, morbid obesity, neuropathy, chronic embolism and thrombosis right popliteal vein. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had intact cognition. Review of the nursing plan of care dated 09/17/19 and revised 02/09/22, revealed a plan of care was developed to address Resident #7's diagnoses of PVD related to edema, diabetes mellitus with neuropathy, and history of arterial ulcers. Interventions included to monitor/document/report as needed any signs or symptoms of skin problems related to PVD (redness, edema, blistering, itching, burning, bruises, cuts, other skin lesions). On 03/01/21, another nursing plan of care was developed to address the resident's history of ulcers to bilateral lower extremities, PVD, diabetes mellitus neuropathy related to the presence of inflammation and weeping edema to the bilateral lower extremities. Interventions included notify the physician as indicated. Review of the skin and wound evaluation documentation dated 02/21/23 at 9:12 A.M. noted Registered Nurse (RN) #393 had an abrasion to Resident #7's left lateral hip. The abrasion was recorded as in-house acquired on the exact date of 02/16/23 and measurements were as follows: 3.8 centimeters (cm) long by (x) 0.8 cm wide x 0.2 cm deep. The wound characteristics noted 100% granulation tissue to the wound, bleeding, with a light amount of serosanguineous exudate, wound edges were non-attached: edge appeared as a cliff, surrounding tissue had erythema and was fragile. The wound was cleansed and a hydrocolloid dressing was applied. RN #393 stated the date of 02/16/23 was a typing error and the wound was found on 02/21/23 on 03/14/23 at 10:10 A.M. Review of the skin and wound evaluation documentation dated 03/14/23 at 10:35 A.M. revealed the wound was described as in-house acquired abrasion and noted measurements as follows: 3.0 cm long x 1.2 cm wide x 0.3 cm deep. The wound characteristics noted 100% granulation tissue to the wound with a light amount of serosanguineous exudate, wound edges were non-attached: edge appeared as a cliff, discoloration black and blue surrounding tissue and intact unbroken skin. Progress was recorded as deteriorating. Further review of the medical record from 02/21/23 to 03/14/23 revealed there was no documentation the physician was notified of the wound to the left hip area and there was no physician order for treatment of the left hip. Interview on 03/15/23 at 11:58 A.M. with Wound Nurse RN #393 revealed she was first made aware of the resident's abrasion to the left lateral hip on 02/21/23 and assessed as a new wound. Review of the medical at the time of interview verified the record lacked documentation regarding the physician being notified of the skin injury and a physician ordered treatment to the wound. Interview on 03/16/23 at 8:10 A.M. with the Administrator and Director of Nursing (DON) verified no additional information was available indicating Resident #7's left hip wound (abrasion) was reported to the physician. Review of the facility's wound treatment guidelines last revised 06/01/21 revealed wound treatments will be provided in accordance with physician orders, including the cleansing method, dressing type, and frequency of dressing change. In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders.

Based on observation, medical record review, interviews with staff and family, review of a hospice self-reported incident, and review of facility policies, the facility failed to accurately assess and develop a care plan addressing the mental health status, including hallucinations and delusions, fall risk, and level of supervision for Resident #01. This resulted in Immediate Jeopardy on 04/15/22 at approximately 11:50 P.M. when Resident #01 either jumped or fell from a second-floor window and was found on the ground on a concrete patio. Serious harm of bodily injuries occurred when Resident #01 sustained a fractured left ankle, fractured left tibia, and internal swelling. Ultimately, the facility failed to identify mental health needs and provide services to potentially prevent this incident. Additionally, the facility failed to complete a thorough investigation of the incident to potentially prevent the same action, situation, and/or practice from occurring in the future. This affected one (#01) of four residents reviewed for reviewed for mental health identification and services. The facility census was 73. On 04/20/22 at 4:18 P.M., the Administrator was notified Immediate Jeopardy began on 04/15/22 at approximately 11:50 P.M. when Resident #01 either fell or jumped from a second story window without staff knowledge. Stated tested Nurse Aide (STNA) #333, STNA #331, and Licensed Practical Nurse (LPN) #246 heard Resident #01 yell and responded to her room. LPN #246 noted the second story window was open with a blanket over the windowsill. Resident #01 could be heard calling out. LPN #246 looked out the window and observed Resident #01 lying on her right side on the concrete patio, with her belongings. Resident #01 was transported via Emergency Medical Services (EMS) to the local hospital and then life-flighted to a trauma hospital in a metropolitan area. Resident #01 received inpatient treatment, with a one-on-one aide (for supervision) for a fractured left ankle, fractured left tibia, internal swelling, and psychiatric stabilization. Additionally, the facility failed to ensure Resident #01 was assessed properly for psychiatric status, cognitive status, and failed to update the plan of care to address hallucinations, delusions, and fall risk in a timely manner. Lastly, the facility failed to conduct a thorough investigation of Resident #01's fall and/or jump to prevent the same action, situation, and/or practice from occurring in the future. The Immediate Jeopardy was removed on 04/22/22 when the facility implemented the following corrective actions: · On 04/16/22, all windows in resident care areas were secured by maintenance staff so they could not open more than six inches. · Observations on 04/20/22 from 8:53 A.M. through 11:17 A.M. verified windows in resident care areas had been modified and did not open more than six inches. · On 04/21/22, all in house resident admission assessments within 14 days and the last quarterly assessment for any resident admitted over 14 days ago, were audited by nursing management and corporate support staff to ensure all assessments were completed accurately and completely. · On 04/21/22, all licensed nursing staff were educated by nursing management in person or via telephone (including agency staff) to complete all admission assessments completely and accurately. If the nurses were not able to be reached, a message was left, and education would be completed by 04/22/22. Areas of education related to the Nursing Admission Assessment process which included Morse Fall Scale, Braden, Pain, Medication Self-Administration, Wandering, and Abnormal Involuntary Movement Scale (AIMS), if applicable. · On 04/21/22, social service designees were educated by the Executive Director to complete the following admission assessments completely and accurately upon admission: PHQ9 (depression scale) and Brief Interview of Mental Status (BIMS). · On 04/21/22, licensed nurses were educated by nursing management in person or via telephone, including agency staff, to notify the attending physician and resident representative of a significant change in condition. If the nurses were not able to be reached, a message was left, and education would be completed by 04/22/22. · On 04/21/22, licensed nurses were educated by nursing management in person or via telephone, including agency staff, that if a resident exhibits acute psychiatric symptoms including hallucinations and delusions, they would be placed on 15-minute checks and the attending physician and nursing administration would be notified. If the resident verbalized [CONDITION(S)], they wound be placed on one-on-one supervision until they were transferred out of the facility. If the nurses were not able to be reached, a message was left, and education would be completed by 04/22/22. · On 04/21/22, an investigation was completed by the Executive Director, nursing management, and corporate support and the above practices were put in place by 04/21/22 to ensure the same action does not occur in the future. · On 04/21/22, the Quality Assurance and Performance Improvement (QAPI) committee, including the Executive Director, Nursing Administration, Social Services Designee, and Medical Director, met to review this investigation and new processes to ensure similar incidents do not happen in the future. · Beginning 04/22/22, new admissions and quarterly assessments would be audited five times weekly for one month and then three times weekly for two months by the clinical team at clinical meetings to ensure all admission assessments were completed in their entirety and accurately. · Beginning 04/22/22, resident changes in psychiatric symptoms would be reviewed and audited five times weekly for one month and then three times weekly for two months by the clinical team at clinical meetings to ensure there were no new psychiatric symptoms. · Interviews on 04/22/22 from 11:15 A.M. to 2:30 P.M. with LPN #310 and LPN #246 verified they received recent training regarding the facility's protocol for the completion of admission assessments and how to respond if a resident was experiencing psychiatric symptoms, such as delusions and hallucinations. · Medical record reviews for three additional residents (#02, #49, and #50) revealed cognition, wandering, and depression assessments were completed, and care plans were accurate. Although the Immediate Jeopardy was removed on 04/22/22, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimum harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings included: Review of the medical record for Resident #01 revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #01 received hospice services. Review of hospice referral dated 04/07/22 revealed a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nursing Admission Screening/History dated 04/10/22 revealed Resident #01 received hospice services, was oriented to person, place, and situation, but not oriented to time, had intact cognition, and was angry, resistive, had disorganized thinking, and was yelling when she initially arrived. Review of physician orders dated 04/10/22 revealed Resident #01 was prescribed [MEDICATION(S)] (anti-anxiety medication) 0.5 mg one tablet by mouth four times per day for anxiety, agitation, and restlessness and [MEDICATION(S)] HCI (anti-depressant medication) tablet 10 mg one tablet by mouth at bedtime for depression. Review of a physician order dated 04/15/22 revealed Resident #01 was prescribed [MEDICATION(S)] (used to treat [CONDITION(S)]) 50 mg give one tablet by mouth two times a day for depression and [CONDITION(S)]. Review of the Admission Care Plan, dated 04/10/22, revealed the areas of cognition, mood, and fall risk were not addressed. Review of the Wandering Risk Assessment, dated 04/11/22, revealed the assessment was not completed in its entirety. Resident #01 was assessed to be combative and severely agitated. The assessment did not accurately identify medications Resident #01 was ordered, with anti-depressants and anti-anxiety medications not indicated, and the assessment did not include responses to Resident #01's orientation and mobility status. Review of the plan of care, initiated 04/11/22, revealed Resident #01's psychiatric symptoms of hallucinations and delusions were not addressed. Additional review revealed a care plan focus area for high risk for falls was not initiated until 04/14/22. Review of the Morse Fall Scale dated 04/12/22 revealed Resident #01 was at high risk for falls. Review of a nursing progress note dated 04/12/22 at 7:54 P.M. revealed Resident #01 locked her door, refusing to allow staff in. Review of nursing progress note dated 04/12/22 at 9:20 P.M. revealed Resident #01 was sitting on the floor in front of her door, refusing to allow staff in. Nursing called Resident #01's daughter, who called the resident. Resident #01 allowed an unknown STNA in her room. Review of the social services progress note dated 04/14/22 at 1:14 P.M. revealed Resident #01 had periods of inattention and disorganized thinking. Resident #01 could be accusatory as well as paranoid. In addition, Resident #01 expressed she had little interest at times, was depressed daily, was tired daily, had problems sleeping but medication helped with that, had poor appetite, had trouble concentrating, felt bad about herself, was anxious, and felt she would be better off dead but would not harm herself. Review of the nursing progress note dated 04/15/22 at 1:34 A.M. revealed Resident #01 was in her room moaning and crying out. Resident #01 declined pain medication stating if she took it, someone would come into her room and take her things again. Review of the nursing progress note dated 04/15/22 at 11:16 A.M. revealed a verbal order was received to start [MEDICATION(S)] 50 mg twice per day. Review of the nursing progress note dated 04/15/22 at 5:33 P.M. revealed at approximately 2:00 P.M. Resident #01 was having delusional episodes, hearing voices, and believed she had a direct line to the President, the Centers for Disease Control and Prevention (CDC), and the secret service. Resident #01 continued to have periods of calm mixed with periods of delusional thinking and yelling out. Review of the nursing progress note dated 04/15/22 at 6:29 P.M. revealed Resident #01 had removed her call light cord from the wall. Resident #01 was holding her bag. The call light cord was in the resident's bag. Resident #01 was told by staff they would only return when the resident was willing to cooperate and to use the call light if any further assistance was needed. Review of a hospice Self-Reported Violation Report Form, dated 04/16/22, revealed hospice was notified by facility nursing staff Resident #01 fell or jumped out of a second-floor window and sustained injuries. Per report, Resident #01 was alert and talking to staff when EMS arrived. Additional information received from the local hospital revealed life flight was on site when Resident #01 arrived at the hospital via EMS and was immediately transported to a trauma hospital in a metropolitan area. Hospice was unable to verify the extent of Resident #01's injuries due to admission under, private identity. Review of a late entry nursing progress note, effective 04/16/22 at 11:50 P.M. and created on 04/19/22 at 11:07 P.M., revealed staff heard Resident #01 yelling from her room. Resident #01 was not observed in her room. The nurse looked out the window, which was open and had a blanket over the windowsill and Resident #01 was observed lying on her right side on the patio, yelling out. The nurse went downstairs and out to the patio to assess Resident #01. The resident had her belongings with her. Resident #01 had stated, God told me I would get better going out the window, but when I got out window there was nothing to hold onto. The nurse called 911 and Resident #01 was transported via ambulance to the hospital. Additionally, the note stated staff last observed Resident #01 at 11:10 P.M. and Resident #01 was heard talking out loud with her belongings scattered on the floor. The incident took place on 04/15/22; however, the facility documented the date as 04/16/22 at the time of the late entry nursing progress note. Review of hospital Emergency Department (ED) documents dated 04/16/22 revealed Resident #01 was seen as a trauma priority after jumping from a window, approximately 12 feet high. Identified problems included traumatic lower extremity fractures. Review of a hospital Behavioral Health Consult note, dated 04/19/22, revealed Resident #01 had a significant past psychiatric history, reported command auditory hallucinations, was paranoid, and stated she had been following God's commands and expected to be saved. The physician recommended a psychiatry unit admission once medically cleared. Review of a hospital note dated 04/20/22 revealed Resident #01 sustained a left tibia fracture, left fibula fracture, and a left malleolus (kneecap) fracture after jumping from a window. Resident #01 was noted to experience auditory hallucinations, had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #01 had surgery on 04/17/22 to intramedullary nailing (surgical method for treating tibia fracture) of the left tibial shaft fracture and Resident #01 was to be admitted to the psychiatry unit once medically cleared, had a one-to-one aide for supervision, and was prescribed [MEDICATION(S)] (used to treat [CONDITION(S)]) five milligrams (mg) nightly. Observation on 04/20/22 at 9:12 A.M. of Resident #01's room revealed the door was locked and LPN #287 had to use a key to open the door. The screen was missing from the double hung window. Screws were observed in the window casing, with one on the left and one on the right side of the casing, preventing the window from opening more than six inches. Observation out of the window verified the window was on the second floor of the facility with a concrete patio located below the window. Interview on 04/20/21 at 9:12 A.M. with LPN #287 revealed Resident #01 was very psychotic and very delusional. LPN #287 stated Resident #01 was paranoid and believed she had a direct line to the President. LPN #287 stated Resident #01 exhibited psychiatric symptoms from the time of admission and continued to escalate throughout her stay at the facility. LPN #287 stated Resident #01 had poured water over herself, believed people were in her room, and would yell out and talk to people who were not there. LPN #287 stated the facility did receive an order the morning of 04/15/22 to start [MEDICATION(S)] that evening, but Resident #01 did not have any orders for medications to treat [CONDITION(S)] prior to that. LPN #287 further explained on 04/15/22, Resident #01 hid her call light cord in her bag. LPN #287 retrieved the cord and re-attached it to the wall. LPN #287 verified Resident #01 had either fallen or jumped from her room window and landed on the concrete patio below the window. Interview on 04/20/22 at 9:31 A.M. with the Administrator, Director of Nursing (DON) and Clinical Director of Operations (CDO) #400 revealed Resident #01 exhibited some hallucinations and delusions but had no verbalizations of self-harm. The DON stated Resident #01 was admitted for a hospice respite and the referral from hospice did not indicate any history of psychiatric challenges. After Resident #01 was admitted , the DON stated the hospice social worker relayed Resident #01 had some delusions, but that information was not relayed to the facility prior to admission. The DON stated the facility was in contact with the physician and hospice daily but verified there was no documentation in Resident #01's medical record of the contacts. In addition, the DON verified the facility was not aware of the medication list indicated in the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator verified the second-floor windows were double hung windows that fully opened until the incident involving Resident #01 on 04/15/22. The Administrator stated on 04/16/22, maintenance staff placed screws in all windows in resident care areas so that they could only open approximately six inches. Interview on 04/20/22 at 11:11 A.M. with STNA #307 revealed Resident #01 frequently screamed, could be heard talking to herself, and had poured water over herself. STNA #307 stated while she was not qualified to make a diagnosis, she believed Resident #01 to be delusional and to experience hallucinations. Interview on 04/20/22 at 11:15 A.M. with STNA #277 revealed Resident #01 frequently yelled, was delusional, heard voices, and talked to people who were not there. Interview on 04/20/22 at 11:17 A.M. with STNA #279 revealed she did not typically care for Resident #01 but was aware she had behaviors, yelled a lot, and refused care. Interview on 04/20/22 at 11:30 A.M. with Resident #01's Power of Attorney (POA) revealed she was aware Resident #01 experienced hallucinations and delusions, but they had gotten worse during the resident's admission at the facility. The POA stated the facility had daily contact with her regarding Resident #01's condition. The POA verified she relayed to facility staff Resident #01's conscious state was, Not right, and what they were reporting was, Not her. The POA stated the facility told her Resident #01 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The POA verified she was present at admission and had relayed to nursing staff Resident #01 experienced hallucinations, delusions, was paranoid, and had a psychiatric hospitalization in October 2021. The POA stated Resident #01 remained in the hospital, had a one-on-one aide, and was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 04/20/22 at 2:44 P.M. with the Administrator verified the facility did not complete an investigation of Resident #01's fall and/or jump from her second story window. Interview on 04/20/22 at 3:24 P.M. with the DON verified Resident #01 had indicated during a social services assessment on 04/14/22 that she felt she would be better off dead, but Resident #01 did not verbalize plans to harm herself. The DON verified Resident #01's nursing admission assessment and wandering assessment were not completed in their entirety. In addition, the DON verified the admission care plan, dated 04/10/22, did not address Resident #01's cognition, mood, or fall risk and the plan of care initiated 04/11/22 was not updated to include Resident #01's fall risk until 04/14/22. Interview on 04/22/22 at 11:49 A.M. with STNA #333 revealed she cared for Resident #01 on 04/15/22. STNA #333 stated Resident #01 was typically accusatory of staff, paranoid, delusional, and talked to herself or to someone who was not there. STNA #333 stated Resident #01 had this presentation from admission. On the evening of 04/15/22, STNA #333 stated Resident #01 was different than her normal. That evening, STNA #333 stated Resident #01 was pleasant, said please and thank you, and allowed staff to clean up her room. Resident #01 tended to hide behind her door and yell out, so STNA #333 stated she tried to look in on the resident every hour or so. In addition, staff were instructed not to enter Resident #01's room alone because of the accusations she made against staff. On 04/15/22, STNA #333 stated she observed Resident #01 approximately 30 to 45 minutes prior to staff hearing Resident #01 scream. When staff heard the resident yell, STNA #333, LPN #246, and STNA #331 responded to the room. Initially, staff did not see Resident #01. LPN #246 noticed the window was open and a blanket was hanging over the windowsill. LPN #246 looked out the window and observed Resident #01 lying on her right side on the concrete patio below. STNA #333 verified Resident #01 fell from a second story window onto a concrete patio. STNA #333 stated the window screen was under the resident on the patio. STNA #333 stated Resident #01 reported, God told her if she went out the window, she would be healed. While Resident #01 appeared to experience delusions, paranoia, and hallucinations, STNA #333 verified there was no formal increased supervision for the resident. Interview on 04/22/22 at 2:30 P.M. with LPN #246 revealed he had assisted with Resident #01's admission to the facility on [DATE]. While Resident #01's POA was present during the admission, LPN #246 did not recall if the POA provided any information related to Resident #01's psychiatric history. During the admission, LPN #246 stated Resident #01 was upset and not cooperative. LPN #246 stated he had heard throughout the week Resident #01 was delusional and experienced hallucinations. On 04/15/22, LPN #246 was assigned to work with Resident #01. LPN #246 stated Resident #01 talked to herself all night long and kept making messes on the floor and the STNAs had to keep going in the resident's room to clean it up. While LPN #246 verified Resident #01 was talking to herself all evening long on 04/15/22, LPN #246 stated he could not say if the resident was experiencing hallucinations or delusions because he was not a psych nurse. LPN #246 verified he and other staff responded to Resident #01's room on 04/15/22 at approximately 11:50 P.M. after hearing the resident yell for help. LPN #246 stated he noticed Resident #01's window was open and when he looked out, Resident #01 was lying on her right side on the concrete patio below. LPN #246 verified Resident #01 fell or jumped from the second-floor window and stated, God told her to go out the window. LPN #246 stated Resident #01 was transported via EMS to the local hospital, where the resident was immediately transported via life-flight to a trauma hospital. LPN #246 did not have any information related to the injuries sustained by Resident #01. Review of the facility policy titled, Behavioral Health Services Policy, revised 07/13/21, revealed the facility would ensure any resident who displayed or was diagnosed with a mental disorder received the necessary care and services to assist her/him to attain or maintain the highest practicable mental and psychosocial well-being. Additionally, the assessment and care plan should include goals that were person-centered and individualized to reflect and maximize the resident's safety. Review of the facility policy titled, Admission of a Resident, dated 07/11/21, revealed as much information as possible should be obtained prior to or upon admission to help the resident adjust to the facility. Review of the facility policy titled, Fall Risk Assessment, dated 05/16/21, revealed the facility would provide an environment that was free from accident hazards over which the facility had control and to provide supervision to each resident to prevent avoidable accidents. Review of the facility policy titled, Fall Prevention Program, undated, revealed upon admission, the nurse would complete a fall risk assessment to determine the resident's level of risk. Additionally, the nurse would indicate the resident's fall risk and initiate interventions on the resident's baseline care plan. For resident's identified as high risk, the facility would implement interventions that addressed unique risk factors such as medications, psychological, and cognitive status. This deficiency substantiates Complaint Number OH 023.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure timely and thorough admissions were completed, including the development of accurate baseline care plans. This affected one resident (#01) out of three residents reviewed for admissions. The facility census was 73. Findings included: 1. Review of the medical record for Resident #01 revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nursing Admission Screening and History dated 04/10/22 revealed Resident #1 received hospice services, was oriented to person, place, and situation, not oriented to time, had intact cognition, and was angry, resistive, had disorganized thinking, and was yelling when she initially arrived. Additionally, Resident #01 was noted to be blind. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Morse Fall Scale dated 04/12/22 revealed Resident #01 was at high risk for falls. Review of the Admission Care Plan, dated 04/10/22, revealed the areas of cognition, mood, and fall risk were not addressed. Review of the plan of care, initiated 04/11/22, revealed Resident #01's psychiatric symptoms of hallucinations and delusions were not addressed. Additional review revealed a care plan focus area for high risk for falls was not initiated until 04/14/22. Interview on 04/20/21 at 9:12 A.M. with Licensed Practical Nurse (LPN) #287 revealed Resident #01 was very psychotic and very delusional. LPN #287 stated Resident #01 was paranoid and believed she had a direct line to the President. LPN #287 stated Resident #01 exhibited psychiatric symptoms from the time of admission and continued to escalate throughout her stay at the facility. Interview on 04/20/22 at 3:24 P.M. the Director of Nursing (DON) verified the admission care plan, dated 04/10/22, did not address Resident #01's cognition, mood, or fall risk and the plan of care initiated 04/11/22 was not updated to include Resident #01's fall risk until 04/14/22 and did not address Resident #01's delusions or hallucinations. This deficiency substantiates Complaint Number OH 877.

Based on medical record review, staff interview, review of the medication error log, and review of facility policy, the facility failed to ensure medications were available for administration for new admissions. This affected one (#02) of three residents reviewed for medication administration. The facility census was 73. Findings included: Review of the medical record for Resident #02 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included cardiac arrhythmia, severe protein-calorie malnutrition, type II diabetes, malignant neoplasm of right female breast, [CONDITION(S)], adjustment disorder, [CONDITION(S)], malignant neoplasm of the bladder, [CONDITION(S)], and [CONDITION(S)]. Review of a Nursing Admission Screening and History, dated 04/06/22, revealed Resident #02 was alert and oriented, had an unsteady gait, and had intact cognition. Review of hospital discharge documents revealed Resident #02 received inpatient care from 04/02/22 to 04/05/22 due to arrhythmia (irregularities in heartbeat). Review of physician orders dated 04/05/22 revealed Resident #02 was prescribed the following: [MEDICATION(S)] 70 milligrams (mg) one time a day every seven days for intervertebral disc degeneration; [MEDICATION(S)] tablet 400 mg one tablet by mouth two times a day for hypomagnesemia; [MEDICATION(S)] tablet 10 mg one tablet by mouth at bedtime related to hyperlipidemia; [MEDICATION(S)] extended release (ER) tablet 24 hour 25 one time a day related to cardiac arrhythmia, [MEDICATION(S)] tablet 20 mg one by mouth one time a day related to malignant neoplasm of right breast, potassium chloride ER tablet 20 milliequivalents (mEq) one table one time a day related to cardiac arrhythmia, [MEDICATION(S)] sodium tablet delayed release 40 mg one time a day for upset stomach, multiple vitamin tablet one time a day, [MEDICATION(S)] HCI tablet 1000 mg one tablet two times a day related to type II diabetes, [MEDICATION(S)] HCI tablet 25 mg one tablet at bedtime for itching, [MEDICATION(S)] tablet 4 mg one tablet one time a day related to type II diabetes, [MEDICATION(S)] tablet 1 mg one time a day related to type II diabetes, [MEDICATION(S)] tablet 20 mg one time a day related to cardiac arrhythmia, [MEDICATION(S)] sulfate tablet 325 mg one tablet one time a day related to [CONDITION(S)], calcium 1200 tablet 1200-1000 mg-unit one tablet one time a day related to moderate protein-calorie malnutrition, [MEDICATION(S)] HCI tablet 200 mg one tablet one time a day related to cardiac arrhythmia, and [MEDICATION(S)] HCI tablet 20 mg one tablet one time a day related to adjustment disorder. Review of the Medication Administration Record (MAR) from 04/05/22 through 04/06/22 revealed Resident #02 was not administered any of her medications. Interviews on 04/20/22 from 9:05 A.M. through 9:12 A.M. with Licensed Practical Nurse (LPN) #310 and LPN #287 revealed physician orders were entered into the resident's electronic medical record upon admission. Nursing staff were to fax the orders to the pharmacy. If physician orders were received after hours, the nurse was to call the pharmacy on-call to alert them of the new orders so the pharmacy could process the order and get medications delivered to the facility. Each of the nurses verified the facility had a contingency supply (C-box) of medications for use if the pharmacy did not deliver medications before the next scheduled dose. However, each stated the C-box was limited and medications were not always available for administration. Interview on 04/21/22 at 12:58 P.M. the Director of Nursing (DON) verified Resident #02 did not receive her medications on the evening of 04/05/22 or the morning of 04/06/22. The DON verified Resident #02 was admitted to the facility on [DATE] at approximately 4:00 P.M. and the resident's medications were not ordered from the pharmacy until almost midnight. In addition to faxing physician orders to the pharmacy, nursing staff were required to call the pharmacy after hours to alert them of new orders. The DON stated the admitting nurse reported she called the pharmacy after hours, but the pharmacy stated they had no record of the phone call. While not all of Resident #02's medications were in the facility's C-box, some were, and nursing staff still did not administer what was available at the facility. The DON stated Resident #02's medications were not delivered by the pharmacy until 04/06/22 at approximately 11:00 A.M., when the Resident was ready to discharge with family. The DON further revealed staff were educated on utilization of C-box, but education did not include ensuring admission orders were called into the pharmacy timely. Interview on 05/04/22 at 12:34 P.M. the DON verified there was no official audit tool used to ensure admission orders were called to the pharmacy timely. Review of the Medication Error Log, dated April 2022, revealed an entry on 04/05/22 reporting Resident #02 did not receive all scheduled evening medications. Additional review of an entry dated 04/06/22 revealed Resident #02 did not receive all scheduled morning medications. Review of nursing education dated 04/07/22 revealed nursing staff were in-serviced on the utilization of C-box medications for residents, including new admissions, if the next scheduled medication was due and the resident's medications had not been delivered by the pharmacy and the medication was available in the C-box. The education did not include new admission orders being called into the pharmacy timely. Review of the facility's audit tool revealed the facility began auditing to ensure admission orders were called to the pharmacy timely on 04/25/22. Review of facility policy titled, Medication Administration, dated 06/01/21, revealed medications were administered as ordered by the physician. This deficiency substantiates OH 877.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure timely and thorough admissions were completed, including admission assessments. This affected two (#01 and #02) of three residents reviewed for admissions. In addition, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 73. Findings included: 1. Review of the medical record for Resident #01 revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nursing Admission Screening and History dated 04/10/22 revealed Resident #1 received hospice services, was oriented to person, place, and situation, not oriented to time, had intact cognition, and was angry, resistive, had disorganized thinking, and was yelling when she initially arrived. Additionally, Resident #01 was noted to be blind. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Care Plan, dated 04/10/22, revealed the areas of cognition, mood, and fall risk were not addressed. Review of the Wandering Risk Assessment, dated 04/11/22, revealed it was not completed in its entirety. Resident #01 was assessed to be combative and severely agitated. The assessment did not accurately identify medications Resident #01 was ordered, with anti-depressants and anti-anxiety medications not indicated, and the assessment did not include responses to the resident's orientation and mobility status. Review of the Morse Fall Scale dated 04/12/22 revealed Resident #01 was at high risk for falls. Interviews on 04/20/22 from 9:05 A.M. through 9:12 A.M. with Licensed Practical Nurse (LPN) #310 and LPN #287 revealed admission nursing assessments were to be completed as soon as possible upon a resident's arrival to the facility. This included the nursing admission assessment, skin assessment, fall assessment, and baseline care plan. Interview on 04/20/22 at 3:24 P.M. the Director of Nurse (DON) verified Resident #01's nursing admission and wandering assessments were not completed in their entirety. 2. Review of the medical record for Resident #02 revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nursing Admission Screening and History dated 04/06/22 at 2:35 A.M. revealed Resident #02 was alert and oriented, had an unsteady gait, and had intact cognition. The assessment was not completed in its entirety, including relevant social history, sleep patterns, cardiac history, and bowel and bladder function. Additionally, activities of daily living (ADLs) and functional devices was marked as not assessed. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, Resident #02 was to have blood glucose checked one time daily. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. as ordered. Review of the Pain Assessment, dated 04/06/22, revealed all areas were marked as not assessed. Review of the Wandering Risk Assessment, dated 04/06/22, revealed Resident #02 was low risk for wandering. Additional review revealed none of the sections had a response, including recent experiences of admission to the facility or the use of anti-depressant/anti-anxiety medication. Review of the Admission Care Plan, dated 04/05/22, revealed the following areas were not addressed: wandering, fall risk, mobility, or preferences. Additional review of the medical record revealed no fall risk assessment was completed. Interviews on 04/20/22 from 9:05 A.M. through 9:12 A.M. with Licensed Practical Nurse (LPN) #310 and LPN #287 revealed admission nursing assessments were to be completed as soon as possible upon a resident's arrival to the facility. This included the nursing admission assessment, skin assessment, fall assessment, and baseline care plan. Interview on 04/21/22 at 12:58 P.M. the DON verified Resident #02's admission assessments were not completed timely or in their entirety. The DON verified Resident #02 arrived to the facility on [DATE] at approximately 4:00 P.M. and the nursing admission assessment was signed as completed on 04/06/22 at 2:35 A.M. Additionally, the DON verified Resident #02's pain and wandering assessments were not thoroughly completed, a fall risk assessment was not completed, and the admission care plan did not address wandering, fall risk, mobility, or preferences. The DON stated the facility expectation was for nursing staff to greet new admissions upon arrival and begin the admission assessment process, with the full assessment being completed within four hours of arrival to the facility. The DON verified the assessments guided the development of the baseline care plan and the information needed to pass on to other staff, including State tested Nurse Aides (STNA) for the provision of care to new admissions. Additionally, the DON stated in the fall of 2021, the facility had identified an area of concern related to admission assessments and had implemented corrective action, including a non-mandatory in-service and all nurses had to sign they were competent to complete admission assessments by 11/01/21. The DON stated audits had been conducted to ensure assessments were entered and signed as completed but the audits had not included ensuring each area of the various assessments were completed. Lastly, the DON verified Resident #02's blood glucose level was not checked, as ordered, on 04/06/22. Review of facility policy titled, Admission of a Resident, dated 07/11/21, revealed as much information as possible should be obtained prior to or upon admission to help the resident adjust to the facility. This deficiency substantiates Complaint Number OH 877.

Based on observation, resident and staff interview and review of facility policy, the facility failed to have a call light system which sent alerts directly to a staff member or to a centralized nurses' station. This affected four (#1, #2, #3, and #4) of four residents reviewed for call light activation. The facility census was 78. Findings include: Observation on 05/18/21 at 8:55 A.M., of the second floor revealed a call light sounding on a call light panel at the nurses' station. The panel was found to exclude rooms 231 to 238. Rooms 231, 233, 236 and 237 were noted to have Resident #1, #2, #3 and #4 residing in them. Interview on 05/18/21 at 8:58 A.M., with Licensed Practical Nurse (LPN) #303 revealed there was a second panel at the East end of the hallway which the last four of five rooms at the end hallway registered on. LPN #303 stated the call light board for rooms 231, 233, 236, and 237 were at the end of the long hallway and to the right. Interview on 05/18/21 at 9:03 A.M., with State tested Nursing Assistant (STNA) #200 verified the location of the call light board for rooms 231, 233, 236, and 237 was located on the closed hallway by a nurses' station that was not in use and was not able to be heard or seen from the main hallway. STNA #200 reported staff relied on rounding to observe for overhead call lights for the four residents at the end of the hallway. Interview on 05/18/21 at 9:10 A.M., with Resident #1 who resided on the Two East Wing revealed concerns regarding her call light not sounding like the others in the hallway. Resident #1 reported she lived in no [NAME] land and she put her call light on and no one could hear it. She stated they had to come all the way down to hallway to find out if she needs something or if her call light was on. She said it was lousy being down at the end. Coinciding triggering of Resident #1's call light revealed it functioned properly and the call light went to the panel on the closed hallway. Resident #1's call light was not able to be heard in the hallway outside her door. The call light sound was not audible until standing in the closed hallway. Interview on 05/18/21 at 9:14 A.M., with Resident #4 who resided on the Two East Wing revealed no concerns for call light functionality or staff response time. Coinciding triggering of Resident #1's call light revealed it functioned properly and the call light went to the panel on the closed hallway. Resident #4's call light was not able to be heard in the hallway outside his door. The call light sound was not audible until standing in the closed hallway. Interview on 05/18/21 at 9:18 A.M., with Licensed Social Worker (LSW) #310 revealed she was also a certified aide and would assist with resident care when needed. LSW #310's office was noted to be in room 235 which was noted to be located in the middle of the four residents who call lights triggered in the closed hallway. LSW #310 verified she was not able to hear the call lights from her office for rooms 231, 233, 236, or 237, but she was able to visually see room 236's above the door light and would assist Resident #3 from time to time. Interview on 05/18/21 at 9:22 A.M., with Resident #3 who resided on the Two East Wing revealed no concerns for call light functionality or staff response time. Coinciding triggering of Resident #3's call light revealed it functioned properly and the call light went to the panel on the closed hallway. Resident #3's call light was not able to be heard in the hallway outside his door. The call light sound was not audible until standing in the closed hallway. Interview on 05/18/21 at 9:24 A.M., with Resident #2 who resided on the Two East Wing revealed no concerns for call light functionality. Resident #2 reported being there only a short time but when he has put his call light on it takes the staff a long time to come and check on him. He said he sees his call-light light up but it was like they didn't know it was on until they came down the hallway. Coinciding triggering of Resident #2's call light revealed it functioned properly and the call light went to the panel on the closed hallway. Resident #2's call light was not able to be heard in the hallway outside his door. The call light sound was not audible until standing in the closed hallway. Interview on 05/18/21 at 11:23 A.M., with the Administrator verified the call lights for the four residents at the end of the hall triggered at the closed nurses' station. The Administrator stated the lights above the resident doors illuminated when the call light was activated, and staff responded to resident needs by observing the over the door call lights. Interview on 05/18/21 at 12:12 P.M., with the Director of Nursing (DON) revealed the residents on the end of the hallway were down there for about a week to ten days. The long-term plan was to open up the wing with new admissions and add a nurse on that hallway. The DON verified there was not staff currently working at the nurses station on the closed hall which had the second call light panel. The DON reported speaking with the STNA's at the end of last week to see how things were going and they were now trying to come up with another solution as the STNA's had concerns with the way things were set up. The DON reported they were meeting today 05/18/21 to initiate the move plan. Review of facility policy titled Call Lights: Accessibility and Timely Response, dated 03/28/18, revealed the facility was to ensure the call system alerted staff members. This deficiency substantiates complaint number OH 433.

Based on review of the physician orders, review of the medication administration records (MAR), staff interview, and review of the facility policy, the facility failed to ensure medications were administered per physician orders. This affected three (#03, #04, #06) of six residents reviewed for medication administration. The facility census was 66. Findings include 1. Review of the medical record for Resident #03 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had intact cognition. Review of a physician order dated 02/08/21, revealed the resident was order a chest x-ray. Review of the radiology report dated 02/08/21, revealed the resident had left lower lobe pneumonia and the physician was notified. Review of a physician order dated 02/09/21 revealed the resident was ordered the antibiotic [MEDICATION NAME] 500 milligrams (mg) daily at bed time by mouth for seven days for an upper respiratory infection. Review of the MAR indicated [REDACTED]. Review of a nurses progress note dated 02/15/21 at 2:33 P.M., revealed the physician was notified the [MEDICATION NAME] was started late. Interview on 03/10/21 at 8:33 A.M. with the Director of Nursing (DON), verified the resident's antibiotic was not started on 02/09/21, per physician orders. T he DON verified the medication was available in the contingency medication supply box but was not pulled. The DON stated the physician was notified and the medication was restarted. 2. Review of the medical record for Resident #04 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated [DATE], revealed the resident had intact cognition. Review of a physician order dated 02/15/21, revealed the resident was ordered an additional dose of [MEDICATION NAME] 20 mg by mouth every 24 hours as needed if the resident gained greater than two pounds. Review of the resident weight documentation revealed the resident weighed 114 pounds on 02/14/21. The resident had no daily weights documented from 02/15/21 through 02/25/21. On 02/26/21, the resident weighed 105 pounds. The resident had no daily weights documented on 02/27/21 and 02/28/21. On 03/01/21, the resident weighed 111 pounds. The resident had no daily weights documented from 03/02/21 through 03/06/21. The resident had daily weights documented from 03/07/21 through 03/15/21. Review of the MAR indicated [REDACTED]. The resident weighed 109 pounds on 03/09/21, and weighed 112 pounds on 03/10/21. On 03/11/21, the resident weighed 108 pounds and on 03/12/21 weighed 112 pounds. Review of the MAR's dated 02/15/21 through 03/15/21, revealed the resident was not administered [MEDICATION NAME] 20 mg as needed for a weight increase of greater than two pounds. Interview on 03/10/21 at 11:30 A.M. with the DON, verified the resident's daily weights were not initiated until 03/07/21. Further interview on 03/16/21 at 11:34 A.M., verified the resident had not received any of the as needed doses of [MEDICATION NAME]. 3. Review of the medical record for Resident #06 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated [DATE], revealed the resident had mild cognitive impairment. Review of the physician orders dated 01/30/21, revealed Resident #06 was ordered [MEDICATION NAME] Sodium tablet four mg by mouth daily for [MEDICAL CONDITION]. On 01/31/21, Resident #06 was also ordered [MEDICATION NAME] Sodium tablet one mg, give 0.5 tablet by mouth every Monday, Wednesday, Friday and Sunday for [MEDICAL CONDITION]. Review of the 02/01/21 through 02/28/21 MAR, revealed the resident was not administered the four mg dose of [MEDICATION NAME] on 02/01/21. Further review of the MAR indicated [REDACTED]. Interview on 03/16/21 at 3:30 P.M. with the DON, verified the two doses of [MEDICATION NAME] were not administered on 02/01/21, per physician orders. Review of facility policy titled, Medication Administration, revised 10/20/20, revealed medications would be administered as ordered by the physician. This deficiency substantiates Complaint Number OH 456.

Based on review of the physician orders, review of the Medication Administration Record [REDACTED]. This affected two (#03, #06) of six residents reviewed for medications. The facility census was 66. Findings include 1. Review of the medical record for Resident #03 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had intact cognition. Review of the physician order dated 02/08/21, revealed the resident was ordered a chest x-ray. Review of the radiology report dated 02/08/21, revealed the resident had left lower lobe pneumonia and the physician was notified. Review of a physician order dated 02/09/21, revealed the resident was ordered the antibiotic [MEDICATION NAME] 500 milligrams (mg) daily by mouth at bed time for seven days for an upper respiratory infection. Review of the MAR indicated [REDACTED]. Review of a nursing progress note dated 02/15/21 at 2:33 P.M., revealed the physician was notified the [MEDICATION NAME] was started late. Interview on 03/10/21 at 8:33 A.M. with the Director of Nursing (DON) verified the resident's antibiotic was not started on 02/09/21, per physician orders. The DON verified the medication was available in the contingency medication supply box but was not pulled. The DON stated the physician was notified and the medication was restarted. 2. Review of the medical record for Resident #06 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated [DATE], revealed the resident had mild cognitive impairment. Review of the physician orders dated 01/30/21, revealed Resident #06 was ordered [MEDICATION NAME] Sodium tablet four mg by mouth daily for [MEDICAL CONDITION]. On 01/31/21, Resident #06 was also ordered [MEDICATION NAME] Sodium tablet one mg, give 0.5 tablet by mouth every Monday, Wednesday, Friday and Sunday for [MEDICAL CONDITION]. Review of the MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. Interview on 03/16/21 at 3:30 P.M. with the DON verified the two doses of [MEDICATION NAME] were not administered on 02/01/21, per physician orders. Review of the facility policy titled, Medication Administration, revised 10/20/20, revealed medications would be administered as ordered by the physician. This deficiency substantiates Complaint Number OH 456.

Based on observations, staff interviews, review of the facility policy, and review of the Centers for Disease Control (CDC) and Prevention, the facility failed to adhere to recommended infection control practices to prevent the spread of Coronavirus Disease 2019 (COVID-19) related to the following: N95 respirator fit testing for all direct care workers had not been completed; unapproved KN95 respirators were utilized on the COVID-19 units; staff were not ensuing proper storage of N95 respirators; staff were not properly donning and doffing personal protective equipment (PPE) and utilizing PPE appropriately; and new resident admissions were without transmission-based precautions in place. This had the potential to affect 77 of 77 residents who reside in the facility. Findings include: 1. Review of the facility's Respirator Fit Test Record dated 05/21/20, revealed only six employees (Director of Nursing (DON), Licensed Practical Nurse (LPN) #208, LPN #210, LPN #212, LPN #214, LPN #216), had been properly fit tested for N95 respirators in compliance with Occupational Safety and Health Administration (OSHA) standards. During interview on 01/11/21 at 12:20 P.M. with State tested Nursing Assistant (STNA) #101, stated she had not received fit testing for a N95 respirator. During interview on 01/11/21 at 12:30 P.M. with Licensed Practical Nurse (LPN) #202, stated she had not received fit testing for a N95 respirator. During interview on 01/11/21 at 4:05 P.M. with LPN #204, stated she had not received fit testing for N95 respirator. During interview on 01/12/21 at 5:00 A.M. with Registered Nurse (RN) #306 stated, she had not received fit testing for N95 respirator. During interview on 01/11/21 at 2:30 P.M. with the Administrator, verified not all of the staff had been fit tested for the N95 respirators. The Administrator stated the employees who did receive fit testing were nurses. Review of CDC website (cdc.gov/coronavirus/2019-ncov/hcp/nursing-home-long-term-care.html), Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic dated 12/14/20, revealed respirator use must be in the context of a complete respiratory protection program in accordance with OSHA Respiratory Protection standard (29 CFR 1910.134external icon). Healthcare Personnel (HCP) should be medically cleared and fit tested if using respirators with tight-fitting facepieces (e.g., a NIOSH-approved N95 respirator) and trained in the proper use of respirators, safe removal and disposal, and medical contraindications to respirator use. 2. Observation on 01/07/21 at 11:30 A.M., of the dementia unit (COVID-19 unit), revealed LPN #202 had a KN95 face mask with ear loops which was not a respirator-quality face mask. LPN #202 verified it was the only face mask she had been given to use. During observation/interview on 01/12/21, of the dementia unit (COVID-19) at 6:10 A.M. with STNA's #103 and #105, revealed both employees had KN95 face masks with ear loops in place. Both STNA's verified they were the only face masks given to them to use. Review of the CDC's guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID19 Pandemic dated 07/15/20, revealed staff who enter the room of a patient with suspected or confirmed COVID-19 infection should adhere to Standard Precautions and use a National Institute for Occupational Safety and Health (NIOSH) approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection. 3. During interview on 01/07/21 at 11:30 A.M. with LPN #202, who was working the dementia unit (COVID-19), stated she takes her KN95 face mask with her when she leaves for the day and keeps the face mask in a paper bag and stores it in her car. During interview on 01/12/21 at 5:50 A.M. with LPN #218, working the dementia unit (COVID-19), stated she takes her N95 respirator with her when she leaves the unit and stores the N95 in her car in a paper bag. During interview on 01/12/21 at 6:10 A.M. with STNA's #103 and #105, working the dementia unit (COVID-19), both stated they put their K95's face masks in a plastic bag and take them home with them. Review of CDC website(https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html#respreuse) dated 03/27/20, revealed, staff were to hang used respirators in a designated storage area or keep them in a clean, breathable container such as a paper bag between uses. To minimize potential cross-contamination, store respirators so that they do not touch each other and the person using the respirator was clearly identified. Storage containers should be disposed of or cleaned regularly. 4. During observation on 01/12/21 at 6:20 A.M. of the dementia unit (COVID-19), revealed a non-biohazard trash can in the doffing area overflowing onto the floor with biohazard waste. There was no biohazard trash can in the doffing area upon exiting the facility. Interview on 01/12/21 at 6:20 A.M. with LPN #218, verified the non-biohazard trash can was overflowing onto the floor of the doffing area to the outside of the building. Review of facility policy titled, Infection Prevention and Control Program, dated 11/14/19, revealed all contaminated disposable items shall be discarded in a waste receptacle line with a red plastic bag. Red bagged items shall be placed in an appropriately labeled container marked with a biohazard label that meets FDA and OSHA guidelines and standards. 5. During observation on 01/07/21 at 11:30 A.M. of the dementia unit (COVID-19), revealed Activities Aide #420 exited the COVID-19 unit into a common area without removing (doffing) her N95 respirator or completing hand washing. The COVID-19 unit had no doffing area upon exiting into the common area (non-COVID-19). Interview on 01/07/21 at 11:30 A.M. with LPN #202, verified Activities Aide #420 exited the COVID-19 unit without removing her N95 respirator or completing hand washing. 6. Observation on 01/12/21 at 5:50 A.M. of the dementia unit (COVID-19), revealed no PPE donning area before entering the unit or upon entering onto the unit. The door to the COVID-19 unit did have a sign that read COVID-19 unit. Interview on 01/12/21 at 5:50 A.M. with LPN #202, verified the unit did not have a donning area before entering the COVID-19 unit. 7. Observation on 01/10/21 at 3:00 P.M. of new admission Resident #38, revealed no door signage or isolation cart outside of the resident's room. Interview on 01/10/21 at 3:05 P.M. with LPN #208, verified Resident #38 was a new admission and should be on transmission-based precautions and stated the facility was out of isolation carts. Review of the CDC website (https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes responding.html), dated 04/30/20, revealed facilities will need to create a plan for managing new admission and readmission whose COVID-19 status was unknown. All recommended COVID-19 personal protective equipment (PPE) should be worn during care of residents under observation, which included the use of an N95 or higher-level respirator (or facemask if respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. 8. Observation on 01/10/21 at 4:15 P.M. of the second floor (COVID-19 unit), revealed STNA #107 entered Resident #40's (COVID-19 positive) room to deliver his meal tray. The STNA did not have a gown or gloves upon entering the resident's room. Interview on 01/10/21 at 4:20 P.M. with STNA #107, verified she did not apply personal protective equipment (PPE) when she entered Resident #40's room. STNA #107 stated she was aware the resident was COVID-19 positive. Interview on 01/07/21 at 9:40 A.M. with Purchasing Coordinator #726, denied any concerns regarding a shortage of PPE's. Purchasing Coordinator #726 stated the facility had not needed to contact the local emergency management agency (EMA) for PPE supply. Observation of the PPE storage in the basement of the facility, revealed an adequate amount of gowns, gloves, face shields, and N95 respirators. Interview on 01/10/21 at 3:05 P.M. with LPN #208, denied any concerns regarding a shortage of PPE. 9. Observation on 01/12/21 at 6:00 A.M. of Maintenance Employee #522 revealed the employee on the dementia unit (COVID-19) emptying the red biohazard bins in the dirty utility room without gloves in place. Interview on 01/12/21 with 6:02 A.M. with LPN #202 verified Maintenance Employee #522 did not have gloves on when emptying the biohazard bins. Review of facility policy titled, Novel Coronavirus Prevention and Response, dated 07/30/20, revealed housekeeping staff shall adhere to transmission-based precautions. This deficiency substantiates Master Complaint Number OH 926 and Complaint Number OH 466. This deficiency is an example of continued non-compliance from the survey dated 12/23/20.

Based on medical record reviews, staff interviews and review of facility policy, the facility failed to ensure one (#99) resident received adequate assessment and timely intervention to prevent the worsening of a pressure ulcer. This resulted in actual harm when Resident #99 developed an avoidable stage three pressure ulcer to the right upper heel area. In addition, the facility also failed to adequately assess a pressure ulcer for one (#16) resident. This affected two (#16, #99) of three residents reviewed for pressure ulcers. The facility identified eight residents with pressure ulcers. The facility census was 125. Findings include: 1. Review of the medical record for Resident #99 revealed the resident was admitted to the facility on [DATE] and discharged to home on 06/15/16. [DIAGNOSES REDACTED]. Review of the admission comprehensive assessment, dated 05/10/16 revealed the resident did not have cognitive deficits and did not reject any care during the seven day look back period for the assessment. It further revealed the resident required extensive assistance for bed mobility, dressing, toileting and hygiene and was totally dependent for transfers. The assessment further revealed the resident had weight loss. The resident had been assessed for and was at risk for skin breakdown. The assessment revealed unhealed pressure ulcers as of 05/10/16 included a stage one ulcer and a stage two ulcer, with pressure reliving mattress in place and a pressure relieving cushion to a chair. A turning and repositioning program was in place and therapies had been provided. A significant change assessment dated [DATE] revealed there continued to be no rejection of care during the look back period of 05/10/16 - 05/17/16. The significant change assessment revealed one stage two pressure ulcer was present and had been present on admission, as well as one newly developed stage three ulcer. Review of nurses' notes dated 05/03/16 revealed the resident was admitted to the facility and refused to allow the staff to remove a right leg brace to perform a skin assessment. Review of the Pressure ulcer/Non-pressure ulcer healing record also dated 05/03/16 revealed Licensed Practical Nurse (LPN) #305 did perform a skin assessment for Resident #99 on 05/03/16 which revealed a stage one pressure ulcer 1.2 centimeters (cm) wide by 1.0 cm long by less than 0.1 cm deep, with a white center and pink surrounding skin just above the right heel. It further revealed the physician, dietician and family were notified and a plan of care was initiated. Review of nurses' notes dated 05/04/16 revealed Resident #99 continued to refuse to allow staff to remove the leg brace to assess the skin and a physician order was obtained from the orthopedic physician to remove the brace for showering. Further review of the nurses' notes dated 05/04/16 revealed Registered Nurse (RN) #304 observed a blanchable red area with a white center over the right heel. The Pressure ulcer/Non-pressure ulcer healing record dated 05/03/16 was not updated to reveal any change to the initial status of the pressure ulcer above the right heel. Review of a physician order dated 05/04/16 revealed RN #304 obtained an order for [REDACTED]. Review of the primary physician progress (PCP) notes revealed Resident #99 was seen on 05/05/16. The physician progress notes [REDACTED]. Interview with the Director of Nursing (DON) on 08/03/16 verified the physician progress notes [REDACTED]. Review of physician progress notes [REDACTED].#99 was seen by her orthopedic physician on 05/06/16. Further review of the progress notes revealed the physician wrote new orders for weight bearing status, however did not address the skin under the brace. Review of nurses' notes dated 05/06/16 revealed Resident #99 refused to allow the staff to remove the right leg brace after the resident returned from the orthopedic physician. The coccyx wound was addressed. One additional nurse's note dated 05/07/16 revealed one additional time the resident refused to allow staff to remove the brace for a skin assessment. The right heel achilles tendon area was not mentioned again until 05/13/16. Review of nurses' notes dated 05/13/16 revealed a skin assessment was completed and a pressure area was noted in the right achilles tendon area due to the brace. It further revealed the area was creamy, milky and 60 percent of the ulcer and was scabbed over. The note further revealed a treatment was initiated with antibiotic ointment, and a dressing, and the physician, family and therapy were notified. Review of PCP orders dated 05/13/16 revealed the staff could remove the brace from the right lower extremity and check the skin once per shift, as well as a dressing with triple antibiotic ointment to the right Achilles tendon area after a soap and water cleanse, cover with a [MEDICATION NAME] dressing, cover with an abdominal pad and wrap with kling daily until it was healed. Further review of the Pressure Ulcer/Non-Pressure ulcer healing record dated 05/03/16 revealed the stage one pressure ulcer above the right heel had not been resolved. The next assessment dated was 05/13/16 was initially marked as healed and then documented to see the attached skin grid, also dated 05/13/16. At this point the area above the achilles tendon was documented as a stage two ulcer, which was defined as a partial thickness skin loss, superficial and presents as an abrasion, blister or shallow crater. It was described as 1.5 centimeters (cm) long by 1.0 cm wide and less than 0.1 cm in depth. The wound bed was 60 percent slough. A diagram was drawn to show a scabbed on the top of the wound. Review of Weekly skin Evaluation sheet dated 05/04/16 through 05/10/16 revealed on 05/04/16 the see skin grid sheet was marked. On 05/05/16, 05/16/16, 05/07/16, 05/08/16, 05/09/16 and 05/10/16 it was documented as no new areas. Review of the weekly skin evaluation sheet for weekly skin checks revealed an entry for 05/12/16 with see skin grid. No new areas of skin impairment was documented. Further review of the pressure ulcer, non-pressure ulcer healing record, revealed no entries were documented on 05/04/16 or 05/12/16. Review of the Treatment Administration (TAR) for 05/2016 revealed the resident had pressure relieving mattress and a pressure relieving cushion to the wheelchair. There were no interventions for the stage one pressure ulcer to the right heel. There was additionally no intervention to check the skin under the right brace where the stage one pressure ulcer was. It revealed no interventions to the right heel ulcer and brace were present until 05/13/16. It further revealed the knee immobilizer was maintained to the right leg. Further review of the TAR revealed skin prep was applied to the left heel but not the right heel. Interview with the Director of Nursing (DON) on 08/13/16 at 3:00 P.M. revealed the orthopedic physician was not notified of the continued resident refusals to allow staff to assess the skin the first four days of admission or of the stage one ulcer under the brace. She stated the PCP was notified of the stage one ulcer per the facility policy. She further stated there was no documentation the orthopedic physician was ever notified of the ulcer under the brace or if the PCP had been informed the resident had a stage one ulcer under the brace and had not allowed the staff to assess the skin during the first four days. The DON further stated there was no documentation to verify the PCP was aware there was an order to remove the right leg brace to check the skin until 05/13/16. She further stated the nurse who initially informed the PCP of the stage one area did not work here any longer and was unable to be reached. The DON verified the Pressure Ulcer/non-pressure ulcer healing record, dated 05/03/16 had not been updated to show the wound had been healed and a skin assessment should have been performed on 05/10/16 and was not completed until 05/13/16 when therapy notified the staff of a wound the resident's right heel. She further verified there was no documentation in the nurses' notes of staff providing education to the resident during the first four days of the need to allow the staff to assess the skin and of the potential complications of not assessing the skin. She verified there was no documentation on the right heel wound on the Pressure ulcer/non-pressure ulcer record from 05/03/16 until 05/13/16. The DON confirmed the right heel wound, and the wound described as the achilles tendon area above the right heel were the same wound. She verified the right heel pressure ulcer on the pressure ulcer healing record was inaccurately marked as a stage two wound and should have been a stage three wound due to the slough that was noted. The DON stated the resident had been seen by therapy and stated the therapy department had informed her there was no wound present on 05/12/16. The DON further verified no treatment had been obtained for the right heel stage one pressure ulcer until it had been assessed as a stage three ulcer (recorded as a stage two inaccurately per the DON). Interview Physical Therapy Assistant (PTA) on 08/04/16 at 11:00 A.M. revealed she was the main therapist for Resident #99 and saw the resident daily. She stated she did not remove the right leg brace completely, however opened the brace to perform the exercises. She stated she did not notice any issues with the skin on the right heel, however she did not look either. She stated she would not have known if the heel had been red prior. She stated on 05/13/16 the resident informed her the right heel was bothering her so she looked and saw on open sore and she informed the nursing staff. She stated she was not trained in pressure ulcers and was not qualified to assess skin. There were no opportunities for observation to the wound as the resident was discharged to home in 06/2016. Discharge instructions included wound care to the coccyx and right heel areas. Review of the facility policy Prevention/treatment of [REDACTED]. It further revealed if a skin issues was identified, it was to be completed on the first observation of a skin problem and then weekly and as needed and an individualized and specific plan of care was to be developed. The policy further revealed the licensed nurse was to notify the resident, primary care physician, dietician and family of the skin problem and treatment and must document in the medical record or pressure ulcer form, the notification, who spoke to and what their response was. 2. Review of Resident #16's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Further review of the medical record revealed the resident was admitted to the facility with shearing on the coccyx. On 06/29/16 a physician order was received to apply [MEDICATION NAME] every shift to the coccyx area for preventative measures. On 07/05/16 the pressure area worsened and a physician order was received to apply Duoderm to the coccyx area every three days. Review of Resident #16's Pressure Ullcer/Non-Pressure Ulcer Healing Record revealed documentation that the coccyx pressure area was measured and assessed on 07/05/16, 07/06/16, 07/09/16, 07/19/16 and 07/24/16. This revealed a lapse in documentation of 10 days from 07/09/16 to 07/19/16 and of 10 days between 07/24/16 and 08/03/16. On 08/03/16 at 4:20 P.M. an interview with Licensed Practical Nurse (LPN) #200 revealed no wound documentation had been charted since 07/24/16. LPN #200 also revealed she did examine the wound on 07/30/16, however did not document the information. Review of the facility policy titled Prevention/treatment of [REDACTED].