Every finding on record at Suburban Healthcare and Rehabilitation

Based on closed medical record review, review of hospital records, review of photo and video records, review of facility witness statements, review of facility staffing and payroll documents, policy review and interview, the facility failed to protect Resident #419's right to be free from neglect. This affected one resident (#419) of two residents reviewed for neglect. The facility census was 119.Actual Harm occurred on 07/01/26 when Resident #419 was transferred to the hospital for a scheduled procedure and hospital staff identified the resident with caked feces, a maggot infestation, and multiple superficial wounds to both feet with cellulitis of the lower extremities which required medical intervention and subsequent admission to the hospital. The facility failed to recognize the incident as a situation of neglect even though hospital staff notified the facility (on 07/01/26) that the resident's condition on arrival to the hospital constituted neglect. The resident did not return to the facility following hospitalization. Findings include:Review of the closed medical record for Resident #419 revealed the resident was admitted on [DATE] and discharged on 07/01/26. Resident #419 had diagnoses including schizoaffective disorder (a mental disorder characterized by a breakdown in thoughts, emotions, and behaviors), bipolar disorder (a mental health condition that causes shifts in mood, energy, and concentration), type two diabetes mellitus, chronic obstructive pulmonary disease, hypertension, and obesity. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #419 was cognitively intact with mood symptoms including little interest in doing things, feeling down, depressed, or hopeless, and trouble concentrating on things. The assessment revealed Resident #419 was dependent on staff for all activities of daily living except eating, oral hygiene and upper body dressing. A wheelchair was required for mobility, and Resident #419 was always incontinent of bowel and occasionally incontinent of urine.Review of Resident #419's care plan initiated 04/02/26 and revised 06/04/26 revealed problematic behaviors which included resisting care and refusing toileting and incontinence care. Interventions initiated 04/02/26 included calling the guardian when the resident refused and educating the resident of the risks of refusing care. It did not specify Resident #419 as having behaviors of refusing to remove his shoes for bathing.Review of the progress notes from admission on [DATE] until discharge on [DATE] revealed only one documented instance on 04/23/26 where Resident #419 refused to take his shoes off which was when he refused wound care. It was not documented whether the guardian was notified. The only documented bathing refusal in the progress notes was on 05/15/26 when the guardian was notified and then Resident #419 allowed the care. On 06/03/26, the resident refused morning care, and the guardian was called but it did not specify whether that involved bathing or removing his shoes. It also did not stipulate whether contacting the guardian was used as an intervention for Resident #419's compliance or its effect. In all the progress notes, there was no documentation which identified Resident #419 refused bathing of his feet or to remove his shoes to receive bathing. Review of an outpatient urologist order dated 06/22/26 at 12:32 P.M. revealed Resident #419 was scheduled for urinary catheter placement (outpatient hospital visit) on 07/01/26 at 7:30 A.M.Review of the progress note dated 07/01/26 at 1:26 P.M. completed by Registered Nurse (RN) #242 revealed Resident #419 went to a scheduled hospital appointment for urinary catheter placement. Resident #419 was transported to the hospital by scheduled transportation and a facility-assigned escort. Following the appointment, the resident was sent from the appointment to the emergency room for further evaluation and subsequently admitted for a diagnosis of failure to thrive. The nurse practitioner and the resident's guardian were notified. There was no documentation on this date regarding Resident #419's condition prior to leaving the facility.Review of the hospital radiology physician note dated 07/01/26 at 9:11 A.M. revealed Resident #419 was scheduled for urinary catheter placement. The hospital nursing staff reported the resident arrived in urine soaked clothing and numerous maggots over both feet. The resident was cleaned and sent to the emergency room for further evaluation and care management.Review of the hospital emergency department (ED) provider note dated 07/01/26 revealed Resident #419 presented with concerns for neglect from the nursing facility. Maggots were removed and the resident was cleaned prior to the ED arrival. Physical examination revealed both legs/feet had two to three plus edema (a moderate level of fluid swelling) with indurated erythema (red, swollen skin that feels firm, hardened and thick) with multiple superficial wounds on both feet. Feces were noted on the resident's bilateral feet and reflected poor hygiene. There was possible cellulitis due to redness and warmth of the lower extremities, maggot infestation, and failure to thrive. The maggot infestation in the toes between the nails and nail beds were removed. The resident was started on intravenous antibiotics and steroid therapy, given a podiatry and wound care consult, and case management for alternate facility placement.Review of the hospital podiatric medicine note dated 07/01/26 at 4:51 P.M. revealed Resident #419's toenails one to five appeared thickened, deformed and discolored with debris under the nails. The spaces between the toes had moderate debris and a foul odor. Review of a facility witness statement dated 07/01/26 by Licensed Practical Nurse (LPN) #195 revealed the hospital radiology department contacted the facility and reported to her that when Resident #419's socks and shoes were removed, maggots fell from his shoes. LPN #195 reported the incident to management.Review of a facility witness statement dated 07/01/26 by LPN #254 revealed that during the night shift on 06/30/26 to 07/01/26 from 7:00 P.M. to 7:00 A.M., Resident #419 was scheduled for a shower at 4:00 A.M. with transportation pickup at 6:30 A.M. The statement included an unnamed Certified Nursing Assistant (CNA) attempted to shower the resident who chose to go outside to smoke instead, stating he was not going to the appointment. The guardian of the resident was notified by the nurse of the resident's refusal. The guardian called back at 6:11 A.M. and said she would speak to the resident and meet him at the appointment. The statement included the guardian was notified the resident had not been showered. At 6:30 A.M., the resident returned to the unit and requested to be changed. Transportation had arrived at the facility, and the guardian who was on the phone at the time, requested the resident go to the appointment. The resident left the facility at 6:36 A.M.Review of a facility witness statement dated 07/02/26 by CNA #122 revealed she provided Resident #419 a bed bath on 06/30/26 and the resident refused to take his shoes off, claiming the aides do not put the shoes on correctly. No skin issues were noted by the aide on the visible parts.Interview on 07/09/26 at 10:30 A.M. with Social Service Designee (SSD) #244 revealed Resident #419 refused to wear briefs and would urinate on the floor or even acknowledge he was incontinent on the floor and preferred to go outside to smoke instead of toileting. A condom catheter (an external covering to drain urine) was attempted by the guardian that did not work. Interview on 07/09/26 at 10:59 A.M. with the Administrator described the resident as not being in a great state when he left the facility and receiving a call from the hospital reporting the maggots on the resident's feet; however, explained he did not receive the hospital's reporting as neglect, so he did not treat the situation as an allegation. The Administrator described Resident #419 as having a long history of refusing care, hygiene products, and would not take his shoes off for a shower; however, refusing to remove shoes for bathing was not routinely reflected in Resident #419's progress notes or plan of care during his stay. Interview on 07/09/26 at 1:45 P.M. with the Director of Nursing (DON) revealed Resident #419 did not wear his shoes in the shower, but staff said he would refuse to take his shoes off because he had lymphedema (swelling of soft tissues caused by lymph fluid) and the staff did not know how to take on or off his shoes. The DON did not express any steps the facility took to prevent or educate Resident #419 on the negative consequences of not removing his shoes for bathing or to ensure staff knew how to take on and off his shoes.Interview on 07/09/26 at 1:50 P.M. with Registered Nurse Manager (RNM) #242 revealed she had no knowledge about Resident #419's feet condition but stated the resident's preference was bed baths. He spent most of his time outside smoking and liked to have his shoes on all the time. RNM #242 did not express any steps the facility took to prevent or educate Resident #419 on the negative consequences of not removing his shoes for bathing.Interview on 07/09/26 at 2:00 P.M. with CNA #126 who stated Resident #419 always wanted a bed bath, and when he was given a bed bath, he refused to take off his shoes because he did not believe staff knew how to take them on or off. The resident also slept with his shoes on. CNA #126 did not express any steps taken to prevent or educate Resident #419 on the negative consequences of not removing his shoes for bathing.Interviews on 07/15/26 at 11:40 A.M. and on 07/22/26 at 1:52 P.M. with Resident #419's guardian revealed she observed the resident's feet while at the hospital after hospital staff cleaned his feet and was very upset. The resident's toenails were black, there was a dark crusty substance around the toes, and a maggot crawling from under his great toe. The guardian stated during Resident #419's facility stay, the staff did not call to report the resident refusing to take his shoes off for bathing; however, the guardian described calling staff several times about Resident #419 wanting to get cleaned up but they would respond that it was not his shower day or it was too hard to get him in the shower, so he got a bed bath. The staff complained he was too big and it took too many staff or there was not enough room in the shower, so he just got bed baths. The guardian stated she was unaware of any refusals to bathe his feet, and it was not discussed during the care conference. Review of care conference notes revealed one undated meeting for Resident #419 who attended with the resident's guardian. There was no evidence in the notes of concern with Resident #419 refusing to remove his shoes for bathing his feet or discussion for interventions to address bathing his feet.Review of photographic pictures and one video (of Resident #419's feet and shoes on 07/01/26) submitted by Resident #419's guardian on 07/15/26 at 4:34 P.M. revealed the following:Picture one revealed Resident #419's left foot with significant swelling and redness, a darkened circular area to the medial side of the foot, and an elongated darkened area to the underside of the foot.Picture six revealed Resident #419's right foot with a dark black/brown substance on the toes and under the great toenail. The great toenail was thickened, dark in color, with the dark substance under the nailbed.Picture seven revealed Resident #419's right lower leg with significant swelling and redness.Picture eight revealed Resident #419's left great toenail significantly thickened and raised with a blackened substance caked under the nailbed. A small white protrusion (alleged maggot) was evident under the nailbed.Picture nine revealed Resident #419's left foot with a dried black substance under the toes and the nailbed of the second through fifth toes. The nailbeds were thickened and elongated.Picture ten revealed Resident #419's left lower leg with significant swelling and redness.Video one revealed Resident #419's shoes bagged in a clear plastic bag with a visible live white maggot crawling on the side of the bag.Interview on 07/15/26 at 2:00 P.M. with MDS Nurse #213 verified Resident #419's care plan did not reflect the resident refusing to remove his shoes for bathing of the feet or include any staff intervention to ensure Resident #419's feet received care. MDS Nurse #213 denied being informed by staff or having documentation of Resident #419 not wanting to remove his shoes. She indicated just finding out about it from the social worker on this date.Review of Resident #419's medical record plan of care (POC) for nursing assistant care revealed the resident was totally dependent on staff for bathing. A task for shower/bed bath per resident preference and to provide nail care on every shower day. Refusals were to be documented. For the two weeks prior to the incident on 07/01/26 (from 06/17/26 through 06/30/26), there were no refusals documented. A shower was documented as provided on 06/25/26 and two bed baths on 06/19/26 and 06/29/26. Bathing on 06/30/26 was documented as not applicable. Review of Resident #419's Bath and Shower Sheets for April 2026 and May 2026 revealed for the dates bathing was provided, the documentation did not indicate Resident #419 refused to remove his shoes for bathing. A sheet dated 05/01/26 indicated the resident's toenails needed cut. Record review revealed no evidence of follow-up with this. Additional review of June 2026 documentation revealed staff documented the resident received a bed bath on 06/05/26, 06/06/26, 06/09/26, 06/12/26, 06/19/26 and 06/23/26. For the dates bathing was provided, the documentation did not indicate Resident #419 refused to remove his shoes for bathing. During an interview on 07/16/26 at 10:30 A.M., the DON reviewed and verified the findings for Resident #419's Bath and Shower Sheets from April to June 2026.Review the weekly skin checks located on June 2026 Treatment Administration Record revealed on 06/30/26 at 5:00 P.M. LPN #195 documented Resident #419's skin condition as normal, normal moisture, no new wounds, skin color normal, temperature normal, and skin turgor good. (This is contrary to the hospital documentation and photographic pictures.)A telephone interview on 07/16/26 at 11:15 A.M. and 11:45 A.M. with LPN #195 revealed on 06/30/26 during the day shift, Resident #419 had let the aide remove his shoes and wash his feet. His feet had some dry spots on them. LPN #195 continued to explain about being one of the people the resident would let remove his shoes and apply new socks, and that he never refused her giving him care. During the interview, she stated she believed the CNA was CNA #142 or CNA #122 who had provided care. LPN #195 also stated she received the phone call from the hospital radiology department and was surprised about the maggots because the aide had just washed his feet (which is contrary to the hospital documentation and photographic pictures).Review of the facility daily staffing sheet and payroll report dated 06/30/26 revealed CNA #122 (whose witness statement indicated giving Resident #419 a bed bath and refusing to remove his shoes on 06/30/26) and CNA #142 were not on the schedule or evidence of either being in the facility on 06/30/26. Interview on 07/16/26 at 12:10 P.M. with Human Resources Director (HRD) #106 verified CNA #122 and CNA #142 did not work on 06/30/26.Interview on 07/16/26 at 12:25 P.M. with RNM #242 verified Resident #419's bathing sheet for 05/01/26 indicated his toenails needed cut and stated when that was marked, the social worker was notified to get on the podiatrist list; however, at the time of Resident #419's 05/01/26 bath sheet, the facility was going through a transition with podiatric services and there was a temporary podiatrist for the facility. RNM #242 stated the podiatrist visit for Resident #419 may have been overlooked.On 07/16/26 at 3:00 P.M. the Administrator was notified of the photographic pictures of Resident #419's feet that had been provided; however, the Administrator refused to look at the pictures stating he could imagine what maggots would look like and did not need to see them.Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriate Prevention Program, revised April 2021, revealed the facility would develop and implement policies and protocols to prevent and identify all possible incidents of abuse, neglect or mistreatment. However, the policy did not include a definition of neglect or provide staff guidance to illustrate what might constitute situations of neglect. The policy included under the area of prevention that the facility would establish and maintain a culture of compassion and caring for all residents, particularly those with behavioral or emotional problems.This deficiency represents non-compliance investigated under Master Complaint Number 3075582, Complaint Number 3072587, Complaint Number 3067393, and Complaint Number 2602874.

Based on medical record review, review of email communication, fall investigation review, resident and staff interview, and facility policy review, the facility failed to ensure Resident #334 was free from an incident of involuntary seclusion. This affected one resident (#334) of two residents reviewed for quality of care and services. The facility census was 119.Actual physical and psychosocial harm occurred on 06/20/26 when Resident #334, who had quadriplegia (partial or total loss of function in all four limbs) and was dependent on staff for toileting, was left alone without supervision on a toilet in a locked common bathroom requiring a code to open without evidence of a functional call signal system. After assisting Resident #334 to this bathroom, the Certified Nursing Assistant (CNA) responsible for Resident #334's supervision left the facility without telling any staff. Resident #334 who was unable to call for help without a functioning call light, subsequently placed himself on the ground, crawled to a wall, and banged on it trying to call for help. Based on the survey findings, after approximately two to four hours, staff noticed the resident's absence, searched and found the resident inside this common bathroom on the floor near the door. Resident #334 had a swollen and painful wrist and described feeling abandoned, angry, miserable, and fearful because of the incident.Findings include:Review of Resident #334's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included toxic encephalopathy, peripheral vascular disease, quadriplegia, traumatic brain injury, major depressive disorder, anxiety disorder, delusional disorder, and antisocial personality disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #334 was cognitively intact and had no signs or symptoms of delirium or abnormal mood. The assessment revealed Resident #334 required full staff assistance (dependent) for all activities of daily living (ADL). The resident used an electric wheelchair for mobility with set up assistance and required a mechanical lift for all transfers. Review of a progress note dated 06/20/26 at 8:05 P.M. revealed Licensed Practical Nurse (LPN) #253 was notified by a Certified Nursing Assistant (CNA) that Resident #334 had not been seen for a while, but that another CNA had placed the resident on the toilet in the common bathroom before she left for the day. Upon approaching the common bathroom, knocking was heard and the resident was observed on the floor laying on his left side. Resident #334 reported to LPN #253 the CNA placed him on the toilet and left him there, resulting in him rolling himself off the toilet and across the floor to knock on the door to be let out.Review of the progress note dated 06/21/26 at 10:13 A.M. completed by LPN #189 revealed Resident #334 complained of pain and had swelling to the left wrist. Tylenol 650 milligrams (mg) was administered for pain and a STAT (immediately) x-ray to rule out a wrist fracture was ordered. The x-ray results completed on 06/21/26 revealed no acute fracture or dislocation.Review of the facility document titled, Post Fall Investigation Form, signed and dated by the Director of Nursing (DON) on 06/22/26 revealed the contributing factor was the resident being left unattended in the central bathroom. A prevention plan included interventions of keeping a call light in reach and not leaving unattended when toileting. Review of email communication dated 06/30/26 at 3:22 P.M. sent by Staffing Coordinator (SC) #248 to the staffing agency manager revealed a request for CNA #257 to be placed on the Do Not Return (DNR) list for the facility due to a serious resident (Resident #334) safety incident. CNA #257 left Resident #334 unattended on the toilet for an extended period before leaving the facility. Resident #334 was reportedly left for hours and ultimately had to crawl in attempt to get help by knocking on the door. Based on the seriousness of the incident, CNA #257's assignment for the following day was cancelled. Resident #334 was sent for an x-ray for evaluation, and facility management determined that it would not be safe for CNA #257 to continue providing care to the residents. Review of the interdisciplinary team incident note dated 07/01/26 at 3:00 P.M. revealed (on 06/20/26) Resident #334 was observed on the floor in the common bathroom without injury. The resident reported that an aide placed him on the toilet and due to the aide not returning timely, he had to roll himself off the toilet onto the bathroom floor. The new intervention was to ensure the call light was within the resident's reach when toileting in the central bathroom.Review of Resident #334's current care plan revealed an ADL self-care performance deficit related to impaired dexterity and mobility. Interventions included use of a pressure sensitive call bell, and a mechanical lift). Resident #334 was at risk for falls (revised on 11/07/21) and included an intervention dated 06/21/26 to ensure the call light was within his reach when toileting him in the central bathroom (the previous intervention dated 02/08/22 was to be sure call light was within reach and encourage him to use it for assistance as needed).Interviews on 07/13/26 at 2:35 P.M. and 07/14/26 at 10:44 A.M. with Resident #334 while using an assistive device, a laptop/computer activated communication tool, revealed he was left on the toilet for over four hours because the call lights were down. He stated he had to push himself off the toilet and scoot himself to the door to knock on it for help. Resident #334 stated because of it he had pain in his wrist from crawling that lasted three days. The resident reported one staff (an agency CNA) had assisted him to the toilet in the bathroom and there was no working call light in reach. During and since the incident, the resident expressed feeling angry and miserable because it was so difficult to crawl for help. Additionally, Resident #334 stated he felt abandoned, and further stated he remained fearful to use the common bathroom because the call light might not always work. Additional review of Resident #334's progress notes from June to 07/13/26 revealed there was no evidence the resident's psychosocial concerns were assessed or treated after the incident on 06/20/26.Interview on 07/14/26 at 10:05 A.M. with the DON revealed an agency aide, CNA #257, had stayed over from the day shift and was the person who assisted Resident #334 to the toilet at 6:00 P.M. but after placing him on the toilet, she left and went home. Afterwards, CNA #258 who was then assigned to Resident #334 and other staff found the resident on the floor in the central bathroom at approximately 8:00 P.M. The DON denied speaking to the agency CNA about the incident and had no written witness statements for the incident investigation, including no evidence of another CNA who assisted agency CNA #257 with the transfer. Even though Resident #334 intentionally placed himself on the floor, she determined he had not actually fallen but was secluded in the bathroom for approximately two hours. The DON stated she believed the call light system was working at the time of the incident but could not confirm this or provide evidence of it.Attempted interview on 07/14/26 at 10:12 A.M. with agency CNA #257 revealed no answer and a full voicemail box.Interview on 07/14/26 at 10:23 A.M. with SC #248 revealed she called agency CNA #257 on the night of the incident because nursing staff had called SC #248 and asked her where the agency CNA was as she had left Resident #334 on the toilet. CNA #257 was supposed to work until 7:00 P.M. but she left early at 6:00 P.M. After calling the CNA, the CNA reported she put Resident #334 on the toilet with another CNA (not named) and that person was supposed to take him off the toilet. CNA #257 claimed the staff knew she was leaving that early, but SC #248 stated it seemed to her that CNA #257 had not told anyone that she was leaving.Interview on 07/15/26 at 12:08 P.M. with CNA #151 revealed she worked the day shift of 06/20/26 until 3:00 P.M. CNA #151 revealed on this day the facility call system was not working so cowbells (a manual bell) were placed close to the residents, either on the bed or on the nightstand. CNA #151 was uncertain whether cowbells were in the common bathrooms. Interview on 07/16/26 at 3:30 P.M. with CNA #142 revealed after dinner (on 06/20/26) while picking up trays and the 7:00 P.M. nurses coming on duty, one of the nurses said she heard banging. The CNA stated staff put the code in on the common bathroom door and tried to open the door. Resident #334 was laying on the floor blocking the door from opening all the way, but his face was visible. It looked like the resident had scooted to the door; there was no call light going off. The CNA revealed staff couldn't find the mechanical lift pad, so three staff assisted the resident from the floor back into his chair. CNA #142 stated at the time of the incident, nobody knew CNA #257 (who had previously been assigned to Resident #334) had left the facility. The CNA revealed the supervisor was called, and the two nurses were upset.Interview on 07/16/26 at 4:10 P.M. with CNA #258 revealed (on 06/20/26) an agency aide (CNA #257) stayed over from the previous shift, so she asked her to help put Resident #334 on the toilet (unable to recall the time) using a mechanical lift (this was contradictory to Resident #334's statement). There was a call light string to the resident's left-hand side connected to the wall, not a pressure sensitive call bell as in the resident's care plan or a cow bell. Since she knew the call light system was not working correctly, she asked CNA #257 to stay near Resident #334 and to come and get her to help get him off the toilet. CNA #257 never came to get her and never heard from her, so she assumed CNA #257 got Resident #334 off the toilet with someone else. CNA #258 stated she went on helping other residents and later noticed she had not seen Resident #334 in a while, so she went looking for him. She asked the second shift nurse about him, and they both walked toward the elevators when they heard banging. Resident #334 was found on the floor in the common bathroom, and there was no call light on. (This interview was contradictory to Resident #334's account and could not be corroborated.)Interview on 07/16/26 at 4:30 P.M. with CNA #261 revealed she was working on the floor (on 06/20/26) when the incident with Resident #334 occurred. She was in a room assisting another resident, but when she came back to the common bathroom area, all the staff surrounded the bathroom area with Resident #334 on the floor. It was reported that one aide had put him on the toilet and then left the building early.Review of the facility policy titled, Answering the Call Light, revised March 2021, revealed to be sure the call light was plugged in and functioning at all times, was within reach per resident preference, and residents unable to use their call light should be checked frequently, and to report all defective call lights to the nurse supervisor promptly.Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, revealed the residents have a right to be free from abuse, neglect, misappropriation of resident property and exploitation and includes but not limited to be free from involuntary seclusion.This deficiency represents non-compliance investigated under Master Complaint Number 3075582, Complaint Number 3072587, Complaint Number 3067393, and Complaint Number 2602874.

Based on interviews, record review and facility policy review, the facility failed to have an adequate functioning call light system in place and staff did not follow the facility plan while the call light system was down by providing adequate resident supervision documented with attestation statements. This affected nine residents (Residents #326, #334, #335, #340, #341, #342, #348, #354 and #355) and had the potential to affect all residents residing in the facility. The facility census was 119.Findings include:1. Interview on 07/09/26 at 8:00 A.M. and 07/14/26 at 12:08 P.M. with Administrator and review of a timeline for a failed call light system revealed the call light system started malfunctioning on 05/28/26 when a few of the resident room call lights (Residents #334, #335, #340, #341, #342, #354 and #355) were not showing up as activated, so those residents were provided manual hand bells and staff were educated on performing room checks at least every two hours. On 06/01/26, maintenance attempted to reset the entire call light system, and when doing so the entire system went down, so all residents were given a manual hand bell. While the manual call bells were used, the certified nursing assistants (CNA) were required to document their resident checks by filling out attestations and turning them in. On 06/04/26, the facility purchased an interim system, and it was in place by 06/10/26 and by 06/16/26 the facility made a deposit for a new call light system with a plan to be in place within 30 days.Interview on 07/13/26 at 3:39 P.M. with Resident #348 revealed that while the call light system was broken the resident was given a manual hand bell to use but it sometimes took hours for staff to respond to it. Interview on 07/15/26 at 11:35 A.M. with Resident #326 revealed that manual bells were used about a month ago. Staff did not come when you rang the bell, so sometimes Resident #326 waited for an hour, two hours, or had no help at all.Interview on 07/16/26 at 1:55 P.M. with CNA #125 revealed when the call system went down, the manual bells were given to each resident. If there were two residents in a room, then two bells were issued. The placement of the bells were on the bedside table or sometimes in the bed with the resident. CNA #125 could not verify the manual bells were placed anywhere else other than next to resident beds. Interview on 07/16/26 at 2:00 P.M. with Licensed Practical Nurse (LPN) #253 revealed while the call system was down, each resident was assigned a manual bell. The aides would sit in the halls and the nurse would round. If the residents needed help while in the bathroom, they would have to bring the little bell with them. Review of the CNA attestations used to document resident checks while manual bells were utilized dated from 06/01/26 to 06/14/26 revealed there were 15 CNAs who did not document attestations of resident checks on 06/01/26, 13 CNAs without attestations on 06/02/26, seven CNAs without attestations on 06/03/26, 12 CNAs without attestations on 06/04/26, 18 CNAs without attestations on 06/05/25, 16 without attestations on 06/06/26, 17 CNAs without attestations on 06/07/26, 20 aides without attestations on 06/08/26, 20 CNAs without attestations on 06/09/26, 23 CNAs without attestations on 06/10/26, 21 CNAs without attestations on 06/11/26, 19 CNAs without attestations on 06/12/26, 17 CNAs without attestations on 06/13/26, and 20 CNAs without attestations on 06/14/26. There was no other documented evidence the facility residents received adequate routine checks while the call light system was not functioning and manual bells were used. Interview on 07/15/26 at 1:55 P.M. with Administrator and Director of Nursing (DON) confirmed there were no CNA attestations from 06/01/26 to 06/14/26 to provide evidence staff provided resident checks while the call system was down. 2. Review of Resident #334's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included toxic encephalopathy, peripheral vascular disease, quadriplegia, traumatic brain injury, major depressive disorder, anxiety disorder, delusional disorder, and antisocial personality disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #334 was cognitively intact and required full staff assistance (dependent) for all activities of daily living. The resident used an electric wheelchair for mobility with set up assistance and required a mechanical lift for all transfers. Review of a progress note dated 06/20/26 at 8:05 P.M. revealed LPN #253 was notified by a CNA that Resident #334 had not been seen for a while, but that another CNA had placed the resident on the toilet in the common bathroom before she left for the day. Upon approaching the common bathroom, knocking was heard and the resident was observed on the floor laying on his left side. Resident #334 reported to LPN #253 the CNA placed him on the toilet and left him there, resulting in him rolling himself off the toilet and across the floor to knock on the door to be let out.Interviews on 07/13/26 at 2:35 P.M. and 07/14/26 at 10:44 A.M. with Resident #334 while using an assistive device, a laptop/computer activated communication tool, revealed he was left on the toilet for over four hours because the call lights were down. He stated he had to push himself off the toilet and scoot himself to the door to knock on it for help. Resident #334 reported one staff (an agency CNA) had assisted him to the toilet in the bathroom and there was no working call light in reach. Interview on 07/14/26 at 10:05 A.M. with the DON revealed an agency aide, CNA #257, had stayed over from the day shift and was the person who assisted Resident #334 to the toilet at 6:00 P.M. but after placing him on the toilet, she left and went home. Afterwards, CNA #258 who was then assigned to Resident #334 and other staff found the resident on the floor in the central bathroom at approximately 8:00 P.M. The DON stated she believed the call light system was working at the time of the incident but could not confirm this or provide evidence of it.Interview on 07/15/26 at 12:08 P.M. with CNA #151 revealed she worked the day shift of 06/20/26 until 3:00 P.M. CNA #151 revealed on this day the facility call system was not working so cowbells (a manual hand bell) were placed close to the residents, either on the bed or on the nightstand. CNA #151 was uncertain whether cowbells were in the common bathrooms. Interview on 07/16/26 at 3:30 P.M. with CNA #142 revealed after dinner (on 06/20/26) while picking up trays and the 7:00 P.M. nurses coming on duty, one of the nurses said she heard banging. The CNA stated staff put the code in on the common bathroom door and tried to open the door. Resident #334 was laying on the floor blocking the door from opening all the way, but his face was visible. It looked like the resident had scooted to the door; there was no call light going off. Interview on 07/16/26 at 4:10 P.M. with CNA #258 revealed (on 06/20/26) an agency aide (CNA #257) stayed over from the previous shift, so she asked her to help put Resident #334 on the toilet (unable to recall the time) using a mechanical lift (this was contradictory to Resident #334's statement). There was a call light string to the resident's left-hand side connected to the wall, not a pressure sensitive call bell as in the resident's care plan or a cowbell. Since she knew the call light system was not working correctly, she asked CNA #257 to stay near Resident #334 and to come and get her to help get him off the toilet. CNA #257 never came to get her and never heard from her, so she assumed CNA #257 got Resident #334 off the toilet with someone else. CNA #258 stated she went on helping other residents and later noticed she had not seen Resident #334 in a while, so she went looking for him. She asked the second shift nurse about him, and they both walked toward the elevators when they heard banging. Resident #334 was found on the floor in the common bathroom, and there was no call light on.This deficiency represents non-compliance investigated under Master Complaint Number 3075582, Complaint Number 3072587, Complaint Number 3067393, and Complaint Number 2602874.

Based on medical record review, observation, and interviews, the facility failed to maintain a clean and sanitary resident room environment. This affected one resident (Resident #360) of two residents reviewed for environment. The facility census was 119. Findings include:Review of the medical record for Resident #360 revealed an admission date of 04/07/26 with diagnoses which included chronic kidney disease, emphysema, depression, anxiety, hypertension, epilepsy, and alcohol abuse. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #360 had no cognitive impairment. Interview on 07/09/26 at 8:50 A.M. with Director of Maintenance/Housekeeping (DMH) #210 revealed there had been a couple of bed bug sightings, and sometimes field mice that got into the building, a chipmunk the prior week, and gnats. A pest control company came out on a regular basis and there were bait stations. Housekeeping cleaned resident rooms daily which included sweeping, wiping down high touch surfaces, mirrors, toilets, dusting and mopping the floor.Interview on 07/09/26 at 9:12 A.M. with Housekeeper (HSK) #204 revealed the resident rooms were dusted, trash was pulled, furniture and high touch surfaces wiped down, bathrooms cleaned and the floors mopped daily. Seasonally, mice came into the building, and there were gnats. Monthly maintenance was completed and housekeeping notified the director if there was an issue.Interview on 07/13/26 at 3:31 P.M. with Resident #360 complained she had bugs, mice, moths, and flies in her room. The staff opened her window and there was no window screen, so the bugs came in. The housekeeping staff sometimes mopped, but they did not sweep the floor. Observation at the time of the interview revealed Resident #360's room with DMH #210 confirmed there was no screen on Resident #360's window and stated there should be a window screen on it. There were several dead bugs on the windowsill, two insects with wings on the wall near the window, two insects on the wall behind Resident #360's bed under the overhead light near the window, two moth-like bugs on the wall near the overhead light bedspace closer to the door, one moth on the wall near the door, three to four flying gnats in the bathroom, and one moth on the wall next to the toilet. The floor had multiple small dead bugs scattered with other unknown debris. DMH #210 verified the above findings. This deficiency represents non-compliance investigated under Complaint Number 3072587 and Complaint Number 2602874.

Based on medical record review, staff interview, and facility policy review, the facility failed to revise or update care plans to address the needs of residents. This affected two residents (Resident #367 and #419) of 11 residents reviewed for care plans. The facility census was 119.Findings include:1. Review of the medical record for Resident #367 revealed an admission date of 12/16/25 with diagnoses that included vascular dementia, mild protein calorie malnutrition, type two diabetes mellitus, hypertension, and cerebral infarction (stroke).Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #367 had mild cognitive impairment, required staff assistance with activities of daily living (ADL), and had one stage two (partial thickness skin loss) pressure ulcer to the coccyx.Review of the wound provider notes dated 07/07/26 revealed Resident #367 had a stage three (full thickness skin loss) pressure ulcer to the coccyx with an onset date of 05/21/26. Review of Resident #367's care plan last revised on 02/11/26 revealed potential for pressure ulcer development. The care plan was not revised or updated to include actual pressure ulcer development to the coccyx, onset of 05/21/26, and interventions for its care and treatment including enhanced barrier precautions which were not added until 07/14/26 during the survey.Interview on 07/15/26 at 2:00 P.M. with MDS Nurse #213 verified Resident #367's care plan was not revised or updated to include the onset of a pressure ulcer wound on 05/21/26 and interventions for it care and treatment. Enhanced barrier precautions for the wound was not added until 07/14/26 during the survey. 2. Review of the medical record for Resident #419 revealed an admission date of 03/26/26 with diagnoses that included schizoaffective disorder (a mental disorder characterized by a breakdown in thoughts, emotions, and behaviors), bipolar disorder (a mental health condition that causes shifts in mood, energy, and concentration), type two diabetes mellitus, chronic obstructive pulmonary disease (COPD), hypertension and obesity.Review of the five-day MDS 3.0 assessment dated [DATE] revealed Resident #419 had no cognitive impairment, mood symptoms that included little interest in doing things, feeling down, depressed, or hopeless, falling or staying asleep, feeling tired or little energy, poor appetite or overeating, and trouble concentrating on things. The resident required staff assistance with ADLs and was incontinent with bowel and bladder.Interview on 07/09/26 at 10:59 A.M. with Administrator revealed Resident #419 had a long history of refusing care, hygiene products, and would not take his shoes off for a shower. Interview on 07/09/26 at 1:45 P.M. with Director of Nursing (DON) revealed Resident #419 did not wear his shoes in the shower, but staff said he would refuse to take his shoes off because he had lymphedema (swelling of soft tissues caused by lymph fluid) and the staff did not know how to take on or off his shoes. DON revealed the resident did not always sleep in his bed and did wear socks with his shoes. Interview on 07/09/26 at 1:50 P.M. with Registered Nurse Manager (RNM) #242 revealed the resident's preference was a bed bath. He spent most of his time outside smoking, liked to have his shoes on all the time, and stayed in his electric wheelchair instead of sleeping in the bed so he could go out and smoke.Interview on 07/09/26 at 2:00 P.M. with CNA #126, revealed the resident always just wanted a bed bath and when she gave the resident his bed bath, he wouldn't let her take off his shoes. He always had his shoes on because he didn't think the staff knew how to take it on or off. Review of photographic pictures and one video (of Resident #419's feet and shoes on 07/01/26) submitted by Resident #419's guardian on 07/15/26 at 4:34 P.M. revealed the following:Picture one revealed Resident #419's left foot with significant swelling and redness, a darkened circular area to the medial side of the foot, and an elongated darkened area to the underside of the foot.Picture six revealed Resident #419's right foot with a dark black/brown substance on the toes and under the great toenail. The great toenail was thickened, dark in color, with the dark substance under the nailbed.Picture seven revealed Resident #419's right lower leg with significant swelling and redness.Picture eight revealed Resident #419's left great toenail significantly thickened and raised with a blackened substance caked under the nailbed. A small white protrusion (alleged maggot) was evident under the nailbed.Picture nine revealed Resident #419's left foot with a dried black substance under the toes and the nailbed of the second through fifth toes. The nailbeds were thickened and elongated.Picture ten revealed Resident #419's left lower leg with significant swelling and redness.Video one revealed Resident #419's shoes bagged in a clear plastic bag with a visible live white maggot crawling on the side of the bag.Interview on 07/15/26 at 2:00 P.M. with MDS Nurse #213 verified Resident #419's care plan did not reflect the resident refusing to remove his shoes for bathing of the feet or include any staff intervention to ensure Resident #419's feet received care. MDS Nurse #213 denied being informed by staff or having documentation of Resident #419 not wanting to remove his shoes. She indicated just finding out about it from the social worker on this date.Review of the facility policy titled, Care Planning-Interdisciplinary Team undated revealed the interdisciplinary team was responsible for the development of an individualized comprehensive care plan for each resident.

Based on medical record review, observation, and staff interview, the facility failed to accurately document a wound assessment and treatment orders. This affected one resident (Resident #307) of three residents reviewed for wound care. The facility census was 119.Findings include:Review of the medical record for Resident #307 revealed an admission date of 08/15/24 and diagnoses which included anemia, gastro-esophageal reflux disease (GERD), hypertension (high blood pressure), osteoporosis, chronic kidney disease, and cognitive communication deficit. Review of the progress note dated 07/04/26 at 3:31 P.M. by Registered Nurse (RN) #252 revealed Resident #307 had a wound described as two small, conjoined circles to the left buttock. Review of the wound provider progress note dated 07/07/26 revealed Resident #307 had a pressure ulcer wound, stage two (partial thickness) to the right buttocks. Review of Resident #307's physician orders and July 2026 Treatment Administration Record (TAR) revealed an order dated 07/05/26 for bordered foam to the left buttock every dayshift for wound healing, and to cleanse, pat dry and cover with a clean, dry dressing. The order was discontinued on 07/08/26. An order dated 07/08/26 was initiated for the right buttocks to cleanse with normal saline solution, apply wound gel to the wound bed and cover with dry dressing daily and when needed. The TAR revealed the right buttock wound order was signed off as completed on 07/09/26, 07/10/26, 07/11/26 and 07/12/26. Observation on 07/13/26 at 9:20 A.M. of wound care for Resident #307 by Licensed Practical Nurse (LPN) #200 revealed the LPN verified the treatment order was to the right buttocks to wash with normal saline, apply wound gel and cover with a dry dressing. LPN #200 then performed the right buttocks wound treatment on the resident's left buttocks instead, as the wound was observed to be on the left buttocks. There was no evidence of a wound on the right buttocks. Interview at the time of the observation with LPN #200 verified the wound provider progress note, physician order and treatment were written incorrectly with Resident #307's wound being on the right buttocks when it was on the left buttocks. This deficiency represents non-compliance investigated under Complaint Number 3067393.

Based on medical record review, observation, staff interview, and facility policy review, the facility failed to follow enhanced barrier precautions (EBP) during wound care. This affected two residents (Resident #367 and #402) of three residents reviewed for wound care. The facility census was 119.Findings include:1. Review of the medical record for Resident #367 revealed an admission date of 12/16/25 with diagnoses that included vascular dementia, mild protein calorie malnutrition, major depressive disorder, type two diabetes mellitus, hypertension, and cerebral infarction (stroke).Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed mild cognitive impairment, and one stage two (partial thickness skin loss) pressure ulcer.Review of the wound provider progress note dated 07/07/26, revealed Resident #367 had a stage three (full thickness) wound with an onset date of 05/21/26.Review of Resident #367's physician orders revealed an order dated 07/08/26 to cleanse the coccyx with normal saline or wound cleanser, pat dry, apply collagen (a wound dressing used for healing) and cover with a foam dressing every three days on dayshift. Review of Resident #367's care plan dated 02/11/26 revealed potential for pressure ulcer development. It did not include stage three pressure ulcer to the coccyx with an onset date of 05/21/26.Observation on 07/13/26 at 9:28 A.M. of wound care for Resident #367 by Licensed Practical Nurse (LPN) #200 revealed an EBP sign at the resident's doorway leading into the room which indicated staff must wear gloves and gown for high-contact resident care activities which included any skin opening requiring a dressing. LPN #200 performed hand hygiene, put on clean gloves, did not put on a gown and performed wound care on the resident's open coccyx wound. Interview at the time of the observation with LPN #200 verified not wearing a gown for EBP during Resident #367's wound care and stated a gown was not needed because there was no infection to the wound. LPN #200 also confirmed there was an EBP sign at the resident's doorway. Additional review of Resident #367's care plan revealed it was updated on 07/14/26 with interventions for EBP related to a wound.2. Review of the medical record for Resident #402 revealed an admission date of 10/23/24 with diagnoses that included mild protein calorie malnutrition, peripheral vascular disease, lymphedema, hypertension, paranoid schizophrenia, and dementia.Review of Resident #402's care plan dated 12/18/25 revealed EBP related to wound with interventions to wear gown and gloves when providing care.Review of Resident #402's physician orders revealed an order dated 12/18/25 for EBP related to wounds and an order dated 07/08/26 to cleanse the left buttocks with normal saline, pat dry, apply collagen and cover with foam dressing daily on dayshift. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #402 had no cognitive impairment, and one stage three pressure ulcer.Review of the wound provider progress note dated 07/07/26 revealed Resident #402 had a stage three wound with an onset date of 04/09/26.Review of the July 2026 Treatment Administration Record revealed EBP was signed off twice a day by licensed nursing staff.Observation on 07/13/26 at 9:45 A.M. of wound care for Resident #402 by LPN #200 revealed an EBP sign at the resident's doorway leading into the room which indicated staff must wear gloves and gown for high-contact resident care activities which included any skin opening requiring a dressing. LPN #200 performed hand hygiene, put on clean gloves, did not put on a gown and performed wound care on the resident's open left buttocks wound. Interview at the time of the observation with LPN #200 verified not wearing a gown for EBP during Resident #402's wound care and when the posted EBP sign was referenced stated she would have to ask about it.Review of the facility policy labeled, Enhanced Barrier Precautions Policy undated, revealed EBP should be employed during high contact resident care that included wound care for any skin opening requiring a dressing.This deficiency represents non-compliance investigated under Complaint Number 3067393.

Based on medical record review, staff interview, and policy review, the facility failed to administer medications as ordered. This affected one (#10) of three residents reviewed for medications. The census was 115.Findings include:Record review for Resident #10 revealed the resident was admitted to the facility on [DATE] with diagnoses including dysphagia, dysarthria, end stage renal disease, diabetes, and hypothyroidism. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 99. The resident was assessed to require staff assistance with personal care, bathing, and dressing.Review of Resident #10 ' s hospital Discharge summary dated [DATE] in her medical record revealed an order for levothyroxine 175 micrograms (mcg) once per day to treat hypothyroidism and an order for aspirin 81 milligrams (mg) once daily to decrease the risk of a subsequent stroke occurring. Review of Resident #10 ' s medication administration records (MARs) since admission revealed Resident #10 did not receive the prescribed aspirin 81 mg until 10/20/24 because they were not properly added to her orders at the time of admission intake. Further review of the MARs revealed Resident #10 did not receive the prescribed levothyroxine until 06/25/25, also due to an oversight during admission intake.Interview with the Director of Nursing (DON) on 08/15/25 at 3:50 P.M. confirmed the facility failed to administer Resident #10's levothyroxine and aspirin as ordered at the time of admission. Review of the facility ' s policy titled, Administering Medications, dated 04/18, revealed medications must be administered in accordance with the orders, including any required timeframe.This deficiency represents non-compliance investigated under Complaint Number 2562828.

Based on observations, staff interview, and facility policy review, the facility failed to date and store food in the kitchen appropriately. This had the potential to affect 109 of 113 residents who ate food from the kitchen (Residents #21, #36, #38, and #95 did not receive food from the kitchen). The census was 113. Findings Include: Observations on 03/15/25 from 10:40 A.M. to 11:05 A.M. revealed the following items in the main kitchen walk in refrigerator. A plastic bag of whipped cream that was opened, undated, and had no covering on the opened end of the bag leaving the contents open to air. There was a plastic container of cooked sausage patties with the prepared/cooked date on the container of 02/03/25. There were five cups of pudding on a tray that were undated and uncovered; open to air. There was a plastic container of prepared/cooked oatmeal with the cooked/prepared date of 02/06/25. There were two gallons of milk with the best by date of 02/27/25. There was an opened bag of shredded cheese that did not have a used by or date as to when it was opened. There was a metal pan of cooked noodles with no date as to when they were cooked or when they should be used by/discarded. There was a plastic bag of prepared salad that was opened but had no date as to when it was opened or when it should be discarded. Lastly, there were three peanut butter and jelly sandwiches in individual plastic bags that had no date as to when they were prepared or when they should be discarded. All three sandwiches were hard to touch, indicating they were stale. Interview with Dietary Manager #110 on 03/15/25 at 11:05 A.M. revealed they removed items from the refrigerator within five days of it being stored/cooked or removed from the original packaging, unless otherwise dated on the packaging. Dietary Manager #110 confirmed all the dates, non-dates, and uncovered items as needing to be thrown out or covered. Review of facility Food Receiving and Storage policy, dated December 2008, revealed all food stored in the refrigerator or freezer would be covered, labeled, and dated. Refrigerated food would be stored in such a way that promoted adequate air circulation around food storage containers. Food items and snacks kept on the nursing units were to be maintained as indicated: all food items to be kept below 40 degrees Fahrenheit must be placed in the refrigerator located at the nurse's station and labeled with a use by date. This deficiency represents non-compliance investigated under Complaint Number OH00163214.

Based on medical record review, staff interview, and facility policy review, the facility failed to monitor and address significant weight loss. This affected one (Resident #121) of three residents reviewed for nutrition. The facility census was 113. Findings Include: Medical record review revealed Resident #121 was admitted to the facility on [DATE]. Diagnoses included anemia, other nondisplaced fracture of upper end of left humerus and left femur, pain, arteriovenous fistula, pneumonitis, thrombocytopenia, pulmonary embolism, dysplasia, type II diabetes, infection and inflammatory reaction due to other cardiac and vascular devices, depression, hemiplegia and hemiparesis, moderate protein calorie malnutrition, cognitive communication deficit, difficulty walking, other abnormalities of gait and mobility, osteoarthritis, morbid obesity, hypotension, chronic kidney disease (stage V), atrial fibrillation, hypertension, hyperlipidemia, asthma, hypothyroidism, and end stage renal disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #121 was cognitively intact. Review of Resident #121 weights revealed on 01/04/25 she weighed 261.8 pounds, on 02/07/25 she weighed 236.9 pounds. This represented a 9.5% weight loss in one month. There were no other weights taken to verify the significant weight loss prior to her discharge date of [DATE]. Review of Resident #121 progress and nutritional notes dated 02/07/25 to 02/22/25 revealed no documentation to support the significant weight loss was addressed. Review of Resident #121 nutritional assessment dated [DATE] revealed a documented current weight of 261 pounds. There was nothing within the nutritional assessment to confirm or address the significant weight loss. Review of Resident #121's MDS assessment, section K, dated 02/09/25, revealed a current weight of 261 pounds. The MDS nutritional assessment was dated after the significant weight loss was documented, so it should have been identified and addressed within that assessment, but was not. Interview with the Director of Nursing (DON) on 03/15/25 at 2:45 P.M. confirmed they did not identify or address Resident #121 significant weight loss. The DON indicated they should have informed the dietitian and the physician of the significant weight loss. The DON also indicated they should have taken another weight to determine if the weight loss was accurate. Review of facility Weight Assessment and Intervention policy, dated December 2008, revealed weights would be recorded in each unit's weight record chart or notebook and in the individual's medical record. Any weight change of 5% or more since the last weight assessment would be retaken the next day for confirmation. If the weight was verified, nursing would immediately notify the dietitian in writing. Verbal notification was to be confirmed in writing. The physician and the multidisciplinary team would identify conditions and medications that could be causing anorexia, weight loss or increasing the risk of weight loss. This deficiency represents non-compliance investigated under Complaint Number OH00163214.

Based on medical record review, resident interview, staff interview, and facility policy review, the facility failed to timely report and investigate a resident incident. This affected one (Resident #76) of three residents reviewed for incidents. The census was 112. Findings Include: Resident #112 was admitted to the facility on [DATE]. Her diagnoses were cerebral infarction, dysarthria and anarthria, cognitive communication deficit, need for assistance, difficulty in walking, cerebral infarction, end stage renal disease, obstructive sleep apnea, hypertensive chronic kidney disease (stage V), chronic embolism and thrombosis, congestive heart failure, type II diabetes, hypothyroidism, morbid obesity, anemia, and hemiplegia and hemiparesis. Review of her minimum data set (MDS) assessment, dated 09/14/24, revealed she was cognitively intact. Review of Resident #112 occupational therapy notes, dated 08/20/24 but not written until 08/27/24, revealed patient complete opposition exercises, table top activities for grasp, heat with passive range of motion. Patient let go of two pound free weight and it rolled down leg and therapist tried to push away. Therapist asked if she was ok, and did not state she was having pain. Review of Resident #112 medical records, including progress notes, care plans, skin assessments, and investigation documentation, dated 08/20/24 to 08/22/24, found no evidence that this incident/accident was reported to the nursing staff or that a full assessment of Resident #112 leg was completed to ensure no injury was present. Review of Resident #112 progress notes, dated 08/23/24, revealed a nurse spoke with the facility physician and received an order for x- ray of Resident #112 left ankle. This was in response to Resident #112 complaining of left ankle/foot pain, level eight out of ten. Review of Resident #112 x-ray documentation, dated 08/23/24, revealed on 08/23/24, there is a nondisplaced fracture noted of the distal tibia of unknown acuity. The ankle mortise and talar dome appear normal. There is soft tissue swelling. Recommended clinical correlation. Axial imaging may be performed for further evaluation. Review of Resident #112 orthopedic appointment documentation, dated 08/29/24, revealed Resident #112 did not have a fracture but soft tissue injury; she was ordered to wear a boot and return for observation/review in one month. Interview with Resident #112 on 09/27/24 at 1:45 P.M. confirmed she had an incident in the therapy room where she dropped a free weight dumbbell on her ankle/foot. She confirmed it hurt. She stated no one ever did a full assessment of her ankle. The therapist asked if she was ok and moved the weight, but did not do a full assessment. She confirmed she did not tell anyone how painful her ankle/foot was after the incident, but she stated, they should have known by my facial expressions. Interview with Therapist #200 on 09/27/24 at 2:05 P.M. confirmed Resident #112 dropped a two pound dumbbell on her left foot/ankle. She stated there was no redness or tenderness to her ankle, and Resident #112 was not complaining of pain. She confirmed she did not report the incident to anyone else, and did not document the incident until 08/27/24. She confirmed she did not document a skin/injury assessment as well. She confirmed that with an incident like this, she should have written an incident report and reported it to nursing at the time it happened. Review of facility Change in Condition policy, undated, revealed the facility shall notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been an accident or incident involving the resident, a discovery of injuries of an unknown source, and a significant change in the resident's physical/emotional/mental condition. A significant change of condition is a decline or improvement is a decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. Unless otherwise instructed by the resident, the nurse supervisor/charge nurse will notify the resident's family or representative when the resident is involved in any accident or incident that results in injury including injuries of an unknown source or there is a change in the resident's physical, mental, or psychosocial status. Except in medical emergencies, notification will be made within 24 hours of a change occurring in the resident's medical/mental condition or status. The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status as necessary.

Based on observation, interview and record review the facility failed to provide adequate mouth care for dependent residents. This affected two (#22 and #88) of two residents observed for mouth care. The facility census was 112. Finding include: 1. Review of Resident #22's medical records revealed an admitted [DATE]. Diagnoses included stroke with left sided weakness, paraplegia and respiratory failure. Review of Resident #22's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was dependent for mouth care, bathing and personal hygiene. Review of Resident #22's care plan dated 07/10/24 revealed Resident #22 had self care performance deficits related to paraplegia. Interventions included provide mouth care every shift and as needed. Observation on 09/03/24 at 9:01 A.M. of Resident #22 with the Assistant Director of Nursing (ADON) revealed Resident #22's mouth and lips were dry and cracked and Resident #22 had skin hanging from his lips. ADON confirmed Resident #22 required mouth care from staff due to his dry and cracked lips and stated mouth care should be completed daily. Resident #22 was not interviewable. Review of facility's undated policy Activities of Daily Living revealed appropriate care and services would be provided for residents who were unable to carry out ADLs independently including oral hygiene. 2. Review of Resident #88's medical records revealed an admitted [DATE]. Diagnoses included quadriplegia, traumatic brain injury and muscle weakness. Review of Resident #88's MDS assessment dated [DATE] revealed Resident #88 was rarely understood. Resident #88 was dependent for mouth care, bathing and personal hygiene. Review of Resident #88's care plan dated 07/23/24 revealed Resident #88 had oral problems related to poor oral hygiene. Interventions included provide mouth care per activities of daily living (ADLs). Observation on 09/03/24 at 12:41 P.M. of Resident #88 with the ADON revealed Resident #88's top lip was stuck to his upper teeth and his mouth was dry and lips were cracked. Resident #88 had a large amount of plaque build up on his upper and lower teeth. The ADON confirmed Resident #88 required mouth care and stated mouth care should be completed daily. Resident #88 was not interviewable. Review of facility's undated policy Activities of Daily Living revealed appropriate care and services would be provided for residents who were unable to carry out ADLs independently including oral hygiene. This deficiency represents non-compliance investigated under Complaint Number OH00155857.

Based on observation, interview and record review the facility failed to provide timely incontinence care and adequate urinary catheter care. This affected one (#22) of three residents observed for incontinence care and urinary catheter care. The facility census was 112. Findings include: Review of Resident #22's medical records revealed an admitted [DATE]. Diagnoses included bladder dysfunction and stroke with left sided weakness. Review of Resident #22's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had impaired cognition, was incontinent of bowel and had a urinary catheter. Review of the care plan dated 07/10/24 revealed Resident #22 was incontinent of bowel. Interventions included provide pericare after incontinence episodes. Resident #22 had an indwelling urinary catheter. Interventions included check for incontinence and check tubing for kinks each shift. Observation of incontinence care on 08/28/24 at 11:53 A.M. for Resident #22 with State tested Nursing Assistant (STNA) #278 and STNA #328 revealed Resident #22's mattress pad underneath him was saturated with urine and stool that had dried in some areas and had soaked through the mattress pad onto the mattress. Further observation revealed Resident #22 had a urinary catheter. The urinary catheter had dried crusted debris around the insertion site and a thick white discharge, with a foul odor was observed. Interview with STNA #278 at time of observation, revealed she had not cared for Resident #22 since she had started her shift at 7:00 A.M. and was unaware when Resident #22 had last received incontinence care or catheter care. Resident #22 was unable to state when he had last received incontinence care or catheter care. Observation on 09/03/24 at 9:01 A.M. of Resident #22 with the Assistant Director of Nursing (ADON) revealed Resident #22's absorbent pad underneath him was saturated with urine that had soaked through to his sheets. At time of observation STNA #355 entered the room to provide assistance with incontinence care for Resident #22. STNA #355 stated she was not assigned to Resident #22 but had come to assist with providing Resident #22 with care. The ADON and STNA #355 stated they were unaware of when Resident #22 had last received incontinence care. Resident #22 was sleepy during care and did not answer questions appropriately. Review of facility's undated policy titled Activities of Daily Living revealed appropriate care and services would be provided for residents who were unable to carry out activities of daily living independently which included toileting. Review of facility policy Catheter Care revised 11/27/23 revealed catheter care would be performed every shift and as needed by nursing personnel. This deficiency represents non-compliance investigated under Complaint Number OH00155857.

Based on observation, interview and record review the facility failed to provide appropriate care related to Resident #22's Percutaneous Endoscopic Gastrostomy (PEG) tube (feeding tube inserted through the abdominal wall and into the stomach to provide nutrition and hydration). This affected one (#22) of two residents observed for PEG tubes. The facility census was 112. Findings include: Review of Resident #22's medical records revealed an admitted [DATE]. Diagnoses included dysphasia (difficulty swallowing), inhalation of food and stroke with left sided weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had impaired cognition, had a feeding tube, and was dependent for feeding. Review of care plan dated 07/10/24 revealed Resident #22 required tube feedings. Interventions included checking feeding tube for placement, and monitoring for infection at the tube site. Observation of Resident #22 on 08/28/24 at 11:53 A.M. with State tested Nursing Assistant (STNA) #278 revealed Resident #22 had a PEG tube. Resident #22's PEG tube site had dark colored crusted debris surrounding the insertion site and the surrounding skin was reddened. Interview with STNA #278 at time of observation revealed she did not provide care for PEG tubes, the nurses were to provide the care. Observation of Resident #22 on 08/28/24 at 12:29 P.M. with Licensed Practical Nurse (LPN) #202 confirmed the crusted debris around Resident #22's PEG tube insertion site. LPN #202 stated she had not provided care of the PEG tube on this date and PEG tubes and the skin around the insertion site were to cleaned daily and as needed. Observation on 09/03/24 at 9:01 A.M. of Resident #22 with the Assistant Director of Nursing (ADON) revealed Resident #22's PEG tube had a split gauze around the insertion site that had a large amount of dried brownish colored crusted debris. The ADON removed the split gauze and further observation revealed a large amount of dried crusted debris surrounding the insertion site. The ADON cleansed the PEG tube site with normal saline and the surrounding skin was reddened. The ADON stated PEG tube sites were to be cleaned daily and as needed. This deficiency represents non-compliance investigated under Complaint Number OH00155857.

Based on observations, resident interviews, staff interviews, medical record review, and policy review, the facility failed to ensure a resident who required supervision with smoking, was provided supervision, assistive devices to safely smoke and smoke in a designated safe area. Actual harm occurred to one resident (#31) when Resident #31, who was observed smoking in the dining room, unsupervised and without a cigarette holder, was found to have two blisters, verified as cigarette burns on the right index finger near the nail and on the middle finger between the first and second knuckle. In addition, the facility failed to ensure smoking materials including lighters were kept secured while not in use, ensure residents were not smoking inside the facility, ensure residents who required supervision by staff while smoking had staff supervision available, and ensure residents were assessed for smoking and care plans for smoking were established. This affected two (#71 and #76) of three residents reviewed for smoking. The facility identified 27 residents (#1, #4, #9, #23, #31, #35, #36, #38, #40, #44, #47, #49, #50, #52, #63, #66, #69, #70, #71, #75, #76, #85, #92, #95, #98, #102 and #110) who currently smoke. The facility census was 109. Findings include: 1. Review of Resident #31's medical record revealed an admitted [DATE]. Diagnoses included traumatic ischemia of muscle, hemiplegia and hemiparesis following cerebral infarction affecting unspecified side, need for assistants with personal care, muscle weakness, cognitive communication deficit, and schizophrenia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was cognitively intact. Resident #31 has impairment to one side of the upper and lower extremity, used a wheelchair, required substantial, maximum assistance with eating, dependent for toileting, dependent for upper and lower body dressing, and dependent for personal hygiene. Resident #31 was a current tobacco user. Review of the care plan for Resident #31 updated 04/20/22 revealed Resident #31 is a smoker and expressed the desire to smoke at the facility. Interventions included to remind the resident that staff will be observing and supervising smoking related behavior; smoking may be limited to specific times; and smoking may not occur in residents rooms, bathrooms, hallways, stairwells, elevators, and other non-designated areas. Review of the smoking risk evaluation for Resident #31 dated 06/15/23 completed by Registered Nurse (RN) #265, revealed Resident #31 had a cognitive loss, and smoked morning, afternoon, evening, and night. Resident #31 was unable to light her own cigarette, required a smoking apron, cigarette holder, and supervision. Plan of care was initiated to assure the resident was safe while smoking. Review of the Current Designated Smoking Times revealed the facility smoking times were established for 9:00 A.M., 11:00 A.M., 2:00 P.M., 4:00 P.M., 7:00 P.M. and 9:00 P.M. Observation on 04/12/24 at 9:50 A.M., while walking through the dining room on the first floor with Dietary Technician #370, revealed Resident #31 was sitting in the dining room next to Resident #76. Resident #31 had a smoking apron on. Resident #31 did not have a cigarette holder in her hand and was observed actively smoking a cigarette in the dining room. Dietary Technician #370 instructed Resident #31 she needed to go outside to smoke. Business Office Human Resource (HR) Manager #288 walked by as Resident #31 began to go out the exit door into the courtyard and HR Manager #288 stated, Yea, I am supposed to go out with her. HR Manager #288 confirmed Resident #31 was to have supervision while smoking and confirmed residents were not to smoke in the facility. Interview on 04/12/24 at 10:00 A.M., with the Administrator revealed he was already made aware Resident #31 was smoking in the dining room. The Administrator confirmed residents were not to smoke in the facility. Interview on 04/12/24 at 11:33 A.M. with HR Manager #288 revealed Resident #76 lit the cigarette in the dining room for Resident #31. HR Manager #288 revealed she didn't know if residents were allowed to keep their cigarettes and lighters on them. HR Manager #288 stated she just fills in sometimes for staff and monitors/supervises residents on their smoke breaks. Observation and interview on 04/12/24 at 12:46 P.M. with Licensed Practical Nurse (LPN) #313, revealed staff were supposed to keep resident's cigarettes and lighters locked up in the utility room or downstairs on a cart. LPN #313 revealed there were independent residents who could smoke anytime but they were to ask for the cigarette and lighter each time then return them when done. There were also residents who were unsafe to smoke independently and required staff go out with them at designated smoking times. LPN #313 stated Resident #31 was unsafe to smoke independently as her left hand was contracted. Observation of Resident #31's right hand with LPN #313 revealed Resident #31 had multiple scarred areas on the inner portions of the right index finger and middle finger. There was one large fluid filled blister on the right index finger near the nail bed and one fluid filled double blister on the inner middle finger between the first and second knuckle. LPN #313 revealed she did not know the blisters were there. When LPN #313 asked Resident #31 what happened, Resident #31 did not verbally respond. Resident #31 looked down and did not look back at the surveyor or nurse. LPN #313 confirmed Resident #31 was alert and oriented but was unsafe to smoke by herself. Interview on 04/12/24 at 1:36 P.M. with Wound Care Nurse Registered Nurse (RN) #265 revealed Resident #31 was a smoker. Wound Care Nurse RN #265 revealed she had noticed blisters on her hands before, from smoking. The blisters healed badly due to repetitive smoking and burning her fingers repetitively. Resident #31 was supposed to be using the smoking apron and extender to prevent burning her fingers. Resident #31 often just sat all day in the dining room. Wound Care Nurse RN #265 revealed they don't treat the blisters on Resident #31's fingers because they were not infected so she would not have received any treatment orders. Review of Resident #31's progress notes for March and April 2024 revealed no documentation of blisters or scars on Resident #31's fingers. Wound Care Nurse RN #265 confirmed there was no documentation she could find from admission of Resident #31 burning her fingers or having scars or blisters on her fingers and confirmed she had personally seen them on many occasions. Interview on 04/12/24 between 3:23 P.M. and 4:07 P.M. with the Director of Nursing (DON) confirmed Resident #31 required supervision while smoking. The DON stated residents were not to smoke inside the facility. Cigarettes and lighters were to be kept locked up for all residents, independent residents could go outside anytime but they were required to return the cigarettes and lighters after each time they smoked. Residents who required supervision had designated times to smoke. The DON revealed the staff delegated to supervise smokers included herself, HR, activity personnel, nursing staff and the social worker. The DON verified the last skin assessment completed for Resident #31 in the medical record was dated 03/19/24 which revealed no new areas. The DON confirmed skin assessments were to be completed weekly. 2. Review of Resident #71's medical record revealed an admitted [DATE]. Diagnoses included diabetes mellitus, muscle weakness, cognitive communication deficit, need for assistance with personal care, and tobacco use. Review of the annual MDS assessment dated [DATE] revealed Resident 71 was cognitively intact. Resident #71 used a wheelchair for mobility, required set up or clean up assist with eating, toileting, independent with dressing and personal hygiene. Review of the care plan for Resident #71 revealed no care plan was in place for smoking. Review of the paper form titled Smoking Assessment for Resident #71 dated 01/22/24 revealed Resident #71 was an independent smoker. Observation on 04/12/24 at 10:42 A.M., revealed Resident #71 was in the dining room on the first floor smoking a lit cigarette. Observation revealed no staff were within sight of the area. Resident #66 was sitting near Resident #71 and both Residents #71 and #66 confirmed Resident #71 was smoking a cigarette in the dining room. Resident #71 revealed she was getting ready to go outside then exited the facility through the door, located in the dining room into the courtyard. Observation on 04/12/24 at 10:44 A.M. revealed the Administrator was in his office. The surveyor informed the Administrator, Resident #71 was observed in the dining room smoking a cigarette. The Administrator stated, Well, I guess I am going to need to put someone in there. Interview on 04/12/24 at 4:07 P.M. with the DON revealed Resident #71 was an independent smoker. The DON confirmed Resident #71 did not have a care plan for smoking. 3. Review of Resident #76's medical record revealed an admitted [DATE]. Diagnoses included heart failure, muscle weakness and difficulty in walking. Review of the quarterly MDS assessment dated [DATE] revealed Resident #76 was cognitively intact. Resident #76 used a wheelchair for mobility, was independent for eating, toileting, dressing and personal hygiene. Review of the care plan for Resident #76 revealed no care plan was in place for smoking. Review of the resident assessments revealed no smoking assessment was completed for Resident #76. Interview and observation on 04/12/24 at 12:22 P.M., revealed Resident #76 was sitting in the dining room on the first floor. Resident #76 took his cigarettes and lighter out of his pants pockets. Resident #76 stated some residents cannot light their own cigarettes, so he does it for them. Resident #76 stated, No one ever told me I couldn't keep my cigarettes and lighter or couldn't help others light their cigarettes. Interview on 04/12/24 at 3:52 P.M. with Activities Director #322 revealed Resident #76 was an unsupervised smoker, he could go outside to the smoking area whenever he wanted, and he has his own lighter and cigarettes he can carry them and keep them himself. Interview on 04/12/24 at 4:07 P.M. with the DON revealed once a resident was admitted , they did a 72-hour care conference and determined if the resident was a smoker. The DON revealed then either herself, the Unit Manager, Charge Nurse, or the Social Worker would do a smoking assessment at that time. The DON revealed she did not know Resident #76 currently smoked cigarettes. Resident #76 had prior surgery and the doctor said he should not smoke. She did not know he was smoking but revealed she knew he used to. The DON confirmed Resident #76 did not have a smoking assessment or care plan completed for smoking. Interview on 04/12/24 at 4:20 P.M. with Resident #76 revealed he smoked cigarettes the whole time he had been at the facility and nobody ever asked him if he smoked. Interview on 04/12/24 at 4:32 P.M. with LPN #313 confirmed she was Resident #76's charge nurse. LPN #313 revealed Resident #76 was an independent smoker, and he had always smoked. LPN #313 revealed she did not know if Resident #76 had his own cigarettes and lighter, but she did know he smoked. Observation on 04/12/24 at 4:35 P.M. revealed Resident #76 was sitting outside in the smoking area smoking independently. No staff was present. Review of the policy titled, Smoking, revised 01/02/24, revealed upon admission, residents shall be informed of the facility smoking policy, including designated smoking areas, smoking times, and the extent to which the facility can accommodate their smoking preferences. Residents will be evaluated upon admission and routinely to determine if he or she is able to smoke without supervision per the smoking assessment. Residents who require supervision shall have the supervision of a staff member, family member, visitor, or volunteer worker at all times while smoking. Smoking is only permitted in designated smoking areas. Residents who require supervision must store smoking materials with staff except under supervision. Residents who do not require supervision when smoking must store smoking materials, with staff, secured on their person or in a locked container. Residents are not permitted to supervise, assist other residents with smoking, or give smoking materials to other residents. Smoking inside of the building, such as in common areas of the facility or in resident rooms is strictly prohibited. The following deficiency is based on incidental findings discovered during the course of this complaint investigation and represents continued noncompliance from the 03/07/24 survey.

Based on observation, staff interview, and review of the dietary staffing schedule, the facility failed to provide sufficient staff to meet the dietary needs of the residents. This had the potential to affect all residents, except Resident #25, #89, and #90, who received nothing by mouth (NPO). The facility census was 109. Findings include: Observation of the breakfast tray line on 04/12/24 at 9:11 A.M., revealed the resident's breakfast was being served in Styrofoam containers with Styrofoam cups. Dietary Cook #294 revealed all residents were getting Styrofoam because there was no staff, all the scheduled kitchen staff called off except for her. Observation revealed Business Office Human Resource (HR) Manager #288, Maintenance Director #278, Central Supply #367, Speech Therapist #371, and Director of Activities #322 were on the tray line. No other Dietary staff was observed. Dietary Cook #294 was made aware to provide a test tray which would be the last tray served placed on the last cart served. Dietary Cook #294 revealed she was unable to test the food on the test tray with the surveyor because she did not have enough time. Dietary Cook #294 revealed the Dietary Manager was off work for a while and was working from home. Interview on 04/12/24 at 2:01 P.M., with Dietary Cook #294 confirmed the lunch meal was served on Styrofoam also for all residents. Dietary Cook #294 revealed they used Styrofoam containers to serve residents their meals when there was low staff. Dietary Cook #294 revealed the dietary department had no backup staff when people called off. The dietary department required three to four Dietary Aids per shift. For the dinner meal, one Dietary Aid agreed to come in and one Cook was scheduled, but that meant she would need to stay over. Dietary Cook #294 confirmed for the lunch meal, the same Department Heads assisted in the kitchen. Interview on 04/12/24 at 3:08 P.M., with HR Manager #288 confirmed the staffing for Dietary Aids in the kitchen was to be three to four Dietary Aids per shift. Review of the Dietary staffing schedule with HR Manager #288 confirmed for April 2024: There were 0 days first shift had four Dietary Aids. On 04/01/24, the first shift only had two Dietary Aids. On 04/03/24, the second shift only had two Dietary Aids. On 04/06/24, the first shift only had two Dietary Aids, second shift only had one Dietary Aid. On 04/11/24, first shift only had two Dietary Aids This deficiency represents non-compliance investigated under Complaint Number OH00152244.

Based on observation, staff interview, resident interviews, and testing of a test tray, the facility failed to ensure food was served that was visually pleasurable and palatable. This had the potential to affect all residents except Resident #25, #89, and #90 who received nothing by mouth (NPO). The facility census was 109. Findings include: Observation and interview on 04/11/24 at 12:22 P.M., revealed Resident #33 was sitting in his room with his lunch tray in front of him. Resident #33 was not eating. Resident #33 revealed the food was horrible and it tasted the same way it looked. Observation of Resident #33's lunch tray revealed an unidentifiable main entree, carrot squares, a roll and juice. Interview on 04/11/24 between 12:55 P.M. and 4:19 P.M., with Residents #47, #76, and #98 revealed the food was not edible, they had too much pasta, and the food did not taste good. Interview on 04/12/24 between 8:36 A.M. and 4:37 P.M., with Resident #44, #46, #47, #85, #102, #105, and #107, revealed they never liked the way their food tasted, it was horrible, gross, it did not look right, and the food did not taste good. Resident #44, #46, #85, #102, #105, and #107, revealed some days their food and drinks were served in Styrofoam containers, Resident #44, and #47 revealed they preferred regular plates. Observation of the breakfast tray line on 04/12/24 at 9:11 A.M, revealed the residents' breakfast was being served in Styrofoam containers with Styrofoam cups. Dietary Cook #294 revealed all residents were getting Styrofoam because there was no staff, all the scheduled kitchen staff called off except for her. Review of the menu served included cream of rice, quiche, toast, jelly, and margarine. Dietary Cook #294 revealed the quiche consisted of liquid eggs topped with green peppers, the facility had not used regular eggs in three years and nothing else would be added. Dietary Cook #294 was made aware to provide a test tray which would be the last tray served placed on the last cart served. Observation revealed three of the four pans used to cook the quiche had a thick layer of burnt brown quiche stuck to the bottom. Dietary Cook #294 revealed the quiche was burnt because she had to bake them in the oven because there was no steamer. Dietary Cook #294 revealed she was unable to test the food on the test tray with the surveyor because she did not have enough time. Dietary Cook #294 revealed the Dietary Manager was off work for a while and was working from home. Observation on 04/12/24 at 9:43 A.M., revealed the last resident tray was served. The test tray was temped and tasted with Dietary Tech #370. The quiche had a rubbery texture and there was no flavor of egg, only a flavor of cooked green pepper. Dietary Tech #370 confirmed she could not taste any egg, only green pepper. The toast was slightly cooked on one side, the opposite side was not cooked, and the bread was room temperature. The cooked rice cereal had no flavor at all and had a mush, pastie texture. The meal was not pleasurable to taste or appearance. Observation on 04/12/24 at 12:06 P.M., of the lunch tray line revealed the lunch meal was also being served in Styrofoam containers and cups. Interview on 04/12/24 at 2:01 P.M., with Dietary Cook #294 confirmed the lunch meal was served on Styrofoam also for all residents. Dietary Cook #294 revealed they used Styrofoam containers to serve residents their meals when there was low staff. Dietary Cook #294 revealed the toaster was not working right and confirmed it only toasted one side of the bread. Interview on 04/12/24 at 4:07 P.M., with Director of Nursing (DON) stated, We hear complaints of food all the time, but it's about preference. This deficiency represents non-compliance investigated under Complaint Number OH00152313.

Based on observation, staff interview, and policy review, the facility failed to safely store food and maintain a clean and sanitary kitchen. This had the potential to affect all residents except Resident #25, #89, and #90 who received nothing by mouth (NPO). The facility census was 109. Findings include: Interview on 04/12/24 at 9:32 A.M., with Dietary Cook #294 revealed she did not have time to observe the refrigerators with the surveyor. Observation and interview on 04/12/24 at 9:33 A.M., of the walk-in refrigerator with Business Office Human Resources (HR) Manager #288 revealed a large container of partially used potato salad was undated, a partially used container of macaroni and hamburger had no date, multiple preset salads and puddings were on three shelves in small containers, none had dates. There were two large containers of partially used salad dressings with no date. There were large stacks of opened cheese, none were dated. Under the wire racks of food on the floor there were large spills that included food particles and dried multicolored liquid. HR Manager #288 verified the undated food products and the spills on the floor. Observation of the small refrigerator (located on the other side of the kitchen) with HR Manager #288 revealed Dietary Cook #294 was actively dating the food items in the refrigerator as the surveyor approached. Dietary Cook #294 verified she was dating the food items in the small fridge and revealed, I told the staff last night to do it, they didn't so yes that's what I am doing. Items not yet dated included four premade cheese sandwiches, multiple partially used stacks of cheese, a container of partially used liquid eggs, and a wrapped portion of a pizza. Dietary Cook #294 revealed she did not remember which of the other multiple food items (that were in facility metal containers and covered in saran wrap) she just dated. Review of the policy titled, Food Receiving and Storage, revised December 2008, revealed Food Services, or other designated staff, will maintain clean food storage areas at all times. All foods stored in the refrigerator or freezer will be covered, labeled, and dated use by date. This deficiency represents non-compliance investigated under Complaint Number OH00152313 and the continued non compliance from the survey 03/07/24.

Based on medical record review, review of a wound care report, investigative report, and staff and resident interviews, the facility failed to ensure Resident #39's environment remained free of an accident hazard when the resident's soup was served at an unsafe temperature causing an injury. This affected one resident (#39) of six residents reviewed for accidents. The facility census was 111. Actual harm occurred on 01/29/24 between approximately 5:00 P.M. and 6:00 P.M. when Resident #39 sustained first and second degree burns to her right anterior thigh after spilling soup which a State tested Nursing Assistant (STNA) had warmed up in a microwave and served to Resident #39. The burn went unreported until the next day, 01/30/24, when Resident #39 asked a nurse to assess the area. The wound team observed the area on 01/30/24. The wound physician documented the wound as a as a scald burn to anterior right thigh, first and partial thickness second degree (Involves the top two layers of skin. The burn forms a blister and is very painful) measuring 15 centimeters (cm) length by 16 cm width with <0.1 depth. The resident voiced she had pain at the time of incident as a result of the injury and also reported as of 03/05/24 the burn was still healing and there was a bad scar. Findings Include: Review of the medical record for Resident #39 revealed an initial admitted [DATE]. Diagnoses included muscle weakness, diabetes mellitus, and systemic lupus erythematosus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had intact cognition, no behaviors, and no skin issues. Review of a skin/wound note dated 01/30/24 timed 9:34 A.M. revealed Resident #39 was seen by the wound team. Resident #39 was observed to have first and second degree burns to the right anterior thigh. Measurements were 15 cm length by 16 cm width with 0.1 cm depth. One hundred percent epithelial tissue was noted with no exudate or signs or symptoms of infection. Treatment included application of Alocane Burn gel and cover with 7 x 7 border gauze. The skin/wound note indicated nursing was to offload pressure. Review of the skin/wound note dated 01/30/24 timed 7:29 P.M. revealed the nurse was exiting the elevator when Resident #39 approached the nurse and asked if the nurse would look at her thigh. The nurse observed blisters and burn areas to the right thigh. The nurse asked Resident #39 what happened, and Resident #39 said she was in bed for the night and asked one of the aides to warm up her soup and Resident #39 ended up spilling the soup on her lap. The skin/wound note indicated the physician was aware. Review of the Wound Assessment and Plan note dated 01/30/24 authored by the wound physician revealed Resident #39 had a right anterior thigh burn that measured 15 cm length by 16 cm width by <0.1 depth. The burn was described as a scald burn to anterior right thigh, first and partial thickness second degree. The plan indicated to offload pressure; Skin prep (protective barrier) to areas of serous blisters; Alocane burn gel to remaining areas twice a day, and protein supplementation and daily multivitamins. Review of the facility's investigation dated 01/30/24 (untimed) revealed on 01/30/24 at 7:30 A.M. Licensed Practical Nurse (LPN) #314 was exiting the elevator when Resident #39 approached and asked her to look at her thigh. LPN #314 observed blisters and burn areas to the right thigh. LPN #314 asked Resident #39 what happened and the resident stated she was in bed for the night and asked one of the aides to warm up her soup and she ended up wasting the soup on her lap while lying in bed. The investigation indicated immediate action included the wound nurse and wound physician were on the hall making rounds and LPN #314 asked for their assistance. The wound nurse and physician took it from there and once they were done with their wound rounds, the wound nurse provided education on warming resident meals and liquids. Review of the plan of care dated 01/30/24 revealed Resident #39 had a potential for impairment to skin integrity related diabetes type 2, incontinence, and second degree burns to right thigh (01/29/2024). Interventions included informing and instructing staff of causative factors and measures to prevent burns; monitor/document location, size and treatment of wound, and report abnormalities, failure to heal, signs and symptoms of infection, maceration (softening of the skin which occurs when skin is in contact with moisture for too long) etc. to the physician. Review of the skin/wound note dated 03/05/24 timed 10:14 A.M. revealed Resident #39 was seen by the wound team. The note indicated the right anterior thigh burn was healing. The burn wound measured 6.5 cm length by 3.6 cm width with 0.1 cm depth with 100 percent epithelial tissue. There was no exudate or signs/symptoms of infection. Treatment included cleaning the wound with Dial antibacterial soap, applying Xeroform (petroleum based gauze), covering with ABD (large padded gauze dressing) and placing tape on edges to keep ABD in place. Nursing was to continue to offload pressure. Review of the March 2024 physician orders revealed active orders to clean the right anterior thigh with Dial antibacterial soap, apply Xeroform, cover with ABD, place tape on edges to keep ABD in place every dayshift and every 24 hours as needed for burn. Interview on 03/05/24 at 4:58 P.M. with Resident #39 revealed at the time of the incident on 01/29/24, she had not been feeling well and had not eaten much for a couple of days. Resident #39 wanted soup and asked one of the aides to warm up the soup for her. Resident #39 was in bed and spilled the soup on herself as she was trying to eat the soup. There were two STNAs in room and one STNA left the room. Resident #39 thought the STNA left the room to get the nurse; however, the nurse did not come. Resident #39 thought they were busy and had forgotten about her. Resident #39 said STNA #449 was the STNA that stayed in the room with her and STNA #449 put barrier cream on the burn which helped to cool it down and soothe the pain. When Resident #39 woke up the next morning the skin had welted up. Resident #39 stated she did not see a nurse the night the burn occurred but saw a nurse with the wound physician the next day on 01/30/24. Resident #39 did not know the name of the STNA that brought her the soup, but the STNA came back to her room that next day (01/30/24) and apologized for making the soup too hot. Resident #39 did not think the STNA worked at the facility any longer because she had not seen her since then. Resident #39 stated the burn was still healing and there was a bad scar. Interview on 03/05/24 at 5:22 P.M. with STNA #449 revealed she was not in the room when Resident #39 spilled the soup onto herself and was not the STNA who brought her the soup. STNA #449 stated she saw the burn a few hours later on 01/29/24 sometime between 7:00 P.M. and 8:00 P.M. while changing Resident #39. STNA #449 asked Resident #39 what happened, and she told her she had spilled soup onto herself. STNA #449 put barrier cream on the area and then reported it to one of the nurses working that evening but was not sure which nurse she had told. Interview on 03/06/24 at 2:48 P.M. with Wound Nurse (WN) #363 revealed on 01/30/24, while she was making wound rounds, the nurse reported Resident #39 had a burn wound. WN #363 contacted the night nurse from 01/29/24 via phone to see why it had not been reported that night. The night nurse told her she was not aware that it happened. WN #363 stated she thought Resident #39 did not tell anyone what happened because she did not want to get the STNA in trouble. WN #363 stated the STNA who warmed up the soup never came back to work and did not provide a statement. WN #363 stated Resident #39's burn was massive, and she was more worried about treating the burn. WN #363 described the burn wound as one large intact blister. WN #363 said Resident #39 did not complain of pain and had stated she was okay. WN #363 stated it was okay STNA #449 applied barrier cream because it had a Vaseline base. WN #363 said she educated staff on reporting because the burn was not reported timely. WN #363 stated she was glad they caught it on the day of wound rounds because treatments were put in place. Follow-up interview on 03/06/24 at 3:45 P.M. with STNA #449 revealed she did not remember what the burn on Resident #39's thigh looked like when she first saw it on 01/29/24. STNA #449 stated maybe it was a little burn that night but she remembered seeing it the next day and it was bigger and puffier due to the blistering. Follow-up interview on 03/07/24 at 9:52 A.M. with Resident #39 revealed she could not wear pants because of the bandage covering the burn. Resident #39 stated she was not in pain but wearing pants would pull the bandage off. Resident #39 was observed up in her wheelchair with a blanket covering her lower extremity. Resident #39 pulled the blanket back revealing a large white bandage on the top portion of Resident #39's right thigh, lap area. The facility did not provide evidence of education or in-services regarding heating foods or reporting injuries.

Based on observation, interview, and record review the facility failed to maintain a clean and sanitary kitchen and nursing unit refrigerators. This had the potential to affect all residents except three residents (#6, #19, and #50) who received nothing by mouth. The facility census was 111. Findings Include: Observations on 03/04/24 from 8:00 A.M. to 8:18 A.M. during a tour of the kitchen revealed on the bottom shelf of the prep table across from the walk-in freezer table there was a clear container of bulk sugar with a silver scoop stored inside of it. The blue lid of the sugar container was dirty with food debris, and the shelf itself had various food debris, crumbs, and grease. Behind the prep table there was a silver pipe that ran along the wall which had various food debris and crumbs on it. There was various food debris and crumbs on the floor behind the prep table. Observation of the walk-in cooler revealed a large stain on the floor under the rack next to the door and various food debris, crumbs, small juice containers, and liquid spillage on the floor. Interview with Dietary Cook (DC) #348 on 03/04/24 between 8:00 A.M. and 8:18 A.M., during the tour of the kitchen, verified the findings. Follow-up observation of the kitchen on 03/05/24 at 9:58 A.M. revealed near the fryer and stove area, the grout on the floor was heavily dirty, and what appeared to be a drain in the floor was heavily dirty with a built up black substance and debris. The wall near the fryer was missing several tiles and appeared dirty with dried grease and food splatter. Observation of the reach-in cooler near the stove revealed various food crumbs and tannish colored spillage. Interview, at the time of the observation, with Certified Dietary Manager (CDM) #447 verified the observations and stated they attempted to power wash the area near the fryer and some of the tiles started to come off. Observations on 03/05/24 from 10:02 A.M. to 10:14 A.M. of the nursing unit refrigerators with CDM #447 revealed the first floor refrigerator was cluttered and had various food debris inside the refrigerator. Observation of the second floor nursing unit refrigerator revealed various food debris on the outside and inside of the refrigerator. Observation of the third floor refrigerator revealed various food debris inside of the refrigerator. Interview on 03/05/24 between 10:02 A.M. and 10:14 A.M. with CDM #447 verified the findings. Review of the facility Sanitation policy revised December 2008 revealed the food service area would be maintained in a clean and sanitary manner. Review of a list provided by the facility revealed Residents #6, #19, and #50 received nothing by mouth.

Based on observation, resident and staff interviews, record review, and policy review, the facility failed to provide routine dental and oral care for a resident dependent on staff for all activities of daily living. Actual Harm occurred when Resident #65 was not provided routine dental/oral care and treatment resulting in the resident expressing pain in his mouth, the resident's gums being red and inflamed with areas of dried blood, multiple broken, cracked, split, black upper and lower teeth, and foul-smelling breath. The lack of routine dental care had the potential to lead to serious complications including but not limited to infection and/or sepsis. This affected one (#65) of five residents reviewed for dental care. The facility census was 113. Findings include: Record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including traumatic subdural hemorrhage, muscle weakness, and contractures unspecified joint. Review of the physician's orders dated 07/12/22 revealed Resident #65 received Isosource 1.5 formula via gastrostomy (peg) tube every shift and also a regular (oral) diet as tolerated. A physician order dated 07/12/22 indicated may have dental evaluation and treatment as indicated. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 had no abnormal mouth tissue, no inflamed or bleeding gums, but had obvious or likely cavity or broken natural teeth. Review of the care plan dated 02/15/23 revealed Resident #65 had dental health problems related to cavities and poor dentition. Interventions include monitor/document/ report to MD signs or symptoms of oral/dental problems needing attention such as pain, abscess, debris in mouth, lips cracked or bleeding, teeth missing, loose, broken, eroded, decayed. Provide mouth care as per activity of daily living personal hygiene and dental consult as needed. Review of the medical records for Resident #65 for March 2023 revealed no documentation of Resident #65 refusing oral care, Resident #65's condition of oral cavity or refusal to see a dentist. Review of the physician's orders dated 03/20/23 revealed an order for chlorhexidine gluconate solution 0.12% give 15 milliliter (ml) by mouth two times a day for oral hygiene, swab patients mouth with solution. Review of the form titled Dental Hygiene Encounter for Resident #65 dated 03/29/23 completed by Registered Dental Hygienist #380 revealed Resident #65 suffered from muscle atrophy and could not brush or floss teeth. Resident #65 tolerated scaling and debridement. Further review of the medical record revealed no further description or update provided of the resident receiving dental care. Review of the annual MDS dated [DATE] revealed Resident #65 had no abnormal mouth tissue, no inflamed or bleeding gums, but had obvious or likely cavity or broken natural teeth. Review of the quarterly MDS assessment dated [DATE] revealed Resident #65 was cognitively intact and had no dentures. Resident #65 was dependent for all activities of daily living and received routine pain medication. This MDS assessment only included information regarding dentures and does not evaluate the resident's overall oral condition/status. Record review revealed no comprehensive oral assessment was completed for the resident at this time. Review of the care plan dated 11/13/23 revealed Resident #65 had an activity of living self-performance deficit which included related to weakness and contractures. Interventions included Resident #65 required total staff participation with personal hygiene and oral care. Review of the progress notes for Resident #65 from 10/01/23 through 01/09/24 revealed no assessment or follow up documented regarding Resident #65's oral status. Review of the documentation on the Medication Administration Record (MAR) for Resident #65 for December 2023 through January 2024 revealed nursing staff were documenting Resident #65 was receiving chlorhexidine gluconate solution 0.12% give 15 ml by mouth two times a day per nursing staff. Observations and interview on 01/09/24 between 9:52 A.M. and 12:25 P.M., revealed Resident #65 was lying in bed with continues tube feeding running. Resident #65 was severely contracted in the upper and lower extremities. Resident #65 had a strong foul mouth odor as he spoke. Observation revealed Resident #65's gums were red and inflamed with areas of dried blood. Resident #65 had multiple broken, cracked, split, and black upper and lower teeth. An interview with Resident #65 at the time of the observation revealed he had not seen a dentist since admission to the facility. Resident #65 revealed he didn't like mouth care because it was painful when mouthcare was provided. During the interview, the resident indicated he would like to see the dentist. Interview on 01/09/24 at 12:42 P.M., with Licensed Practical Nurse (LPN) #304 confirmed Resident #65's foul mouth odor, swollen red inflamed gums with multiple broken black teeth. LPN #304 stated Resident #65's mouth, gums and teeth had always been that way. LPN #304 stated Resident #65 frequently refused oral care (she was unsure why), but felt staff offered and he refused. LPN #304 stated Resident #65 never refused a dentist but felt he would need to see an oral surgeon because of his contractures and oral surgeons didn't come to the facility. Interview on 01/09/24 at 5:02 P.M., with the Director of Nursing (DON) revealed she was unaware of any concerns with Resident #65's teeth and gums. Observation of Resident #65's oral condition with DON confirmed Resident #65 had a foul odor from his mouth while speaking, the upper and lower gums continued to be swollen, red and the resident had multiple broken and black teeth. Dried blood was noted on the resident's teeth. The DON confirmed Resident #65's oral condition needed addressed and stated Resident #65 needed to consult with a dentist. Interview on 01/10/24 between 11:52 A.M. and 11:55 A.M., with LPN #374 and State tested Nursing Assistant (STNA) #282 revealed they had both worked with Resident #65 for several months. Resident #65's teeth and gums had been in the same condition, broken teeth, multiple carries, swollen and bleeding. Interview on 01/10/24 at 4:40 P.M., with Social Worker Designee (SWD) #238 revealed the dentist and dental hygienist visited residents at the facility monthly or every other month but not on the same date, they would come at different visits and see residents. They would give her a list of according to payment source who they were going to see on the scheduled visit. SWD #238 revealed she was unsure how frequently or when a resident should be scheduled to see a dentist. SWD #238 revealed Resident #65 was seen by the Dental Hygienist on 03/29/23 and verified Resident #65 had never seen a dentist since residing at the facility. Per SWD #238, Resident #65 refused to see a dentist at that time and since then, there were no consultations with the dentist offered or scheduled for Resident #65. Interview on 01/17/24 at 10:47 A.M., with Resident #65 revealed he gets his food through a bag (tube feed), so he does not need to use his teeth. Resident #65 went on to state if I leave them (teeth) alone, they don't hurt, I don't want to eat because I have my bag (tube feed). Observation at the time of the interview revealed Resident #65's gums were inflamed and bright red, and multiple broken, cracked, split, black upper and lower teeth. Interview on 01/17/24 at 11:31 A.M., with State tested Nurse Aide (STNA) #282 confirmed she routinely cared for Resident #65. STNA #282 revealed Resident #65 never allowed anyone to do mouth care on him in the past. STNA #282 revealed today was the first day he agreed to do mouth care. STNA #65 confirmed she provided mouth care for Resident #65 this A.M. STNA #282 revealed she did not document Resident #65's refusals of mouth care in the past and confirmed with record review of the documentation of oral care in the electronic medical record, there was a section in the electronic medical records where she could document refusals. STNA #282 revealed, I need to get on it. Interview on 01/17/24 at 11:40 A.M., with LPN #304 confirmed she routinely cared for Resident #65. LPN #304 confirmed she documented on the MAR administering the chlorhexidine gluconate solution 0.12%. LPN #304 stated Resident #65 had never allowed staff to administer it, he always refused. LPN #304 revealed the nurses documented they attempted to do it when they signed the MAR. LPN #304 confirmed she never documented he refused the chlorhexidine gluconate solution 0.12%. Review of the State tested Nursing Assistant (STNA) electronical documentation of activities of daily living for Resident #65 revealed a section for oral care. Within the section was an area for documentation of resident refusals of oral care. Record review for January 2024 revealed no documentation of refusals of oral care for Resident #65. Staff were documenting care was being provided, even though per interview the resident was frequently refusing the care. Review of the undated policy titled, Dental Services, revealed routine and emergency dental services were available to meet the resident oral health services in accordance with the resident assessment and plan of care. Social Service Representatives would assist residents with appointments, transportation, arrangements and for reimbursement for dental services under the state plan, if eligible. This deficiency represents non-compliance investigated under Complaint Number OH00149864.

Based on record review, facility policy review and interview, the facility failed to ensure Resident #56 was transported to an appointment in a safe manner to prevent a fall with injury. Actual harm occurred on 08/17/23 when Central Supply/Driver #805 failed to properly secure Resident #56 using a wheelchair safety harness (as required) during transportation to an appointment in the facility van resulting in the resident sustaining a fall out of the wheelchair with injury. Resident #56 was assessed to have a left upper extremity fracture as well as bilateral lower extremity fractures which required surgical intervention. This affected one resident (#56) of three residents reviewed for accidents/hazards. Findings include: Review of Resident #56's medical record revealed an admitted [DATE] with diagnoses including type two diabetes, chronic kidney disease with dependence on renal dialysis and muscle weakness. Review of Resident #56's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of a witness statement form authored by Central Supply/Driver #805 dated 08/17/23 revealed around 2:30 P.M. he approached the exit ramp traffic. Resident #56, at this point, slid out of the wheelchair and landed on both knees. State tested Nursing Assistant (STNA) #814 attended to Resident #56 and the transportation van was pulled over into the nearest parking lot. Central Supply/Driver #805 called the Administrator and explained what happened. Resident #56 indicated both of her knees hurt and Central Supply/Driver #805 called 911 and the emergency medical squad (EMS) was activated. Resident #56 stated she had pain to both knees and she was alert and willing to go to the emergency room . The EMS transported her to the hospital. Review of a witness statement form authored by STNA #814 indicated on or about 08/17/23, she was Resident #56's escort. As they were coming back from an appointment, Central Supply/Driver #805 was driving and they were getting off the freeway. A car in front of the transport bus hit their brakes and Central Supply/Driver #805 hit his brakes. Resident #56 slid out of her chair and she caught herself on the back of the chair and slid down to the floor slowly. EMS was called after Central Supply/Driver #805 called the facility and she went to the hospital. Review of Resident #56's Hospital After Visit Summary dated 08/24/23 revealed the resident had a closed fracture of the right distal femur. The history indicated the resident was brought into the emergency medical center (EMS) following a fall. The resident was in her wheelchair when she fell and hit her head on the seat. A physical examination revealed bilateral lower extremity weakness. Imaging revealed a subsegmental pulmonary embolism of the right lower lobe, a nondisplaced fracture of the left humeral head and bilateral distal femur fractures. The resident went to the operating room (OR) with orthopedics for an open reduction internal fixation (ORIF) of the bilateral distal femurs with reported estimated blood loss (EBL) of 600 ml (milliliters). The documentation confirmed on 08/18/23, Resident #56's surgical repairs included ORIF of the bilateral distal femurs and a closed reduction of the left humerus. Review of Resident #56's progress note dated 08/25/23 at 2:44 P.M. revealed the resident was readmitted to the facility from the hospital with a discharge plan for an evaluation after rehabilitation. Interview on 09/05/23 at 6:52 A.M. with Resident #56 revealed she was on the transport bus and Central Supply/Driver #805 was driving. She stated he missed his exit and braked hard causing her to fall out of her wheelchair. She stated she tried to brace herself but she fell to the floor of the transport bus. She stated Central Supply/Driver #805 asked her if she would like to go back to the facility or to the emergency room and she told him to call the facility and ask them what they wanted to do. She stated she was transported to the emergency room and had to have surgery on her bilateral lower legs. Interview on 09/05/23 at 7:00 A.M. with Central Supply/Driver #805 revealed he transported Resident #56 to a doctor's office approximately three weeks ago. Central Supply/Driver #805 indicated Resident #56 did not like the safety harness to prevent her from coming out of her wheelchair during the drive and had requested that he not use the safety harness, so he did not put the harness on her. He stated all people have different body sizes and he felt maybe this was why she did not want the harness. During the interview, he confirmed he was required to use the harness for resident safety and stated he had to apply the brakes (of the van) because there were a lot of brake lights in front of him. He stated STNA #814 was in the back with the resident and then the resident slid out of the chair and onto the floor. He stated he pulled over and went to the nearest parking lot and called EMS. He stated approximately fifteen minutes later, the EMS squad arrived and transported the resident to the hospital. He denied Resident #56 had lost consciousness. Central Supply/Driver #805 revealed following the incident, he was educated on the appropriate procedures when transporting residents including using the safety harness and he had denied any accidents or incidents had happened in the past. However, Central Supply/Driver #805 then indicated he had transported another resident recently without the safety harness but stated he could not remember that resident's name. Interview on 09/05/23 at 10:25 A.M. with the Administrator revealed he was aware Central Supply/Driver #805 did not use the safety harness when transporting Resident #56 to an appointment and the resident sustained fractures requiring surgical intervention. He stated Central Supply/Driver #805 received a final written warning and was educated on the appropriate procedures when transporting residents. Interview on 09/05/23 at 11:11 A.M. with STNA #814 revealed she was the escort when Resident #56 was transported to the appointment. She stated when they arrived at the appointment, it was canceled so they were on their return trip to the facility. STNA #814 indicated a car jumped in front of the bus and hit their brakes causing the transport van driver to hit the brakes and Resident #56 to slide out of her wheelchair. STNA #814 indicated she was in one of the front passenger seats and was not close enough to the resident to help the resident. She stated she observed the resident hit her knees on the back of the last row of seats and then roll out of the wheelchair onto the floor of the transport van. STNA #814 indicated she was told Resident #56 refused the safety harness. When questioned, she stated she did not actually hear Resident #56 refuse the restraint harness as she was standing outside the bus when Resident #56 was loaded. An additional interview on 09/05/23 at 12:52 P.M. with Resident #56 revealed she had never refused the safety harness and stated the driver just did not put it on her. Review of the Transportation, Diagnostic Services policy, revised 04/2009 revealed the facility would assist residents in arranging transpiration to/from diagnostic appointments when necessary. Review of the Van Transport policy (put in place as a result of the accident involving Resident #56) revealed if a resident was noted, or you were made aware of a resident, sliding out of a chair prior to transport, notify the Director of Nursing (DON) or Administrator to ensure the resident was transported by a stretcher. Ensure that the resident was appropriately secured with a seat belt prior to any resident transport. The seat belt should be secured around the resident, not the arm rests. In case of a fall during transportation or vehicle accident involving the transport van, notify 911 immediately, notify the Administrator and/or DON, never move the resident, or allow the chaperone to move the resident, even if the resident did not appear hurt. Never attempt to transfer the resident back to the chair. Advise them to stay where they were until a medical professional arrived on the eocene to check on them. This deficiency represents non-compliance investigated under Complaint Number OH00146049.

Based on record review, observation, interview, and policy review the facility failed to ensure Resident's #2, #11 and #66 were free from abuse and neglect. Actual harm occurred when lack of activities of daily living care (showers and oral care) resulted in Resident #66 lips having excessive dead skin and the entire top layer of skin on his bottom lip was lifting off the lip and hanging loosely from it. In addition there was a heavy accumulation of dead skin on the crown of his head in an approximately five-inch diameter circular pattern. Further harm occurred when Resident #11's bonnet (device used to protect hair) became stuck to Resident #11's head and had an accumulation of dried/dead skin and a large nodule of dry skin approximately a quarter size in diameter and a half inch in height. The facility also failed to protect Resident #2 from resident-to-resident physical abuse. This affected three (Resident's #2, #11 and #66) of three residents reviewed for abuse and neglect. The facility census was 81. Findings included: 1.Record review was conducted for Resident #66 who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #66's mother was his legal guardian. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #66 was cognitively impaired, totally dependent on two staff for bed mobility. He was bed bound so he did not transfer, and totally dependent on one staff person for his feedings, toileting, hygiene, and dressing. Review of the bath and shower sheets which contained a section on skin monitoring were reviewed for the date range of 11/01/21 to 01/17/22. There were no bath and shower sheets for the entire month of December 2021. Six bath and shower sheets were provided for November 2021, all bed baths were provided, and all indicted the resident's skin was impaired but gave no location or description of impairment, and there was no signature of the nurse on the forms. Only one bath and shower sheet for 01/17/22 was given to the surveyor which also indicated the skin was impaired. There was no location or description of the impairment and no signature from a state tested nurse aide (STNA) or nurse. Initial observation on 01/25/22 at 11:17 A.M. revealed the resident was bed ridden with contractures to his upper and lower extremities. Resident #66 had an enteral feeding pump which was supplying him nutrition and hydration. Resident #66's hygiene was poor as he had an excess of skin built up on his eyebrows, lips, and feet. Resident #66's bottom lip had so much dead skin on it the entire top layer of skin on his bottom lip was lifting off the lip and hanging loosely from it. When Resident #66 opened his mouth to say yes to the surveyor his teeth had a heavy yellow-white coating of biofilm-like substance as if he had not had mouth care done for an extended period. Resident #66's hair was dull and there was a heavy accumulation of dead skin on the crown of his head in an approximately five-inch diameter circular pattern. The dead skin had grown out from the length of his short, brown hair so it was easily visible to the surveyor. Interview was conducted on 01/31/22 at 8:30 A.M. with Resident #66's mother who was his guardian. She stated Resident #66 was supposed to get showered twice a week but only got bed baths whenever the staff had time to do it. Interview was conducted on 01/31/22 at 2:45 P.M. with STNA #636 who said she gave Resident #66 a bed bath but did not wash his hair because she did not have time. STNA #636 whispered to the surveyor Resident #66 was not being taken care of right, looking like he was not being washed up enough. Observation was conducted on 01/31/22 at 3:26 P.M. of Resident #66 with the Director of Nursing (DON) and the Administrator. The DON put on a disposable glove and touched the top of Resident #66's head to see if the dead skin would come off and verified, Resident #66 needed care to his scalp and have his head washed. The DON also verified the dead skin on Resident #66's face and general lack of mouth care. Observation on 02/01/22 at 9:25 A.M. of Resident #66 with STNA #132 revealed his hair had been washed and all the dead skin removed from his head. STNA #132 stated she only worked per diem and most of the STNAs caring for Resident #66 were agency STNAs so there was little consistency with his care. Interview was conducted on 02/01/22 at 3:17 P.M. with the DON who verified she could not find any bath and shower sheets for Resident #66 for the month of December 2021. Record review and interview were conducted on 02/02/22 at 10:08 A.M. with Assessment Coordinator (AC) #161 of the activities of daily living (ADL) sheets for December 2021 and January 2022, as printed from the electronic medical record. AC #161 indicated there was so much staff turnover in the facility she could not keep track of the staff documenting care for the residents. Review of the December 2021 bathing records from the electronic medical record revealed Resident #66 received a bed bath on 12/07/21 and received some type of bathing on a few other days in the month, but she was not certain of the frequency or exactly what care was provided to him. AC #161 verified when a bed bath was given, the STNAs were to fill out a hard copy of the bath and shower sheets and do a skin assessment. Review of the undated Personal Care policy stated bed baths should be given on days showers cannot be given. Bathing was the opportunity to check the condition of the skin and all body parts should be bathed. 2. Review of the medical record for Resident #11 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care dated 10/05/21 revealed Resident #11 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . No interventions were created or implemented. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #11 had impaired cognition and was dependent on staff for bed mobility, transfers, ambulation, and toilet use. During observations and interview on 02/01/22 at 3:40 P.M., Licensed Practical Nurse (LPN) #170 informed the surveyor that Resident #11 had a bonnet on her head that was hard to remove. Observations revealed Resident #11 was wearing a bonnet on her head. LPN#170 attempted to remove the bonnet; however, the bonnet was attached to Resident#11's scalp. Observations of the scalp revealed an accumulation of dried/dead skin and a large nodule of dry skin approximately a quarter size in diameter and a half inch in height. The bonnet was attached to the nodule and the side of Resident #11's scalp. LPN#170 was afraid to pull on the bonnet due to possible injury of the skin. During observations and interview on 02/01/22 at 3:40 P.M., with the Administrator and DON, the DON observed the bonnet and stated Resident #11 has had a skin disease and the nodule for years. The DON removed the bonnet with some effort. Observations revealed Resident #11's scalp was covered with dry/flaky skin. The DON also stated Resident #11 would refuse care frequently. Review of the mediation administration record (MAR) revealed staff had documented completing the treatments to Resident #11's scalp daily. The DON could not state why Resident#11's scalp appeared the way it did if staff were completing treatments daily. Review of the progress note dated 02/01/22 at 4:48 P.M., LPN #170 indicated the DON was aware that the bonnet was difficult to remove from Resident #11's scalp. The scalp was assessed, and Resident #11 was noted with chronic condition of seborrheic [CONDITION(S)]. During observation and interview on 02/02/22 at 8:30 A.M., the DON took the surveyor to visit with Resident #11. Observations revealed Resident #11's scalp was clean/smooth looking, the nodule was removed as well. No observations of dry/flaky skin were noted. The DON stated that staff washed Resident#11's head. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Review of the medical record for Resident #2 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #2 required two-person assist for activities of daily living. Review of the quarterly Social Service assessment note dated 01/10/22 revealed Resident #2 was alert and oriented to person, place, and was prescribed [CONDITION(S)] medication for [CONDITION(S)] and major depressive disorder. Review of the facility Self Reported Incident (SRI) to the State Agency dated 10/14/21 at 4:45 P.M. revealed on 10/14/21 the facility reported Resident's #2 and #47 were in the resident designated smoking location with staff supervision. Staff stated Resident #47 got out of his chair and hit Resident #2 on the right side of his head and sat back down. Resident #2 winced but did not respond to the attack and continued to smoke his cigarette. Residents #2 and #47 were separated immediately, interviewed, and assessed. Resident #2 was assessed by the DON with no injuries noted. Resident #47 was interviewed by the DON and Administrator, and it was discovered that Resident #47 was displaying symptoms of past behaviors. Resident #47 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 02/02/22 at 9:47 A.M. with the DON confirmed the resident-to-resident abuse occurred. The DON revealed Resident #47 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficiency substantiates Complaint Number OH 131.

Based on record review, observation, interviews and policy review the facility failed to provide the care and services to prevent and treat facility acquired pressure ulcers for Residents #11 and #66. Actual harm occurred when lack of wound care and interventions led to the deteriorating pressure ulcers of two (Resident's #11 and #66) of three residents (#11, #66 and #67) reviewed for pressure ulcers. The facility census was 81. Findings included: 1.Record review was conducted for Resident #66 who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #66's mother was his legal guardian. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #66 was cognitively impaired, totally dependent on two staff for bed mobility, he was bed bound so he did not transfer, and totally dependent on one staff for feedings, toileting, hygiene, and dressing. Resident #66's speech, vision, and hearing were adequate, and he could be understood and understood others. Review of Section M of the MDS 3.0 assessment dated [DATE] revealed Resident #66 had one, Stage two (partial thickness loss of the dermis presenting as a shallow, open ulcer) pressure ulcer that was not present upon admission, two Stage three (full-thickness tissue loss) pressure ulcers with only one being present upon admission. Review of the facility documents titled Wound Assessment and Plan, dated 11/02/21 through 02/01/22, revealed the following: a. 11/09/21 Wound Physician (WP) #900 documented Resident #66 had a Stage three pressure injury on the right medial calf with a wound onset date of 08/10/21. The wound measured 2.4 centimeters (cm) in length by 1.8 cm in width by 0.1 cm in depth. The peri wound (area surrounding the wound) was normal, moderate amount of exudate. The wound bed had 100% hyper granulation and no signs or symptoms of infection. The recommended treatment was to cleanse the wound with normal saline or sterile water, apply collagen alginate (treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional orders were to offload pressure between the right medial calf and left medial knee. b. 11/30/21 WP #900 documented the Stage three right medial calf pressure injury with the wound onset date of 08/10/21 had declined. The wound measured 2.6 cm in length by 1.8 cm in width by 0.1 cm in depth. The reason was listed was unable to adhere to offloading. The peri wound was normal, moderate amount of exudate, wound bed 100% granulation and no signs or symptoms of infection. c. 12/14/21 WP #901 documented a newly developed Stage two (partial-thickness skin loss with exposed dermis) pressure injury to the right lateral knee with the wound onset date of 12/14/21. The wound measured 2.0 cm in length by 2.5 cm in width by 0.0 cm in depth. The peri wound was normal, no exudate and no signs or symptoms of infection. The treatment was to cleanse with normal saline or sterile water, apply collagen alginate to the wound bed daily, cover with a clean dry dressing, and offload per facility policy. The right medial calf pressure injury with the wound onset date of 08/10/21 was noted as stable/same measuring 2.5 cm in length by 1.7 cm in width by 0.1 cm in depth. The peri wound was normal, moderate amount of exudate, 100% hyper- granulation, and no signs or symptoms of infection. d. On 12/30/21 WP #901 documented the pressure injury to the right lateral knee with onset date of 12/14/21 remained at a Stage two measuring 1.3 cm in length by 1.6 cm in width by 0.0 cm depth. The peri wound was normal, and there was no exudate or signs or symptoms of infection. The right medial calf with an onset date of 08/10/21 was noted as stable measuring 1.8 cm in length by 1.4 cm in width by 0.0 cm in depth. The peri wound was normal, there was a moderate amount of exudate, and no signs or symptoms of infection. e. 01/04/22 WP #901 documented the right lateral knee was healing, and the right medial calf was stable. There was no change in the stages of either pressure injury. f. 01/11/22 WP #901 documented the right lateral knee Stage two pressure injury was stable measuring 1.3 cm in length by 0.9 cm in width by 0.0 cm in depth. The right medial calf stage three pressure injury was stable measuring 2.3 cm in length by 1.4 cm in width by 0.0 cm in depth. There were no other wounds documented on at this visit. g. 01/18/22 WP #901 identified a new (in-house acquired) pressure ulcer on the right heel at a Stage three with a wound onset date of 01/18/22. It measured 1.8 cm in length by 1.0 cm in width by 0.0 cm depth, 100% granulation, normal peri wound, minimal exudate, and no signs or symptoms of infection. The treatment was to cleanse the wound with normal saline or sterile water, apply collagen to the wound bed and cover with a clean dry dressing. Heels to be floated and offload pressure per the facility protocol. The right lateral knee and the right medial calf were noted to be healing. f. 01/25/22 WP #901 assessed a left medial knee Stage three pressure injury with a wound onset date of 01/25/22 measuring 1.4 cm in length by 1.3 cm in width by 0.0 cm in depth. The peri wound was normal, no exudate or signs or symptoms of infection. WP #901 noted it was a new (in-house acquired) pressure area, and the treatment should include offloading pressure between the right medial calf and left medial knee using a pillow between the knees. WP #901 noted the right heel pressure injury was healed. The right lateral knee Stage two pressure injury declined due to unable to adhere to offloading. WP #901 noted it was a reopened wound to the right lateral knee measuring 1.5 cm in length by 0.6 cm in width by 0.0 in depth. The right medial calf was stable. g. 02/01/22 WP #900 indicated the left medial knee was stable, the right medial calf was healing, and the right lateral knee was healed. Review of the Treatment Administration Records (TAR) from 11/01/21 to 01/31/22 revealed the treatments to the left medial knee were not documented as completed as ordered for 41 days, the treatments to the right lateral knee were not documented as completed as ordered for 47 days, and the offloading of pressure to help heal the pressure ulcers were not documented as completed for 46 days. The daily order for the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Bath and Shower sheets which contained a section on skin monitoring were reviewed for the date range of 11/01/21 to 01/17/22. There were no sheets for the entire month of December 2021. Six sheets were provided for November 2021, all bed baths and all indicted Resident #66's skin was impaired but gave no location or description of impairment, and there were no nursing signatures on the forms. Only one sheet for 01/17/22 was given to the surveyor which also indicated the skin was impaired. There was no location or description of the impairment and no signature from a state tested nurse aide (STNA) and/or a nurse. Initial observation of Resident #66 on 01/25/22 at 11:17 A.M. revealed he was bed ridden with contractures to his upper and lower extremities. Resident #66 had an enteral feeding pump which was supplying him nutrition and hydration. Resident #66's hygiene was poor as he had excesses of skin built up on his eye browns, lips, and feet. Resident #66's hair was dull and there was an excess build-up of dry skin which could be seen through his short brown hair. Resident #66 was dressed only in a disposable brief with his back and head on the mattress and his lower body rotated to the right. Resident #66's right leg was drawn up and bent at the knee resting on the bed while his left leg was drawn up, bent at the knee which was resting against his right medial calf. The side of his right hip and buttock was the only part of his pelvic girdle touching the bed. There was no pillow between his legs or feet. His right heel was against the bed, and his left heel was hanging slightly over the side of the mattress resting against the inside of his left ankle. The mattress on his bed was not a specialty air mattress, it did not plug in nor have any capability to change inflation or deflation settings to move air around in the bed. Observation of Resident #66 with Licensed Practical Nurse (LPN) #101 on 01/26/22 at 9:42 A.M. revealed Resident #66 had a dressing on his left medial knee and two dressings each located on his right lateral knee and right medial calf. Resident #66 did not have a pillow between his legs, and his left leg was resting against the right medial calf and the bed. Observation of Resident #66 on 01/27/22 at 10:45 A.M. revealed he was in the same position with his back and head against the mattress and his lower body rotated to the right under the blankets. Resident #66 was resting quietly in the bed and did not arouse to the surveyor's verbal greeting. Interview was conducted on 01/31/22 at 8:30 A.M. with Resident #66's mother who was his guardian. She reported she had not been in to visit for about a month but had been in every Monday, Wednesday, and Friday during part of December 2021 and prior. She stated she would sit with him most of the day, and the only time staff would come in to reposition him was at shift change or if she had to go get someone because he looked uncomfortable. Observation on 01/31/22 at 11:15 A.M. of Resident #66 in his room revealed he was in bed with his eyes open lying in his same position with his lower body rotated to the right with his head and shoulders resting on the mattress. A stained, navy-blue neck pillow approximately 10 to 12 inches in diameter was laying on the floor at the foot of his bed. Interview was conducted on 01/31/22 at 11:20 A.M. with STNA #636 who was assigned to care for Resident #66. When asked if she could explain his turning and repositioning needs, she said she was not sure and had not been able to turn or reposition him since she started at 7:00 A.M. STNA #636 was unaware Resident #66 had pressure injuries. Interview was conducted on 01/31/22 at 2:45 P.M. with STNA #636. When asked if Resident #66 had any type of pillow between his legs to offload pressure, she said she did find a neck pillow in his room and noticed he had bandages on his legs so she put the pillow between his legs but was not really sure if that was his pillow. Observation was conducted on 01/31/22 at 3:26 P.M. of Resident #66 with the Director of Nursing (DON) and the Administrator. The DON lifted his blankets to reveal a stained navy-blue neck pillow had been placed between his legs which only partially separated his legs from having pressure against each other and was not offloading pressure to his feet or ankles. Observation was made on 02/01/22 at 9:25 A.M. of Resident #66 with STNA #132 who verified due to the residents' contractures it took two people to reposition him, but his repositioning was limited due to the contractures. STNA #132 said Resident #66 favored the position he was currently in and all she could really do for him was to keep a pillow between his legs. Upon lifting the sheet, a full-length pillow was observed placed parallel to the length of his shins which was offloading pressure for his knees, calves, ankles, and feet. STNA #132 stated she only worked per diem and most of the STNAs caring for Resident #66 were agency STNAs so there was little consistency with his care. During observation on 02/01/22 at 10:50 A.M., LPN #174 provided wound care for Resident #66. Resident #66 was observed to have a pillow between the knees. LPN #174 followed infection control practices as she changed the dressing to the right inner calf and the left inner knee. Resident #66 displayed no signs of pain. Interview on 02/01/22 at 10:50 A.M. with LPN #174 verified the lack of wound treatment documentation in the TAR and MAR. Interview was conducted on 02/02/22 at 10:57 A.M. with Physical Therapist (PT) #910 via telephone. She was asked if any education had been provided to the floor staff regarding ways to reposition Resident #66. PT #910's reply was any education she had done would have been done directly with the STNAs on the unit, but she had not been in the facility to work with Resident #66 since November 2021. Interview was conducted on 02/02/22 at 11:00 A.M. with Director of Therapy #105 who verified she had no documented evidence staff education had been provided to the STNAs currently working in the facility regarding the repositioning needs of Resident #66 to assist with healing his pressure injuries. Interview was conducted on 02/04/22 at 10:49 A.M. via telephone with the DON regarding the 07/30/21 order for the specialty air mattress to be on his bed. The DON reported Resident #66 at one time had that mattress after he returned from a hospitalization on [DATE]. The DON stated Resident #66 did not need it, so she was going to discontinue the order. The DON verified the mattress currently on his bed was not a specialty air mattress. Review of the undated facility policy titled Prevention of Pressure Ulcers/Injuries stated risk factors and interventions designed to reduce or eliminate pressure injuries should be known by all staff caring for the at-risk resident. The skin should be inspected daily with personal care and bed bound residents should be repositioned every at least two hours. 2. Review of the medical record for Resident #11 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care dated 10/05/21 revealed Resident #11 was at risk for pressure ulcers due to impaired mobility, and incontinence of bowel and bladder. Interventions included for staff to apply barrier cream to the peri area and coccyx. Review of the pressure ulcer risk assessment dated [DATE] revealed Resident #11 was at moderate risk for the development of pressure ulcers. Review of the quarterly MDS 3.0 assessment, dated 01/06/22, revealed Resident #11 had impaired cognition and was dependent on staff for bed mobility, transfers, ambulation, and toilet use. The assessment indicated Resident #11 had no pressure ulcers. Review of the nurses noted dated 01/22/22 at 3:10 P.M. revealed staff had documented Resident #11 had skin alteration to the coccyx measuring 5.0 centimeters (cm) in length by 2.0 cm in width by 0.2 cm in depth. The physician, DON, and the family were notified. Review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the TAR dated November 2021, December 2021, and January 2022 revealed an order dated 05/22/21 for staff to apply barrier cream to Resident #11's coccyx three times a day and after each incontinence episode. There was no documented evidence the treatment was provided as ordered on 11/09/21, 11/12/21, 11/12/21, 11/13/21, 11/20/21, 11/24/21, 11/25/21, 11/26/21, 12/03/21, 12/04/21, 12/07/21, 12/08/21, 12/09/21, 12/10/21, 12/18/21, 12/29/21, 12/31/21, 01/01/22, 01/02/22, 01/03/22, 01/04/22, 01/8/22, 01/09/22, 01/12/22, 01/15/22, 01/17/22, 01/18/22, 01/20/22 and 01/21/22. Interview on 02/01/22 at 12:15 P.M. with LPN #170 verified the missing documentation and could not confirm Resident #11's treatments were completed as ordered by the physician. During interview on 02/02/22 at 10:01 A.M., WP #900 stated he was not aware of Resident #11 having a wound on the coccyx. WP #900 stated Resident #11 was not assessed/treated during wound rounds on 02/01/22 due to lack of information. Review of the wound monitoring sheets revealed no wound assessment was completed by the wound physician for Resident #11 until 02/02/22 when prompted by the survey team. Review of the WP #900 wound assessment dated [DATE] revealed the wound measured 5.5 cm in length by 3.2 cm in width. This deficiency substantiates Complaint Numbers OH 224, OH 902 and OH 399.

Based on record review, facility fall investigation review and staff interview the facility failed to ensure care planned safety precautions were implemented. This resulted in actual harm when Resident # 112 sustained a fractured left arm, fractured right leg, and hematoma of left forehead after she rolled out of bed. This affected one of three residents reviewed for falls. Findings include: Resident #112 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a care plan dated 10/27/17 revealed Resident #112 as at high risk for falls related to cognition, debility, poor trunk control, and spontaneous jerking of arms. Interventions included bed in low position at all times (dated 11/04/176), air mattress with bolsters (dated 11/12/17), keep resident in the center of the bed (dated 03/09/18), bilateral floor mats to floor (dated 06/04/18). Review of a physician order [REDACTED]. A nursing progress note dated 06/16/18 at 11:30 A.M. documented Licensed practical nurse (LPN) #3 found Resident #112 on the floor, face down with her head at the foot of the bed. The resident was assessed and LPN #3 and two state tested nursing assistants (STNAs) placed Resident #112 in a wheelchair. The resident's left arm appeared to be displaced. A physician order [REDACTED].#112 was sent to the emergency room . An interdisciplinary team (IDT) progress note dated 06/28/18 at 6:31 P.M. documented the IDT reviewed the incident on 06/16/18. Resident #112 appeared to have rolled out of bed. Her left arm appeared displaced and there was a hematoma to the left side of the forehead. Review of the facility investigation of the fall on 06/16/18 revealed the bed was at an improper height. Interview with the assigned STNA, STNA #1 revealed she had prepped Resident #112 to get up using a mechanical lift. STNA #1 realized the mechanical lift was not charged and she left the room to get another mechanical lift battery. STNA #1 was prompted by a nurse to take other residents out on a smoke break. When STNA #1 returned to the floor she was informed Resident #112 was found on the floor. Review of the Fall with Injury Report, Incident Description statement by LPN #3 revealed Resident #112 was found on the floor, face down with arms underneath her. Upon assessment a hematoma was noted to the left side of the forehead and the left arm appeared displaced. Review of the handwritten statement by LPN #3 revealed that upon entering the resident room the bed was noted in the higher position. Review of the handwritten statement by STNA #4 revealed that upon entering the resident room to assist LPN #3, the bed was not in the lowest position. Review of the handwritten statement by STNA #1 revealed there were no floor mats in the room or around the bed. Review of the handwritten statement by STNA #5 revealed that upon entering the resident room to assist LPN #3 the bed was not in the lowest position. Interview on 07/01/18 at 2:45 P.M. with the director of nursing (DON) verified all of the above information. The DON stated that upon admission to the hospital Resident #112 was also diagnosed with [REDACTED]. The DON stated the bed should have been in the low position and floor mats should have been by the bed whenever the resident was in the bed. The DON stated it appeared Resident #112 rolled out of the bed when left unattended. This deficiency substantiates Complaint Numbers OH 756, OH 629, and OH 409.

Based on observation, clinical record review, family interview, resident interview, staff interview, and review of policies and procedures for restraint use and for refusal of medications, the facility failed to ensure one resident (Resident #103) was free from physical restraints imposed by staff for staff convenience. This resulted in Immediate Jeopardy and the potential for serious physical and psychological risks for Resident #103 when he was physically restrained by two staff members while being given an injection of a medication which he had repeatedly refused. This affected one resident reviewed for an allegation of physical abuse. The facility census was 140. On 03/06/18 at 1:36 P.M. the administrator, director of nursing (DON) and the regional director of clinical operations were notified Immediate Jeopardy began on 03/01/18 at 10:00 P.M. when Licensed Practical Nurse (LPN) #3 and LPN #4 witnessed LPN #1 and State tested Nursing Assistant (STNA) #2 hold Resident #103 down, restrain his arms and administer an insulin injection in Resident #103's left arm. The Immediate Jeopardy was removed on 03/04/18 at 9:00 A.M. when the facility implemented the following corrective actions: · On 03/02/18, upon receipt of the allegation, LPN #1 and STNA #2 were removed from the schedule. · On 03/02/18 the DON, Registered Nurse (RN) #11, LPN #8, Assistant Director of Nursing (ADON) #23 and the administrator began educating all staff on abuse, neglect, misappropriation, resident right to refuse medication and treatment, and resident right to be free of restraints. The facility educated 191 staff including nursing, administration, housekeeping and laundry, maintenance, business, social work, activities, and dietary staff. All education was completed on 03/03/18 at 8:30 P.M. · On 03/02/18, ADON #23, Director of Social Services #6, LPN #8, RN #11, Social Service Designee #7 and RN #22 began interviewing all interviewable residents in regard to staff treatment, abuse of staff, observation of abuse of other residents, and the right to refuse care and treatment, and to whom any concerns should be reported. Resident interviews were completed on 03/03/18 at 2:00 P.M. There were no concerns identified. · On 03/02/18, the DON, ADON #23 and nursing unit managers completed head to toe assessments of non-interviewable residents to ascertain the presence of any injuries. Assessments were completed 03/03/18 at 8:00 P.M. No injuries were discovered. · On 03/04/18 at 9:00 A.M. a house wide audit of resident refusals of care and/or treatments and medications within the previous thirty days was completed by the DON, ADON #23, and nursing unit managers. · On 03/04/18 the facility began audits of refusals for three residents to be done three times per week for three weeks, then on three residents one time per week for three weeks, then on one resident one time per week for three weeks. Audits are to be completed by the nursing unit managers. The results of the audits would be reported to the Quality Assurance Committee for further review and recommendation. · Interviews on 03/08/18 between 7:40 A.M. and 8:40 A.M. revealed MDS Coordinator #12, Human Resource Director #13, Housekeeper #14, Staffing Coordinator #15, LPN #16, LPN #17, STNA #18, STNA #19, STNA #20, Assistant Business Office Manager were knowledgeable regarding abuse, neglect, misappropriation, restraints, resident rights, resident choices, notification. Although the Immediate Jeopardy was removed on 03/04/18 at 9:00 A.M., the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated Resident #103 had none to mild cognitive impairment. Review of a physician order dated 06/08/17 revealed Humalog insulin( used to control blood sugar levels in diabetes) inject as per sliding scale subcutaneously (sq) before meals for diabetes. Another physician order dated 01/25/18 indicated [MEDICATION NAME] 100 units/milliliter (ml) inject 90 units sq at bedtime for diabetes. Review of a care plan dated 04/14/17 and revised 02/09/18 identified a concern of refusal of insulin coverage and refusal of medications. Interventions included administer medications as ordered, monitor/document for side effects and effectiveness, anticipate and meet the resident's needs, explain all procedures to resident before starting and allow 'X' minutes to adjust to changes (number of minutes not specified), if reasonable discuss behaviors, explain/reinforce why behavior was inappropriate and/or unacceptable to resident, intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention, remove from situation and take to alternate location as needed, two staff members at all times for care and medication administration due to refusals and false accusations. Review of the Medication Administration Record [REDACTED]. Resident #103 refused the sliding scale Humalog insulin on 01/02/18, 01/06/18, 01/07/18, 01/10/18, 01/11/18, 01/16/18, 01/19/18, 01/21/18, 01/24/18, 01/25/18, 01/30/18,02/25/18, 02/26/18, 02/27/8, 02/28/18, and 03/02/18. Review of the progress notes from January, February, and (MONTH) of (YEAR) revealed Resident #103 refused insulin injections on 02/21/18, 02/25/18, and 02/27/18. A progress note dated 02/28/18 at 5:22 P.M. revealed the nurse practitioner was notified of the resident's continuous refusal of routine and sliding scale insulin coverage. The resident's power of attorney (POA) was in the facility and was asked to discuss the risks and benefits of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] with the resident and she said she would. A progress note dated 02/28/18 at 6:41 P.M. revealed Resident #103 allowed the nurse to take his blood sugar and refused coverage for a blood sugar level of 352. The resident was re-educated on the risk of [MEDICAL CONDITION] and he stated he told his doctor he was not taking insulin, he was only getting it one time a day. A handwritten progress note (due to computer going down) dated 03/01/18 at approximately 10:00 P.M. revealed the nurse checked Resident #103's blood sugar without difficulty, blood sugar results were 399. The nurse left the room to obtain insulin and returned to the room to administer the medication. During the injection the resident became combative and attempted to strike the nurse and the STNA. The STNA intercepted the resident's right arm to prevent him from striking the nurse. The nurse stabilized the left arm and completed the injection. On 03/05/18 at 11:55 A.M. the surveyor was approached by a family member of Resident #103. The family member stated that either last Wednesday or Thursday, Resident #103 was held down by two staff members and given an insulin injection. The family member stated the resident had the right to refuse the insulin and was yelling and screaming. Resident #103 said he did not want to take the insulin. The incident was heard by two other residents on the unit (a resident name and room were provided). The family member received three anonymous phone calls and advised of the incident. The following day the police were in the facility to investigate. The incident happened Wednesday or Thursday of last week at around 10:00 P.M. The family member stated Resident #103 had dementia but was able to tell what happened. An interview on 03/05/18 at 12:10 P.M. with the facility administrator revealed LPN # 3 reported to him on Friday (03/02/18) that LPN #1 and STNA #2 were rough with Resident #103. Both LPN #1 and STNA #2 were removed from the schedule. It was reported early on the morning of 03/02/18 that the incident occurred on 03/01/18 during the evening. An interview on 03/05/18 at 12:26 P.M. with LPN #3 revealed last Thursday evening (03/01/18), around 10:00 or 10:30 P.M. she heard yelling from Resident #103's room. She went to the room and heard the resident say no I don't have to take this. She entered the room and observed STNA #2 holding the resident down and LPN #1 had his arm on the resident's chest and with his other arm he gave Resident #103 an injection in his left arm. LPN #3 yelled for him to stop. This was reported to the charge nurse on the first floor (RN #5) who told her to report it to the facility administrator. LPN #3 notified the administrator via phone at about 4:00 A.M. LPN #3 stated STNA #2 told her it should not have happened and would never happen again and he did it at the direction of LPN #1. LPN #3 stated another nurse (LPN #4) also witnessed the incident with her. An interview on 03/05/18 at 1:11 P.M. with Resident #103's POA revealed she received a phone call last Friday (03/02/18) notifying her about the incident on Thursday night. The POA spoke with Resident #103 who told her they forced him down, one held his arm the other held and twisted his arm and they forced him to take the insulin shot. Resident #103 stated it was two male nurses. The POA went and got the unit manager who stated the incident was under investigation and the two staff members were suspended pending completion of the investigation. The POA called the local police department who came to the facility. The police interviewed Resident #103. The POA stated a resident down the hall (Resident #69) heard the incident as well as Resident #77. The police did not interview either resident. The POA stated Resident #103 sometimes took the insulin and sometimes refused the insulin. When he refused, the facility called her and notified her of the refusal. This was the first time this had happened, the facility had not forced the medication until now. The POA stated the resident usually took the insulin in the morning but not at night. On 03/05/18 at 1:40 P.M. interview with Resident #103 revealed he was alert, oriented and answered questions appropriately. When asked what happened last Thursday evening, Resident #103 stated two male nurses twisted his arms and made him take an insulin shot. When asked what exactly they did, Resident #103 stated they held him down, he was yelling they were hurting him. Resident #103 stated he told them he was not supposed to get insulin at night, he was supposed to get it at dinner time around 6:00 P.M. Resident #103 indicated he got the shot in the top of his left arm. Resident #103 stated this was the first time this happened. Resident #103 stated he was upset by what happened because they shouldn't make him take the insulin. On 03/05/18 at 2:30 P.M. interview with Resident #77 revealed last Thursday night something happened in Resident #103's room. He heard a lot of yelling, noise, loud talk but did not know anything more about it. On 03/05/18 at 2:44 P.M. interview with Resident #69 revealed she heard a big commotion the other night. She heard hollering and screaming in Resident #103's room, but did not know anything more about it. On 03/05/18 at 2:10 P.M. interview with RN #11, the second floor unit manager, revealed she arrived to work on Friday, 03/02/18, around 11:30 A.M. She was told on 03/02/18 (no time specified) Resident #103 had marks on his arms. RN #11 assessed Resident #103 and noted bruises on his left knuckle, wrist, and left arm from needle sticks while in the hospital. He also had bruises on his right inner arm from labs sticks. At the time of the assessment RN #11 was not aware of any incident where staff had held the resident down. After she completed the assessment she heard from other nurses about the incident the night before (03/01/18). RN #11 was told the night before nurses tried to give Resident #103 insulin, he was hollering, they did not identify the staff. She went to the DON and asked if there was an incident. The DON said the nurses the night before noted bruises and hollering. The DON said an investigation would be conducted. On 03/06/18 at 9:28 A.M. interview with social worker (SW) #5 revealed Resident #103 was alert and oriented and able to describe what happened on Thursday evening. SW #5 interviewed Resident #103 on Friday morning (03/02/18). Resident #103 told her he did not want the insulin, he believed he did not need the shot. Resident #103 told her two men came to his room, one was on each side of his bed, one grabbed one arm, one grabbed the other and they held him down and gave him the shot. On 03/06/18 at 9:40 A.M. interview with the first floor unit manager, LPN #8, revealed she was at the above interview and verified the above information. LPN #8 stated she assessed Resident #103's arms and observed fading bruises from recent needle sticks while at the hospital. On 03/06/18 at 10:26 A.M. interview with LPN #4 via telephone revealed that last Thursday, 03/01/18 she and LPN #3 were walking down the hall on which Resident #103 resided. LPN #1 was walking ahead of them. She heard LPN #1 say he is getting this insulin. She observed LPN #1 enter Resident #103's room and tell STNA #2 to hold him down. Resident #103 was lying in bed, STNA #2 held one arm down, LPN #1 put his forearm on Resident #103, held his other arm and gave him the shot in his left arm. This was about 10:30 P.M. (unable to give exact time). Resident #103 was yelling, kicking and said he did not want the shot. LPN #3 and LPN #4 told STNA #2 to leave the room. LPN #4 stated she definitely heard LPN #1 tell STNA #2 to hold Resident #103 down. Review of the undated facility policy and procedure for use of restraints revealed a restraint was not to be used for discipline or convenience and were not required to treat medical symptoms. Convenience was defined as any action taken by the center to control resident behavior or maintain residents with a lesser amount of effort by the center and not in the resident's best interest. Freedom of movement was defined as the ability of the resident to move around within the context of the resident's functional capacity as assessed by the center. Functional capacity included cognitive, perceptual and psychosocial functioning. It encompassed the ability to rationally determine ones actions and their consequences and the ability to refrain from impulsive acts. Review of the facility policy and procedure for refusal of medication or treatment, revised 11/01/13, indicated if three consecutive doses/treatments were refused by the resident the physician would be notified. When a resident refuses a prescribed medication or treatment, documentation of the refusal was made by circling the nurse's initials on the medication or treatment administration record and recording the reason in the space provided. Documentation of notification and related actions would be recorded in the nurses' notes.

Based on observation, resident interview, medical record review, staff interview, witness statement review, climate report review and policy review, the facility failed to provide adequate supervision to prevent the elopement of Resident #13, a [AGE] year old woman who was moderately cognitively impaired, independently mobile via wheelchair and assessed as being at moderate risk for elopement. This resulted in Immediate Jeopardy on 10/10/16 at 7:33 P.M. when Resident #13 exited the building unsupervised sounding an alarm which Registered Nurse (RN) #11 turned off without taking further action. The potential for serious harm occurred when Resident #13 exited the front entrance of the building after sunset in a wheelchair, wheeled through the facility parking lot and down a steep incline and was approximately 0.25 miles down a two-lane road before being seen by a passer-by who alerted the facility that they may have a missing resident. This affected one (Resident #13) of 12 residents assessed as being at risk for wandering and elopement. On 10/20/16 at 2:40 P.M. the Administrator and Regional Director of Clinical Operations (RDCO) #13 were notified Immediate Jeopardy began on 10/10/16 at 7:10 P.M. when Resident #13 was last seen prior to exiting the building unsupervised resulting in activation of a door alarm which RN #11 turned off without initiating a resident search. The Immediate Jeopardy was removed on 10/12/16 when the facility implemented the following corrective actions: · On 10/10/16 between 7:30 P.M. and 8:30 P.M. 30 employees were educated by Licensed Practical Nurse (LPN) #12 regarding the facility's policy and procedure for a missing resident and what to do if a door alarm was sounding. · On 10/10/16 the facility assigned a staff member to monitor the front doors during the hours of 8:00 P.M. to 7:00 A.M. when the receptionist was off duty. The facility indicated they would continue to assign a monitor until a WanderGuard system was installed on the first, second and third floor elevator doors. A WanderGuard system automatically locks and/or alarms when a resident wearing a bracelet enters a defined area or attempts to exit through the doors. · On 10/11/16 from 9:30 A.M. to 5:00 P.M., 117 employees were educated by the Administrator, Therapy Director #15, RN #16, Dietary Director #17, Activities Director #18, Human Resources Director #19, Business Office Manager (BOM) #20, Central Supply Director #21, Social Service Designee #22, Medical Records Coordinator #23, Assistant BOM #24, Scheduler #25, Social Service Director #26, RN #27, LPN #28, LPN #29 and RN #30 regarding the facility ' s policy and procedure for a missing resident and what to do if an alarm was sounding. · On 10/11/16 all residents were re-assessed for their wandering risk to ensure the wandering assessment was completed accurately and the risk score reflected the residents' current status. · On 10/11/16 the residents identified at risk for elopement had their WanderGuard bracelets checked for placement and proper functioning by Maintenance Director #31 and RDCO #13. · On 10/11/16 the facility confirmed all residents identified at risk for elopement were in the elopement binder kept at the receptionist desk and the nursing stations. · An elopement drill was completed on 10/11/16 at 6:24 P.M. by the Administrator. · Elopement drills were completed on 10/12/16 at 6:10 A.M. and at 2:20 P.M. by Maintenance Director #31, RDCO #13 and Maintenance Technician #32, respectively. · Interviews on 10/20/16 from 10:00 A.M. to 10:40 A.M. with LPN #2, LPN #3, LPN #5, LPN #6, Stated tested Nurse Aide (STNA) #7 and STNA #8 revealed they were educated on the elopement policy and procedure and what to do if a door alarm was sounding. Although the Immediate Jeopardy was removed, the deficiency remained at Severity Level 2 (no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy) as the facility was in the process of inservicing all staff regarding the facility's policy and procedure for a missing resident and what to do if an alarm was sounding, and the installation of a WanderGuard system for the elevators had not been completed. Findings include: Record review of Resident #13 revealed an initial admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #13 was moderately cognitively impaired, required supervision with locomotion on and off the unit and used a wheelchair for mobility. Review of the October, 2016 physician orders [REDACTED].#13's left ankle and the door transmitter was to be checked daily by appropriate staff. Review of a care plan initiated on 03/25/15 revealed Resident #13 had a history of [REDACTED]. Review of the wandering observation tool assessment dated [DATE] revealed Resident #13 was at low risk for elopement. Review of the 11/16/15 incident note timed 6:37 P.M. revealed Resident #13 was found by a visitor in the facility parking lot and was brought back into the facility by the visitor. When Resident #13 was asked why she left the building, Resident #13 stated she was trying to go to her mother's house. Review of the 12/12/15 incident note timed at 6:40 P.M. revealed a STNA informed the nurse Resident #13 was exiting the first set of double doors as a group of visitors were leaving the facility, the STNA redirected Resident #13 and she did not leave the facility. Review of an 08/22/16 clinical daily progress note timed at 7:40 P.M. revealed Resident #13 had made several attempts to exit the building through the ambulance doors and the patio gate and stated she was going down to her brother's house. The alarm sounded due to Resident #13's WanderGuard bracelet and her exit was not successful. Review of the wandering observation tool dated 08/22/16 revealed Resident #13 was at moderate risk for elopement. Review of the 10/11/16 incident note timed 12:52 A.M. revealed the nursing supervisor, LPN #12 called LPN #9 and instructed the staff to do a head count and Resident #13 was not accounted for. The nursing supervisor stated Resident #13 was outside and had been brought back into the facility by staff. Resident #13 stated she was going to her sister-in-law's house. A skin check was completed upon arrival back to the facility and no skin issues were present. Review of the witness statement signed by LPN #2 dated 10/10/16 revealed shortly after 7:00 P.M., Resident #13 was seen on the first floor in her wheelchair. Review of the witness statement signed by LPN #12 dated 10/10/16 revealed at approximately 7:35 P.M., LPN #12 received a phone call from someone stating I think you have a patient going down the two lane road the facility is on, in a wheelchair. LPN #12 called the second and third floors to complete a head count and RN #11 went outside to look to see if a resident was outside. LPN #12 walked outside with STNA #10 and as LPN #12 and STNA #10 were walking towards the end of the driveway, RN #11 was walking with Resident #13. Review of the witness statement signed by RN #11 dated 10/10/16 revealed RN #11 was on the second floor at approximately 7:20 P.M., upon returning to the first floor RN #11 shut the front door alarm off; there were no residents near the front door. RN #11 returned to the nurse's station and someone called stating they saw someone in a wheelchair at 7:35 P.M. going up the two-lane road the facility was on. RN #11 immediately went outside looking for a resident and found Resident #13 wheeling up the two lane road the facility was on near an intersection towards another two lane road. RN #11 returned Resident #13 to the facility. Review of the witness statement signed by Maintenance Director #31 dated 10/11/16 revealed on 10/10/16 at 9:30 P.M. he took a WanderGuard bracelet and checked the main entrance, ambulance, foyer and the employee entrance doors and all the doors locked and alarmed when the WanderGuard bracelet was in range. He went to the security room to review the camera system which showed at 7:33 P.M. Resident #13, who was wearing a WanderGuard bracelet, pushed on the door at the main entrance until the door released, and wheeled herself out the door. At 7:40 P.M. the cameras showed a nurse and other staff pushing Resident #13 back in through the front door. The staff took her up to the planter in the lobby then back to the doors to see if the WanderGuard system worked, which it did. Maintenance Director #31 then observed the staff member enter the code on the key pad near the door to re-engage the locks. Observation on 10/20/16 at 10:30 A.M. revealed Resident #13 sitting in a wheelchair by the third floor nurse's station. An attempt to interview the resident was unsuccessful; she smiled and laughed when asked questions. Observations on 10/20/16 from 10:00 A.M. to 10:40 A.M. revealed the elevator doors on the first, second and third floors were not WanderGuard protected. Interview on 10/20/16 at 12:25 P.M. with LPN #3 revealed the last time she observed Resident #13 on 10/10/16 was at 7:15 P.M. when Resident #13 was sitting by the third floor nurse's station. Interview on 10/20/16 at 2:46 P.M. with RN #11 revealed RN #11 was working on the first floor on 10/10/16, went to the second floor, came back down to the first floor and heard the alarm ringing and turned the alarm off. RN #11 went back to the nurse's station and LPN #12 stated a resident was going towards a two-lane road. RN #11 went outside and got Resident #13 who was calm and said she was going to her sister-in-law's house. RN #11 stated she did not go outside to look for a resident when she turned the alarm off, she said the alarm sounding at that time of day was normal as there were always a lot of visitors going in and out of the building. A second attempt to interview Resident #13 on 10/10/16 at 3:30 P.M. was unsuccessful. She continued to smile and laugh when asked questions and leaned down to touch the WanderGuard bracelet on her left ankle. Review of the National Weather Office Service Forecast (www.weather.gov) daily climate report revealed a high temperature on 10/10/16 of 65 degrees Fahrenheit (F) and a low of 41 degrees F. Sunset was at 6:54 P.M. Review of the missing resident policy effective 06/17/16 and revised on 10/10/16 revealed if an alarm was sounding, staff must respond to the identified alarm sounding, assess the area including the perimeter and if a resident was not found after the search, a head count was to be completed to ensure resident safety. This deficiency substantiates Complaint Number OH 538.

Based on interview, closed record review and review of policy and procedures, the facility failed to implement preventative measures to prevent pressure ulcer development for one resident. This resulted in Actual Harm to Resident #209 who developed unstageable pressure ulcers and a suspected deep tissue injury while in the facility. This affected one of three residents reviewed for pressure ulcers. Findings include: Review of Resident #209's closed medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Braden scale dated 05/14/15 revealed the resident was at high risk for pressure ulcer development. Review of the physician's orders [REDACTED]. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #209 was cognitively intact. He required extensive assistance of two staff for bed mobility, transfers, dressing, toilet use and hygiene. The resident had an indwelling Foley catheter and was frequently incontinent of bowel. He had no pressure areas, but was at risk for pressure ulcer development. He had a pressure reducing cushion to his wheelchair and a pressure reducing device for the bed, but no turning and repositioning program. Review of a Care Area Assessment (CAA) dated 05/19/15 stated Resident #209 did not have any pressure ulcers at the time. He did have a blister area to the groin that was being treated. The resident was at risk for pressure ulcer development related to immobility. This deficiency substantiates Complaint Number OH 655. Review of the treatment administration records (TARs) for July and August 2015 revealed the zinc barrier cream was not applied per the physician's orders [REDACTED]. Review of the TARs for July and August 2015 revealed the heels were not floated per the physician's orders [REDACTED]. Review of the TARs for July and August 2015 revealed the skin checks were not completed per the physician's orders [REDACTED]. Review of a skin grid dated 08/19/15 revealed an open area to the right buttock measuring 1.0 cm long by 1.0 cm wide by 0.1 cm deep, described as moisture associated skin disorder (MASD). Review of a skin grid dated 08/19/15 revealed a Stage II pressure ulcer to the left buttock measuring 1.3 cm long by 1 cm wide by 0.1 cm deep. Review of a skin grid dated 08/19/15 revealed an unstageable (Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined) pressure ulcer to the left buttock buttock measuring 2.0 cm long by 1.5 cm wide. Review of a skin grid dated 08/19/15 skin revealed a suspected deep tissue injury (SDTI) (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue) pressure ulcer to the left heel measuring 2.4 cm long by 4.0 cm wide. Review of the progress notes dated 8/19/15 at 9:01 P.M. stated the state tested nurse aide (STNA) alerted the nurse at 6:00 P.M. that Resident #209 had multiple open areas on his buttocks. The nurse went in to assess the resident. The resident had an MASD 1.0 cm long by 1.0 cm wide by 0.1 cm deep to the right buttocks. The left buttock had an unstageable area, dark purple black in color (blood blister), 2 cm long by 1.5 cm wide. Directly below that was a Stage II pressure area measuring 1.3 cm long by 1.0 cm wide by 0.1 cm deep, 100% granulation noted. The nurse stepped out of the room and upon returning, the STNA stated the resident also had an area to his heel. The left heel was assessed to have a deep tissue injury (DTI), dark purple in color. The right heel was assessed and had blanchable redness. An interview with the Director of Nursing (DON) on 09/17/15 at 10:30 A.M. verified that the area to Resident #209's left buttock was first observed as an unstageable pressure ulcer, and the area to the left heel was first observed as a DTI. The DON also verified the multiple dates in July and August 2015 that the physician's orders [REDACTED]. This deficiency is a recite to the complaint surveys dated 05/13/15 and 07/13/15, and substantiates Complaint Numbers OH 655 and OH 592.

Based on record review and staff interview, the facility failed to address significantly low blood levels of the [MEDICAL CONDITION] medication [MEDICATION NAME] for one of four residents (Resident #159) reviewed for discharge to the hospital. Harm occurred when Resident#159 sustained multiple witnessed [MEDICAL CONDITION] on 03/08/15 and required hospitalization due to the low levels of the anti-[MEDICAL CONDITION] medication in the blood. Three facility residents had [DIAGNOSES REDACTED]. Findings include: Record review for Resident#159 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission history revealed Resident #159 was admitted to the hospital for [MEDICAL CONDITION] because the resident had not been taking his anti-[MEDICAL CONDITION] medications which resulted in low blood levels of the medications. Admission physician orders [REDACTED]. Admission physician exam dated 02/27/15 revealed new orders for laboratory (lab) tests that included a [MEDICATION NAME] blood level to be completed on 03/03/15. Review of medication administration records (MAR) for February and March 2015 revealed Resident #159 refused his anti-[MEDICAL CONDITION] medications on 02/28/15, 03/01/15, and 03/02/15. Review of the [MEDICATION NAME] blood level lab results drawn on 03/03/15 revealed a significantly low [MEDICATION NAME] blood level of 2.2 micrograms/milliliter(ug/ml). The therapeutic blood level was 10-20 ug/ml. Review of physician orders [REDACTED].M. revealed while new orders were received after the lab results were reported, there was no new order for a repeat blood level or additional medication to monitor and treat the significantly sub-therapeutic [MEDICATION NAME] level. Review of nurse's notes dated 03/08/15 at 4:28 P.M. revealed Resident #159 had a witnessed [MEDICAL CONDITION] at 12:30 P.M. that afternoon for one and one half minutes duration and an additional [MEDICAL CONDITION] (no time documented) that was called to the staff's attention by another resident. The nurse documented staff witnessed about 20 seconds of the second [MEDICAL CONDITION] after being notified. There was no documentation the physician was notified at the time of the [MEDICAL CONDITION] for additional treatment orders. Three late entry nurse's notes dated 03/09/15 between 12:25 A.M. and 06:40 A.M. revealed additional information about the events on 3/08/15. The notes revealed the certified nurse practitioner (CNP) #1 was notified on 03/08/15 at 4:30 P.M. of the [MEDICAL CONDITION] activity that occurred four hours earlier in the day and stat (immediate) [MEDICATION NAME] and [MEDICATION NAME] levels were ordered at that time. Lab test results revealed the stat [MEDICATION NAME] level was drawn on 03/08/15 at 6:30 P.M. and the subtherapeutic result was faxed to the facility at 7:36 P.M. The nurse's note on 03/09/15 at 6:40 A.M. indicated when the family arrived around 8:00 P.M. on 03/08/15, Resident #159 had two additional witnessed [MEDICAL CONDITION]. The family requested he be transferred to the emergency room . The note indicated at 8:10 P.M., CNP #1 was notified of the low [MEDICATION NAME] level and the family request for transfer. An order was obtained to send the resident to the hospital for treatment of [REDACTED]. The note continued to identify the resident was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. Resident #159 did not return to the facility. Interview with the Director of Nursing (DON) on 06/03/15 at 4:30 P.M., revealed the physician was notified of abnormal lab results and the staff documented any new orders obtained. The DON confirmed Resident #159 was admitted to the facility following a hospitalization for [MEDICAL CONDITION] from a low [MEDICATION NAME] blood level. The DON confirmed when CNP #1 was notified of lab results that indicated a significantly low [MEDICATION NAME] blood level for Resident#159, there were no new medication orders to treat the low blood level. The DON confirmed there was no repeat [MEDICATION NAME] level ordered in response to the low blood level to monitor the resident until Resident #159 had four witnessed [MEDICAL CONDITION] on 03/08/15 that required hospitalization to treat the low [MEDICATION NAME] level. This deficiency substantiates Complaint Number OH 162 conducted 06/03/15 and is an example of continued noncompliance from the complaint survey for Master Complaint Number OH 039 and Complaint Number OH 964 investigated on 05/13/15.

Based on interview, observation, review of nurses notes, facility investigation report, pressure ulcer care plan and skin grids, the facility failed to properly position one resident (Resident #146), who was dependent for positioning, in his air bed. This resulted in actual harm when Resident #146 developed two unstageable pressure ulcers to the right outer knee and right ankle. This affected one of one residents reviewed for pressure ulcers. The facility census was 160. Findings include: Review of Resident #146's medical record revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #146's activities of daily living check list revealed he was bed bound and required total assist of two for bed mobility. Resident #146's care plan for pressure ulcer development dated 02/26/15 indicated interventions included to apply bilateral heel protectors, education for causes of skin breakdown including repositioning and transfers, report any skin changes to the physician, apply an air mattress to the bed and a pressure cushion to the wheelchair. On 04/01/15 the care plan was updated to include ensuring extremities were on the mattress and not resting on the built-in bolster. Review of Resident #146's physician orders [REDACTED]. Review of the skin risk assessments dated 03/02/15 revealed Resident #146 was a moderate risk for development of pressure areas. Review of Resident #146's nursing notes dated 04/01/15 at 10:45 P.M., revealed a State-tested Nurse Aide (STNA, identity unknown)) reported finding wounds to Resident #146's right knee and right ankle. Upon assessment both wounds were identified as unstageable pressure wounds. The right lateral knee was described as black leather-like with necrotic tissue and reddened edges. The right lateral ankle wound was hardened black eschar and slightly reddened. Review of the skin grid dated 04/01/15 completed by Registered Nurse (RN) #38 revealed Resident #146 developed a 2.5 centimeter (cm) by 2.8 cm by an undetermined depth pressure area to his right knee. The wound was unstageable, defined as a full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. An assessment of the right outer ankle had not been documented. Interview with RN #20, the wound nurse, on 05/12/15 at 12:01 P.M. revealed Resident #146 did not have any wounds to his ankles or knee on his 03/02/15 re-admission. On 04/01/15 an STNA found the wounds to the right knee and the wounds were assessed that day. RN #20 stated the facility did not know when the wounds developed. RN#20 stated Resident #146 is severely compromised, is unable to move himself, has daily spasms, lies mostly on his right side, and had been in and out of the hospital. RN #20 stated it was determined that Resident #146's knee was resting on a hard ridge on the bed bolster. RN #20 stated she assessed the right outer ankle and the right knee. Resident #146's right knee wound measured 1.5 cm by 2.0 cm by an unstageable depth; the right outer ankle measured 1.5 cm by 1.0 cm by an unstageable depth. The wound bed was hard with dry eschar, the peri-wound was intact and there was no drainage. RN#20 stated she applied skin prep and left the wound open to air. Observation of Resident #146's wounds was not able to be completed. The dressing changes had been completed and the resident stated he experienced pain with repositioning. Resident #146 acknowledged education of the importance of turning, but indicated it caused him pain. Observation and interview with Resident #146 on 05/12/15 at 1:35 P.M. revealed he was alert and oriented and was lying on an air mattress with his legs positioned to the right side of the bed. Resident #146 was able to move his lower bilateral arms and hands minimally and had obvious uncontrollable spasms. His legs were positioned to the right side of the bed and he was covered with blankets and sheets. Resident #146 indicated he had wounds to his right ankle which were almost healed and a knee wound that was getting better. Resident #146 stated he refused to turn at times because of pain. Resident #146 stated he had spasms that seemed to move him to the same position on his right side. Resident #146 acknowledged education of the importance of turning, but indicated it caused him pain. He stated even with turning he migrated back to the right side due to spasms. Resident #146 stated the wounds were due to his right leg resting up against a hard spot on a raised area on the air bed that was not padded. Interview with the director of nursing (DON) on 05/13/15 at 9:58 A.M. revealed Resident #146 did not have the wounds when he was readmitted from a hospital stay on 03/02/15. The DON indicated the STNAs completed Resident #146's skin checks on 03/31/15 at 6:59 A.M., and there was no record of a wound being present at that time. The DON stated the pressure areas were discovered on 04/01/15 around 8:40 A.M. The DON verified Resident #146 was very compromised, and was total care. The DON indicated staff had not implemented an intervention to prevent Resident #146's right leg from resting on the air bed bolster and developing a pressure area. This deficiency was an incidental finding at the time of the Complaint Investigation.

Based on observation, interview and review of nursing notes revealed the facility failed to ensure oxygen 'E' tanks were stored in approved holders. This resulted in actual harm for one resident (Resident #112) who sustained a laceration to her right shin requiring a hospital visit with five day antibiotic treatment, tetanus administration and dressing changes. This affected one of four residents reviewed. The facility census was 160. Findings include: Review of Resident 112's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with Resident #112 on 05/12/15 at 7:45 A.M. revealed in January or February, 2015 when she came out of the bathroom the door hit an oxygen E tank and it hit her leg. She stated there were six empty E tanks in her room that were not in holders. The tank cut her leg. Resident #112 stated Registered Nurse (RN) #20 put a gauze bandage on her leg and she was sent out the hospital on the next shift. Observation of Resident #112's right shin on 05/12/15 at 7:45 A.M. revealed scar tissue extending from her lower right shin to her ankle area and was approximately three inches long and a half inch wide with a remaining deep impression. Review of nursing notes dated 01/16/15 at 8:27 P.M. revealed RN #20 was called to Resident #112's room by a state tested nursing assistant (STNA, identity unknown) who stated that Resident #112 was bleeding. The note indicated blood was dripping from the right lower leg onto the floor. The wound was assessed and a gauze pressure dressing was applied. The nurses note indicated Resident #112 was medicated for pain twice on that shift. There was no documented evidence the physician or family were notified of the incident. Review of the nursing notes dated 01/17/15 revealed at 9:15 P.M. RN #1, nursing supervisor, measured Resident #112's right shin wound and noted a moderate amount of sanguineous drainage. Resident #112 complained of pain at the site. RN #1 notified Certified Nurse Practitioner #1 on 01/17/15 at 10:20 P.M., of Resident #112's leg wound and her complaints of pain. Resident #112 was sent to the emergency room . On 01/17/15 at 12:40 A.M., the hospital notified the facility that Resident #112 received a tetanus shot, her right shin wound was cleansed and a dressing was applied. Resident #112 was started on an antibiotic, Keflex 500 milligrams, four times day for five days. New orders were obtained for a dressing change and nursing staff were to monitor for signs and symptoms of infection and continue with pain medication as ordered. Resident #112 returned to the facility on [DATE] at 2:00 A.M. Interview with RN #20 on 05/12/15 at 12:36 P.M. revealed the incident occurred the morning of 01/16/15 at 8:40 A.M., around morning medication pass. The right shin wound measured 7.5 centimeters (cm) long by two cm wide by 0.2 cm in depth. The wound bed was granular and bleeding. The peri-wound was intact and a moderate amount of blood was continuously oozing from the wound. Observation of the facility on 05/12/15 at 1:00 P.M. revealed no unsecured oxygen 'E' tanks. Review of an inservice dated 01/16/15 revealed staff were educated on the storage and placement of 'E' tanks using tank holders. Review of Resident #112's plan of care indicated not to leave empty 'E' tanks in the resident's room. This deficiency was an incidental finding at the time of the Complaint Investigation.

Based on staff interview, resident interview, and record review, the facility failed to ensure one resident was free of verbal/ physical/ psychological abuse. This affected one resident (Resident #60) of two residents reviewed for allegations of abuse. Harm occurred to Resident #60 when STNA #200, pushed the resident's wheelchair, hit the resident on her arm, and called the resident a cry baby when she was observed crying. Findings include: Review of a self-reported incident dated 06/24/13 at 5:36 P.M. revealed an allegation of physical abuse with Resident #60 as the victim of a facility staff or other caregiver. Although the self-reported incident did not name a perpetrator, witness statements provided by the facility showed State-tested Nurse Aide (STNA) #200 as the alleged perpetrator. Interview with Resident #60 on 06/26/13 at 12:00 P.M. revealed the resident had hit STNA #200 with her wheelchair and STNA #200 had pushed the wheelchair back and hit the resident on her right arm. The resident indicated she had hit STNA#200 back. The resident said she did not have a bruise or anything on her arm and her arm was not hurt. When asked if she felt safe, the resident replied "yes 'cause she is gone and she won't be back no more. I don't see her here no more." When asked "would you feel OK if she came back?" Resident #60 replied "No, I don't want to be bothered with her." On 06/26/13 at 12:10 P.M. an interview with Registered Nurse (RN), #201, the unit manager, in the presence of the director of nursing and administrator revealed she had been called by RN #202, unit supervisor at 5:40 P.M. on 6/23/13 because Resident #60 was crying. On 06/26/13 at 12:51 P.M. interview with RN #202 revealed STNA #200 had come to her crying because STNA #205 had told her a family member had a concern over an interaction she had with Resident #60. The charge nurse was informed by STNA #205 that STNA #200 was teasing Resident #60 and the resident was in tears. A family member had said "Oh wow" and STNA #205 felt the family member might have a concern. RN #202 indicated she called RN #201 on 06/23/13 and asked her to call her back with a witness statement. RN #202 indicated she had pulled STNA #200 into her office while she collected witness statements. After RN#202 again called RN #201 and read her the witness statements, STNA#200 was put back on the floor, but was not assigned to Resident #60 for the rest of the evening. Review of a witness statements associated with the incident on 06/23/13 revealed STNA #206 witnessed Resident #60 crying and telling STNA #200 to leave her alone. STNA #200 and Resident #60 were "going back and forth" and the resident went in the solarium where she continued to cry. STNA #200 walked up to Resident #60 "saying crybaby you don't like it when people do it to you". The statement indicated a family member was watching and shaking her head. Interview with the facility's administrator on 06/26/13 at 1:25 P.M. confirmed the "teasing" should have resulted in STNA #200 being sent home on 06/23/13. The administrator confirmed she should have been made aware by staff members and not by the ombudsman on her visit the afternoon of 06/24/13. This deficiency substantiates complaint OH 716.

Based on medical record review and staff interviews, the facility failed to provide adequate assistance during care to prevent actual harm to Resident #153 who hit her head on a bed side table resulting in a hematoma, laceration and head injury with admission to the hospital. This deficient practice affected one resident (Resident #153) of three residents reviewed for injuries of unknown origin. The total facility census was 152. Findings include: Review of the medical record revealed Resident #153 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set 3.0 (MDS) with a completion date of 07/17/12 and the most recent quarterly assessment with a completion date of 04/15/13 revealed Resident #153 required total assistance of two people for bed mobility (defined as how the resident was moved to and from lying position, turned side to side and positioned body while in bed). Review of the Resident Summary the State tested Nurse Aides (STNA's) used for delivering care, identified Resident #153 as requiring the total assist of two people for turning and positioning. Review of the self-deficit care plan for bed mobility indicated the resident required extensive assist of two people. Review of a facility investigation dated 05/12/13 revealed STNA #1 had indicated she was changing Resident #153 because her linens were wet. The STNA turned the resident to the left side and may have turned her too hard because her head hit the dresser drawer which may have been slightly open. The STNA realized the resident hit her head when she turned the resident back and saw her head bleeding. On 05/13/13 STNA #1 provided additional information and indicated she went in the resident's room around 6:30 A.M. to 6:45 A.M. to change Resident #153. The STNA turned the tube feeding off, lowered the head of the bed and turned Resident #153 towards the wall. The STNA revealed she started pulling the sheets and the pad under the resident when she heard "a hit." She turned the resident back towards her and noticed the resident was bleeding. The STNA put towels on the laceration and reported the incident to the nurse. The nursing supervisor was notified at 7:05 A.M. Review of a progress note dated 05/12/13at 7:10 A.M. revealed upon assessment by the nurse, the resident had a hematoma with a laceration. The hematoma was the size of a silver dollar. There was a laceration that measured 1.8 centimeters (cm) x 0.3 cm x 0.1 cm. The area was cleaned with normal saline, triple antibiotic cream was applied, steristrips and the laceration was covered with border gauze. An ice pack was applied. The resident's vital signs were obtained and her temperature was 98.3 degrees Fahrenheit (F), pulse 100, respirations 16 and blood pressure 130/60. The physician was called without success at 7:30 A.M. and paged a second time at 7:50 A.M. The physician returned the call at 7:55 A.M. and ordered a stat CT (X-ray) scan of head. The resident's daughter was notified at 7:55 A.M. Neurological checks were started by the nurse and indicated the resident's pupils were equal and reactive to light. Resident #153's pulse, respirations and blood pressure were stable and her pulse oxygen level was 99 percent on oxygen at 2 liters per nasal cannula. Review of the medical record revealed the resident's daughter arrived on the floor. The nursing supervisor was notified and spoke with the resident's daughter. The resident was transferred to the hospital and remained in the hospital at the time of the survey. Review of a progress note dated 05/12/13 at 2:00 P.M.revealed Resident #153 was admitted to the hospital with [REDACTED]. Review of the investigation dated 05/12/13 revealed a report from the hospital indicated the resident was on a neurological unit and stable. On 05/15/13 at 10:00 A.M. Resident #153's room was observed. The resident had a bed without siderails. She had a pressure reduction mattress in place. The night stand was positioned on the left side and next to the bed. Observation revealed a suction machine on the nightstand and a tube feeding pole in the room on the right side of the bed. Interview with the Acting Unit Manager RN #2 on 05/15/13 at 10:15 A.M. revealed Resident #153 did not speak, was unable to follow directions but may look at a person who called her name. The unit manager indicated the resident was a two person assist with turns and she verified only one person was turning the resident at the time of the incident on 05/12/13. Interview with the Director of Nursing (DON) on 05/15/13 at 1:00 P.M. verified Resident #153 was a two person assist to turn. The DON verified the STNA turned Resident #153 by herself. This citation substantiated allegations contained in complaint #OH 201. This deficiency is an example of continued non-compliance from the annual survey completed on 03/28/13.

Based on interview and medical record review, the facility failed to provide adequate assistance during care to prevent actual harm to Resident #5 who fell and fractured his arm during morning care. This affected one (Resident #5) of three residents reviewed for falls. The facility census was 143. Findings include: Resident #5 was re-admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set 3.0 (MDS 3.0) dated 06/02/13 revealed Resident #5 was dependent upon the assistance of at least one other person for hygiene and toileting. He required the extensive assistance of at least one other person for dressing. Review of a nursing progress note dated 06/20/13 at 12:00 P.M. revealed Resident #5 was standing in his bathroom as State tested Nursing Assistant (STNA) #9 attempted to place a disposable brief on the resident. The resident fell backward in the bathroom and hit the back of his head. He was assisted back to his bed and complained of pain to his left arm and elbow. Resident #5 rated his pain as a "ten" on a zero to ten scale. His left elbow was swollen. The nurse practitioner was notified and X-rays were ordered. Review of a radiology report dated 06/20/13 at 5:44 P.M. revealed a spiral fracture of the mid to distal humerus (arm). Further review of Resident #5's medical record revealed both of his hands and arms were paralyzed. A physician's progress note dated 06/04/13 revealed the resident's bilateral upper extremities were flaccid. Review of the facility fall investigation revealed a written statement by STNA #9 that indicated that after she washed Resident #5 in the bathroom, she asked him to lift his leg so she could put his undergarment on him. When Resident #5 lifted his leg, he started to stumble. He fell backward and hit his head and his left arm. An observation of Resident #5 on 06/22/13 at 1:55 P.M. revealed the resident was supine in bed. His left arm was in a sling. His arm and wrist were enclosed in a type of soft cast and were covered with an elastic wrap. Resident #5 was alert and oriented. He stated that he had injured his arm when he fell in the bathroom while an aide was getting him dressed. He indicated that staff sometimes had him sit down while they dressed him, but sometimes dressed him while he was standing up. He stated that his left arm felt "itchy" under the cast. Review of the employee file for STNA #9 revealed she was terminated on 06/21/13 for violation of work rules. The above findings were confirmed with the director of nursing on 06/22/13 at 2:50 P.M.