Every finding on record at Summit Acres Nursing Home

Based on observation and interview, the facility failed to ensure the building was maintained in a sanitary and homelike environment. This had the potential to affect all residents residing in the facility. The facility census was 93. Findings include: On [DATE] at 10:16 A.M. thru 10:41 A.M., a tour of the facility was conducted of all areas of the nursing home. The facility had four separate units (Home B, Unit 1, Unit 2, and Speret Hall, which was the facility's secured memory care unit). Home B had a short hall and a long hall and the other units were just one hallway. The hallway that led from the facility's independent living section of the building to Home B Short hall was noted to have a musty/ mildew odor on it. There were no signs of mildew, mold, or evidence of any recent water damage, but the odor was quite noticeable. The hall between the two included some offices, as well as the facility's therapy room and chapel that were accessible to residents. Home B unit (short and long halls) had FRP boarding on the bottom half of the walls in the hallways just below the handrails that went down the halls. The upper half of the walls above the handrails were all painted drywall. The FRP boarding was a tan color and the upper half of the walls were painted a beige/ yellow color giving it a two tone look. The building presented as an older building, as it was not of newer construction, and was outdated overall. The flooring was of a vinyl material that had the look of wood. A darker brown was around the edges of the flooring providing it with a border. There was some dust/ debris built up along the edge of the wall on Home B Long near room [ROOM NUMBER]. The walls on Home B long were noted to have chipped paint outside of Rooms #14, #17, #18, #19, #20, and #21. The chipped paint was where adhesive tape had been applied, and when removed, had peeled the paint off along with it leaving a white area that did not match the paint of the rest of the wall. Some of the areas had been painted over without patching first, and had a different color of paint applied that did not match the color of the rest of the walls. Multiple door jams and doors were scuffed/ scraped and in need of being painted. There was some debris (wrappers, paper, disposable gloves etc.) noted on the floors in some of the resident rooms that were in need of being swept. Unit 1, which was located between Home B and the front lobby area and the facility's assisted living unit, was noted to have chipped paint outside of room [ROOM NUMBER]. There were only minor scuffs on the doors and door jams on Unit 1. Unit 2 was noted to have peeled paint on the walls outside of room [ROOM NUMBER], #204, #205, #206, #208, and #210. The secured memory care unit was noted to have paint that had been peeled off the wall by the removal of adhesive tape outside of room [ROOM NUMBER]. There was also paint peeled off the wall near the computer that was hanging on the wall at the end of the hall on the right, as you enter into the dining room/ lounge area. On [DATE] at 10:20 A.M., an interview with Housekeeper #100 revealed the facility typically had two housekeepers working at a time and they worked five days a week. She worked 6:00 A.M. to 2:00 P.M. and the other housekeeper that was there was working 8:00 A.M. to 4:00 P.M. They both worked five days a week rotating every other weekend, so there were two days through the week that they only had one housekeeper working. She denied they had housekeeping staff on the afternoon or night shifts. She felt the facility was adequately staffed with housekeepers to be able to keep up with the cleaning that was needed. She was responsible for cleaning every resident room in her assigned area daily. Cleaning of the resident rooms involved emptying out the trash, dusting, cleaning the bathroom, checking supplies, and sweeping/ mopping floors. They only deep cleaned resident rooms when a resident was out to the hospital, discharged home, or was deceased . On [DATE] at 1:38 P.M., an interview with Resident #43 revealed housekeeping staff only came in her room to sweep and mop about once a week. She felt that was probably enough to keep things tidy and commented it was fine. An observation of Resident #43's shared bathroom revealed her trash was overly filled and someone had left an incontinent brief in the trash that was over the top edge of the trash can. A wrapper to a toilet paper roll was noted lying on the floor next to the trash can. There was a folded towel that was on the floor in front of the toilet. The towel was under the front right leg of the raised toilet seat that was in place over the toilet. It was not clear what the purpose of the towel was, if it was to stabilize the raised toilet seat, or if it was there to address any leaks. No active water leaks were noted, but there was what appeared to be a dried white sediment on the floor in front of and to the right of the toilet. The raised toilet seat and the inside of the commode was noted with feces splatter all around it. Follow up observations of the resident's bathroom on [DATE] at 8:39 A.M. revealed no concerns with the cleanliness of the bathroom. The trash had been emptied and the the feces splatter that was noted inside the commode and the raised toilet seat had been cleaned. On [DATE] at 8:41 A.M., a walk through of the facility was conducted again with focus on the environment. No changes were noted with the condition of the walls where tape had been used and removed peeling the paint off with it. The musty/ mildew odor that was noted on the hall between Home B Short and the independent living side continued to be present. The floor in the hall on Home B Long continued to have dust/ dirt/ grime along the edge of the wall where it had been seen the day before. On [DATE] at 8:57 A.M., an interview with Maintenance Director #125 revealed he had been the facility's maintenance director for a year now. He was asked how the facility identified environmental issues within the facility that needed to be addressed. He indicated the nurses and aides had access to work orders at the nurses' stations they could fill out anytime they noticed something that needed addressed. He also did daily checks, weekly checks, monthly checks, semi-annual checks, and annual checks that were required through the facility's TELS system. He also took care of the day to day stuff that broke. He walked the halls all day long, so if he seen something that needed to be addressed, he would take care of it. He commented that he could not always see the forest through the trees and did not always notice things others may, since he was in it daily. He was asked about the odor on the hall between Home B short hall and the facility's independent living section. He reported he had an employee, who had an office on that hall, mention something to him about it last week. That employee reported a musty smell. He was not able to smell odors well, so he had three other employees see if they smelled anything. All three denied that they did. He was informed there was a distinct musty/ mildew smell on that hall. He denied any recent flooding or water damage to the floors/walls that may have been the source of that kind of odor. He stated he was dealing with a leak in the roof around that area of the building. He had worked on sealing the roof last year, but had not made it to the roof over that section yet. He was hoping that he would be able to do that, but had to wait until the weather permitted him to pressure wash it before putting down the sealant. He was then asked what his opinion was of the overall cleanliness of the facility. He indicated the housekeeping staff seemed to run short handed to him and thought it was a battle for them to keep up with the cleaning they had to do. He described the overall cleanliness of the facility as not being terrible, but it was not top notch either. He was asked about peeled paint off the walls in the hallways in different areas of the building. He indicated his boss from the corporate office was in last week for a walk through and noted the same concern. He indicated those areas were caused by new activity staff that had been hanging birthday signs up outside a resident's room for the resident's birthday and when the signs were taken down and the tape was removed it was peeling the paint off with it. He questioned if there was some kind of tape that they may be able to use that did not pull the paint off with it. He denied he was the one that painted over some of those areas using a different color of paint. He was not sure who had done that but acknowledged that the damaged area needed some type of filler put over it so the wall was a smooth surface and the spots where the paint had been pulled off would not still be visible. He acknowledged there were multiple doorways (jams and doors) that were in need of being touched up with paint, due to scuff and scrape marks. He also acknowledged the FRP boarding that was on the lower half of the wall on Home B Long and Short hall needed to be cleaned to remove scuff marks from that. He verified the floor on the front end of Home B Long near room [ROOM NUMBER] was still dirty (as seen the previous day) and was in need of being swept and mopped. He reported the building had been built in 1965 and was in need of some updates. He was not aware of any plans for further remodeling and he had been trying to get them (corporate office) to replace the roof. On [DATE] at 10:40 A.M., an interview with Certified Nursing Assistant (CNA) #150 revealed she did not feel the facility had enough housekeepers. The housekeeping staff struggled a lot with keeping up and they only had two available. She felt they did do a good job with what they were able to clean, but did not feel they had enough to keep up with everything that needed to be cleaned. Some of the residents would say that it had been a couple of weeks since someone had been in their room to clean. She stated she would try to clean it if she noticed it was dirty, as she did not feel anyone would want to use a bathroom that was not clean. On [DATE] at 10:52 A.M., an interview with RN #175 revealed she did not feel the facility had enough housekeeping staff to keep up with the cleaning. She reported there had been times she has noticed the floors in the halls were dirty and looked like they needed to be swept and mopped. She recalled one male resident's sister calling into the facility and complained about his room being a mess. This deficiency represents non-compliance investigated under Complaint Number 2796085 and 2793565.

Based on record review, interview, policy review, and facility investigation report review, the facility failed to ensure residents were free from verbal abuse. This affected two (#12 and #22) of six residents reviewed. The facility census was 89. Findings include:1.Record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of brain and unsteadiness on feet. Review of a care plan dated 07/03/25 revealed Resident #12 had behaviors including but not limited to demanding medications and becoming upset when pain medications are not due. Review of a minimum data set (MDS) completed 07/09/25 revealed Resident #12's cognition remained intact. Review of a self-reported incident (SRI) dated 07/21/25 revealed an employee (Certified Nursing Assistant (CNA) #178) entered Resident #12's room and initiated care but also engaged in conversation which upset the resident. Resident #12 reported she is upset by CNA #178 at least a dozen times and CNA #178 had been asked to leave and not come back. The employee was suspended pending investigation and the allegation was determined to be unsubstantiated after an investigation was completed and showed CNA #178 did not willfully intend to harm the resident. Review of a witness statement dated 07/21/25 by Resident #12 transcribed by the Administrator revealed CNA #178 had entered the resident's room several times for the purpose of arguing with her for no reason at least a dozen times. Resident #12 stated she asked CNA #178 to get out and never come back several times. Resident #12 stated she did not know why CNA #178 would do that because they don't know each other outside the facility but she thought CNA #178 enjoyed upsetting her. Resident #12 stated sometimes CNA #178 would enter the room to answer the call light and then start an argument on purpose which is upsetting but there had never been physical altercations. Review of a witness statement dated 07/21/25 by CNA #178 revealed she answered Resident #12's call light with another CNA, (#301), and Resident #12 wanted her medications which were not due until 4:00 P.M. CNA #178 stated she explained countless times Resident #12 could not have her medication and had told her a previous time when she was in the room with another CNA, (#305). CNA #178 reported Resident #12 raised her voice numerous times during those visits but denied wanting to make the resident mad or antagonizing her. CNA #178 stated she tried her best to calm the resident or leave the situation. Review of a witness statement dated 07/21/25 by Registered Nurse (RN) #138 revealed she was approached by CNA #103 to ask if she would get CNA #178 out of Resident #12's room because Resident #12 did not like her and had asked her to not come back to her room. RN #138 stated Resident #12 would get upset with CNA #178 which would cause her to be upset with CNA #103. RN #138 stated she asked CNA #178 to please go to the unit while she took care of Resident #12. Resident #12 reported CNA #178 had her so upset she was shaking. Resident #12 requested pain medications. Review of a witness statement dated 07/21/25 by CNA #301 revealed at 3:30 P.M., she and CNA #178 entered Resident #12's room to answer a call light, the resident asked for her medications and was told it was not time yet and CNA #178 stated the correct time for medications was 4:30 P.M. Resident #12 then got mad and stated it was ridiculous and she was in pain. CNA #178 stated there was nothing she could do, Resident #12 stated another nurse had passed medications early before, and CNA #178 responded at some point, well if your brain isn't working, don't you think you could have forgot? The nurse then entered the room and had both aides return to their hall. Review of a care plan dated 07/26/25 revealed Resident #12 was at risk for pain related to cancer, gout, chronic pain syndrome, and diabetic neuropathy. The goal was to maintain a daily routine and verbalize they are comfortable daily by target date. Interventions included but were not limited to administer pain medications as ordered and observe for effectiveness, observe and report any side effects; coordinate with therapy as needed to provide medications as ordered and as needed by resident to promote comfort and encourage participation with therapy; observe for episodes of breakthrough pain and medicate as ordered or contact physician as needed; offer additional non-pharmacologic interventions, dim lights, soft music, position changes, music, television, and conversations/distractions; and remind resident that reporting pain early may improve effectiveness of pain medication. Interview on 12/09/25 at 4:45 P.M. with the Administrator confirmed a witness statement stated Resident #12 was so upset she was shaking and one revealed Resident #12 was told her brain is broken. During the interview, the Administrator disagreed this was abuse because there were no negative outcomes and no intent to harm the resident. 2. Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including autosomal dominant limb girdle muscle dystrophy and weakness. Review of an MDS dated [DATE] revealed Resident #22's cognition remained intact. Review of a self-reported incident (SRI) dated 09/19/25 revealed an allegation of verbal abuse from Dietary Coordinator (DC) #310 to Resident #22. Witnesses stated DC #310 cussed and yelled at Resident #22 after the resident cussed and insulted her about his missing lunch tray. After the exchange, DC #310 left the room and continued to cuss under her breath as she went up the hallway passing residents and staff. A thorough investigation was completed and the allegation of verbal abuse was unsubstantiated due to lack of willful intention to harm Resident #22, however DC #310 was terminated for unprofessional behavior or conduct. Review of a witness statement dated 09/19/25 by DC #310 revealed she received a call stating Resident #22 did not get a tray, but she knew good and well he received a tray. DC #310 went to check the cart when Resident #22 called her into his room and yelled at her for always getting his tray wrong. DC #310 explained she did not get his tray wrong, but Resident #22 called her an expletive (f**king b*tch) and she told the resident to shut up. DC #310 stated she knew she should not have said that but she reached her boiling point. Review of a witness statement dated 09/19/25 by the Assistant Director of Nursing (ADON) #155 revealed she was standing in the dining area speaking with staff members during lunch time, witnessed DC #310 walk into the dining area stating she made the food Resident #22 requested and you guys need to find the f**king tray. DC #310 then walked into Resident #22's room and ADON #155 was not able to hear the entire conversation but did hear DC #310 use the word f*ck and the resident began screaming in response. DC #310 left the resident's room and walked back through the dining area stating I'm over this f**king place loud enough for family members and residents in the area to hear. Resident #22 continued screaming after DC #310 left his room so ADON #155 entered the room to ensure he was safe and to attempt therapeutic communication. Resident #22 stated nobody is going to come in here and talk to me like that calling me f**king stupid. ADON #155 did not hear DC #310 call Resident #22 stupid and only heard the profanity. Review of a witness statement dated 09/19/25 by CNA #224 revealed she was coming back to a resident room to fix food and DC #310 headed towards Resident #22's room, they began fighting and Resident #22 called DC #310 a f**king b*tch then she said f*ck you to him. CNA #224 stated she was standing at Resident #22's door way then left to get another resident their food. Resident #22 would always complain his food was messed up. Review of a witness statement dated 09/19/25 by Licensed Practical Nurse (LPN) #177 revealed while passing medications, she heard yelling and saw DC #310 come out of a room yelling, f*ck this place, I'm over it. Review of a witness statement dated 09/19/25 by Resident #22 transcribed by the Administrator revealed he had no issues at lunch, did not need anything, and had no issues with DC #310. Interview on 12/09/25 at 3:51 P.M. with the Administrator revealed staff did witness DC #310 yelling and cussing in the facility and DC #310 admitted to telling Resident #22 to shut up but because there was no willful intention to abuse, it would not substantiated as an allegation of verbal abuse. The Administrator stated Resident #22 could not recall an incident or did not feel bothered enough to discuss it. The Administrator stated DC #310 was fired for unprofessionalism and misconduct. Interview on 12/09/25 at 4:29 P.M. with Resident #22 revealed he was able to recall the incident with DC #310 and he was over it now. Resident #22 stated in the moment, he was very angry a staff at the facility would tell him to shut the f*ck up. Resident #22 admitted he did also yell at DC #310. Review of a policy titled Resident Rights dated 05/01/25 revealed the facility would make every effort to assist each resident in exercising his/her rights to assure the resident is always treated with respect, kindness, and dignity. Review of an undated policy titled Abuse, Mistreatment, Neglect, Injuries of Unknown Source, and Misappropriation of Resident Property revealed the facility will not tolerate abuse by anyone. Abuse is defined by the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This deficiency represents an incidental finding of non-compliance investigated under Master Complaint Number 2655536.

Based on record review, interview, policy review, and facility investigation report review, the facility failed to ensure allegations of abuse were thoroughly investigated. This affected one (#22) of two residents reviewed for abuse. The facility census was 89. Findings include:Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including autosomal dominant limb girdle muscle dystrophy and weakness. Review of an minimum data set (MDS) assessment dated [DATE] revealed Resident #22's cognition remained intact. Review of a self-reported incident (SRI) dated 09/19/25 revealed an allegation of verbal abuse from Dietary Coordinator (DC) #310 to Resident #22. Witnesses stated DC #310 cussed and yelled at Resident #22 after the resident cussed and insulted her about his missing lunch tray. After the exchange, DC #310 left the room and continued to cuss under her breath as she went up the hallway passing residents and staff. A thorough investigation was completed and the allegation of verbal abuse was unsubstantiated due to lack of willful intention to harm to Resident #22, however DC #310 was terminated for unprofessional behavior or conduct. Review of a witness statement dated 09/19/25 by DC #310 revealed she received a call stating Resident #22 did not get a tray, but she knew good and well he received a tray. DC #310 went to check the cart when Resident #22 called her into his room and yelled at her for always getting his tray wrong. DC #310 explained she did not get his tray wrong, but Resident #22 called her an expletive (f**king b*tch) and she told him to shut up. DC #310 stated she knew she should not have said that but she reached her boiling point. Review of a witness statement dated 09/19/25 by the Assistant Director of Nursing (ADON) #155 revealed she was standing in the dining area speaking with staff members during lunch time, witnessed DC #310 walk into the dining area stating she made the food Resident #22 requested and you guys need to find the f**king tray. DC #310 then walked into Resident #22's room and ADON #155 was not able to hear the entire conversation but did hear DC #310 use the word f*ck and the resident began screaming in response. DC #310 left the resident's room and walked back through the dining area stating I'm over this f**king place loud enough for family members and residents in the area to hear. Resident #22 continued screaming after DC #310 left his room so ADON #155 entered the room to ensure he was safe and to attempt therapeutic communication. Resident #22 stated nobody is going to come in here and talk to me like that calling me f**king stupid. ADON #155 did not hear DC #310 call Resident #22 stupid and only heard the profanity. Review of a witness statement dated 09/19/25 by certified nursing assistant (CNA) #224 revealed she was coming back to a resident room to fix food and DC #310 headed towards Resident #22's room, they began fighting and Resident #22 called DC #310 a f**king bitch then she said f*ck you to him. CNA #224 stated she was standing at Resident #22's door way then left to get another resident their food. Resident #22 would always complain his food was messed up. Review of a witness statement dated 09/19/25 by Licensed Practical Nurse (LPN) #177 revealed while passing medications, she heard yelling and saw DC #310 come out of a room yelling, f*ck this place, I'm over it. Review of a witness statement dated 09/19/25 by Resident #22 transcribed by the Administrator revealed the resident had no issues at lunch, did not need anything, and had no issues with DC #310. There was no evidence additional residents were interviewed regarding allegations of abuse despite staff statements indicating family and residents were in the dining area while DC #310 walked away cussing on 09/19/25 during the interaction with Resident #22. Interview on 12/09/25 at 3:51 P.M. with the Administrator revealed staff did witness DC #310 yelling and cussing in the facility and DC #310 admitted to telling Resident #22 to shut up but because there was no willful intention to abuse, it would not substantiated as an allegation of verbal abuse. The Administrator stated Resident #22 could not recall an incident or did not feel bothered enough to discuss it. The Administrator stated DC #310 was fired for unprofessionalism and misconduct. The Administrator confirmed no additional residents were interviewed because no additional residents were affected since the incident happened in Resident #22's room and in the hallway. Review of an undated policy titled Abuse, Mistreatment, Neglect, Injuries of Unknown Source, and Misappropriation of Resident Property revealed the facility will not tolerate abuse by anyone. Abuse is defined by the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Allegations of abuse should be investigated and the investigation should be completed within five working days which do not include weekends or legal holidays. The investigation should include interviewing the resident, the accused and all witnesses. Witnesses generally include anyone who witnessed or heard the incident; came in close contact with the resident the day of the incident (including other residents and family members); and employees who worked closely with the accused employee and/or alleged victim. If there are no direct witnesses, then the interviews may be expanded to cover all employees on the unit, or as appropriate, the shift. Written statements from the resident, if possible the accused, and each witness should be obtained, the record should be reviewed, and employment files should be reviewed. The investigation should be documented. This deficiency represents an incidental finding of non-compliance investigated under Master Complaint Number 2655536.

Based on record review, review of the facility's infection control tracking logs, observation, interview, and policy review, the facility failed to ensure all infections that occurred in the facility was included on their monthly infection control tracking log, trends/ patterns were identified by the infection preventionist when they occurred, and a resident with wounds was placed on enhanced barrier precautions as required. This affected one resident (#14) of five residents reviewed for unnecessary medications, one resident (#22) of four residents reviewed for pressure ulcers, and had the potential to affect all other residents residing in the facility. The facility's census was 84. Findings include: 1. Review of the facility's infection control tracking log for Unit 2 in March 2025 revealed there were five separate residents that were identified as having had infections on that unit during that month. Three of the five infections involved the organism of Methicillin-Resistant Staphylococcus Aureus (MRSA). The three MRSA infections identified included the following: 1 a.) Resident #24 was indicated to have been treated with an antibiotic for conjunctivitis (pink eye) between 03/03/25 and 03/13/25. A culture of the eye drainage was obtained and was positive for MRSA. The infection was identified as being healthcare associated (infections acquired in a healthcare facility such as a nursing home) as opposed to being community acquired (contracted outside of healthcare settings). 1 b.) Resident #79 was indicated to have been treated with an antibiotic for an abscess between 03/18/25 and 03/27/25. A culture was obtained of the drainage from the abscess and was positive for MRSA. His infection was identified as being a healthcare associated infection and not community acquired. 1 c.) Resident #64 was indicated to have been treated with an antibiotic for a wound infection between 03/26/25 and 04/04/25. A culture was obtained of the wound drainage and was found to be positive for MRSA. His infection was also indicated to be a healthcare associated infection and not community acquired. On 05/28/25 at 1:50 P.M., an interview with the facility's Director of Nursing (DON), who was also their Infection Preventionist revealed she did not identify any trends or patterns when tracking infections on Unit 2 for the month of March 2025. She was asked, if three of the five infections occurring involved MRSA, would that not indicate a trend/ pattern had occurred. The first documented MRSA infection was with a resident who had conjunctivitis with eye drainage that tested positive for MRSA. The other two residents that tested positive for MRSA on that unit had MRSA that were in wounds. All three residents were identified as having healthcare associated infections and none of the three were community acquired. The three residents were also indicated to have been placed in contact isolation precautions when their infections were noted to have involved MRSA. She denied she identified that as a trend/ pattern and did not provide any education to the staff working that unit on hand hygiene, wound care, or following appropriate contact isolation precautions. She acknowledged, with half of the infections recorded that month on that unit involving the same multi-drug resistant organism (MDRO) a trend/ pattern should have been identified and education provided to the staff to try to limit the spread to the other residents residing on that unit. Review of the facility's policy on Infection Surveillance and Monitoring Program updated November 2019 revealed it was the facility's policy for the infection surveillance program to determine baseline information about the frequency and type of healthcare associated infections (HAI) and ensure the standards in accordance with State regulations were followed. The procedure included reviewing the tracking and trending of infections. 32801 2. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI), fibromyalgia, and need for assistance with personal care. Review of Resident #14 nursing note dated 03/17/25 revealed Resident #14's urine was noted to be foul smelling and dark amber in color. The Nurse Practitioner (NP) was notified and new orders received for urinalysis (UA) and culture and sensitivity (C&S). On 03/18/25 the resident was straight cathed for UA and C&S. On 03/20/25 the UA and C&S results received. The NP ordered Ceftriaxone (antibiotic) one gram intramuscular (IM) daily for three days. Review of Resident #14's event report dated 03/20/25 revealed the resident had a urine culture that grew proteus mirabilis and the resident was placed on antibiotics. Review of Resident #14's observation report for McGeer's criteria dated 03/20/25 revealed the resident had a UTI and was treated with Ceftriaxone as evidenced by new or marked increase of urgency and frequency and at least 100 colony-forming unit (cfu)/milliliter (ml) of any number of organism in a specimen collected by in-and-out catheter. Review of Resident #14's C&S results dated 03/20/25 revealed the resident grew greater than 100 cfu/ml of proteus mirabilis and Ceftriaxone was sensitive to the organism. Review of the infection control log dated 03/2025 revealed no documented evidence Resident #14 was listed on the infection control log. Interview on 05/21/25 at 10:10 A.M., with the Director of Nursing (DON) confirmed Resident #14 had a UTI and was treated with antibiotic (Ceftriaxone), however she did not document the infection on the control log. 52003 3. Review of the medical record for Resident #22 revealed admitted [DATE] with diagnoses including acute diastolic (congestive) heart failure, need for assistance with personal care, depression, weakness, lack of physical exercise, other reduced mobility, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, hyperlipidemia, non-ST elevation (NSTEMI) myocardial infarction, type 2 diabetes mellitus without complications. Review of physician's orders dated 05/19/25 included wound care instructions for the left and right buttocks cleanse with soap and water, pat dry, apply triad paste and leave open to air. Review of the wound nurse practitioner note dated 05/19/25, wound measurements 1 centimeter (cm) length by 1cm width x 0.1cm depth with bloody exudate. The adhesive border dressing was discontinued on 05/19/25. Review of Resident #22's care plan revealed no care plan for enhanced barrier precautions. Observation on 05/20/25 at 9:24 A.M. revealed wound care being performed on Resident #22 by Registered Nurse (RN) #112. During the procedure, RN #112 confirmed that the wounds on the resident's buttocks were open and that the skin was not intact. RN #112 acknowledged that Enhanced Barrier Precautions were not followed, as required by CDC guidance. Review of facility policy titled Enhanced Barrier Precautions dated 05/01/25, states for procedures staff will wear gloves and a gown when performing high contact resident care activities. Review of CDC guidance dated 04/02/24 titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) states Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Wound care: any skin opening requiring a dressing.

Based on observation, interview, self reported incident review, and record review the facility failed to treat residents in a dignified manner as evidenced by one resident being told to stay in her damn room and two residents being assisted with their meals by Certified Nursing Assistants who were standing above them. This affected three of six residents (#33, #36 and #57) reviewed for dignity. The facility census was 84. Findings include: 1. Review of Resident #33's medical record revealed an admitted [DATE] and diagnoses including Wernicke's encephalopathy, hyperlipidemia, anxiety, major depressive disorder, and alcohol abuse in remission. Review of Resident #33's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero indicating severe cognitive impairment and wandering behavior for one to three days of the review period. Further review revealed Resident #33 was independent with ambulation and transfers. Review of Resident #33's behavior plan of care revealed Resident #33 exhibited the behavioral symptoms of verbal aggression, wandering- wandering into other resident rooms, cursing at staff, taking other resident's food and drinks, aggravating other residents, not leaving other resident's personal items alone, rummaging, tearful, and unplugging equipment. Interventions for Resident #33 include redirecting her from other resident's rooms, removing her from overly stimulating situations, taking her for a walk in the facility, and offering to take her to smoke at scheduled smoke break times. Review of the facility self-reported incident investigation started on 02/03/25 at 6:36 P.M. revealed that on 02/03/25 at 6:00 P.M. Certified Nursing Assistant (CNA) #307 was witnessed to have one hand on Resident #33's back and one hand on her arm and was pushing/guiding her fast, almost like running from another resident's room to her room across the hall. CNA #307 stated to Resident #33 stay in your damn room and slammed the door shut. This was witnessed by Licensed Practical Nurse (LPN) #126 and CNA #309. LPN #126 reported the incident to the administrator and CNA #307 was suspended pending investigation. A head-to-toe assessment was completed of Resident #33 and no concerns were noted. Resident #33 did not remember the incident and did not appear to have any harm or distress. Observation of Resident #33 throughout the survey revealed the resident was moving about the secure unit and interacting with the facility staff and her peers. Resident #33 showed no signs of fear or distress. In an interview on 05/20/25 at 2:12 P.M. LPN #126 stated on 02/03/25 she was working on the secure unit and had stepped off the unit to fax something and was returning when she saw CNA #307 with her hand on Resident #33's arm and her other hand on her back pushing her out of another resident's room and across the hall to her own room. Once Resident #33 was in the room CNA #307 told the resident to stay in her damn room. She immediately sent CNA #307 home and notified the administrator of the incident. LPN #126 assessed Resident #33 and found no physical injuries. LPN #126 stated that Resident #33 has dementia and is not really aware of what happened and was not upset by the incident. LPN #126 stated that Resident #33 did not change from her baseline. LPN #126 further stated that an alert resident would have been very upset with the treatment Resident #33 received from CNA #307. LPN #126 did not feel Resident #33 was treated with dignity and respect in the situation. She would have been upset if she was spoken to that way or if it had been her family member who was spoken to that way. LPN #126 stated she wants the residents she cares for to be cared for like she would want her family to be cared for. In an interview on 05/20/25 at 2:49 P.M. Speret Hall Program Director LPN #178 revealed she did not feel Resident #33 had been treated with dignity during the 02/03/25 incident when CNA #307 told her to stay in her damn room. She would not have wanted to be treated that way if it was her. 28923 2 a.) On 05/18/25 11:58 A.M., an observation during the lunch meal service for the residents eating in their rooms on Unit 2 noted Certified Nursing Assistant (CNA) #187 to be feeding Resident #36, while the resident was in her bed. CNA #187 was standing at the side of the bed while feeding the resident. She was not noted to be sitting in a chair at the bedside to provide the resident with a dignified dining experience. 2 b.) On 05/18/25 at 12:00 P.M., an observation during the lunch meal service for the residents eating in their rooms on Unit 2 noted CNA #500 to be feeding Resident #57, while the resident was in her bed. CNA #500 was standing at the side of the bed while feeding the resident. She was not noted to be sitting in a chair at the bedside to provide the resident with a dignified dining experience. On 05/18/25 at 12:10 P.M., an interview with CNA #187 and CNA #500 confirmed they did feed Resident #36 and #57 in bed, while they stood at the residents' bedside. CNA #187 stated they stood while feeding the residents because it was easier for them to feed the residents while standing. They denied they were standing while feeding those residents for any reason that was beneficial to the residents. When asked why they were not sitting at the side of the bed to feed the residents to promote a more dignified eating experience, CNA #187 reported they were not trained that way to do so. They acknowledged it was considered a dignity issue to stand over a resident while feeding them. They further acknowledged they should be sitting in a chair beside the bed at the resident's eye level to promote a more dignified dining experience. CNA #187 was noted to leave Unit 2 returning a short time later with a folding chair. She provided the folding chair to CNA #500, so CNA #500 could continue to assist Resident #57 with her meal while in a seated position. Review of the facility's policy on Meal Service updated 05/01/25 revealed it was the facility's policy to serve nutritional meals promptly and to provide meal assistance as needed. Residents requiring feeding assistance would be provided assistance at the time they received their meal. Staff providing assistance would be seated next to the resident and engaging in conversation with the resident or offering cueing during the meal.

Based on review of self-reported incident (SRI), review of the facility's investigation, interviews, and policy review the facility failed to prevent resident neglect. This affected one resident (#73) of one resident reviewed for abuse. Findings included: Record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses including cardiac arrhythmia, heart failure, muscle weakness, abnormalities of gait and mobility, weakness, retention of urine, right knee pain, benign prostatic hyperplasia without lower urinary tract symptoms, obstructive and reflux uropathy, and reduced mobility. Review of Resident #73's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) was 11. The resident was dependent for toiling. He required partial to moderate assistance for personal hygiene, dependent for sitting to lying, lying to sitting, sitting to stand, chair to bed, toilet, and shower transfer. He required substantial/maximal assist to roll left to right. He was always incontinent of urine and bowel. He was not on a toileting program. No rejection of care noted. Review of Resident #73's urinary incontinence plan of care dated 05/29/24 revealed to check and provide incontinence care as needed. Maintain dignity when checking/providing incontinence care for the resident. Review of the facility investigation SRI #258993 revealed Resident #73 was interviewed by the Administrator on 04/04/25. The resident reported he had trouble getting someone to answer his call light. The first female (staff) hit the button but did not change him as asked. She said she would be right back but never returned to his room. Another female (staff) and a co-worker changed his wet under pad sometime around 4:00 P.M. He told the Administrator he pushed his call light three times to get help. The Administrator asked if he had a sore bottom or butt area and the resident said no. The Nurse completed a physical assessment on the resident with no excoriation places or pain. Review of a handwritten sheet authored by the Administrator undated revealed Agency Certified Nursing Aide (CNA) #303 name and phone number was on the top of the paper. The first question asked was who she had worked with on Thursday (04/03/25), and the CNA responded CNA #102. The second question asked was why she went in and shut the resident's call light off. The response was he (the resident) was a two person assist. The third question was not answered. Question four asked was why did you go out to your car for an extended amount of time. The answer was she was on the phone Grandpa- surgery. Question five was asked why she was seen by various employees hanging out in the activity room. The answer was a number 1. Question six was not answered. Review of CNA #102's written statement dated 04/03/25 revealed at about 4:45 P.M., she went into Resident #73's room, and he told her a blonde girl came into his room and shut off the call light three times when he told her he needed to be changed. When the CNA changed his brief it nearly disintegrated and he was brinking on a major blowout. The only blonde girl we had was the Agency CNA #303 and she was barely doing anything all night. Review of handwritten sheet authored by the Administrator undated revealed CNA #102's name and number was on the top of the sheet of questions. CNA #102 reported the Agency CNA #303 told her she had turned off Resident #73's call light without providing care to the resident. CNA #102 reported to Licensed Practical Nurse (LPN) #129 that the Agency CNA didn't do anything all night around 9:45 P.M. She had witnessed CNA #303 loafing in the activity room for 30 minutes. There were additional comments on the bottom of the sheet that the CNA #303 walked past call lights and went to others, took 1.5-to-two-hour break, would tell her to do things and she would give attitude. It was too late for LPN #129 to talk to her. Review CNA #193's written statement dated 04/03/25 revealed she witnessed CNA #303 standing in the activities room from 7:45 P.M. till 9:30 P.M., then proceeded to continue outside for 15 minutes. Review of CNA#184's written statement dated 04/03/25 revealed CNA #303 was on Home B. There was multiple instances of her walking past lights, walking past people yelling out the door, telling residents that she would be back to help them and turning their lights off and then not coming back, staying in the activity room for very long periods of time. Just overall acts of neglecting residents. We ended up leaving without all residents in bed because we did not have the help we would expect from having another aide on staff. Review of the Administrator's handwritten letter undated revealed CNA #184's name and number was on top of the letter and phone number. CNA #184 reported CNA #303 had walked past Resident #73's and #17's call light and she dropped Resident #35 hard. CNA #303 told Resident #73 she would be back. When asked which residents were neglected there was an arrow and comment to see statement. Three residents were left up and night shift took out the trash. The CNA reported the incident to LPN #129 and Registered Nurse (RN) #170. Review of the Administrator's handwritten letter undated revealed LPN #129's name and phone number was on the top of the letter. The LPN reported that all three staff reported the incident to him around 9:45 P.M. The LPN reported he was not aware CNA #303 was walking pass call lights, and she was off the unit most of the shift and he told her late in the shift. CNA #184 did not use the term neglect when reporting CNA #303's poor job performance and he was unaware the staff thought it was neglect. The LPN reported he had staff write statements but never read them and gave them to someone else to pass on to the Administrator. The LPN never said anything to CNA #303 due to it being late in the shift and he was not aware of the neglect. Review of an email from the agency staffing company dated 04/04/25 at 1:06 P.M. revealed the staffing company was thankful for the information and was going to suspend the CNA (#303). Further review of the investigation revealed there was a copy of Resident #73's face sheet, a progress note from 04/04/25 at 3:07 A.M. that revealed episodes of incontinence reported last night. Follow up this morning with skin check. No areas noted. Resident stated that his bottom feels fine. Incontinence care provided. Resident resting in recliner. Call light and fluids remain in reach. There was a follow note dated 05/07/25 that indicated a follow up from the SRI (04/04/25) regarding call light being turned off. Resident reported there were no further issues or concerns related to his call light being turned off and he notes that it is being answered timely. He was satisfied with resolution. Resident's wife in room and agrees. There was no documented evidence that the additional resident mentioned in the SRI was interviewed or assessed. There was no statement from RN #170 who staff indicated they reported the incident to and there was no evidence residents on Home B, the unit the CNA was assigned to, were interviewed or assessed. Interview on 05/19/25 at 3:29 P.M. with Resident #73, revealed call lights not answered timely was still an issue on second shift. Sometimes he has to wait up to an hour for someone to answer his call light. Interview on 05/19/25 at 3:40 P.M., with the Administrator confirmed the surveyor had the complete investigation for Resident 73's SRI and there was no additional information. The surveyor reviewed the information in the folder with the Administrator. The Administrator confirmed he did not interview other residents on the unit or residents' staff had mentioned during the investigation to ensure they were not affected. The Administrator reported he was just focused on Resident #73 because he was upset about the incident. The Administrator could not recall why he wrote Resident #35 was dropped hard. The Agency CNA #303 confirmed she was outside for extended period of time but had permission due she was outside on the phone because her grandfather had surgery. The Administrator reported that the CNA was in the activity room watching residents play pool, however the resident didn't require supervision, and she should have been on the floor assisting residents. The Administrator confirmed he notified the staffing agency to ensure she was not providing care to other facility residents during the investigation. Interview on 05/02/25 at 1:58 P.M., with Resident #73 and his daughter revealed he felt he was neglected when the agency staff member left him in a saturated depends (incontinence brief) and didn't return to provide incontinence care timely. Follow up interview on 05/21/25 at 7:54 A.M., with the Administrator to confirm timeline of events on 04/03/25 revealed the Agency CNA (#303) worked 2:00 P.M. to 10:00 P.M. on 04/03/25. The resident reported he started to ring his light around 4:00 P.M. The Agency CNA answered the call light three times, however, didn't communicate the need of two people to provide the care and it frustrated the resident. The Administrator reported he was unsure of the time the two CNAs ended up providing care to the resident. The Administrator was not sure of the times the Agency CNA was off the floor for lunch, when she went to her car, or when she was in the activity room. The Agency CNA confirmed she was off the floor for extended amounts of time because she was worried about her grandfather, however he explained to her she still had job duties to perform. Interview on 05/21/25 at 10:19 A.M., with CNA #184 and #102 via phone revealed they felt the Agency CNA #303 had neglect Resident #73. The surveyor reviewed the facility's definition of neglect with the CNAs, and they agreed the Agency CNA did not provide a good or service to the resident by turning off his call light several times and not returning to provide care, which resulted in mental anguish to the resident. The CNA's reported the resident usually doesn't get upset and he was upset that night and feared staff would not return to provide care. CNA #102 reported she tried to reassure the resident she would return. CNA #102 reported that she worked 2-10 P.M., on 04/03/25 and there were several residents upset about the care they received or didn't receive from Agency CNA #303. She had gone to Resident #73's room between 4:30 P.M. to 5:00 P.M. and he was upset. Resident #73 reported Agency CNA #303 had come in his room [ROOM NUMBER]-4 times and turned his call light out and never provided incontinence care. The CNA reported she explained to the resident she was going to get help, and she would be right back. The resident was upset and was afraid she was going to leave him like the other aide did. The CNA reported she provided him with reassurance and left the room to get the lift and CNA #184 to help. When she removed the resident depends (incontinence product) it was almost disengaged. CNA #102 reported she had confronted Agency CNA #303, and she confirmed she had turned out Resident #73's call light several times and reported she forgot because she was pulled to another room. The CNA (#102) reported she tried to explain to the CNA (#303) about prioritizing. CNA #102 confirmed the Agency CNA never asked her for help. The Agency CNA continued to answer other residents call lights and did not address their needs or she would walk past call lights and not answer them. The CNA's reported they didn't realize the significant of the concerns until they started to assist residents with nighttime care and the residents were mad. CNA #102 confirmed she used the word Neglect in her written statement because she felt the Agency CNA had neglected Resident #73. Resident #73's depends/incontinence product was like jelly. It was upsetting to her as well as the resident. The CNA felt the Agency CNA #303 had neglected other residents as well by not providing care to them timely. CNA #184 reported she felt the Agency CNA (#303) had neglected to provide care to several residents that evening. Resident #35 was crying as well. Resident #35 has a history of crying, but when she went to check on the resident she found her crying. Resident #35 reported the Agency CNA #303 had dropped her when she was assisting her on the toilet and she hit her back on the toilet seat. The resident had a pink mark on her back, but no bruising was noted. The CNA reported she had checked on the resident several times during her shift. She had reported the incident to the nurse. Review of the facility's policy titled Abuse, Mistreatment, Neglect, Misappropriation of Resident Property, and Exploitation (dated 2016) revealed it was the facility's policy to investigate all allegations, suspicions and incidents of Abuse, Neglect, Misappropriation of Resident Property and Exploitation, as well as injuries sustained by its residents. Neglect was defined as the failure of the facility, its employees or facility service providers to provide good and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Prevention and identification included the deployment of staff on each shift in sufficient numbers to meet the needs of the residents and ensure that the staff assigned have knowledge of the individual residents' care needs. The supervision of staff to identify inappropriate behaviors, such as ignoring residents while giving care, derogatory language, rough handling, and directing resident who need toileting assistance to urinate or defecate in their beds. The assessment, care planning, and monitoring of resident with needs and behaviors which might lead to conflict or neglect. The social service department should be notified of the incident so that it may take appropriate interventions to care for eh psychosocial needs of any involved resident. All incidents and allegation of abuse must be reported immediately to the Administrator or designee. The incident or allegation should be reported to state department of health as soon as possible but not later than 24 hours form the time of the incident/allegation was made known to the staff member. Investigation protocol included the person investigating the incident should generally take the following action: Interview the resident, the accused, and all witnesses. Witnesses generally include anyone who: witnessed or heard of the incident; came in close contact with the resident the day of the incident; and employees who worked closely with the accused employee and/or alleged victim the day of the incident. Obtain written statement form the resident, if possible, the accused, and each witness. Obtain all medical reports and statement from the physician and or hospital Review the resident medical records. Document of the investigation.

Based on interview and medical record review the facility failed to ensure Resident #78 had an accurate Minimum Data Set (MDS) 3.0 assessment. This affected one resident (#78) of 22 residents reviewed for MDS assessments. The facility census was 84. Findings include: Review of Resident #78's medical record revealed an admitted [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia, type 2 diabetes, bipolar disorder, depression, post-traumatic stress disorder (PTSD), adjustment disorder with depressed mood, and attention-deficit hyperactivity disorder. Interview on 05/19/25 at 3:26 P.M. with Resident #78 stated her PTSD continues. She has triggers to loud noises and has flashbacks due to a car accident at the age of 16. She continued to wake up with nightmares and is paranoid. She reports staff have not questioned her regarding the PTSD. Review of Resident #78's comprehensive MDS 3.0 assessment dated [DATE] revealed the diagnoses of PTSD and bipolar disorder were not identified. Interview on 05/20/25 at 8:14 A.M. with MDS nurse #108 stated those diagnoses were not checked because she was not on any medications. They only code it if they are on medications and if it is listed as an active diagnosis. Review of Resident #78's physician's orders revealed Resident #78 did receive psychotropic medications Cymbalta 60 milligrams (mg) twice a day and Zoloft 100 mg daily. She was also prescribed Melatonin 5 mg at bedtime as a sleep aid. Interview on 05/20/25 at 8:41 A.M. with MDS nurse #108 confirmed Resident #78 was on psychotropic medications and the resident's MDS assessment was not accurate.

Based on interview and medical record review the facility failed to ensure Preadmission Screening and Resident Review (PASARR) was completed accurately on admission. This affected one resident (#78) of one resident reviewed for PASARR. The facility census was 84. Findings include: Review of Resident #78's medical record revealed an admitted [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia, type 2 diabetes, bipolar disorder, depression, post-traumatic stress disorder, adjustment disorder with depressed mood, and attention-deficit hyperactivity disorder. Review of Resident #78's PASARR, dated 02/28/25, did not include the diagnosis of Post traumatic stress disorder (PTSD) or identify psychotropic medications prescribed. Interview on 05/20/25 at 3:20 P.M. with Social Worker #158 including PASARR review verified the PASARR did not include the PTSD diagnosis. Review of the DSM-5 PTSD is classified as a trauma and stressor related disorders. Interview on 05/21/25 at 9:17 A.M. with regional director of SS and activities #306 verified inaccuracy of the PASARR as it did not include residents' diagnosis of PTSD or psychotropic medications.

Based on record review, observation, interview, and policy review, the facility failed to ensure dental services were provided to Resident #32 and pressure ulcer prevention interventions were implemented for Resident #64 as per the plan of care. They also failed to ensure a comprehensive care plan was developed to address Resident #78's diagnosis of Post traumatic Stress Disorder (PTSD). This affected three residents (Resident #32, #64, and #78) of 27 residents reviewed for care plans. Findings include: 1. Review of Resident #32's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included moderate protein-calorie malnutrition, stroke without residual deficits, adult failure to thrive, and legal blindness. Review of Resident #32's payer status in the electronic medical record revealed the resident was admitted to the facility on [DATE] under Ohio Medicaid (MCD). His payer status did not change until 04/18/25, when he was changed to Hospice MCD. Review of Resident #32's clinical admission documentation dated 01/10/25 revealed the resident had the use of an upper denture that was in fair condition and was missing one tooth. He was indicated to have lower dentures, but did not wear them and they weren't brought to facility with him. Review of Resident #32's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. He required set up or clean up assistance with his oral hygiene. He was assessed on the MDS as being edentulous and there was no indication that he had any broken dentures. Review of Resident #32's care plans revealed he had a care plan in place for an alteration in dental/ oral status related to not having any natural teeth and wearing upper dentures as he chooses. The goal was for the resident to be free of dental/ oral discomfort and to have proper fitting dentures in good repair. The interventions included the need for a dentist to evaluate and treat as needed (prn). If the resident wore dentures, they were to observe the condition and proper fit. They were to report any chips, cracks, or rough edges and to notify the dentist prn. Review of Resident #32's ancillary services consent form dated 05/09/25 revealed the resident was not known to have declined any of the ancillary services. He was to receive dental services per his request. Resident #32's electronic medical record (EMR) was absent for any evidence of the resident having been seen by a dentist since his admission to the facility on [DATE]. Progress notes were absent for any attempts to arrange dental services for the resident to replace his current dentures. Review of a dental list showing when the facility's contracted dentist had last visited the facility revealed the contracted dentist had last visited the facility on 03/19/25. Resident #32 was not one of the 22 residents who had been seen on that date. On 05/19/25 at 8:45 A.M., an interview with Resident #32 revealed he did not have his lower denture plate at the facility due to them being broken. He had the same set of dentures for the past [AGE] years. He was interested in being seen by a dentist to get a new set of dentures. On 05/20/25 at 9:52 A.M., an interview with Certified Nursing Assistant (CNA) #212 revealed he was not aware of Resident #32 wearing dentures and was not sure if he even had them. He was not aware the resident had the use of full upper dentures, or that he did not have his lower dentures with him due to them being broken and left at home. On 05/20/25 at 10:20 A.M., an interview with the Director of Nursing (DON) confirmed Resident #32 had not received any dental services while in the facility. She further confirmed the resident had consented to receive ancillary services when he was most recently asked on 05/09/25. She alleged the resident did not go under MCD until 03/19/25, and it was retroactive to 01/10/25. She was not able to provide any documentation to support that or to dispute the EMR showing he had been covered under MCD since 01/10/25, as was indicated under the census tab of the EMR. 2. Review of Resident #64's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included a history of a stroke, muscle weakness, need for assistance of personal care, difficulty walking, and age related physical debility. Review of Resident #64's annual MDS assessment dated [DATE] revealed the resident's cognition was moderately impaired. He was not known to reject any care. He was dependent on staff for bed mobility and transfers. The MDS identified him as being at risk for pressure ulcers, but did not have any unhealed pressure ulcers at the time the assessment was completed. Review of Resident #64's active care plans revealed the resident was at risk for skin breakdown related to impaired mobility, impaired cognition, and poor sensory perception. The goal was for the resident not to develop skin breakdown. The interventions included the need to encourage/assist the resident to float heels as tolerated. That intervention was added on 05/20/24. Review of Resident #64's nurses' progress notes for the past 30 days revealed no evidence of the resident not allowing the facility staff to offload his heels when in bed. He was also not indicated to remove any pillows or other devices that were being used to offload his heels. On 05/18/25 at 3:40 P.M., an observation of Resident #64 noted him to be lying in bed on an air mattress. His feet were not offloaded as his heels were noted to be in direct contact with the mattress. On 05/19/25 at 1:30 P.M. and again on 05/20/25 at 8:30 A.M., further observations of Resident #64 noted him to be lying in bed without his heels being offloaded. His heels remained in direct contact with the mattress and there was no evidence of any pillows or other offloading devices being used to elevate his heels off the mattress. On 05/20/25 at 11:19 A.M., an interview with CNA #212 revealed Resident #64 has had a recent decline in his condition and did not want out of bed. The resident was not one who wanted up even before his decline in condition that occurred over the past several weeks. He denied the resident had any current pressure ulcers, but was at risk due to his limited mobility. He was questioned about the resident's skin prevention interventions that were in place to prevent the development of his pressure ulcers. He stated the facility staff would use heels up (device to offload heels) or would use pillows to offload a resident's heels, if it was ordered by the physician. They did not offload any residents' heels, unless the physician said to. They had access to the resident's care plans in the computer kiosk. He verified Resident #64's care plans did include the need to encourage/ assist the resident to offload his heels. He was asked to accompany the surveyor back to the resident's room. He verified the resident was in bed without his heels offloaded on a pillow or other offloading device on 05/20/25 at 11:26 A.M. He was aware the resident was to have pillows to his sides, but he denied they were using pillows under the heels in an effort to offload the resident's heels. He stated he worked that unit five days a week during the day shift and had never tried putting pillows under the resident's heels. On 05/23/25 at 11:32 A.M., an interview with LPN #132 revealed Resident #64 did not have any pressure ulcers at present. She would consider him to be at risk for pressure ulcers. She denied she was aware of the resident removing any pillows that they used for positioning. She verified the resident's active care plans for being at risk for an alteration in skin integrity included the need to encourage the resident to off-load heels, as part of his skin prevention interventions. She informed CNA #212, who accompanied the survey to the nurses' station, that Resident #64 should have his heels up on a pillow from what she was able to determine. 52003 3. Review of Resident #78's medical record revealed an admitted [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia, type 2 diabetes, bipolar disorder, depression, post-traumatic stress disorder (PTSD), adjustment disorder with depressed mood, and attention-deficit hyperactivity disorder. Review of Resident #78's comprehensive care plan revealed no care plan or interventions regarding PTSD. Interview on 05/19/25 at 2:16 P.M. with Social Worker #158 revealed that on resident admission a trauma informed care observation is completed by the social worker and a care plan is based off of resident answers. There is a specific template in matrix titled: Trauma or PTSD related. Even if they have a history of PTSD it is still addressed. Social Worker #158 confirmed when Resident #78 was readmitted to facility on 02/28/25 a trauma informed care observation was not completed and she was not aware of the resident diagnosis and there is no care plan in place for PTSD.

Based on observation, record review, interview, and policy review, the facility failed to ensure care conferences were completed timely following a resident's significant change Minimum Data Set (MDS) assessment and care plans were revised in the areas of dental status and to reflect a resident's reported non-compliance with non-pressure skin impairment interventions. This affected one resident (#32) of two residents reviewed for care conferences and two residents (#7 and #16) of 22 residents reviewed for care plans. Findings include: 1. Review of Resident #7's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included reduced mobility, difficulty walking, and the need for assistance with personal care. Review of Resident #7's dental consults revealed the resident was seen on 03/23/22 and was indicated to have partial dentition. The resident informed the dentist that she had a dentist in a local community that was going to extract all her remaining teeth. Further review of Resident #7's dental consults revealed the resident was seen again by the dentist on on 09/25/24. The dentist referenced dentures the resident had that was about one year old. The dentist adjusted the lower left denture around the #18 tooth. The dentures were indicated to fit well and the resident was satisfied with them. Review of Resident #7's quarterly MDS assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She was not identified on the MDS assessment as having any dental issues. Review of Resident #7's active care plans revealed the resident had a care plan in place for being edentulous (without any natural teeth) and did not wear dentures. The care plan was initiated on 09/14/22 and was not revised to reflect the resident had since received dentures. On 05/20/25 at 3:33 P.M., an interview with Aide in Training #177 revealed she thought Resident #7 had her own teeth. She denied the resident had the use of any dentures. On 05/20/25 at 3:35 P.M., an interview with Resident #7 confirmed she had full upper and lower dentures. She stated the staff assisted her with brushing and soaking her dentures at night. On 05/20/25 at 3:37 P.M., an interview with Licensed Practical Nurse (LPN) #132 revealed she was not sure if Resident #7 had dentures or her own teeth. She did not want to say without checking the resident's electronic medical record (EMR) first. She reported the resident's dental care plan indicated she was edentulous. She was informed the resident had full upper and lower dentures and there was a dental consult note that indicated the resident has had dentures since 2023. 2. Review of Resident #32's medical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included unspecified glaucoma, bilateral blindness, anxiety, depression, congestive heart failure, adult failure to thrive, chronic obstructive pulmonary disease, and cognitive communication deficit. Review of Resident #32's face sheet revealed his contacts included his father as his resident representative. Review of Resident #32's completed MDS assessments revealed the resident's latest MDS assessment was a significant change MDS assessment that was completed on 04/24/25. His prior MDS assessment was an admission MDS completed on 01/17/25. The significant change MDS assessment completed on 04/24/25 identified the resident as not having any communication issues and being cognitively intact. Review of Resident #32's care conferences revealed the resident had his initial care conference completed on 01/14/25. There was no evidence of any other care conferences being held on the resident's behalf since the initial care conference was completed. Review of Resident #32's nurses' progress notes from 04/21/25 to 05/20/25 revealed no evidence of the facility attempting to set up a care conference for the resident around the time of the completion of Resident #32's significant change MDS assessment on 04/24/25. There was not a progress note until 05/12/25 that indicated a phone call was placed to the resident's representative on that date to schedule a care conference meeting. The note indicated that a care conference was scheduled and agreed upon for 05/20/25 at 2:30 P.M. On 05/19/25 at 8:43 A.M., an interview with Resident #32 revealed he did not recall being part of any care conference since he had been in the facility. He did not recall the initial care conference that was held on 01/14/25 and denied being aware of any care conferences being held since. On 05/20/25 at 8:13 A.M., an interview with Social Service Director #158 revealed she had been the facility's social worker since 04/29/25. She reported she was the employee in charge of scheduling care conferences. She stated care conferences were to be completed upon admission and then quarterly thereafter. If an initial care conference had been done on 01/14/25, a quarterly care conference should have been completed during the month of April 2025. She stated she tried to keep them on an every three month schedule. She was not sure why a care conference had not been completed for Resident #32 in April 2025, when he had a significant change MDS assessment completed. She confirmed they had one scheduled for the resident that was to be completed that day (05/20/25) at 2:30 P.M. She reported she was trying to get everything together and was still trying to get the initial care conferences completed for those residents that had been admitted since she took over. She had not been able to get to anything that was outstanding prior to her taking over as the social service director. She was asked what prompted her to schedule a care conference for the resident on that day. She stated it was just in her May 2025 folder for her to do. Review of the facility's policy on Comprehensive Care Planning updated 05/01/25 revealed the facility's interdisciplinary team (IDT) was responsible for the development of an individualized comprehensive care plan for each resident. The comprehensive care plan would be updated by a member of the IDT team as changes in the resident's condition occurred. The comprehensive care plan would be reviewed by the IDT at least quarterly or when a significant change in condition occurred, in which a MDS assessment was completed. The resident and the resident's representative would be invited to care conferences in which the resident's comprehensive care plans would be reviewed. 52003 3. Review of Resident #16's medical record revealed an admitted [DATE] with diagnosis including chronic kidney disease, stage 4 (severe), weakness, dysphagia, pharyngeal phase, acute respiratory failure with hypoxia, and unspecified diastolic (congestive) heart failure. Review of Resident #16's medical record revealed a history of skin tears on 01/26/25, 02/14/25, 02/27/25, 04/15/25, 05/10/25, 05/15/25 and 05/17/25. Review of Resident #16's care plan revised 05/12/25 revealed intervention for geri-sleeves to both arms. The non-adherence care plan revised 04/28/25 revealed no non-compliance interventions for geri-sleeves. Observations of Resident #16 on 05/27/25 2:51 P.M. revealed no geri-sleeves in place. Interview on 05/28/25 at 12:08 P.M. certified nurse aide (CNA) #219,stated Resident #16 was previously getting geri-sleeves but refused, so they removed the task from the charting. Interview on 05/28/25 at 1:00 P.M. with Regional Nurse #301 confirmed the care plan was not revised to address the non-compliance, the MDS nurse revises the care plans annually and quarterly.

Based on observation, interview and record review the facility failed to provide timely incontinence care for a resident and failed to provide timely nail care for a resident. This affected two residents (#2 and #14) of seven residents reviewed for activities of daily living. Findings include: 1. Review of Resident #2's medical record revealed an admitted [DATE] and diagnoses including dementia, dysphagia, diabetes, chronic obstructive pulmonary disease, epilepsy, and schizoaffective disorder. Review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of four indicating severe cognitive impairment. Further review of the MDS revealed Resident #2 required setup assist with toilet hygiene and supervision with toilet transfer and was frequently incontinent of urine. An observation on 05/19/25 at 2:14 P.M. revealed Resident #2 seated at a dining room table on the secure unit. Resident #2 was observed to urinate while seated in the chair and a large puddle of urine formed under the chair. Certified Nursing Assistant (CNA) #162 assisted Resident #2 to the bathroom for incontinence care. In an interview on 05/19/25 at 2:22 P.M. CNA #162 stated it was normal for Resident #2 to sit and sleep in a chair. CNA #162 stated Resident #2 uses a pullup style incontinence product and will frequently urinate enough to overflow the incontinence product. CNA #162 stated Resident #2 was to be changed after meals and when needed. An observation on 05/20/25 from 2:30 P.M. to 4:00 P.M. revealed the resident in bed during the observation with no staff interaction. An observation on 05/21/25 at 2:31 P.M. revealed Resident #2 to be resting in bed on her left side, dressed in brown pants and a pink and white shirt, with her back and buttocks toward the door. A dark, wet-appearing stain was observed on the resident's pants covering her buttocks area. An observation on 05/21/25 at 3:24 P.M. revealed the dark, wet-appearing stain, remained on the resident's pants. In an interview on 05/27/25 at 11:10 A.M. CNA #221 revealed CNAs were to check incontinent residents at least every two hours or more often if needed. CNA #221 stated Resident #2 prefers to use a pullup style incontinence product because the resident will sometimes take herself to the bathroom and this style is easier for her to manage. CNA #221 stated that Resident #2 seems to be incontinent more frequently now than in the past and stated Resident #2 can be difficult to get to go to the bathroom at times. An observation on 05/27/25 at 12:41 P.M. revealed Resident #2 seated at a dining room table on the secure unit. An observation on 05/27/25 at 2:42 P.M. revealed Resident #2 remained seated at a dining room table on the secure unit. An observation on 05/27/25 at 3:11 P.M. revealed Resident#2 was assisted with toileting tasks at this time. An interview at the same time with Speret Hall Program Director Licensed Practical Nurse (LPN) #178 revealed Resident #2 was previously assisted with toileting tasks at around 12:30 P.M. Review of the policy titled Routine Resident Checks updated 10/20/22 revealed a resident check would be completed at least every two hours by nursing personnel and involved entering the resident's room to determine if the resident had needs, such as assist with toileting or incontinence care, that needed to be met. 32801 2. Record review revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including Parkinson disease, weakness, fibromyalgia, and need for assistance with personal care. Review of Resident #14's quarterly minimal data set (MDS) dated [DATE] revealed the resident required partial/moderate assistance with personal hygiene. Review of Resident #14's profile dated 05/16/25 revealed Resident #14 was dependent on staff for nailcare. Observation on 05/18/25 at 10:20 A.M., of Resident #14 revealed the resident had one nail broken half the way off and a brown substance was under all her nails. The resident reported her nails looked awful and needed cleaned and the broken nail had been like that for a few days. Interview on 05/18/25 at 10:20 A.M., with hospitality aide (HA) #164 confirmed the resident had one nail half broken off and she had brown substance under her nails. Certified Nurse's Aide (CNA) #196 approached the resident during the interview and reported she saw Resident #14's broken nail this morning but didn't feel comfortable cutting it due to it was broke back into the quick of the nail. CNA #196 reported she would tell the nurse and help the resident clean her nails. The CNA went to the resident room and obtained a bush and warm soapy water and started soaking the resident nails. Review of the facility's policy and procedure titled Nail Care Finger/Toe undated 05/01/25 revealed it was the facility's policy to clean, trim, and maintain nail care to enhance the resident state of well-being. This deficiency represents non-compliance investigated under Complaint Number OH00165414.

Based on observations, medical record review, staff interview, and policy review, the facility failed to comprehensively assess and provide treatment to skin integrity concerns. This affected one resident (#73) of two reviewed for non-pressure skin impairments. The facility census was 84. Findings include: Record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses including cardiac arrhythmia, heart failure, muscle weakness, abnormality of gait and mobility, weakness, retention of urine, right knee pain, benign prostatic hyperplasia without lower urinary tract symptoms, obstructive and reflux uropathy, and reduced mobility. Review of Resident #73's quarterly Minimum Data Set, dated dated dated [DATE] revealed the residents Brief Interview for Mental Status (BIMS) was 11. The resident had no behaviors or rejection of care. The resident required set up for meals, dependent on staff for toileting, bathing, lower body dressing, and putting on and taking off footwear, and partial to moderate assist with personal and oral hygiene. The resident was dependent of staff for mobility. He had no skin alteration but was at risk for pressure ulcers. a. Review of Resident #73's progress note dated 05/08/25 revealed the Certified Nursing Aide (CNA) reported that when she was transferring the resident from recliner to wheelchair, the resident bumped his left arm on causing a skin tear. The skin tear was cleansed with normal saline, patted dry, applied xeroform and covered with a dry dressing. Review of Resident #73's alteration of skin integrity plan of care dated 05/09/25 revealed the resident had a skin tear to left arm. The plan of care was updated on 05/19/25 to include callus to left and right heel and right arm. Intervention included observe alteration in skin integrity for redness, swelling, drainage, increased or onset of pain and notify physician or Nurse Practitioner (NP), observe and change dressing(s) if soiled, saturated, or not adhering complications, and observe resident for any complaints of pain related to the alteration in skin integrity. Inform physician, NP and medicate after non pharmalogical approaches were / are not successful. Perform treatment(s) as per physician order see TAR. Review of Resident #73's progress note dated 05/17/25 at 2:20 A.M., and edited on 05/18/25 at 2:23 A.M., revealed weekly skin check completed no new areas noted. Continue treatment to right arm as ordered. (There was no evidence the facility had initiated an order to the right arm until 05/19/25). Review of Resident #73's progress note dated 05/19/25 revealed skin tear noted to right elbow; dressing applied. Wound nurse notified and confirmed with measurements during rounds. Resident representative notified. Observation on 05/18/25 at 10:49 A.M., of Resident #73 revealed the resident had two foam dressings on bilateral arms dated 05/17/25. The resident was not able to answer what happened to his arms at that time. Observation on 05/19/25 at 9:18 A.M., of Resident #73 with the Assistant Director of Nursing (ADON) #171 and Corporate Registered Nurse (CRN) #302 revealed the dressing on the left arm was dated 05/17/25, however the dressing on the right arm was undated. CRN #302 reported he would assume both dressing were changed on 05/17/25 due to the date on the left arm dressing. Review of Resident #73's orders dated 05/01/25 to 05/19/25 revealed no evidence of an order for a dressing to the right arm until 05/19/25 when a new order was entered on 05/19/25 to cleanse skin tear to right arm with normal saline, pat dry, apply Xeroform. Cover with dry clean dressing every third day and as needed. Review of Resident #73's events and observation documentation dated 05/01/25 to 05/19/25 revealed no evidence of skin assessment to the right arm, however there was a skin tear assessment for the left arm dated 05/08/25. Interview on 05/20/25 at 1:58 P.M., with Resident #73 and his daughter revealed her dad frequently had skin tears. She didn't know if it was related to the sit to stand lift and it was a tight squeeze to get through the bathroom door or how he was acquiring so many skin tears. The daughter confirmed the resident was dependent on staff for care. Interview on at 05/20/25 at 4:52 P.M. with the Director of Nursing (DON) revealed the facility was not aware of the skin tear to the right arm until 05/19/25 (even though a progress note dated 05/17/25 indicated continue treatment to right arm and surveyor observed a dressing on the right arm on 05/18/25). The DON had the nurse complete a statement form indicating she had interviewed the resident on 05/19/25 and he reported the skin tear to the right elbow was a result of catching his arm on the wheelchair rest. b. Review of Resident #73's medical record revealed no evidence of skin alteration to the left or right heels. Observation on 05/19/25 at 9:18 A.M., of Resident #73 with the Assistant Director of Nursing (ADON) #171 and Corporate Registered Nurse (CRN) #302 revealed the resident had two skin alteration on the left and right outer heel. The areas were pea size and slightly raised. The ADON reported the areas appeared to calluses. The resident reported they were painful to touch. The ADON reported he was not sure how the resident acquired the areas, and he was no longer being seen by the visiting wound Nurse Practitioner. The ADON confirmed the wounds were not comprehensively assessed or documented in the medical record due to calluses were not required to be monitored. An additional observation on 05/20/25 at 2:16 P.M. of Resident #73's feet with the ADON #171 and CRN #303 revealed the skin on the left outer heel was starting to flake off. The area on the right outer heel was still intact. The ADON reported he was not aware of the callus areas until yesterday and he had the visiting wound nurse look at them. The ADON reported staff would not normally document or complete a skin grid for a callus, nor did he document his assessment or the visiting wound NP assessment that was completed yesterday (05/19/25). The resident voiced complaints of pain during the exam when touching the heels and up the back of the heel. Interview on 05/20/25 at 1:58 P.M., with Resident #73 and his daughter revealed the areas on the left and right-outer heels developed about the first of February (2025). The resident has never had skin alteration on the outer side of the heels in the past. The daughter reported she had just left a care conference with the facility and had concerns regarding her father's heel pain and treatment. The daughter reported she doesn't feel the facility was being aggressive enough. The family had requested he see the podiatrist. Review of Resident #73's visiting wound NP note dated 05/19/25 revealed she was asked by the wound nurse to assess areas to bilateral feet. The resident had one callused area to the left outer heel that was dry and flaky and an order was given for skin prep to the area twice daily. The resident had a small flat callused area to the right heel that was dry. Skin prep twice daily was ordered. Both areas were closed, and wound nurse will follow areas. Will see on wound rounds as necessary. Review of Resident #73's orders dated 05/2025 revealed skin prep to bilateral heels twice a day for prevention since 05/30/24. The order was updated on 05/19/25 to include special instructions callus. Review of the facility's policy titled Skin abrasion, Skin tears dated 05/01/25 revealed the facility's policy of care for alteration in skin integrity was using professional standards of practice. The guidelines included verifying that there was a physician order for the procedure. Review the residents' care plan, for any special needs,. The policy didn't include document assessment of the wound.

Based on record review, observation, staff interview, and policy review, the facility failed to ensure skin prevention interventions were implemented for residents at risk for or having had pressure ulcers and also failed to ensure a resident's pressure ulcer was comprehensively assessed weekly to monitor for wound healing. This affected three residents (#16, #64, and #73) of four residents reviewed for pressure ulcers. Findings include: 1. Review of Resident #16's medical record revealed the resident was admitted to the facility on [DATE]. She was readmitted to the facility on [DATE] following a multiple day hospitalization stay. Her diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) following a stroke affecting her left dominant side, peripheral vascular disease, adult onset diabetes mellitus, reduced mobility, muscle weakness, and dependence on a wheelchair. Review of Resident #16's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had adequate hearing and clear speech. She was usually able to make herself understood and was usually able to understand others. Her cognition was severely impaired and the resident was dependent on staff for bed mobility and transfers. She was identified as being at risk for pressure ulcers and was also identified as having an unhealed pressure ulcer that was a Stage III Pressure ulcer (full thickness skin loss, where subcutaneous fat was visible, but bone, tendon, or muscle was not) that was present upon admission. Review of Resident #16's active care plans revealed the resident had a care plan in place for having a pressure ulcer/ injury to the right heel. The goal was for the resident's pressure ulcer to show progressive signs of healing. The interventions included the need to observe the wound for any redness, warmth, drainage, odor, and report to physician as needed. They were also to perform the current treatment as ordered and to observe the treatment for effectiveness. Review of Resident #16's physician's orders revealed the resident had an order in place to cleanse the resident's right heel with normal saline, pat dry, apply skin prep, cover and protect with foam dressing changing every other day. That treatment order had been in place since 04/28/25. The special instructions included with that order indicated the treatment was for a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red/ pink wound bed, without slough) to the right heel. Review of Resident #16's weekly wound grid observations that the facility used to assess and document the wound evaluation revealed the pressure ulcer to the right heel was identified on 04/23/25 and was initially classified as a suspected deep tissue injury (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 pressure ulcer was indicated to have been present upon the resident's re-admission to the facility and measured 2 centimeters (cm) x 1.5 cm. Review of Resident #16's subsequent weekly wound grid observations revealed on 04/28/25 the pressure ulcer was classified as a Stage III pressure ulcer to the right heel. Measurements obtained as part of the weekly wound evaluation revealed the length was 2 cm and the width was 1.5 cm. There was no depth recorded despite it being an open wound and classified as a Stage III pressure ulcer. There was no indication of any slough being present or any other reason to explain why the depth of the wound bed was not measured. Review of the resident's weekly wound grid observations for 05/05/25 and 05/12/25 revealed the resident's pressure ulcer to the right heel remained a Stage III pressure ulcer. Measurements were obtained that included a length and width, but again there were no depths recorded. The assessment on 05/05/25 included comments that indicated half of the open area was a closed blister and the wound healing progress was declining. The assessment on 05/12/25 did not mention anything in the comments about the open area being covered or partially covered with a closed blister. It indicated that the wound was noted to have a light growth of serosanguineous exudate (drainage) when assessed and documented as improving. Review of the last two weekly wound grid observations for 05/19/25 and 05/26/25 revealed the weekly assessment did not include a staging of the pressure ulcer. Measurements of a length and width was obtained and the wound was not indicated to have any exudate. Tissue type indicated the wound bed was closed/ resurfaced, but the wound healing status indicating it was improving, not healed or resolved. On 05/28/25 at 9:55 A.M., an interview with Registered Nurse (RN) #171 revealed he was the facility's wound nurse that assessed pressure ulcers weekly. He indicated he was not wound certified at the time, but it was his intention to become wound certified, after he finished the infection preventionist training/ testing. Due to him not being wound certified, the facility had a visiting nurse practitioner that was assessing their wounds weekly. He completed rounds with her and used her information, as part of his weekly wound evaluations, until he became wound certified. He confirmed Resident #16 returned to the facility from the hospital on 04/23/25, with a SDTI to her right heel. It then became a Stage III pressure ulcer. He acknowledged the weekly wound assessments were identifying the pressure ulcer as a Stage III pressure ulcer, but his measurements did not include a depth of the wound. He acknowledged if a wound was a Stage III pressure ulcer, a depth should be able to be recorded as part of their wound assessment/ evaluation. He further acknowledged the last two weekly wound assessments completed did not include a stage of the pressure ulcer. He acknowledged part of a comprehensive weekly wound assessment should include a staging of the pressure ulcer. He reported the nurse practitioner that was following the resident's pressure ulcer initially classified it as a Stage II, after it had opened from originally being a SDTI. He knew it could not be a Stage II pressure ulcer since it had previously been identified as a SDTI, which included the involvement of deep tissue being affected. 2. Review of Resident #64's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included a history of a stroke, muscle weakness, need for assistance of personal care, difficulty walking, and age related physical debility. Review of Resident #64's annual MDS assessment dated [DATE] revealed the resident's cognition was moderately impaired. He was not known to reject any care. He was dependent on staff for bed mobility and transfers. The MDS identified him as being at risk for pressure ulcers, but did not have any unhealed pressure ulcers at the time the assessment was completed. Review of Resident #64's active care plans revealed the resident was at risk for skin breakdown related to impaired mobility, impaired cognition, and poor sensory perception. The goal was for the resident not to develop skin breakdown. The interventions included the need to encourage/assist the resident to float heels as tolerated. That intervention was added on 05/20/24. Review of Resident #64's nurses' progress notes for the past 30 days revealed no evidence of the resident not allowing the facility staff to offload his heels when in bed. He was also not indicated to remove any pillows or other devices that were being used to offload his heels. On 05/18/25 at 3:40 P.M., an observation of Resident #64 noted him to be lying in bed on an air mattress. His feet were not offloaded as his heels were noted to be in direct contact with the mattress. On 05/19/25 at 1:30 P.M. and again on 05/20/25 at 8:30 A.M., further observations of Resident #64 noted him to be lying in bed without his heels being offloaded. His heels remained in direct contact with the mattress and there was no evidence of any pillows or other offloading devices being used to elevate his heels off the mattress. On 05/20/25 at 11:19 A.M., an interview with Certified Nurse Aide (CNA) #212 revealed Resident #64 has had a recent decline in his condition and did not want out of bed. The resident was not one who wanted up even before his decline in condition that occurred over the past several weeks. He denied the resident had any current pressure ulcers, but was at risk due to his limited mobility. He was questioned about the resident's skin prevention interventions that were in place to prevent the development of his pressure ulcers. He stated the facility staff would use heels up (device to offload heels) or would use pillows to offload a resident's heels, if it was ordered by the physician. They did not offload any residents' heels, unless the physician said to. They had access to the resident's care plans in the computer kiosk. He verified Resident #64's care plans did include the need to encourage/ assist the resident to offload his heels. He was asked to accompany the surveyor back to the resident's room. He verified the resident was in bed without his heels offloaded on a pillow or other offloading device on 05/20/25 at 11:26 A.M. He was aware the resident was to have pillows to his sides, but he denied they were using pillows under the heels in an effort to offload the resident's heels. He stated he worked that unit five days a week during the day shift and had never tried putting pillows under the resident's heels. On 05/23/25 at 11:32 A.M., an interview with LPN #132 revealed Resident #64 did not have any pressure ulcers at present. She would consider him to be at risk for pressure ulcers. She denied she was aware of the resident removing any pillows that they used for positioning. She verified the resident's active care plans for being at risk for an alteration in skin integrity included the need to encourage the resident to off-load heels, as part of his skin prevention interventions. She informed CNA #212, who accompanied the survey to the nurses' station, that Resident #64 should have his heels up on a pillow from what she was able to determine. Review of the facility's policy on Pressure Ulcers: Assessment, Prevention, and Treatment updated 05/01/25 revealed it was the facility's policy to identify residents at risk for developing pressure injuries, implement interventions to prevent the development of pressure injuries, and provide care for existing pressure injuries. Interventions and preventative measures as indicated based on resident risk factors included floating heels and keeping heels off of the bed. 32801 3. Record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses including cardiac arrhythmia, heart failure, muscle weakness, abnormality of gait and mobility, weakness, retention of urine, right knee pain, benign prostatic hyperplasia without lower urinary tract symptoms, obstructive and reflux uropathy, and reduced mobility. Review of Resident #73's observation report dated 03/11/25 and 05/19/25 revealed the resident was at high risk for pressure ulcer/skin breakdown and his treatment plan included pressure reducing device for bed and chair. Review of Resident #73's pressure ulcer plan of care related to incontinence, impaired mobility, cancer, poor nutritional intake, low protein, anemia, friction concerns, shearing concerns, and behaviors of crossing legs and feet dated 05/20/24 revealed the resident's intervention included pressure re-distribution cushion to chair and heelzup cushion when in bed. Review of Resident #73's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had pressure relieving devices to bed and chair. Review of Resident #73's care conference note dated 05/20/25 at 1:31 P.M., revealed the family had requested staff to prompt the resident to put socks on at night and continue to put cream on his feet. The family had also requested that a soft type of barrier/mat be placed by his feet at night as well. Consent for Podiatry signed as well per request. Interview on 05/20/25 at 1:58 P.M., with Resident #73 and his daughter revealed the daughter just had a care conference with the facility and she was not too confident the facility was being aggressive enough in treating her father's sore heels. The family had offered to buy sheep skin to lay at the bottom of the bed because they felt the sheets were rough. The resident and daughter reported the facility was currently using pillows to prop up the heels off the bed, however the staff were not consistently putting the pillows under his feet. The only other intervention the facility was utilizing for the resident feet was cream and the daughter didn't feel that was sufficient due to the resident having a history of pressure ulcer on his heels shortly after he was admitted to the facility. The daughter reported she didn't want that to happen again. The resident reported he spends most of his time in his recliner. Observation during the interview revealed no evidence of heelzup cushion in the room or a pressure relieving device in the recliner/chair. Interview and observation on 05/20/25 at 3:12 P.M., with the Assistant Director of Nursing (ADON) #171 and Corporate Registered Nurse (CRN) #302 confirmed the resident didn't have heelzup cushion in the room nor a pressure relieving cushion in his recliner. CRN #302 reported that the plan of care doesn't specify which chair required the pressure relieving cushion, however the specialized wheelchair seat was a pressure-relieving cushion and would not require an additional pressure relieving cushion to be placed on it. The CRN also reported maybe the heelzup cushion was in the laundry room. The resident had reported pain in the heel region upon touch and up the back of the foot when the ADON and CRN had touched his heels and questioned the resident about the location of the pain. The ADON and surveyor went to the laundry room and there was a shelf where several pressure relieving devices were stored on the shelf. There was no indication/identification to confirm if any of the devices were from Resident #73's room. Interview on 05/21/25 at 7:13 A.M., with Certified Nursing Aide (CNA) confirmed Resident #73 sits in his recliner most of the time. The resident only uses the specialized wheelchair only at lunch time when he goes to his wife's room for lunch. Review and the facility's pressure ulcer policy and procedure dated 05/01/25 revealed it was the facility's policy to identify residents at risk for developing pressure injuries, implement interventions to prevent development of pressure injuries and provide care for existing pressure injuries. A pressure ulcer injury risk assessment would be completed upon admission, quarterly, annually and with significant change. Interventions and prevention measure as indicated based on risk factors. Float heels-keep heels off of the bed. Use pillows, wedges, and/or other devices for positioning. This deficiency represents non-compliance investigated under Complaint Number OH00165414.

Based on observation, record review and staff interviews, the facility failed to provide timely contracture management. This affected one resident (#56) of one resident reviewed for contractures. Facility census was 84. Findings include: Review of the medical record for Resident #56 revealed an admitted [DATE] with diagnosis including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, weakness, dysphagia following cerebral infarction, difficulty in walking, pain, and adult failure to thrive. Review of a quarterly Minimum Data Set (MDS) assessment completed 04/23/25 revealed range of motion limitation to one side. The resident was dependent upon staff for transfers. Review of occupational therapy discharge summary revealed Resident #56 received occupational therapy from 04/15/25 to 04/23/25. It stated the patient will be further assessed for splinting and palm pad during treatment. Upon discharge from occupational therapy, the resident was tolerating the trial of palm guard, and he demonstrated good rehab potential. No recommendations were made for a restorative nursing program for range of motion at discharge from therapy. Interview on 05/21/25 at 12:45 P.M. with Occupational Therapy (OT) #305 revealed the resident was trialed with palm pad which he did tolerate it. He does refuse most care. Therapy discharged due to not having a palm guard which was to be ordered. Interview on 05/21/25 at 1:21 P.M. with Environmental Services Coordinator #204 stated the palm guard was ordered and verified via shipping invoice dated 04/23/25. Interview on 05/21/25 at 3:00 P.M. with Therapy Director #304 confirmed therapy discharged Resident #56 and no restorative program was ordered, palm guard was ordered and therapy did not reevaluate the resident.

Based on record review, staff interview, and policy review, the facility failed to ensure there was consistent communication between the facility and the dialysis center on the days a resident went out for hemodialysis treatments. This affected one resident (#62) of one resident reviewed for dialysis. Findings include: Review of Resident #62's medical record revealed he was admitted to the facility on [DATE] with the diagnoses of end stage renal disease, chronic kidney disease- Stage V, status post nephrectomy (removal of a kidney) in 2022, and dependence on hemodialysis. Review of Resident #62's physician's orders revealed the resident had an order in place to receive dialysis every Monday, Wednesday, and Friday. His chair times varied depending on the day of the week. His chair time was 10:30 A.M. every Monday and Friday. His chair time for Wednesday was 8:00 A.M. Review of Resident #62's active care plans revealed the resident had a care plan in place for an alteration in renal function as the resident received renal dialysis related to end stage renal disease. The goal was for the resident to receive renal dialysis without complications in coordination with the dialysis center and the facility. The interventions included the resident going to dialysis center three days per week on Monday, Wednesday, and Friday. They were to encourage the dialysis center to forward the dialysis treatment notes to the facility. Review of Resident #62's dialysis schedule for the past 30 days (04/27/25- 05/27/25) revealed the resident received dialysis treatments 13 times in that 30 day period. Review of the dialysis treatment sheets revealed there were only dialysis treatment sheets for six of those 13 visits. Seven of the 13 dialysis visits did not have a dialysis treatment sheet for. No dialysis treatment sheets were found for dialysis visits on 05/02/25, 05/05, 05/07, 05/09, 05/12, 05/16, or 05/21/25. Of the six that were found, only two (05/19/25 and 05/26/25) indicated what medications were given during his dialysis treatment. Four were left blank and did not indicate whether the resident had been given any medications during that visit. Of the six that were found, four (04/28/25, 04/30/25, 05/14/25, and 05/23/25) did not indicate if any new orders had been given and five (04/28/25, 04/30/25, 05/14/25, 05/19/25, and 05/23/25) of the six did not indicate if any problems occurred during the dialysis treatments. The dialysis treatment sheet was left blanks in those areas. On 05/27/25 at 3:47 P.M., an interview with Registered Nurse (RN) #112 revealed Resident #62 did go to dialysis every Monday, Wednesday, and Friday. She reported the dialysis center was not good about sending any paperwork (dialysis treatment sheets) with the resident anymore. The dialysis center's staff were to complete the dialysis treatment sheet and send it back with the resident. She stated if they received anything back, it was usually just the resident's pre and post-dialysis weights and vital signs. They usually did not bother to fill out the sections on the dialysis treatment sheet to show if the resident received any medications or how he tolerated the treatment. They would find the dialysis treatment sheets in the resident's bag or in his pocket, if they were even sent back at all. They would have to search through his bag to find it, and if one was not sent back, then they were expected to call the dialysis center to get it faxed over. She assumed the dialysis center would communicate with them, if there were any new orders, or if there had been any changes in his condition that they should be made aware of. She felt the communication with the dialysis center could be better and denied the dialysis center ever called the facility with any kind of report. Review of the facility's policy on dialysis updated 05/01/25 revealed it was the policy of the facility that all residents utilizing renal dialysis receive comprehensive interdisciplinary monitoring to ensure resident safety and support of dialysis services. The facility should initiate and maintain a professional relationship with the dialysis center for any resident admitted requiring renal dialysis. The dialysis center was to send reports from the resident's dialysis treatments to the facility after each visit.

Based on record review and staff interview, the facility failed to provide services to prevent Resident #78 from experiencing triggers related to post traumatic stress disorder (PTSD). This affected one resident (#78) of one resident reviewed for PTSD. The facility census was 84. Findings include: Record review revealed Resident #78 was admitted on [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia, type 2 diabetes, bipolar disorder, depression, post-traumatic stress disorder (PTSD), adjustment disorder with depressed mood, and attention-deficit hyperactivity disorder. Review of Resident #78's comprehensive care plan revealed no care plan or interventions regarding PTSD. Interview on 05/19/25 at 3:26 P.M. with Resident #78 reports she continues to have triggers to loud noises and has flashbacks due to a car accident at age of 16. Interview on 05/19/25 at 2:16 P.M. with Social Services #158 and Regional Director of Social Services and Activities #306, on admission a trauma informed care observation is completed by the social worker. During the observation the resident is asked about triggers. The care plan will reflect what answers the resident provides. Social Services #306 confirmed no trauma informed care observation was completed on admission due to the Resident #78 was discharged home in December of 2024 and readmitted in February of 2025. The previous social worker entered a progress note. Social Services #158 was not aware of Resident #78's diagnosis due to no trauma informed care observation being completed for the most recent admission.

Based on record review, staff interview, review of a drug reference resource, and policy review, the facility failed to ensure a resident received a short acting anti-anxiety medication in accordance with their physician's orders to adequately manage anxiety. This affected one resident (#48) of five residents reviewed for behavioral-emotional care. Findings include: Review of Resident #48's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included anxiety disorder and major depressive disorder. Review of Resident #48's physician's orders revealed the resident had an order to receive Xanax (a benzodiazepine used in the treatment of anxiety disorders) 0.5 milligrams (mg) by mouth (po) four times a day (QID). The order originated on 04/23/25 and included specific times for administration that included 8:00 A.M., 1:00 P.M., 5:00 P.M., and 9:00 P.M. Review of Resident #48's medication administration history from 05/01/25 through 05/21/25 revealed the Xanax 0.5 mg po QID was for anxiety as evidenced by excessive worry. The medication administration history showed the Xanax was scheduled for administration at 8:00 A.M., 1:00 P.M., 5:00 P.M., and 9:00 P.M. as was indicated in the physician's orders. The nurses initialed the box to indicate the medication had been administered. 20 of the 82 doses administered during that time had an asterisk added in the box with the nurse's initials. The legend on the medication administration history indicated an asterisk meant a comment in reasons/ comments was added. Review of the comments included under the reasons/ comments revealed those 20 doses had been administered late. Dates where the nurses added an asterisk in the boxes with their initials was for the 8:00 A.M. doses on 05/01/25, 05/03, 05/06, 05/07, 05/08, 05/09, 05/14, 05/15, 05/16, 05/19, and 05/21/25; 1:00 P.M. doses on 05/12/25, 05/16, and 05/20/25; 5:00 P.M. doses on 05/20/25; and 9:00 P.M. doses on 05/08/25, 05/12, 05/17, and 05/18/25. The reasons/ comments added for those dates indicated the medication was administered late. The reasons/ comments added for those dates included columns for the scheduled date and time the Xanax was to be administered, the charted date and time, the reasons/ comments pertaining to that particular medication administration, and the name of the nurse creating the reasons/ comments for each scheduled administration. The Xanax was indicated to have been administered outside the hour window the nurses had to administer the medication for that scheduled time. The Xanax was noted to have been administered as late as 11:36 A.M. for the 8:00 A.M. dose, 2:28 P.M. for the 1:00 P.M. dose, 7:26 P.M. for the 5:00 P.M. dose, and as late as 10:35 P.M. for the 9:00 P.M. dose. On 05/18/25 at 4:13 P.M., an interview with Resident #48 revealed he did not feel he was receiving his Xanax as he should be. He reported his doses of Xanax were scheduled, but he received them at inconsistent times and often late. He reported he became anxious, as a result of his medication not being given on time, and felt like he could go off on someone when it was given to him a couple hours late. He did not know what the nurses were not giving him his Xanax when they were due. On 05/20/25 at 2:20 P.M., an interview with Licensed Practical Nurse (LPN) #147 confirmed she did not administer Resident #48's Xanax that was scheduled to be given at 8:00 A.M. that morning until around 10:30 A.M. She reported it should have been given sooner, but it was late. She indicated the time documented on the medication administration history was the time the medication was given and not just when it had been charted. She was not sure how long they had to administer a scheduled medication to a resident. She was not aware of the hour window they had before or after the scheduled time. She reported she was not over on the resident's unit to pass medications that much and was still trying to get her routine down. She was also responsible for passing medications on the residents on the assisted living unit. She passed them first and then passed her medications to the residents on Unit 2, where Resident #48 resided. She did not start the morning medication pass until after she was done with report. That was generally anywhere between 7:20 A.M. and 7:30 A.M. She did not feel she would have trouble passing the medications more timely once she got her routine down. Review of medication information on Xanax from Drugs.com revealed Xanax was used to treat anxiety disorders and anxiety caused by depression. Xanax was to be taken exactly as prescribed by the physician. The times of administration should be distributed as evenly as possible throughout the waking hours. Review of the facility's policy on Medication Administration - General Guidelines dated May 2020 revealed medications were to be administered within 60 minutes of the scheduled time. Unless otherwise specified by the prescriber, routine medications were administered according to the established medication administration schedule for the facility. Review of the facility's policy on Med Pass updated 05/01/25 revealed medications that were not every day (qd), twice a day (BID), or three times a day (TID) would require a specific time order by the physician.

Based on medical record review, review of pharmacy recommendation, and interviews the facility failed to implement pharmacy recommendation and physician orders. This affected one resident (#14) of five residents reviewed for unnecessary medication review. Findings include: Medical record review revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including iron deficiency anemia, weakness, fibromyalgia, and Parkinson's disease. Review of Resident #14's pharmacy recommendation undated revealed the resident had received ferrous sulfate 325 milligrams (mg) daily since 2023. Her complete blood count (CBC) was within normal limits on 04/28/25. Recommendation to discontinue ferrous sulfate. On 05/16/25 the physician checked the agree box and wrote an additional comment under the other box to discontinue the monthly CBC. Further review revealed there was a handwritten not authored by the Director of Nursing (DON) dated 05/18/25 that indicated the resident doesn't have monthly CBC and would readdress. Review of Resident #14's orders and medication administration records dated 05/2025 revealed the ferrous sulfate was not discontinued and the resident was still receiving and ordered ferrous sulfate 325 mg daily for anemia. Further review of Resident #14's orders revealed since 09/15/23 the resident CBC's have been ordered the first Wednesday in June and December. Review of Resident #14 Physician note dated 05/16/25 revealed to monitor CBC periodically to monitor the resident's iron deficiency anemia. Interview on 05/21/25 at 1:02 P.M., with the Physician revealed he had spoken to the DON regarding several pharmacy reviews on Friday and he could not remember the exact order but his initial gut feeling was he discontinued the ferrous sulfate and wanted to monitor the CBC periodically. Interview on 05/21/25 at 4:14 P.M., with the DON revealed the Physician did not relay to her to discontinue the ferrous sulfate and she had interpreted the pharmacy recommendation as the physician agreed to discontinue monthly CBC, however the DON confirmed the resident was not ordered monthly CBC, nor was discontinuing monthly CBC a recommendation the pharmacist had made.

Based on observation, interview and facility policy review, the facility failed to ensure insulin pens were dated when opened. This affected three residents (#26, #49 and #192) of three residents reviewed for insulin use. Findings include: Observation on 05/19/25 at 8:15 A.M. of the unit short B medication cart revealed opened insulin containers with no open dates for the following medications: Resident #49 one Lantus long-acting insulin pen with the dispensed date of 05/06/25, Resident #192 one Lantus long-acting insulin pen with the dispensed date of 05/04/25. Interview on 05/19/25 at 8:15 A.M. with Licensed Practical Nurse (LPN) #186 verified insulin pens were not dated when opened in the unit short B medication cart. Observation on 05/19/25 at 8:32 A.M. of the unit 2 medication cart revealed opened insulin pens with no opened dates for the following medications: Resident #26 one Lantus long-acting insulin pen with the dispensed date of 03/27/25 and Resident #26 one Insulin Lispro pen with the dispensed date of 11/27/24. Interview on 05/19/25 at 8:32 A.M. with Registered Nurse (RN) #188 verified insulin pens were not dated when opened in the unit 2 medication cart. Review of the facility policy titled Medication Storage in the facility last revised May 2020 revealed the nurse shall place a date opened sticker on the medication and enter the date opened.

Based on record review, review of the facility's contracted dental company's visit list, resident interview, and staff interview, the facility failed to ensure a resident, who consented to receive dental services while in the facility, received those services to replace a broken lower denture plate. This affected one resident (#32) of three residents reviewed for dental services. Findings include: Review of Resident #32's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included moderate protein-calorie malnutrition, stroke without residual deficits, adult failure to thrive, and legal blindness. Review of Resident #32's payer status in the electronic medical record revealed the resident was admitted to the facility on [DATE] under Ohio Medicaid (MCD). His payer status did not change until 04/18/25, when he was changed to Hospice MCD. Review of Resident #32's clinical admission documentation dated 01/10/25 revealed the resident had the use of an upper denture that was in fair condition and was missing one tooth. He was indicated to have lower dentures, but did not wear them and they weren't brought to facility with him. Review of Resident #32's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. He required set up or clean up assistance with his oral hygiene. He was assessed on the MDS as being edentulous and there was no indication that he had any broken dentures. Review of Resident #32's care plans revealed he had a care plan in place for an alteration in dental/ oral status related to not having any natural teeth and wearing upper dentures as he chooses. The goal was for the resident to be free of dental/ oral discomfort and to have proper fitting dentures in good repair. The interventions included the need for a dentist to evaluate and treat as needed (prn). If the resident wore dentures, they were to observe the condition and proper fit. They were to report any chips, cracks, or rough edges and to notify the dentist prn. Review of Resident #32's ancillary services consent form dated 05/09/25 revealed the resident was not known to have declined any of the ancillary services. He was to receive dental services per his request. Resident #32's electronic medical record (EMR) was absent for any evidence of the resident having been seen by a dentist since his admission to the facility on [DATE]. Progress notes were absent for any attempts to arrange dental services for the resident to replace his current dentures. Review of a dental list showing when the facility's contracted dentist had last visited the facility revealed the contracted dentist had last visited the facility on 03/19/25. Resident #32 was not one of the 22 residents who had been seen on that date. On 05/19/25 at 8:45 A.M., an interview with Resident #32 revealed he did not have his lower denture plate at the facility due to them being broken. He had the same set of dentures for the past [AGE] years. He was interested in being seen by a dentist to get a new set of dentures. On 05/20/25 at 9:52 A.M., an interview with Certified Nursing Assistant (CNA) #212 revealed he was not aware of Resident #32 wearing dentures and was not sure if he even had them. He was not aware the resident had the use of full upper dentures, or that he did not have his lower dentures with him due to them being broken and left at home. On 05/20/25 at 10:20 A.M., an interview with the Director of Nursing (DON) confirmed Resident #32 had not received any dental services while in the facility. She further confirmed the resident had consented to receive ancillary services when he was most recently asked on 05/09/25. She alleged the resident did not go under MCD until 03/19/25, and it was retroactive to 01/10/25. She was not able to provide any documentation to support that or to dispute the EMR showing he had been covered under MCD since 01/10/25, as was indicated under the census tab of the EMR.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of the facility incident and accident log and corresponding investigation, review of the Facility Assessment, review of the Elopement Risk Assessment Policy and Procedure and staff, family and resident interviews, the facility failed to provide adequate supervision to Resident #74, who was actively exit seeking, cognitively impaired (with a Brief Interview Memory Score of six indicating severe cognitive impairment), identified as an elopement risk and resided on the secured unit, to prevent the resident from exiting the secured unit and the facility unsupervised. This resulted in Immediate Jeopardy and the potential for serious, life-threatening harm, injuries and/or death on [DATE] at approximately 5:50 P.M. when Resident #74 was granted access through the secured unit door by Cook #99 (who was unaware if the individual was a resident or visitor), passed by Licensed Practical Nurse #106 (who was unsure if the individual was a resident or visitor) and was then granted access through the secured facility main entrance by Receptionist #400 who had no knowledge if the individual was a resident or visitor. At the time of the investigation, it was unknown who located the resident, the time the resident was located and the actual whereabouts of the resident due to the lack of a thorough investigation by the facility but it was believed the resident was either located by an (unidentified) female visitor/individual on or near a road in front of the facility or at the State Route located approximately 100 yards from the facility, at the bottom of a wooded, downhill, paved road. The resident was noted with a skin tear and bruising thought to have occurred during a fall, on the facility main entrance/ exit ramp. This affected one resident (#74) of two residents reviewed for accidents and/or supervision. The facility identified 21 residents at risk for elopement (Resident #1, #7, #11, #22, #29, #30, #42, #46, #47, #48, #56, #60, #68, #70, #72, #74, #76, #138, #180, #181, and Resident #184). The facility census was 85. On [DATE] at 4:38 P.M., the Licensed Nursing Home Administrator (LNHA), Regional Nurse Consultant (RNC) #151 and Regional Nurse Consultant #375 were notified Immediate Jeopardy began on [DATE] at approximately 5:50 P.M. when the facility failed to follow proper protocols permitting Resident 74 to exit the secured unit and secured facility main entrance with assistance of staff (Cook #99, LPN #106 and Receptionist #400). Staff working on the secured care unit on [DATE] were unaware the resident, who was identified at risk for elopement, was cognitively impaired and had actively been exit seeking since admission to the facility, had exited the facility. At around 6:12 P.M. an unidentified female/visitor observed Resident #74 unsupervised, outside of the facility with the exact location unknown. The unidentified female notified Receptionist #400 an individual who she thought may be a resident, was outside of the facility, without staff knowledge. The Immediate Jeopardy was removed and subsequently corrected on [DATE] when the facility implemented the following corrective actions: On [DATE] at 6:12 P.M., Resident #74 was returned to his room and assessed by Licensed Practical Nurse (LPN)/Program Director (PD) #128 (the director of the secured unit, also known as Speret Hall). A head-to-toe skin assessment, vital signs, range of motion, and neurological checks were completed. An Elopement Observation form was completed, and frequent checks for the next 24 hours were initiated. Certified Nurse Practitioner (CNP) #200 was notified at approximately 6:20 PM. Resident #74's Responsible Party (RP) #250 was notified at 6:49 P.M. and 6:58 P.M. regarding the resident's elopement. This was completed by LPN/PD #128. On [DATE] at 6:12 P.M. the Director of Nursing (DON) was notified of the elopement and the Licensed Nursing Home Administrator (LNHA) was notified at 6:15 P.M. An investigation was initiated. During the investigation, the LNHA and DON attempted to determine who the individual was who alerted the receptionist of Resident #74 being outside during the staff interviews with LPN #106, LPN/PD #128, Receptionist #400, and State tested Nursing Assistant (STNA)# 82. No one was able to identify the unknown female. On [DATE] (no identified time) the DON instructed LPN/PD #128 to obtain statements from the three staff directly involved with Resident #74's elopement, LPN #106, Receptionist #400 and Cook #99 before the end of their shift on [DATE]. On [DATE] at 7:00 P.M. a facility head count was completed by Registered Nurse (RN) #146 and #84, LPN #106, LPN/PD #128 and all 76 residents were verified to be in the facility. On [DATE] at 9:00 A.M. the LNHA and DON reviewed the statements from Cook #99, LPN #106 and Receptionist #400 and determined the root cause of the elopement was the fact that three staff members did not know Resident #74 was a facility resident and not a visitor. Cook #99 allowed the resident to exit the secured unit without verifying if the individual was a resident or visitor. LPN #106 allowed the resident to exit Unit 2 (the unit outside of the secured unit) thinking Resident #74 was a visitor and Receptionist #400 allowed the resident to exit the facility without verifying whether he was a resident or a visitor. On [DATE] at approximately 10:00 A.M. the LNHA and DON provided LPN #106, Receptionist #400 and Cook #99 with one-to-one education regarding the Elopement Policy, and to ensure they distinguished the actual identity of the person as a resident or visitor prior to allowing the individual to exit the secured unit or facility. On [DATE] at 10:00 A.M. the LNHA, DON, and Staff Coordinator (SC) #100 began mandatory in-services for all staff via OnShift Alert (Scheduling software that the facility utilizes to communicate with all staff members. Staff received their schedules and notifications through this software), 1:1 verbal education and handouts related to a new entry and exit process for Speret Hall (when management becomes aware that visitors know the codes to either enter or exit Speret Hall, the LNHA or DON will have Maintenance Coordinator #110 change the codes to keep the unit as safe as possible), visitor badge process (visitor badges will be provided or encouraged to Speret Hall visitors by the receptionist upon arrival for visitation), and the Elopement Policy. Education continued through [DATE] with a plan for any staff educated as of this time to be addressed. On [DATE] at 12:00 P.M. Maintenance Coordinator #110 completed an audit of all facility magnetic door locks (15 locks) to ensure they were functioning appropriately. Observational audits of door locks continued four times weekly for four weeks and as needed. On [DATE] at 3:20 P.M. Maintenance Coordinator #110 completed an elopement drill. A plan was also implemented to conducted one drill per shift, weekly, for four weeks and as needed was completed. On [DATE] at 3:47 P.M. elopement risk assessments (observations) were completed for all 76 residents currently in the facility by the DON, RN #84 and RN #146 and LPN/PD #128. Changes in elopement risk scores were addressed through initiation of care plans and/or adding photos and information to the elopement binder. The facility identified 21 residents at risk for elopement (Resident #1, #7, #11, #22, #29, #30, #42, #46, #47, #48, #56, #60, #68, #70, #72, #74, #76, #138, #180, #181, and Resident #184). On [DATE] at 4:15 P.M. LPN #116 reviewed and updated four elopement binders to include photographs and the resident identification information form. Information for Resident #74 and all residents who were at moderate to high risk for elopement. One binder was located at Home B Nurses station, one at Unit 2 Nurses station, one at Speret Hall nurses' station and one at the reception desk. The Elopement scores were also discussed during the Clinical Meeting for any new admissions, readmissions and when a Minimum Data Set (MDS) is completed. The DON, Assistant Director of Nursing (ADON) #72, ADON #132 or MDS Nurse #87 were responsible for auditing the Elopement score. The Elopement binders would be updated by LPN #116, or the DON, Assistant Director of Nursing (ADON) #72, ADON #132 or MDS Nurse #87 with any change in a resident's Elopement Risk score. The Clinical Meeting is held Monday through Friday at 9:00 A.M. On [DATE] at 5:00 P.M. the facility implemented a plan all newly admitted residents' photos would be posted at the receptionist desk for one week and completed by Lead Receptionist #81. The lead receptionist/designee was responsible for posting the pictures of the new admissions at the front desk. The Designee could be any staff member working as the receptionist for that day. The LNHA and DON were responsible to verify this was being completed and have verified all new admission photos have been posted since implementation. On [DATE] at 4:00 P.M. 76 resident care plans were reviewed by MDS Nurse #87 to ensure care plans were accurate for residents at risk for elopement. A care plan for Resident #74 was created this date. On [DATE] the LNHA sent a letter via the United States Postal Service to responsible parties/families of residents residing on Speret Hall, providing education on the facility visitor badge protocol. On [DATE] at 9:30 A.M. an AD HOC Quality Assurance/Performance Improvement meeting was held with Medical Director #600, LNHA, DON, MDS Nurse #87, LPN #116, Dietary Coordinator #68, Intake Coordinator #61, Environmental Services Coordinator #123, and Lead Receptionist #81 to review the incident investigation and prevention plan. The LNHA would then refer adverse audit findings to the QAPI committee for review as needed and at monthly scheduled meetings. On [DATE], the LNHA and DON began audits to ensure visitor badges were in place or encouraged, three times weekly for four weeks and as needed. On [DATE] (no time identified), audits were implemented to ensure the doors to the smoking patio were secured with the alarm turned on three times a week for four weeks and as needed. (The door alarm to the smoking patio on Unit 2 was turned off at the time of the elopement). The LNHA, DON and/or Lead Receptionist #81 were responsible for completing the audits. On [DATE], the LNHA and/or DON initiated audits to validate the Speret Hall residents had their identifier wrist band on, or the Refused Wristband care plan was in place. The audits were completed once per week for four weeks and as needed. As of [DATE], 98 of 106 employees had received facility education. The remaining eight employees were identified as Cook #142, Housekeeping #139, STNA #56, #57, #66, #82 and #96 and LPN #63. STNA #57 and STNA #66 were currently on leave and would be educated upon return to work. The remaining six staff (Cook #142, Housekeeping #139, STNA #56, #82 and #96; LPN #63) work as needed and were removed from the scheduled effective [DATE] due to not receiving the education despite communication the education was required for continued employment. If the staff were not educated by [DATE], their employment with the facility would be terminated due to lack of participation. Findings include: Review of the medical record revealed Resident #74 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, anxiety, and depression. Resident #74 was admitted to the facility Speret Hall, a secure unit that required a code to enter and exit the unit. Clinical admission documentation dated [DATE] at 3:25 P.M. authored by Licensed Practical Nurse (LPN)/Program Director (PD) #128 revealed Resident #74 had short and long-term memory impairment and no mobility limitations. Resident #74's gait and balance were normal. The assessment revealed Resident #74 was not at risk for falls but was at high risk for elopement. An elopement risk observation form dated [DATE] authored by LPN/PD #128 revealed Resident #74 was able to ambulate, had a diagnosis of dementia, noted to be staying near windows or exit doors, was searching, and made verbal statements of needing to leave. The elopement risk observation form revealed Resident #74 was at high risk for elopement. Review of Secure Unit Pre-Admission assessment dated [DATE] revealed Resident #74 had cognitive impairment and exhibited poor safety awareness within the past three months. Resident #74 had resided in a private home and had wandered off and was unable to find his way back home. The history of mood/behavior revealed Resident #74 was easily confused and was recently at the emergency room after wandering out of his apartment. The pre-admission assessment revealed Resident #74 was compatible with admission criteria for secured unit. Further review of the medical record revealed Resident #74 did not have a care plan for his identified high risk for elopement identified on admission to the facility. Review of a nursing note dated [DATE] at 3:30 P.M. authored by Registered Nurse (RN) #450 revealed Resident #74 walked up and down the hallway. Resident #74 did go to the front and back door and tried to open the doors. No intervention was documented. Review of a nursing note dated [DATE] at 2:57 P.M. authored by LPN/PD #128 revealed Resident #74 had been trying to get out the door nearest the end of the building. No intervention was documented. Review of a nursing note dated [DATE] at 10:37 A.M. authored by LPN/Supervisor #130 revealed Resident #74 continued to walk throughout the unit wandering from room to room and to the exit doors and asking to go home to Cambridge. No intervention was documented. Review of a nursing note dated [DATE] at 6:39 P.M. authored by LPN/PD #128 revealed Resident #74 continued to walk up and down the hall and asked if the doors could be opened. No intervention was documented. Review of a nursing note dated [DATE] at 3:11 P.M. authored by LPN/PD #128 revealed Resident #74 had been wandering around and asked three times if he could get out. Redirection helped for short periods of time. Review of a nursing note dated [DATE] at 5:54 P.M. authored by LPN/PD #128 revealed Resident #74 had tried to exit the building. The note indicated Resident #74 would be redirected to his apartment but would return to the day area. Resident #74's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #74 had severe cognitive impairment and wandering behavior that was not at significant risk for getting to a potentially dangerous place. Review of a nursing note dated [DATE] at 2:17 P.M. authored by LPN/PD #128 revealed Resident #74 had been walking up and down the hall. Resident #74 continued to go to the door and try to open the door. No intervention was documented. Review of a nursing note dated [DATE] at 1:18 P.M. authored by LPN/PD #128 revealed Resident #74 had been on the unit for two weeks. Resident #74 continued to go to the outside doors. Resident #74 tried to open the doors and would ask staff to let him out. Staff redirected the resident without problems. Review of a nursing note dated [DATE] at 5:50 P.M. authored by LPN/PD #128 revealed LPN/PD#128 was called to the lobby to get Resident #74. When LPN/PD #128 asked how Resident #74 got to the front lobby, LPN/PD #128 was told Resident #74 was mistaken as a visitor and allowed to exit Speret Hall and the facility. Staff were educated not to let anyone out of Speret Hall without asking. LPN/PD#128 noticed Resident #74 had a skin tear to the right wrist that measured one centimeter (cm) long, 0.5 cm wide, and 0.1 cm deep. It was also noted Resident #74 had a bruise to the right elbow and left hand near the thumb. Another resident reported Resident #74 fell outside on the sidewalk. (The progress note did not identify who the other resident was). Review of the incident and accident log revealed on [DATE] at 5:50 P.M. Resident #74 eloped from the facility. Review of the facility safety event report-fall with injury event dated [DATE] at 7:40 P.M. authored by LPN/PD #128 revealed an (unidentified) visitor found Resident #74 on the ground on the ramp in front of the facility (however, this visitor was not identified by the facility or interviewed as part of the facility investigation to determine the time the resident was located, the location of the resident or any additional information pertinent to the investigation). State tested Nursing Assistant (STNA) #82 assisted Resident #74 to stand (later interview with STNA #82 and Resident #6, who witnessed the fall, said Resident #74 was already standing or stood up by himself and brought Resident #74 into the facility. A skin tear was noted on Resident #74's right wrist that measured one cm long, 0.5 cm wide and less than 0.1 cm deep. Resident #74 also had a bruise to the right elbow and near the left thumb. Interventions put in place included frequent checks for 24 hours. The incident was documented as occurring on the sidewalk. Fall interventions included staff education about residents on the secure unit. Further review of the safety event report-fall with injury event revealed no information related to Resident #6's interview/statement (Resident #6 witnessed the Resident's fall on [DATE]). An elopement risk observation form dated [DATE] at 8:04 P.M. authored by LPN/PD #128 revealed Resident #74 was at high risk for elopement. A written statement dated [DATE] (no time) by LPN/PD #128, revealed at 5:30 P.M. Resident #74 was observed sitting at the table in the day area eating dinner. LPN/PD #128 gave Resident #74 medication at this time. After Resident #74 finished dinner, Resident #74 went down the hallway and then back to the day area to the exit door and tried to open the door. LPN/PD #128 redirected Resident #74 and told Resident #74 he had an apartment down the hall. Resident #74 went down the hall like he was going to his room. Cook #99 came down the hall with a bowl of food and LPN/PD #128 was administering medication to another resident. The statement indicated at 5:50 P.M. LPN/PD #128 was called to the front lobby to get Resident #74. A written statement dated [DATE] (no time) by Cook #99 revealed on [DATE] at approximately 5:50 P.M. Cook #99 walked past a room on Speret Hall and saw a man leaning over a bed and it looked like the man was talking to someone. Cook #99 assumed the man was a visitor. When Cook #99 got closer to the door (coded exit door leading off of Speret Hall onto Unit 2) the man (Resident #74) said there we go. Cook #99 put the code in to unlock the door while Resident #74 was standing at the doorway to a resident room. When Cook #99 opened the door, Resident #74 zoomed out (of the secured unit). Cook #99 asked Resident #74 if he was allowed out and Resident #74 said yes. Cook #99 wrote if I had closed the door, it would have hit Resident #74. Cook #99 thought Resident #74 was a visitor. A written statement dated [DATE] (no time) by LPN #106 revealed on [DATE] at approximately 5:50 P.M. Resident #74 stated he needed to come through the door as he exited the door from Speret (secure) Hall. Cook #99 was coming off Speret Hall at the same time. Resident #74 seemed like a visitor, walking full stride with a steady gait and at a fast pace. The statement revealed LPN #106 had not seen or dealt with Resident #74 before. A written statement dated [DATE] (no time) by State tested Nursing Assistant (STNA) #82 revealed STNA #82 was sitting at the assisted living desk (the unit located near the main entrance) when a woman walked into the building and was talking to Receptionist #400. STNA #82 overheard the woman say there was possibly a resident outside. STNA #82 walked over to the door and saw Resident #74 outside. STNA #82 walked outside to see if it was one of the residents from the facility. Resident #74 was bleeding from his right arm and had told the unidentified lady that he needed a ride to Cambridge. STNA #82 asked Resident #74 if he would walk back into the building to have his arm checked out. STNA #82 asked STNA #90 if Resident #74 was one of the residents on Speret Hall. A written statement dated [DATE] (no time) by STNA #90 revealed STNA #90 went to the kitchen to get a cup of juice for LPN/PD #128. STNA #82 asked STNA #90 what unit they were working on and asked if any residents were missing from Speret Hall. STNA #90 stated they were working on Speret Hall, and no residents were missing. STNA #82 said the man (that was outside) stated his name was (not his name). STNA #90 then walked closer to see the man STNA #82 was talking about. STNA #90 stated it was Resident #74. STNA #82 said someone found Resident #74 in the road. STNA #90 asked how Resident #74 got off the unit. STNA #82 stated a girl from the kitchen thought Resident #74 was a visitor and allowed Resident #74 to leave Speret Hall. Receptionist #400 called LPN/PD #128 to come get Resident #74. LPN/PD #128 made phone calls to the Director of Nursing and Administrator and asked staff to do a head count. A written statement dated [DATE] (no time) by Receptionist #400 revealed a man (Resident #74) walked from Unit 2 onto the smoker's patio. Resident #74 entered the front lobby from the smoking patio. Resident #74 then walked to the main entrance door and stood inside for a minute. Receptionist #400 thought Resident #74 had paused to look at the cats on the smoking patio. Resident #74 then started walking to the main entrance door without any questions or hesitation. Resident #74 looked like other visitors, so Receptionist #400 did not question Resident #74 and had no way of knowing Resident #74 was a resident. After Resident #74 exited the building, a visitor then came inside and said there was an older man outside asking for a ride to Cambridge. The visitor stated the man (Resident #74) did not seem familiar with where he was. STNA #82 came to the receptionist desk and spoke to the woman and then went outside to talk to Resident #74. STNA #82 brought Resident #74 back in and Receptionist #400 called LPN/PD #128. A written statement dated [DATE] (no time) that was signed by Resident #6 revealed Resident #6 observed a man (Resident #74) fall onto the concrete at the bottom of the ramp. Resident #74 was able to get up unassisted. The statement was received from the resident by LPN #106. The facility investigation of an elopement dated [DATE] revealed Resident #74 exited the secure unit onto Unit 2. Resident #74 went through the Unit 2 smoking patio door then walked through the smoking patio area and through the door into the front lobby. Resident #74 then exited the facility out the front lobby door. A new dietary aide (Cook) #99 thought Resident #74 was a visitor and allowed Resident #74 to exit Speret Hall. Resident #74 walked past LPN #106 on Unit 2. LPN #106 also thought Resident #74 was a visitor. Resident #74 then entered the lobby and exited out the lobby door where Resident #74 was seen by Receptionist #400 who also thought Resident #74 was a visitor. Resident #74 was last seen by Cook #99 at 5:50 P.M. Resident #74 left the unit at approximately 5:50 P.M. Director of Nursing (DON) received a call from LPN #128 at 6:12 P.M. It was believed Resident #74 was out of the facility for no longer than ,d+[DATE] minutes. Resident #74 got 77 feet away from the facility (this cannot be confirmed through staff statements or interviews because no staff could report the resident's exact location when discovered by the unidentified female individual as she was not interviewed for this information). Resident #74 was wearing blue jeans, a long sleeve plaid shirt, and shoes. The earliest Resident #74 exited the facility was at 5:50 P.M. The DON was called at 6:12 P.M. and the LHNA was called at 6:15 P.M. The temperature at 6:00 P.M. was 70 degrees Fahrenheit. A plan of care dated [DATE] (not initiated until four days after the elopement) revealed Resident #74 was at risk of eloping related to the resident's ability to self-propel (resident ambulated independently), Alzheimer's/dementia, history of alcoholism, express delusions, express hallucinations, near windows/exit, searching, verbal statements about leaving, and a history of elopement. Interventions included to check Resident #74 frequently and re-direct from exit doors as needed, inform facility staff including the interdisciplinary team and receptionist of the potential for elopement, complete the resident identification sheet due to risk factors, staff to report immediately to the nurses any statements by the resident of needing to leave, encourage activity involvement, attempt to determine what Resident #74 wanted or was searching for and try to convince Resident #74 that there is no need to look outside, notify family of the potential for elopement and encourage their help keeping Resident #74 safe, redirect to outside only with one-on-one staff supervision and instruction of the nurse, and educate/encourage family/friends to inform staff prior to Resident #74 leaving the facility with them. Interview on [DATE] at 2:49 P.M. with LNHA revealed a dietary staff member (Cook#99) was going down the hall and Resident #74 followed the staff member out the door from Speret Hall. Cook #99 thought Resident #74 was a visitor. Resident #74 went through a door on Unit 2 to the smoking patio and then through another door to the main lobby. Resident #74 told Receptionist #400 he was ready to go home. Receptionist #400 unlocked the front door to let Resident #74 out of the facility. A visitor talked to Resident #74 outside and thought Resident #74 seemed confused and notified Receptionist #400 there was a possible resident outside. Resident #74 had a skin tear and some bruises from a fall that occurred outside the facility. The LNHA revealed he was notified of the elopement at 6:15 P.M. by LPN/PD #128. The LNHA verified Resident #74's information had not been placed in the elopement binders located at the nurse's station and receptionist desk. The LNHA also verified the doors to the smoking patio were to alarm when opened on Unit 2 and the main lobby. However, the doors were not alarmed at the time Resident #74 went out the door to the smoking area. LNHA also verified the time of elopement and time Resident #74 was found were both listed as 5:50 P.M. on some information. During the interview, the LNHA could not verify how long Resident #74 was off the secure unit, how long Resident #74 was outside of the facility, exactly where Resident #74 was found or had been, and/or who the visitor was that reported finding Resident #74 outside of the facility. The LNHA also verified he was unaware of the resident's location when the resident was discovered by the unidentified female. He verified this information should have been clarified during the investigation and that the inconsistencies were not identified until this interview. Interview on [DATE] at 3:03 P.M. with Cook #99 revealed upon hire Cook #99 had been educated about not letting residents off Speret Hall. Cook #99 stated Resident #74 was walking without difficulty and was nicely dressed and had his shirt tucked in. Cook #99 thought Resident #74 was a visitor and asked Resident #74 if they were permitted off the unit. Resident #74 stated he was permitted to leave. Cook #99 stated LPN #106 was asked if she recognized Resident #74. LPN #106 stated she did not know Resident #74. Interview on [DATE] at 3:30 P.M. with Regional Nurse #151 verified the elopement care plan was initiated after Resident #74 eloped from the facility despite the resident being identified as an elopement risk on admission and displaying frequent exit seeking behaviors prior to his elopement. Interview on [DATE] at 10:20 A.M. with STNA #90 revealed Resident #74 always wandered. STNA #90 stated she was working Speret Hall and was not aware Resident #74 had left the unit until STNA #82 asked if anyone was missing from Speret Hall. STNA #90 saw Resident #74 standing at the front desk. LPN/PD #128 was notified and assisted Resident #74 back to Speret Hall. Interview on [DATE] at 10:27 A.M. with Responsible Party #250 of Resident #74 revealed she was notified a new kitchen staff member had let Resident #74 off the secure unit and Resident #74 had fallen outside the facility. Resident #74's Responsible Party #250 was not sure where Resident #74 fell but stated it was possibly on the smoking patio. LPN/PD #128 called Resident #74's daughter and stated Resident #74 was found on State Route (SR) 78 (a two-lane road with no sidewalks and speed limits of 55 miles per hour mph), trying to hitchhike to Cambridge (a town approximately 20 miles from the facility). A lady stopped on SR 78 and brought Resident #74 to the facility to see if Resident #74 resided there. The daughter stated Resident #74 was admitted to the facility because he kept wandering away from home and trying to hitch hike. Interview on [DATE] at 10:34 A.M. with LPN/PD #128 revealed Cook #99 let Resident #74 off Speret Hall. LPN #106 was working on Unit 2 and was not aware Resident #74 was from Speret Hall. LPN #106 did not stop Resident #74 from leaving Speret Hall or Unit 2. LPN/PD #128 was not aware Resident #74 was missing until Receptionist #400 called stating Resident #74 was in the main lobby. LPN/PD #128 stated Resident #74 was not found near SR 78 but found on the road in front of the facility, near the parking lot and the ramp from the main entrance. Further interview revealed Receptionist #400 reported to her the resident was on the roadway, in front of the facility. The LPN also stated she was unsure why the resident's information was not in the elopement binder but LPN/PD #128 usually verbally informed medical records when a resident was identified at risk for elopement because the medical records staff (LPN #116) was usually working. LPN/PD #128 verified she did not know who located the resident while he was outside of the facility. Interview on [DATE] at 10:51 A.M. with Resident #6 revealed he saw Resident #74 fall on the ramp in front of the facility. Resident #74 got up unassisted. Resident #6 stated he reported to LPN/Supervisor #106 someone had fallen outside. Resident #6 provided no additional information related to the incident. Interview on [DATE] at 11:00 A.M. LPN/Medical Records #116 revealed the nurses would notify Medical Records #116 if a resident was an elopement risk. Medical Records #116 would then take the resident's picture, complete the Resident Identification Form, and place the information in the elopement binder. Medical Records #116 did not know why Resident #74 did not have information in the elopement binder. Medical Records #116 verified she was not aware Resident #74 was at high risk for elopement and Resident #74's information was not in the elopement binder at the time Resident #74 had exited the facility without staff knowledge. Interview on [DATE] at 12:44 P.M. with STNA #82 revealed she did not witness Resident #74 exit the facility. A female entered the facility and reported she was driving up the hill to the facility and saw a man walking past the independent living apartments. (The apartments are attached to the right side of the skilled facility located at the end where the road goes down a steep hill to SR 78.) STNA #82 went outside and found Resident #74 at the bottom of the ramp leading from the front door of the facility. STNA #82 stated she did not recognize Resident #74 but brought Resident #74 back into the facility. Interview on [DATE] at 12:49 P.M. with Receptionist #400 revealed she thought Resident #74 was a visitor and let Resident #74 exit the facility. Receptionist #400 stated Resident #74 was outside the facility for approximately 10 to 15 minutes. Receptionist #400 stated the female visitor who reported Resident #74 was outside was someon [TRUNCATED]

Based on observation, record review, facility policy and procedure review and interview, the facility failed to prevent the development of an unstageable pressure ulcer and failed to ensure a pressure ulcer treatment was provided as ordered for Resident #50. Actual Harm occurred on 09/19/22 when Resident #50, who was cognitively impaired, high risk for skin breakdown and required extensive two person staff assistance for bed mobility was found to have an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer to the right Achilles area. There was no evidence the ulcer was identified prior to being found unstageable with eschar and drainage or evidence comprehensive and individualized interventions were being provided for the resident to prevent the development of the unstageable pressure ulcer. This affected one resident (#50) of two residents reviewed for pressure ulcers. Findings include: Medical record review revealed Resident #50 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed the resident's skin was intact on admission. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 08/19/22 revealed Resident #50's Brief Interview for Mental Status (BIMS) score was 99, which indicated the interview was not attempted as the resident was rarely/never understood. There were no behaviors or rejection of care identified on the assessment. The MDS assessment revealed the resident required extensive, two-person assistance with bed mobility, transfers, dressing, eating and toileting. The MDS revealed there were no unhealed pressure wounds on admission. Review of Resident #50's Braden Skin Assessment, dated 08/24/22 revealed the resident was assessed to be at high risk for the development of a pressure ulcer with an assessment score of 12. The assessment noted the resident's risk was associated with his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/30/22 a physician order was noted for an air mattress to the resident's bed and a pressure redistribution cushion to the chair. Record review revealed on 09/01/22 an order was obtained for the resident to receive Hospice services related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 09/01/22 a physician's order was noted for the resident to be out of bed to a specialized (Broda) chair for comfort and safety. Record review revealed the resident had no physician's order(s) for any type of pressure reduction for his heels/feet. The resident had no order for off-loading boots to be utilized. Review of a Wound Grid Documentation Report, dated 09/19/22 at 11:22 A.M. revealed the resident was identified to have an in-house unstageable pressure ulcer, located on the right Achilles, with an onset date of 09/19/22. The wound measured 2.1 centimeters (cm) length by 1.0 cm width with an undetermined depth. The ulcer was assessed to be pink with 25% eschar tissue, a small amount of serous exudate and no odor. The wound treatment was to clean the right Achilles with normal saline/wound wash, apply Medi-honey, and cover with a foam dressing. Record review revealed no corresponding nursing progress note related to the development or identification of the unstageable pressure ulcer was completed on 09/19/22. Review of the physician's orders revealed an order, dated 09/20/22 to cleanse the right Achilles with normal saline, gently pat dry, apply Medi-honey to wound bed and cover with foam dressing, every other day and as needed for soiling or dislodgement. Review of the care plan, initiated 09/20/22 revealed the resident had a right Achilles/right lateral foot pressure ulcer/injury related to impaired mobility, impaired cognition, diabetes mellitus, urinary and bowel incontinence, poor nutritional intake, poor sensory perception, friction and shearing concerns. Interventions included the use of off-loading boots while in bed (with a start date of 09/21/22), pressure redistribution cushion to care, air mattress to bed, observation of wound for any redness, warmth, drainage, odor, and report to physician as needed, and nutritional assessment as needed. Record review revealed no Hospice documentation related to the development of the unstageable pressure ulcer to the resident's right Achilles. On 09/21/22 at 11:45 A.M., observation with Licensed Practical Nurse (LPN) #203 revealed no dressing was in place to Resident #50's right Achilles pressure wound at that time. The resident was observed seated in the Broda chair in the common area on the secured unit at the time of the observation. At the time of the interview, interview with LPN #203 verified the pressure ulcer was first identified to the resident's right Achilles on 09/19/22. On 09/21/22 at 11:50 A.M. interview with Unit Manager/Licensed Practical Nurse (LPN) #203 confirmed there was no foam dressing applied to Resident #50's right Achilles pressure wound and indicated there should have been a foam dressing applied. On 09/21/22 at 12:05 P.M. interview with Regional Registered Nurse (RN) #204 verified Resident #50's pressure ulcer was first identified on the resident's right Achilles on 09/19/22. On 09/21/22 at 3:10 P.M. interview with the Director of Nursing (DON) confirmed Resident #50's pressure wound located on the right Achilles should have been covered with a foam dressing as ordered by the physician. During the annual recertification survey, the facility failed to provide evidence to determine the development of the right Achilles unstageable pressure ulcer was unavoidable or that comprehensive and individualized interventions were being provided for the resident to prevent the development of the unstageable pressure ulcer. Continued random observations of the resident during the annual recertification survey and interviews with direct care staff revealed the resident spent the majority of his time out of bed and in the Broda chair in the common area of the unit. The resident was not observed with off-loading boots in place when seated in the Broda chair. Review of the facility undated policy titled Pressure Injures: Assessment, Prevention, and Treatment, revealed it was the facility policy to identify residents at risk for developing pressure injuries, implement interventions to prevent the development of pressure injuries and provide care for existing pressure injuries. This deficiency substantiates Complaint Number OH 937 and Complaint Number OH 826.

Based on closed record review, review of an emergency medical service (EMS) run report, facility Postmortem policy and procedure review, staff interview, family interview and interviews with Paramedic #202, Mortician #200 and Medical Director #401 the facility failed to provide adequate and immediate postmortem care to Resident #79 following the resident's death in the facility on [DATE] resulting in neglect of the resident's corpse. This resulted in Immediate Jeopardy, when on [DATE] at approximately 11:00 A.M. Resident #79's body was released to the funeral home without evidence of postmortem care having been provided. An interview with Mortician #200 revealed upon arrival to the nursing home, Resident #79 was observed strapped to a back board with a large amount of feces covering her body. The resident's arms were pulled up/contracted towards her face. Mortician #200 indicated it was evident no personal care/postmortem care had been provided to the resident since her time of death on [DATE] around 10:00 P.M. Actual harm occurred as the reasonable person concept involves caring for a deceased resident's body with sensitivity and in a manner consistent with a resident's religious and cultural beliefs. Postmortem care should be provided immediately or as soon as possible to prevent tissue damage or disfigurement of a resident's body as the body starts decomposition immediately after death. The body should be preserved to delay decomposition so funeral services may take place. This affected one resident (#79) of three resident reviewed for death. The facility census was 77. On [DATE] at 11:51 A.M. the Administrator and Regional Corporate Nurse (RCN) #100 were notified Immediate Jeopardy began on [DATE] at approximately 11:00 A.M. when funeral home staff/Mortician #200 arrived to the facility to transport Resident #79 to the funeral home. At that time it was identified that postmortem care had not been provided to the resident following her death on [DATE] at approximately 10:00 P.M. On [DATE] at approximately 11:00 A.M. (over 12 hours after her death) the resident was noted to be strapped to the back board cardiopulmonary resuscitation (CPR) had been provided on, covered with feces with her arms pulled up towards her face. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE] at 12:20 P.M. Regional Nurse Consultant (RNC) #100 reviewed three of three records for residents who had expired from [DATE] and [DATE]. No concerns regarding postmortem care or neglect were identified. · On [DATE] at 2:30 P.M. the facility Quality Assessment and Performance Improvement (QAPI) Committee, which included the Administrator, Director of Nursing (DON), Chief Nursing Officer #212, Regional Vice President (RVP) #213, and RNC #100 reviewed the facility postmortem care policy and procedure. No changes were made to the policy. · On [DATE] at 2:30 P.M. and additional QAPI meeting was held with the Administrator and DON to review the issue and the facility plan of action. · On [DATE] at 11:00 A.M. the Director of Nursing (DON) and State tested Nursing Assistant (STNA) #402 began education for all nursing staff on the postmortem care and neglect policies. The education was completed on [DATE] at 4:05 P.M. for 46 STNAs, two agency STNAs, five LPNs, eight RNs and one agency RN. A plan for education for nursing staff to be required to complete education prior to their next scheduled shift was implemented. No nursing staff would be permitted to work until educated. · On [DATE] at 12:15 P.M. RNC #100 reviewed resident records and the resident concern log for [DATE] and [DATE]. There were no concerns related to post mortem care documented. · On [DATE] at 12:05 P.M. the DON spoke with the Medical Director (MD) #400 via phone to discuss the proposed Immediate Jeopardy deficiency and facility action plan. · On [DATE] at 1:30 P.M. three staffing agency companies (used by the facility) were provided education materials, which included postmortem care and neglect). The agency staffing companies are responsible for educating their staff prior to starting their scheduled shift at the facility. The DON must receive a sign off sheet prior to next worked day that the training was completed. · Beginning [DATE] a plan for audits to be completed by the DNS/designee daily for 2 weeks, 3 times per week for 2 weeks, weekly for 2 weeks and then as needed (PRN) to ensure postmortem care was completed appropriately for a deceased resident. · Beginning [DATE] a plan for audits to be completed by the DNS/designee daily for 2 weeks, 3 times per week for 2 weeks, weekly for 2 weeks and then PRN to ensure neglect did not occur related to postmortem care of a deceased resident Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings Include: Review of Resident #79's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident expired in the facility on [DATE]. Review of an EMS run report, dated [DATE] revealed the sheriff's department was notified at 10:00 P.M. of a female resident who had fallen on the floor on her face and the facility was unsure if there were any injuries. EMS was notified at 10:02 P.M. and arrived to the facility at 10:09 P.M. Upon arriving, EMS staff found facility staff performing CPR and assumed care of the resident as CPR was not being performed correctly. (See finding under F678). Resident #79 was placed on a cardiac monitor that showed asystole (absence of ventricular contractions of the heart/a lethal heart rhythm). EMS called a local hospital physician and advised him of the situation, resident down time and the care provided prior to the EMS arrival. The resident was pronounced deceased . Review of Resident #79's electronic and hard chart/paper medical record dated [DATE] and [DATE] revealed no evidence facility staff provided Resident #79 any type of postmortem care. The medical record contained no information related to when the resident's body was released to the funeral home. Review of Resident #79's expiration observation note, dated [DATE] at 11:59 P.M. revealed the resident expired on [DATE] at 10:00 P.M. The form was incomplete except for a box checked yes that the physician, power of attorney, guardian, family and funeral home were notified. The note revealed the progress notes contained events regarding the resident expiration. The date and time the body was released to the funeral home was blank. On [DATE] from 9:00 A.M. to 2:10 P.M. interviews with staff who wished to remain anonymous revealed the following concerns: Staff member #106 revealed it was reported to her Resident #79 had expired at 10:00 P.M. on [DATE]. The resident was strapped on a body board so she could be transferred from the floor to the bed by the paramedics. On [DATE] at 10:00 A.M. the resident's body was still strapped to the body board and no postmortem care had been provided. Night shift had reported the night nurse had directed the staff does not provide care. Staff member #107 revealed Resident #79 had fallen out of bed on [DATE] and had expired. Staff had not provided postmortem care and the resident was left strapped to a body board with her elbows extended up to her face for over 12 hours. Staff member #108 revealed staff had reported Resident #79 had expired on [DATE] at 10:00 P.M. per information passed on in report. The resident was still strapped to a body board with her elbows bent and extended up towards her face. The resident's hands were closed in a fist position. The resident had not been provided postmortem care and was covered in bowel movement and urine for over 12 hours. The family had not been notified until the next morning when the resident's sister-in-law came in to visit. The facility reported they had the wrong contact information for the family member. Staff member #110 reported she heard staff had not provided postmortem care for Resident #79 for over 12 hours and left the resident on a body board the entire time. On [DATE] at 3:02 P.M. and [DATE] at 8:54 A.M. interview with Mortician #200 revealed he had arrived to the facility on [DATE] around 11:00 A.M. per the request of Resident #79's son. The mortician denied contact from the nursing home regarding the resident's death. Upon arrival, Resident #79 was still in her room strapped to a body board lying in a hospital bed. The resident had bowel movement/urine on her and the bed. There was no evidence postmortem care had been provided. The resident's elbows were bent towards her face and rigor mortis had set in. Mortician #200 revealed he had never had a facility hold a body for over two to three hours after death and indicated the funeral home had a holding unit to hold bodies to preserve them while arrangements were being made even if the family decided not to use his funeral home. Mortician #200 revealed EMS staff had offered to transfer Resident #79's body to the funeral home to hold the body until the facility could reach family, but the facility declined. The mortician revealed staff at the funeral home had to exercise the resident's arms to return them to a neutral position for the funeral. The family was upset they were not notified timely, and that the resident's body had to lay 12 hours in the nursing home without being preserved. The mortician reported it would be upsetting to a family and himself if it was his loved one that laid strapped to a body board with no postmortem care being provided for 12 hours. On [DATE] at 3:09 P.M. telephone interview with Resident #79's son (#201) revealed he had concerns the facility had left his mother's body for twelve hours without being preserved and the delay in notification to the family regarding his mother's death. On [DATE] at 2:10 P.M. interview with State tested Nursing Assistant (STNA) #111 revealed she had helped assist the mortician with transferring the resident from the bed to the stretcher (on [DATE]). The resident was still strapped to the board and her arms could not be straightened. STNA #111 verified the resident had not been provided any type of postmortem care by facility staff. The resident had bowel movement/urine noted on the bed and on her body. On [DATE] at 2:32 P.M. interview with the DON revealed it was determined staff had obtained Resident #79's family phone numbers from the hospital records and they were not confirmed to be correct with the family upon admission. The son's number was listed under the sister in laws. A second number (FM #202) on the hospital records was not recorded in the nursing home records. On [DATE] at 5:01 P.M. interview with the Administer and DON revealed they were not aware Resident #79 was not provided immediate postmortem care and not aware she had been left on a body board for over 12 hours. On [DATE] at 8:39 A.M. telephone interview with Paramedic #202 revealed he had to call another local EMS squad to come and assist the resident off the floor and into the bed after he arrived onsite. Paramedic #202 revealed facility staff were available, but no one was willing to assist them in the transfer. The EMS strapped the resident to a body board so they could transfer her from the floor to the bed. Upon completion of the call, they left the resident on the back board and turned care back over to the nursing home. The paramedic reported they had returned the next day on [DATE] to assist with another resident and Resident #79 was still in her room. The paramedic reported rigor mortis (result of death of cells in the muscle fibers of the human body, which leads to chemical changes in those fivers causing shortening, or stiffening, of the muscles. Rigor mortis sets in within two hours of death) had set in. The paramedic reported the nursing home would not permit the EMS staff to transfer the resident's body to the funeral home on [DATE] and indicated the resident should have not been left on the body board for 12 hours. On [DATE] at 10:29 A.M. telephone interview with Family Member (FM) #203 (Resident 79's sister-in-law) revealed on [DATE] she had spoken to the nurse regarding contacting her for information since Resident #79's sons worked. RN #101 confirmed with FM #203, that a phone number was in the computer, however, did not verify the number with her. The facility had contacted Resident #79's son and he had called FM #203 to report the facility was trying to call her but was calling his number. FM #203 reported she was already on her way to see the resident around 7:00 A.M. on [DATE]. FM #203 revealed at the time she arrived to visit on [DATE] she was not aware Resident #79 had expired. FM #203 revealed upon arrival she was asked to wait in a waiting area and sat there for what felt like forever. Finally, an ex-relative who worked at the facility, approached her and informed her the resident had expired on [DATE] at around 10:00 P.M. FM #203 revealed she was then able to see Resident #79. At the time she saw her, the resident was strapped to a body board. FM #203 revealed because the resident's death was unexpected, no funeral pre-arrangements had been made. On [DATE] at 11:48 A.M. and 2:38 P.M. interview with RN #101 verified postmortem care was not provided to Resident #79 as staff did not want to unstrap her from the board following her death. On [DATE] at 2:55 P.M. interview with the facility previous medical director (MD) #401 who was also Resident #79's primary care physician during her stay in the nursing home revealed he was notified on [DATE] (at unknown time) from a paramedic who called and reported Resident #79 had flat lined. MD #401 revealed the facility did not know if the resident had a choice for funeral home and paramedics usually didn't transport bodies to the funeral home because they charge for the transportation services, so he told the facility to call the funeral home. MD #401 revealed he was not aware Resident #79 had laid at the nursing home for 12 hours, until he had spoken to the mortician. MD #401 revealed he was also the county corner and was investigating another death when the mortician had voiced concerns the facility had left Resident #79 for a long period of time. MD #401 revealed the funeral home usually liked to receive a resident's body so the head could be blocked up as soon as possible to prevent the person's face from turning purple. MD #401 revealed he had not been aware the family had not been notified of the resident's death until the next morning ([DATE]) and the resident's body had been left on the body board. The MD confirmed it would be emotionally harmful and disrespectful to the resident's family and not acceptable for the corpse. MD #401 revealed he would not want this type of care for his own mother or anyone else's mother. Review of the facility undated policy and procedure titled Post-Mortem Care revealed it was the facility policy to provide guidelines for the preparation of the deceased resident prior to release to the mortuary. The procedure included to cleanse the body, apply a clean gown and replace dirty linens. Straighten the body, close eyelids, place dentures in mouth, comb hair and place a rolled towel under chin. This deficiency is an incidental finding to Complaint Number OH 596.

Based on observation, closed record review, an Emergency Medical Service (EMS) squad run report, review of staff witness statements, review of the facility cardiopulmonary resuscitation (CPR) policy, review of the Association of Anesthetist's publication titled Multidisciplinary Guidelines for the Management of [CONDITION(S)] and Laryngectomy Airway Emergencies, staff interview, family interview and interviews with Paramedic #202, Medical Director #400 and Medical Director #401 the facility failed to initiate adequate cardiopulmonary resuscitation (CPR) for Resident #79 who had a [CONDITION(S)] tube and required supplemental oxygen. This resulted in Immediate Jeopardy on [DATE] at approximately 10:00 P.M. when Resident #79 sustained an unwitnessed fall and subsequently became unresponsive without vital signs. The facility failed to properly assess the resident's respiratory status and properly provide CPR (ventilation) using the resident's [CONDITION(S)] tube. On [DATE] at 10:09 P.M. EMS arrived on-site and identified facility staff were not properly providing CPR using the resident's tracheotomy valve nor was the [CONDITION(S)] valve covered/capped. Ventilation by staff was incorrectly being provided over the resident's nose/mouth. EMS staff assumed care of the resident at that time and properly initiated CPR. Life threatening harm and death resulted when Resident #79 did not receive proper/adequate CPR by facility staff and expired in the nursing home. This affected one resident (#79) of three residents reviewed for an emergent change in condition and death. The facility identified having no additional residents residing in the facility designated with full code status and [CONDITION(S)]. The facility census was 77. On [DATE] at 11:51 A.M. the Administrator and Regional Corporate Nurse (RCN) #100 were notified Immediate Jeopardy began on [DATE] at approximately 10:00 P.M. when facility staff, including Registered Nurse (RN) #101, Licensed Practical Nurse (LPN) #102, and State tested Nursing Assistant (STNA) #103 failed to initiate adequate/proper CPR procedures for Resident #79 after she stopped breathing. Resident #79 subsequently expired in the facility. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE] at 12:15 P.M. Regional Nurse Consultant (RNC) #100 reviewed the medical records for all current in-house residents and did not identify any additional residents who had a [CONDITION(S)]. · On [DATE] at 2:20 P.M. the Admissions Coordinator (AC) #211 was notified by the Administrator to hold any admission for a resident with a [CONDITION(S)] until further notice, thus eliminating imminent risk to any current or future residents. · On [DATE], at 2:30 P.M. the facility Quality Assessment and Performance Improvement (QAPI) Committee, including the Administrator, Director of Nursing (DON), Chief Nursing Officer (CNO) #212, Regional Vice President (RVP) #213 and RNC #100 reviewed the facility CPR policy and identified no updates were needed. · On [DATE] at 2:30 P.M. an additional QAPI meeting was held with the Administrator, DON, CNO #212, RVP #213 and RNC #100 to review Immediate Jeopardy deficiency and facility plan of action. · On [DATE] 11:00 A.M. the DON initiated education for all licensed nurses on the CPR policy, including the need to confirm patency of airway during CPR and what to do if airway was not patent in accordance with the American Heart Association (AHA) guidelines. Education was completed on [DATE] 4:05 P.M. for five Licensed Practical Nurses (LPNs), nine RNs, and one agency RN. A plan for no licensed staff to be permitted to work until education was received was implemented. RN #214 assisted with training of the licensed staff. · On [DATE] at 11:00 A.M. the DON Initiated education and RN #214 continued education for all licensed nurses on the process for determining code status and the location of the resident's code status in the medical chart. On [DATE] at 4:05 P.M., five LPNs, nine RNs and one Agency RN had completed the education. A plan for no licensed staff to be permitted to work until education was received was implemented. · On [DATE] at 12:05 P.M. the DON spoke via phone with Medical Director (MD) #400 regarding the proposed Immediate Jeopardy deficiency and facility action plan. · On [DATE] at 1:10 P.M. AC #211, the DON and Administrator were educated by RNC #100 that the Facility Assessment was updated to reflect that the facility would no longer admit or retain residents with a [CONDITION(S)]. · On [DATE] at 1:30 P.M., three staffing agency companies were provided education materials via email regarding the facility CPR policy. The staffing agencies are to educate their staff prior to starting their next scheduled shift at the facility. The agency staff must provide a sign off sheet to the DON prior to working their next shift confirming they had received education on the facilities CPR policy. · On [DATE] a plan for audits to be completed by the DON/designee daily for 2 weeks, 3 times per week for 2 weeks, weekly for 2 weeks and then as needed (prn) to ensure ventilation of a resident was performed correctly during a code was implemented. · On [DATE] a plan for audits to be completed by the DON/designee daily for 2 weeks, 3 times per week for 2 weeks, weekly for 2 weeks and then PRN to ensure nursing staff could identify the location of the code status in residents' medical records was implemented. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings Include: Review of Resident #79's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #79 expired in the facility on [DATE]. Review of Resident #79's admission assessment dated [DATE] and functional assessment dated [DATE] revealed the resident was admitted for hypoxemic respiratory failure. The resident's memory was intact and she communicated by nodding her head yes or no. The resident had difficulty with communication, some words and her speech were unclear or mumbled. The resident was incontinent at times of bowel and bladder. The resident required substantial/maximal assistance (help to do more than half the effort) with toileting. The resident required partial/moderate assistance (help to do less than half the effort) with rolling (turning in bed). The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was not assessed for transfers or ambulation. Review of Resident #79's baseline plan of care and printed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #79's code status. Further review of Resident #79's hard (paper) chart revealed no evidence of the resident's code status documented in the medical record. Review of the baseline plan of care revealed the resident had respiratory issues due to acute hypoxemia respiratory failure. Interventions included oxygen as ordered, keep head of bed elevated, check oxygen saturation (no frequency indicated) and report any signs or symptoms of respiratory distress. There was no evidence of a plan of care for the resident's [CONDITION(S)]. The resident had a plan of care related to fall risk with interventions to check every two hours, orient resident to room and call light, observe resident and report safety concerns. Review of Resident #79's medical record revealed the resident was not receiving Hospice services and/or palliative care during her stay at the facility. The plan of care revealed the resident's goal was to return home. Review of the admission physician orders, dated [DATE] and subsequent orders, dated [DATE] revealed Resident #79 had a [CONDITION(S)] with orders for an [MEDICATION(S)] six millimeter (mm) shiley [MEDICATION(S)]. There was no order for suctioning the resident. The resident had an order ([DATE]) for oxygen via [CONDITION(S)] collar at 35% humidification during bedtime hours and to check placement during bedtime hours (7:00 P.M. to 7:00 A.M.). There was no evidence of the amount of oxygen to deliver or to check saturation levels during bedtime hours. The resident had an order ([DATE]) for oxygen two to six liters per nasal cannula during daytime hours (7:00 A.M. to 7:00 P.M.). This order did not include to cap the resident's [CONDITION(S)] tube when using the nasal cannula or parameters for how much oxygen to administer to maintain a specific saturation level. The resident had a new order, dated [DATE] (no time noted) for oxygen six to eight liters continuously via [CONDITION(S)] collar with 35% humidification. Although this order indicated via [CONDITION(S)] collar, the resident had an order indicating the use of collar ([CONDITION(S)]) or cannula (nasal) for oxygen delivery depended on resident tolerance, preference and oxygen saturation every shift. However, the resident did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, at the time of the new order on [DATE], for six to eight liters continuous via [CONDITION(S)] collar with 35% humidification, the previous oxygen orders from [DATE] were not discontinued which resulted in a discrepancy in oxygen administration orders for staff to follow. Review of Resident #79's medication and treatment administration records for [DATE] revealed no documented evidence on either administration record the resident was provided any oxygen or suctioned during her stay in the facility (on [DATE] or [DATE]). In addition, none of the progress notes following the admission note on [DATE] provided any information as to whether the resident was administered oxygen via nasal cannula or [CONDITION(S)] mask, the amount of oxygen administered, whether the resident required suctioning or the resident's saturation level. Review of Resident #79's progress note revealed an entry documented on [DATE] at 12:45 P.M. which indicated the resident had arrived to the facility via a transport company on a cot. The resident was noted to be alert, pleasant and denied discomfort. The resident was transferred onto the bed with assistance of five staff. Oxygen was applied at two liters per minute per nasal cannula and the resident's oxygen saturation levels were assessed to be 79% (low). Oxygen was increased to three liters and the resident's oxygen saturation level increased to 92%. The note revealed Resident #79 had a #60 (order indicated #6) [MEDICATION(S)] [CONDITION(S)] that was intact with a dressing in place with no drainage noted. The note did not indicate if the [CONDITION(S)] was capped at the time of admission. No cough or congestion were noted, the resident's lungs were clear to the upper lobes and diminished to the lower lobes. The resident was able to shake her head yes and no, but her speech was slow and broken. The next progress note, dated [DATE] at 6:38 P.M. revealed the physician was into visit the resident and reviewed her chart. New orders were received for as needed Tylenol. Review of the nursing progress notes revealed no entries completed between [DATE] at 6:38 P.M. and [DATE] at 10:52 P.M. for Resident #79. The progress note, dated [DATE] at 10:52 P.M. and completed by LPN #102 revealed she was notified at 10:00 P.M., the nurse on Home B (RN #101) needed help. Upon arrival to Resident #79's room she assisted the nurse in doing CPR on the resident until the ambulance arrived and then they (EMS) took over doing CPR. The note completed by LPN #102 did not provide any information as to why CPR was provided, evidence of an assessment of the resident nor did it detail the actual care provided by the LPN. The next progress note, dated [DATE] at 12:32 A.M. and completed by RN #101 revealed she was summoned by STNA #104 and STNA #105 at approximately 10:00 P.M. for a resident (Resident #79) who needed help. Upon entering the resident's room, the resident was noted to be face down between the bed and wall (with her head towards the bottom of the bed), there was a bed pan on the bed and a smear of bowel movement noted on the sheets. The nurse called the resident's name and asked her if she was hurting anywhere. The note indicated the resident attempted to answer. The note revealed RN #101 placed a nasal cannula (oxygen) back in the resident's nose. RN #101 documented the connection tubing for the resident's ventilator disconnected (the tubing was not long enough to reach where she was at on the floor), so the nurse rearranged the tubing to make it long enough to connect to the resident's [CONDITION(S)] ([CONDITION(S)]). RN #101 documented Resident #79 was still breathing at that time, but her breaths were shallow. STNA #104, STNA #105 and the nurse were able to roll the resident over. RN #101 documented the resident's respirations stopped and CPR was started. STNA #104 went to call 911 and get the crash cart. The progress note revealed CPR was continued until the paramedics arrived and took over CPR. The DON was notified at approximately 10:20 P.M. and the physician was notified at 10:30 P.M. Attempts to contact the resident's family were made on [DATE] at 10:32 P.M., 11:15 P.M. and again at midnight ([DATE]). Review of the above nursing progress note, dated [DATE] at 12:32 A.M. and completed by RN #101 failed to contain any respiratory assessment for the resident. There was no evidence the resident's [CONDITION(S)] tube or respiratory status were assessed at the time of the incident. There was no evidence the resident's oxygen saturation level was immediately checked at the time she was found on the floor, what her oxygen delivery was set at, how oxygen was being delivered/provided (nasal cannula or [CONDITION(S)] collar) or that her [CONDITION(S)] was assessed for patency. The note also failed to contain any specific information related to how CPR was provided to the resident. The next and last entry in the resident's progress notes, dated [DATE] revealed staff attempted to contact the resident's family at 1:15 A.M., 3:00 A.M. and 6:00 A.M. An expiration observation note, dated [DATE] at 11:59 P.M. revealed the resident expired on [DATE] at 10:00 P.M. The form was incomplete except for a box checked yes that the physician, power of attorney, guardian, family and funeral home were notified. The note revealed the progress notes contained events regarding the resident expiration. Review of the EMS run report, dated [DATE] revealed the sheriff's department was notified at 10:00 P.M. of a female resident (Resident #79) who had fallen to the floor on her face and the facility was unsure if there were any injuries. EMS was notified at 10:02 P.M. and arrived to the facility at 10:09 P.M. Upon arriving, nursing home staff asked EMS to hurry as staff were providing CPR to the resident. EMS staff found Resident #79 lying on the floor on her back with staff administering CPR with a bag-valve-mask (BVM) ventilation with a face mask hooked to an oxygen concentrator. The resident had a [CONDITION(S)]; however, staff were not properly providing CPR using the resident's tracheotomy valve nor was the [CONDITION(S)] site covered/capped. Ventilation by staff was incorrectly being provided over the resident's nose/mouth. EMS staff assumed care of the resident, properly initiated CPR and began ventilation using the BVM to the resident's [CONDITION(S)] with oxygen at 15 liters. Resident #79 was placed on a cardiac monitor that showed asystole (absence of ventricular contractions of the heart/a lethal heart rhythm). Per staff, Resident #79 had been found on the floor without oxygen. Staff reported the resident was down for a little bit before they got someone to call. Staff were unsure of the resident's code status stating she had arrived the day before. EMS called a local hospital physician and advised him of the situation, resident down time and the care provided prior to the EMS arrival. The resident was pronounced deceased . Record review revealed no formal investigation had been completed related to this incident. The facility provided written staff statements, dated [DATE] and [DATE] which included: A statement from RN #101 revealed at approximately 9:55 P.M., she was notified by the aides that a resident needed help. Upon entering Resident #79's room the resident was noted to be face down on the floor between the bed and wall (head towards the bottom of the bed) and a smear of bowel movement was noted on the bed. The resident was able to acknowledge her name. The resident's oxygen was not in-place. The nurse replaced oxygen via nasal cannula. The resident's [CONDITION(S)] tube was unhooked from the fall. The nurse re-inserted the tubing connection and turned the vent on. The resident's respiration began to slow. The aide and nurse were able to turn the resident on her back. The resident's respirations ceased and CPR was initiated. The aide called 911 and grabbed the crash cart. CPR was continued until paramedics arrived. There was no evidence following the statement from RN #101 the facility obtained additional information/clarification from the RN. No follow up questions were asked or information obtained to determine the care provided prior to or at the time of the incident related to the resident's [CONDITION(S)], respiratory needs or provision of CPR. In addition, there was no information as to why the RN noted the resident was on a ventilator as this was incorrect. A statement from LPN #102 revealed she was notified at 10:00 P.M. the nurse on Home B needed help. Upon arrival she assisted RN #101 with CPR on Resident #79. The resident was not responding, and CPR was continued until the ambulance arrived. The paramedics took over CPR and the nurse went to the desk to print paperwork out. The paramedics stopped CPR at 10:26 P.M. There was no evidence following the statement from LPN #102 the facility obtained additional information/clarification from the LPN. No follow up questions were asked or information obtained to determine the care provided prior to or at the time of the incident related to the resident's [CONDITION(S)], respiratory needs or provision of CPR. A statement from STNA #103 (a traveling STNA for the facility corporation) revealed she was giving report to night shift staff when STNA #104 ran past her at the nurses' station on the assisted living unit and said she needed the nurse because Resident #79 could not breathe and she ran towards unit two. STNA #103 revealed she ran to Resident #79's room and RN #101 was already doing compressions and an unidentified aide was bagging (providing ventilation). After 15 more compressions the nurse instructed STNA #103 to take over compressions and the RN took over bagging from the STNA. The statement revealed the STNA switched off twice (performing CPR) with the nurse before the EMS arrived. There was no evidence following the statement from STNA #103 the facility obtained additional information/clarification from the STNA. No follow up questions were asked or information obtained to determine how CPR was being provided. A statement from STNA #104 revealed another aide (STNA #105) and herself had placed Resident #79 on the bedpan at approximately 9:30 P.M. When they left the room, the resident stated she would turn the call light on when she was finished. When the call light turned on the STNA's walked into the room and found the resident face down on the floor beside the bed. The resident was still breathing. STNA #104 went and told the nurse. When the nurse arrived, the staff rolled the resident to her back and compressions were started and 911 was called. Another STNA grabbed the crash cart and the nurse took over. When the paramedics arrived, they took over. A statement from STNA #105 revealed Resident #79 was put on the bedpan on [DATE] at approximately 9:30 P.M. by STNA #104 and herself. The STNAs gave the resident her call light to push when she was done and the resident said she would. The STNAs went to assist other residents and when they came back they saw the resident's call light was going off at 9:59 P.M. The STNAs walked in the room and the resident was on the flood beside her bed face down and still breathing. Both STNAs ran outside the door yelling for the nurse. The RN and two STNAs ran into the room and rolled the resident on her back. They noticed she wasn't getting enough oxygen and they started CPR. CPR was done until the paramedics arrived and took over. Review of Resident #79's vital sign records revealed the last set of vital signs obtained for the resident prior to her being unresponsive were dated [DATE] at 8:12 A.M. The residents blood pressure was ,d+[DATE], pulse 82 beats per minute, respirations 18 per minute and her oxygen saturation was documented to be 95% on six liters of oxygen. This record did not indicate if the oxygen was provided via nasal cannula or [CONDITION(S)] collar. On [DATE] from 9:00 A.M. to 2:10 P.M. the following staff interviews were obtained from staff who wished to remain anonymous regarding their knowledge of the incident involving Resident #79 on [DATE]: Staff Member #107 revealed Resident #79 had fallen out of bed on [DATE] and expired. She was told the resident was still alive until the staff had flipped her over on her back. Staff had reported CPR was not performed correctly as staff were using the bag valve mask (ambu) bag over the resident's mouth instead of her [CONDITION(S)]. Staff Member #108 revealed staff had reported Resident #79 was not provided adequate CPR. The staff reported concerns that the involved staff were using an ambu bag over the resident's mouth and not her [CONDITION(S)]. In addition, Staff Member #108 revealed concerns the resident's family were not notified timely of the resident death and when the family member came the next morning ([DATE]) to visit, no one wanted to tell her that Resident #79, her sister in law had expired. Finally, LPN #109 who was an ex-relative of the family, informed the sister in law of Resident #79 passing. The staff member reported the nurses were not familiar with applying oxygen correctly for Resident #79 from the time of admission and an STNA had to assist the nurse with application of the oxygen and humidification. Staff Member #110 reported she had heard staff did not perform CPR correctly to Resident #79 on [DATE]. On [DATE] at 2:32 P.M. and 5:01 P.M. interview with the Administer revealed the facility did not complete a complete investigation regarding Resident #79's fall and death on [DATE]. The administrator reported at first, she only had four staff statements from staff who had provided direct care to the resident. The administrator reported the incident happened during shift change and there was additional staff standing outside the room, however she only obtained statements from the staff she thought were directly involved with the resident's care. Later the Administrator reported she thought she might have a fifth statement, but indicated she would have to look. A fifth statement was provided as noted above. On [DATE] at 3:09 P.M. telephone interview with Resident #79's son (#201) revealed there was something not right about the timeline and the incident involving his mother on [DATE]. The son revealed he had not been provided any answers regarding the details of the (fall) incident or his mother's death in the facility. The son indicated the resident had been admitted to the facility for a short term stay for therapy and the plan was for her to return home. On [DATE] at 8:39 A.M. telephone interview with Paramedic #202 revealed he was one of the paramedics who responded to the facility call on [DATE]. Paramedic #202 revealed the local sheriff's department received a call that a woman had fallen out of bed and landed on her face. Upon arrival to the facility a staff member had met them at the door and reported the resident was coding and to hurry up. At that time, the paramedics had to return to their vehicle for additional equipment as the call initially was only related to a resident who had fallen. Upon arrival to the resident's room the resident was cool to touch, but not cold. Some staff reported the resident was breathing when found and others reported she had just released gas when she was turned over onto her back. There was conflicting information on how long the resident was down and her code status. He believed STNA staff were performing CPR upon arrival and indicated there were a lot of staff standing around. Paramedic #202 revealed facility staff were not providing proper ventilation (as part of CPR) to the resident. Staff had a BVM on the resident's mouth and not the [CONDITION(S)]. They had her hooked to an oxygen concentrator that would only provide six liters of oxygen. The paramedic stated they took over applying 15 liters of oxygen and attempted to use the BVM mask over the [CONDITION(S)]. The paramedic reported the [CONDITION(S)] was full and there was possibly a [MEDICATION(S)] plug or something blocking the airway. Paramedic staff called the local hospital physician to get order to cease CPR as the resident had been down without proper oxygenation for more than ,d+[DATE] minutes. The time of death was noted to be 10:00 P.M. based on information provided from facility staff even though the paramedics did not arrive to the facility until 10:09 P.M. During the interview, the paramedic indicated facility staff did not provide adequate oxygenation as the oxygen was not set at 15 liters, there was improper use of the BVM and the resident's [CONDITION(S)] appeared plugged. The paramedic reiterated if a resident had a [CONDITION(S)], the BVM should be applied over the [CONDITION(S)] during CPR to provide ventilation after ensuring the [CONDITION(S)] site was patent and tube properly placed. On [DATE] at 9:05 A.M. interview with LPN #102 revealed she was working on the secured unit (Speret Hall) the night Resident #79 had expired. Around 10:00 P.M. an unidentified girl came running down the hallway and reported the nurse needs you. LPN #102 reported it took her about three to four minutes to get to Resident #79's room as the resident's room was on the other side of the building. Upon arrival to Resident #79's, LPN #102 revealed STNA #103 was providing inhalation via ambu bag to the resident's mouth and RN #101 was providing compressions. The LPN was not sure if oxygen was applied, however the LPN revealed a gray box and tubing was connected to the resident's [CONDITION(S)]. LPN #102 revealed it was reported to her that the resident was found around 9:55 P.M. and at that time it could not be determined how long she had been down. LPN #102 revealed she performed one cycle of compressions and then went back to the desk to print paperwork. The LPN reported staff should have used the resident's [CONDITION(S)] instead of the mouth when performing CPR, however everything was happening so fast. The LPN reported she had not been provided any training by the facility for how to perform CPR for a resident with a [CONDITION(S)]. The LPN also revealed she could not find any advance directive paperwork in the resident's chart, so she assumed the resident was a full code. LPN #102 revealed she had not seen or provided care to the resident prior to the incident. On [DATE] at 11:14 A.M. interview with STNA #104 revealed there were three STNA staff and one nurse working on Resident #79's unit on [DATE]. Around 10:00 P.M. the STNAs were doing their last rounds when they noticed Resident #79's call light was activated. Upon entering the room, the resident was found on the floor beside her bed and her [CONDITION(S)] tubing was unhooked. The resident was blue in color. The resident was turned onto her back. STNA #104 called 911 and went to get the other nurse (LPN #102). STNA #103 was assisting RN #101 with CPR. The STNA and RN took turns alternating breaths and compression. An ambu (bag valve mask) bag was placed over the resident's mouth for ventilation breaths. STNA #104 revealed there was a hose connected to the [CONDITION(S)]. On [DATE] at 11:48 A.M. and 2:38 P.M. interview with RN #101 revealed she was Resident #79's assigned nurse the night of [DATE]. RN #101 reported Resident #79 was on a ventilator. Observation of the ventilator with RN #101 at the time of the interview revealed the RN was referencing a gray humidification box that was currently located in the medication room. The device was not a ventilator but rather a box to supply humidification to the resident's oxygen. The RN reported her shift started around 7:00 P.M. and she had received very little information regarding Resident #79 during report. On [DATE] around 8:,d+[DATE]:00 P.M. RN 101 revealed she administered medication to Resident #79. The RN indicated at that time she thought the resident's [CONDITION(S)] tube was capped and she was receiving oxygen via nasal cannula at two liters. Around 9:55 P.M. the STNA staff reported they needed help. RN #101 revealed she had not seen Resident #79's call light activated because the RN was on another hallway at that time. Upon entering the resident's room, the RN noticed a bed pan on the bed and bowel movement smeared on the sheets. The resident was observed to be face down on the floor with her head at the bottom of the bed. The RN revealed it appeared the resident had attempted to get out of bed. However, the bed wheels were not locked and the bed was pushed to the side. The resident was breathing and her eyes were opened, however her skin was gray in color. The RN revealed the resident was able to respond verbally to name but was noted to be in distress. RN #101 revealed she re-applied two liters of oxygen via nasal cannula and re-hooked the resident to the ventilator. An STNA (unable to recall which STNA) called 911. The RN revealed there was not an ambu bag in the room and she didn't think there was a suction machine, however the suction machine was found later in the corner of the room. The STNA went to get the first crash cart, however, there was no suction on the crash cart so they had to go get a second crash cart from Unit 2 on the other side of the building. The RN revealed the resident's [CONDITION(S)] was not capped during CPR because the resident was hooked up to a ventilator. The RN could not recall if adjustments were made to the resident's oxygen during CPR. RN #101 revealed she and STNA #103 provided CPR. An ambu bag was placed over the resident nose/mouth to provide ventilation. During the interview, RN #101 revealed she had not been provided education on how to perform CPR for a resident with a [CONDITION(S)]. However, during the interview the RN indicated the ambu bag should have probably been placed over the resident's [CONDITION(S)] and not the nose/mouth. The RN reported she was not comfortable providing care to [CONDITION(S)] residents, however a nurse had reviewed [CONDITION(S)] care prior to the resident arrival. The staff member read over the procedure for [CONDITION(S)] care and had staff sign a sheet to acknowledge the training. Record review revealed the facility did not have a CPR policy regarding providing CPR for a resident with a [CONDITION(S)]. On [DATE] at 12:42 P.M., interview the DON confirmed staff were not provided education on CPR for a resident with a tracheotomy prior to the resident's admission, nor did the facilit [TRUNCATED]

Based on record review, review of a fall investigation report, review of the facility x-ray contract, facility policy and procedure review and interview the facility failed to ensure Resident #1 received timely and adequate care following a fall that resulted in an acute, traumatic, closed minimally displaced right intertrochanteric femoral fracture requiring surgical repair. Actual Harm occurred on 07/11/21 following a fall at 1:00 A.M. when the facility failed to immediately transport Resident #1 to the hospital or obtain a STAT x-ray which delayed hospitalization and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was subsequently transferred to the hospital on 07/11/21 following an update to the nurse practitioner at 12:55 P.M. (approximately 12 hours after the fall occurred) for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] This affected one resident (#1) of three residents reviewed for falls. Findings Include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's fall assessment, completed on 06/14/21 revealed the resident was at high risk for falls due to cognition, history of falls, assistance with elimination, visual impairment, balance problems while standing/walking, mediations (antihypertensive and hypoglycemics), and co-morbidities. The assessment note indicated the resident remained a high risk for falls and nursing was to monitor falls and update the physician as needed. Review of Resident #1's fall plan of care revealed the resident was at risk for falls related to confusion, poor vision, history of falls, incontinence of urine, use of medications (anti-hypertensive, hypoglycemic, laxatives, and narcotics) and impaired gait. Interventions included to keep phone in reach, non-slid gripper socks, wear glasses and staff to observe resident in room for safety needs. Review of a nurse's note dated 07/11/21 at 1:00 A.M. revealed the nurse (Licensed Practical Nurse (LPN) #502) heard the resident yelling out for help. Upon arrival to the room the resident was noted lying on the floor in front of her recliner. Upon original evaluation, the resident showed no signs or symptoms of pain or discomfort with no abnormal alignment or rotation of the extremities noted. The resident was assisted back to bed with assistance of two staff members without difficulty. When staff attempted to roll resident from one side to the other side to provide incontinence care, the resident grabbed her right leg complaining of pain and grimacing. The note indicated the resident remained able to move both lower extremities but continued to complain of pain to right leg/hip. The physician was notified and orders were received for an x-ray of the right leg, hip, and pelvis. There was no evidence the resident's representative was notified of the fall and/or complaints of pain at that time. Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. staff documented the resident was administered Acetaminophen 1000 milligrams (mg) for right leg pain rated a six out of ten (with 10 being the most severe pain). The record revealed the Acetaminophen was ineffective and the resident's pain had increased to a seven out of ten. Further review of the medical record revealed no evidence the physician was notified the x-ray company had not arrived as of this time to perform the STAT x-ray. On 07/11/21 at 8:36 A.M. the x-ray company arrived to obtain x-rays for Resident #1 and family was notified at that time per the nurses' note. On 07/11/21 at 12:55 P.M. the nurse practitioner (NP) was notified of the x-ray results. New orders were received to transport the resident to a local hospital for evaluation and treatment. Review of Resident #1's hospital notes, dated 07/12/21 revealed the resident was admitted to the hospital with an acute, traumatic, closed minimally displaced right intertrochanteric femoral fracture requiring short gamma nail surgery on 07/13/21. Review of the facility fall investigation report revealed a statement, dated 07/11/21 from State tested Nursing Assistant (STNA) #510. The statement revealed the STNA had been called to Resident #1's room for assistance by the nurse. The resident was noted on the floor. The staff assisted the resident up after the nurse completed an assessment. The resident had complaints of pain in the right hip. Review of the fall investigation report dated 07/12/21 at 4:18 P.M. revealed the resident was in bed and had been assisted to the recliner because she was attempting to get out of bed. After the resident was found on the floor the nurse assessed the resident and the resident was assisted to bed. Once back in bed the resident began to complain of pain and was grabbing her right leg and grimacing. The nurse reported Resident #1 began complaining of pain around 1:30 A.M. The nurse reported she wasn't ignoring the resident, however with the resident having a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Around 2:00 A.M., the nurse reported she realized the resident was really in pain because she was complaining the same spot was hurting and that was when she called the physician to obtain orders for x-rays. The nurse did not notify the resident's family immediately because she was taking care of the resident and getting things done. The nurse verified she didn't medicate the resident until 5:18 A.M. and she did not know why she didn't follow up when the pain medication was ineffective. On 08/03/21 at 10:42 A.M. interview with Licensed Practical Nurse (LPN) #500 revealed she was Resident #1's nurse on 07/11/21 beginning at 7:00 A.M. until the resident was transferred to the hospital. The LPN reported staff should not have moved the resident after she had sustained a fall with possible injury and should have called the physician to have the resident transferred to the hospital for a possible hip fracture. LPN #500 verified the resident had voiced complaints of pain during the x-ray procedure (at approximately 8:36 A.M.). The resident had pain with movement during her exam. LPN #500 revealed she did not notify the physician and thought she would just wait until the x-ray results returned. The LPN revealed she had not assessed Resident #1 prior to that time. On 08/03/21 at 12:03 P.M. during an interview with Regional Nurse Coordinator (RNC) #100, the RNC confirmed Resident #1 was ordered a STAT x-ray at approximately 1:10 A.M., the x-ray company did not arrive until 8:36 A.M. and the resident x-ray results were not reported until 12:55 P.M. The RNC verified Resident #1 was not treated timely for a hip fracture. On 08/03/21 at 1:33 P.M. interview with STNA #510 revealed she was the STNA assigned to care for Resident #1 when she had fallen on 07/11/21. STNA #501 confirmed the resident had complaints of pain during her shift (10:00 P.M. to 6:00 A.M.) The resident was rubbing her hip, had facial grimacing and would scream out oh with movement. On 08/04/21 at 10:04 A.M. interview with the Director of Nursing (DON) revealed she had identified concerns regarding Resident #1's fall. The DON revealed she had provided education to LPN #502 regarding documentation, notification and pain management. However, the incident had not been reviewed as part of the facility Quality Assurance Performance Improvement (QAPI). On 08/10/21 at 1:12 P.M. interview with LPN #502 revealed she was Resident #1's nurse on 07/11/21 and was on duty at the time of the resident's fall. LPN #502 confirmed the resident had fallen around 1:00 A.M., staff transferred her back to bed and about a half hour later the resident began complaining or right leg pain. The LPN reported she did not think the resident had pain but was just answering she had pain as part of her dementia diagnosis. However, the resident was still complaining of pain, so she contacted the physician and obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .M. the x-ray company called to confirm the x-ray was to be completed STAT. At that time, LPN #502 reported she called the resident's family to notify them of the fall and medicated the resident with Tylenol (at 5:18 A.M.) for pain. The LPN reported the Acetaminophen was not effective, however she did not notify the physician, nor did she notify him that the STAT x-ray had not been obtained. The LPN confirmed after looking back the staff should have not moved the resident after she had complaints of hip pain and she should have sent her out to the hospital for an evaluation. On 08/11/21 at 11:35 A.M. interview with Resident #1's daughter (Family Member (FM) #503) revealed she was not notified of Resident #1's fall until 5:15 A.M. on 07/11/21. FM #503 reported staff just told her that her mom had fallen, and the doctor had ordered x-rays. FM #503 called the facility around 8:30 A.M. to see if the x-ray results had come back but was told the company was just arriving. FM #503 revealed she was not aware the resident was having pain (this had not been reported to her during the phone call), until she arrived at the facility. FM #503 reported if she had known her mother had fallen at 1:00 A.M., was having pain and had to wait on the x-ray company she would have requested her mother be sent to the emergency room due to her mother taking a blood thinner (medication). When she arrived at the facility, shortly after she had called the facility (at 8:30 A.M.) her mother was in terrible pain. FM #503 revealed she had voiced concerns to the facility and had questions about the fall, however she still had not received any answers as of this date. On 08/11/21 at 9:00 A.M., interview with the DON and Administrator confirmed Resident #1's STAT x-ray was not obtained in a timely manner. The DON reported the expectation would be a STAT x-ray would be obtained within two hours of order. The Administrator confirmed the contract with the x-ray company did not include a time frame for STAT orders. The facility had a call out to the x-ray company regarding the time frame for STAT orders and had started an investigation to see what time the STAT order was called and why it was not obtained timely for Resident #1. Review of facility x-ray contract, dated 12/01/15 revealed no information regarding the timeframe for completion of STAT orders. Review of the facility Fall Investigation policy, dated 06/03/19 revealed if there was any evidence of an injury, nursing staff would provide appropriate aid. The nursing staff would notify the resident's representative in a timely manner. Nursing would observe for any change of condition. Review of the facility undated Fall with Injury Checklist revealed a complete head to assessment would be completed. Assess for injury and if a significant injury was noted and not treatable in the facility, stabilize the resident, do NOT lift and call the physician and 911. This deficiency substantiates Complaint Number OH 309.

Based on closed record review and interview the facility failed to meet the respiratory care needs of Resident #79, a new admission resident admitted with a [CONDITION(S)] and supplemental oxygen. Actual Harm occurred on [DATE] when Resident #79 was admitted to the facility and staff failed to obtain complete and comprehensive oxygen and [CONDITION(S)] care orders from the physician, failed to develop a baseline comprehensive and individualized [CONDITION(S)] plan of care, failed to ensure delivery of respiratory/oxygen therapy was documented, failed to ensure emergency supplies were readily available at the resident's bedside and failed to ensure all staff providing care to the resident were knowledgeable related to caring for residents with a [CONDITION(S)]. This affected one resident (#79) of three residents reviewed for an emergent change in condition and death. At the time of the survey, the facility identified having no additional residents residing in the facility designated with full code status and [CONDITION(S)]. The facility census was 77. Findings Include: Review of Resident #79's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #79 expired in the facility on [DATE]. Review of Resident #79's admission assessment dated [DATE] and functional assessment dated [DATE] revealed the resident was admitted for hypoxemic respiratory failure. The resident's memory was intact, and she communicated by nodding her head yes or no. The resident had difficulty with communication, some words and her speech were unclear or mumbled. The resident was incontinent at times of bowel and bladder. The resident required substantial/maximal assistance (help to do more than half the effort) with toileting. The resident required partial/moderate assistance (help to do less than half the effort) with rolling (turning in bed). The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was not assessed for transfers or ambulation. Review of the baseline plan of care revealed the resident had respiratory issues due to acute hypoxemia respiratory failure. Interventions included oxygen as ordered, keep head of bed elevated, check oxygen saturation (no frequency indicated) and report any signs or symptoms of respiratory distress. There was no evidence of a plan of care for the resident's [CONDITION(S)]. Review of the admission physician orders, dated [DATE] and subsequent orders, dated [DATE] revealed Resident #79 had a [CONDITION(S)] with orders for an [MEDICATION(S)] six millimeter (mm) shiley [MEDICATION(S)]. There was no order for suctioning the resident. The resident had an order ([DATE]) for oxygen via [CONDITION(S)] collar at 35% humidification during bedtime hours and to check placement during bedtime hours (7:00 P.M. to 7:00 A.M.). There was no evidence of the amount of oxygen to deliver or to check saturation levels during bedtime hours. The resident had an order ([DATE]) for oxygen two to six liters per nasal cannula during daytime hours (7:00 A.M. to 7:00 P.M.). This order did not include to cap the resident's [CONDITION(S)] when using the nasal cannula or parameters for how much oxygen to administer to maintain a specific saturation level. The resident had a new order, dated [DATE] (no time noted) for oxygen six to eight liters continuously via [CONDITION(S)] collar with 35% humidification. Although this order indicated via [CONDITION(S)] collar, the resident had an order indicating the use of collar ([CONDITION(S)]) or cannula (nasal) for oxygen delivery depended on resident tolerance, preference, and oxygen saturation every shift. However, the resident did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, at the time of the new order on [DATE], for six to eight liters continuous via [CONDITION(S)] collar with 35% humidification, the previous oxygen orders from [DATE] were not discontinued which resulted in a discrepancy in oxygen administration orders for staff to follow. Review of Resident #79's medication and treatment administration records for [DATE] revealed no documented evidence on either administration record the resident was provided any oxygen or suctioned during her stay in the facility (on [DATE] or [DATE]). In addition, none of the progress notes following the admission note on [DATE] provided any information as to whether the resident was administered oxygen via nasal cannula or [CONDITION(S)] mask, the amount of oxygen administered, whether the resident required suctioning or the resident's saturation level. Review of Resident #79's progress note revealed an entry documented on [DATE] at 12:45 P.M. which indicated the resident had arrived to the facility via a transport company on a cot. The resident was noted to be alert, pleasant and denied discomfort. The resident was transferred onto the bed with assistance of five staff. Oxygen was applied at two liters per minute per nasal cannula and the resident's oxygen saturation levels were assessed to be 79% (low). Oxygen was increased to three liters and the resident's oxygen saturation level increased to 92%. The note revealed Resident #79 had a #60 (order indicated #6) [MEDICATION(S)] [CONDITION(S)] that was intact with a dressing in place with no drainage noted. The note did not indicate if the [CONDITION(S)] was capped at the time of admission. No cough or congestion were noted, the resident's lungs were clear to the upper lobes and diminished to the lower lobes. The resident was able to shake her head yes and no, but her speech was slow and broken. The next progress note, dated [DATE] at 6:38 P.M. revealed the physician was into visit the resident and reviewed her chart. New orders were received for as needed Tylenol. Review of the nursing progress notes revealed no entries completed between [DATE] at 6:38 P.M. and [DATE] at 10:52 P.M. for Resident #79. The progress note, dated [DATE] at 10:52 P.M. and completed by Licensed Practical Nurse (LPN) #102 revealed she was notified at 10:00 P.M., the nurse on Home B (Registered Nurse (RN) #101) needed help. Upon arrival to Resident #79's room she assisted the nurse in doing CPR on the resident until the ambulance arrived and then they (EMS) took over doing CPR. The note completed by LPN #102 did not provide any information as to why CPR was provided, evidence of an assessment of the resident nor did it detail the actual care provided by the LPN. (See findings under F678). Review of Resident #79's vital sign records revealed the last set of vital signs obtained for the resident prior to her being unresponsive were dated [DATE] at 8:12 A.M. The residents blood pressure was ,d+[DATE], pulse 82 beats per minute, respirations 18 per minute and her oxygen saturation was documented to be 95% on six liters of oxygen. This record did not indicate if the oxygen was provided via nasal cannula or [CONDITION(S)] collar. On [DATE] at 11:48 A.M. and 2:38 P.M. interview with RN #101 revealed she was Resident #79's assigned nurse the night of [DATE]. RN #101 reported Resident #79 was on a ventilator. Observation of the ventilator with RN #101 at the time of the interview revealed the RN was referencing a gray humidification box that was currently located in the medication room. The device was not a ventilator but rather a box to supply humidification to the resident's oxygen. The RN reported her shift started around 7:00 P.M. and she had received very little information regarding Resident #79 during report. On [DATE] around 8:,d+[DATE]:00 P.M. RN 101 revealed she administered medication to Resident #79. The RN indicated at that time she thought the resident's [CONDITION(S)] was capped and she was receiving oxygen via nasal cannula at two liters. Around 9:55 P.M. the STNA staff reported they needed help. RN #101 revealed she had not seen Resident #79's call light activated because the RN was on another hallway at that time. Upon entering the resident's room, the RN noticed a bed pan on the bed and bowel movement smeared on the sheets. The resident was observed to be face down on the floor with her head at the bottom of the bed. The RN revealed it appeared the resident had attempted to get out of bed. However, the bed wheels were not locked, and the bed was pushed to the side. The resident was breathing, and her eyes were opened, however her skin was gray in color. The RN revealed the resident was able to respond verbally to name but was noted to be in distress. RN #101 revealed she re-applied two liters of oxygen via nasal cannula and re-hooked the resident to the ventilator. An STNA (unable to recall which STNA) called 911. The RN revealed there was not an ambu bag in the room and she didn't think there was a suction machine, however the suction machine was found later in the corner of the room. The STNA went to get the first crash cart, however, there was no suction on the crash cart, so they had to go get a second crash cart from Unit 2 on the other side of the building. The RN revealed the resident's [CONDITION(S)] was not capped during CPR because the resident was hooked up to a ventilator. The RN could not recall if adjustments were made to the resident's oxygen during CPR. RN #101 revealed she and STNA #103 provided CPR. An ambu bag was placed over the resident nose/mouth to provide ventilation. During the interview, RN #101 revealed she had not been provided education on how to perform CPR for a resident with a [CONDITION(S)]. However, during the interview the RN indicated the ambu bag should have probably been placed over the resident's [CONDITION(S)] and not the nose/mouth. The RN reported she was not comfortable providing care to [CONDITION(S)] residents, however a nurse had reviewed [CONDITION(S)] care prior to the resident arrival. The staff member read over the procedure for [CONDITION(S)] care and had staff sign a sheet to acknowledge the training. On [DATE] at 12:42 P.M., interview the DON confirmed staff were not provided education on CPR for a resident with a tracheotomy prior to the resident's admission, nor did the facility have a policy or procedure on how to perform CPR on a [CONDITION(S)] resident. On [DATE] at 2:41 P.M. interview with the DON revealed the new oxygen order, dated [DATE] was just a clarification order for the number of liters of oxygen to administer. The DON reported at this time she was still investigating why nursing staff failed to document oxygen was being provided to the resident on the administration records from [DATE] and [DATE]. On [DATE] at 5:09 P.M. interview with the DON revealed she herself had suctioned Resident #79 during the resident's stay in the facility. The DON verified there were no physician orders to suction the resident, nor did she document when or why the resident had to be suctioned. In addition, record review and interviews during the investigation, revealed no evidence staff attempted to suction the resident via her [CONDITION(S)] site prior to initiating CPR to ensure her airway was clear. On [DATE] at 10:34 A.M. interview with RN #214, who was an agency nurse revealed the facility had been utilizing her as a respiratory consult, however her license as a respiratory therapist had lapsed on [DATE]. RN #214 revealed she had not completed advance life support training for seven to eight years and indicated basic life support (BLS) training did not include emergency [CONDITION(S)] care. During the interview, RN #214 revealed if a resident with a [CONDITION(S)] was found unresponsive, a staff member should be sent to call 911 while another staff member assesses the resident's airways ([CONDITION(S)] and mouth/nose). If the resident's [CONDITION(S)] cap was capped the cap would need to be removed to check the airway. If the airway was not patent, check the airway for obstructions/placement by removing the [CONDITION(S)] cannula and/or suction the resident. If the resident did not have a cuff, use the [CONDITION(S)] for ventilation. The resident would need to be administered 15 liters of oxygen. After checking airway reassess and if no pulse initiate CPR with chest compressions and ventilation via [CONDITION(S)]. Oxygen could be administered through the ambu bag. Humidification should be removed during emergency. RN #214 reported last month she had provided [CONDITION(S)] care education to some of the nurses who had showed up for training but not all nurses were provided education. One staff member was trained on suctioning at that time, but RN #214 indicated she did not have all the equipment to demonstrate [CONDITION(S)] care except for a [CONDITION(S)] kit. She did not have a shiley or replacement [CONDITION(S)]. On [DATE] at 9:13 A.M. during an interview with RN #101, the RN reported she had not been provided training for emergency care for a resident with a [CONDITION(S)] prior to Resident #79's admission. RN #101 revealed she had received updated training yesterday ([DATE]) related to CPR in general. On [DATE] at 2:55 P.M. interview with the facility previous medical director (MD) #401 revealed he had been the facility medical director until [DATE] at which time he had stepped down. MD #401 also indicated he was Resident #79's primary care physician during the resident's stay in the facility. MD #401 revealed he was notified on [DATE] (at unknown time) by a paramedic who called and reported Resident #79 had flat lined. During the interview, MD #401 revealed the facility should have never accepted Resident #79 because staff were not trained to care for her [CONDITION(S)]. The MD verified staff would need more than the BLS training to care for a resident with a [CONDITION(S)]. MD #401 was unaware if the facility had any type of policy or what the policy was for emergency [CONDITION(S)] care. MD #401 revealed he had heard facility staff had not performed CPR adequately from the paramedic who was at the scene but had not received this information from the nursing home staff. MD #401 revealed he had seen Resident #79 earlier in the day on [DATE] and she was holding her own but acknowledged she did have several co-morbidities. Lastly, MD #401 denied giving the oxygen order on [DATE] for oxygen at six to eight liters of oxygen via nasal cannula/[CONDITION(S)] per resident preference. Review of the facility undated policy and procedure titled, [CONDITION(S)] Care revealed the policy provided information for how to clean a resident's [CONDITION(S)]. The facility had no policy/procedure related to [CONDITION(S)] emergencies or suctioning. This deficiency substantiates Complaint Number OH 596.

Based on record review, review of a fall investigation report, interview and policy and procedure review the facility failed to implement an effective and timely pain management program for Resident #1 following a fall (with major injury) with an acute, traumatic, closed minimally displaced right intertrochanteric femoral fracture requiring surgical repair. Actual Harm occurred on 07/11/21 following a fall at 1:00 A.M. when the facility failed to timely recognize and provide effective pain management for Resident #1, who exhibited obvious injury and complaints of pain (including verbal complaints of pain, rubbing her hip, facial grimacing and screaming out oh with movement). The resident was first medicated on 07/11/21 at 5:18 A.M. with Tylenol which was identified to be ineffective. The resident was subsequently transferred to the hospital on 07/11/21 following an update to the nurse practitioner at 12:55 P.M. for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] This affected one resident (#1) of three residents reviewed for pain management. Findings Include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's pain assessment, initiated on 07/07/21 (but not completed until 07/15/21) revealed the resident had no pain and had as needed Acetaminophen 1000 mg every six hours ordered, however never received any. There was no evidence the resident's pain assessment was revised after the change of condition noted on 07/11/21. Review of Resident #1's current pain care plan revealed the resident had episodes of pain related dysuria, chest pain, pain in leg, and peripheral vascular disease. Interventions included to administer pain medication as ordered/observe for effectiveness. Observe for episodes of breakthrough pain and medicate as ordered, or contact the physician as needed. Remind resident that reporting pain early may improve the effectiveness of pain medication. Review of a nurse's note, dated 07/11/21 at 1:00 A.M. revealed the nurse (Licensed Practical Nurse (LPN) #502) heard the resident yelling out for help. Upon arrival to the room the resident was noted lying on the floor in front of her recliner. Upon original evaluation, the resident showed no signs or symptoms of pain or discomfort with no abnormal alignment or rotation of the extremities noted. The resident was assisted back to bed with assistance of two staff members without difficulty. When staff attempted to roll resident from one side to the other side to provide incontinence care, the resident grabbed her right leg complaining of pain and grimacing. The note indicated the resident remained able to move both lower extremities but continued to complain of pain to right leg/hip. Record review revealed no evidence the resident was provided any medication for her complaints of pain/grimacing at that time. The physician was notified and orders received for an x-ray of the right leg, hip and pelvis. There was no evidence the resident's representative was notified of the fall and/or complaints of pain at that time. Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. staff documented the resident was administered Acetaminophen 1000 milligrams (mg) for right leg pain rated a six out of ten (with 10 being the most severe pain). The record revealed the Acetaminophen was ineffective and the resident's pain had increased to a seven out of ten. Further review of the medical record revealed no evidence the physician or nurse practitioner (NP) was notified of the resident's increased pain or ineffective pain management treatment. There was no evidence the resident received anything else for pain or notes related to pain in the resident's progress notes. On 07/11/21 at 8:36 A.M. the x-ray company arrived to obtain x-rays for Resident #1 and family was notified at that time. On 07/11/21 at 12:55 P.M. the NP was notified of the x-ray results. New orders were received to transport the resident to a local hospital for evaluation and treatment. Family was notified of new orders and in agreement. Review of Resident #1's hospital notes, dated 07/12/21 revealed the resident was admitted to the hospital with an acute, traumatic, closed minimally displaced right intertrochanteric femoral fracture requiring short gamma nail surgery on 07/13/21. Review of the facility fall investigation report revealed a statement from State tested Nursing Assistant (STNA) #510, dated 07/11/21. The statement revealed the STNA had been called to Resident #1 room for assistance by the nurse. The resident was noted on the floor. The staff assisted the resident up after the nurse completed an assessment. The resident had complaints of pain in the right hip. Review of the fall investigation report, dated 07/12/21 at 4:18 P.M. revealed the nurse reported Resident #1 began complaining of pain around 1:30 A.M. The nurse reported she wasn't ignoring the resident, however with the resident having a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Around 2:00 A.M., the nurse reported she realized the resident was really in pain because she was complaining the same spot was hurting and that was when she called the physician to obtain orders for x-rays. The nurse did not notify the resident's family immediately because she was taking care of the resident and getting things done. The nurse verified she didn't medicate the resident until 5:18 A.M. and she did not know why she didn't follow up when the pain medication was ineffective. On 08/03/21 at 10:42 A.M. interview with Licensed Practical Nurse (LPN) #500 revealed she was Resident #1's nurse on 07/11/21 beginning at 7:00 A.M. until the resident was transferred to the hospital. LPN #500 revealed the resident voiced complaints of pain during the x-ray procedure (at approximately 8:36 A.M.). The resident had pain with movement during her exam. LPN #500 revealed she did not notify the physician and thought she would just wait until the x-ray results returned. The LPN revealed she had not assessed Resident #1 prior to that time for pain. On 08/03/21 at 12:03 P.M. during an interview with Regional Nurse Coordinator (RNC) #100, the RNC confirmed Resident #1's pain was not adequately managed after the fall sustained on 07/11/21 at 1:00 A.M. which resulted in a fractured hip. On 08/03/21 at 1:33 P.M. interview with STNA #510 revealed she was the STNA assigned to care for Resident #1 when she had fallen on 07/11/21. STNA #510 confirmed the resident had complaints of pain during her shift (10:00 P.M. to 6:00 A.M.) The resident was rubbing her hip, had facial grimacing, and would scream out oh with movement. On 08/04/21 at 10:04 A.M. interview with the Director of Nursing (DON) revealed she had identified concerns regarding Resident #1's fall including ineffective pain management. The DON revealed she had provided education to LPN #502. However, the incident had not been reviewed as part of the facility Quality Assurance Performance Improvement (QAPI). On 08/10/21 at 1:12 P.M. interview with LPN #502 revealed she was Resident #1's nurse on 07/11/21 and was on duty at the time of the resident's fall. LPN #502 confirmed the resident had fallen around 1:00 A.M., staff transferred her back to bed and about a half hour later the resident began complaining or right leg pain. The LPN reported she did not think the resident had pain but was just answering she had pain as part of her dementia. However, the resident was still complaining of pain, so she contacted the physician and obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .M. the x-ray company called to confirm the x-ray was to be completed STAT. At that time, LPN #502 reported she called the resident's family to notify them of the fall and medicated the resident with Tylenol (at 5:18 A.M.) for pain. The LPN reported the Acetaminophen was not effective, however she did not notify the physician. The LPN confirmed the resident's pain was not managed effectively. On 08/11/21 at 11:35 A.M. interview with Resident #1's daughter (Family Member (FM) #503) revealed she was not notified of Resident #1's fall until 5:15 A.M. on 07/11/21. FM #503 reported staff just told her that her mom had fallen and the doctor had ordered x-rays. FM #503 called the facility around 8:30 A.M. to see if the x-ray results had come back but was told the company was just arriving. FM #503 revealed she was not aware the resident was having pain (this had not been reported to her during the phone call), until she arrived at the facility. FM #503 reported if she had known her mother had fallen at 1:00 A.M., was having pain and had to wait on the x-ray company she would have requested her mother be sent to the emergency room due to her mother taking a blood thinner (medication). When she arrived at the facility, shortly after she had called the facility (at 8:30 A.M.) her mother was in terrible pain. FM #503 revealed she had voiced concerns to the facility and had questions about the fall, however she still had not received any answers as of this date. Review of the facility undated Pain Assessment and Management protocol revealed pain management goals included to promote residents' comfort and decrease pain intensity and to reduce the risk of the resident form reaching the next highest pain level. The overall goal of pain management and treatment were established based on the individual resident's pain assessment and with the input from the resident and/or legal representative. Residents who have traumatic pain may require more frequent pain evaluation. This deficiency substantiates Complaint Number OH 309.

Based on record review, review of a facility self reported incident, review of staff witness statement information, interview and policy review the facility failed to implement timely and effective pain management and compassionate care for Resident #36, who had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Actual harm occurred on 01/11/2021 when Resident #36 sustained a fall from bed and was not immediately sent to the hospital after being assessed to have external rotation of his right leg (consistent with a hip fracture). The resident was noted to be [NAME], screaming, yelling and crying with pain in his hip and shoulder while being moved multiple times and mechanically lifted from the floor to bed. While staff were moving the resident, his eyes rolled back and his whole body shook in a [CONDITION(S)] like activity. The resident remained in the facility for over five hours with a recorded pain level of seven on a scale of 0-10 with 10 being the worst pain and with verbal indicators of pain without being administered any pain medication before finally being transported to the hospital and diagnosed with a fractured right hip. Findings include: Review of Resident #36's medical record revealed an admitted [DATE] with diagnoses including [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note indicated the resident arrived on 01/10/21 at 6:25 P.M. post hospitalization for [CONDITION(S)] and [CONDITION(S)]. The resident was alert to self and place and denied pain on admission. A nursing progress note, dated 01/11/21 at 6:53 A.M. recorded as a late entry for 5:00 A.M. by Registered Nurse (RN) #116 revealed Resident #36 was on the floor lying on his left side with no clothes on, and urine puddles around the resident. The resident complained of left shoulder and hip pain and was assessed to have external rotation of the left lower extremity (LLE) and a skin tear to the left elbow. When asked how the resident ended up on the floor, he stated, I thought I could just go on my own. The resident did not activate his call light. Neurological checks were started and within normal limits with exception of his left lower extremity and left upper extremity (LUE). The progress note revealed the resident was assisted off the floor via a mechanical lift and back to bed. The physician was notified and a new order was obtained for a STAT x-ray of the left hip and shoulder. (RN #116 mistakenly referred to the injuries being on the left side instead of the right side in her documentation). Prior to the fall, a fall risk assessment had not been completed by the facility. A progress notes indicated x-rays of the resident's right hip, shoulder, pelvis and elbow were obtained at 8:59 A.M. Review of the right hip and pelvic x-rays revealed an acute nondisplaced multiplanar intertrochanteric fracture of the right hip with mild increased angulation deformity. Orthopedic follow up recommended. The resident was transported by ambulance at 10:21 A.M. and subsequently admitted to the hospital. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. thorough time of discharge at 10:21 A.M. The resident's pain level 01/11/21 on the 7:30 A.M. to 7:30 P.M. shift was documented by LPN #100 as a seven on the treatment sheet with zero being the lowest and 10 being the worst pain. There was no evidence of a comprehensive pain assessment for the level seven pain score completed. Review of Self Reported Incident, tracking number 3 initiated on 01/18/21 revealed a staff member alleged RN #116 did not interact in a caring fashion in response to the fall sustained by Resident #36 (on 01/11/21). The narrative summary of incident and investigation revealed Resident #36 was heard by nursing staff yelling down the hall. Staff entered resident's room and found the resident had fallen trying to get out of bed and did not put his call light on. The resident was assessed by the nurse for injuries. Upon assessment the nurse determined the resident had a skin tear as well as a potentially fractured hip. In addition, the resident had urinated on the floor when he had fallen. RN #116 instructed STNA staff to clean the resident up and to grab a mechanical (Hoyer) lift pad so they could get the resident back into the bed. Once the resident was lifted back into bed, the resident began to have signs of a [CONDITION(S)]. At this point it was alleged RN #116 began to shake the resident in order to get a response from him. Once the resident ceased any signs of a [CONDITION(S)], RN #116 began to ask the resident about pain. Resident #36 responded what pain. The SRI listed STNA #117 and STNA #118 as witnesses to the incident. Review of an event interview form, dated 01/17/21 and handwritten by STNA #117 revealed on 01/11/21 Resident #36 fell and broke his hip. We heard yelling and ran to his room on Unit 1. The resident's arm was moving and he couldn't move without pain. When RN #116 arrived the STNA looked at her (the RN) and quietly said I think his hip is broke. RN #116 told me to shut up that it wasn't my place to say that. RN #116 yelled at another STNA #119 to grab towels to clean up the blood and urine. Once the blood and urine were cleaned up RN #116 yelled go get the Hoyer and pad we are going to get him back in bed. Once the resident was lifted back to bed his eyes rolled into the back of his head and the staff couldn't understand what the resident was saying. RN #116 began to shake the resident to get him to answer staff. RN #116 started touching and moving the resident while he was screaming in pain. RN #116 then told the STNAs to leave the room and we could come back and clean him up when she was finished. The interview statement revealed the STNA staff watched the RN hurt the resident. On 01/20/21 Acting Administrator #111 interviewed STNA #119 via telephone. The notes of the interview revealed the STNA heard yelling and realized it was Resident #36. The RN wanted towels and gloves. His hip was broken. She wanted the Hoyer pad. He was rolled to his left side and back to get the pad under him. He was screaming the entire time. When we lift him in the Hoyer he was screaming more. He was screaming as he was lowered to the bed and his eyes shut and he started shaking. The RN said what was that about? There was a blanket and sheet between his feet and bed. She pulled it out causing his leg to move and he yelled in pain. She said where is your pain at and he said what pain. On 03/08/21 at 1:39 P.M. interview with the Director of Nursing (DON) revealed a resident with a suspected fractured hip should not have been moved or hoyered back to bed. On 03/08/21 at 3:10 P.M. interview with LPN #100 revealed she was the nurse on dayshift the morning of Resident #36's fall. LPN #100 said the resident was in pain, he had a broken hip and his leg and shoulder were hurting. LPN #100 revealed the resident should have been sent out immediately and revealed she didn't know why he wasn't. LPN #100 revealed it wasn't until after x-rays were completed which showed the fracture that he was sent to the hospital. When asked if he was administered pain medication to the resident, LPN #100 revealed she thought Resident #36 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . However, review of the orders and administration record revealed nothing had been provided to the resident following the fall even though staff were aware he was exhibiting pain. On 03/08/21 at 3:42 P.M. attempts to reach RN #116 were unsuccessful. On 03/09/21 at 8:48 A.M. interview with STNA #117 revealed another resident had come through the door to the unit and alerted her there was a resident yelling. She identified the yelling to be coming from Resident #36 and found the resident laying on his right side on the floor in his room. The resident said he had gotten up himself and had his walker. STNA #118 and STNA #119 were working on the unit and also arrived. The resident was yelling and said he was in pain and said his shoulder and hip hurt. The nurse (RN #116) had us roll him to his back and try to straighten his legs. The right one wouldn't straighten and was going outward. Resident #36 was yelling in pain and the STNA stated she told the nurse she thought the resident's hip was broken. STNA #117 stated at first RN #116 agreed and then said she did not feel anything broken. RN #116 told the STNA staff to go get a Hoyer lift. Resident #36 continued to say he was in pain and it was hurting when she (STNA #117) went to tend to another resident. On 03/09/21 at 9:01 A.M. interview with STNA #119 revealed the incident with Resident #36 on 01/11/21 when he fell and broke his hip literally haunts her. The STNA stated she was walking down the short hall while doing rounds and heard a call light and then screaming. Another resident activated their call light to alert staff of a resident yelling. Resident #36 was found on the ground, naked, on his right side with blood coming from his right elbow. The nurse (RN #116) was in the room and she asked her what she needed. STNA #119 stated RN #116 yelled at her don't just stand, there do something, get gloves and towels. She stated she alerted STNA #118 the another STNA and returned with the towels and gloves. RN #116 was assessing the resident. Resident #36 was crying in obvious pain. The resident's leg was rotated out and his hip was obviously broken. RN #116 had us move the resident onto his back after the RN said the resident's hip was broken. Resident #36 screamed the whole time, whaled out and cried in pain. RN #116 was yelling at the resident to calm down and be quiet. When we rolled him over his leg was rotated out and the nurse said, yes it's broken RN #116 had the STNA staff get the Hoyer lift. We rolled him to the right and to the left to put the Hoyer pad under him which made the second and third time we rolled him. Each time we rolled the resident he cried out, [NAME] in pain saying his leg hurt. The resident said, please please, he was begging and crying in pain. As the staff started to lift him up with the Hoyer and the lift pad cradled the resident he whaled out again in pain. RN #116 repeatedly was telling the resident to be quiet and asking him what was wrong? As the resident was laid down on the mattress he yelled out crying. Resident #36's eyes closed and his body started shaking like he was having a [CONDITION(S)] for a few seconds. When he stopped, RN #116 said what was that about? Resident #36 looked around confused like he was trying to figure out what was going on. There was a top sheet under the resident's right foot and the bottom of the bed. RN #116 pulled it out jerking instead of cautiously pulling it out and Resident #36 again started to scream again. The STNAs had to roll the resident two more times to get the Hoyer pad out from under him. The resident yelled in pain the whole time. Then RN #116 looked at the resident and stated she didn't think it was broke. The resident was on his left side and she kept referring to his left side as the injured side when it was actually his right side that was hurting him. Review of the undated Fall policy, protocol, checklist Altercare Fall Checklist revealed if any deformity, rotation or significant injury was noted and not treatable in the facility, stabilize, do not lift, call physician/CNP and 911. Review of the facility undated Pain Assessment and Management Protocol revealed the comprehensive, pain observation should also be completed when a resident complains of new onset of pain or has a significant change in condition. The resident, resident's legal representative and the resident's physician shall be notified of the new onset of pain and/or significant change in condition in accordance with the Change in Resident Condition or Status Policy. At a minimum, the assessment should include: a. Presence of pain verbally or non-verbally b. Location c. Severity d. Nature of pain e. Onset and duration f. Aggravating factors g. What alleviates the pain? When assessing a resident for pain, the nurse would evaluate the resident's verbal expression of a pain score/level as well as non-verbal signs and symptoms that could reflect pain ( e.g., grimacing while being re-positioned, having a dressing changed, elevated heart rate, poor appetite, uncharacteristic agitation or combativeness, etc.). The Help us control your pain today tool, will be utilized to provide consistent and accurate resident pain intensity and supporting Level of pain currently experienced by the resident. On 03/09/21 at 9:49 A.M. interview with Acting Administrator #111 revealed during a phone conversation with RN #116, he verbally educated her related to the incident with Resident #36. Acting Administrator #111 revealed he discussed the importance of providing the highest quality of care to all residents and to appropriately interact with staff and residents at all times. There was no written statement from RN #116 addressing the allegations of the resident yelling out in pain, being moved and hoyered to bed and shaking. There was no evidence the resident was provided timely, appropriate and compassionate care following with fall with obvious injury resulting in the resident experiencing untreated and prolonged pain with no intervention on 01/11/21 until being transported to the emergency room at 10:21 A.M. (over five hours after he fell ). This deficiency is an incidental finding to Master Complaint Number OH 588.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of a closed medical record review, the facility's incident investigation, the facility's Cardiopulmonary Resuscitation policy, the local county Sheriff's incident run sheet, and staff interview, the facility failed to initiate Cardio-Pulmonary Resuscitation (CPR) immediately and properly identify a resident's code status for one resident (Resident #87) who was a Full Code and was found unresponsive without vital signs. Life threatening harm and death occurred when Resident #87 did not receive timely CPR, the code status was not correctly identified in the medical record and Emergency Medical Services (EMS) was not contacted promptly. This resulted in Immediate Jeopardy when Resident #87 expired at the facility. The facility identified 31 residents who resided in the facility and were Full Code Status. The facility census was 86. On [DATE] at 11:34 [NAME]M., the Administrator and Director of Nursing Services (DNS) were notified Immediate Jeopardy began on [DATE] at 12:15 [NAME]M. when Resident #87 was found in bed and unresponsive by State tested Nursing Assistant (STNA) #7. STNA #7 notified Licensed Practical Nurse (LPN) #22, who responded to Resident #87's room to find her unresponsive and not breathing. LPN #22 called for LPN #38, who also assessed Resident #87 and found her unresponsive and without a pulse or respirations. LPNs #22 and #38 both left the room, without initiating CPR, to obtain Resident #87's medical record to check the code status. LPN #22 and #38 incorrectly identified Resident #87's code status as being a Do Not Resuscitate Comfort Care (DNR CC) that was listed on hospital records. LPN #38 contacted the Administrator to notify her there had been a death in the facility (Resident #87). The Administrator contacted the DNS to call in to the facility to ensure the nurses followed proper clinical protocol. The DNS called LPN #38 and was informed that they had not initiated CPR for Resident #87 and that DNR CC had been hand written on the Resident #87's face sheet in her medical record. The DNS instructed them to check the front of the medical record to see if any DNR forms were present. When LPN #38 indicated the DNR form was not present, the DON instructed them to initiate CPR and to call 911. CPR was not initiated until at least 13 minutes after Resident #87 was found unresponsive and without a pulse or respirations. Resident #87 was pronounced dead upon arrival of EMS. The Immediate Jeopardy was removed and the deficient practice corrected on [DATE] when the facility implemented the following corrective actions: · On [DATE] at 12:28 [NAME]M. Resident #87 was confirmed to be a full code, CPR was initiated by LPN #38 and EMS activated at 12:32 [NAME]M. The resident was pronounced dead by EMS at 12:45 [NAME]M. · On [DATE], at approximately 8:30 [NAME]M. Regional Nurse Consultant, Registered Nurse (R.N.) #63 and the DNS began in-service of five agency nurses and 16 facility nurses on the CPR policy, Ohio DNR form location, the proper procedure when a resident is identified to be unresponsive and/or in cardiopulmonary arrest, and the location of the crash carts in the facility. The in-service also included the process for checking Code Status upon admission, obtaining a signed Ohio DNR form, and placement in front of the chart. The in-service included education on how to identify a resident's code status, including whether they are a full code. The Ohio DNR form is kept in the front of the chart and if there is no form, the resident is a full code. No physician order is required for an individual to be a full code. The in-service was completed on [DATE]. There were 20 LPNs and eight RNs that were educated. Nurses who were not in-serviced by [DATE], due to vacation or any other reason, were in-serviced prior to working their next scheduled shift, including new agency staff. The facility identified seven nurses that had been off when the initial education was completed on [DATE]. All seven nurses have since been educated. Per facility policy, only licensed nurses are certified to provide CPR and confirm code status from the record. The chart may be brought to the nurse by any staff member, but the nurse must confirm DNR status by reviewing the front of the chart to determine if an Ohio DNR form is present. · On [DATE], at approximately 11:30 [NAME]M. all resident medical records were checked by the DNS to ensure proper placement of Do Not Resuscitate (DNR) status; and ensure the code status was not documented on the face sheet or any other location in the record. The DNS confirmed that residents who wished to have a DNR order had an Ohio DNR form in the chart. · On [DATE], at approximately 5:40 P.M., the Regional Nurse Consultant RN #63 reviewed all code statuses with residents and families to verify accuracy of code status. · On [DATE], at approximately 12:20 P.M. all four crash carts located at Home B dining hall, activity room, Unit 2 dining hall, and Speret hall dining hall were audited by the DNS to ensure all were appropriately stocked. No issues were identified with the crash carts. · On [DATE] at approximately 1:45 P.M., CPR policy and code status responsibility education were added to the nurse new hire orientation by the Administrator. Monitoring was to be completed by Administrator or designee. The facility has had no new-hires since [DATE]. · On [DATE] at 6:00 P.M., a QAPI meeting was held with the medical director to review the above action plan. · Beginning on [DATE] the DNS/Designee began conducting random interviews and will be conducted five times per week with staff (nurses, state tested nurse aides (STNAs), therapists, etc.) to ensure staff are knowledgeable regarding what to do if a resident is found unresponsive, where to locate a resident's code status and the location of crash carts. All staff responded appropriately to the questions and no additional in-service education was required. · Starting [DATE] the facility will continue to monitor compliance through audits conducted by the DNS or designee of all new admissions, via the admission checklist for four weeks and PRN. · Any changes in current resident code status after the initial audit was completed [DATE] will have an audit completed by DNS or designee for placement or removal the of Ohio DNR form. · On [DATE] at 10:50 [NAME]M. and 3:31 P.M.; on [DATE] at 11:03 [NAME]M. and at 11:11 [NAME]M., four nurses, LPN #96, LPN #38, LPN #100 and LPN #110 were interviewed. All nurses confirmed they received education on the facility's CPR policy specific to properly identifying a resident's code status in the medical record and how to properly run a code. They were knowledgeable regarding what to do when finding an unresponsive resident, aware of the need to initiate CPR immediately if no pulse or respirations were noted, and how to verify a resident's code status by the presence or absence of a DNR form in the front of the medical record. All staff knew the absence of a DNR form indicated the resident was a Full Code Findings include: A review of Resident #87's closed medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #87's hospital discharge records that were included in the closed medical record revealed she was discharged to the facility in stable condition. Resident #87's code status in the hospital was a DNRCC- Arrest (a code status in which a resident chose to receive all standard medical care until the time he or she experienced a cardiac or respiratory arrest). Resident #87's discharge orders from the hospital did not include a code status nor was there a signed DNR form that was sent to the facility from the hospital. The transfer form that was sent from the hospital included a section for advanced directives that included a place to mark DNR CC or DNRCC-Arrest but it was left unchecked. A review of Resident #87's admission orders [REDACTED]. The physician's orders were not updated after [DATE] to include any order specifying what the resident's code status was to be while in the facility. A review of Resident #87's care plans revealed none of the care plans initiated by the facility included anything regarding code status. A review of Resident #87's electronic health record (EHR) did identify the resident as being a Full Code (resuscitative measures were to be taken in the event of a cardiac or respiratory arrest) under the face sheet tab under advanced directives. The hard chart of the closed medical record included a copy of the resident's face sheet but did not specify the resident as being a Full Code. The face sheet in the hard chart had a hand -written notation down at the bottom right corner where someone had written DNR CC on it that had since been marked out with several lines. The mark out was not initialed and there was no way to identify who had completed the mark through. A review of social service observation notes for Resident #87 dated [DATE] revealed the resident's code status was a Full Code. Resident #87's cognitive status on the observation note indicated cognition was moderately impaired and the resident was known to have behaviors. A review of Resident #87's initial resident care conference dated [DATE] revealed facility staff met with the resident and her resident representative to review her goals and plan of care. The resident was planning a discharge home the following day. The care conference reviewed Resident #87's code status as part of the initial care conference and confirmed she was a Full Code. A review of Resident #87's nurses' progress notes revealed a nurse's note dated [DATE] at 12:15 [NAME]M. by LPN #38 that indicated LPN #22 had come to her and reported Resident #87 was found not breathing (there was no specific documentation regarding the condition of the resident). The resident's pulse was absent, and the spouse, DON, and physician were notified as CPR was being initiated. 911 was called and EMS arrived at 12:40 [NAME]M. EMS pronounced Resident #87's time of death as 12:45 [NAME]M. A review of the local county Sheriff's incident run report revealed the 911 call was received by the dispatcher at 12:32 [NAME]M. for a [MEDICAL CONDITION]. EMS was contacted at 12:35 [NAME]M. A second call was received from LPN #38 at 12:39 [NAME]M. indicating she was in Resident #87's room with active CPR in progress. A review of the facility's investigation revealed the following time line was determined: On [DATE] at 12:15 [NAME]M., Resident #87 was found unresponsive by STNA #7. STNA #7 notified LPN #22, who then entered the resident's room to assess the resident. LPN #22 then notified LPN #38 of the unresponsive resident. LPN #22 and LPN #38 checked the resident's chart for her code status and saw a DNR-CC code status listed on hospital records. On [DATE] at 12:23 [NAME]M., LPN #38 contacted the Administrator and asked her to call Resident #87's family and report to the family the resident had expired. On [DATE] at 12:26 [NAME]M., the Administrator contacted the DNS and asked her to call in to the facility to make sure clinical protocol was followed regarding Resident #87's death in the facility. On [DATE] at 12:28 [NAME]M., the DNS called in to the facility and spoke with LPN #38. LPN #38 had informed the DNS that they had not initiated CPR at that time and that a DNR CC status was hand written on the resident's face sheet in the hard chart of the medical record. LPN #38 confirmed to the DNS the resident did not have a DNR form in the chart. The DNS instructed LPN #38 to initiate CPR and call 911. On [DATE] at 12:40 [NAME]M., EMS arrived at the facility and pronounced Resident #87's time of death as 12:45 [NAME]M. At the conclusion of the facility's investigation, staff education had been provided to the nurses (facility staff and agency staff) beginning on [DATE] regarding the CPR policy/procedure. Education was completed for all nurses by [DATE]. Attached to the sign in sheet for those provided the training was the facility's CPR policy. On [DATE] at 10:26 [NAME]M., an interview with LPN #59 confirmed Resident #87 was to be a Full Code in the facility. She reported the resident's husband was heavily involved in her care and was the one who made decisions for her since the resident was cognitively impaired. She stated he confirmed in the resident's initial care conference meeting on [DATE] that the resident was to be a full code. On [DATE] at 10:35 [NAME]M., an interview with RN #63 revealed there were issues with Resident #87's death in the facility as their investigation showed she was to be a Full Code and her code was not initiated timely. She confirmed the facility's investigation showed there was at least 13 minutes between the time the resident was found unresponsive and when CPR was initiated. CPR was not initiated until after the DNS had called into the facility. She also confirmed the resident's medical record included a social service note that indicated the resident was to be a Full Code. Residents without a signed DNR form in the medical record were to be a Full Code in the event of a cardiac or respiratory arrest. She provided the education to the staff on the facility's CPR policy. On [DATE] at 2:22 P.M., interview with Social Worker #84 confirmed she had followed up with Resident #87's family on [DATE] regarding her code status wishes and the family wanted her to be a Full Code. She was known to the facility in the past from a prior admission and she was a Full Code then as well. Social Worker #84 updated the resident's social history, but it had not been uploaded into the computer yet. She indicated she verbally communicated the resident's code status to the DNS as well as the nurses on the floor telling them Resident #87 was remaining a Full Code as she was during her last admission. She indicated, if a code occurred, the nurse was to check the front of the chart. If the resident was a Full Code, they would not have any DNR forms in the front of the chart. If they had a DNR form in the front of the chart, then the resident was not a full code. On [DATE] at 2:39 P.M., an interview with the DNS revealed she received a phone call the night of [DATE] from the Administrator. She confirmed she received the call around 12:26 [NAME]M. and was told by the Administrator LPN #38 had called her. The Administrator wanted her to call LPN #38 back to make sure everything clinically was done regarding Resident #87's death in the facility. She called LPN #38 back at 12:28 [NAME]M. and was informed Resident #87 was found unresponsive. She asked LPN #38 if Resident #87 had a DNR form in her medical record and was told she did not. She then asked LPN #38 if she had initiated CPR and the nurse told her no. She instructed LPN #38 to go initiate CPR and call 911. She confirmed the facility's investigation showed the resident's hard chart of her medical record included a face sheet with a hand written DNRCC on it. She denied that was the proper way the facility documented a resident's code status in the medical record. She confirmed if a resident did not have a DNR form in the front of the medical record they were considered a Full Code. On [DATE] at 2:57 P.M., an interview with the facility's Administrator confirmed there were issues with Resident #87's death in the facility. She confirmed LPN #38 had called her and told her they found Resident #87 unresponsive and that she passed away. LPN #38 wanted her to call the family as she was nervous about making that call and wanted to know what they needed to do next. She told LPN #38 she would contact the DNS and call her back. She had the DNS call back instead to make sure everything clinically was done that needed to be done. The DNS called in to the facility and instructed LPN #38 to do CPR and call 911. On [DATE] at 3:31 P.M., an interview with LPN #38 revealed she did work the night of [DATE] when Resident #87 was found unresponsive. She was assigned a different unit but was called to respond to Resident #87's room by LPN #22. She was informed Resident #87 was not breathing. She responded to the room and assessed the resident and confirmed she was not breathing and did not have a pulse. She stated STNA #7 initiated CPR and she went to get the crash cart and make the phone call to 911 and to the resident's husband to let him know they were doing CPR. She claimed to have obtained the crash cart before she made any phone calls. She stated LPN #22 went to get the medical record to verify the resident's code status. She reported the resident was a Full Code, but the face sheet had scribble on it that identified her as being a DNR. She denied the resident's medical record included any DNR forms in the front of the medical record. LPN #22 allegedly informed them Resident #87 was a Full Code because she did not have any DNR paperwork. She stated LPN #22 went back to the room after checking the medical record but did not indicate if LPN #22 participated in CPR. LPN #38 indicated she took over for STNA #7 with the chest compressions when she got back to the room and STNA #7 then did rescue breathing. She did not observe LPN #22 physically participate in the code. She indicated they continued to do CPR until EMS arrived. EMS hooked up the electrocardiogram (EKG) and the resident was in asystole (no apical pulse) so they pronounced her time of death. She confirmed the facility called her the following morning as part of the investigation. She was asked about the phone calls she said she made to the 911 operator and the husband. She was asked if she made any other calls and denied that she did. When asked specifically if she spoke to the Administrator, she confirmed that she called the Administrator. She was asked if the DNS called in to speak with her and she confirmed she had. She stated she was not sure at what point she called the Administrator. She stated the DNS called when they were looking at the resident's medical record and the DNS confirmed with no DNR paperwork in the front of the medical record the resident was to be considered a Full Code. She believed STNA #7 was already in there at that time. The facility's investigation and time line were reviewed with her and she confirmed it was accurate as it indicated. She was not sure how long it was before CPR was performed after the resident was first found unresponsive. She was asked, if CPR was initiated by STNA #7 as she previously indicated, why the DNS indicated in the time line that CPR had not been initiated at the time she called in and spoke with her. LPN #38 confirmed the facility's timeline was probably accurate on how things occurred. On [DATE] at 5:32 P.M., an interview with RN #63 revealed STNAs were not to assist with CPR as they were not CPR certified. She denied she was told by LPN #38 that STNA #7 was the one who initiated CPR or participated in it in any way. A review of the facility's policy on CPR updated [DATE] revealed it was the facility's policy to provide CPR in accordance with the American Heart Association guidelines to residents who experience respiratory and/ or [MEDICAL CONDITION] unless the resident had a current, valid DNR order. The procedure indicated DNR orders were to be maintained in the medical record. If a resident was identified as pulseless or apneic by a staff member trained in CPR, the staff member was to immediately initiate CPR and call for assistance. If a resident was identified as unresponsive and/ or apneic by a staff member that was not trained in CPR, the staff member would summon the help of a licensed nurse. If the licensed nurse determined the resident was pulseless and/ or apneic, the nurse would immediately initiate CPR. A second staff member was to immediately activate EMS then determine by reviewing the medical record whether the resident was a full code or whether proof of a valid DNR order was in the medical record. If there was not a valid DNR order in the medical record, CPR shall be continued until EMS arrived and assumed the responsibility or the resident began to respond. As soon as practical, the resident's family and physician should be notified. This deficiency substantiates Complaint Number OH 168.

Based on observation, record review, interview and policy review the facility failed to ensure fall interventions were implemented to prevent falls and/or injuries associated with falls and failed to ensure thorough and complete fall investigations were completed. This affected two residents (Resident #4 and #57) of three residents reviewed for falls. Actual harm occurred to Resident #4 when the facility failed to ensure the use of a helmet, a physician ordered fall intervention was in place to prevent an injury to the resident's head during a fall. The resident fell on [DATE] sustaining a large [MEDICAL CONDITION]. Findings include: 1. Review of Resident #4's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the resident at risk for falls/injury plan of care, dated 01/22/19 revealed interventions included the resident was to wear a soft padded helmet when ambulating (initiated 03/20/19), observe resident in room, dining room and meal services for safety needs (initiated 01/22/19) and observe resident safety by looking in his room when passing his room (initiated 01/22/19). Review of the physician's orders [REDACTED]. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 01/28/19 revealed the resident had severe cognitive impairment and required extensive assistance of two staff members with bed mobility, dressing, personal hygiene and toilet use. Review of an incident re-assessment summary, dated 03/20/19 at 4:00 A.M. revealed staff alerted the nurse the resident was on the floor on the lounge area. The resident was noted to be on his hands and knees, crawling near the wall. The wall was noted to have blood on it along with blood on the floor. An abrasion with bruising was noted to the left side of the resident's forehead. The fall intervention implemented after the incident was for a soft padded helmet as the resident would allow. Review of the nursing progress note, dated 04/07/19 at 7:30 A.M. revealed Resident #4 was on the floor in front of his night stand with a moderate amount of bleeding noted from the top of the scalp with a large laceration present to the scalp. Further review of the nursing progress note, dated 04/07/19 at 8:00 A.M. revealed the resident was siting in the dining room, eating breakfast with assistance from his wife when the resident became lethargic, leaning to his left side and unable to to sit upright and not responding to stimuli. The resident was assisted back to bed by two staff members. The resident's blood pressure was assessed to be low at 80/38, with an elevated pulse of 42 beats per minute and respirations were shallow with a rate of 12. The resident's nail beds were pale in color and his pupils were pinpoint without pupillary reaction. The resident's wife requested a Hospice evaluation for the resident instead of sending the resident to the hospital. Further review of the nursing progress note, dated 04/07/19 at 8:30 A.M. revealed the resident remained in bed with his eyes closed with a current blood pressure (low) 90/48. The resident's wife did not want the resident sent to the emergency room . Review of employee statements dated 04/07/19 revealed State tested Nursing Assistant (STNA) #700 was entering the resident's room to get him ready for breakfast and observed the resident on the floor between his roommate's bed and the wall. While assisting the resident from the floor, blood was noted to his head and the nurse was notified. Review of the statement from STNA #725 revealed she had walked into Resident #4's room and he was laying on the floor between his bed and the wall. The nurse was notified. Review of an incident re-assessment summary, dated 04/07/19 at 7:30 A.M. revealed staff summoned Licensed Practical Nurse (LPN) #110 to the resident's room where he was noted to be lying on the floor in front of his night stand. The resident was unable to state what happened but the summary documented the resident was in bed prior to the incident. A head to toe assessment was completed and a skin tear was noted to the left hand, a laceration was assessed to the top of the resident's scalp and a bruise was noted to the left side of the resident's forehead. The immediate intervention was to encourage the resident to wear his helmet and pad the corner of the resident's night stand. On 04/16/19 at 10:00 A.M., 11:00 A.M., 2:00 P.M. the resident was observed ambulating in the day area of the unit, wearing the soft red helmet. On 04/16/19 at 3:20 P.M. interview with LPN #110 revealed she worked the morning Resident #4 fell and sustained a large laceration to the top of his head. LPN #110 stated if the resident was up and dressed for the day, he should have had his helmet in place as this was a fall intervention to prevent head injuries. The LPN verified the resident did not have his helmet in place at the time of the fall but the resident did hit his head and obtain a [MEDICAL CONDITION] as a result of the fall. On 04/16/19 at 5:53 P.M. interview with STNA #700 revealed night shift staff had washed and dressed the resident for the day on 04/07/19 and she had entered the room to wash the resident's face and take him to the bathroom before breakfast. STNA #700 could not recall the location of the resident's helmet the morning of 04/07/19. On 04/16/19 at 6:00 P.M. interview with STNA #800 revealed she worked with Resident #4 the morning he fell in his room but was unable to recall if she had dressed him and put his helmet on for the day. STNA #800 stated care was not always documented because the night shift was busy providing resident care and did not always have time to document if the care was completed. On 04/16/19 at 6:30 P.M. interview with the Director of Nursing verified the fall investigation contained conflicting information about the resident's location in the room when he was discovered post fall. The DON verified the investigation did not determine if the resident's helmet had been placed on his head prior to the fall or the last time the resident was seen prior to the fall. Lastly, the DON verified the fall investigation was not a through investigation. 2. Review of Resident #57's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS 3.0 assessment, dated 04/04/19 revealed the resident had severe cognitive impairment and required extensive assistance of two staff members with bed mobility, transfers, dressing, toilet use and personal hygiene. The resident was always incontinent of bowel and frequently incontinent of urine. Review of the fall plan of care, dated 04/08/19 revealed the resident was at risk for falls related to a [DIAGNOSES REDACTED]. Review of the incident re-assessment summary dated 04/10/19 at 3:07 A.M. revealed the staff alerted the nurse the resident was on the floor on his room, next to his bed. The brakes to the resident's bed were noted to be unlocked and the resident sustained [REDACTED]. An immediate intervention to ensure the brakes were locked on the resident's bed was implemented. On 04/16/19 at 6:30 P.M. interview with the DON verified the resident's brakes on his bed should be locked at all times and despite the intervention not being on the fall care plan prior to the incident, all bed brakes are to be locked at all times. Review of the undated Managing falls and fall risk policy revealed based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. This deficiency substantiates Complaint Number OH 759.

Based on record review and interview the facility failed to ensure measures were in place to prevent the development of pressure ulcers for Resident #1. Actual harm occurred when the facility failed to implement appropriate pressure relieving measures for Resident #1 resulting in the development of a deep tissue injury (a pressure-related injury which presents as a purple or maroon colored skin area or blood filled blister due to damage of underlying soft tissue from prolonged pressure and/or sheering) to her coccyx on 10/28/18 and an unstageable pressure ulcer (a full thickness tissue loss in which the base of the ulcer is covered by slough, which is yellow, tan, gray, green or brown, and or eschar, which is tan, brown or black tissue, which is dead or dying tissue, and prevents accurate staging of the pressure ulcer) to her left lower calf on 12/05/18. This affected one of three residents reviewed for pressure ulcers. Findings include: Record review revealed Resident #1 was admitted on [DATE] and [DIAGNOSES REDACTED]. On 11/05/18 additional [DIAGNOSES REDACTED]. The 10/19/18 computerized admission skin assessment revealed Resident #1 had no pressure ulcers on admission. There was documentation of scattered bruising, old blood draw/intravenous access sites, a skin tear to her right elbow, an abrasion to her left shoulder, a cut with dried blood on the middle of her right inner thigh area and staples to the back of her head. There was no skin impairment or bruising documented to her coccyx area or her left calf. This admission assessment included checkmarks in boxes indicating staff were to encourage Resident #1 to turn and reposition every two hours, to record wound measurements weekly, to inform the physician and/or nurse practitioner for any changes in skin condition, to monitor her for pain, to complete treatments per orders and educate her on disease management. There was no evidence this information was made available to the nurse aide staff who provide daily hands on care for Resident #1. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 10/26/18, revealed Resident #1 was independent for daily decision making and required extensive assistance with two staff for bed mobility, transfers, and walking in her room. This assessment indicated she was at risk for the development of pressure ulcers, had no pressure ulcers on admission and was utilizing a standard pressure reducing mattress. Review of the admission physician orders revealed no pressure relieving interventions were implemented upon admission. Resident #1 was ordered a left knee immobilizer due to her fractured patella (knee cap). There was no evidence a pressure ulcer prevention care plan was developed for Resident #1 since she was identified as being at risk for the development of pressure ulcers on admission. On 10/28/18, review of a wound grid revealed a maroon colored deep tissue injury was identified on Resident #1's coccyx and measured 1.7 centimeters (cm) in length by 0.5 cm wide. There was no depth measurement as the skin was intact. The periwound skin was nonblanchable and red. A physician order was received this day for nursing staff to cleanse the area with normal saline, apply skin prep (a liquid forming dressing which forms a protective film to help reduce friction) to the area and cover it with a foam dressing every three days and as needed. On 10/29/18 a pressure ulcer plan of care was developed after the deep tissue injury was discovered. This plan of care indicated Resident #1 had impaired mobility, impaired cognition at times, urinary and bowel incontinence and [MEDICAL CONDITION] as contributing factors to the development of the pressure area. Interventions included use of the knee immobilizer as ordered, encourage the resident not to slide/scoot when in the bed or chair, encourage/assist resident to turn and reposition frequently when in bed and/or shift her weight and reposition when in the chair as tolerated, encourage/assist the resident to float heels her as tolerated, observe her for any incontinence episodes and provide incontinence care as needed, apply protective barrier after each incontinent episode, observe/report any noncompliance with preventative skin care and notify the physician as needed, observe/report any signs and symptoms of skin irritation such as lack of sensation, tingling or burning feeling, verbal/nonverbal signs of pain, discoloration, [MEDICAL CONDITION], excoriation, and [DIAGNOSES REDACTED] (redness of the skin), provide nutritional support as ordered, and utilize the pressure redistribution mattress. There was no evidence found or provided to indicate Resident #1 was being assisted by staff to turn and be repositioned at least every two hours prior to the development of the deep tissue injury on her coccyx. Resident #1 was sent to the hospital on [DATE] from a doctor appointment due to a low blood pressure and she was admitted with multiple [MEDICAL CONDITION]. Resident #1 was readmitted to the nursing facility on 11/05/18 for less than two hours and was discharged back to the hospital with [MEDICAL CONDITION] emboli. She was readmitted to the nursing facility on 11/18/18. She was admitted to the hospital again on 11/21/18 for pneumonia and [MEDICAL CONDITION] and was readmitted back to the nursing facility on 11/29/18. On 11/29/18, the wound grid for the coccyx ulcer revealed it was unstageable and measured 3 cm long by 2 cm wide with an undetermined depth as the wound bed was covered with 100% slough. The periwound area was red. There was no drainage or odor noted. On 12/05/18, Resident #1 was found with a pressure ulcer on her left lower calf, the leg she had the immobilizer on due to her fractured knee cap. It measured 2.2 cm long by 1 cm wide with an undetermined depth. The wound grid dated 12/05/18 indicated this pressure ulcer developed in the facility and they staged it as an unstageable pressure ulcer since the wound bed had 30% yellow slough and visualization of the entire wound bed prevented accurate staging. The periwound was bruised and nonblanchable. There was a scant amount of serosanguinous drainage noted. A physician order was obtained for nursing staff to cleanse this pressure ulcer with normal saline, pat dry, apply Santyl (an enzymatic [MEDICATION NAME] ointment to break up and remove dead tissue) to the wound bed and cover with a dry dressing daily and as needed. The pressure ulcer plan of care and the profile care plan, which were available to the nurse aides was updated on 12/05/18 and directed staff to place a pillow on the leg rest of Resident #1's wheelchair. There were no other pressure relieving measure in place prior to the development of this left calf pressure ulcer. The only related intervention was for staff to remove the immobilizer for hygiene. Resident #1 was sent to the hospital on [DATE] for lethargy and elevated heart rate and was admitted with [DIAGNOSES REDACTED]. She was readmitted to the facility on [DATE]. On 12/16/18, the wound grid for the coccyx pressure ulcer revealed it was a stage III, a full-thickness skin and tissue loss in which fat is visible in the ulcer and granulation tissue and rolled wound edges are often present and slough and/or eschar may be visible and undermining and tunneling may occur. It measured 11 cm long by 6.6 cm wide by 4.4 cm deep. No slough was present. No odor or drainage was noted. The wound base was red. The treatment section indicated the pressure ulcer was to be cleansed with normal saline, pat dry and apply foam to the wound bed and cover with a [DEVICE] (vac) drape (a wound therapy system that promotes wound healing through negative pressure). The wound vac was to be set at 150 millimeters of mercury (mmHg). This dressing was to be changed every Monday, Wednesday and Friday and as needed. On 12/16/18, the wound grid for the left calf pressure ulcer was documented as a stage III and measured 2.5 cm long by 3.5 cm wide and 0.1 cm deep. The wound bed was pink and no tunneling was observed. The current treatment was listed as cleaning with normal saline and pat dry, apply foam dressing. It was to be changed every three days and as needed. Resident #1 was sent to the hospital for altered mental status and low vital signs on 12/18/18 and was admitted . Resident #1 remained in the hospital as of 01/03/19 and was unavailable for interview and observation of her pressure ulcers. On 01/03/19 at 1:50 P.M. the Director of Nursing (DON) indicated the nurse aides use the resident profile to identify care plan approaches for residents. The DON verified there were no pressure ulcer interventions on the profile until after the development of the deep tissue injury on 10/29/18. The DON verified the only intervention in place was the pressure reducing mattress and she said all of the mattresses in the facility had pressure reducing properties. On 01/03/19 at 4:15 P.M. the DON verified had been no physician orders in place for pressure reduction/prevention until after the discovery of the deep tissue injury on Resident #1's coccyx on 10/28/18. The DON verified there was no document or plan of care available to the nurse aides to direct them in the provision of care of Resident #1. She said there was only the computerized profile sheet, which she verified did not contain any pressure reducing measures until after the development of the pressure ulcers. The DON indicated the nurse aides could look in the medical record for the eleven page admission assessment for care information but she was unaware how many nurse aides would look in the chart/computerized medical record. The DON said care could be directed by word of mouth during report but she had no evidence of what was information was passed on in report to the nurse aides related to pressure ulcer prevention measures for Resident #1. The DON said the facility determined the left calf pressure ulcer was caused by the knee immobilizer and the pressure created while her leg was resting on the hard leg rest of her wheelchair. The only pressure relieving intervention for the leg with the immobilizer was after the development of the unstageable pressure ulcer on her calf and it was for staff to place a pillow between the immobilizer and the leg rest. The DON speculated the deep tissue injury on Resident #1's coccyx may have been present on admission and mistaken as a bruise. However, according to the nursing admission assessment, there was no bruise documented on her coccyx. The DON acknowledged the nurse aides would not look through the whole nursing admission assessment to determine the plan of care for a resident but could and would mostly use word of mouth and the computerized profile page. Review of the facility's undated policy, Pressure Injuries: Assessment, Prevention and Treatment indicated it is the facility's policy to identify residents at risk for developing pressure injuries, implement interventions to prevent the development of pressure injuries and provide care for existing pressure injuries. This citation substantiates Complaint Number OH 838.

Based on observation, medical record review, physician interview, resident interview, staff interview, and policy review the facility failed to timely identify, implement necessary treatments and/or ensure interventions were in-place to prevent a deterioration of pressure ulcers for two of three residents reviewed for pressure ulcers (Residents #67 and #70). Actual harm occurred to Resident #67 when the facility failed to ensure the resident received physician ordered treatments and interventions used to promote healing of a facility-acquired pressure ulcer were implemented resulting in the deterioration of a pressure ulcer to an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar). In addition, actual harm occurred to Resident #70 when the resident had a cast removed and the facility failed to assess the resident's skin and provide treatment for one week to the resident's suspected deep tissue injury (purple or maroon localized area of discolored intact skin) leading to an unstageable pressure ulcer. Findings included: 1. Record review revealed Resident #67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was at risk for development of pressure ulcers and was noted to have an open area on the left heel due to third spacing [MEDICAL CONDITION] (third-spacing occurs when too much fluid moves from the intravascular space (blood vessels) into the interstitial or third space-the nonfunctional area between cells). Review of the physician progress notes [REDACTED]. Review of nurse's note dated 12/27/17 revealed Licensed Practical Nurse (LPN) #7 was summoned to the room by the State tested Nurse Aide (STNA). The resident was lying in bed and LPN #7 noted drained bullae (type of blister, multiple) to left heel measuring 6 centimeters (cm) by 8cm by 0.2 cm, skin flap intact, area under skin flap moist, red, beefy looking area. LPN #7 cleansed the area with normal saline, patted dry, and applied dry dressing with kling. The physician was notified via phone. Review of Resident #67 medical record (progress notes, event, observation) dated 12/06/17 to 01/08/18 revealed no evidence the resident had [MEDICAL CONDITION] or third spacing. However, the notes indicated the resident was having pain in knees and legs. The physician had adjusted his pain medication. Review of the Treatment Administration Record (TAR) dated 11/07/17 to 01/09/18 revealed nursing staff were applying skin prep to bilateral heels to prevent skin breakdown. There was no evidence of the resident's heels being elevated (heels up device). Review of the resident's care guide revealed on 11/29/17 the resident was encouraged not to slide/scoot when in bed or chair, turn and reposition frequently, and float heels as tolerated. The resident was high risk for skin breakdown; required one assist with bed mobility; and was up ad lib. Review of wound notes dated 12/27/17 by LPN #7 revealed the resident had filled bulla (thin walled blister) due to third spacing [MEDICAL CONDITION] on left heel. The area measured 8.0 cm by 6.0 cm by 0.1cm (nurse notes indicated the area was 6cm by 8cm by 0.2 cm). The wound surface was red, with scant amount of serous drainage. The treatment was to cleanse the area daily with normal saline, and apply dry dressing. The Treatment Administration Records (TAR) dated 12/27/17 to 01/08/18 indicated the treatment was administered twice daily. Review of the wound note dated 01/02/18 by Registered Nurse (RN) #10 indicated the wound on the left heel measured 7.5 cm by 5.5 cm by 0.1 cm. The peri wound was normal flesh tone. The wound bed was dark beefy red tissue and shiny in appearance. There was a portion measuring 2.6 cm by 2.4 cm in the center of the wound bed with intact soft light brown scab formation. There was moderate amount of sanguineous drainage noted. Treatment was to cleanse wound with normal saline, pat dry, apply non-adherent pad and wrap with kerlix, secure with tape. Change daily and as needed. The TAR indicted to cleanse daily with normal saline topically, pat dry, apply dry dressing, and kling every shift (twice daily). The physician was notified. On 01/09/18 at 4:27 P.M., observation of Resident #67 with Physician #9 and LPN #7 revealed the resident had an open area on the left heel. In the center of the wound there was a quarter size black eschar area. Physician #9 reported the area was an unstageable pressure ulcer (unstageable pressure ulcer defined as an obscured full-thickness skin and tissue loss) and not related to third spacing [MEDICAL CONDITION]. Physician #9 reported the area appeared to be caused by some type of friction/shearing. Physician #9 reported the resident could have been rubbing his heel on the foot pedal on the wheelchair. He reported the resident was experiencing decrease in range of motion in his lower extremities and only had socks on his feet and the foot pedals were rough. Physician #9 stated the only other reason for blistering would be a burn and that could be ruled out. LPN #7 reported the resident had a respiratory infection and had spent more time in bed than usual. Physician #9 stated he was going to order venous studies just to rule out any vascular disease. Physician #9 reported this was the first he knew about the wound even though the wound notes and progress notes indicated he was notified on 12/27/17. On 01/10/18 at 9:01 A.M., observation of Resident #67 revealed the resident was resting in bed and his feet were not elevated off the bed. LPN #7 verified these findings at the time of observation. On 01/10/18 at 9:44 A.M., interview with STNA #11 revealed she was the one that discovered the blister on Resident #67's heel but had not observed it until it had ruptured in his bed. She was not sure of the date. STNA #11 reported the heels up device was implemented sometime at the end of November, 2017; however, she was not sure exactly when. She indicated the resident was up ad lib with one assist prior to his recent respiratory infection around Christmas time and now he required a two person assist. On 01/10/18 at 12:55 P.M., interview with RN #8 verified the nurse progress notes dated 12/06/17 to 01/08/18 did not reflect the resident's [MEDICAL CONDITION] or third spacing. RN #8 verified Resident #67 did not have orders for [MEDICAL CONDITION]-embolic deterrent (TED) hose or wraps to help with third spacing fluid. On 01/10/18 at 1:00 P.M., interview with RN #10 revealed after reassessing the wound on 01/09/18 he agreed the resident had an unstageable pressure ulcer on his left heel. He was not aware the physician was not notified of the open area on the left heel nor did he notify the physician (the wound notes dated 01/02/18 indicated RN #10 had notified the physician). RN #10 verified the TAR was incorrect and the dressing was to be changed daily not every shift (twice daily) and the skin prep should have been discontinued on the left heel on 12/27/17. RN #10 stated he did not feel the wound had declined on 01/02/18 even though there was a light brown scab area in the center of the wound. RN #10 stated this change didn't warrant a treatment change. RN #10 indicated the wound measured 8.0 cm by 6.0 cm with a 2.0 cm by 2.0 cm necrotic eschar on 01/09/18. RN #10 verified the area around the necrosis was dark pink with smooth/shiny appearance; moderate amount of serous drainage noted; and the peri wound was normal flesh tone. RN #10 verified the resident had pain (two out of 10). Review of the pressure policy, undated, revealed a Stage II pressure ulcer was partial-thickness skin loss with exposed dermis. The wound bed was viable, pink or red, moist, and my also present as an intact or ruptured serum-filled blister. These injuries commonly result from sheer in the skin over the heel. For moderate to heavy drainage consider the need for a foam dressing. An unstageable pressure ulcer was obscured full-thickness skin and tissue loss. Intervention include to protect, manage the drainage, select the method of debridement most appropriate to the resident's condition and goals, and manage the pain. 2. Review of Resident #70's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Further medical review revealed on 11/14/17 Resident #70 had a cast removed from her right ankle. Review of wound assessment documentation forms revealed on 11/21/17 a suspected deep tissue injury (purple or maroon localized area of discolored intact skin) was found to the heel of Resident #70's right foot. Description of the wound described the wound as an intact non fluid filled blister and also identified Resident #70 had a hard cast removal to the foot on 11/14/17. Review of nurses notes from 11/14/17 through 11/21/17 revealed no evidence of staff identifying any wound to Resident #70's right heel until 11/21/17. Interview with Resident #70 on 01/09/18 at 1:17 P.M. revealed the wound to her heel was present when the cast was removed from her foot on 11/14/17. Observation of Resident #70's right heel on 01/10/18 at 8:13 A.M. revealed black/brown eschar (dead tissue appearing like a scab) covering 100% of the wound bed. Interview with Registered Nurse (RN) #10 on 01/10/18 at 3:00 P.M., verified Resident #70 returned from an orthopedic consult on 11/14/17, where the cast to the right foot was removed. No wound assessment or treatment was completed until 11/21/17 due to staff missed seeing the wound at the time of the resident's return from the appointment.

Based on medical record review and staff interview, the facility failed to ensure each resident received adequate supervision and assistance with care. This affected one (Resident #107) of four sampled residents reviewed for falls/accident hazards. The census was 106. Harm occurred when one staff member provided care for Resident #107, who required two staff assistance resulting in the resident rolling out of bed, falling to the floor and sustaining a 2 centimeter (cm) long laceration to the left side of the back of the head requiring surgical staples for closure and a 6 cm by 6 cm hematoma (a collection of blood outside the blood vessel) to the back of her head. Findings include: Review of Resident #107's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was assessed on 05/07/12 for moderate risk for falls. Review of the quarterly minimum data set (MDS) assessment for 06/20/12, revealed Resident #107's decision making ability was severely impaired and required extensive assistance with two plus staff members for bed mobility. The resident was total care of two plus staff members assistance for transfers, hygiene, and bathing, and the resident did not ambulate. Review of the plan of care for Potential for Falls revealed on 12/30/11 the facility implemented a low bed as an intervention. Review of the nurses notes dated 07/15/12 at 4:30 P.M., revealed the nurse was called to the resident's room by state tested nurse aide (STNA) #12. The resident was lying on the floor on her right side. STNA #12 reported staff were providing care when the resident began to roll out of bed and they were unable to keep her from falling. STNA #12 stated the resident hit the left side of the back of her head on the bed frame, then fell to the floor on her back hitting her head on the floor as well. The nurse noted an approximately 2 cm long laceration to the left side of the back of the head with a moderate amount of sanguineous drainage. The nurse also noted a 6 cm by 6 cm hematoma noted to the back of her head. The resident's physician was notified and ordered the resident transferred to the hospital for treatment. The resident was diagnosed with [REDACTED]. On 07/16/12, the Director of Nursing educated staff on safety techniques when turning and repositioning residents. Resident #107's plan of care revealed there was to be two staff assisting with all care. Review of the nurses notes dated 07/25/12, revealed that at 6:30 P.M,. the STNA (not identified in the nurses notes) requested assistance in Resident #107's room. The resident was noted to be lying on the floor on her back with a pillow underneath her head. The STNA reported that when rolling the resident to the right side during bedtime care the resident rolled onto the floor bumping her head on the right side of the dresser. The Registered Nurse assessed the resident and noted a superficial abrasion measuring 0.5 cm by 0.5 cm to the right side of the resident's forehead. On 07/27/12, the Director of Nursing again educated staff on safe turning and repositioning care techniques and two person assistance during resident's care. Interview with the Director of Nursing on 08/07/12 at 9:50 A.M., revealed that it was her understanding on 07/15/12, one STNA rolled Resident #107 toward the other STNA on the opposite side of the bed and she was not up against the bed and the resident rolled out. Interview with STNA #12 on 08/07/12 at 10:12 A.M., revealed that on 07/15/12, she was getting the resident ready to get up and was rolling the resident toward her and the resident's leg came over the other leg and there was no side rail. STNA #12 reported that when the resident rolled she kept rolling toward her (STNA #12) and she was unable to catch her. STNA #12 revealed the bed was in a higher position for care and she was the only STNA in the room for care because she was not getting the resident up because that required two STNA's. This deficiency substantiates Complaint Number OH 493.