Every finding on record at The Convalarium of Dublin

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record reviews, staff interviews, and policy reviews, the facility failed to ensure a resident was safely transported by a trained driver resulting in a resident falling out of a wheelchair on the facility bus. This affected one (#103) of three residents reviewed for transportation. The facility census was 83. Findings include: Review of Resident #103's medical record revealed an admission date of 11/13/25. Resident #103 had diagnoses that included cerebral palsy, generalized anxiety disorder, age-related osteoporosis with current pathological fracture, and chronic peripheral venous insufficiency. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #103 had moderate cognitive impairment, had clear speech, and was able to understand and follow simple instructions. Resident #103 had bilateral range of motion impairment to her upper and lower extremities and was dependent on staff assistance for chair or bed to chair transfers. Review of a nursing progress note dated 03/02/26 at 10:38 A.M. revealed Resident #103 slid out of her wheelchair during facility-provided transportation. Continued review of the progress note revealed there was a hoyer pad between Resident #103 and the seat cushion on her wheelchair. A head-to-toe assessment was done by the nurse unit manager and Resident #103 complained of pain to her right leg and foot. Resident #103 was taken to the emergency room for evaluation and treatment. Resident #103 was noted with a non-displaced fracture of the second metatarsal (toe) bone of her right foot but no further care/treatment was required and the resident returned to the facility. Review of the interdisciplinary team (IDT) progress note dated 03/04/26 at 12:05 P.M. revealed immediate interventions included head-to-toe assessment by the nurse unit manager and transfer to the emergency room for evaluation and treatment. Follow up interventions included adding a Dycem pad (nonskid pad) between the top of the wheelchair cushion and the hoyer pad to prevent sliding. Review of the facility's incident investigation revealed the Administrator reported he transported Resident #103 in the facility's bus to her dental appointment on the morning of 03/02/26. Certified Nurse Aide (CNA) #424 accompanied Resident #103 and the Administrator. The Administrator locked Resident #103's wheelchair into place but did not secure her seat belt. The Administrator reported he made a right turn into a roundabout which caused Resident #103 to slide from her wheelchair onto the floor of the bus. The Administrator reported immediately calling the facility for clinical assistance. Nurse unit manager, Registered Nurse (RN) #425, arrived on the scene, completed a head-to-toe evaluation, and made a clinical determination to send Resident #103 to the emergency room for evaluation and treatment due to Resident #103 reporting pain in her right foot and ankle. Review of CNA #424's incident witness statement revealed the Administrator loaded Resident #103 into the facility's bus. CNA #424 reported Resident #103 slid out of her wheelchair with her hoyer pad underneath her when the vehicle entered the roundabout. Review of RN #425's incident witness statement revealed RN #425 was contacted by the Administrator for clinical assistance when Resident #103 slid from her wheelchair during transportation. RN #425 conducted a head-to-toe assessment, during which Resident #103 vocalized pain in her right foot and ankle and was unable to fully extend her ankle. RN #425 recommended sending Resident #103 to the emergency room for evaluation and treatment. Review of the hospital after visit summary revealed Resident #103 was treated in the emergency room [DATE] and had new orders to buddy tape her first, second, and third toes together and apply a post-op shoe to protect the toes. Resident #103 returned to the facility on the same day. Review of the Transportation Training Form revealed Primary Driver #423 and the Administrator received training in operation of the facility's transportation bus, which included operating of the lift, security straps, seatbelts, passenger door, hazard lights, and reverse lighting and sounds. This training was completed on 03/02/26. Interview on 07/16/26 at 1:43 P.M. with the Administrator revealed there are two main drivers of the facility's bus, and he is the backup if they are not available. The Administrator confirmed he transported Resident #103 in the facility's bus on 03/02/26. The Administrator confirmed he locked Resident #103's wheelchair into the facility's bus but did not secure her seatbelt, resulting in Resident #103 sliding out of her wheelchair. The Administrator confirmed Transportation Training Forms were signed after the incident occurred. The Administrator confirmed the three current drivers, CNA #422, Housekeeping Director #419, and himself, were trained. The Administrator confirmed the transportation team is auditing all facility-provided transportation to ensure all safety protocols are in place. The Administrator confirmed these audits remain ongoing out of an abundance of caution and to ensure resident safety. Review of the policy titled, Transportation, reviewed 04/28/25, stated staff providing transportation for residents will receive bus/van competency training. The deficient practice was corrected on 03/09/26 when the facility implemented the following corrective actions: The plan of correction was reviewed and approved by the Quality Assurance and Performance Improvement (QAPI) team. On 03/02/26 the Administrator was trained on safely transporting resident in the bus. On 03/09/26 CNA #422 and Housekeeping Director #419 received the facility bus safety training. The plan of correction included ongoing audits by the transportation team of all resident transportation by the facility. Review of transportation audits revealed no further incidents or concerns. This deficiency represents non-compliance investigated under Complaint Number 3070341.

Based on observation, interview and record review, the facility failed to ensure residents were safely transported to outside medical appointments. This affected one (#66) of three residents reviewed for outside medical transportation. The facility census was 83.Findings include:Review of the medical record for Resident #66 revealed an admission date of 01/09/25. Diagnoses included heart failure, hypertensive heart and chronic kidney disease with heart failure and with stage five chronic kidney disease, Type II diabetes, anemia, end stage renal disease, obstructive and reflux uropathy, spinal stenosis cervical region, atrial fibrillation, hyperlipidemia, hypertension, and dependence on renal dialysis.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. Resident #66 had no psychosis, no verbal or physical behaviors, and no rejections of care. Resident #66 used a wheelchair for mobility and required dialysis. Review of the care plan initiated 04/10/26 revealed Resident #66 had end stage renal disease (ESRD) and received hemodialysis.Review of the progress note dated 06/11/26 at 6:23 A.M. revealed, per report from staff, Resident #66 was picked up at approximately 5:00 A.M. for his dialysis appointment. About 10 minutes later, staff notified the nurse that the resident had fallen from his electric wheelchair into a ditch. Emergency medical services (EMS) were called, and the resident was transported to local hospital for further evaluation.Review of the EMS run report dated 06/11/26 at 5:06 A.M. revealed Resident #66 was found lying supine (lying flat on back, facing upward) in a grassy area next to the bike path complaining of right-sided rib pain. The resident stated the rib pain was worse when he took a deep breath. The primary impression was acute pain due to trauma. The resident noted the pain was less once he was moved. Resident #66 was transported to the local hospital for evaluation. Review of the facility's fall incident report dated 06/11/26 for Resident #66 revealed the predisposing environmental factors included poor lighting.Review of the hospital notes dated 06/11/26 revealed Resident #66 was admitted to the hospital for a fall. Imaging results were negative for acute fractures. An observation on 06/17/26 at 10:20 A.M. of the path taken from the facility to the dialysis center, with Staffing Coordinator (SC) #155, revealed SC #155 exited the facility through the front door, down the wheelchair ramp into the parking lot, across the facility parking lot, then up ramp to the sidewalk, which led to a short bridge, and then down another sidewalk into an Assisted Living (not part of the facility) facility parking lot. SC #155 then walked through the parking lot to an asphalt sidewalk, which was in an S shaped curve and led to the crosswalk at the street. Concurrent interview with SC #155 revealed it was in the area of the S shaped curve that Resident #66 went straight instead of turning in the curve. When the resident's wheelchair hit the grass, the wheelchair tipped over and Resident #66 fell into the ditch in front of the drain. SC #155 stated Resident #66 fell on his right side. Further observation revealed a rough, uneven patch of blacktop at the area SC #155 stated Resident #66 fell. SC #155 verified Resident #66 fell in the S shaped curved area where there was a rough, uneven patch of blacktop. Further observation on 06/17/26 at 2:53 P.M. of the path taken from the facility to the dialysis center, with the Director of Nursing (DON), revealed there were no streetlights or other lighting after exiting the Assisted Living facility's parking lot. Concurrent interview with the DON verified there was no lighting on the path where Resident #66 fell into a ditch. An interview on 06/17/26 at 9:12 A.M. with Certified Nursing Assistant (CNA) #175 revealed she and Administrative Assistant (AA) #590 scheduled transportation for residents. CNA #175 stated Housekeeping Director (HD) #545 transported Resident #66 to dialysis and she picked the resident up at the end of his treatment. CNA #175 stated if HD #545 could not take Resident #66 to dialysis, then someone else would take him. An interview on 06/17/26 at 9:19 A.M. with HD #545 revealed she provided transportation for the residents and confirmed she transported Resident #66 to dialysis. HD #545 stated Resident #66's dialysis chair time was scheduled for 5:15 A.M. Monday, Wednesday, and Friday and the resident also had dialysis on Saturdays. HD #545 stated she was on vacation last week and heard the Administrator had asked an aide on night shift to walk Resident #66 over to dialysis, which was not far, but there were no sidewalks. HD #545 stated she heard Resident #66 went into a ditch and fell, then went to the hospital. HD #545 stated facility leadership knew a month in advance that she was taking vacation and knew they had to cover Resident #66's dialysis transportation. HD #545 stated Resident #66 was going to dialysis on Thursday, 06/11/26, when the accident happened. An interview on 06/17/26 at 9:49 A.M. with AA #590 revealed her main role was coordinating transportation for resident appointments. AA #590 stated she tried not to hire out transportation, meaning the facility provided their own transportation, but sometimes it was necessary. AA #590 stated Resident #66's dialysis times were changed from Thursdays to Saturdays the first week of June. AA #590 stated HD #545 transported Resident #66 to dialysis, but she was on vacation last week. AA #590 stated the facility contracted with an outside transportation company who could bill the resident's transportation to his insurance to provide transportation for Resident #66. The company transported Resident #66 on 06/08/26 and then stated they could not do it because the dialysis appointments were too early. AA #590 stated she did not know who decided to have an aide walk Resident #66 to dialysis after the transportation company said they could not transport him, but they did a trial run of the route on Tuesday, 06/09/26, at about 5:30 P.M. SC #155 walked with Resident #66 during the trial run and the plan was for a night shift CNA to walk Resident #66 to dialysis and CNA #175 would pick him up after his treatment. AA #590 stated that on Thursday, 06/11/26, Resident #66 was not supposed to have dialysis because his day changed from Thursday to Saturday, but he told staff he did, so they tried to walk him to dialysis.An interview on 06/17/26 at 10:05 A.M. with SC #155 revealed she received a call from the nurse on 06/11/26 asking about Resident #66's dialysis, so she came into the building. SC #155 stated Resident #66 was at the front door around 4:30 A.M. and was ready to go to dialysis. SC #155 stated she and Resident #66 went out the front door, traveled down a paved trail, and were almost to the walkway when he fell before they made it to cross the street. SC #155 stated she called into the building to have the nurse come and assess him. SC #155 stated as the nurse was coming, Resident #66 was complaining of side pain, and she called nine-one-one (911) before the nurse got there. SC #155 stated the time of the 911 call was 5:01 A.M. and the squad transported the resident to the hospital. SC #155 stated the plan was for staff to walk Resident #66 to dialysis that week and the resident was in agreement. An interview on 06/17/26 at 2:53 P.M. with the DON revealed she was not part of the discussion about transportation for Resident #66. The DON stated she learned of the plan for staff to walk Resident #66 to dialysis when he fell. The DON stated the Administrator was over transportation and it was approximately a one-quarter of a mile from the facility by walking along the parking lots from the facility to the dialysis center.An interview on 06/22/26 at 12:57 P.M. with Resident #66 revealed he had not been on the trail leading to the dialysis center prior to 06/11/26, contrary to AA #590's report that a trial run was done of the path on 06/09/26. Resident #66 stated on the morning of 06/11/26, it was dark outside when he and SC #155 left the facility to walk to the dialysis center. Resident #66 was in his electric wheelchair. Resident #66 stated SC #155 turned on the flashlight on her cell phone to provide light and walked approximately 15 feet in front of him. Resident #66 stated he could not see and when he came to the curve, he went straight which caused the wheelchair tire to roll off the asphalt and the wheelchair flipped over on its side. Resident #66 stated he thinks he hit the joystick and the right arm of the wheelchair or something on the ground, causing pain to his right side. Resident #66 stated the wheelchair was lying on top of him when it flipped. Resident #66 stated it was not his choice to use the trail to go to dialysis, adding he did not want to go that way because there were no streetlights. Resident #66 stated he tried to tell SC #155, but she told him he had to go that way, so he followed her. An interview on 06/22/26 at 2:02 P.M. with the Administrator, the DON, and Regional Clinical Nurse (RCN) #680 revealed the Administrator was aware HD #545 was going on vacation and contracted with an outside transportation company to take Resident #66 to and from dialysis for that week. The Administrator stated after transporting Resident #66 on 06/08/26, the company stated the transport time was too early and they could not provide transportation. The Administrator stated his compassionate side allowed CNA #175 to sleep in instead of transporting Resident #66 to dialysis, so the arrangement was made for a CNA to walk with Resident #66 as an escort to dialysis on 06/10/26 and the rest of the week. The Administrator stated SC #155 called him when Resident #66 fell in the ditch, and he told her to call 911 and update him. The Administrator stated he had walked the trail and it did not look like there was any lighting on the asphalt to the crosswalk where Resident #66 fell. The Administrator stated there was no reason arrangements were not made for CNA #175 to provide transportation for Resident #66. The DON verified there were no progress notes or other evidence which indicated SC #155 had discussed transportation with Resident #66 or that the resident had been notified of the changes. Review of the Nursing Home Dialysis Transfer Agreement, dated 08/18/11, revealed the facility had the responsibility for arranging suitable transportation of the designated resident to and from the center, including the selection of the mode of transportation, qualified personnel to accompany the designated resident and transportation equipment usually associated with this type of transfer including the use of appropriate life support measures in accordance with the applicable federal and state laws and regulations. The facility was responsible for ensuring that the designated resident was medically stable to undergo such transportation, was responsible for the designated resident during transfer to and from the center, including medical and non-medical emergencies, and was responsible for all costs of transportation associated with the transfer of the designated resident to and from center and facility. Review of the facility policy titled, Transportation, dated 04/28/25 revealed it was the policy of the facility to arrange and ensure transportation was provided for doctors and specialist appointments if the resident did not have family, friends, or a responsible party available for transport.This deficiency represents non-compliance investigated under Master Complaint Number 3043102 and Complaint Number 3043099.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record reviews, staff and resident interviews, hospital record reviews, incident investigation reports, and policy reviews, the facility failed to ensure two staff were present during resident transfers and failed to utilize a mechanical lift for the transfer. This affected one resident (Resident #06) of three residents reviewed for mechanical lift transfers. Actual harm occurred on 04/30/26 when Resident #06, who required the use of a mechanical lift assisted by two staff members for transfers, was picked up by one staff member, Certified Nursing Assistant (CNA) #206, and transferred from the shower chair to the bed. CNA #206 did not utilize the assistance of a mechanical lift and performed the transfer by himself. This resulted in an acute comminuted overlapping left humeral diaphyseal fracture and required hospitalization and surgical intervention to repair. The facility census was 83. Findings include:Review of the medical record for Resident #06 revealed an admission date of 8/16/24. Diagnoses included chronic congestive heart failure, hypertension, and generalized muscle weakness. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 12, did not have any hallucinations, delusions, or behaviors, had no range of motion impairment in upper of lower extremities and utilized a wheelchair for mobility. Resident #06 required substantial maximal assistance with toileting hygiene, showering, and dressing and was dependent for sit to stand, chair to bed and tub shower transfers. Resident #06 had no falls since admission. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 had moderate cognitive impairment and was dependent on staff assistance for all mobility, showering, transferring in and out of the tub or shower, sit-to-stand transfers, and chair or bed to chair transfers. Review of physician orders revealed no order for how Resident #06 was to be transferred. Review of Resident #06's care plan revealed on 01/05/26 Resident #06 required the use of a stand-up lift and assistance of two staff members (to transfer). This intervention was revised on 05/02/26 documenting Resident #06 required a Hoyer lift and two-person assistance for transfers. This intervention was revised again on 05/08/26 documenting Resident #06 required a mechanical lift and two-person assistance for transfers. Review of physical therapy orders dated 03/25/26 revealed Resident #06 required two-person assistance for transfers, as well as increased time and verbal cues to advance her lower extremities. Review of Resident #06's Kardex Report (summary of a resident's current plan of care, medical interventions, and tasks) dated 04/30/26 revealed Resident #06 required substantial or maximal assistance with chair-to-bed, bed-to-chair, and sit-to-stand transfers. Review of the incident report dated 04/30/26 at 8:30 P.M. completed by Licensed Practical Nurse (LPN) #105 revealed Resident #06 complained to CNA #206 of pain in her left arm following a transfer from her shower chair to her bed by CNA #206. An injury was reported to Resident #06's left upper arm with pain described as an eight out of 10. Reported predisposing environmental factors included assistive devices not in use. No other predisposing physiological or situational factors were reported. Review of a physician progress note dated 04/30/26 at 8:58 P.M. revealed Resident #06 was seen for a primary telehealth appointment at the request of facility staff due to resident-reported left forearm pain after being transferred into her bed. Resident #06 reported she was unable to move her left arm. This physician note did not include new orders for imaging, laboratory tests, or other treatments. Review of a nursing progress note dated 04/30/26 at 11:22 P.M. revealed LPN #105 examined Resident #06 due to a complaint of left arm pain. The assessment was completed and no significant findings were noted; vital signs were obtained and within normal limits. Resident #06 was given an as-needed (PRN) pain medication (Tylenol [analgesic] 325 milligrams [mg], two tablets every six hours as needed for pain) for reported pain six out of 10. LPN #105 notified the facility certified nurse practitioner (CNP) and received new orders for one-time only application of a Lidocaine patch to Resident #06's left arm and an X-ray of the same arm. Review of the radiology interpretation dated 05/01/26 at 12:18 P.M. revealed Resident #06 had X-rays of her left shoulder, left humerus, left elbow, left forearm, and left wrist due to pain from bumping her arm into her bedside railing. The findings were reported to be an acute, oblique fracture through the proximal left humerus, and degenerative changes at the acromioclavicular joint. No other fractures, sprains, dislocations, or other signs of injury were noted. Review of a physician progress note dated 05/01/26 at 2:02 P.M. revealed Resident #06's X-ray results demonstrated an acute angled fracture of the proximal humerus with associated degenerative changes of the acromioclavicular joint. Continued review of this progress note revealed Resident #06 reported that during her shower, a male aide (CNA #206) manually transferred her to her bed by lifting her under her armpits instead of using a Hoyer lift as required. Resident #06 reported her left arm struck the bedside rail and subsequently developed pain in her left shoulder. Review of a nursing progress note dated 05/01/26 at 2:53 P.M. revealed Resident #06's X-ray results came back and documented a left humerus fracture. Registered Nurse (RN) #179 notified Resident #06's physician and emergency contact, and Resident #06 was sent to the emergency room for evaluation and treatment. Review of hospital documentation revealed Resident #06 was admitted to the hospital from [DATE] to 05/05/26. Review of the emergency room intake documentation revealed Resident #06 had an acute comminuted overlapping left humeral diaphyseal fracture requiring hospital admission and surgery to repair. Further review of hospitalization records revealed a description of the fracture as fairly severe. Continued review of the trauma consultation on 05/01/26 at 8:44 P.M. revealed Resident #06 would require an open reduction, internal fixation (ORIF) surgery to repair the fracture, with surgery scheduled for 05/02/26. The description also stated that Resident #06 reportedly had a fall on 04/30/26 and landed on her left arm causing the fracture. Review of occupational and physical therapy evaluations completed in the hospital on [DATE] and 05/03/26, respectively, revealed Resident #06 normally transferred with a Hoyer lift versus a standing pivot transfer, required maximum two-person assistance with sitting-to-lying and lying-to-sitting bed mobility, and was unable to safely progress with sit to stand transfers. Review of the hospitalization trauma service progress notes dated 05/04/26 at 7:39 A.M. revealed a statement regarding the injury: Pathologic fracture due to a combination of osteopenia (low bone density, but not low enough to be osteoporosis) and trauma that alone would not have caused the fracture and Vitamin D level 56 - no replacement needed. No further interpretation regarding the cause of the fracture was reported in this progress note. Review of facility incident investigation revealed a statement from CNA #206 dated 05/04/26 regarding the incident on 04/30/26. Per CNA #206's statement, CNA #206 took Resident #06 to the shower per her usual shower schedule. After Resident #06's shower was completed, CNA #206 reported he took Resident #06 back to her room in the wheeled shower chair and transferred Resident #06 into her bed. CNA #206 reported after putting Resident #06 in her bed, she complained of pain in her left shoulder and CNA #206 immediately notified the floor nurse. Continued review of the facility incident investigation revealed a statement from an unknown employee dated 05/01/26. The employee reported asking Resident #06 how she hurt her arm. Resident #06 reported to the employee that CNA #206 lifted Resident #06 out of her shower chair and put her in her bed. Resident #06 reported that when CNA #206 tried to lift her over the bedside rail, CNA #206 bumped her arm into it. Continued review of the facility incident investigation revealed a communication note between Assistant Director of Nursing (ADON) #177 and CNA #206. In the interview with ADON #177, CNA #206 stated he would confirm a resident's transfer status with a nurse if he was unsure. When asked what CNA #206 would do if a nurse was not available, CNA #206 reported he would seek additional assistance and perform a two-person assisted transfer. CNA #206 revealed he did not use a gait belt when he transferred Resident #06 out of the shower chair as Resident #06 informed him, she had been working with therapy and only required minimal assistance. CNA #206 denied hitting or bumping Resident #06's arm during the transfer, and stated Resident #06 did not complain of pain until after the transfer occurred. CNA #206 stated he believed Resident #06 required one-person assistance and stated he routinely provided Resident #06's cares. Interview on 05/27/26 at 10:33 A.M. with Resident #06 revealed she normally requires a Hoyer lift for transfers because she cannot walk or stand independently and had been working with physical and occupational therapies to increase her strength and mobility. Resident #06 stated on 04/30/26, CNA #206 was assisting her with her shower as he normally did when he worked on her hall. Resident #06 stated CNA #206 lifted her up out of the chair by himself without a Hoyer or other mechanical lift, without using a gait belt, and without the assistance of another person. Resident #06 stated CNA #206 had attempted to transfer her like this one other time before without incident but reported on 04/30/26 it resulted in a fall. Resident #06 stated her arm went down and hit something, maybe the metal part on the bed but was not able to describe the incident with certainty. Resident #06 denied concerns of abuse, neglect, or other mistreatment by CNA #206 or other staff members. Interview on 05/27/26 at 2:20 P.M. with Therapy Director (TD) #208 confirmed at the time of the incident on 04/30/26, Resident #06 required two-person assistance with a gait belt for all transfers. TD #208 confirmed any strengthening exercises being done in PT/OT sessions were not to be completed by nurses or aides during routine care. TD #208 confirmed the incident on 04/30/26 occurred because the aide performing the transfer did not follow therapy orders. Interview on 05/28/26 at 9:49 A.M. with LPN #101 confirmed she was immediately notified of Resident #06's new complaint of pain following a transfer from her shower chair to her bed on 04/30/26 and instructed the floor nurse, LPN #105, to begin an investigation into the new onset of pain. LPN #101 stated further investigation was completed by ADON #177 and she (LPN #101) re-educated staff on where to confirm a resident's transfer status in the electronic medical record and the therapy communication binders at each nurse's station. LPN #101 confirmed during this training, all clinical staff were educated it is their responsibility to confirm a resident's transfer status before performing a transfer. LPN #101 confirmed staff are to ask the floor nurse, unit manager, or other administrative staff for clarification of transfer orders if there is a discrepancy between the electronic medical record and the therapy communication binder. Interview on 05/28/26 at 9:59 A.M. with ADON #177 confirmed Resident #06 complained of pain in her left arm following an improper transfer with one-person assistance from her shower chair to her bed on 04/30/26. ADON #177 confirmed that the CNP was immediately notified and gave new orders for one-time only lidocaine patch to be applied to her left arm for pain management and X-rays of the left arm. ADON #177 confirmed Resident #06 received the X-ray on 05/01/26 around 11:00 A.M. and received the interpretation at 2:53 P.M. on the same day, at which time Resident #06 was sent to the hospital for further evaluation and treatment. ADON #177 confirmed an investigation began on 04/30/26 when Resident #06 complained of new pain in her left shoulder following the transfer. ADON #177 confirmed the accident investigation did not change when the fracture was identified. ADON #177 stated the injury was likely caused when CNA #206 transferred Resident #06 with one-person assistance without a gait belt or mechanical lift and did not follow current therapy orders for two-person assistance. Telephone interview on 05/28/26 at 11:13 A.M. with CNA #206 confirmed he provided Resident #06's shower on 04/30/26 as he has done on every shift he has worked on Resident #06's unit. CNA #206 confirmed he thought Resident #06 required one-person assistance with transfers after checking the electronic medical record. CNA #206 confirmed he lifted Resident #06 up underneath her armpits and did not use a gait belt during the transfer. CNA #206 confirmed Resident #06 did not fall and was not injured during the transfer. CNA #206 confirmed immediately after being put in her bed, Resident #06 reported pain in her left shoulder. CNA #206 confirmed he immediately notified the floor nurse and continued his shift. CNA #206 confirmed he was not aware Resident #06 had a fracture of her left humerus or any other injury that caused the pain in her shoulder. CNA #206 confirmed he completed his 7:00 P.M. to 7:00 A.M. shift on 04/30/26 - 05/01/26, was later suspended on 05/01/26, and his employment was terminated on 05/13/26. Review of the Therapy Communication Binder on Unit 1 on 05/28/26 at 11:26 A.M. confirmed Resident #06's transfer status as of 05/07/26 was listed as two-person assistance using a mechanical Hoyer lift and was non-weightbearing on her left upper extremity. Interview on 05/28/26 at 4:50 P.M. with Director of Nursing (DON) #153 stated this fracture was likely caused because CNA #206 did not transfer Resident #06 correctly based on Resident #06's active therapy orders for transfer status and facility procedure for one-person assistance with transfers. An interview was conducted on 05/29/26 at 10:34 A.M. with Administrator #188 and DON #153 to review past non-compliance and plan of correction documents related to the incident on 04/30/26. Administrator #188 confirmed a root cause analysis was conducted on 05/08/26 and final review and approval of the plan of correction was reviewed and approved by the Quality Assurance Performance Improvement (QAPI) team on 05/28/26. DON #153 confirmed there have been no identified issues of the weekly audits of resident transfers. DON #153 confirmed gait belts have been added to the rooms of every resident that required assistance with transfers. DON #153 confirmed therapy communication binders have been implemented and are being audited and updated regularly. Administrator #188 confirmed CNA #206 was suspended on 05/01/26 pending the outcome of the investigation and was terminated on 05/13/26. Review of the policy titled Activities of Daily Living (ADLs), Supporting, reviewed 08/2025, indicated appropriate care and services will be provided to residents who are unable to carry out ADLs independently, including appropriate support and assistance with mobility (transfer and ambulation, including walking). The policy indicated interventions to improve or maximize a resident's functional abilities will be in accordance with their assessed needs, preferences, stated goals, and recognized standards of practice. The deficient practice was corrected on 05/13/26 when the facility implemented the following corrective actions: On 05/08/26, a Root Cause Analysis was conducted by the Administrator, ADON #177, Unit Manager #1 (LPN #101), Unit Manager #2 (RN #134), MDS Coordinator (LPN #115), and Therapy Director (TD #208), concerning the fracture obtained by Resident #06. On 05/08/26, education was provided by LPN #101 to all clinical staff on how to review the Kardex, where to verify a resident's transfer status, and who to contact if there is a discrepancy in the resident's record. On 05/08/26, TD #208 identified 31 residents in the facility that could potentially be impacted by this deficient practice. On 05/08/26 the facility ordered 50 gait belts and placed them in rooms of residents who require any type of assistance with transfers. On 05/08/26, an ad Hoc Quality Assurance Performance Improvement team meeting occurred with the Administrator, Medical Director and ADON #177. On 05/11/26, clinical staff education and training was conducted by ADON #177, Unit Managers, and the Therapy Director on proper lifting and Hoyer lift techniques. On 05/13/26, audits were implemented by DON #153 and/or the designee to determine if staff were maintaining compliance with functional transfer and assist levels, audit schedule was three times weekly on five residents per day for four weeks. The audit results will be sent to the QAPI team and schedule adjusted based on results. This deficiency represents non-compliance investigated under Complaint Number 3007002.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure tracheostomy care procedures were followed as indicated during routine tracheostomy care. This affected one, (Resident #43), of four residents reviewed for respiratory care services. The facility census was 83.Findings include:Review of Resident #43's electronic health record revealed the resident was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia, encephalopathy, nontraumatic subarachnoid hemorrhage, Type Two Diabetes Mellitus, and tracheostomy status. Resident #43's electronic health record revealed a Brief Interview for Mental Status (BIMS) score was unable to be calculated due to the resident's status of being rarely or never understood, though the resident's cognition was noted to be severely impaired as of the Minimum Data Set (MDS) assessment completed on 04/22/26.Review of Resident #43's physician orders revealed tracheostomy care orders dated 03/17/26 for the following: tracheostomy care every night shift and as needed, change the inner cannula every night shift and as needed, change tracheostomy ties every Thursday night and as needed, and suction the tracheostomy to maintain a patent airway every shift and as needed.Observation on 05/27/26 at approximately 10:10 A.M. of tracheostomy care provided to Resident #43 by Respiratory Therapist (RT) #140 revealed RT #140 removed the old/soiled tracheostomy dressing and inner cannula, and then inserted a new inner cannula and applied a new tracheostomy dressing without washing hands and changing gloves between removal of the soiled tracheostomy dressing and the insertion of the new inner cannula into Resident #43's tracheostomy site.Interview on 05/27/26 at 10:12 A.M. with Respiratory Therapist (RT) #140 revealed they were unsure if they needed to remove their gloves, wash hands, and don new gloves after removing the soiled tracheostomy dressing and before continuing to replace the inner cannula and new dressing at the tracheostomy site. RT #140 stated respiratory staff at the facility haven't done it that way before, but maybe they should.Review of the facility policy titled Tracheostomy Care, revised April 2023 revealed instructions listed for the tracheostomy care procedure that begins with washing hands and putting exam gloves on both hands before removing old dressings and ties and then pulling the soiled gloves over the soiled dressing and discarding all items into the appropriate receptacle. Once the soiled gloves have been removed and properly disposed of, staff hands should be washed and new gloves applied before setting up the tracheostomy care kit and changing out the disposable tracheostomy tube inner cannula.This deficiency represents non-compliance investigated under Complaint Number 3009377.

Based on record reviews, staff and resident interviews, and policy reviews, the facility failed to ensure accurate medical records. This affected one resident, (Resident #6), of six residents reviewed for medical record accuracy. The facility census was 83.Findings include:Review of the medical record for Resident #6 revealed an admission date of 8/16/24. She had diagnoses including chronic congestive heart failure, hypertension, and generalized muscle weakness.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 12, did not have any hallucinations, delusions, or behaviors, had no range of motion impairment in upper of lower extremities and utilized a wheelchair for mobility. Resident #06 required substantial maximal assistance with toileting hygiene, showering, and dressing and was dependent for sit to stand, chair to bed and tub shower transfers. Resident #06 had no falls since admission. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 had moderate cognitive impairment and was dependent on staff assistance for all mobility, showering, transferring in and out of the tub or shower, sit-to-stand transfers, and chair or bed to chair transfers.Review of a therapy to nursing communication note dated 11/04/25 revealed a change in Resident #6's transfer status to manual intervention for sit-to-stand transfers.Review of Resident #6's care plan revealed an intervention initiated on 01/05/26 stated Resident #6 required the use of a mechanical lift with staff assist of two for all transfers. This intervention was changed on 05/08/26 to use of mechanical lift with staff assist of two for all transfers.Review of physical therapy orders dated 03/25/26 revealed Resident #06 required two-person assistance for transfers, as well as increased time and verbal cues to advance her lower extremities.Resident #6's medical record revealed Resident #6 was hospitalized from [DATE] around 3:00 P.M. to 05/05/26 around 6:00 P.M.Review of a nursing progress note dated 05/01/26 at 11:48 P.M. by Licensed Practical Nurse (LPN) #105 revealed Resident #6 received her shower as scheduled from the night shift aide (Certified Nursing Assistant [CNA] #206). Resident #6 was assisted back into her bed and complained of new pain in her left arm. Resident #6 was assessed by LPN #105 with no significant findings noted. LPN #105 reported the pain to the on-call Certified Nurse Practitioner (CNP) and received new orders for one-time-only application of a Lidocaine patch for pain relief and X-rays of the left arm. LPN #105 reported Resident #6 rested in her bed and slept through the night.Review of a therapy to nursing communication note dated 05/07/26 stated Resident #6's transfer status changed to Hoyer lift with staff assist of two for transfers.Interview on 05/28/26 at 3:40 P.M. with LPN #101 confirmed the nursing progress note was dated on 05/01/26 at 11:48 P.M. when Resident #6 was in the hospital.Interview on 05/27/26 at 2:20 P.M. with Therapy Director (TD) #208 confirmed the care plan intervention on 01/05/26 requiring use of a mechanical lift for sit-to-stand transfers was not consistent with the therapy orders at the time (orders on 11/04/25). TD #208 confirmed the care plan intervention on 01/05/26 requiring use of a mechanical lift for sit-to-stand transfers was not updated when therapy orders for transfers changed on 03/25/26. TD #208 confirmed the care plan intervention on 01/05/26 requiring use of a mechanical lift for sit-to-stand transfers was consistent with current therapy orders dated 05/08/26.Review of the policy titled Care Planning, reviewed 08/2025, stated the facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. The policy defined the care planning/interdisciplinary care team to include speech, occupational, and recreational therapists as applicable.This violation represents non-compliance investigated under Complaint Number 3009377.

Based on observation, review of a written statement, review of an electronic mail (email) document, staff interview, employee file review, and review of a facility job description, the facility failed to ensure their activities program was directed by a qualified professional. This had the potential to affect all 80 residents who resided in the facility. The census was 80.Findings include:Review of the employee file for Activity Aide (AA) #517 revealed she was employed with the facility from 03/24/23 to 11/10/25 as the Activities Director. There was no evidence of her being licensed or registered by the state. She became an activity assistant on 11/10/25.Review of an email document from Corporate Representative #800 to the Administrator and AA #517, dated 06/25/25, revealed AA #517 was to enroll in a course to become certified with the National Certification Council for Activity Professional (NCCAP). The facility would reimburse her for any cost after completion.Review of a written statement from AA #517 dated 01/06/26 revealed she started to take the activities courses to be certified and finished part one in June 2025, but did not finish all courses to be certified.Review of the Sampled Residents Medical records (30) revealed the previous Activity Director/AA #517 completed all the activity assessments for residents from 03/24/23 to 11/10/25.Interview on 01/06/25 at 10:30 A.M. with Activity Director #582 confirmed she was hired on 11/07/25 for the Activity Director position because the previous director was not qualified for the position. As of 11/10/25, the previous Activities Director (AA #517) was working as an activity assistant.Interview with the Administrator on 01/06/25 at 10:45 A.M. confirmed the facility Activities Director from 03/24/23 to 11/10/25 was not qualified to be the Activities Director. On 11/07/25, he hired a new Activities Director (#582), and AA #517 became the activity assistant.Observations of AA #517 from 01/05/25 to 01/08/25 at random times confirmed AA #517 was an activity assistant and conducted activities with the residents. Review of a facility job description titled, Activities Director Position Specifics, dated 05/24/25, revealed the purpose of the position was to plan, organize, develop, and direct the overall operations of the Activities Department in accordance with current federal, state, and local standards, guidelines, and regulations. Qualifications include high school diploma or equivalent qualification, a qualified therapeutic recreation specialist or an activities professional who was licensed by this state and was eligible for certification as a recreation specialist or an activity professional.

Based on observation and staff interview, the facility failed to ensure equipment in the kitchen was operating correctly. This had the potential to affect all 70 residents who are served meals from the kitchen. The facility identified 10 (#13, #17, #10, #11, #3, #47, #49, #56, #1, and #68) residents who received nothing by mouth. The census was 80.Findings include:Observation and interview during tour of the kitchen on 01/07/25 from 11:08 A.M. to 12:30 P.M., with Dietary Supervisor (DS) #595, revealed while setting up the drinks for the lunch trays, [NAME] #599 was observed using the plastic scoop to break up the ice in the ice machine. Further observation of the ice machine revealed the ice was not forming cubes, but instead was dropping large sheets of ice into the bin of the machine. An employee had to physically break up the ice to fit into a drinking glass. DS #595 confirmed the findings from the ice machine at the time of the observation. Continued observation of the kitchen revealed the steamer had a metal tray sitting on the table directly under the doors with dirty water in it. The drain tray connected to the steamer was a rusty orange color with no water in it. Interview with DS #595 confirmed the drain in the steam table did not work and administration was aware. DS #595 did not know if the maintenance department was aware of the problem with the ice machine.Interview on 01/07/25 at 1:00 P.M. with Maintenance Director #900 confirmed he was not aware of the problem with the ice machine, and stated he received information about the drain in the steam table a while ago, but he could not fixed it because the steamer was an old unit and the parts were obsolete.

Based on observation, medical record review, resident and staff interview, and policy review, the facility failed to ensure shared glucometers were appropriately disinfected after use and failed to ensure staff wore required personal protective equipment while providing care for residents on infection control precautions as ordered. This directly affected two (#54 and #21) of two residents observed for infection control practices and had the potential to affect eight (#2, #42, #53, #8, #5, #82, #38, and #34) additional residents residing on the Blarney Stone Hall who utilize the shared glucometer. The facility census was 80.Findings include:1. Medical record review for Resident #54 revealed an admission date of 11/13/25 and medical diagnoses of respiratory failure with hypoxia, diabetes type II, metabolic encephalopathy, hepatic encephalopathy, cirrhosis of the liver, alcohol abuse, opioid dependency, insomnia, chronic viral hepatitis B, and chronic viral hepatitis C. Review of Resident #54's care plan last revised 11/24/25 revealed the resident had an alteration in gastrointestinal status due to hepatic encephalopathy, cirrhosis of the liver, and history of hepatitis B and C. Interventions included to obtain and monitor laboratory and diagnostic work as ordered, and report any abnormalities to medical provider. Observation on 01/07/26 at 1:06 P.M. revealed Licensed Practical Nurse (LPN) #562 checked Resident #54 blood glucose with a shared facility glucometer. LPN #562 then cleaned the glucometer with an alcohol wipe. Interview on 01/07/26 at 1:06 P.M. with LPN #562 confirmed the blood glucose monitor was cleansed with an alcohol wipe. Review of the undated facility policy titled, Shared Glucometer Cleaning Protocol, revealed to use a fresh approved low level disinfectant wipe each time the glucometer is used. Interview on 01/07/26 at 4:03 P.M. with Regional Nurse #899 confirmed the facility policy regarding cleaning glucometers and stated cleaning the shared glucometer with an alcohol wipe would not prevent blood illnesses, such as hepatitis. 2. Review of the medical record for Resident #21 revealed an admission date of 10/16/25. Diagnoses included atrial fibrillation, chronic obstructive pulmonary disease, diabetes, dysphagia, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had moderately impaired cognition. Review of Resident #21's physician order dated 12/16/25 to 01/05/25 revealed the resident was ordered contact isolation precautions due to Clostridioides difficile (C.diff) infection. Observation on 01/05/26 at 1:30 P.M. of the outside of Resident #21's room revealed a sign reading, Contact Precautions, with instructions for staff to put on gloves and a gown before room entry. At this time Respiratory Therapist #506 entered the room without donning any personal protective equipment (PPE) prior to entry. Observation and interview on 01/05/26 at 1:55 P.M. revealed Certified Nurse Aide (CNA) #588 was actively performing incontinence care for Resident #21. CNA #588 did not have a gown on during the task and her scrub top was visible. CNA #21 confirmed staff should be wearing personal protective equipment (PPE) in the room, but had to read the sign on the door to identify what PPE was required and for which resident after exiting the resident's room. Resident #21 also confirmed CNA #588 did not have any gown on when proving him care. Interview and observation on 01/05/26 at 2:02 P.M. with Unit Manager #564 revealed Resident #21 had been in contact isolation due to having C.diff diagnosis, and should be coming out of isolation this date as the isolation order had been discontinued. During interview staff came up and handed Unit Manager a sign for enhanced barrier precautions to be placed on the door for staff to follow. Review of facility policy titled, Standard Precautions, dated 08/2022, revealed contact precautions were intended to prevent transmission of infections spread by direct contact or indirect contact and required the use of appropriate personal protective equipment and required the use of gown or gloves upon entering the resident environment. This deficiency represents non-compliance investigated under Complaint Number 1376016 (OH00166478).

Based on observation, medical record review, resident and staff interview, and policy review, the facility failed to provide resident care following a meal to maintain dignity. This deficient practice affected one (#32) of three residents reviewed for dignity. The facility census was 80.Finding Include:Record review for Resident #32 revealed an admission date of 03/22/23. Diagnoses included of hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, morbid obesity due to excess calories, aphasia following cerebrovascular disease, cerebral infarction due to occlusion or stenosis of the right middle cerebral artery, major depressive disorder, anxiety, bipolar disorder, vascular dementia, hyperlipidemia, chronic kidney disease, and lack of coordination.Review of Resident #32's care plan, last revised on 11/03/25, revealed the resident was at risk for activities of daily living (ADLs) performance deficit related to generalized weakness, decreased strength and endurance, and decreased activity tolerance, impaired mobility, and incontinence related to cerebral vascular accident. Interventions include the resident required increased assistance with ADL performance and was able to eat with set up and clean up assistance.Observation on 01/05/26 at 3:46 P.M. revealed Resident #32 resting in bed watching television with corn on his shirt from lunch. Interview with Resident #32 at the time of the observation stated he was not aware of the corn on his shirt and was upset he did not get cleaned up after lunch. Interview on 01/05/26 at 3:48 P.M. with Licensed Practical Nurse (LPN) #604 confirmed Resident #32 had corn on him and the resident was upset about not being cleaned up from lunch.Review of facility policy titled, Dignity, last revised 8/25, revealed staff were to groom residents as they wish to be groomed and to promote resident independence.This deficiency represents non-compliance investigated under Complaint Number 1376013 (OH00164696).

Based on observation, medical record review, staff interview, resident interview, and policy review, the facility failed to ensure adequate finger nail care was provided for a dependent resident. This affected one (#21) of one residents reviewed for activities of daily living. The facility census was 80. Findings include:Review of the medical record for Resident #21 revealed an admission date of 10/16/25. Diagnoses included atrial fibrillation, chronic obstructive pulmonary disease, diabetes, dysphagia, and cognitive communication deficit. Review of the care plan dated 10/29/25 revealed Resident #21 was at risk for an activities of daily living (ADLs) self-performance deficit with interventions to eat with supervision or touching assistance, and the resident was dependent on personal hygiene. Review of Resident #21's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 12 indicating the resident had moderately impaired cognition and required set up assist with oral hygiene and substantial maximum assistance for showering and bathing. Review of shower sheets revealed Resident #21's nails had been documented as last cleaned and trimmed on 12/27/25 and the task was declined on 12/31/25 and 01/03/25. Interview and observation on 01/05/26 at 2:20 P.M. with Resident #21 revealed his nails were long, about a half-inch past the nailbed, and three fingers on his right hand had a dark brownish/red substance caked under the nails. Resident #21 stated he liked his finger nails shorter and stated he would also like them cleaned up. Interview and observation on 01/05/26 at 2:25 P.M. with Certified Nurse Aide (CNA) #588 confirmed Resident #21's nails were longer than his preferred length and were dirty. CNA #558 stated she would talk with the nurse as the resident was diabetic and the podiatrist trimmed his fingernails. Observation and interview on 01/07/26 at 12:25 P.M. of Resident #21 receiving his meal tray revealed the resident still had long and dirty finger nails. Resident #21 reported no staff ever returned to trim and clean up his finger nails. Interview on 01/07/26 at 1:30 P.M. with Registered Nurse (RN) #514 confirmed Resident #21's finger nails were longer than his preference and dirty. She acknowledged she would ensure they get cleaned and trimmed per his request. Interview on 01/07/26 at 4:00 P.M. with Regional Nurse #899 confirmed the podiatrist does not clean and trim finger nails and staff should be performing this as needed and upon resident request. Review of facility policy titled, Activities of Daily Living, dated 08/2025, revealed residents shall be provided care and services for residents unable to carry out activities of daily living including hygiene care.

Based on medical record review, staff interview, and policy review, the facility failed to ensure psychotropic medications were not unnecessarily provided. This affected two (#5 and #8) of five residents review for unnecessary medications. The facility census was 80. Findings include: 1. Review of Resident #5's medical record revealed an admission date of 11/05/25 and medical diagnoses of cerebral palsy, depression, chronic obstructive pulmonary disease, chronic respiratory failure, alcohol abuse, atrial fibrillation, and insomnia. Review of Resident #5's physician orders revealed an active order for the antidepressant, Lexapro five (5) milligrams (mg) with a start date of 11/14/25. Further review of the physician's orders revealed an active order for the antidepressant Zoloft 50 mg with a start date of 12/23/25. Review of psychiatric progress notes dated 12/26/25 and 01/02/26 revealed the plan for Resident #5's depression was to continue Lexapro 5 mg. No documentation for the Zoloft 50 mg order was noted in either progress note. Review of Resident #5's medication administration record dated 12/01/25 to 12/31/25 revealed that both Lexapro 5 mg and Zoloft 50 mg were being administered concurrently. Interview on 01/12/26 at 11:26 A.M. with Nurse Practitioner (NP) #801 confirmed the Zoloft 50 mg medication was not present in Resident #5's psychiatric progress notes on 12/26/25 or 01/02/26. NP #801 stated it was inappropriate to have the resident on both the Lexapro 5 mg and Zoloft 50 mg medication doses since they are in the same class of medications. NP #801 stated when changing medications for a resident, typically the facility will add a new medication and then discontinue the current medication. NP #801 stated Resident #5's orders would be updated to reflex a discontinuation of Lexapro 5 mg and continue the Zoloft 50 mg as ordered.2. Review of Resident #8's medical record revealed an admission date of 08/01/25 and medical diagnoses of chronic obstructive pulmonary disease, major depressive disorder, anxiety disorder, dementia, unspecified hallucinations, congestive heart failure, and muscle weakness.Review of physician's orders for Resident #8 revealed a discontinued order for the antidepressant Remeron (mirtazapine) 15 mg oral tablet with a start date of 08/01/25 and an end date of 09/10/25. Further review of the physician's orders revealed an active order for mirtazapine tablet 7.5 mg with a start date and time of 09/09/25 at 5:00 P.M. Review of a progress note dated 09/09/25 revealed the facility would begin a trial reduction of mirtazapine on 09/09/25 at Resident #8's request, as the resident felt their mood and sleep were good.Review of a progress note dated 09/09/25 revealed new orders received to decrease Remeron from 15 mg to 7.5 mg by mouth at night for depression, and all parties were aware. Review of medication administration record (MAR) dated 09/01/25 to 09/30/25 revealed on 09/09/25 at 9:00 P.M. the Remeron 15 mg dose was administered to Resident #8. Further review of the MAR revealed on 09/09/25 at bedtime the mirtazapine 7.5 mg dose was also administered to Resident #8.Interview on 01/12/26 at 12:17 P.M. with the Director of Nursing (DON) confirmed Resident #8 was administered both the mirtazapine 15 mg dose and the mirtazapine 7.5 mg dose in error on 09/09/25.Review of the facility's policy titled, Administering Medications, revised December 2021, revealed if the dosage is believed to be inappropriate or excessive for a resident, the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns.

Based on medical record review, staff interview, and policy review, the facility failed to timely assess and implement treatment for non-pressure skin conditions. This affected one (#56) of three residents reviewed for wounds. The facility census was 80.Findings include:Review of Resident #56's medical record revealed an admission date of 09/02/25. Diagnoses included respiratory failure with hypoxia, cerebral edema, protein-calorie malnutrition, cerebral infarction, metabolic encephalopathy, hypokalemia, convulsions, paroxysmal atrial fibrillation, peripheral vascular disease, and pneumonia. Review of the Resident #56's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was unable to complete the Brief Interview of Mental Status due to severe cognitive impairment. Further review revealed the resident was fully dependent on staff for all activities of daily living (ADLs).Review the Resident #56's care plan last revised on 11/19/25 revealed the resident was at risk for skin alteration related to generalized weakness, decreased strength and endurance, and decrease activity tolerance, impaired mobility, impaired cognition, and incontinence. Interventions included to administer treatments as ordered and monitor for effectiveness, assess/record/monitor wound healing as ordered and as needed, measure length, width, and depth where possible, and follow facility protocol for the prevention/treatment of skin breakdown.Review of Resident #56's admission assessment dated [DATE] revealed the resident was admitted to the facility with moisture associated dermatitis to the coccyx. Further review revealed the facility performed no skin assessments for the resident until the resident was transferred back from the hospital on [DATE]. Further review revealed the facility did not have treatment orders in place for Resident #56's moisture associated dermatitis on the coccyx. Interview on 01/08/26 at 11:45 A.M. with Wound Nurse #586 confirmed the facility did not have evidence of skin assessments for Resident #56 from 09/02/25 through 09/29/25, and there were no treatment orders for the moisture associated dermatitis on the coccyx until 09/25/25. Interview on 01/12/26 at 8:52 A.M. with the Director of Nursing (DON) confirmed the expectation was for staff to chart and treat skin issues until they are resolved.Review of facility policy titled, Wound Care, last revised 8/25, revealed staff are to measure wounds including length, width, and depth and apply treatments as indicated. This deficiency represents non-compliance investigated under Complaint Number 2606734, Complaint Number 2572222, and Complaint Number 1376017 (OH00167023).

Based on observation, medical record review, and staff interview, the facility failed to ensure pressure ulcer preventative interventions were in place as ordered. This affected one (#35) of five residents reviewed for pressure ulcers. The facility census was 80.Findings include:Record review for Resident #35 revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, diabetes mellitus, chronic obstructive pulmonary disease, schizophrenia, peripheral vascular disease.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 08. The resident was assessed to require self-care and mobility assistance.Review of the care plan dated 11/05/25 revealed Resident #35 previously had a right heel pressure ulcer and was at risk for additional skin breakdown related to her immobility.Review of Resident #35's physician orders revealed an order dated 09/17/24 for the resident to wear Prevalon boots (cushioned boots worn on the feet to reduce pressure) on both of her feet at all times except when the resident was receiving hygiene care.Random observations of Resident #35 between 01/07/26 at 9:00 A.M. and 01/08/26 at 5:30 P.M. revealed the resident was not wearing Prevalon boots. During an interview with Registered Nurse (RN) #589 on 01/08/26 at 6:17 P.M., he verified Resident #35 had not been wearing the Prevalon boots that day, and she did not have them on that morning when he started his shift.This deficiency represents non-compliance investigated under Complaint Number 2606734, Complaint Number 2572222, and Complaint Number 1376017 (OH00167023).

Based on medical record review, review of a risk assessment, resident and resident family interviews, staff interview, and review of an incident log, the facility failed to complete a thorough investigation into a resident accident with injury. This affected one (#92) of three residents reviewed for accidents and injuries. The facility census was 80. Findings include: Review of the medical record for Resident #92 revealed an admission date of 02/18/25 and discharge date of 03/04/25. Diagnoses included respiratory failure with hypoxia, sepsis, heart failure, heart disease, displaced fracture of the scapula, cognitive communication deficit, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #92 had a Brief Interview of Mental Status (BIMS) of 12 indicating moderately impaired cognition and required supervision and touching assist. The assessment revealed the resident had no falls since admission. Review of the plan of care dated 03/10/25 revealed Resident #92 was at risk of falls with interventions to anticipate needs, ensure call light was in reach and encourage use, ensure she was wearing appropriate footwear when ambulating or mobilizing in wheelchair, follow facility protocol, and physical therapy to evaluate and treat as ordered. Review of physician orders from 02/18/25 to 03/04/25 revealed Resident #92 was ordered the pain medication acetaminophen 325 milligrams (mg) with instructions to give two tablets every four hours as needed for mild discomfort. Review of an occupational therapy note dated 02/20/25 revealed Resident #92 required contact guard assistance with toileting transfers and requested a higher height toilet. Review of the progress note dated 02/22/25 revealed Resident #92 had a new complaint of pain on the right upper arm with a pain score of three (on a ten-point scale) and described the pain as aching. Non-pharmacological interventions did not provide relief and as needed medication was provided. Review of an occupational therapy note dated 02/22/25 revealed Resident #92 reported pain of the right shoulder at rest rated five out of ten, and with movement an eight out of ten with exacerbation from reaching. Pain was noted to be a barrier to the therapy session. Review of the progress note dated 02/23/25 revealed Resident #92 had a complaint of pain on the right upper arm with a pain score of three, and described the pain as aching. Non-pharmacological interventions did not provide relief and as needed medication was provided. Review of the progress note dated 02/24/25 revealed Resident #92 complained of right shoulder pain. Staff notified the nurse practitioner and a new order for an x-ray of the right shoulder was ordered. An ice pack was ordered to the right shoulder as needed with instructions to leave it on for up to 15 minutes. A lidocaine four percent (4%) patch was also ordered to be applied to the right shoulder topically once daily for right shoulder pain with instructions to remove after 12 hours. A message was left for the resident's family and the radiology company was notified of the need for a stat x-ray. Review of the progress notes dated 02/24/25 and 02/25/25 revealed Resident #92 reported pain in the right upper arm and scored the pain a two with aching. Review of Resident #92's radiology report dated 02/24/25 revealed a right shoulder x-ray was completed and found evidence of a displaced fracture of the scapula. Degenerative changes at the acromioclavicular (AC) joint and glenohumeral joint were also noted. The result was reviewed by the facility medical provider 02/25/25.Review of Resident #92's occupational therapy notes dated 02/24/25 revealed a family requested a bedside commode over the toilet due to recently injuring her right shoulder during a transfer. The resident practiced sit and stand transfers with stand by assistance with therapy.Review of the risk assessment dated [DATE] revealed Resident #92 reported new pain and stated she walked into the door post while walking into the bathroom. Resident #92 was alert and oriented, and had a pain level of six. The assessment revealed it was privileged and confidential and not part of the medical record. It did not include any follow up on the injury or mention of the x-ray results. The risk assessment did not mention when the injury occurred or whether staff were assisting her or not at the time of the injury. Review of nurse practitioner notes dated 02/24/25 revealed she was informed Resident #92 had pain and was assessed to also have a decreased range of motion and an x-ray was ordered. The note stated the resident ran into a door jam two days prior. Review of Resident #92's medical record, including progress notes, included no details on how the injury/fracture occurred. Review of the incident accident log dated 02/2025 revealed no entry for any fall or injury for Resident #92. Interviews were attempted on 01/07/26 with Registered Nurse (RN) #525, RN #905, and Certified Nurse Aide (CNA) #910 who worked with Resident #92 from 02/22/25 to 02/24/25. All three staff members did not respond or had no memory of Resident #92. Interview on 01/07/25 at 9:28 A.M. with Resident #92's family member reported Resident #92 fractured her shoulder after a toilet transfer with staff assistance. She reported she and the resident informed facility management of the fall and injury and reported management staff told the resident she just bumped into the wall and injured herself. Interview on 01/07/26 from 11:30 A.M. to 5:00 P.M. with the Director of Nursing (DON) and Regional Nurse #899 revealed Resident #92 was admitted for about three weeks and was found to be alert and oriented during her admission. They named a specific nurse (RN #505) and nurse aide (CNA #592) who were knowledgeable about Resident #92 and made statements that after the resident bumped into the wall. The DON and Regional Nurse #899 were unable to state whether staff were present when the injury occurred. They stated it was not an unknown injury as the resident stated she bumped her shoulder on the wall. The facility completed a risk assessment that documented the resident bumped her arm on the wall while going to the bathroom. They confirmed the incident was not on the incident accident log and was not investigated thoroughly. They confirmed they had not obtained staff statements and had no evidence in the resident's medical record related to the cause of the fall. They were unable to explain the discrepancy in what resident and family reported and what facility had documented. Interview on 01/07/26 at 1:52 P.M. with Resident #92 reported she was being assisted in the bathroom by an female aide when she fell and banged into the wall and hurt her shoulder. She stated the staff member ran out and grabbed a nurse who assessed her for injuries. Resident #92 could not recall the individual staff members' names who were involved. Interviews on 01/07/26 from 2:02 P.M. to 2:08 P.M. with RN #505 and CNA #592 revealed neither staff remembered Resident #92 and did not remember a resident situation of getting a resident getting a fracture from an incident with a bathroom transfer. This deficiency represents non-compliance related to Complaint Number 1376013 (OH00164696).

Based on medical record review, review of a concern form, review of written statements, staff interview, and policy review, the facility failed to ensure adequate transportation was provided to residents for outside appointments. This affected one (#96) of three residents reviewed for transportation to outside appointments. The census was 80.Findings include:Review of the medical record for Resident #96 revealed an admission date of 10/03/24. Diagnoses included acute chronic systolic heart failure, type II diabetic mellitus morbid obesity, chronic respiratory failure, and major depression bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #96 was cognitively intact and was dependent on staff for toileting, showers/bath, putting on footwear, and turning side-to-side in bed. She used a wheelchair to transfer throughout the facility. Review of the nursing progress notes for Resident #96 confirmed she had multiple appointments arranged outside the facility. On 04/03/25, she was scheduled for a positron emission tomography (PET) scan and missed the appointment due to location error. On 04/16/25, Resident #96 was notified of new appointment for a PET scan scheduled for 06/02/25. Review of Resident #96's after visit summary from a cardiologist appointment dated 04/03/25 revealed the resident was scheduled for her PET scan at a testing location in Columbus, Ohio with the test time of 2:00 P.M. Review of the physician order entered into Resident #96's medical record revealed the PET scan was on 04/16/25 at a different testing location in [NAME], Ohio at 1:30 P.M. Review of a concern form completed by the Administrator revealed on 04/03/25, Resident #96 was taken to the wrong testing center for a PET Scan. The test had to be rescheduled.Review of a statement by the Administrator dated 04/16/25 confirmed a transportation mistake was made for Resident #96's appointment on 04/03/25. Resident #96 and her spouse contacted the facility to arrange for pick up from the wrong location. Her appointment was rescheduled.Interviewed with the Administrator on 01/12/25 at 10:00 A.M. confirmed Resident #96 was taken to the wrong location, and Administrator Assistant #596, worked with the resident to ensure she was returned to the facility as soon as possible. Resident #96 and her spouse did not wait for transportation to pick them up and decided they would walk back to the facility. Review of facility policy and procedure titled, Transportation, dated 08/24, revealed it was the policy of the facility to arrange and ensure transportation was provided for doctors and specialist appointments. The facility will receive the appointment information from the resident, family, transportation company or doctor's office, and the facility will schedule transportation to and from the appointment as needed.This deficiency represents non-compliance investigated under Complaint Number 2572222, Complaint Number 1376015 (OH00165472), and 1376014 (OH00165055).

Based on medical record review, review of a concern form, and staff interview, the facility failed to ensure dental services were provided in a timely manner. This affected one (#8) of two residents reviewed for dental services. The facility census was 80.Findings include: Review of Resident #8's medical record revealed an admission date of 08/01/25 and medical diagnoses of chronic obstructive pulmonary disease, hemiplegia, congestive heart failure, major depressive disorder, anxiety disorder, dementia, unspecified hallucinations, and muscle weakness. Review of Resident #8's concern form dated 10/30/25 revealed the resident filed a concern form reporting that his teeth (dentures) were missing. Further review of the concern form revealed Resident #8's dentures were found broken and lodged in the toilet. The guardian was notified on 11/04/25 and indicated they would contact the dental company for Resident #8 to be seen by the dentist. Review of Resident #8's care plan dated 11/03/25 revealed to monitor and notify the medical provider as needed of signs and symptoms of oral/dental problems such as pain, toothache abscess, debris in the mouth, lips cracked or bleeding, teeth missing or loose, or broken or eroded teeth. Further review of the care plan revealed the facility documented they would coordinate arrangements for dental care and transportation as needed/ordered for Resident #8.Review of progress notes dated from 11/05/25 to 01/07/26 revealed no documentation of dental visits for Resident #8. Further review of the progress notes also revealed no documentation of contact attempts to Resident #8's guardian regarding dental care. Interview on 01/08/26 at 11:23 A.M. with Social Service Director (SSD) #610 confirmed that no guardian contact attempts were documented in Resident #8's medical record from the dated of 11/04/25 to 01/07/26. SSD #610 stated in order for Resident #8 to receive dental care at the facility, the guardian was required to complete the dental consent form. SSD #610 stated Resident #8's guardian was last contacted on 11/12/25 and given information on the consent form, but confirmed there was no documentation of that in the medical record. SSD #610 confirmed the guardian had not been contacted between 11/12/25 and 01/07/26. SSD #610 stated they are unaware if the facility has a policy on the number of times a guardian should be contacted to resolve resident issues.

Based on observation, medical record review, resident and staff interview, and policy review, the facility failed to provide recommended eating equipment and utensils during meals as specified. This affected one (#21) of four residents reviewed for nutrition. The census was 80. Findings include:Review of the medical record for Resident #21 revealed an admission date of 10/16/25. Diagnoses included atrial fibrillation, chronic obstructive pulmonary disease, diabetes, dysphagia, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had a Brief Interview of Mental Status (BIMS) score of 12 indicating moderately impaired cognition and required set up assist with eating.Review of the care plan dated 10/29/25 revealed Resident #21 was at risk for malnutrition or alteration in nutritional status with interventions for adaptive equipment as ordered, assist with meals as ordered, monitor the resident's ability to chew/swallow, and report changes to the nurse and medical provider. Further review revealed Resident #21 was at risk for activities of daily living (ADLs) self-performance deficit with interventions to eat with supervision or touching assistance, and the resident was dependent on personal hygiene. Review of the dietician note revealed Resident #21 had a modified barium swallow study during hospital admission [DATE]) with recommendations to eat slow, alternating solids and liquids, swallow two times after each bite, take small sips, and place liquids in cups. Observation on 01/05/26 at 2:20 P.M. revealed a sign was posted by Resident #21's bed reading, feeding instructions, with bullet points for no straws, all liquids to be placed in cups, take two swallows between each bite, and alternate food and liquid. Observation and interview on 01/07/26 at 12:32 P.M. to 12:37 P.M. with Certified Nurse Aide (CNA) #609 and Resident #21 revealed food arrived to Resident #21's room and included three scoops of puree food, a cup of juice and milk (in the carton), and a container of applesauce. CNA #609 sat Resident #21 up in bed, placed a clothing protector on him, and set up his tray (opened carton of milk). CNA #609 confirmed the resident did not get his drinks in cups, was unaware of the signage in his room about supervision, and was unsure what the sign and order meant. Interview on 01/07/26 at 1:30 P.M. with Registered Nurse (RN) #514 confirmed Resident #21 had a list of feeding instructions on his wall and stated she was not aware of his needs. Interviews on 01/07/26 from 4:30 P.M. to 5:00 P.M. with the Director of Nursing (DON) and Regional Nurse #899 reported they were unsure where Resident #21's feeding recommendation came from, but confirmed it was in hospital discharge paperwork. They reported they placed a progress note in the resident's medical record indicating the interventions could be discontinued. They denied knowledge of why the recommendations was ordered as well as typed up, printed, and hung on the resident's wall in his room. Interview 01/08/26 at 8:14 A.M. with Nurse Practitioner (NP) #805 confirmed when a resident came from the hospital, the nursing staff and nurse practitioner or physician reviewed the orders for appropriateness. She stated if the order was not appropriate it should be discontinued and any active orders should be implemented. Interview on 01/08/26 at 2:45 P.M. with Dietician #950 revealed Resident #21's feeding recommendations likely came from the barium swallow evaluation after he was in the hospital for aspiration pneumonia and increased difficulty swallowing. Review of the facility policy titled, Medical Nutrition Therapy Recommendations, dated 2021, revealed medical nutrition therapy recommendations shall be implemented in a timely manner including recommendations written in provider notes, nursing notes, and nutrition progress note.

Based on medical record review, staff interview, and facility policy, the facility failed to ensure a resident's comprehensive care plan was updated to include all interventions implemented by the facility to address nutritional concerns. This affected one (#35) of four residents reviewed for nutrition. The census was 80.Findings include:Record review for Resident #35 revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, diabetes mellitus, chronic obstructive pulmonary disease, schizophrenia, and peripheral vascular disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 08. The resident was assessed to require self-care and mobility assistance.Review of the care plan dated 11/05/25 revealed Resident #35 was at risk for malnutrition/alteration in nutritional status related to her chronic progression illness. Review of Resident #35's physician orders revealed an order dated 01/07/26 for the resident to receive the house supplement 237 milliliters (mL) three times per day.During an interview with Licensed Practical Nurse (LPN) #606 on 01/12/26 at 9:15 A.M., she confirmed Resident #35's nutrition care plan did not contain the intervention for the house supplement order. Review of the facility's policy for care planning, dated 08/21, revealed the facility's care planning team was responsible for the development of a comprehensive care plan for each resident.

Based on observation, medical record review, resident and staff interview, review of facility's infection control surveillance log, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to ensure proper personal protective equipment (PPE) was available for staff providing care for a resident (#24) with COVID-19 infection. Additionally, the facility failed to ensure a resident (#25) with known exposure to a COVID-19 resident followed appropriate guidance and physician orders to prevent potential spread of the virus. This had the potential to affect all 83 residents residing in the facility. The census was 83. Findings include: 1. Review of the medical record for Resident #24 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure, type II diabetes mellitus, and pneumonia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 was cognitively intact required limited assistance with activities of daily living (ADLs). Review of a nursing progress note dated 02/04/25 revealed Resident #24 was transferred to the hospital due to shortness of breath. While in the hospital on 02/04/25 she tested positive for COVID-19. Resident #24 returned to the facility on [DATE] and was placed in isolation. The resident had a roommate who was relocated to a private room due to being exposed to Resident #24. Review of a physician order dated 02/05/25 revealed Resident #24 was ordered single room isolation, airborne, droplet, or contact with all services provided in the room through the duration of isolation every shift. 2. Review of the medical record for Resident # 25 revealed an admitted [DATE]. Diagnoses included end stage renal disease, hypertension, congestive heart failure, and cirrhosis of liver. Resident #25 was noted to share a room with Resident #24. Review of the MDS assessment dated [DATE] revealed Resident #25 was cognitively intact and required limited assistance with ADLs. Review of Resident #25's active physician orders revealed an order written on 02/05/25 for the resident to be in COVID-19 exposure isolation every shift for COVID positive for 10 days and re-evaluate on the tenth day to determine if the resident met criteria to discontinue isolation on the eleventh day. The order had an end date of 02/15/25. Review of a nursing progress note revealed Resident #25 agreed to change his room on 02/05/25 at 1:12 P.M. and on 02/06/25 at 12:06 P.M. Resident #25 was unhappy in a private room under isolation and the facility moved him back into the same room as Resident #24. Interview with the Director of Nursing (DON) on 02/11/25 at 11:00 A.M. revealed Resident #25 refused to stay in an isolated private room and demanded he move back into his old room with Resident #24. Resident #25 refused to believe he would contract COVID-19 even after being provided education. Resident #24 agreed to have Resident #25 move back into her room. Observation and interview on 02/11/25 at 12:15 P.M., revealed a bin of personal protective equipment (PPE) was located outside of Resident #24 and Resident #25's room. The bin included gloves, gowns, shoe covers, and N-95 face masks, but contained no PPE to offer eye protection. Interview with Licensed Practical Nurse (LPN) #100 during the observation confirmed the PPE bin contained no eye protection for staff entering the room. Interview and observation at 12:20 P.M. with Resident #24 revealed her roommate (Resident #25) was not currently in the room and explained he was out in the lobby. Observation of the dining room for lunch on 02/11/25 from 12:45 P.M. to 1:25 P.M. revealed Resident #10, Resident #12, Resident #14, Resident #16, Resident #20, Resident #25, Resident #45, Resident #50, and Resident #52 were all in the dining room having lunch together. Further observation revealed Resident #25 was not wearing a mask. Interview with Resident #16 on 02/11/25 at 1:30 P.M. confirmed Resident #25 went to the dining room for each meal and frequently sat in the lobby visiting with staff and residents throughout the day. Resident #16 confirmed Resident #25 does not wear a mask. Interview with LPN #100 on 02/11/25 at 1:30 P.M. confirmed Resident #25 frequently leaves his room and remains in common areas with other residents without wearing a face mask. Interview with the Director of Nursing (DON) on 02/11/25 at 2:00 P.M. confirmed the facility followed the Centers for Disease Control and Prevention (CDC) guidelines when a resident or staff member was positive for COVID-19. The DON confirmed the facility had a sign on the entrance doors of the facility notifying the public they had a COVID-19 positive case in the facility; however, they did not notify the residents and or their representatives that someone in the facility tested positive for COVID-19. The DON stated they do not require the residents to wear masks, however, all employees during outbreak must wear a surgical mask. Interview on 02/11/25 at 2:00 P.M. with Dietary Supervisor #500 stated Resident #25 went to the dining room daily and does not wear a face mask. Review of the infection control surveillance log from 11/01/24 to 02/11/25 revealed Resident #24 was the only resident who tested positive for COVID-19 during that time frame. Review of the CDC website at https://www.cdc.gov/covid/hcp/infection-control/?CDC_AAref_Val=https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html revealed infection control guidance related to SARS-CoV-2 (COVID-19) dated 06/24/24. Review of the guidance revealed healthcare personnel (HCP) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a National Institute for Occupational Safety and Health (NIOSH) approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Ideally, residents with suspected or confirmed SARS-CoV-2 infection should be placed in a single-person room and if limited single rooms are available, or if numerous residents are simultaneously identified to have known SARS-CoV-2 exposures or symptoms concerning for COVID-19, residents should remain in their current location. If cohorting, only patients with the same respiratory pathogen should be housed in the same room. Limit transport and movement of the patient outside of the room to medically essential purposes. Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Source control is recommended for individuals in healthcare settings who have suspected or confirmed SARS-CoV-2 infection or other respiratory infection (e.g., those with runny nose, cough, sneeze); or had close contact (patients and visitors) or a higher-risk exposure (healthcare professionals) with someone with SARS-CoV-2 infection, for 10 days after their exposure. Even when a facility does not require masking for source control, it should allow individuals to use a mask or respirator based on personal preference, informed by their perceived level of risk for infection based on their recent activities (e.g., attending crowded indoor gatherings with poor ventilation) and their potential for developing severe disease if they are exposed. Further review of the CDC website under the section titled, Duration of Empiric Transmission-Based Precautions for Asymptomatic Patients following Close Contact with Someone with SARS-CoV-2 Infection, revealed in general, asymptomatic patients do not require empiric use of Transmission-Based Precautions while being evaluated for SARS-CoV-2 following close contact with someone with SARS-CoV-2 infection. These patients should still wear source control and those who have not recovered from SARS-CoV-2 infection in the prior 30 days should be tested as described in the testing section. Additionally, patients placed in empiric Transmission-Based Precautions based on close contact with someone with SARS-CoV-2 infection should be maintained in Transmission-Based Precautions for the following time periods; patients can be removed from Transmission-Based Precautions after day seven (7) following the exposure (count the day of exposure as day 0) if they do not develop symptoms and all viral testing as described for asymptomatic individuals following close contact is negative. If viral testing is not performed, patients can be removed from Transmission-Based Precautions after day 10 following the exposure (count the day of exposure as day zero) if they do not develop symptoms. This deficiency represents non-compliance investigated under Complaint Number OH00162349.

Based on observations, staff interviews, and review of facility policies and procedures, the facility failed to maintain sanitary food storage and preparation conditions. This had the potential to affect 55 residents who ate food prepared from the facility. The facility census was 79. Findings include: Observation of the kitchen walk in refrigerator on 11/25/24 at 8:38 A.M. revealed that a container that appeared to contain de-stemmed grapes, a container that appeared to contain shredded lettuce and a container that contained a small diced yellow fruit were unlabeled and undated on the refrigerator shelves. Interview on 11/25/24 at 8:38 A.M. with Dietary Manager #235 confirmed that three containers of food in the walk in refrigerator were unlabeled and undated. Dietary Manager #235 was unable to verify when the food items were initially opened. Observation on 11/25/24 at 8:43 A.M. revealed that there was approximately one inch thick of ice and snow like frost build up on the bottom left freezer when the walk in freezer door was opened. There were boxes of food with ice and frost on them. The door frame was observed to have ice build up on the door frame near the seal. Interview on 11/25/24 at 8:43 A.M. with Dietary Manager #235 confirmed that there was visible ice and snow build up on food products in the walk in freezer and ice build up on the freezer door frame. Observation on 11/26/24 at 11:04 A.M. revealed that two ceiling vents were covered in a brown and black fuzz. The dirty ceiling vents were over a food preparation area. Interview on 11/26/24 at 11:04 A.M. with Dietary Manager #235 confirmed the presence of a brown and black fuzzy substance on the ceiling vents located over the food preparation area. Review of a 2023 policy titled, Food Storage, revealed that food will be stored in an area that is clean, dry and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. All containers or storage bags must be legible and accurately labeled and dated. Racks and other storage surfaces should be clean and protected from splashes, overhead pipes or other contaminations (ceiling sprinklers, sewer/waste disposal pipes, vents, etc.) All foods should be covered, labeled and routinely monitored to assure that foods will be consumed by their use by dates. \

Based on observations, record review, resident and staff interviews, and review of the facility policy, the facility failed to provide a safe environment that was free from accident hazards and failed to complete a thorough investigation into a resident's fall. This resulted in Actual Harm for one resident when on 03/04/24, Resident #04 was attempting to enter the main entrance of the facility with an uneven surface transition causing Resident #04 to fall backwards out of his wheelchair sustaining a subdural hematoma (serious condition where the blood collected between the skull and the surface of the brain), retrolisthesis (backward slippage of one vertebral body with respect to the subjacent vertebra) of cervical vertebrae and a scalp laceration requiring three sutures. Additionally, a second resident (Resident #02) was placed at risk for the potential for more than minimal harm that was not actual harm when the cognitively impaired resident was not provided with adequate supervision when he was let outside the secured facility by another resident in the middle of the night and fell behind an emergency squad truck. This affected two (#04 and #02) of three residents reviewed for falls and accidents. The facility census was 82. Finding include: 1. Review of the medical record for Resident #04 revealed an admitted [DATE]. Diagnoses included end stage renal disease with hemodialysis, atrial fibrillation, hepatic encephalopathy, cognitive communication deficit, cirrhosis of the liver, muscle weakness, congestive heart failure, and right above the knee amputation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #04 had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Resident #04 required partial/moderate assistance from staff for shower/bathing and upper body dressing, and substantial/maximal assistance from staff for lower body dressing. Resident #04 utilized a manual wheelchair, had no behaviors, no rejection of care, or wandering during the review period. Review of the plan of care dated 01/25/24 revealed Resident #04 was at risk for increased falls with or without injury, related to right above the knee amputation, dialysis, chronic congestive heart disease, cirrhosis of the liver, neuropathy, and non-compliance with care needs. Interventions included keeping the resident's call light within reach, Dycem to seat of wheelchair, commonly used items within reach, and to encourage the resident to ask for help before opening the door for another resident. Resident #04 was at risk for impaired communication, usually understood and understands others related to respiratory failure, encephalopathy, depression, hypotension, and atrial fabulation. Interventions included ensuring or providing a safe environment. Review of the fall risk evaluation assessment on 03/01/24 revealed Resident #04 was assessed to be at risk for falls. Review of the progress notes dated 03/04/24 at 7:57 P.M. revealed Resident #04 was sent to the hospital following a fall outside. Resident #04 hit the back of his head and was bleeding a lot. Staff called emergency 9-1-1 immediately and responsible parties were notified. Review of the incident report dated 03/04/24 revealed Resident #04 was on the ground and bleeding outside in front of the building. The nurse assessed Resident #04 and emergency services transported Resident #04 to the hospital. No witness statements were provided in the report. The incident report did not identify an environmental hazard where Resident #04 fell outside. There was also no statement from Resident #04 when he returned to the facility on [DATE]. The incident report did not state what was occurring at the time of the fall; however, the new intervention was to educate Resident #04 to not hold onto a powered wheelchair and allow another resident's powered wheelchair to pull him forward. Review of the hospital records for 03/04/24 to 03/07/24 revealed Resident #04 received treatment for traumatic subdural hematoma, retrolisthesis of the cervical five and six vertebrae, and a 1.5-centimeter (cm) laceration to posterior scalp requiring three staples from a fall out of a wheelchair. Resident #04 received treatment for his injuries and was discharged back to the facility on [DATE]. Interview with Resident #04 on 03/19/24 at 7:45 A.M. revealed he went outside to get some fresh air on 03/04/24 in the evening and he talked with other residents in the parking lot area like he had done in the past. At some point, he started to head back to the main entrance when another resident (Resident #50) in an electric wheelchair told him to grab a hold to the back of her wheelchair. Resident #50 proceeded to pull him up to the front entrance where the overhang was located. Once they got to the front door area, there was a transition from pavement to concrete that has a rough transition. Resident #04 explained the bump caused his wheelchair to flip backwards, hitting the back of his head on the pavement. Resident #04 stated Resident #50 who was in the electric wheelchair went in immediately and got help. The nurse held something to the back of his head, and he was transported to the hospital. Interview with Resident #50 on 03/19/24 at 8:35 A.M. revealed on 03/04/24, she attempted to assist Resident #04 from the parking lot area up to the front of the building because of all the potholes on the driveway and the sidewalk being hazardous. Resident #50 stated she had Resident #04 hold onto her electric wheelchair to assist him back to the front of the building, but once she got to the hump at the front of the building (at the covered entrance) she heard and felt Resident #04 get stuck. As she turned her wheelchair around, she saw Resident #04's wheelchair had flipped, and Resident #04 was lying on his back with blood everywhere. Resident #50 went directly into the facility, yelled for help, a nurse came, and Resident #04 went to the hospital. Resident #50 stated she has resided at the facility since July 2023 (approximately eight months) and the parking lot, the entry bump, and the sidewalk have been hazards since she moved in. Resident #50 stated she had told the previous administration and maintenance staff about it, and nothing has been repaired. Resident #50 stated many residents go out in the parking lot area, but they cannot use the sidewalk because it was falling apart and they must avoid all the bumps and potholes in the driveway/parking lot area causing it to be hazardous to navigate. Interview and observations of the main entrance, parking lot/driveway and sidewalk on 03/14/24 at 10:45 A.M. with Maintenance Director #115 revealed there were areas of hazards on the sidewalk marked with six large orange cones. Maintenance Director #115 stated some areas of repair had been completed, and some areas still needed to be repaired. The facility was working towards fixing along with the sidewalk's broken concrete but was hindered by weather. Maintenance Director #115 verified there were cracking edges/missing pieces of concrete at the sidewalk areas leading from the entrance to the parking lot. Observation of the covered front entrance revealed there were approximately two-to-three-inch differentiation in surface transitions between the concrete and pavement at the main entrance under the covered front entrance, and several areas of potholes in the driveway from the front covered entrance to the side parking lot of the facility. Maintenance Director #115 verified residents often use the parking lot throughout the day to get fresh air. Residents were observed in the side parking lot. Maintenance Director #115 verified the differentiation in surface transitions. Maintenance Director #115 stated he had assessed the parking lot/sidewalk and transitioning areas at the main entrance, and he identified they were areas of concern for fall/trip hazards. Maintenance Director #115 verified the height of the transition from pavement to concrete at the main entry was an area of hazard that could have contributed towards Resident #04's fall on 03/04/24. Interview and observation with Director of Nursing (DON) on 03/18/24 at 2:30 P.M. verified the location of Resident #04's fall on 03/04/24. The DON verified the transitional area at the main entrance, under the covered front entrance at the transition between the concrete and the pavement area was an accident hazard and could have contributed to Resident #04's fall on 03/04/24. The DON verified the facility's incident report did not include the environmental hazard which could have contributed to Resident #04's fall and the facility did not obtain witness statements for the incident report. Review of the facility policy titled Falls and Fall Risk Managing, with a reviewed date of 08/2023, revealed staff will identify interventions related to the resident's risks. The environmental factors that contribute to the risk of falls include obstacles in the footpath. 2. Closed medical record review for Resident #02 revealed an admitted [DATE]. Diagnoses included dementia, type II diabetes mellitus with neuropathy, Parkinson's disease, and seizures. Resident #02 was discharged home with his family on 03/05/24. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #02 had severe cognitive impairment and did not wander. Resident #02 required partial or moderate assistance from staff for toileting, bathing, and upper body dressing. Review of the care plan dated 02/20/24 revealed Resident #02 had impaired cognition function /dementia as evidence by impaired thought processes and history of multiple falls. Interventions included to provide supervision/assistance with decision making. Review of the elopement risk assessment dated [DATE] revealed Resident #02 was not at risk for elopement. Review of the fall risk assessment dated [DATE] revealed Resident #02 was at a fall risk. Review of Resident #02's incident report for 03/03/24 at 3:40 A.M. revealed a resident (#45) let Resident #02 out of the building (by entering the facility's door alarm code) because Resident #02 wanted to find his truck. Resident #02 had an unwitnessed fall outside in the front of the building. Resident #02 sustained no injuries. The resident who witnessed the fall (#45) would not provide a witness statement. There was no environmental hazards that contributed Resident #02's fall. The facility's conclusion after speaking with EMS was they felt Resident #02 may have tried to climb into the squad truck because Resident #02 thought it was his truck and fell . Review of Resident #02's physician order dated 03/03/24 revealed an order for Accutech (wanderguard) to his right ankle and check placement every shift. Interview on 03/14/24 at 9:00 A.M. with Maintenance Director #115 stated the facility's door alarm codes were changed routinely and on an as needed basis for safety concern of a non-staff member knowing the code. The front door alarm was turned off at 6:00 A.M. and was turned back on at 5:30 P.M. Maintenance Director #115 stated the facility did not have a policy on how often the door alarm codes were to be changed. Interview with the Director of Nursing (DON) on 03/18/24 at 10:30 A.M. revealed an investigation had been conducted regarding Resident #02's exit and subsequent fall in the A.M. on 03/03/24. At approximately 3:30 A.M. on 03/03/24, emergency services were called for another resident, and the squad was parked outside the front entrance. The emergency services team (EMS) had loaded the other resident into the squad, and were about to leave when they heard yelling. EMS got out of the squad, walked to the back of the squad, and found Resident #02 lying on the ground behind the squad with another resident (#45). EMS called the building to alert staff of Resident #02 and placed him on the bench outside of the building and left for the emergency department with the other resident. The staff rushed outside to find Resident #02 sitting on the bench with no injuries. Resident #02 was immediately placed on one-on-one supervision with staff and a wanderguard was placed. During the facility's investigation, Resident #45 verbally confessed to letting Resident #02 outside with him after putting in the door alarm code so Resident #02 could go see the truck. There was an unknown amount of time had gone by since the door codes had been changed and verified staff members were the only ones that were to have the door alarm codes. This deficiency represents non-compliance investigated under Complaint Number OH00152002 and Complaint Number OH00151683.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, resident and staff interviews, review of facilities self-reported incident (SRI), and review of hospital paperwork, the facility failed to ensure timely medication reconciliation was completed upon residents' admission resulting in a significant medication error involving the resident's diabetic medication. This resulted in actual harm when Resident #01 did not receive two doses of her diabetic medication (insulin) as ordered by the physician resulting in a high blood sugar reading of 496 milligrams (mg)/ deciliter (dL) and subsequently was re-hospitalized on hyperglycemia. This affected one (Resident #01) of three residents reviewed for medications. The facility census was 70. Findings include: Record review of Resident #01 revealed an admitted [DATE] with pertinent diagnoses of end stage renal disease, acute and chronic respiratory failure with hypoxia, type two diabetes mellitus with diabetic neuropathy, dependence on renal dialysis, encephalopathy, epilepsy, convulsions, schizophrenia, hypertensive chronic kidney disease, anemia, hypothyroidism, depression, anxiety disorder, chronic pain, diverticulosis of intestine, dependence on supplemental oxygen, dysphagia, hypertension, long term use of insulin, personal history of sudden cardiac arrest, insomnia, history of transient ischemic attack, retinal disorder, hyponatremia, and hyperlipidemia. Review of the medical record revealed Resident #01 was readmitted to the facility on [DATE] at 3:30 P.M. from a three-day hospitalization for gastroparesis and nausea and vomiting. Review of the 03/06/23 quarterly minimum data set assessment revealed Resident #01 was cognitively intact and required extensive assistance for bed mobility, transfer, walk in room, dressing, toilet use, and personal hygiene. The resident required physical help in part of bathing and used a walker and wheelchair to aid in mobility. The resident was occasionally incontinent of bowel and bladder. Review of the hospital discharge summary dated 02/23/23 at 12:14 P.M. revealed Resident #01 was discharged back to the facility on [DATE] with orders including: insulin Aspart five units under the skin before meals, insulin Lispro sliding scale insulin under the skin before meals, insulin Glargine 35 units under the skin at night, insulin glargine five units under the skin at night, insulin Glargine 32 units under the skin in the morning, Saphris (antipsychotic) 10 milligrams (mgs) place 10 mg under the tongue 2 (two) times a day for schizophrenia, Atorvastatin (drug to lower cholesterol) 40 mg take 40 mg by mouth at bedtime, Calcium (supplement) 667 mg take 1 (one) capsule (667 mg total) by mouth three times a day, Tegretol (antiseizure medication) 100 mg take 5 mL (100 mg total) by mouth three times a day for epilepsy, Coreg (antihypertensive) 25 mg take one tablet (25 mg total) by mouth two times a day, Haldol (antipsychotic) 1 mg take 1 mg by mouth two times a day for schizophrenia, Hydralazine (antihypertensive) 50 mg take 50 mg by mouth three times a day for high blood pressure, Lacosamide (antiseizure) 100 mg take 100 mg by mouth 2 (two) times a day for anxiety, and Detrol (bladder relaxant) 1 mg take one tablet 1 mg total by mouth two times a day. Review of a progress note dated 2/23/23 at 3:30 P.M. revealed Resident #01 returned to facility from Hospital at 3:30 P.M. The Resident was re-oriented to bed and call light. No current complaints of pain or discomfort. The resident consumed lunch at the hospital. Call light and water in reach. Review of a progress note dated 2/24/23 at 8:56 A.M. revealed during rounds this morning Resident #01 complained of generalized weakness and stated, I just don't feel good. The residents blood pressure was 127/70 millimeters of mercury (mm/Hg), temperature was 98.5 degrees Fahrenheit temporal, pulse 72 beats/minute, respirations 16 breaths/minute, and oxygen saturation 97 percent (%) on room air. Resident #01 blood sugar reading was 496 mg/dL. Insulin medication given per physician order. Resident #01 requested this nurse call Power of Attorney (POA). After speaking with the resident's POA, the POA requested this nurse send the patient to the hospital. Resident #01 agreed that she should be sent to hospital and emergency medical transport arrived and Resident #01 left via stretcher at 9:57 A.M. Review of a facility completed SRI revealed on 02/24/23 the medication orders were not correctly entered for Resident #01 upon readmission from the hospital on 02/23/23 due to a communication breakdown between day and night shift nurses. Admission orders were not entered although Licensed Practical Nurse (LPN) #10 (the day shift nurse) had committed to do so. LPN #13 (the night shift nurse) reports that she checked closely on this resident throughout the night and noted no change in Resident #01's normal condition. Resident is alert and oriented and will speak up with staff when she is not feeling herself. LPN #13 also reports checking frequently throughout her shift to check if new orders had been entered by LPN #10. The following morning 02/24/23 revealed about 8:30 A.M., the resident complained of not feeling well, and did not want to go out to her routine hemodialysis appointment. Assessment revealed blood glucose measured 496 mg/dL, all other vital signs were within normal limits. The physician and resident's family were notified of the resident's condition and 911 was called per family request. Review of hospital record dated 02/24/23 revealed Resident #01 was out at the hospital from 02/24/23 to 03/01/23 for observation initially for hyperglycemia but family stated there was a change in her speech and a droopy eyelid and wanted her further evaluated for a stroke. Review of the medication administration record on 03/27/23 revealed Resident #01 did not receive night medications on 02/23/23 and morning medications on 02/24/23 of insulin Aspart five units under the skin before meals, insulin Lispro sliding scale insulin under the skin before meals, insulin Glargine 35 units under the skin at night, insulin Glargine five units under the skin at night, insulin Glargine 32 units under the skin in the morning, Saphris (antipsychotic) 10 milligrams (mgs) place 10 mg under the tongue 2 (two) times a day for schizophrenia, Atorvastatin (drug to lower cholesterol) 40 mg take 40 mg by mouth at bedtime, Calcium (supplement) 667 mg take 1 (one) capsule (667 mg total) by mouth three times a day, Tegretol (antiseizure medication) 100 mg take 5 mL (100 mg total) by mouth three times a day for epilepsy, Coreg (antihypertensive) 25 mg take one tablet (25 mg total) by mouth two times a day, Haldol (antipsychotic) 1mg take 1 mg by mouth two times a day for schizophrenia, Hydralazine (antihypertensive) 50 mg take 50 mg by mouth three times a day for high blood pressure, Lacosamide (antiseizure) 100 mg take 100 mg by mouth 2 (two) times a day for anxiety, and Detrol (bladder relaxant) 1mg take one tablet 1 mg total by mouth two times a day. Review of the facility investigation on 03/27/23 revealed LPN #10 did not input Resident #01's medications in the electronic medical record and the resident missed medications and was subsequently hospitalized . Interview with the Director of Nursing on 03/27/23 at 12:05 P.M. revealed LPN #10 was supposed to input the physician orders for Resident #01 when she was admitted on [DATE] and did not. LPN #10 took the orders home with her, and Resident #01 did not get her medications including insulin on the night of 02/23/23 and the morning of 02/24/23. The deficient practice was corrected on 02/27/23, when the facility implemented the following corrective actions: On 02/24/23, Resident #01 was immediately transferred to a local hospital via emergency medical services after the Medical Director was notified. On 02/24/23, immediate education was provided for all licensed staff per the Director of Nursing (DON). On 02/24/23, a final written warning and one to one education was provided by the DON to both LPN #10 and LPN #13. On 02/24/23, the Administrator and DON spoke with family members regarding the incident. On 02/24/23 and 02/25/23, the DON audited all admission and readmission charts during the past 30 days to ensure there were no errors. On 02/24/23, the DON interviewed all residents for similar allegations, and no other problems were identified. On 02/27/23, the Administrator implemented a new protocol for the DON or designee to audit charts of all new admissions for completion/accuracy. This will include all shifts seven days per week. On 02/27/23, an initial Quality Assurance and Performance Improvement plan was completed and will continue to review weekly with the team. This deficiency represents non compliance investigated under Complaint Number OH00140744.

Based on medical record review, resident and staff interview, review of a fall investigation, review of hospital documentation, review of facility policy, and review of a MedlinePlus article, the facility failed to ensure Resident #16 received appropriate bed mobility assistance. Actual harm occurred when State tested Nurse Aide (STNA) #500 was assisting Resident #16 with changing and bed mobility by himself and rolled Resident #16 away from himself which resulted in Resident #16 falling out of bed and sustaining a finger fracture. This affected one (Resident #16) of two residents reviewed for falls. The facility census was 43. Findings include: Review of Resident #16's medical record revealed Resident #16 was admitted on [DATE] with diagnoses including chronic diastolic heart failure, muscle weakness, Type II diabetes mellitus, hypertension, contracture of right hand, left hand and unspecified joint, and gout. Review of Resident #16's quarterly Minimum Data Set (MDS) assessment, dated 04/06/22, revealed Resident #16 had intact cognition and required extensive assistance from two persons for bed mobility. Review of Resident #16's plan of care, dated 02/23/22, revealed Resident #16 had mobility limitations and had poor endurance caused by shortness of breath which limited her ability to propel herself in her wheelchair. The plan of care further revealed Resident #16 required extensive assist of one to two staff depending on cooperation with bed mobility, refused to bear weight, and required Hoyer transfers when cooperative. Interventions included a bariatric bed, bilateral enabler bars as ordered, monitor for safe and appropriate use of mobility rails, and provide hands on assistance with bed mobility, and when exhibiting weakness staff were to assist with turning side to side. Review of the activity of daily living documentation for bed mobility in January 2022 revealed Resident #16 was documented as receiving support for bed mobility on 36 occasions, and required the assistance of two persons on 27 of the 36 occasions. Review of Resident #16's progress note, dated 01/22/22, revealed at 4:45 A.M. the Director of Nursing (DON) was called to Resident #16's room by the nurse aide (STNA #500). The DON entered the room and found Resident #16 lying face down beside the bed. The DON assessed Resident #16, and noted that she was unable to roll her to her back due to 10 out of 10 pain in her right arm. Resident #16's arm was in an upward position beside her head. Emergency Medical Services were called and arrived at 4:50 A.M., and Resident #16 was transported to the emergency room (ER) at 5:10 A.M. Review of Resident #16's progress note, dated 01/23/22, revealed Resident #16 came back from the ER around midnight with a diagnosis of a right finger fracture. No new orders were received, and staff were to continue to monitor Resident #16. Review of the fall investigation, dated 01/22/22, revealed the DON was called to Resident #16's room by the aide (STNA #500). They entered the room and found Resident #16 lying face down beside the bed. Resident #16 was assessed and was unable to roll to her back. Resident #16 reported 10 out of 10 pain in her right arm. Resident #16's right arm was noted to be in an upward position beside her head. The DON called for emergency services to have Resident #16 sent to the ER for evaluation. The investigation revealed Resident #16 rolled out of bed when being changed. Resident #16 was alert and oriented, and had a predisposing physiological factor of weakness. Review of the hospital After Visit Summary, dated 01/22/22, revealed Resident #16 visited for a fall and was diagnosed with a fractured finger. Interview on 04/26/22 at 11:26 A.M. and 12:14 P.M. with Resident #16 revealed she had a fall in January 2022 when an aide was assisting her. Resident #16 reported she was supposed to have two aides to assist her with bed mobility and changing; however, at times only one aide was available to assist her. Resident #16 reported when she was high up in the bed, she could assist with bed mobility. However, on the day she fell she had told the aide she was too low in bed to assist him and he continued to provide care anyway. Resident #16 reported the aide had been on the left side of the bed and rolled her away from him. Resident #16 stated she then rolled off the right side of the bed, hit the wall, and landed between the bed and the wall. Interview on 04/27/22 at 11:16 A.M. with State tested Nursing Aide (STNA) #71 revealed Resident #16 required the assistance of two staff members for bed mobility. Interview on 04/27/22 at 4:52 P.M. and on 05/02/22 at 11:54 A.M. with the DON revealed Resident #16 had been rolled out of bed when STNA #500 was changing her. The DON reported Resident #16 provided varying levels of assistance with bed mobility and at times Resident #16 was more helpful than others. The DON said STNA #500 had a good working relationship with Resident #16 and would have known when she needed additional assistance. The DON reported on the day of the fall, Resident #16 had been assisting STNA #500 with rolling when the momentum of her body weight took her over the edge of the bed. The DON reported she found Resident #16 between the wall and the bed with STNA #500 standing on the opposite side of the bed. The DON stated STNA #500 had turned Resident #16 away from him. Interview on 05/02/22 at 4:28 P.M. with STNA #204 revealed when assisting a resident with bed mobility staff should turn the resident toward themselves. Review of the facility policy titled Falls Policy and Procedures, last revised 05/21/18, revealed residents with one or more documented falls will be assessed by the nurse, have applicable interventions implemented in accordance with the assessment, and appropriate interventions will be documented on the plan of care in a timely manner. Review of MedlinePlus article titled Turning Patients, found at https://medlineplus.gov/ency/patientinstructions/ 6.htm, dated 10/09/19, revealed when turning a patient, the bed should be made flat, one hand placed on the residents shoulder and one on their hip, standing with one foot ahead of the other, shift weight to the front foot as you gently pull the residents shoulder towards you, then shift your weight to your back foot as you gently pull the person's hip towards you. This deficiency substantiates complaint number OH 890.

Based on observations, open and closed medical record review, staff interview, and policy review, the facility failed to ensure one resident (Resident #66) did not develop an avoidable pressure ulcer, failed to provide the necessary treatment to promote healing and prevent a decline of pressure ulcer for one resident (Resident #50) and failed to implement treatment and preventative measure for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected three of three residents reviewed for pressure ulcers (Residents #50, #65, and #66). The facility census was 60. Findings include: 1. Review of the closed medical record for Resident #66 revealed an admitted [DATE]. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A pressure ulcer risk assessment completed 10/19/21 indicated the resident was at low risk for the development of a pressure ulcer. A Minimum Data Set (MDS) 3.0 assessment completed 10/25/21 indicated the resident had a brief interview for mental status score of two (indicating severe cognitive impairment), no pressure ulcers on admission or current, and required extensive assistance from staff with bed mobility, transfers, and walking. There was no evidence any weekly skin assessments were implemented for Resident #66 and no evidence a weekly skin assessment was completed on 10/26/21 (seven days after admission). There was no evidence any interventions to prevent the development of a pressure ulcer were implemented on admission. Although the resident was dependent upon staff for bed mobility, there was no evidence the resident was being turned/repositioned to prevent the development of a pressure ulcer. On 10/29/21 at 9:53 A.M. nurses notes stated Resident #66 was noted to have a pressure wound to the coccyx measuring 6.1 x 5.6 x 1 in size (not indicated if centimeters, inches, etc and length, width, depth not specified with measurements). There was also no staging of the pressure ulcer. There was no evidence the physician was notified. The nurse documented she cleansed the area with normal saline, applied a cream and dressing to the coccyx. There was no evidence a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/02/21 a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no further documentation of the pressure ulcer until 11/03/21 when the resident was seen by the wound physician. On 11/03/21 the wound physician documented Resident #66 had a 6.4 centimeter by 7.5 centimeter pressure ulcer on the coccyx that was unstagable due to obscured full-thickness skin and tissue loss with 76-100% eschar (Eschar is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound). On 11/03/21 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/04/21 a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care revealed it was not developed until 11/03/21 (five days after developing a pressure ulcer) and stated Resident #66 had a pressure ulcer and potential for pressure ulcer development related to generalized weakness, decreased strength and endurance, decreased activity tolerance, and impaired mobility. The care plan interventions on 11/03/21 included administer treatments as ordered, air mattress, educate family as to causes of skin breakdown including transfer/positioning requirements; importance of frequent positioning, follow protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the treatment administration records for October and November 2021 revealed no evidence a treatment was implemented for the coccyx pressure ulcer until 11/04/21. Resident #66 was transferred to another facility per the family on 11/05/21. Interview with Director of Clinical Services #71 on 12/28/21 at 2:40 P.M. confirmed Resident #66 developed a pressure ulcer in the facility. He confirmed weekly skin assessments were not implemented prior to the development of the pressure ulcer and should have been. He confirmed a preventative pressure ulcer plan was not implemented prior to the development of the pressure ulcer. He confirmed a plan of care for pressure ulcers was not implemented until 11/03/21 (five days after developing a pressure ulcer). He confirmed there was no evidence a physician ordered treatment was provided for the pressure ulcer until 11/04/21 (six days after development). He stated a treatment should have been implemented on 10/29/21, when the pressure ulcer was first noted. He confirmed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated he did not know why the resident developed a pressure ulcer. Without evidence of preventative interventions implemented, Resident #66 developed an avoidable, unstagable pressure ulcer on the coccyx that was not treated for [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Review of the medical record for Resident #50 revealed an admitted [DATE]. The resident was assessed as being at moderate risk for development of pressure ulcers on 11/13/21. The resident was admitted with a stage two pressure ulcer on the sacrum measuring 0.5 centimeters (cm) long by 0.5 cm wide by 0.1 cm deep. (A stage two pressure ulcer is partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible). The resident also had a stage three pressure ulcer on the ischial tuberosity measuring 1 cm long by 2.5 cm wide by 2.5 cm deep (bones at the bottom of each side of the buttocks). Left or right ischial tuberosity was not indicated. (A stage three pressure ulcer is full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed). These measurements were documented on a skin grid by the Director of Nursing on 11/14/21. A MDS assessment completed 11/19/21 indicated the resident had severe cognitive impairment and was totally dependent upon two staff for bed mobility and transfers. The resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Treatments were started on 11/14/21 to cleanse ischial tuberosity/ischium with normal saline, pat dry, apply hydrogel to wound bed and cover with adhesive foam dressing daily and clean sacral wound with normal saline, pat dry, apply thick layer of [MEDICATION(S)] cream every shift (days and nights). Review of the treatment administration records for November and December 2021 revealed 9 documented 14 times by the same nurse for the treatment to the ischial tuberosity. The treatment administration record indicated a 9 was other and to see nurses notes. However, there was nothing documented in the nurses notes. The treatment to the coccyx had a 9 documented 11 times by the same nurse in November and December 2021. There was nothing documented in the nurses notes. Interview with the Director of Nursing on 12/29/21 at 9:40 A.M. revealed she had spoken to the nurse who documented the 9s and stated the nurse told her it meant she was too busy to do the treatment and it was not done. There was no evidence of any further measurements of the areas until 11/24/21 (10 days later). On 11/24/21 a wound log provided to the surveyor (not part of the medical record) indicated Resident #50 had a stage two pressure ulcer on the sacrum measuring 0.4 cm long by 0.5 cm wide by 0.1 cm deep and a stage three pressure ulcer on the ischial tuberosity (no side indicated) measuring 1 cm long by 2.3 cm wide by 2.5 cm deep. There were no skin measurements documented in the medical record between 11/14/21 and 12/06/21. On 12/06/21 a weekly wound assessment form completed by the Director of Nursing indicated a stage two pressure ulcer on the sacrum measuring 0.4 cm long by 0.4 cm wide by 0.1 cm deep and a stage three pressure ulcer on the ischial tuberosity measuring 1 cm long by 2.2 cm wide by 2.4 cm deep. However, a wound log (not part of the medical record) on 12/08/21 indicated the pressure ulcer on the coccyx (sacrum) had declined to a stage three and measured 3 cm long by 3 cm wide by 0.7 cm deep. The stage three on the ischial tuberosity was 1 cm long by 2.3 cm wide by 0.5 cm deep. On 12/11/21 the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no further measurements until the resident was seen by the wound physician on 12/23/21 (15 days later). The wound physician identified a pressure ulcer to the right buttock measuring 2.9 cm long by 2.2 cm wide, with no depth or staging noted. Review of the plan of care revealed it was not initiated until 12/03/21. It stated the resident had pressure ulcer related to immobility, severe cognitive impairment, and bilateral upper and lower extremity impairments. (It did not indicate where the pressure ulcer was located). Interventions included administer treatments as ordered and monitor for effectiveness, follow facility policy for preventions/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations on 12/29/21 at 7:35 A.M., 9:42 A.M., 10:35 A.M., and 11:35 A.M. revealed the resident to be in bed on his back. The resident was observed with a [CONDITION(S)] and a gastrostomy tube. The resident was also observed to have a regular pressure relieving mattress on the bed. (No air mattress). Interview with the nursing assistant assigned to the resident, State tested Nursing Assistant (STNA) #73 on 12/29/21 at 11:40 A.M. revealed she was not aware the resident had any pressure ulcers and did not know the last time the resident had been turned/repositioned. She confirmed he was in bed on his back without any pillows for positioning. Interview with Wound Physician #74 on 12/29/21 at 11:42 A.M. revealed she had only seen the resident once, on 12/23/21. She stated the resident should be turned every two hours and should have an air mattress on the bed as she had recommended that previously. Observations of Resident #50's pressure ulcer on 12/29/21 at 11:45 A.M. with Wound Physician #74 revealed she confirmed he was laying in bed on his back and had his heels resting on the mattress. She stated he should be wearing heel protectors or have his heels floated. Observations and measurements by Wound Physician #74 revealed a stage three pressure ulcer on the sacrum measuring 3.5 cm long by 2.8 cm wide by 0.8 cm deep. She confirmed she did not document a depth prior (12/23/21) but confirmed it was the same depth. She further confirmed there was no pressure ulcer on the ischial tuberosity. Interview with Director of Clinical Services #71 on 12/29/21 at 12:50 P.M. confirmed the pressure ulcer measurements for Resident #50 were not completed weekly and the logs were not part of the medical record. He confirmed the treatment to the ischial tuberosity was still being documented, even though there were no pressure ulcers noted in that area. He confirmed the pressure ulcer on the coccyx/sacrum declined from a stage two to a stage three. 3. Review of the medical record for Resident #65 revealed an admitted [DATE] (the resident was now currently in the hospital and had been transferred on 12/25/21). The resident was admitted [DATE] with a stage four (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location) pressure ulcer on the sacrum measuring 8 cm long by 7 cm wide by 1 cm deep. Review of treatment administration records for November 2021 revealed no evidence a treatment was started for the sacrum pressure ulcer until 11/20/21 (six days after admission). A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident then went out to the hospital on 11/24/21 for elevated potassium levels. While in the hospital, it was noted that debridement of the wound was done on 12/07/21. The resident returned to the facility 12/17/21. On 12/17/21 the coccyx was noted as a stage four pressure ulcer measuring 9 cm long by 10 cm wide by 1 cm deep with undermining. On 12/22/21 the resident was seen by the wound physician and noted with a stage four pressure ulcer of the coccyx measuring 10 cm long by 8 cm wide by 2.7 cm deep with undermining. Review of the plan of care initiated 11/22/21 revealed a pressure ulcer on the sacrum. The interventions included administer treatments as ordered. Review of a nurses note dated 12/25/21 at 2:23 P.M. revealed at approximately 10:20 A.M. the resident was transferred to the hospital. The resident's niece arrived and was yelling at staff. The niece was yelling that the resident was not supposed to be lying on her back due to her ulcer. The nurse assisted to turn the resident onto her side and during that process, the niece showed the nurse the ulcer over her coccyx. The nurse documented she observed the dressing with no initials but a date of 12/22/21 (3 days prior). Review of the treatment administration record for December 2021 revealed the treatment to the coccyx was to be done twice daily. The treatment was documented as completed on 12/22/21 for the AM shift. A 9 was documented for the PM shift on 12/22/21 and 12/24/21. The treatment record indicated a 9 meant other and to see nurses notes. There was nothing documented in the nurses notes. The treatment record was blank indicating the AM treatment on 12/23/21 and 12/24/21 was not completed. Interview with the Director of Nursing on 12/29/21 at 9:40 A.M. revealed she had spoken to the nurse who documented the 9s and stated the nurse told her it meant she was too busy to do the treatment and it was not done. Interview with the nurse who wrote the nurses note on 12/25/21 at 2:23 P.M. (LPN #75) on 12/28/21 at 4:13 P.M. revealed she was an agency nurse and 12/25/21 was her first day to work at the facility. She stated she had been there 2-3 hours when Resident #65's niece came in and was upset over the resident laying on her back and wanted her out of the facility. She confirmed the dressing she observed on 12/25/21 was dated 12/22/21. She stated the niece had the resident transferred to the hospital. Interview with the Director of Clinical Services #71 on 12/28/21 at 4:40 P.M. confirmed Resident #65's treatment to coccyx was not started until 11/20/21 and should have been started on admission. He further confirmed the treatment sheet for December 2021 did not indicate the treatment was completed as ordered. Review of the facility undated policy titled Pressure Injury Prevention and Management Policy revealed the purpose of the policy: To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, the facility would implement evidence-based interventions for all residents assessed at risk or who have a pressure injury present. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. Assessments of pressure injuries will be performed by a licensed nurse and documented in the medical record. The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS. This deficiency substantiates Complaint Number OH 575 and OH 552.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on review of a closed medical record, review of hospital documentation, review of a Police Communications Event Report, review of the Fire Department patient contact note, observations, interviews with staff, the police dispatcher and fireman, review of the facility investigation, review of the local weather report and review of the facility policy addressing Elopement, the facility failed to ensure staff provided adequate supervision to prevent a cognitively impaired resident from leaving the facility unsupervised. This resulted in Immediate Jeopardy when one resident (#200) was placed at risk for serious harm and injury when she eloped from the facility without staff knowledge, was missing for approximately 15 minutes and was found wandering in a parking lot, near a pond, across the street approximately 0.3 miles from the facility by a police officer. This affected one (#200) of four residents reviewed for risk of elopement. The facility identified nine current residents at risk for elopement. The facility census was 65. On 01/25/17 at 3:21 P.M., the Administrator, Director of Nursing (DON), Regional Director of Clinical Operations #88 and Director of Quality Assurance Corporate Regional Nurse #89 were notified Immediate Jeopardy began on 12/07/16 at 9:00 P.M. when Resident #200 exited the building activating the door alarm, which required a key to deactivate the alarm, and Registered Nurse (RN) #87 turned off the door alarm without initiating a resident search and/or accounting for all residents currently residing in the facility. The resident was found wandering in a parking lot, near a pond, across the street approximately 0.3 miles from the facility by a police officer. The resident was only wearing pajamas and socks and she did not have any shoes on. The resident was shivering and blankets were placed on her to warm her due to the cold temperatures that evening. According to the history report on Weather Underground, the local weather forecast, the outside temperature in the area on 12/07/16 at 9:00 P.M. was 33.8 degrees F. The Immediate Jeopardy was removed and the deficient practice was corrected on 12/08/16 when the facility implemented the following corrective actions: · On 12/07/16 at 9:12 P.M., Former Resident #200 was found by the local police approximately 0.3 miles from the facility and was transported to the hospital for evaluation and treatment by emergency medical personnel. · On 12/07/16 at 9:50 P.M., the Administrator arrived at the facility and at 10:00 P.M. the DON and Maintenance Supervisor #26 arrived at the facility. An investigation into the elopement commenced at this time. · On 12/07/16 at 10:00 P.M., the Administrator, DON and Director of Quality Assurance Corporate Regional Nurse #89 implemented all staff in-service education on the elopement and wandering policy. The emphasis was on door alarm response protocols and immediate notification. The in-service education was completed on 12/12/16 at 11:30 P.M. · On 12/07/16 at 10:15 P.M., Maintenance Supervisor #26 checked all doors to ensure the alarms were audible and functioning correctly. · On 12/07/16 at 10:35 P.M., RN #87 was suspended pending the facility's investigation into the elopement. · On 12/07/16 at 11:00 P.M., the DON changed the code to the lock box in the nurses' medication room, validated all door alarm shut-off keys were in the possession of the Administrator, DON and/or Maintenance Supervisor #26. The DON also posted signs on all the exit doors informing staff the Administrator and/or the DON must be notified in order to shut the alarm off. · On 12/07/16, the Administrator and DON initiated audits of staff education by randomly quizzing staff on all shifts. The audits were completed on 12/08/16 at 4:00 P.M. and covered all three shifts. · On 12/08/16 from 7:45 A.M. until 10:00 A.M., the DON and Corporate Staff Nurse #90 re-evaluated all facility residents for elopement risk. At the time of the evaluations, 13 residents were identified as being at risk for elopement. Review of care plans, physician's orders, medication/treatment administration records and the elopement book records were reviewed for all 13 residents identified as an elopement risk. Wander Guard bracelet checks for placement and function were audited to assure completion every shift. In addition, the records of all new admissions are to be audited within 24 hours of admission to assure the elopement risk assessment was completed and care planned accordingly. · On 12/08/16 at 9:00 A.M., a Quality Assurance (QA) meeting was held to review the action plan and audit plan. During the QA meeting, the Director of Quality Assurance Corporate Regional Nurse #89 reviewed the staffing schedules to assure adequate staff was provided on 12/07/16 at the time of the elopement and to account for future staffing needs. Follow up QA meetings were scheduled for 12/12/16 and 12/14/16. · On 12/08/16 at 9:00 A.M., Corporate Director of Maintenance #92 conducted an environmental audit and checked the functioning of all door alarms and elopement prevention devices (door sensors). Corporate Director of Maintenance #92 audited the previous monthly door sensors and alarm checks to ensure compliance with the manufacturer's recommendations. · On 12/08/16 at 12:56 P.M., the DON initiated Random Door Alarm/Elopement Drills to evaluate staff response and effectiveness of the education. The drills will continue on all shifts on a weekly basis until the QA committee decides to change how often the drills are completed. · On 12/12/16 at 8:00 A.M., Regional Director of Clinical Operations #88, Director of Quality Assurance Corporate Regional Nurse #89, the DON and Regulatory Compliance Consultant #93 met to review the elopement procedures and the internal Quality Assurance and Performance Improvement (QAPI) plan to assure comprehensive compliance. The QAPI plan was for elopement drills to be held weekly for 12 months to promote elopement education, awareness and test staff knowledge and response. The QAPI committee will continue to meet monthly to evaluate ongoing performance of elopement prevention and any other unusual events. The meeting concluded at 5:00 P.M. · Interviews on 01/24/17 between 8:00 A.M. and 10:00 A.M. with Dietitian #86 and Licensed Practical Nurses (LPN's) #39 and #35 revealed they were knowledgeable about the procedure to follow if a door alarm sounded. · Interviews on 01/26/17 between 8:00 A.M. and 8:30 A.M. with RN #75 and State tested Nursing Assistants (STNAs) #49, #55 and #56 revealed they were knowledgeable about the procedure to follow if a door alarm sounded. Findings include: Closed medical record review revealed Resident #200 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had short term memory problems, difficulty in focusing attention, disorganized thinking with episodes of delusions and wandering requiring supervision with ambulation. Review of the elopement risk evaluation dated 12/02/16 revealed Resident #200 was not aware of her surroundings, could not be easily redirected when wandering/exit seeking and required a Wander Guard device to alarm when the resident approached the exit doors with wander guard sensors. Review of the care plan dated 12/02/16 revealed Resident #200 had a behavioral deficit of wandering. Interventions included to provide a safe environment, eliminate or decrease exposure to a stressor that may be causing the behavior, initiate a Wander Guard device, and recommended a psychiatric consult. On 12/02/16, a Wander Guard device was placed on Resident #200's ankle. Review of a daily skilled charting notes dated 12/01/16 (not timed) revealed Resident #200 was walking the halls naked, was exit seeking and was setting off the door alarms. On 12/02/16 (not timed), RN #77 documented Resident #200 was delusional and exit seeking. Review of the Police Communications Event Report dated 12/07/16 at 9:21 P.M. revealed Police Officer #145 responded to a suspicious person at a business across the street from the facility. At 9:14 P.M., the fire department responded to the business across the street from the facility, approximately 0.3 miles away from the facility. At 9:24 P.M. the location was changed to the facility address and at 9:43 P.M. the event was cleared. Review of the Fire Department patient contact notes dated 12/07/16 revealed a narrative documenting Resident #200 was found wandering around in a parking lot wearing pajamas and no shoes. The resident indicated she walked away from the Convalarium of Dublin. Fireman #150 documented the outside temperature was 35 degrees Fahrenheit (F) and the length of exposure was unknown. Resident #200 indicated she left because she was scared and needed help. The facility staff were unaware she was missing. A police officer was on site and they were going to notify the facility. The resident's skin was pale, cool, and dry. Her capillary refill was less than three seconds. Her lungs were clear, and she complained of abdominal pain. Her vital signs were blood pressure 170/100, heart rate 130 beats minute, respirations 20 breaths a minute, oxygen blood saturation 97% on room air. Blankets were applied and patient warming was initiated. Review of Resident #200's hospital admission history and physical dated 12/07/16 at 9:36 P.M. revealed the resident had a history of [REDACTED]. The resident's admitting [DIAGNOSES REDACTED]. The resident's triage assessment notes revealed the resident walked away from the facility related to hallucinations and was found walking in the streets by the police. The resident was alert and oriented to person, place, time, and situation. The resident reported other residents were arguing outside her room at the facility and she was a little fearful, no staff members were around so she just walked out of the building. The resident denied any obvious injuries or complaints at that time. Resident #200's family stated she was acting her normal self except she was sundowning (late day confusion). The resident was alert, knew who she was, denied complaints but had a heart rate of 130 beats per minute without any known fever or symptoms. A Computed Tomography (CT) was done of her head and spine and was negative for an acute process. Review of Resident # 200's hospital discharge plan dated 12/08/16 at 5:08 P.M. revealed the resident was to be discharged home with family with home health care services, anticipated discharge date of [DATE]. Review of the facility's investigation revealed on 12/07/16, Former Resident #201 (whose room was next to Resident #200's room) and her nephew heard an alarm, later identified as a door alarm; go off at approximately 9:00 P.M. At 9:12 P.M., the police located Resident #200 at Perimeter Drive (across the street) in a parking lot, approximately 900 feet from the nursing home. At 9:37 P.M, RN #87 called the DON and notified her Resident #200 was out of the facility. The DON notified the Administrator at 9:39 P.M. The Administrator arrived at the facility at 9:50 P.M. and a comprehensive investigation commenced, at the direction of the Administrator and Regional Director of Clinical Operations #88. The investigation included interviews with all witnesses present. Following the investigation it was determined RN #87 reset the back hall alarm without sufficiently checking for a resident elopement. Observation on 01/24/17 at 11:00 A.M. with the Administrator revealed an exit door was approximately 30 feet from Resident #200's room. The exit door did not have a Wander Guard sensor. There was a red octagon shaped device in place and if the door was opened it would alarm. The Administrator revealed prior to 12/07/16 the floor nurse had the key to unlock a box located at the nurse's station to obtain the key to deactivate the alarm. The Administrator indicated a new procedure was in place which directed the floor nurse to notify the Administrator and/or the DON to obtain a code to access the key to deactivate the alarm. A resident head count must be completed in order for the Administrator and/or the DON to give the code to the box where the key to deactivate the alarm is secured. After the elopement procedures are followed the Administrator or DON provides the Nurse with the code to obtain the key to deactivate the alarm. The code to the box (where the key is) will be changed every time the key is removed, to ensure no one can access the key without following the elopement procedures. During a telephone interview with Resident #200 on 01/25/17 at 9:56 A.M., she reported on the evening of 12/07/17, she was upset and fearful of two large men who were fighting outside her door. She indicated she was afraid if she fell asleep the men would come into her room and suffocate her. Interviews with other residents and staff members revealed no evidence of residents fighting. Resident #200 reported she walked out the door, wearing pajamas with no shoes or socks. She heard the alarm sound and walked slowly away from the building as she believed staff would come after her. When no one came after her, she proceeded to walk through the corn field and across the road. She reported she fell twice and hit her head. She reported walking near a pond and was tempted to get in the pond, but changed her mind. She noticed flashing lights coming from a police car and she started waving her arms. She reported she was transported to the hospital and was admitted for Arnold-Chiaris and hypothermia. Review of the hospital reports did not reveal the resident was diagnosed with [REDACTED]. During a telephone interview with Police Dispatcher (PD) #157 on 01/25/17 at 10:25 A.M. revealed the officer who responded on 01/07/17 worked the second shift and a message would be left for the responding officer. PD #157 reported there was no official police report submitted as no crime was committed. PD #157 indicated the Communications Event report indicated the officer found Resident #200 walking in the parking lot of a business across the street from the facility. This was considered a reportable incident, but since no law was broken, no report was written. The responding officer did not return the call. During a telephone interview with Firefighter #150 on 01/25/17 at 11:56 A.M. he stated he assessed Resident #200 the evening of 12/07/16. He reported Resident #200 was alert and oriented to her name and knew she had walked out of the facility. He reported she was only wearing pajamas and socks and she did not have any shoes on. Firefighter #150 reported the resident's blood sugar and blood pressure were okay. He reported she had no visible injuries. He stated he did not assess her body temperature, but she was shivering and he placed blankets on her to warm her as it was cold that evening. Resident #200 was transported to the hospital, which was less than a mile away. He spoke to the resident's daughter and obtained her diagnosis. He reported the daughter was upset that her mother could walk away from the facility without staff knowledge. Later that evening, he spoke with the nurse in the emergency room (ER) and was informed the resident was sleeping and stable. During a telephone interview with RN #87 on 01/25/17 at 12:33 P.M. she stated on the evening of 12/07/16 she observed Resident #200 standing by the medication cart and the resident was anxious but not disoriented. RN #87 reported hearing the door alarm sound at approximately 8:30 P.M. She stated she went to the door and looked through the glass on the side of the door. She did not go outside and look around the perimeter of the building. She went to the nurse's station to obtain the key to deactivate the door alarm. RN #87 reported she deactivated the door alarm without following the elopement procedures. She was not aware Resident #200 was missing until notified by the police who found the resident. She stated she had received training on the appropriate elopement procedures, but she did not follow them. During a telephone interview with State tested Nursing Assistant (STNA) #15 on 01/25/17 at 2:52 P.M. she stated the night of 12/07/16, Resident #200 was exit-seeking, per her normal routine. She reported the resident was very upset and worried about the children. STNA #15 reported there were no children in the facility that evening. She stated she tried to keep the resident near her while she was working her assignment. She reported she was not assigned to Resident #200 but she had a good rapport with her as they talked about girl things. STNA #15 reported she was in another resident ' s room, on another hall way, providing care and she did not hear the alarm. She was not aware Resident #200 was missing until she saw the police in the hall talking to the nurse. During a telephone interview on 01/25/17 at 4:53 P.M. with Former Resident #201, who resided in the room next to Resident #200, revealed on the evening of 12/07/16, Resident #200 came to her room concerned about people fighting outside her room. Resident #201 stated Resident #200 had her cell phone and charger in her hand. Resident #201 and her nephew, who was visiting, walked with Resident #200 to the nurse's station. She reported a staff member was seated at the desk, but she could not remember the name of the staff member. She stated the staff member appeared to be busy. Resident #201 indicated to Resident #200 both of them should go back to their rooms and if there was an issue, the staff would come. Resident #201 reported the staff member glanced up at her, smiled and winked. Resident #201 and her nephew walked Resident #200 back to her room. Resident #200 had the door barricaded and there was just enough room for Resident #200 to squeeze into her room. Resident #201 reported her nephew left between 8:45 P.M. and 9:00 P.M. She further stated he visited regularly and left around the same time every evening. Soon after her nephew left, she heard the alarm go off. She assumed it was the fire alarm and figured if anything was wrong the staff would come to her room. When her nephew left, she went to bed and that is when she heard the alarm. She stated the next day several staff were near the door and setting the alarm off. She reported Resident #200 was confused and prior to 12/07/16, Resident #200 would come to Resident #201's room looking for the children. On 01/25/17 at approximately 5:00 P.M. an observation was conducted of the area where Resident #200 was found. The area was across the street from the facility approximately 0.3 miles away. There was a two lane road in front of the facility and the designated speed limit was 35 miles per hour. The parking lot where Resident #200 was found was surrounded by office buildings and a small pond with no barriers around the pond. During a telephone interview on 01/26/17 at 8:35 A.M. with RN #81 (the nurse assigned to Resident #200 on the evening she eloped) she stated she gave Resident #200 her medications between 7:00 P.M. and 8:00 P.M. on 12/07/16. After receiving her medications, Resident #200 came to RN #81 and said something was burning in there as she pointed to the chart room. RN #81 reported she checked the chart room and nothing was burning. Once her medication pass was completed, she went on break around 9:00 P.M. While on her break, she heard an alarm sound but it stopped shortly after. RN #81 reported she later found out RN #87 had silenced the alarm. RN #81 reported she was new to the facility and it was only her second day of work. She stated she received a phone call from Resident #200 ' s son and he was questioning how his mother could be outside for 20 minutes and no one knew she was missing. Soon after the call, the police came and informed the staff that Resident #200 was found outside and she was transferred to the hospital. Review of the medical records for Residents #13, #35 and #53, who were identified as elopement risks, revealed all had updated elopement risks completed. Care plans were in place for elopement risk and the residents' pictures and information were included in the elopement book. Review of the facility's policy titled Elopement Policy and Wandering Residents Policy - Safety System, dated August 2016, revealed an elopement risk evaluation will be completed on admission, quarterly, significant change, annually and after an elopement attempt, an unauthorized leave or an elopement. Employees are to respond to all door alarms immediately to prevent a resident from wandering off the unit or out of the health care center. Review of the facility's amendment to their Elopement Policy, dated 12/07/16, revealed the only employees who have access to the key and to the code to the safe with the key, that will disable the door alarm, are the DON and the Administrator. Once the elopement procedure has been initiated, floor staff must call the Administrator or DON to help with the process. Once all residents are accounted for then the DON or the Administrator, either in person or on the phone, will then provide the code to get the key to disable the alarm. If the DON or the Administrator is present they will deactivate the door alarm personally. If a family member, vendor, volunteer, or employee sounds the alarm by accident, the floor staff are to stand by the sounding alarm until the DON or Administrator is contacted and reassured all residents are accounted for, only then can the alarm be deactivated. In the event the DON or Administrator gives the code to the nurse to get the key from the safe, the code will be changed no later than the next day. The new code will only be known by the DON or Administrator. This deficiency substantiates Complaint Number OH 115.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on a closed medical record review, staff interviews and facility policy review, the facility failed to ensure one Resident (#72) was free of significant medication errors when the resident failed to receive ordered medications (insulin and intravenous (IV) antibiotic) multiple times over a three day period. This resulted in Immediate Jeopardy when Resident #72 was sent to the hospital and admitted with a [DIAGNOSES REDACTED]. This affected one of five resident records reviewed for significant medication errors. The facility census was 69. On 12/22/15 at 11:00 A.M., the Administrator and Director of Nursing (DON) were notified that Immediate Jeopardy began on 10/24/15 at 11:30 A.M. when Resident #72's blood sugar (BS) reading was 505 milligrams per deciliter (mg/dl.) and the facility failed to administer ordered sliding scale (SS) insulin and notify the physician of the high blood sugar. The facility continued to fail to monitor Resident #72's BS levels, failed to administer ordered insulin and IV antibiotics on 10/25/15, 10/26/15 and 10/27/15. The facility failed to monitor the resident for symptoms of Diabetic Ketoacidosis throughout the Resident's three day stay. On 10/27/15, Resident #72's BS was checked at 1:30 P.M. and had a reading of HI (too high to register a number). The results were called to Resident #72's Certified Nurse Practitioner (CNP) and an order was received to transport Resident #72 to the emergency room for an evaluation. Resident #72 was transferred to the hospital on [DATE] at 2:10 P.M., and admitted with the [DIAGNOSES REDACTED]. Immediate Jeopardy was removed on 10/27/15 at 2:10 P.M., when Resident #72 was admitted to the hospital and the facility audited all current residents in the facility with insulin orders and IV access to ensure accurate transcription and delivery on the Medication Administration Record (MAR). Review of the facility's audit tools including IV access, initialing of MAR's, and transcription of new admission orders [REDACTED] · On 10/27/15 at 2:10 P.M., Resident #72 was admitted to the hospital. · On 10/27/15, the facility audited current residents with insulin orders to ensure the following: orders were transcribed correctly on the MAR, insulin was charted as given, and the insulin order matched flex pens. · On 10/27/15, the facility audited current residents with IV access for the following: medications transcribed correctly, IV access checked for presence and if patent. · On 10/27/15, the DON educated the current nurses on how to transcribe the Continuity of Care form from the hospital and to ensure the nurses read each page. Nurses were also educated to assure the patient has IV access, if an IV is ordered. If the resident does not have IV access, then the nurse is to call the DON. The new information regarding transcription of Continuity of Care from the hospital was added to the orientation packet for new nurses. All new admissions will be reviewed the next day by a nurse manager. If a new admission is late on a Friday, weekend, or holiday, a nurse manager will come in the next morning and review the admission to ensure the orders are transcribed correctly from the Continuity of Care form onto the MAR and physician order [REDACTED]. The processes for flex pens were also reviewed. · On 10/27/15, action plans with audit tools were started. Topics included: IV access, initialing of MAR's, and transcription of new admission orders [REDACTED]. · On 10/27/15, two nurses were terminated, one nurse resigned and another nurse was given a written reprimand. · On 12/22/15 from 8:45 A.M. to 9:05 A.M., Licensed Practical Nurses (LPN's) #21, #40 and #42 and RN #50 were interviewed. The four nurses verbalized they had recently been in-serviced regarding the following: transcription of orders, verification of orders, documentation of medication given, administration of antibiotics and insulin, verification the resident has IV access if ordered. The four nurses verbalized they would notify the physician if a resident had a BS less than 60 mg/dl or greater than 400 mg/dl. · On 12/22/15, the facility provided evidence of ongoing audits. The MAR's audit included completed documentation of medications administered. The transcription and documentation of insulin administration audit included: insulin transcribed correctly and insulin charted as given. The IV Access audit included: medication transcribed correctly and IV access is present and patent. The transcription of continuity audit included transcription of medications completed correctly. Findings Include: Closed medical record review revealed Resident #72 was admitted to the facility on Friday, 10/23/15 at 5:30 P.M. The resident was [AGE] years of age. [DIAGNOSES REDACTED]. The resident was admitted from an acute care hospital. The hospital admitting [DIAGNOSES REDACTED].#72's discharge orders from the hospital included an order for [REDACTED]. Further discharge orders included, [MEDICATION NAME] (long last insulin), 20 units, subcutaneous (SQ), nightly for 30 days. Humalog, four units, three times a day, before meals (routine), and sliding scale (SS) insulin with meals, and at bedtime. Discharge orders also included for blood sugars to be checked before meals and at bedtime. Review of the facility's physician orders [REDACTED]. The physician orders [REDACTED].M.; however, it had been scribbled out. Review of physician orders [REDACTED]. The parameters were as follows: for BS between 151 to 200 mg/dl, give two units, 201 to 250 mg/dl, give four units, 251 to 300 mg/dl, give six units, 301 to 350 mg/dl, give eight units, and greater than 350 mg/dl, give 10 units. The order did not include parameters on when to notify the physician for a specific high or low BS reading. Review of Resident #72's MAR for 10/24/15 revealed Resident #72's BS was 311 mg/dl at 7:00 A.M. The resident was given four units of Humalog insulin, which was routine. The resident was not given the SS insulin, which would have been eight units to cover the 311 mg/dl BS reading. At 11:30 A.M., Resident #72's BS was 505 mg/dl and again was given the routine four units of insulin. No SS coverage was given for the BS of 505 mg/dl, which would have been 10 units of insulin. At 4:30 P.M., the resident's BS was registered as HI (too high for a numerical number) and was given 10 units of SS insulin but the routine 4 units of insulin was not given. There was no documentation the physician was notified of the high blood sugars or for any monitoring for signs and symptoms of Diabetic Ketoacidosis. Further review of the MAR for 10/24/15 revealed no documented BS reading for 9:00 P.M. Resident #72 also did not receive the ordered antibiotic. Review of Resident #72's MAR for 10/25/15 revealed there was not a BS reading taken at 9:00 P.M. The resident again, did not receive the ordered antibiotic. The IV access was not obtained until 10/26/15 (three days after admission). Review of the MAR dated 10/26/15 revealed Resident #72's BS at 7:00 A.M. was 457 mg/dl and she was given 10 units of sliding scale insulin, but no routine four units of insulin was given. At 11:30 A.M. the resident's BS was 566 mg/dl and was given 10 units of SS insulin. The four units of routine insulin was not given. At 4:30 P.M. Resident #72's BS was 336 mg/dl and no insulin was given. Per the parameters, the resident should have been given six units of SS insulin plus the 4 units of routine insulin. There was no documentation of a BS reading taken at 9:00 P.M. or that the 20 units of [MEDICATION NAME] was given. Again, the physician was not notified of the elevated BS's for the entire day and there was no evidence of monitoring for signs and symptoms of Diabetic Ketoacidosis. Review of the nursing notes dated 10/26/15 included a late entry dated 10/27/15 for 10/26/15. The note indicated the CNP was notified Resident #72's BS was elevated. The insulin order was clarified to include the routine four units of insulin was to be given with the SS insulin parameters. The CNP was not notified of the high BS readings for 10/24/15 or 10/25/15. Furthermore, the CNP was not notified the antibiotic was not given for two days, due to no IV access. Review of Resident #72's MAR dated 10/27/15 at 07:00 A.M., revealed a BS check of 576 mg/dl and was given 10 units of Humalog insulin per the SS and in addition the four units prior to meals. The MAR for 10/27/15 at 11:30 A.M. revealed no indication of a BS reading. The resident received four units of Humalog insulin as ordered prior to meals at this time. Review of a nursing note dated 10/27/15 at 1:30 P.M., revealed the physician was notified of the resident's HI BS reading. An order was received to send Resident #72 to the emergency room (ER) for evaluation. The note indicated Resident #72 was transported to the ER at 2:10 P.M. Further review of the record revealed Resident #72 was admitted to the hospital with [REDACTED]. The DON was interviewed on 11/25/15 at 11:30 A.M. The DON verified she received the discharge orders from the hospital for Resident #72 on 10/23/15. The orders included an IV antibiotic medication. The DON indicated she informed the floor nurse Resident #72 would need IV access for the ordered antibiotic. The DON indicated she was not aware Resident #72 missed doses of the antibiotic medication until Monday (10/26/15). The DON's investigation revealed the nurse on 10/24/15 indicated she was not aware the medication was to be given. The nurse on 10/25/15 did realize the medication was to be given, however, did not have IV access. The nurse did call the CNP and an order was received to call the contracted service for the placement of the IV line. The IV line did not get placed until 10/26/15 at 02:00 A.M. The DON further indicated Resident #72 had a high BS reading on 10/27/15 and was sent to the emergency room and was admitted to the hospital with [REDACTED]. On 12/10/15 at 11:50 A.M., per telephone, the CNP was interviewed. She revealed she was notified on the evening of 10/23/15 of Resident #72's admission to the facility and verified the orders. She revealed on 10/24/15 she was called by the facility nurse regarding clarification of the resident's SS insulin orders. The CNP indicated the hospital was contacted regarding the order, however, did not give out any information. She indicated she was at a seminar at the time and was not able to access the hospital records. She stated she had the facility nurse talk with the resident to see what SS insulin she had been using at home, prior to the admission. The CNP revealed she then gave the SS insulin parameters to the nurse. She denied at that time, giving the nurse an order for [REDACTED]. On 12/10/15 at 4:00 P.M., the Administrator, DON, and two corporate staff members were interviewed. They verified the following: 1. The admission physician orders [REDACTED]. 2. The telephone physician order [REDACTED]. The MAR did not have the order for the bedtime BS check and potential SS insulin coverage on the MAR. Resident #72 did not receive the bedtime BS check and potential SS insulin coverage on 10/24/15, 10/25/15 and 10/26/15. The MAR dated 10/26/15 at 4:30 P.M. revealed a BS check of 336 mg/dl; however, there was no documentation the resident received the SS insulin coverage, which would have been eight units. The MAR dated 10/26/15 did not have documentation the 9:00 P.M. [MEDICATION NAME], 20 units was given. The facility failed to obtain IV access in order to administer an order for [REDACTED]. The facility's Medication Administration Policy was reviewed (undated). The policy revealed medications should be administered in accordance with physician orders. On 12/22/15, the facility provided evidence of continued audits to ensure monitoring for on-going compliance. The MAR's audit included completed documentation of medications administered. The transcription and documentation of insulin administration audit included: insulin transcribed correctly and insulin charted as given. The IV Access audit included: medication transcribed correctly and IV access is present and patent. The transcription of continuity audit included transcription of medications completed correctly. This deficiency substantiates Master Complaint Number OH 687.