Every finding on record at The Laurels of Walden Park

Based on observation, open and closed medical record review, interviews and facility policy review, the facility failed to ensure weekly comprehensive wound assessments were completed, ensure skin interventions were in place and ensure wounds were accurately classified. This affected two residents (#117 and #214) of three residents reviewed for wounds. The facility census was 209.Findings Include:1.Review of the closed record for Resident #214 revealed an initial admission date of 07/17/25 with the latest readmission of 08/10/25 with the diagnoses including but not limited to chronic kidney disease, moderate protein calorie malnutrition, bacteremia, chronic bronchitis, acute respiratory failure with hypoxia, metabolic encephalopathy, fatty liver, hypertension, anemia, secondary hyperparathyroidism of renal origin, chronic peripheral venous insufficiency, dysphagia, muscle wasting and atrophy, difficulty in walking, benign neoplasm of colon, dependence on renal dialysis, abdominal aortic aneurysm, gout, benign neoplasm of left kidney, polyneuropathy, chronic pain syndrome, depression, guttate psoriasis, constipation, osteoporosis, hyperlipidemia, anxiety disorder and non-compliance with medication regimen.Review of the resident's nursing comprehensive evaluation dated 07/17/25 revealed the resident was admitted to facility with excoriation to the sacrum, groins, left buttocks and right buttocks possibly related to an allergy to Zosyn. The assessment indicated the resident was incontinent of both bowel and bladder.Review of the nurses note dated 07/18/25 at 4:33 P.M. revealed the resident was seen by the wound nurse for new admission assessment. The resident presented to the facility with an allergic reaction rash to entire body. The resident also presented with dry red patches/flaky tissue due loss of epidermis and crust to entire body and linear scratches and scabs due to resident scratching. The resident also presented with Moisture Associated Skin Damage (MASD) to buttocks secondary to diarrhea. Review of the plan of care dated 07/18/25 revealed the resident had actual impairment to skin integrity related to Moisture Associated Skin Damage (MASD) to buttocks, sacrum, open lesions to right scapula and mid back. Interventions included administer medications as ordered, observe for ineffectiveness and side effects, report abnormal findings to the physician, conduct weekly head to toe skin assessments and report new/abnormal findings to physicians as needed, apply (specify: pressure relieving/reducing mattress, pillows, etc.) to protect the skin while in bed, educate resident/family/caregivers of causative factors and measures to prevent skin injury, encourage good nutrition and hydration in order to promote healthier skin, provide dietary supplements as ordered, instruct resident to avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, keep skin clean and dry, use lotion on dry skin, observe for signs/symptoms of infection of area, observe for side effects of the antibiotics and over-the-counter pain medications, observe location, size and treatment of skin injury, report abnormalities, failure to heal, signs/symptoms of infection, maceration etc. to physician, obtain temperature as indicated while on antibiotic, treatment to skin impairment per order and turn and reposition. Review of the resident's Braden scale dated 07/19/25 revealed a score of 18 indicating the resident was at a low risk for skin breakdown.Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The resident required partial/moderate assistance to sit on the side of the bed. The resident was at risk for skin breakdown and had no skin issues. The facility implemented the interventions pressure reducing device to bed, application of non-surgical dressings and application of dressings to feet. Review of the closed medical record revealed no weekly comprehensive assessment for the MASD until 08/14/25 when the resident was found to have Moisture Associated Skin Damage (MASD) to the sacrum measuring 9.2 centimeters (cm) by 12.0 cm by 0.1 cm and described as being pink and/or red in color with no exudate. The facility implemented to cleanse the areas with soap and water and apply Triad paste. Review of the resident's skin and wound evaluation dated 08/20/25 revealed the MASD to the sacrum measured 6.5 cm by 6.8 cm and described as being pink and/or red in color with light sanguineous/bloody exudate. The facility determined the wound was stable and continued the current treatment.On 09/25/25 at 10:53 A.M., an interview with Licensed Practical Nurse (LPN) #407 who functions as one of the two wound nurses for the facility revealed the resident was admitted to the facility with MASD and also a rash. The LPN revealed she charted on the wound weekly, however failed to document a weekly comprehensive assessment of the wound until 08/14/25. LPN #407 verified the MASD should have been comprehensively assessed weekly.On 09/29/25 at 9:05 A.M., an interview with the Director of Nursing (DON) verified the MASD should have been comprehensively assessed weekly. 2. Review of the medical record for Resident #117 revealed an initial admission date of 06/02/25 with the diagnoses including but not limited to end stage renal disease (ESRD), severe protein calorie malnutrition, chronic obstructive pulmonary disease, diabetes mellitus, alcoholic cirrhosis of liver without ascites, right above the knee amputation (RAKA) anemia, peripheral vascular disease, left below the knew amputation (LBKA), cachexia, dependence on renal dialysis, stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling (see definition of undermining and tunneling) pressure ulcer of sacral region, congestive heart failure (CHF), major depressive disorder, hypertension, hyperlipidemia, anxiety disorder, insomnia and chronic pain syndrome. Review of the plan of care dated 06/03/25 and last revised on 09/25/25 revealed the resident had actual impaired skin related to stage III pressure injury to coccyx and unstageable to left stump. Interventions included conduct skin assessment weekly and measure area(s) and document, cushion to wheelchair, enhanced barrier precautions (EBP), observe for signs of discomfort with dressing changes and administer pain medication as ordered, observe for signs of infection related to areas, refer to dietitian as needed, specialty bed as ordered and treatment as ordered. Review of the resident's Braden Scale dated 06/24/25 revealed a score of 16 indicating the resident was at low risk for skin breakdown. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior revealed the resident had indicators of depression and displayed no behaviors including rejection of care. The assessment indicated the resident required partial to moderate assistance with bed mobility, was dependent on transfers and non-ambulatory. The assessment indicated the resident was frequently incontinent of both bowel and bladder. The assessment indicated the resident was at risk for skin breakdown and had one unhealed stage III pressure ulcer that was present on admission. The facility implemented the interventions pressure reducing device to bed, pressure ulcer/injury care, application of nonsurgical dressings and applications of ointments/medications other than to feet. Review of the wound care progress note dated 09/17/25 at 8:00 A.M. revealed the resident had a new pressure ulcer stage III with 100% eschar with seropurulent drainage to his left below the knee amputation. The resident was started on an antibiotic for cellulitis and the wound treatment of cleanse with normal saline (NS), pat dry, apply betadine soaked gauze to wound bed and cover with bordered foam dressing daily and as needed was implemented. The wound measured 1.5 centimeters (cm) by 1.6 cm and was covered with eschar. The wound had a moderate amount of seropurulent exudate. Review of the progress note dated 09/17/25 at 1:15 P.M. revealed during wound care the resident was noted with a wound to his left below the knee amputation. The wound was 100% eschar measuring 1.5 cm by 1.6 cm. The immediate intervention was to float the stump off the bed with a pillow. Review of the resident's weekly skin and wound evaluation dated 09/17/25 revealed the resident was found to have an unstageable pressure ulcer to his left below the knee amputation site. The wound measured 1.5 centimeters (cm) by 1.6 cm and was covered with eschar. The wound had a moderate amount of seropurulent exudate. The facility implemented the treatment to cleanse with normal saline, apply betadine moistened gauze and cover with a foam dressing. Review of the wound care progress note dated 09/24/25 revealed the resident's unstageable pressure ulcer to the left BKA was now 100% slough with no peri-wound erythema. The resident was to complete the antibiotic therapy for cellulitis on this date. The progress note documented the recommendations to Review of the resident's weekly skin and wound evaluation dated 09/24/25 revealed the resident's unstageable pressure ulcer to the left below the knee amputation site measured 1.8 cm by 1.5 cm by 0.2 cm. Further review of the assessment revealed the wound had no description of the wound. Continue supportive care and should be repositioned frequently. The resident should be supported with pillows or wedges to prevent pressure on wound. The wound measured 1.8 cm by 1.5 cm by 0.2 cm with a moderate amount of serosanguineous exudate. The facility continued the current treatment. Review of the resident's monthly physician orders for September 2025 identified orders dated 06/02/25 wound care practitioner to evaluate and treat as indicated, 09/17/25 cleanse wound to left stump with normal saline, pat dry, apply betadine moistened gauze, cover with foam dressing every shift for wound care and as needed if falls off or becomes soiled, 09/25/25 gel cushion for wound care every shift and alternating air mattress to bed every shift for wound care. On 09/25/25 at 12:16 P.M., observation of Resident #117 revealed the resident was positioned on his left side with the wound to his left stump positioned on the air mattress with no off-loading. Further observation revealed the proactive alternating air mattress was set for the weight of 660 pounds to 750 pounds when the resident's weight obtained on 09/25/25 was 119.2 pounds. On 09/25/25 at 12:22 P.M., an interview with Licensed Practical Nurse (LPN) #481 verified the wound to the resident's left stump had no offloading and the mattress was not set for the resident's currently weight providing no offloading. On 09/29/25 at 9:05 A.M., an interview with the Director of Nursing (DON) revealed the LPN #481 terminated her employment with the facility on 09/26/25 and had purposely been documenting the wounds wrong or not documenting on wounds at all. The DON revealed the Wound Nurse Practitioner reviewed the resident's wound and reclassified the wound as vascular due to the resident's extensive vascular history and bilateral lower limb amputation. Review of the facility policy titled, Skin Management, last revised on 08/14/24 revealed residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. Appropriate preventative measures will be implemented on residents identified at risk and the interventions are documented on the care plan. The licensed nurse will initiate documentation in the electronic medical record, which includes a description of the skin impairment as follows, in the electronic health record the licensed nurse will document weekly until the area is resolved. This deficiency represents non-compliance investigated under Complaint Number 2604004 and a recite to the annual survey conducted on 08/13/25.

Based on closed record review, fall investigation review, interviews and facility policy review, the facility failed to provide the care and supervision to prevent an unavoidable fall. This affected one resident (#214) of three residents reviewed for falls. The facility census was 209.Findings Include:Review of the closed record for Resident #214 revealed an initial admission date of 07/17/25 with the latest readmission of 08/10/25 with the diagnoses including but not limited to chronic kidney disease, moderate protein calorie malnutrition, bacteremia, chronic bronchitis, acute respiratory failure with hypoxia, metabolic encephalopathy, fatty liver, hypertension, anemia, secondary hyperparathyroidism of renal origin, chronic peripheral venous insufficiency, dysphagia, muscle wasting and atrophy, difficulty in walking, benign neoplasm of colon, dependence on renal dialysis, abdominal aortic aneurysm, gout, benign neoplasm of left kidney, polyneuropathy, chronic pain syndrome, depression, guttate psoriasis, constipation, osteoporosis, hyperlipidemia, anxiety disorder and non-compliance with medication regimen.Review of the resident's nursing comprehensive evaluation dated 07/17/25 revealed the resident required one assist with transfers and ambulation and the resident had a history of falls and a fear of falling. Review of the plan of care dated 07/18/25 revealed the resident was at risk for injury and falls related to medication effects, opioid use, impaired vision, hearing loss, depression, anxiety, impaired mobility, incontinence of bowel and bladder, unsteady gait and pain. Interventions included administer medications as ordered, anticipate and meet needs as needed, do not leave resident unattended in the bathroom, encourage the resident to wear appropriate footwear as needed, follow facility fall policy, Hoyer lift for transfers, keep the resident's environment as safe as possible, orient to surrounds as needed, provide resident with activities that minimize the potential for falls while providing diversion and distraction, therapy to evaluate and treat as ordered and as needed, put the call light withing reach and encourage him to use it for assistance as needed and staff educated not to leave the resident unattended at the side of his bed and utilize the Hoyer lift for transfers.Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The resident required partial/moderate assistance to sit on the side of the bed. The assessment indicated the resident had a history of calls prior to admission to the facility. Review of the progress note dated 08/16/25 at 6:00 A.M. revealed the nurse was called to the resident's room due to a fall. The resident was noted on the floor between the bed and his dialysis chair. Two superficial skin tears were observed to his left arm. The resident reported, I slid off the bed as I was waiting on my washcloth. The facility implemented the intervention to not leave the resident sitting on the side of the bed alone. Review of the fall investigation dated 08/16/25 at 6:00 A.M. revealed the nurse was called to the resident's room due to a fall. The resident was noted on the floor between the bed and his dialysis chair, and two superficial skin tears were observed to his left arm. The resident reported, I slid off the bed as I was waiting on my washcloth. Review of the post fall evaluation dated 08/16/25 revealed the resident was sitting on the side of the bed unattended and slipped. The resident was found in between his bed and dialysis chair. The post fall evaluation determined the root cause was the resident was unattended sitting on the side of the bed getting ready for dialysis when he slipped between the bed and dialysis chair. Staff were educated to not leave the resident unattended sitting on the side of the bed. The interdisciplinary team (IDT) also placed the new intervention to make the resident a Hoyer lift with transfers. On 09/25/25 at 12:48 P.M., an interview with the Director of Nursing (DON) verified the resident was left sitting on the side of the his bed alone while the Certified Nursing Assistant (CNA) left the room leaving the resident unsupervised. The DON verified the resident fell from his bed when the CNA left the room leaving the resident unattended.Review of the facility policy titled, Fall Management, last revised on 07/08/25 revealed the facility will identify hazards and resident risk factors and implement interventions to minimize falls and risk of injury related to falls.This deficiency represents non-compliance investigated under Complaint Number 2604004 and a recite to the annual survey conducted on 08/13/25.

Based on observation, record review, staff interview, interviews with staff at orthopedic medical office, review of National Pressure Injury Advisory Panel (NPIAP) guidance, and facility policy review, the facility failed to implement interventions to prevent the development of pressure ulcers when wearing a splint device and failed to timely identify the resident's pressure ulcers until it reached an advanced stage. Actual harm occurred on 07/30/25 when Resident #37 developed two avoidable unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcers to the underside of the index finger and to the left side of the palm hand when the facility did not remove Resident #37's splint device by the orthopedic clinic's instructions. This affected one (Resident #37) of two residents reviewed for pressure ulcers. The facility census was 209. Findings include: Review of the medical record for Resident #37 revealed an admission date of 08/26/25 with diagnoses including rhabdomyolysis, Alzheimer's disease, generalized muscle weakness, restlessness and agitation, anxiety disorder, and primary generalized osteoarthritis. Review of the care plan dated 08/26/24 revealed there was a skin prevention plan for Resident #37. Interventions included conducting weekly head-to-toe skin assessments; document and report abnormal findings to the physician; and follow facility policies/protocols for the prevention/treatment of impaired skin integrity; The care plan was not updated to reflect Resident #37 was wearing a splint device beginning 05/15/25 and no interventions were added to the care plan to reduce the risk of pressure ulcers with the use of splint device. Review of the after-visit summary (AVS) from Medical Center Orthopedic Clinic #500 revealed Resident #37 was seen on 05/15/25 for left wrist pain. The clinic was unable to obtain a meaningful history from the resident largely due to him being nonverbal and unable to recall any details of his condition. Similarly, his aide accompanying him was also unable to provide a history as to how long the condition had been present. During Resident #37's physical exam, his left wrist had persistent flexion, was unable to passively extend past neutral, sat in full flexion, was very tight and spastic in fingers, his wrist was held in full pronation, his elbow was largely unaffected, and he moved this and his shoulder spontaneously. Overall, he was unable to cooperate with the exam. The results of an x-ray for his left wrist showed some concerns for scapholunate (SL) diastasis, which is a widening (or separation) of the space between the scaphoid and lunate bones in the wrist. The physician's assessment and plan for Resident #37's left spastic hemiplegia stated he did not suspect the deformity was caused by an injury or SL ligament tear. The resident had spastic hemiplegia on the left with unclear etiology. The orthopedic physician stated this was likely due to either a stroke or advancing Alzheimer's disease. The orthopedic physician stated he would fit the resident with a wrist splint to keep him closer to neutral for both comfort and hygiene with no plans for surgical intervention. There were no physician orders on the After Visit Summary. Review of the physician orders dated 05/15/25 revealed an order to remove splint to left wrist and assess skin for any irritation, skin breakdown, swelling, or abnormalities, and report to the medical doctor (MD)/certified nurse practitioner (CNP) if any abnormalities were noted, every shift for prevention. Review of the Braden Scale for Predicting Pressure Sores dated 06/11/25, revealed Resident #37 was at low risk for developing pressure sores with a score of 16. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 was cognitively impaired. Resident #37 was at risk for developing pressure ulcers with a pressure-reducing device for bed and had the application of nonsurgical dressings and ointments. Review of a nursing progress note on 07/30/25 at 6:38 A.M. revealed Resident #37 was given a bed bath this shift, left hand skin under splint was assessed, mild edema was noted on the thumb, index, and middle finger, no new skin issues were noted, and the plan of care continued. A nursing progress note dated 07/30/25 at 3:45 P.M. revealed upon assessment of removal of the resident's splint to left hand, nurse noticed guest had dark skin/scab-like tissue to lateral left thumb and lateral pinky finger. No swelling to wrist or hands, slight amount of swelling to middle finger noted. Betadine was applied to site and wrapped with Kerlix with immediate intervention to discontinue splint order. Wound nurse in building assessed site. Review of the skin and wound evaluation dated 07/30/25 revealed Resident #37 developed an unstageable pressure ulcer to the left plantar - second digit (index finger) proximal, in-house acquired on 07/30/25. The initial measurements were 8.4 centimeters (cm) area, 6.0 cm in length, 1.9 cm width, not applicable (N/A) for depth, and 100% of the wound filled with eschar (blood and serous fluid) exudate. Additionally, a second skin and wound assessment dated [DATE] revealed Resident #37 had a second unstageable pressure ulcer to the left dorsum hand, distal, in-house acquired on 07/30/25 measuring 4.7 cm area, 3.8 cm length, 1.6 cm width, N/A depth, and 100% of the wound filled with eschar. Review of the physician order for Resident #37 dated 07/30/25 revealed an order to cleanse left medial hand with normal saline, pat dry, apply Betadine-moistened gauze, cover with ABD pad, wrap with Kerlix, and secure with tape every day shift and as needed (PRN) if soiled or dislodged and cleanse left lateral hand with the same treatment and frequency. Interview on 08/05/25 at 3:53 P.M. with Wound Nurse #870 stated it was not possible for the wound on Resident #37's finger to progress to an unstageable wound from 6:38 A.M. to 3:45 P.M. when she assessed the resident's finger. Interview on 08/07/25 at 8:56 A.M. with Licensed Practical Nurse (LPN) #140 revealed the initial reason for applying the splint was swelling, so an X-ray was ordered to rule out a fracture. When Resident #37 was sent to the orthopedic doctor, staff attempted to obtain an after-visit summary but never received it despite requesting it. She reported there were no instructions on how long the splint should be worn, but therapy worked with Resident #37. She explained the splint was intended to stabilize the wrist, extending approximately two inches above it. She stated she had not seen similar splints on other residents. She also stated the pressure ulcer aligned with where the splint was placed, indicating the splint caused the ulcer. There was no documented evidence that the facility attempted to obtain the after-visit summary. Interview on 08/07/25 at 9:18 A.M. with Clinical Director #600 at the Medical Center Orthopedic Clinic #500 revealed when someone came to the clinic, a staff member should have accompanied them and obtained the after-visit summary. She stated the first line of the visit note indicated an aide had accompanied Resident #37 but could not provide any medical history. Resident #37 was first seen on 05/15/25. On 05/22/25, someone from the nursing home called stating they had not received the after-visit summary. On 05/23/25, the office had documentation that the after-visit summary was sent at 10:18 A.M. and confirmed it was faxed to the facility. The note stated the resident would be fitted with a splint to keep the wrist stable, with no follow-up needed. There was no wearing schedule documented in the note, but Clinical Director #600 stated the splint was for comfort and could be removed whenever needed, including during bathing. She stated it should be removed while sitting at rest, and the only time it should be worn was during activity. It should not be worn 24 hours a day. Interview on 08/07/25 at 9:38 A.M. with the Athletic Trainer #700 at the Medical Center Orthopedic Clinic #500 office revealed Resident #37's splint should be worn for comfort only and removed for hygiene. If the splint was too tight, residents/staff were shown how to loosen the Velcro straps. The splint should also be removed for eating, and it was typically recommended that it be removed at night, worn only during the day for comfort and support. She stated that if a splint was worn continuously without removal, it would cause dry skin and irritation. Athletic Trainer #700 confirmed the splint had been given to Resident #37 in May. Athletic Trainer #700 stated if the splint had been removed twice a day and the skin assessed, no issues should have occurred. If the splint was too tight, it would cause pressure injuries. Interview on 08/07/25 at 2:08 P.M. with LPN #140 confirmed Resident #37's splint was not removed except during the twice-daily skin checks. LPN #140 also confirmed the fax number provided above was correct. She confirmed an aide had accompanied Resident #37 to his appointment but could not recall the aide's name. Observation on 08/07/25 at 2:08 P.M. with Wound Nurse #870 revealed the wound on Resident #37's finger was moist with Betadine, with a scab covering the area and pink tissue visible at the center. After removing the gauze, staff noted the dorsal side of the finger showed scabbed tissue with surrounding pink skin. The wound nurse described the area as having superficial skin involvement. The left dorsal wound appeared to have some depth with a central scab, and the wound nurse noted the depth could not be assessed until the scab detached. Review of the facility policy titled Skin Management dated 05/01/10 with a revision date of 09/19/24, revealed the policy aims to identify and implement interventions to prevent clinically unavoidable pressure injuries. It outlines an overview where residents with wounds, pressure injuries, or at risk for skin compromise are evaluated and treated to promote prevention and healing, with ongoing monitoring. Practice guidelines include a baseline total body skin evaluation upon admission, weekly Braden Scale assessments for four weeks, and appropriate preventive measures and interventions for at-risk residents. Residents with skin impairments receive physician-ordered treatment, with documentation of impairment details. The policy also addresses interdisciplinary team evaluations, weekly skin assessments, and the management of pressure injuries, vascular ulcers, skin tears, and bruises, including notification protocols and documentation requirements. Management tools and cross-references to other guidelines are provided to support compliance. Review of the NPIAP guidance titled 2019 Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide 2019 revealed to reduce the risk of medical device related pressure injuries, review and select medical devices with considerations to minimize issue damage, utilize the correct sizing/shape of the device for the individual and correctly secure the device. Assess the skin under and around medical devices for signs of pressure related injury as part of routine skin assessment. Remove medical device as soon as medically feasible. Use prophylactic dressing beneath a medical device to reduce the risk of medical device related pressure injuries. This deficiency represents non-compliance investigated under Complaint Number OH00167149 (1260022).

Based on observations, resident interviews, staff interviews, and review of facility policy, the facility failed to maintain an effective pest control program. This affected eight residents (#47, #57, #70, #90, #116, #134, #179, and #225) and had the potential to affect all residents living in the facility. The facility census was 209. Findings include: 1. Interview with Resident #90 on 08/04/25 at 9:53 A.M. revealed gnats and roaches were present in the facility on a daily basis. Interview and observation with Resident #57 on 08/04/25 at 9:51 A.M. revealed gnats were present in his room on a daily basis. Several gnats were observed flying around the room and landing on the privacy curtain. Interview and observation with Resident #70 on 08/04/25 at 10:13 A.M. revealed gnats were present in his room on a daily basis. He stated he told management about the gnats in his room. Several gnats were observed to be flying around the room and landing on Resident #70’s tray table. Interview with Resident #116 on 08/04/25 at 10:32 A.M. revealed roaches were in her room on a daily basis and she could feel them crawling on her while she was in bed at times. Interview with Resident #134 on 08/04/25 at 11:12 A.M. revealed roaches and gnats were in her room on a daily basis. Interview and observation with Resident #179 on 08/04/25 at 11:23 A.M. revealed roaches were in the room on a daily basis. A roach was observed crawling across his side table. Resident #179 stated he was concerned they would enter into his continuous positive airway pressure machine or tubing. Interview with Resident #225 on 08/04/25 at 11:35 A.M. revealed he killed multiple roaches crawling across his wall on a daily basis. Observation of a roach crawling on the Unit One hallway was confirmed by Registered Nurse #320 on 08/05/25 at 9:12 A.M. Observation and interview on 08/11/25 at 11:08 A.M. with Maintenance Worker #811 confirmed there were ten gnats that had landed on Resident #57’s privacy curtain. Upon shaking the privacy curtain, the gnats were observed to be alive and flying around the room. Interview with Certified Nursing Assistant (CNA) #205 on 08/06/25 at 11:06 A.M. confirmed there were active roaches in the facility. Interview with Housekeeper #591 on 08/11/25 at 10:49 A.M. confirmed she saw live roaches and gnats in resident rooms on a daily basis. Interview with the Administrator on 08/11/25 at 2:58 P.M. confirmed the pest infestation was ongoing. Although the facility had an active plan to eradicate the pests and pest control education was provided to staff, the facility had not yet assessed the skin of vulnerable residents as part of their correction plan. The Administrator revealed licensed staff would perform skin assessments of vulnerable residents as a part of this correction plan starting immediately. 2. Observation on 08/05/25 at 10:10 A.M. revealed multiple house flies and fruit flies were flying around the tracheostomy unit. The flies were also landing on multiple surfaces during this observation. Observation of Resident #47 on 08/06/25 at 9:45 A.M. revealed the resident's room was located next to an exit door that opens up to the outside. Subsequent observations on 08/06/25 at 12:25 P.M., 08/07/25 at 2:10 P.M., and 08/11/25 at 9:55 A.M. revealed multiple house flies and fruit flies were flying around the tracheostomy unit. The flies were also landing on multiple surfaces during these observations. Interview with Respiratory Therapist #945 on 08/06/25 at 2:45 P.M. verified the tracheostomy and stoma of Resident #47 had been infested with fly larvae and the resident had been sent to the hospital due to the findings on 06/30/25. Review of an undated facility policy titled “Pest Control Policy” revealed the facility would provide an environment free of pests. This deficiency represents non-compliance investigated under Complaint Number OH00167149 (1260022).

Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure residents advance directives were readily available to facility staff and Emergency Medical Service (EMS) personnel. This affected four residents (#17, #129, #198, and #236) of the 51 residents reviewed for advance directives. The facility census was 209. Findings included: 1. Closed record review for Resident #236 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included dementia with severe psychotic disturbance, atrial fibrillation, and repeated falls. Review of the admission Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #236 was severely impaired cognition. Review of the physician's order, dated [DATE], revealed Resident #235's code status was Do Not Resuscitate Comfort Care Arrest (DNRCC-A) and Do Not Intubate (DNI). Review of the facility's advance directive form, signed by Resident #236's son on [DATE], revealed the resident was to not have Cardiopulmonary Resuscitation (CPR) initiated in the event the resident's heart or breathing stopped. The resident was not to be transported to the hospital for emergency intervention. The form was not signed by the physician. No other advance directive forms were present in the resident's electronic health record. Review of the progress note dated [DATE] at 8:10 P.M. revealed Resident #236's oxygen saturation level was 66 percent. Emergency 9-1-1 was called and resident's son notified. The progress note dated [DATE] at 8:29 P.M. revealed emergency medical services (EMS) personnel in facility currently performing CPR. Nurse Practitioner notified for verbal order for no resuscitation and medics unable to take verbal order over the phone due to needing order signed by the attending. Medics continue working on resident at this time. The progress note dated [DATE] at 9:28 P.M. revealed the resident's condition had changed upon their arrival. CPR was performed by paramedics on site and a pulse was successfully restored. Resident transported to hospital. Review of the EMS run report, dated [DATE], revealed EMS dispatched to facility for difficulty breathing. EMS entered the room and found Resident #236 pulseless and without respirations. Due to staff inability to provide a valid DNR, life saving efforts were initiated. Resident was moved to the floor and compressions were initiated. Initial heart rhythm showed Pulseless Electrical Activity (meaning the heart had electrical activity but no detectable pulse). Advanced Life Support continued. Upon next rhythm check possible Ventricular Fibrillation observed. Emergent transport initiated, resident maintained pulses and was monitored closely throughout transport. Arrived at hospital and transferred care to hospital staff. Review of the hospital visit note, dated [DATE], revealed Resident #236 presented to the hospital in cardiac arrest from skilled nursing facility. Per EMS, resident had a DNRCC but facility unable to find the paperwork and there was no family. Life saving measures continued at the hospital and the resident was revived. Family arrived and confirmed the resident was DNRCC. Care was de-escalated and the resident died quietly with multiple family at bedside. Telephone interview with Registered Nurse (RN) #280 on [DATE] at 2:12 P.M. confirmed Resident #236 had a change in condition around the change of shift on [DATE]. RN #280 confirmed Resident #236 went unresponsive and EMS were called. RN #280 confirmed the resident had an order for DNRCC-A code status but the DNR paperwork signed by the physician could not be located. RN #280 confirmed EMS personnel arrived and began CPR, obtained a heartbeat for the resident, then took him to the hospital. 2. Record review for Resident #17 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypoxia, and atrial fibrillation. Review of the significant change MDS assessment dated [DATE] revealed Resident #17 was mildly impaired cognition. Review of the active care plan, dated [DATE], revealed Resident #17 was full code status. Interventions included code status to be reviewed upon readmission, quarterly, with significant changes, and at the desire of the resident or responsible party. Review of the physician's order, dated [DATE], revealed Resident #17 was to be DNRCC-A. Additional record review for the resident revealed no signed DNR paperwork was available for review in the resident's electronic health record. Observation and interview with Unit Manager #110 on [DATE] at 8:10 A.M. confirmed there was a code status book located at each nurse's station. RN Unit Manager #110 confirmed there was to be DNR paperwork signed by the physician for each resident who wished to be DNR code status. Unit Manager #110 confirmed there was not signed DNR paperwork in the code status book for Resident #17. Record review and interview with Unit Manager #110 on [DATE] at 8:30 A.M. confirmed there was not signed DNR paperwork located in the electronic health record of Resident #17. 3. Review of the medical record for Resident #129 revealed an admission date of [DATE]. Diagnoses included cerebral atherosclerosis and type II diabetes mellitus with hyperglycemia. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #129 was cognitively impaired. Review of Resident #129’s medical chart revealed signed DNR paperwork in electronic medical record (EMR). Review of Resident #129’s physician orders revealed he has active no CPR/DNR order. Observation of the code status book on Resident #129’s nursing unit revealed there was not a signed DNR copy in the code status binder for Resident #129. Interview with Unit Manager #130 on [DATE] at 8:12 A.M. confirmed there was a code status book located at each nurse's station. Unit Manager #130 confirmed there was not a copy of signed DNR paperwork in the code status binder for Resident #129. 4. Review of the medical record for Resident #198 revealed an admission date of [DATE]. Diagnoses included disorder of congestive heart failure and dementia. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #198 was cognitively intact. Review of Resident #198’s physician orders revealed she had an advanced directive code status of DNRCC-A, which indicated Resident #198 did not wish for resuscitative measures to be initiated if they experienced cardiac or respiratory arrest; however, until such an arrest occurs, they would receive full medical treatment. Observation of the code status book on Resident #198’s nursing unit revealed there was not a DNRCC-A signed form in the code status binder for Resident #198. Interview with Registered Nurse (RN) #130 on [DATE] at 9:01 A.M. confirmed there was no advanced directives sheet in the code status binder for Resident #198. RN #130 confirmed if a resident was to code, they would need to be able to pull up the advanced directives in the binder to confirm the resident’s code status. Review of the facility policy titled Ohio Advance Directive effective [DATE] revealed the facility will determine whether the resident's physician issued a DNR Order in another setting and whether the resident would like a DNR Order issued while in the facility. Copies of all advance directives will be obtained from the resident and/or family and placed in the medical record. If applicable, a DNR Order will be obtained from the residents physician and placed in the medical record. This deficiency represents non-compliance investigated under Complaint Number OH00167220 (1260023).

Based on record review, guardian and staff interview, and facility policy review, the facility failed to complete quarterly care conferences for the residents. This affected eight (Residents #6, #18, #37, #53, #82, #110, #170, and #198) of 43 residents reviewed for care conferences. The facility census was 209. Findings include: 1. Review of Resident #6's medical record review revealed an admission date of 10/06/23. Diagnoses included alcoholic cirrhosis of the liver without ascites, permanent atrial fibrillation, chronic obstructive pulmonary disease (COPD), and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had severe cognitive impairment. Review of the care conferences for Resident #6 revealed care conferences were held on 10/22/24 and 03/06/25. There were no care conferences held since 03/06/25. Interview on 08/06/25 at 11:32 A.M. with Social Service (SS) #751 and SS #771 confirmed there were only two care conferences on 10/22/24 and 03/06/25 for Resident #6 and confirmed the care conferences should occur quarterly. 2. Review of Resident #37's medical record revealed an admission date of 08/26/24. Diagnoses included rhabdomyolysis, Alzheimer's disease, generalized muscle weakness, and history of falling. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had moderate cognitive impairment. Review of the care conferences from 08/01/24 to 08/06/25 revealed Resident #37 had two care conferences on 08/29/24 and 03/03/25. Interview on 08/06/25 at 11:32 A.M. with Social Services (SS) #751 and SS #771 confirmed Resident #37 had only two care conferences in the last year on 08/29/24 and 03/03/25 and confirmed the care conferences should occur quarterly. 3. Review of the medical record for Resident #53 revealed an admission date of 12/20/24 with diagnoses including chronic obstructive pulmonary disease, asthma, type II diabetes mellitus with other circulatory complications, and type II diabetes mellitus with diabetic neuropathy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 had intact cognition. Review of the care conference schedule and medical record for Resident #53 from 12/20/24 to 08/06/25 revealed there were no care conferences held for Resident #53. Interview on 08/06/25 at 11:32 A.M. with Social Services (SS) #751 and SS #771 confirmed there were no care conferences held for Resident #53 and confirmed the care conferences should occur quarterly. 4. Review of the medical record for Resident #82 revealed an admission date of 05/22/24 with diagnoses including dementia with agitation, moderate protein-calorie malnutrition, localized edema of the right lower extremity, and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82 had severe cognitive impairment. Review of the care conference schedule and medical record for Resident #82 from 08/01/24 to 08/06/25 revealed care conferences were held twice on 08/21/24 and 05/07/25. Interview on 08/06/25 at 11:32 A.M. with Social Services (SS) #751 and SS #771 confirmed Resident #82 had only two care conferences in the past year on 08/21/24 and 05/07/25 and confirmed the care conferences should occur quarterly. 5. Review of the medical record for Resident #110 revealed an admission date of 03/28/25 with diagnoses including vascular dementia with other behavioral disturbance, moderate protein-calorie malnutrition, and chronic diastolic (congestive) heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 had moderate cognitive impairment. Review of the care conference schedule and medical record for Resident #110 from 03/28/25 to 08/06/25 revealed no care conferences were held for Resident #110. Interview on 08/06/25 at 11:32 A.M. with Social Service (SS) #751 and SS #771 confirmed there were no care conferences held for Resident #110 and confirmed the care conferences should occur quarterly. 6. Review of the medical record for Resident #170 revealed an admission date of 04/18/19 with diagnoses including dementia without behavioral disturbance, mild protein-calorie malnutrition, chronic obstructive pulmonary disease (COPD), and chronic diastolic (congestive) heart failure. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #170 had severe cognitive impairment. Review of the care conference schedule and medical record for Resident #170 from 08/01/24 to 08/06/25 revealed Resident #170 had two care conferences on 10/21/24 and 06/24/25. Interview on 08/06/25 at 11:32 A.M. with Social Service (SS) #751 and SS #771 confirmed Resident #170 had only two care conferences in the last year on 10/21/24 and 06/24/25 and confirmed the care conferences should occur quarterly. 7. Review of Resident #18's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizophrenia, polyneuropathy, and anxiety disorder. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] quarterly revealed Resident #18 had severe cognitive impairment. Resident #18 had been court appointed guardian on 01/13/25. Review of Resident #18's medical record revealed the last care conference held for Resident #18 was on 02/10/25. An interview with the guardian of Resident #18 on 08/05/25 at 8:21 A.M. stated they had not had a care conference since February 2025. An interview with Social Worker #751 on 08/05/25 at 3:45 P.M. confirmed Resident #18's last care conference was held on 02/10/25 and did not have a care conference since then. 8. Review of the medical record for Resident #198 revealed an admission date of 10/14/24. Diagnoses included disorder of congestive heart failure and dementia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #198 was cognitively intact. Review of the medical record for Resident #198 from 10/14/24 to 08/05/25 revealed Resident #198 had two care conference on 02/04/25 and 07/30/25. An interview with Social Worker #751 on 08/05/25 at 4:09 P.M. confirmed Resident #198 did not have a care conference between 02/04/25 and 07/30/25. Review of the facility policy titled, Care Planning Conference dated 03/03/25 revealed on admission, quarterly, annually, with a significant change and as needed, the interdisciplinary team will hold a care planning conference with the resident, family, or representative in participation.

Based on observations, resident and staff interviews, medical record review, and policy and procedure review, the facility failed to provide residents who were dependent on staff for activities of daily living (ADLs) adequate care and services for personal hygiene. This affected four (#8, #15, #134, and #209) of eight residents reviewed for ADLs. The facility census was 209. Findings included: 1. Review of the medical record for the Resident #8 revealed an admission date of 06/02/25. Diagnoses included surgical amputation, chronic obstructive pulmonary disease, alcoholic cirrhosis of liver, peripheral vascular disease, and end stage renal disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had intact cognition and was dependent on staff for showering/bathing, upper body dressing, and personal hygiene. Review of Resident #8's progress notes, shower/bathing sheets, and task information charting sheet for grooming from 07/01/25 to 08/05/25 revealed it did not indicate if staff offered to trim or shave Resident #8's facial hair and/or refused to be shaven. Observation and interview on 08/04/25 at 2:25 P.M. revealed Resident #8 was unshaved, his mustache was long covering his top and bottom lips, and his beard was growing down his neck. The hairs appeared to be at least one inch long. His hair was uncombed. He denied anyone asking if he would like his mustache and beard trimmed or completely shaved off. Resident #8 confirmed he would like his beard and mustache shaved. When asked, if he would like his mustache and beard trimmed or shaved, he replied, “yes.” The nurse on duty was notified by State Survey Agency. Interview on 08/04/25 at 3:00 P.M. with the Unit Manager (UM) #120 confirmed the certified nursing aides (CNAs) should be asking the residents if they would like their facial hair shaved when ADL care was performed. UM #120 confirmed Resident #8's beard and mustache needed to be groomed. Observations on 08/06/25 at 1:00 P.M. and 08/07/25 at 9:00 A.M. revealed Resident #8 had not been shaved. 2. Review of the medical record for Resident #134 revealed an admission date of 11/23/22. Diagnoses included multiple sclerosis, contracture right hand, and gastrostomy status. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #134 had intact cognition was dependent on staff for showering/bathing, upper body dressing, and personal hygiene. Review of Resident #134’s care plan dated 02/12/25 revealed Resident #134 had a functional ability deficit and required assistance with self-care and mobility related to multiple sclerosis. A goal listed was to improve or maintain current level of function in personal hygiene. An intervention listed was to keep her fingernails trimmed and clean. Observations of Resident #134’s nails on 08/04/25 at 11:12 A.M. and 08/07/25 at 3:48 P.M. revealed her right hand was contracted. Her long fingernails were resting against the palm of her contracted right hand. Interview with Resident #134 on 08/04/25 at 11:12 A.M. revealed she had asked nursing to cut her fingernails frequently. She stated after she would ask to have her nails trimmed, nursing would state they would be back to perform the task, but then would not perform nail care. Interview with Certified Nurse Aide (CNA) #735 on 08/07/25 at 3:57 P.M. revealed Resident #134 did not refuse grooming or care. Interview with CNA #145 on 08/07/25 at 3:58 P.M. revealed Resident #134 did not refuse grooming or care. Interview with CNA #825 on 08/07/25 at 4:00 P.M. confirmed Resident #134’s nails were long and untrimmed. Review of the facility policy titled “Routine Resident Care” dated 03/12/25 revealed daily personal hygiene minimally includes assisting residents with their nail care. 3. Medical record review revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included dementia, psychotic disturbance, mood disturbance, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had impaired cognitive function or impaired thought processes. Resident #15 was dependent on staff for personal hygiene. Review of Resident #15's plan of care, dated 06/02/25, revealed Resident #15 had an ADL functional deficit, and required substantial to maximal assistance with all self-care. Interventions included assistance with upper body dressing, and personal hygiene. Review of Resident #15's nursing notes and behavior monitoring sheets from 07/29/25 to 08/11/25 revealed no documentation Resident #15 was resistive to care. Observations on 08/04/25 at 10:20 A.M. and 12:10 A.M. revealed Resident #15 was in bed propped on his right side and appeared unshaven with a long beard. An interview with Registered Nurse (RN) #130 on 08/04/25 at 2:46 P.M. revealed the men get shaved as needed, if the resident allows staff to shave them. When the certified nursing aides get the resident up and dressed, they should be offering to shave the resident and then the resident can refuse or accept. An interview with RN #130 on 08/04/25 at 2:50 P.M. confirmed Resident #15 had several days growth beard. RN#130 asked Resident #15 if he wanted shaved and Resident #15’s sister said he needs to be shaved. RN #130 asked the sister of Resident #15 if he needed shaved daily and Resident #15’s sister said yes. 4. Record review for Resident #209 revealed the resident was admitted to the facility on [DATE]. Diagnoses included diabetes mellitus, contracture of the left hand and left elbow, and hemiplegia and hemiparalysis affecting the left non-dominant side. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/25/25, revealed Resident #209 had moderately impaired cognition and a functional limitation in range of motion to one upper extremity. Resident #209 was dependent on staff for assistance with personal hygiene. Review of the care plan, revised 04/16/25, revealed Resident #209 had a functional ability deficit and required assistance with self care/mobility. Interventions included keep fingernails clean and trimmed. Observations on 08/04/25 at 10:40 A.M. and 2:05 P.M. and 08/0525 at 8:10 A.M., 10:15 A.M., and 1:40 P.M. revealed Resident #209 was lying in bed and the resident's left hand was contracted and the fingernails on the left hand were long and dirty. Observation and interview on 08/05/25 at 4:00 P.M. with Certified Nursing Assistant (CNA) #125 confirmed Resident #209 had a contracture of the left hand and the fingernails on the resident's left hand were long and dirty and in need of being cleaned and trimmed. CNA #125 obtained a damp washcloth and gently cleansed inside the resident's left hand. Upon removing the white washcloth from the resident's hand, brown debris was present. CNA #125 confirmed the residents hand had a yeast-like odor to it which should not be present. Observation on 08/06/25 at 10:02 A.M. revealed Resident #209 was lying in bed. The resident's left hand was contracted and the fingernails to the left hand continued to be long and dirty. Review of the facility policy titled Routine Resident Care effective 03/12/25 revealed daily personal hygiene minimally included assisting or encouraging residents with washing their face and hands, shaving, nail care, and brushing their teeth and/or providing denture care. This represents noncompliance investigated under Complaint Number OH00167220 (1260023).

Based on record review, observations, staff interviews, policy review, and review of hospital records, the facility failed to provide adequate respiratory care for Resident #47 who had localized fly larvae infestation to her tracheostomy and stoma and required hospitalization. This affected one (#47) of five residents reviewed for respiratory care. The facility identified 36 residents residing on the tracheostomy unit. The facility census was 209. Findings included: Review of Resident #47's medical record revealed an admission date of 10/23/24. Diagnoses included acute and chronic respiratory failure, hemiplegia and hemiparesis, tracheostomy and ventilator dependent. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had severely impaired cognition. Resident #47 was also totally dependent on staff for all care including tracheostomy care. Review of the active physician orders revealed Resident #47 was to receive tracheostomy care every 12 hours which included changing of the disposable inner cannula and to check the skin under the tracheostomy ties on each shift as well. Review of the Treatment Administration Record (TAR) from 04/01/25 to 07/31/25 revealed all tracheostomy care had been completed and signed off by various Respiratory Therapists. Review of the nursing note from 06/30/25 at 5:13 A.M. from Licensed Practical Nurse (LPN) #680 revealed multiple fly larvae (maggots) in and on the tracheostomy site of Resident #47. An order was received to send the resident to the emergency room for further evaluation. Review of the hospital notes dated 06/30/25 revealed three larvae were identified upon arrival to the emergency room. The infestation was removed locally in the emergency room with all larvae being successfully removed. Infectious Diseases was consulted with no recommendations except local removal. Ventilator dependent pneumonia was also summarily ruled out. Wound care was consulted with no recommendations except local removal. Notes state a debridement of the tracheostomy stoma was not necessary. Resident #47 returned to the facility on [DATE]. Observation on 08/05/25 at 10:10 A.M. revealed multiple house flies and fruit flies were flying around the tracheostomy unit. The flies were also landing on multiple surfaces during this observation. Observation of Resident #47 on 08/06/25 at 9:45 A.M. revealed the resident's room was located next to an exit door that opens up to the outside. No observations were made of staff or residents utilizing this door to the outside as it had a sign posted to be used for emergency purposes only. Subsequent observations on 08/06/25 at 12:25 P.M., 08/07/25 at 2:10 P.M., and 08/11/25 at 9:55 A.M. revealed multiple house flies and fruit flies were flying around the tracheostomy unit. The flies were also landing on multiple surfaces during these observations. Interview with Respiratory Therapist #945 on 08/06/25 at 2:45 P.M. verified the tracheostomy and stoma of Resident #47 had been infested with fly larvae and the resident had been sent to the hospital due to the findings on 06/30/25. He stated tracheostomy care was scheduled once per shift, and the eggs may hatch into their larval form in approximately 12 hours. He also verified that due to the findings on that day, the facility had installed florescent fly traps at the ends of each hall and prohibited entry or exiting from the outside doors located at the end of each hall. Prior to 06/30/25, staff frequently used the exit doors on the tracheostomy for various reasons. Attempts to interview Licensed Practical Nurse #680 and Respiratory Therapist #955, who worked on 06/30/25, during the survey were unsuccessful. Review of the facility's undated policy titled Tracheostomy Suctioning revealed there was no relevant information on the care required for fly larvae infestation. This deficiency represents non-compliance investigated under Complaint Number OH00167441 (1260024) and Complaint Number OH00167149 (1260022).

Based on record review, observations, resident, guardian and staff interviews, and review of facility policy, the facility failed to maintain a safe, clean and homelike environment in resident rooms. This affected two (Resident #18 and #70) of seven residents reviewed for homelike environment. The facility census was 209 residents.Findings include: Record review revealed Resident #18 was admitted to the facility on [DATE]. Resident #18 had been appointed a guardian on 01/13/25. Interview with the guardian for Resident #18 on 08/04/25 at 1:54 P.M. stated the sink in Resident #18's room had been leaking and the faucet that been loose since March 2025. She stated she had notified the facility of this concern and it has never been fixed. Observations on 08/04/25 at 2:48 P.M., 08/07/25 at 8:54 A.M. and 3:46 P.M., and on 08/11/25 at 8:26 A.M. revealed Resident #18's sink faucet was loose and dripping. The baseboard, approximately three feet in length, behind the toilet was separated from the wall, revealing a dark brown and black surface underneath. An interview with the roommate of Resident #18, Resident #70, on 08/07/25 at 8:54 A.M. stated he used the sink when he was up in his wheelchair. He stated the had told the facility about the loose, leaky sink faucet and it has never been fixed. An interview with Registered Nurse (RN) #330 on 08/11/25 at 8:23 A.M. stated he was aware of the loose leaking sink in Resident #18's room but not aware about the baseboard that was separated from the wall. An interview with Maintenance Workers #801 and #821on 08/11/25 at 8:26 A.M. confirmed Resident #18's sink faucet was loose, leaking and that the baseboard was separated from the wall revealing a dark surface area. They stated that they would fix the baseboard and sink. An interview with Housekeeper #591 on 08/11/25 at 10:49 A.M. revealed she was aware of the separated baseboard and the loose and leaking sink faucet in Resident #18's room and she had reported it to her supervisor. Review of the undated facility policy titled Daily Cleaning of Guest Rooms revealed housekeeping is to report any items that need repaired to the maintenance department. Review of the facility policy titled Federal and State- Resident Rights and Facility Responsibilities dated 05/14/24 revealed the resident has the right to a safe, clean, comfortable and homelike environment. Housekeeping and maintenance services will maintain a sanitary, orderly and comfortable interior.

Based on record review, staff interview, policy review, and review of the facilities Self-Reported Incidents (SRI), the facility failed to timely report allegations of physical and verbal abuse and injuries of unknown origin to the State Survey Agency. This affected three (#6, #72, and #183) of eight residents reviewed for abuse. The facility census was 209. Findings include: 1. Review of the medical record for Resident #6 revealed the resident was admitted on [DATE]. Diagnoses included alcoholic cirrhosis of the liver without ascites, permanent atrial fibrillation, chronic obstructive pulmonary disease (COPD), and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had severe cognitive impairment. Review of the nursing notes dated 12/23/24 documented an interdisciplinary team (IDT) meeting regarding an incident of physical aggression received on 12/21/24. The resident was observed with a bleeding nose and stated, He punched me. All involved parties were made aware, an assessment was completed by the floor nurse, and the immediate intervention was to move the resident to another room. The IDT agreed with the room change. The nursing notes dated 12/31/24 at 8:30 A.M. documented the resident was found with bruising and skin tears to the face, blood on the face and bathroom floor, feces smeared on the body, and one gripper sock on foot with urine on the floor. The resident stated, I probably hit my head. Vital signs were stable. The nursing notes dated 01/02/25 documented an IDT meeting was held to address the bruising and skin tears. The injury was consistent with contact with the bathroom door, and a night light was ordered for the resident’s room. Review of the facilities SRIs from 12/21/24 through 01/02/25 revealed there were no SRIs reported for the allegation of physical abuse for Resident #6 for the incident on 12/21/24 and there was no SRI filed for the injuries of unknown origin on 12/31/24. Interview on 08/07/25 at 11:15 A.M. with the Administrator confirmed the facility did not submit an SRI involving Resident #6 for the physical abuse incident on 12/21/24 and injury of unknown origin on 12/31/24. At 2:07 P.M., the Administrator confirmed an SRI was submitted approximately eight months late following discussion during the survey. 2. Record review for Resident #72 revealed the resident was admitted to the facility on [DATE]. Diagnoses included bipolar disorder, intellectual disabilities, and chronic pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 had moderately impaired cognition. Review of the nursing progress note dated 06/27/25 revealed Resident #183 was cursing out Resident #72 calling her a 'fat expletive'. This nurse went to investigate the noise and Resident #183 called the nurse an expletive as well. Resident #183 cursing kept going on even when this nurse intervened. Resident #183 made Resident #72 cry. Review of the facility SRI control number 262200, dated 06/30/25, revealed Resident #183 was witnessed by staff screaming profanity words at Resident #72. This SRI was filed three days after the verbal abuse allegation occurred. The nursing progress note dated 07/30/25 revealed Resident #183 was verbally abusive towards residents in the dining area. Resident #183 used words like 'expletive you' and 'expletive' prompting immediate intervention from this nurse and the day shift nurse. Despite being asked to refrain from using such inappropriate language, Resident #183 got more angry and escalated his behavior using even more explicit language. Resident #183 eventually stopped and was escorted to his room to rest. There was no SRI filed with the Stage Survey Agency (SA) by the facility for the allegation of verbal abuse by Resident #183 on 07/30/25. Interview with the Administrator on 08/11/25 at 10:45 A.M. confirmed an SRI for the allegation of verbal abuse which occurred on 06/27/25 between Resident #183 and Resident #72 was not completed until 06/30/25, three days after the incident occurred. The Administrator additionally confirmed no SRI had been completed for the allegation of verbal abuse by Resident #183 on 07/30/25. Review of the facility policy titled Abuse Prohibition, effective 10/14/22, revealed the Administrator or designee will notify any State or Federal agencies of allegations per state guidelines two hours if abuse allegation or serious injury; all other not later than 24 hours.

Based on record reviews, staff interviews, and review of a facility policy, the facility failed to ensure allegations of verbal and physical abuse and injuries of unknown origin were thoroughly investigated. This affected three (#6, #72 and #183) of eight residents reviewed for abuse. The facility census was 209. Findings include: 1. Record review for Resident #72 revealed the resident was admitted to the facility on [DATE]. Diagnoses included bipolar disorder, intellectual disabilities, and chronic pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 had moderately impaired cognition. Review of the nursing progress note dated 06/27/25 revealed Resident #183 was cursing out Resident #72 calling her a 'fat expletive'. This nurse went to investigate the noise and Resident #183 called the nurse an expletive as well. Resident #183 cursing kept going on even when this nurse intervened. Resident #183 made Resident #72 cry. Review of the facilities investigation revealed it was not initiated until three days later on 06/30/25. The nursing progress note dated 07/30/25 revealed Resident #183 was verbally abusive towards residents in the dining area. Resident #183 used words like 'expletive you' and 'expletive' prompting immediate intervention from this nurse and the day shift nurse. Despite being asked to refrain from using such inappropriate language, Resident #183 got more angry and escalated his behavior using even more explicit language. Resident #183 eventually stopped and was escorted to his room to rest. The facility was unable to provide any investigation into the allegation of verbal abuse by Resident #183 on 07/30/25. Interview with the Administrator on 08/11/25 at 10:45 A.M. confirmed the investigation of the allegation of verbal abuse involving Residents #183 and #72 which occurred on 06/27/25 was not initiated until 06/30/25, three days after the incident occurred. The Administrator additionally confirmed no investigation had been completed for the allegation of verbal abuse by Resident #183 on 07/30/25. 2. Review of the medical record for Resident #6 revealed the resident was admitted on [DATE]. Diagnoses included alcoholic cirrhosis of the liver without ascites, permanent atrial fibrillation, chronic obstructive pulmonary disease (COPD), and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had severe cognitive impairment. Review of the nursing notes dated 12/23/24 documented an interdisciplinary team (IDT) meeting regarding an incident of physical aggression received on 12/21/24. The resident was observed with a bleeding nose and stated, He punched me. All involved parties were made aware, an assessment was completed by the floor nurse, and the immediate intervention was to move the resident to another room. The IDT agreed with the room change. The nursing progress notes dated 12/31/24 at 8:30 A.M. documented Resident #6 was found with bruising and skin tears to the face, blood on the face and bathroom floor, feces smeared on the body, and one gripper sock on foot with urine on the floor. The resident stated, I probably hit my head. Vital signs were stable. The nursing notes dated 01/02/25 documented an IDT meeting was held to address the bruising and skin tears. The injury was consistent with contact with the bathroom door, and a night light was ordered for the resident’s room. The facility was unable to provide any investigations into the physical aggression incident on 12/21/24 and any investigation into the injuries of unknown origin Resident #6 sustained. An interview conducted on 08/07/25 at 11:15 A.M. with the Administrator confirmed although injuries and an incident were documented, no formal investigation was initiated to determine the cause or to identify responsible parties. There was no evidence of staff interviews, injury assessments of other residents, or follow-up actions consistent with a proper abuse investigation. The Administrator acknowledged the facility failed to conduct a thorough investigation into the alleged abuse incidents involving Resident #6. Review of the facility policy titled Abuse Prohibition effective 10/14/22 revealed allegations by anyone who becomes aware of verbal, physical, mental, sexual or emotional abuse and mistreatment, neglect, exploitation, involuntary seclusion or misappropriation of property must be immediately reported to his/her Administrator. A preliminary, on-site investigation will be initiated within twenty-four (24) hours of any report.

Based on medical record review, observation, resident interview, staff interview and review of facility policy, the facility failed to obtain an audiology consult for a resident in a timely manner. This affected one (Resident #46) of four residents reviewed for ancillary services. The facility census was 209.Findings include: Review of the medical record for Resident #46 revealed an admission date of 11/12/18. Diagnoses included Parkinson's disease, dementia, and hearing loss. Review of Resident #46's care plan dated 06/05/19 revealed he had impaired communication related to mixed conductive and sensorineural bilateral hearing loss and that he wore hearing aids. Interventions listed was to check bilateral hearing aide placement and functioning and to refer to audiology for hearing consult. Review of Resident #46's audiology visit on 10/26/22 revealed he was recommended to wear daily hearing aids. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 had moderate cognitive impairment and had moderate difficulty with hearing, no hearing aid, and no behaviors or rejection of care. Resident #46's medical record from 01/01/25 to 08/04/25 did not indicate when Resident #46's hearing aides began to not work, when Resident #46 requested to see an audiologist, and any follow up by social services on getting Resident #46 to be seen by the audiologist. Interview and observation with Resident #46 on 08/04/25 at 12:29 P.M. revealed he was upset that his hearing aids did not work and that he wanted to see an audiologist. Resident #46 was not wearing his hearing aides at the time of the interview. Interview with Social Worker #751 on 08/06/25 at 11:42 A.M. revealed the facility obtained audiology consultations on an as needed basis. She stated that for Resident #46, she needed the Medicaid authorization form to be signed by Resident #46's physician prior to him seeing an audiologist. Social Worker #751 stated she received his authorization form in the summer, such as June or July; however, she confirmed she had not given the authorization form to the physician for a signature yet. She indicated that audiology had visited the facility two or three times since [NAME] 2024 and the physician had made regular facility visits since the summer, as well. Review of the facility policy titled Social Services Referral to Outside Providers dated 10/27/23 revealed for professional services such as hearing and other ancillary services, the social services/designee will make a referral to the outside service and provide demographics and signed consent as needed.

Based on record reviews, observations, staff interviews and review of facility policy, the facility failed to provide residents who had contractures their splint devices as physician ordered. This affected two (Residents #144 and 209) of four residents reviewed for range of motion. The facility identified 19 residents with contractures. The facility census was 209. Findings include: 1. Review of the medical record for Resident #144 revealed an admission date of 03/27/17 . Diagnoses included paralytic syndrome, polyneuropathy, and contracture right hand and wrist 10/01/18. Review of the physician orders dated 11/12/22 revealed Resident #144 was to have a right palm protector applied between 7:00 A.M. and 7:00 P.M. for up to eight hours daily. Review of Resident #144’s care plan dated 10/20/23 and last updated 08/07/25 revealed Resident #144 had a functional ability deficit and required assistance with self-care related to his contracture of his right hand and wrist. A goal was to improve of maintain current level of function in activities of daily living. A listed intervention was to apply right palm protector between 7:00 A.M. and 7:00 P.M. as tolerated for up to eight hours a day. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #144 had moderately impaired cognition and required substantial maximum assistance with upper body dressing and personal hygiene. Review of Resident #144’s comprehensive nursing quarterly assessment dated [DATE] revealed Resident #144 had a decreased range of motion. Observations on 08/04/25 at 12:09 P.M. and 5:15 P.M., 08/05/25 at 7:23 A.M, 10:33 A.M, and 2:29 P.M., and on 08/06/25 at 9:06 A.M. revealed Resident #144 was not wearing his palm protector. An interview with Licensed Practical Nurse (LPN) #630 on 08/06/25 at 9:55 A.M. confirmed Resident #144 was not wearing his palm protector as ordered. LPN #630 stated the restorative aide, Certified Nursing Aide (CNA) #825 was responsible for applying the palm protector for Resident #144. An interview with CNA #825 on 08/06/25 at 10:25 A.M. revealed she did not ever apply the palm protector to Resident #144’s hand. CNA #825 indicated that perhaps the other restorative aide, CNA #885, applied the palm protector to Resident #144. An interview with CNA #885 on 08/06/25 at 10:57 A.M. revealed she did not apply the palm protector to Resident #144 and that the direct daily care CNAs on Resident #144’s hall were responsible for applying the palm protector. 2. Record review for Resident #209 revealed the resident was admitted to the facility on [DATE]. Diagnoses included contracture of the left hand and left elbow, and hemiplegia and hemiparalysis affecting the left non-dominant side. Review of the active physician's order, dated 08/22/23, revealed to apply left c-roll splint for six hours between 7:00 A.M. and 3:30 P.M. Check skin upon removal. Review of the care plan, revised 04/16/25, revealed Resident #209 had a functional ability deficit and required assistance with self care/mobility. Apply left c-roll splint for six hours between 7:00 A.M. and 3:30 P.M. as tolerated. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/25/25, revealed Resident #209 had moderately impaired cognition and a functional limitation in range of motion to one upper extremity. Observations on 08/04/25 at 10:40 A.M. and 2:05 P.M. revealed Resident #209 was lying in bed and the resident's left hand and elbow were contracted with no splints or other devices in place. Subsequent observations on 08/05/25 at 8:10 A.M., 10:15 A.M., and 1:40 P.M. revealed Resident #209 was lying in bed and the resident's left hand and elbow were contracted with no splints or other devices in place. Observation and interview on 08/05/25 at 4:00 P.M. with Certified Nursing Assistant (CNA) #125 confirmed Resident #209 had a contracture of the left hand and used to have a splint but did not anymore and had not had one in place on the day of the observation. Observation on 08/06/25 at 10:02 A.M. revealed Resident #209 was lying in bed and the resident's left hand and elbow were contracted with no splints or other devices in place. Review of the facility policy titled Brace and Splint Program effective 05/01/24 revealed properly used, splints and braces can enhance mobility, correct alignment, and protect a specific extremity while maintaining skin integrity and circulation.

Based on observation, record review, staff interviews, and facility policy review, the facility failed to complete a thorough fall investigations, failed to ensure residents had adequate footwear to prevent accidents, and failed to appropriately secure the resident's smoking materials. This affected three (Residents #70, #84, and #110) of 12 residents reviewed for accidents. The facility census was 209. Findings include: 1. Review of the medical record for Resident #84 revealed a re-admission date of 12/20/24. Diagnoses included Alzheimer’s disease with late onset, dementia, and osteopenia. Review of the fall risk assessment dated [DATE] revealed Resident #84 was at risk for falls. Review of the plan of care dated 05/17/24 revealed Resident #84 was at risk for falls due to impaired cognition and mobility limitations. Interventions included providing adequate lighting, keeping call light and commonly used items within reach, placing the call light within reach and encouraging the resident to use it for assistance, anticipating and meeting needs as needed, observing for fatigue and unsteadiness and encouraging rest periods as needed, and orienting the resident to surroundings as needed. Review of physician orders for December 2024 identified orders related to fall prevention and management of injuries sustained from the fall. Orders included pain management with acetaminophen as needed for pain relief following the right hip fracture diagnosed post-fall. Mobility orders continued to support the use of a walker and wheelchair for locomotion after the resident returned from the hospital on [DATE]. Review of the nursing notes dated 12/13/24 at 7:30 P.M. revealed Resident #84 was found on the floor in her room with the lights off, complaining of right hip pain and rated it a seven on a pain scale of zero (no pain) to ten (most severe pain). The care plan was immediately adjusted to ensure room lighting remained on. A telehealth note dated 12/14/24 reported an acute right hip fracture diagnosed by X-ray after the fall, with the resident transferred to the hospital for further management. Notes dated 12/16/24 and 12/23/24 documented interdisciplinary team (IDT) meetings addressing the fall and the resident’s return from the hospital, agreeing to continue walker and wheelchair use. Review of the fall investigation dated 12/13/24 revealed the resident had turned off the lights in her room, contributing to the fall. The immediate intervention was to ensure adequate lighting. However, the investigation did not include interviews of staff to determine the root cause of the fall or any additional contributing factors. The care plan was not updated to reflect the use of walker and wheelchair as fall prevention interventions following the resident’s return. The facility failed to comprehensively investigate the fall or modify interventions appropriately. Review of the hospitalization after visit summary (AVS) for Resident #84 revealed an admission date from 12/14/24 to 12/20/24. Resident #84 sustained a fall and was found to have an acute right hip fracture. The x-ray presented a displaced subtrochanteric fracture of the right proximal femur. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/08/25, revealed Resident #84 had severely impaired cognition and required maximum assistance for toileting, bathing, chair-to-chair transfers, and toilet transfers; moderate assistance for upper extremity dressing, personal hygiene, rolling left to right, sitting to lying, sit to stand, and walking 10 feet; was dependent on staff for putting on and removing footwear; and used a walker and wheelchair for locomotion. Interview on 08/07/25 at 3:29 P.M. with the Director of Nursing stated she was unsure if the resident was asked what she was attempting to do at the time of the fall. She confirmed the interdisciplinary team met post-return and decided to continue walker and wheelchair use but did not add these to the care plan. She also confirmed the intervention to maintain adequate lighting was not new, having been in place since May 2024, and the lights being off contributed to the fall. Interview on 08/07/25 at 3:46 P.M. with the Unit Manager #140 confirmed the resident used a wheelchair for ambulation requiring staff assistance and the resident slept with the lights off in her room at night. 2. Review of the medical record for Resident #110 revealed an admission date prior to 04/15/25. Diagnoses included dementia, unsteadiness on feet, muscle wasting and atrophy, and agitation managed with olanzapine. Review of the plan of care dated 03/29/25 revealed Resident #110 was at risk for falls due to unsteadiness, muscle weakness, and cognitive impairment. Interventions included encouraging the resident to wear appropriate footwear as needed and maintaining a safe environment with even floors free from spills and clutter. On 04/28/25, a new intervention was implemented to include the resident’s non-skid socks were replaced with a new pair. Review of the nursing notes dated 04/26/25 at 9:30 P.M. revealed Resident #110 was found kneeling in front of the bed with a small skin tear above the right eyebrow and bruising to the right cheekbone and nose bridge after an unwitnessed fall. The resident reported slipping while coming from the bathroom, slipping on the floor with non-slip socks whose grips appeared worn and inadequate. Neurological checks were initiated, pain medication administered, and the socks were replaced with new ones. Review of the fall investigation dated 04/28/25 revealed the cause of the fall was attributed to worn non-slip socks that lacked sufficient grip. Immediate intervention included replacing the socks. The care plan continued to reflect fall prevention strategies but did not specifically address routine inspection or replacement of footwear provided by the facility. Interview on 08/07/25 at 1:42 P.M. with the Director of Nursing stated the root cause of the fall was the resident’s worn non-skid socks. She confirmed the facility provided the socks, which were shared and cleaned between residents, but staff did not routinely check the condition of the socks prior to applying them. She confirmed the only new intervention after the fall was replacing the socks with a new pair. Review of the facility policy titled Fall Management last revised on 07/08/2025 revealed the policy aimed to identify hazards and resident risk factors and implement interventions to minimize falls and risk of injury related to falls. It outlined an overview where residents were assisted in attaining and maintaining their highest practical level of function by providing adequate supervision, assistive devices, and/or functional programs, with appropriate interventions to minimize fall risk. Residents were evaluated by the interdisciplinary team for their fall risk, and a plan of care was developed and implemented with ongoing review. If a fall occurred, the interdisciplinary team conducted an evaluation to ensure appropriate measures were in place, coordinated by the Director of Nursing or designee. Practice guidelines included evaluating residents for fall risk upon admission, re-admission, quarterly, annually, and with significant condition changes, developing an initial plan of care, evaluating for injury post-fall, completing incident reports, and conducting post-fall evaluations within 24 to 72 hours. The interdisciplinary team reviewed all falls, modified care plans, and conducted monthly reviews, while the Director of Nursing or designee documented changes and reported data to the Quality Assurance and Performance Improvement (QAPI) committee for trending and recommendations. 3. Review of medical record for Resident #70 revealed an admission date of 11/08/24. Diagnoses included peripheral vascular disease, right and left above knee amputations, and muscle wasting. Review of the care plan dated 10/27/24 revealed Resident #70 wished to use smoking products and was assessed as being unsafe to smoke and needed supervision. The goal was listed to be safe while using smoking products and complying with the smoking policy. An intervention listed was that staff members were to maintain all smoking paraphernalia for all safe and unsafe smokers, including lighters. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #70 was cognitively intact, had rejection of care for one to three days during the assessment period, and utilized tobacco. Resident #70 required substantial to maximum assistance from staff for personal hygiene and partial to moderate assistance with oral hygiene. Review of Resident #70’s smoking assessment dated [DATE] revealed Resident #70 required supervision during smoke break related to his hands having contractures and weakness. Resident #70 was not safe to light smoking materials and did not utilize not oxygen. Resident #70 was not a safe smoker. Review of Resident #70’s physician orders dated 06/24/25 revealed Resident #70 had an order for oxygen at six liters to maintain an oxygen level above 88 percent (%) every shift for shortness of breath as needed. Observations of Resident #70 on 08/04/25 at 10:13 A.M., 12:26 P.M., and 2:50 P.M. revealed Resident #70 had two lighters with liquid visible in them at his bedside within reach on his bedside table. Interview with Nursing Administration #130 on 08/04/25 at 2:53 P.M. confirmed the presence of two lighters within reach of Resident #70 at his bedside. Interview with Activity Aide #211 on 08/05/25 at 4:25 P.M. and with Activity Aide #191 on 08/11/25 at 8:24 A.M. revealed even safe smokers were unable to keep lighters or other smoking paraphernalia on their person. All smoking materials were to be locked up in a smoking lock box. Review of the facility policy titled “Smoking Policy” dated 06/17/25 revealed staff members will maintain all smoking paraphernalia for all safe and safe smokers, including lighters and lighter fluid. This deficiency represents non-compliance investigated under Complaint Number OH00167527 (1260015).

Based on record review, staff interview, and facility policy review, the facility failed to consistently evaluate the effectiveness of regularly scheduled opioid pain medication in accordance with the resident's comprehensive care plan. This affected one (#159) of five residents reviewed for unnecessary medications. The facility census was 209. Findings include:Review of Resident #159's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included fibromyalgia (long-term condition that involves widespread body pain) and polyarthritis (a form of arthritis affecting five or more joints simultaneously, causing pain, swelling, warmth, and stiffness). Review of the physician order summary dated 03/04/25 revealed Resident #159 had an order for Tramadol (an opioid and treats moderate to severe pain) 50 milligrams (mg) give one tablet by mouth two times a day for polyarthritis. Review of the care plan dated 06/29/25 revealed Resident #159 was at risk for chronic pain and the interventions included evaluate the effectiveness of pain medication as given and review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition as needed. Review of the medication administration record (MAR) from 07/01/25 to 08/11/25 for Resident #159 revealed an order for Tramadol HCL oral tablet 50 mg, give one tablet by mouth two times a day for polyarthritis, scheduled at 8:00 A.M. and 8:00 P.M. There was no pain scale and effectiveness of the medication in association with the administration of Tramadol in the MAR, treatment administration record (TAR), and progress notes. Review of Resident #159's Pain Level Summary from 05/11/25 to 08/11/25 revealed there were no records of a pain level during this time. An interview with Registered Nurse (RN) #660 on 08/11/25 at 9:19 A.M. verified there was no pain scale in Resident #159's MAR or medical record. RN #660 stated that most of the residents have a pain scale and verified there was no documentation the staff were monitoring the effectiveness of Tramadol for Resident #159. An interview with Certified Nurse Practitioner (CNP) #51on 08/11/25 at 9:27 A.M. confirmed any resident receiving scheduled Tramadol should be assessed for pain every time it was given and then evaluated for effectiveness of the Tramadol. Review of the facilities Pain Management policy last revised 3/05/25 revealed each resident identified with pain will have a pain management care plan. The care plan will have: a consistent pain scale to measure the pain and frequency of re-evaluation, a desired level of pain reduction or acceptable level of pain, resident-centered functional outcomes (e.g., ability to participate in favorite activity, visiting with family, ambulating to the dining room, sleeping through the night), pain monitoring and who will monitor for the pain, nursing comfort measures to alleviate pain, and potential adverse effects of treatment.

Based on medical record review, resident and staff interviews, and review of facility policy, the facility failed to identify post traumatic stress disorder (PTSD) triggers on the care plan for Resident #48 and failed to assess Resident #8 for PTSD upon admission. This affected two (Residents #8 and #48) of five residents reviewed for mood and behavior. The facility census was 209.Findings include: 1. Review of the medical record for Resident #48 revealed an admission date of 06/17/25. Diagnoses included PTSD, anxiety disorder, and depression. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #48 was cognitively intact and did not have behaviors. Review of the social services evaluation dated 06/27/25 revealed Resident #48 had experienced a loss of a significant other and a traumatic event of a motor vehicle accident with mass casualties. Symptoms due to her PTSD included flashbacks, hypervigilance, fear, severe anxiety, loneliness and unwanted thoughts. Triggers included people, thoughts and feelings. Review of the care plan dated 07/04/25 revealed Resident #48 had potential for fluctuations in mood due to PTSD. A goal listed was to have stable or improved mood and no signs of symptoms of anxiety. Interventions included administering medications as ordered, approaching in a calm, quiet manner, assisting in developing an activity program, assisting resident to identify coping skills, encouraging resident to verbalize feelings, and observing and reporting to social worker and/or physician when resident has acute change in mood or behavior or when resident is at risk for harm to self. The care plan did not identify any triggers that may help caregivers to not be re-traumatized. Interview with Social Worker #771 on 08/06/25 at 9:23 A.M. confirmed Resident #48’s care plan did not include identified triggers that may re-traumatize Resident #48. 2. Review of the medical record for Resident #8 revealed an admission date of 06/02/25. Diagnoses included surgical amputation, chronic obstructive pulmonary disease , alcoholic cirrhosis of liver, and end stage renal disease. Review of Resident #8's medical record from 06/02/25 to 08/11/25 revealed no indication Resident #8 was accessed for PTSD. An interview on 08/04/25 at 2:28 P.M. with Resident #8 stated he was sad and very depressed. Resident #8 stated he lost his only child (son) to suicide on Easter, April 2025 and recently had his right leg amputated, becoming a bilateral amputee of both legs losing his independence. He denied being suicidal and asked if he could talk to someone. Interview on 08/12/25 at 9:30 A.M. with Social Service Designee #771 confirmed there was no PTSD assessment completed for Resident #8. She was unaware of him losing a son in April of 2025. Review of the facility policy titled “Social Service Documentation” dated 08/01/24 revealed the facility is committed to providing culturally competent, trauma informed care in accordance with professional standards of practice and accounting for residents’ experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. If trauma is identified, care plans to address the trauma, including triggers and interventions to mitigate or lessen re-traumatization will be authored.

Based on observation, review of Food and Drug Administration (FDA) guidance, and staff interviews, the facility failed to ensure medications were properly stored. This affected two of six medication carts observed. The facility identified 11 medication cart in the facility. This affected three residents (#33, #53, and #237). The facility census was 209.Findings include:1. Observation of the 500-hall medication cart on 08/07/25 at 9:30 A.M. revealed an unopened bottle of Chlorhexidine (a topical antiseptic) labeled for Resident #33 with the expiration date of February 2025.Interview with Unit Manager #110 on 08/07/25 at 9:32 A.M. verified the Chlorhexidine was expired.2. Observation of 400-hall medication cart on 08/07/25 at 10:00 A.M. revealed a vial of Novolin 70/30 (insulin) with an open date of 06/27/25 for Resident #237. There was also a Lantus (insulin) pen without an open date for Resident #53.Interview with Licensed Practical Nurse (LPN) #530 on 08/07/25 at 10:02 A.M. verified the vial of Novolin 70/30 should have been discarded after 30 days. LPN #530 added Resident #237 had been discharged from the facility. LPN #530 verified the Lantus pen was in the medication cart and there was no open date and there should be an open date.Review of the FDA guidance for insulin vials and Lantus pens dated 09/19/17 revealed insulin may be left unrefrigerated for up to 28 days.

Based on observation, staff interview, record review, review of Centers for Disease Control and Prevention (CDC) guidance and review of facility policy, the facility failed to ensure staff followed Enhanced Barrier Precautions (EBP) in designated resident rooms. This affected one (Resident #10) of four residents reviewed for EBP. The facility census was 209. Findings included:Review of the medical record for Resident #10 revealed an admission date of 07/15/21. Diagnoses included chronic obstructive pulmonary disease. Review of Resident #10's physician orders for 08/01/25 to 08/11/25 revealed an active order for Resident #10 to be on EBP related to chronic wound. Observation on 08/05/25 at 2:40 P.M. revealed Certified Nursing Assistant (CNA) #115 assisting Resident #10 at the bedside with gloves on. He went into the resident's bathroom and exited out of the room with gloved hands. CNA #115 was not wearing a gown during provision of care. Interview on 08/05/25 at 2:42 P.M. with CNA #115 confirmed he performed incontinence care for Resident #10 with gloves only. CNA #115 confirmed he did not wear a gown as indicated by the EBP sign outside Resident #10's room. Observation on 08/05/25 at 3:52 P.M. of Resident #10 who resided in bed B revealed outside of her room to the right of her door were two signs for EBP for bed A and Resident #10 bed B. The sign indicated providers and staff must clean their hands, including before entering and when leaving the room, wear gloves and a gown for the following activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting. Device care or use central line, urinary catheter, feeding tube, tracheostomy and wound care (any opening requiring a dressing). Review of the facility policy titled “Enhanced Barrier Precautions (EBP)” dated 03/05/25 revealed the facility is to use EBP in addition to standard precautions for preventing transmission of CDC targeted multidrug-resistant organisms (MDROs). EBP are indicated for residents with chronic wounds. Health care personnel caring for residents on EBP should wear gloves and gowns during high-contact resident care such as dressing, bathing showering, transferring providing hygiene(focused on A.M. and P.M. care) changing linens, changing briefs or assisting with toileting, device care or use, central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care: chronic wounds. Review of CDC guidance titled Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) found at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html and dated 04/02/24 revealed MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status.

Based on observations, medical record review, staff interview, and review of the facility policy, the facility failed to ensure the call light was positioned within reach of a resident. This affected one (#15) of 51 residents observed for call light placement. The facility census was 209. Findings include:Medical record review revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included fracture of unspecified part of neck of left femur, dementia, psychotic disturbance, mood disturbance, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had impaired cognitive function and required substantial, maximal assistance with mobility. Review of Resident #15's plan of care, dated 06/02/25, revealed Resident #15 had an Activities of Daily Living (ADL) functional deficit, and required substantial to maximal assistance with all self-care. Interventions for Resident #15 included encourage the resident to use bell/call light to call for assistance. Observations on 08/04/25 at 10:20 A.M. and 11:11 A.M. revealed Resident #15 was sleeping in bed and propped on his right side. Resident #15's call light was hanging on the wall and was not within resident's reach. At 12:10 P.M., Resident #15 was in bed propped on his right side and the call light still hanging on wall out of his reach. Observation and interview on 08/04/25 at 1:48 P.M. with Licensed Practical Nurse (LPN) #670 confirmed Resident #15 was lying in his bed and his call light was hanging on the wall out of his reach. Observations on 08/05/25 at 7:25 A.M., 12:29 P.M., and 2:05 P.M. revealed Resident #15 was in his bed and the call light on the floor at the foot of his bed. Observation and interview on 08/05/25 at 3:38 P.M. with LPN #960 confirmed Resident #15 was propped on right side and his call light lying on the floor at the foot of his bed. Observations on 08/07/25 at 8:52 A.M. and 2:16 P.M. revealed Resident #15 was lying in bed with his call light hanging on wall and out of reach of the resident. Observation and interview on 08/07/25 at 2:16 P.M. with Registered Nurse (RN) #330 confirmed Resident #15 was lying in bed and his call light hanging on the wall out of his reach. Observation and interview on 08/07/25 at 4:26 P.M. with LPN #730 confirmed Resident #15 was lying in his bed with his call light on the floor and out of his reach. Review of the call light policy last revised 03/12/25 revealed call lights will be placed within the resident's reach and answered in a timely manner.

Based on record review, observation, resident and staff interview, and policy review, the facility failed to provide personal privacy to the residents. This affected one (Resident #48) of 51 residents reviewed for privacy. The facility census was 209. Findings include: Review of the medical record for Resident #48 revealed an admission date of 06/17/25. Diagnoses included post traumatic stress disorder, anxiety disorder, and depression. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #48 had intact cognition. Observation of the door to Resident #48's room on 08/04/25 at 10:32 A.M. and 08/06/25 at 1:45 P.M. revealed the door to the Resident #48's room entrance would not close. Interview with Resident #48 on 08/04/25 at 10:45 A.M. stated she was upset that her door would not close because she wanted privacy at times. Review of ninety-days of maintenance work orders revealed there were no work orders to repair the door had been made. Interview with Maintenance #811 on 08/06/25 at 1:50 P.M. confirmed he knew about the door not closing prior to this survey. He called another maintenance employee to fix it as soon as possible. Review of the facility policy titled Federal and State- Resident Rights and Facility Responsibilities dated 05/14/24 revealed the resident has the right to personal privacy.

Based on closed medical record review, hospital record review, review of facility policy and interview, the facility failed to ensure Resident #215 received adequate, timely and necessary care and services to prevent an acute change in condition related to hypokalemia (decreased potassium) level. Actual Harm occurred beginning on 10/25/24 at 3:33 P.M. when Resident #215's laboratory results reflected a low potassium level of 3.0 mmol/L (normal range 3.5 -5.0) (indicative of hypokalemia) which went unreviewed and unaddressed by facility staff. On 10/28/24 Resident #215 began to experience shortness of breath and required supplemental oxygen. On 10/30/24 Resident #215's heart rate was noted to be between 41 and 46 beats per minute (low/bradycardic) and the resident informed staff his automated implanted cardioverter defibrillator (AICD) had alarmed. On 10/31/24 at 7:30 A.M. Resident #215 was noted to have a change in condition including a new irregular pulse with a listed heart rate of 46 (bradycardic), generalized weakness, and signs of delirium. Resident #215 was sent to a local emergency department where he was assessed to have chest pain with an abnormal heart rhythm of Ventricular Tachycardia (VT) and required multiple defibrillations to return to a normal heart rate and rhythm. The hospital records indicated Resident #215's VT was likely precipitated by his significant hypokalemia (low blood potassium) which was listed as 2.6 mmol/ml upon arrival to the emergency department. Resident #215 was subsequently admitted to the hospital and did not return to the facility. This affected one resident (#215) of three residents reviewed for quality of care/emergency care. The facility census was 215. Findings include: Review of the closed medical record for Resident #215 revealed an admitted [DATE]. Medical diagnoses included chronic systolic and diastolic heart failure, chronic obstructive pulmonary disease, type two diabetes, chronic respiratory failure, chronic kidney disease, paroxysmal atrial fibrillation, and encounter for adjustment and management of automatic implantable cardiac defibrillator. Resident #215 was transferred to a local hospital on 10/31/24 and did not return to the facility. Review of Resident #215's hospital discharge notes dated 10/22/24 revealed the resident had a scheduled visit with the cardiologist on 11/06/24. The hospital indicated he had recommended outpatient testing which included obtaining a Basic Metabolic Panel (BMP) and magnesium level in three to five days. Review of Resident #215's physician orders dated 10/24/24 revealed an order to draw a BMP on 10/25/24 and fax the results to the resident's cardiologist. A fax number for the provider was included in the order. Review of Resident #215's BMP result dated 10/25/24 revealed the laboratory specimen was collected that day at 10:20 A.M. The results were reported on 10/25/24 at 3:33 P.M. and revealed his potassium level was low at 3.0 mmol/L. Review of Resident #215's progress notes dated 10/25/24 to 10/31/24 revealed no evidence the physician was notified of the lab results. Review of Certified Nurse Practitioner (CNP) #304's progress note dated 10/29/24 revealed no evidence she was aware of Resident #215's 10/25/24 laboratory result. CNP #304's note referenced labs from the hospital on 10/22/24. The note included Resident #215 had an episode of his defibrillator firing; she suggested an appointment with cardiology and the resident agreed. Review of Resident #215's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #215's progress notes dated 10/30/24 revealed the residents heart rate that morning had been ranging from 41 to 46 beats per minute (BPM), cardiology was contacted, and a message was left. The resident reported to the nurse that his defibrillator had alarmed and needed to be inspected. The nurse placed another call to the resident's cardiologist and an appointment was scheduled for the following day (10/31/24). The physician and resident were informed, and Resident #215 stated he had been feeling better. Review of a change of condition progress note dated 10/31/24 revealed the resident had a new irregular pulse with a listed heart rate of 46, generalized weakness, and signs of delirium. The progress note indicated the provider had been contacted and ordered Resident #215 to be transferred to a local emergency department. Review of Resident #215's hospital record dated 10/31/24 revealed upon arrival to the emergency department, the resident was found to have chest pain with VT and required multiple defibrillations to return to a normal heart rate and rhythm. The hospital records indicated they were able to interrogate the resident's AICD which reflected the resident was defibrillated six times the night prior (10/30/24) for VT. Resident #215's VT was likely precipitated by his significant hypokalemia which was listed as 2.6 mmol/ml upon arrival to the emergency department. Resident #215 was administered potassium supplements and was subsequently admitted to the hospital for laboratory monitoring and cardiology consultation. Resident #215 did not return to the facility. Interview on 11/26/24 at 9:38 A.M. with Registered Nurse (RN) #300 revealed abnormal laboratory results should be reported to the physician. The laboratory only notified the nurses of critical labs, otherwise, nursing needed to check for results. Interview on 11/26/24 at 10:22 A.M. and 11:41 A.M. with Unit Manager #305 revealed the CNP or physician should be notified of all lab results. She reported she spoke to the nurse who put the order for the BMP and the nurse could not recall where the order came from and did not think it was the facility physician. The nurse was also unsure why the results needed to be faxed to the cardiologist. Unit Manager #305 stated she thought the order came from the hospital when he admitted , so the in-house provider did not know to look for results. Unit Manager #305 verified there was no indication anybody reviewed the results or faxed them to the cardiologist. Interview on 11/26/24 at 11:49 A.M., 12:25 P.M., and 2:05 P.M. with the Director of Nursing (DON) revealed she believed Resident #215's BMP was to be completed in preparation for his cardiology appointment on 11/07/24. She verified there was no evidence his BMP was reviewed in the facility and was aware his 10/31/24 hospitalization involved a low potassium level (hypokalemia). The DON verified as far as nursing staff were aware, as of 10/29/24, the resident's defibrillator only went off once so an appointment with cardiology was made. However, the night of 10/30/24 into the morning of 10/31/24 it went off multiple times, so the night nurse called the on-call physician who agreed to send the resident to the hospital. Review of the facility policy 'Notification of change' dated 02/14/24 revealed the facility must inform the resident, consult with the resident's practitioner, and notify the representative when there is a change in status. A change in status included a need to alter treatment significantly or a significant change in the resident's physical, mental, or psychosocial status. This deficiency represents non-compliance investigated under Complaint Number OH00159685.

Based on medical record review, wound notes review, staff interview, hospital paperwork review, and facility policy review, the facility failed to ensure wound care orders were in place, as well as ensure comprehensive wound measurements were completed for Former Resident #300 upon readmission to the facility. Actual Harm occurred when Former Resident #300 was found to have maggots in a pre-existing wound to the left calf/foot area and was admitted to the hospital with a gangrenous left foot with maggot infestation and severe pain. This affected one (Former Resident #300) of three residents reviewed for wound care. The facility census was 201. Findings include: Review of the closed medical record for Former Resident #300 revealed an original admitted [DATE] with a readmitted [DATE]. Former Resident #300 was discharged to the hospital on 07/28/23 and had a final discharge date of [DATE]. Diagnoses included end stage renal disease, acute osteomyelitis of the left ankle and left foot, chronic pain, and peripheral vascular disease. Review of Former Resident #300's 5-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating moderately impaired cognition for daily decision-making abilities. Former Resident #300 required extensive assistance from two staff members for bed mobility, toilet use, and personal hygiene, and required total dependence on two staff members for transfers. Former Resident #300 was noted to experience impairment to one of their lower extremities and required the use of a wheelchair for mobility. Former Resident #300 was noted to have one venous and one arterial ulcer as well as surgical wounds upon admission to the facility. Review of the plan of care dated 05/12/23 and revised 06/16/23 revealed the Former Resident #300 has actual impairment to their skin integrity related to a surgical wound with dehiscence to the left groin requiring a wound vac, surgical wound to the upper right arm, surgical wound to groin, and arterial ulcer to the left heel, and abrasion to the right hand between the 4th and 5th digit. Interventions included administering medication as ordered, apply pressure reducing mattress to protect skin while in bed, conduct weekly head to toe assessments, encourage good nutrition, follow facility protocols for treatment of injury, observe for signs and symptoms of infection of area, observe location, size and treatment of skin injury, report abnormalities, failure to heal signs and symptoms of infection maceration, treatment to skin impairment as ordered, and to turn and reposition every care round and as needed. Review of the treatment orders for Former Resident #300's left calf/foot revealed a wound treatment order dated from 07/20/23 to 07/25/23 to cleanse the arterial wound to the left leg/foot with normal saline, pat dry and apply Betadine. Apply an abdominal (ABD) pad and wrap with Kerlix daily. Further review of the treatment orders revealed a wound treatment order dated from 07/29/23 through 08/01/23 to cleanse the arterial wound to the left lateral leg/heel with normal saline, pat dry and apply Betadine. Then apply an ABD pad and wrap with Kerlix daily. Review of Former Resident #300's treatment orders put in place upon return to the facility from hospital stay from 07/23/23 through 07/25/23 revealed the following orders: -Cleanse the left anterior upper surgical wound with normal saline, apply a non-adherent gauze and secure with border gauze every day. The order had a start date of 07/26/23 and discontinue date of 07/28/23. -Cleanse left upper leg surgical wound with normal saline, pat dry and apply Silver Alginate. Cover with foam dressing daily. The order had a start date of 07/26/23 and discontinue date of 07/28/23. -Clean right groin with normal saline, apply a non-adherent gauze, apply bandage every day and as needed. The order had a start date of 07/26/23 and discontinue date of 07/28/23. -Cleanse arterial wound to the right heel with normal saline, pat dry and apply Betadine then apply an ABD pad and wrap with Kerlix daily. The order had a start date of 07/26/23 and discontinue date of 08/01/23. Review of the progress note, created by Unit Manager #10, dated 07/21/23 at 1:50 P.M. revealed resident (Former Resident #300) was seen this date by the wound care nurse for wounds to left thigh, left heel, left foot, right heel and bilateral heels. The left heel and left foot wounds had merged creating one large wound. The left dorsum foot wound was resolved out in the electronic chart, and the evaluation and measurements were combined with the left heel. The note indicated to continue current treatment orders. The treatments were completed by the wound care nurse. There was no increased pain or discomfort noted. Review of progress note dated 07/23/23 at 6:30 P.M. created by Registered Nurse (RN) #30 revealed, resident (Former Resident #300) had a change in the level of condition and was confused and disorientated, unable to answer questions appropriately, and was experiencing failure to thrive. Resident (Former Resident #300) was not eating meals or drinking fluids. Vital signs were within normal limits. Resident's (Former Resident #300) left eye and left arm were swollen, and the left side of the face was drooping showing characteristics of a stroke. Resident (Former Resident #300) was sent out to the hospital for further evaluation per orders. Review of the progress note dated 07/25/23 at 3:00 P.M. created by Licensed Practical Nurse (LPN) #20 revealed that resident (Former Resident #300) arrived via EMS (Emergency Medical Services) from the hospital, was alert and oriented, a head-to-toe assessment was done, and Former Resident #300 had a wound on the bilateral heel, wound to the left groin, wound to the anterior upper right thigh, open area to the left elbow, and the sacrum was open to air. Review of Former Resident #300's re-entry Nursing Comprehensive Evaluation dated 07/25/23 revealed the resident currently had skin conditions including the groin area, left thigh (front), left elbow, coccyx, left gluteal fold, right heel, and left heel. Description of each wound had not been completed including wound type, size, or tissue type. Review of the progress note dated 07/28/23 at 1:28 P.M. created by Unit Manager #40 revealed, the resident (Former Resident #300) was seen by the wound care nurses for a surgical wound to left and right groin, medial left thigh, right dorsum foot, right heel, and left heel which had extended to the left lateral calf. While assessing the left lateral calf/heel, this RN (Registered Nurse) wound care nurse noticed the presence of maggots, and the resident (Former Resident #300) was recently readmitted from the hospital and was started on Cipro (an antibiotic) 500 milligrams (mg), and Metronidazole (antibiotic) 500 mg for wound infection. Unable to get measurements of the left lateral leg/heel due to pain and the presence of maggots. New orders were received to send the resident (Former Resident #300) out to the hospital for surgical debridement. All treatments were provided with complaints of pain noted to be at a nine out of 10 on the numeric pain scale in the left lateral leg/heel. Review of the hospital Emergency Department note dated 07/28/23 revealed the resident (Former Resident #300) presented for evaluation of a worsening foot wound/necrosis with increased pain and presence of maggots noted within the wound. Clinically, the resident (Former Resident #300) had significant necrosis of the bilateral feet which was worse on the left with maggots, increased pain, and worsening wound. The resident (Former Resident #300) required admission to hospital for treatment with intravenous (IV) antibiotics and possible amputation. Interview on 08/15/23 at 11:32 A.M. with Unit Manager #40 confirmed Former Resident #300 had an arterial wound to the left foot and left calf area that had joined together to form one large wound. Former Resident #300 was seeing a wound clinic outside the facility, but wound measurements and assessment were still being completed every Friday. Unit Manager #40 claimed Former Resident #300's left foot had very poor circulation and her toes were fused together, and the foot was very hard to touch. This resident liked to wear socks or footies and was not known to remove her own dressing or have issues with the dressing falling off. Prior to coming to this facility, doctors had spoken to the resident and recommended an amputation of the extremity which she refused on multiple occasions. Unit Manager #40 claimed she even tried to speak to the resident about it, but the resident told her she did not want to discuss it because she was not having her foot cut off. Former Resident #300 had a diagnosis of chronic pain but never complained of pain in the left foot. The nursing staff was mainly responsible for completing wound care and dressing treatments. Unit Manager #40 verified Former Resident #300 was out of the facility from 07/23/23 through 07/25/23. When the resident returned to the facility, the floor nurse would have been the one who completed the comprehensive nursing assessment along with the skin/wound assessment. Unit Manager #40 claimed she did not physically see Former Resident #300 until that following Friday (07/28/23) which was this resident's regular scheduled wound assessment day. When she completed her assessment on 07/28/23, she reviewed the orders that were put in place and made the appropriate changes that were needed. Maggots were identified in the wound on Former Resident #300's calf/left foot during her wound assessment on 07/28/23. Unit Manager #40 claimed when she removed the old bandage from this resident's left calf/leg, and it was dated 07/26/23. Unit Manager #40 claimed that most likely the nurse who was working when Former Resident #300 was readmitted to the facility from the hospital put her wound treatment orders in, and she likely went from orders this resident had in place prior to going out to the hospital. Unit Manager #40 confirmed no measurements or assessments were completed for Former Resident #300's multiple wounds until she observed the wound three days after being readmitted from the hospital. Interview on 08/15/23 at 12:44 P.M. with RN #30 revealed she was the nurse who was working on 07/26/23 and was the one who completed the dressing change on Former Resident #300's left calf/leg. RN #30 confirmed this resident's treatment orders did not include a treatment order for her left calf or foot, but she completed this treatment anyway because she was aware of this resident's wound history. RN #30 also claimed that when she was reviewing Former Resident #300's treatment orders, she did see there were orders for treatments to the resident's upper thigh, and one was for a non-adherent dressing and the other was for silver alginate so she just figured one of them was for the left calf/foot but did not report this conflicting order to anyone or have the order clarified. Interview on 08/15/23 at 12:55 P.M. with the Director of Nursing (DON) confirmed when Former Resident #300 returned from the hospital, her After Visit Summary did not have any treatment orders listed in the discharge orders for staff to go from or follow. The admitting nurse would go off the resident's previous treatment orders and then once the wound nurse saw the resident, which was normally within 24 hours of admission or readmission, any needed changes would be made. Review of facility's policy titled Skin Management, revised 07/14/21, revealed Guest/residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal guest/resident outcomes. Upon admission-re-admission all guest/residents are evaluated for skin integrity by completing a baseline total body skin evaluation documented in the electronic medical record. Appropriate preventative measures will be implemented on guest/residents identified at risk and the interventions are documented on the care plan. This deficiency represents noncompliance investigated under Complaint Numbers OH00145300, OH00145302 and OH00145148.

Based on medical record review, hospital record review, facility policy review and staff interview, the facility failed to ensure Resident #186 was appropriately assisted during a shower resulting in an avoidable fall. This resulted in Actual Harm when State tested Nurse Aide (STNA) #918 failed to utilize two staff to assist during a shower for Resident #186 and the resident rolled off the shower bed, falling onto the tiled shower floor resulting in Resident #186 fracturing her cervical spine and nose. This affected one (Resident #186) of three residents reviewed for accidents. The facility census was 187. Findings include: Review of the closed medical record for Resident #186 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included convulsions, muscle wasting and atrophy, [CONDITION(S)], borderline personality disorder, dementia, and [CONDITION(S)]. Review of the plan of care dated 01/21/22, revealed Resident #186 was at risk for falls related injury, related to balance problem, history of falls, and unaware of safety needs. Interventions included to assess for fall risk as needed and review the information on past falls and to attempt to determine the root cause of the falls. Review of the plan of care dated 03/17/22 revealed Resident #186 had a self-care performance deficit and required assistance with Activities of Daily Living (ADLs) and mobility related to fatigue, weakness, impaired balance, and pain. Interventions included to provide extensive assistance of two staff for bed mobility and transfers and bathing was noted to be dependent on two staff assistance. Review of the plan of care dated 04/19/22 revealed Resident #186 had behaviors related to [CONDITION(S)] disorder and intellectual disabilities as evidenced by screaming and yelling out and making false allegations against staff. Interventions included to always have two caregivers. Review of the Minimum Data Set 3.0 (MDS) assessment, dated 07/06/22, revealed Resident #186 required extensive assistance of two staff for bed mobility and transfers, and was dependent on staff for bathing. The most recent Brief Interview for Mental Status (BIMS) exam dated 05/20/22 revealed Resident #186 was cognitively intact. Review of the quarterly nursing fall risk assessment dated [DATE] revealed instructions for completing the assessment were printed above the first question. The instruction was as follows: If yes is selected for any question, the resident is at risk for falls. Resident #186 was noted to be not at risk for falls with score of zero even though several assessment questions were answered incorrectly. The assessment had several questions answered 'Yes revealing Resident #86 did have a history of falls, Resident #186 had a fear of falling, muscle weakness, decreased lower extremity joint function, balance deficit or gait deficit, Resident #186 took a medication that may increase falls (antiarrhythmics, anticholinergics, antidepressants, antiepileptics, antihypertensives, antiparkinsonian agents, antipsychotic medications, and benzodiazepines), and Resident #186 had impaired cognition, judgement, memory, safety awareness and/or decision-making capacity. A question was answered no incorrectly stating Resident #186 did not have a diagnosis of [CONDITION(S)]. Review of the nursing progress note dated 07/12/22, at 12:30 P.M. revealed Resident #186 was in the shower and trying to scratch her back and turned in the shower bed. The note revealed STNA #918 was trying to prevent Resident #186 from falling and the resident fell on top of STNA. An assessment was noted to be completed, with excoriation to Resident #186's forehead and left knee. The physician was notified and an order to send Resident #186 to the hospital was given. Resident #186 was noted to be taken by paramedics to the local hospital at 12:50 P.M. On 07/13/22, the progress note revealed the floor nurse called the local hospital and was informed Resident #186 was admitted to the hospital due to an abnormal computer tomography (CT) scan. Another progress note dated 07/13/22 revealed an interdisciplinary team (IDT) meeting was held and the post incident intervention was to have two staff assist Resident #186 in the shower room. Review of the hospital records dated 07/12/22 revealed Resident #186 had a traumatic fracture of the cervical spine and a closed fracture of the nasal bone. The records revealed an MRI was completed on 07/13/22 with an acute fracture visualized along the anterior osteophyte of C7 with the fracture line extending into the anterior inferior endplate of C7 extending into the C7-T1 disc space. Hemorrhage was seen tracking in between the fractured osteophyte and along the anterior aspect of the C7 vertebral body with hemorrhage tracking along the prevertebral space of C7 and T1 measuring with a maximal thickness of six millimeters (mm). A CT was also completed on 07/13/22 and revealed a displaced, comminuted nasal bone fracture involving the right maxillary nasal process, mildly displaced fracture of the nasal septum. Review of the facility's investigation document titled Post fall Evaluation dated 07/12/22 revealed Resident #186 was in the shower bed, trying to turn and scratch her back when she fell . Resident #186 was noted to slip and fall face down to the floor of the shower room while turning and changing position in bed. Interview on 08/01/22 at 12:48 P.M. with STNA #918 revealed she was washing Resident #186's feet when Resident #186 complained of her back itching and tried to roll and scratch her back. STNA #918 reported telling Resident #186 to wait for help but stated by the time STNA #918 got up to side of Resident #186, to assist, Resident #186 was falling. STNA #918 reported she tried to catch/stop the resident from falling and fell with her to the floor. STNA #918 revealed she was aware of the care plan intervention of two staff assisting Resident #186 due to false allegations made against staff. STNA #918 further revealed she normally showers Resident #186 alone, that another aide will assist to transfer Resident #186 to the shower bed and return at the end of the shower to assist with transferring Resident #186 back to her chair from the shower bed. Interview on 08/02/22 at 1:20 P.M. with the Director of Nursing (DON) confirmed the plan of care for Resident #186 noted two staff were to be utilized for bed mobility, transfers, and baths for Resident #186. The DON further reported the plan of care was out of date and Resident #186 had previously been assessed as safe for one staff to assist with showers. Review of the facility's policy titled Fall Management, revised 07/14/21, revealed the facility will identify hazards and resident risk factors and implement interventions to minimize falls and risk of injury. Residents will be evaluated by the interdisciplinary team for their risk for falls. A care plan is developed and implemented based on this evaluation with ongoing review. Review of the facility's policy titled Routine Resident Care, revised 06/16/21, revealed care is taken to always ensure resident safety. This deficiency substantiates Complaint Number OH 368.

Based on medical record review, staff interview, certified nurse practitioner (CNP) interview, and review of the facility policy and procedure for skin management, the facility failed to implement skin integrity monitoring during the use of Multi-podus boots. In addition, the facility failed to accurately document newly developed skin concerns. This affected one resident (Resident #208) of four residents reviewed for pressure ulcers. The facility census was 201. Actual Harm occurred on 07/07/21 when staff failed to monitor the skin integrity for Resident #208 (who required total dependence of two staff members for all activities of daily living due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . ), and one (1) blister (an area of skin covered by a raised, fluid-filled bubble), noted to bilateral lower extremities, each requiring daily dressing changes and treatments. Findings include: Review of the closed medical record for Resident #208 revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission nursing assessment dated [DATE], identified Resident #208 was admitted with the following skin impairment: · a pressure area noted to the left heel (description not provided), · right thigh- small puncture site, · left front lower leg, (description not provided) · left upper lateral calf abrasion, (description not provided) · left lower lateral calf abrasions, (description not provided) · coccyx- unstageable pressure area with small area to anus, · left gluteal fold with open area, · right gluteal fold with open area, and · 1 centimeter (cm) area space, by 1 cm in length, under [CONDITION(S)] plate. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 06/29/21, revealed Resident #208 had a Brief Interview for Mental Status (BIMS) score of 14, indicating a moderately impaired cognition for daily decision-making ability. Resident #208 required total assistance from two staff members for all activities of daily living care. Resident #208 required the use of an indwelling urinary catheter (Foley) for urine elimination and was noted to always be incontinent of bowel function. Resident #208 required the use of a feeding tube for nutrition and was noted to be 63 inches tall with a weight 138 pounds. Resident #208 was noted to have one unstageable pressure ulcer (defined as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) present upon admission. Review of Resident #208's Braden scale for predicting pressure sore risk dated 06/25/21, revealed a score of 10 indicating the resident at a high risk for developing pressure ulcers. Review of the plan of care dated 06/25/21 revealed Resident #208 was at risk for impaired skin integrity/pressure injury related to being incontinent of bowel, and impaired mobility. Interventions included to complete weekly head to toe skin assessments, document and report abnormal findings to physician; follow facility's policy and procedure for prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care dated 06/25/21 and revised 08/02/21(after the resident had discharged from the facility) revealed Resident #208 had actual impairment to skin integrity related to pressure noted: · unstageable to the coccyx, · left rear calf blister, · right rear calf deep tissue injury (DTI), · right lateral calf DTI, · right rear calf near the Achilles DTI, · left medial foot DTI, · Stage II (defined as 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) to left ischium, · right heel DTI, · right medial foot DTI. · Interventions included to provide an air mattress, pressure wound dressing change, and weekly skin assessments. There was no documented evidence of skin monitoring during personal care including bathing and dressing. Review of physician orders for June 2021 identified orders for bilateral Multi-podus (a hard plastic boot covered in lamb's wool used to prevent foot drop and contractures) boots. Review of the wound care note completed by Certified Nurse Practitioner (CNP) #1 dated 06/30/21 revealed, Patient is a [AGE] year-old male with previous medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient is being seen today for wound evaluation and management. 1) Noted to right ischial tuberosity a pressure (ulcer) measuring 2.9 cm in length, by 2.4 cm in width, by 0.1 cm in depth, with 100% granulation (new connective tissue and microscopic blood vessels) tissue noted and a light serous (mostly clear or slightly yellow thin plasma that is just a bit thicker than water) drainage. Periwound (tissue surrounding a wound) noted to be intact. Treatment includes to clean with normal saline, pat dry, and apply calcium alginate and a clean dry dressing, complete twice a day and as needed. 2) Noted to Resident #208's left ischial tuberosity was a pressure (ulcer) measuring 2.6 cm length, by 1.1 cm width, by 0.1 cm depth, with 100% granulation tissue, with light serous drainage. Periwound intact and dressing included to wash with normal saline, pat dry, apply calcium alginate and a clean dry dressing twice a day and as needed. 3) Pressure (ulcer) noted to coccyx measuring 11.6 cm length x 10.3 cm width x 0 cm depth, with 30% granulation tissue, 10% sloughing (refers to the yellow/white material in the wound bed usually wet) , and 60% eschar (collection of dead, dried tissue collected in a wound bed). Noted a moderate amount of serosanguineous (has a light red or pink tinge fluid thin almost like water) drainage. Periwound intact and treatment included to clean with normal saline, pat dry, apply gauze soaked in half strength Dakins (a diluted solution of sodium hypochlorite and other stabilizing ingredients used to cleanse wounds to prevent infections) to wound bed, and cover with a clean dry dressing twice a day and as needed. 4)Pressure (ulcer) noted to left heel with no drainage, periwound intact. Treatment includes to apply skin prep to heel, and leave open to air, twice a day and as needed. 5) Pressure (ulcer) noted to left lateral upper calf measuring 1.6 cm length x 0.7 cm width x 0.1 cm depth, 100% slough noted with moderate amount of serosanguineous drainage. Periwound intact and treatment included to clean with normal saline, pat dry, apply calcium alginate, and a clean dry dressing twice a day and as needed. 6) Pressure (ulcer) noted to left lateral lower calf measuring 1.5 cm length x 0.6 cm width x 0.1 cm depth with 100% granulation tissue and no drainage. Periwound intact and treatment included to apply skin prep to area and leave open to air, twice a day and as needed. Review of the Resident #208's nurse note completed by LPN #142, dated 07/07/21 at 6:04 P.M. revealed, Guest seen by Certified Nurse Practitioner (CNP) #1, after removing multi-podus boots, new areas noted to bilateral, lower extremities. New order to discontinue multi-podus boots as tolerated. Therapy notified to evaluate need and modify if necessary. New order to apply soft cut out boots, apply [MEDICATION(S)] ABD and kerlix daily. Guest and family aware. Review of the nursing skin observation note, completed by Registered Nurse (RN) #150 for Resident #208 dated 07/07/21 at 7:00 P.M. revealed no new skin issues noted. Review of Resident #208's wound care note, completed by CNP #1, dated 07/14/21 revealed: 1) right ischial tuberosity- pressure area resolved, 2) left ischial tuberosity pressure area resolved, 3) Unstageable pressure to coccyx measuring 16.0 cm length x 14.2 cm width x 0 cm depth with 30% granulation, and 70% eschar tissue. Moderate amount of serosanguineous drainage noted, periwound intact. Moderate amount of necrotic devitalized tissue debrided from coccyx wound. Patient tolerated procedure well. Treatment includes to clean with normal saline, pat dry, apply gauze soaked in half strength Dakins (a diluted solution of sodium hypochlorite and other stabilizing ingredients used to cleanse wounds to prevent infections) to wound bed, and cover with a clean dry dressing twice a day and as needed. 4) Blister to left rear calf measured 17.0 cm length x 8.5 cm width x 0.1 cm depth, with 100% granulation tissue and a light serosanguineous drainage. Treatment includes to apply a non-adhering dressing to site and cover with an ABD pad and kerlix every day and as needed. 5) Noted a DTI to right rear calf measuring 9.3 cm length x 3.2 cm width x 0 cm depth, with 100% epithelial tissue. No drainage and treatment include application of a non-adhering dressing, cover with a ABD pad and kerlix daily and as needed. 6) Noted a DTI to right lateral calf measuring 5.0 cm length x 1.8 cm width x 0 cm depth, no drainage with 100% epithelial tissue. Treatment includes application of a non-adhesive dressing, and cover with a ABD pad, and kerlix daily and as needed. 7) Noted a DTI to the right rear calf, Achilles, measuring 8.1 cm length x 2.0 cm width x 0.0 cm depth, no drainage, with 100% epithelial tissue. Treatment includes application of a non-adhesive dressing, and cover with a ABD pad, and kerlix daily and as needed. 8) A DTI to the right medial foot measuring 1.4 cm x 1.1 cm x 0 cm, no drainage, 100% epithelial tissue. Treatment includes application of skin prep to the area twice a day and as needed. 9) DTI noted to right heel measuring 2.2 cm length x 1.2 cm width x 0.0 cm depth, no drainage, 100% epithelial tissue. Treatment includes application of skin prep to area twice a day and as needed. Review of the facility wound observation (completed weekly during rounds with a wound doctor), completed by LPN #142, for Resident #208 dated 06/24/21 revealed: 1) Unstageable pressure to the right ischial tuberosity, present upon admission, measuring 4.7 cm in length x 3.7 cm in width x 2.0 cm in depth, with 100 % granulation. Light amount of serous drainage noted. 2) Unstageable pressure noted to left ischial tuberosity, present upon admission, measuring 2.2 cm in length x 3.4 cm in width x 1.0 cm in depth, light amount of serous drainage and 100% granulation tissue. 3) Pressure noted to left lateral calf, present upon admission, measuring 1.1 cm in length x 3.5 cm in width x 0.6 cm in depth, moderate serosanguineous drainage, 100% granulation tissue. 4) Abrasion to left lateral calf, present upon admission, measuring 0.7 cm in length x 1.5 cm in width x 0.6 cm in depth, and 100% granulation tissue. 5) Pressure to left shin measuring 10.6 cm in length x 6.5 cm in width x 1.9 cm in depth, 90% epithelial tissue, no drainage. 6) Pressure to coccyx, present upon admission, measuring 55.3 cm L x 9 cm W x 8.1 cm D, 30% granulation tissue, 10% slough tissue, and 60% eschar tissue. Review of wound observation completed by LPN #142 for Resident #208 dated 07/07/21 revealed: 1) Pressure to the right ischial tuberosity, Stage II measuring 5.2 cm area x 2.0 cm length x 3.1 cm width x 0.1 cm depth, 100% granulation tissue noted. 2) Stage II pressure to left ischial tuberosity measuring 1.6 cm surface area x 1.2 cm in length x 1.2 cm width x 0.1 cm depth, 30% granulation tissue, 10% slough tissue, and 60% eschar tissue. 3)Pressure to coccyx measuring 98.9 cm length, x 13.3 cm width, x 10.7 cm depth, 30% granulation tissue, 10% slough tissue, and 60% eschar tissue. 4) Blister to left calf (noted to be present upon admission) measuring 33.6 cm surface area, x 10.3 cm length, x 4.4 cm W, x 0.1 cm D. 5) Area to left lateral calf measuring 5.8 cm length x 5.1 cm width x 1.6 cm depth (noted to be present upon admission). 6) DTI pressure to right calf measuring 37.9 cm length, x 10.8 cm width, x 4.5 cm depth (noted to be present upon admission). 7) DTI pressure to right calf measuring 7.3 cm length, x 6.4 cm width, x 1.5 cm depth (noted to be present upon admission) Interview on 11/09/21 at 2:10 P.M. with Rehab Services Director (RSD) #168 revealed Resident #208 presented to the facility receiving three disciplines including physical, occupational, and speech therapy. Resident #208 was noted to be a quadriplegic who required the use of a C-collar neck brace. Positioning this resident was a challenge due to injuries, diagnosis, and devices used. Resident #208 was not able to use a normal call light and had a breath alert call light. Resident #208 was dependent for all care and required a lot of stretching exercises from therapy and range of motion to help prevent contractures. All of Resident #208's limbs were noted to be within functional limit indicating Resident #208 was free of contractures. Resident #208 was receiving therapy five times a week. The current focus for Resident #208 was to be able to sit on edge of the bed successfully for a period of time. According to RSD #168, when Resident #208 admitted to the facility from the hospital, he arrived with a white and gray boot called a multi-podus boot used to prevent foot drop and contractures. These boots were changed to a soft cut out moon boot due to the multi-podus boot causing new skin issues. When asked about orders for removing and applying the boots, RSD #168 stated the boots came off multiple times throughout the day when care was provided, for weekly skin checks, and for bathing. However, RSD #168 verified there was no documentation to support this. Interview on 11/09/21 at 3:08 P.M. with Licensed Practical Nurse (LPN) # 142 revealed Resident #208 had admitted to the facility with multiple wounds and abrasions from his accident. Resident #208 required staff assistance for all care and spoke in a whisper due to his [CONDITION(S)] status. LPN #142 stated Resident #208 ended up developing deep tissue injuries due to the multi-podus boots he had been wearing and provided from the hospital, so he was changed over to a soft cut out boot. Interview on 11/10/21 at 6:16 P.M. with RN #150 revealed she was the nurse who was working the floor on 07/07/21 and had completed a complete head to toe skin assessment on the Resident #208 including removing the multi-podus boots. RN #150 stated she ended up running out of time, so she had to complete a late entry progress note indicating Resident #208 did not have any new skin issues noted. RN #150 stated when she put the late entry in, it should have been entered for earlier that day but was not. Interview on 11/10/21 at 5:00 P.M. with LPN #142 revealed the noted DTI pressure injuries noted to Resident #208's bilateral lower extremities were not present upon admission, as noted on the wound evaluation dated 07/14/21. LPN #142 stated these DTIs were acquired in-house and were caused from pressure and friction caused by the multi-podus boots that were used to prevent foot drop. LPN #142 confirmed there was not an order in place for staff to observe the skin under the boots to ensure skin integrity. LPN #142 stated the therapy staff were responsible for putting the boots on and taking them off the resident. Interview of 11/10/21 at 6:30 P.M. with the Administrator revealed when a resident develops a deep tissue injury it can occur as fast as a week where it starts out as a red area and quickly turns into a DTI. The Administrator provided no answer when the surveyor asked if a complete skin observation had been completed on 07/07/21 by RN #150, during the morning hours and should have revealed any DTIs or skin changes, which were noted on that same day (07/07/21 at 6:04 P.M.) by LPN #142. Interview on 11/11/21 at 4:49 P.M. with the Director of Nursing (DON) revealed the therapy staff claim the nursing staff are the staff who are responsible for putting the multi-podus boots on the resident and taking them off. Interview on 11/16/21 at 12:40 P.M. with Certified Nurse Practitioner (CNP) #2, revealed normally when she recommends the use of multi-podus boots, she will contact physical therapy for a referral and for them to implement the order with specific guidelines as to when to put the boots on and take them off and to check the skin integrity under the boots. CNP #2 revealed the orders received from the hospital was not clear enough in detail regarding the use of the boots and she was not sure if the nursing staff would have the knowledge related to those specific boots and what is form or type of monitoring normally ordered with them. CNP #2 revealed that normally she has seen these boots ordered for a resident with contractures of at risk for developing contractures with additional orders to check the placement of the boots every four (4) hours, check skin integrity under the boots every four (4) hours and there may even be an order to remove the boots for at least two (2) hours every day to allow the resident's extremities a rest period. Review of facility policy titled Skin Management, dated 07/2021, revealed, It is the policy that the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries. Guest/residents with wound and/or pressure injury and those at risk for skin compromise are identified, evaluated, and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal guest/resident outcomes. This deficiency substantiates Complaint Number OH 181.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated [DATE], Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memos, Nursing Home Guidance from the Centers for Disease Control (CDC), data contained on the State of Ohio's coronavirus.ohio.gov dashboard, observations, record reviews, review of the facility Coronavirus (COVID-19) policy and staff and resident interview, the facility failed to implement effective and recommended infection control practices, including the implementation of appropriate quarantine procedures to prevent the spread of COVID-19 within the facility. This resulted in Immediate Jeopardy on [DATE] when residents observed in quarantine throughout the facility were not confined to their rooms and were ambulatory throughout the facility without appropriate personal protective equipment (PPE) use. The lack of current effective infection control practices and prevalence of continued positive cases in the facility placed all residents at risk for harm, complications and/or death related to the facilities failure to control the COVID-19 outbreak. In addition, the facility failed to ensure adequate and timely infection control interventions were in place to promptly identify and isolate residents with potential exposure to staff members who tested positive for COVID-19, failed to ensure a root cause analysis was determined related to the COVID-19 outbreak in the facility and failed to ensure staff properly utilized PPE. This had the potential to affect all 174 residents residing in the facility. On [DATE] at 4:40 P.M. the Administrator, Regional Clinical Coordinator, and Clinical Transition Specialist were notified Immediate Jeopardy began on [DATE] when observations of the facility revealed residents identified to be quarantined with orders for droplet isolation precautions were residing in rooms located throughout each of the facility units among residents who were in non-isolation/non-quarantine with no evidence measures were in place to ensure these residents were confined to their rooms. On [DATE] at 12:25 P.M. and 1:20 P.M. Resident #172, who had an order for [REDACTED].M. Resident #45, who had an order for [REDACTED].#210 and Therapist #209) who tested positive for COVID-19 the facility failed to comprehensively identify and place any potentially exposed residents or staff on quarantine, did not increase resident monitoring for signs and symptoms of COVID-19 and did not timely complete any additional resident COVID testing. The Immediate Jeopardy was removed on [DATE] at when the facility implemented the following corrective actions: · On [DATE], Residents #45 and #172 were re-educated on the smoking policy and the requirements of isolation. · On [DATE], the DON/designee reviewed all current residents in the facility who had been admitted or readmitted to the facility in the past 14 days. 18 residents were identified as being admitted or readmitted in this timeframe. Two of these residents were admitted with a positive COVID-19 [DIAGNOSES REDACTED]. The remaining 16 residents on isolation precautions due to admission or re-admission had isolation orders verified. Orders to evaluate for signs/symptoms of COVID-19 were audited to ensure they were in place and no issues were noted. The 16 residents were evaluated for signs/symptoms of COVID-19 with no negative findings. · On [DATE] by 11:59 P.M., ten of the 18 residents on isolation precautions due to admission or re-admission were moved to a dedicated quarantine area in the facility on the 200 unit to continue isolation precautions. On [DATE] at 3:00 P.M., one resident was moved to the COVID isolation unit. · On [DATE], three residents in isolation due to admission/readmission remain on the secured unit for safety reasons and were separated on the unit in rooms 320 A and B and 322 A. Four residents in isolation due to admission/readmission remained on the respiratory unit due to the need for respiratory therapy intervention and were separated to an area on the unit in rooms 521 A and B, 515 A, and 523 B. Due to the specialized needs of these residents, they could not be moved to the 200 quarantine unit. · On [DATE] a plan for all residents on droplet and contact precautions to have monitoring increased to three times daily was implemented. · On [DATE] residents who were alert and oriented who were currently on 14-day isolation received education regarding the use of appropriate PPE when out of their room, and appropriate social distancing requirements. · On [DATE] nursing staff assessed 158 residents in the facility who were not on 14 day isolation precautions were evaluated for signs/symptoms of COVID-19 with no negative findings. · On [DATE] a plan for all residents in the facility to have monitoring three times daily for signs and symptoms of COVID-19 was implemented due to potential for exposure. · On [DATE], the Administrator/DON and quality assurance performance improvement (QAPI) team members reviewed the infection control policy regarding COVID-19 and deemed it appropriate. · On [DATE], the Administrator/DON and QAPI team reviewed the Bed Management Decision Tree for new and readmission residents and isolation precaution requirements and deemed it appropriate. · On [DATE] the facility created three smoking schedules, one for guests who smoked who were not on isolation precautions and resided on the 100, 400 and 500 halls, one for residents who smoked and were not on isolation and resided on the 200 and 300 halls, and one for residents who were on isolation precautions. The facility also identified a separate wing off the 200 hall for smoking to prevent commingling of isolated and non-isolated residents. The smoking areas have also been marked with social distancing markings and will be monitored by staff to ensure social distancing. Cleansing of the smoking area will occur with an EPA registered disinfectant between smoking times. · On [DATE], the Administrator/DON and QAPI team members reviewed and revised the smoking policy to include social distancing and residents on 14-day isolation precautions. The current residents in isolation for 14 days post admission would be moved to a dedicated area in the facility unless contraindicated. New and readmission residents moving forward will be admitted to the dedicated area, unless contraindicated. The smoking area has been marked with social distancing indicators for six feet distance. The smoking area will be disinfected with an EPA registered cleanser after each smoking session. Smoking sessions will be scheduled and supervised by staff members to ensure social distancing. Residents will wear masks to and from smoking area and maintain mask on their person during the smoking session. The mask will be stored in the residents' room when not out of room smoking. · On [DATE] 100% of employees on duty were educated on the facility policies related to residents in isolation due to admission/readmission status and for COVID positive status, the required mask use by the residents to and from smoking sessions, and on the social distancing requirements of six feet minimum, and the appropriate use of masks and PPE by staff while on duty was completed by the DON/designee. New employees will receive the same education during new employee orientation. A plan to ensure all employees were educated prior to their next scheduled shift was implemented. · On [DATE] all 44 residents who smoked were re-evaluated for smoking, all 44 residents were provided education on the new smoking policy and signed acknowledgement of understanding of the new smoking policy. · On [DATE] a plan for staff to be screened at the start and the end of their shifts for temperature and for signs and symptoms of COVID-19 as a monitoring tool for COVID-19 was implemented. If staff do not pass the screening process, they will be sent home. Staff are provided with appropriate PPE for their shift and the use of PPE is monitored daily through direct observations from the DON and Nurse Managers. · On [DATE] the Administrator and DON/designee will begin to conduct audits five times per week for four weeks, then three times per week for four weeks, then weekly for four weeks of smoking sessions to ensure residents are socially distanced, in proper PPE to and from smoking sessions and that isolation residents are not commingled with non-isolation residents. Any concerns will be addressed immediately. Findings will be forwarded to the QAPI committee for further review and recommendations. · On [DATE] the Medical Director was made aware of the residents that were to be in isolation and were found to be in the smoking area. · On [DATE] education and the incident were reviewed in an Ad Hoc QAPI meeting Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings Include: Review of the Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memo QSO ,[DATE]-ALL dated [DATE] revealed The Centers for Medicare & Medicaid Services (CMS) is committed to taking critical steps to ensure America's health care facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (COVID-19). As part of CMS guidance the Focused Infection Control Survey was made available to every provider in the country to make them aware of Infection Control priorities during this time of crisis, and providers and suppliers may perform a voluntary self-assessment of their ability to meet these priorities. The QSO Memo included additional instructions to Nursing Homes. We are disseminating the Infection Control survey developed by CMS and CDC so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of COVID-19 .We also encourage nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and whom possible incidents of communicable disease or infections should be reported (42 CFR 483.80(a)(2)(i) and (ii)). 1. Review of reporting data for the facility on the coronavirus.ohio.gov website, which reflects current and cumulative cases of COVID-19 among facility staff and residents reported to the Ohio Department of Health revealed as of [DATE] the facility had reported seven current resident cases and 47 cumulative resident cases and 5 current staff cases and 19 cumulative staff cases. Data updated as of [DATE] revealed seven current resident cases and 47 cumulative resident cases and 5 current staff cases and 19 cumulative staff cases. Current case counts are defined as residents or staff that had active COVID-19 infection during the prior week (Wednesday through Tuesday). Cumulative counts are defined as residents or staff that had active COVID-19 infection at any point from [DATE] onward. The cumulative totals do not include patients or staff who have recovered, have been hospitalized , or have passed away prior to [DATE]. During the survey process, the facility was asked to provide evidence of on-gong communication/collaboration with the local health department related to the increased number of positive cases to ensure timely communication of positive cases and to ensure any health department recommendations being made were implemented timely. On [DATE] the facility provided an email communication with the(NAME)Public Health Department which indicated the last correspondence was dated [DATE]. The facility was provided with reading material from the Centers of Disease Control (CDC) to review at that time. On [DATE] at 1:23 P.M. the local health department was contacted to obtain information related to their involvement with the facility during the COVID-19 pandemic. As of [DATE] no information had been received from the local health department. During the survey process, the Director of Nursing (DON) was asked if the facility had conducted an investigation or root cause analysis to determine the cause of the increase in number of COVID-19 cases identified to have occurred during [DATE]. On [DATE] at 11:04 A.M. the DON revealed she did not know what the root cause was for the increase in COVID positive cases within the facility. The DON stated, I guess because of staff, vendors, and new admissions coming and going in and out of the facility. If we knew where it was coming from we wouldn ' t have any corona. On [DATE] at 1:32 P.M. interview with the DON and Infection Control Nurse (ICN) #200 revealed in addition to the residents who had tested positive, there were six residents #186, #187, #188, #189, #190, and #191 who had expired from [DATE] through [DATE] related to COVID-19. In addition, Resident #184 expired on [DATE]. 2. On [DATE] from 12:10 P.M. to 3:15 P.M. onsite observations and interviews conducted at the facility revealed the following concerns: a. The facility had a COVID unit where residents who had confirmed positive COVID tests resided. There were four residents on the COVID unit at the time of the onsite observations. In addition, twelve residents (Resident #20, #45, #172, #126, #31, #155, #87, #36, #5, #138, #73, and #91) were observed to reside in nine rooms and were in droplet (isolation) precautions for COVID-19. These nine resident rooms were observed to be located throughout the entire facility on each of the facility units (excluding the COVID unit). The rooms were intermingled with resident rooms belonging to residents who did not require additional precautions for COVID-19. On [DATE] at 12:23 P.M. interview with Registered Nurse (RN) #228 verified Resident #20, #45 and #172 were in droplet isolation precautions. RN #228 revealed Resident #20 and #45 were new admissions and Resident #172 had been placed on droplet isolation precautions because Resident #45 was her roommate. On [DATE] at 12:40 P.M. interview with LPN #203 and LPN #204 revealed Resident #31, #126, and #155 were on droplet precautions due to being new admissions. On [DATE] at 12:49 P.M. interview with State tested Nursing Assistant (STNA) #205 revealed Resident #87 was on droplet precautions due to being a new admission. On [DATE] at 1:41 P.M. interview with LPN #208 revealed Resident #138, #73 and #91 were on droplet precautions due to being new admissions. On [DATE] at 5:09 P.M. interview with the DON revealed the new admission/re-admission residents were placed in isolation due to an unknown COVID status at the time of admission. The DON revealed the facility was not able to cohort the residents under a quarantined status together because of availability. The DON revealed that was the goal but it became too hard to keep them together. The DON revealed the facility tried to keep residents in need of the same type of precautions together in the same room. Review of email from Medical Director #217 dated [DATE] at 9:54 A.M. revealed it was not appropriate to have quarantined individuals mixed with other residents and it was not appropriate to have quarantined individuals moving about the facility. On [DATE] at 9:25 A.M. interview with the DON again confirmed the facility did not set up a quarantine unit in the facility. The DON stated, it just got crazy. The DON confirmed there were not designated staff assigned to care for only those rooms of residents who were currently under droplet isolation precautions/quarantine status. On [DATE] at 1:15 P.M. interview with Licensed Practical Nurse (LPN) #216 verified Resident #45 and Resident #172 remained in droplet isolation precautions as of this date. On [DATE] at 1:40 P.M. interview with State tested Nursing Assistant (STNA) #222 verified Resident #31 remained under droplet isolation precautions due to being a new admission. On [DATE] at 1:42 P.M. interview with Unit Manager #223 revealed Resident #155 remained on droplet isolation precautions due to being a new admission. On [DATE] at 1:55 P.M. interview with RN #224 verified Resident #36 was on droplet isolation precautions. Review of the Centers for Disease Control (CDC) Responding to Coronavirus (COVID-19) in Nursing Homes, Cohorting Residents, dated [DATE] revealed the facility should create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. Review of Centers for Disease Control (CDC) guidance, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated [DATE] revealed: As a measure to limit health care personnel (HCP) exposure and conserve personal protective equipment (PPE), facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection. Dedicated means that HCP are assigned to care only for these patients during their shift. Limit transport and movement of the patient outside of the room to medically essential purposes. b. On [DATE] at 12:25 P.M. Resident #172, who was identified to be in droplet isolation precautions was observed at the nurse ' s station talking with staff. The resident had a mask on, however the mask was pulled down under her chin area at the time of the observation. Review of the facility policy titled Coronavirus (COVID 19), revised ,[DATE] revealed a guest/resident should wear a facemask or cloth covering when out of the room or in the doorway, if tolerated (per CDC guidance). c. On [DATE] at 12:33 P.M. three residents, Resident #60, #121, and #180 were observed seated together at a table in the common area of the 200 unit talking to each other. The residents were not seated six foot apart and none of the three residents were observed to have properly applied masks in place. Each residents mask was observed under their chin area. Review of the facility policy titled Coronavirus (COVID 19), revised ,[DATE] revealed a guest/resident should wear a facemask or cloth covering when out of the room or in the doorway, if tolerated (per CDC guidance). d. On [DATE] at 12:46 P.M., Resident #110 was observed walking down the hallway with a surgical mask under his chin. On [DATE] at 1:50 P.M., Resident #17 was observed sitting in the common area outside of Unit 3 with a cloth mask over his mouth, however, the mask did not cover his nose. On [DATE] at 1:56 P.M., Resident #110 was observed walking down the hallway with a surgical mask under his chin. Review of the facility policy titled Coronavirus (COVID 19), revised ,[DATE] revealed a guest/resident should wear a facemask or cloth covering when out of the room or in the doorway, if tolerated (per CDC guidance). e. On [DATE] from 1:20 P.M. to 1:35 P.M. observation of the independent smoking patio revealed four residents, Resident #60, #121, #175, and #34, who were identified to be independent smokers, were sitting around a square table smoking cigarettes and talking. None of the residents were wearing masks. On three separate occasions, Resident #45 (who was identified to be in droplet isolation precautions for COVID-19) was observed to approach the table with the other residents and start talking. Resident #45 was not wearing a mask and did not maintain a six foot distance from the other residents. Resident #172 (who was also identified to be in droplet isolation precautions for COVID-19) was also observed in the smoking patio area and was not wearing a mask. On [DATE] at 1:25 P.M. interview with Resident #172 on the smoking patio revealed the resident did not wear a mask while she was smoking. During the interview, the resident revealed she was aware she was in droplet isolation precautions and knew she was supposed to stay in her room unless she was going outside to smoke. The resident did not indicate any changes or requirements had been made related to smoking related to COVID-19 precautions. On [DATE] at 1:35 P.M. Resident #172 and Resident #45 were observed to enter the dining room area together from the smoking patio. Neither resident had a mask covering their nose or mouth. Both residents had a mask, however the mask was observed under their chins. Both residents proceeded to walk from dining room area to the 100 unit. During the observation, no staff including nursing or housekeeping staff were observed cleaning or disinfecting the door handles or frequently touched surfaces around the doors leading out to the smoking patio. On [DATE] at 2:31 P.M. interview with the Regional Nurse #201 revealed the facility had not made any revisions to their smoking policy related to or since the COVID pandemic had started. The regional nurse stated there should have been X ' s marked on the patio to ensure distancing and any residents under droplet precautions were to smoke at different times from any other residents. However, no X ' s were observed during the observations made on [DATE]. On [DATE] at 2:17 P.M. interview with Resident #60 revealed the resident was a smoker and smoked independently. The resident revealed he enjoyed socializing with other residents. During the interview, the resident revealed he recalled meeting the surveyor on [DATE] and shared he had been sitting with Resident #121 and Resident #180 at that time in the common area of his unit as usual. The resident also recalled sitting outside on the smoking patio with Resident #34, #121, and #175 at a table talking and smoking. The resident stated he also talked to Resident #172 and Resident #45, daily when outside on the patio. The resident stated the residents do not wear masks outside on the patio. On [DATE] at 1:20 P.M. observation of the independent smoking patio revealed Residents #20, #45, #172, #121, and #162 were sitting outside together to the left of the door leading onto the patio. None of the residents were wearing masks at time of the observation. Red markers were observed on the patio for distancing, however, the residents were not spaced out at the markers. Residents #45 and #172 were verified to be on droplet precautions. Review of the facility policy titled Coronavirus (COVID 19), revised ,[DATE] revealed a guest/resident should wear a facemask or cloth covering when out of the room or in the doorway, if tolerated (per CDC guidance). f. On [DATE] at 12:20 P.M. LPN #202 who was working on the 100 unit was observed wearing only a surgical mask. Interview with the LPN confirmed she was only wearing a surgical mask. LPN #202 stated she usually wore an N95 mask but she was not going onto the COVID unit today so therefore, only wore a surgical mask. Observation revealed there were residents residing on the 100 unit who were in droplet isolation precautions for COVID-19. On [DATE] at 12:59 P.M. observation of LPN #206 revealed the LPN was wearing a surgical mask under her KN95 mask. The surgical mask was observed across her face with blue showing on both sides underneath of the KN95 mask. Interview with the LPN at the time of the observation revealed she does not typically wear two masks but her face was sweating under the KN95 mask today. On [DATE] at 1:02 P.M. Medical Records #207 was observed on Unit 2 wearing a cloth mask underneath her KN95 mask. The cloth mask was observed across her face with black showing on both sides underneath of the KN95 mask. Medical Records #207 was observed passing lunch meal trays on the unit at the time of the observation. Interview at the time of the observation revealed she confirmed she was assisting with passing meal trays on the unit and the was wearing a cloth mask under a KN95 mask. Medical Records #207 revealed the KN95 mask made her skin rashy. On [DATE] at 1:05 P.M. STNA #207 was observed wearing a surgical mask underneath her KN95 mask. The surgical mask was observed across her face with blue showing on both sides underneath of the KN95 mask. Interview with the STNA at the time of the observation revealed the KN95 mask was very tight on her face. On [DATE] at 3:12 P.M. STNA #215 was observed wearing a surgical mask under his KN95 mask. The surgical mask was observed across his face with blue showing on both sides underneath of the KN95 mask. Interview with the STNA at the time of the observation revealed the STNA stated, I thought I was getting more protection. On [DATE] at 3:14 P.M. LPN #214 was observed wearing a hazmat suit. The suit was observed to have a tear on the right hip area. At the time of the observation, interview with LPN #214 revealed the LPN indicated he did not realize the tear was there. On [DATE] at 9:25 A.M. interview with the DON revealed she did not instruct staff to wear a surgical mask or cloth mask under their N95/KN95 masks. On [DATE] at 2:56 P.M. the facility provided an email from Mask Manufacturer #219 in regards to the use of masks under KN95 masks. The email revealed since you asked about the desire from some of your healthcare professionals wearing surgical masks underneath KN95 masks for added protection, please note the air seal of the KN95 needs to be maintained against the skin at the perimeter of the mask for maximum protection. Given the flexibility of the surgical masks, the users should ensure that the surgical mask is tucked inside of the KN95 so that the edges of the KN95 touch the face. On [DATE] at 4:37 P.M. interview with the DON revealed the facility did not have a policy in place regarding staff wearing two masks or the use of a cloth or surgical mask under a KN95 mask. 3. During the survey process review of two employee's, LPN #210 and Therapist #209, who had tested positive for COVID-19 revealed the following concerns: a. LPN #210's last date worked was on [DATE]. The nurse was scheduled to be off from [DATE] through [DATE]. Review of Questions for employee who has tested positive COVID dated [DATE], for LPN #210 revealed the nurse last worked on [DATE]. The form revealed the LPN had been in contact with all residents on Units 1 and 3, including Resident #8, #84 and #184, and a total of 18 staff. On [DATE] at 3:30 P.M. interview with LPN #210 confirmed her last day of work was [DATE]. The nurse stated while she was at home she started not feeling well with a fever, headache, muscle pain, nausea, and diarrhea and decided to call off from work (on [DATE]) and go to the emergency room . The nurse was tested for COVID-19 and was confirmed to be positive on [DATE] at the hospital. LPN #210 stated on [DATE] she worked the odd side on Unit 1 and had assisted all of the residents on that side of the unit. The nurse stated some of the residents on the unit wore a mask and some of the residents did not wear a mask. The nurse was scheduled to return work on [DATE] and denied having any signs or symptoms of illness. On [DATE] at 2:45 P.M. interview with DON revealed after receiving notification of LPN #210 ' s positive COVID-10 test, the facility did not place any of the potentially exposed residents or staff on quarantine, did not increase monitoring, or complete any additional COVID testing. The DON stated, there was not any reason to do. The DON stated the facility continued with their regular protocol of monitoring residents daily with a respiratory screen and vital signs. Staff were screened prior to working a shift and at the end of their shift. b. Review of an undated Questions for employee who has tested positive COVID for Therapist #209 revealed the therapist last worked on [DATE] and was confirmed positive for COVID-19 on [DATE]. The contact tracing documents revealed Therapist #209 had been in close contact with a total of eight staff and 51 residents, including Resident #8, within a 14 day period of testing positive for COVID-19. On [DATE] at 3:50 P.M. interview with Therapist #209 confirmed she did test positive for COVID-19 on [DATE]. The therapist stated her last day worked was on [DATE]. The therapist reported to work on this date with some dizziness but did not have a fever or any other symptoms at that time. The therapist stated her dizziness worsened and she left work around 11:00 A.M. on [DATE]. The therapist stated she went from work to be tested at a pop-up testing site for COVID-19. During the interview the therapist revealed she had worked with Resident #8 and Resident #8 had refused to wear a mask. The therapist stated she was aware Resident #8 had a roommate, Resident #58. The therapist then stated, I know a lot of people on Unit 1 ended up with COVID. On [DATE] at 2:45 P.M. interview with DON revealed after receiving notification of Therapist #209's positive COVID-10 test, the facility did not place any of the potentially exposed residents or staff on quarantine, did not increase monitoring, or complete any additional COVID testing. The DON stated, there was not any reason to do. The DON stated the facility continued with their regular protocol of monitoring residents daily with a respiratory screen and vital signs. Staff were screened prior to working a shift and at the end of their shift. 4. Review of Resident #8's medical record revealed an admission date of [DATE]. The resident had [DIAGNOSES REDACTED]. Review of Resident #8's progress notes, dated [DATE] through [DATE] documented the resident refused to wear a mask. Record review revealed the resident was tested for COVID on [DATE]. However, the medical record did not include why a COVID test was completed at this time and/or any evidence the resident was moved from his room located in the general population to a quarantine unit or COVID unit at the time testing was completed. On [DATE] the facility received positive COVID-19 test results for Resident #8. At that time (on [DATE]) the resident was moved to the COVID unit. Review of Resident #8's Medication Administration Record [REDACTED]. The resident's vital signs on [DATE] revealed the resident's oxygen level dropped from 93% in the morning to 88% at lunch and at night. On [DATE] at 4:09 P.M. interview with the DON revealed Resident #8 had been identified as having possible exposure to COVID-19 from Therapist #209. The DON confirmed the facility did not place Resident #8 in quarantine/iso (TRUNCATED)

Based on observation, record review and interview the facility failed to implement effective and timely nutritional interventions to prevent one resident (Resident #83) from sustaining a significant weight loss and failed to ensure ordered interventions, including whole milk and double protein portions were provided. Actual Harm occurred on 02/26/20 when Resident #83, who had a [DIAGNOSES REDACTED]. This affected one resident (#83) of six residents reviewed for nutrition. Findings include: Review of Resident #83's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident # 83's annual Minimum Data Set (MDS) 3.0 assessment, dated 11/27/19 revealed the resident's long and short term memory were impaired and she exhibited moderately impaired cognition. Resident # 83 had no behaviors, no indicators of [MEDICAL CONDITION] and rejected care daily. Resident # 83 required supervision of two staff for bed mobility, supervision of one staff to transfer, supervision from staff with set up help to eat. Resident # 83 had no swallowing problems was 66 inches tall, weighed 110 pounds, was on a therapeutic diet and had no significant weight changes during the assessment reference period. Review of the 11/29/19 nutrition assessment revealed the resident's usual body weight was 120 pounds. Resident #83's weight on 11/26/19 was 109.8 pounds, and her body mass index (BMI) was 17.7, indicating she was underweight. Resident #83 refused any medications to stimulate her appetite or nutritional supplements. Resident #83's diet was a regular diet, regular texture, thin consistency liquids with eight ounces of whole milk at each meal. The nutrition goal was to maintain current weight. No new nutritional recommendations were made at that time. Review of Resident #83's progress note, dated 12/18/2019 at 1:20 P.M. revealed the resident appeared to be choking with mucus coming out of her mouth. The resident was sent to the emergency department (ED) of a local hospital. Resident #83 returned the same day from the ED Review of the progress note, dated 12/19/19 revealed Resident #83's was at risk for choking and her diet was downgraded to a puree diet with eight ounces whole milk each meal. Review of Resident #83's quarterly MDS 3.0 assessment dated [DATE] reflected the resident continued to exhibit cognitive impairment and received a mechanically altered diet. Review of Resident #83's dietary note, dated 02/24/20 revealed on 02/20/20 her weight was 101.8 pounds which reflected a weight loss of 6.8 pounds (6.2%) in two months. The recommendation was to ensure Resident #83 eats well at meals and eats enough to maintain her weight. No new nutritional recommendations were made at that time. Review of the dietary note, dated 03/02/20 revealed on 02/26/20 Resident #83 weighed 98.2 pounds which was assessed/documented to be a severe weight loss of 9.5 % in one month. A new recommendation for double protein portions at all meals was made at that time. Observation of Resident #83 on 03/02/20 at 1:44 P.M. revealed she received a chicken salad sandwich, pasta salad, scalloped apples, juice and water. Resident #83 did not receive whole milk and her food was not pureed. Interview with Licensed Practical Nurse (LPN) #267 confirmed the food was not pureed and the resident did not receive milk. Observation of Resident #83 on 03/03/20 at 8:43 A.M. revealed she received thickened juice and water, pureed cereal, pureed omelet, pureed muffin and pureed fruit. She did not receive whole milk and she did not receive double protein portions. Interview with LPN #294 confirmed her portions looked like everyone else's and she received thickened juice and water. Observation of Resident #83 on 03/05/20 at 9:25 A.M. revealed she did not receive milk with the breakfast meal. Interview with LPN #294 at that time confirmed Resident #83 did not receive milk. Interview with Registered Dietitian (RD) #212 on 03/05/20 at 10:53 A.M. revealed Resident #83 should have received whole milk and she would make sure more was sent out with the meals. RD #212 revealed Resident #83 would only accept certain items if too many food items were sent then she would have a behavior. RD #212 was asked why no recommendations were made on 02/24/20 and she replied she would have to investigate it and get back with the surveyor. Interview with RD #212 on 03/06/20 at 11:33 A.M. revealed she forgot to document on 02/24/20 the recommendation for family to bring in a treat the resident liked when they visited. When asked how often the family visited, she stated about one time a week. Interview with State tested Nursing Assistant (STNA) #150 on 03/06/20 at 11:58 A.M. revealed she had not seen Resident #83's family visit. Interview with LPN #294 on 03/06/20 at 12:01 P.M. revealed she had not seen Resident #83's family visit. Interview with Registered Nurse (RN) #326 on 03/06/20 at 12:04 P.M. revealed she had not seen Resident #83's family visit.

Based on observation, record review, interview and review of the facility policy on skin management the facility failed to prevent the development of a pressure ulcer to Resident #70's left lateral ankle and failed to ensure interventions were in place to promote pressure ulcer healing. Actual harm occurred on 10/21/19 when Resident #70, who had a [DIAGNOSES REDACTED].e. turning/repositioning program and pressure relieving heel devices). This affected one resident (#70) of five residents reviewed for pressure ulcers. Findings include: Review of the medical record for Resident #70 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 07/24/19 revealed the resident had severely impaired cognition and required extensive assistance from two staff for bed mobility and transfers. Review of a plan of care initiated 08/14/19 revealed Resident #70 was at risk for impaired skin integrity/pressure injury related to impaired bed mobility and incontinence of bowel and bladder. Review of interventions to minimize the risk of pressure injury indicated to cue the resident to reposition self as needed. There was no evidence of a turning/repositioning program in place for staff to turn/reposition the resident, even though the resident was identified as requiring assistance from two staff with bed mobility. The plan of care also included interventions of air mattress as ordered and soft heel cut out boots as tolerated. Review of a pressure ulcer risk assessment dated [DATE] revealed Resident #70 was identified as high risk for the development of pressure ulcers. Review of a skin and wound assessment completed 10/15/19 revealed no evidence of any skin breakdown. Review of a nursing progress note, dated 10/21/19 at 2:00 P.M. revealed a new area to the left lateral ankle was noted. The physician was notified and a new treatment order was obtained. The treatment to cleanse left lateral ankle with normal saline, apply calcium alginate with silver, and cover with dry dressing was started on 10/22/19. Review of a skin and wound evaluation form completed 10/23/19 revealed Resident #70 developed an unstageable pressure ulcer containing slough and/or eschar on the left lateral malleolus (ankle) on 10/21/19. (Slough is non-viable yellow, tan, gray, green, or brown tissue; usually moist, can be soft, stringy, and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed; An unstageable ulcer is defined as obscured full thickness skin and tissue loss in which the extent of the tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. If slough or eschar is removed, a stage three or four pressure ulcer will be revealed). The area measured 2.5 centimeters (cm) long by 2.5 cm wide with depth documented as not applicable. It stated the wound had 60 percent slough with moderate serous exudate. (Exudate is defined as fluid that has been forced out of the tissue or its capillaries because of inflammation or injury). It was identified as a new wound. Review of a wound evaluation report by the wound physician, dated 10/23/19 revealed the resident had a Stage IV pressure wound of the left lateral ankle for at least one day duration. (A Stage IV pressure ulcer is defined as full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer). There was moderate serous exudate. The area measured 3.1 cm by 3.8 cm by 0.5 cm. and had 20 percent slough, 60 percent granulation tissue, and 20 percent bone. The area was debrided (damaged tissue removed from the wound) on 10/23/19. After the development of the pressure ulcer on the left lateral ankle on 10/21/19, the plan of care was revised to include actual skin impairment of Stage IV pressure. However, the plan still indicated to cue the resident to reposition self as needed. An MDS 3.0 assessment, dated 10/21/19 revealed the resident had severely impaired cognition and required extensive assistance from two staff for bed mobility and transfers. There was no evidence of a turning/repositioning program in place for staff to turn/reposition the resident. An MDS 3.0 assessment, dated 01/08/20 revealed the resident had severely impaired cognition and required extensive assistance from two staff for bed mobility and transfers. Record review revealed Resident #70 had physician's orders, dated 01/14/19 for an air mattress to the bed and 03/18/19 for soft cut out boots to both feet as tolerated every shift. Observations on 03/02/20 at 12:11 P.M., 12:45 P.M., 1:22 P.M., 4:08 P.M. and 5:25 P.M. revealed Resident #70 was in bed on his left side. Observations on 03/03/20 at 7:17 A.M. revealed Resident #70 was in bed on his left side. The air mattress had a low pressure light on and the mattress alarm was sounding by beeping loudly. The door to the resident's room was closed with no staff in the room. On 03/03/20 at 7:43 A.M. the air mattress alarm was still beeping and the resident was still on his left side. On 03/03/20 at 7:49 A.M. the resident was still on his left side but the air mattress alarm was no longer beeping and State tested Nursing Assistant (STNA) #118 was in the room delivering the resident's breakfast tray. On 03/03/20 at 7:58 A.M. the resident was on his left side in bed and the air mattress was flat with the resident sunken down in the middle of the mattress. On 03/03/20 at 9:20 A.M. the resident was in bed on his left side and the air mattress was still flat. On 03/03/20 at 10:07 A.M. the resident was on his left side in bed but the air mattress was inflated and the low air pressure light was off. On 03/03/20 at 12:56 P.M. and 3:20 P.M. the resident was in bed on his left side. Interview on 03/04/20 at 7:30 A.M. with the Licensed Practical Nurse (LPN) #291 who cared for Resident #70 on 03/03/20 revealed she was not aware of any issues with the air mattress on 03/03/20. She stated the air mattress beeps if it is flat. Interview on 03/04/20 at 7:45 A.M. with the STNA #118, who cared for Resident #70 on 03/03/20, revealed she was not aware of any issues with the air mattress on 03/03/20. Interview on 03/04/20 at 7:50 A.M. with Unit Manager #324 revealed she was not aware of any issues with the air mattress on 03/03/20. She stated the hospice aide and nurse were in on 03/03/20 and maybe they reset the air mattress. Interview with Hospice Aide #402 on 03/04/20 at 10:00 A.M. revealed she arrived on 03/03/20 at around 8:30 A.M., provided care for Resident #70, and left around 9:00 A.M. She stated she did not notice anything wrong with the air mattress. Interview with Hospice Nurse #400 on 03/04/20 at 11:45 A.M. revealed he arrived on 03/03/20 at 10:00 A.M. He stated he was with Resident #70 for approximately 15 minutes. (However, no staff were observed in the room on 03/03/20 at 10:07 A.M.) He stated he did not notice anything wrong with the air mattress. He also stated the resident was on his left side when he arrived and when he left. He stated he would have to check with the facility to see if the resident was supposed to be turned/repositioned by staff. He stated the hospice care plan said to assist with repositioning but did not include a frequency. Review of a wound evaluation summary by the wound physician on 03/03/20 revealed Resident #70 had a Stage IV pressure wound of the left lateral ankle for at least 126 days duration. There was moderate serous exudate. The area measured 0.6 cm long by 0.4 cm wide by 0.2 cm deep. The wound was described as 90 percent granulation tissue with 10 percent slough. Observation on 03/04/20 at 7:20 A.M. revealed Resident #70 had a 0.6 cm wide by 0.4 cm long by 0.1 cm deep superficial open area. The center of the wound was primarily pink tissue with a small area of white tissue. At that time, the resident was not observed to have a pressure relieving boot to his right foot. Interview with STNA #118 on 03/04/20 at 10:35 A.M. confirmed Resident #70 was unable to turn himself and was dependent upon staff for turning/repositioning. She stated she turned the resident every two hours and he was usually cooperative with turning. She stated on 03/03/20 she had placed the resident on his left side at 8:00 A.M. (However, the resident was observed on his left side at 7:17 A.M., 7:43 A.M., 7:49 A.M., and 7:58 A.M.). She also stated she placed the resident on his right side at 3:00 P.M. (However, the resident was observed on his left side at 3:20 P.M.). She further stated she was not aware of any boots for the resident to wear on his feet and did not ever put them on. Interview with LPN #291 on 03/04/20 at 10:40 A.M. confirmed Resident #70 was unable to turn himself and required assistance from two staff for turning/repositioning. She stated staff were to turn him every two hours and he was cooperative with turning. She stated he should be repositioned from left side to right side to back every two hours. She stated Resident #70 was unable to stay on his back much in bed but was able to be on his back when he was up in a chair. She stated residents usually get up every day unless they refuse. She stated they did not ask Resident #70 to get up on 03/02/20 or 03/03/20. She stated she was not aware Resident #70 was not repositioned every two hours on 03/02/20 or 03/03/20. She stated the nursing assistants were responsible to apply the pressure relieving boots to the resident's feet. Interview with LPN #293 on 03/04/20 at 11:00 A.M. confirmed she was Resident #70's nurse. She confirmed he was to have pressure relieving boots on both feet. She was not aware the resident did not have one on the right foot on 03/04/20 at 7:20 A.M. Interview with Wound Physician #401 on 03/04/20 at 12:00 P.M. revealed Resident #70 was at high risk for the development of pressure ulcers. He stated the resident should be turned/repositioned every two hours and should wear the pressure relieving boots on both feet. He stated the pressure ulcer on the left ankle was currently healing as long as the pressure was kept off of the area. Review of the facility policy titled Skin Management dated 10/2019 revealed the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries. Residents with pressure ulcers and those at risk for skin compromise were identified, evaluated and provided appropriate treatment to promote prevention and healing. It further stated appropriate preventative measures would be implemented on residents identified at risk and the interventions documented on the care plan. Interview with the Director of Nursing on 03/04/20 at 2:20 P.M. revealed appropriate treatment meant what ever fit the resident. She stated a turning/repositioning program would be appropriate for Resident #70. Interview with the Director of Nursing and Corporate Nurse #147 on 03/05/20 at 8:25 A.M. confirmed Resident #70 did not have a preventative turning/repositioning program in place prior to or after developing the Stage IV pressure ulcer on the ankle. The lack of a turning and repositioning program likely contributed to the area on the left lateral ankle being first identified by staff as an unstageable/Stage IV pressure ulcer.

Based on record reviews, observations, and interviews, the facility failed to ensure physician orders [REDACTED].#181, #188, #191, #196, #200, #202, #206 and #207 and for mechanical ventilator settings for Resident #191. The facility failed to administer oxygen continuously as ordered to Resident #197 who had a [MEDICAL CONDITION], (an opening in the neck with a tube inserted into the windpipe to maintain breathing). Actual harm occurred when State tested Nurse Aide (STNA) #241 removed Resident #197's oxygen during personal care and transported her to the common area. The resident subsequently developed acute respiratory distress. This affected nine of 18 residents reviewed for respiratory care and services. Findings include: 1. Review of Resident #197's medical record revealed an admission date of [DATE], and a readmission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #197 to have severe cognitive impairment. She was also assessed to require total assistance from staff for all her activities of daily living (ADL). Review of special procedures revealed she received oxygen, suctioning, [MEDICAL CONDITION] care and respiratory care times seven days. Review of the current physician's orders [REDACTED]. No specific physician's orders [REDACTED]. Review of the plan of care for Resident #197 revealed the resident was at risk for respiratory distress, [MEDICAL CONDITION] and had a Shiley number six [MEDICAL CONDITION] in place. Interventions included to administer oxygen as prescribed, observe for signs and symptoms of respiratory distress including increased respirations, heart rate, restlessness and accessory muscle usage. Perform pulse oximetry as ordered and prn. Provide [MEDICAL CONDITION] care as ordered and per facility protocol. Suction resident as needed. Review of the nursing progress notes dated 08/26/19 at 12:19 P.M. revealed Resident #197 was in the dayroom on room air (with no oxygen). Her oxygen saturation (O2 sat) was checked, which revealed a 79 percent oxygen saturation and a heart rate of 130 beats per minute. The resident was also noted to have increased jerking. The progress notes documented that Resident #197 was bagged (given artificial respirations using a mechanical ventilating bag/Ambu bag) with oxygen at 15 liters per minute (LPM) which improved her O2 sat to 93 percent. The resident was transported back to her room where she was suctioned for a moderate amount of thick pale-yellow secretions, placed on oxygen at 5 LPM and [MEDICAL CONDITION] care was given. Review of Certified Nurse Practitioner (CNP) #455's progress notes, dated 08/27/19 at 9:33 [NAME]M. revealed Resident #197 was seen for [MEDICAL CONDITION](increased heart rate) on 08/26/19. The condition had improved by 08/27/19. Physical assessment and laboratory testing revealed possible urinary tract infection and possible [MEDICAL CONDITION] activity. On 08/26/19 at 8:20 [NAME]M., Resident #197 was observed being transported out of her room, in her wheel chair, by STNA #241. Resident #197 wore an [MEDICAL CONDITION] (a plastic cover/mask that goes over the [MEDICAL CONDITION] with tubing attached and connected to an oxygen source) covering her [MEDICAL CONDITION], but no oxygen was observed attached to [MEDICAL CONDITION],. No oxygen tank was observed attached to the resident's wheelchair. Resident #197's [MEDICAL CONDITION] was covered with thick yellow mucous. Her [MEDICAL CONDITION] was observed to contain a thick layer of yellow mucous along the bottom edge of the mask. Resident #197 appeared short of breath, was gasping and was observed making jerking movements. Interview on 08/26/19 at 8:21 [NAME]M. with STNA #241, verified there was no oxygen on Resident #197's wheel chair. STNA #241 stated she was taking Resident #197 up to the common room, where she would get her settled and then planned to go back to the resident's room to retrieve her oxygen concentrator. The STNA then proceeded up the hall to the common room with Resident #197. On 08/26/19 from 8:23 [NAME]M. to 8:30 [NAME]M. the surveyor followed STNA #241 and Resident #197 up the hall and immediately requested Respiratory Therapist (RT) #195 and Licensed Practical Nurse (LPN) #177 to assist Resident #197 and check her oxygen saturation. RT #195 checked Resident #197's 02 saturation upon arriving at the resident's wheel chair. Resident #197's O2 sat was 78 percent and her heart rate was elevated at 138 beats per minute. RT #195 called for the crash cart and proceeded to administer oxygen at 15 LPM via an Ambu bag. RT #195 bagged Resident #197 for several minutes until the resident's O2 sat reached 88 percent. Resident #197 was then taken back to her room by RT #195 and STNA #241, where the resident's [MEDICAL CONDITION] was suctioned for large amount of greenish-yellow, thick mucus. The resident was then transferred back to her bed. RT #195 placed the resident on humidified oxygen at 5 LPM. On 08/26/19 at 8:35 [NAME]M., RT #195 confirmed the jerking movements were not normal for Resident #197. She confirmed she had never observed Resident #197 to be without oxygen at any time and stated verified the resident should not go without oxygen. The RT said Resident #195'[MEDICAL CONDITION] very dirty and agreed she needed the mucous suctioned out. RT #195 confirmed Resident #197 should not have been transported without oxygen. In an interview on 08/26/19 at 8:38 [NAME]M. with STNA #241, she confirmed Resident #197 was having jerking movements when she came into her room to provide her morning care. The STNA stated the jerking movements were not normal for that resident. STNA #241 said the resident was on oxygen [MEDICAL CONDITION] during her care, but she had disconnected the oxygen to transfer Resident #197 via Hoyer (mechanical) lift into her wheelchair. She stated she had help from another STNA for the Hoyer transfer but the other STNA left after the transfer was completed. She stated she then exited the resident's room without reconnecting her to the oxygen. She said she planned to get the O2 concentrator once the resident was settled in the common room. STNA #241 stated Resident #197 did not appear short of breath during her morning care. She confirmed she had taken the oxygen off of Resident #197 prior to the Hoyer transfer. On 08/26/19 at 8:43 [NAME]M., RT #195 returned and gave Resident #[MEDICAL CONDITION]. Resident #197 continued to have rhythmic jerking movements. She was also observed to continue to be short of breath. Resident #197's O2 sat was 93 percent during [MEDICAL CONDITION] care. The RT again confirmed Resident #197 should not have been transported without oxygen and the STNA should not have disconnected the oxygen. On 08/26/19 at 8:51 [NAME]M. Resident #197 was observed with an O2 sat of 91 percent and her heart rate was 131. RT #195 suctioned the resident again for a small amount of yellow thick mucus and continued the resident on humidified oxygen at 5 LPM. Interview on 08/26/19 at 8:54 [NAME]M. with Registered Nurse (RN) #500, confirmed the jerking movements were not normal for Resident #197 and she had notified the physician, who had ordered blood tests. On 08/26/19 at 9:24 [NAME]M., no rhythmic jerking was observed from Resident #197. The resident appeared to be asleep in her bed. On 08/26/19 at 3:45 P.M. the Director of Nursing (DON) confirmed STNA #241 should not have taken off Resident #197's oxygen for transport. The DON confirmed STNAs were not allowed to remove or administer oxygen to a resident. Interview on 08/28/19 at 10:30 [NAME]M. with CNP #455 revealed she had never observed Resident #197 without oxygen being administered. She stated she had assessed the resident on 08/26/19 around 10:30 [NAME]M. CNP #455 stated in her opinion if the resident was without oxygen, she would have a decrease in oxygen saturation which could cause her to be in respiratory distress. 2. Review of the physicians' orders for Residents (#181, #188, #191, #196, #200, #202, #206 and #207) who were reviewed for respiratory care, identified orders that read, titrate oxygen to maintain the resident's oxygen saturation greater than 90 percent, every shift. This order failed to indicate the method or route of oxygen administration, the rate of administration in LPM or if the administration was to be continuous or intermittent. On 08/26/19 at 3:45 P.M. interview with the DON, she confirmed the lack of specific oxygen orders in the medical records for Residents (#181, #188, #191, #196, #197, #200, #202, #206 and #207). Interview on 08/28/19 at 10:30 [NAME]M. with CNP #455 confirmed she had never seen a specific oxygen order since she had worked in the facility. She confirmed the order to titrate oxygen did not specify how much oxygen was to be administered, the route oxygen was to be received or if it should be intermittent or continuous. She stated she always thought oxygen orders should be more specific. 3. Review of Resident #191's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the (MONTH) 2019 physicians orders for Resident #191 revealed a ventilator setting order was entered with a start date of 08/14/19. Observation of Resident #191 on 08/26/19 at 2:57 P.M. revealed the resident in bed with a [MEDICAL CONDITION] and ventilator in place. The resident's ventilator tubing and oxygen tubing were appropriately dated. The resident was non-responsive and appeared to be in a vegetative state. Interview with RT #274 on 08/27/19 at 10:39 [NAME]M. revealed the RT was very familiar with Resident #191. RT #274 could not recall if Resident #191 was admitted with ventilator setting orders or not. The RT indicated if there was not an order provided, the facility would use the settings the resident was using when the resident left the facility until an order could be obtained. RT #274 stated he would attempt to call the hospital or physician if needed to obtain an order as soon as possible. Interview with the DON on 08/27/19 at 11:30 [NAME]M. confirmed the physician order [REDACTED]. The DON confirmed the expectation was to have orders entered within 24 hours of admission for any resident. Review of the facility's policy titled Mechanical Ventilation, Positive Pressure, Setup and Application, Respiratory Therapy, undated, stated the first step of implementing a ventilator was to verify the practitioner's order. Review of facility's policy titled Admission of Guest, dated 03/2005, stated the licensed nurse should verify the admission orders [REDACTED]. Review of the facility's policy titled Oxygen Administration, Long-Term Care, undated, revealed the facility policy stated physician's orders [REDACTED]. Review of the American Association for Respiratory Care Clinical Practice Guideline -Oxygen Therapy in the Home or Alternate Site Health Care Facility -2007 Revision & Update P1063-1067- http://www.rcjournal.com/cpgs/pdf/08.07.1063.pdf, revealed all oxygen must be prescribed and dispensed in accordance with federal, state, and local laws and regulations. Review of the State Operations Manual; a Guidance to Surveyors for Long Term Care Facilities, dated 11/22/17, revealed under section 483.25 (i) Respiratory Care, revealed a facility must provide provision of appropriate emergency equipment at the bedside for resident who are respiratory dependent. This deficiency substantiates Complaint Number OH 412.

The following survey finding pertains to an incident of past noncompliance that was subsequently corrected prior to this survey. Based on record review and staff interviews the facility failed to ensure Resident #159 was transferred in a manner to prevent a fall. Harm occurred when the resident slipped from a mechanical lift hitting his head on the floor sustaining a subacrachnoid hemorrhage (bleeding between the brain and the tissue covering the brain) and skull fracture. This affected one of five residents reviewed for hospitalization s. Facility census was 210. Findings include: Clinical record review revealed Resident #159 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was ventilator dependent with a [MEDICAL CONDITION] (a direct airway through an opening in the trachea) and gastrostomy tube (tube inserted in stomach for nutrition). Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition and did not communicate or follow commands. Review of the nursing note dated 11/30/17 at 6:40 P.M. revealed State tested Nursing Assistants (STNAs) called the nurse to Resident #159's room. The resident was on the floor after a Hoyer (mechanical lift) transfer with a pillow under his head and staff applying pressure to his head. He was immediately sent out via the emergency squad to the hospital. The hospital documentation dated 11/30/17 revealed Resident #159 was admitted for an acute small subacrachnoid hemorrhage and skull fracture. The resident was referred to a neurosurgeon and further testing revealed no [MEDICAL CONDITION] activity and no neurosurgery was indicated. The hospital discharge summary dated 12/08/17 revealed the resident had [MEDICAL CONDITION] secondary to a fall and right facial twitching. Review of a physician note revealed on 12/19/17 the physician ordered a helmet to be used while Resident #159 was out of bed and during transfers. Interview with the Administrator on 01/30/18 at 5:52 P.M. revealed the 11/30/17 incident with Resident #159 was isolated. The Hoyer lift did not malfunction; the two STNAs did not have the resident's upper body secured and he tipped out of the Hoyer lift. His head hit the headboard of the bed first then the tile floor. STNA #228 and STNA #88 could not control the resident's upper torso. Interview with STNA #88 on 02/01/18 at 9:02 A.M. revealed they were transferring Resident #159 with the Hoyer lift from his geriatric chair in the hallway to his bed and she was holding the resident's feet. He slipped out of the lift and his head hit floor. The resident was now a three person transfer and staff were required to apply a helmet when he was out of bed. Interview with STNA #228 on 02/01/18 at 9:14 A.M. revealed she was trying to control the resident's upper body and the Hoyer pad with the resident slipped out of the lift; his head hit the floor next to the bed. They now used three staff to transfer this resident with a helmet on his head. There have been no falls from mechanical lifts in the facility since the above incident on 11/30/17. Review of the facility's corrective action with Corporate Registered Nurse #11 on 02/01/18 revealed the following actions were implemented and the deficiency corrected as of 12/31/17. 1. On 11/30/17, the facility began in-servicing all nurses and STNAs regarding safe mechanical lift use and transfers. 2. On 12/07/17, audits of all lifts used in the facility to assure proper function was completed. 3. On 12/08/17, Resident #159's care plan was revised to include transfers with mechanical lift to be completed with three staff. 4. On 12/19/17, the physician ordered a helmet to be worn when Resident #159 out of bed and with transfers. Resident #159's care plan was revised to reflect the use of the helmet. 5. On 12/31/17, competency evaluations on use of mechanical lifts were completed for all STNAs with a nursing preceptor. 6. Audits were completed by nurse managers in December 2017, 01/23/18 and 01/24/18 to ensure ongoing compliance with safe mechanical lift transfers. 7. Observation during the annual survey which was completed on 02/01/18 confirmed all transfers observed, including mechanical lift transfers, were completed according to manufacturer recommendations and facility policy and procedure.

Based on observation, record review and interview the facility failed to ensure adequate interventions were in place to prevent a significant weight loss for Resident #57 and failed to ensure nutritional interventions were provided as ordered to promote wound healing and improve nutritional status for Resident #243. Harm occurred when Resident #57 had poor food intake and lack of assistances with meals which resulted in an avoidable significant weight loss. Harm occurred to Resident #243 when the facility failed to implement ordered nutritional supplements to increase protein stores and aid in the healing of the resident's pressure ulcers. This affected two residents (Resident #57 and #243) of six residents reviewed for nutrition. Findings include: 1. A review of the medical record for Resident #57 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed the resident was sent to the hospital on [DATE] and then re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A quarterly assessment Minimum Data Set (MDS) 3.0, dated 12/03/14 revealed the resident had moderately impaired cognition and required extensive assistance with one to two person physical assistance for bed mobility and transferring and extensive assistance with one person physical assistance for eating. A review of the current State tested nursing assistant (STNA) plan of care revealed Resident #57 was able to feed herself with tray set up assistance. A review of the current self care deficit plan of care revealed the resident would eat with her fingers at times and was independent in eating. A review of the current nutrition plan of care revealed the resident had the potential for nutrition and hydration risk related to receiving a mechanically altered diet because her dentures were lost in the hospital, her meal intakes had declined status [REDACTED]. The nutritional plan of care did not include any interventions to offer food substitutions, cueing, encouragement if meal intake is poor or to offer assistance with feeding as needed. A review of the nutrition assessment on 11/24/14 revealed the resident's estimated energy needs were 1512 to 1602 calories, 54 grams of protein, and 1620 milliliters of fluids and residents usual body weight was 118 to 120 pounds. The resident was readmitted at moderate to high nutrition risk as evidenced by chewing concerns, lost dentures, status [REDACTED]. The new nutrition [DIAGNOSES REDACTED]. On 11/26/14 a RD progress note was written stating the resident's weight of 120# on 11/25/14 was returning to the usual body weight from the significant weight gain on readmission and to continue the current nutrition interventions. Another RD progress note was written on 12/10/14 stating the resident was reweighed at 101# reflecting a 19 pound weight loss in one week and contributed the weight loss due to the resident having a surgical (JP) drain removed on 12/09/14, draining bag along with dressing accounting for some of the weight change and loss of dentures at hospital. On 12/11/14 the RD progress note stated the weight loss was a 22.9 percent significant weight loss in one month and the plan included for staff to assist with meals and to provide double portions at breakfast as it is the resident's favorite meal. As of 12/11/14 at 11:00 A.M., the plan of care nor the STNA plan of care was updated to reflect the new plan for staff to assist with meals. A review of the residents weight history revealed the resident weighed 118 pounds (#) on 11/06/14 prior to hospitalization . The resident was weighed on re-admission, 11/20/14 and weighed 131#. The resident's weight was 120# on 11/25/14 and 12/10/14. On 12/10/14, the surveyor requested the resident be reweighed. The resident was reweighed by STNA #90 and STNA #91, using a Hoyer lift scale. The resident's weight was 95.7#. An interview with STNA #91 on 12/10/14 at 11:45 A.M. revealed the Hoyer pad weighed two pounds, therefore the resident's weight was 93.7 pounds. On 12/09/14 at 12:54 P.M. Resident #57 was observed sitting at a table alone in the lounge/ dining area on the secured unit. The resident was served a pureed diet and no food was eaten off the tray at that time. Nursing staff were observed to provide the resident with cream for her coffee but did not cue or prompt the resident to eat. On 12/10/14 at 12:51 P.M. Resident #57 was observed sitting at a table with another resident and a staff member (identified to be the speech therapist). The speech therapist (ST) sat next to the resident and angled her chair toward the resident. The ST did not provide any conversation or provided any cueing or prompting to the resident. The ST was noted to be resting her elbow on the table and her chin was rested on her hand. The resident was feeding herself a few bites of pureed food. At 12:55 P.M. the ST walked away from the resident without any conversation to the resident. The resident then put her head down and closed her eyes. At 1:02 P.M. the resident wheeled herself away from the table. Unit Manager (UM) #95 was entering the lounge/dining area as the resident was leaving and did not ask her if she was done eating and if wanted anything else to eat and/or a food substitute. An interview with UM #95 at 1:10 P.M. confirmed the resident ate a few bites of her soup and meat and took a sip of the nutritional supplement, equivalent to approximately 25 percent eaten off the tray. The UM stated it was unusual for the resident to not drink her coffee and said she would go down to the resident's room to see why she didn't drink the coffee. An interview with registered dietitian (RD) #86 on 12/10/14 at 3:48 P.M. revealed she was not aware the resident was reweighed and the weight obtained was 93.7 pounds, which reflected a 26.3# weight loss from the last weight obtained. The RD was notified of the two observations of the resident's poor food intake and the lack of assistance with meals. Further interview with RD #86 on 12/11/14 at 7:28 A.M. revealed the weight recorded in the medical record of 120# that stated 12/10/14 was the day it was recorded in the medical record and the day the actual weight was obtained was on 12/08/14. RD #86 stated the facility reweighed the resident on 12/10/14 at 101#. The RD stated she contributed the weight loss due to the appointment when a Jackson-Pratt (JP) drain (a bulb-shaped device used to remove fluids that build up in an area of the body after surgery) was removed on 12/09/14 and the resident disliking the pureed texture that was required because the resident lost her dentures while at the hospital. The RD stated she does not feel the previous weights that were obtained were inaccurate and verified the resident did actually lose the weight. A review of the meal intake percentages for December revealed the resident's meal intakes ranged from refusing to 25 percent of breakfast meals eight out of ten breakfasts. The other two breakfast meals (12/03/14 and 12/04/14) the resident consumed 100 percent. The lunch meal on 12/09/14 was recorded at 75 percent meal consumption compared to the zero percent that was observed by the surveyor on 12/09/14 at 12:54 P.M. A review of the December Medication Administration Record [REDACTED]. An interview with the director of nursing on 12/11/14 at 10:45 A.M. confirmed the above findings for Resident #57. 2. Medical record review revealed Resident #243 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission skin assessment, dated 10/01/14 revealed Resident #243 had a sacral pressure ulcer. Review of the dietary assessment, dated 10/06/14 revealed Resident #243 was at very high nutritional risk. Review of Resident #243's Progress Notes revealed the following: On 10/14/14, add 30 milliliters house protein supplement twice a day to provide an additional 30 grams of protein and 200 calories. On 11/08/14, add fortified juice with breakfast for an additional 200 calories and six grams of protein. Review of Resident #243's physician orders [REDACTED]. On 10/14/14, house protein supplement twice a day and record percent consumed. On 11/08/14, fortified juice six ounces with breakfast and record percent consumed. Review of Resident #243's treatment administration record (TAR) revealed no evidence the house protein supplement and fortified juice was administered as ordered between October 2014 and December 2014. Review of Resident #243's laboratory results dated [DATE] revealed a [MEDICATION NAME] level of 17 milligrams per deciliter (mg/dL) (normal 17-39 mg/dL), [MEDICATION NAME] 2.7 grams per deciliter (g/dL) (norm 3.5-5.0 g/dL) and total protein 6.3 g/dL (normal 6.4-8.3 g/dL). Review of the laboratory results dated [DATE] revealed a [MEDICATION NAME] level of 17 mg/dL, [MEDICATION NAME] 2.9 g/dL, and total protein 6.0 g/dL. Review of the at risk for impaired skin integrity care plan, revised 12/09/14 revealed treatments were to be completed as ordered. Review of the potential for alteration in nutrition care plan, revised 12/03/14 revealed interventions including to monitor labs and provide supplements as ordered. On 12/10/14 at 4:50 P.M., interview with the DON verified there was no evidence the resident's nutritional supplement was administered as ordered between October and December 2014.

Based on observation, record review and interview the facility failed to comprehensively assess and provide treatment to Resident #243, who was admitted to the facility with a pressure ulcer. This resulted in harm to Resident #243, when the resident who was at high risk for skin breakdown, developed additional pressure ulcers to his heels and deterioration to an existing pressure ulcer to the coccyx. The facility did not provide skin treatments as ordered or nutritional supplement interventions as ordered which delayed the healing of the resident's pressure ulcers. This affected one resident (Resident #243) of two residents reviewed for pressure ulcers. The facility identified 12 residents with pressure ulcers. Findings include: Medical record review revealed Resident #243 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission nursing assessment, dated 10/01/14 revealed the resident was at high risk for pressure ulcers. Review of the admission skin assessment dated , 10/01/14 revealed Resident #243 had a sacrum pressure ulcer. Review of the medical record revealed no documented evidence of pressure ulcer measurements or wound description. Review of Resident #243's progress notes revealed the following: The note dated, 10/02/14 revealed Resident #243 had an unstageable coccyx wound measuring 10 centimeters (cm) in length by 9 cm in width (w), a Stage II fluid filled blister to the right heel measuring 3.5 cm in (l) by 3.0 cm in (w) and a SDTI to the left heel. There was no documented assessment of the coccyx wound bed tissue. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 10/08/14 revealed Resident #243 was moderately impaired for daily decision-making, required extensive assist for bed mobility and transfers, had a Stage III pressure ulcer (full thickness tissue loss and depth of tissue loss may be obscured) with granulation, one unstageable pressure ulcer due to slough/eschar and two unstageable suspected deep tissue injuries (SDTI). On 10/14/14 a recommendation was made to add 30 milliliters house protein supplement twice a day. On 11/08/14 fortified juice with breakfast was added. Review of Resident #243's physician orders [REDACTED]. On 10/01/14, [MEDICATION NAME] cream to affected areas. On 10/02/14, an order to cleanse coccyx with normal saline, pat dry, apply alginate silver and cover with a foam dressing every 3 days and as needed. On 10/02/14, the resident developed a Stage II fluid filled blister to the right heel. On 10/06/14, the coccyx treatment frequency was ordered to be completed daily. On 10/14/14, house protein supplement twice a day and record percent consumed. On 11/08/14, fortified juice six ounces with breakfast and record percent consumed. On 11/18/14, an order to cleanse the right heel with normal saline, pat dry, and apply foam dressing every three days. Review of Resident #243's treatment administration record (TAR) dated October 2014 revealed no documented evidence house protein supplement was administered as ordered. Review of Resident #243's TAR dated November 2014 revealed the following: The coccyx treatment was not completed daily as ordered on [DATE], 11/17/14, 11/18/14, 11/23/14, 11/24/14, 11/26/14, 11/27/14, and 11/30/14. The right heel treatment was not completed as ordered on [DATE], 11/24/14, and 11/27/14. There was no evidence house supplement or fortified juice was administered as ordered. Review of the TAR dated December 2014 revealed the following: The right heel treatment was not completed as ordered on [DATE], and the coccyx treatment was not changed daily as ordered on [DATE], 12/03/14, 12/05/14, 12/07/14, 12/08/14 and 12/10/14. There was no evidence house supplement or fortified juice was administered as ordered until 12/10/14. Review of Resident #243's laboratory results, dated 10/17/14 revealed a [MEDICATION NAME] level of 17 milligrams per deciliter (mg/dL) (normal 17-39 mg/dL), [MEDICATION NAME] 2.7 grams per deciliter (g/dL) (norm 3.5-5.0 g/dL) and total protein 6.3 g/dL (normal 6.4-8.3 g/dL). Review of the laboratory results dated [DATE] revealed a [MEDICATION NAME] level of 17 mg/dL, [MEDICATION NAME] 2.9 g/dL, and total protein 6.0 g/dL. Review of the at risk for impaired skin integrity care plan, revised 12/09/14 revealed treatments were to be completed as ordered. Review of the potential for alteration in nutrition care plan, revised 12/03/14 revealed interventions including to monitor labs and provide supplements as ordered. Review of the Skin: Dressings and Wound Care policy, revised November 2006 revealed ulcers were to be treated according to physicians orders. Review of the Skin Assessment-Monitoring of Healing Process policy revised November 2006 revealed a nurse was to assess ulcers and wounds at the time of admission, readmission at least weekly and with a significant change. On 12/10/14 at 3:38 P.M., interview with licensed practical nurse (LPN) #55 verified Resident #243's skin assessment on admission did not include a comprehensive assessment of the resident's sacrum pressure ulcer. On 12/10/14 at 3:40 P.M., interview with LPN #55 verified there was no documented evidence of a comprehensive pressure ulcer assessment of Resident #243's coccyx wound on admission and stated the coccyx was covered with soft necrotic tissue but this was not documented. On 12/10/14 at 4:50 P.M., interview with the director of nursing (DON) verified there was no documented evidence the resident's nutritional supplement was administered as ordered between October and December 2014. On 12/11/14 at 7:24 A.M., interview with the DON verified there was no evidence the resident's coccyx treatment was completed as ordered between 10/06/14 and 10/31/14. On 12/11/14 at 7:53 A.M., interview with the DON verified there was no evidence the resident's coccyx and right heel pressure ulcer treatments were completed as ordered in November and December 2014 and verified the admission MDS was inaccurately coded for granulation. On 12/11/14 at 10:23 A.M., observation of a dressing change to Resident #243's coccyx area, completed by the unit's LPN, revealed the resident continued to have a pressure ulcer present.

Based on medical record review, review of the Pain Management Policy, resident interview and staff interview, the facility failed to provide pain management timely for one of three sampled residents reviewed for pain management (Resident #20). The census was 207. Findings include: Review of the medical record for Resident #20 revealed re-admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had pain on occasion at a moderate level, was not on a scheduled pain medication, did receive as needed pain medication and the pain did not effect daily function in the past five days. The MDS assessment identified the resident was short of breath with exertion and when sitting at rest. Resident #20 was dependent upon staff for bed mobility, eating and personal hygiene. The resident had a gastrostomy tube for nourishment and medication delivery and also received oral nourishment. The resident received 25% or less of nourishment per feeding tube. The document evidenced the resident's speech was unclear. There was no summary score for cognition, and interview questions were left blank in mental status section and documented by staff evaluation. The resident's long and short term memory were "ok" according to the facility's documentation. The resident was assessed as able to recall current season, location of own room, staff names and faces and in a nursing home. The behavior portion of the assessment dated [DATE] revealed he exhibited no behaviors and did not reject care. The document indicated the resident received anti-anxiety medication six of the last seven days and antidepressant medication six of the last seven days. The document evidenced the resident required oxygen therapy, suctioning, [MEDICAL CONDITION] care and was ventilator dependent with respiratory services provided. Review of the physician's orders [REDACTED]. Review of the Plan of Care for Resident #20 related to pain management revealed the goal was for the resident to report pain was reduced or less than daily. Interventions included: calming music or TV per request, medications as ordered to manage pain, monitor for effectiveness of intervention, monitor for increased level of pain and notify physician, pain assessments per facility policy and use pain scale as reported by resident. Observation of Resident #20 on 09/13/13 at 7:40 A.M. revealed the resident was in bed with the artificial ventilator attached to the tracheotomy. A private sitter was at his bed side. The resident had a computer and keyboard for communication. The head of the bed was elevated at 30 degrees and the resident had a mouth piece to use to activate the call light for assistance. Interview of Private Sitter (PS) #30 on 09/13/13 at 7:40 A.M. revealed Resident #20, who she had provided service through the night and morning, requested something for pain at 3:45 A.M. from the nurse caring for Resident #20 on the night shift. PS #30 did not know the nurses name. PS #30 stated she went to the desk one time and to the hall one time to remind the nurse the resident needed something for pain after the resident requested pain medication. PS #30 stated Resident #20 received a medication via the [DEVICE] but was unable to verify what type of medication was administered. PS #30 stated the medication was not administered until about an hour and a half after the request. Interview of Resident #20 on 09/13/13 at 7:45 A.M. revealed the resident typed the responses to the interview due to his respiratory status. The resident typed that he requested pain medication at 3:45 A.M. and did not receive it until 5:58 A.M. an hour and one half after his request. Resident #20 asked if 5:58 A.M. was a typing error, he nodded to indicate yes, it was 5:15 A.M. (this would match the time the nurse documented Resident #20 was given Tylenol 650 milligrams (mg) in the nurse progress note). Resident #20 was asked to describe his pain at the time of his request and the location of the pain. Resident #20 typed level 7 of the lower neck. The resident was asked if the pain level increased before he received the pain medication and he nodded his head to indicate no. The resident typed his anxiety level increased while waiting for the pain medication making it harder to breath. Review of the September 2013 medication administration record (MAR) for Resident #20 revealed the resident received the as needed (prn) [MEDICATION NAME] 10 mg, 12 of 13 days for September 2013. Review of the medication record and the pain intervention flow record revealed no evaluation of the level of pain on any day before the pain medication was administered before nor was there documentation regarding the effectiveness of the medication. Review of documentation dated 09/13/13 on the narcotic count record evidenced [MEDICATION NAME] 10 mg was signed out at 5:00 A.M. by Nurse #23 as well as [MEDICATION NAME] 0.25 mg. for Resident #20. Review of the September 2013 MAR for Resident #20 revealed there was no time entered as to when the medication was administered. The documentation on the MAR only evidenced the resident complained of pain. There was no location of the pain nor was there a pain level assessment completed before or after the medication was pulled from the narcotic box. Review of Resident #20's September 2013 MAR regarding the administration of [MEDICATION NAME] 0.25 mg revealed no documentation the medication was given and the behavior flow record was blank for any evidence the resident was having anxiety or was given medication related to anxiety. Review of the September 2013 MAR and the pain assessment flow record for 27 doses of [MEDICATION NAME] documented as administered to Resident #20 revealed no documentation on any day regarding a pain level assessment before or after the medication was given. Review of the facility's policy and procedure for Pain Management dated March 2011 directed required documentation on the pain management flow record. The record was set up to record pain level assessment before and after administration of a prn pain medication. Review of the progress notes for Resident #20 dated 09/13/13 revealed documentation of administration of Tylenol 650 mg at 5:15 A.M. for increased temperature. Review of the MAR revealed the medication was documented on the MAR as given at 5:15 A.M. There was nothing documented regarding the [MEDICATION NAME] or the [MEDICATION NAME] having been administered. The MAR and flow record for Resident #20 dated 09/13/13 evidenced Resident #20 again requested and was administered pain medication at 9:00 A.M. The September 2013 MAR, narcotic log and the flow records for Resident #20 were reviewed with Unit Manager (UM) #22 on 09/13/13 at 1:50 P.M. UM #22 and Nurse #21 verified [MEDICATION NAME] 10 mg was signed out for Resident #20 on the narcotic log as well as the [MEDICATION NAME] 0.25 mg at 5:00 A.M. on 09/13/13. Nurse #21 verified the narcotic count for Resident #20 was correct at shift change on 09/13/13. Nurse #21 and Nurse #22 verified the documentation on the MAR and the flow records for pain management and behavior management for Resident #20 failed to accurately reflect the medication that was administered to Resident #20 at 5:00 A.M. on 09/13/13. There was no documentation that evidenced Resident #20 actually received the narcotic and anti-anxiety medication after it was removed from the narcotic box. In addition, the records failed to include pain level assessments or anxiety behaviors as required throughout the month of September 2013. This certification deficiency was an incidental finding related to Complaint Control Number OH 816.

Based on medical record review, policy review and staff interview, the facility failed to prevent a resident admitted to the facility with intact skin and at risk for pressure ulcer development from developing three, Stage II pressure ulcers(partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This affected one of three residents reviewed for pressure ulcers (Resident #166). The census was 203. Harm occurred when Resident #166 entered the facility without pressure areas but then developed three in-house acquired pressure ulcers. Findings include: Medical record review revealed Resident #166 was admitted to the facility on [DATE] and was discharged to the hospital on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #166 was dependent on staff for all activities of daily living (ADL) including bed mobility and transfers, was incontinent of bowel and ventilator dependent. Review of the Nursing Admission assessment dated [DATE] revealed Resident #166's skin was warm and dry with no documented evidence of skin breakdown. Review of the Pressure Ulcer Risk assessment dated [DATE] revealed the resident was at high risk for pressure ulcer development. Review of the Nutritional assessment dated [DATE] revealed Resident #166 was receiving continuous enteral nutrition, was bedfast, had no pressure ulcers and laboratory results were pending. Review of Resident #166's physician orders [REDACTED]. a. On 03/27/13, the head of the resident's bed was to be elevated at least 30 degrees while receiving continuous, tube feeding (enteral nutrition), and was receiving a multivitamin and [MEDICATION NAME] sulfate daily. No pressure relieving interventions were ordered. b. On 03/29/13, an order to obtain laboratory bloodwork that included a pre-[MEDICATION NAME] level (a hepatic protein to assess protein deficiency). Review of Resident #166's medical record revealed no documented evidence a pre-[MEDICATION NAME] level was obtained. Review of Resident #166's Laboratory Report dated 04/08/13 revealed a hemoglobin level of 9.1 milligram per deciliter (mg/dl) (normal 13.2 to 17.3 mg/dl.) and a hematocrit level of 28.8 mg/dl (normal 39 to 49 mg/dl). Review of Resident #166's Skin Grid-Pressure Ulcer assessments revealed the following: a. On 04/02/13, a facility-acquired Stage II pressure ulcer to the left earlobe that measured 0.2 centimeters (cm) in length (L) by 0.2 cm in width (w) by 0.1 cm in depth (d) with no odor and a small amount of red drainage. On 04/02/13 an order was written to prop the residents head over to prevent pressure to left ear. b. On 04/11/13, a facility-acquired Stage II pressure ulcer to the left buttock that measured 6.5 cm in (l) by 3.2 cm in (w) by 0.1 cm in (d) with no drainage. c. On 04/12/13, a facility-acquired Stage II pressure ulcer to the right buttock that measured 0.5 cm in (l) by 0.5 cm in (w) by 0.1 cm in (d) with no drainage. Review of Resident #166's medical record revealed no documented evidence interventions were implemented upon admission to prevent the development of pressure ulcers, no documented evidence the resident was turned and repositioned, and no documented evidence the resident was on a pressure relieving mattress. Review of the initial Care Plan Cover Sheet (undated) included Resident #166 was unresponsive with a [MEDICAL CONDITION], on a ventilator and oxygen, required total care with ADL's, was incontinent of bowel and had a suprapubic catheter (surgically placed urinary catheter). Changes in skin condition were to be reported and the resident was to be repositioned every two hours. Review of the Self-care deficit ADL care plan (dated 04/04/13) revealed Resident #166 was dependent on staff for ADL's and interventions included preventative skin care as needed, monitor for any skin breakdown and turn and reposition the resident as needed. Review of the At Risk for Impaired Skin Integrity care plan (dated 04/04/13) related to ear pressure ulcer (dated 04/04/13) revealed interventions that included pressure reduction devices if ordered, and turn and reposition as needed. Review of the Skin-Pressure Ulcers Policy(revised November 2006) revealed a pressure ulcer was any ulcer caused by unrelieved pressure that resulted in damage to underlying tissues. An avoidable pressure ulcer included the resident developed a pressure ulcer and the facility did not implement interventions that were consistent with resident needs. On 08/16/13 at 8:37 A.M., interview with the Director of Nursing (DON) stated residents at risk for pressure ulcers had individualized interventions on the Care Plan Cover Sheet that were to be implemented upon admission. The DON verified Resident #166's Care Plan Cover Sheet was undated. The DON verified the facility does not write physician orders [REDACTED]. The DON stated all the mattresses in the facility were pressure relieving. The DON also verified Resident #166 developed three facility-acquired pressure ulcers between 04/02/13 and 04/12/13 and there was no documented evidence pressure relieving interventions or turning and repositioning was completed for Resident #166. Review of the Skin: Positioning and Pressure Redistribution Policy(revised November 2006) revealed upon completion of the risk assessment and skin assessment, the nurse and/or the Interdisciplinary team will choose and implement the interventions that will best meet the goals for the resident. Residents were to be repositioned at least every two hours and depending on the resident assessment, may require more frequent position changes. If the head of the bed must be elevated, raise the knee gatch and initiate other "seating" interventions and off load every hour for one minute if elevated 30 degrees or more.

Based on clinical record review, review of hospital records and facility staff interviews, the facility failed to provide accurate assessments and preventative treatment to one resident. This resulted in harm when the resident developed an unstageable pressure area and a Stage II pressure area, which was not present on admission. This affected one resident (Resident #201) out of three sampled. The facility identified two residents who developed pressure areas after admission. The facility census was 199. Findings include: Clinical record review revealed Resident #201 was admitted to the facility on [DATE]. Review of her cumulative [DIAGNOSES REDACTED]. Review of her initial minimum data set (MDS) assessment revealed the resident was in a coma. Review of Resident #201's discharge summary from a local hospital dated 05/17/12, revealed she was admitted to the hospital on [DATE], after suffering [MEDICAL CONDITION] at home. Discharge instructions revealed to treat her Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) pressure ulcer to her sacral area with [MEDICATION NAME] and foam, twice weekly and as needed. No other skin areas were noted. Review of the facility's admission assessment dated [DATE], revealed no pressure areas. Review of Resident #201's pressure ulcer risk assessment completed on 05/17/12, revealed she was a high risk for pressure due to currently having a Stage II pressure area to her sacral area, being comatose and bedfast. Her score was a 15, the assessment noted anything greater than an 8 was considered a high risk. Review of Resident #201's progress notes revealed no documentation related to the resident's skin or pressure areas. The resident was noted to have a care plan related to her Stage II sacral pressure area, however, no plan of care was noted related to skin integrity with interventions to prevent further pressure areas. Review of wound management progress note written by facility's certified nurse practitioner dated 06/12/12, revealed Resident #201 had an unstageable pressure area to her right ear. The area was noted to have no granulation, with crusting necrotic tissue. The area measured 0.3 centimeters (cm) in length (l) and 0.4 cm in width (w). On 06/21/12, the area was noted to remain unstageable and measurements were 0.4 cm (l) by 0.4 cm (w) . On 06/29/12, the area was noted as a Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure area measuring 0.5 cm (l) by 0.5 cm (w) with 0.2 cm in depth (d), with bleeding noted. A new order was received to start a hydrogel (type of dressing) to the wound and apply a non-adherent pad. It was noted both ears would be padded at this time. On 07/05/12, the pressure area to her right ear measured 0.6 cm (l) by 0.6 cm (w). Review of skin grid pressure note dated 06/28/12, revealed Resident #201 now had a Stage II pressure area to her left ear. It measured 0.1 cm (l) by 0.1 cm (w) with serosanguineous (mixture of blood and serum) red drainage. On 07/05/12, the area measured 0.3 cm (l) by 0.3 cm (w). Interview with Licensed Practical Nurse (LPN #50) on 07/19/12 at 10:40 A.M., revealed she had been assigned to the care of Resident #201 frequently during her stay at the facility. LPN #50 revealed she was not aware of any areas to Resident #201's ears until the treatments were initiated. She was not aware of who first discovered the areas. Interview with Registered Nurse (RN #70) on 07/19/12 at 10:45 A.M., revealed she was the unit manager on the unit Resident #201 resided. RN #70 revealed she did not remember who initially found the area to Resident #201's ears. She further revealed the areas might have been overlooked as she had long curly hair. She further revealed there was no documentation regarding the areas during weekly skin sweeps or during daily care of the resident until the area was discovered at an unstageable pressure area. This deficiency substantiates allegations contained in Master Complaint Control Number OH 325.

Based on medical record review, policy review, and staff interview, the facility failed to ensure a resident with a [DIAGNOSES REDACTED]. This affected one of two residents reviewed for diabetes mellitus (Resident #60). The facility identified 103 residents with diabetes mellitus. Harm resulted to Resident #60 when the facility failed to obtain daily fasting blood glucose levels between 03/28/11 through 08/07/11, failed to obtain ordered monthly and weekly laboratory bloodwork, and failed to treat rising blood glucose levels between 01/17/11 and 06/21/11 resulting in a critical elevation of blood glucose on 08/07/11 of 674 mg/dL (milligrams per deciliter) resulting in a change in mental status and hospitalization . Findings include: Medical record review revealed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 08/12/11, the resident's [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 had a brief interview mental score (BIMS) of 12 (a BIMS score of 8-12 is moderately impaired). Review of the monthly physician orders [REDACTED]. Review of the medical record revealed no documented evidence daily, fasting blood sugars were obtained between 03/28/11 and 08/06/11. Review of the physician orders [REDACTED]. Review of the medical record revealed no documented evidence blood work was completed during the month of February 2011 or July 2011. Review of Resident #60's laboratory reports revealed the following: a. On 01/22/11, blood glucose was 111 mg/dL. Normal blood glucose levels are 74-106 mg/dL. b. On 03/22/11, blood glucose was 145 mg/dL. There was no documented evidence the physician was notified of the resident's glucose results. c. On 04/27/11, blood glucose was 226 mg/dL. There was no documented evidence the physician was notified of the resident's glucose results. d. On 05/21/11, blood glucose was 211 mg/dL. e. On 05/25/11, blood glucose was 150 mg/dL. f. On 06/21/11, blood glucose was 140 mg/dL. There was no documented evidence the physician was notified of the resident's glucose results. g. On 08/19/11, hemoglobin A1C (bloodwork indicating glucose control over three months) was 12.9%. Normal hemoglobin A1C was 4.7 -5.8%. Review of the physician orders [REDACTED]. Review of the medical record revealed no documented evidence blood work was completed on 06/06/11, 06/13/11 or 06/27/11. Review of the CNP progress notes dated 01/16/11, 02/12/11, 03/19/11, 04/03/11 and 07/17/11 revealed no documented evidence the CNP addressed the monitoring of Resident #60's blood glucose levels. Review of the physician progress notes [REDACTED].#60's blood glucose levels. Review of Resident #60's Health Status Progress Note (dated 08/07/11 at 11:55 A.M.) revealed Resident #60 was acting strange, vital signs were obtained; however, no vital signs were documented, and the residents blood sugar read "high". Certified nurse practitioner (CNP) #2 was notified and ordered to administer [MEDICATION NAME] R (fast acting insulin) 15 units. Resident #60's blood sugar was rechecked at 2:05 P.M. and read "high". CNP #2 was notified and ordered to administer [MEDICATION NAME] R 10 units. Review of the Health Status Progress note (dated 08/07/11 at 3:11 P.M.), revealed Resident #60's blood sugar continued to read "high", vital signs included blood pressure 164/86, heart rate 105, and respirations 20. Emergency Services (911) was called and Resident #60 was sent to the emergency room . On 08/23/11 at 5:35 P.M., interview with the Director of Nursing (DON) verified the Health Status Progress Note dated 08/07/11 at 3:11 P.M. was out of sequence and followed a note in the electronic medical record dated 08/23/11 at 3:23 A.M. Review of the Medication Regimen Review dated 12/19/10 through 08/03/11 revealed no documented evidence the pharmacist notified the DON or attending physician of missing laboratory blood work and lack of daily fasting blood glucose monitoring. Review of the Potential for Alteration in Nutrition and Hydration care plan (revised 12/15/10) revealed labs were to be monitored as ordered. Review of the Hospital Admission Summary (dated 08/07/11 at 3:58 P.M.) revealed chief complaint of the resident having BS reading "high" all day long even after the resident was administered 15 units and 10 units of [MEDICATION NAME] R insulin. On 08/07/11 at 4:14 P.M., Resident #60's respirations were 28 breaths per minute (normal range 12-20 breaths per minute) and pulse 102 beats per minute (normal range 60-90 beats per minute). The resident complained of feeling achy and "not herself". Resident #60 was oriented to self but not place or time. When asked where she was she said a park and that she was a park ranger. The resident was able to answer most other questions. Review of the hospital blood glucose test revealed Resident #60's glucose was critical at 674 mg/dL (normal range 70-110) and urinalysis revealed glucose 1000 mg/d (normal range is zero). Resident #60 was admitted to the hospital telemetry unit with the [DIAGNOSES REDACTED]. Review of the referral for Continuity of Patient Care dated 08/11/11 revealed Resident #60 had a hemoglobin A1C of 14%. Review of the Change of Condition policy (revised April 2003) revealed a significant change in the resident's health status or clinical condition that requires interdisciplinary review or revision of the plan of care included the emergence of an unstable condition or disease. The unit supervisor or charge nurse was to immediately notify the physician and guardian, and document all notifications in the medical record. Review of the Physician Orders-Transcription policy (revised 06/05/07) revealed physician orders [REDACTED]. Review of the Care of the Adult Diabetes Mellitus Resident policy (dated 02/21/07) revealed later signs and symptoms of [MEDICAL CONDITION] (high blood sugar, diabetic detoacidosis) may include deep, labored, rapid respirations, lethargy, and decreased awareness/senses. Documentation was to include level of consciousness, an assessment of the resident's skin color, turgor and temperature, and the resident's vital signs as ordered. On 08/23/11 at 2:50 P.M., interview with licensed practical nurse (LPN) #3 verified Resident #60's medical record had no documented evidence of laboratory bloodwork including glucose monitoring as ordered February 2011, 06/06/11, 06/13/11, 06/27/11 or July 2011. LPN #3 verified the medical record had no documented evidence the physician was notified that ordered bloodwork was not obtained on 06/06/11, 06/13/11 or 06/27/11, and the physician was not notified of Resident #60's elevated glucose results dated 03/22/11, 04/27/11, 05/21/11 and 06/21/11. On 08/23/11 at 2:50 P.M., interview with LPN #3 verified Resident #60's medical record had no documented evidence of daily glucose monitoring between 03/28/11 and 08/06/11, and the physician progress notes [REDACTED]. On 08/23/11 at 3:09 P.M., interview with the DON verified Resident #60 was admitted to the hospital on [DATE] with an elevated blood glucose level of 674 mg/dL and prior to the resident's hospitalization , the facility did not complete blood glucose monitoring as ordered by the physician. This certification deficiency substantiates Complaint Number OH 938.