Every finding on record at The Oaks Rehabilitation and Healthcare Center

Based on medical record review, observation and staff interview, the facility failed to maintain infection control during a wound dressing change. This affected one resident (#18) of one resident observed for a dressing change. The facility census was 71. Findings include:Review of Resident #18's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included osteomyelitis of the left foot and ankle, non pressure chronic ulcer of the left foot with bone involvement, protein calorie malnutrition, COPD, and PVD. Review of the admission minimum data set (MDS) dated [DATE] revealed the resident's cognition was moderately impaired. He was always continent of bowel and bladder. Review of the physician orders dated 07/26/26 revealed an order to cleanse the left heel wound with normal saline, apply Santyl nickel thick, followed by betadine moist gauze. Cover with kerlix and tubi-fast blue. Observation on 08/13/26 at 10:50 A.M. of the dressing change to Resident #18's left heel revealed Licensed Practical Nurse (LPN) #200 washed her hands and put on gloves and an isolation gown. LPN #200 then removed the resident's old dressing and left the old, soiled dressing on the resident's bed. LPN #200 removed her soiled gloves, washed her hands, and opened the wound dressing supplies. At this time, LPN #200 forgot to obtain her Santyl ointment so she removed her gloves and squeezed out a small amount, then removed her old gloves, put on new gloves without washing her hands. LPN #200 then cleansed the wound on the left heel with normal saline soaked gauze, with the same gloves, she moved to the clean dressing supplies, and put Santyl on with a cotton swab, and placed a betadine soaked gauze on the wound with her gloves. LPN #200 then placed an ABD pad over the heel and wrapped it with Kerlix. LPN #200 then removed her gloves and picked up the soiled dressings and supplies off the bed and threw them into the trash. On 08/13/26 at 11:02 A.M. LPN #200 verified that she failed to wash her hands between glove changes, used soiled gloves to place a clean dressing on the resident's wound, and placed the resident's soiled dressing directly on his bed without a barrier. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number 3136545.

Based on medical record review and staff interview, the facility failed to ensure physician ordered supplies were available for the treatment of a pressure ulcer. This affected one resident (#71) of two residents reviewed for wound treatments. The facility census was 71.Findings include:Review of Resident #71's closed medical record revealed he was admitted to the facility on [DATE] with diagnoses of acute kidney failure, osteomyelitis of the vertebrae, Stage 4 pressure ulcer of the sacrum, MRSA, gastrointestinal hemorrhage, protein calorie malnutrition, diabetes, PVD, urostomy and colostomy. A Stage 4 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. Slough and/or eschar may be visible on some parts of the wound bed.Review of the 5-day minimum data set (MDS) assessment revealed his cognition was intact. He required supervision or touching assistance with eating, oral hygiene, was dependent on staff for toileting, required substantial/maximal staff assistance for showering, dependent on staff for dressing and turning and repositioning.Review of July 2026 physician orders revealed a physician order dated 07/28/26 for a wound vacuum in place and functioning properly; every day and night shift check that wound vac is on and functioning every shift. The site for the wound vac was noted to be the sacrum (Stage 4 pressure ulcer). The order identified to cleanse the sacrum with normal saline and pat dry, apply black granufoam (designed to adapt to irregular wound contours), apply the wound vacuum at 125mm/HG continuous pressure on day shift every Monday, Wednesday, Friday for wound care and as needed for leakage or displacement.Further review of progress notes revealed on 08/03/26 Resident #71 had wound changes. The resident's wound vac was taken off and a wet to dry dressing put on due to waiting for the arrival of wound vac drainage canisters. On 08/04/26 the wound vac not in place and the wound nurse was to review in morning. On 08/05/26 a wet to dry dressing was in place. On 08/06/26 the certified nurse practitioner (CNP) was updated that the wet to dry dressing was still being applied; the CNP gave a verbal order to discharge the resident to home with wet to dry dressing order. On 08/07/26 the progress notes revealed the wound vac was not in place at this time due to no canister was available. On 08/08/26 at 9:56 A.M. Resident #71 left the facility for home with his wife.On 08/13/26 at 2:06 P.M. interview of Registered Nurse (RN) #334 revealed they had run out of wound vacuum canisters due to Resident #71 was having a lot of drainage and staff could only get two canisters at a time when ordering. Per RN #334, they do not have a central supply, and the director of nurses (DON) at the time was off work and the DON is the one who orders supplies. RN #334 verified the lack of wound vacuum canisters is the reason Resident #71's had to be changed to a wet to dry dressing instead of the wound vacuum.On 08/13/26 at 2:33 P.M. interview of Licensed Practical Nurse (LPN) #200 revealed Resident #71 had excessive drainage, and the facility ran out of canisters. The resident's order had to be changed due to wet to dry dressing. The canisters were ordered but they had not come in by the time the resident left.On 08/13/26 at 2:38 P.M. interview with Registered Nurse (RN) #334 revealed they do not have any documented evidence of where they ordered the wound vacuum canisters. The supplier is a new company that the facility switched to about a month ago and all the facility had is a phone number.This deficiency represents non-compliance investigated under Complaint Number 3136545.

Based on record review, review of on-call notes, review of the emergency medical services (EMS) run report, review of outside hospital medical records, interview and policy review, the he facility failed to timely respond to a change in condition. This resulted in Actual Harm when on [DATE], Resident #28 had a change in condition. Facility staff failed to notify the medical provider and or respond to the change in condition. Resident #28 suffered a moderate diffuse ileus (the normal wave-like contractions of your intestines have slowed or stopped across a broad area, causing a backup of gas and fluids) which resulted in hypotension, sepsis colitis, respiratory failure, coagulopathy, volume depletion, acidosis and renal failure. Resident #38 died on [DATE]. This affected one (Resident #28) of five residents reviewed for change in condition. The facility census was 69.Findings include: Review of the medical record revealed Resident #28 was admitted on [DATE]. Diagnoses included unilateral primary osteoarthritis, right hip, aftercare following joint replacement surgery, pain due to internal orthopedic devices, implants and grafts, subsequent encounter, type two diabetes mellitus, asthma, hypertension, iron deficiency, vitamin D deficiency, hyperparathyroidism, diverticulosis of large intestine without perforation or abscess without bleeding, obstructive sleep apnea, and restless leg syndrome. Resident #28 was admitted to the to receive therapy services post hip replacement with a plan to discharge home. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact and required supervision with toileting hygiene and moderate assistance with mobility and transfers. Review of Resident #28's bowel movements on [DATE] revealed one loose stool documented. Review of Resident #28's bowel movements on [DATE] revealed one loose stool documented. Review of Resident #28's bowel movements on [DATE] revealed one loose stool documented. Review of the Physical Therapy (PT) note dated [DATE] revealed Resident #28 required long rest breaks due to sets of diarrhea, nausea, and vomiting. Resident #28 had immediate onset of nausea (been feeling ill this entire date with nursing aware) with frequent dry heaving throughout the therapy session. A cold compress was applied and nursing aware. There was no documentation the medical provider was notified. Review of Resident #28's blood pressure log dated [DATE] at 8:08 A.M. revealed Resident #28's blood pressure was 92/67. On [DATE] at 7:46 P.M., her blood pressure was 70/49. Neither incident had documentation that the medical provider was notified. Review of Resident #28's bowel movements on [DATE] revealed three loose stools documented. Review of the provider note dated [DATE] revealed Resident #28 told the medical provider she had been experiencing diarrhea for a few days. Review of the note dated [DATE] at 11:54 P.M. for Resident #28 revealed new order for ondansetron hydrochloride (HCl) four mg give one tablet by mouth every six hours as needed for nausea and vomiting. Review of the MAR/TAR dated [DATE] for Resident #28 revealed Resident #28 received one dose of ondansetron HCl four mg on [DATE] at 11:54 P.M. Review of Resident #28's bowel movements on [DATE] revealed two loose stools documented. Review of Resident #28's bowel movements on [DATE] revealed one loose stool documented. Review of the on-call provider note dated [DATE] at 2:05 A.M. revealed Licensed Practical Nurse (LPN) #34 called and reported Resident #28 had been having nausea, vomiting and diarrhea, had Zofran and Imodium. Her blood pressure was 96/60, temperature 99.4 degrees F, and heart rate 79 beats per minute. Orders for STAT (immediately or without delay) kidney, ureter, and bladder (KUB) (plain imaging test that evaluates the abdominal area to diagnose the cause of belly or flank pain, urinary issues, or digestive blockages) and 500 milliliters (mL) bolus 0.9 percent normal saline at 50mL/hour. Review of the progress note dated [DATE] at 2:08 A.M. revealed the nurse called the on-call medical provider because Resident #28 had nausea, vomiting, and diarrhea for several days as well as a low-grade temperature and complained of dizziness. Resident #28 received a new order for STAT KUB x-ray and sodium chloride solution 0.9% use 50 mL per hour intravenously (IV) every two hours every one day for acute diarrhea and vomiting, run at 50 mL per hour until complete then discontinue. Review of the note dated [DATE] at 10:50 A.M. revealed Resident #28 was cool to the touch. Vital signs were taken and she had a temperature of 97.1 degrees F, blood pressure 90/50, pulse 72, respirations 20 and oxygen saturations (measurement of the percentage of hemoglobin in your blood that is carrying oxygen) 97 percent on four liters (L) of oxygen. There was no documentation of what the oxygen saturation was on room air before the oxygen was administered. Nurse Practitioner (NP) #26 was in the facility and ordered Resident #28 to the local emergency room for evaluation and treatment. Review of the ambulance run report dated [DATE] at 10:47 A.M. revealed the ambulance was called to the facility for an ill female. On arrival, the nurse stated Resident #28 had been ill since Saturday ([DATE]) with nausea/diarrhea and patient had not felt well, stating Resident #28 was unable to eat or take many fluids. The nurse stated she came to check on Resident #28 and she was very cold. The nurse stated they had been running fluids in her for dehydration, IV on dial a flow at 40 mL per hour. Respirations were labored on two liters (L) of oxygen via nasal cannula. Review of the outside hospital emergency room note dated [DATE] at 11:32 A.M. revealed emergency medical services (EMS) had blood pressure of 66/49 and attempted IV access without success. Resident #28 appeared pale and cool, would respond to staff but confused. Resident #28 had labored respiratory effort and increased respirations with pale skin and cool to the touch and diaphoretic (inducing or increasing perspiration). Resident #28 arrived at 11:32 A.M. with primary diagnoses including hypotension, sepsis colitis, respiratory failure, coagulopathy, volume depletion, acidosis, and renal failure. Resident #28 arrived at the hospital hypotensive with blood pressure in the 60's and heart rate over 100. Resident #28 was given IV fluids and her workup revealed evidence of colitis and a white count of 40,000 (normal 4,500-11,000). Resident #28 told the hospital physician she had been having more than 10 bowel movements a day that were very watery and foul-smelling. Resident #28 was started on norepinephrine (to rapidly increase and sustain blood pressure) and vasopressin (to raise blood pressure in adults with vasodilatory shock (such as septic shock) who do not respond to fluids and other medications). Resident #28 was also found to be in renal failure which was new with hyperkalemia. Resident #28 received an ampoule of bicarbonate (an injectable, hypertonic alkaline solution used primarily in emergency or hospital settings to treat severe metabolic acidosis and hyperkalemia) and nebulized aerosol. Resident #28's initial lactate was 6.9 (normal 0.5 to 2.0) and she received additional bicarbonate and fluids with potassium decreased. Resident #28 was admitted to the Intensive Care Unit (ICU) for ongoing management of septic shock and multi-organ failure. Resident #28 had computed tomography (CT) scan (a medical imaging test that combines x-rays and computers to create detailed, cross-sectional images of bones, organs, and soft tissues) of the head, chest, abdomen, pelvis and most noted was the evidence of significant colitis with swelling of the bowel wall throughout the colon. Resident #28 did have bloody diarrhea and International Normalized Ration (INR) (a standardized medical lab test used to measure how long it takes your blood to clot) over five and she was given vitamin K and Fresh Frozen Plasma (FFP) (blood product made from liquid portion of human blood that is separated and frozen within hours of collection. It is primarily used in transfusions to treat clotting disorders, reverse blood-thinning medications, and replace essential proteins). On [DATE], Resident #28 required additional FFP. On [DATE], Resident #28's white count was again over 40,000 and her vasopressor requirement had increased, her renal function had deteriorated so that she was not making urine. A dialysis catheter was placed in Resident #28 due to her clinical condition. Surgery was consulted for toxic colitis and Resident #28 was intubated and subsequently taken to the operating room (OR) where Resident #28 underwent a total colectomy (removal of the entire large intestine). On [DATE], Resident #28's lactate had risen to 15.4 and required four vasopressors including epinephrine. On [DATE], surgery stated Resident #28 was in a nonsurvivable state. The family then made the decision to withdraw aggressive care and Resident #28 died. During an interview on [DATE] at 12:59 P.M., NP #26 verified he did see Resident #28 on [DATE] and was told of her blood pressure being low for a few days. NP #26 stated there is always a provider available for the staff to call and would expect them to call if a resident's blood pressure was dangerous or critically low. He knew Resident #26 had an upset stomach on [DATE] but was not aware of any loose, watery or foul-smelling stools from Resident #28. NP #26 stated on [DATE] Resident #28 was answering his questions, but you could see a level of distress. Resident #28 may have been tachycardic (a condition where the heart beats faster than normal at rest-more than 100 beats per minute-abnormal) but he did not know her vital signs. Resident #28's hands were cold and he warmed them up and her pulse ox went up and her capillary refill (a quick test that measures blood flow to peripheral tissues) seemed ok but Resident #28 had confusion and was short of breath (SOB). NP #26 stated he was not aware of therapy notes for Resident #28 having nausea on movement and was not aware of any fluids running on [DATE] when he was called to Resident #28's room for shortness of breath. During an interview [DATE] at 1:56 P.M., LPN #32 stated on [DATE] Resident #28 had complained of heartburn and indigestion and requested an antacid. LPN #32 stated Resident #28 had diarrhea on [DATE] and staff monitored it but she ate very little for breakfast and lunch. Resident #28 did have low blood pressure. LPN #32 stated on [DATE], Resident #28 was cool to touch, clammy. She could not remember what Resident #28's oxygen saturation was before putting oxygen on Resident #28. LPN #32 stated it was hard to get an IV line in Resident #28 and stated Resident #28 did get some fluids on [DATE] but was unsure of how much of the fluids Resident #28 did receive. During an interview on [DATE] at 2:39 P.M., Assistant Director of Health Services (ADHS) #36 stated normal blood pressures are 100/60 to 160/80 depending on the resident and their baseline. ADHS #36 stated the provider should be notified right away if blood pressure is low and there are other symptoms. ADHS #36 stated the provider should have definitely been called for a blood pressure of 70/49 and stated staff should not wait and recheck but call provider immediately. ADHS #36 stated there was a significant drop in Resident #28's blood pressure on [DATE] at 7:46 P.M. when Resident #28's blood pressure was 70/49. ADHS #36 verified on [DATE] Resident #28's blood pressure was low and stated the provider should have been notified. ADHS #36 stated the provider should have been notified anytime there was a significant change in condition with the residents. During an interview on [DATE] at 11:25 A.M., Certified Nurse Assistant (CNA) #88 stated she worked with Resident #28 on [DATE] and [DATE]. CNA #88 stated Resident #28 did have loose stools, and she reported it to LPN #32 on both days. CNA #88 stated Resident #28 complained of nausea and dry heaving all day on [DATE] and she reported it to LPN #32. CNA #88 stated Resident #28 was continent, and she would place her on the toilet to use and then come back to assist her from the toilet. During an interview on [DATE] at 11:32 A.M., LPN #32 stated she did not remember CNA #88 reporting Resident #28's loose stools, nausea, and dry heaving, but if CNA #88 said she told her then she probably did. During an interview on [DATE] at 4:50 P.M. NP #68 stated she was on call on [DATE] and would have sent Resident #28 to the local hospital for a blood pressure of 70/49 but she was not notified. NP #68 stated she was attributing the low blood pressure on the morning of [DATE] as dehydration with the limited information he had and ordered the KUB out of an abundance of caution and fluids to raise the blood pressure. NP #68 stated she was not aware of multiple days of low blood pressure. During an interview on [DATE] at 3:19 P.M., Physical Therapist (PT) #102 stated Resident #28 was dry heaving during their session and he informed the nurse. PT #102 reported the nurse said the resident had been sick all day. During an interview on [DATE] at 3:30 P.M., Occupational Therapist (OT) #103 stated she worked with Resident #28 on [DATE] and when she entered the room, two aides were cleaning the resident up after loose stools. OT #103 verified the visit ended because Resident #28 was sick. During an interview on [DATE] at 12:47 P.M., Medical Director (MD) #92, who wrote the provider note on [DATE] where Resident #28 reported she was having diarrhea, revealed she was unaware of other symptoms of low blood pressure, vomiting, or nausea. MD #92 was unaware Resident #28 had a history of c-diff. Review of the facility policy titled Change in a Resident's Condition or Status, dated [DATE], stated the nurse will notify the resident's attending physician or physician on call when there has been a(an): significant change in resident's physical, emotional, mental condition, need to alter the resident's medical treatment significantly, and refusal of treatment or medications two (2) or more consecutive times. Additionally, the facility policy Change in a Resident's Condition or Status dated [DATE] stated a significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (is not self-limiting), impacts more that one are of the resident's health status, and requires interdisciplinary review and/or revision to the care plan. Furthermore, the facility policy Change in a Resident's Condition or Status dated [DATE] stated the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. This deficiency represents non-compliance under Complaint Number 3048357.

Based on interview and record review the facility failed to complete respiratory assessments pre and post administration of a nebulizer (aerosol) breathing treatment. This affected one resident (#73) of three residents reviewed for respiratory care. The facility census was 71. Findings include: Review of Resident #73's closed medical record revealed an admission date of 04/05/26, a discharge date of 04/11/26. The resident had diagnoses including hypertensive heart disease with heart failure, non ST elevation myocardial infarction, cellulitis of abdominal wall, acute pulmonary edema, chronic diastolic (congestive) heart failure, depression, peripheral vascular disease, encounter for surgical aftercare following surgery on the digestive system, atrial fibrillation, and generalized anxiety disorder. Review of Resident #73's five day minimum data set (MDS) dated [DATE] revealed a brief interview for mental status score of 13 indicating the resident was cognitively intact. Further review of the MDS revealed the resident required partial/moderate assistance with bed mobility and transfers and requires substantial/maximal assistance for toileting hygiene. Review of Resident #73's physician's orders revealed an order dated 04/10/26 for ipratropium-albuterol solution 0.5-2.5(3) MG/3ML inhale orally every four hours as needed for shortness of breath or wheezing via nebulizer. Review of Resident #73's Medicare/HMO documentation dated 04/11/26 at 1:48 A.M. completed by Licensed Practical Nurse (LPN) # 249 revealed the resident's respiratory status was within normal limits at the time of the assessment. Review of Resident #73's medication administration record dated 04/11/26 revealed the resident received ipratropium-albuterol solution 0.5-2.5(3) MG/3ML inhale orally for complaints of shortness of breath at 12:43 P.M. Review of Resident #73's progress notes dated 04/11/26 at 2:05 P.M. written by LPN #242 revealed the resident complained of shortness of breath and the breathing treatment was not effective. Vital signs were blood pressure 119/81,temperature 98.7, pulse 81, respirations 24, and pulse oximetry (amount of oxygen in the blood normal is 95-100%) 94%. The resident's family was in to visit and the resident's grandson wanted the resident sent to the emergency room. Resident #73's medical provider was notified and requested a STAT chest x-ray be done. The grandson was updated and stated that he wanted the resident sent out. Resident #73's medical provider was updated and stated the resident could be sent out. Resident #73 was sent to the emergency room. Further review of Resident #73's medical record revealed no assessment (lung sounds, rate, rhythm, depth, effort of respirations and skin color, presence or absence of oxygen) of Resident #73's respiratory status prior to or after the breathing treatment administered on 04/11/26 at 12:43 P.M. Review of Resident #73's chest x-ray completed on 04/05/26 revealed the resident had pulmonary edema that had improved since the previous x-ray done on 04/03/26. Review of the chest x-ray completed on 04/11/26 revealed similar moderate pulmonary vascular congestion. Interview on 05/12/26 at 1:30 P.M. with the Administrator revealed her expectation is that the nurse would do a respiratory assessment prior to giving a breathing treatment including lung sounds, vital signs and pulse oximetry. The Administrator verified there was no documentation that a respiratory system assessment was completed for Resident #73 prior to or after she received her as needed breathing treatment on 04/11/26 at 12:43 P.M The Administrator further stated the facility had no specific policy for breathing treatments. This deficiency represents non-compliance investigated under Complaint Number 2989414.

Based on medical record review, staff interview, and facility policy the facility failed to administer medication as prescribed. This affected one resident (Resident #73) of three residents reviewed for medication administration. The facility census was 71.Findings include:Review of the closed medical record for Resident #73 revealed an admission date of 05/13/25 with diagnoses including, but not limited to, myocardial infarction, pulmonary fibrosis, and type two diabetes. The resident was discharged from the facility on 02/07/26.Review of the Quarterly Minimum Data Set (MDS) for Resident #73, dated 11/07/25, revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact.Review of the physician orders for Resident #73 revealed an order dated 11/24/25 for Meclizine (an antihistamine also used to prevent and treat vertigo, nausea, and vomiting) 12.5 milligrams (mg), give 12.5mg by mouth three times a day for vertigo. The order was discontinued on 02/09/26.Review of Resident #73's Medication Administration Record (MAR) for the month of January 2026 revealed the resident was not administered Meclizine 12.5 mg on 01/02/26 (7:00 P.M. dose), 01/08/26 (7:00 A.M. and 11:00 A.M. dose), 01/09/26 (7:00 A.M. and 11:00 A.M. dose), 01/11/26 (11:00 A.M. dose), 01/16/26 (7:00 A.M. and 11:00 A.M. dose), 01/20/26 (11:00 A.M. dose), 01/22/26 (7:00 A.M. and 11:00 A.M. dose), and 01/25/26 (7:00 A.M. and 11:00 A.M. dose).Review of Resident #73's corresponding progress notes revealed medication administration notes associated with the missed medication doses, all of which noted the medication was not on hand or was not available.Interview on 04/14/26 at 2:45 P.M. with the Regional Nurse #200 revealed Resident #73 was receiving Meclizine through a different pharmacy until 01/15/26, when the medication became an in-house medication the facility would maintain. Regional Nurse #200 reported that if a medication was deemed unavailable, the nurses have the expectation of notifying the Director of Nursing (DON). Regional Nurse #200 confirmed Resident #73 was not given their prescribed Meclizine on the dates identified in the MAR for January 2026 and believed this was related to nurses looking for a medication card instead of the now bottle of medication due to the change in supplier source.Interview on 04/14/26 at 5:20 P.M. with the DON revealed the facility maintained their stock of medications in their medication rooms. The DON reported Meclizine had been in stock and confirmed it was in stock in January of 2026. The DON confirmed Resident #73 was not given their prescribed Meclizine on the dates identified in the MAR for January 2026 and identified a nurse employed by the facility who had a history of not looking for medication if they could not be located and would instead deem the medication as being out of stock. The DON further confirmed that during the medication passes on 01/08/26, 01/16/26, 01/22/26, and 01/25/26 were by that nurse. The DON revealed the nurse had been spoken to previously about not looking for medications and marking them as not in stock, but this was done informally and no documentation of the conversation could be provided.Review of the facility policy titled Administering Medications, not dated, revealed medications must be administered in accordance with the orders.This deficiency represents non-compliance investigated under Complaint Number 2980094.

Based on record review and interviews, the facility failed to ensure Resident #35's family was notified of missing hearing aids in a timely manner. This affected one (Resident #35) out of three residents reviewed for notification of change. The facility census was 73. Findings include:A review of Resident #35's medical record revealed admission date 05/01/18 with diagnoses including but not limited to hearing loss, degenerative disease of the nervous system, seizures, and assistance with personal cares. A review of Resident #35's physician orders revealed an order dated 11/30/24 to check bilateral hearing aid batteries and tubes every shift and as needed (PRN), two times per day, and an order dated 05/20/25 for bilateral hearing aids to be placed in a storage case in the medication cart each night at bedtime.A review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of three out of possible 15, had moderate difficulty in hearing, wore hearing aids, and used a custom wheelchair for mobility.A review of Resident #35's October 2025 Medication Administration Record (MAR) revealed the order for bilateral hearing aids to be placed in a storage case in the medication cart each night at bedtime was marked as being completed from 10/01/25 to 10/15/25. From 10/16/25 to 10/31/25, the order was marked as not being completed. Further review of Resident #35's November 2025 MAR dated 11/01/25 to 11/30/25 revealed the order for bilateral hearing aids to be placed in a storage case the in medication cart each night at bedtime was marked as not being completed.A review of Resident #35's progress notes dated 10/16/25 to 11/10/25 revealed there were no notes referencing the bilateral missing hearing aids for Resident #35 and no notes reflecting Resident #35's family was notified of the missing hearing aids. Further review revealed two progress notes dated 11/10/25 related to Resident #35 being assessed by audiology at the facility, and the audiologist will be sending Resident #35's new bilateral hearing aids to the facility.A review of the facility's Resident Concern Form dated 10/29/25 at 6:00 P.M. revealed Resident #35's family member reported several concerns including missing bilateral hearing aids. Resolution of the concerns for the missing hearing aids was to request Resident #35 to be seen by the audiologist for an assessment to replace the hearing aids. The Resident Concern Form was reviewed by the Grievance Officer on 10/31/25.An interview on 12/01/25 at 2:45 P.M. with the Administrator verified Resident #35's bilateral hearing aids were missing with no family notification when first reported to be missing on 10/17/25, and Resident #35's family member had reported the missing hearing aids to the facility on [DATE] via a Resident Concern Form. The Administrator stated the facility looked for the missing hearing aids on 10/17/25 and a group message was sent out to the facility staff asking for any information concerning the missing hearing aids, with the last known observation of the bilateral hearing aids on the night of 10/15/25 when they were removed and placed on the medication cart by Certified Nursing Assistant (CNA) #400.This deficiency represents non-compliance investigated under Complaint Number 2678084.

Based on record review, observation and interviews, the facility failed to ensure the physician ordered diet was followed for Resident #35, who had a swallowing impairment. This affected one (Resident #35) out of three residents reviewed for diet orders. The facility census was 73. Findings include:A review of Resident #35's medical record revealed admission date 05/01/18 with diagnoses including but not limited to hearing loss, degenerative disease of the nervous system, seizures, and assistance with personal cares.A review of Resident #35's speech summary notes dated 01/09/24 to 02/19/24 revealed laryngeal/pharyngeal performances were impaired with a history of penetration of liquids when a straw was used. A review of Resident #35's physician orders revealed an order dated 11/25/24 for regular diet, regular texture, regular/thin consistency, cut up meats, no straws, finger foods as able, plate guard and gray built-up utensils, no spaghetti.A review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of three out of possible 15, had moderate difficulty in hearing, wore hearing aids, and used a custom wheelchair for mobility.An observation of Resident #35's room on 12/01/25 at 11:15 A.M. revealed a white Styrofoam cup with a lid and a straw on the windowsill near the recliner filled with fresh ice water dated 12/01/25.An observation of Resident #35's room on 12/01/25 at 12:30 P.M. revealed a white Styrofoam cup with a lid and a straw on the windowsill near the recliner filled with fresh ice water dated 12/01/25. Further observation revealed a sign located on the wall above Resident #35's bed stating no straws were to be used.An interview on 12/01/25 at 12:35 P.M. with Licensed Practical Nurse (LPN) #373 confirmed the white Styrofoam cup with a lid and a straw was filled with fresh ice water and dated 12/01/25. LPN #373 stated the staff all knew Resident #35 does not use straws for any drinks, and the family provides sip cups or travel type tumblers for Resident #35.An interview on 12/01/25 at 3:45 P.M. with the Administrator revealed the Business Office Manager (BOM) had been helping staff with providing the morning ice and water and had placed the lidded cup with a straw in Resident #35's room. The Administrator stated the BOM was unaware of Resident #35's restriction of no straws for drinking liquids. This deficiency represents non-compliance investigated under Complaint Number 2678084.

Based on medical record review, employee statement review, facility investigation review, hospital record review, employee file review, interviews and facility policy review the facility failed to timely and adequately assess and identify a major injury status post fall resulting in a delay in medical intervention. Actual harm occurred on 06/13/25 at approximately 9:30 P.M. when Resident #54, who was dependent on staff and the use of a mechanical lift for transfers, was discovered by Certified Nursing Assistant (CNA) #250 lying on the floor of her room, in front of her wheelchair. Resident #54 appeared to be in pain and was unable to recall what had occurred. CNA #250 and CNA #169 used a mechanical lift to place the resident in bed, without an assessment or direction from Licensed Practical Nurse #131. On 06/14/25 at 6:51 A.M. the resident complained of pain in her right leg with abnormal range of motion noted. The physician was notified, and an x-ray of the right hip and pelvis was ordered and completed at 7:47 A.M. However, no results were received until 2:00 P.M. when it was identified the resident's right femur was fractured. The resident was transferred to the hospital where she was admitted and subsequently had surgical repair of the right femur fracture. This affected one resident (Resident #54) of three residents reviewed for falls. The census was 65.Findings include: Review of Resident #54's medical record revealed initial admission date of 12/01/24 with diagnoses including multiple sclerosis (MS), pain, neuromuscular dysfunction of bladder and depression. Review of Resident #54's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #54 had impaired cognition and was dependent on staff for transfers with a mechanical lift and used a motorized wheelchair for mobility. Review of Resident #54's care plans revealed an at risk for falls care plan related to functional problems, general weakness dated 01/21/25 with interventions including but not limited to educate the resident and family to call for assistance before transferring, (keep) personal items within reach, and wear non-skid footwear. Further review revealed an Activities of Daily Living care plan dated 05/18/25 that indicated using a mechanical lift for transfers.Review of the medical record revealed no progress note documentation of an incident involving the resident or an assessment, including vital signs, on 06/13/25. There was no fall risk evaluation/assessment located in the resident's medical record prior to 06/14/25.Further review of the medical record revealed a fall occurrence evaluation document dated 06/14/25 at 6:37 A.M. and authored by LPN #131. The document included Resident #54 was not in pain and there were no injuries observed or documented. Review of Resident #54's progress note dated 06/14/25 at 6:51 A.M. and authored by LPN #131 revealed a fall occurrence note where Resident #54 described a fall as I leaned too far forward in my wheelchair. LPN #131 entered the date and time of the incident as 06/14/25 at 6:52 A.M. LPN #131 documented no external injuries, but the patient was experiencing pain in the right hip. The pain was worse with movement. The on-call physician and Director of Health Services (DHS) were notified of the incident.Review of Resident #54's June 2025 Medication Administration Record (MAR) revealed on 06/14/25 at 10:30 A.M. two Extra Strength Tylenol 500 mg were administered to Resident #54 by LPN #255 for pain rated a seven out of 10 on the pain scale (1-10 pain rating scale with 0 being no pain and 10 being the worst pain) to right the leg.Further review of Resident #54's progress note dated 06/14/25 at 10:34 A.M. revealed Resident #54 received two tablets of Extra Strength Tylenol 500 milligrams (mg) for pain.Review of Resident #54's progress note dated 06/14/25 at 2:00 P.M. revealed x-ray results indicated a fractured right femur. LPN #255 notified the on-call physician for further instructions and received an order to send Resident #54 to the emergency department for further evaluation and treatment.Review of Resident #54's x-ray results with an examination date of 06/14/25 at 7:47 A.M. with a reporting date of 06/14/25 at 2:00 P.M. revealed the resident had a comminuted fracture of the midshaft of the right femur.Review of Resident #54's progress notes dated 06/14/25 at 2:15 P.M. revealed emergency medical services (EMS) ambulance arrived at the facility. Resident #54 was transferred to the stretcher and exited the facility with EMS crew. A report was called to the hospital ED and emergency contacts were notified.Review of Resident #54's hospital record dated 06/15/25 at 6:83 P.M. revealed Resident #54 received surgery to repair the right femur fracture. Resident #54 returned to the facility on [DATE].Review of CNA #250's statement dated 06/14/25 and interviewed by the previous DHS #172 revealed an incident (fall) date was 06/13/25. CNA #250 stated he heard yelling as rounds were being completed. CNA #250 entered Resident #54's room and observed the resident on the floor in front of the wheelchair back by the bathroom at approximately 9:00 P.M. - 9:30 P.M. CNA #250 went to get another staff member to assist with the use of the mechanical lift to get the resident off the floor. The nurse was present when CNA #169 was asked to help with transferring Resident #54. CNA #250 did not directly address LPN #131 when asking for assistance. CNA #250 stated he did not follow up with LPN #131 when she did not assess Resident #54 prior to moving the resident to bed. CNA #250 stated he was too concerned with getting Resident #54 up off the floor. The statement included Resident #54 did not complain of pain during the transfer from the floor to the bed. CNA #250's statement was signed by the Administrator and the DHS on 06/14/25, but CNA #250 did not sign the statement.Review of an undated, handwritten statement reported to have been completed by LPN #131, revealed at approximately 11:00 P.M. on 06/13/25 CNA #169 asked LPN #131 if CNA #250 had notified her of any kind of incident involving Resident #54. LPN #131 stated no notifications had occurred. CNA #169 reported to LPN #131 that CNA #250 had requested assistance from CNA #169 to transfer Resident #54 from the floor to the bed. When CNA #169 entered Resident #54's room, there was a mechanical lift sling observed under Resident #54. CNA #169 and #250 transferred Resident #54 from the floor to the bed. LPN #131 stated she went to assess Resident #54 and asked Resident #54 what happened, but Resident #54 was unable to recall what had happened. Resident #54 had no complaints of pain and vital signs were within normal limits. LPN #131 stated she palpated up and down both of Resident #54's legs to determine if this caused pain and Resident #54 denied pain. LPN #131 stated at shift change, CNA #169 asked if CNA #250 had notified her of pain reported by Resident #54. LPN #131 had not been notified but went to reassess Resident #54. LPN #131 palpated Resident #54's hips which resulted in pain in the right hip. LPN #131 notified the on-call physician and received an order for a stat x-ray of the right leg and pelvis. The DHS and family were notified as well. LPN #131 reported to the oncoming day shift nurse (LPN #255) of the new orders for Resident #54. There were no further statements obtained by the facility for review. There was no additional investigation information provided by the facility when requested.An interview on 07/23/25 at 2:15 P.M. with the Assistant Director of Health Services (ADHS) revealed to her knowledge, Resident #54 had been leaning forward in the wheelchair attempting to unhook the catheter drainage bag from the wheelchair when she fell forward out of the wheelchair. The ADHS denied evidence of reported pain initially by Resident #54 and she was transferred into bed by the CNAs. The ADHS revealed she did not believe Resident #54 complained of pain until the following morning on 06/14/25 when an x-ray was ordered and Resident #54 was transferred to the hospital for further evaluation and treatment. However, the ADHS revealed the expectation of the staff would be to not move a resident until the nurse has assessed the resident for injuries and there were no indications of pain from the resident.On 07/24/25 at 1:45 P.M. interview with the ED verified the previous DHS completed the investigation and the ED was unaware of the outcome of the investigation for this incident involving Resident #54. The ED stated she was informed the resident was without pain until the morning after the fall. However, the facility was unable to provide any evidence to support a thorough investigation was completed and also verified the resident's medical record did not have documentation of the incident until 06/14/25 at 6:37 A.M. and 6:51 A.M. and did not accurately reflect the date and time of the incident.Interview on 07/24/25 at 10:47 A.M. with CNA #250 confirmed Resident #54 was observed on the floor in her room (on 06/13/25) and CNA #169 and #250 transferred Resident #54 using a mechanical lift from the floor to her bed without LPN #131 assessing for injuries or approving the resident to be moved. CNA #250 stated Resident #54 appeared to be in pain and when asked what Resident #54 wanted to do she kept stating I don't know. CNA #250 stated he had gone to the nurse's desk where LPN #131 and CNA #169 were sitting and reported Resident #54 had fallen and he needed assistance getting her back in bed. CNA #250 stated Resident #54 was a larger lady and he could not move her without assistance, so CNA #169 assisted with the use of the Hoyer lift to transfer Resident #54 back to bed after the fall. The CNA stated Resident #54 was complaining of pain again but could not report where the pain was located. When Resident #54 was placed in bed her complaints of pain stopped and she stated, I feel better. The CNA stated Resident #54 slept through the night and CNA #250 only emptied the resident's urinary catheter drainage bag during the night. Resident #54 did complain of pain early in the morning and CNA #250 said he reported this to the nurse. The CNA revealed on 06/14/25, the DHS interviewed him concerning the incident with Resident #54 and he explained what had occurred. CNA #250 stated several days after this incident, he quit employment at the facility because he felt the facility was trying to blame him for what had occurred.Review of CNA #250's employee file revealed a resignation date of 06/16/25.Attempts to contact LPN #131, previous DHS, CNA #169 and Nurse Practitioner #260 for interviews were unsuccessful. No return contact was made.Review of the facility policy titled Falls dated 07/2021 revealed based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from failing.Review of the undated facility policy titled Change in a Resident's Condition or Status, revealed the facility notified the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental conditions and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.). The nurse would record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.This deficiency represents non-compliance investigated under Complaint Number OH001378148.

Based on observation, medical record review and interview, the facility failed to ensure infection control guidelines were maintained during a dressing change. This affected one resident (Resident #47) of one residents observed for dressing changes. The facility census was 65. Findings include: Medical record review revealed Resident #47 was admitted on [DATE] with diagnosis including chronic obstructive pulmonary disease, chronic respiratory failure, and hypertension. Review of the physician orders revealed to cleanse the sacral wound with normal saline and apply triad paste and a large dry dressing daily. On 07/23/25 at 8:00 A.M. a dressing change was observed for Resident #47 with Nurse # 129 and the Assistant Director of Nursing #152 completing the resident care. Nurse #129 assisted Resident #47 with pulling her pants down to expose the old dressing and removed the dressing. Nurse #129 proceeded to remove her gloves, perform hand hygiene and donned a new pair of clean gloves. Nurse #129 cleansed the wound with normal saline using a 4x4 gauze and removed her gloves to perform hand hygiene leaving the residents pants touching the wound after cleansing. Nurse #129 donned a new set of clean gloves, pulled Resident #47s pants down exposing her wound and applied Triad paste using a sterile cotton tip applicator and covered the wound with a dressing. Interview on 07/23/25 at 8:25 A.M. with ADON #152 and LPN #129 confirmed Resident #47's pants re-contaminated the wound after cleansing, Nurse#129 stated she did not want to leave the resident exposed while changing her gloves.

Based on medical record review, observation, staff interview, and facility policy review the facility failed to ensure fall interventions were implemented. This deficient practice affected one resident (Resident #61) out of four residents reviewed for accidents and hazards. The facility census was 65. Findings Include: Review of the medical record for Resident #61 revealed an admission date of 06/01/22 with diagnoses including but not limited to Parkinson's disease, dementia, chronic kidney disease, and depression. Review of Resident #61's Minimum Data Set (MDS) dated [DATE] revealed Resident #61 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of two out of possible 15. Resident #61 required assistance from staff for transfers and Resident #61 used a walker and wheelchair for assistance for mobility. Review of Resident #61's assessments revealed a fall risk assessment was completed on 07/07/25 and 07/13/25 with Resident #61 being identified as high risk for falls. Review of Resident #61's fall care plan dated 03/05/25 revealed the following fall interventions to be implemented including; night light in the bathroom, non-skid footwear worn, perimeter mattress, touch pad call light, call before you fall sign, low bed, and call light marked with bright colored tape. An observation on 07/23/25 at 8:42 A.M. revealed the following fall interventions were not in place in Resident #61's room, there was no call before you fall sign and there was no bright colored tape on the call light. An interview on 07/23/25 at 11:36 A.M. with Licensed Practical Nurse (LPN) #184 confirmed there was no call before you fall sign and there was no bright colored tape on the call light for Resident #61. Review of the facility's policy titled Falls dated 07/2021 revealed Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from failing.

Based on medical record review and interview, the facility failed to ensure physician ordered nutritional interventions were implemented for residents with significant weight loss and dietician recommendations were addressed. This affected one resident (Resident #17) of two residents reviewed for nutrition. The facility census was 65. Findings include:Review of Resident # 17's medical record revealed an admission date of 11/19/24 with diagnosis including dementia without behavioral disturbance, type 2 diabetes mellitus, chronic kidney disease stage 3, anxiety disorder, and major depressive disorder. Review of the medical record revealed the Resident #17 experienced a 41-pound significant weight loss (24.4%) from December 2024 through July 2025. The resident's weights were as follows: 12/16/24 172 poundsNo January 2025 weight02/04/25 167.5 pounds03/01/25 168.8 pounds04/01/25 147.8 pounds05/01/25 147.8 pounds05/30/25 138.8 pounds06/21/25 130 pounds07/01/25 128.8 pounds Review of the risk for altered nutritional status related to dementia and depression, chronic kidney disease, significant weight loss, poor intakes, refusing meals with further decline expected care plan with interventions including administer supplements per orders, speech and language pathology (SLP) referral/evaluation/treatment as needed. Further review of the medical record revealed the following: A dietary progress note dated 04/03/25 at 9:55 A.M. revealed the resident's current weight was 147.8 pounds and experienced a 21-pound weight loss (12.4 %) in a month. The dietician documented to add supplements and recommend an appetite stimulant. Review of the dietary recommendation dated 04/03/25 revealed add MedPass (supplement) 120 cubic centimeters (cc) twice a day. (This recommendation was not addressed). A dietician recommendation dated 05/01/25 for an SLP evaluation and increase MedPass to three times a day. Review of the physician orders revealed an order dated 05/03/25 for an SLP evaluation and MedPass 120 cc three times a day. Review of a dietary progress note dated 05/08/25 at 8:19 A.M. revealed the resident weighed 135.2 pounds and she had experienced a 13-pound weight loss in the last 30 days and a 33.6 pounds (19.9%) weight loss during comparison. The dietician recommended an SLP evaluation for the identified significant weight loss. A dietary progress note dated 06/05/35 at 12:02 P.M. revealed the resident had experienced a 25-pound weight loss or 22.1% in the last 180 days. On supplements for weight maintenance. No recommendations were made. Further review of the medical record revealed the MedPass was not provided to Resident #17 from 06/07/25 through 07/03/25. There was no order to discontinue the MedPass but the resident's MedPass was discontinued during that time. A dietary progress note dated 07/03/25 at 9:19 A.M. revealed the resident had experienced 24.4 % weight loss or 42 pounds and would recommend increasing her sugar free supplements. Review of the physician orders revealed MedPass 120 cc three times a day was ordered on 07/03/25. There was no evidence in the medical record to support the SLP evaluation had been completed. On 07/24/25 at 2:48 P.M. interview with Therapy Director #200 verified the SLP evaluation had not been completed as ordered. On 07/24/25 at 3:20 P.M. an interview with the Assistant Director of Nursing (ADON) #152 verified there was an order for an SLP evaluation written on 05/03/25 but the evaluation had not been completed. The ADON also verified MedPass was initially ordered on 05/03/25 but was discontinued from documentation on 06/07/25 and was not administered until the MedPass was re-ordered on 07/03/25. The ADON verified the significant weight loss experienced by Resident #17.

Based on medical record review, interview and policy review the facility failed to ensure non-pharmacologic pain interventions were implemented prior to the administration of as needed pain medication. This affected two residents (#25 and #45) of three residents reviewed for pain management. Findings include: 1. Review of Resident # 45's medical record revealed that he was admitted on [DATE] with diagnoses that included myocardial infarction, spinal stenosis, diabetes, post laminectomy syndrome, diabetes mellitus type 2, and chronic venous insufficiency. Review of Resident #45's Minimum Data Set Assessment, dated 5/20/25 revealed that he was dependent on staff for toileting hygiene and transfers and his BIMS score was 15. Review of Resident #45's Physicians' orders revealed an order for Oxycodone HCl Oral Tablet 15mg; Give 1 tablet by mouth every 6 hours for pain. There was no order for non- pharmacological interventions for his pain medication. Review of Resident #45's Medication Administration Record, dated July 2025, revealed that he had received oxycodone 15mg daily every 6 hours as ordered. There was no indication of any non- pharmacological interventions attempted prior to administration of his pain medication. Review of Resident #45's care plans, dated 07/01/25 revealed an at risk for pain care plan with an intervention that included: Offer non-pharmacological interventions to relieve pain and monitor for effectiveness: like distraction technique, relaxation and breathing exercises, music therapy and repositioning. Interview on 07/23/25 at 2:37 P.M. with LPN (Licensed Practical Nurse) #173 confirmed there were no non-pharmacological interventions for pain medications. 2. Review of Resident # 25's medical record revealed that she was admitted on [DATE] with diagnosis including cerebral infarction due to occlusion or stenosis of small artery, Parkinson's Disease, congestive heart failure, chronic obstructive pulmonary disease, acute respiratory failure, and repeated falls. Review of Resident #25's Minimum Data Set Assessment, dated 5/23/25 revealed intact cognition. Review of Resident #25's Physicians' orders revealed an order for Norco 5/325mg (milligrams) every six hours as needed, give one tablet by mouth every six hours for pain and Tylenol give 650mg every eight hours as needed for pain. There were no orders for non- pharmacological interventions for her pain medications. Review of Resident #25's Medication Administration Record, dated July 2025 and June 2025, revealed that she had received Norco 5/325 mg as needed and Tylenol 659mg as needed. There was no indication of any non- pharmacological interventions attempted prior to administration of his pain medication. Review of Resident #25's care plans, dated 06/20/25 revealed an at risk for pain care plan with an intervention that included: offer non-pharmacological interventions to relieve pain and monitor for effectiveness: like distraction technique, relaxation and breathing, exercises, music therapy, repositioning- if resident will accept. Interview on 07/23/25 at 2:37 P.M. with LPN #173 confirmed there were no non-pharmacological interventions for pain medications. 3. Review of Resident #61 medical record revealed admission date 06/01/22 with diagnoses including but not limited to Parkinson's Disease, dementia, depression and chronic kidney disease. Review of Resident #61's significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #61 had severely impaired cognition with a Brief Interview Mental Status (BIMS) score of two out of a possible 15 and was not receiving any scheduled or as needed (PRN) pain medication. Review of Resident #61's physician orders revealed an order dated 07/14/25 for topical pain medication patch Lidocore External Patch (Lidocaine) apply to right ribs topically for pain for 14 days on in the morning and off at bedtime, an order for Morphine Sulfate (concentrate) solution 20 milligrams (mg) per milliliters (ml) give 0.25 ml by mouth every 2 hours as needed (PRN) for pain, and an order dated 05/22/25 for admission to Shriver's Hospice for malnutrition. Review of Resident #61's Medication Administration Record (MAR) dated 07/01/25 to 07/23/25 revealed Morphine Sulfate (concentrate) solution 20 milligrams (mg) per milliliters (ml) give 0.25 ml by mouth every 2 hours as needed (PRN) was administered on 07/14/25 and on 07/15/25 for pain. There were no non-pharmacological pain interventions attempted and/or documented prior to the administration of the pain medication Morphine. Review of Resident #61's pain care plan dated 07/15/25 revealed to offer non-pharmacological interventions to help relieve pain and to monitor effectiveness of interventions and medications. An interview on 07/23/25 at 1:28 P.M. with the Assistant Director of Health Services (ADHS) confirmed there were no non-pharmacological pain interventions attempted and/or documented for Resident #61 prior to the administration of pain medications. The ADHS stated the expectations for nurses are to offer non-pharmacological interventions to residents which may offer pain management/relief prior to medication administration. Review of the facility's policy titled Pain Assessment and Management dated 07/2021 revealed The pain management interventions shall be consistent with the resident's goals for treatment. Non-pharmacological interventions may be appropriate alone or in conjunction with medications. Review of the facility's policy titled Pain Assessment and Management dated 07/2021 revealed The pain management interventions shall be consistent with the resident's goals for treatment. Non-pharmacological interventions may be appropriate alone or in conjunction with medications.

Based on medical record review, review of facility assessment, review of concerns logs, review of time sheets, review of facility policy, observation, and interviews the facility failed to ensure adequate nursing staff to ensure residents received medication timely and failed to provide adequate supervision. This affected five residents (#20, #23, #26, #32, and #51) of six residents reviewed for medication administration and one resident (#66) of two residents reviewed on the secure unit with the potential to affect all 72 residents residing in the facility. Findings included: 1. Medical record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including anxiety, depression, bipolar, and schizoaffective disorder. Review of resident concern form dated 06/05/25 revealed Resident #20 had concerns regarding medications. The resident reported he never got his night medication on 06/03/25 and night shift staff were not good with nurses and medications. Review of Resident #20's medication administration record (MAR) dated 06/2025 revealed the resident was ordered Risperidone 1 milligram (mg) at bedtime 8:00 P.M., for schizoaffective disorder, Hydroxyzine 50 mg at bedtime 9:00 P.M., for anxiety, and skin prep to bilateral heels every shift. Agency Licensed Practical Nurse (LPN) #300 had signed off the two medications and treatment were administered on 06/03/25. Review of Resident #20's medication administration audit from dated 06/09/25 revealed on 06/03/25 the resident's Risperidone 1 milligrams (mg) at bedtime for schizoaffective disorder and Hydroxyzine 50 mg at bedtime for anxiety was not administered 06/04/25 at 1:33 A.M. by Agency Licensed Practical Nurse (LPN) #300. Further review revealed LPN signed off she administered skin prep to bilateral heels that were due on 06/03/25 at 8:00 P.M. at 3:58 A.M., on 06/04/25. Interview on 06/05/25 at 2:36 P.M., with Resident #20 revealed the facility was having a hard time getting staff, and night shift was the biggest problem. On night shift he doesn't get his medications as ordered. The resident reported he usually gets his medication crushed due to an esophageal issue (had surgery years ago); however, he doesn't trust night shift because there have been too many times he didn't get the correct medication that he asked them to take them whole. The resident reported he might not know all the names of medication, but he knows how many and what color his medications are. The resident reported the night before last (06/03/25) he never got his night medication at all. Around 9:30 P.M., he rang his light and staff member answered his light that he didn't know, and he asked if he could have his medication. The staff member told him she would tell the nurse. There was an agency nurse working that night. The resident reported he waited till midnight, and the nurse never showed up with his medication, so he went to bed. The next day Resident #26 was sitting in the hallway physically upset (crying) and he went to speak to her. Resident #26 told him she was upset because she didn't get her medication till 2:00 in the morning. Resident #20 went to find staff to help her but the nurse on the hall didn't seem to care so he went to 100 hall to get the nurse. He went back and sat with the resident until the nurse on 100 hall came over to help her. The resident confirmed he had reported the incident to the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #146. Interview on 06/05/25 at 3:00 P.M., with the Administrator revealed she was just notified by Resident #20 about not receiving medication on 06/03/25. The Administrator confirmed the resident was a reliable source and the nurse working that evening was an Agency nurse and she would have to look into the issue. Interview on 06/09/25 at 9:10 A.M., with DON and ADON revealed they had spoken to the LPN #300, and she reported if she signed the medication off then she administered them. The DON confirmed the medications were not administered timely because they were ordered on 06/03/25 at 8:00 P.M. and 9:00 P.M., and the Agency LPN #300 did not administer the medication until 06/04/25 at 1:33 A.M. Interview on 06/09/25 at 9:54 A.M., with the Administrator revealed the medication on 06/03/25 may have been related to the agency nurse may have not been familiar with the residents, however medication administered at 1:00 P.M., was not acceptable. 2. Medical record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including pulmonary fibrosis, chronic obstructive pulmonary disease, diabetes, asthma, heart failure, hyperlipidemia, depression, anxiety, restless leg syndrome, epilepsy, obstructive sleep apnea, falls, and history of transient ischemic attack. Review of Resident #23's orders and MAR dated 06/2025 revealed the resident was ordered Metformin 750 mg twice (6:00 A.M. and 7:00 P.M.) daily for diabetes, Ropinirole 1 mg at bedtime (7:00 P.M.) for restless leg, Lubiprostone 24 milliequivalent (mcg) two times daily (6:00 A.M. and 7:00 P.M.) for constipation, Isosorbide 5 mg three times (6:00 A.M., 11:00 A.M., and 7:00 P.M.) daily for chest pain, Metoprolol 12.5 mg twice daily (6:00 A.M. and 7:00 P.M.) for hypertension, check blood sugar two times a day (6:00 A.M. and 7:00 P.M.) for diabetes, Ventolin inhalation two puffs three times (6:00 A.M., 11:00 A.M., and 7:00 P.M.) a day for shortness of breath and wheezing, Nortriptyline 30 mg at bedtime for depression (7:00 P.M.), Acetaminophen four times a day (7:00 A.M.,. 11:00 A.M., 4:00 P.M., and 7:00 P.M.) for pain and to remove thrombo-embolic hose at bedtime. Review of Resident #23's Medication Administration Audit report dated 06/09/25 revealed on 06/03/25 the resident's 7:00 P.M. medications Metformin, Ropinirole, Lubiprostone, Isosorbide, Metoprolol, Ventolin, Nortriptyline, Acetaminophen were not administered until 06/04/25 from 1:36 A.M. to 1:53 A.M. The resident's blood sugar was not checked until 06/03/25 at 1:53 A.M., and her TED hose was not removed until 3:45 A.M. Review of Resident #23's resident concern form dated 06/05/25 revealed the resident doesn't receive evening medications until 11:00 P.M., and she would like them at 9:00 P.M. and she doesn't always get her patch on her back as she is supposed to. The DON explained to the resident that the medications were scheduled at open times from 7:00 P.M. to 11:00 P.M. and she will let staff know her preference was 9:00 P.M. and the nursing documentation shows she gets a new dressing daily. Interview on 06/09/25 at 11:00 A.M., with the DON confirmed Resident #23's medication on 06/03/25 was not administered timely. Interview on 06/10/25 at 7:04 A.M., with Resident #23 revealed her only concerns with the facility were staffing. The resident confirmed she doesn't get her medication timely. 3. Medical record review revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, emphysema, inadequate sleep hygiene, anxiety, and altered mental status. Review of Resident #26's orders dated 06/2025 revealed to administer Melatonin 3 mg at bedtime (7:00 P.M. to 11:00 P.M.) for insomnia. Review of Resident #26's Medication Administration Audit report dated 06/09/25 for 06/03/25 revealed Resident #26 didn't receive Melatonin until 06/04/25 at 2:07 A.M. Interview on 06/09/25 at 10:20 A.M., with the DON confirmed Resident #26 did not receive her Melatonin timely. 4. Medical record review revealed Resident #51 was admitted to the facility on [DATE] with diagnoses including diabetes, depression, anxiety, and leg and hip pain. Review of Resident #51's orders dated 06/02/25 revealed to administer Trazodone 50 mg at bedtime (8:00 P.M.) for depression and Gabapentin 400 mg at bedtime (8:00 P.M.) for pain and anxiety. Review of Resident #51's medication administration audit dated 06/09/25 revealed on 06/03/25 Resident #51 did not receive her 8:00 P.M., Trazodone and Gabapentin until 10:58 P.M. Interview on 06/09/25 at 12:00 P.M., with the DON confirmed Resident #51 did not receive her 8:00 P.M., medication timely. 5. Medical record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including insomnia and anxiety. Review of Resident #32's MAR and orders dated 06/2025 revealed Alprazolam 0.25 mg at bedtime (8:00 P.M.) for anxiety and Trazodone 75 mg at bedtime (8:00 P.M.) for insomnia. Review of Resident #32's concern form dated 06/05/25 revealed the resident reported she didn't get her medication on 06/03/25 until 2:30 A.M. on 06/04/25. The nurse told her she had 57 residents to give medication to. The resident reported she doesn't always get her medication in the evening. She was lucky if she got her blood pressure checked once, and it was supposed to be twice daily. She doesn't see housekeeping often in room. The solution was to change medication to open medication pass times, give agency staff resident preferences. There was an additional note that the nursing documentation showed the resident had gotten blood pressure checks twice daily and medication was administered as ordered. Review of Resident #32's Medication Administration Audit Report dated 06/09/25 revealed on 06/03/25 Resident #32's Alprazolam and Trazadone 8:00 P.M., medication was not administered until 06/04/25 at 2:27 A.M. Interview on 06/09/25 at 11:00 A.M., with the DON confirmed the resident's medication was not administered timely. Interview on 06/10/25 at 7:10 A.M., with Resident #32 revealed there were not enough nursing staff to administer medication timely. Medications were usually late but twice now she did not get medication until 2-3:00 A.M. There have been times she hasn't received her Parkinson medication and had to remind the staff. The resident reported she had two skin alterations, and the staff just gave her the ointment and Band-Aid to apply herself, but she can't' get the Band-Aid tight enough and the blood runs down her leg into her new shoes. 6. Review of Resident #66's medical record revealed Resident #66 was admitted to the facility on [DATE] with diagnoses including heart failure, dementia, diabetes, kidney disease, dementia, and depression. The resident resided on the secure unit, however, was a previous resident of the attached Assisted Living (AL). Review of Resident #66's progress note dated 05/24/25 at 5:30 P.M., revealed the nurse was alerted by staff that the resident was pacing the hallways looking for exit and was not able to be redirected. Provider notified and orders given for Hydroxyzine 25 milligrams every 12 hours as needed. Review of Resident #66 progress note dated 05/24/25 at 6:19 P.M., revealed Hydroxyzine was ineffective. Review of Resident #66's change in condition progress note dated 6:40 P.M., revealed notified granddaughter that the resident had exited the secured unit. The granddaughter was curious how she had gotten out and glad she was okay. Interview on 06/06/25 at 11:39 A.M., with Resident #66's granddaughter revealed she doesn't think there was enough staff on the secure unit to supervise all the residents due to most of the residents having behavioral issues. The granddaughter reported Resident #66 had eloped from the secured unit and was found on the other side of facility which was a pretty good distance from the secure unit on 05/24/25. 7. Review of an anonymous complaint dated 05/12/25 revealed there was only one nurse for the entire facility 04/12/25 and 04/19/25. There was only one aide for two large hallways, staff combining break times resulting in staff being off the floor for over an hour, not enough staff to assist residents in and out of bed or provide routine wellness checks. Review of the schedule and time sheets dated 04/12/25 revealed on night shift (6:00 P.M. to 7:00 A.M.) the licensed nurse in the building was the Director of Nursing (DON). The DON was responsible for 300 hall, the secure unit and assisted living. There was a medication tech (MT) that was responsible for 100/200 hall as well. Further review of the schedule and time sheets dated 04/19/25 revealed there was only one licensed nurse from 2:45 A.M. to 6:05 A.M. and one medication tech on 04/19/25. Review of the census dated 04/12/25 revealed there were 72 resident in the skilled nursing facility and 17 residents in the assisted living (AL) for the total of 89 residents. Review of the census dated 04/19/25 revealed there were 74 residents in the skilled nursing facility and 17 residents in the AL for the total of 91 residents. Interview on 06/11/25 at 12:30 P.M., with the Staffing Coordinator #111 confirmed on 04/12/25 for the night shift there was one licensed nurse for 89 residents and 04/19/25 from 2:45 A.M. to 6:05 A.M., there was only one licensed nurse for 91 residents. The Staffing Coordinator confirmed the facility shares staff with the attached AL. 8. Observation on 06/04/25 at 7:20 A.M., of the three medication carts on 200 hall revealed the cart for rooms 216-223 had seven medication cups filled with medications. The medication cups had a first name and room number. Two of the cups had the same first name, however the room number was different. At the time of the observation, interview with LPN #179 confirmed she pre-sets up the resident medication to make the administration go faster because she must oversee the medication technician, perform assessments, and treatments. 9. Review of the facility assessment dated [DATE] revealed the total licensed skilled beds was 75. There were 12 beds in memory care, 11 beds in rehab, and 64 beds in the long-term care. The average daily census was 56. Based on the resident population and their need for care and support there should be six licensed nurses providing direct care and 14 CNA's. The campus leadership utilizes multiple resources to determine staffing needs and ensure resident needs are being met. Some areas included but not exclusive include resident needs, number of residents assigned to each staff member, medication administration for compliance, pattern of resident care needs (bathing, toileting, call light response time, etc.), monitoring staff appearing to be rushed, and monitoring employee turnover. Review of the concern log dated 03/05/25 to 05/29/25 revealed 22 concerns with grooming, staffing, call lights, not receiving assistance out of bed, oral hygiene, showers, and toileting. The facility assessment didn't include the attached Assisting Living. Interview on 06/05/25 at 11:40 A.M., with the Administrator revealed the staffing ration was based on residents' needs and census. Currently the facility has one full-time night shift positions open and one part-time nurse shift. The facility had two additional night shifts open, but they just filled those positions, and the new staff will start training. The facility currently had no open CNA openings. There were four CNA's that will take the LPN boards soon as well. The facility was currently using Agency staffing. The Administrator felt staffing had been a concern due to new ownership in December 2024, however, feels the residents needs were being met. Interview on 06/05/25 from 7:00 A.M. to 3:00 P.M., with Anonymous Staff #303 revealed facility was having staffing issues especially on night shift. Resident have voiced concerns regarding not receiving pain mediation timely, residents' hygiene had been poor including oral hygiene. Treatments have not been completed per orders. Medication was administered late. Dietary had been helping deliver meal trays and not ensuring the tray was in reach or set up. Pressure and fall interventions were not in place per plan of care. Staff were not staying due to the working conditions. Interview on 06/10/25 at 7:17 A.M., with Resident #41 revealed she was told the facility was the best in the area but there had been changes in ownership and the place had gone downhill especially the night shift staffing. The facility was using travel nurses, and they don't know the residents. You never know when you will get your medications. On nights you have to wait 30 minutes or longer for staff to answer your call light. You never see the doctor because she comes between 4:00 A.M.-5:00 A.M. The resident reported her blood pressure had not been properly managed, and she had been having headaches. Staff were aware of her concerns, and she reached out to social service last week to make a request in for a transfer to another facility. Interview on 06/10/25 from 7:00 A.M. to 4:00 P.M., with anonymous Staff Member #400 revealed it was challenging to answer call lights when there was only one nurse and one aide for two hallways. The staff member reported she heard a lot of complaints from residents regarding not getting medication or not getting medication timely. Dietary staff try to help but they don't place meal trays in reach. She doesn't know if the staffing issue was related to the new staff or agency staff can't handle the workload. Interview on 06/10/25 at 10:05 A.M. with the Staffing Coordinator #111 revealed her staffing goal was 3.2 PPD per day. That number included the skilled nursing facility and AL. On day shift she would like to see five nurses and eight CNA and two nurses and six CNAs on nightshift. On night shift there had been several occasions when there will only be one nurse and one medication tech. The facility had been using agency nursing on night shift as well. The Staffing Coordinator reported she could not really answer if one nurse was adequate on night shift for 72-74 residents in the skilled and 13-17 resident in the AL. She wasn't clinical so she was not aware there was concerns with staffing not administering medication timely. Interview on 06/10/25 at 11:28 A.M. with anonymous Family Member #401 revealed staff were coming and going. The current staff were overworked and short-handed. Staff were transferring her mother by themselves due to there was no staff to assist. Her mom required two staff for transfers. Her mom had laid in urine and bowel movement for hours. It was difficult to find staff for help. Call lights were going off, residents were not getting medications as ordered, showers and oral care was not being performed adequately. Residents were declining due to the poor care. This deficiency represents non-compliance investigated under Complaint Number OH00165582.

Based on review of the Payroll Base Journal (PBJ) Staffing Data Report and interview the facility failed to submit staffing information to Centers for Medicare and Medicaid Services (CMS) timely. This had the potential to affect all 72 residents residing in the facility. Findings included: Review of the PBJ Staffing Data Report ran 05/29/25 revealed the facility failed to submit data for the first quarter (October 1st to December 31st) in 2025. The facility also triggered for a one-star staff rating. Interview on 06/05/25 at 9:08 A.M. and 9:50 A.M., with the Chief of Operation (CEO) confirmed there was no documented evidence the first quarter staffing data was reported to CMS. The CEO reported that the facility changed ownership in December of 2024, and it was the previous ownership responsibility to report the staff data to CMS. The CEO reported on April 1st of 2025 he had received an e-mail that the previous owner sent the data to a contracted company on 02/11/25. The contracted company was responsible for reporting the data to CMS, however there was no documented evidence that the contracted company had sent the data to CMS. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number OH00165582.

Based on observation, interview, and policy review the facility failed to ensure medication carts were properly secured and medication were properly stored and labeled. This had the potential to affect 11 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11) of 11 residents residing on 100 hall and 40 residents (#12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, and #51) of 40 residents residing on 200 hall. The facility census was 72. Findings included: 1. Observation of 100 hall on 06/04/25 at 6:59 A.M., revealed the 100-medication cart was left unlocked and unattended. The medication cart was located between rooms [ROOM NUMBERS]. Interview on 06/04/25 at 7:00 A.M., with Licensed Practical Nurse (LPN) #133 confirmed she had left the medication cart unlocked and unattended. The LPN reported she was on 300 hall getting report. Interview on 06/04/25 at 11:54 A.M., with the Director of Nursing (DON) confirmed medication carts should be locked when unsupervised. The facility had already initiated staff training. 2. Observation on 06/04/25 at 7:20 A.M., of the three medication carts on 200 hall revealed the cart for rooms 216-223 had seven medication cups filled with medications. The medication cups had a first name and room number. Two of the cups had the first same name, however the room number was different. At the time of the observation, LPN #179 confirmed she pre-sets up the medication to make the administration go faster because she must oversee the medication technician, perform assessments, and treatments. Further observation of the medication cart for rooms 201-209 revealed there were 14.5 loose tablets, not labeled or packaged, in the first drawer. At the time of the observation, findings were confirmed with Medication Technician (MT) #107. LPN #179 reported pharmacy was just at the facility last week and did not identify any concerns with the medication carts. The medication cart for rooms 210-215 contained 11 whole pills and 3.5 half loose tablets, not labeled or packaged, in the first and last drawer of the medication cart. At the time of the observation, findings confirmed with Assistant Director of Nursing (ADON) #146 during the observation. Interview on 06/04/25 at 11:54 A.M., with the Director of Nursing (DON) confirmed staff should not be pre-setting up medications. The DON reported she started staff education on ensuring medication carts were locked when unattended, carts must be free of loose of pills and debris, and staff cannot pre-pull medication. Review of the facility's policy titled Storage of Medication dated 09/01/21 revealed the facility should store all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they were received. The nursing staff shall be responsible for maintaining medication storage. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. Compartments including carts containing drugs and biologicals shall be locked when not in use and shall not be left unattended if open or otherwise potentially available to others. Each resident's medication shall be assigned to an individual cubical, drawer, or other holding area to prevent the possibility of mixing medications of several residents. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number OH00165582.

Based on medical record review, review of self-reported incident (SRI), review of the facility investigation, interview, and policy review the facility failed to ensure all allegations of resident abuse was reported immediately to the administrator and to the state survey agency. This affected two residents (#66, #70) of four residents reviewed for abuse. Findings included: Review of Resident #70's medical record revealed Resident #70 was admitted to the facility on [DATE] with diagnoses including Alzheimer's, dementia, mood disorder, paranoid personality disorder, delusional, depression, anxiety, and hypertension. The resident resided on the secure unit. Review of Resident #66's medical record revealed Resident #66 was admitted to the facility on [DATE] with diagnoses including heart failure, dementia, diabetes, kidney disease, dementia, and depression. The resident resided on the secure unit, however, was a previous resident of the attached Assisted Living (AL). Review of the SRI 260860 dated 05/27/25 (four days after the incident) revealed on 05/23/25 staff heard yelling coming from Resident #66's room. Upon entering the room, Resident #70 was noted sitting upright on buttocks with Resident #66 standing over her. Resident #66 informed staff that she wouldn't leave my room, so she pushed her down. Residents were separated and redirected. Resident #66 was able to provide meaningful information. Resident #70 was not able to provide meaningful information due to severe cognition impairment. Review of the facility's investigation revealed a progress note dated 05/23/25 from Resident #66's medical record that indicated on 05/23/25 at 4:00 P.M., Certified Nursing Assistant (CNA) #125 come out of from the secured unit to the assisting living (AL) where (medication technician (MT) #107) was passing medication and told her there was an altercation between two residents (#66 and #70). Resident #70 had walked into Resident #66's room. Resident #66 screamed at Resident #70 and told her to get out and pushed Resident #70 to the floor. Resident #70 was not hurt. MT #107 told the staff to do 15-minute checks on Resident #70 and do an incident report plus vitals since it was unwitnessed, but there wasn't a whole lot she could do since she couldn't do skilled charting, etc., and she would turn it over to the night shift nurse tonight. Review of Certified Nursing Assistant (CNA) #125's typed statement dated 05/27/25 revealed the incident occurred right before dinner. Prior to the incident Resident #66 was in the dining room and said she had to go to her room and proceeded to go there. Resident #70 was last seen walking the halls and was noted to walk towards the top of the hall, the general area of Resident #66's room. Resident #70 had her gripper socks on because she kept removing her shoes. CNA #125 reported she was in the dining room when she heard yelling coming from Resident #66's room. Resident #66 was yelling get the hell out of my room! The CNA ran into Resident #66's room and saw Resident #70 sitting upright on her buttocks in front of the bathroom door with Resident #66 standing over her. Resident #66 reported she wouldn't leave my room, so I pushed her down. The Velcro stop sign was not present on Resident #66's room because she keeps removing it and packing it into her things. Review of Registered Nurse (RN) #302's typed statement dated 05/31/25 revealed she was not notified of any resident incidents on 05/23/25. Review of CNA #167's typed statement dated 05/29/25 revealed the CNA was in the dining room waiting for dinner to arrive. The CNA heard someone yelling out from Resident #66's room. The CNA ran to Resident #66 room with CNA #125 and Resident #70 was on the floor in front of the bathroom sitting on her butt with Resident #66 standing over her. Resident #70 was not able to provide meaningful information about the incident. The CNA's checked her skin and assisted her off the floor. Resident #70 complained that her left elbow was hurting but no skin issues noted. Resident #66 reported the resident wouldn't leave her room, so she pushed her down. The residents were separated, and Resident #66 remained in her room. CNA #125 went to the Assisted Living to get MT #107. MT #107 came to the unit, and the CNA's gave MT the update. CNA #167 reported she thought MT #107 was a nurse. Review of MT's #107 typed statement dated 06/02/25 revealed an aide had stuck her head out of the secure unit and said, Hey I need you. The MT #107 went back and was told that Resident #66 had pushed the other resident down. Resident #66 was yelling and pacing trying to get out of the unit. MT #107 tried to re-direct her, but she kept yelling at me. Resident #70 was already up and sitting on the couch. Resident #66 was yelling at the staff and following them. Directed the aides to do 15-minute checks and monitor her vital signs. Review of Licensed Practical Nurse (LPN) #117's typed statement dated 05/30/25 revealed she was not notified of any resident-to-resident altercation on 05/23/25 and was unaware of the incident. Review of Resident #66's social service note dated 05/28/25 and 05/29/25 revealed Resident #66 remained remorseful for her actions when asked about the incident with the other resident. Further review of the SRI investigation revealed no evidence of 15-minute checks and vital signs being obtained for Resident #70 per the direction of MT #107. Review of Resident #70's medical record revealed no evidence Resident #70 as assessed by the nurse or the physician or families were notified of the incident that occurred on 05/23/25 until 05/27/25. Interview on 06/04/25 at 11:50 A.M. with the Administrator revealed she was not notified of the physical abuse allegation until 05/27/25. The two caregivers had notified the medication tech and there was some confusion on who was going to notify the Administrator. The Administrator reported staff were provided education on the abuse policy. Interview on 06/09/25 at 7:28 A.M., with the Director of Nursing (DON) confirmed Resident #66 had admitted to pushing Resident #70 down due to Resident #70 would not leave her room. The DON confirmed the incident occurred on 05/23/25, however it was not discovered until 05/27/25. The DON confirmed there was no evidence in the SRI investigation or medical record that 15 minute checks, neurological exam, or vital signs were obtained for Resident #70 on 05/23/25, there was no evidence Resident #70 was assessed by a licensed nurse until 05/27/25 and the resident had voiced complaints of arm pain after the incident. The DON also confirmed there was there documented evidence the family or physician was notified on 05/23/25 of the resident to resident incident until 05/27/25. Interview on 06/09/25 at 8:50 A.M., with the DON revealed she had just found 15-minute checks and some vital signs undated in her mailbox for Resident #70. The DON confirmed she didn't know they existed or where they came from until this morning when she found them in her mailbox. The DON confirmed the fall investigation, neurological assessments, notification, and investigation was not initiated on 05/27/25 when the incident was discovered. Review of the facility's Abuse policy (undated) revealed every resident has the right to be free from verbal, sexual, physical, and mental abuse and was strictly prohibited. It is the responsibility of employees to immediately report to the facility administrator, and to other officials in accordance with Federal and State law, and incident of suspected or alleged abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. All employees under the law must report to the state survey agency and at least one local law enforcement entity any reasonable suspicion of a crime committed against a resident or a person receiving care from the facility, within the required timeframe. In response to allegations of abuse the facility would ensure that all alleged violations are reported immediately, but not later than two hours after the allegation is made, in accordance with state and federal laws. There was additional box under reporting that included: -You must report allegations, even if you believe false when first reported to you. -Dementia resident allegation should be taken equally as serious; do not just dismiss these concerns. -You MUST report this to your Administrator IMMEDIATELY. -Immediate means NOW, not at the end of your shift. -It is everyone's responsibility to report allegations and concerns of abuse, neglect, misappropriation, and exploitation. -We have two hours to report an allegation to the state agency. Your timeliness is critical to safety and a complete investigation. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number OH00165582.

Based on medical record review, review of a self-reported incident (SRI) and investigation, and interview the facility failed to ensure a dependent resident was provided adequate oral hygiene. This affected one resident (#36) of one resident reviewed for neglect. Findings included: Review of Resident #36's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including need for assistance with personal care, lack of coordination, dysphagia, and degenerative disease of the nervous system. Review of Resident #36's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognition impairment. The resident had no rejection of care behaviors. It was very important to have her family involved in discussions about her care. The resident had functional limitation of range of motion on one side of the upper extremity and both sides on lower extremity. The resident required substantial/maximal (helper does more than half of the effort) for oral hygiene. The resident had no obvious or likely cavity or broken natural teeth, no inflamed or bleeding gums or loose natural teeth, no mouth or facial pain, and no abnormal mouth tissue. Review of Resident #36's current plan of care (the facility changed ownership in December 2024 and switched electronic medical records (EMR) and the start date on all the care plans was February 2025) revealed the resident was at risk for fluid volume deficit/imbalance related to diuretic use. Interventions were to monitor and report sign and symptoms of dehydration including furrowed tongue, thirst, and cracked lips. Offer fluids of choice. The resident preferences via family request plan of care dated 02/21/25 revealed morning and evening routine: brush teeth. Encourage water to keep her hydrated and cut down on urinary tract infections. She prefers it with flavoring located in her room. The resident was at risk for dental problems related to natural teeth, risk for poor dentition related to assistance needs care plan dated 02/20/25 and revised 05/28/25 revealed assess condition of oral cavity , teeth, tongue and lips. Provide oral hygiene at least once daily Provide assistance as needed. The resident had an activity of daily living (ADL) self-care performance deficit related to anxiety, cognitive impairment, depression, fluctuating ADLs, functional limitation in range of motion, generalized weakness, intellectual disabilities, pain, right sided weakness, wheelchair for mobility, and the resident is deaf and requires staff to speak directly in front of her as she is able to read lips. ADL's fluctuate related to behaviors and weakness. The interventions included to assist with ADL's including oral care. The resident had impaired neurological status related to intellectual disability and/or developmental disability care plan dated 02/21/25 revealed to assist resident with normal daily task as needed. Review of resident concern form dated 03/05/25 revealed Resident #36's family had concerns mouthwash was not being used, laundry, and resident was not put in recliner today. The family member was upset. The Director of Nursing (DON) was notified of mouth care and recliner. To ensure the situation doesn't occur again staff were to put out updated residents preferences. The resolution communicated to family was staff was educated on chair and list put at nurses station and will check daily for clothes to be passed. There was no documented evidence mouth care concern was addressed. Review of dental note (facility dentist) dated 10/17/24 revealed the resident had no pain and ate fine. Restorative tooth charting updated. Oral hygiene instruction provided and x-rays taken. There was no documented evidence of the tooth charting. Review of Resident #36's progress note dated 04/17/25 and 04/18/25 revealed the Nurse Practitioner (NP) assessed resident and no dental abscess noted, family updated, and will continue on dental list for next visit. There was no documented evidence of the NP visit in the electronic medical record. Review of dental note (facility dentist) dated 04/30/25 revealed Tooth #3, #4, #5, #8, #9, #28, and #29 had decay and #2 and #17 were on watch. The resident reported pain on lower left and pointed at Tooth #17. Tooth #17 was difficult to assess but noticed slight decay. Referred to oral surgeon for extraction of Tooth #1, #2, and #17. Poor oral hygiene. Instructions given on brushing any dentition, tongue, tissue along with rinsing and or swabbing mouth out daily to decrease bacteria. The resident had moderate calculus and heavy plaque. Scaling was completed by hand, polishing of coronal services was completed. Recommendation-assistance from staff for daily hygiene. Silver [NAME] fluoride silver diamine fluoride (SDF) has been applied to lower right an upper right anterior areas to arrest decay and prevent further decay from appearing. Review of a dental note (outside dental office) dated 05/07/25 revealed Resident #36 was seen in the office for a comprehensive dental examination on 05/27/25. The resident exhibited extremely heavy plaque buildup, leading to plaque-induced gingivitis and pain. It appears the patient has not been getting adequate home care due to severity of plaque buildup seen today in the office. Our recommendation is that resident was to have teeth brushed at least once per day (ideally, twice a day) to ensure adequate plaque removal, or her gingival condition could worsen. The resident also has some untreated dental needs, such as need for extraction of a heavily-decayed molar in upper right. We have referred the resident to a clinic for treatment due to her extensive medical history. Review of Resident #36's sister statement dated 05/28/25 revealed she had went to the dentist with her sister yesterday and he said the resident's mouth issues were nothing less than negligence. He asked if the resident lived in a nursing home, and the sister said yes, the resident did. Per the resident's sister statement, the dentist said yea that is the problem with all nursing homes. Review of SRI 260967 dated 05/28/25 revealed Resident #36 was seen by the dentist on 05/27/25. Family reported on 05/28/25 during a resident care conference that dentist informed them that plaque on teeth was a result of neglect. Immediate intervention was oral care, continue current order for Tylenol and the resident was assessed for pain and indicated 0/10 on the pain scale. Review of facility documentation revealed Resident #36 was seen by an oral surgeon on 05/27/25. Resident #36's sister reported on 05/28/25 during a resident care conference that dentist informed them that plaque on teeth was a result of neglect. After reviewing notes from 05/27/25 appointment from the oral surgeon the resident was noted with heavy plaque buildup. The note went on to say it appears the resident has not been getting adequate home care due to severity of plaque buildup seen today in the office. Resident noted with routine dental care from 360 Care on 4/30/25, 10/17/24, 3/26/24 and 9/22/23. All visit notes leading up to the 4/30/25 dental visit did not mention concerns with plaque build-up or need for future referrals/care. On the 4/30/25 visit, resident noted with plaque and need for additional dental work. Referral was sent to oral surgeon with appointment date of 05/27/25. Upon review of family concerns, x 1 concern noted in regards to mouthwash not being used. No complaints of oral care not being provided. Careplan noted to encourage resident to complete oral hygiene at least daily. Upon POC review, resident noted to receive oral care daily almost all days through April and May (2025). Those residents that are interviewable were. All residents denied dental concerns. Resident unable to complete interview has an oral assessment completed with no major concerns requiring dental referral. Immediate intervention: oral care, continue current order for Tylenol and assessed for pain and indicated 0/10 on the pain scale. Review of the SRI disposition revealed the SRI was unsubstantiated due to evidence indicates abuse, neglect or misappropriation did NOT occur. Those residents that were interviewable were. All residents denied dental concerns. Resident unable to complete interview has an oral assessment completed with no major concerns requiring dental referral. On going audit/interviews completed. Review of Resident #36's Nurse Practitioner (NP) note dated 06/09/25 revealed on 04/17/25 the resident was seen for acute visit for dental pain. Nursing reports family noticed that the resident appeared to be in pain when eating. Nursing does not report any signs or symptoms of pain. Requested evaluation for possible abscess. Resident was eating and drinking as usual. No new mood changes or behavioral concerns noted. Reviewed vitals, medication list, orders, and nursing notes for additional information. Unable to obtain full review of system due to cognitive impairment. Denies' mouth pain when asked. The resident is deaf and smiles when asked. A cotton tipped applicator was used to examine gums, no abscess or bleeding of gum line noted. Breathing easy on room air. Continue with supportive care. Interview on 06/04/25 at 1:41 P.M., with Licensed Practical Nurse (LPN) #179 confirmed there had been some families including Resident #36's family that has concerns with oral hygiene not being performed frequently. Interview on 06/04/25 at 2:35 P.M. with the Administrator revealed Resident #36 had no dental issues in October 2024 per the dental note, however in April (2025) the facility dentist noted issues and referred the resident to outside dentist. The resident saw the outside dentist a month later (05/27/25) and documented poor oral care and cavities and referred to another dentist, which the facility was working on an appointment. The Administrator reported staff were documenting they were providing oral care. She could not confirm why the resident's teeth were in poor condition in the last six months. The resident was mostly dependent of staff for oral care. Resident #36's sister had reported concerns in March (2025) regarding mouth wash not being used due to she had marked the bottle and noticed staff were not using it. Interview on 06/04/25 at 3:00 P.M. with the Administrator reported oral care should be done at least once daily. Interview on 06/05/25 between 7:00 A.M. and 3:00 P.M. with anonymous Staff Member #303 confirmed oral hygiene was not being performed as frequently as it should to residents and there had been concerns reported to management. This deficiency represents non-compliance investigated under Complaint Number OH00165582.

Based on medical record review, review of self-reported incident (SRI), review of the facility's investigation, interview, and policy review the facility failed to timely assess, monitor, and report weight gain. This affected one resident (#70) of three residents reviewed for falls and one resident (#20) three residents reviewed nutrition. Findings included: 1. Review of Resident #70's medical record revealed Resident #70 was admitted to the facility on [DATE] with diagnoses including Alzheimer's, dementia, mood disorder, paranoid personality disorder, delusional, depression, anxiety, and hypertension. The resident resided on the secure unit. Review of the SRI 260860 dated 05/27/25 (four days after the incident) revealed on 05/23/25 staff heard yelling coming from Resident #66's room. Upon entering the room, Resident #70 was noted sitting upright on buttocks with Resident #66 standing over her. Resident #66 informed staff that Resident #70 wouldn't leave her room, so she pushed Resident #70 down. Residents were separated and redirected. Resident #66 was able to provide meaningful information. Resident #70 was not able to provide meaningful information due to severe cognition impairment. Review of certified nurse aide (CNA) #167's typed statement dated 05/29/25 revealed the CNA was in the dining room waiting for dinner to arrive. The CNA heard someone yelling out from Resident #66 room. The CNA ran to Resident #66's room with CNA #125 and Resident #70 was on the floor in front of the bathroom sitting on her butt with Resident #66 standing over her. Resident #70 was not able to provide meaningful information about the incident. The CNA's checked her skin and assisted her off the floor. Resident #70 complained that her left elbow was hurting but no skin issues noted. CNA #125 went to the Assisted Living to get Medication Tech (MT) #107. MT #107 came to the unit, and the CNA's gave MT the update. CNA #167 reported she thought MT #107 was a nurse. Review of MT #107 typed statement dated 06/02/25 revealed she directed the aides to do 15-minute checks and monitor the resident's vital signs. Review of Licensed Practical Nurse (LPN) #117 typed statement dated 05/30/25 revealed she was not notified of any resident-to-resident altercation on 05/23/25 and was unaware of the incident. Further review of the SRI investigation revealed no evidence of 15-minute checks and vital signs were obtained for Resident #70 per the direction of MT #107. Review of Resident #70's medical record revealed no evidence Resident #70 was assessed by the nurse regarding the incident that occurred on 05/23/25 until 05/27/25. Review of the facility's policy titled Falls dated 09/2021 revealed no evidence of policy or procedure on what to do if a fall occurs. Interview on 06/09/25 at 7:28 A.M., with the Director of Nursing (DON) confirmed Resident #66 had admitted to pushing Resident #70 down due to Resident #70 would not leave her room. The DON confirmed the incident occurred on 05/23/25, however it was not discovered until 05/27/25. The DON confirmed there was no evidence in the SRI investigation or medical record that a physical assessment was completed by a licensed nurse, 15-minute checks, neurological exam, or vital signs were obtained for Resident #70 on 05/23/25, there was no evidence Resident #70 was assessed by a licensed nurse until 05/27/25 and the resident had voiced complaints of arm pain after the incident. Interview on 06/09/25 at 8:50 A.M., with the DON revealed she had just found 15-minute checks and some vital signs undated in her mailbox for Resident #70. The DON confirmed she didn't know they existed or where they came from until this morning when she found them in her mailbox. The DON confirmed the fall investigation, neurological assessments, and investigation was not initiated until 05/27/25 when the incident was discovered. Interview on 06/09/25 at 10:14 A.M., with the DON revealed the facility did not have a policy or procedure for staff to follow when a fall occurred. The DON reported she provided education when she trains new staff on what needs documented and what forms need to be completed. The DON reported that if Agency staff were working and an incident (fall, medication error, etc.) occurs she instructs the Agency staff member to call her and she would walk the staff member through to ensure all forms, documentation, and notification were completed. 2. Medical record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including edema, heart failure, diabetes, anemia, and cirrhosis of the liver. Review of Resident #20's current orders dated 06/2025 revealed on 11/28/24 the resident received orders for daily weights and to call physician if there was two-pound weight gain in 24 hours or five-pound weight gain in a week. Review of Resident #20's impaired cardiovascular plan of care dated 01/22/25 revealed to monitor weights as ordered. Review of Resident #20's impaired hepatic function related to cirrhosis plan of care dated 01/22/25 revealed to report to provider signs or symptoms of complications (increased edema, ascites, significant weight gain). Review of Resident #20's treatment administration record (TAR) dated 05/2025 revealed to weigh resident daily and call if weight gain of two pounds in 24 hours and five pounds in one week. Further review revealed no documented evidence the resident was weighed on 05/03/25, 05/19/25, 05/22/25, 05/26/25, 05/27/25, 05/29/25, and 05/30/25. Further review revealed on 05/14/25 the resident weighed 243 and on 05/15/25 he weighed 245.4 which was a 2.4-pound weight gain. On 05/18/25 the resident weighed 244.6, he was not weighed on 05/19/25, and 05/20/25 he weighed 246.6, which was a two-pound weight gain from previous weight. Review of Resident #20's weights in the electronic medical record revealed no evidence the resident was weighed on 05/03/25, 05/19/25, 05/22/25, 05/26/25, 05/27/25, 05/29/25, and 05/30/25. Review of Resident #20's progress notes revealed no evidence the resident had refused weights, no evidence the resident was weighed on 05/03/25, 05/19/25, 05/22/25, 05/26/25, 05/27/25, 05/29/25, and 05/30/25, nor was there evidence the provider was notified of more than two-pound weight gain on 05/15/25 or 05/20/25 per orders. Interview on 06/09/25 at 9:10 A.M., with the DON confirmed there was no documented evidence the resident was weighed on 05/03/25, 05/19/25, 05/22/26/25, 05/27/25, 05/29/25, and 05/30/25 nor evidence the resident provider was notified of two-pound weight gain on 05/15/25 or 05/20/25. The DON reported the resident weighs himself; however, it was the nurse's responsibility to ensure the weights were obtained, documented, and reported to the provider per orders. Interview on 06/09/25 at 9:32 A.M. with Resident #20 along with the DON revealed the resident doesn't keep track of his own weights. The resident reported he gets weighed daily and he has to have staff help due to once you stand up from the scales the weight goes away, and he can't see the weight. The resident reported it was difficult to find working scales, and he has to go to several units until he can find a scale that works. This deficiency represents non-compliance investigated under Complaint Number OH00165582.

Based on medical record review, review of hospital notes, review of wound clinic notes, and interviews, the facility failed to comprehensively assess and provide treatment as ordered to a resident foot. This affected one resident (#2) of three residents reviewed for skin alterations. Findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including heart failure, cellulitis, diabetes, protein-calorie malnutrition, immunodeficiency, breast cancer, venous insufficiency, and pulmonary hypertension. Review of Resident #2's hospital skin assessment dated [DATE] revealed the resident had a wound on bottom left great toe that measured 1.0 centimeter (cm) by 0.8 cm and unable to determine depth (UTD) with scant sanguineous drainage. The wound bed was dry, red, and crusted with sanguineous drainage. The peri-wound was calloused, red, and purple and the margins were irregular shaped with a purple rim noted. Review of Resident #2's hospital orders dated 04/29/25 revealed to cleanse wound on great toe with normal saline, apply therahoney gel (promotes autolytic debridement) , cover with two-by-two gauze and secure with tape daily. Review of Resident #2's admission assessment revealed the resident had a wound on the left great toe. There was no documented evidence of a comprehensive assessment to include size or characteristics of the wound. Further review revealed no evidence that an assessment of the wound was completed from 05/04/25 to 05/20/25. Review of Resident #4's treatment administration record (TAR) and orders dated 05/2025 revealed the treatment to the left great toe was not ordered until 05/08/25 (four days after admission). The order was to cleanse the bottom of the left great toe daily and apply medihoney and non-adherent dressing daily and as needed. Further review of the TAR from 05/08/25 to 05/19/25 revealed no documented evidence the treatment was completed on 05/09/25, 05/11/25, 05/13/25, 05/17/25, 05/18/25, and 05/19/25. Review of the wound clinic note dated 05/19/25 revealed the resident had a diabetic ulcer to the left great toe measured 1.5 cm by 1.5 cm by UTD. The wound bed was eschar and dry. The peri-wound was dry and flaky, and margins were calloused. The toe wound was debrided and new treatment order to apply Aquacel AG (anti-microbial dressing) to wound bed, cover with dry gauze, secure with two inch conform daily. Review of Resident #2's wound evaluation note dated 05/20/25 revealed the resident had a diabetic ulcer on the left great toe that measured 1.5 cm by 1.5 cm by UTD. The wound bed assessment was blank, and the peri wound appearance was dry and flaky. Review of Resident #2's wound evaluation note dated 05/27/25 revealed the resident had a diabetic ulcer on the left great toe that measured 1.5 cm by 1.5 cm by UTD. The wound bed assessment was blank, and the peri wound appearance was dry and flaky. Review of Resident #2's wound evaluation note dated 06/03/25 revealed the resident had a diabetic ulcer on the left great toe that measured 1.5 cm by 1.3 cm by UTD. The wound bed assessment was blank, and the peri wound appearance was dry and flaky. Review of the TAR dated 05/19/25 to 06/05//25 revealed the new order for Aquacel AG from the wound center dated 05/19/25 was not initiated until 05/21/25. The previous order for the medihoney was not discontinued and staff were administering both treatments until 06/05/25. Review of the wound clinic note dated 06/04/25 revealed the left great toe measured 1.0 cm by 1.1 cm by UTD. The wound bed was eschar and dry. The peri-wound was dry and flaky, and margins was calloused. The toe wound was debrided and new treatment order to apply Aquacel AG to wound bed, cover with dry gauze, secure with two inch conform daily. Interview on 06/09/25 at 3:06 P.M., with Resident #2 revealed there was not sufficient staff to administer medication and treatments timely. The resident reported that she doesn't get treatment done daily to left great toe as ordered. When she went to the wound clinic last week the doctor was upset because there was no dressing at all on her toe. Interview on 06/10/25 at 2:36 P.M., with the Assistant Director of Nursing (ADON) #146 confirmed the resident was admitted on [DATE] however there was no comprehensive assessment of the left great toe wound on admission. The ADON confirmed a treatment was not implemented until 05/08/25 (four days after admission). The DON confirmed there was no documented evidence treatments were completed on 05/09/25, 05/11/25, 05/13/25, 05/17/25, 05/18/25, and 05/19/25. The ADON confirmed the wound center had changed the treatment on 05/19/25 however the facility did not implement the new treatment (Aquacel) until 05/21/25 and the staff did not discontinue the previous treatment (medihoney) and was documenting they were performing both treatments from 05/21/25 to 06/05/25. The ADON also confirmed there was no weekly assessment completed from admission [DATE] until she returned from leave on 05/20/25. The ADON reported she was the facility's wound nurse; however, she was off from 04/18/25 to 05/19/25. The ADON reported she was not wound certified; however she had some training, and the facility just hired a company to come in weekly to help assist with wound care. This deficiency represents non-compliance investigated under Complaint Number OH00165582.

Based on observation, interviews and record review the facility failed to ensure safety measures were implemented to prevent resident injuries. This affected one resident (#34) of three residents reviewed for accidents. Findings Include: Review of the medical record for Resident #34 revealed an admission date 08/07/24. Diagnoses included diabetes mellitus, respiratory failure with hypoxia, chronic kidney disease, heart failure, dysphagia, and other feeding difficulties. Review of the physician orders dated 06/10/25 revealed wound care for left leg to be cleansed with normal saline, apply skin prep and leave upon to air. Monitor steri strips and allow them to fall off on their own. Review of the wound evaluation dated 12/10/24 revealed new skin tear to right lateral calf noted measuring 3.4 centimeter (cm) by 2.8 cm by 0.2 cm. Resident #34 reported the night before the leg piece of the wheelchair hit her leg. The intervention was to pad the leg rest on the wheelchair. Review of the progress note dated 12/10/24 at 9:34 A.M. revealed new skin tear to right lateral calf noted. Resident #34 reported it happened last night on the leg piece of the wheelchair. On 01/02/25 the Inter Disciplinary Team met in regards to a new skin tear to posterior right calf after being transferred to bed. Will add wheelchair leg attachments when transferring resident. On 04/08/25 at 7:20 P.M. revealed Resident #34 transferring with aide and the wheelchair caught on back of leg, causing a skin tear on left back leg area. On 06/05/25 at 8:37 A.M. it was revealed Resident 34 was being assisted into bed when her left calf was bumped by her wheelchair footrest causing a two-inch skin tear, steri stripes were applied and area was wrapped. Review of the plan of care dated 12/10/24 for impaired skin integrity related to fragile skin at risk for skin tears, assistance needed for mobility, transfers and toileting. Interventions included encourage good nutrition and hydration, pad wheelchair leg piece and encourage Resident #34 to wear long pants. Interview on 06/10/25 at 10:56 A.M. with Resident #34's daughter revealed Resident #34 continues to receive skin tears to her lower legs because when staff are transferring her they hit her legs on the leg rests causing multiply skin tears. Resident #34's daughter stated the facility was supposed to pad the leg rests so her mother would not receive new skin tears, and they have not padded the wheelchair leg rests yet. She also stated she brought in pool noodles to be put over the bed frame to help with not receiving new skin tears and they have yet to put them on the bed. Interview on 06/11/25 at 8:50 A.M. with Resident #34 revealed she just got another skin tear on her left calf from hitting the wheelchair when staff are transferring her. Resident #34 stated they were supposed to cover her wheelchair leg rests and they have not. Observation on 06/11/25 at 10:40 A.M. of Resident #34 revealed she was up in her wheelchair; she had long pants on and a short sleeve shirt. Observation of her wheelchair revealed no padding around the leg rests. Interview on 06/11/25 at 10:44 A.M. with Licensed Practical Nurse (LPN) #199 stated Resident #34's got a new wheelchair on 06/10/25 and verified there is no order for the wheelchair leg rest to be padded. LPN #199 verified Resident #34 does receive skin tears from the footrests on her wheelchair. Interview on 06/11/25 at 10:47 A.M. with Certified Nurse Assistant (CNA) #151 and #184 stated the old wheelchair leg rests were not padded and the new wheelchair does not have any padding on the leg rests. Observation on 06/11/25 at 11:00 A.M. of Resident #34's old wheelchair that was in the social services office revealed there was no padding on the wheelchair leg rests. Social Worker Designee #128 verified the old wheelchair did not have any padding on the leg rests to prevent Resident #34 from receiving new skin tears. Interview on 06/11/25 at 3:09 P.M. with Director of Nursing (DON) verified on 12/10/24 Resident #34 received a skin tear and the intervention that was to be put in place, to pad the leg rests on her wheelchair was not put in place. The DON verified due to the intervention not being put in place Resident #34 received multiple skin tears from her wheelchair. This deficiency represents non-compliance investigated under Complaint Number OH00165582.

Based on medical record review, observation, interview, and facility policy review, the facility failed to provide appropriate assistance and follow care planned interventions for Resident #48 to prevent a fall with an injury. The facility failed to complete a fall investigation and neurological checks as ordered for Resident #29 and failed to ensure appropriate interventions were in place to prevent Resident #37 from leaving the secured unit. Actual harm occurred on 04/03/24 when Resident #48, who was severely cognitively impaired sustained a fall and fractured left hip when ambulating wearing inappropriate footwear and without her walker. At the time of the incident, staff told the resident to go put shoes on but failed to provide any additional intervention or assistance to prevent the fall with injury. This affected three residents (#29, #37, and #48) of seven residents reviewed for accidents. The facility census was 69. Findings include: 1.Review of the medical record for Resident #48 revealed an admitted [DATE] with diagnoses including dementia, depression, hypertension, disorientation, dysphagia, osteoporosis, and fracture of unspecified part of neck of left femur acquired 04/04/24. Review of Resident #48 ' s quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had severely impaired cognition. The assessment revealed Resident #48 required supervision or touching assistance with putting on her shoes and supervision or touching assistance with sit to stand transfers. Resident #48 used a walker for ambulation. Review of Resident #48 ' s first meeting (care conference) minutes dated 01/23/24 revealed she was at high risk for falls. This was due to her age being greater than [AGE] years (of age), incontinence with urgency and frequency, receiving two or more high fall risk drugs, requiring assistance or supervision for mobility, transfer, or ambulation, and a lack of understanding of physical and cognitive limitations. Review of Resident #48 ' s physical therapy progress report dated 03/01/24 revealed the resident required supervision or touching assistance for picking up an object and needed a walker for ambulation and transfers. Review of Resident #48 ' s progress note dated 04/03/24 revealed around 4:35 A.M. that morning Former Assistant Director of Health Services (ADHS) #210 was passing medications when Certified Resident Care Associate (CRCA) #211 informed her that there was a fall on the secured unit. The nurse found Resident #48 lying on her back on the floor between her table and the foot of her bed. Upon assessment, the resident ' s left leg was noticeably shorter in length and externally rotated outward. Resident #48 was holding her left hip and leg and stated that was the only area that hurt. Vital signs were assessed with no concerns and the resident denied hitting her head. Emergency services were contacted and arrived around 4:45 A.M., they evaluated the resident, requested a splint for her leg, and initiated intravenous pain medication. The resident was transferred to the hospital at approximately 5:45 A.M. Statement from CRCA #141 revealed she was in the hallway talking to another resident when Resident #48 came to her doorway wearing only socks. CRCA #141 reminded the resident to go back to her room and put her shoes on. Within minutes, CRCA #141 heard a scream and went to Resident #48 ' s room to find her on the floor. Intervention was for therapy evaluation and neon tape to the walker. Review of Resident #48 ' s fall event dated 04/03/24 and closed on 04/08/24 revealed prior to the fall the resident was ambulating with improper or ill-fitting footwear (socks). She experienced 10 out of 10 pain and injury was noted to her left hip and leg. The resident had a cognitive or memory impairment that affected safety and judgement and required use of an assistive device and often forgets to use the device. Review of Resident #48 ' s x-ray dated 04/03/24 revealed an x-ray of the pelvis and left hip were completed. There was an angulated comminuted (producing multiple bone splinters) intertrochanteric fracture of the left hip. No osteoporosis to the area was noted. Review of Resident #48 ' s interdisciplinary team note revealed the team met to discuss Resident #48 ' s 04/03/24 fall. They indicated Resident #48 was attempting to sit in a chair to put her shoes on, she did not get the chair pulled out all the way, and it appeared as though she missed the chair when she went to sit down. The resident was transferred to the emergency room and the intervention upon return was a therapy referral and visual cue to use the walker. Review of Resident #48 ' s plan of care as of 04/04/24 revealed she required staff assistance to complete activity of daily living (ADL) tasks completely and safely. She ambulated without an assistance device and was able to feed herself with set up. It was noted that her ADL ' s may fluctuate with cognitive loss and dementia progression. Interventions included allowing sufficient time to complete all or parts of tasks, encouraging her to do as much as safely possible for self, observing for deterioration ADL abilities, and providing adequate rest periods between activities. The care plan did not address Resident #48 ' s assistance needs for dressing, applying footwear, or transfers from sit to stand. Review of Resident #48 ' s plan of care as of 04/04/24 revealed she was at risk for falling related to syncope and collapse, dementia, and poor safety awareness. Interventions included encouraging the resident to assume standing position slowly, ensuring the floor is free of liquids and foreign objects, keeping personal items and frequently used items within reach, staff to assist with transfers as needed, and providing non-skid footwear. Review of Resident #48 ' s profile care guide as of 04/04/24 revealed she needed supervision assistance with transfers. The profile care guide did not address Resident #48 ' s assistance needs for applying footwear. Interview on 06/24/24 at 12:21 P.M. with CRCA #141 revealed she had been sitting at the desk in the common area talking to another resident when she saw Resident #48 begin to come out of her room. Resident #48 did not have a walker and did not have shoes on, Resident #48 was wearing regular socks. CRCA #141 reported she did not want Resident #48 to fall so she told her to go put her shoes on. She reported a couple minutes later she heard the resident scream; she believed the resident was bending over to get her shoes when she fell . CRCA #141 called the nurse who assessed the resident and sent her out. Interview on 06/24/24 at 3:43 P.M. with the Executive Director (ED) verified that the therapy notes indicated Resident #48 required supervision or touching assistance for picking up an object and a walker for ambulation and transfers. She additionally verified the care plan did not thoroughly address Resident #48 ' s activity of daily living assistance needs. The ED verified Resident #48 ' s plan of care indicated she was at fall risk and required non-skid footwear to prevent falls. Review of the facility policy, Fall Management Program Guidelines, dated 12/31/23, revealed the policy stated, should the resident experience a fall the attending nurse shall complete the Fall Event. This includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the Interdisciplinary Team (IDT) to evaluate thoroughness of the investigation and appropriateness of the interventions. Any orders received from the physician should be noted and carried out. Care plan interventions should be implemented that address the resident ' s risk factors. 2. Review of the medical record for Resident #37 revealed an admitted [DATE] with diagnoses including dementia, depression, diverticulosis, age-related osteoporosis without pathological fracture, repeated falls, mixed-receptive-expressive language. Review of Resident #37's admission assessment dated [DATE] revealed when reviewing her exit seeking or elopement it was noted she had a history of exit seeking, exhibited periods of pacing, agitation or wandering toward the exit, had eloped within the last three and six months, and demonstrated confusion and had the ability to exit campus. Review of Resident #37's physician order dated 11/08/23 revealed an order for a secured or locked unit. Review of Resident #37's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a severe cognitive impairment. She had wandering that placed her at significant risk of getting to a potentially dangerous place. Review of Resident #37's progress note dated 11/11/23 revealed the nurse was notified that an emergency exit alarm was sounding on the locked unit. Resident #37 was noted standing a few feet from the emergency exit in front of the facility on the sidewalk. The aide reported it took her and three additional aides to get the resident back into the building as she was hitting, kicking, and punching staff. She was escorted back to the day room in the locked unit but continued to attempt to exit. There was no exit seeking event (incident investigation) for this incident. Review of Resident #37's progress note dated 11/12/23 revealed the aide reported the resident was attempting to get out of the facility through the fire emergency door. She was agitated and tearful regarding her late husband, she was able to be redirected back to her room and calmed down. Review of Resident #37's plan of care dated 11/27/23 revealed they demonstrated exit-seeking behaviors and wandering. Interventions included monitoring for wandering triggers such as need for toileting inactivity, and time of day, encouraging regular family contact or visits with others, provide structured routine to resident's day, resides on legacy lane for safe wandering, assess need for wander guard and apply as appropriate, offer diversional activities as needed, and re-direct resident away from doors/exits as needed. Review of Resident #37's progress note dated 02/01/24 revealed she was having behaviors and exit seeking. She was aware of the code to the main door and was able to unlock it and try to exit the unit. The resident was redirected back to the common area, the resident was to be on continuous watch until the door code was changed. Review of Resident #37 ' s quarterly observation and data collection dated 05/08/24 revealed the resident wandered. There was no exit seeking event for this incident. Review of Resident #37 ' s exit seeking event dated 02/12/24 revealed the resident came out of her room and said she was leaving and her bags were packed. She headed towards the door and was redirected by staff. No wandering alert device was in place and the intervention was to monitor the residents ' patterns. Review of Resident #37's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #37 had intact cognition. Review of Resident #37's progress note dated 05/16/24 revealed she was found to have placed the code into the memory care door and walked out of the unit. Staff caught up with the resident as she was exiting the exterior doors. Resident #37 stated she was going to go home just over the hill. Staff were able to redirect her back to the secured unit. Review of Resident #37 ' s exit seeking event dated 05/16/24 revealed the resident was seen exiting the building but remained on the property. The resident did not have a wandering alert device in place. She had a cognitive memory impairment that affected safety and judgement but had the ability to learn door codes. The immediate measure taken included placement in the secured unit and changing the door codes. Review of the staff education on 05/16/24 revealed the ED sent a message to all employes indicating the code to the memory care unit had been changed. Staff were to ensure residents did not watch them enter the code and they were to remind families of this as well. Attached to the message was a list of staff indicating whether the message was received or not. 28 employees did not acknowledge they received the message and had no read time for the message. Review of Resident #37's interdisciplinary team note dated 05/17/24 revealed they reviewed the incident on 06/12/24 and noted that the exit door codes were changed to ensure resident's safety. Review of Resident #37's plan of care dated 06/12/24 revealed they demonstrated exit-seeking behaviors and wandering. Interventions included monitoring for wandering triggers such as need for toileting inactivity, and time of day, encouraging regular family contact or visits with others, provide structured routine to resident's day, resides on legacy lane for safe wandering, assess need for wander guard and apply as appropriate, offer diversional activities as needed, and re-direct resident away from doors/exits as needed. Observation on 06/17/24 through 06/20/24 revealed the code to the memory care unit was the same as listed on the 05/16/24 staff education. The keypad inside the memory care unit had no cover obscuring the numbers. Review of an e-mail on 06/18/24 at 6:16 P.M. from the ED verified the only exit seeking events for Resident #37 were completed on 02/12/24 and 05/16/24. Interview on 06/18/24 at 2:44 P.M. with CRCA #104 verified Resident #37 was able to learn and memorize the code to the memory care unit. Reported the memory care unit code was changed last time and for a while they were not telling family members, but some of the families did know the code. CRMA #104 reported due to Resident #37 ' s elopements she did not say the memory care code out loud anymore. Interview on 06/20/24 at 12:55 P.M. and 3:07 P.M. with the ED verified there was no exit seeking event for the 02/01/24 exit seeking incident. She reported an interview with the prior ED (who was employed at the time of the incident) indicated the intervention for the incident was putting the resident on one on one until the code was changed. She reported the physician or nurse practitioner was not notified of this incident because it was considered baseline behavior for residents on a locked unit. The ED reported following the 05/16/24 incident she implemented changing the code monthly and provided communication to staff that they should not enter the code when the resident is around. The education also included asking staff to inform families to do the same. The ED verified that the staff education did not indicate that all staff read the education. The ED was unable to identify how changing the code monthly would prevent the resident from learning it in the time between the code changing. The ED acknowledged that the care plan called for assessing for a wander guard, however, she stated that it was facility policy to not put wander guards on memory care residents. Review of the policy ' Guideline for Elopement or Missing Residents ' dated 12/31/23, revealed when a resident deemed an elopement risk is observed exiting the campus door the provider and responsible party were to be notified and an exit-seeking event form was to be completed. 3. Review of the medical record for Resident #29 revealed an original admitted on 03/14/19 and a readmitted on 06/16/23. Medical diagnoses included Alzheimer's Disease with early onset, malignant neoplasm of prostate, epilepsy, mixed receptive-expressive language disorder, unsteadiness on feet, repeated falls, and need for assistance with personal care. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #29 had impaired cognition and scored an eight out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #29 used a walker and a manual wheelchair. The resident required substantial assistance from staff with toileting and bathing, moderate assistance from the staff for dressing, bed mobility, and transfers, and supervision or touch assistance with ambulation. There were not any falls reported on the assessment. Review of the progress notes dated from 04/01/24 to 06/21/24 revealed Resident #29 had a witnessed fall on 04/06/24 and hit his head, a witnessed fall on 04/11/24 and hit his head, and a witnessed fall on 04/25/24 and did not hit his head. Review of the Event Report dated 04/06/24 at 2:50 P.M. and completed by Licensed Practical Nurse (LPN) #178 revealed Resident #29 was standing on his bed when had a fall. Resident #29 reported he hit his head. The fall was unwitnessed and neurochecks were initiated. Review of the Event Report dated 04/11/24 at 4:55 P.M. and completed by Registered Nurse (RN) #182 revealed Resident #29 was standing and talking with another resident when he had a fall. The fall was witnessed, and it was reported that Resident #29 hit his head. Neurochecks were initiated. Review of the Event Report dated 04/25/24 at 10:53 A.M. and created by LPN #167 revealed Resident #29 had a fall while attempting to clean himself up in the bathroom and slipped on water he spilled on the floor. Resident #29 denied hitting his head and the resident's roommate denied seeing the resident hit his head. Resident #29 did have an abrasion to his right upper leg/gluteal area. There was no further information provided related to the investigation of the fall. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated April 2024 revealed Resident #29 had an order for to complete neurochecks every four hours for five hours dated 04/06/24. The neurochecks were not completed at 1:45 A.M. or 5:45 A.M. Resident #29 had an order to complete neurochecks every 15 minutes for one hour dated 04/11/24. There was not a neurocheck completed at 6:00 P.M. Resident #29 had an order to complete neurochecks every four hours times five dated 04/11/24. There were not any neurochecks completed at 4:00 A.M., 8:00 A.M., 12:00 P.M., or 4:00 P.M. Interview on 06/24/24 at 3:45 P.M. with the Director of Health Services (DHS) and ED confirmed there was no evidence of a fall investigation being completed in Resident #29's medical record. The DHS and ED also confirmed neurochecks were not completed as ordered as listed above. Review of the facility policy, Fall Management Program Guidelines, dated 12/31/23, revealed the policy stated, should the resident experience a fall the attending nurse shall complete the Fall Event. This includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the Interdisciplinary Team (IDT) to evaluate thoroughness of the investigation and appropriateness of the interventions. Any orders received from the physician should be noted and carried out. Care plan interventions should be implemented that address the resident ' s risk factors.

Based on observation, record review and interview the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent, assess, adequately monitor and treat pressure ulcers. This affected four residents (#49, #53, #61, and #66) of four residents reviewed for pressure ulcers. The facility census was 69. Actual harm occurred on 07/11/23 when Resident #66, who was cognitively impaired, required extensive assistance from staff for bed mobility, had a pressure ulcer to the gluteal fold and had a left leg contracture was found to have a Deep Tissue Injury (DTI) (intact or non-intact skin with localized area of persistent, non-blanchable, deep red, maroon, or purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister) to the left heel with increased pain and without evidence of effective pressure ulcer prevention interventions in place for the resident's heels. The resident's heels were observed directly on the mattress during observation. Findings include: 1.Record review revealed Resident #66 was admitted to the facility on [DATE] with diagnoses including unstageable pressure ulcer right buttocks, hemiplegia and hemiparesis affecting left non-dominated side, type two diabetes mellitus with diabetic neuropathy, heart failure, and neuromuscular dysfunction of bladder. Review of Resident #66's physician's orders and treatment administration records revealed on 01/31/23 an order was written to offload the resident's left foot/leg to relieve pressure. A plan of care, dated 03/10/23 for skin integrity revealed the resident was at risk for skin breakdown related to receiving antiplatelet and diuretic medication, left side hemiplegia, incontinence of bowel/bladder and risk for malnutrition. Interventions included treatment to coccyx as ordered, avoid shearing, conduct weekly skin assessment, encourage to turn and reposition, float heels as needed and pressure reduction cushion in chair and mattress. A plan of care, dated 03/10/23 for activity of daily living (ADL) and resident's care guide revealed the resident required staff assistance to complete ADL tasks completely and safely due to left side hemiplegia, impaired cognition and poor safety awareness related to dementia and short term memory loss. The resident had bed rails for mobility, required a Hoyer (mechanical) lift for all transfers, and a wheelchair for transport. Review of Resident #66's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #66 had range of motion impairment to one side on the upper extremity and both sides of the lower extremity. The assessment revealed the resident required extensive assistance from two staff for bed mobility and was totally dependent on staff for transfers, dressing, locomotion, toilet use, personal hygiene, and bathing. The assessment reflected the resident had no pressure ulcers noted, however had pressure reducing device for her chair and bed, was receiving a nonsurgical dressing application, and application of ointment/medication to an area other than her feet. The resident was not receiving a treatment to her feet. Record review revealed a right heel assessment dated [DATE] which reflected Resident #66 had a scabbed area on the right heel measuring two centimeters in length by one centimeter (cm) width that was not present on admission. The nurse's description of the area noted it was pressure, statis, and a diabetic wound. An additional note indicated the area didn't have characteristics of a pressure sore; however, the aides reported the resident frequently had her foot in a position that could compromise the skin integrity. There was no evidence the resident was re-evaluated for additional pressure relieving interventions at this time. The next assessment, dated 06/22/23 revealed the resident had a right heel wound that measured three cm by two cm with 2.3 cm depth. The peri wound was described as being moist and macerated. The wound had a moderate amount of serosanguinous drainage, no odor present and the surrounding tissue was pink, and blanchable. Then there was second note, also dated 06/22/23 indicating the right heel was not a pressure ulcer but rather a scabbed area that was healed. Record review revealed no additional assessments or documentation of the resident's heel(s) after 06/22/23. On 07/10/23 at 4:15 P.M. observation of Resident #66's heels with Registered Nurse (RN) #107 revealed the resident's heels were not floated off the bed and there was dark purple non-blanchable area on the resident's left heel. The resident reported the area was very painful. The resident was noted to have her legs folded up under her in bed. The RN reported the resident left leg was contracted making it difficult to float her heels. Record review revealed no evidence this observed pressure ulcer was previously identified. The ulcer was discovered as a DTI. On 07/11/23 at 9:44 A.M. interview with the Director of Nursing (DON) revealed she was not previously aware of a pressure area to Resident #66's left heel but was told by staff the resident's heels were not floated off the bed during the surveyor's observation with RN #107. The DON verified the resident had a physician's order and plan of care with interventions to float the resident's heels. The DON reported the resident's left leg was contracted and it was hard for the resident to straighten out her left leg. The DON indicated possibly the nursing assessment completed on 06/16/23 was inaccurate and should have been for the left heel and not the right heel. The nurse had started an assessment on the right heel but the DON felt that was an error and should have possibly been for the left heel. The DON reported the resident had scabs originally on the left heel, however she did not feel scabs were pressure related. The DON provided no additional explanation as to what the areas of skin impairment would have been caused from if not pressure. The facility did not have a specific pressure ulcer prevention, identification or treatment policy and procedure. The DON only provided a copy of a book she had received during her training related to staging wounds. 2. Record review revealed Resident #66 was admitted to the facility on [DATE] with diagnoses including unstageable pressure ulcer right buttocks, hemiplegia and hemiparesis affecting left non-dominated side, type two diabetes mellitus with diabetic neuropathy, heart failure, and neuromuscular dysfunction of bladder. A plan of care, dated 03/10/23 for skin integrity revealed the resident was at risk for skin breakdown related to receiving antiplatelet and diuretic medication, left side hemiplegia, incontinence of bowel/bladder and risk for malnutrition. Interventions included treatment to coccyx as ordered, avoid shearing, conduct weekly skin assessment, encourage to turn and reposition, float heels as needed and pressure reduction cushion in chair and mattress. Review of the plan of care revealed it was not updated to reflect the development of any actual pressure ulcers for Resident #66. Review of Resident #66's medical record revealed the resident was being followed by an outside wound clinic for a pressure ulcer to the right gluteal fold. A visit note, dated 04/26/23 revealed Resident #66 had a Stage III (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss) pressure injury to the right gluteal fold that measured four-centimeter (cm) length by four cm width by four cm depth. The wound bed was full thickness, granulation, red and the peri-wound was excoriated and macerated. There was tunneling noted at the 7 o'clock position that was four cm. The wound had moderate amount of serosanguineous drainage. The wound clinic note revealed the ulcer had been present since 10/29/22. During this visit, a new dressing/treatment order was implemented to pack the wound with lightly moist Dakin's conform followed by gauze, abdominal dressing, and secure with tape daily and as needed if it becomes soiled was ordered. The resident was to return in three weeks on 05/15/23. The resident was seen by the physician assistant (PA) on 05/12/23. The PA reflected the resident had a Stage III pressure injury of buttock. New orders to follow-up with wound center as scheduled and obtain repeat wound culture of area due to history of pseudomonas. However, the wound culture was not collected until 05/18/23 (six days after being ordered by the PA). Review of Resident #66's wound clinic note dated 05/15/23 revealed the pressure ulcer to the right gluteal fold wound had deteriorated. The wound bed had bone exposure and slough. The peri wound was now non-blanchable, erythema, moist, and purple. The pressure ulcer measured 5.5 cm in length by 6.5 cm width with 2.7 cm depth. The wound was assessed to have stool in it and large amount of serosanguineous drainage. New treatment orders included to stop the Dakin's due to maceration of the wound and to cleanse the wound daily (normal saline/soap and water), pack wound with conform followed by gauze, abdominal dressing, and secure with tape. The dressing was to be changed daily and as needed if it becomes soiled. The resident was to return on 05/29/23. Review of the wound clinic note and facility documentation revealed no evidence of an investigation or determination as to why the ulcer had deteriorated at this time. There was no evidence the resident's skin needs were re-assessed at this time to ensure adequate and effective interventions were in place to promote healing and to prevent additional decline. In addition, review of the administration records revealed no evidence the facility implemented this new wound care order following the wound clinic visit on 05/15/23. The administration records from 05/15/23 to 07/10/23 revealed staff continued to cleanse the wound with wound cleaner/normal saline, lightly pack with Dakin's moist gauze, and apply abdominal dressing once daily. Review of Resident #66's wound culture results, dated 05/25/23 revealed the aerobic culture was positive for pseudomonas aeruginosa. The organism was susceptible to the antibiotics listed except for Ticarcillin (which it was resistant to). Record review revealed no evidence the PA or physician were notified of the wound culture results or evidence the resident was assessed for the need for an antibiotic based on the wound culture results. Review of Resident #66's wound clinic note dated 05/31/23 revealed the pressure ulcer to the right gluteal fold measured four cm in length by three cm width with 2.3 cm depth and had moderate serosanguineous drainage. The wound bed assessment was not legible. The treatment orders were to cleanse the wound daily with soap and water, pack wound with conform followed by gauze, abdominal dressing, and secure with tape. Change the dressing daily and as needed if it becomes soiled. The resident was to return on 06/28/23. Review of Resident #66's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #66 had range of motion impairment to one side on the upper extremity and both sides of the lower extremity. The assessment revealed the resident required extensive assistance from two staff for bed mobility and was totally dependent on staff for transfers, dressing, locomotion, toilet use, personal hygiene, and bathing. The assessment, which was inaccurate based on wound clinic and PA documentation, reflected the resident had no pressure ulcers noted, however had pressure reducing device for her chair and bed, was receiving a nonsurgical dressing application, and application of ointment/medication to an area other than her feet. The resident was not receiving a treatment to her feet. Review of Resident #66's wound clinic note dated 06/28/23 revealed the pressure ulcer to the right gluteal fold measured two cm in length by four cm width by 2.5 cm depth. The wound bed had slough and peri-wound was noted to have erythematous and moisture. The wound was draining moderate amount of serosanguineous drainage. There was no change in wound orders. Although the resident was being following for wound care by the outside wound clinic (approximately monthly), review of the facility wound assessments/documentation revealed no evidence facility staff assessed (including a description or staging of the pressure ulcer) weekly on 04/26/23, 05/04/23, 05/11/23, 05/18/23, 05/25/23, 06/01/23, 06/08/23 or 06/22/23. Further review revealed an order dated from 02/15/23 to 07/10/23 for staff to cleanse right buttocks with wound with cleanser or normal saline, apply Medi-honey, and cover with a foam dressing as needed. However, review of the administration records revealed there was no evidence the Medi-honey was applied from 05/01/23 to 07/10/23. Review of Resident #66's care plans revealed no evidence of an actual pressure ulcer plan of care. On 07/10/23 at 4:15 P.M. observation of Resident #66's buttocks with Registered Nurse (RN) #107 revealed the resident had an undated dressing on the right gluteal fold. RN #107 reported the DON called the wound clinic yesterday to update the physician due to the not receiving the correct treatment that was ordered. The RN reported she could not assess or describe the wound to the surveyor because she was not properly trained nor had she taken a wound certification class. The wound was difficult to observe due to poor lighting and the location of the wound. The wound appeared deep and tunneled. There was no drainage noted on the old dressing or signs of infection noted. Interview on 07/10/23 at 12:20 P.M. with the DON revealed she was also the facility wound nurse and had just taken a class on wound care but felt she had not been provided proper training on wound assessment, staging, or appropriate treatments. On 07/11/23 at 9:44 A.M. interview with the DON revealed she had not been completing wound assessments for Resident #66's right gluteal fold wound because she had been told by the corporate nurse the area was not pressure due to the location of the wound not being on a pressure point area, even though the PA and wound clinic had indicated the wound was a Stage III pressure injury. The corporate nurse was no longer employed by the facility. The DON reported she had called the wound clinic to inform them the resident Dakin's was not discontinued on 05/15/23 per the wound clinics orders and the facility had still been administering the Dakin's soaks in error. The DON also indicated the order for the use of Medi-honey as needed should have been discontinued months ago when the order was changed to Dakins'. On 07/11/23 at 12:10 P.M. interview with the DON confirmed Resident #66's wound culture was ordered on 05/12/23 and not obtained until 05/18/23, which was not timely obtained. The DON reported she had no evidence the wound culture had been addressed (as of this date) and she had since called the ordering PA who reported she did not recall reviewing the wound culture results or ordering antibiotics to treat the organism the culture was positive for. The PA reported she would probably have forwarded the wound culture to the wound clinic to let them treat the organism but could not state for certain. The DON then indicated there was no evidence the wound culture had been sent to the wound clinic for review/follow up. 3. Record review revealed Resident #61 was admitted to the facility on [DATE] with diagnoses including pressure ulcer, chronic kidney disease, anemia, heart failure. Review of Resident #61's skin integrity plan of care dated 09/22/21 and revised 05/11/23 revealed the resident was at risk for skin breakdown and pressure ulcer development related to weakness, requiring assist with her bed mobility, peripheral vascular disease, and incontinence of bowel and bladder. Intervention included to conduct weekly skin assessments. The care plan wasn't updated to reflect the resident's pressure ulcer to the sacrum. Review of Resident #61's quarterly MDS dated [DATE] revealed Resident #61 was at risk for developing pressure ulcers, totally dependent for bathing and required limited assist times one with eating, required extensive assist of two for bed mobility, transfers, and hygiene. Review of Resident #61's progress note dated 05/16/23 revealed the hospice aide informed the nurse about an open area on the resident's bottom. An area was noted in the mid/left upper coccyx. Hospice nurse gave orders to clean area with normal saline or wound cleanser, pat dry and cover with a dry clean dressing three times a week. Review of Resident #61's wound assessments revealed no evidence an initial comprehensive assessment of the pressure ulcer was completed on 05/16/23. Further review of Resident #61's wound progress notes dated 05/18/23 revealed the resident had a Stage II (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) pressure ulcer to the sacrum that measured 2 cm by 2.5 cm by 0.2 cm. Hospice in agreement to cleanse area with wound cleanser, pat dry, then apply Medi- honey and cover with adhesive foam dressing and change every third day and as needed. Further review of Resident #61's wound management notes revealed on 05/30/23 the sacrum wound measured 1.0 cm by 1.5 cm by 0.01 cm and was a Stage II pressure ulcer. The wound bed was covered with 30% of slough. On 06/06/23 the wound remained a Stage II pressure ulcer that measured 1.0 cm by 1.3 cm by 0.1 cm with 10% of slough in the wound bed. On 07/06/23 the wound measured 1.0 cm by 1.0 cm and no depth was noted. Review of Resident #61's MAR/TAR revealed from 05/18/23 to 06/22/23 the order was to cleanse the sacrum wound with wound cleanser or normal saline, apply Medi-honey, and cover with foam dressing every three days and as needed. However, the frequency was entered every five days instead of every three days therefore during this time frame, the dressing was only changed every five days. On 06/22/23 the order was changed to cleanse the pressure ulcer with wound cleanser or normal saline, apply skin prep around the wound then apply bacitracin with zinc ointment, and cover with foam dressing every five days. Review of Resident #61's hospice notes dated 06/06/23 to 07/10/23 revealed hospice only measured the resident's sacrum pressure ulcer twice. On 06/27/23 the note indicated the resident had a Stage II sacrum pressure ulcer that measured 2.2 cm by 2.7 cm by 0.3. The wound bed was noted to have 20% slough. On 07/10/23 the wound measured 2.2 cm by 2.7 cm by 0.4 cm. Observation on 07/10/23 at 2:32 P.M., of Resident #61 with RN #107 and the DON revealed the resident had an open area the size of pea with depth on sacrum. The DON confirmed the wound had depth. Interview on 07/10/23 at 2:34 P.M., with the DON confirmed there was no comprehensive assessment completed on 05/16/23 when the area was discovered. The DON confirmed there were discrepancies in the depth of the wound due to sometimes she charted 0.1 and 0.01 or no depth. The DON confirmed the staging of the wound was inaccurate as well due to the wound had slough and according to staging recommendation a Stage II has no slough. The DON confirmed the dressing was not changed per orders because she had entered the frequency of Medi-honey as every five days, and it should have been changed every three days and the bacitracin should have been changed daily not every five days. The DON confirmed the care plan was not updated to reflect new sacrum pressure ulcer. 4. Record review revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including Stage IV pressure ulcers, diabetes, heart failure, anemia, and necrotizing fasciitis. Review of Resident #49's wound clinic notes dated 05/24/23 revealed the resident was noted to have a Stage IV pressure ulcer on the sacrum that measured 1.5 cm by 1.5 cm by 4 cm that had moderate amount of foul-smelling serosanguineous drainage. Discharge instruction included to apply zinc to peri wound, lightly pack wound with aquacel rope followed by dry gauze and mepilex daily and as needed if it becomes soiled. Return in one week. Review of Resident #49's MAR/TAR dated May 2023 revealed no evidence treatment orders to apply zinc to the peri wound, lightly pack wound with aquacel rope followed by dry gauze and mepilex daily and as needed was completed. Review of Resident #49's wound clinic note dated 05/31/23 revealed the sacrum pressure ulcer measured 2.2 cm by 2.3 cm by 2.5 cm with undermining at 12 and 4 o'clock with a depth of 2.3 cm. The wound bed was red with slough and granulation. The resident required an Actigraft procedure. Discharge instruction included to leave mepitel and steri-strips in place for one week. Do not get wet. Change gauze and abdominal dressing. Review of Resident #49's progress note dated 06/01/23 revealed the wound center returned call at this time and stated the Actigraft was placed yesterday, and outer dressing is to be changed daily or as needed. Once dissolved continue to cover with dry clean dressing only until next appointment. Review of Resident #49's MAR/TAR dated June 2023 revealed no evidence the treatment order to leave mepitel and steri-strips in place for one week; do not get wet; change gauze and abdominal dressing was ordered was completed. Review of Resident #49's wound clinic note dated 06/13/23 revealed the sacrum pressure ulcer measured 2.4 cm by 2.0 cm by 3.5 cm with 3.0 cm undermining at 12 o'clock. Interview on 07/11/23 at 12:42 P.M., with the DON confirmed the wound clinic orders on 05/24/23 and 05/31/23 were not documented as being completed as ordered. 5. Record review revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including pressure ulcer chronic kidney disease, heart failure, and left femur fracture. Review of Resident #53's hospital discharge orders dated 06/16/23 revealed to irrigate wound with Dakin's daily. The resident had a Stage IV pressure ulcer on the sacrum. Review of Resident #53's orders and TAR revealed to cleanse coccyx/sacrum pressure ulcer with wound cleanser or normal saline, soak gauze with Dakin's solution and lightly pack wound, cover with abdominal dressing, and change daily as needed. The resident's TAR for June 2023 and July 2023 revealed the wrong order was transcribed on the TAR and the resident's pressure ulcer was being treated by soaking gauze with Dakin's solution and lightly packing the wound instead of the correct order to irrigate the wound with Dakin's daily. Review of Resident #53's wound management report dated 06/22/23 to 07/06/23 revealed no evidence the stage of the sacrum pressure ulcer was assessed. Interview on 07/12/23 at 12:35 P.M., with the DON verified the wound orders were incorrectly transcribed on the TAR and the resident was not receiving the correct treatment to her sacrum pressure ulcer. The DON also confirmed the facility had not completed staging of the pressure ulcer. Observation on 07/12/23 at 12:42 P.M., with the DON revealed Resident #53 had dried and fresh drainage noted on a pillow placed under her feet while she was in bed. The DON reported the resident had an area on her right heel, but it had resolved. The surveyor asked to look at the resident's left heel. The resident had an open area noted on the left heel that was draining. The resident reported the area on the left heel had been there since the beginning of summer. The DON verified she was not aware of the pressure ulcer on the left heel. Review of Resident #53's medical record revealed no evidence of a pressure ulcer to the left heel. Review of the facility pressure ulcer staging guidelines (dated 2020) from the Wound Care Education Institute revealed a Stage II pressure ulcer was partial-thickness loss of skin with exposed dermis. Granulation tissue, slough, and eschar are not present. A Stage III pressure ulcer was full-thickness loss of skin in which fat is visible in the ulcer and granulation tissue and rolled wound edges are often present. Bone is not exposed. A Stage IV pressure ulcer was full thickness skin and tissue loss with exposed or directly palpable fascia, muscle tendon, ligament, cartilage, or bone in the ulcer. A deep tissue pressure injury was intact or non-intact skin with localized area of persistent, non-blanchable, deep red, maroon, or purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. This deficiency represents non-compliance investigated under Complaint Number OH00144145.

Based on record review, facility policy and procedure review and interview the facility failed to develop and implement a comprehensive and individualized pain management program to provide adequate pain control for Resident #35. Actual harm occurred on 06/21/22 when Resident #35, who received Hospice services for terminal [CONDITION(S)], complained of continued, unrelieved pain despite scheduled and as needed narcotic pain medication doses, exhibited by verbal complaints of pain and moaning. The facility failed to comprehensively assess the resident's pain and notify Hospice services and/or the primary care physician regarding the resident's increased pain resulting in the resident being very restless and unable to get adequate rest due to increased pain despite additional dosages of as needed pain medication. This affected one resident (#35) of one resident reviewed for pain. The facility identified 12 residents receiving Hospice services and 50 residents on a pain management program. The census was 71. Findings include: Review of Resident #35's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was also admitted with a pressure ulcer that was determined to be a Kennedy (terminal) ulcer by Hospice staff. Review of the Admission Observation and Data Collection form, dated 02/25/22 revealed the resident did not report pain on admission to the facility. Review of the plan of care, dated 03/04/22 revealed the resident was at risk for pain related to acute pain, pressure ulcer and treatments, cervical disc degeneration and history of femur and pubis fracture. Interventions including notify physician of increased pain, observe for and record verbal and non-verbal signs of pain. Review of the Hospice team care plan (provided by the Hospice provider), dated 04/13/22 revealed the Hospice team was responsible for professional management of care in all settings as care related to the (resident's) terminal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing, psych/social/pastoral care and volunteer visits as needed 24 hours per day for symptom management, emotional and spiritual support. Patient/caregiver informed of 24/7 access to all services and phone numbers provided. Review of the significant change Minimum Data Set (MDS) 3.0 assessment, dated 04/25/22 revealed the resident had moderate cognitive impairment and required extensive assistance of two staff to total dependence of one staff for activities of daily living. Further review revealed the resident occasionally had pain during the assessment and rated his pain an eight on a 1-10 pain scale, which indicated a moderate pain level and staff relied on non-verbal indicators such as protective body movements and vocal complaints of pain. The assessment revealed the resident received opiate pain medications seven days during the assessment period. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The [MEDICATION(S)] 10 mg was scheduled at 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M. and 8:00 P.M. A plan of care, dated 05/09/22 revealed the resident was receiving Hospice services for terminal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included to administer drugs as needed for palliation per physician orders, administer pain medication as ordered and as needed, communicate with Hospice when any changes were indicated to the plan of care, coordinate care with the Hospice provider with the contact number and address of Hospice provided. On 06/21/22 at 5:15 P.M. interview with Resident #35's son revealed he wanted to ensure the resident's pain was controlled and he was comfortable. The son stated there were recent issues with the resident's pain control and the resident having extreme pain. Review of a progress note, authored by Registered Nurse (RN) #385, dated 06/21/22 at 10:03 P.M. revealed the resident was moaning out in pain. Scheduled pain medications given with negative results noted. As needed pain medications given twice with negative results noted. One on one and repositioning negative. The resident complained of pain in his kidneys, back and all over. The resident refused dinner, offered and accepted fluids. The note indicated this nurse would continue to monitor. Review of a progress note, authored by RN #385, dated 06/22/22 at 12:00 A.M. revealed the resident continued to complain of pain. This nurse administered scheduled pain medications with an additional dose of as needed (PRN) pain medications after one on one, toileting and repositioning were ineffective. The resident stated his hips felt like they were breaking through his skin. The resident stated he was miserable. The note revealed the nurse provided fluids to the resident. The resident continued to have no urine output at this time. Further review of the progress note, dated 06/22/22 at 4:07 A. M. revealed the resident continued to moan in discomfort while laying in bed. The resident continued to have zero urine output at this time. The nurse completed a bladder scan with results of greater than 400 milliliters of urine in the bladder. A urinary catheter was inserted per order due to urinary retention. The resident tolerated the procedure with greater than 400 milliliters of milky yellow urine obtained. The urine was noted to have a large amount of sediment upon return. The note revealed the nurse medicated the resident with scheduled pain medication as well as a dose of the PRN pain medication. The resident stated the pain was still terrible. The resident remained alert and able to make his needs known during the night. The resident was very restless and unable to get adequate rest due to increased pain despite additional dosages of PRN pain medication. On 06/22/22 at 5:25 A.M. Hospice was notified of the change in resident condition as well as increased pain. The nurse asked for a possible re-assessment for the need of [MEDICATION(S)] pain medication. Awaiting a return call from the hospice nurse. Further review of the progress notes revealed no additional documentation regarding the Hospice notification or the resident's pain until 06/22/22 at 2:25 P.M. when RN #309 documented the Hospice nurse visited and a new order was received to change the resident's scheduled pain medication and increase the dosage of the PRN [MEDICATION(S)]. Review of the PRN [MEDICATION(S)] doses revealed staff documented the resident received additional [MEDICATION(S)] on 06/21/22 at 5:31 P.M. (effective), 10:03 P.M. (effective); 06/22/22 1:14 A.M. (effective) and 3:35 A.M. (effective). However, the effectiveness documented on the PRN medication sheets were not reflective of the narrative nurse progress notes documented in the medical record. On 06/23/22 at 12:40 P.M. interview with Hospice Registered Nurse (RN) #401 revealed she visited Resident #35 from Hospice and revealed Hospice staff were unaware of the resident's continued complaints of unrelieved pain until 06/22/22 during the 5:00 A.M. hour when the Hospice triage nurse was notified. RN #401 verified Hospice was not updated on the intensity of the resident's pain or his inability to rest during the night and the message relayed was not as stated in the facility nurse's progress notes. RN #401 indicated had this been described to the triage nurse, Hospice would have visited the resident sooner for his pain management. RN #401 revealed the Hospice goal for Resident #35 was to achieve the best level of pain control for the resident as possible. RN #401 revealed the resident would never be pain free due to his chronic pain but Hospice wanted the resident as comfortable as possible. RN #401 revealed the resident received scheduled [MEDICATION(S)] (narcotic pain medication) every four hours and [MEDICATION(S)] every two hours as needed. RN #401 revealed the facility staff were told hospice could be called any time, day or night, if they need to report something or the resident needed anything and the expectation would be the same for uncontrolled pain. Further interview revealed, for a Hospice resident with uncontrolled pain, offering food and fluids would be an ineffective intervention to attempt and if he was having issues with pain control as indicated in the progress notes, a call should have been placed to the triage nurse to evaluate the resident and hopefully get new orders and something different for pain control started sooner. The RN also revealed there were always options for Hospice patients for pain control and if the resident was not achieving comfort, he should not have been left in that amount of pain for the night, affecting his ability for rest. Lastly, the RN stated residents with Hospice services needed to have the best pain control possible and verbalizations of unrelieved pain and/or moaning indicated the resident did not have the best pain control for him. RN #401 revealed the resident's pain management regimen was changed to longer acting medications and a higher dose of [MEDICATION(S)] every two hours, as needed, to prevent additional issues with pain management. On 06/23/22 at 3:28 P.M. interview with the Assistant Director of Nursing verified the progress notes indicated the resident had uncontrolled pain and the nurse working should have contacted Hospice for the resident before the end of her shift to ensure the resident had effective pain management. The ADON revealed the nurse should have called the primary care physician if Hospice wasn't available but indicated Hospice was available with an on-call nurse after hours seven days a week. The ADON also verified there was no comprehensive pain assessment completed with the resident's uncontrolled pain on 06/21/22 into 06/22/22. The ADON verified the facility pain management policy required a comprehensive pain assessment be completed with changes in pain and the plan of care indicated the physician or hospice should be contacted with changes in pain. Lastly, the ADON verified the nursing progress notes indicated the resident had severe, uncontrolled pain affecting his quality of life and his ability to sleep and/or rest with a terminal diagnosis. The ADON also verified there was no evidence the primary care physician was notified. On 06/23/22 at 5:06 P.M. interview with RN #309 revealed she was the nurse who relieved night shift on 06/22/22. The night shift nurse reported the resident had excruciating pain throughout the night. The Hospice nurse came that day and ordered medication changes. The RN verified Resident #35's pain was usually controlled and it was unusual for him to have uncontrolled pain like he had during the shift. Attempts to reach RN #385 during the survey process were unsuccessful. Review of the Guidelines for Pain Observation and Management Policy, dated 05/11/16 and revised 05/23/17 revealed the purpose of the policy was to ensure each resident's pain including it's origin, location, severity, alleviating and exacerbating factors, current treatment and response to treatment was observed and documented according to the needs of each individual. If there was a change in pain indicators or verbalizations from resident, a pain event form would be completed to indicate changes and care plan update. Educate the resident/family/care givers on the pain management interventions and importance of notifying staff of changes in pain status. Implement the care plan approaches to assist with pain management. Evaluate the effectiveness of pain management interventions and modify as indicated.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of a closed medical record, hospital records, a death certificate, laboratory tracking and guidelines for residents with [MEDICAL CONDITION] policies and interviews with Physician Assistant (PA) #8, Physician #20, Resident #[AGE]'s sister and facility staff the facility failed to ensure one resident (Resident #[AGE]) was provided adequate and timely care, treatment and laboratory testing prior to the resident being diagnosed with [REDACTED]. This resulted in Immediate Jeopardy and serious life-threatening harm beginning on [DATE] when a stool specimen sent for[DIAGNOSES REDACTED] testing could not be completed by the laboratory due to an inadequate sample and the facility failed to re-obtain a specimen. The resident continued to have medium to large loose bowel movements between [DATE] and [DATE] with no evidence the resident was assessed for an infection or received any form of treatment. On [DATE] Resident #[AGE] experienced a change in level of consciousness, chest pain, abdominal pain, [MEDICAL CONDITION] and rectal bleeding and was sent to the hospital. The resident expired in the hospital on [DATE] with the cause of death listed [MEDICAL CONDITION] due to[DIAGNOSES REDACTED]. This affected one of three residents reviewed for[DIAGNOSES REDACTED] infections. On [DATE] at 5:45 P.M. the Executive Director, Director of Health Services (DHS) Regional Clinical Support Registered Nurse (CSRN) #5 and CSRN #7 were notified Immediate Jeopardy began on [DATE] at 2:16 P.M. when the facility was notified the stool sample sent for Resident #[AGE] for[DIAGNOSES REDACTED] testing could not be completed due to there being an insufficient quantity of stool. The resident continued to have medium to large loose bowel movements until [DATE] with no evidence the stool for[DIAGNOSES REDACTED] was ever completed and no evidence any treatment was initiated. On [DATE] Resident #[AGE] was sent to the hospital due to a change in level of consciousness, chest pain, abdominal pain, [MEDICAL CONDITION] and rectal bleeding. Resident #[AGE] expired in the hospital on [DATE] with the cause of death listed on the death certificate [MEDICAL CONDITION] due to[DIAGNOSES REDACTED]. The Immediate Jeopardy was removed, and the deficient practice corrected on [DATE] when the facility implemented the following corrective actions: · On [DATE] Resident #[AGE] was transferred to the hospital. The resident did not return to the facility. · On [DATE] Resident #[AGE]'s sister contacted the facility and notified the Director of Health Services (DHS) the resident had passed away in the hospital related to[DIAGNOSES REDACTED]. The DHS initiated an investigation at that time (on [DATE] at 9:00 A.M.) which included a review of the resident ' s medical record, review of hospital records, interviews with staff and review of the resident ' s roommates medical record. The DHS also reviewed the facility infection control log for November and [DATE] and determined no residents in the facility had been treated for [REDACTED]. · On [DATE] at 10:00 A.M. CSRN #5 conducted a review of Resident #[AGE]'s chart. CSRN #5 identified a[DIAGNOSES REDACTED] stool culture was ordered (on [DATE]) but on [DATE] a sufficient specimen was not sent to the lab. The resident ' s bowel record was noted to have a number of continued loose stools. CSRN #5 revealed an interview with Physician Assistant (PA) #8 revealed the PA indicated she would not have recollected the specimen after the lab couldn't complete the test (on [DATE]), however no order to discontinue the testing was completed. Following CSRN #5's review, a plan of correction was implemented by the DHS and clinical support staff (which included CSRN #5). · On [DATE] the DHS notified the medical director/Physician #20 who was also Resident #[AGE]'s attending physician via telephone of the concerns voiced by the resident ' s family. The medical director was onsite on [DATE] and reviewed with the DHS the facility action plan and was in agreement with the monitoring and auditing being implemented by the facility. · On [DATE] at 2:30 P.M. a regular monthly nursing meeting was held with one registered nurse (RN), seven Licensed Practical Nurses (LPNs), two med techs and 21 certified registered care aides (CRCAs) in attendance. The meeting agenda included a review of infection prevention policies, notification of change policies, review of bowel protocols and completion of bowel documentation, lab reporting and follow up on lab results. On [DATE] at 10:00 P.M. this same monthly meeting was held for staff on night shift which included one RN, two LPNs, one med tech and six CRCAs in attendance. · On [DATE] CSRN #5 provided infection prevention and[DIAGNOSES REDACTED] education to two RNs, eight LPNs, three med tech and 17 CRCA staff. · On [DATE] the DHS and Assistant DHS reviewed all current facility residents for loose stools/signs of[DIAGNOSES REDACTED] and any outstanding[DIAGNOSES REDACTED] cultures. There were no residents identified as having loose stools or that had outstanding stool culture orders. · On [DATE] the facility implemented a plan for the DHS and/or designee to begin audits Monday through Friday to discuss during the daily clinical care meeting all residents for episodes of loose stools and outstanding lab[DIAGNOSES REDACTED] cultures. The audits would be overseen by the Executive Director (ED) or designee to ensure the clinical nursing team was checking orders and outstanding lab cultures and had timely follow up within facility policy. · On [DATE] at 5:00 P.M. the DHS provided education to seven RNs, 12 LPNs, three med techs and 32 CRCAs using the facility Red-e App Education system (an electronic messaging system). Education included if a resident had a loose stool, the nurse needed to be immediately notified. If a stool sample was obtained and lab reported the sample was insufficient, notify physician, collect and resend. The education also revealed CRCA staff needed to notify the nurse of every loose stool and the nursing staff must follow up immediately. · On [DATE] at 11:30 A.M. and 2:30 P.M. CSRN #5, the ED and the DHS provided education to five RNs, 11 LPNs, two med techs and 20 CRCA staff related to: Shift to Shift/Stand Down Process/What to do if Unable to Obtain a Culture within 24 Hours and Reporting Loose Bowel Movements. Education included shift to shift reporting and the use of a facility activity report (FAR), a tool utilized to ensure continuity of care between nurses. Education also included that during report, nurses must review items still needed for follow up, immediately notifying the physician of three loose stools, completing a bowel event, documentation, orders and power of attorney (POA) notification. Education also included if a stool sample was collected and the sample was insufficient, notify physician and obtain further orders. CRCAs were educated to notify nurses of loose stool episodes. Nurses were re-educated on how to enter a lab culture order into the electronic medical record and the procedure if they were unable to obtain lab culture and document reason culture was not obtained, until it is obtained. The facility provided evidence that between [DATE] and [DATE] all facility nursing staff had received education. · On [DATE] at 9:00 A.M. the facility leadership team consisting of the DHS, Assistant DHS, RN Minimum Data Set 3.0 (MDS) Nurse and LPN Scheduler were re-educated by the ED and CSRN #5 on the expectations of daily review of bowel movements and ensuring any indication of loose stools had been reported to the physician. Loose stools would be transcribed to the facility activity report (FAR) for floor nurse follow up and monitoring and event initiation. Education was provided for this process to be completed daily by the DHS or designee and monitored by the ED or designee Monday through Friday. · On [DATE] at 12:00 P.M. the ED and CSRN #5 provided education to PA #8. The education included to monitor labs daily and record her findings in the resident's record. In the event a[DIAGNOSES REDACTED] culture was to be discontinued, this was to be recorded in the progress note. PA #8 was provided a copy of the facility lab tracking policy and how to discontinue a lab specimen. · On [DATE] a quality assessment and performance improvement (QAPI) meeting was held which included the ED, DHS, PA #8 (who attended in place of the medical director/Physician #20), CSRN #5, LPN #3, RN #15, the dietary director, Payroll Coordinator #2, Business Office Manager #4 and Social Service Designee #17. The meeting discussed: onboarding of new employees to include education on Infection Prevention,[DIAGNOSES REDACTED] and shift to shift reporting. In addition, as a measure of ongoing compliance, the DHS or designee will audit all resident ' s bowel report, review outstanding labs, new lab results, new orders and progress notes to ensure timely identification of a change in condition; daily in the Monday through Friday clinical care meeting. The DHS or designee will ensure proper notification to the provider and ensure a[DIAGNOSES REDACTED] culture is collected, if ordered. The executive director will review for ongoing compliance daily Monday through Friday. The results of the audit observations will be reported, reviewed and trended for compliance thru the campus Quality Assurance Committee for a minimum of 6 months then randomly thereafter for further recommendation. · On [DATE] the medical director/Physician #20 reviewed the facility audits and monitoring that had been completed between [DATE] and [DATE]. Ongoing communication has also occurred between the medical director and the ED regarding the corrective action plan. Findings include: Review of Resident #[AGE]'s closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed the resident was a Full Code status. A bowel plan of care, initiated on [DATE] revealed the resident experienced frequent episodes of bowel incontinence related to [MEDICAL CONDITION] and weakness and required assistance for toileting needs. Interventions included to assist with toileting as needed or requested and incontinence care as needed. The care plan did not include any interventions related to monitoring the consistency or frequency of bowel movements or identification of an infectious disease process related to frequent episodes of bowel incontinence or diarrhea. Review of Resident #[AGE]'s nursing progress note, dated [DATE] revealed the resident was noted to have a bowel movement at 3:07 P.M. There was no assessment of the consistency of the bowel movement at that time. At 9:36 P.M., the resident was noted to have her pants down having another bowel movement in her room (not in the bathroom). Again, there was no assessment of the consistency of the bowel movement. Record review revealed no nursing progress notes on [DATE] related to bowel incontinence or diarrhea. On [DATE] the physician was onsite and wrote a new order for a stool culture (to test for[DIAGNOSES REDACTED]), laboratory testing including a complete metabolic panel (CMP) and complete blood count (CBC) and an order for [REDACTED]. Review of the physician;s progress note, dated [DATE] revealed staff had requested the resident be seen due having diarrhea the past few days and decreased appetite. The note revealed the plan to obtain a stool culture. Review of Resident #[AGE];s quarterly Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed the resident required extensive assistance from two staff for toilet use. The MDS assessment also revealed the resident was frequently incontinent of bowel. On [DATE] at 10:24 A.M. an interdisciplinary (IDT) note revealed the resident was reviewed and discussed due to bowel movements throughout the room and on the roommate's side of the room. The note revealed labs and stool sample ordered, will monitor. There was no evidence the resident was placed in isolation at this time pending the laboratory stool testing or comprehensively assessed for any signs/symptoms of infection and/or need for treatment. Review of Resident #[AGE]'s laboratory testing results, dated [DATE] at 2:16 P.M. revealed Resident #[AGE]'s stool for[DIAGNOSES REDACTED] testing could not be completed as the sample sent was insufficient in quantity. Documentation of the laboratory result revealed the lab contacted the facility via telephone and notified LPN #9 the test could not be completed. There was no evidence the stool sample was recollected and sent for testing at that time. There was also no nursing progress note completed by LPN #9 at this time. On [DATE] at 6:26 A.M. record review revealed PA #8 documented the[DIAGNOSES REDACTED] sample was still pending for Resident #[AGE]. There was no evidence the PA visited or assessed the resident on this date. On [DATE] at 12:08 P.M. a nutrition assessment revealed the resident had recent loose stools. On [DATE] record review revealed PA #8 documented labs, the CBC and CMP were reviewed and no new orders were provided. There was no documentation related to the status of the stool specimen on this date or evidence the PA assessed the resident on this date. Review of the nursing progress notes revealed no documentation related to the resident's bowel movements or diarrhea on [DATE] or [DATE]. On [DATE] the resident left the facility for an outside doctor's appointment. During the doctor's appointment, the resident became hypotensive with an altered mental status and was transported to the emergency room . The resident was treated with two liters of intravenous fluids and then returned to the nursing facility on [DATE]. Review of the hospital documentation, dated [DATE] at 10:24 A.M. revealed the resident presented with a chief complaint of [MEDICAL CONDITION]. The resident arrived to the emergency room from a doctor's visit where she was being seen for follow up for a [MEDICAL CONDITIONS]. The resident was noted to be more lethargic and her blood pressure at the doctor's office was low at ,[DATE]. A physical assessment revealed the resident was not in acute distress but was weak and sickly, with slow but appropriate responses. A review of systems under gastrointestinal revealed the resident was positive for diarrhea. An emergency department provider note revealed, family states stool studies have recently been obtained at patient's care facility, results not yet known. On [DATE] Resident #[AGE] was seen by PA #8. The PA note revealed the resident had decreased oral intake and overall was not feeling well. The resident denied nausea and vomiting but felt she was ready to give up and hadn't felt well for a long period of time. The note revealed the resident had fluctuations with her blood pressure and intermittent diarrhea with periods of formed stool. However, there was no reference to the previously ordered stool specimen for[DIAGNOSES REDACTED] or assessment related to the resident possibly having[DIAGNOSES REDACTED] at this time. Resident #[AGE] was again seen by PA #8 on [DATE] at which time the PA documented the resident had further decline, had declined to eat and spent the majority of time in her room. The PA noted the resident had intermittent [MEDICAL CONDITION] and had been seen in the emergency room for fluid replacement. PA #8 recommended a Hospice evaluation at this time. There was no reference to the previously ordered stool specimen for[DIAGNOSES REDACTED] or that PA #8 was aware of the resident's bowel movements (which had been documented in the CRCA bowel documentation). Review of Resident #[AGE]'s bowel records (completed by CRCA staff) dated [DATE] to [DATE] revealed the resident had 26 documented loose bowel movements during this time period. The documentation in the record did not describe the consistency or characteristics of the bowel movements or assess for potential bowel infection. In addition, there were no nursing progress notes during this time period to support the resident was being comprehensively assessed for diarrhea/loose bowel movements and/or signs of infection. Review of the Medication Administration Record [REDACTED]. Review of the medical record and laboratory testing results revealed no evidence the stool specimen that was ordered on [DATE] to be tested for[DIAGNOSES REDACTED] was ever re-collected for the resident. On [DATE] at 8:45 A.M. a nursing progress note revealed the resident was resting in bed, alert and cooperative with no complaints of pain and staff would continue to monitor. The next nursing progress note entry, dated [DATE] at 10:54 A.M. revealed Resident #[AGE]'s incontinence brief (depends) was full of bright red blood from her rectum. The resident's blood pressure was hypotensive/low at 62/palpable and her pulse was [AGE] beats per minute. The note indicated the resident could be aroused by sternal rub, however she would not answer questions when asked. Resident #[AGE] was holding her abdomen, her eyes were rolling (in her head) and she would not focus. The resident's skin tone was ashen. PA #8 was notified and an order was obtained to send the resident to the emergency room . Review of Resident #[AGE]'s hospital records dated [DATE] revealed the resident presented to the emergency department with abdominal and chest pain, low blood pressure, fatigue, confusion, and possible rectal bleeding. On [DATE] at 3:19 P.M. a stool culture revealed the resident was positive for[DIAGNOSES REDACTED]. emergency room documentation revealed the resident presented gravely ill. She was assessed to be septic with an elevated white blood count (WBC) of 113 (normal WBC 4.5 to 10.8). A computerized tomography (CT) scan was consistent with pan [MEDICAL CONDITION] (an inflammation of the entire colon caused by infections like[DIAGNOSES REDACTED]). The resident was assessed to have[DIAGNOSES REDACTED], developed acute liver failure. During Resident #[AGE]'s first night she became hypothermic, hypotensive with agonal breathing and the decision was made by the family to change her code status to a Do Not Resuscitate Comfort Care (DNR CC). Resident #[AGE] expired on [DATE] at 8:39 A.M. Review of Resident #[AGE]'s death certificate dated [DATE] revealed Resident #[AGE]'s immediate cause of death [MEDICAL CONDITION] due to [DIAGNOSES REDACTED]. Interview on [DATE] at 3:16 P.M. with PA #8 revealed she had provided care to Resident #[AGE] during the resident's stay. During the interview, PA #8 verified the note she documented on [DATE] indicated the stool specimen for[DIAGNOSES REDACTED] was still pending (even though the lab had reported on [DATE] it could not be completed). The PA indicated on [DATE] she planned to discontinue the stool for[DIAGNOSES REDACTED] order as she believed the resident was no longer having diarrhea. However, an order was not written. The PA denied knowledge of the resident having 26 loose stools between [DATE] and [DATE] when she was transferred to the emergency room . During the interview PA #8 revealed the resident had reported to her she was ready to give up. PA #8 was aware the resident had diagnostic testing after being sent to the hospital on [DATE] which showed [MEDICAL CONDITION] which could be caused by[DIAGNOSES REDACTED] or ulcerative [MEDICAL CONDITION] (per the PA). However, the resident was never comprehensively assessed or tested for[DIAGNOSES REDACTED], as ordered, prior to being sent to the hospital on [DATE] where she subsequently expired due [MEDICAL CONDITION] from[DIAGNOSES REDACTED]. Interview on [DATE] at 9:37 A.M. with CRCA #1 revealed she had cared for Resident #[AGE] during her stay in the facility. The CRCA revealed the resident required one to two staff for assistance with toileting and at the end of her stay she was too weak to use the bathroom so staff checked and changed her. CRCA #1 revealed she recalled Resident #[AGE] having loose bowel movements during her stay but could not provide any additional information related to the characteristics of the bowel movements or evidence the resident was being treated for [REDACTED]. She indicated the resident was not in any type of isolation during her stay. On [DATE] at 9:54 A.M. an interview with Resident #[AGE]'s sister via telephone revealed she visited her sister frequently during her nursing home stay. The resident's sister revealed she frequently found the resident incontinent of stool and would have to get staff to provide car or she would provide incontinence care herself. Resident #[AGE]'s sister indicated the resident's stools were runny, watery, yellow in color and terrible smelling. During the interview, the sister revealed she even asked CRCA staff how they could handle the smell of the resident's stool due to the odor being so strong and terrible. She stated the resident's diarrhea started on Sunday [DATE]. Interview on [DATE] at 11:31 A.M. with Resident #[AGE]'s physician, Physician #20 revealed he had assumed Resident #[AGE]'s stool sample was not collected due to the resident not having a sufficient amount of stool to sample. He could not recall being notified of the resident's continued frequent loose stools or that the actual stool culture had not been obtained. As part of the facility investigation, a statement provided by LPN #9 dated [DATE] revealed she denied being notified by the lab that the stool specimen could not be tested on [DATE] due to there not being enough stool to test. Attempts to interview LPN #9 during the onsite complaint survey were unsuccessful as the LPN was not working. In addition, there was no evidence any nursing staff identified or followed up between [DATE] and [DATE] related to the lack of testing for the[DIAGNOSES REDACTED]. Interview on [DATE] at 4:47 P.M. with CSRN #5, the ED and DHS revealed they were aware of concerns involving Resident #[AGE] due to the resident's sister calling and voicing concerns (on [DATE]) after Resident #[AGE] had expired in the hospital on [DATE]. The sister revealed she had reported Resident #[AGE] had been diagnosed with [REDACTED].#[AGE] was ordered a stool to check for[DIAGNOSES REDACTED] on [DATE], however it was rejected by the lab on [DATE] due to an insufficient sample being collected. The stool sample was not re-collected. The administrative staff indicated Resident #[AGE] continued to have loose bowel movements and on [DATE] was transferred to the hospital due to a decline in her condition and subsequently expired in the hospital on [DATE]. The administrative staff verified the cause of death on the death certificate [MEDICAL CONDITION] due to[DIAGNOSES REDACTED]. Review of the lab tracking guidelines policy dated [DATE] revealed the facility would facilitate a method of tracking laboratory tests ordered and monitor that testing had been completed in a timely manner to identify and/or make medication adjustments. For an open ended/unable to obtain order, a lab order would be placed as well as an ancillary order and a daily progress note would be written until obtained, i.e. stool sample, urine collection, sputum. The nursing staff or person designated shall monitor the Ancillary Results Queue under the facility tab to ensure tests have been completed per the physician orders. Review of the Guidelines for Management of Resident's with[DIAGNOSES REDACTED] policy, dated [DATE] revealed diagnostic studies would be performed on residents with symptomatic diarrhea. Recommendation for testing: Note most labs would reject a specimen that was not liquid or soft. Testing should be restricted to one specimen in seven days. Contact precautions should be initiated at the onset of diarrhea of unknown origin and continue until disease was ruled out or resolved. Staff should wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident environment. This deficiency substantiates Complaint Number OH 822.

Based on closed record review and staff interview the facility failed to prevent Resident #71 from sustaining a fall out of bed during personal care being provided by a facility staff member. Actual harm occurred on 10/31/18 when Resident #71, who was dependent on staff for bathing/personal care sustained a fall out of bed resulting in a [MEDICAL CONDITION] and subsequent hospitalization . This affected one resident (Resident #71) of three residents reviewed for falls. Findings include: Review of Resident #71's closed medical revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Further review of hospital records revealed Resident #71 had fallen at home resulting in the femur fracture prior to admission. Fall risk assessments completed following admission identified Resident #71 was at high risk for falls. Review of the Minimum Data Set (MDS) 3.0 assessments completed on 09/14/18 and 10/14/18 revealed the resident was totally dependent on one staff member for bathing. Review of a nursing progress note, dated 10/31/18 revealed Resident #71 sustained a fall out of bed during a bed bath and sustained a 2.5 by 0.5 (unit of measure not stated) laceration to the forehead. The resident was transported to the hospital for evaluation and treatment at that time. Resident #71 did not return from the hospital. On 11/15/18 at 12:40 P.M. interview with the director of nursing (DON) verified Resident #71 sustained a fall when she rolled out of bed while State tested Nursing Assistant (STNA) #10 was giving the resident a bed bath. The DON indicated the STNA had placed the resident on her side, turned to reach for a basin and the resident rolled out of bed onto the floor. The resident was subsequently transferred to the emergency room due to a laceration to head. The resident did not return to the facility following the incident. On 11/15/18 at 1:15 P.M. interview with the assistant director of nursing (ADON) revealed the resident had experienced a decline in condition prior to the incident on 10/31/18 and required frequent repositioning and incontinence care from staff. The ADON indicated the facility had discussed the possibility of Hospice services prior to the resident being sent to the emergency roiagnom on [DATE]. Record review revealed no updated assessments or changes to the resident's plan of care for personal care needs had been made related to the decline identified. Interview with State tested Nursing Assistant (STNA) #10 on 11/15/18 at 1:20 P.M. verified she was the staff member who was giving Resident #71 a bed bath on 10/31/18 when the resident fell out of bed. She stated she was standing at the side of the bed and the resident was laying on her side in the bed. She stated as she reached to a water basin on the bedside stand, the resident rolled out of the bed. She stated she tried to catch the resident but her gloved hands were wet and soapy and the resident slid out of her hands. STNA #10 revealed Resident #71 landed on the floor and hit her head causing a laceration and she was transferred to the hospital. This deficiency substantiates Complaint Number OH 147.

Based on record review, review of bed specifications, review of the facility's guidelines for the use of bed rails, policy review and staff and resident interviews, the facility failed to ensure one resident's (resident #8) safety was maintained during routine incontinence care. Actual Harm occurred when Resident #8 was being turned over in bed by a staff member and rolled out of the bed onto the floor and sustained a fractured distal femur requiring hospitalization and surgical repair. This affected one of three residents reviewed for accidents. Findings include: A review of Resident #8's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #8's quarterly Minimum Data Set 3.0 ((MDS) dated [DATE] revealed Resident #8 had short and long term memory impairment and cognitive skills for daily decision making were moderately impaired. The resident did not display any behaviors and did not reject care. Resident #8 required extensive assist of two staff for bed mobility and toilet use. Ambulation did not occur. Resident #8 was always incontinent of bladder. A review of Resident #8's medical record revealed a care plan for activities of daily living (ADL's). The care plan was initiated on 11/11/15 and indicated the resident required extensive assist of one to two for bed mobility and toileting. Resident #8 was assessed at risk for falls. The interventions were updated to reflect a bariatric extension was added to her bed on 12/31/17. That care plan indicated Resident #8 was alert and oriented to all spheres (person, place, and time) and was her own person when it came to decisions about her care. Resident #8 was able to make her needs known and was able to understand others. A review of Resident #8's nurse's progress notes revealed a nurse's note dated 12/31/17 at 5:19 P.M. that indicated the nursing assistant reported to the nurse that the resident fell out of bed during a check and change. She complained of pain in her left knee that she rated a seven out to 10. She was placed back into bed with the use of a Hoyer lift (a mechanical lift) and no other injuries were noted. The physician was notified and instructed the staff to notify her of any other changes. Resident #8 continued to complain of left knee pain through the night of 01/01/18 and was medicated for pain. A review of an event report of Resident #8's fall on 12/31/17 revealed the resident's fall was witnessed and identified State tested Nursing Assistant (STNA) #15 as being the witness. The nurse on duty who initiated the event report for the resident's fall was Licensed Practical Nurse (LPN) #29. A personal inspection of the environment indicated no bed rails were noted. No adaptive equipment was used at the time of the fall. The assessment of the resident documented Resident #8 had left knee pain and range of motion that was painful or limited in her lower extremity. No rotation, shortening or deformity was noted at that time. The assessment of her neurological status revealed the resident was alert and responded appropriately. Her extremities were weak which was normal for her. The resident was described as being agitated. The reason for the fall was documented on the event form as no bed rails present. The immediate intervention added was for a two person assist be provided during all checks and changes. A review of Resident #8's progress notes revealed an interdisciplinary team (IDT) note dated 01/02/18 at 11:15 A.M. The note indicated Resident #8 fell out of bed while repositioning herself and it did not specify the fall occurred during a check and change as reported by the STNA who was providing the care or by the nurse who documented the incident in the nurses' progress notes. The IDT note originally included the circumstances of the fall as being the same as what the STNA reported and the LPN on duty at the time of the fall documented but it was edited and the reason given was that more data was available. The event report was updated after the IDT reviewed the fall and despite STNA #15 reporting the fall occurred when he was performing a check and change they indicated in the report Resident #8 fell out of bed when repositioning herself. The event report was updated to reflect the addition of bariatric extension set to the bed for more room in bed due to obesity. A review of nurse's progress note dated 01/02/18 at 10:40 P.M. revealed Resident #8 did not have any bruising noted from her previous fall. The resident reported to the nurse that she felt much safer in the bed she was put in after the fall. A review of a physician progress notes [REDACTED].#8 was seen for a problem visit. Staff had reported to the physician that the resident fell on [DATE]. The resident reported to the physician that she fell out of bed on Monday hitting her knee. The physician assessed the resident and noted her left knee to be [MEDICAL CONDITION] (swollen) with slight ecchymosis (bruising) and had decreased range of motion. The physician ordered an x-ray to be done of the left knee. A review of a nurse's progress note revealed an x-ray of the left knee was obtained on 01/04/18 at 3:19 P.M. X-ray results were received at 7:27 P.M. and revealed a fracture involving the left distal femoral metaphysis with mild displacement. The physician was contacted and an order was received to send Resident #8 to the emergency room for an evaluation. She was transported at 7:43 P.M. to the local hospital's emergency room . She was transferred to another hospital for surgical repair on 01/05/18 before returning to the facility on [DATE] following an open reduction internal fixation with femoral plating with intramedullary nailing of the left distal femur. A review of Resident #8's hospital records confirmed she was admitted on [DATE] for a surgical procedure to repair a fractured distal femur. She remained hospitalized until her return to the facility on [DATE]. The hospital records indicated her CT scan showed a traumatic comminuted intraarticular distal femur fracture with the fracture line extending to the intercondylar notch. On 01/23/18 at 9:25 A.M., an observation of Resident #8 revealed she was lying in bed in a supine position with the head of her bed up. She was noted to have bariatric extensions to her bed that extended past the headboard and footboard of her bed with a mattress that had a wider width than the head and footboard. The footboard measured 36 inches across. The previous mattress the resident had, before the bariatric extensions and new mattress was placed on the bed, would have been the same or similar width as the head and footboard. The resident had about four inches to each side of her with a line from the edge of the headboard and footboard on each side. There were no bed rails, assist bars or any other assistive devices in place to aid the resident in bed mobility. She had bilateral heel protectors on and her feet were elevated on pillows. Her legs were covered so any dressing that may still be present to her surgical site was not visible. On 01/23/18 at 9:27 A.M., an interview with Resident #8 revealed she did have a fall from bed that resulted in a fracture to her left leg. She stated she was in a smaller bed at the time and was being turned over in bed while being changed. Resident #8 stated when she was turned in bed she rolled out onto the floor and injured her knee. She stated she had to have surgery to repair her broken leg. She indicated the prior bed they had her in was too small for her size and she did not have much room on either side to roll over on. She stated every time they turned her in the old bed she felt like she was on the edge of the bed. Only one staff member used to change her and turn her before her fall but now they require two people to be there. One person would make sure she did not roll out of bed and the other would change her. She confirmed when she fell there was only one staff member providing care to her and she identified that staff member as STNA #15. She recalled she fell out of bed onto the floor from the left side of the bed towards the door falling onto her knee. She reported she immediately had pain in her left knee and informed the staff when they asked if she was okay. Her knee continued to hurt for a about a week before they did anything about it. She was asked where STNA #15 was when he was changing her and she rolled out of bed. She stated STNA #15 was on the right side of her between her bed and window. She denied he was on the left side of the bed towards the door when she rolled out onto the floor. She stated he pushed her towards the left side of the bed and away from him. She felt if she had bed rails or assist bars on the bed she could grab onto them and help them with turning and repositioning. She stated she was told the State made them do away with the use of bed rails. She felt even before her fall there should have been two staff members there to change her or turn her. She indicated STNA #15 still comes in and performs incontinence care or assisted her with turning and repositioning by himself even after her fall. He does make sure she had plenty room on both sides before turning her. Resident #8 stated since her fall she was still fearful of being turned over in bed. She again stated she felt the cause of her fall was the size of the bed they had her in and not having bed rails any more. She indicated they did not do an x-ray on her for four or five days after her fall occurred before they realized she had a fracture. On 01/23/18 at 2:10 P.M., an interview with the Director of Nursing (DON) revealed the facility did fall and bed rail assessments on all residents in November, 2017 when the new regulations pertaining to the use of bed rails went into effect. She stated Resident #8 had assists bars on her bed prior to the assessment being completed. As a result of the bed rail assessment, they determined Resident #8 was not appropriate for the use of bed rails as she was not able to use them independently without the assistance of staff. She denied they had the type of assist bars that could be raised when the resident was being turned and repositioned or lowered when not in use. She felt Resident #8's previous bed was the appropriate size for her as she met the weight and height requirements. The bed was able to hold up to 450 pounds and the resident weighed 263 pounds. She acknowledged the mattress on her old bed was only 35 inches wide leaving the resident about four inches on each side of her to be turned. She did confirm after her fall occurred on 12/31/17 the IDT decided to include the use of bariatric extensions to the bed to widen her bed. She reported Resident #8 was an extensive assist of one or two for bed mobility despite the quarterly MDS dated [DATE] reflecting she was an extensive assist of two for bed mobility. She stated the level of assistance coded on the MDS was the highest level of assistance she required during the assessment period. She acknowledged the manner in which Resident #8 described being turned when her fall occurred on 12/31/17 was not appropriate as the resident should not have been pushed in the direction away from the STNA but should have instead been pulled in the direction of the staff member. She verified since that incident they were ensuring two staff members were there when the resident was checked and changed. She acknowledged the discrepancy in the nurse's progress note and the fall event completed by the IDT as the nurse's note indicated the resident fell during a check and change and the IDT note indicated the resident fell while repositioning herself. She reported the IDT note did include consistent information as documented in the nurse's progress note pertaining to the fall initially but it had been edited to show the fall occurred when the resident repositioned herself in bed. She acknowledged she had said the resident's bed rails were removed due to her bed rail assessment completed in November, 2017 showed she was not capable of independently transferring herself in bed. She denied she was there when that IDT review was completed as she was off but it was reviewed by the Assistant Director of Nursing (ADON) and another nurse. She was asked to provide a copy of the bed specifications for the bed Resident #8 previously had when her fall occurred and for their guidelines for the use of bed rails. A review of the bed specifications for the Joerns Care 100 bed Resident #8 had at the time of her fall on 12/31/17 revealed its safe workload was 450 pounds. The specifications indicated the width of the bed was 35 inches which would have left the resident with only about four inches on each side of her when lying in a supine position as was determined by her relationship in her current bed compared to the width of the head and footboard. The product information for the Joerns Care 100 bed included accessory options that included a CareWide width extension kit. The CareWide width extension kit could be used to transform the Care 100 bed to 39 or 42 inches instantly without the need for tools. It was indicated to be great for added comfort and fall prevention. A review of facility's policy on guidelines for the use of bed rails initiated 11/28/17 revealed there was no evidence that bed rails could not be used within the facility if it was used as an assistive device and benefited the resident's functional ability including strength and balance with bed mobility. The policy did not indicate the resident would have to be independent with its use to be able to have side rails on the bed. The resident's bed rail evaluation included an algorithm that only asked if the resident was able to demonstrate upper body strength and mobility to reposition self away from the bed rail as needed. It did not say they had to be independent in their ability to use the bed rail to turn themselves as stated by the DON. The administrative staff was reporting the resident only required minimal assist with bed mobility at the time of her fall on 12/31/17 as part of their explanation as to why they were not at fault with the resident's fall as they claimed she was capable of and assisted with turning herself over and at a speed where the staff member could not stop her momentum. If the resident was capable of assisting as much as the facility's administrative staff was describing, she should have been able to move her upper body enough in bed to move it away from the bed rail as needed which would mean the use of a bed rail or assistive device would be appropriate for that resident. On 01/23/18 at 2:50 P.M., a phone interview with LPN #29 revealed he was the nurse on duty on Resident #8's unit when she fell out of bed on 12/31/17. He confirmed STNA #15 informed him that the resident rolled out of bed when he was performing a check and change on her. He indicated they were not allowed to use bed rails any more and STNA #15 was the only staff member who was checking and changing the resident. He mentioned the STNA was smaller in size and Resident #8 was larger. He was told by STNA #15 that the STNA was on the right side of the bed between the bed and window when he rolled her towards the left side of the bed in the direction of the door. When he rolled her to the left, the resident rolled out of the bed and onto the floor. LPN #29 indicated before the fall they typically only had one STNA provide care to the resident. LPN #29 reported Resident #8 was alert and oriented at the time of her fall and when he assessed her. She did have complaints of left knee pain she rated a seven on a one to 10 scale. LPN #29 stared he did not access her as having any limitations in her range of motion so he put her back into bed with the use of a Hoyer lift. He medicated her for pain and a couple hours later he reassessed her and her pain was only a three. LPN #@9 stated he notified the physician and they were supposed to monitor the resident and update the physician on any changes. LPN #29 indicated he had worked with Resident #8 after 12/31/17 and before she was sent to the emergency roiagnom on [DATE] and indicated her pain was better than it was at the time of her fall. On 01/23/18 at 3:10 P.M., a phone interview with STNA #15 revealed he was the STNA providing care to resident #8 when she had her fall on 12/31/17. He denied any other staff was assisting him with her care. STNA #15 confirmed Resident #8 fell while he was doing a check and change on her. He initially stated, while he was changing the resident, she rolled over towards him and was going too fast and too far and he could not stop her from rolling out onto the floor. He stated she was heavy and he was not able to do anything to prevent her from falling. When asked specifically which side of the bed he was on when he was providing care to the resident, he reported he was to the right of the resident between her bed and window. When asked how the resident fell out of the left side of the bed if he was pulling her towards him, he changed his story. He confirmed he was to the right of her between the bed and window and pulled her towards him but them pushed her over towards the left of the bed in which she rolled out onto the floor. He stated he always provided care to her himself prior to and at the time of the fall but since the fall they require two people to be in there when a check and change was done. A review of the facility's policy on turning and repositioning revised 05/11/16 revealed proper turning techniques should be utilized to prevent injury to the resident. It did not provide any directive on what proper turning techniques were when a one person assist was provided. This deficiency substantiates Complaint Number OH 742.

Based on observation, record review and interview the facility failed to prevent the development of a right heel pressure ulcer and failed to ensure pressure relieving interventions were in place as ordered for Resident #73. Actual Harm occurred when Resident #73, who was assessed to be at low to moderate risk for skin breakdown, developed an avoidable in-house acquired unstageable (a full thickness tissue loss in which the base of the ulcer was covered by slough and/or eschar in the wound bed) pressure ulcer to the right heel. This affected one resident (Resident #73) of one resident reviewed for pressure ulcers. Finding include: Review of list of resident with pressure ulcers requested on 08/14/17 revealed Resident #73 had an unstageable pressure ulcer on the left heel and a Stage II (partial thickness loss of skin with exposed dermis) pressure ulcer to the sacrum. No other pressure ulcer areas were identified for the resident. Record review revealed Resident #73 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #73 had a skin risk assessment (Braden Scale) score dated 05/23/17 which indicated the resident was at low to moderate risk for pressure ulcer development. Review of admission Minimum Data Set (MDS) 3.0 dated 05/30/17 indicate that Resident #73 did not have pressure ulcers on admission. Review of wound management documentation revealed: A. On 05/31/17 a Stage II pressure ulcer was identified on the sacrum measuring 1 cm in length by 0.8 cm width. Depth could be measured however no measurements were documented. The note indicated the area was present on admission. On 08/15/17 the area measured 0.2 cm in length by 0.2 cm width with no depth documented. The only treatment order from admission to present was [MEDICATION NAME] protectant three times daily. B. On 05/31/17 an unstageable pressure ulcer was identified on the resident's left heel measuring 2.2 cm in length by 1.4 cm width. The note indicated the area was resent on admission. On 08/15/17 the area measured 0.9 cm in length by 0.8 cm width and continued to be documented as unstageable. The only treatment that had been ordered from admission to present was skin prep to bilateral heels. C. On 08/13/17 a unstageable deep tissue pressure ulcer was identified to the right heel that was not present on admission measuring 4.2 cm in length by 6.2 cm width with 70% slough and 30% eschar tissue identified. Registered Nurse (RN) #12 confirmed on 08/17/17 at 9:30 A.M., the wound documentation was not entered the electronic medical record till 08/14/17 in the afternoon. During the interview RN #12 also verified the sacrum and left heel treatments had been the same since admission (05/23/17). Review of skin integrity care plan initiated on 06/08/17 and updated on 08/15/17 revealed Resident #73 currently had an open area on the sacrum and right and left heel. Interventions included on 06/22/17 encourage resident to float heels while in bed and on 08/14/17 a z-flex boot to bilateral heels as resident allows. There was no evidence the resident was non-complaint with pressure relieving interventions. Review of a nurse's note, dated 08/13/17 revealed on 08/13/17 a draining blister was noted to the resident's right heel, dressing applied, and doctor updated. On 08/14/17 a new area was noted to the resident's right heel caused by improper positioning of resident's foot. Area presented as a suspected deep tissue injury (persistent; on blanchable; deep red, maroon, or purple discoloration); wound bed was dark purple in the center with a calloused edge. The area measured 4.2 centimeters in length by 6.2 cm width with an undetermined depth. Review of the current orders for 08/2017 revealed skin prep to bilateral heels three times daily, turn and reposition with care, rounds, and as needed, float heels, and [MEDICATION NAME] cream to bilateral buttocks three times daily. Further review revealed an order on 08/13/17 for treatment to right heel however did not indicate what the actual treatment to the heel was. On 08/14/17 and order was written for padding and kerlix to the area which was subsequently discontinued and a new order for a Hydrogel treatment was obtained. On 08/14/17 at 10:12 A.M., interview with Licensed Practical Nurse (LPN) #47 revealed Resident #73 did not have any current pressure ulcers. At 12:46 P.M., LPN #47 was re-interviewed after viewing Resident #73's medical record that indicated the resident had a Stage II pressure area on the sacrum and an unstageable pressure area on left heel. Verified with LPN #47 the areas were present on re-admission on 05/23/17 per the medical record. There was no evidence in the medical record the resident had an area on the right heel nor did the nurse report an area on the right heel even though LPN #47 had documented on 08/13/17 the resident had a dressing that was dry and intact to right heel and documented on the treatment administration record that she administered the treatment to the right heel on 08/13/17. On 08/14/17 at 2:54 P.M., observation of Resident #73 revealed the resident was lying in bed on her back. There was no evidence the resident's bilateral feet were elevated off the bed. On 08/15/17 at 10:15 A.M., observation of Resident #73 with Registered Nurse (RN) #12 revealed Resident #73's heels were not elevated off the bed nor were the z-boots applied. The z-boots were observed on the resident's night stand. RN #12 reported Resident #73 currently had a pressure ulcer on the sacrum and left heel. On 08/17/17 at 8:42 A.M. observation of the resident's dressing change with RN #12 and RN #38 assisting revealed a dressing dated 08/16/17 was in place. The dressing was removed from the resident's right heel. There was a small amount of serosanguineous drainage noted on the old dressing and small amount on the resident's sock. The area measured four cm in length by centimeter (cm) by six cm in width and was unstageable. On 08/17/17 at 9:30 A.M., interview with RN #12 verified the pressure ulcer on the right heel was identified by floor staff on Sunday August 13, 2017 however he did not enter the pressure ulcer in the medical record until later Monday afternoon around 4:55 P.M. RN #12 verified the resident had an order to be receiving skin prep to the right heel since re-admission on 05/23/17. RN #12 reported the nurse that identified the area Sunday did not write a correct order for type of dressing and she re-wrote an order on 08/14/16. However, he did not agree with the treatment order so he rewrote an appropriate order on 08/14/17 for Hydrogel and cover daily. On 08/17/17 at 10:28 A.M. observation of Resident #73 with RN #12 and Licensed Practical Nurse (LPN) #94 revealed the area on the sacrum was observed to be closed and slow to blanch. The left heel had a semi-fluid filled blister on the outer aspect of the foot. When RN #12 applied pressure to the area the resident pulled foot back and moaned. Review of the pressure ulcer documentation dated 10/05/16 revealed the appropriate skin event will be completed for each impaired area.

Based on observation, staff interview, resident interview, review of the facility's Abuse policy, review of a facility self-reported incident (SRI), and review of the facility abuse investigation, the facility failed to ensure Resident #64's allegation of abuse was thoroughly investigated. This resulted in Immediate Jeopardy for one resident (Resident #64) when State tested Nurse Aide (STNA) #87 resumed working after the director of nursing (DON) unsubstantiated an allegation of abuse without completing a thorough investigation. Resident #64 sustained actual harm as evidenced by a negative psychosocial outcome demonstrated by verbalization of recurrent anxiety and fear and preparations to move to another facility. This affected one of six residents reviewed for abuse and had the potential to affect all 68 residents that resided in the facility. On 07/12/16 at 4:20 P.M., the Director of Nursing (DON) was notified Immediate Jeopardy began on 07/02/16 at 4:20 P.M. when Resident #64 reported to a nurse a bruise on her arm was caused by the actions of STNA #87. The Immediate Jeopardy was removed on 07/13/16 at 2:56 P.M. when the facility implemented the following corrective action: · On 07/12/16 at 5:15 P.M. STNA #87 was terminated from the facility. · On 07/12/16 at 6:15 P.M. the DON was suspended. · On 07/12/16 beginning at 6:30 P.M. Registered Nurse (RN) #107 and RN #108 assessed all residents for any concerns related to abuse. Ongoing resident audits regarding abuse would continue four times a week for four weeks, then three times a week for four weeks, then two times a week for four weeks. The Quality assurance committee to meet monthly for three months to determine if continued audits warranted. · On 07/11/16 beginning at 6:30 P.M., RN #107, RN #108, RN #109, Licensed Practical Nurse (LPN) #88, LPN #56, Medical Records Clerk #59, began educating all staff on resident ' s rights and the abuse policy. All staff was educated in person or via phone by 07/13/16 at 2:56 P.M. Although the Immediate Jeopardy was removed, 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). The facility investigation of the abuse remained ongoing to determine the extent of staff knowledge regarding STNA #87's actions and Resident #63's repeated verbalizations of anxiety and fear and to reassess the thoroughness of the investigation completed by the DON. Findings Include: Review of Resident #64's medical record revealed the resident was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #64 had a Brief Interview of Mental Status (BIMS) score of six indicating moderate cognitive impairment, was dependent on staff for transfers, toileting and personal hygiene. Review of a nurse progress note dated 07/02/16 at 8:07 P.M. revealed Resident #64 called for nursing staff to come to her room. At that time Resident #64 was assessed to have a 10 cm by 9 cm bruise to her left forearm. When asked what happened the resident replied I asked the nursing assistant to take me to the bathroom and in transferring me to the wheelchair her arm came in contact with mine. The note further revealed the resident was on aspirin and had a medical history of [REDACTED]. Review of a SRI ( 2) with a category of allegation emotional /verbal abuse, submitted by the facility on 07/02/16, revealed on 07/02/16 at approximately 1:40 P.M. Resident #64 requested nursing staff come to her room. When nursing staff arrived the resident complained of arm pain and a bruise was noted to the left forearm which Resident #64 stated she received when STNA #87 inappropriately transferred her the day before. The SRI further revealed STNA #87 was suspended during the investigation. The conclusion of the facility investigation completed by the DON was the allegation was unsubstantiated. Review of the facility investigation that began on 07/02/16 and was completed on 07/06/16 revealed a statement from STNA #87 indicating Resident #64 had put on her call light and when STNA #87 entered her room the resident asked to use the restroom. STNA #87 indicated she assisted Resident #64 to a standing position from her recliner by placing her hand on and underneath the resident's left arm and assisting Resident #64 to a standing position. STNA #87 then took the resident to the restroom. Review of the written statement dated 07/02/16 provided by STNA #60 revealed that she was coming back from lunch as STNA #87 was taking Resident #64 out of her room in a wheelchair. STNA #87 stated to STNA #60 that when she worked she liked to take her for a little stroll. STNA #60 said Resident #64 then asked to use the bathroom. STNA #60 walked with STNA #87 and Resident #64 to the whirlpool room to use the bathroom then STNA #60 took over for STNA #87 so that STNA #87 could go to lunch. The statement further indicated Resident #64 declined to use the bathroom in the whirlpool room and asked to use the bathroom in her own room. STNA #60 took the Resident 64 back to her room and assisted her to the bathroom and back to her recliner. Review of the undated written statement provided by LPN #88 revealed she spoke with Resident #64 regarding the discoloration to her left forearm and Resident #64 stated the area happened during a transfer from her recliner to her wheelchair. LPN #88 indicated the resident said the nursing assistant leaned down to assist her with transfer coming in contact with her left arm. Resident #64 told LPN #88 that she felt the care STNA #87 provided was inconsiderate. No other staff interviews were included in the investigation and there was no documentation to support other residents in the building were interviewed regarding the care provided by STNA #87. An interview on 07/12/16 at 9:05 A.M. with Resident #64 revealed STNA #87 had grabbed her left arm and pulled her up out of her recliner. Resident #64 stated that she was scared of STNA #87 even though she did not work on her hallway anymore. Resident #64 then became tearful and stated I can't even defend myself. Resident #64 appeared visibly shaken by the conversation. An observation of Resident #64 at the time of the interview revealed a dark purplish brown bruise to the top of her left forearm just above the wrist. An interview on 07/12/16 at 9:43 A.M. with STNA #60 revealed that she was working on a hall with STNA #87 on 07/01/16. STNA #60 stated she was returning from lunch and it was STNA #87's turn to go to lunch. STNA #60 saw STNA #87 pushing Resident #64 in a wheelchair to the whirlpool room. STNA #87 said the resident needed to use the bathroom. STNA #60 took over so that STNA #87 could go to lunch. STNA #60 said the resident refused to use the bathroom in the whirlpool room because everyone uses that bathroom and requested to be taken back to her room. STNA #60 returned Resident #64 to her room and assisted her to the bathroom and back to her recliner. An interview on 07/12/16 at 10:04 A.M. with LPN #96 revealed the residents on the 200 hall had complained about STNA #87 being mean to them and Resident #64 had reported to her that STNA #87 had grabbed her arm. LPN #96 reported this allegation to LPN #88 who was the manager on call for the day. An interview on 07/12/16 at 11:15 A.M. with Family Member (FM) #300 revealed she was called on 07/02/16 by her brother who was visiting Resident #64 because he had observed a bruise to her left forearm. The brother sent several pictures of the bruise. Resident #64 told FM #300 STNA #87 bruised her arm by grabbing it and because Resident #64 was scared of STNA #87 the family was in the process of moving her to another facility. An interview 07/12/16 at 11:46 A.M. with Social Service Designee (SSD) #19 revealed she interviewed Resident #64 on 07/07/16 because the DON wanted to see if her accounts of the events matched what was reported on 07/02/16. SSD #19 stated Resident #64 expressed to her that she was nervous since STNA #87 was still working in the facility. An interview on 07/12/16 at 11:54 A.M. with the DON revealed on 07/02/16, LPN #88 called her and stated there was an incident involving Resident #64 and STNA #87. The DON instructed LPN #88 to send STNA #87 home and begin an investigation. The DON stated two or three days later she sat down with STNA #87 and had her write a statement. The DON stated she had spoken with FM #300 and was aware Resident #64 was nervous because STNA #87 was still working in the facility. An interview on 07/12/16 at 2:06 P.M. with STNA #74 revealed the residents in the facility had voiced concerns to her that they thought STNA #87 was mean. STNA #74 said STNA #87 would bully residents in to doing something that they had refused to do. STNA #74 also said residents had voiced to her that they didn't want STNA #87 taking care of them. STNA #74 did not report the resident concerns. An interview on 07/12/16 at 4:50 P.M. with RN #63 revealed that numerous residents on the 100 hall had expressed to her that STNA #87 was mean and they didn't want her taking care of them. STNA #87 had been moved to another hall after the complaints but was working on the 100 hall again due to the concerns with Resident #64. An interview on 07/12/16 at 4:50 P.M. with RN #41 revealed that numerous residents on the 100 hall had also expressed to her that STNA #87 was mean and they didn't want her taking care of them. RN #41 said STNA #87 had been moved to another hall after the complaints but was back working on the 100 hall due to the concerns with Resident #64. An interview on 07/13/16 at 10:30 A.M. with RN #107 revealed that on the evening of 07/12/16 the DON was sent home pending investigation. RN #107 stated this was normal procedure during an Immediate Jeopardy situation. RN #107 further revealed that on the morning of 07/13/16 additional statements from staff were found in the DON's office that were not provided as part of the investigation given to the surveyor for review on 07/12/16. Review of LPN #54's written statement dated 07/02/16, which was not initially provided for review, revealed she entered Resident #64's room to assess the bruise to Resident #64's left forearm. LPN #54 indicated Resident #64 stated she grabbed me hard. When asked who? Resident #64 identified STNA #87. The written statement also indicated Resident #64 voiced concern STNA #87 was going to take it out on her because she didn't like her. Review of LPN #96's written statement dated 07/02/16, which wan not initially provided for review, revealed a nurse aide asked her to look at Resident #64's arm. LPN #96 entered Resident #64's room and observed a bruise to the left forearm. LPN #96 asked the resident how she received the bruise and Resident #64 stated it happened on 07/01/16 when STNA #87 grabbed her arm and jerked it real hard. Review of SSD's written statement dated 07/13/16, which was not initially provided for review, revealed on 07/11/16 an employee from another local nursing facility came to evaluate Resident #64 for a possible transfer to their facility. SSD #19 indicated Resident #64 was scared of STNA #87 and wanted to move because STNA #87 was still working in the facility. SSD #19 notified the DON on 07/11/16 Resident #64 was scared of STNA #87 and was potentially moving to another nursing facility. An interview on 07/13/16 at 2:10 P.M. with SSD #19 revealed that as of 07/11/16 the DON was aware that Resident #64 was scared of STNA #87. SSD #19 further confirmed that STNA #87 worked on 07/12/16. A review of the facility policy titled Abuse and Neglect procedural guidelines dated 09/16/11 revealed the facility had developed processes to ensure prevention and reporting of suspected abuse and neglect. Any report of abuse was to be fully investigated. The policy stated that mental emotional abuse included but was not limited to humiliation, harassment, and threats of punishment. The policy stated staff was required to report concerns, incidents and grievances immediately to their manager and or executive director. This deficiency substantiates Complaint number OH 435

Based on observation, staff interview, resident interview, review of the facility's Abuse policy, review of a facility self-reported incident (SRI), and review of the facility abuse investigation, the facility failed to ensure Resident #64 was free from abuse and Residents #1, #3, #13, #16 and #35 were not mistreated and/or intimidated. This resulted in Immediate Jeopardy for one resident (Resident #64) when State tested Nurse Aide (STNA) #87 was verbally and physically abusive. Resident #64 sustained actual harm when she was found to have a 10 centimeter (cm) by 9 cm bruise to the forearm from an unknown injury and a negative psychosocial outcome demonstrated by verbalization of recurrent anxiety and fear and preparations to move to another facility. This affected six residents (#1, #3, #13, #16, #35, #64) reviewed for abuse and had the potential to affect all 68 residents that resided in the facility. On 07/12/16 at 4:20 P.M., the Director of Nursing (DON) was notified Immediate Jeopardy began on 07/02/16 at 4:20 P.M. when Resident #64 reported to a nurse a bruise on her arm was caused by the actions of STNA #87. The Immediate Jeopardy was removed on 07/13/16 at 2:56 P.M. when the facility implemented the following corrective action: · On 07/12/16 at 5:15 P.M. STNA #87 was terminated from the facility. · On 07/12/16 at 6:15 P.M. the DON was suspended. · On 07/12/16 beginning at 6:30 P.M. Registered Nurse (RN) #107 and RN #108 assessed all residents for any concerns related to abuse. Ongoing resident audits regarding abuse would continue four times a week for four weeks, then three times a week for four weeks, then two times a week for four weeks. The Quality assurance committee to meet monthly for three months to determine if continued audits warranted. · On 07/11/16 beginning at 6:30 P.M., RN #107, RN #108, RN #109, Licensed Practical Nurse (LPN) #88, LPN #56, Medical Records Clerk #59, began educating all staff on resident ' s rights and the abuse policy. All staff was educated in person or via phone by 07/13/16 at 2:56 P.M. Although the Immediate Jeopardy was removed, 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). The facility investigation of the abuse remained ongoing to determine the extent of staff knowledge regarding STNA #87's actions and Resident #63's repeated verbalizations of anxiety and fear and to reassess the thoroughness of the investigation completed by the DON. Findings Include: Review of Resident #64's medical record revealed the resident was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #64 had a Brief Interview of Mental Status (BIMS) score of six indicating moderate cognitive impairment, was dependent on staff for transfers, toileting and personal hygiene. Review of a nurse progress note dated 07/02/16 at 8:07 P.M. revealed Resident #64 called for nursing staff to come to her room. At that time Resident #64 was assessed to have a 10 cm by 9 cm bruise to her left forearm. When asked what happened the resident replied I asked the nursing assistant to take me to the bathroom and in transferring me to the wheelchair her arm came in contact with mine. The note further revealed the resident was on aspirin and had a medical history of [REDACTED]. Review of a SRI ( 2) with a category of allegation emotional /verbal abuse, submitted by the facility on 07/02/16, revealed on 07/02/16 at approximately 1:40 P.M. Resident #64 requested nursing staff come to her room. When nursing staff arrived the resident complained of arm pain and a bruise was noted to the left forearm which Resident #64 stated she received when STNA #87 inappropriately transferred her the day before. The SRI further revealed STNA #87 was suspended during the investigation. The conclusion of the facility investigation completed by the DON was the allegation was unsubstantiated. Review of the facility investigation that began on 07/02/16 and was completed on 07/06/16 revealed a statement from STNA #87 indicating Resident #64 had put on her call light and when STNA #87 entered her room the resident asked to use the restroom. STNA #87 indicated she assisted Resident #64 to a standing position from her recliner by placing her hand on and underneath the resident's left arm and assisting Resident #64 to a standing position. STNA #87 then took the resident to the restroom. Review of the written statement dated 07/02/16 provided by STNA #60 revealed that she was coming back from lunch as STNA #87 was taking Resident #64 out of her room in a wheelchair. STNA #87 stated to STNA #60 that when she worked she liked to take her for a little stroll. STNA #60 said Resident #64 then asked to use the bathroom. STNA #60 walked with STNA #87 and Resident #64 to the whirlpool room to use the bathroom then STNA #60 took over for STNA #87 so that STNA #87 could go to lunch. The statement further indicated Resident #64 declined to use the bathroom in the whirlpool room and asked to use the bathroom in her own room. STNA #60 took Resident #64 back to her room and assisted her to the bathroom and back to her recliner. Review of the undated written statement provided by LPN #88 revealed she spoke with Resident #64 regarding the discoloration to her left forearm and Resident #64 stated the area happened during a transfer from her recliner to her wheelchair. LPN #88 indicated the resident said the nursing assistant leaned down to assist her with transfer coming in contact with her left arm. Resident #64 told LPN #88 that she felt the care STNA #87 provided was inconsiderate. No other staff interviews were included in the investigation and there was no documentation to support other residents in the building were interviewed regarding the care provided by STNA #87. An interview on 07/12/16 at 9:00 A.M. with Resident #3 revealed there was an aide that was mean to her when she provided care. Resident #3 identified STNA #87 as the aide who was mean to her. Resident #3 stated my legs hurt and when she turns me she grabs them and makes them hurt worse. Resident #3 said STNA #87 did not talk nicely to her. An interview on 07/12/16 at 9:05 A.M. with Resident #64 revealed STNA #87 had grabbed her left arm and pulled her up out of her recliner. Resident #64 stated that she was scared of STNA #87 even though she did not work on her hallway anymore. Resident #64 then became tearful and stated I can't even defend myself. Resident #64 appeared visibly shaken by the conversation. An observation of Resident #64 at the time of the interview revealed a dark purplish brown bruise to the top of her left forearm just above the wrist. An interview on 07/12/16 at 9:10 A.M. with Resident #16 revealed there was an aide that was mean to her but she did not want to identify the aide. When asked if it was STNA #87, Resident #16 said yes. Resident #16 said she had asked that STNA #87 not to take care of her three months ago because she was mean to her. An interview on 07/12/16 at 9:15 A.M. with Resident #1 revealed STNA #87 was mean to her and didn't want to help her. Resident #1 said that sometimes she needed assistance in the bathroom. When she turned her call light on and STNA #87 came in the room STNA #87 stated you're not done yet sit there for a while and put your light on again. Resident #1 said she didn't like it when STNA #87 took care of her. An interview on 07/12/16 at 9:43 A.M. with STNA #60 revealed that she was working on a hall with STNA #87 on 07/01/16. STNA #60 stated she was returning from lunch and it was STNA #87's turn to go to lunch. STNA #60 saw STNA #87 pushing Resident #64 in a wheelchair to the whirlpool room. STNA #87 said the resident needed to use the bathroom. STNA #60 took over so that STNA #87 could go to lunch. STNA #60 said the resident refused to use the bathroom in the whirlpool room because everyone uses that bathroom and requested to be taken back to her room. STNA #60 returned Resident #64 to her room and assisted her to the bathroom and back to her recliner. An interview on 07/12/16 at 10:04 A.M. with LPN #96 revealed the residents on the 200 hall had complained about STNA #87 being mean to them and Resident #64 had reported to her that STNA #87 had grabbed her arm. LPN #96 reported this allegation to LPN #88 who was the manager on call for the day. An interview on 07/12/16 at 11:15 A.M. with Family Member (FM) #300 revealed she was called on 07/02/16 by her brother who was visiting Resident #64 because he had observed a bruise to her left forearm. The brother sent several pictures of the bruise. Resident #64 told FM #300 STNA #87 bruised her arm by grabbing it and because Resident #64 was scared of STNA #87 the family was in the process of moving her to another facility. An interview 07/12/16 at 11:46 A.M. with Social Service Designee (SSD) #19 revealed she interviewed Resident #64 on 07/07/16 because the DON wanted to see if her accounts of the events matched what was reported on 07/02/16. SSD #19 stated Resident #64 expressed to her that she was nervous since STNA #87 was still working in the facility. An interview on 07/12/16 at 11:54 A.M. with the DON revealed on 07/02/16, LPN #88 called her and stated there was an incident involving Resident #64 and STNA #87. The DON instructed LPN #88 to send STNA #87 home and begin an investigation. The DON stated two or three days later she sat down with STNA #87 and had her write a statement. The DON stated she had spoken with FM #300 and was aware Resident #64 was nervous because STNA #87 was still working in the facility. A follow up interview on 07/12/16 at 1:45 P.M. with Resident #3 revealed she felt STNA #87 bullied her and made her do things her way, not the way the resident wanted. A follow up interview on 07/12/16 at 2:00 P.M. with Resident #1 revealed STNA #87 was a bully and made her do things her way. An interview on 07/12/16 at 2:06 P.M. with STNA #74 revealed the residents in the facility had voiced concerns to her that they thought STNA #87 was mean. STNA #74 said STNA #87 would bully residents in to doing something that they had refused to do. STNA #74 also said residents had voiced to her that they didn't want STNA #87 taking care of them. STNA #74 did not report the resident concerns. An interview on 07/12/16 at 4:30 P.M. with Resident #35 revealed STNA #87 had been working on the 100 hall and that she wasn't very nice. Resident #35 said STNA #87 was mean and wanted to do everything in a hurry. Resident #35 did not like it when STNA #87 was assigned to her room. An interview on 07/12/16 at 4:40 P.M. with Resident #13 and FM #200 revealed FM #200 was not aware of any one treating her husband badly. Resident #13 stated she was mean when asked if any of the aides did not treat him with respect. Resident #13 became very animated and kept repeating she is mean. After a description of STNA #87 was provided, Resident #13 identified STNA #87 as who was mean to him. FM #200 said that on 07/11/16 the resident called her and his children several times during the night but they could not determine why he called. An interview on 07/12/16 at 4:50 P.M. with RN #63 revealed that numerous residents on the 100 hall had expressed to her that STNA #87 was mean and they didn't want her taking care of them. STNA #87 had been moved to another hall after the complaints but was working on the 100 hall again due to the concerns with Resident #64. An interview on 07/12/16 at 4:50 P.M. with RN #41 revealed that numerous residents on the 100 hall had also expressed to her that STNA #87 was mean and they didn't want her taking care of them. RN #41 said STNA #87 had been moved to another hall after the complaints but was back working on the 100 hall due to the concerns with Resident #64. An interview on 07/13/16 at 10:30 A.M. with RN #107 revealed that on the evening of 07/12/16 the DON was sent home pending investigation. RN #107 stated this was normal procedure during an Immediate Jeopardy situation. RN #107 further revealed that on the morning of 07/13/16 additional statements from staff were found in the DON's office that were not provided as part of the investigation given to the surveyor for review on 07/12/16. Review of LPN #54's written statement dated 07/02/16, which was not initially provided for review, revealed she entered Resident #64's room to assess the bruise to Resident #64's left forearm. LPN #54 indicated Resident #64 stated she grabbed me hard. When asked who? Resident #64 identified STNA #87. The written statement also indicated Resident #64 voiced concern STNA #87 was going to take it out on her because she didn't like her. Review of LPN #96's written statement dated 07/02/16, which wan not initially provided for review, revealed a nurse aide asked her to look at Resident #64's arm. LPN #96 entered Resident #64's room and observed a bruise to the left forearm. LPN #96 asked the resident how she received the bruise and Resident #64 stated it happened on 07/01/16 when STNA #87 grabbed her arm and jerked it real hard. Review of SSD's written statement dated 07/13/16, which was not initially provided for review, revealed on 07/11/16 an employee from another local nursing facility came to evaluate Resident #64 for a possible transfer to their facility. SSD #19 indicated Resident #64 was scared of STNA #87 and wanted to move because STNA #87 was still working in the facility. SSD #19 notified the DON on 07/11/16 Resident #64 was scared of STNA #87 and was potentially moving to another nursing facility. An interview on 07/13/16 at 2:10 P.M. with SSD #19 revealed that as of 07/11/16 the DON was aware that Resident #64 was scared of STNA #87. SSD #19 further confirmed that STNA #87 worked on 07/12/16. A review of the undated facility policy titled Resident Rights revealed residents had the right to be treated with kindness, respect and dignity. A review of the facility policy titled Abuse and Neglect procedural guidelines dated 09/16/11 revealed the facility had developed processes to ensure prevention and reporting of suspected abuse and neglect. Any report of abuse was to be fully investigated. The policy stated that mental emotional abuse included but was not limited to humiliation, harassment, and threats of punishment. The policy stated staff was required to report concerns, incidents and grievances immediately to their manager and or executive director. This deficiency substantiates Complaint number OH 435.

Based on observation, staff interview, resident interview, review of the facility's Abuse policy, review of a facility self-reported incident (SRI), and review of the facility abuse investigation, the facility failed to implement their abuse policy and procedure to ensure Resident #64 was free from abuse and Residents #1, #3, #13, #16 and #35 were not mistreated and/or intimidated. This resulted in Immediate Jeopardy for one resident (Resident #64) when State tested Nurse Aide (STNA) #87 was verbally and physically abusive. Resident #64 sustained actual harm when she was found to have a 10 centimeter (cm) by 9 cm bruise to the forearm from an unknown injury and a negative psychosocial outcome demonstrated by verbalization of recurrent anxiety and fear and preparations to move to another facility. This affected six residents (#1, #3, #13, #16, #35, #64) reviewed for abuse and had the potential to affect all 68 residents that resided in the facility. On 07/12/16 at 4:20 P.M., the Director of Nursing (DON) was notified Immediate Jeopardy began on 07/02/16 at 4:20 P.M. when Resident #64 reported to a nurse a bruise on her arm was caused by the actions of STNA #87. The Immediate Jeopardy was removed on 07/13/16 at 2:56 P.M. when the facility implemented the following corrective action: · On 07/12/16 at 5:15 P.M. STNA #87 was terminated from the facility. · On 07/12/16 at 6:15 P.M. the DON was suspended. · On 07/12/16 beginning at 6:30 P.M. Registered Nurse (RN) #107 and RN #108 assessed all residents for any concerns related to abuse. Ongoing resident audits regarding abuse would continue four times a week for four weeks, then three times a week for four weeks, then two times a week for four weeks. The Quality assurance committee to meet monthly for three months to determine if continued audits warranted. · On 07/11/16 beginning at 6:30 P.M., RN #107, RN #108, RN #109, Licensed Practical Nurse (LPN) #88, LPN #56, Medical Records Clerk #59, began educating all staff on resident ' s rights and the abuse policy. All staff was educated in person or via phone by 07/13/16 at 2:56 P.M. Although the Immediate Jeopardy was removed, 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). The facility investigation of the abuse remained ongoing to determine the extent of staff knowledge regarding STNA #87's actions and Resident #63's repeated verbalizations of anxiety and fear and to reassess the thoroughness of the investigation completed by the DON. Findings Include: Review of Resident #64's medical record revealed the resident was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #64 had a Brief Interview of Mental Status (BIMS) score of six indicating moderate cognitive impairment, was dependent on staff for transfers, toileting and personal hygiene. Review of a nurse progress note dated 07/02/16 at 8:07 P.M. revealed Resident #64 called for nursing staff to come to her room. At that time Resident #64 was assessed to have a 10 cm by 9 cm bruise to her left forearm. When asked what happened the resident replied I asked the nursing assistant to take me to the bathroom and in transferring me to the wheelchair her arm came in contact with mine. The note further revealed the resident was on aspirin and had a medical history of [REDACTED]. Review of a SRI ( 2) with a category of allegation emotional /verbal abuse, submitted by the facility on 07/02/16, revealed on 07/02/16 at approximately 1:40 P.M. Resident #64 requested nursing staff come to her room. When nursing staff arrived the resident complained of arm pain and a bruise was noted to the left forearm which Resident #64 stated she received when STNA #87 inappropriately transferred her the day before. The SRI further revealed STNA #87 was suspended during the investigation. The conclusion of the facility investigation completed by the DON was the allegation was unsubstantiated. Review of the facility investigation that began on 07/02/16 and was completed on 07/06/16 revealed a statement from STNA #87 indicating Resident #64 had put on her call light and when STNA #87 entered her room the resident asked to use the restroom. STNA #87 indicated she assisted Resident #64 to a standing position from her recliner by placing her hand on and underneath the resident's left arm and assisting Resident #64 to a standing position. STNA #87 then took the resident to the restroom. Review of the written statement dated 07/02/16 provided by STNA #60 revealed that she was coming back from lunch as STNA #87 was taking Resident #64 out of her room in a wheelchair. STNA #87 stated to STNA #60 that when she worked she liked to take her for a little stroll. STNA #60 said Resident #64 then asked to use the bathroom. STNA #60 walked with STNA #87 and Resident #64 to the whirlpool room to use the bathroom then STNA #60 took over for STNA #87 so that STNA #87 could go to lunch. The statement further indicated Resident #64 declined to use the bathroom in the whirlpool room and asked to use the bathroom in her own room. STNA #60 took Resident #64 back to her room and assisted her to the bathroom and back to her recliner. Review of the undated written statement provided by LPN #88 revealed she spoke with Resident #64 regarding the discoloration to her left forearm and Resident #64 stated the area happened during a transfer from her recliner to her wheelchair. LPN #88 indicated the resident said the nursing assistant leaned down to assist her with transfer coming in contact with her left arm. Resident #64 told LPN #88 that she felt the care STNA #87 provided was inconsiderate. No other staff interviews were included in the investigation and there was no documentation to support other residents in the building were interviewed regarding the care provided by STNA #87. An interview on 07/12/16 at 9:00 A.M. with Resident #3 revealed there was an aide that was mean to her when she provided care. Resident #3 identified STNA #87 as the aide who was mean to her. Resident #3 stated my legs hurt and when she turns me she grabs them and makes them hurt worse. Resident #3 said STNA #87 did not talk nicely to her. An interview on 07/12/16 at 9:05 A.M. with Resident #64 revealed STNA #87 had grabbed her left arm and pulled her up out of her recliner. Resident #64 stated that she was scared of STNA #87 even though she did not work on her hallway anymore. Resident #64 then became tearful and stated I can't even defend myself. Resident #64 appeared visibly shaken by the conversation. An observation of Resident #64 at the time of the interview revealed a dark purplish brown bruise to the top of her left forearm just above the wrist. An interview on 07/12/16 at 9:10 A.M. with Resident #16 revealed there was an aide that was mean to her but she did not want to identify the aide. When asked if it was STNA #87, Resident #16 said yes. Resident #16 said she had asked that STNA #87 not to take care of her three months ago because she was mean to her. An interview on 07/12/16 at 9:15 A.M. with Resident #1 revealed STNA #87 was mean to her and didn't want to help her. Resident #1 said that sometimes she needed assistance in the bathroom. When she turned her call light on and STNA #87 came in the room STNA #87 stated you' re not done yet sit there for a while and put your light on again. Resident #1 said she didn't like it when STNA #87 took care of her. An interview on 07/12/16 at 9:43 A.M. with STNA #60 revealed that she was working on a hall with STNA #87 on 07/01/16. STNA #60 stated she was returning from lunch and it was STNA #87's turn to go to lunch. STNA #60 saw STNA #87 pushing Resident #64 in a wheelchair to the whirlpool room. STNA #87 said the resident needed to use the bathroom. STNA #60 took over so that STNA #87 could go to lunch. STNA #60 said the resident refused to use the bathroom in the whirlpool room because everyone uses that bathroom and requested to be taken back to her room. STNA #60 returned Resident #64 to her room and assisted her to the bathroom and back to her recliner. An interview on 07/12/16 at 10:04 A.M. with LPN #96 revealed the residents on the 200 hall had complained about STNA #87 being mean to them and Resident #64 had reported to her that STNA #87 had grabbed her arm. LPN #96 reported this allegation to LPN #88 who was the manager on call for the day. An interview on 07/12/16 at 11:15 A.M. with Family Member (FM) #300 revealed she was called on 07/02/16 by her brother who was visiting Resident #64 because he had observed a bruise to her left forearm. The brother sent several pictures of the bruise. Resident #64 told FM #300 STNA #87 bruised her arm by grabbing it and because Resident #64 was scared of STNA #87 the family was in the process of moving her to another facility. An interview 07/12/16 at 11:46 A.M. with Social Service Designee (SSD) #19 revealed she interviewed Resident #64 on 07/07/16 because the DON wanted to see if her accounts of the events matched what was reported on 07/02/16. SSD #19 stated Resident #64 expressed to her that she was nervous since STNA #87 was still working in the facility. An interview on 07/12/16 at 11:54 A.M. with the DON revealed on 07/02/16, LPN #88 called her and stated there was an incident involving Resident #64 and STNA #87. The DON instructed LPN #88 to send STNA #87 home and begin an investigation. The DON stated two or three days later she sat down with STNA #87 and had her write a statement. The DON stated she had spoken with FM #300 and was aware Resident #64 was nervous because STNA #87 was still working in the facility. A follow up interview on 07/12/16 at 1:45 P.M. with Resident #3 revealed she felt STNA #87 bullied her and made her do things her way, not the way the resident wanted. A follow up interview on 07/12/16 at 2:00 P.M. with Resident #1 revealed STNA #87 was a bully and made her do things her way. An interview on 07/12/16 at 2:06 P.M. with STNA #74 revealed the residents in the facility had voiced concerns to her that they thought STNA #87 was mean. STNA #74 said STNA #87 would bully residents in to doing something that they had refused to do. STNA #74 also said residents had voiced to her that they didn't want STNA #87 taking care of them. STNA #74 did not report the resident concerns. An interview on 07/12/16 at 4:30 P.M. with Resident #35 revealed STNA #87 had been working on the 100 hall and that she wasn't very nice. Resident #35 said STNA #87 was mean and wanted to do everything in a hurry. Resident #35 did not like it when STNA #87 was assigned to her room. An interview on 07/12/16 at 4:40 P.M. with Resident #13 and FM #200 revealed FM #200 was not aware of any one treating her husband badly. Resident #13 stated she was mean when asked if any of the aides did not treat him with respect. Resident #13 became very animated and kept repeating she is mean. After a description of STNA #87 was provided, Resident #13 identified STNA #87 as who was mean to him. FM #200 said that on 07/11/16 the resident called her and his children several times during the night but they could not determine why he called. An interview on 07/12/16 at 4:50 P.M. with RN #63 revealed that numerous residents on the 100 hall had expressed to her that STNA #87 was mean and they didn't want her taking care of them. STNA #87 had been moved to another hall after the complaints but was working on the 100 hall again due to the concerns with Resident #64. An interview on 07/12/16 at 4:50 P.M. with RN #41 revealed that numerous residents on the 100 hall had also expressed to her that STNA #87 was mean and they didn't want her taking care of them. RN #41 said STNA #87 had been moved to another hall after the complaints but was back working on the 100 hall due to the concerns with Resident #64. An interview on 07/13/16 at 10:30 A.M. with RN #107 revealed that on the evening of 07/12/16 the DON was sent home pending investigation. RN #107 stated this was normal procedure during an Immediate Jeopardy situation. RN #107 further revealed that on the morning of 07/13/16 additional statements from staff were found in the DON's office that were not provided as part of the investigation given to the surveyor for review on 07/12/16. Review of LPN #54's written statement dated 07/02/16, which was not initially provided for review, revealed she entered Resident #64's room to assess the bruise to Resident #64's left forearm. LPN #54 indicated Resident #64 stated she grabbed me hard. When asked who? Resident #64 identified STNA #87. The written statement also indicated Resident #64 voiced concern STNA #87 was going to take it out on her because she didn't like her. Review of LPN #96's written statement dated 07/02/16, which wan not initially provided for review, revealed a nurse aide asked her to look at Resident #64's arm. LPN #96 entered Resident #64's room and observed a bruise to the left forearm. LPN #96 asked the resident how she received the bruise and Resident #64 stated it happened on 07/01/16 when STNA #87 grabbed her arm and jerked it real hard. Review of SSD's written statement dated 07/13/16, which was not initially provided for review, revealed on 07/11/16 an employee from another local nursing facility came to evaluate Resident #64 for a possible transfer to their facility. SSD #19 indicated Resident #64 was scared of STNA #87 and wanted to move because STNA #87 was still working in the facility. SSD #19 notified the DON on 07/11/16 Resident #64 was scared of STNA #87 and was potentially moving to another nursing facility. An interview on 07/13/16 at 2:10 P.M. with SSD #19 revealed that as of 07/11/16 the DON was aware that Resident #64 was scared of STNA #87. SSD #19 further confirmed that STNA #87 worked on 07/12/16. A review of the undated facility policy titled Resident Rights revealed residents had the right to be treated with kindness, respect and dignity. A review of the facility policy titled Abuse and Neglect procedural guidelines dated 09/16/11 revealed the facility had developed processes to ensure prevention and reporting of suspected abuse and neglect. Any report of abuse was to be fully investigated. The policy stated that mental emotional abuse included but was not limited to humiliation, harassment, and threats of punishment. The policy stated staff was required to report concerns, incidents and grievances immediately to their manager and or executive director. This deficiency substantiates Complaint number OH 435

Based on medical record review, observation, staff interview and review of a hospital emergency room report and review of the facility's Fall Circumstances Report, the facility failed to ensure the safe use of a Hoyer lift when transferring a resident and failed to ensure safety devices were implemented as ordered. This affected two of five sampled residents reviewed for accidents (Residents #64 and #123). The census was 103. Harm occurred when Resident #64 was transferred via a Hoyer lift (Hoyer lift is a brand name for a device that allows caregivers to lift people who are unable to stand without assistance) by one staff member when there should have been two. Resident #64 partially fell from Hoyer body lift which resulted in a concussion and laceration to the head which required four staples. Findings include: 1. Review of Resident #64 medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was non-ambulatory and required extensive assistance for bed mobility and transfers with the assistance of two staff members. Review of the physician orders [REDACTED]. Review of the Fall Circumstance Investigation dated 7/09/12 at 2:15 A.M. revealed the resident was being transfer to the bed from the wheelchair using the Hoyer lift when the resident fell from lift. According to the report, the staff member was in error and the Hoyer lift was caught on the bed control cords under the bed. The nurse was called to the residents room by the State tested nurse aide (STNA) who was transferring the resident, STNA #1. Upon entering the room, the nurse saw part of the resident's body on the floor and part of the his body remained in the Hoyer lift. The lift was moved away from the resident and an ambulance was called immediately. The resident was bleeding from the back of the head. Review of the emergency room Report dated 07/09/12, revealed the resident was being transferred via a Hoyer lift and fell out of the top strap causing his body to fall approximately four feet with the resident's leg remaining in the Hoyer lift. The resident struck his head on a tile floor. He was noted to have significant bleeding. He was boarded and collard by the ambulance personnel. The resident had a history of [REDACTED]. Apparently, when the ambulance arrived at the hospital and throughout transport, he would not respond to them at all. The resident's scalp was cleansed and prepped in the usual sterile fashion. The wound was explored to its base. The wound was anesthetized with 1% Lidocaine with epinephrine with good anesthia. The wound was then closed with four staples. The approximation was closed. There were no complications. The patient tolerated the procedure well. The impression of the incident revealed the resident fell from a Hoyer lift and had a closed head injury, scalp laceration and concussion. On 02/07/13 at 6:45 A.M., interview with Registered Nurse (RN) #19 revealed STNA #1 came and got her. When she went into the resident's room, part of him Resident #64's legs still in the Hoyer sling. Resident #64's head was on the floor and he was bleeding from his head. STNA #1 told her that he didn't want to go to bed earlier and he came and got her while the other STNA was at lunch. The surveyor asked if the STNA was putting the resident to bed by herself and RN #19 revealed "yes she was because the other aide was at lunch". 2. Medical record revealed Resident #123 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the plan of care dated 12/31/12 revealed an intervention for a mat to the floor. On 02/05/13 at 3:43 P.M., Resident #123 was observed on the floor next to her bed. The mat was observed leaning against the wall. On 02/05/13 at 3:46 PM., STNA # 2 verified the mat was not on the floor and was leaning against the wall when Resident #123 was found on the floor by the surveyor. STNA #2 stated she knew the mat was supposed to be on the floor.

Based on medical record review, staff interview, resident interview, observation, physician interview and review of the facility's policy and procedure regarding pain control and [MEDICAL TREATMENT], the facility failed to ensure pain medication was available and failed to monitor a [MEDICAL TREATMENT] site and inform dietary of fluid restriction related to [MEDICAL TREATMENT]. This affected one of two residents reviewed for pain (Resident #29) and one of one resident reviewed for [MEDICAL TREATMENT] (Resident #148). The census was 103. Harm occurred when the facility failed to ensure pain medication was available for administration for Resident #29 who had a recent ankle fracture. Resident #29 was not medicated with the ordered narcotic pain medication from 8:00 P.M. on 02/04/13 until after an order was received at 4:50 P.M. on 02/05/13. Findings include: 1. On 02/05/13 at 4:30 P.M., interview with Resident #29 revealed she had a physician's orders [REDACTED]. Resident #29 stated she had not received the prn pain medication since 02/04/13 at 10:30 P.M.. Resident #29 stated the facility had told her there was a problem with the refill of the prescription and the facility had been unable to reach the physician for a new refill order. Observation at the time of the interview revealed Resident #29 was lying in bed, on her right side and she was rubbing her left leg. Resident #29 was tearful with moist eyes and she had facial grimacing. Resident #29 stated she was having pain from the left knee to the left foot and rated the pain as a nine on a one to 10 (1-10) Pain Scale with 1 being the least pain to 10 being the worst pain. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Review of the pain assessment dated [DATE] revealed Resident #29 had acute pain to the left ankle and had rated the pain at a level 10. Resident #29 had limited activities as a result of the pain. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 received prn ordered pain medication and stated she experienced frequent moderate pain. Review of the plan of care dated 01/29/13 revealed Resident #29 experienced acute pain related to a fracture to the ankle with surgical repair. The goal of the plan of care revealed Resident #29 would express relief of the pain to a tolerable level. Review of the interventions revealed staff were to administer, monitor for effectiveness, and for side effects from the prn ordered pain medication. Review of the physicians orders dated 01/31/13 revealed an order for [REDACTED]. Review of the Record of Controlled Drug Use dated 01/26/13 revealed Resident #29 had been delivered 30 tablets of [MEDICATION NAME] 5/325 mg and on 02/04/13 at 8:00 P.M., the resident had received the last dose of [MEDICATION NAME] 5/325 mg. from the supply. The existing balance was zero. The Controlled Count sheet indicated there were no refills left on the prescription for the [MEDICATION NAME] 5/325 mg. Review of the nurses note dated 02/04/13 revealed there was no documented evidence the physician had been notified of the need for an order to refill the [MEDICATION NAME] 5/325 mg tablets. Review of the nurses note dated 02/05/13 at 10:30 A.M., revealed Resident #29 complained of pain and had an order for [REDACTED]. Review of the nurses note dated 02/05/13 at 4:50 P.M., revealed the physician returned the facility's telephone call and had stated he could not write the prescription for [MEDICATION NAME] 5/325 at that time as he was out of his office. Review of the nurses note dated 02/05/13 at 6:30 P.M., revealed the facility's pharmacy was telephoned by the nurse who than telephoned the physician. The physician gave permission for the [MEDICATION NAME] 5/325 mg to be refilled. On 02/06/13 at 12:40 P.M., telephone interview with the physician revealed he first became aware of the need for the narcotic pain medication [MEDICATION NAME] 5/325 mg for Resident #29 on the afternoon of 02/05/13. The physician further stated he was present at the facility on 02/04/13 and 02/05/13. Had the facility made him aware of the need for a refill for Resident #29's [MEDICATION NAME], he would have written the prescription while he was at the facility. Review of the Guidelines for Pain Assessment and Management (not dated) revealed an assessment of resident pain would be completed upon admission and a plan of care would be imitated related to the pain. The effectiveness of pain management interventions would be evaluated and modified as indicated. Review of the facility's policy and procedure related to pharmacy for ordering and receiving medications (not dated) revealed refill medications were ordered by pulling the label on the bottom right portion of the current package and placing it on the order form and faxed to the pharmacy. For Schedule II controlled medications it was noted the narcotic medications would be delivered to the facility on ly if a written prescription had been received by the pharmacy prior to dispensing. In an emergency situation, the pharmacy could accept a telephone order. A follow-up written original prescription was to be sent to the pharmacy by the facility or the physician within 7 days. On 02/05/13 at 4:50 P.M. interview with Registered Nurse (RN) #3 revealed Resident #29 had a current order for [MEDICATION NAME] 5/325 mg. However, the amount of refills the physician had ordered was zero. The pharmacy would not give the facility permission to give Resident #29 the ordered pain medication without the physicians verbal permission by telephone or written prescription faxed to them of the approval for an additional refill for the pain medication [MEDICATION NAME] 5/325 mg. RN #3 stated Resident #29 complained of pain and had been administered Tylenol at 4:30 P.M. that day. RN #3 revealed she was attempting to reach the physician so the physician could provide approval to the pharmacy and upon the facility receipt from the pharmacy of a valid refill for the controlled medication Resident #29 would be provided with the medication. On 02/05/13 at 4:55 P.M., interview with RN #3 verified Resident #29 was ordered [MEDICATION NAME] 5/325 mg every six hours prn for pain with the maximum dose of three tablets per day. On 02/04/13 Resident #29 received a dose of [MEDICATION NAME] at 8:00 P.M. and had not received any further [MEDICATION NAME]. Resident #29 had complained of pain on the morning of 02/05/13 and throughout the day and there was no documentation the facility notified the physician of the need for Resident #29's [MEDICATION NAME] 5/325 to be refilled until 02/05/13 at 4:50 P.M. 2. Medical record review revealed Resident #148 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician order [REDACTED]. Review of Resident #148's meal ticket did not indicate the resident was ordered any fluid restriction. On 02/06/13 at 2:48 P.M., interview with Dietary Manager (DM) #10 verified the fluid restriction was not directed on Resident #148's meal ticket. DM #10 stated the previous day (02/05/13) Resident #148 asked DM #10 for a drink and she gave it to her because she was unaware of the fluid restriction. Review of admitting physician's orders [REDACTED]. On 02/06/13 at 3:26 P.M., interview with Licensed Practical Nurse (LPN) #11 stated Resident #148 had an ASH catheter in her right chest.(An Ash Split Cath is a brand name of a type of catheter that is a long term catheter that is inserted into a central vein for the purpose of accessing blood for [MEDICAL TREATMENT]). LPN #11 stated the ASH catheter should be assessed every shift and she could not find documentation on the treatment administration sheets (TARS) or in nurses notes that it had been assessed/monitored.

Based on clinical record review, review of laboratory blood test results, review of hospital documentation, staff interviews, and review of the Change in Condition Form, the facility failed to monitor and administer blood thinning medication ([MEDICATION NAME]) in the proper dosage prescribed by the physician resulting in hematuria (blood in the urine), critically high laboratory results and hospitalization . This resulted in Immediate Jeopardy for one of 11 residents who received [MEDICATION NAME] therapy (Resident #103). On 01/23/13 at 4:15 P.M., the corporate registered nurse (CRN), the director of nursing (DON), the assistant director of nursing (ADON), the corporate vice president of operations and the administrator were notified Immediate Jeopardy began on 09/01/12 at approximately 8:00 P.M. when Resident #103 received the wrong dosage of [MEDICATION NAME]. The resident was ordered 1 milligram (mg) of [MEDICATION NAME] alternating with 2 mg daily. Resident #103 received [MEDICATION NAME] 6 mg in error on 09/01/12, 09/02/12, 09/03/12, 09/04/12 and 09/05/12. The resident's Pro-time (PT) was over 100 seconds (normal 9.1-11.9 seconds) and the International Normal Ratio (INR) was 11.3 (normal values were 0.88 to 1.17) (laboratory studies to monitor bleeding and clotting times). Resident #103 was admitted to the hospital with [REDACTED]. The Immediate Jeopardy was removed on 09/08/12 when the facility implemented the following corrective actions: ? On 09/06/12, the facility reassessed the remaining ten residents in the facility who were receiving [MEDICATION NAME] for signs and symptoms of bleeding, appropriate physician orders, accurate administration of the medication and monitoring and reporting of the laboratory blood values. ? On 09/08/12, 26 professional licensed nursing staff 10 RN 's and 16 licensed practical nurses (LPN) were educated regarding Monitoring of [MEDICATION NAME], Dosage of [MEDICATION NAME], Side Effects Awareness of [MEDICATION NAME] and ensuring the accurate transcription of medications to be administered. Although the Immediate Jeopardy was removed when the facility reassessed the ten other residents receiving anticoagulant therapy to ensure medication administration was provided according to the physician orders and residents were free from signs of bleeding, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy) from 09/09/12 until 02/01/13, when Resident #49 received the wrong dose of [MEDICATION NAME] on 09/01/12, 09/02/12 and 09/03/12. The resident was ordered 5 mg of [MEDICATION NAME] and administered 7.5 mg in error. On 01/14/13, Resident #38 had an order to hold [MEDICATION NAME] 6 mg that date, but, the [MEDICATION NAME] was administered in error. On 02/01/13, review of six open medical records for two existing residents (Resident's #38 and #49) and one new admission (Resident #90) revealed all three had new physician orders for [MEDICATION NAME]. The PT/INR lab values were appropriately monitored and the [MEDICATION NAME] orders were accurately transcribed and administered as ordered. Review of the document entitled QA/CQI for [MEDICATION NAME] Medication Administration which chronologically addressed implementation of new plans to prevent reoccurrence from 09/06/12 until 01/22/13 revealed on 01/17/13, the director of health services (DHS) and clinical team were rounding each unit at 4:00 P.M. to check that each resident who received [MEDICATION NAME] was checked and reviewed regarding the following: 5 R's (Right resident, right drug, right dose, right route and right time) before administering [MEDICATION NAME]. On 01/22/13, professional staff were also inserviced regarding Safety Administration of [MEDICATION NAME], Adverse Effects of [MEDICATION NAME], ensure the MAR indicated [REDACTED]. The first inservicing was completed for 20 professional staff on 01/22/13 (time not identified) and again at 4:45 P.M., for 17 remaining professional staff. At the inservicing, the professional staff were notified that two nurses would be required to verify the correct order and dose of [MEDICATION NAME] before administering the medication. Nurse #1 would administer the medication and verify it was correct and sign off her name on the MAR. Nurse #2 would watch, verify the correct dose and sign off her name on the MAR. On 02/01/13 at 4:35 P.M., interview with LPN #500 stated they now have to have two nurses to check the order and the MAR, look at the medication card, count the number of pills, check the order and go over the 5 Rights for medication administration. On 02/01/13 at 4:50 P.M., interview with LPN #501 revealed the [MEDICATION NAME] was counted at the beginning of the shift and at the end of shift, there has to be two nurses present to administer the medication. On 02/01/13 at 5:01 P.M., interview with LPN #502 reiterated the above interviews. On 02/01/13 at 5:03 P.M., interview with RN #503 verified the above interviews. Observation of the above stated procedure at the time of the interviews revealed the professional staff were implementing the two nurse procedure. The interviewed staff stated they count [MEDICATION NAME] as you would narcotics. The facility was determined to be in substantial compliance as of 02/01/13. Findings include: 1. Clinical record review revealed Resident #103 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders dated 08/30/12, revealed Resident #103 was ordered [MEDICATION NAME] 1 mg every other day alternating with [MEDICATION NAME] 2 mg every other day and to recheck the PT/INR in one week. Review of the laboratory blood test result dated 09/06/12 revealed Resident #103' s PT was greater than 100 which was high and the INR was greater than 11.30 which was critically high. Review of the laboratory test revealed the physician was notified on 09/06/12 at 10:15 A.M. Review of the nurses notes revealed Resident #103 was assessed at 10:15 A.M. and was noted to have blood in the urine (dark, rusty brown in color), bruising was noted to both arms and a hematoma was noted to the right lower extremity. Resident #103 was alert and oriented to her person, answered questions appropriately, and her level of consciousness was normal. The physician ordered Vitamin K 10 mg intramuscularly (IM), hold the [MEDICATION NAME], recheck the PT/ INR on 09/07/12 and send the resident to the emergency room for an evaluation. Resident #103 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. Review of the September 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The order was transcribed incorrectly from the August 2012 MAR indicated [REDACTED] Review of the hospital physician's progress report dated 09/06/12, identified Resident #103 presented with hematuria. Examination of the extremities revealed ecchymosis (bruising) to the distal aspect of the right leg and no clubbing, cyanosis or [MEDICAL CONDITION] to the left leg. Resident #103's hemoglobin (HGB) was 10.6 (normal 12-16 grams per deciliter (g/dl) and her hematocrit (HCT) was 33.8 (normal 36-48 grams per deciliter). Review of the hospital physician's progress report dated 09/07/12 revealed the resident was noted to have [MEDICATION NAME] colored urine in her catheter and her extremities were normal. On 09/08/12, the hospital physician notes revealed there was no longer evidence of hematuria. On 09/09/12, hospital physician progress notes [REDACTED]. On 09/10/12, the resident was readmitted to the facility. 2. Clinical record review revealed Resident #49 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 08/31/12, Resident #49 was ordered to receive [MEDICATION NAME] 5 mg every day. However, on 09/01/12, 09/02/12 and 09/03/12, Resident #49 received [MEDICATION NAME] 7.5 mg. The medication error was discovered on 09/04/12. The physician was notified on 09/04/12 (no time identified) and ordered to obtain a PT/INR on 09/05/12. The medication error was discovered during medication administration when RN #67 questioned the dose of [MEDICATION NAME] Resident #49 was to receive. Review of the laboratory test results dated 09/05/12 revealed Resident's #49's PT was 30.0 (Normal 9.1-11.9 seconds) and INR was 3.19 (Normal 0.88-1.17). There were no specific parameters ordered for Resident #49. The physician was notified on 09/05/12 (not time documented) and ordered [MEDICATION NAME] 5 mg alternating with [MEDICATION NAME] 2.5 mg daily. There were no additional incidents for Resident #49 after this date. 3. Review of Resident #38's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 01/14/13, the laboratory results reflected the PT was 28.6 seconds and the INR was 3.19. The physician ordered the [MEDICATION NAME] to be held that day; however Resident #38 was administered [MEDICATION NAME] 6 mg. A physician ' s order was written on the laboratory results for a PT/INR to be drawn on 01/14/13. The order was to hold the [MEDICATION NAME] 6 mg for 24 hours then administer 4mg alternating with 6 mg daily and then recheck the PT/INR in one week. No physician's order was written in the medical record. Interview with the ADON on 01/23/13 at 11:13 A.M. revealed the order was never transcribed from the laboratory sheet to a physician's order sheet, therefore the new order was not transcribed to the MAR. Review of the laboratory test results on 01/22/13 revealed Resident #38's PT was 16.1 and the INR was 1.73. 4. On 01/23/13, the surveyor interviewed 7 LPN's #1, #2, #5, #6 and RNs #3, #4 and #7 and all were knowledgeable regarding [MEDICATION NAME] administration and verified they had recently received training. On 01/23/13 at 11:39 A.M., interview with the Consultant Pharmacist revealed she was not aware of any [MEDICATION NAME] errors until it was brought to her attention earlier this date. The pharmacist was not aware of the [MEDICATION NAME] errors that occurred in September 2012. She visits the facility two days a month and had been since August 2012. On 01/23/13 at 12:30 P.M., interview with the medical director (MD) revealed he had been the medical director since 1992 and was involved with the quality assurance committee. The physician verified [MEDICATION NAME] errors had been discussed; however he believed the problems were resolved. He was aware of the recent medication error dated 01/14/13. The MD stated the PT/INR laboratory results were communicated to him by facility staff. The physician stated when an INR was between 3-5, he orders to recheck the laboratory testing, when the INR was 4-5, he treated with Vitamin K, and when the INR was 11 or above it was 'dangerous'. 5. 01/23/12 at 2:06 P.M. interview with the DON revealed on 01/15/13, nine of 28 LPN's and RNs were reeducated on [MEDICATION NAME] therapy and the facility has not completed any further education with additional staff since 01/15/13.