Every finding on record at Valley Oaks Care Center

Based on observation, interview and facility policy review, the facility failed to ensure proper sanitation and food storage practices. This had the potential to effect all 38 residents (#01, #02, #03, #04, #05, #06, #07, #08, #09, #10, #11, #13, #15, #17, #18, #19, #20, #23, #24, #25, #26, #27, #28, #29, #32, #34, #36, #37, #38, #39, #40, #42, #43, #45, #46, #47, #55, #56) who ate food from the facility kitchen. The facility census was 43.Findings include:Observation on 03/16/26 at 10:30 A.M., the walk in freezer contained undated breadsticks stored in an unmarked clear bag. The dry storage area contained multiple food items open to air, not sealed, and not dated, including: a two pound three ounce bag of Corn Flakes, a two pound three ounce bag of Bran Flakes (closed but undated), a 16-ounce bag of Lays Classic chips, a 25 pound bag of all purpose flour, and three unlabeled, undated bags containing a brown colored substance. Dietary Manager #524 reported, I am not sure what that could be.Observation on 03/17/26 at 10:00 A.M. with Dietary Manager #524 revealed a grease residue line along the side of the grill. The walk-in freezer floor was observed to have spilled sherbet on the floor, and Dietary Manager #524 verified the walk-in cooler had peeling paint on the floor under the stored milk.Observation on 03/17/26 10:20 A.M., Dietary Manager #524 verified grease residue along the side of the grill, dirty surfaces, and spilled sherbet on the freezer floor that had not been cleaned. Peeling paint was observed on the walk in cooler floor beneath stored milk. During an interview, Dietary Aid #638 stated he did not remember seeing the posted cleaning schedule. Additional observations with Dietary Manager #524 revealed improper food storage above the prep area, including an open, unsealed box of corn starch; undated containers of Italian seasoning (32 ounce), cilantro leaves (0.5 ounce), black pepper (16 ounce), cinnamon (16 ounce), and ground mustard (16 ounce), as well as grime on the bottles and multiple crumbs on the prep shelf.On 03/23/26 at 9:40 A.M., a dented six pound can of sliced apples was observed on the shelf for active use. Dietary Aid #638 verified the dented can had been kept for use and stated that dented cans were supposed to be placed by the outgoing kitchen door for pickup and disposal by the food service delivery truck.Additional observation on 03/23/26 at 10:00 A.M. revealed a dark residue on the plastic lip inside the ice machine, which transferred to a paper towel when wiped. Dietary Aid #638 stated he was unsure whether a tracking sheet existed for emptying and cleaning the ice machine.Review of the undated facility's document titled Daily Tasks and Cleaning Checklist for Dietary Aides indicated that each shift was required to clean and sanitize all counter areas, move the steam table and scrub underneath, and sweep and mop the walk in. Review of the Daily Cooks Checklist (undated) showed requirements to clean and sanitize all surfaces and prep tables, wipe down the steam table and its cracks, ensure all food items in coolers were labeled, sealed, wrapped, and dated, and clean the stove top, backsplash, steamer top, grill, floor, and spice rack.Review of the facility policy titled Sanitization, revised October 2008, stated that food service areas must be maintained in a clean and sanitary manner, counters and shelves must be kept clean and in good repair, and non-food contact surfaces must be cleaned regularly and frequently enough to prevent buildup of grime.

Based on observation, interview and record review, the facility failed to ensure a comfortable, homelike environment when maintenance failed to maintain water temperatures in resident rooms. This affected six (Residents #24, #37, #26, #14, #46, and #42) residents reviewed for homelike environment and had the potential to affect all residents in the facility. The facility census was 43.Findings include:On 03/16/26 at 8:42 A.M., an interview with Resident #24 revealed the water in her sink did not get warm unless it ran for a really long time. Observation at the time of the interview revealed the water in the sink was cold, even after running for over two minutes. The resident stated, I shower in the shower room, so it really only is a problem to wash my face. She indicated the certified nurse aides (CNAs) mainly used the water to clean up her roommate (Resident #37), so she just dealt with it.On 03/16/26 at 8:44 A.M., an observation of water temperature in Resident #26's room revealed the water was cold at the sink. After running the water for five minutes, the water still was cold to the touch. This was confirmed by CNA #518 on 03/16/26 at 8:45 A.M.On 03/16/26 at 8:50 A.M., an observation of water temperature in Resident #14's room revealed the water was cold at the sink. After running the water for approximately five minutes, the water remained cold to the touch. This was confirmed by CNA #518 on 03/16/26 at the time of the observation.On 03/16/26 at 9:03 A.M., an observation of water temperature in Resident #46's room and interview with Resident #46 revealed the water was cold in the sink. The shelf beside the sink was noted to have dirty adaptive equipment, and the resident stated, the water in that bathroom sink does not get hot. If it ever does, I would wash that silverware.On 03/16/26 at 9:20 A.M., an interview with Maintenance Supervisor (MS) #555 revealed he noticed a circulation tank for the water system was bad on 03/13/26. He called a plumber who was to be at the facility on 03/16/26. He felt with the residents being old, they would shower in the shower room, so only the CNAs would use the sink, so he did not see the temperature of the water as a problem.On 03/16/26 at 9:30 A.M., an observation with MS #555 revealed a low water temperature in Resident #42's room. After running the water for a timed five minutes, the water temperature at the sink reached 99.2 degrees Fahrenheit (F). Observation of the water temperature at the sink of room [ROOM NUMBER], which was unoccupied, revealed a temperature of 98.7 degrees F after three minutes of running. These temperatures were confirmed by MS #555 at the time of observation.On 03/17/26 at 11:07 A.M., an interview with MS #555 revealed he completed water temperatures in rooms weekly. He did not mark which rooms he was testing. If the temperature was too high or too low, which he believed was 90 degrees F to 120 degrees F, he would adjust the water temperature up or down. If it was still an issue, he would bleed off the line, which could have been clogged. He would then re-check the temperatures, but he did not document these temperatures or any of the follow up maintenance.Review of facility logbook of hot water temperatures, dated 01/15/26, revealed an E Hall temperature of 103 degrees F. This was confirmed by MS #555 on 03/17/26 at 11:07 A.M.Review of facility logbook of hot water temperatures, dated 03/13/26, revealed an E Hall temperature of 104 degrees F. This was confirmed by MS #555 on 03/17/26 at 11:07 A.M.Review of a facility policy titled Homelike environment, dated February 2021, revealed the facility residents were provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management would maximize the characteristics of the facility to reflect a personalized, homelike setting, which included comfortable and safe temperatures. Review of an undated facility policy titled Water Temperatures revealed the water in the facility should be kept within a temperature range to prevent scalding. Water temperatures in resident rooms, bathrooms, common areas and tub/shower areas should be between the temperatures of 105-120 degrees F. Maintenance staff was to be responsible for checking thermostats and temperature controls of and record these in a maintenance log. Any time the water temperature felt excessive to the touch, staff would report the finding to the immediate supervisor.

Based on record review and interview, the facility failed to ensure assessments were accurately completed for Residents #7 and #12. This affected two residents (#7 and #12) of 16 residents reviewed for Minimum Data Set (MDS) 3.0 assessments. The facility census was 43.Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 04/15/25 with diagnoses including depression, dementia and anxiety. Review of the physician's orders for Resident #7 revealed she had an order for Risperdal 0.25 milligrams (mg) at bedtime for paranoia and agitation dated 07/16/25. Risperdal was classified as an antipsychotic medication. Review of the 02/19/26 modified annual MDS 3.0 assessment for Resident #7 revealed on section N415 under high-risk drugs classes she was taking an antipsychotic. However, under section N450 antipsychotic medication review, the facility answered that antipsychotics were not received since admission or the prior assessment. Interview on 03/23/26 at 9:43 A.M. with Registered Nurse (RN) #535 verified Resident #7's MDS dated [DATE] section N was incorrectly entered for question N450 for her receiving antipsychotics as Resident #7 was on Risperdal. 2. Review of the medical record for Resident #12 revealed an admission date of 01/22/26. Diagnoses included metabolic encephalopathy, urinary tract infection, pneumonia, insomnia, generalized anxiety disorder, disorder of thyroid, chronic pain, chronic respiratory failure unspecified, neuromuscular dysfunction of the bladder, acquired absence of other organs, chronic obstructive pulmonary disease, essential hypertension, tracheostomy, dependence on a respirator, hyperlipidemia, type two diabetes mellitus, rheumatoid arthritis, fracture of left femur, history of transient ischemic attack and cerebral infarction without residual deficits, unspecified osteoarthritis, unspecified fracture of the shaft of the humerus, left arm, other specified disorders of bone density, personal history of other diseases of the nervous system and sense organs, and unspecified convulsions. Review of a quarterly MDS version 3.0 assessment, dated 02/23/26, revealed a Brief Interview for Mental Status (BIMS) score of 13 on a 0-15 scale. A score of 13 indicated Resident #12 had intact cognitive function or normal thinking and memory. The resident had impairment on one side for both upper and lower extremities. She was dependent on staff for toileting hygiene, showering and/or bathing, lower body dressing and putting on footwear. She required supervision to perform personal hygiene and dress her upper body. The resident had an indwelling Foley catheter and was always incontinent of bowel. Resident #12 revealed a determination of pressure ulcer risk. For question M0100, the facility answered no to the question did the resident have a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. For question M0210, the facility marked yes to the question does the resident have one or more unhealed pressure ulcers/injuries? On M0300, the facility indicated the resident had one Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough, may also present as an intact or open/ruptured serum filled blister) which was present on admission. This was confirmed by RN #603 on 03/18/26 at 10:00 A.M.For question N0300, the facility recorded the resident had one injection during the past seven days (prior to the completion of the MDS). For question N0350, the facility recorded the resident received insulin injections on one day during the seven days prior to the completion of the MDS. This was confirmed by RN #603 on 03/18/26 at 10:00 A.M. Review of the medical record for Resident #12 revealed on 02/19/26 the resident had a blood glucose of 166 which required insulin coverage by subcutaneous injection of 2 units of Humalog Kwikpen 100 units per milliliter (u/ml) . The record also revealed on 02/20/26, the resident had a blood glucose of 185 which required insulin coverage by subcutaneous injection of 2 units of Humalog Kwikpen 100 u/ml. This was confirmed by RN #603 on 03/18/26 at 10:00 A.M. An interview with RN #603 on 03/18/26 at 10:00 A.M. revealed Resident #12 had two Stage II pressure ulcers on 02/23/26 when the MDS was completed. The pressure ulcer on the resident's coccyx was resolved on 02/25/26, and the pressure ulcer on her buttocks was resolved on 02/26/26. RN #603 also reported that the resident received subcutaneous insulin injections according to a sliding scale. In the seven days prior to 02/23/26, Resident #3 received insulin coverage on both 02/19/26 and 02/20/26. On 03/23/26 at 9:43 A.M., an interview with RN #535 revealed she had been an MDS coordinator for two years and was responsible for the entire building. She confirmed the MDS section M question M0100 for Resident #12 was incorrect. The correct answer should have been yes.

Based on observation, record review, review of facility policy and interview, the facility failed to ensure oxygen was provided to Resident #3 as ordered by the physician and/or failed to ensure orders were updated to reflect the current plan for treatment. This affected one resident (#3) of two residents reviewed for respiratory care. The facility census was 45. Findings include:Review of the medical record for Resident #3 revealed an admission date of 11/18/25 with diagnoses including chronic atrial fibrillation, depression, diffuse traumatic brain injury with loss of consciousness of unspecified duration, dysphagia, heart failure and muscle weakness.Review of physician orders for Resident #3 revealed an order dated 11/18/25 to obtain the resident's vital signs monthly. Review of a care plan for Resident #3, (revised 12/01/25), revealed a focus of care for impaired respiratory status related to the resident being oxygen dependent. The goal was for the resident to be free from signs and symptoms of hypoxia. Interventions (dated 11/19/25) included oxygen as ordered or as needed (PRN), monitoring lung sounds for wheezing or crackles PRN, monitoring vital signs and pulse oximetry PRN. Review of physician orders for Resident #3 revealed an order dated 12/02/25 for oxygen. The order read for continuous oxygen one (1) liter per minute (LPM) received via nasal cannula. Review of a Minimum Data Set (MDS) assessment, dated 01/28/26, revealed Resident #3 had a Brief Interview of Mental Status (BIMS) score of 12 on a 0-15 scale. A BIMS score of 12 would indicated moderate impairment with thinking and memory. Review of the special treatment section of the MDS revealed the resident was on oxygen but did not include the frequency of the oxygen therapy. Review of the medical record for Resident #3 revealed pulse oximeter readings at a minimum of daily from 12/18/25 through 01/20/26, and then a reading on 02/18/26 and 03/18/26. Readings completed on 01/15/26 indicated the resident was receiving oxygen by ventilator. A reading on 01/26/26 indicated the resident was receiving oxygen by trach. However, the resident did not have a tracheostomy, nor was he on a ventilator. This was verified by the Director of Nursing (DON) during an interview on 03/18/26 at 1:56 P.M.On 03/16/26 at 9:59 A.M., Resident #3 was observed in his room without oxygen in place. An interview with Resident #3 at the time of the observation revealed he had difficulty holding a conversation but could answer yes or no questions appropriately. There was an oxygen concentrator observed in the resident's room with dated tubing, which was not being used, and the resident could not access. The resident indicated he did not know if he was supposed to be on oxygen or not.On 03/17/26 at 12:00 P.M., an observation of Resident #3 revealed he was not wearing any form of oxygen. His room contained an oxygen concentrator, which was not on, with the cannula wrapped up and on the opposite side of the room. The resident said hello; however, he did not interact beyond that.On 03/17/26 at 1:40 P.M., an observation of Resident #3 revealed he was sleeping with sonorous respirations. He was not wearing oxygen. The oxygen concentrator was not on, was on the opposite side of the room and could not be accessed by the resident.On 03/18/26 at 8:05 A.M., an observation of Resident #3 revealed he was not on oxygen. The oxygen concentrator was not on and was on the opposite side of the room. The resident appeared pale, his lips were cyanotic, his bilateral arms showed signs of mottling (purple, marble-like discoloration). The resident appeared minimally responsive when his name was called by this surveyor.Review of the medical record for Resident #3 revealed a treatment administration record (TAR) for the month of March 2026. The record reflected the nurses were documenting Resident #3 was wearing continuous oxygen one LPM via nasal cannula twice daily per the record. This was verified during an interview with the DON on 03/18/26 at 1:56 P.M.On 03/18/26 at 8:38 A.M., an interview with Registered Nurse (RN) #630 revealed the nurses check each resident's oxygen level (SpO2) daily. She stated she had checked Resident #3 in the morning, and he had a SpO2 of 92%. During the interview, the RN revealed she could not recall the last time the resident had oxygen by nasal cannula. She thought it had been quite some time.On 03/18/26 at 8:42 A.M., an observation of Resident #3 revealed a pulse oximeter reading of 98% with the resident wearing two liters of oxygen. Resident #3 was able to answer surveyor question regarding breakfast and about shaving at this time. On 03/18/26 at 12:36 P.M., an interview with Physician (MD) #652 revealed (Resident #3) has progressed with his demise. He had been basically end of life care since the first week of January (the facility providing end of life care although the resident did not receive Hospice services). During the interview, the MD denied Resident #3 had an order for oxygen. However, the surveyor verified the current order and noted MD #652 had signed the physician order for oxygen administration. The MD indicated she thought the oxygen was ordered as needed. She stated they had a discussion in January (2026), and the resident's family thought he needed oxygen due to his traumatic brain injury (TBI). On 03/18/26 at 1:56 P.M., an interview with the DON confirmed nurses had documented Resident #3 was receiving oxygen at one LPM via nasal cannula twice daily from 03/01/26 until the morning of 03/18/26. The DON further confirmed the resident had not actually been provided the oxygen (as physician ordered) during this time. The DON confirmed the most recent care plan for Resident #3 indicated the resident was oxygen dependent and was to have vital signs and pulse oximeter monitored PRN. His oxygen was to be delivered continuously via nasal cannula, and he did not have a trach and was not on a ventilator.On 03/18/26 at 2:26 P.M., an interview with the Resident Representative (RR) for Resident #3 revealed the staff had reported to family they were not going to leave the resident's oxygen on because it was causing him agitation (this was not documented in the resident's medical record). The representative revealed she was under the impression that as soon as the resident was no longer agitated, the oxygen would be continuous again. She believed it had been at least two weeks since the agitation had subsided and indicated she believed the resident did require oxygen. Review of a facility policy titled Oxygen Administration, dated October 2021, revealed guidelines for safe oxygen administration. The policy indicated there was to be a physician order for oxygen, the care plan should address any special oxygen needs for the resident, and the oxygen should be administered by the route (nasal cannula, oxygen mask, etc.) ordered. Documentation should include time, date, who administered, rate of oxygen flow, all assessment data obtained before, during and after oxygen was applied, and how the resident tolerated the procedure. If a resident refused the procedure, the supervisor should be notified, and any other information should be reported in accordance with the facility policy and professional standards of practice.Review of an undated facility policy titled Oxygen Therapy Monitoring revealed nursing staff would monitor the need for oxygen therapy by checking oxygen saturation levels with a handheld pulse oximeter machine to maintain a saturation level above 92% or a level specified by the physician. The policy indicated if a resident showed signs of hypoxia (shortness of breath, tachycardia or rapid heart rate, cyanosis, agitation or confusion), an oxygen saturation level should be checked. If below 92%, oxygen should be applied starting at two liters per minute and re-checked after two minutes to be sure the level was rising. The policy further indicated after resident's saturation level was stabilized above 92%, the physician should be informed of the resident's condition along with oxygen saturation level before and after oxygen was applied. Oxygen orders could be written as follows: Oxygen at 2LPM via nasal cannula to maintain SpO2 above 92%, check pulse ox every shift and PRN, or titrate oxygen PRN to maintain a SpO2 greater than 92%, if saturation levels are above 95% titrate oxygen to room air.

Based on record review, interview and facility policy review, the facility maintain a medical record in accordance with accepted professional standards and practices, resulting in inaccurate documentation for Resident #3. This affected one resident (#3) of 16 residents whose records were reviewed for accuracy. The facility census was 43.Findings include:Review of the medical record for Resident #3 revealed an admission date of 11/18/25. Diagnoses included alcohol abuse, anemia, dementia, mild without behavioral disturbance, difficulty in walking, disorder of prostate, essential hypertension, history of falling, insomnia, neuromuscular dysfunction of the bladder, pressure ulcer of right buttock Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) of the sacral region, alcoholic polyneuropathy, chronic atrial fibrillation, depression, diffuse traumatic brain injury with loss of consciousness of unspecified duration, dysphagia, heart failure, unspecified, hyperlipidemia, muscle weakness, osteomyelitis of vertebra, sacral and sacrococcygeal region, other fracture of base of skull, and unspecified convulsions.Review of a care plan for Resident #3, last updated 12/01/25, revealed a focus of care for impaired respiratory status related to the resident being oxygen dependent. The goal was for the resident to be free from signs and symptoms of hypoxia. Interventions included oxygen as ordered or as needed, monitoring lung sounds for wheezing or crackles as needed, monitoring vital signs and pulse oximetry as needed, with all interventions updated last on 11/19/25.Review of physician orders for Resident #3 revealed an order dated 12/02/25 for oxygen. The order read: Continuous oxygen 1 liter per minute (LPM) received via nasal cannula. Review of the Treatment Administration Record (TAR) for Resident #3 revealed nursing staff had marked the administration as completed for his order of continuous oxygen 1 LPM via nasal twice daily from 03/01/26 to 03/17/26. The Director of Nursing (DON) verified on 03/18/26 at 1:56 P.M. that nursing staff had documented they were administering oxygen at 1 LPM despite not being utilized.Review of a Minimum Data Set (MDS) version 3.0 assessment, dated 01/28/26, revealed Resident #3 had a Brief Interview of Mental Status (BIMS) score of 12 on a 0-15 scale. A BIMS score of 12 indicated moderate problems with thinking and memory. Review of the special treatment section of the MDS revealed the resident was on oxygen but did not reveal the frequency of the oxygen therapy. Review of the medical record for Resident #3 revealed pulse oximeter readings at a minimum of daily from 12/18/25 through 01/20/26, and then a reading on 02/18/26 and 03/18/26. Readings completed on 01/15/26 indicated the resident was receiving oxygen by ventilator. A reading on 01/26/26 indicated the resident was receiving oxygen by trach. The resident did not have a tracheostomy, nor was he on a ventilator. This was verified by the DON on 03/18/26 at 1:56 P.M.On 03/18/26 at 8:38 A.M., an interview with Registered Nurse (RN) #630 revealed the nurses check each resident's pulse ox (SpO2) daily. She checked Resident #3's SpO2 in the morning, and he had a SpO2 of 92% at 6:42 A.M. She could not recall the last time the resident had oxygen by nasal cannula. She thought it had been quite some time.On 03/18/26 at 1:56 P.M., an interview with the DON confirmed nurses had documented Resident #3 was receiving oxygen 1 LPM via nasal cannula twice daily from 03/01/26 until the morning of 03/18/26. She further confirmed he had not been wearing the oxygen all of those dates. She confirmed the most recent care plan for Resident #3 indicated the resident was oxygen dependent and was to have vital signs and pulse oximeter monitored as needed. His oxygen was to be delivered continuously via nasal cannula, and he did not have a trach and was not on a ventilator.Review of a facility policy titled Charting and Documentation, revised 07/17, revealed all services provided to a resident toward the care plan goals or any changes in the resident's medical, physical, functional or psychosocial condition would be documented in the medical record. The documentation should be objective, complete, and accurate.

Based on observation, interview, review of facility policy, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure staff implemented proper infection control practices while providing care to residents on enhanced barrier precautions. This affected two of three residents (#13 and #45) reviewed for infections and had the potential to affect 25 additional residents (#29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #31, #42, #43, #44, #46, #47, #48, #49, #50, #52, #52, #53 and #54) who resided on the 200 hall where State tested Nurse Aide (STNA) #340 contaminated high touch surfaces. The facility census was 54. Findings include: 1. Review of the medical record for Resident #13 revealed an admitted [DATE] with diagnoses including pneumonia, type two diabetes mellitus, dependence on renal dialysis, dislocation of the tarsometatarsal joint of the right foot, and osteomyelitis (infection of the bone) of the right ankle and foot. Review of the admission Minimum Data Set (MDS) assessment completed on 02/24/24 revealed Resident #13 had intact cognition, was frequently incontinent of bowel and bladder, had a surgical wound, and an infection of the foot. Review of the physician orders revealed an order dated 02/22/24 indicating Resident #13 had an external fixator to her right lower extremity and an order dated 03/13/24 revealed Resident #13 had a dialysis catheter in her right subclavian. Review of the care plan revealed Resident #13 was placed in enhanced barrier precautions (EBP) on 02/21/24 secondary to a wound and medical device. Interventions included staff were to wear a gown and gloves for care per recommendations for EBP. Random observation on 03/25/24 at 10:40 A.M. revealed a sign posted to the left of Resident #13's door signaling visitors Resident #13 was on EBP. There was no personal protective equipment (PPE) outside her room at the time of this observation. Observation from outside Resident #13's room on 03/25/25 at 11:46 A.M. revealed the sign indicating Resident #13 was on enhanced barrier precautions, but no cart, stand, or drawers containing PPE was found outside the door to her room. Further observation revealed Physical Therapist (PT) #357 was sitting on Resident #13's bed moving her right leg with the external fixator, and she was not wearing a gown at the time of care. As the observation continued, PT #357 was noted completing additional exercises with Resident #13 then repositioning her in the bed. Interview on 03/25/24 at 11:55 A.M. with PT #357 confirmed she was sitting on Resident #13's bed with no gown while assisting with therapeutic exercises. Further interview revealed PT #357 did not realize Resident #13 was still on EBP, since there was no PPE outside the door. At this time, PT #357 confirmed the sign indicating Resident #13 was in EBP was still posted beside her door. Interview on 03/25/24 at 11:58 A.M. with Registered Nurse (RN) #350 confirmed Resident #13 was on EBP due to her wound status and further confirmed there was no PPE outside the door to Resident #13's room. During the interview, RN #350 confirmed PPE was supposed to be outside the resident rooms when they were on any type of precautions. Interview on 03/25/24 at 5:1 P.M. with RN #319 confirmed PPE should be available outside the resident's rooms when on enhanced barrier precautions and should be checked and restocked at the end of every shift and as needed. Review of the undated facility policy titled Enhanced Barrier Precautions revealed wounds and indwelling medical devices were indications for being placed on EBP and the facility was to ensure PPE was maintained outside the resident's room. Further review of the policy revealed staff were to wear gowns for high touch resident care activities. 2. Review of the medical record for Resident #45 revealed an admitted [DATE] with diagnoses including infection and inflammatory reaction due to an indwelling urethral catheter, neuromuscular dysfunction of the bladder, atrial fibrillation, bipolar disorder, dysphagia, kidney failure, and dementia. Review of the Minimum Data Set (MDS) assessment completed on 03/04/24 revealed Resident #45 had severely impaired cognition, had an indwelling catheter, was always incontinent of bowel, and was dependent on staff for bathing, toileting, and personal hygiene. Review of the care plan revealed Resident #45 was placed in enhanced barrier precautions (EBP) on 06/01/23 secondary to a suprapubic catheter, wounds, and a percutaneous endoscopic gastrostomy (PEG) tube (a tube through the resident's stomach for nutrition and/or medications). Interventions included staff were to wear a gown and gloves during care per recommendations for EBP. Observation on 03/25/24 at 2:45 P.M. of catheter care revealed State tested Nurse Aide (STNA) #340 did not bag the soiled linen, then used soiled gloved hands to open and close Resident #45's bedroom door and the soiled linen cart in the hallway. During the observation, STNA #340's soiled gloved hands touched both the inside and the outside doorknobs, as well as the soiled linen cart other staff were observed pushing through the hallway throughout the day of the survey. This process occurred twice during the observation of catheter care. Interview on 03/25/24 at 2:50 P.M. with STNA #340 confirmed she opened and closed Resident #45's door and handled the linen cart in the hallway with soiled gloves both times she removed soiled linen from Resident #45's room. During the interview, STNA also confirmed staff were supposed to place soiled linen into plastic bags as they were used during care and close the bags filled with soiled linen prior to removing them from residents' rooms. Interview on 03/2/24 at 3:10 P.M. with the Administrator confirmed Resident #45's doorknobs should not have been handled with soiled gloves. Interview on 03/25/24 at 5:20 P.M. with the Director of Nursing (DON) confirmed exposed linen was not supposed to leave the resident's room and that the linen should first be bagged. Interview with the DON further confirmed soiled gloves should not be used to manipulate high touch surfaces like doorknobs. Review of the policy titled Laundry and Bedding, Soiled, dated September 2022 revealed contaminated linen and laundry bags should not be held close to the body, should be handled with minimal agitation, and staff should use appropriate standard precautions. Review of CDC Updates as of July 12, 2022 revealed the following. 1. Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. 2. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. 3. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: o Wounds or indwelling medical devices, regardless of MDRO colonization status o Infection or colonization with an MDRO. 4. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care. 5. Standard Precautions, which are a group of infection prevention practices, continue to apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. Review of the resident census provided by the facility dated 03/24/25 revealed Residents #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #31, #42, #43, #44, #46, #47, #48, #49, #50, #52, #52, #53 and #54 resided on the 200 hall. This deficiency represents non-compliance investigated under Complaint Number OH00151588.

Based on interview, food committee meeting minutes and facility menu review, the facility failed to provide a menu which offered a variety of items served at the breakfast meal. This had the potential to affect 52 residents who received meals from the kitchen. The facility identified Resident #13 as receiving nothing by mouth. The facility census was 53. Findings include: Review of facility food committee meeting minutes dated 07/31/23 revealed concern related to repeating menu items was noted. Review of the facility's fall 2023-24 four-week (28 day) menu revealed scrambled eggs were served 14 out of 28 days. For week three, scrambled eggs were served five days (Sunday, Monday, Tuesday, Thursday, and Saturday) out of seven days and three days in a row between the end of week four and the beginning of week one (week four Saturday, week one Sunday, and week one Monday). Interview on 01/17/24 at 11:56 A.M. with the Dietary Supervisor revealed she did have residents complain to her there was too much repetition of some items on the menu. Interview on 01/17/24 at 1:14 P.M. with the Registered Dietitian confirmed, upon review of the menus, there was a lot of scrambled eggs, but scrambled eggs were a cheap option. She stated the menus came pre-made, but she had the option to adjust the menu. Interview on 01/17/24 at 3:24 P.M. with Resident #38 revealed there were too many scrambled eggs on the menu.

Based on medical record review, observation, and interview, the facility failed to accurately reflect residents' status on Minimum Data Set (MDS) assessments related to mental health status and oxygen use. This affected three (Residents #11, #21, and #33) of 24 residents whose assessments were reviewed. The facility census was 53. Findings include: 1. Review of Resident #11's medical record review revealed diagnoses including schizoaffective disorder (bipolar type), psychosis, pseudobulbar affect, depression, bipolar disorder and anxiety disorder. A Preadmission Screen and Resident Review dated 07/05/22 indicated Resident #11 had no indications of serious mental illness. Resident #11 was hospitalized between 11/14/22 and 12/07/22. Review of a Preadmission Screen and Resident Review Determination (PASRR) determination revealed Resident #11 was approved for nursing facility services. The attached summary report dated 12/01/22 indicated Resident #11 was first medically hospitalized ( for increased ammonia level in the blood and diagnosed with pneumonia and metabolic encephalopathy) and when stable was transferred to the inpatient psychiatric unit. The summary indicated Resident #11 had mental health diagnoses of psychotic disorder, language disorder - cognitive communication deficit, major depressive disorder, bipolar disorder, and dependence on psychotropic medications with induced mood disorder and anxiety disorder. The summary indicated Resident #11 was hospitalized for having unreal thoughts and seeing and hearing things that were not there. Resident #11 also exhibited physical aggression. The summary indicated Resident #11 had one inpatient psychiatric hospitalization in the past two years and was receiving psychotropic medication. There were no recommendations for disability specific services. However, the summary indicated services and supports which would be needed to be provided included an Occupational Therapy evaluation, a safety plan, ongoing evaluation of the effectiveness of psychotropic medications on target symptoms, ongoing medication review by a psychiatrist or similarly-credentialed professionals, medication evaluation and monitoring by a designated physician, family involvement in care, and socialization and recreation activities to decrease isolation, improve mood and increase social interaction. Review of Resident #11's annual MDS dated [DATE] indicated Resident #11 was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or related conditions. During an interview on 01/18/24 at 9:48 A.M., Registered Nurse (RN) #355 verified the annual MDS dated [DATE] was marked incorrectly regarding serious mental illness. 2. Review of Resident #21's medical record revealed diagnoses including bipolar disorder, schizoaffective disorder, brief psychotic disorder, and anxiety disorder. Resident #21 was admitted to the facility 06/19/20. Review of a facsimile (fax) dated 06/17/20 revealed the facility in which Resident #21 previously resided provided PASRR information they had available. A PASRR identification screen dated 06/22/17 indicated Resident #21 had a diagnosis of bipolar disorder and had continuously received ongoing case management from a mental health agency over two years. Due to the mental health disorder, Resident #21 had experienced functional limitations on a continuing or intermittent basis over the prior six months. Resident #21 was determined to have indications of serious mental illness. A level II determination dated 04/02/18 indicated Resident #21 was located in a nursing facility and was requesting continued placement in a nursing facility. A resident review assessment was completed on 04/01/18. Resident #21 did not have the potential to live in the community and was receiving case management. The determination indicated Resident #21 had a history of serious mental illness with diagnoses including Bipolar 1 Disorder, mixed and severe major depressive disorder. The determination indicated Resident #21 had an unspecified personality disorder by history. No specialized services were recommended. The determination indicated services recommended included ongoing medication review by a physician to assure medical conditions were appropriately treated, medication education on the value of taking medication as prescribed, and a behavior management safety plan to decrease inappropriate behaviors and ensure safety. Review of Resident #21's annual MDS dated [DATE] indicated Resident #21 was not currently considered by state II PASRR process to have a serious mental illness. On 01/16/24 at 12:47 P.M., RN #355 verified the annual MDS section A1500 was marked incorrectly as the most recent PASRR determination indicated Resident #21 did have a serious mental illness. 46195 3. Review of medical record for Resident #33 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD) with (acute) exacerbation and chronic respiratory failure. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #33 was cognitively intact and did not use oxygen. Review of Resident #33's physician orders revealed an order dated 11/18/22 for oxygen two liters via nasal cannula, may titrate as needed. Review of Resident #33's care plan dated 09/25/21 revealed the resident had an impaired respiratory status related to anxiety, being a current smoker, and having shortness of breath. Interventions included oxygen as ordered by the physician. Observation on 01/16/24 at 10:35 A.M. of Resident #33's room revealed the resident was not in the room, but there was an oxygen concentrator in room. Observation on 01/17/24 at 9:42 A.M. revealed Resident #33 was in room receiving oxygen via nasal cannula. Interview on 01/18/24 at 10:02 A.M. with RN #354 confirmed the Resident #3's quarterly 12/13/23 MDS was incorrectly marked, since Resident #33 should have been marked as receiving oxygen.

Based on medical record review and staff interview the facility failed to ensure preadmission screening and record review assessments were resubmitted after a new major mental illness diagnosis was added for Resident #43. This affected one (Resident #43) of four residents reviewed for preadmission screening and resident review. The facility census was 53. Findings include: Review of Resident #43's medical record revealed an admitted [DATE] with diagnoses that included chronic obstructive pulmonary disease, hyperlipidemia, major depression and anxiety. A Preadmission Screening and Resident Review (PASARR) completed on 04/11/23 indicated Resident #43 had only anxiety. Upon admission to the facility, Resident #43 was prescribed Navane (antipsychotic medication) five milligrams (mg) twice daily which the resident was on long term prior to admission. Further review of the medical record, including psychiatrist evaluations, revealed the Navane was gradually reduced and discontinued on 06/06/23. Review of Resident #43's progress notes indicated the resident had a new onset of paranoid behaviors and was transferred and admitted directly to a geriatric in-patient psychiatric unit on 06/13/23. On 06/27/23 Resident #43 was readmitted to the facility with a new diagnosis of paranoid schizophrenia added. Review of hospital records revealed Resident #43 had a prior history of mental illness including schizophrenia with Navane use. On 06/22/24 the geriatric in-patient psychiatric hospital resubmitted a PASARR which indicated major depression with psychotic features. No evidence of schizophrenia was noted. No evidence of any new PASARR was submitted by the facility after readmission on 06/27/23 despite the new mental illness diagnosis of schizophrenia. On 01/17/24 at 10:48 A.M., interview with the Administrator verified no PASARR assessment was submitted following readmission with the identified new diagnosis of schizophrenia for Resident #43.

Based on observation, interviews, record review and facility policy, the facility failed to ensure oxygen tubing was changed weekly for Residents #33 and #51. This affected two residents (#33 and #51) of four residents reviewed for respiratory care. The facility census was 53. Findings include: 1. Review of the medical record for Resident #33 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD) with (acute) exacerbation and chronic respiratory failure. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #33 was cognitively intact. Review of Resident #33's physician orders revealed an order dated 11/18/22 for oxygen two liters via nasal cannula, may titrate as needed. Review of Resident #33's care plan dated 09/25/21 revealed the resident had an impaired respiratory status related to anxiety, being a current smoker, and having shortness of breath. Interventions included oxygen as ordered by the physician. Observation and interview on 01/16/24 at 10:37 A.M. with Respiratory Therapist (RT) #354 revealed Resident #33 oxygen tubing was dated 12/20. RT #354 confirmed, at the time of observation, the tubing had a date of 12/20 and the tubing should be changed weekly. RT #354 stated it was his first day on the job, and he was getting ready to change it out. Interview on 01/16/24 at 10:38 A.M. with Resident #33 confirmed the oxygen tubing was not changed weekly, but it was usually changed every other week. 2. Review of the medical record for Resident #51 revealed an admitted [DATE]. Diagnoses included unspecified diastolic (congestive) heart failure and chronic obstructive pulmonary disease (COPD) with (acute) exacerbation. Review of the 11/30/23 admission Minimum Data Set (MDS) revealed Resident #51 was cognitively intact and used oxygen. Review of Resident #51's physician orders revealed an order dated 11/28/23 to change oxygen tubing and set up every night shift every Tuesday and an order dated 01/17/24 for three liters oxygen via nasal cannula as needed, may titrate as needed. Review of care plan dated 11/29/23 revealed Resident #51 had impaired respiratory status related to congestive heart failure (CHF) and COPD with emphysema. Interventions included provide oxygen as needed when the resident exhibits signs/symptoms of difficulty breathing (short of breath, cyanosis, and low oxygen saturation levels). Observation and interview on 1/16/24 at 10:27 A.M. with Respiratory Therapist (RT) #354 revealed Resident #51's oxygen tubing was dated 12/20. RT #354 confirmed, at the time of observation, the tubing had a date of 12/20 and the tubing should be changed weekly. RT #354 stated it was his first day on the job, and he was getting ready to change it out. Interview on 1/17/24 at 10:29 A.M. with Resident #51 confirmed his oxygen tubing was not changed out weekly. Review of facility policy Departmental (Respiratory Therapy), revised November 2011 revealed oxygen tubing should be changed every seven days and dated.

Based on observation, medical record review, and interview the facility failed to monitor circulatory status of a resident who had an edematous (swollen) left foot and studies indicating a thrombus (blood clot). This affected one (Resident #97) of 17 residents observed for evidence of [CONDITION(S)]. Findings include: Observations on 02/01/22 at 8:38 A.M. and 11:06 A.M. and on 02/02/22 at 7:50 A.M. and 12:20 P.M. revealed Resident #97 sitting on the side of his bed with his legs dangling off the side of the bed and his feet on the floor. Review of Resident #97's medical record revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/30/21 an order was written for a venous ultrasound of the left lower extremity due to increased [CONDITION(S)]. Venous doppler results dated 12/31/21 indicated there appeared to be a thrombus (a blood clot formed in situ within the vascular system of the body and impeding blood flow) in the left gastrocnemius vein (The gastrocnemius vein is considered a deep muscular vein of the calf.) There was no evidence of circulatory assessments related to the thrombus. On 02/03/22 at 10:55 A.M., the Director of Nursing (DON) verified she was unable to locate any evidence of circulatory checks and stated she understood the concern of circulatory checks not being completed for a resident with a blood clot.

Based on observation, medical record review and staff interview the facility failed to ensure range of motion services were provided for residents identified with a limitation in joint mobility. This affected one (Resident #26) of two residents reviewed for range of motion services. The facility census was 46. Findings include: Review of Resident #26's medical record revealed an admitted [DATE] and a readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) 3.0 assessment with a reference date of 12/31/21 indicated Resident #26 had limitation in range of motion to both upper and lower extremities. Further review of the medical record including a hospice recertification completed on 12/31/21 indicated Resident #26 had contractures to the bilateral legs and hands. Further review of the medical record found no evidence of any splint device use or any restorative services for joint mobility. No documentation was found to indicate a reason for joint mobility services not provided. Interview with the Director of Nursing on 02/03/22 at 8:55 A.M. verified Resident #26 had limitation in joint mobility to bilateral hands and legs, does not receive any joint mobility services and there was no documentation to indicate a reason for not providing joint mobility services.

Based on medical record review and staff interview the facility failed to ensure monthly pharmacy reviews identified physician orders were not being followed regarding acetaminophen administration. This affected one (Resident #12) of five residents reviewed for monthly pharmacy reviews. The facility census was 46. Findings include: Review of Resident #12's medical record revealed an admitted [DATE] with diagnoses that included Alzheimer's disease with dementia, [CONDITION(S)] and [CONDITION(S)]. Review of the physician's orders revealed current orders for acetaminophen (analgesic) 650 milligram (mg) three times daily and [MEDICATION(S)] ([MEDICATION(S)] and acetaminophen analgesic) 5 mg - 325 mg four times daily. A total of 3250 mg of acetaminophen was administered daily. Review of the Medication Administration Record (MAR) revealed acetaminophen and [MEDICATION(S)] administered daily as ordered for a total of 3.25 gm of acetaminophen administered each day. An additional physician's order indicated to not exceed 3 grams (gm) of acetaminophen daily. Review of monthly pharmacy recommendations revealed no indication the acetaminophen dosage exceeding physician orders was identified by the reviewing pharmacist. Interview with the Director of Nursing on 02/02/22 at 1140 A.M. verified Resident #12 received 3.25 gm of acetaminophen on a daily basis and monthly pharmacy recommendations did not address the acetaminophen dosage exceeding physician orders.

Based on medical record review and staff interview the facility failed to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 46. Findings include: Review of Resident #12's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A total of 3250 mg of acetaminophen was administered daily. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An additional physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Director of Nursing on 02/02/22 at 8:40 A.M. verified Resident #12 received 3.25 gm of acetaminophen on a daily basis despite the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interviews, record review and facility policy review, the facility failed to notify Resident #3's legal guardian of changes in condition. This affected one (Resident #3) of four residents reviewed for change in condition. The facility census was 49. Findings include: Review of the medical record for Resident #3 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/2/21, revealed the resident had intact cognition with a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The resident exhibited no behaviors, was independent in all activities of daily living (ADL's), and was always continent of bowel and bladder. No skin impairment was identified. Review of the plan of care dated 04/29/21, revealed Resident #3 had impaired gastrointestinal (stomach and bowel) function related GERD, obesity, constipation, lactose intolerance, gastritis (inflammation of the stomach), occurrences of nausea, bloating, and indigestion. Further review of the care plan indicated the resident was purchasing snacks form the vending machine, ordered fast food, and drank iced tea and pop. A colonoscopy revealed abnormalities, and the resident was to have a [MEDICATION(S)] enema. The care plan also indicated Resident #3 would need a fluoroscopy (specific bowel test) due to a malrotation of the colon. The colon was noted to be in the right side of the abdomen, and the small bowel was noted to be in the left side of the abdomen. Interventions included arranging out of facility testing as ordered, completing procedure labs and instructions as ordered, medications as ordered, and encouraging resident to avoid foods that cause stomach discomfort including carbonated beverages, chocolate, and acidic, spicy, or fried foods. Review of the progress notes dated 03/01/21 at 6:28 A.M. revealed Resident #3 was transported to a local hospital for a colonoscopy (test for bowel function). On 03/01/21 at 9:44 A.M. the resident returned to the facility without complications. Both entries lacked documentation of the legal guardian being notified of the procedure. Interview on 10/07/21 at 11:48 A.M. with the Director of Nursing (DON) verified the lack of documentation regarding notifying Resident #3's guardian of the colonoscopy on 03/01/21. Interview on 10/07/21 at 1:10 P.M. with Human Resources (HR) #500 revealed from 04/2020 to 06/2021, HR #500 was working in medical records and was the scheduler. Although HR #500 stated Resident #3's guardian was notified of the colonoscopy via phone, it was verified there was no documented evidence of the conversation in the progress notes. Review of facility policy titled Change in a Resident's Condition or Status, revised December 2016, revealed the facility did not implement the policy regarding the allegation. This deficiency substantiates Complaint Number OH 080.

Based on resident, family and staff interviews, record review and policy review, the facility failed to provide sufficient staffing levels to consistently provide care and services to assure resident safety and meet the basic care needs of the residents. This affected 19 (Residents #1, #2, #6, #9, #10, #13, #17, #18, #20, #25, #26, #32, #33, #40, #56, #59, #60, #63, and #70) and had the potential to affect all 69 residents who resided in the facility. Findings include: 1. Review of the Resident Council meeting minutes from 03/28/18 through 04/24/19 revealed residents had numerous staffing related concerns over many months. A breakdown of the concerns by months is as follows: a). Residents had concerns about showers not being completed during the following months: 11/29/18 and 03/12/19. b). Residents identified concerns related to staffing and services provided by State tested Nurse Aides (STNA)'s during the following months: 05/30/18, 07/25/18, 10/31/18, 11/29/18, and 03/12/19. During the survey Resident Council meeting, held on 05/20/19 at 10:13 A.M., Residents #20, #33, and #59 verified the ongoing concerns and stated the correct department responded to their concerns, however the concerns did not seem to be resolved and continued to reoccur month to month. Interview with the Administrator on 05/21/19 at 1:54 P.M. revealed the Resident Council meeting minutes and concerns were discussed in the morning meeting following Resident Council, however the Administrator indicated she could not speak to the lack of communication between the Activity Director (who normally ran the Resident Council) and residents and staff. The Administrator also stated the facility was currently in process of trying to find a new Activity Director. 2. Interviews from 05/20/19 to 05/27/19. with Registered Nurse (RN) #73, Licensed Practical Nurses (LPN) #119, #127, #128, and STNAs #70, #77, #79, #80, #8, #91, #501, #502, and #503 revealed when asked about staffing, stated they felt the facility was often short staffed and found it very difficult to deliver adequate care to the residents because of the staffing levels. 3. Interviews on 05/20/19 and 05/21/19 with twelve alert and oriented residents (Resident #6, Resident #2, Resident #13, Resident #17, Resident #18, Resident #25, Resident #26, Resident #32, Resident #33, Resident #56, Resident #60, Resident #63, and Resident #70), indicated they thought the facility did not have enough nurses and aides. They stated they had to wait excessive amounts of time to have the call lights answered and/or receive care. 4. Interviews with Residents and/or Families (#17, #18, #26, #32, #60, and #70) during the screening portion of the survey from 05/19/19 at 10:56 A.M. to 05/20/19 at 9:23 A.M. yielded concerns including: a). The facility was short-handed with aides. b). There was no one to toilet or put them to bed on 05/18/19. c). At times there was one aide to one side of the building, and residents have had to wait up to 40 minutes to go to the bathroom. d). There were concerns related to residents having to stay in bed because there was not enough staff to get them up. e). There were concerns related to not being checked on during the night, and call lights were being left out of reach. f). Staffing at night was being referred to as horrible with complaints of waiting over a half hour to get help. 5. Confidential interviews with staff revealed they were fearful of reprisal including termination from the Administrator. Three RN's and five STNA's were interviewed between 05/10/19 at 6:10 A.M. and 05/28/19 at 2:17 P.M. all reported the facility did not provide enough personnel to be able to meet the resident's basic needs such as bathing. 6. On 05/23/19 at 1:00 P.M. review of the staffing tool, posted staffing information, staffing schedules and employee punch detail reports from 05/12/19 through 05/18/19 with the facility's Assistant Director of Nursing (ADON) with oversight by the Administrator revealed the facility failed to meet the minimum daily direct care requirement of 2.50 hours on 05/12/19, with a total of 2.43 hours. The ADON verified there was not sufficient staff on 05/12/19 to meet the minimum daily direct care requirement of 2.50 hours. 7. Interview with Resident #1 and Resident #63 on 05/28/19 at 1:30 P.M. and 1:45 P.M. reported they missed two smoke breaks on 05/27/19 because there were not enough staff to take them outside. 8. Confidential interviews, due to fear of reprisal, with 18 staff between 05/20/19 from 5:46 A.M. to 05/28/19 at 2:17 P.M. verified they felt there was not enough staff to provide care to the residents as evidenced by the following comments: a). Staff were not able to provide showers when only one aide and one nurse were scheduled on a side. They indicated with one aide, they were absolutely not able to provide care and respond to call lights/requests. b). There were a lot of call offs, and they were not replaced causing staff to be mandated to work beyond their scheduled shift. c). There was not enough staff to turn and reposition residents as needed. d). Showers were not always completed, and at times staff would provide bed baths instead of showers. e). Staff were not able to provide restorative services because of having to work as a STNA on the floor. Staff appeared nervous and some were tearful while being interviewed. 9. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the elopement risk assessment dated [DATE] indicated Resident #13 was at moderate risk for elopement. The note indicated Resident #13 was actively expressing a desire to leave the facility but was able to be re-directed at that time. She was placed on 15-minute checks for safety. The elopement risk assessment dated [DATE] identified her at high risk and on 01/23/19 she was identified at moderate risk for elopement. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated she was moderately cognitively impaired, and she displayed no [MEDICAL CONDITION] or behavioral symptoms. Review of the plan of care related to Resident #13 stated she was at risk for elopement/wandering. The plan of care indicated she had a history of [REDACTED]. The interventions included to attempt to distract her, offer pleasant diversions, structured activities, food, conversation, television and books; identify a pattern of wandering; monitor her location as needed; 30-minute safety checks and document the wandering behavior and attempted diversional interventions in the behavior log. Review of the social service note dated 07/25/18 at 10:54 A.M. indicated a meeting was held with the family regarding Resident #13's risk for elopement and possible consideration to have her transferred to a locked unit. The family refused the idea of a transfer and asked if 15-minute checks could continue and they would work with the facility in any way so long as the resident was not moved to a locked unit. It was noted the Director of Nursing agreed with 15-minute checks to visualize her safety at that time. Review of the nurse's progress note dated 07/30/18 at 4:35 P.M. Resident #13 was found outside the facility by another resident. The resident was placed on one to one observation for the remainder of the night. Review of the social service note dated 09/14/18 at 12:14 P.M. indicated another meeting was held with the family regarding falls and continuous exit seeking behavior. The family was educated regarding the need for a secured dementia unit. The family refused the idea of a transfer. It was noted educated was provided for immediate and 30-day discharge notices due to the concern of the resident's safety. Review of the nurses note dated 03/17/19 at 5:33 P.M. a resident witnessed Resident #13 exit the doors in her wheelchair and go down the sidewalk in front of the building. The resident alerted staff who brought her back into the facility. Review of the 03/17/19 investigation revealed there were three nurses and six STNA's on duty. There were statements obtained by three nurses and two STNA's. RN #75's statement indicated he went out to retrieve her and she had made it to the visitor parking lot. A head to toe assessment was completed, and she was found without injury. There was no investigation provided for the 07/30/18 incident. Interview with Resident #63 on 05/23/19 at 8:30 A.M. said she saw Resident #13 outside by the pond in (MONTH) 2019 and went and got help. She said she knew some residents who wander but should not get out of the facility but did not know all who could not be out unattended. She said she went inside and got staff immediately. Interview with LPN #122 on 05/23/19 at 9:32 A.M. verified she authored the 07/30/18 progress note when Resident #13 was found outside. She was not able to recall what resident found her and could not remember how long she was out of the facility unattended. She did say Resident #13 wanted to go outside all the time because that's what she loved to do. She verified she did not write a witness statement for the incident. Interview with the Administrator on 05/23/19 at 9:40 A.M. indicated they reached out to the family regarding an alternative locked facility, but they absolutely refused. She indicated several things were done such as monitoring for urinary tract infections and medication changes. She said that did not work so they re-approached the family and again they refused. She said they were in process of obtaining a Wanderguard system (departure alert system), but there were Federal hoops to go through. She said they had 15-minute checks in place when she left unattended on 07/30/19. She said the resident exit seeks when the daughter leaves and did not know how they could have prevented it. Interview with the family on 05/23/19 at 1:22 P.M. voiced being upset thinking the State wanted her mother out of the facility. It was explained to them facility was responsible to provide enough supervision to keep her safe. The Regional Nurse #600 interjected saying the facility would provide one to one supervision until the Wanderguard system could be installed. The family also offered a suggestion of when staff takes the smokers outside to take Resident #13 outside also. 10. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual comprehensive MDS 3.0 assessment dated [DATE] indicated she was alert, oriented and independent in daily decision-making ability. She did not have symptoms of [MEDICAL CONDITION] or behaviors. She received five days of restorative transfer services during the assessment period. Review of the plan of care initiated on 04/27/18 related to having impairment with self-transfer due to limited mobility and weakness indicated the interventions included a restorative active range of motion program to bilateral lower extremities six to seven days per week for 15 minutes and a restorative transfer program for six to seven days per week for 15 minutes. Review of the restorative quarterly review dated 04/29/19 indicated Resident #10 attended the therapy gym after breakfast. She was able to tolerate the current number of repetitions and the program would continue as outlined. Review of the restorative data records revealed Resident #10 was marked not applicable on 12 days in (MONTH) 2019, 15 days in (MONTH) 2019 plus one blank and 11 days in (MONTH) 2019 plus one blank. Interview with restorative STNA #77 on 05/28/19 at 2:05 P.M. indicated when she was not able to get restorative services completed when working on the unit she would mark not applicable. She verified restorative services were not always provided as planned. On 05/29/19 at 8:49 A.M. Resident #10 was seated in her wheelchair in the doorway of her room. She was very difficult to understand and drooled when she tried to speak. She indicated she received restorative services and the rest was unintelligible. 11. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive MDS 3.0 assessment dated [DATE] indicated she was alert, oriented and independent in daily decision-making ability. She had no symptoms of [MEDICAL CONDITION] or behaviors. She received five days of restorative active range of motion Review of the restorative assessment dated [DATE] indicated active range of motion to bilateral upper extremities six to seven days per week and ambulation six to seven days per week. Review of the restorative quarterly review dated 04/05/19 indicated she was compliant with bilateral upper extremity and bed exercises. The restorative program remained appropriate. Review of the plan of care related to restorative services initiated on 07/28/17 indicated she was at risk for decline in functional range of motion related to limited mobility, pain in her left shoulder and latent complexities of polio syndrome. The interventions included to provide active range of motion for bilateral upper extremities 15 minutes per day six to seven days per week. Review of restorative data revealed Resident #33 was marked as not applicable or was blanks for four days and marked as refusing service on four days in (MONTH) 2019. She was marked as not applicable for four days and had five blanks for (MONTH) 2019 and was marked as not applicable for five days, not available for one day and had 10 blanks for (MONTH) 2019. Interview with Resident #33 on 05/19/19 at 10:40 A.M. said the facility did not have enough staff to provide her restorative services. She said the restorative aide was being pulled to the floor as an STNA and couldn't provide service. Interview with the restorative STNA #77 on 05/28/19 at 2:05 P.M. indicated when she was not able to get restorative services completed when working on the unit she would mark not applicable. She verified restorative services were not always provided as planned. 12. Interview with Residents and/or Families (#6, #9, #13, #18, #25, #32, #33 and #70) between 05/19/19 at 10:40 A.M. and 05/20/19 at 9:25 A.M. voiced concerns they were not receiving showers as planned as evidence by: a). Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the significant change MDS 3.0 comprehensive assessment dated [DATE] and quarterly MDS 3.0 assessment dated [DATE] revealed she had moderate impairment in daily decision making. She required the extensive assistance of two plus persons for personal hygiene and total dependence of two plus persons. Review of the admission assessment dated [DATE] indicated her preference was a shower three times per week in the mornings on Monday, Wednesday and Friday. Review of the plan of care related to activities of daily living revealed Resident #25 required one staff participation with bathing and to provide her a sponge bath when a shower could not be tolerated. Review of the STNA documentation indicated she preferred a bath or shower every night. Review of the last 30 days of data revealed not applicable was documented on 14 days and refused was documented on one day. (04/26/19, 04/30/19, 05/01/19,05/02/19, 05/05/19, 05/06/19, 05/07/19, 05/09/19, 05/10/19, 05/11/19, 05/13/19, 05/16/19, 05/17/19, and 05/20/19). Review of the bathing activity record revealed she received one shower in (MONTH) 2019 (02/05/19) and seven showers in (MONTH) 2019 (03/01/19, 03/04/19, 03/08/19, 03/11/19, 03/13/19, 03/15/19 and 03/26/19). Interview with Resident #25's family on 05/19/19 at 12:45 P.M. indicated there was not enough staff to provide the care. She said residents were often wet when she visited. b). Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual comprehensive MDS 3.0 assessment dated [DATE] and review of the quarterly MDS 3.0 assessment dated [DATE] indicated she was alert, oriented and independent in daily decision-making ability. She displayed no [MEDICAL CONDITION] or behavioral symptoms. Choice in what to wear, taking care of personal belongings, the type of bathing and going outside to get fresh air was very important to her. She required physical help for bathing. Review of the admission assessment dated [DATE] indicated her preferences prior to coming to the facility was daily showers in the morning. She indicated she would like to receive three showers per week at the facility on Monday, Wednesday and Friday. Review of the activity of daily living plan of care indicated Resident #33 required assistance with bathing/showering and as necessary would be provided a sponge bath when a shower could not be tolerated. Review of the bathing activity record revealed she refused on 03/04/19 but received seven showers in (MONTH) 2019, six showers in (MONTH) 2019 and three showers in (MONTH) 2019. Review of the STNA documentation revealed she was scheduled for showers on Mondays, Wednesdays and Fridays in the morning. Review of the data for the last 30 days revealed she received three showers on 04/30/19, 05/02/19 and 05/22/19 and should have received 12. Interview with Resident #33 on 05/19/19 at 10:40 A.M. said she had had only one shower in the last week and she was supposed to get a shower on Monday, Wednesday and Friday. c). Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual comprehensive MDS 3.0 assessment dated [DATE] indicated she was alert, oriented and independent in daily decision-making ability. She had no symptoms of [MEDICAL CONDITION] or behaviors. It was very important to her to choose her clothing, care for personal belongings, choose the type of bath, choose own bedtime. She required the supervision of one-person physical assistance for personal hygiene and bathing. Review of the admission assessment dated [DATE] indicated her preferences were daily showers prior to admission but indicated she would like to receive three showers per week in the morning on Sunday, Monday and Wednesday. Review of the shower documentation provided by the facility indicated she preferred morning showers Mondays, Wednesdays and Fridays. Review of the documentation revealed in the last 30 days she received eight showers on 04/23/19, 04/27/19, 04/28/19, 05/02/19, 05/13/19, 05/15/19, 05/19/19 and 05/22/19 out of the 13 she should have been provided. Review of the bathing activity records for (MONTH) 2019 indicated she was provided six of 13 showers and for (MONTH) 2019 she was provided four of 13 showers scheduled. Interview with Resident #40 and her daughter on 05/22/19 from 12:00 P.M. to 1:15 P.M. voiced concerns that she was not receiving her scheduled showers because there was not enough staff. The resident said there was a bath aide, but she was often called to the floor to work. She said she had only received two showers since surgery and one was because her son requested she receive one. He returned in an hour to confirm it. d). Review of the medical record revealed Resident #70 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS 3.0 dated 05/07/19 indicated she was alert, oriented and independent in daily decision making. She displayed no indicators of [MEDICAL CONDITION]. She displayed verbal behaviors directed toward others on one to three days of the seven-day assessment reference period. She required the physical assistance of one person for bathing. Review of the activity of daily living plan of care revealed she required the assistance of staff for bathing and toileting. Review of the admission assessment indicated she preferred a tub bath every other day and she received three in the last 30 days (05/03/19, 05/07/19 and 05/17/19). Review of the activity of daily living plan of care indicated she required the assistance of staff for bathing and toileting Interview with Resident #70 on 05/19/19 at 11:24 A.M. said she had been wet all night and was not able to reach her call light. She said she needed attention, and no one was helping her. She said she had not received a bath since before her surgery. Interview with RN #88 and STNA #85 on 05/19/19 at 11:30 A.M. verified Resident #70's incontinence brief was heavily soiled with urine. e). Resident #18 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #18's (MONTH) 2019 physician orders [REDACTED]. Resident #18's medical record revealed a five-day admission MDS 3.0 assessment, with an Assessment Reference Date (ARD) of 04/17/19, which revealed Resident #18 to be cognitively intact. The admission MDS also revealed Resident #18 to required extensive assist of two people for transfers, extensive assist of one person for personal hygiene, and was independent with bathing once in the tub. Resident #18's medical record revealed a preference for bed baths and showers during the evenings on Monday, Wednesday, and Fridays. Further medical record review revealed Resident #18 received a shower or bed bath on the following ten dates: 03/17/19 at 3:28 A.M., 04/03/19 at 1:49 A.M., 04/16/19 at 8:49 P.M., 04/21/19 at 1:05 A.M., 04/27/19 at 7:36 P.M., 05/06/19 at 1:04 A.M., 05/10/19 at 7:22 P.M., 05/12/19 at 9:16 P.M., 05/14/19 at 12:27 A.M., and 05/16/19 at 2:45 A.M. Resident #18's medical record revealed Resident #18 with refused a shower/ bed bath, a shower/ bed bath was not available, or a shower/ bed bath was not applicable on the following 33 dates: 03/15/19 at 12:07 A.M., 03/18/19 at 11:45 P.M., 03/24/19 at 12:49 A.M., 03/25/19 at 11:50 P.M., 03/27/19 at 10:39 P.M., 03/28/19 at 8:16 P.M., 03/29/19 at 11:34 P.M., 03/31/19 at 10:08 P.M., 04/02/09 at 2:56 A.M., 04/04/19 at 7:06 P.M., 04/05/19 at 11:29 P.M., 04/06/19 at 11:41 P.M., 04/07/19 at 9:05 P.M., 04/08/19 at 10:03 P.M., 04/09/19 at 9:44 P.M., 04/11/19 at 12:55 A.M., 04/12/19 at 8:34 P.M., 04/14/19 at 1:05 A.M., 04/15/19 at 1:37 A.M., 04/18/19 at 3:59 A.M., 04/22/19 at 10:38 P.M., 04/23/19 at 11:10 P.M., 04/24/19 at 2:36 A.M., 04/26/19 at 9:24 P.M., 04/29/19 at 10:59 P.M., 05/02/19 at 2:40 A.M., 05/03/19 at 5:59 A.M., 05/04/19 at 3:51 A.M., 05/05/19 at 3:03 A.M., 05/07/19 at 2:28 A.M., 05/08/19 at 8:45 P.M., 05/18/19 at 1:48 A.M., and 05/20/19 at 5:48 A.M. Interview with Resident #18 on 05/20/19 at 09:25 A.M. revealed Resident #18 stated she is supposed to receive showers three days a week, and she does not get them. Resident #18 further stated she must go out to [MEDICAL TREATMENT] and appointments, and she had refused in the past, however she was concerned she does require more showers than she received. Staff interview with STNA #501 on 05/20/19 at 6:10 A.M. revealed STNA #501 had worked with only one STNA on each unit. STNA #501 stated when only one STNA was staffed on each unit, showers were unable to be completed secondary to the need to be able to supervise other residents and to respond to call lights. Staff interview with STNA #502 on 05/20/19 at 6:28 A.M. revealed STNA #502 had also worked with only one STNA on each unit. STNA #502 stated secondary to resident's needs, it was impossible to get everything done. STNA #502 also stated the ability to give resident showers when one STNA was working was dependent on the nurse working as some of the nurses did not help or answer call lights so showers could not be given because there would be nobody to answer the needs of the other residents. Staff interview with STNA #503 on 05/20/19 at 2:37 P.M. revealed the facility had two STNA's identified as specific shower STNA's who worked Monday through Friday, however due to low staffing, the two shower STNA's usually worked on the units and were not able to complete showers. During staff interview on 05/21/19 at 12:15 P.M., the Director of Nursing (DON) verified Resident #18 had received only ten showers or bed baths out of 43 opportunities from 03/15/19 through 05/20/19 per computer documentation. f). Resident #32 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #32's medical record revealed a quarterly MDS assessment with an ARD of 04/05/19 which indicated Resident #32 had intact cognition, required total dependence of two people for transfers, extensive assistance of two people for hygiene, and was dependent for bathing. Resident #32's ADL plan of care dated 01/31/15 and preferences plan of care dated 01/22/16 stated Resident #32 required a mechanical lift with transfers and would prefer a sponge bath when a full bath or shower could not be tolerated, and her following morning routine preference upon rising was to shower, get dressed, and have breakfast. Resident #32's medical record revealed under the STNA task section for Resident #32 to receive a bath as necessary and her scheduled bathing preference was daily showers. Further review of Resident #32's medical record revealed Resident #32 received a shower or tub bath on the following 12 dates: 04/21/19 at 3:11 P.M., 04/22/19 at 7:28 A.M., 04/24/19 at 9:17 A.M., 04/27/19 at 8:30 A.M., 04/30/19 at 8:38 A.M., 05/02/19 at 11:02 A.M., 05/08/19 at 3:27 P.M., 05/10/19 at 11:53 A.M., 05/12/19 at 8:07 A.M., 05/13/19 at 11:30 A.M., 05/15/19 at 4:40 P.M., and 05/19/19 at 1:29 P.M. Resident #32's medical record revealed Resident #32 with her shower or bed bath either listed as not applicable, refused, or with nothing listed on the following 18 dates: 04/23/19 at 11:13 A.M., 04/25/19 at 5:35 P.M., 04/26/19, 04/28/19 at 7:26 A.M., 04/29/19 at 9:36 A.M., 05/01/19 at 2:58 P.M., 05/03/19, 05/04/19 at 6:42 A.M., 05/05/19 at 11:10 A.M., 05/06/19, 05/07/19 at 3:18 P.M., 05/09/19 at 2:16 P.M., 05/11/19 at 3:18 P.M., 05/14/19 at 3:21 P.M., 05/16/19, 05/17/19, 05/18/19 at 1:26 P.M., and 05/20/19 at 11:33 A.M. Interview with Resident #32 on 05/20/19 at 8:43 A.M. revealed she was supposed to get a shower every day, and it did not happen. Resident #32 further stated the reason she required daily showers was because she had urinary problems, and sweats heavily at night. Resident #32 also stated she had gone to physician and other appointments outside of the facility where she had attempted to mask her body odor with perfume, however stated this just made the smell worse. Staff interview with STNA #501 on 05/20/19 at 6:10 A.M. revealed STNA #501 had worked with only one STNA on each unit. STNA #501 stated when only one STNA was staffed on each unit, showers were unable to be completed secondary to the need to be able to supervise other residents and to respond to call lights. Staff interview with STNA #502 on 05/20/19 at 6:28 A.M. revealed STNA #502 had also worked with only one STNA on each unit. STNA #502 stated secondary to resident's needs, it was impossible to get everything done. STNA #502 also stated the ability to give resident showers when one STNA was working was dependent on the nurse working as some of the nurses did not help or answer call lights so showers could not be given because there would be nobody to answer the needs of the other residents. Staff interview with STNA #503 on 05/20/19 at 2:37 P.M. revealed the facility had two STNA's identified as specific shower STNA's who worked Monday through Friday, however due to low staffing, the two shower STNA's usually worked on the units and were not able to complete showers. During staff interview on 05/21/19 at 12:15 P.M., the DON verified Resident #32 had received only 12 showers or bed baths out of 30 opportunities from 04/21/19 through 05/20/19 per computer documentation.

Based on observation, interview and document review, the facility failed to ensure resident's food preferences were accommodated and appealing substitutions of similar nutritive value were provided to all 67 residents receiving food from the kitchen. Findings include: On 05/19/19 at 11:49 A.M. the main dining room was observed for the lunch meal. Each table had a caddy in the center with a laminated card identifying the always available items. The items were listed as pizza, hamburger/cheeseburger, hot dog cottage cheese and fruit plate, grilled cheese, peanut butter and jelly, deli sandwich and side salad. The laminated cart had pictures of pizza and a cheeseburger and also a note at the bottom indicating to see the menu board for the daily alternative. The lunch meal on 05/19/19 consisted of roast beef, mashed potatoes with gravy, carrots and apple crisp. A couple of residents requested a cheeseburger and another requested a cottage cheese plate. There was no other daily alternative observed. Observation of the menu board on 05/19/19 lacked indication of an alternative. Interview with Resident #60's family on 05/19/19 at 1:00 P.M. reported her beverage of choice was ginger ale. He said she was receiving it regularly but was told now she could only get ginger ale if she was sick. He said she did not drink much water but staff only pass ice water once in a while. Interview with Resident #40 and her daughter on 05/22/19 at 12:00 P.M. reported all of the meals were high in carbohydrates. She had diabetes and had to order other stuff. She said if she asked for a salad, she was told it was not on the menu and she could not get one as a meal. She did say she could get a small side salad that came in a small bowl. She felt salad as a meal was a better choice then a hamburger, hot dog or their regular meals with all of the gravy and carbohydrates. They said they were informed that salad was limited by the State because of budget cuts. She said she would request vegetables, but often they were out or they were overcooked. The resident said the kitchen puts gravy on everything and felt the facility should offer a chef salad every day with egg. They were also upset the facility limited snacks between meals. They provided a copy of a letter sent out indicating effective 05/01/19 the dietary department would no longer be providing snacks in between meals. The letter indicated each resident received a money stipend as determined by the Department of Job and Family Services. This money was to be used to purchase snacks, cigarettes or personal care items that you prefer over what was issued by the facility. Please note there will continue to be a snack cart provided during the evening hours with a selection of items that were diet appropriate. Please do not ask a State tested Nurse Aide (STNA) or dietary staff member for snack food items as they will no longer be provided between meals. Interview with Resident #63 on 05/19/19 at 3:39 P.M. said she was upset they took the chef salad and other items off the menu. She said she did not like the regular menu items and was relying on snacks. She said she preferred to choose a chef salad as a meal as a healthy choice. She said she had gone to Resident Council in the past but nothing was ever resolved. She indicated if you wanted a snack between meals you would have to pay for it. Interview with Resident #12 on 05/28/19 said the menu's were nasty and all carbohydrates. She said she used to order a chef salad at lunch and dinner but they took it away and she could not have it anymore. Interview with Dietary Manager #112 on 05/21/19 at 10:37 A.M. verified pizza was taken off the always available menu. She said chef salads were not on the anytime menu but residents routinely ordered them. She said they were now part of the menu being service one time per month and residents could no longer get one for a meal, the same as a pizza. She verified the residents were upset with the changes. She said if they wanted a salad as a meal they could only get a small bowl side salad. She indicated the Administrator informed her of the changes and it was due to the budget. She also indicated she did not want to get into trouble for saying this. She confirmed the anytime menu currently posted at each table listed pizza at the top of the list. On 05/21/19 at 1:00 P.M. the Administrator and Dietary Manager #112 approached the survey team. The Administrator had the Dietary Manager recant the information she had provided related to budget cuts. The Administrator reported their were not budget cuts in dietary in the last three years and dietary was always over budget. She reported the pizza was taken off the anytime menu because some residents were only requesting pizza for lunch and dinner. She said removing it from the menu was in hopes they would make healthier choices. She said a chef salad was never on the anytime menu but acknowledged residents were requesting them. She said again it was not allowed so residents would make better choices. She said as far as substitutions were concerned left overs were available as were items from the anytime menu which included hamburgers and hot dogs. Interview with Registered Dietitian (RD) #111 on 05/22/19 at 2:06 P.M. said he was in the facility one day per week. He indicated a diabetic diet the facility followed was a low concentrated sweets diet. Dietary had a form listing the substitutes and allowances to provide for diabetics. He said alternates and preferences were to be followed because excessive carbohydrates would increase blood sugar levels. He said they should avoid cakes, cookies and ice cream. He said if they were served items they felt were inappropriate they could choose a hamburger, fruit, salads and vegetables. He said he often heard complaints of the taste of the food because it was not what they were used to at home. He said when he visited weekly he completed food rounds. RD #111 said he was unaware chef salads were not available to the residents. He was aware that several residents enjoyed them. He said if the residents wanted chef salads it should be an option for them. He also indicated pizza should be allowed as an option. He said he was not made aware these items were no longer available to the residents. Further interview with RD #111 on 05/28/19 at 11:25 A.M. regarding the letter that was sent to residents and families regarding snacks. He said the Regional Dietitian had sent out the letter. He was not involved or aware. He said he believed each resident was provided two beverages per meal but agreed they were provided more if they wanted it. He said he understood that residents were not eating the main meal and taking extra snack food items. He said he thought it was a budget issue. He confirmed he was not consulted. He said he had to speak with residents about their weight gains and offer education and hope they would follow his advice. He was asked about similar nutritive meals being offered. He said the always available list was the nutritive alternate. Confidential interviews with staff who were fearful of retaliation between 05/20/19 at 6:28 A.M. and 05/28/19 at 12:45 P.M. indicated residents were no longer permitted to have pizza, chef salad and no longer permitted to have ginger ale unless they were vomiting. There were also limits on fluids. On 05/29/19 at 11:00 A.M. STNA #503 was observed to come to the kitchen to request a nutritional supplement for Resident #13 per the daughter's request. Dietary Manager #112 said no because the supplement was ordered with breakfast, lunch and dinner. STNA #503 appeared frustrated. The surveyor intervened and asked if someone wanted a beverage between meals what could she have. She then offered a milk to be taken to the resident. Review of the medical record revealed she was ordered Ensure Plus three times a day. There was no specific order for it to be provided at meals. Review of Resident Council minutes since (MONTH) (YEAR) revealed residents complained about food during the following meetings on 03/12/19, 02/27/19, 11/29/18, 09/26/18, 07/25/18 and 06/28/18. Review of the Food Committee minutes since (MONTH) (YEAR) revealed in (MONTH) (YEAR) (no date listed) residents wanted more toppings for salads and fresh fruit for desserts, on 08/30/18 they did not want soup and sandwich every day, on 10/30/18 they asked for better ingredients in their salad, on 12/27/18 the residents would like different choices for the always available menu, on 02/27/19 they wanted more homemade Jello, fresh fruit and salad choices. The residents were notified the always available menus were changing to tossed salad, baked potato, soup of the day, chicken or ham salad, which would be alternated through the week, on 03/28/19 requesting more fruit on the snack cart and on 04/25/19 changes to selective menus were discussed. Review of the four week menu cycle revealed a chef salad was offered once during week one and cheese pizza was offered once during week four.

Based on observation, staff interview and policy review, the facility failed to prevent cross contamination in the kitchen. This had the potential to affect all 67 residents. Findings include: On 05/21/19 beginning at 10:25 A.M. the puree process was observed for the lunch meal. Cook #136 was observed using gloved hands to remove three livers that were soaking in a milk bath, dip them into a flour mixture and place them on the flat top grill. Cook #136 positioned the coated livers using tongs which knocked off the coating from the gloves. She squeezed liquid butter onto the grill and used her soiled gloved hand to add onion rings onto the butter to saute. Cook #136 used tongs to turn and flip the livers then placed one liver onto a white dinner plate and put a probe thermometer into the liver to measure the temperature. Blood was observed coming from the liver onto the white plate. Cook #136 returned the liver to the grill and continued to cook them and the onion. After a period of time she placed all three cooked livers onto the bloody plate and measured the temperature. These three livers were placed into the food processor to puree by Dietary Manager (DM) #112. Cook #136 then put the same soiled gloved hands into oven mitts to pull a pan of cooked green beans from the oven with DM #112 overlooking. DM #112 acknowledged problems with infection control during the observation and indicated she would provide training. Review of the handwashing/hand hygiene policy and procedure revised in (MONTH) (YEAR) indicated to wash hands with soap and water when visibly soiled.

Based on record review, review of Quality Assurance Performance Improvement (QAPI) plan, and interview, the facility failed to implement and revise quality improvement projects to address residents' concerns regarding failure of staff to provide showers. This had the potential to affect all 69 residents. Findings include: During the annual survey, review of records, review of resident council minutes, interviews and policy review, the facility failed to provide showers for nine (Resident's #9, #13, #18, #25, #28, #32, #33, #40 and #70) of ten residents reviewed for activities of daily living. Review of the facility's QAPI plan, reviewed 02/01/19, revealed QAPI activities would cross service areas and departments and members would work together to assure all concerns were addressed and the team would strive to continuously improve the provided services. When a need was identified, corrective actions plans or performance improvement projects would be implemented to improve processes, systems, outcomes and satisfaction. During an interview with the Administrator on 05/29/19 at 12:33 P.M., she stated one of the concerns identified for which an action plan was developed was shower concerns which were identified in (MONTH) (YEAR). The facility had two shower aides, one who worked each side, when the concern was identified. The QAPI plan involved placing the two shower aides together to provide showers as a team. The prior Director of Nursing (DON) and State tested Nursing Assistant (STNA) supervisor were responsible for oversight of the program. The prior DON terminated employment with the facility 05/03/19 and it was determined the plan to pair up the shower aides was unsuccessful in ensuring residents were receiving showers as scheduled so the facility reverted back to having a shower aide for each side of the facility, making no other changes.

Based on review of Resident Council meeting minutes, interviews and policy review, the facility failed to provide timely responses and resolutions to all Resident Council concerns. Of the 14 months of Resident Council meeting minutes reviewed, concerns regarding cleanliness of the facility were identified six times, food concerns were identified six times, ice and water availability concerns were identified three times, staffing concerns were identified three times, laundry not being available was identified two times, and concerns regarding the outside environment were identified two times. This had the potential to affect all 69 residents residing in the facility. Findings include: Review of the Resident Council meeting minutes from 03/28/18 through 04/24/19 revealed residents had numerous repetitive concerns over many months. A breakdown of the concerns by months are as follows: Residents had concerns about the cleanliness of the facility during the following months: 05/30/18, 07/25/18, 08/29/18, 09/26/18, 11/29/18, and 03/12/19. Residents had concerns about food including timeliness and variety during the following months: 06/28/18, 07/25/18, 09/26/18, 11/29/18, 02/27/19, and 03/12/19. Residents had concerns about ice and water not being passed enough during the following months: 05/30/18, 10/31/18, and 11/29/18. Residents had concerns about consistency and availability of staff during the following months: 05/30/18, 07/25/18, and 03/12/19. Residents had concerns about showers not being completed during the following months: 11/29/18 and 03/12/19. Residents had concerns about laundry not being returned during the following months: 07/25/18 and 11/29/18. Residents had concerns about the outside environment during the following months: 06/28/18 and 09/26/18. Further review of Resident Council minutes revealed the Council was displeased with the minutes from the previous month on 11/29/18, and it was not documented whether residents were pleased or not during the months of 07/17/18, 09/26/18, and 12/26/18. The Resident Council minutes also had concern forms generated for each concern which was given to the appropriate department, and the form stated it needed to be returned within three days. Of the 22 generated forms, only five were dated when completed and of these five, only three were completed within three days. None of the forms were dated as to when the information was conveyed to the Resident Council. During the survey Resident Council meeting, held on 05/20/19 at 10:13 A.M., Residents #20, #33, and #59 verified the ongoing concerns and stated the correct department responded to their concerns, however the concerns did not seem to be resolved and continued to reoccur month to month. Review of the facility policy titled, Resident Council, revised (MONTH) (YEAR), does not address a time for response of Resident Council concerns back to the Resident Council. Interview with the Administrator on 05/21/19 at 1:54 P.M. revealed the Resident Council meeting minutes and concerns are discussed in the morning meeting following Resident Council, however the Administrator indicated she could not speak to the lack of communication between the Activity Director (who normally runs the Resident Council) and residents and staff. The Administrator verified the Resident Council concern forms were not dated upon return or upon conveyance to residents and stated the facility was currently in process of trying to find a new Activity Director.

Based on observation, record review and interview the facility failed to ensure ongoing comprehensive assessments of Resident #73's coccyx pressure ulcer were completed to promptly identify a change in the condition of the ulcer. The facility failed to promptly identify and prevent the development of a pressure ulcer on Resident #73's left posterior thigh, until it was assessed to be unstageable Actual harm occurred when on 01/31/17 Resident #73's coccyx pressure ulcer was assessed to have declined to an unstageable pressure ulcer and the resident was assessed to have developed a new unstageable pressure ulcer to the left posterior thigh, from her urinary catheter leg bag. The facility also failed to ensure a timely, comprehensive assessment for Resident #75's facility acquired right heel pressure ulcer. This affected two residents (Resident #73 and #75) of three residents reviewed for pressure ulcers. Findings include: 1. Record review Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #73 had a Brief Interview of Mental Status (BIMS) score of 15 reflecting the resident had no cognitive impairment. The assessment revealed Resident #73 required extensive assistance of two persons for bed mobility, dressing and toilet use and was totally dependent for transfers. The MDS 3.0 assessment indicated Resident #73 was continent of urine by way of a suprapubic urinary catheter and was always incontinent of bowel. Record review revealed the resident was hospitalized from [DATE] until 10/06/16 at which time she was readmitted to the facility. A re-admission skin assessment, dated 10/06/16 revealed Resident #73 was readmitted to the facility with a Stage II pressure ulcer to her coccyx that measured 0.1 centimeters (cm) in length by 0.1 cm width with a depth of 0.1 cm. A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissues. A Stage II pressure ulcer is defined as a partial thickness skin loss presenting as a shallow open ulcer with a red/pink wound bed. A physician's orders [REDACTED]. A plan of care (initiated on 10/12/16) identified the pressure ulcer upon hospital readmission. Interventions included: to assess/record/monitor would healing weekly or as needed, including length, width and depth, (when possible) and to document status of the wound perimeter, wound bed and healing progress. A physician's orders [REDACTED]. Alginate dressings are used to drain wet wounds. Alginate dressings are dry when applied on or into a wound, and can absorb up to twenty times their weight. Record review revealed the treatment was changed on 01/11/17 with a new order to clean Resident #73's coccyx wound with normal saline solution, pat dry, pack with silver alginate rope and cover with a DCD, three times per week, and as needed. Silver is used as an anti-microbial and is used to prevent or manage wound infections. Silver Alginate in rope form is used pack deep wounds. Review of weekly wound documentation revealed no evidence the ulcer was assessed between 11/30/16 until 01/13/17. Weekly wound documentation from 01/31/17 revealed Resident #73's coccyx wound had declined as evidenced by a measurement of 1.4 cm in length by 1.0 cm width with an undetermined depth, thereby rendering the wound unstageable. The assessment indicated the wound bed was covered with 100% biofilm. The weekly wound assessment revealed the peri wound area (defined as 4.0 cm surrounding the wound) had macerated wound edges. Maceration is the softening and breaking down of the skin caused by excessive amounts of fluid remaining in contact with the skin or the surface of a wound for extended periods. A physician's orders [REDACTED]. Medi-honey is medical grade honey used for the management of hard to heal wounds. [MEDICATION NAME] is a padded foam dressing. The weekly wound documentation of 01/31/17 also identified a second unstageable pressure ulcer to Resident #73's left upper (posterior) thigh that measured 0.5 cm in length by 0.4 cm width with an undetermined depth. The left thigh wound was described as 60% [MEDICATION NAME] and 40% crust (eschar). Eschar is described as thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue that has lost its usual physical properties and biological activity. Weekly wound documentation dated 03/21/17 revealed Resident #73's coccyx pressure ulcer was assessed to be a Stage IV pressure ulcer. A Stage IV pressure ulcer is defined as a full thickness tissue loss with exposed bone, tendon or muscle. The wound measured 1.9 cm in length by 1.5 cm width with a depth of 0.6 cm. The wound bed was described at 10% granulation tissue and 90% slough and large serosanguineous exudate. Slough is necrotic (dead) tissue in the process of separating from the viable portions of the body. The documentation revealed the peri-wound with moisture associated skin [MEDICAL CONDITION]. The weekly wound documentation dated 03/21/17 was silent to the resident's left upper posterior thigh wound. During an interview on 03/21/17 at 3:03 P.M., the Administrator and Corporate Quality Assurance Nurse/Registered Nurse (RN) #52, revealed Resident #73 had refused the weekly wound assessment on 12/07/16. The Administrator and RN #52 verified Resident #73's coccyx wound had not been assessed, including measurements and description of the wound from 11/30/16 until 01/31/17 when the wound was found to be unstageable during a skin sweep. The Administrator and RN #52 acknowledged the facility's wound nurse, (who was no longer employed by the facility), should have resumed weekly wound assessments subsequent to the refusal on 12/07/16. The Administrator and RN #52 verified the skin sweep on 01/31/17 also identified an unstageable, facility acquired pressure ulcer on Resident #73's left posterior thigh. On 03/22/17 beginning at 7:24 A.M., Licensed Practical Nurse (LPN) #58 was observed providing wound care for Resident #73. LPN #58 removed the intact dressing and packing to Resident #73's coccyx wound. Both the dressing and packing were noted to be saturated with a pale pink exudate, revealing a deep, Stage IV pressure ulcer. LPN #58 confirmed the wound had been measured the previous day at 1.9 cm in length by 1.5 cm width with a depth of 0.6 cm. LPN #58 packed the wound and reapplied the dressing, as per order. A dressing was intact to Resident #73's left posterior thigh. LPN #58 indicated the left thigh wound was healed, and the dressing was in place only to pad and protect the remaining scar tissue. LPN #58 removed the dressing, which revealed a moderate amount of yellowish exudate. Upon further inspection, LPN #58 verified the wound had re-opened and was seeping. She described the wound as pin-point in size. LPN #58 revealed the thigh ulcer was originally caused by pressure caused by Resident #73's urinary catheter leg bag. 2. Resident #75 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS 3.0 assessment, dated 01/14/17 indicated Resident #75 had a Brief Interview for Mental Status (BIMS) of 14 indicating no cognitive impairment. The current skin impairment plan of care included an intervention to address any identified areas of impaired skin integrity and to notify physician/wound care specialty of any wounds/skin healing issues accordingly and to monitor/document location, size and treatment. A nursing progress note, dated 01/19/17 at 8:17 A.M., revealed Resident #75 complained of right heel discomfort. The nurse indicated she removed Resident #75's sock and observed, dry cracked skin encompassing the majority of the heel. The nurse indicated she notified the wound nurse to inspect the heel. A nursing progress note, dated 1/20/17 at 06:31 A.M. revealed Resident #75 had a right heel open area that measured 1.5 cm in length by 3.0 cm width with no depth measurement documented. No description of the wound bed was included in this documentation. Weekly Wound Documentation dated 01/24/17 identified an acquired right heel wound that measured 4.0 cm by 4.5 cm by 0.1 cm. The wound bed was described as 100% red in color and the peri-wound with loose skin. The assessment indicated a moderate amount of serosanguineous exudate noted. The nurse documented the wound had a foul odor present, which resolved after cleansing. The assessment revealed the peri wound area (4 cm around the wound) was red in color and mushy. Deep tissue injury may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to the adjacent tissue. Weekly Wound Documentation dated 03/14/17 (last assessment prior to resident's discharge to the hospital) revealed the right heel pressure ulcer had advanced to Stage III, measuring 1.2 cm by 1.0 cm by 0.2 cm. A Stage III pressure ulcer is described as a full thickness tissue loss. The wound was described as 60% granulation tissue, and 40 % slough. A nursing progress note, dated 03/14/17 at 11:55 P.M., indicated Resident #75 had been admitted to the intensive care unit at the local hospital. Resident #75 had not returned to the facility at the time of the complaint investigation. During an interview on 03/21/17 at 12:01 P.M., the Administrator and RN #52 verified there was no documentation for the wound discovered on 01/19/17, (which included complete measurements and full description of the wound) until 01/24/17. The facility's policy and procedure entitled Prevention of Pressure Ulcers was revised 09/13. The policy indicated the facility should have a system/procedure to assure assessments are timely, appropriate and changes in condition are recognized and evaluated. This deficiency substantiates Complaint Number OH 060. This deficiency is also an example of continued non-compliance from the survey dated 02/09/17 and 01/19/17.

Based on medical record review, staff interview, observation and policy review, the facility failed to ensure pressure ulcer prevention measures were in place and pressure ulcers were assessed, monitored and treated. This affected three of four residents reviewed for pressure ulcers of six residents identified in the facility with pressure ulcers (Resident's #11, #24 and #51). Actual Harm occurred when Resident #24 obtained pressure ulcers including a Stage III ulcer on the left buttock and a deep tissue injury on the right buttock when prevention measures were not put in place for a resident at high risk for pressure ulcers. Once the pressure ulcers developed, positioning and further pressure reduction measures were not put in place for four days. The physician was not notified of the pressure ulcer for treatment orders for five days. A Stage III is a full thickness tissue loss in which subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed; slough (necrotic/vascular tissue in the process of separating from the viable portions of the body usually yellow to white and may be stringy or thick and may appear as a layer over the wound bed) may be present but does not obscure the depth of tissue loss and may include undermining and tunneling. A deep tissue injury is a pressure related injury to subcutaneous tissues under intact skin presenting as a non-blanchable deep red, maroon or purple discoloration. Findings include: 1. Resident #24 was admitted [DATE] with [DIAGNOSES REDACTED]. Resident #24 was readmitted [DATE] post hospitalization for a urinary tract infection, pneumonia, dysphasia (difficulty swallowing),[MEDICAL CONDITION] and the insertion of a gastrostomy tube (GT), a tube inserted into the stomach through the abdominal wall for nutrition and/or the administration of medications. Review of the 01/12/17 significant change Minimum Data Set (MDS) 3.0 assessment revealed Resident #24 was moderately impaired cognitively for daily decision making, needed extensive assistance of two staff for bed mobility and transfers, was frequently incontinent of urine and always incontinent of bowel. Resident #24 was identified to be at risk for the development of pressure ulcers but had no current pressure ulcers. This significant change assessment was completed in part due to a significant weight loss. Resident #24 went to the hospital and was readmitted on [DATE]. The readmission skin assessment revealed Resident #24 returned to the facility with skin alterations including pressure ulcers and reddened buttocks. There was a 4.5 centimeter (cm) by 3.0 cm blister to the left heel, a 6.0 cm by 4.0 cm blister to the right heel and a 1.4 cm by 1.0 cm open area to the coccyx. There was no evidence a comprehensive assessment of these pressure ulcers was completed upon readmission including identification of the stage, depth measurement for the coccyx ulcer, wound base description, the presence of granulation tissue (pink or beefy red tissue), the presence of eschar/necrotic tissue (dead tissue, gray to black and dry or leathery in appearance), slough, and [MEDICATION NAME] (new often pink shiny tissue that grows in from the edges or as an island on the wound surface), the presence of any undermining or tunneling, the periwound (skin/tissue around the pressure ulcer), if any drainage (amount, color, and if any odor) was present, the characteristic of the wound edges and/or if pain was present. Review of the admission physician orders upon readmission on 01/28/17 revealed an order for [REDACTED].#24 or for a pressure reducing cushion to be used in the wheelchair. Review of Resident #24's weights revealed on 01/29/17 Resident #24 was 134.3 pounds which was an 18.1 percent/29.7 pound weight loss in the last six months and a 5.4 percent/7.7 pound weight loss in the last 30 days. On 01/29/17, physician orders were written for Prevalon boots (pressure relieving boots) to both heels to prevent skin breakdown. Treatments were ordered for the pressure areas including for staff to cleanse the buttocks with soap and water, rinse, pat dry and apply [MEDICATION NAME] ointment every shift and as needed for reddened buttocks, float both heels while in bed, and pad and protect the right heel with [MEDICATION NAME] (an absorbent foam dressing) and secure with Kerlix (a gauze wrap). This dressing was to be done daily and as needed till the area resolved. There was no treatment ordered for the pressure ulcer identified on Resident #24's coccyx which was 1.4 cm by 1.0 cm or for the left heel blister. On 01/30/17 a physician order was received to pad and protect the left heel with [MEDICATION NAME] and secure with Kerlix wrap to be changed daily and as needed until the area resolved. On 01/31/17 at 8:38 A.M. a nurse's note indicated Resident #24's heels were fluid filled with purple edges. This note indicated the nurse practitioner (NP) for wounds would see Resident #24 that day. This note said both buttocks had incontinence related [MEDICAL CONDITION] that measured 8.0 cm by 13.0 cm by 0.1 cm with an order for [REDACTED]. Review of the Weekly Wound Documentation from 01/31/17 at 6:36 P.M. revealed no evidence the NP for wounds assessed Resident #24's buttocks. The right and left heels were classified as suspected deep tissue injuries. The right heel was 5.4 cm long by 4.0 cm width with no depth and the left heel 4.4 cm by 4.5 cm with no depth. Both areas were described as intact, fluid filled blisters, with pink periwounds. There was no visible drainage or signs or symptoms of infection. The heels did not show signs of improvement. On 01/31/17, a physician order directed staff that the Prevalon boots must be removed by the nurse and the nurse must complete skin checks every shift for wound management. The pad and protect orders to the heels were discontinued. A new physician order was written to cleanse both heels with normal saline solution, pat dry, apply skin prep, cover with dressing and wrap with Kerlix three times a week and as needed. Resident #24 was assessed as being high risk for pressure ulcer development on a 02/02/17 related to weight loss with recent insertion of the GT for nutrition, immobility, current pressure ulcers, medications, [DIAGNOSES REDACTED]. Review of the state tested nurse aide (STNA) transferring task revealed Resident #24 was transferred out of bed to a wheelchair on 01/20/17, 01/30/17, 02/01/17, 02/06/17, 02/07/17 and 02/08/17. There was no evidence that Resident #24 was provided a pressure reducing cushion to be used in the wheelchair to aid in the healing of the pressure ulcer and attempt to prevent new areas. On 02/02/17 at 6:05 A.M. a nurse's note revealed an unidentified STNA alerted the nurse to a new open pressure ulcer to Resident #24's left upper buttocks measuring 1.0 cm by 1.0 cm. The note indicated it was cleansed with normal saline and a dressing was applied. There was no evidence Resident #24's physician was notified in order to receive treatment orders and no evidence Resident #24's responsible party was notified of the new pressure area. There was no evidence a comprehensive assessment was completed including a depth measurement, periwound appearance, wound bed appearance, staging of the area and if there was any drainage. On 02/03/17 at 9:00 A.M., a standing nursing order was written to cleanse the left upper buttock pressure ulcer with normal saline and apply a dressing until resolved twice a day, three days a week on every Sunday, Tuesday and Friday to prevent further breakdown. Review of the undated standing orders revealed for Open Areas with no Drainage staff were to apply Vitamin A&D ointment every shift and with incontinence care/over bony prominence, and cover with a silicone bandage as a pad and protect. Staff were also to use skin prep and replace the bandage three times a week and as needed if soiled. If the skin area was moist, staff were to use a zinc based barrier cream to treat the area. These standing orders indicated residents with open areas should be on a turning program as a preventative measure. For open areas with moderate to large drainage staff should use calcium alginate and a skin safe dressing to be changed three times a week and should be changed daily for wounds with a large amount of drainage. Review of the facility undated Change in Condition Notification policy revealed a change in condition will be communicated to the physician and the resident's first contact in a timely manner. The nurse is to notify the physician when the resident has a change in condition that requires physician intervention as soon as reasonably possible so as not to interrupt appropriate and timely treatment. The nurse will notify the first contact or responsible party when there is a change in condition resulting in a change in treatment. Review of the facility Pressure Ulcer Prevention and Management policy dated 05/2015 revealed initial approaches to assist with the prevention of alterations in skin included a pressure reduction cushion to the chair if needed and to turn and/or reposition the person at least every two hours or as needed, including those residents in chairs/wheelchairs. If a pressure ulcer develops after admission, a risk assessment will be done and the care plan will be reevaluated by the interdisciplinary team. The physician will be notified and orders for treatment will be obtained. Staff were to describe and monitor the pressure ulcers characteristics. When a pressure ulcer is present, daily monitoring will include an evaluation of the ulcer if no dressing is present, an evaluation of the status of the the dressing if there is a dressing including the status of the area surrounding the dressing, the presence of any complications and whether pain is present and controlled. There were no physician orders for a pressure reducing cushion to Resident #24's wheelchair or for staff to turn and reposition Resident #24 at least every two hours to aid in healing the current pressure ulcers and attempt to prevent new pressure ulcers until 02/06/17. This was after the development of a new left upper buttock pressure ulcer. On 02/07/17 at 9:28 A.M. the Physician Assistant (PA) for wounds documented they were following the patient for blisters from pressure on both heels acquired in the hospital very recently. The note indicated nursing staff indicated the areas were not open. The note also said Resident #24 had a new pressure ulcer area on the coccyx that was noticed last week. The nursing staff were directed to get a low air loss mattress and Resident #24 was not to wear regular shoes. On 02/07/17 at 10:36 A.M. the Weekly Wound Documentation revealed a new left buttock Stage III pressure ulcer measuring 1.0 cm by x 1.1 cm width and 0.1 cm depth, with less than 25% white slough and 75% granulation tissue. The periwound had the purple non-blanchable discoloration of a deep tissue injury. A small amount of serosanguinous (bloody, serous fluid) drainage was noted. There was no odor or signs or symptoms of infection noted. The responsible party was notified. The pressure ulcers to the left and right heels remained intact with the right heel measuring 4.9 cm by 3.8 cm and the left heel measuring 4.8 cm by 4.5 cm. On 02/07/17, physician orders were obtained for a foam wedge cushion to aide in side to side positioning while in bed for skin integrity and staff were to cleanse the pressure ulcer on Resident #24's left buttock with normal saline, pat dry, apply [MEDICATION NAME] to the wound bed, apply calcium alginate and cover with a sacral dressing three times a week on night shift and as needed. On 02/08/17 review of the treatment sheets revealed no evidence of a treatment being provided for Resident #24's coccyx pressure ulcer, present since readmission on 01/28/17. An interview was conducted on 02/08/17 at 1:55 P.M. with Licensed Practical Nurse (LPN) #5. LPN #5 indicated when a new skin area was identified a standing order was initiated until the wound PA made weekly rounds. The PA would then do a comprehensive assessment and write treatment orders. LPN #5 verified Resident #24's readmission wound assessments were not comprehensive and did not include measurement of depth, color, drainage or characteristics of the wound bed. LPN #5 verified there was no physician or family notification when the open pressure ulcer was identified on 02/02/17 to Resident #24's left buttock, per policy. LPN #5 indicated that cleansing the pressure ulcer with normal saline and applying a dressing twice a day, three days a week was not an approved standing order for any type of wounds included in the standing orders. This was the standing order written on 02/03/17 for Resident #24's left upper buttock pressure ulcer. LPN #5 verified no additional pressure relieving measures were implemented until 02/06/17 when a pressure reducing wheelchair cushion and a formal turn and reposition every two hours schedule was put in place. LPN #5 verified Resident #24's left buttock ulcer was a Stage III pressure ulcer when first comprehensively assessed and a treatment put in place on 02/07/17. LPN #5 verified the responsible party and the physician were not notified of the left buttock pressure ulcer until 02/07/17, five days after development. LPN #5 verified no physician order was written for the low air loss mattress the PA ordered in her progress note on 02/07/17. LPN #5 affirmed as of 02/08/17 there still was not a treatment ordered for the pressure ulcer area identified on Resident #24's coccyx on readmission on 01/28/17. LPN #5 affirmed there was no evidence the PA or staff assessed the pressure ulcer on Resident #24's coccyx since readmission. On 02/08/17 at 3:34 P.M., Executive Director #2 verified there was a lack of education with the assessment and staging of pressure ulcers. Review of Resident #24's pressure ulcer plan of care current thru 05/03/17 revealed Resident #24 required a pressure reducing device on the bed and standard facility turning and repositioning. Resident #24 returned from the hospital with weight loss and decline in mobility, pressure ulcers, nothing by mouth, increased respiratory compromise/medical health decline and a recent left buttock wound. On 02/08/17 at 7:09 P.M. Resident #24 was observed on her right side, a wedge cushion was behind her back with pressure relieving boots on both feet and a pillow between the knees. [MEDICATION NAME] 1.5 tube feeding was infusing at 40 milliliters an hour via the GT. Resident #24 had her eyes closed and was not moving. Observation 02/09/17 at 12:56 P.M. of Resident #24's pressure ulcers accompanied by Regional Nurse #4 and the Director of Nursing (DON) revealed the left buttock contained a deep purple deep tissue injury (DTI), was non-blanchable and soft measuring 6.0 cm by 5.7 cm. There were three open areas in the deep tissue injury, two of which were not assessed by the staff, with the largest area measuring 1.0 cm by 2.4 cm. The open areas were observed with bloody yellow drainage. The right buttock contained two distinct deep purple DTI's, 3.0 cm by 2.0 cm and 2.0 cm by 2.0 cm. These areas had not been previously identified or assessed by the facility. There was an open area to the coccyx measuring 1.6 cm by 0.4 cm by 0.1 cm. This ulcer was identified on readmission as a 1.4 by 1.0 open area. There was no evidence any assessments or treatments were provided to the coccyx wound since readmission. Observation of both of Resident #24's feet revealed deep purple mushy heels with the skin intact as assessed. Observation revealed additional pressure areas that had not been previously identified or assessed by the facility. The right great toe at the first joint had a 1.0 cm by 1.1 cm deep purple mushy, non-blanchable deep tissue injury. The left foot had a 0.7 cm by 1.0 cm deep purple mushy non-blanchable deep tissue injury to the fifth toe on the first joint. The great toe on the left foot on the first joint had a 1.0 cm by 1.0 cm deep purple mushy non-blanchable deep tissue injury. At the time of the observations, Regional Nurse #4 verified all the pressure ulcers on the buttocks and feet had not been comprehensively assessed and treated. Regional Nurse #4 affirmed the weekly wound documentation was not an accurate depiction of the Stage III pressure ulcer to Resident #24's left buttock and deep tissue injuries to both buttocks. Regional Nurse #4 verified there was no documentation of ongoing monitoring, assessing or treatment of [REDACTED]. Review of the physician orders as of 02/09/17 at 1:17 P.M. revealed the low air loss mattress had still not been ordered. Review of the Weekly Wound Documentation revealed the physician and responsible party were notified on 02/09/17 at 5:30 P.M. of the new areas to Resident #24's feet. There was no evidence the second and third open areas to the left buttock, the DTI's to the right buttock or the pressure ulcer on the coccyx had been reported to the physician for treatment initiation. On 02/09/17 at 6:50 P.M., Regional Nurse #4 verified there was no evidence the physician or family were notified of the new pressure ulcers identified on Resident #24's buttocks earlier in the day. Regional Nurse #4 verified there was still no treatment orders the new pressure ulcers on the buttocks or for the coccyx ulcer present since readmission. Regional Nurse #4 verified the facility staff were not following their policies for the prevention, notification, assessment, treatment and documentation of pressure ulcers as described in their pressure ulcer policy. 2. Medical Record review revealed Resident #51 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #51 was readmitted to the facility on [DATE] after having left knee replacement surgery. Review of the quarterly 01/09/17 MDS 3.0 assessment revealed Resident #51 was independent for daily decision making, required extensive assist of one staff for bed mobility, required extensive assist of two staff for transfers, was at risk for pressure ulcers and currently had a Stage III pressure ulcer and two Unstageable pressure ulcers. Review of a nurse's note from 12/23/16 revealed the discovery of new, facility acquired pressure ulcers, observed when Resident #51's left knee brace was removed. A left lateral proximal (outer, upper) ankle pressure ulcer was found measuring 6.0 cm by 2.0 cm and a left lateral distal (outer, lower) ankle pressure ulcer measuring 5.0 cm by 2.0 cm. There was also a left medial (inner) ankle pressure ulcer measuring 6.0 cm by 7.0 cm. There was no evidence that comprehensive pressure ulcer assessments were completed when these pressure ulcers were discovered including the stage, the depth measurements, the appearance of the periwound and the wound bed, any drainage, and if there was any pain. Review of the 01/24/17 Weekly Wound Assessment revealed the left medial ankle was 2.5 cm by 2.0 cm by 0.1 cm and was listed as a Stage III. There were no measurements the Unstageable pressure ulcer documented on Resident #51's left lateral proximal ankle. The left lateral distal ankle pressure ulcer had no measurements documented and was staged as a Stage IV pressure ulcer. Review of the 01/31/17 Weekly Wound Assessment revealed the left medial ankle was a Stage III with no measurements documented. There were no measurements recorded for the Unstageable pressure ulcer to the left lateral proximal ankle. The left lateral distal ankle had no measurements documented and was staged as a Stage IV. Review of the 01/31/17 Braden Scale for predicting pressure ulcer risk revealed Resident #51 was a moderate risk for pressure ulcers. Resident #51 had very limited sensory perception, very moist skin, was chairfast, very limited mobility, adequate nutrition and friction and shear was a potential problem. Review of the treatment record revealed an order initiated 01/03/17 to cleanse the area to Resident #51's left medial ankle with normal saline, pat dry, apply Santyl (an ointment to assist in the removal of dead tissue), [MEDICATION NAME] (a non-adhering dressing), and dry clean dressing daily and as needed for wound care. There was no evidence the dressing was changed on 01/26/17, 01/30/17 or 01/31/17. Review of the treatment record revealed an order initiated 01/25/17 to cleanse area to left lateral distal ankle with normal saline, pat dry, apply collagen, and cover with a dry clean dressing daily and as needed every day shift for wound care. There was no evidence the dressing was changed on 01/26/17, 01/30/17 or 01/31/17. Review of the treatment record revealed an order initiated 01/03/17 to cleanse area to left lateral proximal ankle with normal saline, pat dry, apply calcium alginate and cover with a dry clean dressing daily and as needed every day shift for wound care. There was no evidence the dressing was changed on 01/26/17, 01/30/17 or 01/31/17. Review of the 02/07/17 Weekly Wound Assessment revealed the left medial ankle was a Stage III. There were no measurements for the Unstageable pressure ulcer to the left lateral proximal ankle. The left lateral distal ankle had no measurements documented and was staged as a Stage IV. On 02/08/17 at 5:01 P.M. interview with Resident #51 revealed the physician ordered a knee brace after his knee surgery to be on except when he was in therapy or during bathing. He received it on 12/21/16. He indicated the bleeding areas were found on 12/23/16. He said the brace was put on wrong. He indicated the two holes at the top of the brace were supposed to be above his knee but the facility had applied so the holes were below his knee. Resident #51 indicated when he returned to the physician the physician discontinued the knee brace and he said the staff were then elevating his left leg on a pillow. On 02/09/17 at 2:40 P.M., Resident #51's left ankle was observed with Regional Nurse #4 and the DON. There were two pressure ulcer areas on his left lateral ankle and one on the left medial ankle. There was also a large black scab to the left anterior (top) ankle measuring 1.3 cm by 1.8 cm. Review of the facility documentation revealed no evidence of the origin of the scab on top of Resident #51's ankle area or any documented assessments or treatments. On 02/09/17 at 5:28 P.M., Regional Nurse #4 affirmed the facility did not provide pressure ulcer dressing changes as ordered in January, 2017. Further, the facility failed to document comprehensive pressure ulcer assessments on 01/24/17 and 01/31/17 including measurements of pressure ulcers per facility policy. Regional Nurse #4 affirmed the absence of documentation and treatment related to the black scab on Resident #51's left anterior ankle. 3. Record review of Resident #11 revealed an admission on 01/24/16 with [DIAGNOSES REDACTED]. Admission physician orders on 01/24/17 included cleanse the area to the left medial knee with normal saline, pat dry, apply Hydrogel (a gel based dressing to promote a moist, healing wound bed), cover with dry clean dressing three times a week and as needed; cleanse area to coccyx with normal saline, pat dry, apply Calcium Alginate to the wound bed (be sure to pack undermining, which is tissue damage along/under the wound edges), pack loosely with wet to dry 4 inch by 4 inch gauze, cover with a sacral dressing every other day and as needed; weekly skin assessment every Tuesday; apply protective barrier to the peri-area and buttocks after incontinence care every two hours and/or as needed; urinary catheter due to Stage IV pressure ulcers with care twice daily and as needed; empty fecal incontinence bag every shift; mechanical lift for transfers; turn and reposition every two hours; wedge pillow for repositioning; resident to wear a Medline Heel Raiser Pro II at all times with skin checks every two hours; and cleanse area to left heel with normal saline, pat dry, apply [MEDICATION NAME], calcium alginate, cover with a dry clean dressing and wrap with conforming gauze every other day and as needed. The 02/07/17 admission MDS 3.0 assessment revealed Resident #11 was severely impaired cognitively for daily decision making, was totally dependent on two staff for bed mobility and transfers, was ventilator dependent, was at risk for pressure ulcer development and had a Stage IV pressure ulcer. The 02/07/17 Braden scale assessment revealed Resident #11 was a high risk for pressure ulcers related to his very limited sensory perception, probable inadequate nutrition, being occasionally moist, being completely immobile and with friction and shearing being listed as a problem. Review of the admission skin assessment revealed Resident #11 had a sacral pressure ulcer measuring 7.0 cm by 8.0 cm by 1.0 cm, a right heel unstageable pressure ulcer measuring 2.0 cm by 2.0 cm and an anterior (front/top) left knee pressure ulcer measuring 2.0 cm by 1.0 cm. There was no evidence that comprehensive assessments of these pressure ulcers were completed on admission including the staging of the knee and sacrum ulcers, a depth measurement for the knee ulcer, any wound base description, the presence of any undermining or tunneling, the presence of any drainage (amount, color, and if any odor), the characteristics of the wound edges and periwound and if pain was present. Review of the nurse's notes from 01/24/17 at 10:04 A.M. revealed Resident #11 was being admitted with a tube feeding, a [MEDICAL CONDITION] and ventilator,[MEDICAL CONDITION] of the coccyx wound, a wound vac (a dressing with a device that creates a vacuum to remove fluid from the wound) to the coccyx for a Stage IV pressure ulcer, a urinary drainage catheter and a device for stool collection. Review of the nurse's notes on 01/24/17 at 2:30 P.M. revealed the wound vac was removed due to Resident #11 developing scattered blood blisters around the tape of the dressing. A new order to cleanse the pressure area to the coccyx with normal saline, pat dry, apply Calcium Alginate to the wound bed (be sure to pack undermining), pack loosely with wet to dry 4 inch by 4 inch gauze, cover with a sacral dressing every other day and as needed was obtained. On 01/25/17 a physician order was written to observe the blood blisters to both buttocks and leave them open to air. Resident #11 was also ordered to wear heel protectors at all times and for them to be removed for a skin assessment every shift. The Medline Heel Raiser Pro II device was discontinued. On 01/26/17 physician orders included for the Glucerna tube feeding to be increased to 70 ml per hour, for nurses to cleanse the area to Resident #11's left ear with normal saline, pat dry, apply Duoderm (a [MEDICATION NAME], moisture retention dressing) three times a week and as needed, cleanse area to left heel with normal saline, pat dry, apply [MEDICATION NAME], calcium alginate, cover with a clean dry dressing, and wrap with conforming gauze every other day and as needed. On 01/30/17 the treatment to the left heel was discontinued as it resolved. On 01/31/17 the Weekly Wound Documentation indicated Resident #11 had a pressure ulcer to the left ear measuring 1.0 cm by 0.6 cm by 0.1 cm and was listed as a Stage II (a partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed without slough), which was a community acquired pressure ulcer and a Stage IV sacrum pressure ulcer measuring 8.5 cm by 7.0 cm by 1.1 cm. There was no mention of the right heel pressure ulcer or the scab on the front of the knee. Although this assessment indicated the left ear pressure ulcer was present on admission to the facility, the admission skin assessment did not list or describe a pressure ulcer to Resident #11's left ear. On 01/31/17 a physician order was written to cleanse the pressure ulcer to Resident #11's sacrum with normal saline, pat dry, pack the wound bed and undermining with Dakin's 0.25% solution loosely, cover with dry 4 inch by 4 inch gauze and cover with sacral dressing daily and as needed. There was also an order to cleanse the left ear pressure ulcer with normal saline, pat dry, and apply Duoderm three times weekly and as needed. Review of the Physician Assistant wound note on 01/31/17 at 9:13 P.M. revealed a wound consult for a Stage IV sacral pressure ulcer, a right knee skin tear and the left ear pressure ulcer. This note indicated the sacral wound was fairly large and extensive with undermining from 12 o'clock to 6 o'clock. The wound had over 90% pale pink tissue with small amounts of slough on the edges. There was moderate serosanguinous drainage that was somewhat malodorous. There was no surrounding [DIAGNOSES REDACTED] (redness) or warmth. This note indicated the left ear pressure ulcer was small, superficial and pink without [DIAGNOSES REDACTED], warmth or infection. This note indicated Resident #11 had a Clinitron bed (a specialized air-fluidized bed used to remove pressure from the person to aid in pressure ulcer and wound healing). Review of a nurse's note from 02/03/17 at 7:15 A.M. revealed the nurse entered the room and noticed the Resident #11's air mattress was turned off. The nurse turned the mattress back on and observed the resident for any new wounds. No new wounds were noticed. Staff was addressed to ensure they properly maintained the equipment. Review of a nurse's note on 02/04/17 at 12:00 P.M. revealed STNA's were doing peri-care and noticed Resident #11's fecal bag was falling off. The fecal bag was removed and the physician discontinued the fecal bag. Orders were in place for staff to provide incontinence care every 2 hours. The Weekly Wound assessment dated [DATE] revealed Resident #11's sacral ulcer measured 9.2 cm by 7.0 cm by 1.2 cm and was a Stage IV. The assessment indicated there was 100% beefy, red wound bed, with a large amount of serosanguinous drainage noted without any odor. There was undermining present around wound bed with the deepest being 2.0 cm with no signs or symptoms of infection. The Stage II pressure ulcer to the left ear measured 0.6 cm by 0.2 cm by 0.1 cm. It was documented as having a 100% pink superficial wound bed without drainage, odor or infection. The left knee was healed with 100% intact pink tissue and the treatment was discontinued. Review of a nurse's note from 02/07/17 at 1:42 P.M. revealed the shower aide called the nurse into Resident #11's room during a bed bath and was concerned about several pressure ulcer areas on his back and coccyx. Staff had been in providing wound care earlier and had Resident #11 turned over to change the dressing on the coccyx but they did not assess the rest of the pressure ulcers on his buttocks or back. A large pressure ulcer area to Resident #11's upper back measured 5.0 cm by 2.0 cm with a smaller pressure ulcer area attached measuring 4 cm by 0.5 cm. There were also two pressure ulcer areas to Resident #11's lower back, one measuring 5.0 cm by 5.5 cm and the other measuring 6.0 cm by 1.0 cm. There was a pressure ulcer open on Resident #11's coccyx measuring 2.5 cm by 1.5 cm. This note indicated dry clean dressings were in place and Duoderm was applied over pressure areas for protection. Review of the medical record revealed no evidence Resident #11's physician or responsible par

Based on review of medical records, review of the facility policy regarding medication administration for controlled substances, staff and resident interviews, and observation of the resident, the facility failed to ensure Resident #102 was free from a significant medication error when licensed nurses failed to consecutively administer three doses of a physician ordered anti-[MEDICAL CONDITION] medication, Klonopin, on 1/06/17 and 1/07/17. Actual Harm occurred when Resident #102 subsequently suffered a [MEDICAL CONDITION] with loss of consciousness on 01/08/17. This resulted in Immediate Jeopardy for one resident (Resident #102) out of six residents reviewed for unnecessary medications. On 01/11/17 at 2:24 P.M., Executive Director (ED) #1, the Director of Nursing (DON), regional Registered Nurse (RN) #80, and Regional Director of Operations #79 were notified Immediate Jeopardy began on 01/06/17 at 8:00 P.M. when Resident #102 did not receive his scheduled Klonopin medication to manage his [MEDICAL CONDITION] disorder. Resident #102 also did not receive the next two scheduled consecutive doses of Klonopin on 01/07/17 at 8:00 A.M. and at 8:00 P.M. This resulted in Resident #102 having a [MEDICAL CONDITION] with loss of consciousness on 01/08/17, sometime between 8:00 A.M. and 9:00 A.M. The exact time and details of the [MEDICAL CONDITION], including any assessments and care provided was not documented by nursing staff. The Immediate Jeopardy was removed on 01/13/17 at 3:03 P.M. when the facility implemented the following corrective actions: · On 01/11/17 at 12:36 P.M., Assistant Director of Nursing (ADON) #3 notified Medical Doctor #76 of Resident #102's missed doses of Klonopin on 1/06/17 and 1/07/17. · On 01/12/17 at 12:50 P.M., ED #1 requested clarification of Resident #102's orders from Neurologist #82. The physician orders, faxed to the facility at 3:13 P.M., indicated the original order was for 0.25 mg of Klonopin twice a day but indicated the facility should continue to give 0.5 mg twice a day to Resident #102. · On 01/12/17 at 2:00 P.M., Consultant Pharmacist #83 in-serviced 16 of the 18 nurses (RNs #3, #15, #16, #17, #18, LPNs #20, #21, #22, #24, #84, #25, #26, #27, #28, #29 and #30) on the proper process for medications, what to do when medications are not available, and pharmacy protocols and procedures. On 01/15/17 at 7:00 A.M., RN #3 in-serviced LPN #23, prior to starting her shift. LPN #31 is scheduled to be in-serviced prior to starting her next shift on 01/19/17 by RN #3. · On 01/12/17 at 2:00 P.M., regional Director of Clinical Operations #80 and the DON began mandatory in-services with 16 of 18 nurses (RNs #3, #15, #16, #17, #18 and LPNs #20, #21, #22, #24, #84, #25, #26, #27, #28, #29 and #30) on the medication ordering protocol, immediate physician notice when medications are not available, accuracy of controlled substance audits, the need for immediate notification to the DON for any discrepancies, accuracy of medication administrator records, identification of general changes in condition with added emphasis on [MEDICAL CONDITION] activity, recognizing signs of [MEDICAL CONDITION], immediate physician notification of change in condition, immediate assessment and accurate, objective clinical documentation post-change in condition, ongoing monitoring of resident upon change in condition, review of [MEDICAL CONDITION] procedures, review of importance of black box warning awareness and review of new requirement for all physician orders to be double verified by two nurses prior to the end of each shift. On 01/15/17 at 7:00 A.M., RN #3 in-serviced LPN #23, prior to starting her shift. LPN #31 is scheduled to be in-serviced prior to starting her next shift on 01/19/17 by RN #3. · On 01/12/17 at 6:30 P.M., the DON and RN #3 initiated shift-change huddles to meet with all outgoing and incoming nursing staff to assure 12 hour shift to shift continuity and to identify any residents with signs of significant change in condition. On 1/19/17 the E/F hall huddle was observed at 6:05 P.M. with RN #3, LPN's #24, #25, STNA's #33, #46 and #57. · On 01/12/17 at 7:00 P.M., Pharmacist #83 completed audits for 100 percent of all controlled substances on-hand in the facility to ensure no discrepancies were found. · On 01/12/17 at 10:00 P.M., the DON and ED #1 posted a notice to remind nurses of the directive to double check double check all new physician ' s orders obtained during that shift with two nurses by the end of each shift. · On 01/13/17 at 2:00 P.M., corporate nurse managers (RNs #85, #87, #91, LPNs #86, #92, #88, #89 and #90) reviewed all 78 residents ' progress notes for changes in condition during the prior 30 days to assure all 78 residents were assessed, treated, and/or adequately monitored, physicians were immediately notified and documentation was complete. · On 01/13/17 at 3:03 P.M., corporate nurse managers (RNs #85, #87, #91 and LPNs #86, #92, #88, #89 and #90) reviewed all 78 residents ' medical records to ensure accurate transcription of the physician orders to the medication administrator records (MAR's). · On 01/19/17 between 5:00 P.M. and 6:25 P.M., interviews with ED #1, RNs #3 and #15 and LPNs #24 and #25 verified the nursing staff had been trained related to verifying correct order transcription from the physician orders to the MAR. They indicated the transcription of physician orders was being double checked by two nurses. They also indicated training included ensuring the accuracy of the controlled substance log, access to the switchbox, notification of the physician when medications were not available as ordered and reporting and identifying change in condition. Although the Immediate Jeopardy was removed, the deficiency remained at a Severity 2 level, (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy), as the facility was in the process of implementing ongoing monitoring of the corrective actions and continuing staff education. Findings include: Resident #102 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident required supervision of two or more staff for ambulation with a walker. Review of the [MEDICAL CONDITION] plan of care, initiated 02/24/16, revealed the resident had a [MEDICAL CONDITION] disorder, a history of falls and may not recall falling due to black outs with the falls. The interventions included nurses to administer [MEDICAL CONDITION] medications as ordered and to monitor for side effects and effectiveness of medications. Post [MEDICAL CONDITION] treatment should include nurses obtaining vital signs and completing neurological checks, monitoring for [MEDICAL CONDITION] (speech deficits caused by a [MEDICAL CONDITION]), headache, altered loss of consciousness, paralysis, weakness and pupillary changes. [MEDICAL CONDITION] documentation should include the location of the [MEDICAL CONDITION], the type of [MEDICAL CONDITION] activity (jerks, convulsive movement, trembling), duration of the [MEDICAL CONDITION], level of consciousness, any incontinence, and information about sleeping or being in a dazed postictal state (the altered state of consciousness after a [MEDICAL CONDITION]). [MEDICAL CONDITION] precautions included for staff to stay with the resident during the [MEDICAL CONDITION], protect the resident from injury, gently hyperextend their head to open the airway, provide oxygen as needed and to remove or loosen tight clothing. Review of the fall plan of care initiated 02/24/16 revealed Resident #102 was at risk for falls due to [MEDICAL CONDITION], had a history of [REDACTED]. The interventions directed staff to see (the) [MEDICAL CONDITION] care plan. Review of the nursing notes dated 02/28/16 at 4:50 P.M., revealed Resident #102 came to Licensed Practical Nurse (LPN) #26 and stated he fell on the floor from the wheelchair. He said he was not sure if he had a [MEDICAL CONDITION] but he blacked out. He said the last thing he remembered was about 40 minutes ago when a state tested nursing assistant (STNA) came in to make his roommate's bed. The resident stated he hit his head on the bed frame and complained of a pounding headache and said all of his muscles were aching. The nursing note said Resident #102 had a small bump on the back of his head. Review of the nursing notes dated 04/18/16 at 4:50 P.M., revealed LPN #28 was called by an unidentified STNA into the dining room because staff thought Resident #102 had a [MEDICAL CONDITION]. When observed, the resident was sitting at the table alert and oriented and talking with another resident. The resident said his hands got real shaky. Review of the progress note by the neurologist dated 05/25/16 revealed it was virtually impossible to know how long the resident had been having [MEDICAL CONDITION] or how frequently the resident had been having [MEDICAL CONDITION]. The neurologist indicated the resident's biggest concern was his frequent falls. The neurologist made no changes with his current medications but recommended an electroencephalogram (EEG), a test to record electrical activity in the brain, be obtained and for staff to observe the resident over the next several weeks to see if he had any recognizable [MEDICAL CONDITION]. The EEG was completed on 07/13/16 and revealed the resident currently had [MEDICAL CONDITION] activity. Review of the nursing notes dated 08/03/16 at 3:23 P.M., revealed Resident #102 had a witnessed fall from his wheelchair when in the therapy room, hitting his head on the floor. Resident #102 did not remember the fall but sustained a laceration to the head. There was no documentation of any treatment to the laceration, the size of the laceration, the physician was notified and no new orders were given. Review of the follow-up assessment from the neurologist dated 08/17/16 revealed the chief complaint was management of Resident #102's [MEDICAL CONDITION] and tremors. The neurologist indicated Resident #102 had intractable [MEDICAL CONDITION] with frequent falls. The resident was allergic to [MEDICATION NAME] and [MEDICATION NAME], medications typically used to treat [MEDICAL CONDITION] disorders. The neurologist directed staff to call and report any future [MEDICAL CONDITION]. The neurologist indicated his medications may need to be adjusted, including increasing [MEDICATION NAME], a medication he was already taking for [MEDICAL CONDITION] disorders. The neurologist indicated a follow-up would be completed in four months. Review of the nursing notes dated 11/02/16 at 8:24 A.M. by RN #3 revealed Resident #102 was in the bathroom and fell hitting his head on the back of the toilet paper holder before falling to the ground. There was no investigation to determine if the fall was actually witnessed or to determine if the fall was caused by a [MEDICAL CONDITION]. There was no evidence the neurologist or the resident's medical doctor was notified. On 01/12/17 at 4:20 P.M., interview with RN #3 verified there was no fall investigation and no evidence either the neurologist or medical doctor were notified of the fall. Review of the nursing notes dated 11/03/16 at 2:08 P.M. by LPN #24 revealed Resident #102 fell in his room. There was no fall investigation completed to attempt to determine if the resident sustained [REDACTED].M., interview with RN #3 verified there was no fall investigation and no evidence either the neurologist or medical doctor were notified of the fall. Review of the nursing note dated 11/23/16 revealed staff heard a loud bang and found Resident #102 on the floor in the shower room. No investigation was completed to determine if the fall was caused by a [MEDICAL CONDITION]. The physician was notified of a fall and there were no new orders given. On 01/12/17 at 4:20 P.M., interview with RN #3 verified a fall investigation was not completed. Review of the nursing note dated 12/08/16 at 7:50 A.M. by LPN #25 revealed the bathroom call light was activated and Resident #102 was found on the floor beside the toilet with his back against wall and his legs outstretched forward. He had been incontinent of urine. There was no evidence the facility attempted to determine if the fall was caused by a [MEDICAL CONDITION]. The physician was notified of a fall with no new orders. On 01/12/17 at 4:20 P.M., interview with RN #3 verified the facility did not complete a fall investigation. Review of the nursing notes dated 12/09/16 at 3:47 P.M. by LPN #3 revealed Resident #102 was found lying on the floor in between the bed and bathroom. The resident was not able to give a description of what happened since he had some confusion. He was oriented to himself but was not exhibiting his usual level of orientation. There was no investigation completed to see if the resident hit his head and no neurological checks were completed. The physician was notified and ordered urine testing with was negative for infection. This nurse checked on Resident #102 an hour after the fall and he had no memory of the fall. On 01/12/17 at 4:20 P.M., interview with RN #3 verified the facility did not complete a fall investigation. Review of the nursing notes dated 12/10/16 at 1:38 P.M. by LPN #26 revealed the resident was lethargic and confused. Review of the 12/11/16 nursing note at 6:33 P.M. by LPN #26 revealed Resident #102 was having increased behaviors with verbal aggression, repeating himself, closing one eye when he was talking and was saying he now had a lazy eye. The physician was notified and the resident was sent to the hospital for evaluation. Review of the hospital transfer form dated 12/11/16 revealed the resident was sent to the hospital with primary [DIAGNOSES REDACTED]. Behaviors included lethargy, confusion, agitation, aggression and being non-compliant with safety precautions and trying to leave the facility. Review of the neurologist's progress note dated 12/21/16 revealed an order to start Klonopin, a medication used to treat [MEDICAL CONDITION], 0.5 mg, a half tablet, twice a day. The neurologist indicated this would help control Resident #102's [MEDICAL CONDITION] in the short-term period until the [MEDICATION NAME], another [MEDICAL CONDITION] medication, could slowly be increased to an effective dose. The neurologist indicated they would then wean Resident #102 off of the Klonopin slowly. The neurologist directed the staff to not suddenly stop giving the Klonopin. The [MEDICATION NAME] order was for a 25 mg tablet to be given every evening for two weeks and then be increased as ordered for [MEDICAL CONDITION]. The neurologist physician's order dated 12/21/16 directed staff to give Klonopin, 0.5 mg tablet, half a tablet (0.25 mg) twice a day for a total of dose of 0 .50 mg daily. Review of the transcription of this medication order dated 12/21/16 completed by LPN #26 revealed the nurse inaccurately wrote on the medication administration record (MAR) for the Klonopin to be given at 0.5 mg tablet twice a day, a total of 1.0 mg daily, twice the ordered dosage, instead of the intended 0.25 mg twice a day for a total of 0.50 mg. Review of the MAR for December 2016 revealed the resident received 0.5 mg of Klonopin starting in the evening on 12/21/16 in conflict with Resident #102's individual controlled substance record (ICSR) which indicated the first dose of Klonopin was not given until 12/22/16 in the morning. The MAR and the ICSR indicated 0.5 mg was given in the morning of 12/22/16. The MAR revealed on 12/22/16 that Klonopin, 0.5 mg, was given in the evening but the ICSR indicated 0.25 mg was given in the evening showing a discrepancy of 0.25 mg. Further review of the MAR revealed staff administered 0.5 mg of Klonopin to Resident #102 twice a day through 12/31/16. The ICSR indicated 0.50 mg was given on all of the days except for the evening doses on 12/22/16 and 12/28/16, when the evening dose was given correctly at 0.25 mg. Review of the MAR for January 2017 revealed Resident #102 received Klonopin, 0.5 mg, twice a day from 01/01/17 through the evening of 01/05/17. The ICSR indicated 0.25 mg was given for the evening doses on 01/02/17 and 01/05/17. On 01/06/16, the ICSR indicated no dose had been administered on 01/06/16 in the morning or the evening. Review of the MAR for 01/07/16 revealed neither the morning nor the evening dose of Klonopin was given because the facility was out of the medication. Review of the ICSR for 01/07/17 indicated no Klonopin was given for the day. This was verified with the narcotic contingency supply record which indicated no Klonopin was taken from the emergency supply on 01/07/17. In summary, no Klonopin was given for the evening dose on 01/06/17 or for the morning or evening doses on 01/07/17. Review of the nursing note dated 01/07/17 at 12:55 P.M. by LPN #26 stated the Klonopin medication was not available at this time. At 9:50 P.M., LPN #29's nursing note said the medication was on order. There were no further nursing notes for Resident #102 after 01/07/17 at 10:30 P.M. until 01/09/17 at 6:47 A.M. Further review of the 24 hour reports dated 01/06/17, 01/07/17 and 01/08/17 revealed there was no documentation related to the missed doses of Klonopin on 01/06/17 and 01/07/17. There was no documented evidence the resident had a [MEDICAL CONDITION] the morning of 01/08/17. Review of the faxed order to the pharmacy to request more Klonopin revealed it was sent on 01/07/17 at 12:54 P.M. On 01/09/17 at 1:59 P.M., Resident #102 was observed in bed. He was interviewed at 2:00 P.M. and stated he had a [MEDICAL CONDITION] on 01/08/17 in the therapy room. He said he was in the wheelchair doing arm strengthening exercises and the next thing he knew staff were putting him in bed. The resident stated, I had to be out for a while because the therapy room is on the other side of the facility. He said he has had many [MEDICAL CONDITION] at the facility causing him to fall. He said he blacks out especially when standing and stated the staff do not want him to walk by himself and wanted him to move about in the wheelchair. He stated he was walking with a walker with staff to get stronger. He stated he had a [MEDICAL CONDITION] a day or so before going to the hospital. He said he had to go to hospital because he hit his head when he fell after a [MEDICAL CONDITION] and it made him crazy. On 01/10/17 at 8:55 A.M., interview with Therapy Director (TD) #75 verified Resident #102 frequently received his restorative therapy in the therapy room. TD #75 verified she was aware he had multiple [MEDICAL CONDITION] but couldn't say when. On 01/10/17 at 9:20 A.M., restorative aide, STNA #52, was interviewed and verified Resident #102 was on a restorative ambulation program because he was not safe to walk independently because of his [MEDICAL CONDITION]. She stated it was reported to her the resident had a [MEDICAL CONDITION] over the weekend. On 01/10/17 at 10:22 A.M., phone interview with restorative aide STNA #34 verified Resident #102 was with her in the therapy room doing arm exercises on 01/08/17 when his eyes rolled back in his head. She said he became stiff and started to fall out of the wheelchair. She said she was able to grab his head so it did not hit the floor and continued to lower the resident to the floor. She was the only one in the therapy room and she left and got LPN #26 to assist. She said he had to have lost consciousness for several minutes and then they put him back in the wheelchair and put him in bed. She said she checked on him an hour later and he was still in bed and he did not remember anything. On 01/10/17 at 1:06 P.M., phone interview with LPN #26 verified she was the nurse present on 01/07/17 who did not administer the Klonopin as ordered for the 8:00 A.M. dose because the pharmacy made a mistake and did not give them enough medication. LPN #26 verified she called the pharmacy and was told they should not have ran out of the medication because he was to receive 0.25 mg twice a day. LPN #26 said she told the pharmacy he was ordered 0.50 mg twice a day. The pharmacy would not refill the Klonopin so she had to re-write the physician order for [REDACTED]. LPN #26 verified the facility had a contingency box of medication that contained Klonopin which she could have used. She indicated it was then 11:00 A.M. and past the time to give the medication and said she could not give it. LPN #26 said she told the night nurse, LPN #29, there was no Klonopin and she faxed the order to the pharmacy. The Klonopin was due again at 8:00 P.M. LPN #26 verified STNA #34 called her into the therapy room on 01/08/17 in the morning between 8:00 A.M. and 9:00 A.M. and Resident #102 was observed on the floor unresponsive. LPN #26 stated she went and got the resident's nurse for the day, LPN #21. LPN #26 said she was aware the resident has had [MEDICAL CONDITION] since being at the facility but couldn't say when or how often. On 01/10/17 at 2:01 P.M., phone interview with LPN #29 verified the resident did not receive his evening dose of Klonopin on 01/07/17 because there was none available. He said he was waiting to see if the shipment from pharmacy had the medication when it arrived, usually between 8:00 P.M. and 10:00 P.M. He said the shipment came later. LPN #29 said he was going to give the Klonopin to Resident #102 but he was sleeping so he did not give the resident the medication. LPN #29 stated the order of Klonopin was 0.5 mg twice a day. He verified he could have gotten the Klonopin from the contingency box but there was only himself and another nurse working so he did not want to pull the other nurse from her unit to sign when the medication was signed out, since it required two nurses. He verified he worked 01/08/17 in the evening and was told about Resident #102 having a [MEDICAL CONDITION] that day but was not sure of the time. He said he thought it was around morning medication pass time. On 01/10/17 at 3:00 P.M., interview with Resident #102 verified his [MEDICAL CONDITION] on 01/08/17 occurred in the morning but he could not remember if it happened before or after breakfast. The resident stated he was doing stretches with the arm band and the next thing he remembered was staff putting him in bed. He said he had to have been out for a while because STNA #34 said his eyes rolled to the back of his head, he became stiff and started to fall out of the wheelchair. He said she told him she helped him to the floor and went and got help. Then they put him back in the wheelchair and wheeled him back in bed. He couldn't remember anything until they were putting him in bed. He said he couldn't remember if he received his Klonopin in the morning of 01/08/17 before or after his [MEDICAL CONDITION]. He said none of the staff had been checking his eyes (neurological checks) or asking me questions related to hitting his head or his confusion. On 01/10/17 at 3:30 P.M., phone interview with Resident #102's physician verified he is also Medical Director (MD), MD #76. He verified he did not recall anyone notifying him of Resident #102 missing any doses of Klonopin on 01/06/16 or 01/07/17 and he said he was not notified this resident was receiving 0.5 mg instead of the 0.25 mg as ordered by the neurologist on 12/21/16. He said he was not notified of Resident #102's [MEDICAL CONDITION] on 12/10/16 or 01/08/17. MD #76 verified that Resident #102 missing those doses of Klonopin could have contributed to his [MEDICAL CONDITION] on 01/08/17. MD #76 verified he was not aware the resident had any [MEDICAL CONDITION] in December 2016 or January 2017. MD #76 verified he saw the resident on 12/29/16 and was told the resident was ordered 0.5 mg Klonopin twice a day by the neurologist. He was reviewing his progress note from 12/29/16 and verified he had not documented any evidence of [MEDICAL CONDITION] activity. The surveyor reviewed and verified with MD #76 the order on 12/21/16 written by the neurologist for 0.25 mg of Klonopin for [MEDICAL CONDITION] and it appeared there was a transcription error onto the MAR. The facility nurses were following the MAR and were administering Klonopin, 0.5 mg twice a day. MD #76 verified it was possible the higher dose of Klonopin could also be attributed to a [MEDICAL CONDITION]. On 01/10/17 at 3:50 P.M., phone interview with Pharmacy Tech (PT) #77 verified LPN #26 called her on 01/07/17 and was arguing with her because the facility ran out of Klonopin. PT #77 said they could not have ran out because it was packaged with 0.25 mg tablets to be given twice a day. She told the nurse they would not send more medication unless there was a physician order faxed for 0.50 mg of Klonopin to be given twice a day. At that time, Pharmacist #78 got on the phone and verified that missing doses of Klonopin could contribute to a [MEDICAL CONDITION] and missed doses would decrease the [MEDICAL CONDITION] threshold. On 01/10/17 at 4:48 P.M., interview with ED #1, Corporate Executive Director #79, Regional Nurse #80 and the DON verified the above concerns. On 01/10/17 at 7:12 P.M., phone interview with the restorative aide, STNA #34 verified LPN #21 and LPN #26 assisted her with putting Resident #102 back into the wheelchair and taking him to his room when he was still not acting himself. On 01/11/17 at 9:10 A.M., phone interview with LPN #21 verified when she arrived at the therapy room on 01/08/17, in the morning, she was told the resident was on the floor unresponsive for a couple minutes. She said STNA #34 and LPN #26 were in the room. LPN #21 said when the resident awakened he able to make very little eye contact and was not talking. When LPN #23 got to the therapy room a short time later the resident was able to say he had a [MEDICAL CONDITION]. She stated they did vital signs and checked his pupils. She said she and STNA #34 and LPN #26 put him back in his chair and he was still kind of out of it. STNA #34 and LPN #26 wheeled him back to his room and put him in bed. LPN #21 verified she did not document anything in the medical record or notify the physician. She said LPN #23 was his assigned nurse and she should have completed the documentation and called the physician. On 01/11/17 at 10:50 A.M., interview with ED #1 verified the lack of documentation related to Resident #102's [MEDICAL CONDITION] activity in the nursing notes. He verified there was no documentation related to his [MEDICAL CONDITION] on 01/08/17. On 01/12/17 at 11:12 A.M., an interview was completed with the DON, ADON, and RN #3. The ADON explained the process to reconcile narcotic/controlled medications. Each resident had an individual Controlled Substances Record for each prescribed narcotic medication. The record included the date, time, amount given and the quantity of remaining medication. If a narcotic medication was unavailable, the medication was taken from the narcotic stock supply. A Narcotic Switchout Box Lock Tracking Form was completed. The form included the date, resident's name, medication and quantity removed. The process required two nurses to reconcile the removal of the medication and the Narcotic Switchout Box Lock Tracking Form required each nurse's signature. RN #3 verified there was no evidence any Klonopin was taken from the switchout box when Resident #102 ran out of Klonopin for the 8:00 P.M. dose on 01/06/17 and review of the individual controlled substances record revealed the resident ran out of the Klonopin after the 8:00 A.M. dose on 01/06/17. Observation verified each resident had an individual Controlled Substances Record for each prescribed narcotic medication. Review of the notification of change in resident condition or treatment, updated 08/22/16, revealed in the event there was a significant change in health status the first priority was to meet the needs of the resident, communicate with the physician, implement any changes in orders, stabilize the resident and document the situation. It was the policy all physicians and families be notified of the following situations in regards to a resident: with an accident involving injury and had the potential to require physician intervention, a significant change in physical, mental, or psychosocial status in life threatening conditions such as a [MEDICAL CONDITION], pressure ulcers, uncontrollable behavior that cannot be managed by the facility requiring intervention, a need to alter treatment significantly, discontinue an existing form of treatment because of adverse consequences or begin a new treatment and decision to transfer or discharge resident from the facility. The change should be communicated at the time of the occurrence or before 10:00 P.M. If the situation occurs through the night and was without serious injury of effect on the resident the physician would be notified in the morning. Review of the pharmacy series and procedure manual for emergency medication supplies revised 01/03/17 revealed if emergency medication was needed the staff person would complete the interim/Stat/Emergency box withdrawal form to indicate the resident was in need of the medication. The facility must maintain a list of all medications in the box. For scheduled IV, controlled medications such as Klonopin, before the facility may access the medication the staff must receive authorization from the pharmacy confirming the pharmacy received: a faxed, written prescription transmitted by the physician/prescriber to pharmacy OR an oral prescription directly from the physician/prescriber to pharmacy. Review of the [MEDICAL CONDITION] precautions and support policy, not dated, revealed precautions and support would be performed according to Electro hyper sensitivity (EHS) procedure and implemented for residents who have a recent history of [MEDICAL CONDITION], head injury and or head surgery. The procedure included padded bedside rails and an airway at the bedside when indicated, do not move resident during [MEDICAL CONDITION] activity, maintain an adequate airway, protect resident from injury, place pad under head, loosen constrictive clothing and move furniture out of the way. After the [MEDICAL CONDITION], when respiration returns with flaccid state, turn head to side to facilitate drainage of mucous and prevent aspiration, stay with resident until fully conscious, reorient the resident to the environment, institute emergency care procedures if a second [MEDICAL CONDITION] activity follows and notify the physician. Document [MEDICAL CONDITION] activity and nursing actions in the nursing progress notes.

Based on observation, record review and interview, the facility failed to ensure appropriate and timely wound care treatments and assessments for Resident #131. This resulted in actual harm when Resident #131's stage one right ankle pressure ulcer dressing was not changed for seven days and the wound deteriorated to unstageable. The facility failed to ensure timely assessment, monitoring and interventions for Resident #91. This resulted in actual harm when Resident #91's heel pressure ulcer deteriorated to stage III. This affected two of four residents reviewed for pressure ulcers. Findings include: 1. Review of the medical record revealed Resident #131 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment was in progress, but had not yet been completed. Review of a Social Service note dated 01/09/17 at 09:27 A.M., indicated Resident #131 was alert and oriented times three and was independent for decision making skills. The Braden Scale, (tool for predicting the risk of developing pressure ulcers) dated 12/30/16 indicated Resident #131 was not at risk for developing pressure ulcers with a score of 21. The admission skin assessment dated [DATE] indicated Resident #131 was admitted with a stage one pressure ulcer to the right ankle that measured 1.0 centimeter by 1.0 centimeters with no depth. A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). A stage one pressure ulcer is an observable, pressure related alteration of intact skin. Review of a physician's orders [REDACTED].M. indicated to cleanse the right outer ankle with normal saline solution, pat dry, apply [MEDICATION NAME] with calcium alginate and a dressing. The order indicated the treatment was to be done once daily, on night shift. Review of a nurses' note dated 1/09/17 at 12:09 P.M. indicated Resident #131 was sent to the emergency room for evaluation. A nurse's note dated 1/09/17 at 14:54 revealed the resident was admitted to the hospital and a nurse's note dated 1/10/17 at 2:17 P.M. indicated Resident #131 was readmitted to the facility. The note indicated, no skin issues to report at this time. The re-admission skin assessment dated [DATE] at 2:19 P.M. indicated Resident #131 had No skin issues at this time. During an interview on 1/11/17 at 4:45 P.M., Resident #131 reported that she was feeling much better. However, Resident #131 reported to the surveyor that her right ankle was painful. She revealed she had a sore on her ankle and they (facility nurses) had not changed the dressing in days. Resident #131 permitted the surveyor to observe the dressing. An intact dressing was in place on Resident #131's right ankle that was dated 1/04/17. On 1/11/17 at 4:55 P.M., Registered Nurse (RN) #16 verified the dressing on Resident #131's right ankle was dated 1/04/17. RN #16 acknowledged the dressing was to be changed once per day. RN #16 removed the old dressing; a small amount of yellowish drainage was noted on the dressing. The wound was approximately 1.5 cm by 1.5 cm with an undetermined depth. The wound bed was covered with a white (puss like) substance with a yellow area noted in the center. The periwound was noted to be white. The observation was verified with RN #16. The pressure ulcer was consistent with an unstageable pressure ulcer. A pressure ulcer is unstageable when the depth of the wound cannot be determined, due to the wound bed being covered. 2. Resident #91 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Brief Interview of Mental Status (BIMS) assessment dated [DATE] revealed Resident #91 was cognitively intact. Review of an MDS assessment dated [DATE] revealed Resident #91 required extensive assistance with dressing and bed mobility. Review of a nurse progress note dated 12/07/16 revealed Resident #91 was hospitalized for [REDACTED]. Review of a nurse-to-nurse report progress note dated 12/13/16 revealed Resident #91 was admitted to the hospital for shortness of breath and exacerbation of the [MEDICAL CONDITION]. Resident #91 was dependent on oxygen, had periods of confusion and required maximum assistance for transfers from the bed to chair. Resident #91 was incontinent of urine. Resident #91 was being treated with intravenous (IV) antibiotics for positive blood cultures. The IV antibiotics were to continue upon readmission to the nursing facility. The same nurse-to-nurse report revealed Resident #91 did have complaints of left foot pain and the left foot was slightly swollen. However, the test to determine the presence of a [MEDICAL CONDITION] (blood clot) was negative. The pain was treated with Tylenol and [MEDICATION NAME] (a narcotic [MEDICATION NAME]). Resident #91 returned to the nursing facility and was readmitted the afternoon of 12/13/16. Review of a readmission skin assessment dated [DATE] revealed Resident #91 had bruises on both knees and on the abdomen. The resident's skin was intact. Review of an assessment for predicting the risk for developing a pressure ulcer dated 12/15/16; revealed Resident #91 was at a low risk for development of a pressure ulcer. Review of a BRADEN Scale dated 12/22/16 revealed Resident #91 remained at a low risk for development of a pressure ulcer. However, the score declined related to changes in sensory perception and friction and shear. Sensory perception declined from slightly limited (some sensory impairment which limits the ability to feel pain or discomfort in one or two extremities) to very limited (sensory impairment which limits the ability to feel pain or discomfort in over half of the body). Friction and shear declined from no apparent problem (moves in bed and chair independently and has sufficient muscle to lift up) to a potential problem (moves feebly or requires minimum assistance. During a move, skin probably slides to some extent against sheets, chair, restraints or other devices). Review of Occupational Therapy notes dated 12/21/16 and 12/22/16 revealed Resident #91 required maximum assistance to put on both shoes. A Reacher (adaptive device) was provided to promote independence in lower body dressing tasks. Review of a physical therapy note revealed Resident #91 participated in gait training with the use of a wheeled walker. Review of an occupational therapy note dated 12/25/16 revealed Resident #91 complained of left foot pain. Resident #91 identified the pain on a scale of 1 (minimum) to 10 (maximum) as a 9. The same note revealed the therapist notified the nurse to provide pain medication. Review of a Weekly Wound Documentation dated 12/26/16 and Physician Assistant (PA) #222 progress note dated 12/26/16 revealed, a Stage III pressure ulcer was found on Resident #91's left heel on 12/25/16. A Stage III pressure ulcer is defined as a full thickness tissue loss. Slough (dead tissue) may be present but does not obscure the depth of tissue loss. The wound measured 2.1 centimeters (cm) length x 3.0 cm width x 0.1 cm depth. The wound was 100% pink tissue with macerated wound edges and loose skin. A small amount of serosanguinous exudate noted. Resident #91 reported mild pain with wound care. The same note revealed Resident #91 did not have off-loading boots. An observation of wound care was completed on 01/11/17 at 10:35 A.M. The resident's left heel pressure ulcer measured 2.5 cm x 2.9 cm x 0.1cm. The wound bed was less than 25% white tissue (slough) and 75% pink tissue. A small amount of serosanguinous drainage was noted. An interview was completed with Resident #91 at the time of the dressing change. Resident #91 revealed she believed she developed the heel wound because her feet were rubbing on the bed sheets. An interview was completed with the wound nurse, Licensed Practical Nurse (LPN) #25, on 01/11/17 at 10:42 A.M. upon completion of the wound care. LPN #25 verified the heel wound developed in the facility and was identified on 12/25/16 as a Stage III pressure ulcer. However, review of the occupational and physical therapy notes revealed services including gait training and application of socks and shoes continued on 12/27/16, 12/28/16, 12/29/16, 12/30/16 and 01/02/17. The first reference of a heel wound was 01/03/16 with the application of a PRAFO boot (an ankle/foot orthotic device to eliminate pressure) to the left lower extremity for heel wound care and prevention. Review of PA #222 ' s progress note dated 01/02/17 revealed Resident #91 was ordered PRAFO boot last week. An interview was completed with Therapy Rehabilitation Director, Physical Therapy Assistant (PTA) #75, on 01/11/17 at 11:02 A.M. PTA #75 was asked when the therapy department became aware Resident #91 had a pressure ulcer on the left heel. PTA #75 checked her morning meeting notes and revealed she was notified of the heel wound on 01/03/17. PTA #75 also verified Resident #91 wore white sneakers everyday while gait training therapy continued, through 01/03/17. PTA #75 revealed gait training would not be done without shoes, and shoes should never be applied over a pressure ulcer on the heel. During the same interview PTA #75 revealed the therapy staff may not have seen the dressing because the shoes were probably applied by the staff on the unit. Review of current physician orders [REDACTED]. 12/26/16 Float bilateral heels while in bed 01/03/17 PRAFO boot to left heel when out of bed. 01/05/17 Give (Resident #91) one ounce of Prostat twice a day (Prostat is a protein supplement to promote wound healing) 01/09/17 Prevalon boots (thick, soft heel protectors) to bilateral heels while in bed. An interview was completed with the Director of Nursing (DON) on 01/11/17 at 4:49 P.M. The DON verified there was no evidence of routine skin assessments for Resident #91.

Based on record review and interview, the facility failed to ensure a baseline [MEDICATION NAME] level was obtained at the time of admission for Resident #131, on 12/20/16. This resulted in actual harm when Resident #131's lab work on 01/09/17 revealed elevated [MEDICATION NAME] levels requiring her to be sent immediately to the emergency room . Resident #131 was admitted to the hospital on the telemetry unit for [MEDICATION NAME] toxicity. The facility also failed to ensure Resident #102 was assessed, monitored and educated on the risks of a new medication, [MEDICATION NAME], related to a potentially life threatening rash. This affected two of six residents reviewed for unnecessary medications. Findings include: 1. Resident #131 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment was in progress, but had not yet been completed. A social service progress note dated 01/09/17 at 9:27 A.M. indicated Resident #131 was alert and oriented times to person, place and time and was independent for decision making skills. On 12/20/16, the physician ordered [MEDICATION NAME], extended release tablets, 450 milligrams (mg) to be given once per day at bedtime. [MEDICATION NAME] is a mood stabilizer prescribed for the treatment of [REDACTED]. This warning also indicated prompt and accurate serum [MEDICATION NAME] determinations should be available before initiating therapy. [MEDICATION NAME] toxicity can result in coma, brain damage or death. On 01/02/17, blood was drawn for laboratory testing for Resident #131, however no [MEDICATION NAME] level was obtained. Laboratory test results from blood collected on 01/09/17 at 7:05 A.M., revealed Resident #131's [MEDICATION NAME] level was high at 1.59 with the normal reference range being 0.60 to 1.20. Resident #131 was interviewed on 01/09/17 at 9:43 A.M. and she reported she was not feeling well. She said she had been in therapy, however she said she had to leave early because she was feeling very tired. The nurse's note dated 01/09/17 at 12:09 P.M. revealed Resident #131 was sent to the emergency room , per physician's direct order, due to abnormal laboratory results. The nurse's note dated 01/09/17 at 2:54 P.M. revealed Resident #131 was admitted to the hospital with [REDACTED]. The Hospital Patient Health Summary dated 01/10/17 revealed Resident #131 presented in the emergency room with generalized weakness. Resident #131 reported becoming confused in the morning. Resident #131 complained of leg pain and weakness and stated she had felt generally weak that morning. Resident #131 was admitted to the hospital and was monitored on telemetry, a unit where special equipment is used to continuously monitor the electrical activity of the heart, heart rate, blood pressure, breathing and oxygen levels for a person. The hospital Discharge Summary dated 01/10/17 listed the admitting [DIAGNOSES REDACTED]. The nurse's note dated 01/10/17 at 2:17 P.M. indicated Resident #131 was readmitted to the facility. During an interview on 01/11/17 at 10:50 A.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON), Registered Nurse (RN) #3, acknowledged there were certain medications, including [MEDICATION NAME], that mandated strict monitoring of blood levels of the medication, due to their narrow therapeutic range and potential for toxicity. The ADON verified Resident #131 was prescribed [MEDICATION NAME] and said she had reviewed Resident #131's physician's orders [REDACTED]. The DON and ADON verified the physician did not order an admission [MEDICATION NAME] level and acknowledged that physicians miss those things at times. The DON and ADON agreed that an order to obtain [MEDICATION NAME] levels should have been requested upon admission. The DON indicated it would have been her expectation for the facility to acquire a serum [MEDICATION NAME] level upon admission for any resident admitted on [MEDICATION NAME]. The DON indicated for any new resident, staff should obtain a copy of the medication orders at the time of referral, so that such things would be caught. The DON and ADON verified the Black Box warning indicated that serum [MEDICATION NAME] levels should have been obtained prior to initiating [MEDICATION NAME] for Resident #131. 2. Resident #102 was admitted to the facility on [DATE] with including major [MEDICAL CONDITIONS], dementia without behavior disturbances, [MEDICAL CONDITION], tremors and unspecified [MEDICAL CONDITION]. The MDS 3.0 assessment dated [DATE] indicated Resident #102 was alert and oriented and was independent for decision making abilities. Resident #102's [MEDICAL CONDITION] medication plan of care was effective until 04/03/17. The plan of care expressed a goal for Resident #102 to remain free of drug related complications. An intervention included for Resident #102 to be observed for side effects and adverse reactions related to medications. The consultant neurologist's progress note dated 12/21/16 included an order to start [MEDICATION NAME] (an anti-[MEDICAL CONDITION] medication) slowly, to be increased to an effective dose. The physician wrote for the [MEDICATION NAME] to be gradually increased, as follows: give 25 mg weeks one and two; 50 mg weeks three and four; 100 mg week five; 150 mg week six and 200 mg weeks seven and eight. The neurologist cautioned that [MEDICATION NAME] had a small risk for the development of a dangerous rash that could be life threatening, called Stevens-Johnso[DIAGNOSES REDACTED]. He explained the rash usually developed in the first two to eight weeks while taking the [MEDICATION NAME]. He indicated the risk of the rash was much lower if the dose was slowly increased, rather than started suddenly at a high dose. The neurologist wrote, It is very important that you follow the instructions to slowly increase the dose to reduce the risk of this dangerous rash. The neurologist wrote, in bold print: If you develop any rash while taking [MEDICATION NAME], do not take additional [MEDICATION NAME]. Stop taking it immediately. These instructions indicated the neurologist should be notified if a rash developed. If the rash was severe or spreading rapidly, she directed the staff to send Resident #102 to the emergency room . The Black Box warning, located next the the name of the drug on the electronic MAR, warned that Serious skin rashes could occur and that [MEDICATION NAME] can cause serious rashes requiring hospitalization and would require discontinuation of the medication. The incidence of these rashes, which have included Stevens-Johnso[DIAGNOSES REDACTED] and rare cases of toxic [MEDICATION NAME] necrolysis and/or rash related death have been reported in adults and pediatric patients. The nurse's notes from 12/21/16 to 01/11/17 did not reveal any nursing assessments related the potential rashes caused by [MEDICATION NAME]. There was no documentation found in these notes to indicate education was provided to Resident #102 related to the potential rash and the need to report any rashes immediately. During an interview on 01/11/17 at 10:10 A.M., Resident #102 verified he went to the neurologist and she changed his medications. Resident #102 indicated that no one in the facility explained to him that he should notify them of any skin changes or rashes. Resident #102 said none of the facility nurses were checking him for skin changes or rashes. During an interview on 01/12/17 at 2:58 P.M., the DON and ADON #3 verified Resident #102's neurologist's progress note on 12/21/16 explained the risk of a dangerous, possibly life threatening reaction, presenting as a rash, especially during the first eight weeks after starting [MEDICATION NAME]. They also verified the Black Box warning on the computerized MAR indicated [REDACTED]. They verified there was no documented evidence of education for Resident #102 related to the potential adverse reactions of [MEDICATION NAME] nor was there any documentation that facility nurses had performed on-going assessments of Resident #102 for the rash. The DON revealed that it was her expectation, when residents return from physician appointments, the nurses were to review the progress notes very carefully, so that things like this were not missed. The DON indicated this was basic nursing. During an interview on 01/12/17 at 4:11 P.M., Licensed Practical Nurse (LPN) #30 verified that she was not aware of the Black Box warning for [MEDICATION NAME]. After notifying the facility of the potential life threatening rash, nurse's notes from 01/12/17 through 01/13/17 at 2:22 P.M. still did not included any documentation to indicate Resident #102 had been educated related to the potential life threatening rash or that facility nurses had completed any skin assessments. This concern was reviewed and verified on 01/13/17 at 2:22 P.M. with Corporate Regional RN #80.

Based on medical record review, policy review, review of a self-reported incident (SRI) and facility investigation, review of Ohio Board of Nursing complaint form, review of personnel files, and staff interview, the facility failed to ensure one resident (Resident #71) was free from neglect. Resident #71 was not provided services and treatment to obtain sustained relief from repetitive complaints of shortness of breath. Resident #71 was denied requests for oxygen and immediate requests to be sent to the hospital for evaluation and treatment. This resulted in Immediate Jeopardy for Resident #71 who sustained actual harm when she experienced respiratory distress resulting in hospitalization and intubation. Resident #71 expired the day following hospital admission. This affected one of three residents reviewed for hospitalization and/or death. The Administrator and Director of Nursing (DON) were notified on [DATE] at 1:40 P.M. Immediate Jeopardy began on [DATE] at 10:00 A.M. when Resident #71 complained of shortness of breath and began requesting to go to the hospital. Throughout the remainder of the shift, which ended at 6:00 P.M., Resident #71 continued to make multiple complaints of shortness of breath, requesting oxygen and making additional requests for transfer to the hospital, asking what she was supposed to do when her requests were denied. Resident #71 became fearful of being left alone and grabbed the arm of State tested Nursing Assistant (STNA) #122 at 6:15 P.M., pleading for help. Resident #71 was admitted to the hospital on [DATE] (no time documented) and placed in intensive care on a ventilator. Licensed Practical Nurse (LPN) #100 , the nurse assigned to care for Resident #71 on the 6:00 A.M. to 6:00 P.M. shift on [DATE] continued to work. The Immediate Jeopardy was removed on [DATE] at 5:30 P.M. when the facility implemented the following corrective actions: · On [DATE] at 6:38 P.M., LPN #101 notified Physician #60 and received an order to send Resident #71 to the hospital for evaluation. Resident #71 was admitted to the hospital with [REDACTED]. · On [DATE], an allegation of neglect was reported to the Administrator by STNA #120. · On [DATE], the Executive Director, DON, and Administrative Assistant began investigating the allegations of neglect against LPN #100. Forty-three (43) of 58 staff members were interviewed and voiced no knowledge of similar occurrences. · On [DATE] starting at 6:00 P.M., LPN #100 was suspended pending investigation of allegations of neglect. · On [DATE], the Executive Director, DON, and Administrative Assistant began re-educating 43 of 58 staff regarding the Mistreatment, Abuse, Neglect and Misappropriation of Resident Property policy. All but one nurse, who was on vacation, were educated during a monthly nursing meeting held [DATE]. The Executive Director, DON, and Administrative Assistant began doing 1:1 education regarding the neglect policy for those 43 staff who worked on [DATE]. The education was completed between 2:00 P.M. and 6:00 P.M. · On [DATE], LPN #100 ' s employment was terminated. · On [DATE] by 5:30 P.M. nursing assistants received additional education of the policy on neglect during a STNA meeting. Three STNAs who did not attend the meeting were provided one on one education by the DON. One of the STNAs worked on an as necessary basis and was trained the first shift she worked and one was on medical leave. · On [DATE] between 9:05 A.M. and 9:27 A.M. interviews with Housekeeper #141, LPN #105 and STNA #121 verified they were knowledgeable in regard to recognizing and reporting neglect and had received education regarding the facility policy on neglect. · On [DATE] all LPNs and registered nurses (RNs) had received education regarding the facility neglect policy. · On [DATE] at 7:50 A.M. and 4:28 P.M. interviews with Housekeeper #140 and STNA #120 verified they were knowledgeable in regard to recognizing and reporting neglect and had received education regarding the facility policy on neglect. · On [DATE] the Executive Director began completing evaluations of 12 of 58 employees to determine if they were able to recall the proper steps to take if neglect was suspected or witnessed. · On [DATE] all staff except one STNA, who remained on medical leave, had received training on the neglect policy. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level II (no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy) as the facility has not developed a formal systemic plan to ensure residents were free from neglect and a monitoring system to ensure continued compliance. Findings include: Review of Resident #71 ' s closed medical record revealed an initial admission date of [DATE]. Resident #71 was hospitalized on [DATE] with a [DIAGNOSES REDACTED]. Resident #71 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the March, 2016 Medication Administration Record [REDACTED]. There was no documented evidence to support if the resident requested the prn breathing treatments. Review of the April, 2016 MAR indicated [REDACTED].M. and was effective. Coding on the MAR indicated [REDACTED]. The April, 2016 MAR indicated [REDACTED].M. for pain and was effective. Other than the notes regarding medication administration, there was no documentation on Resident #71 ' s medical record on the 6:00 A.M. to 6:00 P.M. shift on [DATE]. A nursing note by LPN #101 (the night shift nurse) dated [DATE] at 6:30 P.M. indicated Resident #71 ' s intake of food and/or fluid was decreased, she had shortness of breath, nausea /vomiting and pain. The note indicated the symptoms started in the morning on [DATE]. Resident #71 ' s vital signs were recorded as follows: blood pressure ,[DATE], pulse 102 and regular, respirations 20, and temperature 99.2 temporal. No changes were noted in Resident #71 ' s mental status, she needed more assistance with activities of daily living, and she was exhibiting labored breathing and had abnormal lung sounds. A subsequent nursing note written by LPN #101 dated [DATE] at 6:38 P.M. indicated Resident #71 complained of increased shortness of breath and pain throughout her chest. Resident #71 ' s oxygen saturation was 79% on room air. After oxygen at two liters per nasal cannula was applied, the oxygen saturation was 98%. A [MEDICATION NAME] treatment was administered. Respirations were hard and labored. Lungs were wheezy throughout the upper lobes. The DON and Physician #60 were notified and LPN #101 was advised to send Resident #71 to the emergency room . A nursing note dated [DATE] at 1:45 A.M. indicated Resident #71 was admitted to the hospital intensive care unit and was on a ventilator due to acute [MEDICAL CONDITION]. On [DATE] at 5:10 P.M., LPN #100 documented that on [DATE] (the previous day) Resident #71 was complaining of shortness of breath throughout the day but vital signs remained stable with a blood pressure of ,[DATE], pulse of 20, oxygen saturation of 90% on room air, and a temperature of 98.9. LPN #100 documented Resident #71 ' s vitals stable at this time . A social service progress note dated [DATE] at 10:04 A.M. revealed Resident #71 expired at the hospital on [DATE]. Review of an Emergency Department report dated [DATE] indicated Resident #71 was a [AGE] year old who presented to the emergency department via Emergency Medical Services (EMS) for shortness of breath. There was conflicting history submitted of cyanosis and shortness of breath all day versus one hour according to nursing staff. EMS reported they gave Resident #71 a breathing treatment en route but were unable to obtain intravenous access. Resident #71 reported she had a cough but could not say if it was productive. The emergency department report dated [DATE] indicated the physical exam revealed Resident #71 was in moderate respiratory distress with coarse rhonchi (rattling respiratory sounds) and rales (abnormal rattling sound heard when examining unhealthy lungs with a stethoscope) bilaterally and her extremities were cyanotic (had a blue or purplish discoloration). Resident #71 was awake and oriented. A chest x-ray revealed bilateral alveolar infiltrates suspicious for pneumonia. Resident #71 ' s pulse oximetry was 74% on room air at 7:44 P.M. and she had [MEDICAL CONDITION] (a deficiency in the amount of oxygen reaching her tissues). Resident #71 ' s blood pressure was ,[DATE] at 7:35 P.M. and ,[DATE] at 7:50 P.M. Resident #71 was placed on bi-pap (a form of non-invasive ventilation) at 7:30 P.M. but after her pulse ox failed to rise, a decision to intubate was made at 10:08 P.M. with resident consent. Resident #71 was given antibiotics ([MEDICATION NAME] and [MEDICATION NAME]) in the emergency department, fluids, Versed (medication used for anesthesia, procedural sedation, trouble sleeping, and severe agitation) and started on a [MEDICATION NAME] drip (medication generally used in emergency situations when blood circulation is compromised, causing an individual to go into shock). A 12-lead electrocardiogram (EKG) showed sinus [MEDICAL CONDITION] a heart rate of 134. Medical problems were listed as acute [MEDICAL CONDITION] with [MEDICAL CONDITION] and hypercapnia (carbon [MEDICATION NAME] retention), [MEDICAL CONDITION] of the liver, peripheral arterial occlusive disease, [MEDICAL CONDITION]. Review of the facility SRI form revealed on [DATE] an unidentified STNA reported to the facility ' s Executive Director that Resident #71 was asking for help because she was having difficulty breathing. The STNA reported the need for help to LPN #100 and the STNA alleged proper steps were not taken to help Resident #71. The incident was reported to have occurred on [DATE] at 10:00 A.M. in Resident #71 ' s room. The reporting STNA indicated Resident #71 was using her call light more frequently, as often as 15 minute intervals requesting assistance. The STNA stated Resident #71 requested to go to the hospital and LPN #100 was notified of the request. During the investigation, LPN #100 ' s nursing documentation was inconsistent with her investigative statement. The STNA was unable to continually observe the nurse in question. A second interview of the reporting STNA revealed her assessment of the 15 minute intervals was an assumption of time passed and not actually times. The facility did not substantiate the allegations of neglect. Review of the facility ' s investigation, including witness statements, revealed the following: A witness statement by STNA #120 indicated on [DATE] Resident #71 asked for help more than she normally did. Resident #71 asked for a breathing treatment and suctioning. Resident #71 complained she could not get her breath to talk. Resident #71 requested her vital signs be taken. All her requests were reported to the nurse. Resident #71 asked to be sent to the hospital. STNA #120 indicated she got the equipment to monitor the vital signs and Resident #71 ' s pulse ox was ranging from 70% to 72%. Resident #71 continued to ask for help. STNA #120 reported LPN #100 said if Resident #71 turned blue she would not help. Resident #71 ' s son visited and wanted Resident #71 sent to the hospital but was told she was fine. STNA #120 indicated she did not feel resident care was a priority for LPN#100. STNA #120 indicated Resident #71 started asking for help at 9:00 A.M. A witness statement by STNA #121 indicated on [DATE], he noticed Resident #71 ringing her call bell often due to vomiting or lack of air. When he told LPN #100 the first time, LPN #100 indicated she had given Resident #71 something for vomiting. Later in the day, STNA #121 stated he was walking by and noticed Resident #71 waving as if in distress and he placed her breathing treatment back on her face and informed LPN #100 it had been off and she seemed to be struggling. LPN #100 responded Resident #71 would be fine, that she had checked her oxygen and it was in the 90's and she was just being a cry baby and drama queen . STNA #121 documented LPN #100 went to check on Resident #71 and told her to leave her breathing machine on or she was going to take it off. STNA #121 indicated he started working on Resident #71 ' s hall at 6:00 P.M. on [DATE]. Resident #71 put her light on again so the other aide got the midnight nurse's pulse ox clip to check the oxygen level. It read in the mid 70% ' s and action was taken by the midnight nurse. STNA #121 indicated in his opinion, Resident #71 ' s initial cries for help were not taken as seriously as they should have been. A witness statement by LPN #102 revealed she was sitting at the nursing station with LPN #100, Resident #71 ' s nurse, on [DATE] when aides informed LPN #100 that Resident #71 wanted to go to the hospital and was complaining of shortness of breath. LPN #100 asked the aide to go get the machine the facility used to record vital signs. LPN #100 went to Resident #71 ' s room then returned to ask for LPN #102 ' s automatic blood pressure cuff because she could not get a reading. After LPN #100 returned to the desk, Resident #71 continued to continuously put her call light on. LPN #102 indicated STNAs were answering the call light and went to LPN #100 several times to tell her Resident #71 requested to go to the hospital, get breathing treatments and to report she was short of breath. When Resident #71 ' s son visited, LPN #100 requested LPN #102 go into the room with her. LPN #100 explained to Resident #71 ' s son that Resident #71 ' s blood pressure was stable and her oxygen saturations were around 90% to 91%. LPN #102 indicated she never re-entered Resident #71 ' s room the rest of the shift but Resident #71 continued to put her call light on throughout the shift. A form with questions and responses by LPN #102 signed [DATE] revealed around 10:00 A.M. on [DATE], Resident #71 was complaining of shortness of breath and wanted to go to the hospital. Resident #71 ' s voice was raspy and she had some labored breathing. LPN #102 indicated she was unsure if an assessment was completed and she only recalled LPN #100 taking vital signs around 3:00 P.M. because she asked to use her blood pressure cuff. LPN #102 indicated she did not witness a change in condition form being completed. The physician was not notified and LPN #102 was not sure why. LPN #102 indicated Resident #71 notified her son but LPN #100 did not notify any family. LPN #102 indicated she did not feel the situation was handled appropriately because the physician, DON, and family were not notified by staff. A witness statement by LPN #100 indicated when Resident #71 returned from smoke break (did not indicate a time), she complained of shortness of breath and a [MEDICATION NAME] treatment was administered according to her request. LPN #100 indicated Resident #71 ' s oxygen level was 90% on room air. LPN #100 indicated Resident #71 ' s son visited around 12:00 P.M. and she took Resident #71 ' s vital signs again and they were within normal limits. A breathing treatment was requested at 5:00 P.M. due to shortness of breath and her oxygen saturation was (looks like started to write 90 but changed to 92%). The statement indicated a breathing treatment was administered. An additional form with questions and responses by LPN #100 signed [DATE] indicated Resident #71 complained of dizziness after the 10:00 A.M. smoke break and she got the STNAs to help lay her down. LPN #100 indicated she took vital signs around 10:30 A.M. and they were stable. Resident #71 did request to go to the hospital around 10:45 A.M. Vitals were taken again and her oxygen saturation was 91%. A [MEDICATION NAME] treatment was administered and Resident #71 seemed pleased. Around 11:45 A.M., Resident #71 turned her call light on and reported she was hot and wanted the window open. No care path was followed. No change in condition was initiated. The statement indicated a pain pill ([MEDICATION NAME]) was administered according to resident request at 11:45 A.M. for back pain (note: not supported by MAR indicated [REDACTED]. Resident #71 notified her son and he visited the facility around 12:30 - 1:00 P.M. Around 4:30 - 5:00 P.M., Resident #71 complained of shortness of breath again and another [MEDICATION NAME] was administered (not supported by documentation on the MAR). A witness statement by RN #160 signed [DATE] indicated she was doing walking rounds on [DATE] at approximately 11:20 A.M. on the front hall and responded to Resident #71 ' s call light. Resident #71 indicated she felt short of breath and wanted a breathing treatment. RN #160 indicated she reported the request to LPN #100. Both LPN #100 and LPN #102 were sitting at the nursing station. LPN #100 stated she would give her a breathing treatment. RN #160 indicated she asked LPN #100 and LPN #102 if they had any resident concerns and both denied any, indicating it was quiet . A witness statement by LPN #101 indicated on [DATE] LPN #100 reported Resident #71 complained of shortness of breath and pain throughout the shift. LPN #100 reported oxygen saturations were high 80 ' s to low 90 ' s on room air. LPN #102 reported Resident #71 had been on her call light all shift constantly. LPN #100 and LPN #102 reported Resident #71 wanted to go to the hospital but did not need to, She was just being normal (resident ' s name). At approximately 6:25 P.M., after count was complete, STNA #122 requested LPN #101 ' s pulse oximeter and reported an oxygen saturation of 79%. A concentrator was obtained and oxygen was applied at two liters via nasal cannula. Resident #71 was instructed on proper breathing technique and vital signs were obtained. A [MEDICATION NAME] treatment was provided. Resident #71 was alert and oriented but extremely anxious, not wanting to be left alone for a moment. The DON and physician were notified and transfer to the hospital was approved. A witness statement by STNA #122 indicated about 6:15 P.M. on [DATE], she responded to Resident #71 ' s call light. Resident #71 was noticeably wheezing and slightly yellow. Resident #71 grabbed STNA #122 ' s wrist and stated just please help me . Resident #71 ' s pulse ox at 6:20 P.M. was 79%. Resident #71 was very afraid to be alone. Review of an Ohio Board of Nursing complaint form and supplemental information form sent to the Ohio Board of Nursing revealed LPN #100 had previous discipline history for practice issues. The report indicated an error on [DATE] in which a resident was sent to the hospital and the error may have contributed to or resulted in the patient ' s death. The form indicated the resident was observed and monitored but documentation was inconsistent with what allegedly occurred. Poor judgment in delegation and supervision of other staff members and inappropriate acceptance of assignment or accepting a delegated action beyond nurse's knowledge and skills were listed as clinical reasoning being factors in practice breakdown. Preventive measure for resident well-being were not taken and LPN #100 did not provide skillful and timely intervention, did not follow standard protocol/order, failed to advocate for patient safety and clinical stability, did not refer to additional services as needed, and specific resident requests or concerns were unattended. During an interview with STNA #121 on [DATE] at 9:27 A.M., he reported on [DATE] he observed Resident #71 waving and in distress, clenching at her shirt. Resident #71 complained of difficulty breathing and it was reported to LPN #100 who told STNA #121 she had checked on Resident #71 and her numbers were fine. Resident #71 complained of shortness of breath throughout the day. STNA #121 stated Resident #71 was a smoker and although she usually stayed in bed a lot of the time, she always made sure she was up for smoke break. That day, Resident #71 missed smoke breaks. Resident #71 asked to go to the hospital multiple times. Although Resident #71 had a history of [REDACTED]. STNA #121 reported LPN #102 was observed meeting with Resident #71 ' s son on [DATE] and assured him LPN #100 was checking on Resident #71. STNA #121 stated he worked over on [DATE] and within 20 minutes of the next shift starting, Resident #71 was sent to the hospital. STNA #121 stated Resident #71 was audibly wheezing and struggling to breathe during the day. STNA #121 verified Resident #71 had an aerosol machine running around 4:30 - 5:00 P.M. on [DATE] but LPN #100 was not in the room during the medication administration and Resident #71 had removed the mask. STNA #121 stated he assisted Resident #71 in reapplying the mask and instructed her about the importance of keeping it on so she could get the full treatment. During an interview on [DATE] at 12:19 P.M., STNA #123 reported on [DATE] she responded to Resident #71 ' s call light soon after her shift started at 12:00 P.M. Resident #71 complained of shortness of breath. STNA #123 stated Resident #71 had a raspy voice but she had noticed it three days prior. Resident #71 requested her window be opened. STNA #123 stated she reported Resident #71 ' s complaints of shortness of breath and the request to have the window opened to LPNs #100 and #102. Resident #71 turned her call light on again because she still did not feel she was getting enough air. STNA #123 was unaware of the time. Resident #71 requested a breathing treatment which STNA #123 reported to LPN #100 who said it was too early because Resident #71 had a breathing treatment when she went out for smoke break (smoke break at 10:00 A.M.). STNA #123 stated when she reported LPN #100 ' s response to Resident #71; the resident asked what she was supposed to do. STNA #123 stated she went back and asked LPN #100 who said she would talk to Resident #71. Before LPN #100 went to talk to Resident #71, the call light was on again and Resident #71 stated her son told her to get oxygen on. STNA #123 stated she asked LPN #100 and LPN #102 if Resident #71 could have oxygen applied. LPN #100 stated Resident #71 did not have an order for [REDACTED]. During an interview on [DATE] at 2:01 P.M., LPN #102 stated on [DATE] Resident #71 put the call light on a lot. Nursing assistants kept telling LPN #100 that Resident #71 wanted to see her. Resident #100 was complaining of shortness of breath and wanted to go to the hospital. This all started around 10:00 A.M. Between 3:00 and 4:00 P.M., Resident #71's son visited and LPN #100 requested LPN #102 go into Resident #71's room with her to talk to the son. LPN #102 stated Resident #71's voice was very raspy and she had labored breathing but labored breathing was not unusual for the resident. LPN #102 verified Resident #71 did not usually complain of difficulty breathing and was acting differently. LPN #102 verified Resident #71 was alert and oriented. LPN #102 stated Resident #71 ' s behaviors and the prolonged, frequent complaints of shortness of breath did not set off any alarms at that time. LPN #102 reported LPN #100 did not monitor Resident #71 ' s vital signs while they were meeting with Resident #71 ' s son. LPN #102 verified RN #160 (the nurse supervisor) was working [DATE] but she never reported Resident #71 ' s ongoing complaints, ineffectiveness of the actions of LPN #100 to relieve Resident #71 ' s distress, or Resident #71 ' s multiple requests to go to the hospital to RN #160. LPN #102 was asked if alert and oriented residents with medical complaints requested to go to the hospital, what the facility's policy was on sending them. LPN #102 stated she would contact the DON after assessing the resident. On [DATE] at 2:11 P.M, the DON, who was present due to LPN #102 ' s request, stated nobody called her on [DATE] about Resident #71's condition or her requests to go to the hospital. The DON stated when residents requested to go to the hospital, nurses were expected to do a head to toe assessment of the resident and determine if the resident could be treated in house and notify her. If it was believed the resident could be treated in house, the resident would be educated. If a resident was adamant about going to the hospital, it was their right. During an interview on [DATE] at 7:53 A.M., RN #160 stated she worked [DATE] from 11:00 A.M. to 4:30 P.M. RN #160 stated she answered Resident #71 ' s call light and told LPN #100 of the request for a breathing treatment. LPN #100 indicated she would give Resident #71 a breathing treatment and did not state it was too early for her to have one or indicate one had been administered after the 10:00 A.M. smoke break. RN #160 stated none of the staff who witnessed Resident #71 ' s distress or heard her requests to be sent to the hospital alerted her to Resident #71 ' s ongoing concerns with shortness of breath. During an interview on [DATE] at 4:28 P.M., STNA #120 stated Resident #71 was more needy than usual on [DATE]. STNA #120 stated nursing assistants kept reporting Resident #71 ' s concerns to LPN #100. STNA #120 stated LPN #100 stated to her she would not help Resident #71 if the resident was turning blue. STNA #120 stated she obtained the vital sign machine for LPN #100 and observed the oxygen saturation was reading in the low 70 ' s. STNA #120 stated when Resident #71 ' s son visited he was very loud and stated clearly he wanted Resident #71 sent to the hospital. Resident #71 ' s son met with LPN #100 and LPN #102 and STNA #120 verified she did not know what the conversation was after they entered Resident #71 ' s room. During a telephone interview on [DATE] at 3:32 P.M., the medical director stated if a resident had labored breathing and use of breathing treatments were ineffective, he would expect staff to phone the physician and the resident would be sent to the emergency room . If a resident had mild shortness of breath, he would expect the nurse to use his or her judgment and assess the resident. If counseling in relaxation technique or use of oxygen and breathing treatments were effective, he would expect the nurse to monitor the resident. If the resident had moderate shortness of breath or if the resident complained of shortness of breath over an extended period without relief, he would expect the physician to be contacted. If a nurse waited eight hours to contact him, he would ask her why he was not called sooner. Review of the facility's policy, Mistreatment, Abuse, Neglect and Misappropriation of Resident Property, dated ,[DATE], identified neglect as the failure to provide goods and necessary services to avoid physical harm, mental anguish or mental illness. Any employee, resident and/or family member was encouraged to report any known or suspected episode of neglect. The report could be made to the administrator, DON, social worker, or charge nurse or to the ombudsman or the Department of Health. The preliminary reports and findings of all alleged incidents of neglect were to be documented on a risk management report form on the shift in which the incident occurred. The report was to be provided to the administrator within 24 hours of the incident. It was the responsibility of any employee, facility consultant, attending physician, family member, visitor or other individuals to immediately report any incident or suspected incident of resident neglect. If such incidents occurred or were discovered after hours, the administrator and/or DON or designees must be contacted at home and informed of the incident. All key management staff had phone numbers and/or cell phone numbers that were available to all staff. Review of the Change in Condition notification policy (not dated) indicated the nurse was to notify the physician when the resident had a change in condition that required physician intervention as soon as reasonably possible so as not to interrupt appropriate and timely treatment. The nurse was instructed to update the physician and first contact if the resident's condition did not improve when reasonably expected to do so. Review of LPN #100 ' s personnel file revealed a hire date of [DATE]. A job description indicated duties included ensuring all nursing service personnel were in compliance with their respective job descriptions and to admit, transfer, and discharge patients as required, notify residents ' attending physician and guardian when there was any change to the plan of care, act efficiently in handling emergency situations, ensure residents and families received the highest quality service in a caring and [MEDICATION NAME] atmosphere which recognized the needs and rights of each individual, supervise charge nurses and STNAs, accept responsibility, and address resident and family concerns. Review of disciplinary action dated [DATE] revealed LPN #100 received discipline for documenting she did dressing changes and treatments when they were not completed. Documentation revealed a notice of suspension beginning [DATE] at 6:00 P.M. pending an investigation regarding Resident #71 ' s care. A notice of disciplinary action dated [DATE] indicated on [DATE] it was reported to the executive director by another staff member that LPN #100 failed to perform her job duties as a nurse on [DATE]. This information resulted in a thorough investigation of the care of the resident. After an investigation, due to the egregious nature of the offense, termination from the company was effective immediately. This certification deficiency substantiates Complaint Number OH 618.

Based on record review, interview, observation and policy review, the facility failed to ensure one resident (Resident #48) received appropriate assessment and interventions to prevent a decline in urinary continence status. This affected one of two residents reviewed for urinary incontinence. The facility census was 65. Actual Harm occurred when Resident #48, continent of urine on admission, declined to frequently incontinent of urine without any interventions put into place to restore continency or to prevent further decline. Findings include: Review of Resident #48's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #48's Minimum Data Set 3.0 ((MDS) dated [DATE] revealed Resident #48 was always continent of urine. Review of Resident #48's MDS dated [DATE] revealed Resident #48 was occasionally incontinent (less than 7 episodes of incontinence) of urine. Review of the plan of care dated 06/02/15 revealed Resident #48 had occurrences of bladder incontinence. Interventions included for Resident #48 to use disposable briefs and change as needed, encourage fluids during the day to promote prompted voiding responses and to check the resident as needed for incontinence. Review of the activities of daily living flow record from 05/05/15 through 05/11/15 revealed Resident #48 was documented as being incontinent on two shifts. Review of Resident #48' s bladder screening dated 05/21/15 revealed no program was needed for the resident and indicated the Resident #48 was always continent. Review of the nurse ' s notes dated 05/23/15 revealed the resident was sent to the hospital related to penile bleeding and there was a consult to be completed with an urologist. The facility did not provide any evidence the follow up with the urologist was completed. Review of the change in condition form dated 07/07/15 at 10:36 A.M. revealed Resident #48 was having stoke/mini [MEDICAL CONDITION] and new neurological signs. Resident #48 was discharged from the facility and readmitted on [DATE]. Review of Resident #48's bladder screening dated 07/14/15 revealed the resident was never continent. Review of Resident #48's admission screen dated 07/14/15 revealed conflicting information that Resident #48 was always continent. Review of Resident #48's MDS dated [DATE] revealed Resident #48 was frequently incontinent with seven or more episodes of urinary incontinence but at least one episode of continent voiding. Review of the plan of care revealed no revision related to Resident #48's decline in urinary incontinence. Review of the activities of daily living flow record from 09/27/15 through 10/07/15 revealed Resident #48 was incontinent at least one time a day each day with exception of 10/02/15 to 10/04/15. Interview on 10/07/15 at 1:40 P.M. with Resident #48 revealed he was able to tell when he had to urinate. Resident #48 indicated that he was incontinent while sleeping at times. Resident #48 stated he had seen a physician in the past related to his urinary incontinence and the physician told him it would take time to heal itself. Interview on 10/07/15 at 3:27 P.M. with State tested Nurse Aide (STNA) #19 revealed Resident #18 did use the urinal but verified the resident did have episodes of incontinence at times and wore a brief. Interview on 10/08/15 at 4:50 P.M. with the Director of Nursing revealed Resident #48 did not need a toileting program because the resident was continent 95 percent of the time. Interview on 10/08/15 at 1:21 P.M. with STNA #20 revealed Resident #48 sometimes was wet in his brief and sometimes the resident asked for the urinal. STNA #20 stated his incontinence was noted when the resident was in bed. Interview on 10/08/15 at 2:30 P.M. with LPN # 12 revealed the nurses on the floor completed the bladder screening. LPN #12 stated a resident would be put on a program based on the resident's needs and if they were willing to do the program. LPN #12 stated she would educate the resident on the need to try a program and the cons of not doing one. LPN #12 stated any refusals to participate would be documented in the medical record and a program would be offered multiple times. Observation on 10/09/15 at 8:36 A.M. revealed STNA #20 provided incontinence care to Resident #48. STNA #20 confirmed Resident #48 was found as incontinent a few minutes prior to the observation and urinated inside the disposable brief. Interview on 10/09/15 at 8:26 A.M. with the DON revealed the bowel and bladder screen dated 07/14/15 indicating Resident #48 was never continent was inaccurate. Information related to Resident #48's progress notes from the physician were requested from the DON at that time and the DON stated she thought Resident #48 was seen by a urologist. However, no further information from the urologist was provided to the survey team. Interview on 10/09/15 at 8:40 A.M. with Resident #48 stated he would urinate in his sleep sometimes and would not be aware of it. Resident #48 stated the facility staff had not discussed a toileting program with him and he stated he would comply if they did. Resident #48 stated that his incontinence had increased since he had his stroke a couple months ago. Interview on 10/09/15 at 10:15 A.M. with Administrative Assistant # 65 confirmed there was not a complete assessment performed of Resident #48's urinary status including the type of incontinence and appropriate tracking of incontinent episodes. Administrative Assistant #65 stated if it's not in the record we do not have it. Administrative Assistant #65 provided the survey team with a progress note from the resident's family physician which did not address any problems related to Resident #48's incontinence. Review of the undated facility Bladder Program policy revealed the procedure to evaluate continence status, determine underlying cause of incontinence as able, identify the type of incontinence and to establish a toileting plan when clinically appropriate.

Based on medical record review, resident interview and staff interview, the facility failed to ensure appropriate pain control for newly admitted residents. Actual harm occurred when Resident #42, who had a recent right total hip replacement and rated her pain as an "8" (on a pain scale of 1-10), did not receive the ordered narcotic pain medication for over 16 hours after admission. This deficient practice affected one (Resident #42) of four residents reviewed for medication administration. The facility also failed to ensure residents with surgical wounds were provided care. This affected two (Resident #42 and Resident #64) of three residents reviewed for surgical wounds. The facility census was 71. Findings include: 1. Review of Resident #42's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Upon admission, the resident was prescribed [MEDICATION NAME]-[MEDICATION NAME] (narcotic [MEDICATION NAME]) 325-5 milligrams (mg) one tablet every four hours as needed for pain rated between seven and eight (on a 1-10 scale) or two tablets for pain rated between nine and ten. On 04/17/15 an additional physician's orders [REDACTED]. Review of the nurses ' notes dated 04/17/15 revealed Resident #42 was admitted to the facility at 9:25 P.M. and last received [MEDICATION NAME] medication at 4:45 P.M. at the hospital. An admission assessment completed on 04/17/15 at 10:54 P.M., identified the resident with a pain rating of 8. Review of the Medication Administration Record [REDACTED]. No evidence of narcotic [MEDICATION NAME] administration was noted until 04/18/15 at 1:39 P.M. Interview with Resident #42 on 04/28/15 at 11:30 A.M. revealed she arrived to the facility on [DATE] after 9:00 P.M., and she requested pain medication at that time but did not receive until the next afternoon, and remained in pain from admission until provided the medication on 04/18/15 at 1:39 P.M. Interview with Registered Nurse (RN) #10 on 04/29/15 at 10:35 A.M., verified the pain medication was not administered from admission on 04/17/15 until 04/18/15 at 1:39 P.M. 2. Review of Resident #42's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the nurses ' notes dated 04/17/15 at 5:56 P.M. revealed the hospital nurse informed the facility of a surgical incision to the right hip and further instructions to keep the incision covered with a dry dressing daily. Review of the physician's orders [REDACTED]. An admission skin assessment completed on 04/17/15 at 10:54 A.M., failed to identify the surgical incision to the right hip. Additional medical record review found no evidence of assessment or treatment to the surgical incision. Interview with RN #10 on 04/28/15 at 1:45 P.M., verified the surgical incision to the right hip was not assessed or treated following admission as indicated by the discharging hospital nurse report. 3. Review of Resident #64's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the nurses ' notes dated 04/25/15 at 2:38 P.M. revealed the hospital nurse informed the facility of a surgical incision to the left radius and left femur and further instructions to keep left radius dressing intact and change left femur with dry dressing daily. Review of the physician's orders [REDACTED]. An admission skin assessment completed on 04/25/15 at 7:18 P.M. identified the surgical incisions. Additional medical record review found no evidence of treatment to the surgical incisions. Interview with RN #10 on 04/28/15 at 1:45 P.M., verified the surgical incision to the left femur was not treated following admission as indicated by the discharging hospital nurse report. This deficiency substantiates Complaint Number OH 829.

Based on medical record review, observation, and staff interview, the facility failed to routinely assess a resident with pressure ulcers and implement interventions to prevent the worsening and/or healing of pressure ulcers. This resulted in actual harm to one resident (Resident #40) whose pressure ulcers deteriorated to unstageable after staff failed to do routine assessments and implement ordered interventions. This deficient practice affected one of three residents reviewed for pressure ulcers. The facility census was 73. Findings include: Review of Resident #40's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Resident #40 had pressure ulcers on the right and left buttock. On 03/07/14, an order was written to discontinue the pressure relief mattress that was being used and to initiate a low air loss and alternating pressure relief mattress on the bed. There was no evidence the low air loss/alternating pressure mattress was initiated. Review of a nursing note dated 03/27/14 revealed both wound beds were pink and intact. The next documentation of the wounds' appearance was from a dietary progress note dated 05/16/14 when the dietitian documented the left buttock had scabbed and the right buttock was "doing good" according to wound nurses. Review of a Weekly Wound Data Collection form dated 05/29/14 indicated the right buttock pressure ulcer was a stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough or as a blister) which measured 2.3 centimeters (cm) x 1.0 cm x 0.1 cm and the left buttock pressure ulcer was a stage II ulcer which measured 0.5 cm x 0.5 cm x 0.0 cm. The wound description indicated there was scabbing eschar (dead tissue that appears tan, brown or black) to the left buttocks noted. The tissue was dark brown and the scab was not loosening. The right buttocks had slough (dead tissue which appears yellow, tan, gray, green, or brown) on the wound bed. The wound was draining with description of the drainage as serosanguineous (containing both blood and serous fluid) with tan tinge. On 07/10/14 and 07/16/14, the pressure ulcer on the right buttock had the stage of the ulcer assessed as "N/A" (not available). On 07/15/14 at 10:50 A.M., 1:14 P.M., and 3:10 P.M., Resident #40 was observed lying in bed. At 1:35 P.M. State tested Nursing Assistant (STNA) #51 was interviewed. Upon being asked if she was aware of what kind of mattress Resident #40 used, STNA #51 went to Resident #40's room and looked at the mattress. The mattress was a two tone blue mattress but the printing on the mattress had worn off and was unreadable. It was not a low air loss/alternating pressure mattress. On 07/17/14 at 1:11 P.M., Registered Nurse (RN) #19 was interviewed and verified Resident #40 did not have a low air loss/alternating pressure mattress on her bed. RN #19 stated she was unable to find an order indicating the mattress was discontinued. On 07/17/14 at 2:20 P.M., Corporate Registered Nurse (CRN) #79 was interviewed and verified pressure ulcer staging was incorrect on 05/29/14. CRN #79 stated pressure ulcer documentation prior to 05/29/14 would be in nursing progress notes. CRN #79 stated she was not sure why pressure ulcers were staged as "N/A" (not available) on 07/10/14 and 07/16/14. The nurse who did the assessments was on vacation and unable to be reached. Documentation from the wound clinic was not available. On 07/17/14 at 2:35 P.M., STNA #49 was interviewed and stated she did not recall Resident #40 ever having a low air loss/alternating pressure mattress. On 07/17/14 at 2:40 P.M., STNA #52 was interviewed and stated she did not recall Resident #40 ever having a low air loss/ alternating pressure mattress. On 07/17/14 at 2:45 P.M., RN #19 verified she was unsure if the low air loss/alternating pressure mattress was ever initiated. On 07/17/14 at 2:50 P.M., RN #22 stated he did not recall if Resident #40 ever had a low air loss/alternating pressure mattress. An interview on 07/17/14 at 2:55 P.M. with CRN #79 verified the facility had no documented assessments of the wounds between 03/27/14 and 05/29/14 when documentation regarding the left buttock ulcer indicated the wound deteriorated to "scabbing eshar" and the right buttocks was documented as "slough." This deficiency substantiates Complaint Number OH 438.

Based on observation, interview and record review, the facility failed to ensure pain medication was administered prior to wound care. This resulted in pain during a dressing change for Resident #22. This affected one of two residents sampled for wound care. The facility census was 71. Finding include: Resident #22 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had long and short term memory problems with severely impaired decision making skills, disorganized thinking, and difficulty focusing. Resident #22 was dependent for activities of daily living and had vascular wounds on the legs and feet. She had a surgical wound on the right foot due to an amputation of the right great toe. Resident #22 had daily indicators of pain which she expressed by non-verbal sounds, verbal complaints, facial expressions and protective body movements or posture. A physician's orders [REDACTED]. Review of the undated Alteration in Comfort care plan, revealed Resident #22 was at risk for pain due to arthritic joints, chronic pain, vascular wounds on the feet and legs and an amputation of the right great toe. Interventions included: Monitor the resident for non-verbal communication of discomfort such as, increased restlessness, facial grimacing and moaning. Administer pain medication as needed. Acknowledge the presence of pains and discomfort, listen to the resident's concerns, administer pain medication as needed and notify the physician if the pain medication is ineffective. Encourage the resident to describe pain in her own terms and provide pain relief as indicated. Review of the facility's Managing Pain at Dressing Change policy dated October 2010, revealed: "Pain by definition is an individual and subjective experience. The most accurate and reliable evidence of the existence of pain and its intensity is an individual's report. Regular assessment of pain leads to improved pain management. Assessment and measurement of pain are fundamental to the practice of assisting in the [DIAGNOSES REDACTED]. Untreated pain prevents healing and can lead to chronic pain. The pain experienced by resident's during wound interventions and dressing changes will be appropriately managed to minimize distress to the individual." On 01/04/11 at 8:30 A.M., Registered Nurse (RN) #40 was observed completing Resident #22's dressing changes. Prior to removing the resident's old dressing, she revealed Resident #22 was going to move her legs around because "she doesn't like the dressing change." RN #40 removed the dressings from Resident #22's right foot and ankle. The resident began to wince, moan and withdraw her foot. Resident #22 complained "It's sore. The devil is on my foot. I wish you would leave it alone." RN #40 offered reassurance but continued to complete the wound care. RN #40 applied wound cleanse with a four by four gauze. When RN #40 touched the gauze to the right great toe site and the right ankle, Resident #22 called out "Oh, Lord have mercy!" She again winced, groaned and began to withdraw her foot. RN #40 completed the wound care. RN #40 removed the dressing on the left ankle. Resident #22 winced. When the nurse cleansed the area, Resident #22 winced and groaned. RN #40 completed the wound care at 9:09 A.M. During an interview after completing the dressing changes, RN #40 revealed she was not aware of the time Resident #22 received pain medication. She revealed it was the medication nurse's responsibility to administer the pain medication each morning, prior to the dressing change. During an interview on 01/04/10 at 9:15 A.M., the medication nurse, Licensed Practical Nurse #35, verified Resident #22 had not received pain medication since 01/02/11 at 8:00 A.M.