Every finding on record at Village at the Greene

Based on medical record review, staff interviews, and policy review, the facility failed to ensure a resident was not inappropriately discharged when the facility issued a resident a 30- day discharge notice without proper cause. This affected one (#52) out of three residents reviewed for discharge notices. The facility census was 47. Findings include:Review of the medical record for Resident #52 revealed an admission date of 07/05/24 with medical diagnoses of multiple sclerosis, left hemiplegia, cerebral infarction, diabetes mellitus, and chronic kidney disease stage IV. Further review, revealed Resident #52 was transferred to the hospital on [DATE], readmitted to the facility on [DATE], and then discharged to another facility on 09/24/25. Review of the medical record for Resident #52 revealed a quarterly Minimum Data Set (MDS) assessment, dated 06/30/25, which indicated Resident #52 was cognitively intact and was dependent for bed mobility, bathing, toileting and transfers. The MDS indicated Resident #52 received nutrition via tube feeding. Review of the medical record for Resident #52 revealed a Social Service note, dated 08/28/25 at 10:47 A.M. which stated daughter was informed of 30-day discharge notice due to resident does not have any remaining bed hold days and would be returning skilled. The note stated the daughter understood the information and was notified a list of facilities for her to choose from would be emailed to her. Review of a nurse's note, dated 08/28/25 at 2:09 P.M. stated resident arrived to the facility at approximately 1:30 P.M. Further review revealed a Social Service note dated 09/03/25 at 4:13 P.M. which stated 30-day discharge noticed was mailed to resident's daughter. The note stated the discharge was due to the welfare and needs of the resident could no longer be met in the facility. Review of the medical record revealed a document titled, Discharge Notice dated 09/03/25 which stated this was a notice that the resident would be discharged from the facility. The document indicated date of discharge was 10/03/25 to another skilled nursing facility and the reason for discharge was that the welfare and needs of the resident could not be met at the facility. Interview on 02/25/26 at 10:03 A.M. with Resident Service Coordinator (RSC) # 158 confirmed Resident #52 was sent to the hospital on [DATE] and returned to the facility on [DATE]. RSC #158 confirmed she had notified Resident #52's daughter on 08/028/25 that Resident #52 did not have any bed hold days available and that insurance denied a skilled stay at the facility. RSC #158 stated Resident #52 was issued a 30-day discharge notice due to not having a payer source. RSC #158 stated she was not aware if Resident #52 had been issued a bill for her stay since her return to the facility on [DATE] or if Resident #52 had failed to pay any bills. RSC #158 stated the 30-day discharge form issued to Resident #52's daughter was filled out incorrectly and that Resident #52 was being discharged due to payment concerns not that the welfare and needs of the resident could not be met at the facility. RSC #158 confirmed Resident #52 discharged to another nursing facility. Interview on 02/25/26 at 2:16 P.M. with Regional Business Office Manager (RBOM) #501 stated Resident #52 stay at the facility was covered by a managed Medicaid product and was approval of coverage was from 08/23/25 to 09/11/25. RBOM #501 confirmed the Notice of Discharge was issued on 09/04/25 even though Resident #52's insurance had approved coverage until 09/11/25 and confirmed Resident #52 or representative had not been issued a bill for non-payment at the time the Notice of Discharge was issued. Review of the facility policy titled, Admissions, Transfers, Discharge, and Room Change, stated it would be the responsibility of the Director of Nursing to assure that resident discharges are made only upon the physician's written order unless the resident is leaving AMA and that transfers and discharges are documented in the resident's clinical record. The policy stated residents for discharge included: 1) welfare and needs cannot be met in the Manor 2) has improved sufficiently so that the resident no longer needs the services provided by the Manor, 3) the safety of other individuals in the Manor would otherwise be endangered, 4) the health of ither individuals in the Manor would otherwise be endangered, 5) resident has failed to pay, or to have payment made on their behalf, for the care provided by the Manor, 6) the Manor's license has been revoked, the Manor is being closed, or otherwise ceases to operate, or 7) resident is recipient of Medicare, Medicaid, or Veteran's Affair benefits and the Manor's participation in such program is terminated or denied. The policy stated the Manor's policy to notify residents and/or responsible party in writing, by certified mail, return receipt requested, in advance to any proposed transfer or discharge from the Manor. The notice shall be provided at least thirty days in advance of the proposed transfer or discharge.This deficiency represents non-compliance investigated under Complaint Number 2631508.

Based on medical record reviews, staff interviews, and review of the facility policies, the facility failed to complete discharge summary/recapitulation of stays and failed to obtain physician discharge orders prior to discharge. This affected two (#48 and #52) out of three residents reviewed for discharges. The facility census was 47. Findings include: 1.Review of the medical record for Resident #48 revealed an admission date of 01/01/22 with medical diagnoses of anemia, diabetes mellitus, morbid obesity, bipolar disease with psychotic features, and congestive heart failure. Review of the medical record revealed a discharge date of 10/16/25. Review of the medical record revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE], which indicated Resident #48 was cognitively intact and was dependent upon staff for bathing, toilet hygiene, bed mobility and transfers and required set-up assistance with eating. Review of the medical record for Resident #48 revealed no documentation to support a discharge summary/recapitulation of stay was completed or the facility obtained physician orders for the residents discharge from the facility on 10/16/25. 2. Review of the medical record for Resident #52 revealed an admission date of 07/05/24 with medical diagnoses of multiple sclerosis, left hemiplegia, cerebral infarction, diabetes mellitus, and chronic kidney disease stage IV. Further review, revealed Resident #52 was transferred to the hospital on [DATE], readmitted to the facility on [DATE], and then discharged to another facility on 09/24/25. Review of the medical record for Resident #52 revealed a quarterly MDS assessment, dated 06/30/25, which indicated Resident #52 was cognitively intact and was dependent for bed mobility, bathing, toileting and transfers. The MDS indicated Resident #52 received nutrition via tube feeding. Review of the medical record for Resident #52 revealed no documentation to support a discharge summary/recapitulation of stay was completed or the facility obtained physician orders for the resident's discharge from the facility on 09/24/25. Interview on 02/25/26 at 10:15 A.M. with Director of Nursing (DON) confirmed the medical records for Residents #48 and #52 did not contain documentation to support the facility completed discharge summary/recapitulation of stay or obtained physician orders prior to discharges. Review of the facility policy titled, Admissions, Transfers, Discharge, and Room Change, stated it would be the responsibility of the Director of Nursing to assure that resident discharges are made only upon the physician's written order unless the resident is leaving AMA and that transfers and discharges are documented in the resident's clinical record. Review of the facility policy titled, Discharge Summary, stated when the Manor (facility) anticipates discharge of a resident they must have a discharge summary that includes recapitulation of resident's stay, a final summary of the resident's health status at the time of discharge that is available for release to authorized persons and agencies, with consent of the resident or representative, reconciliation of all pre-discharge medications with the resident's post-discharge medications, and a post discharge plan of care that was developed with the participate of the resident and his/her family, which will assist the resident to adjust to his/her new living environment. This deficiency was based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, observations, resident and staff interviews and policy review, the facility failed to obtain a physician order prior to administering a c-pap machine and oxygen. This affected one (#09) out of three residents reviewed for following physician orders. The facility census was 47. Findings include: Review of Resident #09's medical record revealed an admission date of 12/06/25 with diagnoses of stress fracture of the left femur, chronic obstructive pulmonary disease, type 2 diabetes mellitus with other specified complication, and morbid (severe) obesity due to excess calories. Review of the care plan for Resident #09, dated 12/08/25 revealed resident had altered cardiovascular status r/t Hypertension, iron deficiency anemia with intervention of to give oxygen as ordered by the physician. Further review of the care plan, dated 12/08/25 revealed resident had altered respiratory status/difficulty breathing related to sleep apnea and chronic obstructive pulmonary disease (COPD) with intervention of provide oxygen as ordered. Review of admission Medicare 5-Day Minimum Data Set (MDS) dated [DATE] revealed Resident #09 was cognitively intact. Resident #09 required set-up assistance with eating and oral hygiene. Resident #09 required supervision assistance with personal hygiene. Resident required partial assistance with bathing. Resident #09 required substantial assistance with toileting hygiene, bed mobility, and transfers. Resident #09 was dependent on staff assistance with dressing and wheelchair. Resident #09 used oxygen therapy. Review of the physician orders for Resident #09 revealed no physician order to a c-pap machine. Further review revealed no physician order for oxygen administration. Review of the clinical admission progress note dated 12/07/25 at 12:10 A.M. revealed Resident #09 on oxygen (O2) via mask with oxygen saturation at 94 %. Review of the skilled evaluation note dated 12/25/25 at 3:43 A.M. revealed Resident #09 on oxygen (O2) via continuous positive airway pressure (CPAP) oxygen saturation at 93%. Review of the skilled evaluation note dated 01/03/26 at 2:58 A.M. revealed Resident #09 on oxygen (O2) via nasal cannula with oxygen saturation at 95%. Review of the skilled evaluation note dated 02/01/26 at 10:16 A.M. revealed Resident #09 on oxygen (O2) via nasal cannula with oxygen saturation at 92%. Review of the skilled evaluation note dated 02/08/26 at 10:52 A.M. revealed Resident #09 on oxygen (O2) via nasal cannula with oxygen saturation at 96%. Review of the skilled evaluation noted dated 02/11/26 at 12:33 A.M. revealed Resident #09 was on room air with oxygen saturation at 96%. Review of the skilled evaluation noted dated 02/22/26 at 8:44 A.M. revealed Resident #09 was on room air with oxygen saturation at 90%. Observation on 02/23/26 at 9:40 A.M. revealed a CPAP machine, and oxygen concentrator and a portable oxygen tank in Resident #09's room. All of the items were off and not in use. Observation on 02/24/26 at 7:06 A.M. revealed Resident #09 in bed with CPAP mask on resident with oxygen on at 2 liters attached through CPAP tubing with CPAP on at 6 cmH20. Interview on 02/24/26 at 7:15 A.M. with Resident #09 revealed uses her CPAP with oxygen attached every night while sleeping. Interview with Resident #09 also confirmed she uses two liters of oxygen and she has used both since admission. Observation on 02/25/26 at 7:08 A.M. revealed Resident #09 in bed with CPAP mask on resident with oxygen on at 2 liters attached through CPAP tubing with CPAP on at 6 cmH20. Interview on 02/25/26 at 7:47 A.M. with Licensed Practical Nurse (LPN) #132 confirmed Resident #09 uses her CPAP and oxygen every night and it is removed by staff off the resident in the morning when she wakes up. Interview also confirmed the resident did not have a physician's order for the CPAP setting of 6cmH20 or the oxygen of 2 liters. Interview on 02/25/26 at 11:48 A.M. with the Director of Nursing (DON) confirmed Resident #09 is on oxygen and has oxygen in her room. Interview on 02/25/26 at 12:00 P.M. with the DON confirmed Resident #09 has not had a physician's order for oxygen or a physician's order for the CPAP use since admission on [DATE]. Review of the Oxygen Policy, dated 11/2022 revealed oxygen will be used in a safe manner. This deficiency represents non-compliance investigated under Complaint Number 1319833 (OH00165332).

Based on medical record review, resident and staff interviews, and policy review, the facility failed to provide therapy services to ensure a resident maintained highest practicable level of physical and functional mobility. This affected one (#10) out of three residents reviewed for cares and services. The facility census was 47. Findings include: Review of the medical record for Resident #10 revealed an admission date of 01/19/26 with medical diagnoses of malignant neoplasm of cerebellum, malignant neoplasm of right lung, congestive heart failure, and chronic obstructive lung disease (COPD). Review of the medical record for Resident #10 revealed an admission Minimum Data Set (MDS) assessment, dated 02/01/26, which indicated Resident #10 had modified independence with decision making, required substantial/maximum staff assistance with toilet hygiene and was dependent upon staff for bed mobility and transfers. The MDS indicated Resident #10 received physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services. Review of the medical record for Resident #10 revealed an Activities of Daily Living (ADL) deficit care plan with interventions for one staff assistance with toilet use, transfers, and bathing and PT and OT evaluation and treatment per physician orders. Review of the medical record for Resident #10 revealed physician orders dated 01/19/26 for PT, OT, and ST to eval and treat. Review of the medical record for Resident #10 revealed PT, OT, and ST evaluations dated 01/20/26. Review of the OT Discharge summary dated [DATE]- 02/12/26 which stated Resident #10 had not met goals and would benefit from continued therapy for functional mobility, ADLs, transfers and safety. Review of PT discharge note dated 02/11/26-02/12/26 stated patient was discharged from PT services due to insurance exhaustion and would remain in the facility. The PT discharge note indicated Resident #10 had not met therapy goals. Review of the ST Discharge summary dated 02/1126-02/12/26 stated services discharged due to insurance exhaustion and appeal lost. The note stated Resident #10 remained with cognitive and communication deficits and dysphagia.Interview on 02/24/26 at 1:09 P.M. with Resident #10 stated she was no longer provided therapy services after her insurance ended her skilled services. Resident #10 stated her therapy services ended a few weeks ago. Resident #10 stated she had applied for Medicaid because she would not be able to return home until she got stronger and able to do more for herself. Resident #10 stated her goal was to discharge home eventually. Resident #10 stated nursing staff do not assist her with standing and only use a mechanical lift to transfer her to a chair. Resident #10 stated when she was participating in therapy services she was able to stand and transfer with one therapy staff assistance but is no longer able to transfer without hoyer lift. Interview on 02/24/26 at 1:18 P.M. with Case Manager (CM) #183 stated Resident #10's insurance discontinued her skilled service stay and Resident #10 was not on therapy caseload at this time due to change in payer source and was Medicaid pending. CM #183 confirmed Resident #10's goal was to return home. Interview on 02/24/26 at 1:43 P.M. with State Tested Nursing Assistant (STNA) #107 stated when Resident #10 was on therapy services she had observed Resident #10 transfer with one staff assistance. STNA #107 stated the nursing staff use a mechanical lift for all Resident #10 transfers and were not informed or instructed by therapy services that staff could manually assist Resident #10 with transfers. Interview on 02/24/26 at 2:33 P.M. with Physical Therapy (PT) #503 stated Resident #10 was discharged from therapy services due to skilled insurance coverage being discontinued. PT #503 stated Resident #10 would benefit from therapy services. Interview on 02/25/26 at 7:32 A.M. with Director of Rehab (DOR) #502 stated Resident #10' therapy services were discontinued on 02/12/26 because skilled services were denied by insurance company. DOR #502 stated if a resident's skilled services ended and the resident continued to need therapy services then services would be provided under their Part B coverage once the insurance had been verified. DOR #502 confirmed Resident #10's Part B coverage had not been verified by the facility yet and that Resident #10 had not received therapy services since 02/12/26. DOR #052 confirmed the facility did not have Restorative programs. Review of the facility policy titled, Specialized Rehabilitative/Restorative Services, stated Occupational, Physical, and Speech Therapy services are ordered by a physician, or upon a physician's referral and provided to a resident by or under the supervision of an OT, PT, or ST therapy. The policy stated therapy services are to assist the residents in reaching their maximum functional performance through specialized therapy interventions and to transition to restorative nursing program, when appropriate. The policy also stated therapy services would collaborate between therapy services and the interdisciplinary team. This deficiency represents non-compliance investigated under Complaint Number 2631508.

Based on observation, medical record review, staff interview, and policy review, the facility failed to provide care and services for residents who required staff assistance with Activities of Daily Living (ADLs). This affected five (#09, #22, #43, #53, and #73) of five residents reviewed for ADLs. The facility census was 76. Findings include: 1. Review of the medical record of Resident #22 revealed an admitted [DATE]. The resident transferred to the hospital on 12/18/24 and readmitted to the facility on [DATE]. Diagnoses included hemiplegia affecting right dominant side, type 2 diabetes mellitus, bipolar disorder with psychotic features, heart failure, atrial fibrillation, anxiety, depression, and cervical cancer. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident required supervision for eating, toileting, personal hygiene, and bed mobility, and partial/moderate assistance with bathing, dressing, and transfers. Review of the plan of care dated 11/08/24 revealed the resident had an ADL self-care deficit related to hemiplegia affecting the right dominant side. Interventions included to provide one-person assistance for grooming, hygiene, and bathing. Observation on 02/24/25 at 12:21 P.M. revealed Resident #22's fingernails on both hands were long, extending approximately one half inch beyond the finger tip. Resident #22's right hand was contracted. Interview at the same time revealed Resident #22 stated she wanted her fingernails cut and was unable to cut her fingernails and relied on staff to ensure her fingernails were not too long. Observation on 02/26/25 at 9:12 A.M., Resident #22's fingernails remained long, extending approximately one half inch beyond the finger tip. Interview at the same time revealed Resident #22 stated she had been given a shower on 02/25/25 and staff did not cut her fingernails. Resident #22 again stated she was unable to cut her own fingernails. Resident #22 stated she preferred to keep her fingernails cut short and stated her nails were way too long. Interview on 02/26/25 at 9:13 A.M. with Certified Nursing Assistant (CNA) #70 verified Resident #22's fingernails were long, extending approximately one half inch beyond the fingertip, and needed to be trimmed. CNA #70 stated she was not sure who was responsible for cutting Resident #22's finger nails. Observation on 02/27/25 at 9:28 A.M. revealed Resident #22's fingernails remained long, extending approximately one half inch beyond the finger tip. Interview at the same time revealed Resident #22 stated she was still waiting for someone to cut her fingernails. Interview on 02/27/25 at 9:28 A.M. CNA #102 verified Resident #22's fingernails were long and needed to be cut. CNA #102 stated she was unable to cut Resident #22's fingernails because she had diabetes. Interview on 02/27/25 at 9:29 A.M., Licensed Practical Nurse (LPN) #76 verified Resident #22's fingernails were long and needed to be cut. LPN #76 stated she was unsure of who was supposed to provide nail care to Resident #22 since she was diabetic. Interview on 02/27/25 at 10:23 A.M., the Administrator stated nurses were responsible for cutting fingernails of residents with diabetes. 2. Review of the medical record of Resident #43 revealed an admitted [DATE]. Diagnoses included frontotemporal neurocognitive disorder, repeated falls, dementia with psychotic disturbance, depression, breast cancer, anxiety, and history of multiple wedge compression fractures, clavicle fracture, and multiple rib fractures. Review of the comprehensive MDS assessment dated [DATE] revealed the resident had severely impaired cognition. The resident required supervision for bed mobility, partial/moderate assistance for eating, substantial/maximal assistance for toileting, bathing, dressing, and was dependent on staff for transfers. Review of the care plan dated 01/09/25 revealed the resident was at risk for falls related to her diagnoses. Interventions included to get the resident up on third shift. Review of the care plan dated 02/06/25 revealed the resident had an ADL self care performance deficit related to Alzheimers and dementia. Interventions included to utilize a hoyer lift for transfers. Observation on 02/27/25 at 9:32 A.M. revealed Resident #43 was laying in bed with covers over her body. Observation on 02/27/25 at 12:45 P.M. revealed Resident #43 was laying in bed with covers over her body. 3. Review of the medical record of Resident #09 revealed an admitted [DATE]. Diagnoses included Parkinson's disease, hemiplegia and hemiparesis, right clavicle fracture, dysphagia, epilepsy, dysphagia, dementia with agitation, and cognitive communication deficit Review of the quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognition. The resident required setup assistance with eating, supervision for bed mobility, substantial/maximal assistance for transfers, and dependent for toileting, bathing, dressing, and personal hygiene. Review of the plan of care dated 02/12/25 revealed the resident had an ADL self care performance deficit related to impaired balance, left hand contracture, and non-displaced fracture of lateral right clavicle. Interventions included to provide 1-person extensive assistance with transfers. Observation on 02/27/25 at 9:33 A.M. revealed Resident #09 was laying in bed, with covers over her body and a breakfast tray in front of her, fully consumed. Observation on 02/27/25 at 12:45 P.M. revealed Resident #09 was laying in bed with covers over her body. 4. Review of the medical record of Resident #53 revealed an admitted [DATE]. Diagnoses included hyperosmolality and hypernatremia, alzheimer's disease, muscle weakness, syncope and collapse, heart failure, and osteoporosis. Review of the quarterly MDS assessment dated [DATE] revealed the resident had a severe cognitive impairment. The resident required supervision for eating, partial/moderate assistance for transfers, toileting, and bathing. Review of the plan of care dated 12/30/24 revealed the resident had an ADL self care performance deficit related to weakness and impaired mobility and alzheimers disease. The resident required 2-person assistance with a hoyer for transfers. Observation on 02/27/24 at 9:32 A.M. revealed Resident #53 was laying in bed with covers over her body. Observation on 02/27/25 at 12:45 P.M. revealed Resident #53 was laying in bed with covers over her body. Interview on 02/27/25 at 12:48 P.M., Certified Nursing Assistant (CNA) #113 verified Residents #09, #43 and #53 were still in bed. CNA #113 stated she was the only CNA on the unit from when she came in at 7:00 A.M. until noon, when another CNA came in to help. Review of the facility policy titled, Activities of Daily Living, dated 04/29/16, revealed the facility would provide the necessary care and services to residents who are unable to carry out ADLs. 34291 5. Medical record review for Resident #73 revealed an admitted [DATE]. His medical diagnoses included cirrhosis, neurogenic bladder, urinary tract infection, and asthma. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #73 was cognitively intact. Functional status was setup or clean-up for eating, dependent for toileting and transfers, and partial/moderate assistance for bed mobility. Review of the care plan for Resident #73 dated 01/11/25 revealed he had a activities of daily living deficit related to C-4/C-5 syndrome and arthritis. Review of the showers for Resident #73 from 01/15/25 through 02/25/25 revealed he received eight showers out of 11 opportunities. Further review of the documentation for showers revealed the resident had a shower on 02/09/25 and not again until 02/24/25. Interview with Resident #73 on 02/24/25 at 1:59 P.M. revealed he was not getting his showers in timely manner. He stated he is an easy going guy and was willing to switch days for his showers, but he felt the aides took advantage of his goodness and keeps telling him he would get a shower tomorrow and he doesn't get his shower. He stated he has received three showers in a little over three weeks. Interview with the Administrator on 02/27/25 at 8:06 A.M. confirmed the showers for Resident #73 was not documented as completed and therefore wasn't given to the resident. Review of the policy titled, Activities of Daily Living, dated 04/29/16 revealed each resident will receive and the facility will provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being. in accordance with the comprehensive assessment and plan of care. This deficiency represents non-compliance investigated under Complaint Number OH00162997.

Based on observation and staff interview, the facility failed to ensure gloves were changed between contaminated surfaces and food. This had the potential to affect 12 residents (#11, #18, #25, #28, #32, #34, #39, #40, #41, #54, #59, and #73) who were served from this kitchenette on the Pine Club unit. The census was 76. Findings included Observation on 02/24/25 at 12:00 P.M. revealed Dietary Aide (DA) #122 had on gloves and was using his gloved hands to touch the trays, silverware, and reaching into the cabinets. He trayed up a meal with the gloves on and reached into the package of rolls and used his gloved hands to place the roll on the plate. He removed his gloves and left the kitchenette and returned with two pots of coffee placed gloves on both hands and reached up into the cabinet with his right hand and gets down two coffee cups and fills one with his right hand placed the coffee on the tray. He continued with the gloves to plate up another meal and went to the bag of rolls and used his right hand to place a roll on the plate and covers the plate with the lid. He walks over to the microwave and hits the timer to heat up the tea. He continued to plate another tray of food and reach into the bag of rolls with his right gloved hand and placed it on the tray. He left the kitchenette and got a teabag right out of the kitchenette ledge and went back into the kitchen with his gloves on and continued to plate another tray and place his right gloved hand into the bag of rolls. Interview with the DA #122 on 02/24/25 at 12:10 P.M. confirmed he touched his contaminated gloves into the package of rolls and placed them on the plates of food for the residents. DA #122 verified he was serving Residents #11, #18, #25, #28, #32, #34, #39, #40, #41, #54, #59, and #73.

Based on medical record reviews, observations, staff interviews, and policy review, the facility failed to ensure resident's medications were administered as ordered resulting in three medication errors out of 29 opportunities or a 10.34 percent (%) medication error rate. This affected two (#33 and #62) residents out of the four residents reviewed for medication administration. The facility census was 76. Findings included: 1. Review of the medical record for Resident #33 revealed an admitted [DATE] with medical diagnoses of chronic kidney disease Stage III, morbid obesity, left hemiplegia, diabetes mellitus, heart failure, depression, and spina bifida. Review of the medical record for Resident #33 revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE], which indicated Resident #33 was cognitively intact and was dependent for toilet hygiene, bathing, and transfers and required substantial/maximum assistance with bed mobility. Review of the medical record for Resident #33 revealed a physician order dated 08/29/24 for Stiolo Respimat inhalation aerosol 2.5-1.5 micrograms (mcg) per activation (act) two puffs orally daily and an order dated 09/26/24 for fluticasone propionate suspension (Flonase) 50 mcg/act two sprays in each nostril daily. Observation on 02/25/25 at 7:43 A.M. revealed Licensed Practical Nurse (LPN) #52 prepared Resident #33's medications. LPN #52 was observed to administer one puff of Stioto Respimat inhalation aerosol orally and one spray of Flonase to each of Resident #33's nostrils. Interview on 02/25/25 at 8:03 A.M. with LPN #52 she only administered one puff of Stiolo Respimat inhalation aerosol and one spray of Flonase to each nostril for Resident #33. 2.Review of the medical record for Resident #62 revealed an admitted [DATE] with medical diagnoses of left femur fracture, anemia, nondisplaced fracture of greater trochanter, diabetes mellitus, atrial fibrillation, Alzheimer's disease, and Depression. Review of the medical record for Resident #62 revealed an admission MDS assessment, dated 02/08/25, which indicated Resident #62 moderately cognitively impaired and required partial/moderate staff assistance with toilet hygiene, bathing, bed mobility, and transfers. Review of the MDS indicated Resident #62 received antidepressant medication. Review of the medical record for Resident #62 revealed a physician order dated 02/03/25 for sertraline 100 milligram (mg) one tablet by mouth daily. Observation on 02/25/25 at 8:30 A.M. revealed LPN #94 prepared Resident #62's medications for administration. The observation revealed LPN #94 administer one sertraline 25 mg tablet to Resident #62. Interview on 02/25/25 at 8:28 A.M. with LPN #94 confirmed she administered Resident #62 one sertraline 25 mg tablet during medication administration and not 100 mg tablet as ordered. Review of the facility policy titled, Medication administration policy, reviewed 12/19/24 stated medications are to be administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. The policy stated prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR) is compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician orders are checked for the correct dosage schedule. The policy stated medications are administered in accordance with written orders of the attending physician.

Based on observation, medical record review, and staff interview, the facility failed to prevent a significant medication errors when staff did not prime an insulin pen prior to administration. This affected one (Resident #33) of four residents observed for medication administration. The facility census was 76. Findings include: Review of the medical record for Resident #33 revealed an admitted [DATE] with medical diagnoses of chronic kidney disease Stage III, morbid obesity, left hemiplegia, diabetes mellitus, heart failure, depression, and spina bifida. Review of the medical record for Resident #33 revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE], which indicated Resident #33 was cognitively intact and was dependent for toilet hygiene, bathing, and transfers and required substantial/maximum assistance with bed mobility. Review of the medical record for Resident #33 revealed a physician order dated 01/21/25 for Novolog solution 100 units per milliliter (ml) to inject 28 units subcutaneously (SQ) at breakfast daily. Observation on 02/25/25 at 7:43 A.M. revealed Licensed Practical Nurse (LPN) #52 prepared Resident #33's medications. The observation revealed LPN #52 set Humalog insulin kwikpen (substitute for Novolog solution) to 28 units and placed needle on the kwikpen. Interview on 02/25/25 at 8:03 A.M. with LPN #52 confirmed she did not prime Humalog insulin kwikpen with two units prior to administration of 28 units.

Based on medical record review, observation, staff interview, and policy review, the facility failed to follow infection control procedures during tracheostomy care. This affected one (#13) resident of one resident observed for tracheostomy care. The facility census was 76 Findings include: Review of the medical record for Resident #13 revealed an admitted [DATE] with medical diagnoses of persistent vegetive state, respiratory failure, epilepsy, anoxic brain injury, quadriplegia, and tracheostomy. Review of the medical record for Resident #13 revealed a quarterly Minimum Data Set (MDS) assessment, dated 02/01/25 which indicated Resident #13 was in a persistent vegetative state and was dependent upon staff for all activities of daily living. Review of the MDS revealed Resident #13 had a tracheostomy. Review of the medical record for Resident #13 revealed a physician order dated 01/25/25 for tracheostomy care/oral care three times per day and an order dated 01/15/25 to change inner cannula two times per day. Review of the physician orders revealed no documentation to support an order for Enhanced Barrier Precautions (EBP). Observation on 02/24/25 at 10:14 A.M. revealed Respiratory Therapist (RT) #46 performing tracheal suctioning and oral care on Resident #13. RT #46 was observed wearing a mask and gloves. The observation revealed an EBP sign was posted on the wall behind Resident #13's bed. Continued observation of Resident #13's room revealed masks and gloves were available for staff but did not reveal gowns available for staff to use when providing care to Resident #13. Interview on 02/24/25 at 10:21 A.M. with RT #46 confirmed he did not wear a gown when providing tracheal suctioning or oral care for Resident #13. RT #46 verified Resident #13 coughed when he was providing the tracheal suctioning. RT #46 confirmed Resident #13's room did not have a sign posted to follow EBP or gowns available to wear during cares. Review of the facility policy titled, Enhanced Barrier Precautions, dated August 2022, stated it was the intent of the facility to use EBP in addition to Standard Precautions for residents to prevent transmission of multidrug resistant organisms (MDRO) in the care community. The policy stated an impervious gown should be worn when high-contact resident care activities are being performed. The policy also stated high-contact resident care activities included device care or use: central line, urinary catheter, feeding tube, and tracheostomy/ventilator.

Based on medical record review, staff interview, and policy review, the facility failed to ensure dialysis communication forms were completed and sent to the dialysis center prior to dialysis. This affected one (#47) resident who attended hemodialysis. The facility census was 76. Findings included: Review of the medical record for Resident #47 revealed an admitted [DATE] with medical diagnoses of end stage renal disease, dependence on dialysis, diabetes mellitus, and hypertension. Review of the medical record for Resident #47 revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE], which indicated Resident #47 was cognitively intact and required substantial/maximum assistance with toilet hygiene, bed mobility, and transfers and dependent upon staff for bathing. The MDS indicated Resident #47 received dialysis. Review of the medical record for Resident #47 revealed a physician order dated 11/05/24 to attend dialysis Monday, Wednesday, and Friday with pick up time at 6:00 A.M. and an order dated 11/20/24 to obtain residents weight and vital signs prior to dialysis and upon return to the facility. Review of the medical record for Resident #47 revealed documentation to support the facility obtained Resident #47's weight and vital signs prior to and upon return from dialysis. Review of Resident #47's dialysis communication book revealed no documentation to support the facility sent a communication form to Resident #47's dialysis on 02/03/25, 02/05/25, 02/10/25, 02/19/25, 02/21/25, 02/24/25. Interview on 02/27/25 at 10:59 A.M. with Administrator confirmed the facility did not have documentation to support dialysis communication forms were sent to the dialysis center on 02/03/25, 02/05/25, 02/10/25, 02/19/25, 02/21/25, and 02/24/25. Administrator stated Resident #47's vital signs were taken prior to and after each dialysis and stated the facility was in contact with the dialysis center via phone often. Administrator confirmed the medical record did not have documentation to support the facility contacted the dialysis center and updated on Resident #47 health condition via phone. Review of the facility policy titled, Dialysis Care Policy, dated February 2018, stated the Manor would ensure that residents who require dialysis receive such services, consistent with professional standards of practice and the comprehensive, person-centered plan of care. The policy stated the manor would provide ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility and ongoing assessment. The policy also stated the Manor would provide ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.

Based on medical record review, staff interview, and policy review, the facility failed to ensure weights were obtained in a timely manner. This affected three (#49, #51, and #64) of four residents reviewed for nutrition. The facility census was 76. Findings include: 1. Review of the medical record of Resident #49 revealed an admitted [DATE]. The resident transferred to the hospital on 12/25/24 and returned to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, emphysema, acute and chronic respiratory failure with hypoxia, moderate protein-calorie malnutrition, vascular dementia, hemiplegia and hemiparesis following cerebral infarction, thyroid cancer, anxiety, and hypothyroidism. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition. The resident required set-up assistance with eating and oral hygiene, however was dependent on staff for all other ADLs. Review of Resident #49's weights revealed the resident was weighed on 12/06/24 and 01/11/25. There were no weights documented between 12/06/24 and 01/11/25, including on 12/28/24 when the resident readmitted from the hospital. Further review revealed no documentation of any rationale for not obtaining Resident #49's weight upon readmission on 12/28/24. Interview on 02/26/25 at 2:59 P.M., Dietetic Technician (DT) #78 verified Resident #49 was not weighed upon readmission to the facility on [DATE]. DT #78 verified Resident #49 was weighed on 12/06/24 and on 01/11/25. DT #78 stated she expected admission and readmission weights to be obtained within 24 hours of admission. 2. Review of the medical record of Resident #51 revealed an admitted [DATE]. Diagnoses included hypertensive heart disease with heart failure, hallucinations, polyosteoarthritis, repeated falls, chronic kidney disease, chronic pain syndrome, psychosis, hypothyroidism, depression, anxiety, hypertension, colon cancer, unspecified hearing loss, amnesia, history of transient ischemic attack. Review of the quarterly MDS assessment dated [DATE] revealed the resident had moderately impaired cognition. The resident rejected care 1-3 days during the assessment period. The resident was independent with bed mobility, required setup assistance for eating, partial/moderate assistance for toileting, bathing, and transfers. Review of a Nutrition Services progress note dated 09/20/24 revealed Resident #51 triggered for significant weight loss on 09/17/24, with a weight of 215.4 pounds. The resident weighed 234.5 pounds on 08/24/24, indicating an 8.1% loss in the last 25 days. A reweigh was requested. Review of a Nutrition Services progress note dated 01/31/25 revealed the resident triggered significant weight loss on 01/27/25, when she weighed 205.2 pounds from 11/09/24, when she weighed 222.4 pounds. The progress note indicated the resident had a 17.2 pound loss (7.7%) in 80 days. A reweigh was requested. Review of Resident #51's weights revealed, on 09/17/24, the resident weighed 215.4 pounds. On 11/09/24, the resident weighed 222.4 pounds. On 01/27/24, the resident weighed 205.2 pounds. There were no additional weights documented between 09/17/24 and 11/09/24 and there were no weights documented after 01/27/25. Interview on 02/26/25 at 3:14 P.M., DT #78 verified reweights were not obtained as requested on 09/20/24 and 01/31/25. DT #78 stated the expectation was for reweights to be obtained within 48 hours. 34291 3. Medical record review for Resident #64 revealed an admitted [DATE]. Medical diagnoses included neurogenic bladder, seizure disorder, and respiratory failure. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #64 was moderately cognitively impaired. Her functional status was eating was non-applicable, toileting was dependent, bed mobility was partial/moderate assistance and transfers was substantial/maximal assistance for transfers. She was always incontinent for bowels and bladder. Review of the care plan for Resident #64 dated 12/18/24 revealed she was at risk for alteration in nutrition and has had a significant weight loss. Intervention was to take weekly weights. Review of physician orders dated 08/26/24 for Resident #64 revealed weekly weights. Review of weights from 12/17/24 through 02/25/25 revealed out of eleven opportunities she had seven weights taken. Interview with the Registered Diet Tech (RDT) #78 on 02/26/25 at 2:58 P.M. confirmed the weights for Resident #64 was not taken weekly as ordered. Review of the facility policy titled, Weight Policy-Scales, dated 04/2024 revealed residents would be weighed within 24 hours of admission/readmission and residents would be re-weighed in a reasonable time frame if their weight shows a significant weight change of 5% from their previous weight.

Based on medical record review, staff interview, and review of facility skills documentation form, the facility failed to ensure tracheostomy care/oral care was completed as ordered. This affected one (#13) of one resident reviewed for tracheostomy care. The facility census was 76. Findings included: Review of the medical record for Resident #13 revealed an admitted [DATE] with medical diagnoses of persistent vegetive state, respiratory failure, epilepsy, anoxic brain injury, quadriplegia, and tracheostomy. Review of the medical record for Resident #13 revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE] which indicated Resident #13 was in a persistent vegetative state and was dependent upon staff for all activities of daily living. Review of the MDS revealed Resident #13 had a tracheostomy. Review of the medical record for Resident #13 revealed an order dated 01/25/25 for tracheostomy care/oral care three times per day and an order dated 01/15/25 to change inner cannula two times per day. Review of the medical record for Resident #13 revealed a February 2024 Respiratory Administration Record (RAR) which did not contain documentation to support the facility completed tracheostomy/oral care as ordered on 02/02/25 through 02/04/25, 02/08/25, 02/09/25, 02/14/25, 02/21/24 through 02/24/25. Interview on 02/27/25 at 9:30 A.M. with Administrator confirmed the medical record for Resident #13 did not contain documentation to support tracheostomy/oral care was completed as ordered on 02/02/25 through 02/04/25, 02/08/25, 02/09/25, 02/14/25, 02/21/24 through 02/24/25. Administrator stated the facility did not have a tracheostomy care policy. Review of a facility form titled, Skills Documentation/Evaluation Record Tracheostomy- disposable inner cannula stated staff are to chart procedure on treatment record.

Based on medical record review, staff interview, and policy review, the facility failed to ensure significant change assessments were completed in a timely manner. This affected three (#43, #45, and #51) of three residents reviewed for hospice services. The facility census was 76. Findings include: 1. Review of the medical record of Resident #43 revealed an admitted [DATE]. Diagnoses included frontotemporal neurocognitive disorder, repeated falls, dementia with psychotic disturbance, depression, breast cancer, hypertension, anxiety, and history of multiple wedge compression fractures, clavicle fracture, multiple rib fractures. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition. The resident required supervision for bed mobility, partial/moderate assistance for eating, substantial/maximal assistance for toileting, bathing, dressing, and was dependent on staff for transfers. Review of the medical record revealed the resident began receiving hospice services on 02/06/24. Review of the significant change MDS assessment dated [DATE] revealed the assessment was completed on 02/22/24. Interview on 02/27/25 at 1:42 P.M., Registered Nurse (RN) #139 verified Resident #43's significant change assessment dated [DATE], was not completed within 14 days of the identification of a significant change. RN #139 verified an MDS must be completed within 14 days of the identification of a significant change and Resident #37's significant change assessment should have been completed by 02/19/24. 2. Review of the medical record of Resident #45 revealed an admitted [DATE]. The resident transferred to the hospital on 12/18/24 and returned to the facility on [DATE]. Diagnoses included chronic kidney disease, dementia with agitation, chronic obstructive pulmonary disease, prostate cancer. Review of the comprehensive MDS assessment dated [DATE] revealed the resident had severely impaired cognition. Review of the medical record revealed the resident was picked up by hospice on 01/02/25. Review of the medical record revealed a significant change MDS with a reference date of 01/09/25 was completed on 01/22/25. Interview on 02/27/25 at 1:52 P.M., RN #139 verified Resident #45's significant change MDS dated [DATE] was not locked within 14 days of being picked up by hospice and should have locked by 01/15/25. 3. Review of the medical record of Resident #51 revealed an admitted [DATE]. Diagnoses included hypertensive heart disease with heart failure, hallucinations, polyosteoarthritis, repeated falls, chronic kidney disease, chronic pain syndrome, psychosis, hypothyroidism, depression, anxiety, hypertension, colon cancer, unspecified hearing loss, amnesia, history of transient ischemic attack. Review of the quarterly MDS assessment dated [DATE] revealed the resident had moderately impaired cognition. The resident rejected care 1-3 days during the assessment period. The resident was independent with bed mobility, required setup assistance for eating, partial/moderate assistance for toileting, bathing, and transfers. The resident weighed 232 pounds and did not have any significant weight loss. Review of the medical record revealed the resident was picked up by hospice on 02/06/25. Review of the medical record revealed a significant change MDS with a reference date of 02/09/25 was completed on 01/22/25. Interview on 02/27/25 at 1:59 P.M., RN #139 verified Resident #51's significant change MDS dated [DATE] was completed on 02/22/25, and should have been completed by 02/19/25. Review of the facility policy titled, Resident Assessment, dated 11/19/15 revealed a comprehensive MDS assessment should be completed within 14 days of a significant change.

Based on medical record review, staff interview, and policy review, the facility failed to ensure nephrostomy tube care was completed as ordered. This affected one (#234) resident out of the one resident reviewed for urinary catheters. The facility census was 76. Findings included: Review of the medical record for Resident #234 revealed an admitted [DATE] with medical diagnoses of end stage renal disease, atrial fibrillation, hypertension, anemia, and malignant neoplasm of cervix. Review of the medical record for Resident #234 revealed an admission Minimum Data Set (MDS) assessment, dated 02/17/25, which indicated Resident #234 was cognitively intact and was dependent upon staff for toilet hygiene, required substantial/maximum assistance with bathing, and partial/moderate assistance with bed mobility and transfers. The MDS indicated Resident #234 had an indwelling catheter. Review of the medical record for Resident #234 revealed a physician order dated 02/18/25 to change gauze dressing every other day to bilateral nephrostomy tubes. Review of the medical record for Resident #234 revealed hospital discharge orders dated 02/10/25 to change dressing to nephrostomy tube every other day and empty the bag as needed. Review of the medical record for Resident #234 revealed February 2024 Treatment Administration Record (TAR) which did not have documentation to support nephrostomy tube dressing changes were completed until 02/18/25. Interview on 02/27/25 at 10:50 A.M. with Administrator confirmed the facility did not have documentation to support the treatment for bilateral nephrostomy tube care was ordered until 02/18/25 and no documentation to support nephrostomy tube care was done as ordered until 02/18/25. Administrator stated the facility did not have a nephrostomy tube care policy.

Based on medical record review, staff interview, and policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately. This affected three (#22, #37, and #51) of 22 residents reviewed for assessment accuracy. The facility census was 76. Findings include: 1. Review of the medical record of Resident #37 revealed an admitted [DATE]. Diagnoses included alzheimer's disease, dementia with severe agitation, age-related osteoporosis, and muscle weakness. Review of the quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognition. The resident required set-up assistance with eating, supervision with bed mobility, and partial/moderate assistance with toileting, transfers, and dressing. The resident weighed 145 pounds. Review of weights revealed on 01/29/25, the resident weighed 132.4 pounds. On 02/07/24, the resident weighed 133.2 pounds. Interview on 02/26/25 at 3:06 P.M., Dietetic Technician (DT) #78 verified the weight entered on the MDS assessment dated [DATE] was not accurate. DT #78 verified the weight should have been entered as 132 pounds. Review of the plan of care dated 02/11/25 revealed the resident had an ADL self care performance deficit related to cognition and limited mobility. The resident required the use of a hoyer lift for transfers. Review of the documentation survey report for February 2025 revealed Resident #37 was dependent on staff for transfers on 02/01/25, 02/02/25, 02/04/25, 02/05/25, and 02/06/25. Interview on 02/27/25 at 1:57 P.M., Registered Nurse (RN) #139 verified Resident #37 was dependent on staff for transfers during the assessment period, which was not accurately reflected on the MDS dated [DATE]. 2. Review of the medical record of Resident #22 revealed an admitted [DATE]. Diagnoses included hemiplegia affecting right dominant side, chronic obstructive pulmonary disease, type 2 diabetes mellitus, and cervical cancer. Review of the quarterly MDS dated [DATE] revealed the resident had intact cognition. The resident required supervision for eating, toileting, and bed mobility, and partial/moderate assistance with bathing, dressing, and transfers. The resident weighed 238 pounds and had a significant, non-prescribed weight loss. Review of the medical record revealed on 01/13/25, the resident weighed 225.2 pounds. On 01/17/25, a weight of 238.4 pounds was noted, but was struck out on 01/22/25 at 1:55 P.M., indicating the resident was reweighed. On 01/22/25, the resident weighed 225 pounds. Review of the quarterly MDS assessment dated [DATE] revealed the resident had a weight of 238 pounds, which was signed by DT #78 on 01/27/25. Interview on 02/26/25 at 3:11 P.M., DT #78 verified Resident #22's weight was entered incorrectly and should have been 225 pounds. 3. Review of the medical record of Resident #51 revealed an admitted [DATE]. Diagnoses included hypertensive heart disease with heart failure, psychosis, hypothyroidism, and colon cancer. Review of the quarterly MDS assessment dated [DATE] revealed the resident had moderately impaired cognition. The resident rejected care 1-3 days during the assessment period. The resident was independent with bed mobility, required setup assistance for eating, partial/moderate assistance for toileting, bathing, and transfers. The resident weighed 232 pounds and did not have any significant weight loss. Review of Resident #51's weights revealed, on 01/27/25, the resident weighed 205.2 pounds. On 12/09/24, the resident weighed 220.2 pounds. On 08/12/24, the resident weighed 232.2 pounds. Interview on 02/26/25 at 4:47 P.M., DT #78 verified the information entered on Resident #51's MDS dated [DATE] was inaccurate. DT #78 stated she should have entered a weight of 205 and coded for a non-prescribed significant weight loss. Review of the facility policy titled, Resident Assessment, dated 11/19/15, revealed the MDS assessment would accurately reflect the resident's status.

Based on medical record reviews, observations, staff interviews, review of insulin pen checklist, and policy review, the facility failed to ensure over the counter medication bottle and insulin pen were dated after opened and failed to ensure medications were not left at the bedside. This affected two (#33 and 51) residents out of the four residents reviewed for medications. The facility census was 76. Findings included: 1. Review of the medical record for Resident #33 revealed an admitted [DATE] with medical diagnoses of chronic kidney disease Stage III, morbid obesity, left hemiplegia, diabetes mellitus, heart failure, depression, and spina bifida. Review of the medical record for Resident #33 revealed a quarterly Minimum Data Set (MDS) assessment, dated 12/06/24, which indicated Resident #33 was cognitively intact and was dependent for toilet hygiene, bathing, and transfers and required substantial/maximum assistance with bed mobility. Review of the medical record for Resident #33 revealed a physician order dated 09/29/24 for Vitamin B12 1000 micrograms (mcg) one tablet by mouth daily and an order dated 01/21/25 for Novolog solution 100 units per milliliter (ml) to inject 28 units subcutaneously (SQ) at breakfast daily. Observation was made on 02/24/25 at 10:22 A.M. revealed Resident #33 had Sevelamer Carbonate (to control high blood phosphate levels) was mixed with water in a cup sitting on her bedside table. The resident stated the nurses normally leave the medication at the bedside. Interview with the Licensed Practical Nurse (LPN) #76 on 02/24/25 at 10:27 A.M. confirmed she left the medication at the bedside for Resident #33. Observation on 02/25/25 at 7:43 A.M. revealed Licensed Practical Nurse (LPN) #52 prepare Resident #33 medications for administration. The observation revealed LPN #52 set Humalog insulin kwikpen (substitute for Novolog solution) to 28 units and placed needle on the kwikpen. The observation revealed the kwikpen did not indicate a date when the kwikpen was opened. The observation also revealed LPN #52 removed a Vitamin B12 tablet from an open bottle that was not dated and placed into the medication cup. LPN #52 was observed to administer 28 units of Humalog insulin kwikpen SQ and Vitamin B12 tablet to Resident #33. Interview on 02/25/25 at 8:03 A.M. with LPN #52 confirmed the Humalog insulin kwikpen and the Vitamin B12 bottle did not indicate the date the items were opened. 42731 2. Review of the medical record of Resident #51 revealed an admitted [DATE]. Diagnoses included hypertensive heart disease with heart failure. Review of the quarterly MDS assessment dated [DATE] revealed the resident had moderately impaired cognition. The resident rejected care 1-3 days during the assessment period. The resident was independent with bed mobility, required setup assistance for eating, partial/moderate assistance for toileting, bathing, and transfers. Review of the plan of care dated 12/23/24 revealed the resident had a behavior problem related to holding medications under her tongue and spitting them out after the nurse leaves the room. Interventions included to monitor the resident and document observed behavior and attempted interventions. Review of physician orders revealed an order dated 12/06/24 for a Century Oral Tablet daily upon rising. Observation on 02/26/25 at 9:41 A.M. revealed an orange pill laying on the foot of Resident #51's bed. Interview at the same time, LPN #93 verified the pill was laying on Resident #51's bed. LPN #93 stated the pill was a multivitamin and stated she was not aware how long it had been there and stated she had watched the resident take her pills earlier that morning. Review of the facility policy titled, Medication Administration-General Guidelines, dated 12/19/24, revealed the resident is always observed after administration to ensure medications are completely ingested. Medications are administered at the time they are prepared Review of the facility policy titled, Medication Storage in the Facility, dated 12/19/24, revealed medications are stored safely, securely, and properly, following manufacturer's or supplier recommendations. Outdated medications are immediately removed from stock.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, resident and family interview, review of video camera footage, review of facility investigation and incident report, and policy review the facility failed to ensure a resident was properly transferred and provided a mechanical lift (Hoyer) during transfer. This resulted in actual harm when Resident #27 who was a high fall risk, dependent for transfers, and required the utilization of a mechanical lift (Hoyer) for all transfers suffered a right distal femur fracture from a fall that occurred during a transfer. This affected one (#27) of three residents reviewed for falls. The census was 83. Findings include: Medical record review for Resident #27 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), cancer, neurogenic bladder, cerebrovascular attack (CVA), non-Alzheimer's dementia, hemiplegia, or hemiparesis, and respiratory failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 was severely cognitively impaired, had impaired functional status on one side for both upper and lower extremities, used a wheelchair, required supervision for eating, required maximal assistance for toileting and bathing, and was dependent for bed mobility, and transfers. Review of the care plan dated 02/21/24 revealed Resident #27 was at risk for falls related to her current diagnoses and change in environment. Interventions included the need for a safe environment with even floors that were free from spills and/or clutter, adequate lighting, a workable call light within reach, a bed in the lowest position and personal items within reach. Additionally, staff were to anticipate and meet resident needs by keeping items within reach, assisting with toileting, and encouraging Resident #27 to use the call light for assistance. Resident #27 required the use of side rails to assist with turning and repositioning while in bed, physical therapy (PT) and occupational therapy (OT) consults as needed. Review of therapy notes dated 07/16/24 revealed Resident #27 and the staff were provided education on the importance of utilizing appropriate assistive devices properly to increase Resident #27's mobility in the facility and reduce the burden of care for staff. Resident #27 was educated on proper safety techniques for in-room mobility along with safety education to increase functional mobility. Therapy also communicated with staff the need for increased monitoring of Resident #27 due to risk of falls. Review of the fall risk assessment dated [DATE] revealed Resident #27 had an increased risk of falling due to impaired balance. Review of a fall risk assessment dated [DATE] revealed Resident #27 was a high risk for falls as Resident #27 was unable to independently come to a standing position and exhibited loss of balance while standing. Review of the progress notes dated 12/17/24 at 6:50 A.M. revealed Resident #27 had a fall that was witnessed by Certified Nurse Aides (CNA) #93 and #95. Resident #27 was unable to bear weight while transferring and was lowered to the floor. The resident had on non-skid footwear at the time of the fall, was wearing prescribed oxygen and was incontinent at the time of the fall. The physician and the family were notified. Further review of a progress note dated 12/18/24 revealed family reported to LPN #125 Resident #27 had a swollen knee and upon observation of Resident #27's knee with family the physician was notified and an order for an x-ray was obtained. Resident #27 had an x-ray completed on 12/18/24 at 12:25 P.M. with results reported at 2:06 P.M. Resident #27 had an acute right distal femur fracture. Resident #27 was transferred to the hospital for further evaluation on 12/18/24 after x-rays completed revealed a right distal femur fracture. Review of the incident report dated 12/17/24 revealed Resident #27 was not able to perform functions for gait and balance. Review of the hospital report dated 12/18/24 revealed Resident #27 fell at the nursing home after being dropped and developed a right distal femur fracture. Family was undecided on surgical intervention and Resident #27 was sent back to the facility with a knee immobilizer. Review of the Interdisciplinary Team (IDT) note dated 12/18/24 revealed the IDT collaborated and determined the root cause of Resident #27's fall was weakness, requiring Resident #27 to be lowered to the floor during two-person transfer from a shower chair to bed. Interventions put into place included to educate staff on proper transfer techniques including the utilization of proper assistive devices for lifting a resident. Resident #27's care plan and Kardex (a resource that provides a brief overview of each resident's needs) was updated to reflect the need to utilize a mechanical lift (Hoyer) for all transfers. Review of the statement dated 12/19/24 written by CNA #95 revealed she was asked by CNA #93 to help with Resident #27's transfers on 12/17/24. The statement revealed CNA #93 put her hands under resident's arm and her other hand grabbed the back of the resident's pants to transfer Resident #27 into the shower chair from the wheelchair. After the shower, CNA #95 returned to the shower room to help CNA #93 transfer Resident #27 into a wheelchair. During the transfer Resident #27 had a bowel movement, both CNA #93 and #97 escorted Resident #27 to her room to put Resident #27 on the bed, during the transfer Resident #27 started to fall (drop). CNA #93 yelled for Resident #27 to stand, and the resident said, I am trying. CNA #95 said the resident was heavy and should have been transferred using a mechanical lift (Hoyer). CNA #93 said to the resident twice you are not standing and the resident dropped into a squatting position. CNA #93 was on the resident's right side holding the resident under the arm and CNA #95 was on the left side holding the resident under the other arm. CNA #93 pushed Resident #27's feet out from under her and the resident was lowered to the floor. A review of the statement dated 12/19/24 written by CNA #93 revealed when transferring Resident #27 from the wheelchair to the bed with CNA #95, they tried to stand Resident #27, and when the resident was unable to fully stand she proceeded to drop to her knees and was lowered to the floor by CNA #93 and #95. Interview with CNA #95 on 12/30/24 at 9:41 A.M. verified she assisted CNA #93 transfer Resident #27 from the wheelchair to the bed on 12/17/24. CNA #95 stated she had previously helped CNA #93 transfer Resident #27 to and from the shower chair and with cueing the resident was able to transfer. CNA #95 stated when they took Resident #27 back to her room in the wheelchair, they did not utilize a gait belt or a mechanical lift (Hoyer) to transfer Resident #27 back to bed. CNA #95 stated Resident #27 was not able to stand and when CNA #93 told Resident #27 to stand up and transfer and the resident told her she could not, and Resident #27 was lowered to the ground in a sitting position. CNA #95 stated she told CNA #93 Resident #27 was too heavy and a mechanical lift (Hoyer) should have been used. CNA #95 assumed CNA #93 was doing the transfer per Resident #27's care planned needs, but later found out Resident #27 should have been transferred using a mechanical lift (Hoyer). CNA #95 verified she did not review Resident #27's medical record or Kardex prior to the transfer and further denied the use of a gait belt, stating a gait belt should have been used. Interview with CNA #93 on 12/30/24 at 9:49 A.M. revealed Resident #27 was a two-person assist with a mechanical lift (Hoyer). CNA #93 denied the used of mechanical lift device (Hoyer) or a gait belt when transferring Resident #27 on 12/17/24. CNA #93 stated she and CNA #95 had assisted Resident #27 out of bed on 12/17/24 and transferred the resident in and out of the shower chair with maximal assistance. CNA #93 said Resident #27 must have been tired after the shower because when they attempted to transferred Resident #27 out of the wheelchair in her room the resident was not able to stand and needed to be lowered to the floor. CNA #93 said when the resident was lowered to the floor the resident was bouncing in a sitting position, almost like squatting. CNA #93 stated there was no way the resident broke her hip because she did not complain about her hip and denied pain at the time. Interview with the Administrator on 12/30/24 at 10:40 A.M. revealed in August 2024 therapy recommended to use a mechanical lift (Hoyer) for Resident #27 and an order was entered into the medical record. The order was discontinued after the family did not know if they wanted to use the mechanical lift after Resident #27's arm got crinkled in the lift pad. The Administrator stated she did not have any evidence regarding the family request not to use the mechanical lift for transfers. The Administrator stated some of the aides were using the mechanical lift (Hoyer) for Resident #27's transfers and others where not. The Administrator also verified the Kardex for Resident #27 did not reflect the need to use a mechanical lift (Hoyer) for transfers, and further stated the expectation was for a mechanical lift (Hoyer) to be used for all of Resident #27's transfers. Review of the video from the camera in Resident #27's room with Resident #27's family on 12/30/24 at 11:30 A.M. revealed on 12/17/24 at 6:05 A.M. CNA's #95 and #93 transferred Resident #27 into a shower chair by lifting the resident from under her arms and it appeared Resident #27 was not baring weight on her legs. The CNAs took Resident #27 out of the room and all three come back into the view at 6:36 A.M. and Resident #27 is now in a wheelchair. One of the CNAs is carrying a lift pad for the mechanical lift (Hoyer) and laid it on the bed. CNA #93 and #95 place their arms underneath Resident #27's arms and pulled Resident #27 out of the wheelchair. Resident #27 was observed as unable to stand, and you can hear the aides say, you got to help us and tells Resident #27 to stand. Resident #27 replies I am trying to stand, and I cannot. The aides trying to hold onto Resident #27, lower the resident to the floor. Resident #27's legs were not visible in the video due to the position of the bed. CNA #93 and #95 attempted twice to pick Resident #27 up off the floor before calling for assistance. LPN #125 came into the room, CNA's #93 and #95 reached under Resident #27's arms and LPN #125 grabbed both of Resident #27's legs and lifted Resident #27 onto the bed. LPN #125 did not assess Resident #27 and left the room within one minute of entering. CNA #93 and #95 provided incontinence care and changed Resident #27's brief. Using the mechanical lift (Hoyer) Resident #27 was transferred from the bed to the wheelchair and positioned in front of the television in the room. CNA #93 and #95 exited the room at 7:00 A.M. Interview with Resident #27's family on 12/30/24 at 12:21 P.M. revealed the staff had been using the mechanical lift (Hoyer) on all transfers for Resident #27 for the past couple of months. The family shared initially they were concerned about using the mechanical lift (Hoyer) because one day when observing a transfer, Resident #27 hit her head and developed a scratch when staff placed Resident #27 incorrectly in the mechanical lift (Hoyer). The family denied telling the facility not to use the mechanical lift (Hoyer). The interview with LPN #125 on 12/30/24 at 2:12 P.M. revealed she was the nurse on duty on 12/17/24 when Resident #27 fell . LPN #125 stated the aides asked her to help them get Resident #27 onto the bed after Resident #27 had been lowered to the floor. LPN #125 verified she did not complete a full head to toe assessment and only eye balled Resident #27 when she assisted the CNAs in getting the resident onto the bed. LPN #125 stated this was not her normal practice and Resident #27 should have been assessed but she was in a hurry. Interview with Therapy Manager (TM) #352 on 12/30/24 at 2:43 P.M. revealed during the time therapy was working with Resident #27 in July and August 2024 the recommendation was for a mechanical lift (Hoyer) to be used for transfers. The interview with the LPN #124 on 12/31/24 at 8:40 A.M. revealed she took care of Resident #27 on 12/18/24. LPN #124 stated Resident #27's family reported the resident had a swollen knee and upon assessment of Resident #27 the physician was notified and an order to x-ray Resident #27 lower extremities was obtained. LPN #124 when made aware of the x-ray results of a right femur fracture, the physician was notified and Resident #27 was sent to the hospital for further evaluation. LPN #124 stated LPN #125 imformed her Resident #27 had a witnessed fall when the resident was lowered to the floor, but nothing about the Resident #27's knee. Review of the policy entitled Accidents and Incidents dated 06/21/05 revealed the facility will ensure the resident's environment remains as free of accident hazards and each resident receives adequate supervision and utilizes assistive devices to reduce accidents. A licensed professional nurse shall examine a resident for any physical injury following an accident or injury. The deficient practice was corrected on 12/26/24 when the facility implemented the following corrective actions: -On 12/19/24 all staff were educated by the Director of Nursing to utilize the resident's plan of care to determine proper mode of transfer, including the use of gait belts when appropriate. Return demonstration was completed during the education by staff of where to find a residents plan of care. -On 12/20/24 all residents were assessed for fall risk, care plans were reviewed, Kardex were reviewed, and both were updated, as needed, to reflect each residents transfer status and the assistive devices needed for transfer. Each residents care plan and Kardex were compared for accuracy. -Audits were completed by the Director of Nursing and the Administrator on 12/26/24, 12/27/24 and 12/30/24 of resident transfers to ensure transfers were completed according to the residents care plan and Kardex. The care plan and Kardex for reach resident was also reviewed for accuracy. Ongoing audits to continue for two weeks. -Action plan was presented at an ad hoc Quality Assurance ad Performance Improvement QAPI meeting December 2024. Ongoing audits will be presented and reviewed at future QAPI meetings. Review of the medical records on 12/31/24 for Residents #39 and #52 revealed the resident's care plan and Kardex correctly represented the residents transfer status. Interview with CNAs #111 and #78 on 12/31/24 between 6:44 A.M. and 6:50 A.M. revealed they were recently trained on the proper use of a mechanical lift (Hoyer) and where to look in the Kardex to determine how a resident transfers. CNAs #111 and #78 verified they performed a resident transfer with a member of management. Interview with CNA #116 on 12/31/24 at 10:59 A.M. revealed a member of management watched her complete a transfer of a resident. CNA #116 was also shown how to use the Kardex to find out what kind of transfer a resident requires. This violation represents non-compliance investigated under Complaint Number OH00160906.

Based on medical record review, staff interview, review of facility self-reported incidents, and policy review the facility failed to ensure the abuse policy was implemented. This affected one (#57) of three residents reviewed for abuse. The census was 73. Findings include: Medical record review for Resident #57 revealed an admitted [DATE]. Diagnoses included non-traumatic brain dysfunction, renal insufficiency, Alzheimer's disease, and dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #57 was severely cognitively impaired. Resident #57's functional status required setup and clean-up for eating, moderate assistance for toileting, and supervision for bed mobility and transfers. Resident #57 was always incontinent for bladder and frequently incontinent for bowel. Interview with Certified Nursing Assistant (CNA) #116 on 12/31/24 at 10:59 A.M. revealed at the end of her shift on 12/29/24 a message was sent over What's AP (which is a program the facility used to send out messages to the staff) to the Administrator and the Director of Nursing. CNA #116 stated she wanted to report an incident which happened on 12/29/24 around lunch time between Resident #57 and CNA #165. CNA #116 reported CNA #165 was rough with Resident #57 and CNA #116 did not like the way the CNA #165 spoke to Resident #57. Interview with the Administrator on 12/31/24 at 11:27 A.M. revealed CNA #116 did send a text through the What's AP program on 12/29/24 at 3:21 P.M. to a facility phone and not to the Administrator's personal phone. The Administrator stated she was off on 12/29/24 and did not get the message until returning to work on 12/31/24. The Administrator stated the staff are to report any abuse concerns immediately to the supervisor on duty and then the supervisor would report such concerns to management. At the time of the interview, the Administrator reported she had not yet spoke to CNA #116. Interview with the Director of Nursing (DON) on 12/31/24 at 11:39 A.M. revealed a text message was received from CNA #116 on the What's AP program at the end of CNA #116's shift on 12/29/24. CNA #116 stated she wanted to report CNA #165. The DON claimed she responded via text, for what and then called CNA #116. The DON stated CNA #116 wanted to report CNA #165 for the way talked to Resident #57. The DON told CNA #116 if the situation was clinical, CNA #116 needed to call the Administrator. The DON then stated she hung up on CNA #116 and went back to sleep. The DON verified CNA #165 worked on 12/30/24 on the day shift from 7:45 A.M. to 3:00 P.M., and further verified the abuse policy was not followed, and, she, the DON should have immediately suspended CNA #165 pending an investigation. A subsequent interview with CNA #116 on 12/31/24 at 11:45 A.M. revealed she needed help with transferring Resident #57 around lunch time and asked CNA #165 to help. CNA #116 said Resident #57 could be combative at times and was not being cooperative at the time and CNA #165 said to the resident I don't have time for this and grabbed Resident #57's arm and threw her into the wheelchair. CNA #116 stated she attempted to report the incident to the nurse on duty, but the nurse was not listening to her, so she texted the Director of Nursing and the Administrator. CNA #116 verified she did not follow the policy for reporting the incident as soon as it happened. Review of the time punch for Certified Nursing Assistant (CNA) #165 dated 12/29/24 revealed CNA #165 worked from 7:08 A.M. to 3:00 P.M. and on 12/30/24 she worked the same unit from 7:45 A.M. to 3:00 P.M. Review of the facility Self-Reported Incidents (SRIs) dated 12/29/24 and 12/30/24 revealed no evidence this allegation was reported to the state agency. Review of the policy entitled Abuse, Neglect, Exploitation, Misappropriation of Resident Property revised on 10/01/22 revealed the facility will not tolerate Abuse, Neglect, Exploitation of its residents or the Misappropriation of Resident Property. Facility staff are to immediately report all such allegations to the Administrator. All alleged violations involving abuse, neglect, misappropriation of resident property, exploitation or mistreatment, including injuries of unknown source, are investigated immediately and reported to the Ohio Department of Health (ODH) in accordance with the procedures in the policy. In cases where a crime is suspected, staff should also report the same to local law enforcement in accordance with the facility's crime reporting policy.

Based on medical record review, staff interview, review of facility self-reported incidents, and policy review the facility failed to ensure the abuse policy was implemented. This affected one (#57) of three residents reviewed for abuse. The census was 73. Findings include: Medical record review for Resident #57 revealed an admitted [DATE]. Diagnoses included non-traumatic brain dysfunction, renal insufficiency, Alzheimer's disease, and dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #57 was severely cognitively impaired. Resident #57's functional status required setup and clean-up for eating, moderate assistance for toileting, and supervision for bed mobility and transfers. Resident #57 was always incontinent for bladder and frequently incontinent for bowel. Interview with Certified Nursing Assistant (CNA) #116 on 12/31/24 at 10:59 A.M. revealed at the end of her shift on 12/29/24 a message was sent over What's AP (which is a program the facility used to send out messages to the staff) to the Administrator and the Director of Nursing. CNA #116 stated she wanted to report an incident which happened on 12/29/24 around lunch time between Resident #57 and CNA #165. CNA #116 reported CNA #165 was rough with Resident #57 and CNA #116 did not like the way the CNA #165 spoke to Resident #57. Interview with the Administrator on 12/31/24 at 11:27 A.M. revealed CNA #116 did send a text through the What's AP program on 12/29/24 at 3:21 P.M. to a facility phone and not to the Administrator's personal phone. The Administrator stated she was off on 12/29/24 and did not get the message until returning to work on 12/31/24. The Administrator stated the staff are to report any abuse concerns immediately to the supervisor on duty and then the supervisor would report such concerns to management. At the time of the interview, the Administrator reported she had not yet spoke to CNA #116. Interview with the Director of Nursing (DON) on 12/31/24 at 11:39 A.M. revealed a text message was received from CNA #116 on the What's AP program at the end of CNA #116's shift on 12/29/24. CNA #116 stated she wanted to report CNA #165. The DON claimed she responded via text, for what and then called CNA #116. The DON stated CNA #116 wanted to report CNA #165 for the way talked to Resident #57. The DON told CNA #116 if the situation was clinical, CNA #116 needed to call the Administrator. The DON then stated she hung up on CNA #116 and went back to sleep. The DON verified CNA #165 worked on 12/30/24 on the day shift from 7:45 A.M. to 3:00 P.M., and further verified the abuse policy was not followed, and, she, the DON should have immediately suspended CNA #165 pending an investigation. A subsequent interview with CNA #116 on 12/31/24 at 11:45 A.M. revealed she needed help with transferring Resident #57 around lunch time and asked CNA #165 to help. CNA #116 said Resident #57 could be combative at times and was not being cooperative at the time and CNA #165 said to the resident I don't have time for this and grabbed Resident #57's arm and threw her into the wheelchair. CNA #116 stated she attempted to report the incident to the nurse on duty, but the nurse was not listening to her, so she texted the Director of Nursing and the Administrator. CNA #116 verified she did not follow the policy for reporting the incident as soon as it happened. Review of the time punch for Certified Nursing Assistant (CNA) #165 dated 12/29/24 revealed CNA #165 worked from 7:08 A.M. to 3:00 P.M. and on 12/30/24 she worked the same unit from 7:45 A.M. to 3:00 P.M. Review of the facility Self-Reported Incidents (SRIs) dated 12/29/24 and 12/30/24 revealed no evidence this allegation was reported to the state agency. Review of the policy entitled Abuse, Neglect, Exploitation, Misappropriation of Resident Property revised on 10/01/22 revealed the facility will not tolerate Abuse, Neglect, Exploitation of its residents or the Misappropriation of Resident Property. Facility staff are to immediately report all such allegations to the Administrator. All alleged violations involving abuse, neglect, misappropriation of resident property, exploitation or mistreatment, including injuries of unknown source, are investigated immediately and reported to the Ohio Department of Health (ODH) in accordance with the procedures in the policy. In cases where a crime is suspected, staff should also report the same to local law enforcement in accordance with the facility's crime reporting policy.

Based on medical record review, staff interview, review of facility self-reported incidents, and policy review the facility failed to ensure the abuse policy was implemented. This affected one (#57) of three residents reviewed for abuse. The census was 73. Findings include: Medical record review for Resident #57 revealed an admitted [DATE]. Diagnoses included non-traumatic brain dysfunction, renal insufficiency, Alzheimer's disease, and dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #57 was severely cognitively impaired. Resident #57's functional status required setup and clean-up for eating, moderate assistance for toileting, and supervision for bed mobility and transfers. Resident #57 was always incontinent for bladder and frequently incontinent for bowel. Interview with Certified Nursing Assistant (CNA) #116 on 12/31/24 at 10:59 A.M. revealed at the end of her shift on 12/29/24 a message was sent over What's AP (which is a program the facility used to send out messages to the staff) to the Administrator and the Director of Nursing. CNA #116 stated she wanted to report an incident which happened on 12/29/24 around lunch time between Resident #57 and CNA #165. CNA #116 reported CNA #165 was rough with Resident #57 and CNA #116 did not like the way the CNA #165 spoke to Resident #57. Interview with the Administrator on 12/31/24 at 11:27 A.M. revealed CNA #116 did send a text through the What's AP program on 12/29/24 at 3:21 P.M. to a facility phone and not to the Administrator's personal phone. The Administrator stated she was off on 12/29/24 and did not get the message until returning to work on 12/31/24. The Administrator stated the staff are to report any abuse concerns immediately to the supervisor on duty and then the supervisor would report such concerns to management. At the time of the interview, the Administrator reported she had not yet spoke to CNA #116. Interview with the Director of Nursing (DON) on 12/31/24 at 11:39 A.M. revealed a text message was received from CNA #116 on the What's AP program at the end of CNA #116's shift on 12/29/24. CNA #116 stated she wanted to report CNA #165. The DON claimed she responded via text, for what and then called CNA #116. The DON stated CNA #116 wanted to report CNA #165 for the way talked to Resident #57. The DON told CNA #116 if the situation was clinical, CNA #116 needed to call the Administrator. The DON then stated she hung up on CNA #116 and went back to sleep. The DON verified CNA #165 worked on 12/30/24 on the day shift from 7:45 A.M. to 3:00 P.M., and further verified the abuse policy was not followed, and, she, the DON should have immediately suspended CNA #165 pending an investigation. A subsequent interview with CNA #116 on 12/31/24 at 11:45 A.M. revealed she needed help with transferring Resident #57 around lunch time and asked CNA #165 to help. CNA #116 said Resident #57 could be combative at times and was not being cooperative at the time and CNA #165 said to the resident I don't have time for this and grabbed Resident #57's arm and threw her into the wheelchair. CNA #116 stated she attempted to report the incident to the nurse on duty, but the nurse was not listening to her, so she texted the Director of Nursing and the Administrator. CNA #116 verified she did not follow the policy for reporting the incident as soon as it happened. Review of the time punch for Certified Nursing Assistant (CNA) #165 dated 12/29/24 revealed CNA #165 worked from 7:08 A.M. to 3:00 P.M. and on 12/30/24 she worked the same unit from 7:45 A.M. to 3:00 P.M. Review of the facility Self-Reported Incidents (SRIs) dated 12/29/24 and 12/30/24 revealed no evidence this allegation was reported to the state agency. Review of the policy entitled Abuse, Neglect, Exploitation, Misappropriation of Resident Property revised on 10/01/22 revealed the facility will not tolerate Abuse, Neglect, Exploitation of its residents or the Misappropriation of Resident Property. Facility staff are to immediately report all such allegations to the Administrator. All alleged violations involving abuse, neglect, misappropriation of resident property, exploitation or mistreatment, including injuries of unknown source, are investigated immediately and reported to the Ohio Department of Health (ODH) in accordance with the procedures in the policy. In cases where a crime is suspected, staff should also report the same to local law enforcement in accordance with the facility's crime reporting policy.

Based on medical record review, review of fall investigations, observations, staff interviews, and review of facility policy on falls, the facility failed to adequately assess the root cause of falls, identify trends and patterns of falls, implement appropriate fall prevention interventions, assess the effectiveness of interventions, ensure previously implemented interventions were in place, and failed to update care plans timely for fall interventions for Residents #11, #29, #38, #61, and #81. This resulted in Immediate Jeopardy when Resident #29 sustained a fall on 01/29/22 that caused a head laceration, which was repaired with skin glue. On 07/03/22, Resident #11 fell and fractured her clavicle. On 08/21/22, Resident #38 fractured her hip during a fall. On 08/30/22 Resident #81 had a fall that resulted in a head laceration, which required staples. On 09/18/22, Resident #61 sustained a fall that resulted in a nasal fracture. Additionally, the facility failed to thoroughly investigate and implement interventions for Resident #64 following several falls. This affected six (Residents #11, #29, #38, #61, #64, and #81) out of seven residents reviewed for falls. The facility also failed to ensure steam table covers were applied to prevent residents turning on the steam table when the kitchenette was not in use. This affected the Cypress, [NAME] View, Pine Glen and Juniper unit kitchenettes. The census was 89. On 11/09/22 at 1:04 P.M., the Administrator, Director of Nursing (DON), and Regional Director of Clinical Services (RDCS) #400 were notified Immediate Jeopardy began on 01/29/22 when the facility failed to thoroughly investigate and conduct a root cause analysis to prevent the same actions, situations, and/or practices from occurring in the future to prevent further falls for after Resident #29 sustained a laceration to the head from a fall that required skin glue for repair. On 07/03/22, Resident #11 fractured her clavicle during a fall. On 08/21/22, Resident #38 sustained a hip fracture during a fall that required surgical intervention. On 08/30/22, Resident #81 received a head laceration from a fall that required staples and on 09/18/22, Resident #61 fell and sustained a nasal fracture. Furthermore, the facility failed to thoroughly investigate and implement interventions following several falls for Resident #64. The Immediate Jeopardy was removed on 11/14/22 when the facility implemented the following corrective actions: On 11/10/22, the floor nurses, Staff Development Nurse (SDN) #312, Minimum Data Set (MDS) Registered Nurse (RN) #232, and Case Manager (CM) Licensed Practical Nurse (CMLPN) #502 completed fall risk assessments on Residents #11, #29, and #38. On 11/10/22, the Director of Nursing (DON), RDCS #400, and Director of Quality (DOQ) #401 reviewed and revised the care plans for Residents #11, #29, and #38 to ensure fall prevention interventions are in place and consistent with the resident's fall assessment and prior fall reviews. On 11/10/22, the DON, RDCS #400, and DOQ #401 reviewed all resident falls that occurred in the last 30 days to ensure that the falls were thoroughly investigated, and they were reviewed for trends or patterns and root cause analysis was completed. The DON, RDCS #400, and DOQ #401 also reviewed to ensure care plan interventions put in place after the fall were appropriate and consistent with the fall review and root cause. On 11/10/22, the Administrator reviewed and revised the Facility Assessment to ensure supervision is provided by staff based on resident acuity and needs. On 11/11/22, the floor nurses, SDN #312, MDSRN #232, and CMLPN #502 completed fall risk assessment on all other residents. On 11/11/22, the Interdisciplinary Team (IDT) which consisted of Business Office Manager (BOM) #276, Maintenance Director (MD) #220, Housekeeping Director (HD) #229, Dietary Technician (DT) #251, Human Resource Coordinator (HRC) #263, Nutrition Service Supervisor (NSS) #233, Activities Director (AD) #314, Business Development (BD) #246, Social Services Coordinator (SSC) #218, SDN #312, MDSRN #232, CMLPN #502 and the Administrator were in serviced by the RDCS #400, on the need to ensure that the facility thoroughly investigates all falls to determine the root cause, reviewing for trends or patterns, and the need to assess the appropriateness of interventions put in place after the fall in an effort to prevent the same action, situation, and/or practice from occurring in the future. The IDT will establish an appropriate fall intervention based on the root cause analysis of each fall. On 11/11/22, the IDT was in serviced by the RDCS #400 on the need to ensure care plans are reviewed and revised as needed after every fall to ensure fall prevention interventions are developed and implemented for each fall. All licensed nursing staff will be in serviced on or before 11/11/22 by the DON/Designee on the need to ensure all falls are thoroughly investigated and that the care plans are reviewed and revised after each fall with appropriate interventions, consistent with the investigation, root cause analysis and any trends or patterns identified in the investigation. Any staff members not in serviced by 11/11/22 will be removed from the schedule and not be permitted to work until the in service is completed. All nursing staff will be in serviced on or before 11/11/22 by the DON/designee on the need to ensure all fall prevention interventions are implemented in accordance with the plan of care, including adequate supervision based on the resident's acuity and needs. Any staff members not in serviced by 11/11/22 will be removed from the schedule and not be permitted to work until in service is completed. Beginning 11/12/22, the DON or designee will audit all resident falls to ensure that they are thoroughly investigated, trends or patterns are identified, if applicable, and post fall interventions are appropriate and consistent with the investigation and the root cause analysis and fall prevention interventions, including supervision, is being implemented in accordance with the plan of care. The random audits will be done 5 times a week for 4 weeks. All adverse findings will be referred to the Quality Assurance and Performance Improvement (QAPI) committee for review and recommendation. On 11/14/22, the DON, RDCS #400, SDN #312, MDSRN #232, and CMLPN #502 reviewed and revised the care plans for all other residents in the facility to ensure fall prevention interventions are in place and consistent with the resident's fall assessment and prior fall reviews. Observations on 11/16/22 from 12:10 P.M. through 12:30 P.M. revealed fall prevention interventions were in place for Residents #11, #29, #38, and #81. Observations on 11/03/22 from 8:04 A.M. through 4:05 P.M., 11/07/22 at 12:49 P.M., and 11/08/22 at 8:57 A.M. revealed fall interventions were in place for Resident #61. Resident #64 had interventions to call for assistance and proper footwear; however, the resident was not observed out of bed. Review of the medical records for Residents #11, #29, #38, and #81 were reviewed for updated fall risk assessments and care plan revisions. Interviews on 11/16/22 from 12:20 P.M. through 12:30 P.M. with Licensed Practical Nurse (LPN) #405, LPN #219, and State tested Nursing Assistant (STNA) #202 revealed they had all been educated on the fall policy recently and were knowledgeable regarding the fall protocol at the facility. Although the Immediate Jeopardy was removed, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of the medical record for Resident #29 revealed she was admitted to the facility on [DATE]. Diagnoses included cerebral atherosclerosis, poly-osteoarthritis, spondylosis without myelopathy or radiculopathy, lumbar region, mixed hyperlipidemia, hypothyroidism, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and hypertensive heart disease with heart failure. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/15/22, revealed this resident had severely impaired cognition. This resident was assessed to require extensive assistance for bed mobility, transfer, dressing, personal hygiene, toileting, and supervision for eating. Review of the plan of care for Resident #29, initiated 07/02/20, revealed the resident was at high risk for falls related to multiple falls. Interventions included anticipate and meet resident needs, review information on past falls and attempt to determine cause of falls, record root causes, alter/remove any potential causes if possible, educate resident/family/caregivers/IDT as to causes, educate resident on use of call light, bed in lowest position at all times except during care, ensure resident has fresh water, resident to reside on memory care unit to give greater supervision, administer meds as ordered, resident places self on the floor, visual reminders in bathroom to remind resident to call for help when toileting/transferring, visual reminders in room to remind resident to call for help with transfers/toileting, non-skid footwear to be worn at all times and floor mats next to bed while resident is in bed. The intervention for floor mats was canceled on 08/05/22. Additionally, staff were to encourage resident to call for help when she needs to reach an item in the closet, Dycem (anti-slip mat/pad) to wheelchair, and physical therapy referral. There was also an intervention for the resident to wear a soft helmet while out of bed, which was created on 09/16/20 and canceled on 04/13/21. The intervention of the soft helmet when out of bed was added to the plan of care again on 11/02/21 and canceled on 11/10/21. Review of the assessment titled Nursing Fall Review, dated 01/11/22, revealed Resident #29 was at moderate risk for falls. Review of the progress notes for 01/25/22 revealed no documentation related to a fall on this date. Review of the fall investigation, dated 01/25/22, revealed maintenance staff reported Resident #29 was on the floor. Resident #29 was observed lying on the floor on her left side near the bathroom door. Resident #29's arms were out in front of her, and she had a small amount of blood on her left hand as well as an egg sized knot on her left temple. The investigation indicated the resident was alert to herself and was lifted to her wheelchair by staff. Vitals were obtained and the nurse practitioner was notified as well as the resident's family. Review of the assessment titled Nursing Fall Review, dated 01/25/22, revealed it was unknown what Resident #29 was doing at the time of the fall. An immediate intervention was not documented. Review of the progress note, dated 01/26/22, revealed the interdisciplinary team met to discuss Resident #29's fall on 01/25/22. It was noted Resident #29 was referred to physical therapy. There was no documentation related to the root cause of the fall. Review of the progress note, dated 01/29/22, revealed Resident #29 was found lying on her left side on the floor of her room. Resident #29 was observed to have a laceration on the back of her head on the left side. The on-call provider was notified of the laceration and gave an order to send Resident #29 out to the hospital. The note indicated Resident #29 was unable to describe what she was doing when the fall occurred. Review of the assessment titled Nursing Fall Review, dated 01/29/22, revealed not applicable was documented for what the resident was doing at the time of the fall. The immediate intervention was non-skid socks and call light. Review of the fall investigation, dated 01/29/22, revealed the nurse was walking by the resident's room and observed the resident lying on the floor and bleeding from her head. Resident #29 was unable to explain what she had been doing at the time of the fall. Review of the progress note, dated 01/29/22, revealed Resident #29 returned to the facility from the hospital, and the laceration on her head had been closed with Dermabond (skin glue), which would fall off in the next ten to 14 days. Review of the progress note, dated 01/31/22, revealed the interdisciplinary team met to discuss Resident #29's fall on 01/29/22. The note indicated interventions continue and remain appropriate. There was no documentation regarding a root cause analysis of the fall. Review of the progress note, dated 02/12/22, revealed Resident #29 was sent to the hospital after she fell out of bed and hit her head on the nightstand by the bed and floor. Review of the assessment titled Nursing Fall Review, dated 02/12/22, revealed Resident #29 was getting out of bed at the time of the fall. Immediate interventions were documented as vitals taken, range of motion assessed, and family and doctor notified. Review of the fall investigation, dated 02/12/22, revealed an aide alerted the nurse that Resident #29 was in her room and on the floor. The investigation indicated the nurse and aide assessed Resident #29, the nurse called the physician and family, and the resident was transported to the hospital. Review of the progress note, dated 02/13/22, revealed Resident #29 returned from the hospital with a hematoma on her forehead and sutures to a laceration on the scalp. Resident #29 had a new order to remove sutures on 02/19/22. The note indicated frequent checks were in place and staff would continue to monitor. Review of the progress note, dated 02/17/22, revealed the interdisciplinary team met to discuss Resident #29's fall on 02/12/22. It was noted interventions continue and remain appropriate. There was no documentation related to the root cause of the fall. Review of the progress note, dated 02/28/22, revealed Resident #29 had an unwitnessed fall and was found by aides sitting on the floor in the hall next to a room. A head-to-toe assessment was completed, the nurse practitioner, DON, and family were notified. Resident #29 was transferred to the hospital due to an open laceration on the back of the head. Review of the assessment titled Nursing Fall Review, dated 02/28/22, revealed Resident #29 was attempting to transfer self at the time of the fall on 02/27/22. The immediate intervention was a head-to-toe assessment. Review of the fall investigation, dated 02/28/22, revealed Resident #29 had an unwitnessed fall outside of her room, was confused, and attempted to transfer herself. Review of the progress note, dated 02/28/22, revealed the interdisciplinary team met to discuss Resident #29's fall on 02/27/22. The note indicated the resident was sent to the emergency room for a laceration to the head and returned to the facility with staples. A referral for physical and occupational therapies was submitted. The note also revealed other interventions continue and remain appropriate. There was no documentation related to the root cause of the fall. Review of the progress note, dated 04/09/22, revealed Resident #29 was observed on the floor of the room and was bleeding from a laceration on the back of her head. There is no documentation regarding any medical treatment provided to Resident #29 to address the bleeding. Review of the assessment titled Nursing Fall Review, dated 04/09/22, revealed it was unable to be determined what Resident #29 was doing at the time of the fall. The immediate intervention was head-to-toe assessment, neuro checks, and vitals. Review of the fall investigation, dated 04/09/22, revealed Resident #29 was observed on the floor and was bleeding from the back of her head. The immediate action taken included head-to-toe assessment, vitals, and neuro checks. Review of the progress notes from 04/09/22 through 04/12/22 revealed no documentation of follow-up from the interdisciplinary team regarding the fall on 04/09/22, including a root cause analysis of the fall. Review of the progress note, dated 04/12/22, revealed a call was placed to Resident #29's responsible party regarding a fall. There is no documentation regarding the details of the fall on this date. Review of the assessment titled Nursing Fall Review, dated 04/12/22, revealed Resident #29 was unable to explain what she was doing at the time of the fall. The immediate intervention was assessment of body for wounds. Review of the fall investigation, dated 04/12/22, revealed Resident #29 was found on the floor in the hall. The investigation indicated the nurse practitioner was observed next to the resident. Resident #29 was noted with an injury to the left temple with some bleeding and swelling. Resident #29 was unable to describe what happened at the time of the fall. Review of the plan of care for falls revealed an intervention of a medication review request was added on 04/12/22. Review of the progress note, dated 04/13/22, revealed Resident #29 was found on the floor at the foot of the bed by an aide. Resident #29 was noted to be lying on her left side and was barefoot. The call light was noted to be in reach and not on. Resident #29 was observed to have a skin tear to the left temple with some blood. Review of the assessment titled Nursing Fall Review, dated 04/13/22, revealed Resident #29 was self-ambulating at the time of the fall. The immediate intervention was non-skid socks. Review of the fall investigation, dated 04/13/22, revealed Resident #29 was found on the floor on her left side at the foot of the bed, and was unable to describe what happened. Resident #29's call light was within reach and not on. Resident #29 was barefoot, but no environmental hazards were noted. The immediate action taken included an assessment, neuro checks, and the resident was assisted to wheelchair and moved to the common area. Review of the progress notes from 04/13/22 through 04/23/22 revealed no documentation of follow-up from the interdisciplinary team regarding the falls on 04/12/22 and 04/13/22, including a root cause of the fall or information regarding effectiveness of fall prevention interventions in place. Review of the plan of care for falls revealed interventions of encourage resident to remain in common areas during the day for closer supervision by staff and toilet resident frequently were added on 04/14/22. Review of the progress note, dated 04/23/22, revealed the nurse returned to the memory care unit and heard Resident #29 yelling out for assistance. The nurse and one of the aides entered the room and found Resident #29 lying on the floor and in a puddle of blood as she was bleeding from her head. Review of the assessment titled Nursing Fall Review, dated 04/23/22, revealed Resident #29 was unable to describe what she was doing at the time of the fall. The immediate intervention was a head-to-toe assessment, vitals, and pressure was applied to the wound. Review of the fall investigation, dated 04/23/22, revealed the incident description was a summary of the progress note regarding the fall. The immediate action taken was pressure applied to the laceration until paramedics arrived. Review of the progress notes from 04/23/22 through 05/02/22 revealed no documentation of follow-up from the interdisciplinary team regarding the fall on 04/23/22, including the root cause of the fall or information regarding fall prevention interventions, such as implementation of new interventions or the effectiveness of interventions in place. Review of the discontinued orders revealed an order dated 04/25/22 to remove staples on 04/30/22. Review of the plan of care for falls revealed an intervention of hospice notified to evaluate resident for wheelchair type for safety and medication review completed with changes made on 04/25/22. Review of the progress note, dated 05/02/22, revealed Resident #29 was found crawling on the floor in the hallway from her bed. The note indicated a head-to-toe assessment was completed with no injuries identified. Review of the fall investigation, dated 05/02/22, revealed the aide informed the nurse that Resident #29 was on the floor. The investigation indicated Resident #29 appeared to have crawled out of her bed and into the hallway. A head-to-toe assessment was completed, and vitals were taken with no injuries noted. There were no immediate fall prevention interventions documented. Review of the progress notes from 05/02/22 through 05/08/22 revealed no documentation of follow-up from the interdisciplinary team regarding the fall on 05/02/22, including root cause of the fall or assessment of fall prevention interventions. Review of the plan of care for falls revealed an intervention for a perimeter mattress was added on 05/04/22. Review of the progress note, dated 05/08/22, revealed the nurse was in the room across the hall from Resident #29, and when she exited the room after administering medications, Resident #29 was observed sitting on the floor in the doorway of her room with her legs stretched out, and it was noted that her call light was on. Resident #29 denied pain and reported she was unsure what happened. Resident #29 then attempted to scoot herself across the floor, but staff assisted her back to her wheelchair. The note indicated no injuries were noted upon assessment, and Resident #29 was sitting in the common area with staff to be monitored. Review of the fall investigation, dated 05/08/22, revealed Resident #29 was found sitting on the floor in the doorway of room. The investigation indicated the call light was noted to be in use. Resident #29 denied any pain and was unable to explain what happened. Review of the progress note, dated 05/09/22, revealed Resident #29 was found sitting on the floor of the room and was scooting herself across the floor on her buttock. Review of the assessment titled Nursing Fall Review, dated 05/09/22, revealed it was unknown when Resident #29 was last toileted, and it was noted she was found sitting on floor at the time of the fall. There was no immediate intervention documented. Review of the fall investigation, dated 05/09/22, revealed the nurse observed Resident #29 sitting on the floor of her room and scooting across the floor on her buttock. The immediate action take included a head-to-toe assessment, neuro checks, and vitals with no injuries noted. There was no immediate intervention documented. Review of the progress notes from 05/09/22 through 05/20/22 revealed no documentation of follow-up from the interdisciplinary team regarding the falls on 05/08/22 and 05/09/22, including root cause analysis of the falls and assessment of fall prevention interventions. Review of the plan of care for falls revealed interventions for a medication review and nurse practitioner to review falls for further possible intervention were added on 05/11/22. An intervention of resident known to refuse to wear soft helmet was also added on 05/11/22 and resolved on 08/05/22. Review of the progress note, dated 05/20/22, revealed Resident #29 was observed by staff on the floor of her room. Resident #29 denied hitting her head or having any injuries but was confused at baseline. The note indicated vital signs were obtained and a head-to-toe assessment was completed. Review of the assessment titled Nursing Fall Review, dated 05/20/22, revealed it was unknown when Resident #29 was last toileted, or what she was doing at the time of the fall. There was no immediate intervention documented. Review of the fall investigation, dated 05/20/22, revealed Resident #29 was found on her side next to her wheelchair. Resident #29 denied hitting her head and denied having any pain. The investigation noted Resident #29 was alert but was confused at baseline. The immediate action taken included head-to-toe assessment and vitals with no injuries documented. There was no documentation of immediate interventions. Review of the progress notes from 05/20/22 through 06/02/22 revealed no documentation of follow-up from the interdisciplinary team regarding the fall on 05/20/22, including a root cause of the fall or effectiveness of fall prevention interventions. Review of the progress note, dated 06/02/22, revealed Resident #29 was observed coming out of her room by scooting on her bottom and yelling for help. Staff assisted Resident #29 to her wheelchair, and vital signs, neuro checks, and a head-to-toe assessment were done with no injuries observed. The note indicated Resident #29's call light was in reach and staff would continue to monitor. Review of the assessment titled Nursing Fall Review, dated 06/02/22, revealed it was unknown what Resident #29 was doing at the time the fall occurred, and no immediate intervention was documented. Review of the fall investigation, dated 06/02/22, revealed Resident #29 scooted herself into the hall from her room and was yelling for help. It was noted her wheelchair was in her room and next to her bed. A head-to-toe assessment was completed, vitals were obtained, and neuro checks were started with no injuries observed. Review of the progress note, dated 06/03/22, revealed fall interventions and goals reviewed and remain appropriate. There was no documentation regarding the root cause of the fall. Review of the progress note, dated 06/24/22, revealed Resident #29 was observed on the floor on her buttock next to her bed and was scooting on her buttock and pushing her wheelchair. A skin assessment revealed she had a bruise on her left shin. Resident #29 reported no pain, dizziness, and range of motion was within normal limits. Review of the fall investigation, dated 06/24/22, revealed Resident #29 was observed on the floor on her buttock next to her bed with her feet out in front of her, and was scooting on her buttock and pushing her wheelchair. Resident #29 was unable to describe what happened. A skin assessment revealed a bruise on her shin, but Resident #29 reported she did not have any pain. Vital signs were obtained, neuro checks were done, and range of motion was within normal limits. There was no documentation regarding root cause of the fall or immediate interventions implemented. Review of the progress notes from 06/24/22 through 08/05/22 revealed no documentation of follow-up from the interdisciplinary team regarding the fall on 06/24/22. Review of the plan of care for falls revealed an intervention of a care conference with family to discuss resident plan of care was added on 06/27/22. Review of the progress note, dated 08/05/22, revealed Resident #29 was found on the floor on this date. Review of the assessment titled Nursing Fall Review, dated 08/05/22, revealed it was unknown what Resident #29 was doing at the time of the fall. The immediate intervention was assisted Resident #29 to her wheelchair and then back to bed. Review of the fall investigation, dated 08/05/22, revealed Resident #29 was observed lying on her left side in front of her wheelchair, but was unable to describe what happened. The immediate action taken included an assessment, which revealed no injuries, and staff assisted the resident to her wheelchair. There was no documentation regarding immediate interventions. Review of the progress notes from 08/05/22 through 08/15/22 revealed no documentation of follow-up from the interdisciplinary team regarding the root cause of the fall or assessment of fall prevention interventions. Review of the plan of care for falls revealed an intervention of offer toileting throughout the night was added on 08/05/22. Review of the progress note, dated 08/15/22, revealed Resident #29 was found beside the bed on the floor. The note indicated Resident #29 was confused and unable to explain what happened, which was noted to be not a new onset. Resident #29 was observed bleeding from the top of her head. Staff applied pressure and ice and contacted emergency services. Resident #29 was transferred to the emergency room for evaluation and treatment. Review of the assessment titled Nursing Fall Review, dated 08/15/22, revealed it was unknown what Resident #29 was doing at the time of the fall. The immediate intervention was to send to the emergency room for evaluation and treatment. Review of the fall investigation, dated 08/15/22, revealed the incident details were a summary of the progress note regarding the fall. The immediate action taken was Resident #29 was sent to the emergency room . Review of the progress note, dated 08/15/22, revealed Resident #29 returned to the facility with four staples. Review of the progress notes from 08/15/22 through 08/21/22 revealed no documentation of follow-up from the interdisciplinary team regarding the fall on 08/15/22, including a root cause analysis or information regarding review of fall interventions. Review of the plan of care for falls revealed an intervention to send to emergency room for evaluation and treatment on 08/16/22. Further review of the plan of care revealed another intervention to monitor the resident frequently while in room was added on 08/22/22. Observation on 11/09/22 at 9:35 A.M. revealed Resident #29 did not have Dycem in her wheelchair, which was confirmed during an interview with STNA #290 at the time of the observation. Interview on 11/09/22 at 10:31 A.M. with the DON confirmed the intervention for the refusal to wear the soft helmet was not entered into the plan of care for falls until 05/11/22, which was after four falls with injuries to the head that required skin glue, staples, or sutures to repair the lacerations. Interview on 11/09/22 at 11:10 A.M. with RDCS #400 revealed there was no documentation of care conference with Resident #29's family per the intervention on 06/27/22. RDCS #400 stated she was unable to find any documentation of Resident #29's refusals to wear the soft helmet. RDCS #400 reported the facility had reached out to hospice as there was no documentation at the facility that hospice had completed an evaluation for wheelchair safety as listed in the plan of care for falls as a fall prevention intervention. 2. Review of the medical record for Resident #38 revealed she was admitted to the facility on [DATE]. Diagnoses included acute cystitis with hematuria, acute kidney failure, unspecified, hyperglycemia, hypo-osmolality and hyponatremia, nontraumatic subdural hemorrhage, unspecified, other specified cardiac arrhythmias, hypoglycemia, hypokalemia, hypertension, hypothyroidism, generalized anxiety disorder, hyperkalemia, Alzheimer's disease with late onset, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, heart failure, unspecified, and other lack of coordination. Review of the quarterly MDS assessment, dated 09/02/22, revealed this resident had moderately impaired cognition. This resident was assessed to require extensive assistance for bed mobility, transfer, dressing, toileting, and personal hygiene as well as supervision for eating. Review of the plan of care for Resident #38, initiated 09/05/18, revealed the resident was at risk for falls related to diagnosis of transient ischemic attack (stroke). Interventions included ensure non-skid footwear, keep call light within reach, keep frequently used items within reach, keep room free of clutter, and refer to physical therapy and occupational therapy as needed, resident re-educated about using walker while ambulating or getting up from chair, encourage resident to use call light for assistance, educate resident about applying footwear before ambulation and keep bed in lowest position, scoop mattress to bed at all times, re-educate resident on use of call [NAME] [TRUNCATED]

Based on observation, interview, record review, review of the National Pressure Ulcer Advisory Panel (NPUAP) information, and policy review, the facility failed to assess and identify pressure ulcers and failed to implement interventions and treatments to prevent the development and promote healing of pressure ulcers. The facility failed to identify multiple unstageable (blackened in color with necrotic tissue) deep tissue injuries (DTI), failed to contact the physician to implement treatments, resulting in worsening tissue damage and failed to follow infection control protocols during pressure ulcer dressing changes. This resulted in Immediate Jeopardy and serious life-threatening harm and/or injuries when one resident (#286) was hospitalized with septic shock as she had a large Stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed) sacral decubitus ulcer, as well as bilateral heel decubitus ulcers and a urinary tract infection. Additionally, Resident #20 developed an avoidable pressure ulcer to the left ankle that resulted in actual harm that was not immediate jeopardy as the pressure ulcer deteriorated to a Stage III (full thickness tissue loss; subcutaneous fat may be visible, but bone, tendon or muscle are not exposed; slough may be present but does not obscure the depth of tissue loss). Furthermore, Resident #05 developed avoidable pressure ulcers that were not treated timely that placed the resident at risk for more than potential harm that was not immediate jeopardy. This affected three (Residents #286, #20 and #05) of five residents reviewed for pressure ulcers. The facility identified a total of six residents with pressure ulcers, three in-house acquired and three out of house acquired. The facility census was 89. On 11/09/22 at 1:04 P.M., Regional Director of Clinical Services (RDCS) #400, Director of Nursing (DON) #213 and Administrator #278 were notified Immediate Jeopardy began on 08/02/22 when Resident #286 was hospitalized with septic shock as she had a large sacral decubitus ulcer, as well as bilateral heel decubitus ulcers and a urinary tract infection. A Stage IV chronic sacral ulcer and a Stage III left heel ulcer was documented to be present on admission to the hospital. Prior to the hospitalization , the facility documented Resident #286 had only a sacral wound measuring 1.6 cm by 0.2 cm. and the skin around the wound was pink with fragile scar tissue. Resident #286's wounds continued to deteriorate, and she was hospitalized a second time for sepsis on 09/27/22 and received surgical debridement of a Stage IV ulcer to the coccyx. Additionally, Resident #20 developed an avoidable pressure ulcer to the left ankle that deteriorated to a Stage III and Resident #05 developed avoidable pressure ulcers that were not treated timely. The Immediate Jeopardy was removed on 11/11/22, when the facility implemented the following corrective actions: On 11/10/22, Staff Development Nurse (SDN) #312, Minimum Data Set (MDS) Registered Nurse (RN) #232 and Case Manager Licensed Practical Nurse (CMLPN) #502 completed skin assessments on Residents #20, #05 and #286. On 11/10/22, SDN #312, MDS Nurse #232, and CMLPN #502 notified the physicians of the updated assessments for Residents #05 and #20. On 11/10/22, SDN #312, MDS Nurse #232, and CMLPN #502 completed audits of medical records for all residents with wounds to ensure appropriate physician orders were in place. On 11/10/22, SDN #312, MDS Nurse #232, and CMLPN #502 completed an in-house audit of all residents with wounds to ensure that treatments were completed per physician order. No issues were identified. On 11/10/22, SDN #312, MDS Nurse #232, and CMLPN #502 completed audits off all residents to ensure that pressure-relieving and offloading interventions were in place as per the plan of care. On 11/10/22, SDN #312, MDS Nurse #232, and CMLPN #502 completed skin assessments of all remaining residents in the facility. All nursing staff will be in-serviced by the Director of Nursing (DON)/Designee on or before 11/11/22 on identifying skin concerns/ulcers and reporting any skin concerns/skin ulcers to the nurse or physician, as appropriate, and off-loading and/or ensuring pressure-relieving interventions are implemented in accordance with the plan of care. Any staff members not in serviced by 11/11/22 will be removed from the schedule and not be permitted to work until in-service is completed. All licensed nurses will be in-serviced by the DON/Designee on or before 11/11/22 on the policy and procedure for assessing/reassessing residents skin conditions, documentation of assessments, implementing treatments in accordance with the physician order, reviewing and revising care plans, accordingly, monitoring of skin and wound conditions and physician notification for the same, and the need to ensure correct physician orders are in the medical record. Any staff members not in serviced by 11/11/22 will be removed from the schedule and not be permitted to work until in-service is completed. Beginning 11/12/22, the DON/Designee will audit all active residents with skin conditions, concerns, or skin ulcers to ensure pressure relieving interventions are in place, treatments are in place in accordance with the physician orders, assessments are current, and the physician has been notified of the current status of the wound. Audits will be completed 5 times a week for 4 weeks. All adverse findings will be referred to the Quality Assurance and Performance Improvement (QAPI) committee for review and recommendation. During the survey on 11/14/22 through 11/16/22, the survey team verified interventions to prevent pressure ulcers and/or promote healing of pressure ulcers were in place for identified residents. Although the immediate Jeopardy was removed on 11/11/22, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of medical record for Resident #286 revealed an admitted [DATE]. Diagnoses included peripheral vascular disease, atherosclerosis of native arteries of extremities right and left, depression and dementia. Review of the care plan dated 11/04/20 revealed a Stage IV pressure ulcer to right heel with interventions to administer treatments as ordered and monitor for effectiveness, dressing as ordered, pressure relieving device to bed/chair, and monitor dressing to ensure intact and adhering. Review of a wound note dated 01/13/22 documented a Stage IV pressure ulcer present on admission from 05/04/21 to her right heel and an arterial ulcer to her left foot acquired in house on 08/17/21. No other wounds were documented. Resident #286 was hospitalized on [DATE] for concerns of dehydration since a Covid-19 infection and she returned to the facility on [DATE] after a hospitalization . The skin assessment on this date documented open, pink and red areas to her coccyx, with intact area in the middle of open areas, entire area measuring three inches by four inches. There was an area to her left heel measuring 3.0 centimeters (cm) by 0.5 cm by 0.75 cm and an area to her right heel measuring 8.0 cm by 5.0 cm by 0.5 cm. No further description of the wounds was documented. A care plan was created on 01/27/22 for a Stage IV sacral pressure ulcer with interventions to observe area, pressure reducing/relieving mattress and provide skin assessments. There was a physician order dated 01/25/22 for a pressure reducing cushion to chair when out of bed. Review of the wound consultation note dated 01/27/22 revealed documentation of an unstageable sacral wound measuring 7.0 cm by 6.0 cm with a wound base of 90 percent eschar and 10 percent granulation tissue. The resident had a Stage IV pressure ulcer to the right heel measuring 2.5 cm by 2.5 cm by 0.2 cm. The resident had an arterial ulcer to her left foot measuring 0.8 cm by 0.2 cm by 1.0 cm. The resident was seen weekly and on 07/28/22, the wound consultation note documented the sacral wound as improved, measuring 1.6 cm by 0.2 cm and the skin around the wound was pink with fragile scar tissue. There was no mention of any wounds to the feet. Review of a progress note dated 08/02/22 documented the nurse was alerted that Resident #286 was lethargic with a heart rate of 117 beats per minute and oxygen saturation was 90 to 92 percent on room air. Certified Nurse Practitioner (CNP) #403 was notified with the change in condition and orders were received to send the resident to the hospital for further evaluation. Review of the hospital discharge summary documented the resident was hospitalized from 08/02/22 through 08/07/22 with septic shock, sepsis infection multifactorial as she had a large sacral decubitus ulcer, as well as bilateral heel decubitus ulcers and a urinary tract infection. A Stage IV chronic sacral ulcer and a Stage III left heel ulcer was documented to be present on admission to the hospital. Magnetic Resonance Imaging (MRI) of both feet did not reveal osteomyelitis and the sacral ulcer was evaluated by surgery who did not feel further debridement was needed. Review of the admission skin assessment dated [DATE] revealed documentation of a Stage III pressure ulcer on the resident's right heel, left heel and coccyx. No other skin concerns were documented. The care plan for skin integrity, dated 08/07/22, documented interventions including education of the resident and family of causative factors for prevention, encourage good nutrition, keep skin clean and dry, monitor/document location, size and treatment of skin injury and report any abnormalities. Pressure ulcer interventions included pressure reducing device on bed and chair, barrier cream, positioning with pillows and reposition frequently. Review of the progress note dated 08/09/22 revealed CNP #403 assessed Resident #286 and documented an area on the resident's right hip as a deep tissue injury measuring 6.0 cm by 6.0 cm with the surrounding tissue warm to the touch. Concern was documented the area could easily evolve into something more significant. Wound consult and offloading were ordered. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/11/22, revealed Resident #286 was moderately cognitively impaired. She required extensive two-person assistance for transfers, dressing, toileting, one person assistance for bed mobility and for personal hygiene and supervision for eating. The skin section of the MDS documented one unstageable area and three unstageable Stage IV (muscle and or bone visible) pressure areas which were not present on admission. Review of the wound note dated 08/11/22 revealed Wound Nurse Practitioner (WNP) #404 documented an unstageable wound to the left ischium measuring 3.6 cm by 2.9 cm by 0.3 cm and a deep tissue injury to the right hip measuring 7.0 cm by 8.0 cm. Also documented was a Stage IV sacral wound measuring 0.6 cm by 4.0 cm by 1.0 cm. Review of the physician orders revealed an order dated 08/11/22 to cleanse left ischium with Dakin's solution, pat dry, apply Prisma, a cellulose, collage and silver nitrate dressing, and cover with Optifoam, an occlusive dressing daily. There was no documentation this was completed on 08/13/22, 08/14/22, 08/22/22, 08/23/22, 08/25/22, 08/31/22, 09/02/22, 09/06/22, 09/07/22 and 09/08/22. The order was discontinued on 09/15/22. Review of the physician orders revealed an order dated 08/11/22 for Optifoam every other day to the right hip. There was no documentation this was completed on 08/14/22 or 08/22/22. The order was discontinued on 09/01/22. Review of the Braden scale for predicting pressure score risk, dated 08/14/22, revealed Resident #286 scored a 12, high risk for developing pressure ulcers. Review of the wound progress note dated 09/01/22 revealed a Stage IV pressure ulcer to the sacrum measuring 2.6 cm by 1.2 cm by 1 cm, serosanguinous drainage noted, no odor present. Continue to cleanse with Dakin's solution, pat dry, apply Prisma and cover with Optifoam. Right heel Stage IV pressure area has resolved. Unstageable pressure ulcer to right hip measuring 7.2 cm by 5.0 cm, eschar present, area noted with serosanguinous drainage and foul odor. Cleanse area with normal saline, pat dry, apply calcium alginate, cover with Optifoam change every other day and as needed (PRN). Unstageable pressure ulcer to left ischium measuring 2.0 cm by 2.0 cm by 2.3 cm, serosanguinous drainage noted, foul odor noted. Continue to cleanse area with Dakin's solution, pat dry, apply Alginate, cover with Optifoam and change daily and PRN. Resident #286 did have complaints of pain to feet during assessment. Record review of the wound progress note dated 09/08/22 revealed a Stage IV pressure ulcer to the sacrum measuring 4.0 cm by 2.0 cm by 1.0 cm, serosanguinous drainage noted, no odor present. Continue cleanse with Dakin's solution, pat dry, apply Prisma and cover with Optifoam. Right heel Stage IV pressure area reopened, measuring 3.5 cm by 3.1 cm by 0.1 cm serosanguinous drainage present. New order to cleanse area with Dakin' s, apply Prisma, cover with Optifoam and change daily and PRN. Unstageable pressure ulcer to right hip measuring 7.0 cm by 5.0 cm, eschar present, area noted with serosanguinous drainage and foul odor. Cleanse area with normal saline, pat dry, apply calcium alginate, cover with Optifoam change daily and PRN. Unstageable pressure ulcer to left ischium measuring 2.0 cm by 2.0 cm by 2.0 cm, serosanguinous drainage noted, foul odor noted. Orders were to continue to cleanse area with Dakin's solution, pat dry, apply Alginate, cover with Optifoam and change daily and PRN. Resident #286 did have complaints of pain to feet during assessment. Review of practitioner note by CNP #403, dated 09/13/22, revealed a concern for increased purulent wound drainage with increased odor. A Complete Blood Count (CBC), Complete Metabolic Panel (CMP), Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) laboratory tests were ordered as well as an antibiotic, Keflex, 500 milligrams (mg) for seven days. Resident #286's Power of Attorney (POA) was contacted and updated on the significant worsening condition of the wounds, concerns for osteomyelitis, sepsis and gangrene secondary to her severe peripheral artery disease. Recommendations of code status change (currently full) and hospice referral was made, discussion of quality versus quantity of life for this resident. Review of wound progress note dated 09/15/22 revealed a Stage IV pressure ulcer to the sacrum measuring 3.0 cm by 1.8 cm by 1.0 cm, serosanguinous drainage noted, no odor present. Continue to cleanse with Dakin's solution, pat dry, apply Prisma and cover with Optifoam. Right heel Stage IV pressure area reopened, measuring 3.0 cm by 3.0 cm by 0.1 cm, serosanguinous drainage present. Continue to cleanse area with Dakin's, apply Prisma, cover with Optifoam change daily and PRN. Unstageable pressure ulcer to right hip measuring 8.0 cm by 6.0 cm by 3.0 cm, area debrided this visit, area noted with purulent drainage and foul odor. Order to cleanse area with normal saline, pat dry, apply silver alginate, cover with Optifoam change daily and PRN. Unstageable pressure ulcer to left ischium measuring 2.0 cm by 2.0 cm by 2.6 cm, area was debrided this visit, purulent drainage noted, foul odor noted. New order to cleanse area with Dakin's solution, pat dry, pack loosely with Dakin's-soaked gauze, cover with Optifoam, change daily and PRN. Resident #286 complained of severe generalized pain, Physician #406 was in the facility and updated. Review of the provider note by CNP #403, dated 09/16/22, revealed an acute visit was made on this date. Pain medication was adjusted from Oxycodone to long-acting OxyContin ten milligrams twice daily and every four hours as needed. Discussion was had with Resident #286 regarding advanced care planning, poor nutritional intake to aid in wound healing, ongoing weight loss and severe vascular impairment to no avail. The note revealed communication with the POA, who did speak to Resident #286 regarding code status and no decision was made. He was informed of the concern for sepsis/bacteremia and the need for a potential hospital transfer to rule out osteomyelitis and further treatment if Resident #286 remained a full code. Review of the wound progress note dated 09/23/22 revealed a Stage IV pressure ulcer to the sacrum measuring 7.0 cm by 5.0 cm by 2.8 cm, purulent drainage noted, slight odor present. Continue to cleanse with Dakin's solution, pat dry, apply Prisma and cover with Optifoam. Right heel Stage IV pressure area reopened, measuring 3.0 cm by 3.0 cm by 0.1 cm, serosanguinous drainage present. Continue to cleanse area with Dakin's solution, apply Prisma, cover with Optifoam, change daily and PRN. Unstageable pressure ulcer to right hip measuring 8.0 cm by 6.0 cm by 2.5 cm, area noted with purulent drainage and foul odor. Cleanse area with normal saline pat dry, pack lightly with Dakin's-soaked gauze, cover with Optifoam change daily and PRN. Unstageable pressure ulcer to left ischium measuring 2.0 cm by 2.5 cm by 2.6 cm, purulent drainage noted, foul odor noted. Continue to cleanse area with Dakin's solution, pat dry, pack loosely with Dakin's-soaked gauze, cover with Optifoam, change daily and PRN. Resident #286 complained of severe generalized pain. WNP #404 was in the facility and was updated. New order was written to culture wounds of the right hip and left ischium. Review of progress note dated 09/27/22 revealed resident was found incoherent and difficult to arouse, pulse was 102 beats per minute and oxygen saturation was 77 percent. The nurse practitioner was notified and orders to send to the hospital were received. Review of the hospital documentation revealed Resident #286 was hospitalized from 09/27/22 to 10/06/22 for sepsis, end organ encephalopathy, urinary tract infection, pneumonia and infection of decubitus ulcers. The history of present illness documented Resident #286's family member voiced concern the care at the nursing facility has worsened since a management change and the resident had not received assistance with her activities of daily living, as turning and repositioning and has had an overall decline over the last three weeks. The skin assessment documented decubitus ulcers to heel, hips and buttocks which were draining green purulent, foul-smelling discharge. A surgical debridement of the sacral ulcer with involvement of underlying bone was performed on 09/29/22. Review of the hospital documentation revealed Resident #286 was admitted to long term acute care facility (LTAC) from 10/06/22 until 10/26/22 for osteomyelitis and continued wound support. She returned to the nursing facility on 10/26/22. Review of the care plan for skin integrity revealed interventions dated 10/28/22 of pressure relieving cushion to chair when out of bed, pressure reduction mattress to the bed and moon boots to both feet while in bed. During an interview on 11/02/22 at 10:51 A.M., Resident #286 stated she had complaints of pain in her feet. Upon questioning, State tested Nurse Assistant (STNA) #202 stated she had turned Resident #286 around 7:00 A.M. at the start of the shift. She further shared she had been the only STNA until recently and it has been a crazy day, a new resident was admitted , and she had to give report and was unable to turn and or reposition Resident #286. Observation on 11/07/22 at 1:58 P.M. of the dressing change for Resident #286 by Licensed Practical Nurse (LPN) #600 revealed she removed the left heel dressing. Without changing her gloves, she applied Dakin's solution to the nickel sized ulcer and patted it dry. She removed her gloves and donned clean gloves without sanitizing her hands. She applied Calcium Alginate to the wound and wrapped the foot in Kerlix. The same dressing change was done to the right heel, but with proper hand hygiene and glove changing. LPN #600 removed the dirty dressings from the right hip, left hip and ischium. She did not change her gloves or sanitize her hands in between wound sites. LPN #600 stated there was no physician order to treat the wound on the ischium. She applied the same treatment to the left ischium as she did to the left hip of cleansing with Dakin's solution, calcium alginate and ABD pad to both the left hip wound and the ischium. During interview after the completion of the dressing change, LPN #600 stated she did not use proper hand hygiene or change her gloves intermittently during the dressing change. During an interview on 11/07/22 at 4:40 P.M., DON #312 and RDCS #400 stated nursing staff are doing weekly skin assessments to address any new skin concerns but are not documenting on known skin issues. RDCS #400 stated it is the expectation of the facility nurses document wound and drainage assessment with each dressing change and verified this had not been completed. During an interview on 11/08/22 at 9:54 A.M., Registered Nurse (RN) #312 stated she does rounds with WNP #404 and puts the orders into the electronic charts for residents. She stated she is new to the position, hired within the last two months. She verified for Resident #286 there was on order for bilateral hips to cleanse with normal saline, apply calcium alginate and cover with Optifoam. There were also separate orders for each hip. For the left hip, cleanse with normal saline, apply calcium alginate and cover with Optifoam. For the right hip, cleanse with Vashe wound cleanser, pat dry and cover with an ABD pad. There was an order for the sacrum and the coccyx in the electronic chart for Resident #286 and verified although the treatment was the same, due to the number of pressure wounds this may cause confusion. RN #312 verified there were no wound orders in the electronic charting system for the left ischium wound. She further acknowledged wounds assessments/description and drainage assessments/description should be documented with each dressing change to determine a decline. This is a known concern, and the use of agency makes continuity more difficult. During interview on 11/08/22 at 2:07 P.M., WNP #404 stated she did not have a concern for Resident #286's sacral wound when she saw her on 07/28/22. WNP #404 stated the facility became aware of a Stage III ulcer to Resident #286's left heel prior to her next scheduled wound visit on 08/04/22. She was unclear if the facility found it after her 07/28/22 visit, or the hospital reported it; however, it caused the facility to perform a skin sweep of all residents resulting in six new wound referrals. Upon review, there was no documentation of a Stage III ulcer to the left heel for Resident #286 in her electronic chart prior to her hospitalization on [DATE]. 2. Review of medical record for Resident #20 revealed an admitted [DATE]. The resident was admitted with diagnoses including stroke, anxiety, unspecified dementia, hemiplegia and hemiparesis of left non-dominant side. Review of the weekly skin assessment dated [DATE] revealed a new area was discovered to the left outer ankle. It was described as a small opening measuring 0.3 cm by 0.3 cm by 0.1 cm. There was no further documentation of the wound. The medical record contained no physician notification or treatment orders for this pressure ulcer on 08/02/22. Resident #20 was admitted to hospice on 08/03/22. Review of the wound note dated 08/04/22 revealed the left lateral ankle was documented as unstageable measuring 2.0 cm by 2.0 cm and described as non-blanching, deep purple discoloration. A care plan for deep tissue injury dated 08/04/22 revealed individualized interventions which included monitoring and documentation of wound size and description of wound and drainage, treat wound as per facility protocol and position resident off the affected area. A Braden scale for pressure ulcer risk was completed on 08/05/22. The resident scored an 11, which was high risk. The significant change MDS assessment dated [DATE] revealed the resident was severely cognitively impaired. She required extensive two-person assistance for bed mobility, one person assistance for eating and total dependence for toileting. The MDS indicated one deep tissue injury which was not present upon admission. A Braden scale for pressure ulcer risk was completed again on 08/21/22. The resident scored 14, which was high risk. Review of the progress note dated 10/10/22 revealed CNP #403 assessed Resident #20's left ankle and found no signs or symptoms of cellulitis with orders to continue previously ordered Keflex (antibiotic), as it appeared to be effective. The resident's pressure reducing boot (moon boot) was completely saturated with skin debris, evidence of dried blood and scabs covering the entire bottom of the moon boot with the boot itself having a significant odor. Instructed nursing staff to throw these away and to order new moon boots as these would only increase risk of infection with evidence of poor skin care/maintenance. Review of the wound note dated 10/13/22 revealed documentation the wound was a Stage III pressure ulcer and measured 2.5 cm by 1.3 cm by 0.2 cm with a moderate amount of serosanguinous exudate. On 10/27/22, the wound measured 1.0 cm by 1.0 cm by 1.0 cm with a moderate amount of serosanguinous drainage present and was documented as improved. During interview on 11/07/22 at 4:40 P.M., RDCS #400 and DON #213 verified there was no documentation on 08/02/22 the physician was notified, or a treatment was put into place after an assessment of a new skin issue, to prevent further avoidable skin damage. 3. Record review revealed Resident #05 was admitted on [DATE]. Medical diagnoses included acute and chronic respiratory failure, neurogenic bladder, Parkinson's disease, and malnutrition. Review of the Braden Scale for pressure ulcer risk, dated 07/13/22, revealed Resident #05 scored a 13, indicating moderate risk for developing a pressure ulcer. Review of the care plan, dated 07/14/22, revealed there was an unstageable pressure ulcer to the sacrum. Interventions were to avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Educate resident and family of causative factors and measures to prevent skin injury. Encourage good nutrition and hydration to promote healthier skin. Follow facility protocols for treatment of injury, keep skin clean and dry. Use lotion on dry skin. Monitor and document location, size, and treatment of skin injury. Report any abnormalities, failure to heal, signs and symptoms of infection or maceration to the physician. Provide pressure relieving/reducing mattress, pillows, sheepskin padding to protect skin. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces. Review of the admission MDS assessment, dated 07/18/22, revealed Resident #05 was cognitively intact. She was totally dependent on two persons for all activities of daily living. She had an indwelling urinary catheter and was frequently incontinent for bowel. She had one Stage II pressure ulcer. She was on oxygen, required suctioning, tracheostomy, and a mechanical ventilator. Review of the skin assessment dated [DATE] revealed an unstageable wound to the sacrum that measured 2.0 cm by 2.0 cm by 0.1 cm with light serosanguinous drainage that was present upon admission. There wasn't another documented skin assessment until 11/01/22. Review of the medical record for Resident #05 from 09/26/22 through 10/16/22 revealed there wasn't any documentation for turning and repositioning. Review of progress note dated 10/02/22 written by RN #242 revealed there was a new open wound observed on the mid-right back and redness to the mid left back for Resident #05. There was no further description of the wound. The open wound was cleaned with normal saline and left open to air. Review of the physician orders and the treatment administration record (TAR) from 10/02/22 through 10/07/22 revealed no order or treatment to the area on the back. Review of progress notes dated 10/07/22 revealed WNP #404 documented an open wound to the mid right back that measured 3.0 cm by 3.0 cm with no depth. The wound was non blanching deep purple tissue with no drainage, induration, crepitus, or edema noted. The wound was cleaned with normal saline and an Optifoam dressing was placed. An intervention was implemented to turn Resident #05 from side to side. Review of the physician orders revealed no order for a treatment to the open wound to the right mid back. Review of progress note dated 10/12/22 at 1:57 A.M. documented to make sure WNP #404 was notified to see Resident #05's right ear for suspected pressure ulcer. At 1:53 P.M., CNP #405 ordered the right ear cleansed with normal saline, pat dry, apply calcium alginate and cover with Optifoam. Place rolled towel in between right ear and shoulder and to be seen by WNP #404. Review of progress notes dated 10/13/22 revealed WNP #404 did not assess the wound on the Resident #05's ear. She discovered the wound on Resident #05's coccyx which was DTI measuring 2 cm by 1.8 cm by 0.1 cm. This wound was non blanching deep/red purple discoloration no induration, no crepitus, or edema. Cleanse with normal saline, pat dry, apply calcium alginate and cover with Optifoam. Review of the physician orders revealed the treatment recommended by the wound nurse practitioner was not implemented. Review of the treatment administration record (TAR) for October 2022 revealed no documentation any treatments were provided to the back, ear or coccyx wounds. Resident #05 went out to the hospital on 10/16/22 and returned on 10/31/22. Review of the skin assessment dated [DATE] revealed Resident #05 had a chronic sacral wound measuring 5.0 cm by 4.0 cm by 0.1 cm, unstageable; a coccyx wound measuring 5.5 cm by 2.5 cm by 0.1 cm; a right upper/mid back wound measuring 9.5 cm by 7.0 cm by 0.1 cm; a right outer ankle wound measuring 3.0 cm by 3.0 cm by 0.1 cm; a right foot wound measuring 1.0 cm by 1.0 cm with no depth; and a right ear wound measuring 1.5 cm by 2.5 cm by 0.1 cm. During observation of Resident #05 on 11/01/22 at 2:06 P.M., she did not have any pressure relieving padded boots on her feet. She was on a pressure relieving mattress. During observation on 11/02/22 at 9:11 A.M, Resident #05 was in bed on her left side. At 11:23 A.M., dressing changes were completed by RN #232 and LPN #405 on all wounds. There was a new wound on the left lateral foot that was not blanching, and it was oval size and reddened. The nurse did not measure the area at this time. Resident #05 was placed back on her left side. There was no pressure relieving device applied to her feet. During observation at 2:57 P.M., Resident #05 was still on her left side. RN #232 was questioned about the turning schedule for Resident #05. At this questioning, RN #232 turned the resident to her right side. She still did not have any pressure relieving devices applied to her feet. Interview with LPN #405 on 11/02/22 at 2:57 P.M. confirmed the resident had not been turned every two hours from side to side. She had been positioned on her left side for six hours. During observation on 11/03/22 at 11:56 A.M. with RN #232, Resident #05 had a wound on the left lateral foot. It was approximately 8.0 cm by 3.0 cm with discoloration that was red, and a light purple ran down the side of her foot and it was non blanching. Review of progress notes dated 11/03/22 at 6:05 P.M. revealed WNP #404 came into see Resident #05 and assessed her left la [TRUNCATED]

Based on medical record review, review of the hospital record, staff and family interview, observation, review of the skills checklist for catheter care, and policy review, the facility failed to ensure Resident #10 was timely sent to the hospital when the resident exhibited signs and symptom of sepsis. This resulted in Immediate Jeopardy and serious life-threatening harm and/or injuries when Resident #10 had symptoms of lethargy, foul-smelling urine, and had no urinary output for 48 hours. Subsequently, Resident #10's condition progressively worsened, was sent to the hospital, and diagnosed with sepsis/bacteremia with proteus [a gram-negative rod-shaped bacterium that is a main pathogen causing complicated urinary tract infection (UTI) especially catheter-associated UTI] growing in her urine and blood, an indwelling urinary catheter obstruction with bilateral hydronephrosis (an enlargement of the parts of the kidney that collects the urine), and an acute kidney injury. This affected one (#10) out of three residents reviewed for indwelling urinary catheter use. The facility identified six residents with an indwelling urinary catheter in the facility. The facility census was 89. On 11/15/22 at 11:54 A.M., the Administrator, the Director of Nursing (DON) and Regional Director of Clinical Services (RDCS) #40 were notified Immediate Jeopardy began on 08/17/22 at 2:03 P.M., when Resident #10 presented with lethargy, foul smelling urine, and no urine output, and a physician was notified and made no return call. This continued to 08/18/22 at 10:09 A.M. when another physician was contacted and gave orders to send the resident to the hospital at 11:21 A.M. when Resident #10 was unresponsive, diaphoretic, and had a blood pressure reading of 151/118 millimeters of mercury (mm/Hg), heartrate was 140 beats per minute, respirations were 26 breaths per minute, and there was no urine output for two days. Upon admission to the hospital, Resident #10 had an observed catheter obstruction with bilateral hydronephrosis, acute kidney injury, and sepsis/bacteremia (the body's overactive and extreme response to an infection and is a life-threatening medical emergency and without quick treatment, it can lead to tissue damage, organ failure, and death) with proteus growing in the urine and blood. The Immediate Jeopardy was removed on 11/16/22 when the facility implemented the following corrective action: On 11/15/22, the DON assessed Resident #10 to ensure she was having urinary output and showing no signs and symptoms of urinary sepsis, lethargy, or having foul smelling urine. The care plans were reviewed to ensure appropriate interventions and care was in place and staff were aware of what to monitor and assess for Resident #10. On 11/15/22, all other residents with a diagnosis or history of urinary retention, cystitis, and catheter use were assessed by the DON and Unit Manager (UM) #312 and #232 to ensure within the past 30 days they were having urinary output and showing no signs of urinary sepsis, lethargy, or having foul smelling urine. The medical records were reviewed to ensure appropriate interventions and care plans were in place and staff were aware of what to monitor and assess for residents (#03, #05, #15, #29, #39 and #63). There were no findings identified for those residents reviewed. On 11/15/22, Nurse Practitioner (NP) #403 and Medical Director (MD) #406 were consulted to develop a procedure for staff to know what to do in case the physician could not be reached. If the facility was unable to reach the physician, they notify the DON for further instruction which may include sending the resident to the emergency room (ER) for evaluation and treatment. The on-call schedule was revised to ensure accuracy of who the nurses should notify. All new nursing staff will be trained during orientation on recognizing signs and symptoms, monitoring urinary output and documenting in the resident's plan of care. All nursing staff will be educated by the DON/Designee on or before 11/16/22 to ensure appropriate interventions and care plans are in place and staff are aware of what to do in terms of monitoring, and the assessment of residents who are not having urinary output, showing signs of urinary sepsis, lethargy, or having foul smelling urine. They were also educated on notification and following output amount parameters in place for residents with indwelling urinary catheters. Any nursing staff members not educated by 11/16/22 will be removed from the schedule and not be permitted to work until the education is completed. Beginning 11/17/22, the DON/Designee will audit all active residents with a diagnosis or history of urinary retention, cystitis, and catheter use to ensure they are having urinary output and showing no signs of urinary sepsis, lethargy, or having foul smelling urine. They will also audit notification and following output amount parameters if in place for residents with indwelling urinary catheters. Each of these residents will be audited to ensure appropriate interventions and care plans are in place and staff are aware of what to monitor and assess of these residents. The audits will be completed by the DON/Designee five times a week for four weeks. All adverse findings will be referred to the Quality Assessment and Performance Improvement (QAPI) committee for review and recommendation. Although the Immediate Jeopardy was removed on 11/16/22, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #10 revealed an admitted [DATE]. Diagnoses included stroke, cancer, pneumonia, septicemia, urinary tract infection in the past thirty days, retention of urine, and cystitis. Review of the bladder assessment dated [DATE] revealed Resident #10 was a poor candidate for toileting or bladder retraining. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was severely cognitively impaired. Her functional status was extensive assistance for bed mobility, total dependence for transfers, eating, and toilet use. She was coded for an indwelling urinary catheter. She was frequently incontinent of bowel. Review of the care plans revealed Resident #10 had no plan for catheter use. Review of a progress note by Nurse Practitioner (NP) #407 dated 08/17/22 at 2:03 P.M. revealed there was a low growth urinalysis (UA) and nursing reported increased lethargy and foul urine and Ceftin (antibiotic) was added. Review of a progress note dated 08/17/22 at 3:54 P.M. by Licensed Practical Nurse (LPN) #408 revealed Resident #10 had no urine output on the shift. The catheter was reinserted without output. The nurse called the on-call physician two times without an answer. The UM #224 was made aware of the situation. The resident denied pain and discomfort. Resident #10's lower abdomen was distended, and the nurse was awaiting a call back from the physician. Review of a progress note dated 08/18/22 at 6:40 A.M. revealed Registered Nurse (RN) #221 found a minimal amount of mucoidal and dark red discharges from Resident #10's genital and stains on her bed pad while being changed. The resident would be monitored and follow-up for any significant changes on the discharges. The on-call NP would be notified. Review of NP #403's progress note dated 08/18/22 at 10:09 A.M. revealed a phone call was received from the nursing staff of Resident #10 who was experiencing increased shortness of breath despite oxygen in place via nasal cannula at eight liters. There was hypertension reported with a systolic blood pressure at 160 mm/Hg, heart rate of 120 beats per minute and minimal responsiveness. The nursing staff reported there was zero output for the past twenty-four hours and the bladder scan showed zero. This was despite increased orders for free water of 250 cubic centimeter (cc) every four hours from an examination completed on 08/15/22. Further review of the note revealed there had been no reports of this condition until this report. The NP offered clysis (the introduction of large amounts of fluid into the body by parenteral injection to replace lost fluids, to provide nutrients, or to maintain blood pressure) and laboratory testing, but the family refused and wanted the resident sent out to the hospital. Review of the change in condition note dated 08/18/22 at 11:21 A.M. by UM #224 revealed Resident #10 was not responding after a sternal rub, was diaphoretic, had a blood pressure of 151/118 mm/Hg, the heart rate was 140 beats per minute, respirations were 26 breaths per minute, and no urine output in two days even with bolus flushes via the gastrostomy tube (G-tube) every four hours. Review of the hospital records dated 08/18/22 revealed upon admission to the emergency room Resident #10 had an observed catheter obstruction with bilateral hydronephrosis and a new catheter was placed, and two liters of urine was drained. The computed tomography (CT) scan showed severe sepsis proteus bacteremia. Resident #10 had an acute kidney injury, likely related to obstructive hydronephrosis and sepsis. Observation of catheter care on 11/03/22 at 3:48 P.M. with State tested Nursing Assistant (STNA) #409 revealed she had a basin full of water and took a washcloth and wiped the catheter tubing away from Resident #10 but had not touched the meatus. STNA #409 took the washcloth and put soap and water on the cloth and washed the perineum area on both sides in a downward motion. She rinsed and dried this area. STNA #409 had not washed the labia at all during the observed care. Interview with agency STNA #409 on 11/03/22 at 4:24 P.M., revealed she was nervous and had been doing catheter care for a few years. She verified she had not wiped the tubing with soap and water on or around the meatus and admitted she had not cleaned the labia area and knew she should have. Interview with NP #403 on 11/07/22 at 1:12 P.M., revealed she had been notified about the condition of Resident #10 on 08/15/22 of dark odorous urine and ordered a 250 cc's G-tube flush. Then on 08/18/22 she was notified of the change in condition of the resident, and she was sent out to the hospital. She denied anyone had contacted her on 08/17/22 or the on-call NP. Interview with NP #407 on 11/07/22 at 1:44 P.M., revealed she ordered the Ceftin for Resident #10 on 08/17/22 but denied she had heard from the facility after that and if she had she would have called back and she would have placed a note into the record. Interview with Medical Director (MD) #406 on 11/14/22 at 9:53 A.M., revealed the staff read the on-call posting incorrectly and called someone who was not on-call, and that person would not call back. If nursing could not get in touch with the on-call person, then the facility should have called her. Interview with agency LPN #408 on 11/14/22 at 2:38 P.M., revealed she provided care for Resident #10 on 08/17/22 for first shift. She said she was aware the resident had not had any urine output in her catheter and even the bladder scanner read zero output on her shift. She tried to see if the catheter was inserted all the way and pulled on it and pushed it back into the resident but didn't get any output and urine wasn't leaking around the catheter either. She said she tried to call the on-call NP twice, with no response. She reported all of this to UM #225 and left the facility and had not taken care of the resident again. She felt she followed proper procedure in telling the UM of the situation. Interview with RDCS #400 on 11/14/22 at 3:12 P.M., revealed if the nursing staff was not getting any urine output, they should have called the physician and if they had not called back the staff should have sent the resident out to the hospital. RDCS #400 had no rationale why the staff had not timely sent the resident to the hospital. She further revealed the nurses who took care of Resident #10 on 08/18/22 at 6:40 A.M. (RN #221 and UM #224) no longer worked at the facility. Interview with the Power of Attorney (POA) for Resident #10 on 11/15/22 at 12:39 P.M., revealed she went out to the hospital on 08/18/22 because her catheter was clogged, and she wasn't producing any urine output. He said when she arrived at the hospital, she was septic, and the hospital drained 2.1 liters of urine from her bladder. Review of the skills checklist for catheter care (undated) revealed to wet and soap one washcloth and grasp catheter close to the meatus and avoid tugging on it. Cleanse around the meatus and down the catheter at least four inches from the meatus. The staff should change to a clean area of the washcloth and wipe the labia from front to back and using a clean area of the washcloth for each stroke. Review of the policy titled Notification of Changes, dated 11/02/16 revealed the facility will inform the resident, the attending physician and the resident's representative or interested family member of changes which affect the resident. I. The facility must inform the resident immediately, the attending physician and the resident's representative or interested family member when there is: a. An accident involving the resident, which may or may not result in injury. b. A significant change in the resident's physical. mental or psychosocial status. c. A need to alter treatment significantly. d. A decision to transfer or discharge the resident from the Manor.

Based on medical record review, resident interview, family interview, and staff interview, the facility failed to prevent a resident from developing Moisture Associated Skin Damage (MASD). This resulted in actual harm when it was discovered Resident #08 was left on a wet mattress, resulting in significant MASD needing antibiotic treatment. This affected one (Resident #08) of one reviewed for MASD prevention. Findings include: Review of the medical record for Resident #08 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, congestive heart failure, and peripheral vascular disease. Resident #08 was cognitively impaired. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #08 required extensive two-person assistance for bed mobility, toileting, supervision for eating and total dependence for transfers. Review of the care plan revised 08/04/22 revealed Resident #08 was at risk for alteration in skin integrity related to MASD. Interventions included use of barrier cream every shift, frequently change incontinent products, turn, and reposition frequently and positioning with pillows. Review of the progress note dated 10/25/22, written by Registered Nurse (RN) #221, revealed Resident #08 complaint of skin integrity concern and had scratched on his back with, oozing/drainage, and redness. The Director of Nursing (DON) was informed. Review of the progress note dated 10/26/22, written by the DON, revealed spoke with Resident #08 regarding recent concerns voiced by his daughter. Resident #08 stated he was given bed bath and sheets were left wet after the bath, which caused irritation to his back. Assessment found Resident #08's back was very excoriated with purulent and foul-smelling drainage. The on call Certified Nurse Practitioner (CNP) was updated and a treatment order was received, and a full evaluation by CNP #404 would be completed on 10/27/2022. Review of the physician note dated 10/27/22 revealed Resident #08 had a right flank wound, with flank dermal injury, suspected moisture associated denuding (the loss of epidermis, caused by prolonged moisture and friction) now with odor and findings concerning for superficial infection verses Cellulitis, warranting antibacterial treatment along with aggressive wound care; Doxycycline (antibiotic) for seven days and wound consult. Review of the wound note dated 10/27/22 revealed staff reported a new area to Resident #08's back to the right side. An antibiotic (Doxycycline) was ordered by Physician #406, and the resident reported some pain to the area with palpitation. CNP #404 documented the in-house acquired MASD to Resident #08's back measured 15 centimeters (cm) by 15 cm by 0.5 cm, with a small amount of serosanguinous drainage (wound drainage secreted by an open wound in response to tissue damage), mild odor, and redness with partial thickness pink/red denuded (loss of skin caused by exposure to urine, feces, body fluids, wound exudate [wound liquid] or friction) skin with moisture component. Interview on 10/31/22 at 11:50 A.M. with Resident #08 and his daughter revealed an unknown State tested Nursing Assistant (STNA) had placed an incontinent pad under the resident's head to catch the water she poured over his head to wash his hair. Resident #08's daughter believed this occurred on a Wednesday (10/19/22). Resident #08's daughter stated she had purchased Resident #08 a memory foam mattress for the top of the facility provided mattress, and the mattress got wet during his bed bath. She believed the mattress remained wet until the following Friday (10/21/22) when Resident #08 told staff his back was bothering him. Resident #08's daughter further shared the mattress was gone by the time she got to the facility on Monday (10/24/22), but she did see, and take pictures of his back. Resident #08's daughter verified she voiced her concerns with staff and management but was unable to recall names. Observation on 11/01/22 at 10:03 A.M. of Resident #08's back with RN #232, revealed an approximate 5.08 cm by 5.08 cm reddened, excoriated area to the resident's back. Interview on 11/07/22 at 3:30 P.M. with DON #213 and Corporate Director of Clinical Services (RDCS) #278 revealed a staff member reported Resident #08's daughter's concerns to DON #213. DON #213 spoke with Resident #08 and assessed the rash. DON #213 was unaware Resident #08 had an extra mattress on his bed, until this incident. The mattress was not found on the bed when she assessed Resident #08's back. DON #213 was unaware of who removed the mattress, or what happened to it. RDCS #278 stated it was the expectation maintenance staff would be made aware of family brining in personal items for a resident, so it could be approved for use and an order could be obtained. DON #213 further reported she was unsure which staff member informed her of Resident #08's daughter's concerns of the resident lying on a wet mattress. DON #213 further verified she did not investigate the incident including finding out when Resident #08 was bathed, how long he laid on a wet mattress, and who removed the mattress from the bed. DON #213 verified she assessed Resident #08's back, charted her findings, and notified Physician #406 and CNP #404. Interview on 11/08/22 at 8:28 A.M. with Administrator #278 regarding the foam mattress for Resident #08 revealed his knowledge of the situation was the mattress was disposed of and his daughter was contacted and denied wanting it replaced. He stated he was unaware of a wet mattress concern as the reason the mattress was disposed of. He then shared it would be the expectation of the facility to investigate the cause and duration of a wet mattress. Interview on 11/08/22 at 2:07 P.M. with CNP #404 revealed she was informed of a wound consultation for Resident #08, after he laid on a wet sheet. CNP #404 stated Physician #406 had started him on an antibiotic (Doxycycline) prior to her assessment. When CNP #404 assessed Resident #08's back, It looked like someone had taken a potato peeler to the top layer of his skin, in which she diagnosed as MASD. Interview on 11/15/22 at 2:22 P.M. with RN #221 revealed he assessed Resident #08's back on 10/25/22 and found redness with scratches. RN #221 stated he turned Resident #08 and found his, egg mattress was wet, and was unsure how the mattress got wet or how long it was wet. The mattress was removed from the bed, and he was unsure what an unidentified State tested Nursing Assistant did with the mattress. Interview on 11/16/22 at 9:30 A.M. with Regional Director of Clinical Services #400 revealed the facility did not have a policy for skin assessments, wound documentation, or dressing changes.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of hospital documentation, observations, resident and staff interviews, review of alarm reports and review of facility policy, the facility failed to ensure staff provided adequate supervision to prevent a cognitively impaired resident from leaving the facility unsupervised. This resulted in Immediate Jeopardy for one (#28) of four residents reviewed for risk of elopement when the resident left the facility without staff knowledge and was gone for approximately 25 minutes before being found. The resident sustained [REDACTED]. The facility identified three residents at risk for elopement. The facility census was 72. On 10/24/16 at 1:30 P.M., the Administrator was notified that Immediate Jeopardy began on 10/18/16 at 2:45 P.M. when Resident #28, who was assessed as being an elopement risk, was last seen by staff. Resident #28 exited the building unsupervised and without staff knowledge through the Pine Glen exit door. The Pine Glen exit door was equipped with a Vigil system that alerts staff via a paging system if the door is opened; however, staff did not timely respond to the page regarding the door being opened and the audible alarming system on the door had been disabled. Resident #28 was found in the parking lot at 2:25 P.M. by visitors. While outside Resident #28 had fallen in the parking lot. Resident #28 was assessed by the nursing staff to have lacerations above his left eyebrow and chin as well as abrasions to the left side of the face, palms of the hands and bilateral knees. Subsequently, Resident #28 was sent to the emergency room for evaluation and treatment, required sutures above the left eyebrow and sustained multiple facial fractures. The Immediate Jeopardy was removed and the deficient practice corrected on 10/22/16 when the facility implemented the following corrective actions: · On 10/18/16 at 3:31 P.M., Resident #28 was assessed by nursing staff and placed on one-on-one supervision. Resident #28 was subsequently sent to the hospital for evaluation and treatment. · On 10/18/16 at 3:35 P.M., Case Manager #88 began in-service education with all twenty staff present with emphasis on making sure doors are armed and secured at all times. In-service education continued to be provided by Case Manager #88 for all facility staff. The in-service training was completed by 10/22/16 at 12:38 A.M. · On 10/19/16 at 4:15 A.M., Registered Nurse (RN) #87 initiated a door alarm drill to audit and evaluate staff response and effectiveness of the education. Eleven staff participated in the initial drill. The Administrator arrived at 5:30 A.M. and reviewed the drill response with RN #87. · On 10/19/16 at 6:37 A.M., the Administrator reviewed the security of the Vigil system with the Vigil technician to ensure continued door security. There were no concerns identified with the functionality of the Vigil system. · On 10/19/16 at 9:15 A.M., the Administrator and Director of Nursing (DON) completed in-service education to the management team (Business Office Manager, Maintenance Director, Director of Environmental Services, Minimum Data Set Coordinator, two nurse managers, Case Manager, Therapy Director, Marketing Manager, Human Resources, Activity Director and Social Services) regarding elopement procedures and instructions to initiate random rounding observation audits to be completed by management team/designee four times daily of audible door alarms being in the armed position and to test for functioning of pagers and staff response time. These audits were completed four times per day. · On 10/19/16, the DON/designee conducted a wander assessment for all 72 residents residing in the facility. The wander assessments were completed on 10/21/16 at 7:41 P.M. · On 10/20/16, Resident #28 was readmitted to the facility and placed in another room located away from an exit door where increased staff supervision could be provided. · On 10/20/16 at 1:20 P.M., the DON conducted an unannounced elopement drill with eighteen staff members present. Staff responded appropriately to the elopement drill. · On 10/21/16 at 9:30 A.M., the Administrator requested the Maintenance Supervisor to complete an environmental risk assessment of the Vigil system and complete a door alarm in-service for eleven members of the management team. The Administrator directed the Maintenance Supervisor/designee to include Preventative Maintenance for daily monitoring of the door alarms, both audible and silent, beginning 10/21/16 conducted indefinitely or until the Quality Assessment and Performance Improvement (QAPI) team indicated to change the frequency of the audits. · On 10/21/16 at 1:00 P.M., a QAPI meeting was held to review the results of the audits. The QAPI committee determined the audits were successful. · On 10/21/16 at 3:13 P.M., the DON conducted an unannounced elopement drill with fifteen staff members present. Staff responded appropriately to the elopement drill. · On 10/21/16, the Administrator implemented unannounced elopement drills monthly for the next twelve months to promote ongoing elopement education, awareness, and test staff knowledge and response. The QAPI committee will continue to meet monthly to evaluate ongoing performance and concerns. · On 10/24/16 and 10/25/16, Resident #24, #64 and #72 were also reviewed for elopement risk, supervision and care planning related to elopement risk. There were no concerns identified. · On 10/25/16 between 1:00 P.M. and 1:45 P.M. interviews were conducted with State tested Nursing Assistant (STNA) #80, STNA #81, Licensed Practical Nurse (LPN) #82, LPN #84, LPN #86, Housekeeper #83 and Housekeeper #85. The staff interviewed were knowledgeable on the elopement policy and were able to correctly give detailed information regarding elopements and the door alarms. · On 10/25/16, the facility's audits of the exit doors were reviewed. The review revealed the facility completed audits of the exit doors to ensure the audible alarms were in place and functioning properly. The facility completed the audits more than four times a day. There were no concerns identified. Findings include: Review of the medical record for Resident #28 revealed he was admitted to the facility on [DATE] and was readmitted on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was severely cognitively impaired. The resident wanders one to three days during the assessment period, exhibits hallucinations, delusions, and displays physical and verbal behavior directed towards others. He also had rejection of care and wandering for one to three days of the seven day assessment period. The resident required supervision for bed mobility, transfers, walking, locomotion, eating, toilet use and personal hygiene. The resident required limited assistance of one staff for dressing and bathing. He was continent of urine and stool. On 10/07/16, Resident #28 was assessed as being at high risk for elopement. The resident had a care plan, dated 05/31/16, identifying the resident as an elopement risk related to wandering due to impaired safety awareness and history of attempts to leave facility unattended. Review of Resident #28's medical record revealed an extensive history of attempting to leave the facility via the door near the resident's room by pulling the fire alarm. Review of the case manager notes for 05/12/16, 06/13/16, 07/29/16, 08/12/16 and 10/10/16 revealed Resident #28 was identified as having increased anxiety and exit seeking behaviors. Review of Resident #28's medical record revealed on 07/25/16 the resident was combative with staff and exited the building. Resident #28 refused to be redirected back into the building. The local police were notified and they were able to convince the resident to go back into the building. The resident was sent out to the hospital at that time for an evaluation. Review of nurse's notes on 10/09/16 at 3:45 A.M. revealed Resident #28 pushed open the exit door on Pine Glen and walked out approximately 30 feet. The door alarm was sent to the pagers. Resident #28 re-entered the building with two staff. The resident was alert to place, however, he did not understand what time of day it was. Resident #28 was calm and redirection was simple and effective. Discrete continuous monitoring afterward proved effective. Nurse's notes on 10/10/16 at 4:00 P.M. revealed Resident #28 continued with exit seeking behaviors. One-on-one with staff was effective for short periods. Intramuscular Ativan was administered. Nurse's notes dated 10/18/16 at 4:25 P.M. documented the nurse was notified by an STNA at 3:05 P.M., the Pine Glen exit door was unlocked and she stated that she can't find (the resident). Two nurses immediately activated the elopement protocol and the door alarm was found not activated at this time. Resident #28 was found outside in the parking lot by a visitor at 3:25 P.M. Resident #28 was brought back into the building and immediately assessed. Resident #28's assessment revealed a laceration to the left eye brow, left cheek, chin, abrasions to both knees and an abrasion to the cheek. The Certified Nurse Practitioner #90 was notified and gave orders to send Resident #28 to the hospital for physical and psychiatric evaluations. Review of Resident #28's hospital records revealed the resident had a laceration to his left eyebrow and chin. A computerized tomography (CT) scan of the resident's head was completed and revealed Resident #28 had an acute displaced fracture of the anterior and lateral walls of the left maxillary sinus with blood in the left maxillary sinus. The CT scan further showed additional fractures of the lateral wall of the left orbit, left zygomatic arch (cheek bone), an acute displaced fracture of the right mandibular neck, an acute fracture of the left orbital floor with no downward herniation of the intra-orbital contents. Resident #28 was admitted to the behavioral health unit for safety and stabilization. An interview with the Administrator on 10/24/16 at 8:50 A.M. revealed she and the DON were notified on 10/18/16 at 3:26 P.M. and told that Resident #28 had exited the building. The Administrator stated Resident #28 was last seen at 2:45 P.M. and staff were searching for him. The Administrator stated Resident #28 was found at 3:31 P.M., he was brought back into the facility and was placed on one-on-one supervision. The Administrator stated Resident #28 had a bloody nose and a laceration above his left eye. Resident #28 stated he fell down. The Administrator stated at 5:26 P.M. Resident #28 was transported to the hospital. The Administrator stated it was discovered that the Pine Glen exit door audible alarm was disarmed; however, they were unable to determine who disarmed the alarm. An observation was made of the Pine Glen exit door on 10/24/16 at 10:00 A.M. The door was equipped with the Vigil system and an audible alarm. The audible alarm was noted to be on. The audible alarm system had a locking device which took a key to turn it off and on. The Vigil system alerts staff via a pager when an exit door is opened. The Pine Glen exit door led outside to a small landing area which leads down to a concrete ramp and then to the asphalt drive going around the facility. The main entrance door had a Wanderguard alarm on it; however, no other exit door had the Wanderguard device. During the observation it was noted that Resident #28 was relocated to a different room so he was farther away from the Pine Glen exit doors and in an area more observable by staff; however, prior to the staff moving the resident to a different room the resident's previous room was within sight of the Pine Glen exit door. On 10/24/16 at 11:00 A.M. Resident #28 was observed walking in the hall. The resident accompanied the surveyor to the family sitting room. Resident #28 had a healing laceration above his left eyebrow, abrasions on the left side of his face and abrasions on the palms of both hands. Resident #28 was confused but pleasant. Resident #28 talked about his mobile home and how he wanted to go home. Resident #28 was asked about the wounds on his face and he stated he fell on the asphalt; however, he could not remember where or when. When the surveyor got up to leave the family lounge, Resident #28 stated that he was going to go home now. Resident #28 was walking towards a door. A nurse stopped Resident #28 and told him the door was locked and he could not get out of it. Resident #28 asked her what door he could get out of and she asked him to sit and relax awhile. Resident #28 resumed walking. An interview with Administrator on 10/25/16 at 11:40 A.M. revealed there was one key to the audible alarms and the Pine Glen nurse has control of the key. The Administrator stated when it was discovered the audible alarm was turned off on the Pine Glen exit door, they immediately checked for the key and it was where it was supposed to be. The Administrator stated they do not know when the key was used or who used it to turn the audible door alarm to the off position. Review of the call history for the Vigil system revealed an alarm or message was noted for the Pine Glen door and was activated on 10/18/16 at 2:49 P.M. The alarm was silenced after 21 minutes and was reactivated at 3:10 P.M. for one minute when staff checked the door. At 3:11 P.M. it was activated when staff went out the door to look for Resident #28. At that time the alarm was silenced after 22 minutes. The facility's Missing Resident Policy dated 2014 was reviewed. According to the policy, upon discovery that a resident is missing an overhead announcement of Code Brown is made. The building and grounds are searched simultaneously by staff as assigned by the person in charge. The resident sign-out sheet will be checked. Internal areas will be checked, resident rooms, lobbies, hallways, dining rooms, closets, bathrooms, public rooms, lounges, therapy rooms, basements and employee break areas. An external search will be conducted including patios, grounds, parking lots, vehicles, outside structures, storage buildings and dumpster's. If the resident is not found within 15 minutes, the following will be called for assistance: Administrator, DON, Law Enforcement, and Corporate office personnel. The resident's physician and family will be notified immediately if the resident is not found. This deficiency substantiates Complaint Number OH 566.

Based on observations, medical record review, review of the Resident Transfer form, hospital records, the facility's Daily Boiler Logs, Quality Assurance documentation, staff interviews, and the manufacturer's Information Specifications and Dimensions Documentation for the baseboard heating units, the facility failed to ensure a cognitively impaired resident ' s environment was safe to prevent third degree burns. This resulted in Immediate Jeopardy for one resident (#63) who sustained third degree burns to her left foot, left heel and right buttock from the baseboard heating unit next to her bed. The facility identified eight (#9, #15, #20, #28, #29, #50, #63 and #99) of 61 residents currently residing in the facility who were cognitively impaired and dependent on staff for care. On 05/01/15 at 3:07 P.M., the Administrator, Director of Nursing (DON) and Corporate Registered Nurse #85 were notified Immediate Jeopardy began on 04/08/15 at 7:10 A.M. when State tested Nurse Aide (STNA) #120 found Resident #63 on the left side of the bed in a kneeling position with her upper body across the bed. The resident was noted as pale, unable to respond to commands or questions, unable to maintain body position, her eyes were rolling back into her head and she was diaphoretic. Nine-one-one (911) was notified and the resident was transferred to the hospital for evaluation. Resident #63 was subsequently diagnosed with [REDACTED]. The Immediate Jeopardy was removed on 04/28/15 when the facility had a full inspection of the heating system by an outside heating technician who reset the set points on the boiler not to exceed 120 degrees, and the facility implemented the following corrective actions: · On 04/08/15, Resident #63 was immediately sent to the hospital for evaluation and treatment. No other residents were identified with burns. · On 04/14//15, Environmental Services Supervisor (ESS) #96 turned the temperature of the water supply from the boiler down to the baseboard heater in Resident #63 ' s room which resulted in the temperature of the heater decreasing from 128 degrees Fahrenheit (F) to 112 degrees F. · On 04/15/15, ESS #96 checked the heat in Resident #63 ' s room and verified the room temperature measured at 78 degrees F. · On 04/27/15, the Director of Nursing (DON) initiated education to the nurses and state tested nurse aides regarding monitoring of the baseboard heaters for appropriate temperatures and resident safety. Staff was instructed to report any problems noted immediately to the Administrator, DON and maintenance staff. ESS #96, Maintenance Assistant #88 were inserviced by the Administrator. · On 04/28/15, the facility had a full inspection of the heating system by an outside heating technician who reset the set points on the boiler not to exceed 120 degrees. No malfunctions were found during the inspection. · On 05/01/15, head-to-toe assessments were completed by the RN Charge Nurse #110 on all in-house residents to assess for burns. There were no other residents identified with burns. · On 05/01/15 at 4:00 P.M., all staff members on duty were in-serviced by the Director of Nursing, Administrator, Licensed Social Worker, ESS #96 and Corporate RN #85 regarding monitoring of the baseboard heaters for appropriate temperatures and resident safety. Staff was instructed to report any problems noted immediately to the Administrator, DON and maintenance staff. All staff not on duty was in-serviced via telephone. For any employee not available by phone, a message was left by the Department Head for the employee to call the facility prior to reporting for duty. All staff educated by phone was told they must report to the Charge Nurse or their Department Head prior to working a shift to be educated in person and sign the in-service sheet. A facility Onshift electronic text message was sent to all nursing and dietary staff about the need to check in with the shift supervisor or nursing supervisor prior to the start of the shift for any/all departments. · On 05/01/15, ESS #96 measured the surface temperature of each heater in the resident ' s rooms and confirmed they were all less than 120 degrees F. · On 05/01/15, the Administrator verified all other residents identified as cognitively impaired were not positioned next to the baseboard heaters or resided in resident rooms with a different type of heating unit in the room. (The facility had three different types of heating units in resident rooms). · On 05/01/15, ESS #96 and/or his designee began monitoring the surface temperatures of the baseboard heaters in each resident room at least three times per week for six weeks. Results will be reported to the Administrator and the facility ' s Quality Assurance Performance Improvement Committee. · On the weekend of 05/02/15, the facility implemented a plan that if the boiler came on during the weekend, staff was directed to check the surface temperature of each baseboard radiator every shift to ensure proper temperatures were maintained. Any concerns were to immediately be phoned to ESS #96 and the Administrator. Although the Immediate Jeopardy was removed on 04/28/15, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of initiating on-going audits of the surface temperatures of the heating units to ensure the corrective action taken is monitored for continued compliance. Findings Include: Review of the medical record of Resident #63 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident ' s cognitive status was unable to be assessed due to her severe cognitive impairment. The MDS indicated the resident exhibited no mood or behavior disorders and she required extensive assistance of two persons for all activities of daily living to include bed mobility and transfers. The MDS further indicated the resident had a history of [REDACTED]. Review of the resident's quarterly MDS assessment dated [DATE] revealed no changes from the 01/20/15 admission MDS. Review of a Fall Risk assessment dated [DATE] revealed Resident #63 was identified at high risk for falls due to her history of falls, physical weakness and poor ambulation. Fall prevention approaches included to place the resident ' s call light within reach, make frequent observations of the resident, provide support appliances, and apply bed/chair alarm. Review of Resident #63 ' s plan of care, initiated 01/13/15 for risk for falls related to weakness and rheumatoid arthritis, revealed interventions included alarm to bed to alert staff of unassisted transfers, encourage resident to use adaptive devices as recommended by therapy, ensure non -skid footwear, follow fall protocol per facility, keep room free of clutter, mechanical lift for transfers, refer to Physical Therapy/Occupational Therapy as needed, and a tab alarm to resident when up in the wheelchair. Review of the resident's Shower Sheet Skin and Body Assessments, dated 04/01/15 and 04/04/15, revealed Resident #63 had no skin issues identified. Nurses Notes dated 04/08/15 revealed State tested Nurse Aide (STNA) #120 alerted former Registered Nurse (RN) #14 to Resident #63's room after responding to the resident ' s bed alarm. The note documented Resident #63 was found on the left side of the bed in a kneeling position with her upper body across the bed. The note indicated Resident #63 was moved to a sitting position. The note further indicated the resident was very pale, was unable to respond to commands or questioning, was unable to maintain body position, her eyes were rolling back into her head, and she was diaphoretic. The resident ' s respirations were 44, pulse was 80, and oxygen saturation was 97 percent on room air. The note documented 911 was notified. There was no documentation of Resident #63 having any skin issues at that time. Review of the facility's undated Resident Transfer Form revealed the reason documented for Resident #63 ' s transfer to the hospital was the resident was found on the floor in her room, pale, diaphoretic, with increased respirations and decreased level of consciousness. The documentation indicated the resident had no skin issues. Review of the facility's Quality Assurance documentation dated 04/08/15 revealed the resident was documented with a wound to the bottom of her left foot. Review of the hospital History and Physical dated 04/08/15 revealed the chief complaint was altered mental status. The documentation noted Resident #63 had a history of [REDACTED]. The documentation indicated the resident's family was at the bedside and reported the resident was recently found to have bilateral sacral ulcers as well as a left plantar ulcer. The resident was diagnosed with [REDACTED]. Review of the facility's Daily Boiler Log revealed on 04/08/15 the outside temperature was 59 degrees F and the water temperature of the boiler measured 139 degrees F. Review of Nurses Notes dated 04/11/15 revealed Resident #63 arrived back to the facility per stretcher with two staff from the ambulance company. The note documented an assessment of the resident was completed with multiple skin areas noted. Review of a readmission Nursing assessment dated [DATE] revealed the resident was nonverbal, unable to voice her needs/wants and had dementia. Per the 04/11/15 Nursing Assessment, the resident had a wound on the right buttock that measured 10.1 centimeters (cm) by 3 cm, a wound on the left ball of her foot described as a busted blister that measured 6 cm by 4 cm and an intact blister on the left heel that measured 6.6 cm by 7.4 cm. There was no documentation regarding the origin of the wounds. Review of facility fall investigation documentation regarding the resident's fall on 04/08/15 revealed the resident was observed and provided care on 04/08/15 at 5:44 A.M. and found on the floor in a praying position between the bed and the baseboard heater at 7:10 AM. The investigation documentation revealed the resident's family notified the DON on 04/13/15 they were concerned about the burns to the resident's foot and buttocks. The documentation indicated the DON began an investigation on 04/13/15 and interviewed STNA #120 and former RN #14 who were on duty at the time of the resident's fall. The documentation indicated the DON observed the resident's wounds and found the wound on the resident ' s buttock was consistent with the shape of the heater. The documentation noted STNA #120 reported hearing the resident's alarm go off and went to the room where she found the resident on the floor on her knees. STNA #120 reported the heating unit next to the resident's bed was hot to the touch. Nurses Notes dated 04/15/15 at 2:00 P.M. revealed the resident complained of pain, was grimacing, and nodded her head when asked if she was in pain. The note indicated the resident was medicated with a narcotic pain medication (Tylenol #3) with positive results. The notes documented the physician was notified and the resident ' s family member requested the resident go to the burn clinic. The notes indicated the appointment was made for that day. Review of a Report of Consultation dated 04/15/15 from a local hospital burn clinic revealed Resident #63 had deep partial thickness burns to the lower back and plantar surface of the left foot. There was no further description of the resident's wounds to include the origin of the wounds. Review of the facility's wound documentation dated 04/16/15 revealed the wound to the resident's left foot wound measured 3 cm by 4 cm, the wound to the left heel measured 6 cm by 7 cm and the wound to the right buttock measured 10 cm by 3 cm. Facility wound documentation dated 04/22/15 documented the wound to the resident ' s left foot measured 4 cm by 3.5 cm by less than 0.1 cm, the wound to the left heel measured 2 cm by 2.5 cm by less than 0.1 cm, and the wound to the right buttock measured 10 cm by 2.5 cm by less than 0.1 cm. Review of the Report of Consultation dated 04/22/15, from the local hospital burn clinic, revealed Resident #63's left heel was epithelizing, the left upper foot had full thickness burns with eschar, and the right buttock had half slough and half granulating tissue. The documentation revealed the resident had a third degree burn to the left foot, and the right buttock had deep to full thickness burn. The documentation indicated a treatment for [REDACTED]. Facility wound documentation dated 04/22/15 noted Resident #63 presented with burns to the left ball of her foot, her left heel, and her right buttock after falling out of bed on 04/08/15, burning herself on the wall heater. Review of a facility facsimile transmittal dated 04/24/15 revealed the physician was notified the resident was receiving Tylenol #3 every four hours for pain and was still having breakthrough pain from her burns. Facility wound documentation dated 04/29/15 documented the wound to the resident ' s left foot measured 4 cm by 2.2 cm by less than 0.1 cm, the wound to the left heel measured 2.0 cm by 1.8 cm by less than 0.1 cm, and the wound to the right buttock measured 9.0 cm by 2.2 cm by less than 0.1 cm. During an interview on 05/01/15 at 3:10 P.M., STNA #120 stated she cared for Resident #63 and was familiar with the resident ' s condition and care needs. When asked to see the resident's wounds, STNA #120 stated Resident #63 had burn wounds to her left foot and right buttock that happened at the same time. STNA #120 stated she was at the nurse ' s station when Resident #63's alarm went off. She stated she immediately went to the resident ' s room where she found the resident on the floor in a praying position. STNA #120 stated she went behind the resident to pick her up because she thought the resident was going to pass out. STNA #120 stated the heater was burning her leg (STNA #120) as she assisted Resident #63 so she had to put a pillow between her leg (STNA #120) and the heater to keep her leg (STNA #120) from getting burned. STNA #120 stated she noticed Resident #63 had a blister to the ball of her left foot, a burn to the right top of her foot, and a burn to her right buttock area. STNA #120 stated the facility was unaware the resident had the burn to her left heel until she came back from the hospital. STNA #120 stated when she found the resident she immediately called for former RN #14 and the resident was assessed and sent to the hospital. When asked if she was aware the baseboard heaters were that hot, STNA #120 stated they had been for years and some areas were hotter than others. STNA #120 stated she had not been in-serviced regarding the heaters until after the incident occurred with Resident #63. STNA #120 stated staff was then told to monitor for any excessive heat and to let management and/or maintenance know promptly. STNA #120 stated she was unaware of any other resident ever being burned by the heaters in the [AGE] years she has been employed at the facility. Interview with ESS #96 on 05/01/15 at 10:44 A.M. verified he was aware the baseboard heaters in the resident rooms got pretty hot. ESS #96 stated hot water went through the heaters and they had cast iron covers, which conducts heat. ESS #96 stated the boiler monitors the outside temperature outside and increases the temperature of the baseboard heaters. ESS #96 stated an outside heating company came to the facility on [DATE] and turned the temperature of the boiler down so it now couldn't go above 122 degrees F. ESS #96 stated the boiler was not previously set at a particular temperature and would adjust according to the temperature outside. He stated the facility was not maintaining documentation of the surface temperatures of the baseboard heaters prior to 05/01/15. Observations of all rooms with baseboard heaters with ESS #96 on 05/01/15 beginning at 4:33 PM revealed no concerns with temperatures of the heaters. ESS #96 verified the boiler was not running at that time due to the warm temperatures outside. Observation of wound care provided by Licensed Practical Nurse (LPN) #91 on 05/04/15 at 10:00 A.M. revealed the resident's right buttock wound was pink with red granulation tissue and measured 9 cm by 3 cm. The left heel wound measured 5.5 cm by 5.5 cm and, the left ball of the foot wound measured 4.5 cm by 4 cm and, had black eschar and pink granulation. During an interview on 05/04/15 at 11:10 AM, Corporate Registered Nurse #85 and the facility wound nurse, LPN #16 stated the hospital history and physical indicating the resident fell from a wheelchair and had sacral ulcers and a plantar ulcer was incorrect. Both staff adamantly stated the resident's wounds were burns sustained from contact with the baseboard heater on 04/08/15 when the resident was found kneeling next to her bed. Review of the Baseray Baseboard manufacturer's Information Specifications and Dimensions Documentation revealed the Baseray Baseboard provided more than five times the amount of radiant heat to a room due to the fact the cast iron surface area was much larger than that found on conventional thin metal baseboards.