Every finding on record at Vista Center of Boardman

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on interview and record review the facility failed to verify a nursing license prior to training nursing staff for the position of registered nurse. This had the potential to affect all residents in the facility. The facility census was 43. Findings include:Review of a police report dated 08/04/26 revealed police were dispatched to the facility in reference to an identity theft report. Officers met with facility staff who stated Certified Nursing Assistant (CNA) #863 had provided them with a falsified Registered Nurse (RN) license. The officers were informed CNA #863 had been working at the facility as a CNA, a position for an RN came open, and CNA #863 presented an RN license from the Ohio Board of Nursing (OBN). The CNA began shadowing nurses to begin her training for the RN position but had not yet been officially promoted. The nurses who the CNA was shadowing became suspicious because the CNA seemed to lack understanding of very basic nursing principles so reported this to administration. On 07/31/26 an e-license check was done, and the results indicated the RN license number did not belong to the CNA, but someone else. The victim was contacted and wished to pursue criminal charges. Review of the personnel file for CNA #863 revealed a Date of Hire (DOH) of 07/09/26 and a termination date of 08/04/26. The signed job description in the file was for the position of CNA. An interview on 08/19/26 at 11:24 A.M. with Human Resource Director (HRD) #815 revealed CNA #863 was hired as a CNA but CNA #863 provided her with a copy of an RN license so when a position for an RN was open, HRD #815 assigned her for orientation as an RN on the C wing unit on 07/29/26 and 07/30/26. HRD #815 stated she just took CNA #863's word for it that she was an RN and did not do a licenses verification with the Ohio Board of Nursing (OBN). An interview on 08/19/26 at 12:22 P.M. with Licensed Practical Nurse (LPN) #824 revealed on 07/29/26 and 07/30/26 she was assigned to mentor CNA #863 in the RN role. LPN #824 stated she started to notice inconsistencies with her work and nursing knowledge. LPN #824 stated CNA #863 took resident blood sugars, checked medications against physician orders, took medications to residents that the LPN had put into medication cups, took vital signs, and provided wound care under the direction of LPN #824. During this time, LPN #824 noticed CNA #863 lacked basic nursing knowledge of how to complete these tasks and began to question where she obtained her nursing education from, and CNA #863 answered with a school that did not have an RN program. LPN #824 stated she notified management of the discrepancies she noticed and that she had real concerns if CNA #863 was actually an RN. An interview on 08/24/26 at 11:57 A.M. with the local police department Detective revealed criminal charges were being filed against CNA #863 and a warrant would be issued for her arrest for fraud, falsification of documentation and other felony charges. An interview on 08/24/26 at 12:25 P.M. with HRD #815 revealed she confirmed the normal hiring process was to complete a license verification on all candidates and this was not done for CNA #863 when the RN license was given to HRD #815. As a result of the incident, the facility took the following corrective actions beginning on 08/04/26: On 08/04/26 the Administrator, Medical Director and Director of Nursing (DON) completed a root cause analysis and determined an employee was permitted to begin orientation as an RN before a nursing license was verified through OBN. The employee was immediately suspended pending license verification. On 08/04/26 the Administrator provided education to the Human Resources Director (HRD) on license verification, what to do if there are discrepancies, and obtaining appropriate documentation verifying the staff members' credentials. On 08/04/26 the HRD audited employee files for all licensed nurses. This was completed on 08/06/26 and no inconsistencies were found. On 08/04/26 the DON and Assistant Director of Nursing (ADON) reviewed all medical records for all residents who resided on the units on which CNA #863 was oriented, skin checks were completed and no negative outcomes were identified. On 08/04/26 the DON and ADON interviewed all residents who were able to be interviewed to ensure no negative outcomes had occurred. This was completed on 08/05/26 and no negative outcomes were identified. The Administrator will conduct audits of all newly hired nurses to ensure licensure through OBN, weekly for four weeks then randomly thereafter. The results of audits will be reviewed in the Quality Assurance Performance Improvement (QAPI) meetings. An interview on 08/24/26 at 1:35 P.M. with the Administrator and Regional Director of Operations (RDO) revealed on 08/04/26 they notified the local police department of CNA #863's fake nursing license and wanted an investigation started. They stated when LPN #824 notified them of her concerns, CNA #863 was removed from the schedule until further information could be obtained and once they found out the nursing license was falsified, they terminated her. The Administrator and the RDO stated they immediately started a Plan of Correction (POC) including completing education with HRM #815, verification of all current nursing license, assessing all residents CNA #863 was assigned to and completing interviews with all residents to see if they had any concerns. Through these interviews and assessments, it was found no negative resident outcomes happened and there were no other issues with nursing licenses of staff. The Administrator and the RDO both confirmed the hiring process broke down when the HRD did not complete a license verification with the OBN.This deficiency represents non-compliance investigated under Complaint Number 3029372.

Based on record review and interviews, the facility failed to provide adequate supervision and implement interventions to prevent accident hazards for Resident #14. This affected one (Resident #14) of three residents reviewed for accidents. The facility census was 43. Findings include:Review of Resident #14's medical record revealed an admission date of 05/19/26 with diagnoses including psychotic disorder, Alzheimer's disease, dementia, and delirium due to known physiological condition.Review of Resident #14's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition and was supervision to touching assistance for all Activities of Daily Living (ADLs). Review of Resident #14's comprehensive care plan revealed the resident required a secured unit related to alterations in mental status, Alzheimer's disease progression, confusion, dementia and wandering. Interventions included assessments completed quarterly, assess resident's feelings about their behavioral problems, negative feelings about self, ability to communicate, anxiety, depression, and feelings of powerlessness, staff to provide rest periods, avoid situations that cause frustration, agitation or sensory overload. Review of the facility incident report dated 05/26/26 revealed Resident #14 was found inside another resident's room breaking the window. Close monitoring of Resident #14 by the nurse and Certified Nursing Assistant (CNA) was initiated and the window was secured and fixed immediately by maintenance. Review of the facility incident report dated 05/29/26 revealed Licensed Practical Nurse (LPN) #833 was passing medications and heard noise coming from a resident room. LPN #833 assessed the situation and found that Resident #14 broke the window in the resident room, exited out the window and was walking through the facility parking lot. Resident #14 had an abrasion to the left elbow and a dressing was applied. The physician was notified and the resident was sent to the hospital for further evaluation. An interview on 08/20/26 at 10:15 A.M. with the Administrator revealed on 05/29/26 the secured unit was only staffed with an LPN and had CNA's covering from other units. At the time of the incident the LPN was the only one on the unit. The Administrator stated adequate supervision was not maintained on the secured unit on 05/29/26 when Resident #14 broke the window. The Administrator verified after the incident on 05/26/26 when Resident #14 broke the window, the resident was to be closely monitored to prevent further incidents. This deficiency represents non-compliance investigated under Complaint Number 3133177.

Based on observation, interview, policy review and review of the microessentiallab.com website, the facility failed to have unexpired test strips to test for proper sanitization levels at the three-sink manual dish washing area. This had the potential to affect 45 residents receiving food from the facility kitchen. There was one (Resident #19) identified by the facility as receiving nothing by mouth. The facility census was 46.Findings include:An observation during the initial tour of the kitchen on 02/17/26 at 8:15 A.M. revealed Hydrion test strips (test strips used to test for proper sanitization levels of chemicals to ensure efficacy) with an expiration date of 11/01/25 at the three-sink manual dish washing area. Dietary [NAME] #513 verified the expiration date of 11/01/25 on the Hydrion test strips at the time of the observation.A review of the undated facility policy titled; Manual Ware Washing revealed manually washed pots, pans and cooking utensils shall be adequately sanitized using a three-part process including wash, rinse, and sanitize. The policy further revealed sanitizer concentration should be checked and recorded prior to each use. Proper test strips should be readily available.A review of the undated facility policy titled; 3 Compartment Sink Sanitizer Strength Record revealed sanitizer strength shall be monitored and recorded to ensure that all manually washed utensils, pots and pans are properly sanitized. The policy further revealed sanitizer strength in the third tank of the three-compartment sink shall be monitored prior to each use and recorded by the food and nutrition services staff.A review of the website microessentiallab.com revealed the color chart on the Hydrion strip package is marked with the expiration and lot number for that specific roll. The pH paper will remain accurate until the expiration date listed.

Based on observation, interview and facility policy review, the facility failed to maintain a sanitary garbage storage area. This had the potential to affect all residents. The facility census was 46.Findings include:An observation of the outside dumpster area on 02/17/26 at 8:30 A.M. revealed approximately six pairs of used vinyl medical gloves scattered on the ground around the dumpster. The lid to the dumpster was open. The side slide door was open. Dietary [NAME] #513 verified the findings at the time of the observation.A review of the facility policy titled; Garbage Removal and Dumpster, dated 12/21/21, revealed garbage can attract pests and contaminate food, equipment and utensils if not handled correctly. The policy further revealed the garbage dumpster must have a tight-fitting lid and or slide door and must be covered at all times.

Based on record review, observation, interview, review of the Centers for Disease Control and Prevention (CDC) guidelines and facility policy review, the facility failed to maintain a clean and sanitary laundry environment to prevent the spread of germs, failed to ensure staff performed hand hygiene to prevent cross contamination of germs during medication administration for Resident #33 and Resident #21, failed to properly clean the glucometer after use to obtain Resident #39's blood sugar, failed to contain Resident #60's contaminated linen and personal protective equipment (PPE) appropriately and failed to provide Resident #1 with a sanitary area to eat his meal. This affected three (Residents #21, #33, #39) out of six residents observed for medication administration, one (Resident #39) out of two residents observed for blood glucose monitoring, one (Resident #1) out of one resident observed for dining, one (Resident #60) of one resident reviewed for isolation precautions and had the potential to affect all the residents in the facility. The facility census was 46.Findings include:1. A review of Resident #21's clinical record revealed an admission date of 07/24/25 with diagnoses including chronic obstructive pulmonary disease (COPD), morbid obesity, obstructive sleep apnea (OSA), shortness of breath (SOB), kidney disease, polyneuropathy, high blood pressure, depression, hypothyroidism, heart failure, acute and chronic respiratory failure with hypoxia dependence on a ventilator status, and periapical abscess without sinus (a pocket of infection around the root of a tooth or surrounding tissue).A review of Resident #21's Medication Administration Record (MAR) dated 02/01/26 to 02/28/26 indicated to administer Lorazepam 2 milligrams (mg) (antianxiety) orally at 4:00 P.M.An observation on 02/17/26 at 3:36 P.M. revealed Registered Nurse (RN) #537 administered Lorazepam 2 mg orally to Resident #21. RN #537 obtained the Lorazepam from the medication cart and walked in Resident #21's room and administered the Lorazepam to Resident #21. RN #537 exited the room and did not perform hand hygiene and proceeded to obtain medications for Resident #33.A review of Resident #33's clinical record revealed an admission date of 09/26/25 with diagnoses including dysphagia (trouble swallowing), encephalopathy, vitamin D deficiency, hypo-osmolality and hyponatremia, demyelinating disease of the central nervous system, high blood pressure and cholesterol, epilepsy with convulsions, bipolar disorder and depression, COPD, Crohn's disease, anemia, and malnutrition.A review of Resident #33's MAR dated 02/01/26 to 02/28/26 indicated to administer Lurasidone hydrochloride 20 mg (antipsychotic) orally three times a day.An observation of RN #537 on 02/17/26 at 3:41 P.M. revealed RN #537 obtained one medication from the medication cart and administered the Lurasidone hydrochloride 20 mg to Resident #33 orally. RN #537 was then asked to perform hand hygiene before continuing to administer medications to other residents.An interview with RN #537 on 02/17/26 at 3:50 P.M. verified she had failed to perform hand hygiene before and after administering medications to Resident #21 and Resident #33.The facility policy titled: Hand Washing, dated 09/2025, indicated to perform hand hygiene at the following times: When reporting to work and before going home Before eating and drinking Before and after using the bathroom After sneezing. coughing or blowing your nose After touching your hair, face etc. After smoking a cigarette Before and after each resident contact After touching a resident or handling his/her belongings Whenever hands are obviously soiled After contact with any body fluids After handling any contaminated items 2. A review of Resident #60's clinical record revealed an admission date of 05/16/25 and readmission date of 02/02/26 with diagnoses including diabetes mellitus, hypo-osmolality, hyponatremia, hypokalemia, alcoholic polyneuropathy, viral hepatitis, arthritis, high blood pressure and cholesterol, Parkinsonism, gastroesophageal reflux disease (GERD), and generalized anxiety.An observation on 02/17/26 at 3:00 P.M. revealed outside of Resident #60's bedroom there was a sign indicating Resident #60 should have contact isolation precautions implemented to prevent the spread of infection. There were two large boxes lined with yellow biohazard bags located outside Resident #60's room containing discarded PPE in one box and soiled linen in another box. An interview with RN #537 at the time of the observation verified the boxes were located outside of Resident #60's room. RN #537 was unsure where the boxes were supposed to be located. RN #537 stated Resident #60 had a Methicillin Resistant Staphylococcus Aureus (MRSA) infection of his right foot and contact isolation precautions were implemented to prevent the spread of the infection.An interview with RN #542 on 02/17/26 at 3:05 P.M. revealed the two boxes of PPE and linens outside of Resident #60's room should be placed inside his room per the facility policy.A review of the Centers for Disease Control guidelines titled Management of Multidrug-Resistant Organisms in Healthcare Settings, dated 2006, indicated contact isolation precautions should be implemented for patients with MRSA infections. Discarded used PPE and soiled linens should be stored inside of the patient's room in a plastic bag labeled bio-hazardous material. Staff should remove their PPE prior to exiting the patient's room and place the discarded PPE in the waste contained with a plastic bag labeled bio-hazardous material. 3. A review of Resident #39's clinical record revealed an admission date of 01/30/26 with diagnoses including heart failure, respiratory failure, diabetes mellitus, kidney failure, soft tissue disorder, polyneuropathy, high blood pressure, peptic ulcer, gout, testicular, bilateral foot and right knee pain, and alcohol abuse.A review of Resident #39's MAR dated 02/01/26 to 02/28/26 indicated to administer Lispro insulin 100 units/milliliter 3 units subcutaneously before meals related to diagnosis of diabetes mellitus.An observation of Licensed Practical Nurse (LPN) #524 on 02/18/26 at 7:44 A.M. revealed LPN #524 obtained Resident #39's blood glucose level using a glucometer. LPN #524 obtained Resident #39's blood sugar and administered the above listed Lispro insulin to Resident #39. LPN #524 proceeded to clean the glucometer with a sanitized disposable wipe. An inspection of disposable sanitizing wipes container revealed the sanitizing solution did not contain bleach.An interview on 02/18/26 at 7:50 A.M. with LPN #524 verified the above findings and stated she was aware she should have used a sanitizing wipe solution that contained bleach and but there were no sanitizing wipes with bleach available to use to clean the glucometer in her medication cart.A review of the facility's policy titled Glucometer Cleaning Solution (undated) revealed to use a disposable sanitizing wipe with bleach to clean the glucometer after each use. Allow wet time per manufacturer's guidelines.4. A review of Resident #1's clinical record revealed an admission date of 10/16/23 with diagnoses including respiratory failure, COPD, emphysema, dysphagia, encephalopathy, atrial fibrillation (heart arrhythmia), epilepsy, OSA, dementia, depression, kidney failure and suicidal ideations.An observation of Resident #1 on 02/18/25 at 8:00 A.M. revealed Resident #1 was seated on the side of his bed eating his breakfast. Resident #1's breakfast meal tray was located on the over-the-bed table with a urinal filled two thirds of the way full of dark yellow urine sitting on the table beside his meal tray. An interview with Resident #1 at the time of the observation revealed he had used the urinal prior to the staff serving him his breakfast meal. Resident #1 stated the staff delivered his meal tray and placed it beside the urinal filled urine. An interview at 8:05 A.M. on 02/18/26 with Certified Nursing Assistant (CNA) #571 agreed she had delivered Resident #1's meal tray and should have moved Resident #1's urinal prior to serving him his breakfast meal and not placed the meal tray beside his urinal with urinal two thirds full of urine.5. An observation on 02/19/26 at 8:41 A.M. with Laundry Assistant (LA) #523 revealed there were three rooms in the basement of the facility used for washing, drying and folding the laundry. The following observations were verified by LA #524 at the time of the observations:- In the room containing the two dryers miscellaneous unfolded lost and found resident's clothing were piled on two shelves of a wheeled cart and on two plastic milk cartons with a thick layer of lint/dust covering the clothing. There were miscellaneous unfolded blankets piled on a chair with dirt and debris on the blankets. A five-shelf metal cart contained various unfolded clothing items piled on each shelf with some of the clothing dangling over the edge on to the floor. A wheeled cart with a shelf on the bottom and rod across the top to hang clothing contained clean resident's clothing. There were various clothing items on the bottom shelf of the cart hanging over the edge and touching the floor. There was lint piled up on the floor along the edges of the room. The tile floor was stained with dried liquid and built-up brown grit/grime.- In the room containing the two washing machines there were multiple pillows stacked waist high on the floor against the wall. There was a large box of new linens with some soiled blankets on top of the boxes sitting on the floor. There were bed linens in plastic wrap and a resident's belt sitting on top of the red hazardous waste container. There was a blanket on the floor in front of the washing machine to catch the water dripping from a hose in need of repair on the front of the washing machine. There were three black non-skid mats in front of the washing machines with thick packed debris in the creases of the non-skin mats. There were several missing/loose tiles in front and behind the washing machines. There was a thick layer of dried cleaning products and peeling rusty brow colored substance behind the washing machines. A utility sink contained bed, bath and personal resident's linen soiled with feces placed in a bucket located inside the sink. The floors were covered with grit/grime and dirt.An interview with LA #524 on 02/19/26 at 9:00 A.M. stated she was the only staff member working in the laundry room and did not have time to clean the laundry rooms as needed. LA #524 agreed that the floors in the laundry areas had not been thoroughly cleaned routinely and the two rooms were dirty and unorganized. LA #524 stated the facility needed to hire another laundry person to assist her with maintaining a sanitary washing area.A review of the CDC guidelines for Infection Control Assessment of Laundry Facility Preparedness indicated implementing the following guidelines for prevention of spread of infection:-Staff Training and Certification: Ensure that laundry facility supervisors and frontline personnel have completed training in managing healthcare laundry and are certified in laundry management. -PPE Availability: Make sure that PPE such as gowns, gloves, and face masks is readily available for personnel working on the soiled side. - Cleanliness Standards: Verify that surfaces throughout the facility are constructed from materials that withstand wet cleaning and high humidity, and that handwashing sinks are functional with soap and drying equipment. - Soiled Textiles Handling: Ensure that soiled textiles are contained in leak-resistant bags and that Universal/Standard Precautions are followed when sorting soiled textiles. - Air Quality and Ventilation: Check that there is proper ventilation in the facility, either through negative airflow to the soil side or positive airflow from the clean side to the soil side. - Equipment Maintenance: Conduct regular maintenance and calibration of laundry equipment according to manufacturer recommendations. - Infection Control Practices: Follow best practices for handling dirty laundry, including proper procedures and temperatures for laundering.

Based on record review, observation, interview and facility policy review, the facility failed to ensure proper grooming for Resident #53 related to removal of facial hair. This affected one (Resident #53) of three residents reviewed for activities of daily living. The facility census was 46.Findings include:Review of Resident #53's medical record revealed an admission date of 07/20/10 and pertinent diagnoses of Multiple Sclerosis, bipolar disorder, dysphagia, muscle wasting and atrophy, vascular dementia, lack of coordination, hypertensive retinopathy, corneal deformity and congenital malformation of the eye.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Basic Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment. Resident #53 was dependent on staff for all activities of daily living (ADL) and mobility and required a Hoyer (mechanical) lift for all transfers.Review of the care plan dated 12/05/25 stated Resident #53 was totally dependent with ADL and all care, and interventions included staff would assist with daily hygiene.On 02/17/26 at 1:22 P.M. an observation of Resident #53 revealed an excessive amount of facial hair on her chin.On 02/18/26 at 9:32 A.M. an additional observation of Resident #53 revealed an excessive amount of facial hair on her chin which was confirmed by Certified Nursing Assistant (CNA) #535.On 02/18/26 at 9:32 A.M. an interview with CNA #535 revealed Resident #53's chin hair was often long as staff could not keep up with how quickly it grew. CNA #535 further stated staff shaved the resident twice per week during her showers, but they did not shave her more often than that.On 02/19/26 at 9:33 AM an interview with CNA #548 confirmed excessive chin hair on Resident #53 and stated she never shaved this resident and had no knowledge of how often the resident was supposed to be shaved.Review of the facility's policy titled Resident Care, revised 06/2018, revealed typical personal hygiene for a resident included removal of women's facial hair.

Based on record review, observation, interview and facility policy review, the facility failed to change nasal cannula tubing (a plastic tube with two prongs that goes into the nose to deliver oxygen) weekly for appropriate respiratory infection control. This affected one (Resident #1) of one resident reviewed for respiratory care and had the potential to affect 10 additional residents (2, #4, #13, #19, #21, #22, #23, #24, #30, and #38) identified by the facility as receiving oxygen therapy. The facility census was 46.Findings include:Review of the medical record for Resident #1 revealed the date of admission to be 10/16/23. Significant diagnoses included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), and acute respiratory failure. Significant orders included change oxygen tubing/cannula/mask every week, every night shift, on every Saturday, dated 11/01/25, and oxygen at four liters per minute via nasal cannula as needed (PRN) to keep oxygen saturation above 90%, dated 10/30/25.Review of the annual Minimum Date Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status to have a score of 15 out of 15, indicating resident #1 was cognitively intact. The MDS also revealed oxygen therapy was in use.Review of the care plan dated 02/05/26 revealed Resident #1 had an alteration in respiratory function and required oxygen use. An intervention included administering oxygen as ordered.An observation on 02/17/26 at 11:26 A.M. revealed Resident #1 seated in his wheelchair with oxygen being administered via nasal cannula at four liters per minute. The nasal cannula was dated 01/25/26. Registered Nurse (RN) #537 verified the date on the nasal cannula at the time of the observation. RN #537 stated oxygen tubing was to be changed weekly.Review of the undated facility policy titled; Nasal Cannula revealed the nasal cannula is recommended to be changed weekly and as needed.

Based on record review, observation, interview and facility policy review, the facility failed to ensure medications were not left at the bedside for one resident (Resident #33) out of seven residents observed for medication administration. The facility census was 46.Findings include:Review of the medical records for Resident #33 revealed the initial date of admission of 06/03/24 and a readmission date of 09/26/25 with a diagnosis of chronic obstructive pulmonary disease (COPD). Significant orders included Advair diskus (a prescription dry powder inhaler to manage COPD) inhalation aerosol powder 250/50, inhale one puff two times a day for COPD. There were no orders noted in the medical record for Resident #33 to have the medication left at the bedside, nor were there any orders within the medical record for Resident #33 to self-administer the Advair. There were also no orders in the medical record for Resident #33 to have an Advair aerosol inhaler.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating Resident #33 had moderate cognitive impairment.Review of the assessments within the medical record revealed no medication self-administration assessment (an assessment done to ensure a resident can self-administer medications safely and effectively) for Resident #33.Review of the care plan dated 02/07/26 revealed no medication self-administration interventions.An observation on 02/17/26 at 9:51 A.M. revealed an Advair diskus powder inhaler and an Advair aerosol inhaler on the over-the-bed table of Resident #33. Assistant Director of Nursing (ADON) #507 verified the two inhalers on the over-the-bed table of Resident #33 at the time of the observation. ADON #507 stated the inhalers should not have been left at the bedside of Resident #33 and further stated Resident #33 did not have an order to self-administer medications.Review of the facility policy titled; Medication Storage/Storage of Medication, dated 2007, revealed medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. The policy further revealed medication rooms, cabinets and medication supplies should remain locked when not in use or attended to by persons with authorized access.Review of the facility policy titled; Medication Administration General Guidelines, dated 01/25, revealed medications are to be administered at the time they are prepared. The policy further revealed residents are allowed to self-administer medications when specifically authorized by the prescriber, the nursing care centers interdisciplinary team in in accordance with procedures for self-administration of medication and state regulations.

Based on record review, observation, interview and facility policy review, the facility failed to ensure Resident #11's call light activation button was within reach to ensure it could be utilized. This affected one (Resident #11) of 46 residents screened for call light placement. The facility census was 46.Findings include:Review of the medical record for Resident #11revealed the date of admission as 04/22/23. Significant diagnoses included dementia, unspecified severity without behavioral disturbance, need for assistance with personal care, and muscle weakness. There were no significant orders regarding the call light placement.Review of the care plan dated 12/16/25 revealed Resident #11 was at risk for falls. Interventions included commonly used articles within easy reach: water, call light, remote control, telephone etc.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine indicating Resident #11 had moderate cognitive impairment. Resident #11 was dependent for toileting and showers.An observation on 02/17/26 at 9:56 A.M. revealed Resident #11 lying in bed. The call light activation button was located on top of a mini refrigerator to the left side of the bed underneath several papers on top of the mini refrigerator. The mini refrigerator was approximately three feet from the bedside of Resident #11. Certified Nurse Aide (CNA) #562 verified the placement of the call light activation button at the time of the observation.Review of the facility policy titled; Call Light Answering, dated 12/24, revealed the purpose of the policy is to assure the facility is adequately equipped with a call light at each residence bedside, toilet, and bathing facility to allow residents to call for assistance. The policy further revealed all staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. Finally, the policy revealed staff will ensure the call light is within reach of each resident and secured as needed.

Based on record review, observation and interview, the facility failed ensure Resident #9's room was in good repair. This affected one (Resident #9) 46 during the initial screening and initial tour. The facility census was 46.Findings include:Review of the medical record for Resident #9 revealed the date of admission as 02/06/25. Significant diagnoses included type one diabetes mellitus, immunodeficiency due to conditions classified elsewhere and difficulty walking. There were no significant orders regarding noncompliance for room disrepair.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating Resident #9 was cognitively intact.Review of the care plan dated 12/05/26 revealed no indications that Resident #9 refused housekeeping and maintenance services.An observation on 02/18/26 at 8:35 A.M. revealed Resident #9's room was in general disrepair. The wall between the sink and bathroom had a large deep gouge just above the baseboard approximately three feet long. The floor along the baseboard had a visible buildup of dirt and debris. There was visible buildup of dirt and debris behind the entrance door in the corner. The baseboard behind bed A was missing. Resident #9 was noted to be in bed B of the room. The baseboard at the entrance door was noted to be coming away from the wall. Maintenance Director (MD) #532 verified the findings at the time of the observation. MD #532 stated he was not sure when the gouge happened in the wall between the bathroom and the sink. MD #532 also stated he was not sure when the baseboard went missing behind bed A of the room.

Based on observation, record review, interview and policy review, the facility failed to provide interventions to prevent the development of an unstageable pressure ulcer, failed to timely and accurately document the initial assessment and weekly comprehensive assessments of the pressure ulcer, failed to timely coordinate ancillary wound care services to mitigate complications related to pressure ulcers, and failed to follow proper infection control procedures during wound care. This affected one (Resident #41) of two residents reviewed for pressure ulcers. The facility census was 51. Findings include:Review of the medical record for Resident #41 revealed an admission date of 03/09/25 and a re-entry date of 05/28/25. Resident #41 had diagnoses including unspecified dislocation of the right hip, adult failure to thrive, presence of bilateral artificial knee joints, Parkinson's disease, tachycardia, primary hypertension, osteoarthritis, and need for assistance with personal care. Review of the weekly skin assessment completed on 05/28/25 revealed Resident #41 had some bruising on the right arm and right leg but otherwise had intact skin. Review of the care plan dated 05/28/25 revealed Resident #41 was at risk for impaired skin integrity and pressure ulcers related to impaired mobility and incontinence. The care plan listed three interventions: apply barrier cream after each incontinent episode as needed (PRN), elevate heels off mattress, and encourage fluids. The care plan did not include turning or repositioning to redistribute weight off Resident #41's pressure points while in bed. Review of the admission Minimum Data Set (MDS) 3.0 assessment completed on 06/10/25 revealed Resident #41 had intact cognition and was dependent on staff for toileting hygiene, bathing, transfers in and out of bed and required substantial assistance to roll left and right in bed. Further review of the MDS revealed Resident #41 had occasional bladder incontinence and was at risk for pressure injury but had no pressure injuries, ulcers, lesions, rashes, surgical wounds, burns, skin tears, or moisture associated skin damage (MASD) at the time of the assessment. Review of the weekly skin assessment completed on 06/11/25 revealed Resident #41 had redness noted to the coccyx and a barrier cream was applied. There were no progress notes or additional assessment details noted in the medical record related to the size of the reddened area or whether the area was blanchable. No additional interventions were added to the care plan. Review of the orders revealed a physician order dated 06/12/25 (discontinued on 07/10/25) to cleanse the coccyx of Resident #41 with normal saline solution (NSS) and apply calcium alginate and a foam dressing daily and PRN. Review of the Treatment Administration Record (TAR) from June 2025 revealed documentation of wound care treatments daily from 06/12/25 through 06/30/25, except for 06/18/25, when Resident #41 was in the emergency room (ER). Review of the progress notes from 06/12/25 revealed there were no notes related to the new wound care orders for Resident #41's coccyx. Review of all assessments for Resident #41 revealed there were no assessments related to the wound care orders that were initiated on 06/12/25. The care plan revealed no new interventions were added to the skin integrity care plan, and no care plan focus was added related to actual skin impairment until 08/14/25. Review of the assessment titled Skin Grid Pressure 3.0 - V 2 completed on 06/19/25 revealed Resident #41 had a Stage two (II) pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough, may also present as an intact or open/ruptured serum filled blister) to the sacrum that measured 1.5 centimeters (cm) by 1.2 cm by 0.2 cm with an onset date documented as 06/19/25 related to a leave of absence (LOA) or ER visit. The wound tissue was documented as 100 percent (%) pink with moderate serosanguinous exudate (drainage) and no signs of infection. The peri wound (tissue surrounding the wound) was intact, fragile, and moist. The medical record revealed no comprehensive wound assessment or tracking between 06/19/25 and 07/03/25, including the wound size (length, width, depth), wound stage, amount, color, consistency, and odor of wound exudate, wound bed tissue, wound edges and surrounding skin, signs of infection or inflammation, presence of pain, and status (healing, stalled, stable, declined). However, there was a weekly skin assessment completed on 06/25/25 which revealed Resident #41 had an open lesion. The note further revealed Open areas to coccyx. The assessment did not indicate there had been a previously identified pressure area and there was no comprehensive wound assessment documented. Review of the physician orders revealed orders dated 06/26/25 for Resident #41 to have house liquid protein supplements, 30 milliliters (ml), twice daily by mouth for 60 days (the pressure ulcer was first identified on 06/12/25). Review of the Skin Grid Pressure 3.0 - V 2 assessment completed on 07/03/25 revealed Resident #41 had an unstageable pressure area (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) to the sacrum which measured 2.0 cm by 1.5 cm by an undeterminable depth. The wound was listed as in-house acquired and contained 80% slough. The wound was noted to have a moderate amount of serosanguinous exudate, and the peri-wound area was moist and reddened. The wound status was listed as having declined since the previous assessment. The Skin Grid Pressure 3.0 - V 2 assessment completed on 07/10/25 revealed a full-thickness unstageable pressure ulcer to the sacrum that measured 2.0 cm by 2.0 cm by an undeterminable depth. The wound bed contained 20% granulation tissue and 80% slough with undermining to an undeterminable extent due to the slough. The peri-wound was reddened and Resident #41 experienced tenderness with wound care. The assessment indicated no assessment of the wound healing status. Review of the Encore Wound Care visit note dated 07/10/25 revealed this was the date of the initial wound provider consultation for an unstageable pressure ulcer that was in-house acquired. Further review of the note revealed Resident #41 had a sharp excisional debridement of one square centimeter where loose slough was excised to better visualize the wound base and the debrided tissue went down to the subcutaneous tissue. At the time of the visit, new orders for wound care were initiated and recommendations included offloading pressure, proper nutrition and protein supplementation with a nutrition consult per facility policy, pressure reducing devices to the bed and wheelchair, repositioning per facility protocol, proper hygiene, avoiding contamination, and changing dressings PRN to keep clean and dry. The treatment order was to clean the wound with NSS, pack with silver alginate rope (if the facility was able to order the reinforced silver alginate rope), and cover with a silicone super absorbent dressing daily and PRN. Review of the physician orders dated 07/10/25 revealed Resident #41 was to have the coccyx wound cleansed with NSS, packed with calcium alginate rope, and covered with a foam dressing daily and PRN. There were no progress notes dated 07/10/25 indicating the facility was unable to order reinforced silver alginate rope or silicone super-absorbent dressings or that the facility had discussion with and/or received additional order clarification from Wound Advance Practice Registered Nurse (APRN) #325, the practitioner managing the wound care from Encore Wound Care. Review of the TAR from July 2025 revealed this treatment was documented daily from 07/10/25 through 07/31/25, except 07/21/25, which contained no electronic signature. Review of the assessments, progress notes, and wound provider (Encore) visit notes revealed no comprehensive wound assessment or tracking was completed between 07/10/25 and 07/24/25, although there was a weekly completed on 07/16/25 which noted Resident #41 had a bruise and a previously identified pressure area with a treatment in place. Review of the Encore Wound Care visit note dated 07/24/25 revealed Resident #41 reported the wound was on fire at the time of the visit. Further review of the note revealed the wound had declined and was reclassified as a Stage four (IV) pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough may be present on some parts of the wound bed. Often include undermining and tunneling). The note also revealed Resident #41 had poor nutritional intake, had an overall poor health condition, was incontinent, and had poor compliance with offloading. Review of the visit note revealed the wound had grown to 3.0 cm by 2.8 cm by 1.6 cm with undermining from 12 o'clock to 12 o'clock for a maximum of 1.9 cm depth at three o'clock and 1.2 cm at six o'clock, 60% exposed fascia, and heavy serosanguinous drainage. The wound care orders were changed during this visit due to the heavy drainage with new recommended treatment consisting of cleansing the wound with NSS, packing with calcium alginate rope, and covering with a silicone super absorbent dressing every shift and PRN. Review of the Skin Grid Pressure 3.0 - V 2 assessment completed on 07/24/25 mirrored the assessment from the Encore wound visit note for this date. Review of the orders revealed no new treatment orders after Encore APRN #325 changed the order recommendation during the visit on 07/24/25. Review of the Encore Wound Care visit note dated 07/31/25 revealed Resident #41 was positive for Clostridioides difficile (C. diff., a bacterium that causes diarrhea and inflammation of the bowel), was on oral antibiotics, and appeared not well-nourished. The wound was classified as improving during the visit and no new wound care orders or recommendations were made (the treatment order remained for Resident #41 to have the wound cleansed with NSS, packed with calcium alginate rope, and covered with a silicone super absorbent dressing every shift and PRN). Review of the physician orders revealed a new treatment order dated 08/01/25 which was for Resident #41 to have the sacral wound cleaned with NSS or wound cleanser, pat dry, lightly pack with calcium alginate rope, and cover with a silicone super absorbent dressing every day shift for wound management (not every shift and PRN as specified by Wound APRN #325 on 07/24/25 and 07/31/25). Review of the TAR from August 2025 revealed wound care was documented once daily, except on 08/04/25, where there was no electronic sign-off the treatment had been completed. Review of the Encore Wound Care visit note dated 08/07/25 revealed Resident #41's wound status was measuring 4.0 cm by 3.0 cm by 2.0 cm with deepest undermining at 11 o'clock at 3.0 cm and the wound bed contained 60% granulation, 10% bone, and 30% fascia. Further review of the note revealed Resident #41 was advised that further wound decline was possible and was informed further work-up could be done, which included possible hospitalization and intravenous antibiotics, but Resident #41 declined further evaluation or treatment at that time, and the facility was to continue with the same plan of care for another one to two weeks and then the wound care orders would be reviewed for continued appropriateness. The continued wound care order per Wound APRN #325 was to clean the wound with NSS, pack with calcium alginate rope, and apply a silicone super absorbent dressing every shift and PRN (The August 2025 TAR revealed treatments continued to be performed every day shift instead of every shift). Review of the physician orders revealed an order dated 08/07/25 for Resident #41 to have an alternating pressure air mattress to the bed and staff were to check the mattress for proper functioning every shift. Review of the care plan (initiated on 05/28/25) revealed an update was made on 08/14/25 to reflect Resident #41 had actual impaired skin integrity related to a Stage II pressure ulcer to the sacrum (note: the impaired skin integrity/pressure ulcer initially developed on 06/12/25 and had been reclassified as a Stage IV on 07/24/25). Interventions included referring to a wound physician PRN, administering medications and wound care per physician orders, completing skin documentation and skin assessments per facility policy, explaining procedures prior to care, monitoring signs of infection, and notifying the physician of wound deterioration. Interview on 08/13/25 at 2:35 P.M. with Certified Nurse Aide (CNA) #354 revealed Resident #41 had a large wound that was believed to be noted after a recent hospital visit. CNA #354 denied any concerns related to wound care at the time of the interview. Interview on 08/13/25 at 3:15 P.M. with Licensed Practical Nurse (LPN) #350 revealed Resident #41 had a wound on her coccyx area for a couple weeks that had gotten larger. During the interview, LPN #350 confirmed the wound treatment was scheduled to be completed once a day (Wound APRN #325 ordered for wound care to be completed every shift) and it would get changed on a PRN basis if it was soiled. At the time of the interview, when asked of the dressing change had been completed earlier in the shift, LPN #350 did not respond definitively. Observation on 08/13/25 from 3:18 P.M. to 3:35 P.M. of wound care for Resident #41 performed by LPN #350 revealed a gown, mask, face shield, and two pairs of gloves were donned prior to entering the room of Resident #41. As the personal protective equipment (PPE) was being applied, LPN #350 stated double-gloving would be used to minimize movement around the room during wound care between steps of the procedure so that one pair could be removed once the old dressing was off and the other pair of gloves could be used to continue wound care without stepping away to perform hand washing between glove changes. Before wound care commenced, two normal saline bullets, dry gauze, a package containing calcium alginate rope, and a package containing a silicone absorbent border dressing were laid on the bedside stand without the bedside stand being cleaned or a barrier set-up for the dressing supplies. The packaging for the calcium alginate rope and silicone border dressing were opened slightly (the seal was opened one edge of each package, but the other three edges remained intact, and the packages remained closed over top of the dressing supplies). LPN #350 was observed removing the old dressing, which was undated and soiled in urine and stool, wrapped the old dressing in the top layer of gloves, removed the top layer of gloves, and discarded in the trash can at the bedside. While wearing the bottom layer of gloves, LPN #350 squirted two 15 milliliter (ml) saline bullets onto the wound bed, wiped around the wound bed with dry gauze, used the gloved hands to manipulate the package containing the calcium alginate rope, used the same gloved hands to press the calcium alginate rope into the wound bed and undermined edges, then grabbed the package containing the silicone border dressing, removing the dressing from the package, and secured the border dressing over the wound. With the same gloved hands, LPN #350 repositioned Resident #41 in bed and adjusted the bed linen. At this time, LPN #350 was observed removing the old gloves and applying new gloves to raise the head of the bed for Resident #41 and assisting with a drink of water. No hand hygiene was performed between the glove changes. An interview with LPN #350 on 08/13/25 at 3:40 P.M. confirmed double gloving was the process always used to provide wound care in the facility so there was less need to go back and forth to perform hand hygiene. During this interview, LPN #350 also confirmed no hand hygiene was performed between glove changes after the wound care observation. Interview on 08/14/25 at 9:00 A.M. with the Director of Nursing (DON) confirmed Encore Wound Care was the outside company the facility used to manage wounds. The DON further confirmed residents with any type of wound, not just chronic wounds, were to be referred to Encore Wound Care for an initial consultation and that Wound APRN #325 from Encore is the Provider who managed wound care orders for Resident #41. During the interview, the DON reported Resident #41 acquired the pressure ulcer during an ER visit (on 06/18/25) and presented the Skin Grid Pressure 3.0 - V 2 assessment from 06/19/25 indicating the onset date of 06/19/25 acquired after a leave of absence (LOA) or ER visit. At this time, the DON verbalized uncertainty regarding treatments to the coccyx being initiated one week prior to the facility documented wound onset of 06/19/25 and confirmed if there were wound assessments completed on 06/26/25 and 07/17/25, she would produce them. No documentation of weekly comprehensive wound assessments were presented during the survey. Also, during this interview, the DON confirmed hand hygiene was to be performed between glove changes and double gloving was not common practice for the facility, but she would look further into it. The DON further confirmed nurses were supposed to clean the bedside stand and set up a clean barrier prior to setting up their dressing supplies. Interview on 08/14/25 at 9:42 A.M. with Regional Quality Assurance (QA) Nurse #320 confirmed nurses should not double glove to provide wound care. Interview on 08/14/25 at 3:10 P.M. with Resident #41 confirmed no wound was present upon readmission to the facility (05/28/25) and that the wound was acquired while in the facility, not in the hospital, and that it hurt. Resident #41 further confirmed the wound had already been present and nurses were doing dressings on her backside before any of the visits to the ER. Interview on 08/14/25 at 2:48 P.M. with Regional QA Nurse #320 confirmed the original care plan focus for Resident #41 being at risk for altered skin integrity or pressure ulcer development was not all inclusive of possible preventative measures and the care plan would be re-evaluated. During the interview, Regional QA Nurse #320 confirmed she updated the care plan on 08/14/25 to reflect the actual altered skin integrity and that the alteration noted Resident #41 had a Stage II pressure ulcer. At this time, Regional QA Nurse #320 was notified the pressure ulcer had regressed to a Stage IV as of 07/24/25 and Regional QA Nurse #320 confirmed the care plan would need updated. Telephone interview with LPN #357 on 08/18/25 at 3:39 P.M. confirmed the aide working on the date the new treatment orders were obtained (06/12/25) discovered and reported an open area on the coccyx of Resident #41. During this interview, LPN #357 confirmed the wound was probably the size of a dime with some slough noted, appearing to be an unstageable pressure ulcer. LPN #357 further confirmed an order was obtained from the nurse practitioner and a calcium alginate and foam dressing were applied per orders. During the interview, LPN #357 verbalized a lack of knowledge related to initiating a Skin Grid Pressure 3.0 - V 2 assessment when a new pressure area was identified and confirmed a progress note detailing the new skin concerns must not have been created. Review of the telephone message recorded on 08/19/25 at 5:26 P.M. revealed Wound APRN #325 confirmed that on 07/24/25, the wound care orders for Resident #41 reflected an increase in frequency and were to be performed every shift (twice daily) and that ordered frequency had not been changed since 07/24/25. Review of the undated policy titled Dressing Change - Clean revealed wound care protocol was to clean the bedside stand and establish a clean field prior to wound care. The policy further revealed the process was to perform hand hygiene, apply clean gloves, remove the soiled dressing and discard into the nearby plastic or biohazard bag, perform hand hygiene, open the clean, dry dressing by pulling only the exterior corners outward and only touching the exterior surface of the packaging, open all needed dressing supply products, put on clean gloves, cleanse the wound per orders, apply ordered treatment, remove and discard gloves, wash hands thoroughly, reposition the resident, then perform hand hygiene again. The policy did not mention the practice of double-gloving. Review of the updated policy titled Pressure Ulcer Prevention Intervention revealed residents at risk for pressure ulcers were to be kept clean and dry, avoid sheering and friction, be provided a gel cushion (or equivalent) for sitting, and be repositioned every two hours to relieve or redistribute pressure. Review of the policy further revealed a specialty mattress, which included a low air loss or alternating mattress was to be used for Stage III and Stage IV pressure ulcers, and a Clinitron or comparable specialty mattress was to be used for an unstageable pressure ulcer or a complicated Stage IV pressure ulcer. The policy further revealed a high-protein nutritional supplement should be added for residents at risk for pressure ulcers. This deficiency represents non-compliance investigated under Complaint Number 2570357.

Based on observation, interview, medical record review, review of facility policy, and review of the Centers for Disease Control and Prevention (CDC) on-line guidance for use of personal protective equipment (PPE) for care of persons with COVID-19 (the novel coronavirus, also known as severe acute respiratory syndrome two or SARS-CoV-2), the facility failed to ensure the appropriate type of transmission-based precautions for Resident #41was identifiable to staff and visitors, failed to ensure proper infection control procedures were maintained during wound care for Resident #41, and failed to ensure appropriate precautions were maintained when providing care for Resident #35. This affected two residents (Residents #35 and #41) but had the potential to affect eight residents who were identified by the facility as having wounds (Residents #21, #28, #33, #41, #42, #44, #45, and #50) and six residents who were in droplet isolation (Residents #19, #21, #26, #27, #35, and #44). The facility census was 51. Findings include: 1. Review of the medical record for Resident #41 revealed an admission date of 03/09/25 and a re-entry date of 05/28/25. Diagnoses included unspecified dislocation of the right hip, adult failure to thrive, presence of bilateral artificial knee joints, Parkinson's Disease, tachycardia, primary hypertension, osteoarthritis, and need for assistance with personal care. Review of the care plan dated 05/28/25 revealed Resident #41 was at risk for infection related to a chronic wound. Interventions included maintaining enhanced barrier precautions (EBP) as indicated. Review of the admission Minimum Data Set (MDS) 3.0 assessment completed on 06/10/25 revealed Resident #41 had intact cognition and was dependent for toileting hygiene, bathing, transfers in and out of bed and required substantial assistance to roll left and right in bed. Further review of the MDS revealed Resident #41 had occasional bladder incontinence and was at risk for pressure injury but had no pressure injuries, ulcers, lesions, rashes, surgical wounds, burns, skin tears, or moisture associated skin damage (MASD) at the time of the assessment. Review of the physician orders revealed an order dated 07/29/25 for Resident #41 to be in contact isolation with no further description or instructions. Further review of the order revealed contact isolation was discontinued on 08/11/25. Review of the physician orders also revealed a treatment order dated 08/01/25 which was for Resident #41 to have the sacral wound cleaned with NSS or wound cleanser, pat dry, lightly pack with calcium alginate rope, and cover with a silicone super absorbent dressing every day shift for wound management. Observation on 08/13/25 at 2:35 P.M. revealed one cart containing PPE, one covered bin for trash, and one covered bin for linen in the hall outside the door to the room of Resident #41. Further observation revealed there were two signs hanging on Resident #41's door, one that specified Resident #41 was in EBP and one identifying Resident #41 as requiring contact isolation. Interview on 08/13/25 at 2:35 P.M. with Certified Nurse Aide (CNA) #354 revealed the belief Resident #41 was in EBP for a large wound and no knowledge as to why the contact isolation sign was on the door. Interview on 08/13/25 with Licensed Practical Nurse (LPN) #350 revealed a statement that contact isolation and EBP were the same thing and the contact isolation sign was probably there to remind staff which PPE to wear when providing care to Resident #41 because she had a large wound. Observation on 08/13/25 from 3:18 P.M. to 3:35 P.M. of wound care for Resident #41 performed by Licensed Practical Nurse (LPN) #350 revealed a gown, mask, face shield, and two pairs of gloves were donned prior to entering the room of Resident #41. As the PPE was being applied, LPN #350 stated double-gloving would be used to minimize movement around the room during wound care between steps of the procedure so that one pair could be removed once the old dressing was off and the other pair of gloves could be used to continue wound care without stepping away to perform hand washing between glove changes. Before wound care commenced, two normal saline bullets, dry gauze, a package containing calcium alginate rope, and a package containing a silicone absorbent border dressing were laid on the bedside stand without the bedside stand being cleaned or a barrier set-up for the dressing supplies. The packaging for the calcium alginate rope and silicone border dressing were opened slightly (the seal was opened one edge of each package, but the other three edges remained intact, and the packages remained closed over top of the dressing supplies). LPN #350 was observed removing the old dressing, which was undated and soiled in urine and stool, wrapped the old dressing in the top layer of gloves, removed the top layer of gloves, and discarded in the trash can at the bedside. While wearing the bottom layer of gloves, LPN #350 squirted two 15 milliliter (ml) saline bullets onto the wound bed, wiped around the wound bed with dry gauze, used the gloved hands to manipulate the package containing the calcium alginate rope, used the same gloved hands to press the calcium alginate rope into the wound bed and undermined edges, then grabbed the package containing the silicone border dressing, removing the dressing from the package, and secured the border dressing over the wound. With the same gloved hands, LPN #350 repositioned Resident #41 in bed and adjusted the bed linen. At this time, LPN #350 was observed removing the old gloves and applying new gloves to raise the head of the bed for Resident #41 and assisting with a drink of water. No hand hygiene was performed between the glove changes. An interview with LPN #350 on 08/13/25 at 3:40 P.M. confirmed double gloving was the process always used to provide wound care in the facility so there was less need to go back and forth to perform hand hygiene. During this interview, LPN #350 also confirmed no hand hygiene was performed between glove changes after the wound care observation. Interview on 08/14/25 at 9:00 A.M. with the Director of Nursing (DON) confirmed hand hygiene was to be performed between glove changes and double gloving was not common practice for the facility, but she would look further into it. The DON further confirmed nurses were supposed to clean the bedside stand and set up a clean barrier prior to setting up their dressing supplies. During this interview, the DON confirmed Resident #41 had previously tested positive for Clostridioides difficile (C. diff., a bacterium that causes diarrhea and inflammation of the bowel), but had completed the antibiotics, was having formed stools, and the sign should no longer be posted outside the door. Interview on 08/14/25 at 9:42 A.M. with Regional Quality Assurance (QA) Nurse #320 confirmed nurses should not double glove to provide wound care. Review of the undated policy titled Dressing Change - Clean revealed wound care protocol was to clean the bedside stand and establish a clean field prior to wound care. The policy further revealed the process was to perform hand hygiene, apply clean gloves, remove the soiled dressing and discard into the nearby plastic or biohazard bag, perform hand hygiene, open the clean, dry dressing by pulling only the exterior corners outward and only touching the exterior surface of the packaging, open all needed dressing supply products, put on clean gloves, cleanse the wound per orders, apply ordered treatment, remove and discard gloves, wash hands thoroughly, reposition the resident, then perform hand hygiene again. The policy did not mention the practice of double-gloving. 2. Review of the medical record for Resident #35 revealed an initial admission date of 07/08/24 and a re-entry date of 07/30/24 with diagnoses including unspecified mood disorder, unspecified psychosis, ulcerative colitis, pulmonary fibrosis, Alzheimer's disease, malignant neoplasm of the colon, and colostomy status. Review of the diagnoses revealed Resident #35 also had COVID-19 as of 08/10/25. Review of the annual MDS 3.0 assessment completed on 07/16/25 revealed Resident #35 had moderately impaired cognition and had been independent with eating, oral hygiene, and toileting hygiene, and required supervision of touching assistance with bathing. Review of the MDS further revealed Resident #35 had an ostomy for bowel elimination. Review of the orders revealed and order dated 08/11/25 for Resident #35 to be in strict isolation with droplet precautions through 08/20/25 secondary to COVID-19 infection. Review of the care plan dated 08/15/25 revealed Resident #35 had an actual infection related to COVID-19 and was in isolation until 08/20/25. Interventions included providing isolation per protocol through the infectious period. Review of the progress notes revealed a noted dated 08/11/25 at 3:10 P.M. indicating Resident #35 tested positive for COVID-19 and droplet precautions were to be maintained. Observation on 08/18/25 at 8:25 A.M. revealed Medication Aide #380 entered the room of Resident #35 with an N-95 mask over a surgical mask, no gown, no gloves, and no face shield or goggles. Medication Aide #380 was observed assisting Resident #35 with drinking sips of orange juice and with eating breakfast. After approximately three minutes into observation, Medication Aide #35 closed the door to the room to assist Resident #35 with additional needs. Interview on 08/18/25 at 8:35 A.M. with Registered Nurse (RN) #371 confirmed Resident #35 was in droplet isolation until 08/20/25 for testing positive for COVID-19. During the interview, RN #371 stated staff were to don gloves, a face shield, and an N-95 mask prior to entering the room of Resident #35 to provide care and any direct personal care would also require a gown. At the time of the interview, RN #371 verbalized that a gown was typically not needed for residents in droplet isolation unless close direct contact was required. Observation on 08/18/25 at 8:46 A.M. revealed Medication Aide #380 exited the room of Resident #35 wearing the N-95 on top of a surgical mask, with the N-95 positioned under her nose (the surgical mask was over the nose) and then clearing a meal tray from the dining room and another resident's room. Interview with Medication Aide #380 at 8:50 A.M. confirmed masks were to be removed and discarded upon exiting rooms with droplet isolation and replaced as necessary. Medication Aide #380 further confirmed no gown, gloves, or face shield were used to assist Resident #35 with breakfast, adding that a face shield was initially put on, but taken off because it was too hot. During the interview, Medication Aide #380 denied the need to gown to enter the room of a COVID-19 positive resident, confirming there was a sign outside the door only indicating a mask and face covering was needed. A nursing progress note dated 08/18/25 at 10:47 A.M. revealed Resident #35 had a temperature of 102.4 degrees Fahrenheit (F), a pulse of 102 beats per minute, poor oral intake of foods, drinks, and medications, and an altered mental status. The note further revealed Resident #35 was to be transferred to the hospital. Interview on 08/18/25 at 1:40 P.M. with the Administrator confirmed there was no facility policy on donning and doffing PPE, but the facility followed CDC guidelines. Interview on 08/18/25 at 2:48 P.M. with Regional Quality Assurance (QA) Nurse #320 confirmed the appropriate PPE required for staff to assist a COVID-19 positive resident with meals included a gown, gloves, mask, and eye protection and that the N95 mask should be removed when leaving the resident's room. Review of the Centers for Disease Control and Prevention (CDC) on-line guidance for use of personal protective equipment (PPE) for care of persons with COVID-19 positive infection dated 06/24/24 revealed health care workers should use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection, such as goggles or a face shield, that covered the front and sides of the face. This deficiency was an incidental finding identified during the complaint investigation.

Based on record reviews and interviews, the facility failed to ensure there was a Registered Nurse (RN) present in the facility eight consecutive hours seven days a week. This had potential to affect all residents. The facility census was 47.Findings include:Record review was conducted of the nursing services staffing schedule and completion of the staffing tool for the date range of 06/22/25 to 06/27/25 with Human Resources Manager (HRM) #807. The facility met or exceeded the minimum staffing requirement of 2.5 hours of direct care per resident per day, however, on 06/25/25 an RN was not on staff for eight consecutive hours that day. Interview on 07/02/24 at 3:30 P.M. with HRM #807 revealed the facility was staffed based on acuity and census numbers. There should be one nurse on each unit and one aide. The DON was full-time, and they were required to have an RN eight hours a day seven days a week. HRM #807 confirmed on 06/25/25 they did not have required RN coverage for this day.This deficiency represents non-compliance identified during investigation of Complaint Number OH00167011.

Based on record review, interview and review of facility policy, the facility failed to ensure all allegations of abuse were reported to the state agency as required. This affected four residents (#9, #10, #16, and #51) out of five residents reviewed for abuse. The facility census was 47.Findings include:1. Review of the medical record for Resident #9 revealed an admission date of 10/09/24. Diagnoses included acute kidney failure, cognitive communication deficit, type two diabetes, adult failure to thrive, and depression.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/18/25 revealed the resident had impaired cognition. The resident required setup or clean up assistance for eating, supervision for oral hygiene, dressing, and bed mobility, and were dependent on staff for showers, toileting hygiene, and personal hygiene.Review of the nurse progress notes dated from 06/05/25 to 07/02/25 revealed on 06/05/25 the resident was ordered Silvadene cream (a cream used to treat burns) one percent twice a day times 10 days for burns to face with no other documentation regarding how they received the burns.2. Review of Resident #10's medical record revealed an admission date of 04/16/25. Diagnoses included dementia, benign prostatic hyperplasia, and acute gastritis without bleeding.Review of Resident #10's admission MDS 3.0 assessment dated [DATE] revealed the resident had slight impairment in cognition, they were independent for eating, oral hygiene, and bed mobility, they required supervision for showers, dressing and personal hygiene and set up assistance with toileting hygiene.Review of Resident #10's care plan dated 05/14/25 revealed an alteration in cognitive function related to dementia.Review of Resident #10's progress notes dated 06/05/25 at 12:09 P.M. authored by Licensed Practical Nurse (LPN) #840 revealed the resident became agitated when Resident #9 cut in line for coffee. Resident #10 then took the cup of coffee he had in his hands and threw it in Resident #9's face.Review of the facility Self-Reported Incidents (SRI) revealed there was no SRI submitted by the facility on 06/05/25 regarding an incident allegation of resident-to-resident abuse involving Resident #9 and Resident #10.An interview on 07/01/25 at 12:42 P.M. with the Administrator and the DON revealed Resident #10 threw coffee at Resident #9 which hit him in the face and caused burns which were treated with Silvadene one percent cream twice a day for 10 days. They both confirmed they did not report this incident of resident-to-resident abuse to the state agency and they did not do a thorough investigation as to why this incident occurred.An interview on 07/01/25 at 2:52 P.M. with both of Resident #9 ' s responsible parties revealed they were not notified of Resident #10 throwing coffee in Resident #9 ' s face and that he was treated for burns.Interview on 07/01/25 at 3:53 P.M. with Certified Nursing Assistant (CNA) #850 revealed Resident #9 had coffee thrown in his face by Resident #10 and sustained burns to his face and was treated. CNA #850 described the burns as red marks without blisters.Interview on 07/02/25 at 5:55 P.M. with LPN #840 revealed Resident #9 had burns to his face related to Resident #10 throwing coffee at him. The burns did not blister and were not open. The areas were red. LPN #840 notified the physician who implemented an order for Silvadene cream to be applied twice a day for 10 days to affected areas. LPN #840 stated she reported the incident to the DON when it happened.3. Review of Resident #16's medical record revealed an admission date of 10/15/24. Diagnoses included transient cerebral ischemic attack, vascular dementia, adult failure to thrive, type two diabetes, and major depressive disorder.Review of Resident #16's quarterly MDS 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition they were independent with eating, oral hygiene, dressing, personal hygiene, and bed mobility, and they required set up help only with toileting.Review of Resident #16's care plan dated 02/24/25 revealed no concerns regarding resident behavior.4. Review of Resident #51's medical record revealed an admission date of 05/01/25 and a discharge date of 06/24/25. Diagnoses included elevated sodium levels, muscle weakness, unsteadiness on feet, need for assistance with personal care, hypertension, atrial fibrillation, and dementia.Review of Resident #51's discharge MDS 3.0 assessment revealed the resident had intact cognition. They required setup assistance with eating, oral hygiene, were independent with bed mobility and required partial to supervision assistance with toileting, showers, dressing, and personal hygiene.Review of Resident #51's care plan revealed no concerns related to aggressive behaviors.Review of Resident #51's progress notes dated 06/13/25 at 1:30 P.M. revealed the resident was observed by staff to be standing above his roommate Resident #16 verbally abusing and swearing at him. When asked what happened Resident #51 stated his roommate would not stop talking. Nursing staff placed the resident in a different room. Additional review of Resident #51's progress notes revealed on 06/17/25 at 3:30 A.M. a guest at the facility (Resident #50's family) reported to them Resident #51 was seen hitting Resident #16. The staff assessed Resident #16, and asked Resident #51 about the allegation and Resident #51 denied punching or having an issue with Resident #16.Review of facility SRIs revealed there was no SRI submitted by the facility on 06/13/25 regarding the incident between Resident #16 and Resident #51.An interview on 07/01/25 at 10:26 A.M. with the Administrator and the DON revealed they were notified by Resident #50's family member Resident #16 and Resident #51 were fighting in their room. The Administrator and the DON stated they interviewed Resident #16 and Resident #51 who stated this did not happen. They both confirmed they did not report this allegation of Resident-to-Resident abuse to the state agency and did not conduct a thorough investigation. They stated they took Resident #51 and Resident #16's word this incident did not occur. They both confirmed Resident #16 had cognitive impairment and they should have investigated further and reported the incident to the state agency.Review of facility undated policy titled Abuse, Neglect, and Misappropriation, revealed abuse can be defined as the willful infliction of injury resulting in physical harm, pain or mental anguish. The facility would report allegations of abuse to the state agency and conduct a thorough investigation. This deficiency represents non-compliance identified during the investigation of Complaint Number OH00161011.

Based on record review, interview and review of facility policy, the facility failed to ensure all allegations of abuse were thoroughly investigated. This affected four residents (#9, #10, #16, and #51) out of five residents reviewed for abuse. The facility census was 47.Findings include:1. Review of the medical record for Resident #9 revealed an admission date of 10/09/24. Diagnoses included acute kidney failure, cognitive communication deficit, type two diabetes, adult failure to thrive, and depression.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/18/25 revealed the resident had impaired cognition. The resident required setup or clean up assistance for eating, supervision for oral hygiene, dressing, and bed mobility, and were dependent on staff for showers, toileting hygiene, and personal hygiene.Review of the nurse progress notes dated from 06/05/25 to 07/02/25 revealed on 06/05/25 the resident was ordered Silvadene cream (a cream used to treat burns) one percent twice a day times 10 days for burns to face with no other documentation regarding how they received the burns.2. Review of Resident #10's medical record revealed an admission date of 04/16/25. Diagnoses included dementia, benign prostatic hyperplasia, and acute gastritis without bleeding.Review of Resident #10's admission MDS 3.0 assessment dated [DATE] revealed the resident had slight impairment in cognition, they were independent for eating, oral hygiene, and bed mobility, they required supervision for showers, dressing and personal hygiene and set up assistance with toileting hygiene.Review of Resident #10's care plan dated 05/14/25 revealed an alteration in cognitive function related to dementia.Review of Resident #10's progress notes dated 06/05/25 at 12:09 P.M. authored by Licensed Practical Nurse (LPN) #840 revealed the resident became agitated when Resident #9 cut in line for coffee. Resident #10 then took the cup of coffee he had in his hands and threw it in Resident #9's face.Review of the facility Self-Reported Incidents (SRI) revealed there was no SRI submitted by the facility on 06/05/25 regarding an incident of resident-to-resident abuse involving Resident #9 and Resident #10.An interview on 07/01/25 at 12:42 P.M. with the Administrator and the DON revealed Resident #10 threw coffee at Resident #9 which hit him in the face and caused burns which were treated with Silvadene one percent cream twice a day for 10 days. They both confirmed they did not report this incident of resident-to-resident abuse to the state agency and they did not do a thorough investigation as to why this incident occurred.An interview on 07/01/25 at 2:52 P.M. with both of Resident #9 ' s responsible parties revealed they were not notified of Resident #10 throwing coffee in Resident #9 ' s face and that he was treated for burns.Interview on 07/01/25 at 3:53 P.M. with Certified Nursing Assistant (CNA) #850 revealed Resident #9 had coffee thrown in his face by Resident #10 and sustained burns to his face and was treated. CNA #850 described the burns as red marks without blisters.Interview on 07/02/25 at 5:55 P.M. with LPN #840 revealed Resident #9 had burns to his face related to Resident #10 throwing coffee at him. The burns did not blister and were not open. The areas were red. LPN #840 notified the physician who implemented an order for Silvadene cream to be applied twice a day for 10 days to affected areas. LPN #840 stated she reported the incident to the DON when it happened.3. Review of Resident #16's medical record revealed an admission date of 10/15/24. Diagnoses included transient cerebral ischemic attack, vascular dementia, adult failure to thrive, type two diabetes, and major depressive disorder.Review of Resident #16's quarterly MDS 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition they were independent with eating, oral hygiene, dressing, personal hygiene, and bed mobility, and they required set up help only with toileting.Review of Resident #16's care plan dated 02/24/25 revealed no concerns regarding resident behavior.4. Review of Resident #51's medical record revealed an admission date of 05/01/25 and a discharge date of 06/24/25. Diagnoses included elevated sodium levels, muscle weakness, unsteadiness on feet, need for assistance with personal care, hypertension, atrial fibrillation, and dementia.Review of Resident #51's discharge MDS 3.0 assessment revealed the resident had intact cognition. They required setup assistance with eating, oral hygiene, were independent with bed mobility and required partial to supervision assistance with toileting, showers, dressing, and personal hygiene.Review of Resident #51's care plan revealed no concerns related to aggressive behaviors.Review of Resident #51's progress notes dated 06/13/25 at 1:30 P.M. revealed the resident was observed by staff to be standing above his roommate Resident #16 verbally abusing and swearing at him. When asked what happened Resident #51 stated his roommate would not stop talking. Nursing staff placed the resident in a different room. Additional review of Resident #51's progress notes revealed on 06/17/25 at 3:30 A.M. a guest at the facility (Resident #50's family) reported to them Resident #51 was seen hitting Resident #16. The staff assessed Resident #16, and asked Resident #51 about the allegation and Resident #51 denied punching or having an issue with Resident #16.Review of facility SRIs revealed there was no SRI submitted on 06/05/25 regarding Resident #16 and Resident #51.An interview on 07/01/25 at 10:26 A.M. with the Administrator and the DON revealed they were notified by Resident #50's family member Resident #16 and Resident #51 were fighting in their room. The Administrator and the DON stated they interviewed Resident #16 and Resident #51 who stated this did not happen. They both confirmed they did not report this allegation of Resident-to-Resident abuse to the state agency and did not conduct a thorough investigation. They stated they took Resident #51 and Resident #16's word this incident did not occur. They both confirmed Resident #16 had cognitive impairment and they should have investigated further and reported the incident to the state agency.Review of facility undated policy titled Abuse, Neglect, and Misappropriation, revealed abuse can be defined as the willfull infliction of injury resulting in physical harm, pain or mental anguish. The facility would report allegations of abuse to the state agency and conduct a thorough investigation. This deficiency represents non-compliance identified during the investigation of Complaint Number OH00161011.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests on the secured unit A. This affected 19 Residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, and #19) out of 47 residents observed for physical environment. The facility census was 47. Findings include:Observations made on 07/01/25 at 9:30 A.M. and 07/02/25 at approximately 11:45 A.M. of rooms occupied by Residents' #12, #13, #16, #17 and #18 revealed there were bed bugs present in each room on the secured A unit.An interview on 07/01/25 at 3:33 P.M. with Licensed Practical Nurse (LPN) #811 revealed there were bed bugs found on the secured unit A approximately one week ago and the facility did not treat them until today. The staff caught a few and put them into a container and gave them to the maintenance director and the Director of Nursing (DON).An interview on 07/01/25 at 3:38 P.M. with LPN #830 revealed they caught three bed bugs the morning of 07/01/25 in the room of Resident #12 and #13 and bagged up all the resident clothing per policy in yellow bags and notified laundry. They then sprayed down the residents' bed and showered the resident.An interview on 07/01/25 at 3:53 P.M. with Certified Nursing Assistant (CNA) #850 revealed there were bed bugs on the secured A unit in the rooms of Resident #12, #13, #16, #17 and #18. CNA #850 stated the bed bugs were found on residents in these rooms and one was found on a staff member. A interview on 07/02/25 at 10:00 A.M. with Maintenance Director (MD) #815 revealed Orkin pest control found and treated for bed bugs in rooms of Resident #12, #13, #16, #17 and #18. MD #815 stated there were additional bed bugs found in the dining room/lounge area on the secured A unit and MD #815 had to throw away four chairs, and the mattress and chair in the room of Resident #12 and #13. MD #815 stated Orkin did a chemical treatment only today and would be back on 07/16/25 for a second treatment of affected rooms.Review of invoices dated 07/02/25 at 12:11 P.M. from Orkin exterminating revealed they inspected the rooms of Resident #12, #13, #16, #17 and #18 and the dining/lounge area on the secured A unit and found bed bugs present. They completed a chemical treatment only to all affected areas and would be returning on 07/16/25 to complete a second treatment.An interview on 07/02/25 at 2:15 P.M. with the Pest Exterminator (PE) #900 via phone revealed they confirmed no heat treatment was completed at the facility for bed bugs, just a chemical treatment and a heat treatment was the treatment needed to stop the bed bug activity in the facility. PE #900 stated they would be returning on 07/16/25 to complete a second treatment.This deficiency represent non-compliance identified during investigation of Complaint Number OH00167011 and OH00166114.

Based on observation, record review,interview, and facility policy review, the facility failed to ensure Resident #8 received timely incontinence care and failed to ensure Residents #8, #22, #46 and #47 received staff assistance for showering. This affected four residents (#8, #22, #46, and #47) of five residents reviewed for assistance with Activities of Daily Living (ADL) needs. The facility census was 43. Findings include: 1. Review of Resident #8's medical record revealed an admitted [DATE]. Diagnoses included epilepsy, muscle weakness, abnormal posture, hemiplegia, hemiparesis right dominant side, aphasia, gastrostomy status, and pseudobulbar affect. Review of Resident #8's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition. Resident #8 was dependent on staff for all Activities of Daily Living (ADLs) including eating, oral hygiene, toileting hygiene, showers, dressing, personal hygiene, incontinence care and bed mobility. Review of Resident #8's care plan dated [DATE] revealed the resident was incontinent of bowel and bladder. Goals and interventions included the resident would remain clean and odor free. Staff to administer treatments per physician orders, assist with incontinence care every two hours and as needed, apply house barrier cream as needed, monitor for signs and symptoms of urinary tract infections, monitor for skin impairments, and provide peri care as needed. Review of Resident #8's shower schedule revealed they were to receive showers every Monday, Wednesday and Friday. Review of Resident #8's shower sheets from [DATE] to [DATE] revealed the resident only received six out of the 30 scheduled showers. Observation on [DATE] at 2:33 P.M. of incontinence care for Resident #8 by Certified Nursing Assistant (CNA) #803 and CNA #804 revealed the resident was in Enhanced Barrier Precautions and required staff who were performing hands-on care to wear a gown and gloves, signage was outside of the door on the wall, isolation bins were inside the resident ' s room with proper Personal Protective Equipment (PPE) in them. CNA #803 and CNA #804 did not put on proper PPE to perform incontinence care. Resident #8 was incontinent through brief onto incontinence pad under him and had a strong odor of urine. Interview on [DATE] at 2:49 P.M. with CNA #803 and CNA #804 revealed they confirmed Resident #8 had not received incontinence care since 11:00 A.M. and was dependent on staff and should be completed every two hours and as needed. CNA #803 and CNA #804 confirmed Resident #8 had not received incontinence care in three and a half hours. CNA #803 confirmed Resident #8 had soaked through his brief onto the incontinence pad and had a strong odor of urine. CNA #803 and CNA #804 confirmed Resident #8 was in Enhance Barrier Precautions (EBP) with proper signage outside of room on the wall next to the door and Personal Protective Equipment (PPE) in bins in the resident room. CNA #803 and CNA #804 confirmed they should have been wearing gowns and gloves for incontinence care. CNA #804 confirmed that after she wiped Resident #8 she place the dirty wipes on the fitted sheet instead of putting them in the trash. CNA #803 and CNA #804 confirmed they did not change the fitted sheet on Resident #8 ' s bed after placing dirty wipes on them. 2. Review of Resident #22's medical record revealed an admitted [DATE]. Diagnosis included acute kidney failure, difficulty in walking, need for assistance with personal care, cognitive communication deficit, type II diabetes, heart failure, hypertension, and artificial left hip. Review of Resident #22's MDS assessment dated [DATE] revealed the resident had impaired cognition but was able to make his needs known. They required setup or clean up assistance with eating, supervision or touching assistance with oral hygiene, upper body dressing, and bed mobility and finally they were dependent on staff for transfers, lower body dressing, toileting hygiene, personal hygiene and showers. Review of Resident #22's care plan dated [DATE] revealed the resident required assistance with ADLs related to weakness, difficulty in walking and cognitive deficit. Goals and interventions included the resident would continue to participate in ADLs as able and have no decline in ADLs through the review date. Staff were to monitor for decline and report to clinical staff as needed, staff to adjust care as needed to meet the resident's needs, staff to encourage residents to participate in ADLs during care, staff were to assist with daily hygiene and were to assist with showering the resident per facility policy. Review of Resident #22's shower schedule revealed they were to receive a shower every Tuesday, Thursday and Saturday. This deficiency represents non-compliance under Complaint Number OH00164239. Review of Resident #22's shower sheets form [DATE] to [DATE] revealed the resident only received one shower in February, eight showers in March, seven showers in April and one shower in May. 3. Review of Resident #46's medical record revealed and admitted [DATE] and a discharge date of [DATE]. Diagnosis included cerebral infarction, acute respiratory failure with hypoxia, muscle wasting and atrophy, difficulty in walking, hypertension, anxiety and mood disorder, congenital tuberculosis, hemolytic anemia, urinary retention, opioid abuse, rhabdomyolysis, and history of falls. Review of Resident #46's discharge MDS assessment dated [DATE] revealed the resident had intact cognition. They required setup or clean up assistance for eating, and oral hygiene. They required supervision or touching assistance for toileting hygiene, upper body dressing, personal hygiene, and bed mobility. Finally, they required partial to moderate assistance for showers, transfers and lower body dressing. Review of Resident #46's shower schedule revealed they were supposed to receive a shower every Tuesday, Thursday, and Saturday. Review of Resident #46's shower sheets from [DATE] to [DATE] revealed the resident only received two out of 17 scheduled showers on [DATE] and on ,d+[DATE].25. 4. Review of Resident #47's medical record revealed an admitted [DATE] and a discharge date of [DATE]. Resident #47 expired in the facility. Diagnosis included heart failure, cognitive communication deficit, muscle weakness and wasting, need for assistance with personal care, contracture of left and right knee, anxiety, major depressive disorder, history of falling, restless leg syndrome, hypertension and history of pulmonary embolism. Review of Resident #47's quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. They required supervision or touching assistance for eating, partial to moderate assistance for oral hygiene and personal hygiene, substantial to maximal assistance for upper body dressing and bed mobility and finally, the resident was dependent on staff for toileting hygiene, lower body dressing and showers. Review of Resident #47's shower scheduled revealed the resident was to receive showers every Tuesday, Thursday and Saturday. Review of Resident #47's shower sheets dated from [DATE] to [DATE] revealed the resident only received four showers out of 17 scheduled showers. Interview on [DATE] at 10:15 A.M. with Certified Nursing Assistant (CNA) #805 revealed they confirmed they completed their assigned showers gut there were times when they did not get done. Interview on [DATE] at 10:20 A.M. with Licensed Practical Nurse (LPN) #801 the CNAs complete their showers but there are times when the residents complain they are not getting them. Interview on [DATE] at 10:25 A.M. with Registered Nurse (RN) #802 revealed CNAs do not always get to all the showers scheduled on their shift. RN #802 stated it depends on how their day is going but they try hard. Interview on [DATE] at 2:49 P.M. with CNA #803 and CNA #804 revealed they confirmed Resident #8 had not received incontinence care since 11:00 A.M. and was dependent on staff and should be completed every two hours and as needed. CNA #803 and CNA #804 confirmed Resident #8 had not received incontinence care in three and a half hours. CNA #803 confirmed Resident #8 had soaked through his brief onto the incontinence pad and had a strong odor of urine. Additionally, CNA #803 and CNA #804 stated they only complete their assigned showers if they had the time too. Interview on [DATE] at 4:10 P.M. with the Administrator, the DON, and the Interim DON revealed they reviewed and confirmed for Resident #46 she admitted on [DATE] and did not receive their first shower until [DATE] and was supposed to receive at least three a week on Tuesday, Thursday and Saturdays. The Administrator, the DON, and the Interim DON all confirmed Resident #46 only received two showers out of 17 scheduled showers on [DATE] and [DATE]. The Administrator, the DON, and the Interim DON confirmed Resident #47 was to receive three showers a week on Tuesday, Thursday and Saturday. They confirmed Resident #47 only received four showers out of the 17 scheduled showers with no additional documentation provided. The Administrator, DON and Interim DON verified for Residents #8 they only received six out of thirty scheduled showers, and for Resident #22 they only received one shower in February, eight showers in March, and only seven showers in April. Interview on [DATE] at 12:18 P.M. with LPN #809 revealed showers are not always completed as scheduled. LPN #809 stated some residents and families have complained to then regarding not getting showers were scheduled. Interview on [DATE] at 1:45 P.M. with Resident #22 revealed they do not always receive showers as scheduled and had to remind staff they wanted a shower. Interview on [DATE] at 2:15 P.M. with LPN #808 revealed Resident #46 complained to them she was not getting her showers and wanted one. Review of the undated facility policy titled, Bathing, Showering, revealed the purpose was to establish frequency of bathing by resident choice. The procedure included Residents were to be interviewed during the admission process regarding the frequency they want to bathe/shower. If the resident is unable to relay this information, attempts are to be made to obtain this from the responsible party or person that would know the resident. The frequency of the bath/shower is reviewed at least quarterly during the care planning conference with the resident. Changes were to be implemented if indicated by the resident's choice. This policy was reviewed will all staff during the employee orientation and periodically thereafter as well the policy is reviewed with the resident during the admission process and quarterly thereafter.

Based on interview, observation, record review and facility policy review, the facility failed to ensure effective infection control techniques were practiced during incontinence care. This affected one resident (Resident #8) out of five residents reviewed for infection control. The facility census was 43. Findings include: Review of Resident #8's medical record revealed an admitted [DATE]. Diagnoses included epilepsy, muscle weakness, abnormal posture, hemiplegia, hemiparesis right dominant side, aphasia, gastrostomy status, and pseudobulbar affect. Review of Resident #8's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition. Resident #8 was dependent on staff for all Activities of Daily Living (ADLs) including eating, oral hygiene, toileting hygiene, showers, dressing, personal hygiene, incontinence care and bed mobility. Review of Resident #8's care plan dated 03/04/25 revealed the resident was incontinent of bowel and bladder. Goals and interventions included the resident would remain clean and odor free. Staff to administer treatments per physician orders, assist with incontinence care every two hours and as needed, apply house barrier cream as needed, monitor for signs and symptoms of urinary tract infections, monitor for skin impairments, and provide peri care as needed. Review of Resident #8's physician orders dated May 2025 revealed Resident #8 was ordered to be in Enhanced Barrier Precautions every shift due to wounds and presence of peg tube for enteral feedings. Observation on 05/01/25 at 2:33 P.M. of incontinence care for Resident #8 by CNA #803 and CNA #804 revealed the resident was in EBP and required staff who were performing hands-on care to wear a gown and gloves, signage was outside of the door on the wall, isolation bins were inside the resident's room with proper PPE in them. CNA #803 and CNA #804 did not put on proper PPE to perform incontinence care. Interview on 05/01/25 at 2:49 P.M. with Certified Nursing Assistant (CNA) #803 and CNA #804 revealed CNA #803 and CNA #804 confirmed Resident #8 was in Enhance Barrier Precautions (EBP) with proper signage outside of room on the wall next to the door and Personal Protective Equipment (PPE) in bins in the resident's room. CNA #803 and CNA #804 confirmed they should have been wearing gowns and gloves for incontinence care and they were not. Review of the facility policy titled Enhanced Barrier Precautions, dated July 2022, revealed the purpose was to reduce the transmission of multidrug-resistant organisms (MDROs) by when high contact resident care activities for residents with known colonized or infected with MDRO as well as those at increased risk to acquire and MDRO. Under the procedure section it stated Residents with the following triggers will receive EBP and indicates it should be followed for any resident in the facility with 1. An open wound requiring a dressing change, 2. Has an indwelling catheter for the duration of their stay and 3. Is colonized with MDROs and contact precautions do not apply. EBP requires the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. This deficiency represents non compliance under Complaint Number OH00164239.

Based on observation, interview and review of facility documents and policy, the facility failed to provide therapeutic activities as scheduled and on weekends and evenings to meet the needs and preferences of the resident population. This had the potential to affect all 50 residents in the facility. The facility census was 50. Findings include: Review of the facility activity calendars dated October and September 2024 for the Secured Unit A revealed no activities were scheduled after 3:00 P.M. for the month of October. Review of the September 2024 Activity Calendar for Secure Unit A revealed no activities were scheduled past 4:00 P.M. Review of the October 2024 Unit B/C activity calendar revealed no activities were scheduled after 3:00 P.M. each day except for each Wednesday an activity was scheduled for 5:00 P.M. Review of the activity department staffing schedules for September 2024 and October 2024 which listed former Activities Director (AD) #801, former Activities Aid (AA) #800 and AA #536 as the staff for the department revealed no activity aid was scheduled in the building on Saturday 09/21/24, Thursday 09/26/24, Friday 09/27/24, Saturday 09/28/24, Sunday 09/29/24, Monday 09/30/24, Tuesday 10/01/24, Wednesday 10/02/24, Friday 10/04/24, Saturday 10/05/24, Sunday 10/06/24, Monday 10/07/24, Wednesday 10/08/24, Friday 10/11/24, Saturday 10/12/24, Sunday 10/13/24. Review of the facility job description for the Activity Director revealed they must be a qualified therapeutic recreation specialist or an activities professional who was licensed by this state and was eligible for certification as recreation specialist or as an activity professional. Review of the personnel file for the former AD #801 revealed a date of hire of 05/16/23 as the Activities Director and last day worked was 09/16/24. No certification from the Activity Directors Network was available in the file. Review of the personnel file for the former AA #800 revealed a hire date of 07/25/24 and last day worked was 09/25/24. Review of Behavioral Health Service Agreement dated September 19, 2024 revealed [NAME] Counseling and Recovery was to provide behavioral health and support services. [NAME] Health Services was to provide services Monday to Friday from 9:00 A.M. to 5:00 P.M. each day. There was no evidence in the agreement that BHS was responsible to ensure activities were provided to the residents in the facility. Interview on 10/15/24 at 9:36 A.M. with Resident #18 revealed she had not participated in activities because she felt there was no activities department. Resident #18 stated no activities came to visit her. Interview on 10/16/24 at 2:31 P.M. with the Director of Nursing ( DON) revealed there was no Activity Director for the past month. The facility was utilizing the [NAME] Counseling social worker and two counselors. The facility currently had one activity aid employee. The DON verified no activity department staff were scheduled on Saturday 09/21/24, Thursday 09/26/24, Friday 09/27/24, Saturday 09/28/24, Sunday 09/29/24, Monday 09/30/24, Tuesday 10/01/24, Wednesday 10/02/24, Friday 10/04/24, Saturday 10/05/24, Sunday 10/06/24, Monday 10/07/24, Wednesday 10/08/24, Friday 10/11/24, Saturday 10/12/24, Sunday 10/13/24. Interview on 10/16/24 at 3:19 P.M. with the Assistant Director of Nursing #501 verified no activities were planned after 3:00 P.M. for the Secure Unit A for the month of October 2024 and the facility did not assign a State tested Nurse Aid over the weekends when the facility Activities Aid was not in the building. Interview on 10/16/24 at 3:57 P.M. with [NAME] counseling Case Manager #566 revealed [NAME] Counseling was in the facility to do one on one counseling with Medicaid and Medicare residents only. No counselors were certified in Activities. No Case Manager from [NAME] Counseling came in on the weekend or worked past 4:00 P.M. Case Manager #566 also stated because the Activities Director and an Activities Aid quit this past month [NAME] Counseling had helped incorporate activities into counseling sessions, but [NAME] Counseling was not the activities department. Case Manager # 566 stated the [NAME] Counseling social worker made the October 2024 Activities Calendar. The facility had one activity aid who worked every other weekend and nursing staff was to provide activities on the weekends the activities aid was not on site. Interview on 10/16/24 at 4:00 P.M. with Resident #33 revealed there was not always activities on the weekends, so the residents have to entertain themselves. Resident #33 also stated it gets boring after 5:00 P.M. because there were no activities. Observation on 10/17/24 at 9:10 A,M. of the Secure Unit A activities room revealed Current Events was scheduled on the activities calendar at 9:00 A.M. on 10/17/24. No staff were in the Secure Unit A activities room and one resident was present but sleeping in the activities room. The Administrator verified at the time of the observation that no staff was engaged with residents at that time. Observation on 10/17/24 at 9:24 A.M. of the B/C Activities room revealed no staff was engaged with residents in the activities room. One resident was sitting in front of the television watching a sitcom. Review of the Activities Calendar for 10/17/24 at 9:00 A.M. an activity was planned for Current Events and coffee. No coffee was available in the activities room. The Administrator verified at the time of the observation that no coffee was in the activities room and no staff was engaged with residents for current events. Observation on 10/17/24 at 10:10 A.M. of the Secure Unit A activities room revealed staff were not engaged with residents during the planned game activity at 10:00 A.M. listed on the October 2024 activities calendar. Residents were scheduled to play a card game. STNA #507 verified there was one aid on the secure unit therefore the aid could not engage in activities at that time. Interview on 10/17/24 at 10:10 A.M. with State tested Nurse Aid ( STNA) #507 revealed STNAs can help with activities on the secure unit if two STNAs were scheduled. If one STNA was scheduled it was difficult to provide the planned activities so activities were not always provided to those residents. STNA #507 revealed the facility did not provide drums for the planned activity titled Drumming to Music for the Secure Unit A activity on 10/21/24 at 10:00 A.M. so the activity was unable to be implemented for the residents. STNA #507 also stated the secure unit did not have an activity aid since the aids stay on the B/C unit's activities room. Observation on 10/17/24 at 10:13 A.M. revealed the cativities room B/C had three residents watching television. All residents were poor historians. Review of the B/C activities calendar revealed relaxation exercises were planned on 10/17/24 at 10:00 A.M. There were no staff conducting relaxation exercises with any of the residents. STNA #507 verified the findings. Interview on 10/21/24 at 10:00 A.M. with [NAME] Counseling Licensed Social Worker (CLSW) #565 revealed [NAME] Counseling Services was not the activities department but were willing to provide activities to the residents. CLSW #565 verified they did not hold certification as a qualified Activity Director. Observation on 10/21/24 at 10:22 A.M. of the activity room for the Secure Unit A revealed four residents sitting in the activity room with the television on. One STNA was in the room playing music on her iPhone. Review of the activity calendar dated October 21, 2024 at 10:00 A.M. indicated an activity was scheduled titled Drumming to Music. Review of the facility policy titled Activity Programming, undated, revealed the Activities Director shall plan and organize a program of activities for residents on a group level and for individuals to meet the resident's interests and preferences. If a particular service or activity was canceled or changed it would be reported to the activity director to assure that proper notification or other personnel and department can be made. The resident should be notified of the change in the schedule and alternatives should be offered. Review of the facility policy titled Activity Programming Secure Unit , revised May 2022, revealed a therapeutic plan of care would be developed to meet the resident's needs and interests and provide social interaction and at the same time protect the resident from environmental over-stimulation. Participation in therapeutic activities would improve self-esteem, self confidence and quality of life.

Based on record review, interview and review of facility policy, the facility did not ensure a qualified activity director was overseeing the activity department to ensure therapeutic activities were being provided to the residents. This affected all 50 residents living in the facility. The facility census was 50. Findings include: Review of the facility job description for the Activity Director (AD) revealed they must be a qualified therapeutic recreation specialist or an activities professional who was licensed by the state and was eligible for certification as recreation specialist or as an activity professional. Review of the personnel file for the former AD #801 revealed a date of hire of 05/16/23 as the Activities Director and last day worked was 09/16/24. No certification from the Activity Directors Network was available in the file. Interview on 10/16/24 at 2:31 P.M. with the Director of Nursing (DON) revealed there was no Activity Director for the past month. The facility was utilizing the [NAME] Counseling social worker and two counselors to provide activities in the facility. The DON confirmed the facility currently had only one activity aid employed in the activity department. Review of the Behavioral Health Service (BHS) Agreement dated September 19, 2024, revealed [NAME] Counseling and Recovery was to provide behavioral health and support services Monday to Friday from 9:00 A.M. to 5:00 P.M. each day. There was no evidence in the agreement that BHS was responsible to ensure activities were provided to the residents in the facility. Interview on 10/16/24 at 3:57 P.M. with [NAME] counseling Case Manager #566 revealed [NAME] Counseling was in the facility to do one on one counseling with Medicaid and Medicare residents only. No counselors were certified in Activities. No case manager from [NAME] Counseling came in on the weekend or worked past 4:00 P.M. Case Manager #566 also stated because the Activities Director and an Activities Aid quit this past month [NAME] Counseling had helped incorporate activities into counseling sessions, but [NAME] Counseling was not the activities department. Case Manager # 566 stated the [NAME] Counseling social worker made the October 2024 Activities Calendar. The facility had one activity aid who worked every other weekend and nursing staff was to provide activities the weekend the activities aid was not on site. Interview on 10/21/24 at 10:00 A.M. with [NAME] Counseling Licensed Social Worker (CLSW) #565 revealed [NAME] Counseling Services was not the activities department but they were willing to do activities with the residents. CLSW #565 verified they did not hold certification as a qualified Activity Director. Review of facility policy titled Activity Programming, undated, revealed The Activities Director shall plan and organize a program of activities for residents on a group level and for individuals to meet the resident's interests and preferences.

Based on medical record review, review of a facility Self-Reported Incident (SRI) and investigation, review of the facility Abuse policy and interviews with staff, resident and family, the facility failed to ensure Resident #5, who was assessed to have severe cognitive impairment and unable to provide consent, was free from resident-to-resident sexual abuse. This resulted in Immediate Jeopardy and the potential for psychosocial and physical harm on 03/12/24 at 3:17 P.M. for Resident #5, when Resident #42, who was cognitively intact, and had a known history of sexual behaviors towards other residents and staff prior to 03/12/24 and without planned interventions, was observed on her knees, naked from the waist down, performing oral sex on Resident #5. During an interview with Resident #5 he stated he would not be sexually interested in anyone but his wife. This affected one resident (Resident #5) of seven residents reviewed for abuse. The facility census was 41. On 03/20/24 at 4:30 P.M. the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 03/12/24 when Resident #5 was sexually abused by Resident #42. Resident #42 was observed performing oral sex on Resident #5, a resident who was assessed to have severe cognitive impairment and lacked the cognitive ability to consent to the sexual activity. The facility failed to address Resident #42's history of sexual behaviors on admission to the facility, failed to address Resident #42's sexual behaviors when observed toward other residents and staff and failed to provide appropriate interventions to prevent sexual interactions/sexual abuse towards residents on the secured unit. At the time the situation occurred, the facility had made no changes to their admission process/review of residents' information prior to accepting residents for admission and failed to make any staffing changes to provide for additional supervision for residents on the secured care unit to prevent situations of sexual abuse. The Immediate Jeopardy was removed on 03/20/24 when the facility implemented the following corrective actions: On 03/12/24 at 1:50 P.M., upon discovery of the incident in Resident #42's room, State tested Nursing Assistant (STNA) #110 and Medication Aide #111 immediately separated Resident #5 and #42. Resident #5 was returned to his room. Resident #42 was immediately placed on 1:1 supervision (the resident remained on 1:1 supervision until discharge on [DATE]). At 2:43 P.M. and 2:44 P.M., skin assessments were completed on Resident #5 and #42 with no new findings identified. The assessments were completed by Licensed Practical Nurse (LPN) #116 and Registered Nurse (RN) #137. At 3:04 P.M., Resident #5's physician (Physician #155) and Resident #5's daughter were notified by the Director of Nursing with no new orders. On 03/12/24 routine staff who work A wing, STNA #100, Medication Aide #107, Medication Aide #111, Medication Aide #112, LPN #115, LPN #116, Medication Aide #141, STNA #135, LPN #147, RN #137, and Medication Aide #145 were interviewed by the DON and Administrator regarding sexual interactions, both physical and verbal, between any residents. On 03/14/24 from 10:00 A.M. to 11:00 A.M. skin checks were completed for residents not able to be interviewed (Residents #3, #4, #6, #10, #44). The skin checks were completed by LPN #143 and LPN #147 with no findings indicating any suspicion or concern for abuse. On 03/14/24 residents (Residents #1, #2, #8, #9, #11, #12, #13, #14, #15 and #16) who were able to be interviewed (due to cognitive levels) were interviewed by Activity Director #127 regarding any sexual interactions both physical and verbal with or by another resident with no interactions reported. On 03/15/24 Resident #42 was discharged from the facility. On 03/18/24 between 7:00 P.M. and 8:00 P.M. all 56 staff members were provided 1:1 education regarding the abuse policy, reporting behaviors and allegations, if working and by phone if not working at the time, by the Administrator and DON On 03/19/24 Resident #5 was seen by Psychiatric Nurse Practitioner (NP) #156. With no new orders. Resident #5 remains in the facility with no negative social changes in mood or behavior identified by staff at this time. On 03/19/24 at approximately 5:30 P.M., the Director of Nursing and Administrator were educated by Regional Quality Assurance (QA) Nurse #157 on reviewing resident referrals for behaviors or history of behaviors and initiating immediate interventions as needed. On 3/20/24 at 5:00 P.M. the facility Admission Form was updated to reflect the inquiry of behaviors and behavioral interventions of referrals by Regional QA Nurse #157. The Admissions Director would complete the Admissions Form and the Administrator and/or Director of Nursing would review the form beginning 03/20/24. On 03/20/2024 at 5:15 P.M. Regional QA Nurse #157 educated Admissions Director #109, the Administrator, and Director of Nursing on utilizing the updated Admission Form and to inquire about behaviors and behavior interventions during review of resident referrals. On 03/20/24 from 5:00 P.M. to 5:30 P.M. the facility conducted additional skin checks for residents unable to be interviewed (Residents #3, #4, #5, #6, and #10). These assessments were completed by LPN #143 with no new findings indicating any suspicion or concern for abuse were identified. On 03/20/24 from 5:30 P.M. to 6:00 P.M. residents who could be interviewed (Residents #1, #2, #7, #8, #9, #11, #12, #13, #14, #15, and #16) were re-interviewed by Activity Director #127 regarding any sexual interactions, both physical and verbal with or by another resident, with one sexual verbal interaction reported by Resident #1. Resident #1 reported someone had commented on the size of her chest but was unable to recall who said it, when this was said or any details regarding the incident besides it happening before 03/20/24 and Resident #1 had not reported it to the staff. Psychiatric NP #156 visited Resident #1 on 03/19/24 and reported that there were no concerns shared by Resident #1 regarding sexual comments or behaviors at that time. On 03/20/24 between 6:00 P.M. to 7:00 P.M. all 56 staff members were re-interviewed by the DON, Administrator, Dietary Manager #105, LPN #106, Admissions Director #109, Maintenance Director #138, LPN #143, Business Office Manager #144, and Activity Director #127 regarding resident behaviors on Unit A and were educated one to one on the types of behaviors that could be exhibited and potentially provoke a response from other residents and immediate reporting. No staff reported, at the time, any sexual behaviors they were aware of. On 03/20/24 at 5:30 P.M. staffing was reviewed by the Regional Director of Operations and was adjusted to add 48 direct care staffing hours to meet the residents' needs. Staffing would include three staff members scheduled to work on the secure unit per shift. The facility model currently was a med tech with two additional aides or three STNAs plus a nurse who oversees the unit. Those staff members would be assigned to be on the unit. As census grows or acuity increases based upon individual resident needs, staffing would be adjusted as needed. On 03/20/24 a root cause analysis was completed and determined the facility failed to follow policy and procedure as previously educated on processes regarding abuse, sexual behaviors, admission and referral process, and staffing. On 03/20/24 at approximately 5:45 P.M. the Quality Assurance Performance Improvement team (Administrator, DON, LPN #143, LPN #106, Admissions Director #109, Activity Director #127, Dietary Manager #105, Maintenance Director #138, and Physician #155 (the medical director), reviewed and interpreted all investigation and audit findings as well as a root cause analysis. All ongoing audits and findings would be discussed monthly, or as needed for a minimum of three months or until the pattern of compliance was maintained. On 3/20/24 between 7:00 P.M. to 8:30 P.M., referral paperwork for existing residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #16) were reviewed by LPN #106, the Administrator, the DON, LPN #143, Regional QA Nurse #157, and Admissions Director #109 to ensure the facility was aware of all behaviors and resident plan of care were updated as needed. Newly identified behaviors, if any, were care planned. None of the reviews revealed unidentified sexual behaviors. Beginning on 03/21/24 the facility implemented a plan for staffing on Unit A to be reviewed each day by the Administrator/Designee to ensure adequate supervision was provided. This would be reviewed for two weeks and then twice per week for two weeks. Three random staff interviews would also be completed to consider unit staffing needs. Beginning on 03/21/24, Administrator/Designee would complete three random resident interviews and three random staff interviews weekly to ensure any behaviors were identified and interventions initiated for four weeks. The interviews would be directed toward residents and staff on the secure unit and would include staff members over different shifts. Beginning 03/21/24, the Director of Nursing would review three random resident nurses' notes (residents on the secured unit) daily to ensure any documented behaviors have appropriate interventions initiated as needed for four weeks. Although the Immediate Jeopardy was removed on 03/20/24, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #5's medical record revealed an admitted [DATE] with diagnoses including depression, homicidal and suicidal ideations, and osteoarthritis. Resident #5 resided on the facility secured care unit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed although Resident #5 was able to understand others and make himself understood, he had a Brief Interview for Mental Status (BIMS) score of six of 15, indicating severe cognitive impairment. The MDS assessment revealed the resident had no behavioral symptoms. Review of a nursing note dated 03/12/24 at 3:04 P.M. and authored by the DON indicated Resident #5's daughter was notified of an inappropriate sexual incident involving Resident #5 and that no injury was noted. The note indicated Resident #5 did not voice any upset over the incident. Review of a care plan initiated 03/15/24 revealed Resident #5 had a behavior problem related to thinking other residents were family members and had engaged in sexual activity with other residents. Interventions included intervening and redirecting Resident #5 if needed, monitoring and assessing for behaviors and referring Resident #5 for psychiatry services as needed. Review of a facility initial submission for Self-Reported Incident (SRI), tracking number 245134 revealed on 03/12/24 staff (not identified) made an allegation of sexual abuse. Residents #5 and #42 were in a room together with alleged inappropriate contact. An investigation was initiated. Review of the facility's investigation revealed a statement by the Administrator dated 03/14/24 which indicated the Administrator and DON reviewed camera footage of A wing during the time of the alleged incident between Resident #5 and #42. The statement included it was apparent that Resident #42 stayed inside her room only coming out of the room briefly and then re-entering her room. At 1:09 P.M., Resident #5 was witnessed self-propelling down the hallway past Resident #42's room. Resident #5 stopped, backed up and entered Resident #42's room. It was noted that someone from inside the room pushed the door shut. Forty minutes later, STNA #110 entered the room and Resident #5 was removed immediately by staff. Review of Resident #42's closed medical record revealed an admitted [DATE] with diagnoses including schizoaffective disorder, difficulty walking, bipolar disorder, post-traumatic stress disorder, personality disorder, generalized anxiety disorder, mild cognitive impairment, and psychosis. Resident #42 resided on the facility secured care unit. Review of the referral documentation (from the prior long term care facility in which Resident #42 resided) provided for Resident #42 revealed a progress note dated 07/19/23 at 5:33 P.M. indicating Resident #42 had increased sexually inappropriate behaviors during dinner, poking staff in their buttocks. One on one supervision and redirection were ineffective. Review of the admission assessment authored by LPN #143 and dated 12/20/23 revealed Resident #42 was alert and oriented to date, time and place and was mobile in her wheelchair. Review of the admission physician orders dated 12/20/23 revealed Resident #42 was appropriate to reside on the secured unit. Review of the admission MDS assessment dated [DATE] revealed Resident #42 was cognitively intact and used a wheelchair for mobility. Review of the February 2024 Treatment Administration Record (TAR) revealed on 02/08/24, 02/09/24, 02/10/24, and 02/11/24 Resident #42 exhibited physical behavior toward others. There was no documentation in the nurse's progress notes regarding what the behavior was or who it was directed toward. Review of the March 2024 TAR revealed on 03/05/24 and 03/06/24 Resident #42 exhibited verbal behavior symptoms toward others. There was no further documentation regarding the content of what was said or who it was said to. Review of a nursing note dated 03/12/24 at 3:15 P.M. and authored by the DON revealed the DON spoke to Resident #42's guardian via phone to notify (the guardian) of an incident of inappropriate sexual behavior. The nursing note indicated the guardian was informed Resident #42 did not verbalize any upset over the incident and was informed increased supervision was in place for Resident #42 until a more suitable facility was found for her. A late entry nursing note created on 03/13/24 at 12:24 P.M. by LPN #116 indicated on 03/12/24 at 3:17 P.M. the nurse was walking onto the hallway (secure) to do treatments when the medication tech (later identified as Medication Aide #111) and Occupational Therapist (OT) (not identified) were standing outside of Resident #42's room and stated they had a problem. A State tested Nursing Assistant (STNA) (later identified as STNA #110) was propelling a male resident (later identified as Resident #5) out of Resident #42's room with his pants pulled halfway up but not exposed and Resident #42 was kneeling next to the bed attempting to put her (incontinence) brief back on. Resident #42 insisted nothing happened. STNA #110 informed LPN #116 she saw Resident #42's head in Resident #5's nude lap. Increased supervision was ongoing. A nursing note dated 03/13/24 and authored by LPN #116 revealed instead of OT being outside the door it was Physical Therapy (PT) (later identified as PT #151). A nursing note dated 03/15/24 at 2:36 P.M. and authored by LPN #147 indicated Resident #42 was discharged to another facility. On 03/18/24 at 12:42 P.M., interview with Medication Aide #141 revealed there needed to be two nursing assistants on the secure unit at all times related to resident behaviors. A follow-up interview at 12:49 P.M. with Medication Aide #141 revealed Resident #42 exhibited inappropriate sexual behaviors toward multiple male residents, grabbing at the men and making obscene gestures toward them. Resident #42 would leave her room dressed inappropriately and was able to transfer herself from the bed to chair independently. Medication Aide #141 revealed there was no one male Resident #42 focused on. Medication Aide #141 stated she was not working the day Resident #42 was observed with Resident #5. However, one day (she was unable to recall the date) she had observed Resident #42 on her knees touching another confused male resident (Resident #15) in his private area over his clothing and had seen Residents #42 and Resident #15 kissing a couple of times (she was unable to recall the dates). Medication Aide #141 stated she reported this to the Administrator (she was unable to recall the dates). Medication Aide #141 stated Resident #42 was aware of what was happening and denied ever witnessing Resident #42 with any confusion. Medication Aide #141 revealed Resident #5 and Resident #15 were both confused. Medication Aide #141 reported Resident #5 thought Resident #42 was his wife or mistress (the medication aide stated she had heard Resident #5 refer to Resident #42 as his wife before). On 03/18/24 at 1:27 P.M., interview with STNA #110 revealed after providing care to another resident on 03/12/24, she was trying to locate Resident #5 to weigh him. STNA #110 stated she inquired if Medication Aide #111 knew of Resident #5's whereabouts. When Medication Aide #111 was unable to state with certainty where Resident #5 was, the smoking area and therapy departments were searched. When Physical Therapist (PT) #151 heard STNA #110 was having difficulty finding Resident #5, she went back to the secure unit with STNA #110 to help search for the resident. A room-by-room search was conducted. STNA #110 stated she located Resident #5 in Resident #42's room, slouched down in his wheelchair, twiddling his thumbs while Resident #42 was on her knees, naked from the waist down, providing him oral sex. STNA #110 stated Resident #42 was alert and oriented. Resident #5 was confused and unable to make independent decisions and would propel around in his wheelchair looking for his wife. Resident #42 and #5 were immediately separated and one on one supervision was started with Resident #42. STNA #110 stated she worked two hours past her scheduled shift on 03/12/24 to provided supervision for Resident #42, who stated to her that she (STNA #110) had entered the room too soon as she (Resident #42) planned on climbing on top of Resident #5. On 03/18/24 at 1:49 P.M. interview with Admissions Director #109 revealed when she received the referral for Resident #42, there was no mention of inappropriate sexual behaviors. Admissions Director #109 stated she had provided a copy of the referral information to the Administrator before she started her maternity leave and a copy to the DON for review. Admissions Director #109 indicated during her interactions with Resident #42 she was alert and oriented. During an interview with Resident #5 on 03/18/24 at 2:25 P.M., Resident #5 believed he had only been at the facility two to three months (instead of almost one year). Resident #5 believed the year was 1953 and he indicated he had been married to his wife for [AGE] years and would not be interested in having a sexual relationship with anybody but his wife. Resident #5 could not recall the incident with Resident #42. On 03/18/24 at 2:42 P.M. interview with LPN #147 revealed although she had never personally witnessed inappropriate sexual behavior from Resident #42 toward other residents, she had received information during report regarding those behaviors occurring. LPN #147 stated she was not aware of any interventions being implemented prior to the incident on 03/12/24 to prevent them from occurring. LPN #147 stated Resident #42 was alert and oriented but Resident #5 was absolutely not. On 03/18/24 at 3:57 P.M., interview with the DON from Resident #42's referring facility (DON #152), reported Resident #42's behaviors used to include making sexual gestures with her body, making sexual comments and innuendos, trying to grab other residents with her hands, and sticking her tongue out and waving it back and forth. DON #152 stated their facility did not try to hide any behaviors when they referred Resident #42. On 03/18/24 at 4:12 P.M., interview with Activity Director #127 revealed he was aware Resident #42 had sexual encounters and would grab at other resident's private areas and it did not matter who it was although, she did not touch anybody. Resident #42 would talk to staff and other residents stating a certain body part looked good in those clothes or would state she bet the person could do sexual activities (would state a specific activity) good. Activity Director #127 stated he had addressed the behaviors in morning meetings which included the DON, Administrator, and assistant DON. Activity Director #127 indicated Resident #42 was slightly confused at times, but stated she was aware of what she was doing. The Activity Director stated Resident #5 was very confused. On 03/19/24 at 6:48 A.M., interview with RN #139 revealed she had been informed of Resident #42 making inappropriate sexual comments and touching others inappropriately on multiple occasions but was not aware of any specific interventions implemented prior to the incident on 03/12/24 with Resident #5. On 03/19/24 at 7:04 A.M., interview with STNA #122 revealed Resident #42 was always trying to get naked then exit her room. STNA #122 stated Resident #42 would try to go into male residents' rooms and would claim the male residents were her boyfriends. On 03/19/24 at 8:16 A.M., interview with the Administrator verified she had seen Resident #42's name as a referral prior to taking maternity leave but did not review the information. The DON, who was present, stated she did not recall reviewing the information provided when Resident #42 was referred for admission, so she was unaware of inappropriate sexual behaviors prior to admission. On 03/19/24 at 8:35 A.M., interview with the DON verified documentation on Resident #42's February 2024 and March 2024 TAR which revealed physical and verbal behavioral symptoms directed toward others had occurred but there was no documentation to determine what the behavior was or whom it was directed toward. On 03/19/24 at 3:44 P.M., interview with [NAME] President of Clinical Operations #150 revealed corporate always reviewed referrals. However, she was unable to state with certainty that the sexually inappropriate behaviors of Resident #42 were addressed or whom corporate might have spoken to at the referring facility. During the onsite investigation, attempts were made to contact the Medical Director, Physician #155 via calls and voicemail. No return call was provided. On 03/20/24 at 12:24 P.M., interview with the Administrator verified there had been no changes made in the facility's policy or procedure for reviewing potential admissions. However, because Resident #42's referral information revealed a history of inappropriate sexual behaviors, which were not investigated to determine appropriateness of admission, the facility was discussing more thorough reviews of referral information and possibly doing on-site visits prior to residents being admitted to the facility. The Administrator stated there had been no changes in staffing which would increase supervision in the secure unit. The DON was present and agreed. On 03/21/24 at 1:13 P.M., interview with Resident #5's responsible party revealed Resident #5 would have never permitted Resident #42 to provide oral sex if he was not confused. On 03/21/24 at 3:02 P.M., interview with STNA #100 revealed there needed to be more staff on the secure unit due to behaviors and increased supervision needed. On 03/21/24 at 3:36 P.M., interview with the DON revealed she reviewed referrals for admission. However, if the facility believed they could care for a potential resident she did not have to review provided documentation. The DON stated she likely reviewed the paperwork provided by the referring facility, but she did not recall seeing anything about sexual behaviors for Resident #42. On 03/25/24 at 11:39 A.M. interview with the DON revealed had the facility been aware of Resident #42's inappropriate sexual behaviors there would have been a more in-depth discussion regarding admission and placement on the secure unit. The DON stated she was uncertain if Resident #42 would have been admitted had the facility been aware. The DON stated if she had been made aware of behaviors referred to by staff such as making sexual comments to or toward other resident or grabbing at the genitalia of male residents, she would have addressed those behaviors immediately. Review of the facility's Admission Process (Secured Unit) policy (last reviewed/revised January 2024) revealed the secured unit was designed to provide specialized care for the cognitively impaired that included but were not limited to special activities, increased staffing, environmental designs and other programs as needed. Based on potential admission referral information provided to the facility, the Admissions Director, DON, and Administrator would determine the need for the secured unit until an assessment was completed. The secondary goal was to decrease, when appropriate, agenda behavior through meaningful interaction with facility staff that would provide the resident with a consistent and comforting response to their behavior. Nursing staff would consult with the physician and responsible party for need for Secured Unit placement. An order would be obtained by the physician for placement into the Secured Unit. Review of the facility's Abuse, Neglect, and Exploitation of Residents and Misappropriation of Property policy (last reviewed/revised in September 2020) revealed residents would not be subjected to abuse by anyone. Sexual abuse was identified as including, but not limited to, sexual harassment, sexual coercion, or sexual assault. Residents identified to be potentially abusive shall have individualized care plans with interventions in an effort to prevent abuse as well as possible psychological services. After all possible interventions were implemented, if the potentially abusive resident continued to be considered threatening to other residents, then the facility would issue a transfer in accordance with government regulations. This deficiency represents non-compliance investigated under Master Complaint Number OH00152116 and Complaint Number OH00152008.

Based on medical record review, observations, staff interview, review of the medication error report, pharmacy delivery sheets, the 2015 Drug Handbook, an employee counseling form, and review of the facility policy, the facility failed to ensure antidiabetic and anticoagulant medications were administered accurately and according to physician orders for Resident #131 and Resident #22. This resulted in Immediate Jeopardy for two (#22 and #131) of 15 residents reviewed for medication administration. Additionally, one resident (#30) was placed at risk for more than minimal harm that is not Immediate Jeopardy due to the facility's failure to ensure an antibacterial medication was administered according to physician orders. A total of 15 residents were reviewed for medication errors, including 12 residents reviewed for insulin administration. On 04/23/15 at 12:20 P.M., the Administrator was notified that Immediate Jeopardy began on 03/12/15 when Resident #22 did not recieve prescribed [MEDICATION NAME] for three days related to errors with the computer system. Prior to the medication error with Resident #22, a medication error occurred on 01/30/15 for Resident #30 when [MEDICATION NAME] was not administered for a total of nine missed does related to computer transcription errors. The facility was aware of issues with medication administration beginning on 01/30/15 with Resident #30, and failed to take corrective actions resulting in the Immediate Jeopardy beginning on 03/12/15 when Resident #22 was not provided medication as ordered. The Immediate Jeopardy continued on 03/20/15 at 12:10 P.M. when Resident #131's Insulin orders were entered incorrectly into the facility's computer system. According to the facility's Insulin Policy, the physician's order for [MEDICATION NAME] N insulin (a long acting insulin) 35 units subcutaneously twice a day was to be discontinued due to a therapeutic interchange to [MEDICATION NAME](a long acting insulin), and the [MEDICATION NAME]35 units subcutaneously twice a day was entered into the computer system as a physician order at this time. However, the [MEDICATION NAME] N insulin was not discontinued on this date, and remained in the facility's computer system as an order prompting the nurses to administer this medication at 8:00 A.M. and 4:30 P.M. The [MEDICATION NAME]was scheduled for 9:00 A.M. and 9:00 P.M. When Registered Nurse (RN) #11 entered the orders into the computer system, she incorrectly discontinued another physician's order for [MEDICATION NAME] sliding scale insulin (a short acting insulin) that was to be given every six hours subcutaneously, instead of discontinuing the order for the [MEDICATION NAME] N insulin. This resulted in Resident #131 not receiving the [MEDICATION NAME] sliding scale insulin, as originally ordered by the physician from 03/20/15 at 6:00 P.M., through the resident's transfer from the facility on 03/23/15 at 9:00 A.M. As a result, Resident #131 missed 10 potential doses of [MEDICATION NAME] sliding scale insulin and the corresponding physician ordered blood glucose level monitoring. An additional medication error occurred on 03/23/15 at approximately 8:00 A.M., when Resident #131 was administered [MEDICATION NAME] 35 units subcutaneously in error, as there was no evidence of this medication order in the resident's record. On 03/23/15 at approximately 8:45 A.M., Resident #131's continuous tube feeding was held for a pending transfer to the hospital for a swallowing study. On 03/23/15 at 9:00 A.M., Resident #131 was transferred to the hospital for a scheduled modified [MEDICATION NAME] swallow evaluation. On 03/23/15 at approximately 10:30 A.M., Resident #131 was found unresponsive, diaphoretic and drooling while at the hospital in the registration waiting area. Resident #131 was then taken to the hospital emergency department where a blood glucose level was obtained and the results were too low to register on the glucometer. Resident #131 was given 25 grams of glucose intravenously (IV). Resident #131 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. The Immediate Jeopardy was removed on 03/31/15 at 11:20 A.M. when the facility implemented the following corrective actions: · On 03/23/15 at 1:20 P.M., Resident #131's order for [MEDICATION NAME] N 35 units subcutaneously twice a day was discontinued. Resident #131's order for [MEDICATION NAME] sliding scale insulin every six hours was re-entered into the computer. · On 03/23/15, the DON provided one-to-one education to RN #11 (the nurse responsible for the order entry error), related to order entry accuracy and watching for look-a-like and sound-a-like medications. · On 03/26/15, 03/30/15, 04/03/15, 04/06/15, 04/16/15, and 04/20/15, physician orders and blood glucose levels were audited by the DON and RN #11, for order accuracy and appropriate blood glucose monitoring for all residents receiving both oral and subcutaneous antidiabetic medications. The facility was conducting these audits on a weekly basis. · On 03/30/15 at 1:45 P.M., 17 of 17 nurses were in-serviced by the DON on accuracy of medication order entry, insulin, diabetes, critical thinking, and hypo/[MEDICAL CONDITION]. · On 03/31/15 at 11:20 A.M. and 4:30 P.M., a medication pass observation was completed with Licensed Practical Nurse (LPN) #10 who was the nurse who administered the incorrect insulin on 03/23/15. The medication pass was observed by RN #18 and no errors were observed. · On 03/31/15, LPN #10 received employee counseling from the Director of Nursing (DON) regarding administering the incorrect insulin. · On 03/31/15, LPN #10 completed a continuing education course related to diabetes and insulin. · On 04/23/15, interviews with LPN #10, LPN #13, RN #12, and RN #14 revealed they were knowledgeable regarding short and long acting insulin use, and signs and symptoms of hyper/[DIAGNOSES REDACTED]. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy) as the audits of nurses completing medication administration are continuing to ensure accuracy of medication administration in accordance with physician orders. Findings include: 1. Review of Resident #131's closed medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #131 was transferred to the hospital on [DATE] for a swallow evaluation and subsequently admitted to the hospital for [DIAGNOSES REDACTED]. Resident #131 did not return to the facility following this hospitalization . Review of the hospital medication reconciliation physician orders dated 03/19/15 at 12:30 P.M., revealed Resident #131 was to receive [MEDICATION NAME] sliding scale insulin every six hours subcutaneously dependent on the resident's blood glucose levels. The order indicated if the resident's glucose level was 150-199 milligrams/deciliter (mg/dl), one unit of insulin was to be given; glucose level of 200 to 249 mg/dl, two units of insulin was to be given; glucose level of 250 to 299 mg/dl, three units of insulin was to be given; glucose level of 300-349 mg/dl, four units of insulin was to be given; and if the resident's glucose was greater than 350 mg/dl, then the physician was to be notified. Review of Resident #131's physician orders dated 03/19/15, revealed an order for [REDACTED]. Review of the physician's order dated 03/19/15, revealed [MEDICATION NAME] HN was to infuse at 80 milliliters per hour continuously. The physician orders dated 03/19/15 also revealed Resident #131 was to remain nothing by mouth as the resident was on a continuous tube feeding. Review of the physician orders entered into the computer system dated 03/20/15 at 12:10 P.M. revealed [MEDICATION NAME] flex pen solution was to be injected at 35 units subcutaneously twice a day related to Diabetes Mellitus. Review of the physician's order entered into the computer dated 03/20/15 at 12:10 P.M. revealed the [MEDICATION NAME] sliding scale insulin ordered every six hours subcutaneously was discontinued. Review of Resident #131's Medication Administration Record [REDACTED]. There was no further record of the resident receiving the ordered [MEDICATION NAME]sliding scale coverage as ordered by the physician. Resident #131 was not given the [MEDICATION NAME] sliding scale insulin from 03/20/15 at 6:00 P.M. through the resident ' s transfer from the facility on 03/23/15 at 9:00 A.M., thereby missing 10 potential doses of sliding scale insulin and the corresponding blood glucose levels. Review of the MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED].M. and 4:30 P.M. and [MEDICATION NAME] 35 units subcutaneous at 9:00 A.M. and 9:00 P.M. Review of Resident #131's blood glucose results revealed no evidence of glucose monitoring from 03/20/15 at 12:00 P.M. through the time the resident was transferred on 03/23/15 at 9:00 A.M., with the exception of 03/21/15 at 9:31 A.M. when Resident #131's blood glucose was 166 mg/dl. Review of Resident #131's progress notes from 03/20/15 through 03/23/15 at 9:00 A.M. revealed no evidence of blood glucose monitoring or monitoring for signs and symptoms of [DIAGNOSES REDACTED]. Review of Resident #131's progress notes dated 03/23/15 at 9:00 A.M., which was entered as a late entry on 03/30/15 at 3:29 P.M. by LPN #10, revealed Resident #131 left for an appointment for a modified [MEDICATION NAME] swallow study. The resident was alert and oriented times three with no signs or symptoms of hypo/[MEDICAL CONDITION] at this time. The tube feeding was infusing per order prior to leaving for the appointment. Review of Resident #131's progress notes dated 03/23/15 at 1:30 P.M., documented by RN #11, revealed the facility's Speech Therapist (ST) #17 phoned the hospital regarding Resident #131 not returning from the swallow study. ST #17 was notified the resident was sent to the emergency room and at this time the resident was admitted with a [DIAGNOSES REDACTED].M. revealed there was a deviation from the medication regimen and the resident's sister and the nurse practitioner of the resident were notified. Review of Resident #131's hospital record dated 03/23/15 at 10:30 A.M. revealed the resident was brought in by ambulance to the x-ray lobby. The note revealed the resident was found in the wheelchair unresponsive and drooling. The history of present illness revealed Resident #131 was sent in from the nursing home for a swallow study. The resident was dropped off at registration by the ambulance transport company. The resident was called by registration and was found to be unresponsive and diaphoretic. The hospital record revealed the resident's blood glucose was found to be too low to register on the glucometer. The note revealed [MEDICATION NAME] (a form of sugar) was given IV and the resident was again alert and lucid. The note revealed since the resident did not complete the swallow study, one was ordered for immediate evaluation, so the resident could be fed. Review of the re-examination/re-evaluation dated 03/23/15 at 11:53 A.M. revealed the resident went to fluoroscopy for a swallow study but was brought back to the emergency department and the resident's blood glucose was found to be too low to measure again. [MEDICATION NAME] (25 grams) was given IV. The resident was started on [MEDICATION NAME] ten grams in water and was admitted to an inpatient telemetry unit. Review of the facility's pharmacy delivery sheet dated 03/19/15 revealed no evidence [MEDICATION NAME] N was delivered to the facility for Resident #131. Review of the one-on-one education dated 03/23/15 revealed RN #11 discontinued the wrong medication in the computer leading to a potential medication error. RN #11 recognized the error and followed the procedure to correct and report the error. RN #11 needs to watch for look-a-like medications and be more cautious during order entry. The DON observed RN #11 enter medication into the computer following the occurrence to ensure RN #11 is properly entering orders. Review of the facility's Medication Error form dated 03/23/15 revealed a medication error of an omitted dose occurred. The description of the error revealed when discontinuing [MEDICATION NAME] N to change to [MEDICATION NAME], the [MEDICATION NAME] sliding scale order was accidently discontinued, and revealed the [MEDICATION NAME] N was given. Review of how the error could be prevented revealed to slow down and read carefully. Review of the form revealed the incident was reported to the physician and responsible party on 03/23/15 at 2:00 P.M. Review of the deviation from the Medication Regimen was documented in the nurse ' s notes on 03/23/15 at 2:00 P.M. The form was signed on 03/25/15 by the Nurse Practitioner and the DON. Review of an additional Medication Error form revealed the date of the error was 03/23/15 and the form was dated 03/30/15. The form indicated the error was a failure to clarify any medication with the physician whenever there is any question related to the order, and an unordered medication was given. The description revealed the nurse provided the wrong insulin to the resident. The form indicated the error could be prevented by the nurse watching for look-a-like medications and double checking the proper doses. Review of the form revealed the incident was reported to the physician on 03/31/15 at 2:45 P.M. and the form was signed by the physician on 04/02/15. The nurse responsible (LPN #10) signed the form on 03/31/15 and the first person aware of the error (the DON) signed the form on 03/30/15. The pharmacy statement dated 03/30/15 revealed the pharmacy dispensed one [MEDICATION NAME] three milliliter flex touch pen on 03/19/15. The statement revealed a review of the day's deliveries was completed and confirmed the delivery and receipt of the [MEDICATION NAME] pen by the facility. The review revealed no [MEDICATION NAME] products were dispensed from the pharmacy or the pharmacist on call that evening. Also, the pharmacy services does not provide [MEDICATION NAME] N in stock meds. On 03/30/15 [MEDICATION NAME] N appeared on the resident ' s order summary and the pharmacy communicated to the wing that the order had to be changed to [MEDICATION NAME]. Review of the Employee Counseling form dated 03/30/15 revealed LPN #10 was counseled with a written warning and one day suspension related to work performance. The form revealed LPN #10 administered the wrong insulin to a resident causing a medication error. The recommended corrective action revealed the employee was educated on different types of insulin and was to complete a diabetic course online as an educational tool. The corrective action included LPN #10 being audited during a medication pass. LPN #10's remarks regarding the counseling revealed the nurse indicated if the order had been discontinued as it should have, the medication error would not have occurred. A data entry error caused from the other nurse was the cause of the medication error. The form was signed by LPN #10 on 03/31/15. Interview on 04/22/15 at 11:46 A.M. with the DON revealed Resident #131 was admitted to the facility on [DATE] with multiple problems including diabetes. Resident #131 went out on 03/23/15 for a modified [MEDICATION NAME] swallow study. The DON indicated she thought the resident was transferred to the hospital for the swallow study around 9:00 A.M. on 03/23/15 and confirmed that Resident #131 would have been disconnected from the ordered continuous tube feeding during the transportation and for the procedure. The DON revealed ST #17 called the hospital to see what the status of the resident was on that date. The hospital said the resident was sent to the emergency room for a hypoglycemic episode. After this incident was reported, the unit manager was looking through Resident #131's record to see what the resident's most recent blood sugar was and why the resident may have been hypoglycemic. This led to the transcription error being identified. The DON indicated the facility does not use [MEDICATION NAME] N and the [MEDICATION NAME] N is switched out for the [MEDICATION NAME] insulin. The DON indicated the [MEDICATION NAME] sliding scale was discontinued instead of the [MEDICATION NAME] N in the computer program system during the order entry. The DON indicated due to the sliding scale being discontinued the glucose monitoring was also discontinued and the nurses were not prompted to obtain a blood glucose level for the resident. The DON indicated the [MEDICATION NAME] N remained in the system as an order and confirmed that the [MEDICATION NAME] N was documented as given by the nurse on multiple occasions. The DON also confirmed the [MEDICATION NAME] was entered into the system for the interchange. During further interview on 03/23/15 the DON stated she and the unit manager began checking all residents on antidiabetics or insulins and audited the residents' records for accuracy of order entry. This was done on 03/24/15, 03/25/15, and 03/26/15. The DON indicated this was then implemented as a weekly audit to be completed. The DON stated when Resident #131's record was reviewed on 03/23/15, RN #11 thought the [MEDICATION NAME] N was administered as documented and therefore reported the error as the [MEDICATION NAME] N 35 units being administered along with the [MEDICATION NAME] 35 units to the hospital, nurse practitioner and the resident's family. This was how the error appeared according to the documentation completed by LPN #10 in Resident #131's medical record. The DON indicated that on 03/24/15 in the morning, RN #11 called the hospital to check on Resident #131's status and the hospital indicated the resident was stable and was planning on transferring to another nursing facility upon discharge. The DON further stated on 03/30/15 the pharmacy provided information that the pharmacy did not supply the [MEDICATION NAME] N to the facility. The DON indicated at this time the nurses that cared for the resident on 03/20/15, 03/21/15, 03/22/15 and 03/23/15 were interviewed. The DON indicated RN #12, who cared for the resident on 03/21/15 and 03/22/15 during the 7:00 P.M. to 7:30 A.M. shift, was interviewed and indicated RN #12 did take the resident ' s blood glucose in the early morning of 03/22/15, which was normal but she could not remember the number and the results were not documented in the resident's medical record. The DON indicated the resident slept during RN #12's shift but woke up at 4:00 A.M. and was using the call light the rest of RN #12's shift. The DON indicated that LPN #13 was interviewed on 03/30/15 and stated she signed off the [MEDICATION NAME] N as being given but actually gave the [MEDICATION NAME] insulin. The DON indicated LPN #13 stated she signed it off as such because it was interchangeable and the [MEDICATION NAME] needed to be put into the computer system. The DON indicated on 03/30/15 RN #14, who worked the day shift 7:00 A.M. to 7:30 P.M. on 03/21/15 and 03/22/15, was interviewed and stated the insulin was signed in error and the [MEDICATION NAME] was provided to the resident because that is what the facility had. The DON indicated RN #14 stated the resident was alert and oriented during RN #14's shifts and used the call light multiple times. The DON indicated on 03/30/15 LPN #10, who worked the day shift on 03/23/15, was interviewed and said she must have given the [MEDICATION NAME]because she gave two different forms of insulin in two different pens. The DON indicated both [MEDICATION NAME] 35 units subcutaneously and [MEDICATION NAME]35 units subcutaneously were given. The DON indicated the [MEDICATION NAME]is short acting insulin. The DON stated after this interview they followed-up with disciplinary action for LPN #10 and they also made the LPN complete continuing education on diabetes and insulin types. The DON also indicated LPN #10 was observed passing medications. The DON indicated a nursing in-service was completed with all the facility's current nurses regarding critical thinking, diabetes, types of insulin, and accuracy of medication order input. The DON indicated the facility also completes weekly insulin and antidiabetic audits. The DON indicated the [MEDICATION NAME] N would not have been able to be given as documented on Resident #131's Medication Administration Record [REDACTED]. The DON confirmed the pharmacy never sent Resident #131's [MEDICATION NAME] N, and there was no [MEDICATION NAME] N supplied in the starter kit for the facility. Interview on 04/22/15 at 2:09 P.M. with LPN #13 revealed she cared for Resident #131 on 03/20/15. LPN #13 confirmed the [MEDICATION NAME]that was in the pen was given to Resident #131 but she documented that the [MEDICATION NAME] N was given. LPN #13 indicated that the [MEDICATION NAME]was an interchange for the [MEDICATION NAME] N but the order was not entered at the time the medication was given. LPN #13 indicated that if a resident is given short acting insulin then the nurse should make sure food is provided to the resident to prevent [DIAGNOSES REDACTED], and when a resident is neither eating nor receiving nutrition any insulin orders should be questioned. LPN #13 indicated she would check with the physician to see if the insulin needed held prior to going out for a procedure in which the resident was not going to be eating or supplied nutrition. Interview on 04/22/15 at 2:27 P.M. with RN #12 revealed she cared for Resident #131 on 03/21/15 during night shift and 03/22/15 during night shift. RN #12 did not remember what the insulin orders were for Resident #131 or the insulin that was given to Resident #131. RN #12 confirmed on 03/22/15 in the early morning she obtained Resident #131 ' s glucose level. RN #12 indicated the glucose level was obtained per nursing judgment because the resident was sleeping too hard. RN #12 indicated she was able to arouse the resident. RN #12 indicated she was unable to remember what the glucose level was when it was obtained and confirmed it was not documented in the resident's record. RN #12 stated the blood sugar was within normal limits when it was obtained. RN #12 stated every time she checked on Resident #131 on 03/22/15 during the night and early morning, the resident was sleeping which was abnormal to her. RN #12 indicated it was the first night she had taken care of the resident. RN #12 stated Resident #131 did wake up at 4:30 A.M. or 5:00 A.M. in the morning and was activating the call light multiple times for things to be moved and found for the resident the rest of her shift. RN #12 stated once the resident woke up she felt better about the resident's condition. RN #12 indicated normally if a resident is going for a procedure in which they will not be fed, there are orders to hold the insulin. If there are not, then RN #12 indicated she would call to check if the insulin should be given or not. RN #12 indicated if the resident is not receiving some form of nutrition there is potential the resident's blood sugar could drop if the insulin is administered. Interview on 04/22/15 at 2:39 P.M. with LPN #10 revealed on 03/23/15 she was caring for Resident #131. LPN #10 indicated Resident #131 was going out for a [MEDICATION NAME] swallow study and she started the resident's medication first due to Resident #131 going out. LPN #10 stated at about 7:55 A.M. an order popped up for [MEDICATION NAME] N 35 units and she gave [MEDICATION NAME] 35 units subcutaneously instead of the physician ordered [MEDICATION NAME] N. LPN #10 indicated that [MEDICATION NAME] N is long acting insulin and [MEDICATION NAME] is short acting insulin. LPN #10 indicated that rarely do we have anyone on [MEDICATION NAME] N where we pull from a vial and the [MEDICATION NAME] pen was there so that was what was given. LPN #10 indicated at 8:00 A.M. the 9:00 A.M. medications begin to pop up on the computer system. LPN #10 indicated at about 8:15 A.M. she saw the orders for the [MEDICATION NAME] 35 units pop up and she administered the [MEDICATION NAME] 35 units subcutaneously. LPN #10 indicated she questioned the order in her head because it was odd the resident had two insulins ordered near the same time. LPN #10 said there was no hold order for the insulin prior to the resident's [MEDICATION NAME] swallow study. LPN #10 confirmed Resident #131 was receiving a continuous tube feeding and the tube feeding was disconnected from the resident approximately fifteen minutes prior to the resident leaving for the swallow study. LPN #10 stated after the resident was disconnected from the tube feeding she did not see the resident prior to the resident leaving the facility for the study. LPN #10 said although she questioned the medications in her head she just gave what the computer told me to at the time. LPN #10 stated she did not think about the resident being nothing by mouth, and disconnected from the tube feeding when giving the insulin. LPN #10 stated at around 1:00 P.M. ST #17 came up and asked if the resident was back from the hospital and LPN #10 stated no. The speech therapist then called the hospital to check on the progress of the resident and the hospital said Resident #131 was at the emergency room being evaluated because the resident became unconscious. LPN #10 indicated RN #11 then called the emergency room to see what the resident was being treated for [REDACTED]. LPN #10 revealed after this happened the unit manager questioned her about giving the resident insulin and LPN #10 told her yes the resident gets [MEDICATION NAME] and [MEDICATION NAME] and they both were administered. LPN #10 stated a week after it happened she was called to the office and asked what insulin was given to Resident #131. LPN #10 stated I gave what was in the medication cart. LPN #10 indicated she did not know she gave Resident #131 the wrong insulin until she was called a week later. LPN #10 confirmed she did not enter the note about the resident being transferred and the resident's status until 03/30/15 after the error was found. LPN #10 stated the resident was supposed to be on a [MEDICATION NAME] sliding scale but it was not in the computer. The [MEDICATION NAME] N was supposed to be discontinued and someone discontinued the wrong order. LPN #10 indicated she did complete a continuing education class online regarding insulin. LPN #10 stated she was observed during a medication pass. LPN #10 indicated the facility also did an in-service regarding the insulin. Interview on 04/22/15 at 3:01 P.M. with the DON revealed the insulin pens of Resident #131 were never evaluated as part of the medication error investigation. The DON was unsure what was done with Resident #131's insulin pens following the resident ' s discharge. On 04/23/15 at 8:07 A.M., interview with RN #11 revealed when she became aware Resident #131's glucose had dropped on 03/23/15, RN #11 began to investigate what may have happened. RN #11 stated she went into the system and saw the [MEDICATION NAME] N and the [MEDICATION NAME] were both documented as given. At this time RN #11 asked LPN #10 what she gave the resident. LPN #10 indicated she gave two insulins. RN #11 stated on 03/20/15 she obtained an order from the physician to interchange the [MEDICATION NAME] N to [MEDICATION NAME]. When entering the order, RN #11 discontinued the [MEDICATION NAME] sliding scale order instead of the [MEDICATION NAME] N insulin order. On 03/23/15, RN #11 discovered this order entry error which she made, and confirmed she corrected the order entry error on 03/23/15. RN #11 stated she just started in January and was not very familiar with what medications the facility stocked. She did not realize the facility did not have [MEDICATION NAME] N nor supply this medication. RN #11 stated she did remove the resident's medication from the medication cart but did not check the [MEDICATION NAME]or the [MEDICATION NAME]to see what medication was left in the pen to fully investigate the amount of medication the resident may have received. RN #11 stated she spoke to the hospital multiple times regarding Resident #131 and told the hospital the [MEDICATION NAME] N had been given in error along with the [MEDICATION NAME] insulin. Nurse Practitioner #15 and Resident #131's family was also notified that [MEDICATION NAME] N was given in error at the facility and prior to hospitalization . RN #11 said she did not do any further investigation as the DON was notified. RN #11 further stated after the investigation was complete and it was found that [MEDICATION NAME]had been given on 03/23/15 instead of the [MEDICATION NAME] N, the Medical Director (MD) was notified of the final results of the investigation. Interview on 04/23/15 at 11:10 A.M. with the MD revealed Resident #131 was not a patient of his prior to admission to the facility. The MD indicated Resident #131 was his patient once admitted to the facility and for the duration of the resident ' s stay at the facility. The MD indicated he was aware of the incident that occurred with Resident #131 receiving [MEDICATION NAME]in error. The MD stated the resident left the facility after receiving the [MEDICATION NAME]and became hypoglycemic. The MD indicated since the resident was not going to be supplied any nutrition due to leaving for the swallowing screen, Resident #131 should not have received the [MEDICATION NAME] insulin. The MD indicated if a resident is on a tube feeding and the tube feeding is disconnected and the resident is nothing by mouth and insulin is given to the resident, the resident ' s glucose level is going to drop and the resident will become hypoglycemic. The MD indicated the nurses should question the administration of a short acting or long acting insulin when a resident is becoming nothing by mouth and not receiving nutrition. The MD confirmed he was aware the facility has a therapeutic interchange policy related to the insulin. The MD stated the resident was not seen by him after Resident #131 left the facility and the resident went to another facility where the MD is not following the resident. Interview on 04/23/15 at 1:37 P.M. with Pharmacy Manager (PM) #16 revealed he was aware of Resident #131's [MEDICATION NAME] N remaining in the resident ' s profile in the computer system. PM #16 revealed he was responsible for investigating the incident on the pharmacy's side. PM #16 stated Resident #131 was admitted with an order for [REDACTED].#16 indicated the standard formulary change is completed to help prevent errors due to multiple forms of insulin. PM #16 indicated all short acting insulins are interchanged for [MEDICATION NAME]; all long acting insulins are interchanged for [MEDICATION NAME]; and all insulin mixes are interchanged to the [MEDICATION NAME] mix. PM #16 indicated a physician's order is still needed for this change and the physician is able to order other insulin if they prefer. PM #16 indicated the formulary change is a policy that was signed by the MD for appropriateness prior to being put into place three years ago. PM #16 stated when the [MEDICATION NAME] N was noted on the order screen, the [MEDICATION NAME] Pen would have been sent out to the facility instead of [MEDICATION NAME] N. PM #16 stated the [MEDICATION NAME] was sent out on 03/19/15 for the resident. During the review of the medications on 03/24/15, the pharmacy had noticed the [MEDICATION NAME] N was still in the residents profile and the nursing unit was notified by fax that an order was to be obtained for the [MEDICATION NAME] N to be discontinued and the [MEDICATION NAME] to replace the [MEDICATION NAME] N unit for unit. PM #16 stated he was unable to provide the fax to the nurse requesting Resident #131's formulary change request. PM #16 stated during the investigation of the incident it appeared the nurse entered the [MEDICATION NAME]order correctly but instead of discontinuing the [MEDICATION NAME] N, the nurse discontinued the [MEDICATION NAME] sliding scale. PM #16 was unaware the resident received the [MEDICATION NAME]instead of the [MEDICATION NAME] N on 03/23/15. PM #16 stated the resident's medication should have been returned to the pharmacy to be destroyed. PM #16 indicated the pharmacy was not contacted to evaluate the amount of insulin in the insulin pens. PM #16 stated he was unsure if the medication

Based on observation, record review and interview, the facility failed to ensure residents were comprehensively and accurately assessed related to the development and monitoring of pressure ulcers, and that treatments and interventions for prevention and healing were in place. Resident #29 suffered actual harm by developing avoidable pressure ulcers. Interventions were not implemented to promote healing and prevent further breakdown for Resident #65. This affected two residents (Resident #29 and #65) of two residents reviewed related to pressure ulcers. The facility census was 59. Findings include: 1. On 04/01/13 at 8:00 A.M., the surveyor entered the facility to conduct the complaint investigation. Information obtained during the on-site investigation revealed a complaint survey had been conducted at the facility on 03/21/13. As a result of that complaint survey, a deficiency was issued at Data Tag F314 related to the facility's failure to implement urinary continence management to prevent a resident from developing an unstageable pressure ulcer to her buttocks. On 04/01/13, the facility provided a list of current residents who had pressure ulcers. Resident #29, was identified by the facility as having developed a pressure ulcer since the date of the last complaint survey of 03/21/13. A weekly wound tracking log revealed Resident #29 developed a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. The ulcer may also present as an intact or open/ruptured blister) pressure ulcer to her right hip, in the facility on 03/27/13. The pressure ulcer was assessed to be an intact blister which measured one centimeter by 1.5 centimeters with no depth noted. The resident was also noted to have a second Stage II pressure ulcer to her right hip, that developed on 03/04/13, and measured 0.5 centimeters by 0.5 centimeters with no depth noted. In addition, Resident #29 was noted to have a Stage II pressure ulcer to her right buttock, that developed on 03/19/13, and measured two centimeters by one centimeter. Each of the pressure ulcers were described as intact blisters and all three were noted to have developed in the facility. On 04/01/13 at 9:54 A.M., Resident #29 was observed seated in a wheelchair in her room, dressed in her own clothes. Two state tested nursing assistants (STNA's) were observed in the room with the resident at that time. Interview with STNA #4 and STNA #5 revealed they had just completed incontinence care for the resident as she had been incontinent of both bowel and bladder. Upon further interview, the STNA's verified the resident had a treatment in place to her hip. The STNA's indicated there were two intact dressings in place, both on the resident's left hip. The surveyor then asked to observe the intact dressings. STNA #4 and #5 assisted the resident back to bed and removed her pants. The resident was observed with a plastic incontinence brief in place and secured. After unfastening the incontinence brief, two intact dressings were observed to the resident's left hip. The first dressing was noted to be on the left hip itself and the second dressing was observed to be lower, almost to the left buttocks area. Observation of the resident's right hip and buttock area revealed no treatment in place to the right side at all. The resident was observed to have four areas of impairment, two intact blisters and two opened blisters to the right hip and also evidence of a healing open blister to her right buttock. The presence of these areas were verified by STNA #4 and #5. Following the observation, the resident was assisted back up to the wheelchair by the STNA's. The resident was noted to be dependent on staff for personal care and transferring. Review of Resident #29's medical record revealed the resident was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's current physician orders [REDACTED]. The resident did have current physician orders [REDACTED]. On 04/01/13 at 10:48 A.M., interview with Licensed Practical Nurse (LPN) #6 revealed she was the facility wound nurse. The LPN verified wound log documentation and physician orders [REDACTED]. The LPN also verified the resident had treatments in place to her left hip/buttock without any physician orders [REDACTED]. The concern was also shared with LPN #6 during the interview, that Resident #29 was observed with four areas, (two intact blisters and two open blisters), to her right hip that were currently not being treated based on the observation made. The LPN indicated she would re-assess the resident. 2. Resident #65 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review revealed the resident was admitted with an indwelling urinary (Foley) catheter in place. Record review also revealed the resident was admitted with a surgical wound to her left medial foot and an unstageable pressure ulcer to her right heel. Review of the resident's physician orders [REDACTED]. Record review revealed the resident's indwelling urinary catheter was removed on 02/19/13. Record review reveal no bladder assessment was completed for Resident #65 following the removal of the urinary catheter. Record review revealed a plan of care was initiated on 02/20/13, related to the resident's risk for skin breakdown. The care plan reflected the resident was at risk related to limited/poor mobility, inactivity, fragile skin and poor turgor. Interventions included for the STNA to assess the resident's skin condition with daily care and report results to nurse in charge and to use pillows for support. Review of the comprehensive assessment, Minimum Data Set (MDS) 3.0 with an assessment reference date of 02/25/13, revealed the resident required extensive assistance from one staff for bed mobility and extensive assistance from two staff for transfers, toileting and personal hygiene. Skin risk assessments, completed on 02/26/13 and 03/05/13, revealed the resident was at low risk for skin breakdown. Record review revealed a late entry nursing progress note dated 03/04/13, at 10:19 A.M. The note indicated the resident's family was requesting a skin assessment be completed. The resident was assessed to have red, intact, blanchable excoriation to her buttocks and coccyx. The note indicated an antifungal cream was applied to the areas. Following the assessment, the resident was repositioned in bed. On 03/06/13 at 10:30 A.M., nursing progress notes revealed LPN #6 was notified by the floor nurse that Resident #65 was noted to have "new areas". The family was present in the room then and assessment was completed. The resident was assessed to have what appeared to resemble "moisture-related [MEDICAL CONDITION] to upper and lower back, coccyx, buttocks and thighs". The resident was assessed to have an open blister to her right thigh and left outer ankle. The note indicated the resident was incontinent of bowel and bladder at times. Treatment orders were noted to be initiated following the identification of the pressure ulcers to the right thigh and left outer ankle. On 04/01/13 at 12:47 P.M., interview with LPN #6 revealed Resident #65 was admitted with an unstageable pressure ulcer to her right heel. The LPN indicated the resident had an order for [REDACTED]. The LPN indicated she completed the assessment and noted some excoriation but no open pressure ulcers. The LPN indicated she was on-site and also made aware, on 03/06/13, of the development of pressure ulcers to the resident's right thigh and left ankle. When asked if an investigation had been completed to determine why those areas developed, the LPN indicated the thigh area was related to the resident's incontinence. The LPN provided no information related to why or how the resident might develop a Stage II pressure ulcer to her left ankle and indicated she was unaware whether any type of investigation had been done. On 04/01/13 at 1:27 P.M., interview with LPN #9 revealed he was the facility restorative nurse. The LPN verified no bladder assessment had been completed for Resident #65 following the removal of a urinary catheter on 02/19/13, and no comprehensive plan had been initiated to decrease the resident's risk of developing skin breakdown related to urinary incontinence. The LPN provided three incomplete bladder tracking logs, dated 02/23/13 through 02/25/13, 02/28/13 through 03/02/13, and 03/04/13 through 03/06/13. The LPN indicated he was having trouble ensuring the STNA's properly filled out the forms and verified there was no objective data to evaluate the resident's bladder status based on the lack of information obtained. On 04/01/13 at 1:46 P.M., interview with the director of nursing (DON) and administrator revealed they were aware of concerns voiced by Resident #65's family related to incontinence care not being provided to the resident. The resident's daughter had voiced concerns on 03/04/13, that she was finding the resident incontinent and felt her skin was breaking down. The family was reassured that concerns regarding incontinence care would be addressed. On 03/06/13 at approximately 7:45 A.M., the resident's daughter was angry and voiced concerns that she had come to visit the resident and found her "soaked with urine... skin broken down". The daughter voiced concerns that she felt no one had been taking care of the resident during the night and the resident was itching and uncomfortable. The investigative summary, completed by the facility revealed the resident was assessed to have a rash and small area to her left outer ankle where a Spenco boot strap had been. However, the resident did not have an order or Spenco boot to the left foot, per interview with LPN #6 on 04/01/13 at 12:47 P.M. On 04/01/13 at 2:45 P.M., interview with Registered Nurse (RN) #1 revealed she was working, aware and involved in the incident that occurred on 03/06/13, when Resident #65's daughter was upset related to the resident being soaked with urine and developing skin breakdown. RN #1 verified the resident had been incontinent, but was unable to determine when she had last been toileted or provided incontinence care. The RN also indicated that by the time she arrived to the resident's room, the daughter had already begun removing wet bedding from the resident's bed. The RN indicated she apologized to the daughter and reassured the daughter that personal care would be completed for the resident. On 04/01/13 at 3:30 P.M., interview with STNA#10 revealed she was asked by RN #1 to provide incontinence care/personal care to Resident #65 on 03/06/13, at the request of the resident's daughter. The STNA verified the resident's bedding was wet with urine and also verified the development of the pressure ulcer to the left outer ankle and right thigh. When asked about the left outer ankle, STNA #10 indicated she was aware that the resident's daughter thought the area developed because her leg/foot had been propped up on a pillow with no pillow case. The STNA verified the pillow in the resident's room did not have a case on it and was unable to provide any explanation related to why there wouldn't be a pillow case in place. Based on record review and interview, the facility failed to comprehensively assess Resident #65's bladder status and initiate comprehensive and individualized interventions to prevent the development of a Stage II pressure ulcer from urinary incontinence. The facility also failed to ensure adequate interventions were in place, including the application of a pillow case to prevent the resident from developing a Stage II pressure ulcer to her left outer ankle. This deficiency substantiates allegations contained in Complaint Number OH 419. This deficiency also demonstrates continued non-compliance from the complaint investigation of 03/21/13.

Based on observation, staff interview and medical record review, the facility failed to implement urinary continence management to prevent the decline of a pressure ulcer for Resident #49 resulting in an unstageable pressure ulcer to the buttocks. This affected one of three sampled residents and had the potential to affect twelve residents currently in the facility with pressure ulcers. Findings include: A review of the medical record for Resident #49 revealed a medical history of [REDACTED].#49 developed a stage two (partial thickness loss of top layers of skin without slough) pressure ulcer at the right gluteal fold measuring 1.4 centimeters (cm) length, 2.0 cm width and 0.1 cm depth. The Weekly Wound Flow Sheet dated 03/11/13 revealed the stage two pressure ulcer of the right gluteal fold measures 0.5 cm length, 0.5 cm width and 0.1 cm depth (indicating healing). The Weekly Wound Flow Sheet dated 03/19/13 measured the right gluteal fold pressure ulcer at 2.8 cm length by 2.0 cm width and no depth (indicates a worsening, unstageable ulcer). On 03/21/13 at 9:52 A.M., an observation of Resident #49 was initiated due to the strong odor of urine from outside the door in the hallway. State tested Nursing Assistant (STNA) #5 entered the room to provide care as ordered every two hours for urinary incontinence. STNA #5 stated she had not been able to change Resident #49 since coming on shift at 7:00 A.M. due to the fact that she was the only STNA on this wing with twenty-two residents to care for. STNA #5 also stated she had been in earlier to feed her breakfast in her bed but was unable to complete the urinary incontinence care due to the high demands for resident care and assistance with breakfast. STNA #5 stated Resident #49 was supposed to be up for breakfast to eat at the restorative dining table and night shift staff was to make sure Resident #49 was clean, dry and out of bed prior to their departure at 7:00 A.M.. Resident #49 was lying on her back in bed and sleeping. STNA #5 lifted the covers and revealed the incontinence pad underneath the buttocks and thigh region of Resident #49 was soaked with urine and the sheet directly under it had a large brown circle of dried urine. STNA #5 positioned Resident #49 on her right side, observation revealed her backside, as well at the incontinence pad and bed linens, were soaked with urine. The right lower buttocks near the thigh area of Resident #49 had an open pressure sore without a dressing. There was no dressing found in the bed linens on further inspection. The pressure sore appearance was a full thickness wound, macerated, well defined edges and a wound bed of yellow slough material covering 75% of the wound bed. Registered Nurse (RN) #6 entered the room and verified the wound was uncovered and the linens were heavily soiled in urine. RN #6 stated nothing was mentioned from the previous shift in morning report about the dressing being removed. The Wound Nurse, RN #7, also entered the room and verified that the wound was uncovered and damp with urine. On 03/21/13 at 3:30 P.M. An interview with Wound Nurse RN #7 verified the pressure ulcer for Resident #49 had declined to unstageable. Further review of the medical record for Resident #49 revealed current physician orders [REDACTED]. A review of the STNA Restorative Bowel and Bladder Training Record for Resident #49 revealed instructions to check and change the resident every two hours and as needed. The March 2013 record did not contain entries to indicate this task was completed on day shift (7:00 A.M. to 7:00 P.M.) 10 of 21 days and three of 20 nights (7:00 P.M. to 7:00 A.M.), including the night of 03/20/13. A review of the STNA Flow Record for March 2013 revealed Resident #49 was to have a check and change every two hours throughout 24 hours and to turn and reposition every two hours, these tasks were not signed off as completed on 03/20/13. On 03/21/13 at 4:30 P.M. the Director of Nursing verified the STNA Flow Sheet and the Restorative Bowel and Bladder Sheet was to be completed by staff each shift when care is rendered. This deficiency substantiates complaint number OH 366.

Based on observation, record review and interview the facility failed to prevent and identify the development of unstageable pressure ulcers to the right foot and heel of Resident #66. In addition the facility failed failed to ensure ordered treatments were in place resulting in stage II pressure ulcers to the right and left gluteal fold and coccyx for Resident #66. This affected one of three residents reviewed regarding pressure ulcers of six residents in the facility with pressure ulcers. The census was 58 residents. Findings include: Resident #66 was admitted on [DATE] with [DIAGNOSES REDACTED]. The admission skin assessment dated [DATE] revealed the resident had no pressure ulcers on his feet, coccyx or buttocks. Resident #66 was assessed to be at risk for developing a pressure ulcer. The admission minimum data set (MDS) assessment dated [DATE] indicated the resident had no pressure ulcers and required extensive assistance to total dependence for activities of daily living. The care plan dated 08/02/12 revealed the resident had a self care deficit related to decreased endurance. Review of the weekly wound flow sheet dated 08/31/12 indicated an unstageable pressure ulcer was discovered on the right lateral foot. The area measured 2.0 centimeters (cm) long and 2.0 cm wide. The ulcer had 100 percent black eschar (a thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue that has lost its usual physical properties & biological activity.) with wound edges well defined. The ulcer was discovered when the resident's sock was removed. Review of the weekly wound flow sheet dated 08/31/12 indicated an unstageable pressure ulcer was discovered on the right outer ankle that measured 3.0 cm long and 2.5 cm wide. The wound had 75 percent eschar with wound edges well defined. Review of the October physician orders revealed the resident was to have an Allevyn (foam occlusive) dressing on his coccyx to be changed three times a week and as needed as well as protective cream applied to his buttocks. A treatment observation was made on 10/31/12 at 9:40 A.M. State tested Nurse Aide (STNA) #24 assisted Licensed Practical Nurse (LPN) #14 during the dressing change of the two unstageable pressure areas on the right foot and ankle, and pressure areas of the coccyx, right gluteal fold and left gluteal fold. The right ankle and foot wounds were scabbed areas with brown/black eschar. LPN #14 verified they were unstageable pressure areas. There was no dressing on the resident's coccyx as ordered. There was no evidence the dressing had been applied per order. STNA #24 verified the dressing was not on when she performed personal hygiene prior to the dressing change. There was no protective cream on the right and left gluteal folds as ordered. LPN #14 verified there was no dressing on the coccyx as ordered and no protective cream on the right and left gluteal folds. She verified there were open areas on the coccyx, the right gluteal fold and the left gluteal fold that were not there when she changed the dressing on the previous Monday. She stated these were areas that had been healed. Review of the weekly wound flow sheet dated 10/31/12 revealed the left gluteal fold, right gluteal fold and coccyx all had Stage II pressure ulcers (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister.). An interview with LPN #14 on 10/31/12 at 6:15 P.M. verified the right ankle pressure ulcer and the right lateral foot pressure ulcer were discovered in the facility as unstageable ulcers with the black eschar. She verified the resident was dependent on staff for activities of daily living and she verified the resident was assessed as high risk for developing pressure ulcers.

Based on observation, staff interview and clinical record review, the facility failed to implement a comprehensive wound care program designed to identify, assess, treat and/or prevent pressure ulcer development for Residents #10, #20, #53, #56, #63, #85, #95, #98 and #101. Resident #20 sustained harm when found to have an unstageable pressure ulcer to her coccyx. Resident #53 sustained harm when found to have three unstageable pressure ulcers to her right foot on 03/03/11 caused by a casting device that remained unstageable as of 08/19/11. Resident #85 sustained harm when found on 07/18/11 to have an unstageable pressure ulcer to his coccyx and then observed to have no treatment in place during the annual survey. The facility failed to prevent Resident #63 from developing a pressure ulcer to her right ear. The facility failed to complete on-going assessments/monitoring of pressure ulcers to Resident #95's buttock, foot, knee and leg resulting in deterioration of the pressure ulcers. Resident #10 was found, during the annual survey to have two Stage II pressure ulcers, not previously identified by the facility, to her right buttock and was observed without a treatment in place to a pressure ulcer to her left buttock. The facility failed to complete on-going assessments/monitoring of pressure ulcers to Resident #56's right buttock/gluteal fold and right trochanter (hip). The facility failed to ensure timely assessment and treatment initiation for Resident #101 who was admitted with pressure ulcers. Resident #98 was observed to have an incorrect treatment in place to her left upper hip pressure ulcer during the annual and extended survey. As a result of the concerns related to pressure ulcer development and treatment and findings during the annual and extended survey, the facility was found to be in substandard quality care related to this requirement. There were ten residents identified by the facility to have pressure ulcers. Concerns were found with nine of the ten residents reviewed. The facility census was 64. Findings include: During the annual survey, concerns were initially identified related to pressure ulcers within the facility based on observations that had been made of pressure ulcer treatment and also record review. On 08/17/11 beginning at 10:51 A.M. a meeting was held with administrative staff, including Licensed Practical Nurse (LPN) #5, LPN #6, the director of nursing (DON) and the corporate registered nurse (RN) to discuss wound care and pressure ulcer management within the facility. The following information was provided: From February, 2011 through 07/15/11, LPN #5 was responsible for wound care and restorative nursing services for the residents in the facility. This included weekly dressing changes and measurements/assessments and also tracking of the wounds in the facility. The floor nursing staff were responsible to complete the day to day (routine) dressing changes. On 07/15/11, LPN #6 took over the wound program at the facility. LPN #6 had been employed by the facility as a floor nurse on the ventilator wing since 11/08/10. LPN #6 did not have any wound care background or experience as a wound care nurse when she was placed in this position. The facility identified no RN who provided oversight or was directly involved in the facility pressure ulcer prevention and management program. In addition to LPN #5 and then LPN #6, the facility also contracted with a wound management consultant physician. This physician was asked by the facility to see residents with pressure ulcers, although no consult from a primary care physician would be noted, nor would any documentation from the wound management consultant be contained in any residents medical record. The frequency of these consultant visits could not be determined during the annual or extended survey. The administrator was interviewed on 08/17/11 at 3:10 P.M. regarding findings in relation to the extended survey to determine substandard quality care in pressure ulcers. She stated "it is what it is." She informed the survey team that LPN #5 was no longer the contact person for wounds, only LPN #6. She stated she recognized that pressure ulcers was a systemic problem. She stated she would be pulling in a wound nurse from another building to do head to toe assessments in light of the surveyors findings. 1. Resident #20 was admitted to the facility on [DATE] for rehabilitation following a left hip replacement. Information obtained prior to the resident's arrival revealed the resident's skin was free from pressure ulcers. An (undated) admission skin assessment revealed the resident's coccyx was pink and mushy. The assessment did not include any type of measurements of a "pink" area or include any other assessment documentation related to the term mushy. A skin risk assessment (Braden) completed on 07/12/11 revealed the resident was not at risk for skin breakdown. The assessment revealed the resident had no sensory impairment, was rarely moist, walked occasionally, had slightly limited mobility, had adequate nutrition and had only a potential problem with friction and shear as she moved feebly or required minimum assistance. Record review revealed no acute or immediate plan of care was initiated on admission related to any type of risk for skin breakdown or to reflect that the resident's coccyx was "pink and mushy". Continued review of nurse's notes from 07/12/11 through 07/17/11 revealed no written documentation related to the resident's skin condition, whether the "pink and mushy" area had resolved or what the resident's status was related to pressure ulcer development. On 07/18/11 a physician telephone order was received to cleanse the resident's coccyx with wound cleanser, apply Mesalt and cover with a foam dressing once a day. (Mesalt supports the cleansing of moderately to heavily discharging wounds including infected wounds. Mesalt works by releasing sodium chloride which stimulates the cleansing of heavily draining and discharging wounds in the [MEDICAL CONDITION] phase by absorbing exudate, bacteria and necrotic material from the wound, thereby facilitating the natural wound healing process). Record review revealed no written nurse's notes related to the development of a pressure ulcer to the resident's coccyx or any documentation that the pressure ulcer had been there at the time of admission. Review of a wound/skin care management documentation form, dated 07/18/11 revealed the resident was assessed to have an unstageable pressure ulcer to her coccyx that measured 2.4 centimeters (cm) in length by 1.4 cm in width with no depth noted. The pressure ulcer was assessed to have no granulation tissue present and was assessed to be 75% eschar. The assessment revealed the ulcer had a small amount of clear drainage and no odor. The periwound was assessed to have [DIAGNOSES REDACTED] present. Review of treatment administration records revealed the treatment to the coccyx was completed on 07/18/11, 07/19/11 and 07/20/11. There was no written documentation the treatment was completed as ordered on [DATE] or 07/22/11. Resident #20 was transferred to the hospital on [DATE] and did not return to the facility. No additional wound care or skin assessment documentation or evaluation of the unstageable pressure ulcer to the resident's coccyx was noted to have been completed in the resident's medical record. During the interview on 08/17/11 at 11:41 A.M. with LPN #5 and LPN #6 the concern was shared, that Resident #20 who was admitted to the facility on [DATE] with her skin intact and who was at low risk for skin breakdown, was found to have an unstageable pressure ulcer to her coccyx on 07/18/11. LPN #6 indicated she asked the wound consultant physician to see Resident #20 on 07/18/11 because she was concerned that the resident had been staying in bed and had a pink area on her coccyx. The LPN verified that when the physician looked at the area, he assessed her to have an unstageable pressure ulcer. The LPN verified there had been no documentation of the condition of the resident's skin prior to 07/18/11 which reflected any type of skin impairment. LPN #6 also verified the lack of written documentation that the dressing change to the area was being completed as ordered or that it had been completed on 07/21/11 and 07/22/11. 2. Resident #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review and interview with LPN #5 and LPN #6 on 08/16/11 at 12:43 P.M. revealed the resident was admitted on [DATE] with an open area to his left coccyx/upper buttock that measured 4.0 cm by 2.0 cm with no depth noted. LPN #5 verified she did not assess or evaluate the pressure ulcer until 06/14/11, two weeks later. The LPN was unable to provide any explanation related to why the wound was not assessed for that length of time. Record review revealed Resident #85 was hospitalized from [DATE] until 07/12/11. Skin assessment documentation, dated 07/13/11 revealed the resident had two pressure ulcers, a left upper buttock Stage II pressure ulcer measuring 0.5 cm in length by 0.7 cm width with 0.1 cm depth and a left lower buttock Stage II pressure ulcer measuring 0.4 cm in length by 0.4 cm width with 0.1 cm depth. An interview and review of Resident #85's medical record with LPNs #5 and #6 revealed the resident was assessed by the wound consultant on 07/18/11 and found to have an unstageable pressure ulcer to his coccyx area measuring 3.2 cm in length by 0.3 cm width with no depth noted. The pressure ulcer was assessed to have 75% eschar covering the wound bed thus making it unstageable. LPN #5 indicated the wound consultant identified the two pressure ulcers had become one. The LPN indicated the resident had not been seen or evaluated by the wound consultant since 07/18/11. Current facility measurements, dated 08/08/11 continued to reflect the resident had an unstageable pressure ulcer to his coccyx which measured 6.0 cm in length by 9.5 cm in width with no depth noted and 75% eschar. On 08/16/11 at 5:44 P.M., the treatment to Resident #85's coccyx was observed with LPN #5 and LPN #6. After obtaining supplies and entering the resident's room, the LPNs assisted the resident to turn onto his side. As the resident was turned to his side, no treatment was observed in place to the resident's coccyx. The resident was noted to be incontinent of urine at this time. LPN #6 verified the resident did not have a treatment in place as ordered at the time of the observation. The resident was noted to have an area of impairment to his coccyx. In addition, the resident's entire buttock was noted to be reddened and an open area was observed to his left buttock. LPN #6 identified multiple smaller abraised areas with one larger area in which she identified as unstageable to the resident's coccyx area. Interview with LPNs #5 and #6 following the completion of the skin care revealed they had no idea why a dressing was not in place. On 08/16/11 at 6:40 P.M. during an interview with the DON and corporate RN, the concern was shared related to the observation of no treatment being in place to an area identified as unstageable to Resident #85's coccyx. Review of the resident's treatment administration records with the DON and corporate RN at that time also revealed concerns related to the lack of documentation that the treatment was completed as ordered between 07/25/11 and 07/30/11 and between 08/03/11 and 08/08/11. No additional information was provided during the annual and extended survey related to why the resident's dressing was not being completed as ordered. 3. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed the resident was non-ambulatory and dependent on staff for all activities of daily living including bed mobility. The resident was assessed to be incontinent of bowel and bladder and received all of her nutrition/hydration via gastrostomy tube. Review of skin risk assessments, dated 07/04/11 and 07/13/11, revealed the resident was at high risk for skin breakdown. Additionally, record review revealed the resident was hospitalized from [DATE] through 07/13/11. Review of a hospital transfer sheet, dated 07/13/11 revealed the resident's skin was intact. Review of an undated admission skin assessment sheet revealed the resident had a 16 cm long by 15 cm wide reddened area with purple discoloration to her entire buttocks area. The form contained no date and no signature related to who completed it, but interview with LPN #6 on 08/18/11 at 10:26 A.M. revealed the skin assessment form was from 07/13/11 the day the resident was readmitted . Record review revealed no written skin assessments and/or wound documentation completed for Resident #10 between 07/13/11 and 08/11/11. On 08/11/11 a wound/skin care management documentation form revealed the resident was found to have a Stage II pressure ulcer to her left buttock. The ulcer was assessed to measure 2.9 cm in length by 2.6 cm width with 0.1 cm depth. The ulcer was assessed to have a small amount of clear drainage and no odor present. The most current pressure ulcer measurements, dated 08/15/11 revealed the resident continued to have a Stage II pressure ulcer to her left buttock measuring 2.8 cm in length by 2.6 cm width with 0.1 cm depth. On 08/17/11 at 4:29 P.M. the surveyor requested to observe the treatment/dressing in place to Resident #10's left buttock. After obtaining permission from the resident, LPN #19 and State tested Nursing Assistant (STNA) #21 were observed to roll Resident #10 onto her side. Resident #10 was observed to have an Allevyn (absorbent) dressing in place to her right buttock. The dressing was saturated with urine. There was no treatment/dressing in place to the Stage II pressure ulcer on the resident's left buttock. LPN #19 verified there was no treatment in place to the resident's left buttock and also indicated she was unaware of what was under the dressing to the right buttock. On 08/17/11 at 4:36 P.M., review of Resident #10's treatment administration record and physician orders [REDACTED]. LPN #19 verified the treatment was not in place as ordered and also verified there was no treatment order for the right buttock. LPN #19 proceeded to obtain supplies and then returned to Resident #10's room. On 08/17/11 at 4:47 P.M., LPN #19 was observed completing wound care to Resident #10. Upon removing the Allevyn treatment from the resident's right buttock, the resident was observed to have two Stage II pressure ulcers to the right buttock. The pressure ulcers were measured by LPN #19. An area to the right upper buttock measured 0.7 cm in length by 1.0 cm width with less than 0.1 cm depth. An area to the right lower buttock measured 0.7 cm in length by 0.6 width with less than 0.1 cm depth. The pressure ulcer to the left buttock was also measured at this time and found to be 0.5 cm in length by 0.5 cm width with less than 0.1 cm depth. On 08/18/11 at 10:26 A.M., during an interview with LPN #6 the concern was shared that Resident #10 was noted to have some type of skin impairment upon her re-admission on 07/13/11, however no additional assessments or monitoring were noted until 08/11/11 at which time the resident was assessed to have a Stage II pressure ulcer. The concerns related to the observations made on 08/17/11 with LPN #19 in which the physician ordered treatment to the left buttock was not in place as ordered and the development of two Stage II pressure ulcers to the right buttock was also shared. LPN #6 verified there was no documentation of the pressure ulcers to the right buttock and could not explain why the treatment was not in place as ordered to the left buttock. 4. Resident #98 was admitted to the facility on [DATE] with a Stage III pressure ulcer to her left lower hip. The pressure ulcer was assessed on 05/25/11 to measure 12 cm in length by 20 cm width with 0.1 cm depth. The pressure ulcer was noted to have less than 25% slough tissue present. Review of treatment administration records (TAR) revealed admission treatment orders were to cleanse the ulcer with wound cleanser and apply a treatment (aticoat) and foam three times per week and as needed. Treatment administration records revealed the treatment was provided on 05/26/11 but no other day in May, 2011. Record review revealed the next assessment of the pressure ulcer was on 06/16/11, 22 days later. The pressure ulcer was assessed to be a Stage II pressure ulcer measuring 0.5 cm in length by 0.5 cm width with 0.1 cm depth. The next assessment of the pressure ulcer dated 06/20/11 revealed it was a Stage III pressure ulcer measuring 10.5 cm in length by 14 cm in width with 0.1 cm depth. On 08/16/11 at 12:30 P.M., interview with LPNs #5 and #6 verified the lack of written pressure ulcer assessment documentation to ensure Resident #98's skin integrity was being comprehensively and accurately assessed. LPN #5 indicated the assessment dated [DATE] was most likely incorrect and from a different wound. No explanation could be provided related to why assessments were not being completed. Additional record review revealed no pressure ulcer assessment documentation completed between 07/11/11 and 07/28/11. Resident #98 continues to receive treatment to a Stage III pressure ulcer to her left lower hip as of the annual survey. The current treatment order, was to cleanse with wound cleanser, pat dry, apply Mesalt and cover with foam once a day. On 08/17/11 at 8:09 A.M., the treatment to Resident #98's left upper hip was observed with LPN #6 and LPN #5. After obtaining supplies and entering the resident's room, the resident was positioned so that the left hip area could be accessed by LPN #5. The resident was observed to have an Allevyn dressing in place to left hip area. After removing the dressing and cleansing the pressure ulcer, LPN #6 was observed to apply a piece of Mesalt and then covered the pressure ulcer with a combine ABD pad and then secured the dressing with tape. Following the completion of the dressing change, LPN #5 verified the treatment that had been removed from Resident #98's left hip was not the correct treatment. The LPN was unable to explain why the correct treatment had not been in place as ordered at that time. Also, following the completion of the treatment observation, LPN #6 was asked to provide wound tracking/assessment documentation for the residents pressure ulcer. The most current assessment that could be located, dated 08/11/11 reflected the Stage III pressure ulcer which measured 9.2 cm in length by 6.2 cm width with 0.1 cm depth. Additional concerns related to treatment administration were also noted in reviewing Resident #98's treatment administration records. Review of June, 2011 treatment administration records revealed no documentation that the daily dressing was completed as ordered from 06/27/11 through 06/30/11 and there was no written evidence the daily dressing was completed as ordered between 07/01/11 and 07/04/11. 5. Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive assessment (MDS 3.0) completed on 01/28/11 indicated Resident #53 was moderately cognitively impaired and required the extensive assistance of one person for activities of daily living. She used a walker and a wheelchair for mobility and had no fall or pressure ulcer history. The Braden scale pressure ulcer risk assessment dated [DATE], 03/19/11, 07/25/11, and 08/11/11 indicated she was at low risk for the development of pressure ulcers. Review of nursing notes dated 02/11/11 at 6:45 A.M. revealed the resident fell and sustained a laceration that required sutures. X-rays were negative for fracture at that time. On 02/11/11 at 11:00 P.M., 02/12/11 at 1:00 A.M., 02/12/11 at 10:35 P.M. and on 02/13/11 at 5:00 A.M. the resident complaint of right lower extremity pain and was given medication. The physician was notified of her pain an she was sent to the emergency room and returned to the facility on [DATE] at 12:30 A.M. The nurse noted the resident had red areas on the right lower extremity one inch long. The resident continued to complain of pain to the right lower extremity on 02/17/11 and 02/19/11. An X-ray was ordered and on 02/22/11 at 11:00 P.M. the results were negative for a fracture but [MEDICAL CONDITION] joint disease was found in the right ankle, knee and foot. Nurses notes dated 02/23/11 at 10:30 A.M. revealed the physical therapist called the nurse into the room. A raised bruised area was noted on the left lower extremity. The resident had slight discomfort. The physician was notified of the change and had the resident sent to the emergency room for an evaluation. The resident returned to the facility on [DATE] at 7:50 P.M. with a fracture to the right fibula bone. Physician orders [REDACTED]. - ice application for 20 minutes four times daily. - elevate the extremity. - use splint device until follow up appointment. - capillary refill within two seconds. - toes warm to touch. - no tingling/numbness. - resident can wiggle toes. Hospital aftercare instructions included: - monitoring of splint frequently throughout the day - check capillary refill (circulation) in the nail beds. The nail bed should turn white with pressure then promptly return to pink in less than two seconds. - check for swelling of the area beyond the splint - If skin of the foot or toes is excessively cold, pale, or numb to touch, the splint may be too tight. Loosen the wrap holding the splint in place or return to the hospital for adjustment. The following excerpts were taken from the nursing notes: 02/24/11 8:30 A.M. refusing to let ice packs stay in place, right foot pale pink in color with capillary refill less than three seconds. Pedal pulses two plus. 02/24/11 at 11:00 A.M. a physician visited and no new orders were received. 02/24/11 at 5:30 P.M. pedal pulses were two plus, color remains pale pink with capillary refill less than three seconds. 02/24/11 at 9:00 P.M. capillary refill less than three seconds, pedal pulses times two. 02/25/11 at 1:00 P.M. resting quietly, pedal pulses at two plus. 02/27/11 at 12:15 A.M. capillary refill within three seconds, pedal pulses two plus, toes warm to touch and able to move toes. There was no documented evidence the resident's right lower leg and toes were assessed at least daily on 02/26/11, 03/01/11, 03/02/11 and 03/03/11 by the facility. On 03/03/11 the resident was sent to the orthopedic physician at 2:30 P.M. Review of the consultation report dated 03/03/11 indicated when the cast was removed a full thickness skin loss on the dorsum of the right foot/ankle, white in color measuring 5.0 cm by 15 cm, and a heel decubitus (pressure ulcer) that was eschar (black dead tissue). He ordered Resident #53 be sent to the wound clinic as soon as possible and elevate the heels off the bed at all times. In addition he ordered rest and elevate the extremity to aid in [MEDICAL CONDITION] control and prevent further pressure on the heel and a dressing of a non adherent material gauze 4 x 4 and stretch gauze to wrap the area. The wound center document dated 03/07/11 indicated apply an active enzymatic ointment that continually removes necrotic tissue from wounds to the right heel and cover with a dry dressing daily and apply a topical antibacterial ointment to treat infection on the right anterior ankle daily. The plan of care dated 03/07/11 was consistent with the order. However, the facility plan of care dated 03/08/11 indicated to apply a topical mild [MEDICATION NAME] spray (to help keep the wound site free of necrotic tissue once debrided), apply an ABD pad (army battle dressing) and stretch gauze to the right heel every day; apply a topical antibiotic ointment and a non adherent material and stretch gauze to the right foot every day and apply a topical antiseptic/antimicrobial solution for one week on the bilateral heels and between the toes. The treatment was changed on 03/23/11 to apply a topical mild [MEDICATION NAME] spray to all wounds except the dorsal wound on the right foot. Add the non adherent material, ABD pad and a light compression dressing daily. The top of the right foot was to have non adherent material, gauze pad and ABD pad every day. On 03/15/11 the podiatrist visited the resident and wrote orders for her to be sent to the emergency room due to the multiple right foot wounds. He noted the ulcers were believed to be caused by a poorly applied posterior splint which was applied too tight due to the resident's vascular insufficiency. The ulcerations were deteriorating due to the lack of blood flow. The podiatrist and hospital notes lack any description of the pressure ulcers. The resident was readmitted to the facility on [DATE]. Weekly skin grids were reviewed from 03/07/11 until 08/11/11: On 03/07/11 the right lateral foot pressure ulcer measured eight cm by 2.5 cm and was 100% eschar. There was a gap between the 07/06/11 assessment when the pressure ulcer measured 3.0 cm by 3.8 cm 100% eschar and 08/11/11 when the eschar pressure ulcer measured 3.5 cm by 1.3 cm. There were 36 days between assessment/monitoring of the wound. The right heel was measured on 03/07/11 as 5.2 cm by 7.0 cm 100% eschar. There was a gap between the 07/06/11 assessment when the pressure ulcer measured 7.0 cm by 4.8 cm 100% eschar and 08/11/11 when the eschar pressure ulcer measured 4.8 cm by 6.1 cm. There were 36 days between assessment/monitoring of the wound. The top of the right foot was measured on 03/07/11 as a 16 cm by 6.0 cm Stage II pressure ulcer but no depth was indicated. On 03/15/11 the area was measured as 5.2 cm by 7.0 cm with 100% slough but again no depth was indicated. By 03/22/11 the area measured 15.5 cm by 6.0 cm and 100% eschar. LPN #5 had no explanation about the inconsistency of the measurements. There was a gap between the 07/06/11 assessment when the pressure ulcer measured 13 cm by 6.3 cm 100% eschar and 08/11/11 when the eschar pressure ulcer measured 11 cm by 5.5 cm. There were 36 days between assessment/monitoring of the wound. On 08/17/11 at 5:11 P.M. LPN #4 was in Resident #53's room. LPN #4 indicated administrative staff were in the process of assessing all current residents with wounds. Resident #53's entire top of the right foot was necrotic with yellow slough at the end near the ankle. A very strong/foul odor was noted. The outside of the right foot had a black elongated area. The entire right heel was black and was lifting away. There was active bleeding around the edge. The resident expressed no evidence of pain to area. LPN #4 stated Resident #53 sustained a fracture in the facility and was sent to the hospital where she received nonsurgical intervention and was casted. When the cast was removed the ulcers were under cast. Interview with the care plan coordinator, RN #3, on 08/18/11 at 11:30 A.M. verified no plan of care was developed related to the splint or to zero-G boots that had been ordered. On 08/18/11 at 12:10 P.M. the surveyor informed the DON, and corporate RN about the following findings: lack of documentation of the splint, lack of assessment of the splint and of the wound and lack of care planning related to the splint. Interview with the DON on 08/19/11 at 8:00 A.M. indicated there was no order or plan to monitor the splint other than the aftercare sheet from the hospital. 08/19/11 at 6:15 A.M. Resident #53 gave permission to observe the dressing changes to her right foot pressure ulcers. The dressing change was completed by LPN #6 with the assistance of the care plan coordinator RN #3. LPN #6 informed the surveyor Resident #53 was pre-medicated. The zero-G boot was removed from the right foot. The interior of the boot was soiled with dried brown drainage. Upon removal of the dressing a foul odor emanated from the foot and permeated the room. The entire heel was covered in black necrotic tissue that was lifting at one end. LPN #6 stated the area measured 5.3 cm by 6.1 cm. There was a second black necrotic area to the right lateral foot that measured 3.8 cm by 2.4 cm. The top of the right foot had a large area that was black and necrotic three quarters of the way the other quarter had exposed tendon and yellow slough that measured 13.9 cm by 7.5 cm. Each wound was cleansed with normal saline using different gauze to pat dry. The same treatment was performed on each area. A topical antibiotic ointment was applied to the edges of each wound using a Q-tip. Then the area was sprayed with the mild [MEDICATION NAME] agent, a non adherent material was cut to fit each area and applied, a 4 x 4 gauze was placed on top of each ulcer then an ABD pad was put on top of the gauze and the entire foot up beyond the ankle was wrapped in stretch gauze. The pungent foul odor remained in the room during the entire observation. LPN #25 was interviewed on 08/19/11 at 8:15 A.M. She informed the surveyors she cared for Resident #53 during the time when she had the splint. She stated it was a hard cast that went from the middle of the foot up to about the middle of the calf. She stated it was not removable. She stated you could do pedal pulses near the toes. She was unable to recall if the area was swollen. 6. Review of the medical record for Resident #95 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission nursing assessment dated [DATE] revealed Resident #95 was a high risk for skin breakdown. Review of the wound skin grids dated from admission on 04/08/11 through 07/11/11 revealed a left heel pressure ulcer, right heel pressure ulcer, left thigh pressure ulcer, left upper buttock pressure ulcer, left lower buttock pressure ulcer, and a right leg pressure ulcer. Review of Resident #95's care plans revealed a care plan for the prevention of impaired skin integrity was not initiated until 05/10/11. Review of the impaired skin integrity care plan initiated on 05/10/11 revealed interventions including monitor heels every shift and report negative changes to the physician and weekly skin checks, monitor for signs and symptoms of skin breakdown. Review of the treatment administration record (TAR) and the medical record from admission through the time of the annual survey revealed no evidence to indicate Resident #95 received heel and skin checks as required. Review of the TAR dated May, 2011 revealed Resident #95 was ordered cleanse right heel wound with wound cleanser, apply Mesalt and a foam dressing every day on 05/03/11. The TAR did not provide evidence to indicate the right heel wound treatment was done on 05/03/11, 05/04/11, 05/05/11 and 05/06/11. The May, 2011 TAR also revealed Resident #95 was ordered cleanse left buttock with wound cleanser, apply Mesalt, pack with Mesalt, cover with foam dressing daily ordered on [DATE]. The TAR did not provide evidence to indicate the wound treatment to the left buttock was completed on 05/03/11, 05/05/11 and 05/06/11. Review of the wound grids dated 07/11/11 revealed Resident #95's left thigh pressure ulcer measured 1.0 cm long by 4.0 cm wide by 0.1 cm deep and was a Stage II pressure ulcer with 75% granulation and a small amount of bloody drainage. Review of the nurse's notes from 07/11/11 through 07/18/11 revealed no documentation of the resident's wound appearance, a wound assessment or wound measurements. Review of the next documented wound assessment which was documented by the wound care phy

Based on observations, staff interviews and clinical record reviews, the facility failed to ensure adequate and effective administrative oversight was provided to all residents, related to pressure ulcers and skin conditions, pain, incontinence care, positioning, range of motion and [MEDICAL CONDITION] medications. This affected Residents #6, #10, #20, #34, #53, #56, #63, #78, #84, #85, #95, #98, #100, #101 and #103. This affected 12 of 64 residents who reside in the facility plus three discharged resident records. Findings include: 1. The facility failed to ensure adequate monitoring of Residents #20, #34 and #100's condition. See F309. 2. The facility failed to ensure proper positioning for Residents #6 and #84's legs when seated in a wheelchair and failed to ensure Resident #78 was provided timely incontinence care. Reference F312. 3. The facility failed to implement a comprehensive wound care program designed to identify, assess, treat and prevent pressure ulcers for Residents #10, #20, #53, #63, #56, #85, #95, #98 and #101. Reference F314. 4. The facility failed to implement a passive range of motion program for Resident #10. Reference F318. 5. The facility failed to ensure Resident #84's gastrostomy tube site was treated to prevent skin breakdown. Reference F322. 6. The facility failed to ensure a medical diagnosis, assessment and dose reduction attempt of [MEDICAL CONDITION] medication for Residents #85 and #103. Reference F329. This deficiency substantiates allegations contained in Complaint Numbers OH 826, OH 873 and OH 883.