Every finding on record at Wesleyan Village

Based on observations, resident and staff interviews, record reviews for nursing staff schedules, timecards, facility assessment, and Payroll Based Journal, the facility failed to maintain sufficient staffing levels to ensure residents received timely care and services. This affected Residents #3, #13, #24, #37, #62, #64, and #73 and had the potential to affect all 79 residents residing in the facility.Findings include: 1. Interviews with residents during the survey revealed they had concerns with staffing. Residents stated they have to wait too long for their call lights to be answered, and receive timely assistance with incontinence care and activities of daily living (ADLs). During an interview on 07/06/26 at 10:36 A.M., Resident #73 stated a few weeks ago she waited four hours and then two hours another time for her call light to be answered. Resident #73 stated she had to sit in her 'waste' and was lucky she did not get a bed sore. During an interview on 07/06/26 at 11:06 A.M., Resident #3 stated there was not enough staff, and it was an ongoing problem. Staff do not meet her needs timely, it takes hours and she will be 'wet'. During an interview on 07/06/26 at 11:16 A.M., Resident #37 stated it takes a while to get personal care done because they were short staffed. Sometimes there was one certified nursing assistant (CNA) for the whole floor and there were over 30 residents residing on the floor she resided on. During an interview on 07/06/26 at 11:28 A.M., Resident #24 stated staffing was horrible, two CNA and one nurse for the floor she resided on. Call lights and care were not being completed timely. During an interview on 07/06/26 at 2:43 P.M., Resident #62 stated call lights were long and the average was two hour wait time. During an interview on 07/06/26 at 10:50 A.M., Resident #64 stated she has had her call light on for a while and she was 'wet' and need changed. Staff do not answer call lights timely, so residents must just wait. During an interview on 07/06/26 at 3:20 P.M., Resident #13 stated staff do not answer call lights timely. 2. Observation of call lights revealed staffing were not answering the residents' call lights timely. During an observation on 07/06/26 from 10:50 A.M. to 11:50 A.M., Resident #64's call light was on and displaying on the call light board. No staff entered Resident #64's room until 11:36 A.M. Resident #64 had to 46 minutes for their call light to be answered. At 11:42 A.M., Certified Nursing Assistant (CNA) #692 went into Resident #64's room and stated the meal trays were present on the floor and the resident must wait until lunch was over and Resident #64 will be the first person to receive care after lunch. During an interview on 07/06/26 at 11:44 A.M., CNA #692 stated she has been on her assignment since 7:30 A.M. and she was the only CNA for over an hour and then there were two CNAs. CNA #692 stated Resident #64 would have to wait until she passed trays before she could provide incontinence care. CNA #692 stated there was no other staff available to provide incontinence care and CNA #692 would provide it after lunch. At 11:57 A.M., after incontinence care was provided to Resident #64, CNA #692 stated she got in report the last time Resident #64 had been changed was at 5:30 A.M. in the morning. CNA #692 verified this was the first time Resident #64 received incontinence care since 5:30 A.M. This was over six hours that Resident #64 received incontinence care. CNA #692 reported they were short staffed and have not been able to get caught up. During observations and on 07/06/26 from 3:10 P.M. to 4:00 P.M. on the third floor, Resident #13's call light was on of the call light board and in her room. No staff answered her call light during this 50 minutes of observations. At 3:33 P.M., CNA #621 walked down the hall and looked at the call light board and told Registered Nurse (RN) #920 that she was going to document care provided and proceeded down the hall, walked past Resident #13's room and sat at the CNA station. CNA #621 did not answer Resident #13's call light. During an interview on 07/06/26 at 3:20 P.M., Resident #13 stated she has been waiting for her call light to be answered for a while and she wanted staff to provide incontinence care and change her brief. During an interview on 07/06/26 at 3:50 P.M., RN #689 verified Resident #13's call light was on and had not been answered. CNA #621 stated call lights can take 30 minutes to be answered because staff were very busy. CNA #621 verified she did see that Resident #13's call light was on, but Resident #13 was not on her assignment, and she needed to do her documenting from last shift. During an interview on 07/06/26 at 4:00 P.M., Nursing Supervisor #681 stated call lights should be answered within five to ten minutes. 3. Review of the facility assessment dated [DATE] with a revision date of 01/06/26 revealed the staffing plan included staffing on each unit may vary based on acuity and census. There will be at least the following staff per floor: The second floor will have two CNAs and one nurse on all shifts, the third floor will have two to three CNAs, and two nurses all shifts, and the fourth floor will have two CNAs and one nurse all shifts. Interview on 07/13/26 at 3:22 P.M. with Administrator verified the staffing levels documented in the facility assessment. Review of the Payroll Based Journal report revealed the facility had a one-star staffing rating and was identified with low weekend staffing for Fiscal Year Quarter Two 2026 (01/01/26, through 03/31/26). Review of the staffing assignment schedule for 07/04/26 and timecards for third shift on 07/03/26 and day shift on 07/04/26 revealed that there was only one CNA on third floor from 7:53 A.M. to 9:00 A.M. This was verified by Regional Administrator (RA) #908 on 07/13/26 at 1:00 P.M. Review of the resident census sheet dated 07/04/26 for third floor revealed there were 37 residents. Review of the staffing assignment schedule for 07/06/26 and timecards for third shift on 07/05/26 and day shift on 07/06/26 revealed there was only one CNA on third floor from 7:53 A.M. to 8:24 A.M. This was verified by RA #908 on 07/13/26 at 1:00 P.M. Review of the resident census sheet dated 07/06/26 for third floor revealed there were 37 residents. During an interview on 07/09/26 at 1:08 P.M., Scheduler #575 revealed the schedules were based on census. CNAs worked eight-hour shifts and nurses worked 12-hour shifts. Scheduler #575 schedules one nurse on second and fourth floors, third floor gets two nurses on the first 12-hour shift and one for the second 12-hour shift with one nurse who works until 11:00 P.M. Scheduler #575 also stated she schedules two CNAs on second and fourth floor all three shifts, three CNAs on first and second shifts and two CNAs on third shift for the third floor. Review of the staffing assignment schedule for 07/13/26 revealed there was only one CNA on fourth floor from 7:30 A.M. to 9:30 A.M. This was verified by RA #908 on 07/13/26 at 1:00 P.M. Review of the resident census sheet dated 07/13/26 for fourth floor revealed there were 25 residents. During an observation on 07/13/26 from 8:40 A.M. to 8:50 A.M. revealed there was one CNA for the fourth floor for the 22 residents who resided on the fourth floor. During an interview on 07/13/26 at 8:40 A.M., CNA #613 stated she was the only CNA on fourth floor today and could not do Hoyer lifts for residents. CNA #613 stated there was a call off and was waiting for additional assistance to get residents up out of bed. CNA #613 stated the nurse could assist but was busy passing medications. During an interview 07/13/26 at 8:45 A.M., Licensed Practical Nurse (LPN) #635 stated she could assist the CNA but she wanted to complete medication administration first. During interviews on 07/13/26 from 8:55 A.M. to 9:05 A.M., the Administrator and Director of Nursing (DON) revealed they were not aware of only one CNA was working on the floor and would be checking into this. At 9:05 A.M., the Administrator stated the DON was using the second floor CNA for wound rounding and the scheduler would be coming up to the fourth floor to work as a CNA. During an interview on 07/13/26 at 9:10 A.M. with fourth floor staff revealed there were still no additional personnel to work as an CNA. CNA #613 stated the scheduler will be coming up around 11:00 A.M. to assist. During an interview on 07/13/26 at 9:25 A.M., Administrator stated the scheduler will be going upstairs around 11:00 A.M. to assist. This deficiency represents non-compliance investigated under Master Complaint Number 3071909, Complaint Number 3053651, Complaint Number 3019078, Complaint Number 2697068, Complaint Number 2661800, Complaint Number 2647609, Complaint Number 2585604, Complaint Number 2576643, Complaint Number 1257524 (OH00165706), Complaint Number 1257523 (OH00165408), and Complaint Number 1257521 (OH00163978).

Based on observations, policy review, and staff interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect 76 of 79 residents who received food from the kitchen. Three residents (Residents #8, #28, and #57) received enteral nutrition and did not receive meals from the kitchen.Findings include:On 07/06/26 at 8:43 A.M., observations of the kitchen with Director of Dining #533 revealed the stand-up cooler was dirty in the inside with pepperoni, crumbs and a sticky substance on the floor. The shelves above the stove, microwave and prep area were all dirty with crumbs and a greasy film. Observation of the walk-in freezer revealed ice build-up on the freezer floor and a box of clams. In the walk-in cooler, there were two partial boxes of egg patties, a loaf of bread, and a partial box of bagels were all open to air and not sealed. Observation of the clean pots and pans revealed five medium pans were stacked and were stored wet. The front and side of the convection oven was dirty with food splatters and dried liquid. The stand-up warmer was dirty inside with splatters, spillage and food on the shelves and floor. The three plate holders were dirty with food and crumbs containing approximately 30 wet plates. On the cart where clean dessert dishes were kept, approximately 30 eight ounces dessert cups and six four ounce dessert cups were stored wet. Director of Dining #533 confirmed the findings during the observations of the kitchen.Interview with the Director of Dining #533 on 07/06/26 at 9:00 A.M. verified all the above observations. Director of Dining #533 stated all food should be sealed and not left open to air, dishes were not to be put away wet and appliances and shelves should be kept cleaner. Director of Dining #533 stated there was a cleaning schedule for the kitchen but does not think was being followed. The facility identified Resident #8, #28, and #57 were nothing by mouth (NPO).Review of the facility policy titled Food Receiving and Storage dated July 2014 revealed food shall be received and stored in a manner that complies with safe food handling practices. The food services, or other designated staff, will maintain clean food storage areas at all times. All food stored more than 24 hours in the refrigerator or freezer will be covered, labeled and dated. All foods open must be dated and sealed or covered during storage.

Based on observation, staff interviews, and policy review, the facility failed to ensure all narcotic count sheets were signed, completed, and maintained to ensure the disposition of all controlled drugs included accurate receiving, dispensing, and reconciliation of all controlled substance medications at every shift change. This had the potential to affect 31 residents who received controlled substances at the facility. The facility census was 79.Findings include:Observation on 07/09/26 at 10:00 A.M. revealed the narcotic count sheets on the third floor were reviewed with Registered Nurse (RN) #689. There were no co-signatures on the narcotic count sheet for medication cart #1 on: 07/06/26 7:00 A.M., 07/06/26 7:00 P.M., 07/07/26 7:00 A.M., 07/07/26 7:00 P.M., 07/08/26 7:00 A.M., 07/08/26 7:00 P.M., and 07/09/26 7:00 P.M. Medication Cart #2 was missing co-signatures on the narcotic count sheet on 07/06/26 7:00 P.M. and 07/06/26 7:00 A.M.Observation on 07/09/26 at 10:45 A.M. the narcotic count sheets on the fourth floor were reviewed with RN #689. There were no co-signatures on the narcotic count sheets for: 07/06/26 7:00 A.M., 07/06/26 7:00 P.M., 07/07/26 7:00 A.M., 07/08/26 7:00 A.M., and 07/08/26 7:00 P.M.Interview with RN #689 on 07/09/26 at 11:50 A.M. confirmed the multiple missing signatures on the narcotic count sheets on the third and fourth floor. RN #689 stated the staff often forget to sign before leaving facility. RN #689 was also observed signing blank signature lines on the documents after verifying with the State Agency Surveyor.Review of the facility policy titled Controlled Substances revised December 2012 revealed nursing staff must count controlled medications at the end of every shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services.

Based on observations and resident and staff interviews, the facility failed to serve food to the residents at palatable temperatures. This affected nine residents (#9, #12, #13, #34, #38, #53, #73, #77, and #81) and had the potential to affect the residents who receive meal trays in their room. The facility census was 79.Findings include:During interviews with residents who attended the resident council meeting on 07/07/26 at 11:05 A.M., Residents #9, #12, #13, #38, #53 and #81 revealed the food was not served at palatable temperatures during multiple meals.Observations on 07/08/26 from 11:08 A.M. to 12:25 P.M. with [NAME] #546 revealed at 11:08 A.M., the food temperatures on the table warmer revealed the hot food and cold food were being held at appropriate temperatures.At 11:28 A.M., the first food delivery cart left the kitchen and was delivered at 11:30 A.M. to the third floor hall. The food delivery cart was put in the common area for the floor staff to pass out the meal trays to residents in their rooms. At 11:37 A.M., one certified nursing assistant (CNA) (#616)started passing the food trays. The last tray was served at 12:10 P.M. (33 minutes) later. The second food delivery cart was delivered to the third floor at 11:40 A.M. and the last tray was delivered at 12:25 P.M. (45 minutes). At 12:10 P.M., the test tray was completed using the last tray in the first food delivery cart with Director of Dining #533 and Dietary Supervisor #546. The ice cream was melted to a milkshake consistency, milk was at 55-degrees Fahrenheit (F), cold bean salad at 62 degrees F, chicken filet at 121 degrees F and juice was at 47 degrees F. The cold food was too warm and did not taste good and the chicken was lukewarm to taste. Interview on 07/08/26 at 12:12 P.M. with Director of Dining #533 and Dietary Supervisor #546 stated the meal trays should be passed as soon as the food delivery carts were delivered to the floor to ensure the food temperatures were maintained at a palatable temperature and the cold food was cold and the hot food was hot. Dietary Supervisor #533 verified the food was not served at a palatable temperature.Interview on 07/08/26 at 12:15 P.M. with CNA #616 stated she had to pass her meal trays to the residents by herself and that was why the resident's food was not delivered timely. CNA #616 stated it was usually one CNA to pass meal trays on the hall on the third floor.Interview on 07/08/26 at 12:17 P.M. with Resident #77 stated his meals were ok, but the ice cream was melted, and the hot food was a little warm, but he could eat it.Interview on 07/08/26 at 12:19 P.M. with Resident #34 stated her milk was not cold, and her ice cream was melted. Resident #34 stated she would like it colder, but it takes them so long to pass the trays. Interview on 07/08/26 at 12:20 P.M. with Resident #73 stated the food was ok but has to eat her ice cream first because it was already melted.This deficiency represents non-compliance investigated under Complaint Number 2661800.

Based on observations, interviews, and policy review, the facility failed to maintain resident rooms, handrails, and hallways in a safe, clean and orderly manner. This affected 13 residents (#1, #13, #15, #20 #21, #32, #33, #34, #53, #63, #70, #72, and #80) with the potential to affect all 50 residents of the second and third floor. The facility census was 79. Findings include:1. A tour of the facility was conducted on 07/08/26 from 3:21 P.M. to 4:10 P.M. with Maintenance Director #604 and Regional Facilities Director #910 and revealed the following: 1a. Resident #32's room had a significant chipped corner and chipped drywall near the thermostat.1b. The hallway outside of Resident #1's room had wallpaper peeling up at a charting area near the fire door.1c. Resident #33's bathroom had wallpaper peeling by the toilet and under the toilet paper holder.1d. Resident #21 had peeling wallpaper in the bathroom.1e. The charting area across from Resident #21's room had peeling wallpaper.1f. Resident #70's room had linoleum peeling up and drywall damage behind his bed.1g. Resident #15 had baseboard trim laying on the floor behind her bed and worn linoleum.1h. The carpeted hallway outside of Resident #13's room was heavily soiled and stained and wallpaper was peeling near the stairwell entrance door.1i. Resident #63's cork board on the wall beside her bed had numerous stains and dried debris on it. Resident #63's and Resident 20's shared bathroom had a large chip in the counter in front of the sink and duct tape around the corner of the bathroom counter.1j. Resident #34's room had gouges in the drywall.1k. Resident #53's room had peeling wallpaper in the bathroom, scuffs on the wall and a broken corner trim piece.1l. The handrail throughout the third floor had large amounts of scuffs and missing paint.1m. Resident #80's bathroom had discolored trim and flooring around the toilet that appeared to be from an old leak.1n. The handrail throughout the second floor had large amounts of chipped and missing paint. Interviews during the tour of the facility on 07/08/26 from 3:21 P.M. to 4:10 P.M. revealed all findings were verified at the time of observation with Maintenance Director #640 and Regional Facilities Director #910. At 3:50 P.M., Maintenance Director #640 revealed when residents' bathroom counters had large chips they were to be repaired. At 3:52 P.M., Regional Facilities Director #910 revealed facility staff will spot clean the hallway carpet on the third floor, but they were professionally cleaned approximately every six months, but it had been closer to a year since the carpets were professionally cleaned. 2. Observation on 07/06/26 at 11:28 A.M. of Resident #72's room in the secured memory care unit revealed there was no thermostat cover on the wall and wires were exposed. This observation was confirmed by Certified Nursing Assistant (CNA) #622 who indicated she would make the nurse aware. Observation on 07/09/26 at 10:13 A.M. of Resident #72's room revealed there was no thermostat cover on the wall and the wires remained exposed. This observation was confirmed by Licensed Practical Nurse (LPN) #909. Interview on 07/09/26 at 12:36 P.M. with the Director of Nursing (DON) revealed the thermostat cover should have been fixed as it was a hazard and the DON would update the maintenance department. Review of the facility policy titled Maintenance Service dated 12/2009 revealed maintenance service was to be provide to all areas of the building and equipment, and maintenance was responsible for always maintaining the facility in safe and operable manner. Review of the facility policy dated Quality of Life-Homelike Environment dated 05/2017 revealed residents were to be provided a safe, clean, and comfortable environment, and facility staff were to maximize a clean, sanitary, and orderly environment. This deficiency represents noncompliance investigated under Complaint Numbers 2585604 and 2576643.

Based on observations, record review, resident and staff interviews, and policy review, the facility failed to ensure call lights were within reach of residents. This affected two (Residents #10 and #34) of 40 residents reviewed in the initial pool sample. The facility census was 79.Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 05/23/25. Diagnoses included dementia, chronic obstructive pulmonary disease, depression, anxiety, and congestive heart failure. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had impaired cognition, exhibited behaviors, and required staff assistance with activities of daily living (ADL). Review of the care plan dated 05/23/25 revealed Resident #10 had ADL deficits. Interventions included to encourage the resident to use bell to call for assistance. Observation and interview on 07/06/26 at 10:56 A.M. revealed Resident #10 was resting in bed with call light wrapped up and behind night stand away from the resident. Certified Nursing Assistant (CNA) #622 confirmed the location of the call light and verified it was not within Resident #10's reach. Observation and interview on 07/09/26 at 10:13 A.M. revealed Resident #10's call light was wrapped up behind Resident #10's night stand. Licensed Practical Nurse (LPN) #909 confirmed the call light placement and stated she was unsure why it was out of reach as Resident #10 can use her call light. Interview on 07/09/26 at 10:41 A.M. with the Director of Nursing (DON) revealed residents should always have their call lights in reach. 2. Review of the medical record for Resident #34 revealed an admission date 04/01/17. Diagnoses included dementia, palliative care, and intellectual disabilities. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact. Observation and interview on 07/06/26 at 10:58 A.M. revealed Resident #34 was unable to reach her call light. Resident #34 was lying in bed and the call light was hanging over the end of the bed where her feet were. Resident #34 stated she could not reach her call light. Interview on 07/06/26 at 11:02 A.M. with Activities Personnel #507 verified Resident #34's call light was out of reach and Resident #34 was unable to use the call light if she needed anything due to it being out of reach. Review of the facility policy titled Answering the Call Light dated October 2010 revealed when the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident.

Based on record review and staff interview, the facility failed to ensure accurate advanced directive information was present throughout the residents' medical record. This affected one (Resident #1) of one resident reviewed for advanced directives. The facility census was 79.Findings include:Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included polyosteoarthritis and acute and chronic respiratory failure with hypoxia.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 had moderate cognitive impairment.Review of the physicians' orders for Resident #1 in the electronic record revealed an order dated [DATE] for Do Not Resuscitate Comfort Care (DNRCC) code status signifying cardiopulmonary resuscitative (CPR) measures were not to be conducted in case of cardiac or respiratory arrest.Review of Resident #1's hard chart revealed a signed Do Not Resuscitate Comfort Care Arrest (DNRCCA) code status form dated [DATE] (providers will treat patient as any other without a DNR order until the point of cardiac or respiratory arrest at which point all interventions will cease and the DNR comfort care protocol will be implemented).Interview on [DATE] at 10:35 A.M. with Licensed Practical Nurse (LPN) #697 verified that Resident #1 's electronic chart stated DNRCC and the paper in the hard chart stated DNRCC-A. LPN #697 stated that she would look into the electronic chart for code status if someone was coding. Review of the facility policy titled Advance Directives dated 03/2017 revealed the resident's advance directives will be respected.

Based on observations, resident and staff interviews, and medical record review, the facility failed to ensure residents who were dependent on staff with their activities of daily living (ADL) received timely and routine assistance with incontinence care and bathing and adequate nail care. This affected three (Resident #13, #64, and #70) of three residents for ADL care. The facility census was 79.Findings include:1. Review of the medical record for Resident #64 revealed an admission date 10/08/22. Diagnoses included adult failure to thrive, Parkinson's disease and epilepsy.Review of the plan of care dated 01/24/25 revealed Resident #64 was at risk for incontinence of bowel and bladder due to decline in physical and cognitive function. Interventions included checking for incontinence, clean and dry skin if wet or soiled, and using pads/briefs to manage incontinence.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 had impaired cognition and was dependent on staff with toileting and personal hygiene. Resident #64 was frequently incontinent of bowel and bladder.Interview on 07/06/26 at 10:50 A.M. with Resident #64 stated she has had her call light on for a while and she had 'wet' herself and staff do not answer call lights timely, so she has to just wait.Observation of call lights on 07/06/26 from 10:50 A.M. to 11:50 A.M. revealed Resident #64's call light was on outside her door and was displaying on the call light board. No staff entered Resident #64's room until 11:36 A.M.Interview on 07/06/26 at 11:37 A.M. with Occupational Therapy Assistant (OTA) #921 revealed when she came in the room to assist Resident #38 (the roommate), OTA #921 noticed Resident #64's call light was on. Resident #64 wanted a drink and needed to be changed due to being wet. OTA #921 stated she would let nursing know.Observation on 07/06/26 at 11:40 A.M. with Activities Personnel #565 revealed she entered Resident #64's room and asked what Resident #64 needed. Resident #64 stated she was wet and needed to be changed. Activities Personnel #565 stated she would let staff know and left the room. Observation on 07/06/26 at 11:42 A.M. revealed Certified Nurse Assistant (CNA) #692 entered Resident #64's room and stated the meal trays were on the floor and told Resident #64 she would have to wait until lunch was over. CNA #692 told Resident #64 she would be the first person CNA #692 provided assistance with after lunch. Interview on 07/06/26 at 11:44 A.M. with CNA #692 stated she has been working since 7:30 A.M. and there was only one CNA for over an hour and then there were two CNAs. CNA #692 stated Resident #64 would have to wait until she passed trays before she could change her. CNA #692 was asked if someone else could change her and she stated no, but CNA #692 would change her after lunch.Observation on 07/06/26 at 11:50 A.M. of incontinence care for Resident #64 with CNA #692 revealed Resident #64's adult brief was heavily wet with a small bowel movement.Interview on 07/06/26 at 11:57 A.M. with CNA #692 verified the last time Resident #64 was changed was at 5:30 A.M. in the morning. CNA #692 was provided this information when she completed report with the night shift CNA. CNA #692 verified she had not provided incontinence care during her shift until 11:50 A.M. This indicated Resident #64 did not receive incontinence care or was checked for incontinence for over six hours. CNA #692 stated they were short staffed and was just catching up on her assignment. 2. Review of Resident #70's medical record revealed an admission date of 05/26/26. Diagnoses included paraplegia and osteomyelitis (bone infection) of sacral vertebra.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #70 was cognitively intact, did not reject care, and was dependent on staff for bathing. It was very important for Resident #70 to choose between a tub bath, shower, or bed bath. Review of the care plan revealed Resident #70 had an ADL care self-deficit related to paraplegia. Interventions included staff assistance with bathing and to check nail length on bath day and to trim and clean as necessary.Review of the progress notes from 05/26/26 to 07/08/26 revealed the absence of documentation that Resident #70 refused bathing.Review of the facility's shower schedule revealed Resident #70 was to be bathed twice weekly on Wednesday and Saturday.Review of the shower sheets from 05/27/26 to 07/08/26 revealed Resident #70 did not receiving bathing on 06/03/26, 06/10/26, 06/13/26, 06/17/26, 06/27/26, and 07/04/26. There was no documentation that Resident #70 refused bathing those days or was offered a bath/shower any other day of the week. Resident #70 received seven bed baths on 05/27/26, 05/30/26, 06/06/26, 06/20/26, 06/24/26, 07/01/26, and 07/08/26 and received nail care on three days on 05/27/26, 05/30/26, and 07/08/26.Observation on 07/06/26 at 2:21 P.M. revealed Resident #70 had fingernails that were long and jagged.An interview on 07/07/26 at 11:07 A.M. with Resident #81 revealed staff were not providing bathing twice per week.An interview on 07/09/26 at 11:44 A.M. with Licensed Practical Nurse (LPN) #602 revealed residents were to receive bathing twice per week and that nail care was performed on shower days if needed.Observation and interview on 07/09/26 at 12:01 P.M. revealed Resident #70 had fingernails that were long and jagged. During the observation, Resident #70 asked LPN #620 if he could be scheduled for nail care because his fingernails were long. LPN #602 verified Resident #70's fingernails were long and jagged. An interview on 07/13/26 at 10:13 A.M. with the Director of Nursing (DON) verified Resident #70 was not bathed twice weekly according to the shower sheets.3. Review of the medical records for Resident #13 revealed an admission date 03/25/20. Diagnoses included multiple sclerosis, hemiplegia and hemiparesis, and muscle weakness.3a. Review of the plan of care dated 02/12/26 revealed Resident #13 was at risk for bowel and bladder incontinence due to declines in physical and cognitive function related to multiple sclerosis. Interventions included to check for incontinence, clean and dry skin if wet or soiled, and use pads/briefs to manage incontinence.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had impaired cognition. Resident #13 was dependent on staff with toileting, transferring, and personal hygiene. Resident #13 was frequently incontinent with bowel and bladder.Observations on 07/06/26 at 3:10 P.M. of the call light board on third floor revealed Resident #13's call light was turned on. Interview on 07/06/26 at 3:20 P.M. with Resident #13 stated she has been waiting for her call light to be answered for a while and staff do not answer call lights timely. Resident #13 stated her brief needs to be changed. Observation on 07/06/26 at 3:24 P.M. revealed Registered Nurse (RN) #689 sitting at the nursing station working on the computer and certified nursing aides (CNAs) walking around. Resident #13's call light had still not been answered. Observation on 07/06/26 at 3:32 P.M. revealed CNA #610 walked by Resident #13's room and did not answer the call light.Observation on 07/06/26 at 3:33 P.M. revealed CNA #621 walked down the hall and looked at the call light board and told RN #920 she was going to chart and proceeded down the hall and sat at the CNA station which was located by Resident #13's room. CNA #621 did not answer Resident #13's call light. Interview on 07/06/26 at 3:44 P.M. with RN #689 stated call lights should be answered within five to 10 minutes. RN #689 stated anybody can answer call lights. The only way she knows if a call light was on was if she looked at the call light board. Interview on 07/06/26 at 3:50 P.M. verified Resident #13's call light was on and had not been answered. RN #689 asked Resident #13 what she needed, and Resident #13 stated she was dirty and needed changed. She has been waiting for some time. Interview on 07/06/26 at 3:50 P.M. with CNA #621 stated call lights can take 30 minutes to be answered because they were very busy. CNA #621 verified did see that Resident #13's call light was on, but it was not in her assignment, and she needed to do her charting from last shift. Interview on 07/06/26 at 3:52 P.M. with CNA #610 stated she seen the call light was on the call light board but thought it was CNA #621's call light and did not realize it was her call light. CNA #610 stated she was going into Resident #13's room to take care of her. 3b. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed it was very important for Resident #13 to choose between a tub bath, shower, or bed bath.The quarterly MDS 3.0 assessment dated [DATE] revealed Resident #13 was moderately cognitively impaired, did not reject care, and was dependent on staff for most ADLs.Review of the care plan revealed Resident #13 had a self-care deficit related to cognitive function, multiple sclerosis, and stroke. Interventions included staff assistance for bathing and Resident #13 was resistive to care related to bathing which included reapproaching at a different time.Review of the shower schedule revealed Resident #13 was to be bathed twice weekly on Wednesday and Saturday.Review of the progress notes from 04/12/26 to 07/13/26 revealed the absence of documentation Resident #13 refused bathing assistance.Review of the shower sheets from 04/04/26 to 07/11/26 revealed Resident #12 did not receive bathing on 04/08/26, 04/11/26, 04/25/26, 05/16/26, and 06/13/26. There was no documentation that Resident #13 refused bathing those days or was offered a bath/shower any other day of the week. An interview on 07/07/26 at 11:07 A.M. with Resident #81 revealed bathing wasn't provided twice per week.An interview on 07/09/26 at 11:36 A.M. with Licensed Practical Nurse (LPN) #689 revealed residents were to be bathed twice weekly.An interview on 07/13/26 at 3:25 P.M. with the Director of Nursing (DON) verified Resident #13 was not bathed twice per week according to the shower sheets.This deficiency represents non-compliance investigated under Master Complaint Number 3054841, Complaint Number 3053651, Complaint Number 3019078, Complaint Number 2784376, Complaint Number 2696071, Complaint Number 2694632, Complaint Number 2670002, Complaint Number 2661800, Complaint Number 2576643, Complaint Number 1257524 (OH00165706), and Complaint Number 1257523 (OH00165408).

Based on medical record review, staff interviews, and policy review, the facility failed to ensure nutrition recommendations were timely implemented for a resident triggering for a significant weight loss who relied solely on enteral nutrition for their nutritional needs. This affected one (Residents #8) of four residents reviewed for nutrition. The facility census was 79.Findings include:Record review revealed Resident #8 was admitted on [DATE]. Diagnoses included dysphagia, encounter for attention to gastrostomy (feeding tube through stomach), and diabetes mellitus.Review of the care plan for Resident #8 dated 04/02/26 and revised on 07/08/26 revealed Resident #8 had a potential nutritional problem related to diagnoses and receiving nutrition via tube feed. Interventions included to monitor, record and report to physician as needed signs or symptoms of malnutrition to include significant weight loss.Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #8 was rarely understood and was dependent on staff for eating. Resident #8 received nutrition via tube feed with greater than 51 percent (%) of the proportion of total calories and an average of 501 milliliters per day or more received through tube feeding during the seven-day look back period.Review of the physician's orders for June 2026 revealed Resident #8 was ordered an enteral feeding of continuous enteral feeding of Jevity 1.5 at a rate of 55 milliliters (ml)every hour with 200 ml water flush every six hours.Review of Resident #8's weight history revealed Resident #8 weighed 219.0 pounds (lbs.) on 05/21/26 and weighed 199.8 lbs. on 06/16/26. This indicated an 8.77 % significant weight change in less than 30 days. During the survey on 07/08/26, Resident #8's reweigh was 209.0 lbs. This reweigh was 10 lbs from 05/21/26 and indicated a 4.8% weight loss.Review of the nutritional documentation on 06/17/26 revealed Resident #8 triggered for a significant weight loss. Resident #8 continues to be dependent on enteral feeding of Jevity 1.5 (tube feed formula) at a rate of 55 milliliters (ml) every hour with 200 ml water flushes every six hours which provided 1,980 calories, 90 grams of protein, and 1,808 ml of fluid. Resident #8 was also ordered Prostat (protein supplement) for wound healing which provided an additional 200 calories and 30 grams of protein. The enteral tube feeding that was ordered meets Resident #8's nutritional needs. Resident #8 was obese in reference to her body mass index (BMI) of 32.2 and recommended for Resident #8 to be reweighed to confirm significant weight loss.Review of the June 2026 medication administration record (MAR) and treatment administration record (TAR) revealed there was an order to reweigh Resident #8 per registered dietitian every shift for reweigh and to discontinue when completed. On 06/20/26, the TAR stated the resident was not available. There were no other dates/shift to mark if it was done or not on TAR. There were no other dates/shifts to mark if it was done on the MAR until 06/29/26. Check marks were inputed on the MAR indicating it was completed on 06/29/29 night shift and 06/30/26 for both day and night shifts. There was no reweight obtained and no follow up from the registered dietitian, nursing, or the physician on Resident #8's significant weight loss until 22 days later on 07/08/26. There was no evidence the physician was notified of Resident #8's weight loss and the recommendation to reweigh the resident to verify the weight loss.Interview on 07/09/26 at 10:10 A.M. with Registered Dietitian (RD) #906 revealed she was in the facility weekly. She stated that the tube feed exceeds the recommended calories for Resident #8. RD #906 stated that she makes recommendations and puts the recommendation in the recommendation log for the physician. RD #906 stated that she was looking for a reweigh for Resident #8 and it was not obtained until 07/08/26. RD #906 stated that she does not attend a risk meeting but does send an email to nurses about residents with concerns. Interview on 07/13/26 at 10:44 A.M. with Certified Nurse Practitioner (CNP) #907 revealed she was not informed of Resident #8's weight loss.Review of the facility policy titled Weight Assessment and Intervention, dated 01/10/23 revealed any weight change of five % or more since the last weight assessment will be retaken the next day for confirmation.Review of the facility policy titled Change in a Resident's Condition or Status dated 12/2016 revealed that the physician will be notified when a resident has a significant change in status.This deficiency represents non-compliance investigated under Complaint Number 1257522 (OH00164614).

Based on staff interviews, policy review, and record review, the facility failed to ensure Resident #7 was assessed before and after dialysis. This affected one (#7) of one resident reviewed for dialysis. The facility identified one resident (#7) who was on dialysis. The facility census was 79.Findings include:Review of the medical record for Resident #7 revealed a re-entry to the facility on [DATE]. Diagnoses included end stage renal disease (ESRD), dependence on renal dialysis, and dementia.Review of the physician orders dated 05/23/26 revealed an order for dialysis on Tuesday, Thursday, and Saturday with a facility pick up time of 9:45 A.M. for a dialysis center chair time of 10:20 A.M. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #7 was moderately cognitively impaired, did not reject care, had ESRD, and received dialysis.Review of the care plan revealed Resident #7 was at risk for complications related to ESRD and dialysis. A goal for Resident #7 was to be free of signs and symptoms of dialysis complications. Interventions included monitoring vital signs and notify the physician of abnormalities.Review of the progress notes from 06/09/26 to 07/09/26 revealed a single progress note of pre and post-dialysis vital signs on 07/02/06. There was no other documentation for any vital signs obtained and that Resident #7 refused assessments.Review of the vital sign page in Resident #7's electronic record from 06/09/26 to 07/09/26 revealed there were no post-dialysis blood pressures obtained on 06/09/26, 06/11/26, 06/13/26, 06/16/26, 06/18/26, 06/20/26, 06/23/26, 06/25/26, 06/27/26, 06/30/26, and 07/04/26. There no post-dialysis pulse rate obtained on 06/09/26, 06/13/26, 06/16/26, 06/18/26, 06/20/26, 06/23/26, 06/25/26, 06/27/26, 06/30/26, and 07/04/26.An interview on 07/09/26 at 11:36 A.M. with Licensed Practical Nurse (LPN) #689 revealed residents were assessed on return from the dialysis center, but she will use the last set of vital signs from the dialysis center.An interview on 07/13/26 at 10:13 A.M. with the Director of Nursing (DON) revealed dialysis residents who were on dialysis were to be assessed pre and post-dialysis by facility staff, and vital signs were to be documented in the electronic medical record. The DON verified there were no post dialysis blood pressures obtained on 06/09/26, 06/11/26, 06/13/26, 06/16/26, 06/18/26, 06/20/26, 06/23/26, 06/25/26, 06/27/26, 06/30/26, and 07/04/26 and no pulse rates obtained on 06/09/26, 06/13/26, 06/16/26, 06/18/26, 06/20/26, 06/23/26, 06/25/26, 06/27/26, 06/30/26, and 07/04/26for Resident #7.Review of the facility policy titled Hemodialysis dated 2024 revealed the facility would provide dialysis care and treatment consistent with professional standards of practice and the facility was to assess and monitor for complications before and after dialysis.

Based on observation, staff interview, record review, review of Centers for Disease Control and Prevention (CDC) guidance, and policy review, the facility failed to ensure staff implemented enhanced barrier precautions when providing high contract resident care activities. This affected one (Resident #34) of five residents reviewed for infection control. The facility census was 79.Findings include: Review of medical record for Resident #34 revealed the resident was admitted to facility on 04/01/17. Diagnoses included Alzheimer's disease, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 had moderately impaired cognition. Resident #34 required some assistance with activities of daily living (ADLs), hygiene and toileting. Resident #34 was occasionally incontinent of bowels and bladder. Review of the progress notes from 02/04/26 through 07/13/26 revealed Resident #34 had a facility acquired pressure wound to left inner buttocks and coccyx discovered on 02/04/26. Review of the physician orders dated 02/05/26 revealed Resident #34 was placed on Enhanced Barrier Precautions (EBP) due to wounds. Observation on 07/07/26 at 8:30 A.M. revealed Licensed Practical Nurse (LPN) #602 and Certified Nursing Assistant (CNA) #616 entered Resident #34's room to provide care to Resident #34. There was EBP signage on the door and no personal protective equipment (PPE) was placed outside the door for staff. The door signage for EBP revealed staff were to clean their hands, including before entering and when leaving the room, and providers must also wear gloves and gown for high contact resident care activities: dressing, bathing, showering, changing linen, providing hygiene, changing briefs, device care use and wound care. LPN #602 used alcohol based sanitizer prior to putting gloves on but did not don a gown. CNA #616 did not perform any hand hygiene prior to entering the room and did not put a gown or gloves on. CNA #616 was observed to not perform hand hygiene after contact with Resident #34. Observation of care provided to Resident #34 included repositioning the resident, adjusting linen, pillows, hygiene care, and changing the resident's gown. Interview with LPN #602 on 07/07/26 at 8:45 A.M. revealed she thought the EBP was only in effect when treating her wounds. LPN #602 could not state why there was no PPE outside the door for Resident #34. Additionally, there were two other rooms which had PPE outside their doors for staff however none contained any hand sanitizer. There were no hand sanitizers on the hallway wall for staff to use and none in Resident #34's room. LPN #602 did have hand sanitizer on her medication cart that was used for herself. Review of the facility policy titled Enhanced Barrier Precautions (EBP) Policy and Procedure dated April 2024 revealed EBP is an infection control intervention designed to reduce transmission of resistant organisms that employees targeted gown and glove use during high contact resident care activities. Examples of high-contact resident care activities include: dressing, bathing/showering, transferring, hygiene care, linens, changing briefs, device care and wound care. Review of the CDC guidance titled Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) found at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html and dated 04/02/24 revealed MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. EBP is an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status. This deficiency represents non-compliance investigated under Master Complaint Number 3071909 and Complaint Number 2585604.

Based on medical record review, observation, resident interview, and staff interview, the facility failed to provide a clean and homelike environment. This affected one resident (#11) of six residents reviewed for environment. The facility census was 89. Findings include: Review of the medical record revealed Resident #11 was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, heart failure, depression, panic disorder, insomnia, history of falling, restless leg syndrome, and migraine. Review of the Minimum Data Set annual assessment dated [DATE], revealed Resident #11 was cognitively intact. The resident required supervision or touching assistance for transfers and for walking ten feet once standing. Review of Resident #11's medical record revealed no documented information regarding the resident's bed linens. Interview on 02/24/25 at 3:41 P.M. with Resident #11 revealed staff never washed the resident's sheets. Resident #11 reported it had probably been approximately one month since the last time her sheets were changed. Resident #11 reported the top-left corner of the fitted sheet on her bed had been coming off of the corner for awhile and she was unable to put it back on her own. Resident #11 reported having her own sheets due to having a unique bed and that there were extra sheets staff could use. Observation on 02/24/25 at 3:41 P.M. revealed Resident #11's bed had a light purple fitted sheet which was completely off of the top left corner of the bed. There were numerous brownish-red smears covering the side of the sheet which was facing the doorway. There was also a pillowcase hanging off of the siderail attached to the resident's bed, which had numerous brownish-red smears all over it. The resident reported the smears were all dried blood stains due to her picking at her skin. Observations on 02/25/25 at 3:25 P.M. and on 02/26/25 at 9:25 A.M. revealed Resident #11 was resting in bed. The resident's sheets were in the same condition, including the top-left corner coming off of the mattress and the smears located on the fitted sheet and pillowcase. The condition of the sheets was visible from the hallway. Interview on 02/26/25 at 9:34 A.M. with Certified Nursing Assistant (CNA) #940 revealed there was no set schedule for resident bed linens to be changed. CNA #940 verified bed linens should be changed whenever they were visibly dirty or soiled. CNA #940 was unsure of whether Resident #11 had their own sheets. Observation on 02/26/25 at 9:41 A.M. with CNA #940 verified the condition of Resident #11's sheets. CNA #940 asked Resident #11 if CNA #940 could change Resident #11's sheets and the resident responded yes, they have been dirty for awhile.

Based on medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to assist residents in obtaining routine dental care. This affected one resident (#68) of two residents reviewed for dental care. The facility census was 89. Findings include: Review of the medical record revealed Resident #68 was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, depression, anxiety, hypertension, and peripheral vascular disease. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #68 was cognitively intact. The resident did not have any broken teeth or dentures. Review of the current physician orders for February 2025 identified an order dated 06/12/23 for may consult dental as needed. Review of Resident #68's medical record revealed no evidence the resident was ever offered or received routine dental services while residing in the facility. Interview on 02/24/25 at 9:39 A.M. revealed Resident #11 stated they needed dentures because their teeth were rotting. Resident #11 reported no one at the facility had inquired about dental services and the resident had not seen a dentist since residing in the facility. Observation on 02/24/25 at 9:39 A.M. revealed Resident #11 had visibly darkened areas on several of their teeth. Interview on 02/26/25 at 11:30 A.M. with the Regional Director of Clinical Services #721 revealed there was a dentist who came into the facility on a quarterly basis. The Regional Director of Clinical Services #721 reported residents were screened for whether they would like dental services upon admission to the facility. A follow-up interview on 02/27/25 at 11:30 A.M. with the Regional Director of Clinical Services #721 revealed the facility could not find Resident #68's admission documents to confirm whether or not the resident was offered dental services. The Regional Director of Clinical Services #721 verified there was no evidence Resident #68 was ever offered or received routine dental services while residing in the facility. Review of the facility policy titled Dental Services, revised December 2016, revealed routine and emergency dental services were available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. The policy also stated all dental services provided would be recorded in the resident's medical record.

Based on record review, observation, resident interview, and staff interview, the facility failed to ensure Resident #68 timely received an evaluation by therapy services for a motorized wheelchair. This affected one (Resident #68) of five residents reviewed for rehabilitation services. The facility census was 89. Findings include: Review of the medical record revealed Resident #68 was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, depression, anxiety, hypertension, and peripheral vascular disease. Review of the Minimum Data Set quarterly assessment dated [DATE] revealed Resident #68 was cognitively intact. The resident was dependent on assistance from staff for activities of daily living. Review of Resident #68's general progress notes dated 08/07/24 and timed 5:51 P.M. revealed a nurse practitioner was in to see the resident. The resident requested to get a motorized wheelchair with a new order for a therapy consultation for a motorized wheelchair evaluation. Review of Resident #68's general progress notes dated 12/09/24 and timed 3:03 P.M. revealed a nurse practitioner was in the facility making rounds with a new order for a therapy evaluation for a motorized wheelchair. Review of the current physician orders for February 2025 identified an order dated 12/09/24 for consultation with therapy for a motorized wheelchair evaluation. Review of Resident #68's medical record revealed no evidence the resident was ever evaluated by therapy for a motorized wheelchair. Interview on 02/24/25 at 9:30 A.M. revealed Resident #11 stated they had requested a motorized wheelchair multiple times but had never been evaluated for or received one. Observation on 02/24/25 at 9:30 A.M. revealed there was no wheelchair in Resident #11's room. Interview on 02/26/25 at 8:34 A.M. with the Director of Therapy Services #742 verified Resident #11 had an order dated 12/09/24 for therapy to evaluate the resident for a motorized wheelchair and the resident had never been evaluated for one. Interview on 02/27/25 at 11:30 A.M. with the Regional Director of Clinical Services #721 verified Resident #68 had expressed interest in a motorized wheelchair on 08/07/24 and on 12/09/24 with a new order to be evaluated by therapy. The Regional Director of Clinical Services #721 verified there was no evidence or documentation the resident had ever been evaluated by therapy for a motorized wheelchair.

Based on medical record review, resident and staff interview, and review of the facility policy, the facility failed to have sufficient staffing to meet the care needs of all residents. This directly affected three (#4, #15, and #16) of five residents reviewed for staffing and had the potential to affect 18 (#5, #8, #12, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, and #45) additional residents residing on the fourth floor. The facility census was 84. Findings include: 1. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, muscle weakness, need for assistance with personal care, hypertension, chronic kidney disease, anxiety, and depression. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 was cognitively intact. Review of the current physician orders for Resident #4 identified an order dated 09/22/24 for insulin lispro 100 units per milliliter solution with instructions to inject per sliding scale before meals up to 10 units per dose. The resident also had an order dated 10/30/24 for weekly weights for four weeks and then monthly. Review of the medication administration record (MAR) for October 2024 revealed Resident #4's blood glucose level was not documented as obtained before the lunch meal on 10/11/24 and on 10/20/24. Review of the nursing progress notes dated 10/11/24 and timed 5:37 P.M. revealed Resident #4's blood glucose level was not obtained. Review of the nursing progress notes dated 10/20/24 and timed 3:39 P.M. revealed Resident #4's blood glucose level was not obtained. Review of the weight record revealed Resident #4's weight was last obtained on 10/20/24 and was not obtained again until 12/04/24. There was no documentation indicating weekly weights were obtained in accordance with physician orders. Interview on 12/04/24 at 10:44 A.M. with Licensed Practical Nurse (LPN) #970 verified Resident #4's weight not was obtained per physician order between 10/30/24 and 12/04/24. An interview on 12/09/24 at 12:00 P.M. with LPN #802 verified Resident #4's blood glucose level was not obtained as ordered on 10/11/24 and 10/20/24. LPN #802 reported it was due to insufficient staffing. LPN #802 stated by the time they were able to get to Resident #4, the resident's next blood glucose level check was due. LPN #802 also reported staff were often unable to obtain resident weights due to insufficient staffing. Interview on 12/05/24 at 2:10 P.M. with Resident #4 revealed there were not enough staff to meet his needs. 2. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, chronic kidney disease, muscle weakness, and hypertension. Review of the nutritional assessment dated [DATE] revealed Resident #15 was at risk for malnutrition. The resident's weight was to be maintained with no significant changes and a new order for weekly weights for four weeks was recommended. Review of the weight record revealed Resident #15's weight was obtained on 07/10/24 and was not obtained again until 08/20/24. There was no documentation indicating weekly weights were obtained in accordance with physician orders. An interview on 12/05/24 at 11:26 A.M. with Regional Director of Clinical Operations #994 verified the weekly weights for Resident #15 were not obtained per the dietitian recommendations. Interview on 12/04/24 at 11:17 A.M. with LPN #642 stated resident weights were often not obtained due to insufficient staffing. LPN #642 reported weights were often not obtained due to staff attempting to focus on the more immediate needs of the residents. Review of the facility policy titled, Weight Assessment and Intervention, dated 01/10/23, revealed the multidisciplinary team would strive to prevent, monitor, and intervene for undesirable weight loss for residents. In addition, monthly weights would be completed by the tenth of each month, and weekly weights would be completed on a designated day each week. 3. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE]. Diagnoses included rheumatoid arthritis, pain in right shoulder, pain in left shoulder, chronic pain syndrome, peripheral vascular disease, muscle weakness, need for assistance with personal care, and heart failure. Review of the quarterly MDS assessment dated [DATE] identified Resident #16 was cognitively intact. Review of the plan of care dated 10/23/24 identified Resident #16 had chronic pain related to arthritis and peripheral vascular disease. Interventions included administering pain medication as ordered. Review of the current physician orders for Resident #16 identified an order dated 07/16/24 for Lac-hydrin 12 percent (%) external lotion with instructions to apply to the soles of the feet topically every morning and at bedtime. Further review of the current physician orders for Resident #16 identified an order dated 07/28/24 for the pain medication gabapentin oral capsule 300 milligrams (mg) by mouth every morning and at bedtime for neuropathy, and an order dated 09/18/24 for the narcotic pain medication Ultram oral capsule 50 mg by mouth every morning and at bedtime for pain. Review of the MAR for October 2024 revealed on 10/11/24 the Lac-hydrin lotion was not administered on the mornings of 10/10/24, 10/11/24, 10/20/24, and 10/28/24. Further review of the MAR for October 2024 revealed on 10/11/24 the morning doses of Ultram and gabapentin were not documented as administered and were coded with a 9. In addition, on 10/19/24, the morning dose of gabapentin was not documented as administered and was coded with a 9. Review of the nursing progress notes dated 10/11/24 and timed 7:09 P.M. revealed Resident #16's Ultram and gabapentin were not administered due to timing. Review of the nursing progress notes dated 10/19/24 and timed 2:43 P.M. revealed Resident #16's gabapentin was not administered due to a time constraint. Interview on 12/04/24 at 12:24 P.M. with Resident #16 revealed the resident did not always receive medications as ordered and often had to wait long periods of time for staff assistance. An interview on 12/09/24 at 12:00 P.M. with LPN #802 verified Resident #16's lotion was not applied as ordered on the above mentioned dates. LPN #802 also confirmed Resident #16's Ultram was not administered as ordered on 10/11/24 and confirmed gabapentin was not administered on 10/11/24 and 10/19/24 as ordered. LPN #802 verified staff were unable to administer medications within the prescribed timeframes due to staffing, and therefore did not administer medications. Review of the facility policy titled, Administering Medications, revised December 2012, revealed medications shall be administered in a safe and timely manner, and as prescribed. In addition, the policy revealed medications must be administered in accordance with the orders, including any required time frame. Review of the facility policy titled, Staffing, revised April 2007, revealed the facility would provide adequate staffing to meet needed care and services for their resident population. This deficiency represents non-compliance investigated under Master Complaint Number OH00159786, Complaint Master Number OH00159769, Complaint Number OH00159718, Complaint Number OH00159400, and Complaint Number OH00159147.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure resident weights were obtained and monitored in accordance with physician orders, dietitian recommendations, and the plan of care. This affected two (#4 and #15) of three residents reviewed for weights. The facility census was 84. 1. Review of the medical record revealed Resident #4 was initially admitted to the facility on [DATE]. The resident discharged to the hospital on 10/23/24 and readmitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, muscle weakness, need for assistance with personal care, hypertension, chronic kidney disease, anxiety, and depression. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 was cognitively intact. Review of the current physician orders for Resident #4 identified an order dated 10/30/24 for weekly weights for four weeks and then monthly. Review of the plan of care dated 10/31/24 revealed Resident #4 was at nutritional risk related to diagnoses, recent surgery, and therapeutic diet restrictions. Interventions included monitoring the resident's weight per policy and monitoring the need for further nutritional interventions. Review of the weight record revealed Resident #4's weight was last obtained on 10/20/24 and was not obtained again until 12/04/24. An interview on 12/04/24 at 10:44 A.M. with Licensed Practical Nurse (LPN) #970 verified Resident #4's weight had not been obtained per physician order. An interview on 12/05/24 at 11:26 A.M. with Regional Director of Clinical Operations #994 also verified the weekly weights for Resident #4 were not obtained per physician order. 2. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, chronic kidney disease, muscle weakness, and hypertension. Review of the Significant Change MDS assessment dated [DATE] identified Resident #15 was cognitively impaired. Review of the plan of care dated 11/18/23, and revised 10/18/24, revealed Resident #15 had a nutritional problem or potential nutritional problems related to therapeutic diet restrictions and insulin. Interventions included monitoring, recording, and reporting signs and symptoms of malnutrition including significant weight loss, and evaluating and making diet change recommendations as needed. Review of the nutritional assessment dated [DATE] revealed Resident #15 was at risk for malnutrition. The resident's weight was to be maintained with no significant changes and a new order for weekly weights for four weeks was recommended. Review of the weight record revealed Resident #15's weight was obtained on 07/10/24 and was not obtained again until 08/20/24. An interview on 12/05/24 at 11:26 A.M. with Regional Director of Clinical Operations #994 verified the weekly weights for Resident #15 were not obtained per the dietitian recommendations/orders. Review of the facility policy titled, Weight Assessment and Intervention, dated 01/10/23, revealed the multidisciplinary team would strive to prevent, monitor, and intervene for undesirable weight loss for residents. In addition, monthly weights would be completed by the tenth of each month, and weekly weights would be completed on a designated day each week. This deficiency represents non-compliance investigated under Complaint Number OH00159400.

Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to administer medications in accordance with physician orders. This affected two (#6 and #16) of four residents reviewed for medication administration. Findings include. 1. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE]. The resident discharged on [DATE]. Diagnoses included type II diabetes mellitus, muscle weakness, unspecified age-related cataracts, and heart failure. Review of physician orders identified an order dated 09/27/24 for Olopatadine solution 0.2 percent (%) with instructions to instill one drop in both eyes one time per day for dry eyes. Review of the medication administration record (MAR) for Resident #6 revealed the eye drops were not administered on 09/27/24, 09/28/24, 09/29/24, 09/30/24, 10/01/24, 10/02/24, 10/05/24, 10/06/24, 10/10/24, 10/11/24, and 10/25/24. An interview on 12/09/24 at 2:56 P.M. with Regional Director of Clinical Operations #994 verified staff likely could not locate the eye drops and therefore did not administer them. Regional Director of Clinical Operations #994 verified there was no documentation Resident #6 received eye drops as ordered on the dates listed above. 2. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE]. Diagnoses included rheumatoid arthritis, pain in right shoulder, pain in left shoulder, chronic pain syndrome, peripheral vascular disease, muscle weakness, need for assistance with personal care, and heart failure. Review of the quarterly Minimum Data Set assessment dated [DATE] identified Resident #16 was cognitively intact. Review of the current physician orders for Resident #16 identified an order dated 07/16/24 for Lac-hydrin 12% external lotion with instructions to apply to the soles of the feet topically every morning and at bedtime. Review of the MAR for October 2024 revealed on 10/11/24 the Lac-hydrin lotion was not administered on the mornings of 10/10/24, 10/11/24, 10/20/24, and 10/28/24. An interview on 12/04/24 at 12:24 P.M. with Resident #16 revealed the resident sometimes did not receive medications including lotion. An interview on 12/09/24 at 12:00 P.M. with Licensed Practical Nurse #802 verified Resident #16's lotion was not applied as ordered on the above mentioned dates. Review of the facility policy titled, Administering Medications, revised December 2012, revealed medications shall be administered in a safe and timely manner, and as prescribed. In addition, the policy revealed medications must be administered in accordance with the orders, including any required time frame. This deficiency represents non-compliance investigated under Complaint Number OH00159718.

Based on medical record review and staff interview, the facility failed to adequately monitor resident blood glucose levels for sliding scale insulin as ordered. This affected one (#4) of three residents reviewed for insulin administration. The facility census was 84. Findings include: Review of the medical record revealed Resident #4 was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, muscle weakness, need for assistance with personal care, hypertension, chronic kidney disease, anxiety, and depression. Review of the current physician orders for Resident #4 identified an order dated 09/22/24 for insulin lispro 100 units per milliliter solution with instructions to inject the insulin per sliding scale before meals up to 10 units per dose. Review of the plan of care dated 10/31/24 revealed Resident #4 had a history of type II diabetes mellitus. Interventions included Accu-checks (blood glucose level monitoring) as ordered, administering medications as ordered, and monitoring blood glucose levels-covering abnormal levels per sliding scale ordered by physician. Review of the medication administration record (MAR) for October 2024 revealed Resident #4's blood glucose level was not documented as obtained before the lunch meal on 10/11/24 and 10/20/24. Review of the nursing progress notes dated 10/11/24 and timed 5:37 P.M. revealed Resident #4's blood glucose level was not obtained. Review of the nursing progress notes dated 10/20/24 and timed 3:39 P.M. revealed Resident #4's blood glucose level was not obtained. An interview on 12/09/24 at 12:00 P.M. with Licensed Practical Nurse #802 verified Resident #4's blood glucose levels were not obtained as ordered on 10/11/24 and 10/20/24 and therefore, there was no way to know how much insulin was supposed to be administered or if the insulin would have not been given. This deficiency represents non-compliance investigated under Complaint Number OH00159718.

Based on medical record review, resident and staff interview, and review of the facility policy, the facility failed to ensure residents were free from significant medication errors. This affected one (#16) of four residents reviewed for medication administration. The facility census was 84. Findings include: Review of the medical record revealed Resident #16 was admitted to the facility on [DATE]. Diagnoses included rheumatoid arthritis, pain in right shoulder, pain in left shoulder, chronic pain syndrome, peripheral vascular disease, muscle weakness, need for assistance with personal care, and heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #16 was cognitively intact. Review of the plan of care dated 10/23/24 identified Resident #16 had chronic pain related to arthritis and peripheral vascular disease. Interventions included administering pain medication as ordered. Review of the current physician orders for Resident #16 identified an order dated 07/28/24 for the pain medication gabapentin oral capsule 300 milligrams (mg) by mouth every morning and at bedtime for neuropathy, and an order dated 09/18/24 for the narcotic pain medication Ultram oral capsule 50 mg by mouth every morning and at bedtime for pain. Review of the medication administration record (MAR) for October 2024 revealed on 10/11/24 the morning doses of Ultram and gabapentin were not documented as administered and were coded with a 9. In addition, on 10/19/24, the morning dose of gabapentin was not documented as administered and was coded with a 9. Review of the nursing progress notes dated 10/11/24 and timed 7:09 P.M. revealed Resident #16's Ultram and gabapentin were not administered due to timing. Review of the nursing progress notes dated 10/19/24 and timed 2:43 P.M. revealed Resident #16's gabapentin was not administered due to a time constraint. An interview on 12/04/24 at 12:24 P.M. with Resident #16 revealed the resident did not always receive medications as ordered. An interview on 12/09/24 at 12:00 P.M. with Licensed Practical Nurse (LPN) #802 verified Resident #16's Ultram was not administered as ordered on 10/11/24 and confirmed gabapentin was not administered on 10/11/24 and 10/19/24 as ordered. Review of the facility policy titled, Administering Medications, revised December 2012, revealed medications shall be administered in a safe and timely manner, and as prescribed. In addition, the policy stated medications must be administered in accordance with the orders, including any required time frame. This deficiency represents non-compliance investigated under Complaint Number OH00159718.

Based on medical record review, review of shower schedules, and staff interview, the facility failed to ensure residents were provided adequate bathing as scheduled. This affected three (#212, #277, and #300) of three residents reviewed for activities of daily living. The facility census was 82. Findings include: 1. Review of the medical record for Resident #212 revealed an admitted [DATE]. Diagnoses include generalized weakness, hypertension, Alzheimer's dementia, depression, and elevated cholesterol. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #212 was assessed as severely cognitively impaired and required substantial/maximal assistance with showering and bathing as well as hygiene. Review of facility shower schedule revealed Resident #212 was scheduled for showers/baths every Monday and Friday on day shift. Review of the facility shower schedule for 06/01/24 through 08/26/24 revealed Resident #212 was scheduled to receive 25 showers/baths. Review of facility shower documentation revealed Resident #212 received showers/baths on 06/06/24, 06/17/24, 07/01/24, 07/05/24, 07/10/24, 07/15/24, 08/09/24, and 08/17/24. Further review of Resident #212's medical record revealed the resident was in the hospital on 06/21/24. 2. Review of the medical record for Resident #277 revealed an admitted [DATE]. Diagnoses include seizures, asthma, generalized muscle weakness, abnormalities of gait and mobility, need for assistance with personal care, major depressive disorder, anxiety disorder,and hypertension. Review of the annual MDS assessment dated [DATE] revealed Resident #277 was assessed as cognitively intact and required substantial/maximal assistance with showers/baths as well as hygiene. Review of the facility shower schedule revealed Resident #277 was scheduled for showers/baths every Monday and Thursday in the evening. Review of the facility shower schedule for 06/01/24 through 08/26/24 revealed Resident #277 was scheduled to receive 25 showers/baths. Review of facility shower documentation revealed Resident #277 received showers/baths on 06/06/24, 06/20/24, 06/21/24, 06/27/24, 07/18/24, 07/25/24, 07/29/24, 08/01/24, 08/05/24, 08/12/24, 08/15/24, and was bathed twice on 08/19/24. 3. Review of the medical records for Resident #300 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses include end stage renal disease, displaced comminuted fracture of the left femur, mild protein-calorie malnutrition, type II diabetes mellitus, chronic obstructive pulmonary disease, generalized muscle weakness, other abnormalities of gait and mobility, hypoglycemia, and need for assistance with personal care. Review of the quarterly MDS assessment dated [DATE] revealed Resident #300 was dependent for showers/baths and hygiene. Review of the facility shower schedule revealed Resident #300 was scheduled for showers/baths every Monday and Thursday in the evening. Review of the facility shower schedule for 06/01/24 through 08/01/24 revealed Resident #300 was scheduled to receive 18 showers/baths. Review of facility shower documentation revealed Resident #300 received a showers/bath on 06/06/24 and refused a shower/bath on 06/27/24. Interview on 08/26/24 at 2:08 P.M. with the Regional Director of Clinical Services (RDCS), the Administrator, the Director of Nursing (DON), and the Regional Director of Operations (RDO) confirmed Resident #212, Resident #277, and Resident #300 were not bathed as scheduled and stated there was no further documentation of the residents being provided adequate bathing as scheduled. This deficiency represents non-compliance investigated under Complaint Number OH00156525.

Based on observation, review of medical records, review of facility self-reported incidents (SRI), interviews with staff, interview with family, interview with the Wound Care Certified Nurse Practitioner (WCCNP), interview with the Medical Director (MD), review of timecard punches and review of the facility policy, the facility failed to ensure residents were free from staff-to-resident physical and verbal abuse. This resulted in Immediate Jeopardy and the potential for serious injuries, negative health outcomes, and/or psychosocial harm when on 05/19/24 at approximately 5:30 P.M., the facility failed to recognize and appropriately respond to an allegation of staff-to-resident abuse when Registered Nurse (RN) #500 was witnessed by State tested Nursing Assistant (STNA) #465 and STNA #501 swearing and yelling at Resident #19. RN #500 removed Resident #19 from the dining room, took the resident to her room, slammed the door and remained alone in the room with Resident #19 for approximately 10 to 15 minutes. During this time, STNA #465 and STNA #501 heard RN #500 yelling and swearing at the resident and heard Resident #19 crying louder. No staff intervention occurred to protect the safety of Resident #19. After RN #500 exited Resident #19 ' s room, the resident was found by STNA #501 to be crying and holding up her arms, which had blood spots on the Geri sleeves she was wearing, and a bruise on her hand. Resident #19 had a total of nine wounds confirmed and measured by WCCNP #502. The facility failed to incorporate effective interventions to prevent further abuse from occurring when RN #500 was permitted to return to work with Resident #19, unsupervised, on 05/27/24. Additionally, a reasonable person in Resident #19's position would potentially have experienced severe psychosocial harm from the verbal and physical abuse/assault. This affected one (#19) of three residents reviewed for abuse. The facility census was 86. On 06/06/24 at 11:35 A.M., the Administrator, Regional Director of Operations (RDO) #503, and Regional Director of Clinical Services (RDCS) #510 were notified Immediate Jeopardy began on 05/19/24 at approximately 5:30 P.M. when Resident #19, a cognitively impaired resident residing on the memory care unit, was removed from the dining room by RN #500 who expressed frustration with the resident. RN #500 took Resident #19 to her room, slammed the door and RN #500 remained in the room with Resident #19 for approximately 10 to 15 minutes. During that time, STNA #465 and STNA #501 reported Resident #19 was heard screaming. RN #500 exited the room and STNA #501 entered and found Resident #19 crying, with blood noted on the Geri sleeves on her arms and bruising on her hand. STNA #501 got RN #500 to assess the injuries noted to Resident #19. STNA #501 reported RN #500 stated Wow. She is something else. She tried to get me, and we got into it. Resident #19 was subsequently seen on 05/22/24 by wound care for a total of nine identified wounds as a result of the incident on 05/19/24. The Immediate Jeopardy was removed on 06/07/24 when the facility implemented the following corrective actions: On 05/19/24 at 9:40 P.M., RN #521 notified Resident #19's daughter/Power of Attorney (POA) of new skin tears and bruising to the resident's arms. On 05/19/24 at 9:45 P.M., RN #521 notified Assistant Director of Nursing (ADON) # 522 Resident #19 had skin tears and bruising to bilateral arms. On 05/19/24 at 10:00 P.M., ADON #522 notified the Administrator of the skin tears and bilateral bruising to the arms on Resident #19. On 05/19/24 at 10:03 P.M., the Administrator notified RDCS #510 of Resident #19's skin tears and bilateral bruising to the arms. On 05/19/24 at 10:05 P.M., the Administrator notified RDO #503 of Resident #19's injuries. On 05/19/24 at 10:21 P.M., the Administrator opened an SRI for an injury of unknown origin. On 05/19/24 at 10:30 P.M., the Administrator interviewed RN #521, via phone, regarding Resident #19's injuries. Per RN #521, STNA #465 and STNA #501 reported Resident #19 had bruising and blood on her Geri sleeves. RN #521 cleansed the resident ' s arms with normal saline (NS), applied Steri-Strips and xeroform dressing and wrapped the resident ' s arms in kerlix. RN #521 performed a skin assessment on Resident #19. On 05/19/24 at 10:57 P.M., RN #521 notified CNP #524 of Resident #19's new skin tears and bilateral bruising to arms. New orders were obtained for bilateral x-rays of hands and arms. On 05/20/24 at 9:00 A.M., the Director of Nursing (DON) interviewed RN #500, via phone, due to staff report of RN #500 feeling frustrated with Resident #19 on the night of the incident. RN #500 stated she took Resident #19 to her room, around dinner time, for approximately 10 minutes. RN #500 was suspended pending the outcome of the investigation. On 05/20/24, Assistant Administrator (AA) #523 interviewed 12 random staff; STNA #602, STNA #627, STNA #609, STNA #620, STNA #515, STNA #631, STNA #671, STNA #673, STNA #675, STNA #676, STNA #619, and Licensed Practical Nurse (LPN) #632 regarding witnessing abuse or reporting abuse, with no findings. On 05/20/24 beginning at 10:00 A.M. and completed on 05/24/24 at 8:30 P.M., ADON #522 initiated Residents Rights and Abuse Inservice for all staff. This was completed in person and via phone. On 05/20/24 at 2:00 P.M., Resident #19 was seen by CNP #524. New orders were received for oxycodone for pain from skin tears and bruising and Keflex (antibiotic) for prevention of infection from skin tears. On 05/20/24 at 3:00 P.M., CNP #524 ordered Resident #19 ' s assist rails be removed from the resident ' s bed to reduce risk of injury. The assist rails were removed from Resident #19's bed at 3:30 P.M. On 05/21/24 at 7:00 A.M., laboratory (lab) orders, which included a Complete Blood Count (CBC) with differential, was completed for Resident #19. On 05/21/24 at 12:30 P.M., Resident #19's lab results were received and reported to the physician. No new orders were received. On 05/21/24 at 1:30 P.M., the Administrator and DON re-interviewed RN #500. No additional information was obtained. On 05/21/24 at 4:27 P.M., an x-ray was completed for Resident #19's bilateral arms and hands. On 05/22/24 at 8:00 A.M., Resident #19 was evaluated by WCCNP #502 for skin tears to bilateral arms. On 05/22/24 from 10:30 A.M. until 11:30 A.M., ADON #522 interviewed alert residents on the memory care unit regarding abuse reporting, witnessing abuse and ensured residents felt safe with no negative findings. On 05/22/24 from 2:00 P.M. to 4:45 P.M., ADON #522 completed skin assessments of all residents on the memory care unit with no negative findings. On 05/22/24 at 3:00 P.M., Resident #19 was evaluated by Medical Director (MD) #750. No bruising was noted to the resident ' s face at the time of the examination. A new order was received for referral to hematology. An appointment was scheduled for 05/30/24. On 05/23/24 at 1:00 P.M., x-ray results of bilateral arms and hands received for Resident #19 with no fractures identified. On 05/24/24 at 7:21 P.M., the SRI for injury of unknown origin was closed with an unsubstantiated finding. No abuse concerns were identified. On 05/27/24 at 1:42 P.M., the DON informed RN #500 Resident #19's family requested, due to the incident on 05/19/24, she no longer work with the resident. RN #500 was offered the option to work on another unit. RN #500 refused the reassignment and immediately terminated her employment at the facility. On 05/29/24 at 10:10 A.M., Resident #19 was seen by psychiatric services, Psychiatric CNP (PCNP) #700, with no negative findings. On 05/30/24 at 8:00 A.M., Resident #19 was evaluated by hematology and no new orders were received. On 06/06/24 at 11:50 A.M., the Administrator, RDCS #510 and RDO #503 interviewed MD #750 regarding potential causes of Resident #19 ' s injuries on 05/19/24. MD #750 indicated it was possible to sustain ecchymosis (bruising) with normal handling. On 06/06/24 at 12:00 P.M., the Administrator, RDCS #510 and RDO #503 completed a root cause analysis and determined a thorough investigation was not completed related to the incident involving RN #500 and Resident #19 on 05/19/24 and abuse likely occurred. On 06/06/24 at 12:15 P.M., an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held by the Administrator to review the Immediate Jeopardy findings and reviewed prevention of resident abuse and facility policies related to prevention, identification and investigation of allegations of resident abuse. The QAPI meeting was attended by the Administrator, RDO #503, RDCS #510, Transportation Director (TD) #525, Activities Director Assisted Living (ADAL) #526, Activities Director (AD) #900, Housekeeping and Laundry Director (HLD) #527, Medical Records Clerk (MRC) #528, Chaplin #529, Central Supply (CS) #530, Marketing Director #531, Scheduler #515, Human Resources Director (HRD) #520, Minimum Data Set Coordinator (MDSC) #532, Business Office Manager (BOM) #533, Admissions/Social Services Designee (SSD) #535, Assistant Administrator (AA) #523, and Director of Maintenance (DOM) #540. On 06/06/24 at 12:30 P.M., RDO #503 and RDCS #510 re-educated all department heads, including the Administrator and DON, on the facility ' s abuse policy and prevention, reporting and investigation of allegations of abuse. Additionally, education was provided related to SRI reporting categories. On 06/06/24 at 2:35 P.M., the Administrator filed a report with the Ohio Board of Nursing related to suspected resident abuse on 05/19/24 involving RN #500. On 06/06/24 at 2:45 P.M., the Administrator filed a police report with the local police department related to suspected staff-to-resident abuse on 05/19/24. On 06/06/24 from 8:00 P.M. through 9:30 P.M., department heads re-educated all staff on the facility's Abuse Policy, Abuse Prevention Policy and Abuse Investigation Policy. Staff who could not be reached for their education were left a voicemail message indicating they could not return to work until they received the education. Interviews on 06/06/24 from 8:12 P.M. through 8:15 P.M. with STNA #671, STNA #609 and RN #521 verified each had received education on the facility's abuse prevention and reporting policies and procedures. On 06/06/24 from 9:00 P.M. through 11:35 P.M., AA #523 completed interviews with all staff who worked on 05/17/24, 05/18/24 and 05/19/24, including STNA #465, STNA #600, STNA #501, STNA #601, STNA #602, STNA #603, STNA #604, STNA #605, STNA #606, STNA #607, STNA #608, STNA #609, STNA #470 and STNA #611, LPN #612, LPN #613, LPN #614, LPN #615 and LPN #616, RN #617 and RN #521, AD # 500, Occupational Therapist (OT) #618, MRC #528, CS #530, Marketing Director #531, TD # 525, HRD #520, DOM #540 and SSD #535. Voicemail messages were left for those staff who could not be reached, including STNA #619, STNA #620, STNA #621, STNA #622, STNA #623, STNA #624, STNA #625, STNA #626, STNA #627, STNA #628, STNA #629, STNA #630, STNA #631 and LPN #632, LPN #633 and LPN #634 to complete interviews. No new information or areas of concern were identified in the staff interviews. On 06/06/24 at 9:35 P.M., RDCS #510, RDO #503 and the Administrator interviewed WCCNP #502 regarding Resident #19's injuries. On 06/06/24 from 10:00 P.M. through 11:30 P.M., the DON and ADON #522 completed skin audits on all residents. No negative findings were identified. Beginning on 06/06/24, the Administrator will review all potential SRIs with [NAME] President of Operations (VPO) #640 and [NAME] President of Clinical Services (VPCS) #641 to ensure the appropriate SRI category is filed and thoroughly investigated. Beginning on 06/06/24, the Administrator, or designee will ensure written staff statements are validated for authenticity by reviewing the statement with the reporting staff. The statement will be signed by the reporting staff and counter signed by the Administrator or designee. Beginning on 06/06/24, VPO #640 and VPCS #641 will audit each initial SRI prior to submission to ensure the facility files incidents under the correct investigation category for four weeks. Beginning on 06/06/24, RDO #503, RDCS #510 or designee will audit every SRI submitted for four weeks, then as needed, to ensure a thorough investigation was completed. Beginning on 06/06/24, the Administrator or designee will conduct 10 random resident interviews with alert residents to ensure residents are free from abuse for four weeks, then as needed. Beginning on 06/06/24, the DON or designee will conduct 10 random skin assessments weekly for four weeks, then monthly thereafter, on non-interviewable residents to ensure residents are free from abuse. Beginning on 06/07/24, SSD #535 will meet with Resident #19 three times weekly for four weeks to assess psychosocial well-being and provide additional support. Results of audits will be reviewed at the QAPI meeting weekly for four weeks, then monthly thereafter to determine on-going compliance. Review of two (#34 and #62) additional open resident records revealed no concerns related to resident abuse. Although the Immediate Jeopardy was removed on 06/07/24, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Record review for Resident #19 revealed an admitted [DATE]. Diagnoses included neurocognitive disorder with Lewy Bodies, Parkinson's disease, dementia, anxiety disorder and Pseudobulbar affect (a medical condition that causes sudden and uncontrollable crying and or laughing). Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/17/24, revealed a Brief Interview of Mental Status (BIMS) score of 00, indicating Resident #19 was severely cognitively impaired. Resident #19 used a wheelchair for mobility, required assistance with activities of daily living (ADLs) and the resident had no skin tears. Review of the care plan, dated 04/17/24, revealed Resident #19 had a behavior problem related to crying and yelling. Interventions included to anticipate and meet the needs of the resident and caregivers to provide opportunities for positive interactions, attention, and speak in a calm manner. Review of the Weekly Skin Assessments from 04/01/24 through 05/18/24 for Resident #19 revealed two weekly skin assessments were documented, one on 04/19/24 at 6:45 A.M. completed by LPN #702 and one on 05/03/24 at 6:18 A.M. completed by LPN #703. Each assessment revealed Resident #19 had no bruises, skin tears, lesions, cuts or abrasions noted. Review of the nursing progress notes from 04/01/24 through 05/18/24 revealed no documentation of incidents of bruises, skin tears, lesions, cuts or abrasions for Resident #19. Review of the shower sheets for Resident #19, dated 03/02/24, 03/06/24, 03/08/24, 03/13/24, 03/23/24, 04/27/24, 05/01/24, 05/04/24, 05/08/24, 05/11/24 and 05/15/24 revealed no skin tears or bruising to the arms or face. Review of a nursing progress note, dated 05/19/24 at 10:11 P.M. completed by RN #521, revealed the STNA reported Resident #19 developed skin tears during the day. RN #521 went into the room and observed the resident had multiple skin tears to bilateral upper extremities and new bruising to both hands. The skin tears were cleansed with normal saline, skin folded back over with Steri-Strips and a xerofoam dressing was applied and wrapped in kerlix. ADON #522 was updated, and the daughter was notified. A message was left for the on-call physician for MD #750, awaiting response. Review of a nursing progress note, dated 05/19/24 at 10:53 P.M. completed by RN #521, revealed Resident #19 had kerlix wrapped on her upper extremities before RN #521 cleansed the skin tears and rewrapped. RN #521 asked the STNA if Resident #19 had been wearing Geri sleeves during the day and the STNA confirmed Resident #19 had been wearing them. Review of the facility SRI revealed an injury of unknown origin was initiated by the Administrator for Resident #19, with a date of discovery of 05/19/24. Resident #19 complained of pain and the nurse medicated the resident. The nurse received report from staff that the resident was found with bruises and skin tears on bilateral arms. Resident #19 had a history of removing Geri sleeves and picking at skin. Staff became aware of the injuries on 05/19/24 at 9:45 P.M. The Administrator was notified at 10:00 P.M. by ADON #522, aids reported to the nurse and no other agencies were notified. Interventions included Geri sleeves were discontinued due to resident removing them causing injury. Review of the physician orders dated 05/20/24 revealed Resident #19 was ordered oxycodone oral tablet five milligrams (mg), give 2.5 mg by mouth every six hours as needed for moderate pain and Keflex oral capsule 250 mg give one tablet by mouth every six hours for seven days. Review of the Medication Administration Record (MAR) for Resident #19 for May 2024 revealed Resident #19 used the oxycodone oral tablet five mg tablet 11 times from 05/21/24 through 05/29/24 for pain. Review of a wound care note, dated 05/22/24 completed by WCCNP #502, revealed Resident #19 was being seen for initial consultation for wound care services in the setting of a skilled nursing facility. The note stated Resident #19 was weak and poorly mobile and lived on the memory care unit. Resident #19 was resting in bed and confused. Neurological assessment included positive for weakness and tremors or other involuntary movements. Musculoskeletal assessment included positive for stiffness, tenderness and limitation of motion. Resident #19 was alert and confused. Abnormal findings included traumatic lesion to the head and scattered bruising. Resident #19 was noted to have decreased bulk, tone, limited range of motion, stiffness, disoriented and decreased motor ability. Further review of the documentation revealed the following wounds: Wound #1: left upper arm skin tear full thickness 4.2 x 3.5 x 0.1 centimeters (cm), scant bloody, ecchymotic (small bruise caused by blood leaking from broken blood vessels into the tissue of the skin or mucous membranes) with flaking skin, dry. Skin flap is partially adhered over wound bed, Steri-Strips intact. Wound #2: left forearm skin tear full thickness 5.2 x 1.2 x 0.1 cm scant bloody, ecchymotic, dry Steri-Strips in place. The resident had mild transient pain during wound assessment which resolved post assessment. Wound #3: left wrist skin tear full thickness 1.1 x 0.9 x 0.1 cm moderate bloody ecchymotic, dry. Wound #4: left inner forearm skin tear full thickness 1.4 x 0.5 x 0.1 scant bloody ecchymotic, dry. Exposed tissue with a portion of dry scabbing, Steri-Strips intact. Wound #5: left cheek abrasion, intact skin, 5.5 x 3.8 x 0 cm dry ecchymotic skin is flat with light purple and red ecchymotic discoloration. Wound #6: right forearm skin tear, scabbed/crusted, 11.1 x 6.5 x 0 cm clustered wound, dry, ecchymotic. Scattered skin tears across dorsal side of right forearm. Four areas measured as one with dry intervening skin. Three skin tears located near right wrist (ulnar side), and one skin tear located on the dorsal/medial side of forearm. Steri-Strips intact with dry scabbing. Wound #7: right chin abrasion, intact skin, 0.8 x 1.0 x 0 cm circular area dark purple, ecchymotic discoloration. Wound #8: left chest abrasion ecchymosis 2.5 x 2.0 x 0 cm, intact skin. Wound #9: right hand skin tear full thickness 1.7 x 1.2 x 0.1 cm scant bloody with no visible skin flap. Review of the daily schedule for 05/19/24 revealed from 2:30 P.M. through 6:30 P.M. a total of three staff members were scheduled for the unit/floor Resident #19 resided on. The three staff members scheduled were RN #500, STNA #465 and STNA #501. Observation on 06/03/24 at 1:50 P.M. of Resident #19 revealed the resident was sitting in a wheelchair in her room. Resident #19 was calm and did not respond to questions asked by the surveyor. Resident #19 had bilateral Geri sleeves on, and a visible dressing was located on the right hand, partially covered by the Geri sleeve. The left side of Resident #19 ' s face had three small red areas in a vertical line on the outer portion of her cheek. Resident #19 had a visitor who introduced herself as a sitter. Resident #19 ' s daughter called the sitter on the phone and inquired who was in the room. Concurrent interview with Resident #19 ' s daughter revealed she had a camera placed in the resident ' s room because Resident #19 was hurt by someone at the facility and received skin tears down her arms, a bruise to her right cheek and blood spots to the other side of her face. Resident #19's daughter revealed on 05/19/24 she received a phone call from RN #521, who stated two staff members reported there was an incident. Resident #19's daughter stated it was a nurse who caused the resident ' s injuries and she subsequently quit after being offered assignment on another floor and refused. Interview on 06/03/24 at 1:57 P.M. with STNA #607 revealed she worked on first shift (6:30 A.M. until 3:00 P.M.) on 05/19/24 with Resident #19. STNA #607 stated Resident #19 did not have any bruises or skin tears anywhere during her shift. STNA #607 revealed RN #500 was the nurse that shift, and Resident #19 was a two person assist for care. STNA #607 stated she heard RN #500 took Resident #19 to her room by herself and slammed the door. When the door opened Resident #19 had a bruised face with multiple markings, one on her chest, and multiple open areas to her arms. The family placed a camera in the resident ' s room after that. STNA #607 stated when Resident #19 was taken to her room, she was not beaten up, but when she came out, she was. STNA #607 stated Resident #19 was not able to tell anyone anything that happened. Additionally, STNA #607 stated on 05/22/24, AA #523 asked her questions about Resident #19, such as how she transferred and changed. STNA #607 stated she asked AA #523 why they called her in about the incident on 05/19/24 with Resident #19 when they did not talk to the two STNAs who were working. Interview on 06/03/24 at 4:49 P.M. and 06/04/24 at 4:42 P.M. with the DON confirmed the bruises on Resident #19's face were not mentioned in the SRI or in the nursing notes completed 05/19/24. The DON stated the bruises showed up a few days later and she did not know how Resident #19 got them because she did not investigate the cause. The DON revealed she concluded Resident #19 caused the bruises to her face and the skin tears to her arms herself from picking at the Geri sleeves. The DON confirmed there was no documentation in Resident #19's medical record from 04/01/24 through 05/19/24 of any picking at her Geri sleeves, causing self-inflicted skin tears or bruises. The DON stated Resident #19 had a low blood count, which could have caused the wounds. The DON confirmed Resident #19 received antibiotics (Keflex) for seven days to prevent an infection from the skin tears. Interview on 06/04/24 at 2:53 P.M. with STNA #465 revealed on 05/19/24 she started her shift at 6:30 A.M. and worked until 11:00 P.M. STNA #465 stated when she started her shift, Resident #19 had no skin tears or bruising. Resident #19 frequently cried her usual cry, which was normal for her. STNA #465 stated it was more of a weeping, with no tears, than an actual cry. STNA #465 stated RN #500 was frustrated with Resident #19 throughout the day and RN #500 was frustrated a lot with Resident #19 because of her whining. STNA #465 revealed she heard RN #500 tell Resident #19 to shut up (using profanity) and telling the resident she was so annoying. STNA #465 revealed she reported in the past to the DON that RN #500 would get angry, sear at, and tell Resident #19 to shut up but she was unaware of the DON following up on this. STNA #465 reported on 05/19/24, RN #500 was swearing at Resident #19 and around dinner time, approximately 5:30 P.M., RN #500 removed the resident from the dining room and states she could not take her whining anymore. STNA #465 stated RN #500 took Resident #19 to her room, slammed the door and then she heard the resident screaming louder and RN #500 was screaming at her to shut up, again using profanity towards Resident #19. STNA #465 stated prior to Resident #19 going in the room alone with RN #500, Resident #19 had no injuries to her arms. While Resident #19 had a history of picking her skin, STNA #465 denied the resident ever caused injuries like those she had after RN #500 left the resident ' s room, noting the wounds were horrible. STNA #465 stated while RN #500 was in the room with Resident #19, the resident was screaming a terrified scream. After about 10 to 15 minutes RN #500 exited the resident ' s room and Resident #19 remained in her room. STNA #465 stated STNA #501 went into Resident #19's room and called her to come to into the room to see Resident #19. STNA #465 stated Resident #19 was reaching out and crying real tears, saying look, look and pointing to her Geri sleeves. STNA #465 revealed Resident #19 ' s Geri sleeves were bloody. STNA #465 stated STNA #501 went to get RN #500 and they both went back into Resident #19 ' s room together. RN #500 wrapped Resident #19 ' s arms, but STNA #465 stated not very well. STNA #465 stated RN #500 came out of Resident #19's room and stated the resident had three new skin tears because they got into it and referred to Resident #19 in a derogatory manner. STNA #465 revealed Resident #19's face was red at the time and the bruises appeared the next morning. RN #521 came in at 6:30 P.M. and both STNA #465 and #501 told him he needed to look at Resident #19 because it was bad. RN #521 removed the bandages placed by RN #500 and reported it. STNA #465 confirmed she wrote a statement with all this information on 05/19/24, but no one ever interviewed her about the incident. Interview on 06/04/24 at 3:13 P.M. with STNA #501 revealed she started her shift at 2:30 P.M. on 05/19/24. Resident #19 was her assigned resident. STNA #501 revealed Resident #19 would make whining noises on and off daily, but never had tears. STNA #501 stated Resident #19 had no skin tears, bleeding, or bruising at the beginning of her shift on 05/19/24. Around dinner time, Resident #19 was in the dining room making whining noises. RN #500 was yelling this is enough and took Resident #19 to her room. STNA #501 stated she heard Resident #19 ' s door slam, with RN #500 remaining alone in the room with the resident. STNA #501 stated she heard Resident #19 screaming very loud and crying louder and louder. STNA #501 stated after RN #500 exited the resident ' s room she entered and found Resident #19 crying real tears, there was blood on her Geri sleeves and upper arms and bruising on her hand. STNA #501 stated she went to get RN #500 who stated Resident #19 was something else, she tried to get me, and we got into it. STNA #501 stated Resident #19 had a history of picking her skin, but she had never seen the resident cause wounds like those she had that day. STNA #501 stated when RN #521 came in for his shift, she reported the incident to him. Interview on 06/04/24 at 4:23 P.M. with the Administrator confirmed a police report was never made regarding the allegation made on 05/19/24 between RN #500 and Resident #19. Interview on 06/05/24 at 10:52 A.M. with WCCNP #502 revealed she visited residents at the facility weekly for wound assessment. WCCNP #502 revealed she had never visited Resident #19 prior to 05/22/24 and noted the resident had multiple skin tears during her assessment on 05/22/24. WCCNP #502 revealed bruising could occur easier with contact if the person had a low blood count and low platelets; however, WCCNP #502 confirmed Resident #19 ' s skin tears and abrasions were not consistent with low hemoglobin, and they were not consistent with self-picking. WCCNP #502 stated staff indicated Resident #19 could be combative, but the resident was not anxious during her examination. WCCNP #502 stated Resident #19 had no evidence of fingernail scratches, which would likely be seen if someone is self-picking their skin. Additionally, WCCNP #502 stated Steri-Strips were needed to reapproximate the skin flaps, also not consistent with skin picking. WCCNP #502 stated she did not believe Resident #19 ' s wounds were the result of skin picking or low hemoglobin levels. At the time of her examination, WCCNP #502 asked the nurse what happened, who stated she was unsure, but WCCNP #502 stated she wanted to get to the bottom of how Resident #19 sustained the wounds because they were bad. Lastly, WCCNP #502 stated all of the wounds happened at the same time, it was not a here and there and it was all one incident. Interview on 06/05/24 at 12:27 P.M. with the DON revealed RN #500 returned to work on Resident #19's unit on 05/27/24. RN #500 was the only nurse that shift for that unit. The DON stated she told RN #500 she had to move to another floor because Resident #19's daughter did not want her caring for Resident #19. The DON revealed RN #500 became very upset and said she should not have to move, she opted to go home, said she wasn ' t feeling well and said she would not be back. The DON stated RN #500 resigned and did not return to work at the facility. Review of the facility investigation revealed a witness statement, typed and dated 05/20/24 signed by the DON, revealed a telephone interview was conducted with RN #500. RN #500 stated she went to administer medications to Resident #19. Upon entering the room, Resident #19 was already agitated and aggressive. The resident started to hit, kick and spit. RN #500 went to administer the medications with a spoon when Resident #19 grabbed her arm, pulling it towards her mouth with strong force. RN #500 further stated when she attempted to pull her arm back from the resident, she proceeded to use more force and grabbed her arm, pulling it to her face. RN #500 stated she placed her other hand on the resident ' s hand and pulled it away gently. RN #500 stated she was not successful in administering medications, walked away and chose to reapproach later, when calm. Review of a handwritten witness statement, dated 05/21/24 and signed with an illegible signature, revealed RN #500 stated Resident #19 had been crying and combative all day and the aides let her stay in bed. Resident #19 was provided breakfast in her room, which staff would do if the resident was being combative. RN #500 stated she attempted to give the resident medications at dinner time and the resident started kicking, hitting and spitting the medications out. RN #500 stated she took Resident #19 back to her room to do treatment on skin tears to her arms. RN #500 states she did the best she could due to Resident #19 being combative and the resident picked at her skin and made her arms bleed. Telephone interview on 06/05/24 at 12:51 P.M. with RN #500 revealed she terminated employment at the facility because they said, I beat up Resident #19. RN #500 stated she was suspended then allowed to return to work. However, on the day she returned to work, RN #500 was told she would have to work on another floor, so she quit. On 05/19/24, RN #500 stated Resident #19 was very combative, attempting to hit, claw, and spit in her face. RN #500 stated Resident #19 was sitting in a wheelchair in her room trying to hurt her. RN #500 stated she entered the resident's room and attempted to give her medication. The resident was already aggressive. RN #500 stated the resident hit her arm. She was able to give a little medication to the resident, who then spit it in RN #500 ' s face. RN #500 stated she left Resident #19's room. RN #500 stated she could not recall if the door was closed to Resident #19 ' s room and stated the resident already had skin tears, she had just reopened t[TRUNCATED]

Based on medical record review, review of self-reported incidents (SRI), interviews with staff, interview with the Medical Director (MD), interview with the Wound Care Nurse Practitioner (WCCNP), review of staff schedules, review of the facility investigation and review of the facility policy, the facility failed to ensure an allegation of staff-to-resident abuse was accurately reported and thoroughly investigated to protect residents from further potential abuse. This resulted in Immediate Jeopardy and the potential for serious injuries, negative health outcomes, and/or psychosocial harm when on 05/19/24 at approximately 10:21 P.M. the Administrator filed an SRI for an injury of unknown origin after State tested Nursing Assistant (STNA) #465 and STNA #501 alleged verbal and physical abuse of Resident #19 by Registered Nurse (RN) #500. Resident #19 sustained nine separate wounds as a result of the incident. The facility failed to accurately file an SRI, failed to interview staff witnesses (STNA #465 and STNA #501) and medical providers regarding the potential cause of Resident #19 ' s injuries, failed to validate staff witness statements, failed to file a police report and failed to notify the Ohio Board of Nursing of suspected staff-to-resident abuse. Furthermore, without thoroughly investigating the allegation, the facility permitted RN #500 to return to work with Resident #19, unsupervised, on 05/27/24. RN #500 subsequently terminated her employment with the facility after Resident #19's family requested she no longer work with the resident. This affected one (#19) of four residents reviewed for abuse investigations. The facility census was 86. On 06/06/24 at 11:35 A.M., the Administrator, Regional Director of Operations (RDO) #503, and Regional Director of Clinical Services (RDCS) #510 were notified Immediate Jeopardy began on 05/19/24 at 10:21 P.M. when the Administrator initiated an SRI for an injury of unknown origin for Resident #19 following an allegation of staff-to-resident abuse, where Resident #19 sustained nine separate wounds as a result of the incident. The facility failed to accurately identify and thoroughly investigate the allegation of staff-to resident abuse and RN #500 was permitted to return to work on 05/27/24, unsupervised, with Resident #19. The Immediate Jeopardy was removed on 06/06/24 when the facility implemented the following corrective actions: On 05/19/24 at 10:21 P.M., the Administrator opened as SRI for an injury of unknown origin. On 05/19/24 at 10:30 P.M., the Administrator interviewed RN #521, via phone, regarding Resident #19's injuries. Per RN #521, STNA #465 and STNA #501 reported Resident #19 had bruising and blood on her Geri sleeves. RN # 521 cleansed the resident's arms with normal saline (NS), applied Steri-Strips and xeroform dressing and wrapped the resident's arms in kerlix. RN #521 performed a skin assessment on Resident #19. On 05/19/24 at 10:57 P.M., RN #521 notified Certified Nurse Practitioner (CNP) #524 of Resident #19's new skin tears and bilateral bruising to her arms. New orders were obtained for bilateral x-rays of the resident ' s hands and arms. On 05/20/24 at 9:00 A.M., the DON interviewed RN #500, via phone, due to staff report of RN #500 feeling frustrated with Resident #19 on the night of the incident. RN #500 stated she took Resident #19 to her room, around dinner time, for approximately 10 minutes. RN #500 was suspended pending the outcome of the investigation. On 05/20/24, Assistant Administrator (AA) #523 interviewed 12 random staff; STNA #602, STNA #627, STNA #609, STNA #620, STNA #515, STNA #631, STNA #671, STNA #673, STNA #675, STNA #676, STNA #619, and Licensed Practical Nurse (LPN) #632 regarding witnessing abuse or reporting abuse, with no findings. On 05/20/24, beginning at 10:00 A.M. and completed on 05/24/24 at 8:30 P.M., Assistant Director of Nursing (ADON) #522 initiated Residents Rights and Abuse Inservice for all staff. This was completed in person and via phone. On 05/21/24 at 1:30 P.M., the Administrator and DON re-interviewed RN #500. No additional information was obtained. On 05/22/24, from 10:30 A.M. until 11:30 A.M., ADON #522 interviewed alert residents on the memory care unit regarding abuse reporting, witnessing abuse and ensured residents felt safe, with no negative findings. On 05/22/24 from 2:00 P.M. to 4:45 P.M., ADON #522 completed skin assessments on all residents on the memory care unit with no negative findings. On 05/24/24 at 7:21 P.M., an SRI for injury of unknown origin was closed with an unsubstantiated finding. No abuse concerns were identified. On 05/27/24 at 1:42 P.M., RN #500 was informed by the DON that Resident #19's family requested, due to the incident on 05/19/24, she no longer work with the resident. RN #500 was offered the option to work on another unit. RN #500 refused the reassignment and immediately terminated her employment at the facility. On 06/06/24 at 11:50 A.M., the Administrator, RDCS #510 and RDO #503 interviewed MD #750 regarding potential causes of Resident #19 ' s injuries on 05/19/24. MD #750 indicated ecchymosis (bruising) could be caused by natural handling of residents. On 06/06/24 at 12:00 P.M., the Administrator, RDCS #510 and RDO #503 completed a root cause analysis and determined a thorough investigation was not completed related to the incident involving RN #500 and Resident #19 on 05/19/24, and abuse likely occurred. On 06/06/24 at 12:15 P.M., an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held by the Administrator to review the Immediate Jeopardy findings and reviewed prevention of resident abuse and facility policies related to prevention, identification and investigation of allegations of resident abuse. The QAPI meeting was attended by the Administrator, RDO #503, RDCS #510, Transportation Director (TD) #525, Activities Director Assisted Living (ADAL) #526, Activities Director (AD) #900, Housekeeping and Laundry Director (HLD) #527, Medical Records Clerk (MRC) #528, Chaplin #529, Central Supply (CS) #530, Marketing Director #531, Scheduler #515, Human Resources Director (HRD) #520, Minimum Data Set Coordinator (MDSC) #532, Business Office Manager (BOM) #533, Admissions/Social Services Designee (SSD) #535, Assistant Administrator (AA) #523, and Director of Maintenance (DOM) #540. On 06/06/24 at 12:30 P.M., RDO #503 and RDCS #510 re-educated all department heads, including the Administrator and DON, on the facility's abuse policy and prevention, reporting and investigation of allegations of abuse. Additionally, education was provided related to SRI reporting categories. On 06/06/24 at 2:35 P.M., the Administrator filed a report with the Ohio Board of Nursing related to suspected resident abuse on 05/19/24 involving RN #500. On 06/06/24 at 2:45 P.M., the Administrator filed a police report with the local police department related to suspected staff-to-resident abuse on 05/19/24. On 06/06/24 from 8:00 P.M. through 9:30 P.M., department heads re-educated all staff on the facility's Abuse Policy, Abuse Prevention Policy and Abuse Investigation Policy. Staff who could not be reached for their education were left a voicemail message indicating they could not return to work until they received the education. Interviews on 06/06/24 from 8:12 P.M. through 8:15 P.M. of STNA #671, STNA #609 and RN #521 confirmed the facility provided education on the facility's abuse prevention and reporting policies and procedures. On 06/06/24 from 9:00 P.M. through 11:35 P.M., AA #523 completed interviews with all staff who worked on 05/17/24, 05/18/24 and 05/19/24, including STNA #465, STNA #600, STNA #501, STNA #601, STNA #602, STNA #603, STNA #604, STNA #605, STNA #606, STNA #607, STNA #608, STNA #609, STNA #470 and STNA #611, LPN #612, LPN #613, LPN #614, LPN #615 and LPN #616, RN # 617 and RN #521, AD # 900, Occupational Therapist (OT) #618, MRC #528, CS # 530, Marketing Director #531, TD #525, HRD #520, DOM #540 and SSD #535. Voicemail messages were left for those staff who could not be reached, including STNA #619, STNA #620, STNA #621, STNA #622, STNA #623, STNA #624, STNA #625, STNA #626, STNA #627, STNA #628, STNA #629, STNA #630 and STNA #631 and LPN #632, LPN #633 and LPN #634 to complete interviews. No new information or areas of concern were identified in the staff interviews. On 06/06/24 at 9:35 P.M., RDCS #510, RDO #503 and the Administrator interviewed Wound Care Certified Nurse Practitioner (WCCNP) #502 regarding Resident #19's injuries. WCCNP #502 indicated she could see how skin damage could be caused if staff were doing something with Resident #19 because the resident had thin, fragile skin and was elderly. On 06/06/24 from 10:00 P.M. through 11:30 P.M., the DON and ADON #522 completed skin audits on all residents. No negative findings were identified. Beginning on 06/06/24, the Administrator will review all potential SRIs with [NAME] President of Operations (VPO) #640 and [NAME] President of Clinical Services (VPCS) #641 to ensure the appropriate SRI category is filed and thoroughly investigated. Beginning on 06/06/24, the Administrator, or designee will ensure written staff statements are validated for authenticity by reviewing the statement with the reporting staff. The statement will be signed by the reporting staff and counter signed by the Administrator or designee. Beginning on 06/06/24, VPO #640 and VPCS #641 will audit each initial SRI prior to submission to ensure the facility files incidents under the correct investigation category for four weeks. Beginning on 06/06/24, RDO #503, RDCS #510 or designee will audit every SRI submitted for four weeks, then as needed, to ensure a thorough investigation is completed. Beginning on 06/06/24, the Administrator or designee will conduct 10 random resident interviews with alert residents to ensure residents are free from abuse for four weeks, then as needed. Beginning on 06/06/24, the DON or designee will conduct 10 random skin assessments weekly for four weeks, then monthly thereafter, on non-interviewable residents to ensure residents are free from abuse. Results of audits will be reviewed at the weekly QAPI meeting for four weeks then monthly thereafter to determine on-going compliance. Review of two (#34 and #62) additional open resident records revealed no concerns related to abuse reporting. Although the Immediate Jeopardy was removed on 06/06/24, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Record review for Resident #19 revealed an admitted [DATE]. Diagnoses included neurocognitive disorder with Lewy Bodies, Parkinson's disease, dementia, anxiety disorder and Pseudobulbar affect (a medical condition that causes sudden and uncontrollable crying and or laughing). Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/17/24, revealed a Brief Interview of Mental Status (BIMS) score of 00, indicating Resident #19 was severely cognitively impaired. Resident #19 used a wheelchair for mobility, required assistance with activities of daily living (ADLs) and the resident had no skin tears identified. Review of the care plan, dated 04/17/24, revealed Resident #19 had a behavior problem related to crying and yelling. Interventions included to anticipate and meet the needs of the resident and caregivers to provide opportunities for positive interactions, attention, and speak in a calm manner. Review of the Weekly Skin Assessments from 04/01/24 through 05/18/24 for Resident #19 revealed two weekly skin assessments were documented, one on 04/19/24 at 6:45 A.M. completed by LPN #702 and one on 05/03/24 at 6:18 A.M. completed by LPN #703. Each assessment revealed Resident #19 had no bruises, skin tears, lesions, cuts or abrasions noted. Review of the nursing progress notes from 04/01/24 through 05/18/24 revealed no documentation of incidents of bruises, skin tears, lesions, cuts or abrasions for Resident #19. Review of the shower sheets for Resident #19, dated 03/02/24, 03/06/24, 03/08/24, 03/13/24, 03/23/24, 04/27/24, 05/01/24, 05/04/24, 05/08/24, 05/11/24 and 05/15/24 revealed no skin tears or bruising to the arms or face. Review of a nursing progress note, dated 05/19/24 at 10:11 P.M. completed by RN #521, revealed the STNA reported Resident #19 developed skin tears during the day. RN #521 went into the room and observed the resident had multiple skin tears to bilateral upper extremities and new bruising to both hands. Treatment was provided for the skin tears. RN #521 notified ADON #522 and the resident's daughter. A message was left for the on-call physician for MD #750, awaiting response. Review of a nursing progress note, dated 05/19/24 at 10:53 P.M. completed by RN #521, revealed Resident #19 had kerlix wrapped on her upper extremities before RN #521 cleansed the skin tears and rewrapped. RN #521 asked the STNA if Resident #19 had been wearing Geri sleeves during the day and the STNA confirmed Resident #19 had been wearing them. Review of the facility SRI revealed an injury of unknown origin was initiated by the Administrator for Resident #19, with a date of discovery of 05/19/24. Resident #19 complained of pain and the nurse medicated the resident. The nurse received report from staff that the resident was found with bruises and skin tears on bilateral arms. Resident #19 had a history of removing Geri sleeves and picking at skin. Staff became aware of the injuries on 05/19/24 at 9:45 P.M. The Administrator was notified at 10:00 P.M. by ADON #522, aids reported to the nurse and no other agencies were notified. Interventions included Geri sleeves were discontinued due to resident removing them, causing injury. Review of a wound care note, dated 05/22/24 and completed by WCCNP #502, revealed abnormal findings included traumatic lesion to the head and scattered bruising. Further review of the documentation revealed Resident #19 had six separate wounds, including skin tears and bruising, to her left upper arm, left forearm, left wrist, left inner forearm, right forearm, and right hand. Additionally, Resident #19 had a left cheek abrasion with bruising, right chin abrasion with bruising, and a left chest abrasion with bruising. Review of the daily schedule for 05/19/24 revealed from 2:30 P.M. through 6:30 P.M. a total of three staff members were scheduled for the unit Resident #19 resided on. The three staff members scheduled were RN #500, STNA #465 and STNA #501. Review of the facility investigation file revealed seven written staff statements. One from STNA #465, STNA #501 and STNA #607, two from RN #500, one from AD #900, and one from RN #521. STNA #607, AD #900 and RN #521 were not working during the time of the incident on 05/19/24. Review of a handwritten statement on lined notebook paper, dated 05/19/24 and untimed, revealed at mealtime, Resident #19 was yelling, screaming and was very disruptive. When STNA #501 removed the tray, she noticed blood on Resident #19's sleeves and reported this to the nurse. The nurse removed Resident #19 from the dining room and took her to her room. The statement included a cursive signature indicating STNA #465 signed the document. Review of a typed statement, dated 05/19/24 and untimed, revealed during dinner time, Resident #19 was making disruptive noises in the dining room. She was crying and screaming. While removing her dinner tray, blood stains were noted on her sleeves and the resident had bruising. STNA #501 reported this to the nurse, who removed Resident #19 and took her back to her room. The statement included a cursive signature indicating STNA #501 signed the document. Review of a typed witness statement, dated 05/20/24 and untimed, confirmed the DON completed a telephone interview with RN #500 related to the events on 05/19/24 with Resident #19. RN #500 indicated Resident #19 was aggressive toward her while attempting to administer medication. Review of a handwritten witness statement, completed by the Administrator and dated 05/21/24, revealed RN #500 was again interviewed over the phone, with the DON present, with no new information provided. Review of a typed statement, dated 05/19/24 and untimed, revealed the Administrator interviewed RN #521 via telephone. RN #521 stated he received in report Resident #19 had behaviors during the day and RN #500 had used derogatory language while speaking about the resident. The aides (STNA #465 and STNA #501) had reported Resident #19 had bruising and blood on her Geri sleeves. RN #521 provided treatment to the resident's arms and notified the Power of Attorney (POA), Certified Nurse Practitioner (CNP) and ADON #522 of new skin tears and bruising. Observation on 06/03/24 at 1:50 P.M. of Resident #19 revealed the resident was sitting in a wheelchair in her room. Resident #19 was calm and did not respond to questions asked by the surveyor. Resident #19 had bilateral Geri sleeves on, and a visible dressing was located on the right hand, partially covered by the Geri sleeve. The left side of Resident #19's face had three small red areas in a vertical line on the outer portion of her cheek. Resident #19 had a visitor who introduced herself as a sitter. Resident #19's daughter called the sitter on the phone and inquired who was in the room. Concurrent interview with Resident #19's daughter revealed she had a camera placed in the resident's room because Resident #19 was hurt by someone at the facility and received skin tears down her arms, a bruise to her right cheek and blood spots to the other side of her face. Resident #19's daughter revealed on 05/19/24 she received a phone call from RN #521, who stated two staff members reported there was an incident. Resident #19's daughter stated it was a nurse who caused the resident ' s injuries and she subsequently quit after being offered assignment on another floor and refused. Interview on 06/03/24 at 1:57 P.M. with STNA #607 revealed she worked first shift (6:30 A.M. until 3:00 P.M.) on 05/19/24 with Resident #19, who had no injuries during her shift. STNA #607 stated she was interviewed by AA #523 regarding the incident. STNA #607 stated she heard RN #500 caused Resident #19's injuries but she had no direct knowledge of the incident between RN #500 and Resident #19 and asked AA #523 why she was not talking to the staff who were there during that time. Interview on 06/03/24 at 4:49 P.M. and 06/04/24 at 4:42 P.M. with the DON confirmed the bruises on Resident #19's face were not mentioned in the SRI or in the nursing notes completed 05/19/24. The DON stated the bruises showed up a few days later and she did not know how Resident #19 got them because she did not investigate the cause. The DON revealed she concluded Resident #19 caused the bruises to her face and the skin tears to her arms herself from picking at the Geri sleeves. The DON confirmed there was no documentation in Resident #19's medical record from 04/01/24 through 05/19/24 of any picking at her Geri sleeves, causing self-inflicted skin tears or bruises. The DON stated Resident #19 had a low blood count, which could have caused the wounds. Interview on 06/04/24 at 2:53 P.M. with STNA #465 revealed on 05/19/24 she started her shift at 6:30 A.M. and worked until 11:00 P.M. STNA #465 stated when she started her shift, Resident #19 had no skin tears or bruising. STNA #465 confirmed she witnessed the incident on 05/19/24 at approximately 5:30 P.M. between RN #500 and Resident #19, in which RN #500 used derogatory language, removed the resident from the dining room, remained alone with the resident in her room and the resident subsequently had nine wounds. STNA #465 reported RN #500 stated the resident had three new skin tears because they got into it and referred to Resident #19 in a derogatory manner. STNA #465 stated RN #521 came in at 6:30 P.M. and both she and STNA #501 told him he needed to look at Resident #19 because her wounds were bad. RN #521 assessed Resident #19 and reported the incident. STNA #465 confirmed she wrote a witness statement on 05/19/24. Interview on 06/04/24 at 3:13 P.M. with STNA #501 revealed she started her shift at 2:30 P.M. on 05/19/24. Resident #19 was her assigned resident, and she had no skin tears or other injuries. STNA #501 verified she witnessed the incident between RN #500 and Resident #19 on 05/19/24, reporting around dinner time, RN #500 stated she had enough of Resident #19, removed her from the dining room, and was alone with the resident in her room. Resident #19 was heard screaming and after RN #500 exited the resident's room, the resident had blood on her Geri sleeves and upper arms and bruising on her hand. STNA #501 reported RN #500 stated Resident #19 was something else, she tried to get me, and we got into it. STNA #501 confirmed she reported the incident to RN #521 when he arrived for his shift at 6:30 P.M. and a handwritten witness statement was completed before she left that night. Review of the witness statement, handwritten on notebook paper and dated 05/19/24, on 06/04/24 at 4:35 P.M. with STNA #465, revealed the document signed with STNA #465's name was not the statement she had written on 05/19/24. STNA #465 further confirmed the handwriting and signature on the document was not hers, her statement was written on plain white paper (no lines) and the statement did not reflect her report of events on 05/19/24. STNA #465 stated her earlier interview with the surveyor was what she had written in her witness statement. STNA #465 had no knowledge of who wrote the statement that was included in the facility investigation and verified the facility administration never interviewed her regarding the incident on 05/19/24. Interview on 06/04/24 at 4:23 P.M. with the Administrator confirmed a police report was never filed regarding the incident on 05/19/24 between RN #500 and Resident #19, nor was RN #500 reported to the Ohio Board of Nursing for suspected abuse. Interview on 06/05/24 at 10:52 A.M. with WCCNP #502 revealed she had never visited Resident #19 prior to 05/22/24 and noted the resident had multiple skin tears during her assessment on 05/22/24. WCCNP #502 stated bruising could occur easier with contact if the person had a low blood count and low platelets. However, WCCNP #502 confirmed Resident #19's skin tears and abrasions were not consistent with low hemoglobin, and they were not consistent with self-picking. WCCNP #502 stated Resident #19 had no evidence of fingernail scratches, which would likely be seen if someone was self-picking their skin. Additionally, WCCNP #502 stated Steri-Strips were needed to reapproximate the skin flaps, also not consistent with skin picking. WCCNP #502 stated she did not believe Resident #19's wounds were the result of skin picking or low hemoglobin levels. WCCNP #502 confirmed she was not interviewed regarding her assessment findings and opinion regarding Resident #19's wounds. Interview on 06/05/24 at 12:27 P.M. with the DON verified RN #500 was permitted to return to work on Resident #19's unit on 05/27/24. RN #500 quit at approximately 1:42 P.M. that day, after Resident #19's family requested she not work with the resident following the incident on 05/19/24. The DON confirmed RN #500 was offered reassignment to another floor, but she refused, and terminated her employment that day. Review of the typed witness statement dated 05/19/24 and located in the facility's investigation file, on 06/05/24 at 3:23 P.M. with STNA #501 revealed the statement was not the handwritten statement she completed on 05/19/24, following the incident with RN #500 and Resident #19. STNA #501 stated she completed a handwritten statement, not typed. STNA #501 stated I wrote my own statement. I did not sign this. This is not mine. I have never seen this before. What I told you was accurate. That is my name, but I did not say that or sign that. Where is mine? STNA #501 verified she was not interviewed by the facility administration regarding the incident on 05/19/24. Interview on 06/05/24 at 3:40 P.M. with MD #750 confirmed he was the primary care physician for Resident #19. MD #750 revealed Resident #19's platelets were not low enough to cause spontaneous bleeding. MD #750 stated he was unaware of the extent of the incident involving RN #500 and Resident #19 and verified he had not been interviewed by the facility regarding the resident's injuries. Interview on 06/05/24 at 4:30 P.M. with the DON revealed STNA #465 and STNA #501's witness statements included in the facility's investigation file were placed under the Administrator's door. The DON stated she assumed both STNA #465 and STNA #501 wrote the statements themselves. The DON confirmed STNA #465 and STNA #501 were the only two staff members present during the incident and confirmed neither were interviewed. The DON stated she did not know where STNA #465 and STNA #501's written statements from 05/19/24 were and did not know where the two statements included in the investigation file came from. Interview on 06/05/24 at 4:34 P.M. with Administrator revealed she did not know if the witness statements included in the facility investigation from STNA #465 and STNA #501 were placed under the DON's door or hers after they were written. The Administrator stated she did not know who wrote or signed the witness statements and confirmed there were no other witness statements she had from STNA #465 or STNA #501. The Administrator verified she did not interview either STNA #465 or STNA #501, who were the only staff witnesses, regarding the incident. The Administrator stated she interviewed RN #500, who she thought was the important one to interview. The DON entered during the interview with the Administrator. Both the DON and the Administrator confirmed STNA #465 and STNA #501 were the only two witnesses and neither were ever interviewed regarding the incident on 05/19/24 between RN #500 and Resident #19. Additionally, the DON and Administrator confirmed neither WCCNP #502 nor MD #750 were interviewed regarding Resident #19's injuries. Both stated they suspected Resident #19's injuries were due to Resident #19 having a low platelet count and picking her own skin. Interview on 06/06/24 at 8:15 P.M. with RN #521 revealed on 05/19/24 he began his shift at 6:30 P.M. RN #500 gave him the nursing shift to shift report, using an explicative to describe Resident #19, and stated the resident had behaviors and got skin tears. RN #521 stated he notified the physician, family, and ADON #522 of the resident's wounds. RN #521 confirmed both STNA #465 and STNA #501 provided handwritten statements that night on plain white paper, and he placed them in the DON's mailbox. Review of the policy titled, Abuse, Neglect, Exploitation and Misappropriation of Resident Property revised 11/01/19 revealed the facility will not tolerate Abuse, Neglect, Exploitation or the Misappropriation of Resident Property. Facility staff should immediately report all such allegations to the Administrator/designee and to the Ohio Department of Health (ODH). In cases where a crime is suspected, staff should also report the same to local law enforcement. The definition of abuse included the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse. In the case of staff to resident abuse, the facility will follow the facilities procedure for discipline or dismissing an employee depending on the circumstances and results of the investigation. The investigation protocol included to interview the resident, the accused, and all witnesses. Witnesses generally include anyone who: witnessed or heard the incident, came in close contact with the resident the day of the incident and employees who worked closely with the accused employee the day of the incident. This deficiency represents non-compliance investigated under Complaint Number OH00153215.

Based on observation, review of medical records, interviews with staff, review of hospital records, review of the Certificate of Death, review of the National Pressure Injury Advisory Panel (NPIAP) and review of the facility policy, the facility failed to provide necessary care and services to prevent and subsequently promote healing and/or worsening of a facility acquired pressure ulcer. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death, when the facility failed to implement interventions to prevent the development of a facility acquired pressure ulcer, such as turning and repositioning and incontinence care for Resident #91, who was at risk for pressure ulcer development. Furthermore, the facility failed to timely and accurately complete skin assessments to identify the resident ' s pressure ulcer, failed to complete wound assessments and failed to provide the necessary care and treatments to promote healing and/or worsening of the wound. Consequently, on [DATE], Resident #91 was transferred to the hospital and admitted due to a fall and weakness secondary to Escherichia coli (E. Coli) bacteremia from an infected decubitus ulcer (pressure ulcer). Resident #91 subsequently died on [DATE]. The primary cause of death was E. coli sepsis (A life-threatening complication of an infection) due to an infected decubitus ulcer. Additionally, Actual Harm occurred to Resident #34, who was at risk for pressure ulcer development and dependent on staff for turning and repositioning and incontinence care, when Resident #34 was not provided weekly assessments of a stage three pressure ulcer, physician ordered pressure ulcer treatments were not completed as ordered, and the resident was subsequently admitted to the hospital on [DATE] with septic shock in setting of coccygeal wound. Lastly, the facility failed to provide care and services for the prevention, identification, and treatment of a pressure ulcer at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) for one (#40) additional resident reviewed for pressure ulcers. This affected three (#91, #34, #40) of four residents reviewed for pressure ulcers. The facility identified a total of 13 residents with pressure ulcers. The facility census was 86. On [DATE] at 1:49 P.M., the Administrator and Regional Director of Clinical Services (RDCS) #510 were notified Immediate Jeopardy began on [DATE] when Resident #91 when was identified to have a pressure wound to the right and left buttocks. Assistant Director of Nursing (ADON) #522 verified wound treatments to the right and left buttocks were not completed as ordered and could not verify Resident #91 received any care planned interventions for the prevention of pressure ulcers. On [DATE], the wound on the left and right buttock merged into one large wound to the sacrum, measuring 7.0 centimeters (cm) by 6.0 cm by 0.0 depth. The wound was noted with inflammation and induration (hardening of the skin and subcutaneous tissue, which may be secondary to infection). The wound had 10% granulation, 90% slough, moderate amount of serosanguinous drainage, and surgical debridement was provided. Resident #91 was not treated for any infection while at the facility. On [DATE], Resident #91 was sent to the hospital following a fall. The hospital notes indicated Resident #91 was admitted after a fall and weakness secondary to E. coli bacteremia from an infected decubitus ulcer. Resident #91 was subsequently discharged from the hospital to hospice care on [DATE] and died on [DATE]. Review of the death certificate revealed the immediate cause of death was E. coli sepsis due to an infected decubitus ulcer. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] between 2:09 P.M. and 5:49 P.M., Regional Minimum Data Set Coordinator (RMDSC) #914 and Minimum Data Set Coordinator (MDSC) #915 completed an assessment of all resident care plans to ensure they were updated with appropriate interventions to prevent and treat pressure ulcers. On [DATE] between 2:20 P.M. and 8:10 P.M., Licensed Practical Nurse (LPN) #916, LPN #917 and ADON #522 completed a skin assessment on all residents. There were no new wounds noted on the whole house skin assessments. On [DATE] at 2:45 P.M., a Root Cause Analysis was completed by RDCS #510, Regional Director of Operations (RDO) #503 and the Administrator. It was determined the Root Cause was the Director of Nursing (DON) and ADON #522 did not ensure preventative interventions and necessary care and treatments were in place to prevent, promote healing and/or worsening of Resident #91's wound. On [DATE] at 2:58 P.M., RDCS #510 re-educated ADON #522 on the facility's Wound Care policy, Prevention of Pressure Ulcers/Injuries, and New Admission/Re-Admission Skin and Wound Care Best Practices Policy. RDCS #510 will provide the education to the DON prior to returning to work on [DATE]. On [DATE] from 3:15 P.M. through 5:30 P.M., RDCS #510 provided in-service education for all licensed nurses, in person and via telephone, on the facility ' s Wound Care Policy, Prevention of Pressure Ulcers/Injuries, and New Admission/Re-Admission Skin and Wound Care Best Practices Policy. The following licensed nurses received the education: LPN #918, LPN #919, LPN #920, LPN #921, LPN #615, LPN #632, LPN #634, LPN #922, LPN #923, LPN #924, LPN #925, LPN #926, and Registered Nurse (RN) #521. Any licensed nurse who could not be reached will receive the education from ADON #522 or RDCS #510 prior to their next scheduled shift. On [DATE] at 4:12 P.M., an AD Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held by the Administrator, with Medical Director (MD) #750, to review the Immediate Jeopardy findings, discuss ensuring necessary care and treatments are in place to prevent and promote healing and/or worsening of wounds, and review facility polices related to prevention, identification, and investigation. Additional QAPI meeting attendees included RDO #503, RCDS #510, MDSC #915 (via phone), RMDSC #914 (via phone), and Assistant Administrator (AA) #523. On [DATE] from 5:40 P.M. through 8:30 P.M., RDCS #510 provided wound care education, including policies and procedures, in person and via telephone, for State tested Nursing Assistants (STNA) #932, STNA #933, STNA #934, STNA #608, STNA #627, STNA #609, STNA #501, STNA #935, STNA #936, STNA #602, STNA #625, STNA #911, STNA #624, STNA #628, STNA #607, STNA #622, STNA #937, STNA #938, STNA #620, STNA #939, STNA #604, STNA #629, STNA #940, STNA #673 and STNA #941. Any STNA who could not be reached will receive the education from the DON or designee prior to their next scheduled shift. On [DATE] from 6:00 P.M. through 8:00 P.M., RDCS #510 completed a Braden Scale (assessment used for predicting pressure ulcer risk) audit for all residents. Beginning on [DATE], the DON or designee will audit all new admissions, Monday through Friday, for four weeks to ensure skin prevention/treatment orders are in place, Braden Scale orders are in place and skin prevention and wound care interventions appropriately care planned. The audits will be completed within 48 hours of admission. Beginning on [DATE], the DON or designee will audit all weekly skin assessments, Monday through Friday, for four weeks to ensure all assessments are completed accurately and any identified areas of concern are timely assessed and treated. Beginning on [DATE], the DON or designee will visually validate all wound treatments are completed as ordered and audit the Treatment Administration Record (TAR) Monday through Friday for four weeks to ensure all treatments have been signed off on the TAR. Beginning on [DATE], the DON or designee will audit all residents with wounds weekly for four weeks to ensure weekly wound assessments are completed, monitor for wound progress and ensure treatment orders and appropriate care plan interventions are in place for each wound. Beginning on [DATE], the DON or designee will audit seven incontinent residents daily, Monday through Friday for four weeks to ensure incontinent residents were checked and changed and incontinence care provided. Beginning on [DATE], the QAPI committee will meet weekly for four weeks, then monthly thereafter, to review all audit findings to ensure continued compliance. Although the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1) Review of Resident #91's closed medical record revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included fracture of unspecified part of neck of right femur, muscle weakness, and the need for assistance with personal care. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #91 was moderately cognitively impaired. Resident #91 had no impairment to the upper extremities and had impairment to one side of the lower extremities. Resident #91 was dependent for activities of daily living (ADLs), including toileting, bathing, dressing, bed mobility and transfers. Resident #91 was always incontinent of bowel and bladder, was at risk for pressure ulcers and had no pressure ulcers. Resident #91 had a surgical wound and skin tears and received surgical wound care. Review of the Admit Screener, dated [DATE] at 2:26 P.M. and completed by ADON #522, revealed Resident #91 was admitted from the hospital with an admitting diagnosis of fractured right hip, status post repair of the right hip fracture. Resident #91 ' s skin color was normal, temperature was warm, turgor was normal, and the resident had a right trochanter hip surgical incision and left forearm skin tear. The assessment indicated diffuse bruising to her bilateral arms, thighs and knees as well as the area surrounding the surgical site. Resident #91 was alert and oriented to person. Review of the Braden Scale, dated [DATE] at 2:24 P.M. and completed by ADON #522, revealed Resident #91 was at risk for pressure sores. Review of the care plan, dated [DATE], revealed Resident #91 had potential/actual impairment to skin integrity. Interventions included air mattress in place, encourage to turn and reposition with rounds every two hours and as needed and tolerated. Further review of the care plan revealed a focus area created on [DATE] to include Resident #91 had an ADL self-care performance deficit. Interventions included staff to turn and reposition in bed and as necessary, required skin inspection, observe for redness, open areas, scratches, cuts, bruises, and report changes to nurse. Additionally, Resident #91 had bladder incontinence. Interventions included to clean the peri area with each incontinent episode. Lastly, review of a care plan focus area created on [DATE] (six days after Resident #91's discharge), revealed the resident had an unstageable pressure ulcer to her sacrum related to immobility. Interventions included administer treatments as ordered and monitor for effectiveness, avoid positioning the resident on sacrum, assist to turn and reposition at least every two hours and more often as needed or requested. Review of the physician orders for Resident #91 revealed the following orders: initiated [DATE], pressure reducing mattress to bed; initiated [DATE] and discontinued [DATE], cleanse right buttocks open area with normal saline (NS) and pat dry, apply foam dressing daily and as needed (PRN); initiated [DATE] and discontinued [DATE], cleanse left buttock with NS and pat dry, apply collagen and foam dressing daily and PRN; initiated [DATE], air mattress to bed; initiated [DATE], cleanse sacral wound with NS and apply mesalt daily and PRN every night shift for wound management; initiated [DATE], cleanse sacral wound with NS and apply mesalt daily and PRN every night shift and as needed if soiled for wound management; and initiated [DATE], cleanse sacral wound with NS, apply mesalt and apply foam dressing daily and PRN. Further review of physician orders revealed Resident #91 had no orders for antibiotics during her stay at the facility. Additional review of Resident #91's medical record revealed no evidence of wound assessments, including measurements or description of the pressure ulcers identified in physician orders beginning on [DATE]. Review of the TAR for [DATE] revealed the wound care to Resident #91's left, and right buttocks was not documented as completed on [DATE] or [DATE]. Further review of the TAR for [DATE] revealed the wound care to Resident #91 ' s sacral wound was not documented as completed on [DATE] or [DATE]. Review of the Wound Weekly Observation Tool for Resident #91, dated [DATE] at 11:58 P.M. and completed by ADON #522, revealed Wound Care Certified Nurse Practitioner (WCCNP) #502 was in for initial evaluation of Resident #91 ' s wound. Family was notified on [DATE], resident is on turning and repositioning routine, wound to sacrum acquired, pressure 10% granulation 90% slough, moderate amount serosanguinous drainage, surgical debridement provided, wound measured 7.0 centimeter (cm) by 6.0 cm by 0.0 cm depth with inflammation and induration present. Review of WCCNP #502's visit note, dated [DATE], revealed Resident #91 was seen for an initial visit for wound care services. Resident #91 had a wound located on the sacrum. The wound was moderate in severity. The wound was an unstageable pressure ulcer with obscured full thickness skin and tissue loss. The wound measurement was seven cm in length by six cm in width with no measurable depth. The note further indicated the wound had a moderate amount of serosanguinous drainage, noted to have no odor. The peri wound did not exhibit signs and symptoms of infection. Lastly, the wound had 90% slough and 10% granulation tissue. Review of WCCNP #502's visit note, dated [DATE], revealed Resident #91 was being seen for a follow up visit for wound care services. Documentation included the unstageable pressure ulcer was full thickness with 20% granulation, 30% slough, 40% necrotic and 10% epithelial. There was moderate serosanguinous exudate and signs and symptoms of infection included odor. The wound was debrided to reduce bacterial load, will consider switching to Dakins next week if no improvement. Wound size was documented at 8.4 cm by 9.9 cm with an undetermined depth. Recommendations included a pressure reduction mattress per facility protocol and reposition per facility protocol. Interview on [DATE] at 1:58 P.M. and [DATE] at 11:30 A.M. with ADON #522 revealed Resident #91 had no pressure wounds on admission and developed a facility acquired stage three pressure ulcer. ADON #522 stated the wound started as two wounds, one on the right buttock and one on the left. ADON #522 confirmed there was no documentation to include the description of the wounds and measurements in the medical record for Resident #91's wounds to the right and left buttocks. ADON #522 revealed the two pressure wounds merged together as one sacral wound. ADON #522 stated she did not know if the staff were turning and repositioning Resident #91. ADON #522 further stated It was found at a stage three, it was bad when I looked at it, that shouldn't happen. ADON #522 revealed when she completed rounds, there were times she found wound dressings dated several days prior, indicating treatments had not been completed, but the nurses were still signing the TAR as completed. ADON #522 reviewed Resident #91 ' s TAR and confirmed there was no evidence the resident ' s treatments were completed on [DATE], [DATE], [DATE] or [DATE]. Additionally, ADON #522 verified there was no evidence in the medical record revealing when the resident transferred to the hospital or why. ADON #522 confirmed the resident was transferred to the emergency room (ER) on [DATE]. Interview on [DATE] at 10:57 A.M. with STNA #906 confirmed she worked with Resident #91 and remembered the resident. STNA #906 stated Resident #91's wound care dressings were not getting done consistently. STNA #906 stated Resident #91 would have a bowel movement and the stool would be impacted in the wound. STNA #906 revealed she would clean the stool out of the wound with wipes then saline and stated, Sometimes the nurses would not put the dressing back on, sometimes there was no dressing when I came on my shift and all day. A follow-up interview on [DATE] at 3:10 P.M. with ADON #522 revealed she initiated Resident #91's wound care on [DATE] and obtained the orders for the treatments to the right and left buttocks. ADON #522 confirmed she looked at the wounds, confirmed they were pressure wounds but did not measure the wounds, describe the wounds, or place any identifiable information describing the wounds in Resident #91's medical record. Review of the hospital admission note, dated [DATE], and an undated hospital physical examination at discharge, completed by Physician #907, revealed Resident #91 was admitted to the hospital after a fall and weakness secondary to E. coli bacteremia from an infected decubitus ulcer. Review of the Certificate of Death, dated [DATE] and signed by Registrar #908, revealed Resident #91's date of death was [DATE]. The immediate cause of death was E. coli sepsis due to an infected decubitus ulcer. 2) Review of Resident #34's medical record revealed an admitted [DATE] and re-admitted [DATE]. Diagnoses included type two diabetes mellitus with diabetic neuropathy and other skin ulcers, stage three pressure ulcer of sacral region, muscle weakness, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact. Resident #34 was dependent for toileting, dressing, personal hygiene, and required substantial/maximal assistance for bed mobility. Resident #34 was always incontinent of bowel and bladder. Resident #34 was at risk for pressure ulcers and had one stage three pressure ulcer that was present upon admission and received pressure ulcer care. Review of the care plan, dated [DATE], revealed Resident #34 was always incontinent of bowel. Interventions included: checking the resident every two hours and assisting with toileting as needed. Additionally, Resident #34 had one pressure ulcer wound on the sacrum (stage three). Interventions included: to provide treatments as ordered and to educate the resident, family, and caregivers as to causes of skin breakdown including transfer/positioning requirements and frequent repositioning. Record review of Resident #34's monthly physician orders for [DATE] and [DATE] revealed orders for: Cleanse sacral wound with NS, pat dry and apply collagen to the wound bed. Cover with bordered foam dressing daily and PRN. The order was discontinued [DATE]; initiated on [DATE] and discontinued on [DATE], cleanse sacral wound with NS, pat dry, apply collagen to the wound bed followed by calcium alginate and cover with bordered foam dressing daily and PRN every night shift for wound management; initiated [DATE], cleanse sacral wound with NS, pat dry, apply Medi honey to the wound bed followed by calcium alginate and foam every night shift; and initiated [DATE], turn and reposition every two hours as tolerated while in bed. Review of the Wound Weekly Observation Tool dated [DATE] at 10:33 P.M. and completed by ADON #522 revealed WCCNP #502 onsite to follow up. Resident #34's sacral wound noted to be 80% granulation, 10% slough 10% epithelial and measured 1.4 cm in length by 0.6 cm in width by 1.0 cm in depth. The wound was unchanged. Further review of the medical record revealed there were no further Wound Weekly Observation Tools completed for Resident #34 in the medical record until [DATE]. Review of the TAR from [DATE] through [DATE] revealed both night shift wound treatment orders (cleanse sacral wound with NS, pat dry, apply collagen to the wound bed followed by calcium alginate and cover with bordered foam dressing daily and as needed every night shift initiated [DATE] and cleanse sacral wound with NS, pat dry, apply Medi honey to the wound bed followed by calcium alginate and foam every night shift initiated [DATE]) were both signed as completed on [DATE] and [DATE]. Review of the progress note dated [DATE] at 7:18 P.M. and completed by LPN #616 revealed Resident #34 returned from dialysis early due to leg/buttocks pain. Resident #34 was feeling blah today, complained of not being able to grab things with her left hand. Resident #34 was encouraged not to keep holding her cell phone in her left hand for long periods of time. Vital signs stable. Plan of care continues. Review of the change in condition evaluation, dated [DATE] at 7:53 A.M. and completed by LPN #616, revealed Resident #34's blood pressure was ,d+[DATE], pulse was 64, respirations 20 and temperature was 97.5 degrees Fahrenheit (F). Review of a progress note dated [DATE] at 1:12 P.M. and completed by LPN #616 revealed at 7:30 A.M., Resident #34 complained of dropping things from her left hand. The on-call Nurse Practitioner (NP) was called, and new order received to send resident to the emergency department (ED) for an evaluation. Resident sent to ED this morning. Review of a progress note, dated [DATE] at 1:12 P.M. and completed by LPN #616, revealed the nurse called the ED for a status update on Resident #34. Resident #34 was being admitted to the Intensive Care Unit (ICU) for septic shock. Review of the Nursing Re-admit Assessment completed [DATE] at 11:45 P.M. and completed by LPN #894, revealed Resident #34 was readmitted from the hospital with an admitting diagnosis of septic shock. Review of the hospital discharge summary, dated [DATE] and completed by Physician #891, revealed Resident #34 was admitted to the ICU and transferred to the medical floor following stabilization. Resident #34 was treated for septic shock in setting of both coccygeal wound and possible proctitis (inflammation of the rectum). Resident #34 was treated with linezolid (antibacterial) and Zosyn (antibiotic) during hospitalization . Review of the re-admission physician orders for Resident #34's wound care to the coccyx included: sacrum: Cleanse with NS, pat dry, apply Dakins ' s wet to dry, cover with ABD (abdominal dressing) and secure with paper tape every day shift. The order was initiated [DATE] and discontinued [DATE]. Further review of physician orders revealed on [DATE], a new order was initiated to cleanse the sacral wound with NS, apply Medi honey, calcium alginate and cover with foam dressing daily and PRN every night shift for wound management. The order was discontinued on [DATE]. Review of the TAR for Resident #34 from [DATE] through [DATE] revealed both treatments were signed off daily from [DATE] through [DATE]. Wound care to the coccyx was not documented as being completed on [DATE] or [DATE]. On [DATE], the cleanse sacral wound with NS, apply Medi honey, calcium alginate, cover with foam dressing daily treatment was initialed. Interview on [DATE] at 10:45 A.M. with Resident #34 revealed she had a sacral pressure ulcer. Resident #34 revealed the staff were supposed to change her wound dressing every day, but they did not. Resident #34 stated she was supposed to be turned every two hours but was only turned once a day. Resident #34 revealed the last time she was changed for incontinence was at 4:00 A.M. and needed changed now but the STNAs did not have time. Observation on [DATE] at 11:13 A.M. of incontinence care provided by STNA #460 for Resident #34 revealed Resident #34 had a large bowel movement (stool). The stool was partially dried on Resident #34's skin. Resident #34 had a boarder dressing to the sacral area. The dressing was partially lifted at the bottom and there was visible stool under the dressing. STNA #460 revealed this was the first time on this day she was able to assist Resident #34 with incontinence care (nearly five hours after her shift began). STNA #460 stated there were not enough staff and too many residents who required total care. STNA #460 revealed residents were usually provided incontinence care at least once per shift, some were changed twice per shift and expressed she could not reposition Resident #34 every two hours as there was just not enough staff, and she could not do it all. STNA #460 stated, Oh, that must be poop (referring to the contents under the dressing located on Resident #34's sacrum). While cleaning the stool from Resident #34's buttocks, STNA #460 removed the dressing from Resident #34's sacrum. STNA #460 then took the same washcloth and cleaned the stool from the wound while rubbing the wound with the soiled washcloth. STNA #460 stated she would apply another dressing to the wound bed if there was one in the room. STNA #460 reported the STNAs reapplied wound dressings when residents were incontinent and had stool on them. STNA #460 then began looking around the room for a wound dressing to apply. The wound to the sacrum was exposed, the wound bed had visible slough, the surrounding tissue was red with visual remnants of stool that remained on the wound bed. STNA #460 revealed there was not another dressing and left the room revealing she would get the nurse to apply the dressing. A nurse did apply a new dressing after the surveyor left. Review of the Wound Care assessment, completed by WCCNP #502 and dated [DATE] at 9:45 A.M., revealed Resident #34 was seen for a follow up visit for wound care services. The resident ' s wound had declined. Treatment order changed to include applying hydrogel to wound bed to help absorb wound exudate along with alginate silver to prevent buildup of new bacteria. If dressing gets soiled, change as needed. The fully updated treatment order included cleanse wound with NS, pat dry, apply hydrogel followed by silver nitrate to the wound bed and cover with bordered foam dressing. Change/apply treatment daily and as needed. Interview on [DATE] at 11:18 A.M., with WCCNP #502 revealed Resident #34's sacral wound was worsening. WCCNP #502 confirmed sitting with stool on a wound would worsen the wound and could cause infection. WCCNP #502 revealed she assessed Resident #34 wounds weekly and had seen the resident frequently soiled with urine and stool. WCCNP #502 revealed she asked the staff to start cleaning residents prior to her visit. WCCNP #502 confirmed the STNAs should not be applying a new dressing or cleaning the wound and revealed she has seen dressings dated for days prior to when the wounds should have been changed. Review of the Wound Weekly Observation Tool dated [DATE] at 3:39 P.M. and completed by ADON #522, revealed Resident #34's wound to the sacrum was worsening with the wound having tunneling and/or undermining. The document included new treatment orders including to cleanse the coccyx wound with NS, apply hydrogel followed by silver alginate to the wound bed and cover with bordered foam dressing. Interview on [DATE] at 1:41 P.M. with ADON #522 stated she and WCCNP #502 had asked the STNAs to clean residents before rounds because they were frequently saturated with urine and/or stool. ADON #522 confirmed, during rounds, she had found wound dressings that were dated two or three days prior to when the wound treatments should have been done, which was daily. ADON #522 verified nurses were signing the wound care as completed on the TAR without completing treatments. ADON #522 revealed she talked to the nurses about it but hasn't had time to write them up yet. ADON #522 revealed the nurses were not completing their weekly skin assessments either. Review of the physician orders for Resident #34 revealed the order given by WCCNP #502 on [DATE] was not placed in the medical record and initiated until [DATE]. Review of the [DATE] TAR for Resident #34 confirmed the wound care treatment ordered on [DATE] was not initiated until [DATE]. Interview on [DATE] at 10:22 A.M. with the DON confirmed Resident #34 had overlapping wound care orders. The DON verified she did not know which treatments were completed for Resident #34. The DON confirmed old treatment orders should be discontinued when new orders were written. Interview on [DATE] at 11:04 A.M. with ADON #522 confirmed on [DATE] WCCNP #502 provided new treatment orders for Resident #34's sacral wound. ADON #522 verified the order was not placed in the resident's orders until [DATE] and not initiated until [DATE], stating she did not get to it because she had to work the floor. ADON #522 confirmed when new orders for treatments were written, the old wound care orders should be discontinued. ADON #522 confirmed when new wound treatment orders for Resident #34 were initiated [DATE], the previous order initiated [DATE] should have been discontinued and the wound care order dated [DATE] should have been discontinued on [DATE], when the new order started, resulting in overlapping orders and nurses signing the TAR as completing both treatments. ADON #522 could not confirm what wound care treatments Resident #34 received. 3) Review of Resident #40's medical record revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus, chronic kidney disease, overactive bladder, muscle weakness, and abnormalities of gait and mobility. Review of the quarterly MDS assessment dated [DATE] revealed Resident #40 was moderately cognitively impaired. Resident #40 was dependent for toileting, personal hygiene, and required substantial/maximum assistance with transfers. Resident #40 used a wheelchair and was dependent for mobility. Resident #40 was frequently incontinent of urine and occasionally incontinent of bowel. Resident #40 was at risk for pressure ulcers and had two stage three pressure ulcers. Resident #40 had a pressure reducing device to her chair. Review of the care plan, dated [DATE], revealed Resident #40 was at risk for alteration in elimination related to episodes of incontinence. Interventions included to check resident every two hours and assist with toileting as needed and monitor for skin redness and irritation and notify nursing. Resident #40 was also at risk for alteration in skin integrity related to impaired mobility, medication, episodes of incontinence and fragile skin. Interventions included turning and repositioning Resident #40 every two hours as tolerated. Review of Resident #40's [DATE] physician orders revealed the following orders: Initiated [DATE], Roho like cushion (pressure relieving) when up in wheelchair, check inflation every shift; initiated [DATE], wound care: cleanse right buttock wound with NS, pat dry, apply silver alginate to wound bed and apply foam dressing daily and as needed on day shift; initiated [DATE], wound care: cleanse right lower buttock abscess with NS daily and as needed, leave open to air scheduled every day shift; and initiated [DATE], encourage resident and assist to turn and reposition every two hours. Review of a Wound Care note, dated [DATE] at 9:45 A.M. and completed by WCCNP #502, revealed Resident #40 had weakness with stiffness and limitation of movement. Upon examination the sacrum stage three pressure ulcer showed complete epithelization, healing was complete, and the wound was fully closed. The right lower buttocks wound (abscess) was slightly smaller in size, flat with a darkened discoloration and firm skin ridge/induration to the medial side of thigh. Orders included to cleanse wound with NS, pat dry to the wound bed, leave open to air and apply treatment daily and as needed. Review of the TAR for [DATE] through [DATE] revealed both orders for wound care to the right buttocks (cleanse right buttock wound w[TRUNCATED]

Based on closed medical record review, hospital record review, staff interviews, and review of facility policy, the facility failed to ensure physician ordered treatments were provided to promote healing of a surgical wound. Actual Harm occurred when Resident #90's surgical wound was not assessed until five days after admission and had 60% slough over then wound, physician ordered treatments were not administered as ordered leading to infection of the surgical wound, requiring a seven-day hospitalization , treatment with intravenous antibiotics, and the placement of a wound vacuum for healing. Upon readmission to the facility, the facility failed to initiate the physician order for a wound vacuum for the surgical wound site for three days and then failed to apply and change as ordered. This affected one (#90) of four residents reviewed for wounds. The facility census was 86. Findings include: Review of Resident #90's closed medical record revealed an admitted [DATE], with re-admitted [DATE] and a discharge date of [DATE]. Diagnosis included unspecified open wound of the abdominal wall with right upper quadrant without penetration into peritoneal cavity. Review of the Admission assessment dated [DATE] revealed Resident #90 had an abdominal surgical incision. There was no description or measurement of the wound. Review of the care plan for Resident #90 dated 04/08/24 revealed Resident #90 had an actual impairment to skin integrity of the mid abdomen related to a surgical wound. Interventions included to follow facility protocols for treatment of injury. Review of the Weekly Wound observation tool assessment dated [DATE] at 8:19 P.M., completed by ADON #522 revealed Wound Care Certified Nurse Practitioner (WCCNP) #502 was in for initial evaluation, wound located on the abdomen, 40% granulation, 60% slough, 12.0 centimeters (cm) by 3.7 cm by 2.1 cm depth, well approximated, sutures intact to center of the wound bed, continue surgical orders and apply Santyl to wound bed. Further review revealed evidence Resident #90's wound was assessed on 04/17/24. Review of the re-admission Medicare five-day [NAME] Data Set assessment dated [DATE] revealed Resident #90 was cognitively intact. Resident #90 had no impairment of upper extremities, impairment both sides lower, required supervision or touch assist with toileting, bathing, transfers, set up or clean up assist with dressing, bed mobility, always continent of bowel and bladder, had two venous/arterial wounds and had a surgical wound. Review of the monthly physician orders for April and May 2024 revealed Resident #90 had the following orders: cleanse abdominal area with normal saline (NS), apply Santyl, then wet to dry saline-soaked gauze, cover with ABD (abdominal dressing) every shift (two times daily, day and night shifts). The order was placed on hold from 04/11/24 to 04/12/23 and discontinued on 04/12/24; initiated on 04/19/24 and discontinued on 04/23/24, Santyl external ointment 250 units per gram, apply to abdominal wound topically every shift for wound; 05/04/24, wound documentation every shift; and 05/07/24, ensure follow up set up with wound care center. Review of the Treatment Administration Record (TAR) for April 2024 revealed no evidence wound care was completed for Resident #90 on 04/06/24 night shift, 04/07/24 on day shift or night shift, 04/19/24 night shift, and 04/20/24 day shift or night shift. Review of a progress note dated 04/23/24 at 11:09 A.M. and completed by LPN #903 revealed Resident #90 had purulent wound drainage from the abdominal wound. Review of a progress note dated 04/23/24 12:47 P.M. and completed by LPN #903 revealed Resident #90 was sent to the emergency room (ER) related to abnormal vital signs, altered mental state (AMS), and ROM (range of motion). Review of the hospital History and Physical (H&P) completed by Hospital Physician #901 revealed Resident #90 had an ulcer wound on the right side of her abdomen. Upon removing the bandage, the wound had some purulent discharge with some surrounding erythema. Intravenous antibiotics were started. Further review of the After-Visit Summary for Resident #90 revealed the resident was hospitalized on [DATE] and discharged on [DATE] for an infected wound. Discharge wound care instructions included: wound site abdomen, change dressing as needed, cleanse with NS, apply bacitracin and zinc oxide and continuous wound vacuum (vac) at 125 mm/hg (millimeters of mercury). Review of a progress note dated 04/29/24 at 5:50 P.M. completed by Assistant Director of Nursing (ADON) #522 revealed Resident #90 arrived from the hospital post hospitalization for hypotension and sepsis. Further review of the TAR from 04/30/24 through 05/13/24 revealed no wound care treatments were documented as provided for Resident #90. Additional review of the physician orders, dated 05/02/24 and discontinued 05/13/24, revealed abdominal wound vac at 125 mm/hg and apply bacitracin and zinc oxide. Review of a progress note dated 05/03/24 at 12:29 A.M. completed by LPN #904 revealed Resident #90 removed her wound vac because it kept beeping and she stated it had too much tape on it. A wet to dry dressing was applied. Further review of the medical record revealed no evidence the physician was notified on 05/03/24 of the new dressing applied and there was no order for wet to dry dressing. Review of a progress note dated 05/08/24 at 4:07 A.M. completed by LPN #905 revealed the nurse was called to Resident #90's room by the STNA. The resident removed her wound vac and stated it fell off. The abdominal area was cleansed and a wet to dry dressing was placed. Further review of the medical record revealed no evidence the physician was notified on 05/08/24 of the new dressing applied and there was no order for wet to dry dressing. Review of the Wound Weekly Observation Tool for Resident #90 dated 05/08/24 at 11:11 A.M., completed by ADON #522, revealed WCCNP #502 was onsite for follow-up. The documentation stated the abdomen wound was improving with granulation, 40% slough. There was also 1.4 cm additional measurement. The peri wound was excoriated. Wound vac at 125 mmHg continuous. Further review of the medical record revealed no evidence of a corresponding WCCNP #502 progress note. Review of a progress note dated 05/09/24 at 6:38 A.M. completed by Registered Nurse (RN) #617 revealed Resident #90 had the wound vac dressing completely off with drainage all over the abdomen, drainage from peg tube under her breast, red and excoriated skin all over the abdomen, and under and over breasts. Resident #90 was noncompliant, constantly picking at dressings and wounds. Review of a progress note dated 05/12/24 at 11:09 A.M. by the Director of Nursing (DON) revealed Resident #90 was sent to the ER due to resident having an emesis after a fall. Review of a progress note dated 05/13/24 at 12:04 P.M. completed by the DON revealed she phoned the hospital and spoke to the nurse in the stepdown intensive care unit (SICU). Resident #90's admitting diagnosis was encephalopathy (brain dysfunction). Interview on 06/04/24 at 10:21 A.M. with ADON #522 confirmed Resident #90 returned from the hospital on 04/29/24. ADON #522 verified Resident #90 had orders for a wound vac upon readmission and physician orders for the wound vac were not placed until 05/02/24 (three days after readmission). ADON #522 confirmed the orders did not specify how frequently to change the wound dressing, which she stated should have been three times a week and as needed per protocol for a wound vac. ADON #522 stated the floor nurses changed Resident #90's wound vac dressings while she resided at the facility. Resident #90's medical records were reviewed with ADON #522, which included physician orders, Medication Administration Record (MAR), and TAR. ADON #522 confirmed the wound vac orders were not located on the MAR or TAR for April or May 2024 for the nurses to view and complete the orders. ADON #522 stated the nurse who placed the order in the electronic medical record (EMR) did not place the order on the TAR, which did not allow the nurses to see the order when they viewed the treatment record. ADON #522 verified the nurses would not have seen the order for the scheduled wound treatments due to the orders being incorrectly placed in the EMR, resulting in nurses not completing the order per physician order/protocol for the routine wound vac dressing changes. ADON #522 verified there was no documentation of wound care treatments being completed on 04/06/24 night shift, 04/07/24 on day shift or night shift, 04/19/24 night shift, 04/20/24 day shift or night shift or from 04/30/24 through 05/12/24. Interview on 06/05/24 at 11:08 A.M. with WCCNP #502 revealed the wound vac not being changed as ordered could have caused the excoriation on Resident #90's abdomen when she assessed her on 05/08/24. Additionally, WCCNP #502 verified not completing treatments could have caused worsening of the wound. WCCNP #502 stated wound vac dressings were to be changed three times a week and as needed. WCCNP #502 confirmed on 05/08/24, Resident #90's wound was improving but stated that was only part of the wound. While the actual outside of the wound was getting smaller, showing improvement, the inside of the wound had new undermining, which was not improvement, and the wound was getting worse. WCCNP #502 stated that was the reason she wanted Resident #90 to go to the wound clinic. Review of the facility policy titled Wound Care, revised October 2010, revealed the purpose of the procedure was to provide guidelines for the care of wounds to promote healing, which included verifying physician orders. This deficiency represents non-compliance investigated under Complaint Number OH00154034.

Based on observation, medical record review, staff interviews, and review of facility policy, the facility failed to ensure residents received timely incontinence care. This resulted in actual psychosocial harm when one resident (#40) was observed sitting in her wheelchair in her room. Resident #40 had a foul odor of urine and stool on her body, as well as her room. A blanket placed on the floor under Resident #40's wheelchair was saturated with urine, which was dripping onto the floor. Additionally, Resident #40 was wearing an adult brief and pull-up, both saturated in urine, as was a bed pad and blanket placed on the wheelchair seat under Resident #40. Resident #40 cried regarding the lack of incontinence care and stated it made her feel horrible. Furthermore, the facility failed to ensure timely incontinence care for two (#34 and #62) additional residents reviewed for incontinence care. Lastly, the facility failed to ensure catheter care and monitoring was provided for one (#98) of three residents reviewed for catheter care. The facility census was 86. Findings include: 1) Medical record review for Resident #40 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus, chronic kidney disease, overactive bladder, muscle weakness and abnormalities of gait and mobility. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was moderately cognitively impaired. Resident #40 was dependent for toileting, personal hygiene, and mobility and was frequently incontinent of urine and occasionally incontinent of bowel. Review of the care plan, dated 04/24/24, revealed Resident #40 was at risk for alteration in elimination related to episodes of incontinence and required assistance with toileting. Related diagnoses included overactive bladder and fluid overload. Interventions included to check Resident #40 every two hours and assist with toileting as needed. Observation on 06/03/24 at 10:56 A.M. revealed Resident #40 was sitting in her tilt-n-space wheelchair. Resident #40, and her room, had a strong, foul urine odor. The gown worn by Resident #40 was visibly saturated with urine. A white blanket observed under Resident #40's wheelchair was also visibly saturated with urine, which was dripping onto the floor. Concurrent interview with Resident #40 revealed she slept in her wheelchair and never got into bed. Resident #40 stated she had been asking for assistance with care, but staff had not been in to change her yet today. Interview on 06/03/24 at 10:59 A.M. with State tested Nurse Aide (STNA) #606 confirmed she was Resident #40's assigned STNA. STNA #606 stated she was busy but hoped to get to Resident #40 in about 20 minutes. Observation on 06/03/24 at 11:32 A.M. of incontinence care provided by STNA #606 for Resident #40 revealed Resident #40 had a strong odor of urine on her body and in her room. Concurrent interview with STNA #606 verified the strong, foul odor of urine. STNA #606 stated, This is the first time I have been in here today, there is not enough staff. STNA #606 confirmed her shift began at 6:30 A.M. and she had not provided incontinence care for Resident #40 prior to this observation (five hours later). STNA #606 pushed Resident #40 in her wheelchair to the bathroom. STNA #606 confirmed the blanket on the floor under Resident #40's wheelchair was saturated with urine and the urine had dripped onto the floor. STNA #606 assisted Resident #40 to stand and the resident held onto the grab bar next to the toilet. The back and front of Resident #40's gown was saturated with urine. Resident #40 was sitting on a bath blanket covered by a pad that were both saturated in urine. STNA #606 removed the saturated bath blanket and pad and revealed the chair cushion underneath was also saturated in urine. STNA #606 removed two incontinent briefs, a pull up and an adult brief, from Resident #40. Both were saturated with urine and stool. Resident #40 had a wound dressing on her sacrum area which fell off when the second brief was removed due to saturation with urine and stool. Resident #40 began crying and stated, It makes me feel horrible, its bad. Resident #40 revealed she did not receive incontinence care very often. STNA #606 confirmed, at times, she could only change residents once a shift and, at most, twice during her eight-hour shift. STNA #606 verified the above observation and stated Resident #40 wore two briefs per her request. Resident #40, who was still crying, interjected and stated she requested two briefs because she did not get changed very often. STNA #606 completed incontinence care and washed Resident #40's upper body. STNA #606 applied a clean pull up and brief, placed a clean blanket and pad on top of the unwashed, urine saturated wheelchair cushion, and assisted Resident #40 back to her chair. STNA #606 stated it was a frequent occurrence for Resident #40 to be saturated with urine and stool. STNA ##606 confirmed she did not clean Resident #40's wheelchair or cushion prior to assisting the resident back into it, stating she did not know how to. Interview on 06/05/24 at 11:18 A.M. with Wound Care Certified Nurse Practitioner (WCCNP) #502 revealed Resident #40 was completely saturated with urine, with the resident's brief falling off, when she visited earlier today. WCCNP #502 stated she visited residents weekly for wound care and frequently found residents, including Resident #40, saturated in urine and stool. WCCNP #502 revealed she started asking the STNAs to clean the residents up prior to being seen by her. Interview on 06/06/24 at 1:32 P.M. with Assistant Director of Nursing (ADON) #522 revealed she did wound rounds weekly with WCCNP #502. ADON #522 confirmed both WCCNP #502 and herself have asked the STNAs to clean the residents prior to wound care because they were frequently saturated with urine and or stool. 2) Medical record review for Resident #62 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus, morbid obesity and acquired absence of right lower leg below the knee. Review of the quarterly MDS assessment dated [DATE] revealed Resident #62 was moderately cognitively impaired. Resident #62 was dependent for transfers, toileting, and required substantial/maximum assistance for personal hygiene. Resident #62 was frequently incontinent of bowel and bladder. Review of the care plan, dated 01/08/24, revealed Resident #62 had bowel incontinence. Interventions included checking the resident every two hours and assist with toileting as needed. Interview on 06/03/24 at 10:05 A.M. with Resident #62 revealed she waited a long time to receive incontinence care, sometimes as long as 45 minutes after requesting assistance. Resident #62 stated no one would like to lay in a wet brief. Observation on 06/03/24 at 11:03 A.M. of incontinence care provided by STNA #605 for Resident #62 revealed the resident was lying in bed prior to care being provided. Resident #62 had two bed pads under her. Observation revealed both pads were wet with urine. STNA # 605 confirmed this was her first set of rounds for Resident #62, approximately 4.5 hours after her shift began at 6:30 A.M. STNA #605 stated there was not enough time to get to everyone. STNA #605 stated incontinence care should be provided at least every two hours and verified that did not occur. 3) Medical record review for Resident #34 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus with diabetic neuropathy and other skin ulcers, muscle weakness, acquired absence of right leg below the knee and need for assistants with personal care. Review of the quarterly MDS assessment dated [DATE] revealed Resident #34 was cognitively intact. Resident #34 was dependent for toileting, personal hygiene, and transfers. Resident #34 used a wheelchair, was dependent for mobility and was always incontinent of bowel and bladder. Review of the care plan, dated 07/21/23, revealed Resident #34 had bowel and bladder incontinence. Interventions included to check and change resident every two hours and as needed. Interview on 6/03/24 at 10:45 A.M. with Resident #34 revealed the last time incontinence care had been provided was around 4:00 A.M. Resident #34 revealed she needed care, but the STNAs did not have time. Resident #34 revealed she was frustrated but felt there was nothing she could do about it. Observation on 06/03/24 at 11:13 A.M. of incontinence care provided by STNA #460 for Resident #34 revealed the resident had a large bowel movement with stool dried on the resident's skin. STNA #460 confirmed this was the first time she had provided incontinence care for Resident #34 since the beginning of her shift, which began at 6:30 A.M. (nearly five hours later). STNA #460 stated there were not enough staff and too many residents who required total care. STNA #460 confirmed she was only able to provide incontinence care once per eight-hour shift, with some residents receiving care twice during her shift. STNA #460 stated she could not do it all. Interview on 06/05/24 at 11:18 A.M. with WCCNP #502 revealed she visited Resident #34 weekly, and the resident was frequently soiled with urine and stool. 4) Record review for Resident #98 revealed an admitted [DATE]. Diagnoses included fracture of other parts of pelvis, type two diabetes mellitus and presence of coronary angioplasty implant and graft. Further review of the medical record revealed no relevant diagnosis for the Foley catheter. Review of the Nursing Admit/Readmit assessment, dated 06/07/24 at 12:40 A.M. completed by LPN #634, revealed Resident #98 was admitted with hip and rib fractures. Resident #98 was alert to person, place, time and situation. Resident #98 was verbally appropriate, required extensive assistance with bed mobility, independent with eating and required extensive assistance with toilet use. Resident #98 had a catheter and was continent of stool. Review of the care plan, dated 06/12/24, revealed Resident #98 had a Foley catheter. Interventions included monitoring intake and output as per facility protocol, monitor/record/report to physician (MD) signs and symptoms of a urinary tract infection (UTI), which included pain, no output and deepening of urine color. Review of Resident #98's physician orders revealed the following catheter care orders were entered on 06/11/24 (five days after admission): Foley output three times a day; Foley catheter to drainage bag, observe every shift; Foley catheter care every shift; and irrigate Foley with 50 cc if clogged or no urine output, if needed. Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) from 06/06/24 through 06/13/24 at 6:00 A.M. revealed Foley catheter care was not initiated for Resident #98 until 06/11/24 (five days after admission) on the night shift. On 06/11/24, night shift, no Foley catheter output was documented. There was no documentation related to Foley catheter output on 06/12/24 or on 06/13/24 at 6:00 A.M. Interview on 06/12/24 at 10:09 A.M. with Resident #98 revealed the Foley catheter had been placed while he was in the hospital. Resident #98 stated he was continent of urine prior to placement of the catheter. Resident #98 stated the facility staff had never cleaned his peri area/catheter at the insertion site (catheter care). Interview on 06/12/24 at 10:23 A.M. with LPN #841 revealed the STNAs reported Resident #98's catheter was leaking earlier that shift. LPN #841 confirmed she had not assessed the resident yet and stated she was going to change the resident's Foley catheter. Further review of the medical record from 06/12/24 through 06/13/24 revealed no evidence LPN #841, or any other staff, provided care for Resident #98's leaking catheter. Interview on 06/12/24 at 1:42 P.M. with the DON confirmed Resident #98 did not have a diagnosis related to the Foley catheter, stating she did not know why the resident had a catheter. The DON verified Resident #98 did not have an initial care plan for the care of the Foley catheter and there were no physician orders placed for the care and treatment of the resident's catheter until 06/11/24 (five days after admission). The DON confirmed the need for the catheter should have been clarified on admission, as well as physician orders for catheter care. Additionally, the DON verified catheter care should be provided daily, beginning upon admission. The DON confirmed there was no evidence Resident #98 was provided catheter care from 06/06/24 through 06/12/24. Review of the facility policy titled Catheter Care, Urinary, revised September 2014, indicated the purpose of the procedure was to prevent catheter-associated urinary tract infections. Staff were to observe the resident's urine level for noticeable increases or decreases, maintain an accurate record of the resident's daily output and provide daily catheter care. This deficiency represents non-compliance investigated under Complaint Numbers OH00154761 and 0H00153967.

Based on medical record review, interviews with facility staff, review of an incident report, review of the emergency medical technician (EMT) report, review of the hospital computed tomography scan (CT), review of the hospital emergency room (ER) documentation, and review of the facility policy titled Falls and Fall Risk, Managing, the facility failed to provide adequate supervision and ensure care planned interventions to prevent falls were consistently implemented for one resident (#86) to prevent a fall with injury in the facility. This resulted in Immediate Jeopardy on [DATE] when Resident #86, who was admitted to the facility with a comminuted and mildly displaced fracture of the left greater trochanter and was assessed as a fall risk, was not provided adequate supervision to prevent an unwitnessed fall and as a result sustained an acute intracranial hemorrhage (bleeding in the brain). Additionally, a second resident (#07) was placed at risk for the potential for more than minimal harm that was not Immediate Jeopardy when care planned interventions to prevent falls were not implemented appropriately by staff during a transfer from the bed to the recliner chair by one staff utilizing the appropriate assistive device, the resident ' s knee ' s buckled, and the resident had to be lowered to the floor. This affected two (Residents #07 and #86) of three residents reviewed for falls. The facility census was 85. On [DATE] at 12:53 P.M., [NAME] President (VP) of Operations #129, VP of Clinical Operations #130, Director of Nursing (DON) #125 and Regional Registered Nurse (RRN) #126 were notified Immediate Jeopardy began on [DATE] when Resident #86 had an unwitnessed fall in the dining room and per the EMT report, no one was on the scene who could provide the EMT with a patient medical history or details of the fall other than the resident arrived at the facility 48 hours ago and had a do not resuscitate comfort care arrest code status (DNRCCA), which allows lifesaving treatments before the patient ' s heart or breathing stops, which could not be furnished. The resident was subsequently transported to the hospital following the fall where she was diagnosed with an acute intracranial hemorrhage (bleeding in the brain) which included bilateral predominately frontal lobe scattered subarachnoid hemorrhages, left frontal parenchymal hematoma/contusion and intraventricular hemorrhage noted with layering blood along the septum pellucidum and left trigone. Resident #86's responsible party declined treatment and the family decided to initiate hospice services and Resident #86 was transferred to a hospice care facility from the hospital where she ultimately expired on [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 1:15 P.M., DON #125, Licensed Practical Nurse (LPN)/Unit Manager (UM) #119 and LPN/UM #111 completed fall risk assessments on all residents to identify all residents who were high risk for falls. On [DATE] at 2:15 P.M., new policies were developed including Routine Resident Check Policy and High Fall Risk Common Area Policy. On [DATE] at 2:30 P.M., an Interdisciplinary Team (IDT) meeting was held with all department heads on the new policies that were developed including Routine Resident. Check Policy and High Fall Risk Common Area Policy as well as education by VP of Clinical Operations #130. Department heads in attendance included: the Administrator, DON #125, LPN/UM #119, LPN/UM #111, LPN/Minimum Data Set (MDS) Coordinator #131, Chaplain #132, LPN/Assisted Living (AL) DON #133, Housekeeping and Laundry Supervisor #134, Central Supply Coordinator #135, Assistant Administrator #124, Admissions Coordinator #136, Marketing and Sales Staff #137, Scheduler #138, Transportation Coordinator #139, Dietary Manager #115, Human Resources (HR) Director #140 and Activities Director #141. On [DATE] at 3:34 P.M., education on the facility ' s Routine Resident Check Policy and High Fall Risk Common Area Policy were provided to all healthcare staff members by department heads including the Administrator, DON #125, LPN/UM #119, LPN/UM #111, LPN/MDS Coordinator #131, Chaplain #132, LPN/AL DON #133, Housekeeping and Laundry Supervisor #134, Central Supply Coordinator #135, Administrator Assistant #124, Admissions Coordinator #136, Marketing and Sales Staff #137, Scheduler #138, Transportation Coordinator #139, Dietary Manager #115, HR Director #140 and Activities Director #141. On [DATE] at 3:35 P.M., a point of care (POC) high fall risk safety check task was placed in each resident ' s electronic medical record who was assessed as a fall risk by VP of Clinical Operations #130 for the staff to provide documentation for the additional safety checks as stated in the Routine Resident Check Policy and High Fall Risk Common Area Policy. On [DATE] at 3:44 P.M., education binders were created by VP of Operations #129 for oncoming agency staff. On [DATE] at 4:50 P.M., a Quality Assurance Performance Improvement (QAPI) meeting was held by the Administrator with the Medical Director via telephone and the Immediate Jeopardy plan was reviewed. The QAPI meeting was attended by DON #125, LPN/UM #119, VP of Operations #129, VP of Clinical Operations #130, RRN #126, Human Resources #140, LPN/AL DON #133, Assistant Administrator #124, and LPN/MDS #131. On [DATE] at 5:26 P.M., all tasks were entered in POC for each resident who was at high risk for falls by RRN #126. On [DATE] at 5:45 P.M., a list of high-risk for fall residents was created to place in the common areas and dining rooms, nursing stations, and medication carts by VP of Clinical Operations #130. On [DATE] at 6:15 P.M., LPN/MDS Coordinator #131 updated all care plans of residents who were assessed as high risk for falls. On [DATE] at 6:30 P.M., education was completed to all healthcare staff on the new policies including the Routine Resident Check Policy and the High Fall Risk Common Area Policy by facility department heads including the Administrator, DON #125, LPN/UM #119, LPN/UM #111, LPN/MDS Coordinator #131, Chaplain #132, LPN/AL DON #133, Housekeeping and Laundry Supervisor #134, Central Supply Coordinator #135, Administrator Assistant #124, Admissions Coordinator #136, Marketing and Sales Staff #137, Scheduler #138, Transportation Coordinator #139, Dietary Manager #115, HR Director #140, and Activities Director #141. The DON or designee will audit the High Risk Fall List five times weekly for four weeks and then weekly for four weeks to ensure ongoing compliance. The DON or designee will audit the Resident Safety Checks five times weekly for four weeks and then weekly for four weeks to ensure ongoing compliance. All Audit findings will be submitted weekly for four weeks to the QAPI committee for review and recommendation. Interviews were conducted on [DATE] to verify staff were educated on the new fall policies and were able to articulate the Routine Resident Check Policy and the High Fall Risk Common Area Policy. Staff interviewed included LPN #112, RN #120, Transportation Coordinator #139, State tested Nursing Assistant (STNA) #142, Housekeeping Staff #143, STNA #144, LPN #145, Director of Rehabilitation #146, Certified Occupational Therapy Assistant (COTA) #147, and RN #148. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1) Review of Resident #86's medical record revealed the resident was admitted to the secured memory care unit (SMCU) assisted living facility (ALF) on [DATE] with diagnoses including repeated falls, muscle weakness, and unspecified dementia. Review of Resident #86's ALF St. Louis University Mental Status (SLUMS) Examination form dated [DATE] revealed the resident scored a seven which was identified as having dementia. Resident #86's medical record revealed the resident was hospitalized on [DATE] with an admitting diagnosis of a fall. Review of Resident #86's hospital documentation dated [DATE] revealed the family elected for no invasive treatment, just medical management, due to advanced Alzheimer ' s dementia, and osteoporosis who presented to the ER from the ALF with recurrent falls. Radiological studies showed a comminuted and mildly displaced fracture of the greater trochanter. The resident hit her head and required stitches to her left eyebrow. Orthopedics had evaluated the resident and recommended no surgery at this time, pain control and toe-touch weight bearing to the left leg. Review of Resident #86's medical record revealed the resident was admitted to the skilled nursing facility (SNF) on [DATE] with diagnoses including a displaced fracture of the greater trochanter of the left femur, laceration of the left eyelid, and unspecified dementia. Resident #86's Minimum Data Set (MDS) assessment, dated [DATE], documented she needed limited assistance of two staff members for transfers, ambulation, and extensive assistance of two staff members for locomotion on and off the nursing unit, and dressing. Review of Resident #86's Fall Scale form dated [DATE] revealed the resident was at high risk for falls. Review of Resident #86's Interim Care Plan form dated [DATE] revealed the resident was cognitively impaired, required a mechanical lift for transferring and total dependence for ambulating, dressing, personal hygiene, and toilet use as well as assistance with eating and the resident used an assistive device for walking. Review of Resident #86's progress note dated [DATE] at 1:54 A.M. documented the resident arrived on [DATE] at approximately 10:00 P.M. and was alert to self. A laceration was noted above the left eyebrow measuring two centimeters (cm) which was scabbed over, and she had a left greater trochanter hip fracture with a transdermal gauze. Resident #86's plan of care, initiated on [DATE], documented a behavior problem related to noncompliance with her weight bearing status of the fractured left hip, had impaired cognition and had a risk for falls. Interventions on the plan of care included to anticipate and meet Resident #86's needs, provide cueing, re-orienting and supervision as needed, and be sure Resident #86's call light was in reach, and encourage Resident #86 to ask for assistance and promptly respond to requests. Review of Resident #86's fall incident report, dated [DATE] at 1:10 P.M., documented Resident #86 had an unwitnessed fall in the dining room. The incident report stated Resident #86 needed supervision and was agitated and attempted to stand alone without staff assistance, use of assistive device, or use of a call light. Resident #86 was found on the floor. Resident #86 sustained a laceration to the right eye and pressure was applied. Resident #86 was sent to the hospital and the incident report documented the facility would reassess her safety needs upon her return to the facility. Review of Resident #86's EMT report, dated [DATE], documented a dispatch was initiated for a report of a female who fell . On contact, the resident was unresponsive to verbal stimuli. Her skin was pink, warm, and dry and her respirations were equal and unlabored. The fall was unwitnessed, and no one was on the scene who could provide the EMT with a patient medical history or details of the fall other than the resident arrived at the facility 48 hours ago and had a do not resuscitate comfort care arrest code status (DNRCCA) which allows lifesaving treatments before the patient ' s heart or breathing stops, which could not be furnished. Review of Resident #86's hospital CT scan (diagnostic imaging procedure to produce images of the inside of the body) of the head without contrast for a trauma protocol dated [DATE] revealed an acute intracranial hemorrhage including bilateral predominately frontal lobe scattered subarachnoid hemorrhages, left frontal parenchymal hematoma/contusion measuring one cm, intraventricular hemorrhage noted with layering blood along the septum pellucidum and left trigone. Review of Resident #86's hospital emergency room documentation, dated [DATE], documented the resident had a history of Alzheimer ' s, who was on Plavix, was sent over from the nursing home for a fall. It was unclear how long the resident had been down. She was found on the ground in the dining hall. Per the EMT, the nursing home was unable to provide any other history. The resident was recently sent back there from the hospital after she had a fall and had a left hip fracture. The left hip fracture was nonoperative. The resident had a hematoma to the left forehead, would open her eyes to name and would not follow commands. Upon discussion with the family, the family had elected for the resident to be comfort care and she would be admitted . During an interview on [DATE] at 9:25 A.M., the DON stated Resident #86 had a fall in the assisted living facility prior to her admission to the long-term care facility. Resident #86 had fractured her hip and due to her advanced Alzheimer's disease, the family decided to transfer her to the long-term care facility for increased supervision. The DON stated Resident #86 had sustained a fall in the long-term care facility while in the dining room and was sent to the hospital for evaluation. The family decided to initiate hospice services and Resident #86 was transferred to a hospice care facility from the hospital and did not return to the facility. During an interview with STNA #114 and STNA #113 on [DATE] at 8:30 A.M and 8:36 A.M. respectively, both stated Resident #86 was very confused and known to attempt to stand unassisted and try to ambulate. Both STNAs stated Resident #86 needed close supervision to prevent a fall. During an interview on [DATE] at 9:12 A.M., LPN/UM #111 stated staff were already in the dining room assessing Resident #86 when she got to the dining room following the resident ' s fall. She could not remember who the STNAs were at the time but stated the nurse was RN #120. LPN/UM #111 stated Resident #86 was observed trying to get out of bed by the DON on [DATE] around 9:00 A.M. and that was why the resident was put in a reclining chair in the common area at that time. LPN/UM #111 stated around 1:10 P.M. (after lunch) the resident was observed by Dietary Aide #122 walking from the reclining chair and falling approximately 20 feet away in the main dining room on the third floor. LPN/UM #111 stated the resident was observed on her side with her arm over her eye and a small amount of blood was observed on the back of her hand. During an interview on [DATE] at 9:24 A.M., LPN #112 stated she was the nurse for Resident #86, but she was in a room passing medications to another resident, two doors down from the dining room. LPN #112 stated she was informed Resident #86 fell but she did not directly assess the resident and instead obtained anything RN #120 and LPN/UM #111 might need as they were assessing the resident. During an interview on [DATE] at 10:14 A.M., RN #120 stated she assessed Resident #86 when she was on the floor. She took vital signs and assessed the resident. She stated the resident was alert and awake and was moaning but would not answer questions. RN #120 stated the resident did not say anything coherent. The resident was lying on her left side with her arm and leg up (bent). She confirmed she was sitting at the desk of the nursing station which had a wall which obstructed the view of the dining room at the time the resident sustained the fall. During an interview on [DATE] at 10:20 A.M., STNA #121 stated she noticed Resident #86 was on the floor and remembered getting the nurse. She observed her chair was still parked at the lunch table and she must have walked to where she had fallen but she did not witness the fall. She remembered a dietary aide had come to inform them of Resident #86's fall and it took approximately one minute to get to the resident. During an interview on [DATE] at 11:15 A.M., Dietary Aide #122 stated she was in the dining room at the steam table when Resident #86 was observed getting up from the reclining chair at the table and walking. She stated she did not think anything of it and turned to finish her work at the steam table. Dietary Aide #122 stated she heard a loud bang and a thump and turned to find Resident #86 had fallen to the floor. Dietary Aide #122 stated no other nursing staff were in the dining room or near the dining room providing supervision to Resident #86, who was at risk for falls. She stated she went down to LPN/UM #111's office to inform her of the fall and then returned to her work. She was unaware of what occurred after she informed LPN/UM #111. A second interview on [DATE] at 11:25 A.M. with LPN/UM #111 confirmed Dietary Aide #122 told her Resident #86 sustained a fall in the dining room. During a telephone interview on [DATE] at 12:21 P.M., Resident #86's responsible party stated he was questioned by the hospital about his mother's care, and he did not know the extent of the injuries. He stated his mother was not alert when he visited her in the hospital. He could not understand how his mother walked across the dining room and fell with a broken hip. During an interview on [DATE] at 12:57 P.M., the DON stated they had put interventions in place for falls for Resident #86 upon admission including keep in common areas for additional staff supervision and call light in reach even though it was not documented on the immediate needs care plan. She also stated she was unaware Dietary Aide #122 had observed Resident #86 walking without assistance. She stated the dietary personnel would not know the resident's fall risk and interventions because of HIPAA (Health Insurance Portability and Accountability Act - a federal law that protects sensitive patient health information from being disclosed without the patient ' s consent or knowledge). The DON stated Resident #86 was not provided one-to-one supervision, but staff would monitor the resident as she was in the common lounge/dining area. The DON confirmed no nursing staff were in the common area providing supervision to Resident #86 when she stood up from her reclining chair and walked across the common lounge/dining area and subsequently sustained a fall with fracture requiring hospitalization . During a telephone interview on [DATE] at 1:45 P.M. with the DON present, the EMT stated Resident #86 was initially not responsive on [DATE] when they found her on the floor and then she started moving around. The resident was transported to the hospital. During an interview on [DATE] at 11:21 A.M., Hospice Staff #127 stated they received Resident #86 as an inpatient for hospice services on [DATE] and she expired on [DATE]. During an interview on [DATE] at 11:50 A.M., STNA #128 stated she had observed Resident #86 in the dining room in her reclining chair on [DATE]. She stated she felt she had observed her within a couple of minutes of her fall but could not remember the exact details. She could not remember if any other staff members were in the dining room at the time of the observation and stated the nursing staff do chart right off the dining room. 2. Resident #07 was admitted on [DATE] with diagnoses including chronic severe kidney disease, depression, anxiety, anemia, osteoarthritis, hyperthyroid, lumbar disc degenerative disease of the vertebrae, gastric ulcer with a history of repeated falls, lack of coordination, muscle weakness, and need for personal assistance with personal care. A review of Resident #07's MDS assessment dated [DATE] indicated extensive assistance of two staff members was needed for bed mobility, transfers, ambulation, and locomotion. Resident #07's most recent fall assessment indicated she had a high risk for falls. Resident #07's plan of care initiated upon admission to the facility revealed a risk for falls related to impaired mobility, impaired balance, medication, incontinence and past medical history of falls. Resident #07 had a diagnosis of a fracture, anxiety, depression, chronic kidney disease, low back pain, and intervertebral disc degeneration of the lumbar region. Interventions on the plan of care revised on [DATE] documented to use a gait belt and on [DATE] to perform transfers with the use of a gait belt and two staff members. Resident #07's nursing progress note dated [DATE] revealed Resident #07 was transferred from the bed to the recliner chair by one staff member. Resident #07's knees buckled, and she was lowered to the floor. Resident #07's fall investigation report dated [DATE] indicated State tested Nursing Assistant (STNA) #117 transferred Resident #07 from the bed to the recliner chair using a walker when Resident #07's knee became weak and STNA #117 lowered Resident #07 to the floor. The result of the investigation was to train staff to use a gait belt and two staff members for transfers. During an interview on [DATE] at 1:30 P.M., STNA #117 verified the above information and stated she was not informed Resident #07 needed two staff members and use of a gait belt for transfers. Review of the facility policy titled Falls and Fall Risk, Managing, dated 2001, revealed the policy statement was based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent residents from falling and try to minimize complication from falling. The staff, with the input of the attending physician, will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). Monitoring subsequent falls and fall risk revealed the staff would monitor and document each resident's response to interventions or recommend whether the measures were still needed if the problem that required the intervention had resolved. If the resident continues to fall, staff will reevaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician would help the staff reconsider possible causes that may not previously have been identified. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. This deficiency represents non-compliance investigated under Compliant Number OH00146589.

Based on medical record review, review of fall investigation, review of hospital records, staff interviews, and facility policy review, the facility failed to ensure wheelchair footrests were in place during a resident transport. This resulted in actual harm when Resident #1 fell forward out of the wheelchair sustaining fractures to the second and third [MEDICATION NAME] vertebrae. This affected one (#1) of three residents reviewed for falls. The facility census was 86. Findings include: Review of the medical record for Resident #1 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the plan of care dated 05/04/18 revealed the resident was at risk for falls due to weakness. Review of the quarterly Minimum Data Set (MDS) assessment completed on 07/30/18 revealed Resident #1 was cognitively intact. Resident #1 was dependent on one staff member for locomotion on the unit. Review of a nurse's note dated 10/15/18 at 7:00 P.M., revealed a State tested Nursing Assistant (STNA) was pushing Resident #1 in her wheelchair when the resident abruptly placed both feet on the ground, went forward and fell out of the chair. Resident #1 was noted to hit her head, left shoulder, and left hip when she fell . Further review of the nursing progress note revealed Resident #1's range of motion was stiff, and the resident was noted to have discomfort. Resident #1 would not allow the nurse to assess her and said she wanted to be sent to the emergency room (ER) to be evaluated. The on-call nurse practitioner gave an order to send the resident to the ER. Review of the ER report dated 10/15/18 at 11:14 P.M., revealed Resident #1 was diagnosed with [REDACTED]. The resident was treated and sent back to the facility. Telephone interview on 10/30/18 at 11:10 A.M., with STNA #102 revealed she was taking Resident #1 back to her room from the dining room in her wheelchair. She revealed about halfway down the hall, it felt like a brake was on. Resident #1 had braced her feet down on the floor and was toppling over. STNA #102 revealed there were no footrests on the wheelchair. Review of the fall investigation during an interview on 10/30/18 at 11:31 A.M., with the Director of Nursing (DON) revealed STNA #102 was transporting Resident #1 back to her room in her wheelchair when Resident #1 abruptly put her feet down and went face first, toward the floor. The DON revealed a nurse assessed Resident #1, however the resident did not want to move and asked to go to the ER. The DON revealed the STNA #102 said she did not know the resident was supposed to have footrests. The DON revealed when staff transported residents down the hall in their wheelchairs, they should have footrests. Review of the facility policy titled Safety and Supervision of Residents, revised 07/17, revealed employees would be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents. This deficiency substantiates Master Complaint Number OH 882.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and staff interview, the facility failed to ensure one resident was transferred safely which resulted in actual harm for one resident (Resident #17) who fell while being transferred by staff and sustained a fracture of the hip. This affected one (Resident #17) of three residents reviewed for recent falls. The facility census was 121. Findings include: Review of Resident #17's medical record revealed an admission date of [DATE]. Review of Resident #17's care plan meeting and comprehensive assessments dated 06/28/16 identified the resident required extensive assistance for transfers and walking. The written fall care plan identified Resident #17 required two person for transfers. The physician's orders [REDACTED].#17 required two people for transfers at all times and the resident was high risk for falling. Further review of the record identified nursing notes dated 08/01/16 revealed Resident #17 required two people for transfers and ambulation. Review of the record identified nursing notes dated 08/27/16 at 3:12 P.M. which revealed state tested nursing assistant (STNA #800) lowered Resident #17 to the floor while being toileted. The note revealed Resident #17 stood up and fell . Review of termination notice for STNA #800 was dated 08/27/16 and identified Resident #17 was transferred with only only staff member and required two resulting in a fractured hip for that resident. Review of Resident #17's hospital records dated 09/01/16 identified Resident #17 was discharged from the hospital following surgery for [REDACTED]. Interview with facility director of Nursing (DON) on 09/14/16 at 11:25 A.M. identified Resident #17 was transferred by one STNA (STNA #800) on 08/27/16. The DON verified the resident should have been transferred by two persons. The DON confirmed Resident #17 sustained a fracture and had surgery following this incident. The DON identified the facility terminated STNA #800's employment that day, following the incident. The DON identified the facility conducted education of all nursing assistants regarding following residents written care plans which started on 09/01/16 and was completed on 09/13/16. As a result of the incident the facility took the following actions to correct the deficient practice by 09/13/16: · On 08/27/16 STNA #800 was terminated for failure to follow care card for the safe transfer of a resident. · On 09/13/16, all facility direct care staff was in-serviced regarding following care cards and specifically regarding number of staff needed to safely transfer individuals. · Observation on 09/15/16 at 8:00 A.M. of a random resident being transferred by two STNA's revealed the staff completed a proper two person transfer. There were no additional residents having falls in the facility related to improper transfers. This deficiency substantiates Complaint Number OH 764.

Based on record review, facility policy review and staff interview, the facility failed to adequately assess a pressure ulcer and notify the physician when the pressure ulcer worsened in condition with an increase in size and staging, thereby delaying a change in the treatment to aide in the healing of the pressure ulcer. This resulted in actual harm when Resident #15's Stage 2 pressure ulcer worsened to an unstageable pressure ulcer. This potential delay in treatment lead to the resident requiring surgical debridement and treatment with a [DEVICE]. This affected one (#15) of three residents reviewed for the care and treatment of [REDACTED]. The facility census at the time of the survey was 127. Findings include: Review of Resident #15's medical record revealed an admission of 01/20/05 and re-admission date of [DATE]. Resident #15's [DIAGNOSES REDACTED]. Review of the admission nursing assessment dated [DATE] revealed the resident had a non pressure ulcer to the right foot, with all other skin described as intact. Review of the skin assessment form dated 01/15/16, reveled the resident was observed to have a Stage 2 pressure ulcer to the lower right buttock, measuring 3 cm (centimeters) by 2 cm by 0.2 cm. Review of the weekly skin assessment forms revealed the nursed documented the following measurements, staging, and notations of the right buttock wound: On 01/18/16, the area was identified as a Stage 2 ulcer and measured 3 cm by 2 cm by 0.2 cm. The description notation documented the resident was out to the wound clinic for wound care management, no changes to this site. The nurse note on the skin assessment form documented the resident is incontinent of both bowel and urine and had poor national intake. The resident required assistance of two staff with transfers and immobile due to a history of cerebral lumbar disease. On 01/31/16, the right buttock wound was identified as a Stage 2 ulcer and measured 1.3 cm by 1.5 cm by 0.1 cm. The description notation had no documentation. The nurse note at the bottom revealed the Certified Nurse Practioner (CNP) assessed the area and ordered a treatment. On 02/01/16, the area was identified as a Stage 2 ulcer and measured 1.3 cm. by 1.5 cm. by 0.2 cm. The description notation documented the site was deteriorating in appearance. On 02/09/16, the right buttock wound was identified as a Stage 2 ulcer and measured 2.8 cm. by 2.2 cm. by 0.2 cm. The description notation documented the site was a previously opened ulcer which re-opened with deterioration noted. On 02/16/16, the area was identified as a Stage 2 ulcer and measured 3.8 cm. by 1.8 cm. by 0.2 cm. The description notation documented no noted improvement. On 2/23/16, the area was identified as a Stage 2 ulcer and measured 4.2 cm. by 2.2 cm. by 0.4 cm deep. The description notation documented the site was previously opened and was deteriorating. On 03/01/16, the right buttock area was identified as an unstageable ulcer and measured 5.5 cm by 3.7 cm by 0.4 cm. The description notation documented the site was identified as a right ischium pressure ulcer by the wound clinic. Review of the skin assessment form for the right lower buttocks wound dated 03/03/16 revealed an increase in the wound size from 03/01/16, identifying the site had 75% slough and the depth had deteriorated. The resident was out to the wound clinic on that day and the right buttocks wound was debrided with slough removed. Measurements of the right buttock wound were identified as 7.0 cm by 4.0 cm by 2.8 cm deep. Orders upon return from the wound clinic included a [DEVICE] to the site. The wound was to be re-evaluated in one week for effectiveness of treatment. Resident #15 was to return to the wound clinic on 03/10/16 for further assessment. Review of the physician order [REDACTED]. Interview on 04/09/16 at 11:25 A.M. with Unit Manager (UM) #33 revealed she was obtaining measurements of the right buttock pressure ulcer, but thought the resident was being seen by the wound clinic for monitoring and treatment of [REDACTED].#33 did not contact the physician for notification of the condition of the wound. UM #33 verified the lack of description of the pressure ulcer in regard to the wound bed which resulted in the change of staging to unstageable per documentation. UM #33 revealed the resident was being assessed at the wound clinic for a foot ulcer. On 03/03/16, the wound clinic noted Resident #15's pants to be soiled during her assessment. When the wound clinic attempted to assist the resident with her soiled clothing, it was noted the pants were soiled due to drainage from the right lower buttocks wound. At that time the wound care clinic initiated a change in the treatment to the wound site on the right buttock pressure ulcers. Interview with the Administrator and UM #33 on 04/09/16 at 11:45 A.M., revealed Resident #15 was not being seen by the facility CNP at this time for wound care. UM #33 stated residents going to the wound clinic cannot be billed for both services of the wound clinic and the facility wound CNP services. UN #33 stated she had assumed the wound clinic was following the right buttock wound. Therefore, she never notified the physician or CNP about the increase in size and worsening of the right buttocks pressure ulcer. Review of facility policy titled Pressure Ulcers Prevention, dated 02/28/14, revealed the charge nurse will inspect any skin issues and review with the Registered Nurse (RN) for treatment. Monthly, the charge nurse will review the resident's skin and review with the RN and initiate treatment as issues arise. Weekly, the RN manager will review all skin issues for progress to goals. Review of facility policy titled Notification of Resident's Changes in Status, dated 04/28/14, revealed the Registered Nurse, Clinical Nurse, Charge Nurse or other designated staff must immediately notify the physician and nursing supervisor of changes in resident status or treatment plan. This included all incidents that are not part of the Resident care Plan such as: skin tears or other skin issues and any changes in resident condition. Physician notification is to be documented in the nurse's notes. Documentation is to include: time of notification, date of notification, individual notified, information shared with physician and pertinent information received. Additionally, noted in the policy regarding notification, the family or Power of Attorney will be contacted as soon as resident is medically stable and will be documented in the medical record. Wishes will be discussed and documented. This deficiency substantiates Complaint Number OH 431.

Based on observations, staff interviews, review of the facility investigation reports, and review of medical records, the facility failed to ensure a mechanical Hoyer lift was maintained in a safe operating condition. This resulted in actual harm when Resident #16 sustained a nine centimeter (cm) by one cm by three tenths cm laceration to her forehead. This required the resident to be transferred to the emergency room , requiring 14 sutures to close the laceration. In addition, the facility failed to ensure Resident #16 was not left unattended in her room per her care plan which resulted in a fall without an injury. This involved one (#16) out of three residents reviewed for falls. The facility census was 145. Findings include: Review of Resident #16's medical record revealed an admission date of [DATE] and re-admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the care plans dated January 2014, revealed Resident #16 was confused, had sustained previous falls, and was non-ambulatory due to weakness. Resident #16 was to be kept in the common area at all times when awake. Review of the fall investigation report dated 02/17/15, revealed Resident #16 sustained an injury during a transfer with a Hoyer lift. The Hoyer lift tipped over sideways during the transfer. The Hoyer legs were spread apart and were locked in place. However, the wheels were sticking and the legs became loose during transfer. The Hoyer lift fell over and the crossbar struck Resident #16 in the face. Resident #16 received a nine centimeter (cm) by one (cm) by a three tenths (cm) laceration to the forehead requiring 14 sutures. The Hoyer lift was taken out of service, and was not to be used. Review of the nursing notes dated 02/26/15 revealed Resident #16 was found on the floor by staff. The nurse assessed Resident #16 with neurological checks and vital signs being within Resident #16's normal range. The facility did not provided a fall investigation of the incident. Observation of Resident #16 on 03/03/15 at 10:50 A.M., revealed she was sitting in a wheelchair with a functioning alarm. She had a large yellowish blue and red area to her forehead with a healing laceration. Her eyes and cheeks had a large yellowish red and blue area. Interview with the Director of Nursing (DON) on 03/03/15 at 11:32 A.M., revealed an incident had occurred with Resident #16 during a transfer on 02/17/15, when the Hoyer lift tipped and the crossbar struck her in the face. She was sent to the emergency room for an assessment, she returned with 14 sutures to her forehead. Interview with Registered Nurse (RN) #1 on 03/03/15 at 12:47 P.M., revealed she arrived after the incident with Resident #16. State tested nursing assistant (STNA) #12 and #13 were present in the room during the transfer. STNA #12 was behind the Hoyer lift and STNA #13 was in front. As Resident #16 was lowered to the chair, the Hoyer fell and the cross bar hit her in the face. Resident #16 had excessive bleeding to the laceration. STNA #12 applied pressure and STNA #13 went and located a nurse. Interview with the Maintenance Director on 03/03/15 at 1:38 P.M. revealed he was not aware the Hoyer was damaged. He stated the tension spring on the Hoyer left had malfunctioned and when he checked the other Hoyer he found other tension springs loose. Interview with STNA #12 via the telephone on 03/03/15 at 3:26 P.M., revealed Resident #16 did not fall off the Hoyer pad. Staff were transferring Resident #16 and she was the one in the back moving the legs. STNA #13 was in front of the lift and the resident. The Hoyer pad was under the resident, and the Hoyer legs were spread apart. They picked Resident #16 up off the bed and as they were moving toward the chair, the legs closed on its own and locked. At that point, they lowered the resident to the chair. The Hoyer tipped over and struck Resident #16 in the face, while she was sitting in the chair. They lifted the Hoyer off Resident #16, and STNA #13 went to get the nurse, while she stayed with Resident #16 and put towels on her face. STNA #12 stated she to the nurse the Hoyer legs were not working. The nurse was to report problems with equipment to maintenance. STNA #12 stated the Hoyer legs have been opening and closing by themselves for " I guess a month." She stated she had reported the problems with the Hoyer lift to RN #1 and she knew the other STNA 's have reported the Hoyer as well. STNA #12 revealed she used the Hoyer, even though it was not working correctly, because the facility left it on the floor. Interview with RN #1 on 03/03/14 at 3:45 P.M. revealed she denied having any knowledge of the Hoyer legs malfunctioning. Interview with STNA #15 on 03/03/15 at 4:00 P.M., revealed the Hoyer lift had not been working correctly. She reported the problems with the lift, which included the battery and the legs not staying open, to the nurse. Interview with STNA #16 on 03/03/15 at 4:05 P.M., revealed she was aware the Hoyer was broken and the legs would not stay open and remained locked. STNA #16 stated she reported the Hoyer to the RN #1. Interview with STNA #17 on 03/03/15 at 4:10 P.M., revealed the Hoyer legs did not stay locked and it was reported to the RN. The DON and the administrator were notified on 03/03/15 at 4:30 P.M. of the STNA's (#15, #16, and #17) responses regarding the Hoyer being broken and notifying RN #1. Review of the employee counseling records revealed STNA #12 and #13 were counseled on reporting broken and/or equipment not functioning properly to the charge nurse, supervisor and unit manager. The counseling included not to use any equipment not functioning properly. STNA #12 and #13 signed the counseling forms. STNA #12 added a written note which documente "we have reported the Hoyer many times as not working." Interview with the DON on 03/05/15 at 4:48 P.M. revealed on the 02/26/15 fall, Resident #16 was in her wheelchair and was taken to her room. STNA #15 left Resident #16 in her room, unattended in the wheelchair to answer another call bell. Resident #16 stood up and fell . The DON verified Resident #16 was not to be left in her room unattended. The citation substantiated the complaint number OH 089.