Every finding on record at Widows Home of Dayton

Based on record review, observations, interview, and facility policy review, the facility failed to provide a sanitary and home like environment in resident rooms. This affected four Residents ( #22, #23, #26 and #27) of seven residents reviewed for sanitary homelike and environment. The facility total census was 64. Findings Include: 1. Record review of Resident #26 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #26 include joint replacement of right femur, osteoporosis, dementia, severe malnutrition, and dysphagia. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition. Observation on 06/14/26 at 8:10 A.M. revealed Resident #26's bed had a broken headboard. The bed headboard was not well attached, with approximately 4 inches movement away from the top pf the bed and the side of the head broad missing an edge piece, which revealed splintered and rough edges. The floor from the entrance of the room and throughout the edges of the resident 's room, revealed a darken gray color with the appearance of dirt and discolored wax. Only the regular walking path appeared to be clean. 2. Record review of Resident #27 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #27 include cerebral infarction, chronic pulmonary embolism, diabetes, dementia, and communication deficit. Review of the Minimum Data Set, (MDS) comprehensive assessment dated 0 6/15/26 revealed the resident had severely impaired cognition. Observation on 06/17/26 at 8:22 A.M. revealed Resident #27's floor had a darken gray color with the appearance of dirt and discolored wax. Only the regular walking path appeared to be clean. Interiew on 06/17/26 at 8:22 A.M. with Resident #27's family memeber verified Resident #27's floor had the appearance of being dirty throughout the room. The family member stated the room was not always cleaned by housekeeping, as he visited nearly daily. He stated Resident #27 always kept her floors clean and would not have wanted her room to have appeared dirty. 3. Record review of Resident #22 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #22 include hemiplegia, cerebral infraction, and hypertension. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had impaired cognition. Observation on 06/17/26 at 8:15 A.M. revealed Resident #22's floor had a heavy build up of a darken gray color with the appearance of dirt and discolored wax. Only the regular walking path appeared to be clean. Interview on 06/17/26 at 12:20 P.M. with Resident #22 revealed the housekeepers only mop the floor and do not do anything to get up the gray on the floors. She stated the housekeepers do not pull any furniture out and get behind it or clean in the corners. She stated she wanted her room to look clean. 4. Record review of Resident #23 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #23 include myocardial infarction, chronic obstruction pulmonary disease and hypertension. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition. Observation on 06/17/26 at 8:22 A.M. revealed Resident #23's floor had a darken gray color with the appearance of dirt and discolored wax. Only the regular walking path appeared to be clean. There was a dust buildup on the television stand along the sides and top. Interview on 06/17/26 at 12:17 P.M. with Resident #23 revealed the housekeepers, nor the maintenance staff use a floor scrubber in the room to clean the darkened areas. She stated the housekeepers do not dust her furniture to her satisfaction and just mop. She stated she would like a cleaner room. Record review of the Resident Council Meeting Notes dated 03/4/26 and 04/01/26 revealed the residents had concerns related to housekeeping not thoroughly cleaning resident rooms. The Housekeeping Supervisor, (HS) #150 planned resolution was to have housekeeping staff in serviced in May of 2026 regarding housekeeping cleaning expectations. There was no documentation provided of the May 2026 housekeeper cleaning in-service. Interview on 06/17/26 at 9:05 A.M. with Housekeeper # 94 verified the broken and loose bed headboard for Resident #26 and the buildup of discolored flooring. Housekeeper #94 stated she did not know who was assigned to clean the floor or when the residents' floors were to be cleaned of the heavily discolored flooring. The Housekeeper #94 stated the floor appeared to be dirty. The Housekeeper #94 stated she had reported the broken headboard to the maintenance department several weeks ago. Interview on 06/17/26 at 10:25 A.M. with Housekeeper Supervisor (HS) #150 stated the darkened color areas on the residents' rooms floors were due to a heavily buildup of wax and appeared dirty. The HS #150 stated the floors needed to be stripped and rewaxed. HS #150 stated the floor technician was to strip and wax the floors. The HS #150 verified there was no deep cleaning resident room schedule for cleaning or for stripping and waxing the floors. HS #150 could not recall when the floors had last been stripped and waxed. The HS #150 verifed the bed headboard of Resident # 26 was broken and splintered and was unaware how long the headboard had been broken. The HS #150 verified there was no documentation the housekeeping staff had been in serviced in May of 2026 of resident room cleaning schedules or cleaning expectations in response to the March and April 2026 resident council meetings. Interview on 06/17/26 at 10:45 A.M. with Maintenance Director, (MD) # 130 verified the residents' room floors appeared dirty and needed to be stripped and waxed. The MD # 130 took a scrapper and demonstrated the buildup on the floor was removable with the scrapper, revealing a clean appearance floor. The MD #130 verifed the bed headboard of Resident # 26 was broken and splintered. Interview on 06/17/26 at 11:50 A.M. with Regional Clinical Operations Nurse, (RCON) # 110 verified the residents' room floors needed cleaned and the bed headboard of Resident # 26 was broken and splintered. Review of facility policy titled, Safe and Homelike Environment , dated 2024 , revealed the facility will provide a safe, clean, comfortable and homelike environment . This deficiency represents non-compliance investigated under Complaint Number 3028369.

Based on observations, interview, and facility policy review, the facility failed to provide a sanitary and home-like environment in common area. This affected 8 residents (Resident #21,#22, #23, #24, #15, #26,#27, and #28) residing on the 200 unit . The facility total census was 64. Findings Include:Observation on 06/17/26 from 8:10 A.M. through 8:22 A.M. of unit 200 hallway and room entrances of Resident #21, #22, #23, #24,#15, #26,#27, and #28 revealed a gray and blackened color with the appearance of a heavy build up blackened wax. There were three hallway flooring sections that had indentations approximately one half inches deep. One floor section was near a floor incline near the 200-nurse station and there were two sections near the middle of the hallway that contained six indented floor tiles. The indented floor tiles contained blackened debris. There were four, 8-foot sections of wooden handrails that had rough and uncleanable surface edges. The outer protective coating was removed and the uncleanable wood was exposed. Interview on 06/17/26 at 10:45 A.M. with Maintenance Director, (MD) #130 verified the unit 200 hallway and room entrances of Resident #21, #22, #23, #24,#15, #26,#27, and #28 rooms had a heavy blacked wax appearance and needed cleaned. The MD #130 verified the six indented floor tiles needed repaired. Interview on 06/17/26 at 11:50 A.M. with Regional Clinical Operations Nurse (RCON) #110 verified the 200 unit hallway rooms needed cleaned and repaired of the wax buildup and indentations. The RCON #110 verified the wood handrails needed repaired to maintain a cleansable surface. Review of facility policy titled, Maintenance Services , undated , revealed the maintenance department is responsible for maintaining the building in a safe manner and maintain a schedule of maintenance service to assure the building is maintained in a safe and operable manner. This deficiency represents non-compliance investigated under Complaint Number 3028369.

Based on record review, review of hospital records, review of an emergency medical services (EMS) report, staff interviews, and policy review, the facility failed to provide timely, adequate and necessary care, monitoring and treatment for Resident #52 following an acute change in condition. Actual Harm occurred on 01/31/26 at approximately 1:00 P.M. when Resident #52 started receiving shocks from his implanted cardioverter defibrillator (ICD) (a battery-powered device placed under the skin to monitor, detect, and treat life-threatening heart arrhythmias). Resident #52 sustained numerous shocks from his ICD throughout the day with no intervention by staff. Resident #52 was sent to the hospital on [DATE] around 1:00 A.M. and required emergency medications to be stabilized and was admitted to the Intensive Care Unit (ICU) for monitoring and treatment. This affected one (Resident #52) of three residents reviewed for a change in condition. The facility census was 65.Findings include: Review of the medical record for Resident #52 revealed an admission date of 09/25/25. Diagnoses included cerebral infarction (stroke), chronic obstructive pulmonary disease (COPD), and acute respiratory failure with hypoxia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #52 was alert and oriented. Review of the nurse's progress note dated 01/31/26 at 10:56 P.M., authored by Registered Nurse (RN) #30, revealed Resident #52 had complaints of a shocking feeling in his chest area. Upon assessment, he had a pacemaker, heart rate was obtained at 64 beats per minute (bpm) and then rechecked at 69 bpm. The on-call provider was contacted with no answer and nurse was awaiting a return call.Review of the nurse's progress note dated 01/31/26 at 11:03 P.M., authored by RN #30, revealed Resident #52 did not feel a shock in his chest and heart rate was 99 bpm.Review of the nurse's progress note dated 02/01/26 at 12:55 A.M., authored by Licensed Practical Nurse (LPN) #23, revealed Resident #52 complained of an implantable cardioverter defibrillator (ICD) shock and stated it had been shocking him for the last four hours. Vital signs were obtained with a blood pressure (BP) of 94/59 millimeters of mercury (mmHg), 92 heart rate, 22 respirations, and oxygen saturation of 96 percent. Resident #52 requested to go to the emergency room because the shocks were scaring him. The on-call provider was contacted and agreed to send Resident #52 to the hospital for evaluation. Resident #52's responsible party and the Director of Nursing (DON) were notified. Review of the EMS report dated 02/01/26, revealed the squad arrived on scene at 12:52 A.M. for a resident complaining of a shocking pain in his chest. Vital signs were taken at 1:02 A.M. with a BP of 118/72 mmHg, 156 heart rate, 18 respirations. At 1:13 A.M., the vital signs were BP 111/58 mmHg, 225 heart rate, 18 respirations. Assessment revealed Resident #52 had reported his ICD had shocked him 12 to 15 times in the last three hours. Resident #52 was in atrial fibrillation with rapid ventricular response. Resident #52 was transported to the hospital at 1:18 A.M.Review of the hospital paperwork dated 02/01/26, revealed Resident #52 presented to the emergency room complaining of experiencing repeated ICD firings. Resident #52 had a history of coronary artery disease caused by ischemic cardiomyopathy with an ejection fraction of 20-25 percent status post three vein coronary artery bypass graft and ICD placement. In the emergency room, Resident #52 required cardiology consultation and initiation of amiodarone (antiarrhythmic medication used to treat and prevent life-threatening, recurring, or persistent heart rhythm disorders, including ventricular arrhythmias and rapid atrial fibrillation). Resident #52 was admitted to the ICU care unit for close monitoring in anticipation of electrophysiology intervention. Review of the physician progress note dated 02/05/26 at 12:00 A.M., authored by Medical Director #100, revealed Resident #52 presented to the emergency room after his internal defibrillator went off 12-15 times in three hours. Resident #52 was in ventricular tachycardia with subsequent defibrillation on his internal defibrillator. Laboratory findings were significant for hypokalemia (abnormally low potassium levels in the blood) with potassium level of 3.1 milliequivalents per liter (mEq/L) (abnormal is below 3.5 mEq/L). The resident's potassium was replaced, Resident #52 was given a bolus of amiodarone, and cardiology was consulted. Resident #52 was shocked greater than 35 times per the ICD report. Resident #52 was started on an esmolol drip (intravenous medication used primarily for rapid, short-term control of heart rate and blood pressure) lidocaine drip (intravenously antiarrhythmic medication to treat irregular heart rhythms), and amiodarone drip. Resident #52's ICD was upgraded to a dual-chamber ICD with insertion of right atrium lead. Resident #52 received five days of prophylactic antibiotics and then returned to the facility. During an interview on 02/19/26 at 2:24 P.M., Resident #52 stated he was being shocked and requested to go to the hospital. Resident #52 stated the staff would not send him out at first but explained he was in a lot of discomfort when he was getting shocked, and it woke him up out of his sleep.During an interview on 02/23/26 at 1:14 P.M., LPN #23 stated she started her shift on 01/31/26 after 11:00 P.M. LPN #23 stated she received a report from RN #30 that Resident #52 had been screaming out in pain most of the day because he was being shocked. LPN #23 stated an hour into her shift, Resident #52 started screaming out in pain. LPN #23 assessed him and reached out to the on-call provider to send him out the hospital to be evaluated. EMS were called and responded to Resident #52, who was later transported to the hospital.During an interview on 02/23/26 at 1:27 P.M., LPN #22 stated she worked on 01/31/26 from 7:00 A.M. to 8:00 P.M. LPN #22 stated Resident #52 was screaming out and reported to her that a man was shocking him in his room, or the bed was shocking him. LPN #22 stated she thought he had a urinary tract infection (UTI) because he was not making any sense. LPN #22 stated she unplugged the bed and ensured the bed was working properly. LPN #22 stated she did not know Resident #52 had an ICD. LPN #22 stated she made an entry in the binder for the provider to follow up with Resident #52 the following day. LPN #22 stated she obtained Resident #52's vital signs but did not document anything in the resident's medical records and did not notify the physician. LPN #22 stated she made a note in the provider's binder so a provider could follow-up with the resident.During an interview on 02/23/26 at 1:47 P.M., the DON stated Resident #52 had behaviors and would scream out. The DON stated the staff should be documenting changes in residents' condition and behaviors in the medical record. She was not made aware of any shocking complaints by Resident #52 until he was sent out to the hospital on [DATE].During an interview on 02/23/26 at 2:04 P.M., RN #30 stated he came in to relieve LPN #22 (day shift nurse) around 8:00 or 9:00 P.M. RN #30 stated he got a report that Resident #52 had been screaming out all day related to being shocked. RN #30 stated Resident #52 was screaming out when he first got on shift, but when he completed his first medication rounds at 8:30 P.M., Resident #52 had his eyes closed in bed. Around 9:30 P.M., Resident #52 started screaming out and when he went in to assess the resident, he reported he was being shocked by his pacemaker. RN #30 stated he did not know Resident #52 had a pacemaker until the resident mentioned it. RN #30 stated he reviewed the resident's record and verified the resident had a pacemaker. RN #30 stated he listened to the resident's heart and noticed an irregular and elevated rhythm. RN #30 reached out to the on-call provider and did not get an answer. RN #30 stated he was relieved by LPN #23 on 01/31/26 at approximately 11:00 P.M. and mentioned in his report that Resident #52 had complained of being shocked by his pacemaker. RN #30 instructed LPN #23 to send Resident #52 out to the hospital if it occurred again. Review of the facility policy titled, Change in Condition, dated 11/06/25 revealed the facility was to ensure timely and appropriate response to changes in resident's conditions and to facilitate effective communication with physicians. Nursing staff must be vigilant in monitoring residents for any changes in condition including alterations in vital signs, mobility, cognition, mood, or behavior. When the nurse was notified of change, the nurse would perform a comprehensive assessment to evaluate the severity and identify potential causes. The nurse would document all findings in the resident's medical record. The nurse must notify the attending physician or on-call physician immediately if the change in condition is significant.This deficiency represents noncompliance investigated under Complaint Number 2735210.

Based on personnel record review, staff interviews, and policy review, the facility failed to ensure employed Certified Nursing Assistants (CNA) were properly licensed with the State of Ohio. This had the ability to affect all 65 residents. The facility census was 65.Findings include: Review of the CNA #13's personnel file revealed a hire date of [DATE] for a housekeeper position. CNA #13's file contained a certificate of completion from an online Nurse Aide Competency Evaluation Program (NATCEP) with completion date of [DATE]. Review of CNA #13's timecard for February 2026 revealed 12-hour shifts were completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], and [DATE].Interview on [DATE] at 10:04 A.M., the Director of Nursing (DON) verified CNA #13 was not licensed as a CNA. The DON stated CNA #13 finished her online CNA program in [DATE] but never took the state test for licensure. The DON stated CNA #13 was initially hired as a housekeeper and worked her way up to being a CNA. Interview on [DATE] at 11:17 A.M., CNA #13 verified she was not licensed as a CNA and was providing personal care to residents. CNA #13 reported she was late scheduling her state test for licensure, but it was cancelled during the government shutdown. CNA #13 stated the DON and Human Resources #70 were not aware that she did not complete her state test for licensure.Interview on [DATE] at 11:39 A.M., Human Resources #70 verified CNA #13 was not licensed as a CNA. HR #70 reported she missed following up with CNA #13 after her test was cancelled due to the shutdown.Review of the facility policy titled, Nursing Services and Sufficient Staff, dated [DATE], revealed the facility was to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care.Review of the facility policy titled Required Training, Certification and Continuing Education of Nurse Aides revised on [DATE], revealed the facility would employ nurse aides that have successfully completed a state approved NATCEP and are awaiting certification results. Staff may be employed full-time and permanent but must provide documentation of certification within four months of their hire date. Facility would verify certification through the appropriate state's nurse aide registry. If an individual has not successfully completed a NATCEP at the time of employment, that individual may only function as a nurse aide if the individual has been verified to be currently enrolled in a State approved NATCEP and is a permanent employee in his/her first four months of employment in the facility.Review of the State of Ohio Nurse Aide Registry website at (https://odh.ohio.gov/know-our-programs/nurse-aide-registry/nurseaideregistry), revealed no current nor expired CNA license for CNA #13. This deficiency represents noncompliance investigated under Complaint Number 2784304 and 2723229.

Based on review of the medical record, staff interviews and policy review, the facility failed to ensure the residents' medical records were complete and accurately documented. This affected one (Resident #52) of three residents reviewed for documentation. The facility census was 65. Findings include: Review of the medical record for Resident #52 revealed an admission date of 09/25/25. Diagnoses included cerebral infarction (stroke), chronic obstructive pulmonary disease (COPD), and acute respiratory failure with hypoxia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #52 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. Review of nurse's progress notes for Resident #52 dated 01/31/26 from 11:00 A.M. to 10:55 P.M., revealed no documentation regarding the resident's acute change in condition reported to Licensed Practical Nurse (LPN) #22 on 01/31/26 around 1:00 P.M. The first note in the medical record about Resident #52's acute change in condition was recorded on 01/31/26 at 10:56 P.M. Review of the EMS report dated 02/01/26, revealed squad arrived on scene at 12:52 A.M. for a resident complaining of a shocking pain in his chest. Resident #52 was in atrial fibrillation (A-fib) with rapid ventricular response (RVR). Resident #52 was transported to the hospital at 1:18 A.M.Review of the hospital paperwork dated 02/01/26, revealed Resident #52 presented to the emergency room complaining of experiencing repeated ICD firings. Resident #52 was a sixty-nine-year-old man with a history of coronary artery disease (CAD) caused by ischemic cardiomyopathy with an ejection fraction of 20-25 percent (%) status post three vein coronary artery bypass graft (CABG) and ICD placement. In the emergency room, Resident #52 required cardiology consultation and initiation of amiodarone (antiarrhythmic medication used to treat and prevent life-threatening, recurring, or persistent heart rhythm disorders, including ventricular arrhythmias [ventricular fibrillation/tachycardia] and rapid atrial fibrillation). Resident #52 was admitted to the ICU care unit for close monitoring in anticipation of electrophysiology (EP) intervention. Interview on 02/19/26 at 2:24 P.M., Resident #52 stated he was being shocked and requested to go to the hospital. Resident #52 stated the staff would not send him out at first but explained he was in a lot of discomfort when he was getting shocked, and it woke him up out of his sleep.Interview on 02/23/26 at 1:14 P.M., LPN #23 stated she started her shift after 11:00 P.M. on 01/31/26. LPN #23 stated she received a report from Registered N #30 that Resident #52 had been screaming out in pain most of the day because he was being shocked. LPN #23 stated an hour into her shift, Resident #52 started screaming out in pain. LPN #23 assessed him and reached out to the on-call provider to send him out the hospital to be evaluated. EMS were called and responded to Resident #52, who was later transported to the hospital.Interview on 02/23/26 at 1:27 P.M., LPN #22 stated she worked on 01/31/26 from 7:00 A.M. to 8:00 P.M. LPN #22 stated Resident #52 was screaming out and reported to her that a man was shocking him in his room, or the bed was shocking him. LPN #22 stated she thought he had a urinary tract infection (UTI) because he was not making any sense. LPN #22 stated she unplugged the bed and ensured the bed was working properly working. LPN #22 stated she did not know Resident #52 had an ICD. LPN #22 stated she obtained Resident #52's vital signs but did not document anything in the resident's medical records and did not notify the physician. LPN #22 stated she made a note in the provider's binder so a provider would follow-up with the resident during the next rounds. Interview on 02/23/26 at 1:47 P.M., the Director of Nursing (DON) stated the staff should be documenting in the residents' medical records when a resident experiences a change in condition. The DON verified Resident #52's medical record lacked any documentation from LPN #22 when the resident experienced the acute change in condition on 01/31/26. Interview on 02/23/26 at 2:04 P.M., RN #30 stated he came in to relieve LPN #22 (day shift nurse) around 8:00 or 9:00 P.M. RN #30 stated he got a report that Resident #52 had been screaming out all day related to being shocked. RN #30 stated Resident #52 was screaming out when he first got on shift, but when he completed his first medication rounds at 8:30 P.M., Resident #52 had his eyes closed in bed. Around 9:30 P.M., Resident #52 started screaming out and when he went in to assess the resident, he reported he was being shocked by his pacemaker. RN #30 stated he did not know Resident #52 had a pacemaker until the resident mentioned it. RN #30 stated he reviewed the resident's record and verified the resident had a pacemaker. RN #30 stated he listened to the resident's heart and noticed an irregular and elevated rhythm. RN #30 reached out to the on-call provider and did not get an answer. RN #30 stated he was relieved by LPN #23 on 01/31/26 at approximately 11:00 P.M. and mentioned in his report that Resident #52 had complained of being shocked by his pacemaker. RN #30 instructed LPN #23 to send Resident #52 out to the hospital if it occurred again. Review of the facility policy titled, Change in Condition, dated 11/06/25 revealed the facility was to ensure timely and appropriate response to changes in resident's conditions and to facilitate effective communication with physicians. Nursing staff must be vigilant in monitoring residents for any changes in condition including alterations in vital signs, mobility, cognition, mood, or behavior. When the nurse was notified of change, the nurse would perform a comprehensive assessment to evaluate the severity and identify potential causes. The nurse would document all findings in the resident's medical record. The nurse must notify the attending physician or on-call physician immediately if the change in condition was significant.This deficiency represents noncompliance investigated under Complaint Number 2735210.

Based on review of the medical record, staff interviews, and policy review, the facility failed to notify the physician or non-physician provider when a resident had an acute change in condition. This affected one (Resident #52) of three residents reviewed for a change in condition. The facility census was 65.Findings include:Review of the medical record for Resident #52 revealed an admission date of 09/25/25. Diagnoses included cerebral infarction (stroke), chronic obstructive pulmonary disease (COPD), and acute respiratory failure with hypoxia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #52 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. Review of nurse's progress notes dated 01/31/26 from 11:00 A.M. to 10:55 P.M., revealed no documented evidence the physician or the non-physician provider was contacted when Resident #52 experienced an acute change in condition at approximately 1:00 P.M.Review of the nurse's progress note dated 01/31/26 at 10:56 P.M., authored by Registered Nurse (RN) #30, revealed Resident #52 had complaints of shocking feeling in his chest area. Upon assessment, he had a pacemaker, heart rate was obtained at 64 beats per minute (bpm) and then rechecked at 69 bpm. The on-call provider was contacted but did not answer. The nurse was awaiting a return call.Review of the nurse's progress note dated 02/01/26 at 12:55 A.M., authored by Licensed Practical Nurse (LPN) #23, revealed Resident #52 complained of an implantable cardioverter defibrillator (ICD) shock and stated it had been shocking him for the last four hours. Vital signs were obtained with a blood pressure (BP) of 94/59 millimeters of mercury (mmHg), 92 heart rate, 22 respirations, and oxygen saturation of 96 percent (%). Resident #52 requested to go to the emergency room because the shocks were scaring him. The on-call provider was contacted and agreed to send Resident #52 to the hospital for evaluation. The family and the Director of Nursing (DON) were notified. Review of the EMS report dated 02/01/26, revealed squad arrived on scene at 12:52 A.M. for a resident complaining of a shocking pain in his chest. Vital signs were taken at 1:02 A.M. with a BP of 118/72 mmHg, 156 heart rate, 18 respirations. At 1:13 A.M., the vital signs were BP 111/58 mmHg, 225 heart rate, 18 respirations. Assessment revealed Resident #52 had reported his ICD had shocked him 12 - 15 times in the last three hours. Resident #52 was in atrial fibrillation (A-fib) with rapid ventricular response (RVR). Resident #52 was transported to the hospital at 1:18 A.M.Review of the hospital paperwork dated 02/01/26, revealed Resident #52 presented to the emergency room complaining of experiencing repeated ICD firings. Resident #52 was a sixty-nine-year-old man with a history of coronary artery disease (CAD) caused by ischemic cardiomyopathy with an ejection fraction of 20-25 percent (%) status post three vein coronary artery bypass graft (CABG) and ICD placement. In the emergency room, Resident #52 required cardiology consultation and initiation of amiodarone (antiarrhythmic medication used to treat and prevent life-threatening, recurring, or persistent heart rhythm disorders, including ventricular arrhythmias [ventricular fibrillation/tachycardia] and rapid atrial fibrillation). Resident #52 was admitted to the ICU care unit for close monitoring in anticipation of electrophysiology (EP) intervention. Interview on 02/19/26 at 2:24 P.M., Resident #52 stated he was being shocked and requested to go to the hospital. Resident #52 stated the staff would not send him out at first but explained he was in a lot of discomfort when he was getting shocked.Interview on 02/23/26 at 1:27 P.M., LPN #22 stated she worked on 01/31/26 from 7:00 A.M. to 8:00 P.M. LPN #22 stated Resident #52 was screaming out and reported to her that a man was shocking him in his room, or the bed was shocking him. LPN #22 stated she thought he had a urinary tract infection (UTI) because he was not making any sense. LPN #22 stated she unplugged the bed and ensured the bed was working properly working. LPN #22 stated she did not know Resident #52 had an ICD. LPN #22 stated she obtained Resident #52's vital signs but did not document anything in the resident's medical records. LPN #22 stated she put a written entry in the provider's binder to follow up with Resident #52 but never called the provider about the acute change in conditions. Interview on 02/23/26 at 1:47 P.M., the DON stated the staff should be documenting in the medical records and notifying the provider when a resident experienced an acute change in condition. The DON stated she was not made aware of any complaints related to the resident being shocked until he was being sent out to the hospital on [DATE] at 1:00 A.M. The DON verified the provider was not notified when Resident #52 had an acute change in condition on 01/31/26.Review of the facility policy titled, Change in Condition, dated 11/06/25 revealed the facility was to ensure timely and appropriate response to changes in resident's conditions and to facilitate effective communication with physicians. The nursing staff must be vigilant in monitoring residents for any changes in condition including alterations in vital signs, mobility, cognition, mood, or behavior. When a nurse was notified of a change, the nurse would perform a comprehensive assessment to evaluate the severity and identify potential causes. The nurse would document all findings in the resident's medical record. The nurse must notify the attending physician or on-call physician immediately if the change in condition is significant.This deficiency represents noncompliance investigated under Complaint Number 2735210.

Based on medical record review, staff interview, review of the facility policy, and review of online guidelines per the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess resident skin and failed to identify pressure ulcers until they had reached an advanced stage. This resulted in Actual Harm for Resident #40 who was admitted to the facility without pressure ulcers, was assessed to be at low risk for the development of pressure ulcers, and developed an unstageable pressure ulcer with slough (nonviable tissue which could impede wound healing) to the left buttock. This affected one (Resident #40) of three residents reviewed for pressure ulcers. The facility census was 68 residents. Findings include: Review of the medical record review for Resident #40 revealed an admission date of 08/14/24 with diagnoses including peripheral vascular disease, diabetes mellitus (DM), hypertension, and depression. Review of the care plan for Resident #40 dated 12/04/24 revealed the resident was at risk for impaired skin integrity and breakdown related to impaired mobility. Interventions included the following: assess nutrition and hydration, encourage the resident to turn and reposition every two hours, pressure relieving cushion to wheelchair, pressure relieving mattress, provide nutritional supplements, weekly skin assessments by a licensed nurse. Review of the shower sheets for Resident #40 dated 03/08/25, 03/13/25, 03/16/25, 03/17/25,03/20/25, 03/26/25, 03/29/25, 03/31/25, 04/02/25, 04/05/25, 04/09/25, 04/22/25, and 04/26/25 revealed there was no documentation of wounds or open areas. Review of the physician's orders for Resident #40 revealed an order dated 03/17/25 for weekly skin assessments every Sunday on night shift. Review of the weekly skin assessment for Resident #40 dated 04/07/25 revealed the resident had no skin issues. Review of the medical record for Resident #40 revealed weekly skin assessments were not completed for 04/14/25, 04/21/25 or 04/28/25. Review of the weekly skin assessment for Resident #40 dated 04/30/25 revealed the nurse identified a new skin issue to the resident's buttocks which was described as moisture-associated skin damage (MASD) with scabbing. Review of the wound note for Resident #40 dated 05/01/25 per Wound Nurse Practitioner (WNP) #500 revealed the NP examined a wound to the resident's left buttock which staff first identified on 04/30/25. WNP #500 classified the wound as an unstageable, facility-acquired pressure ulcer to the resident's left buttock which measured 5.1 centimeters (cm) in length by 4.4 cm in width with a depth unable to be determined. The base of the wound was covered with 100 percent (%) slough tissue and required sharp debridement at the resident's bedside. Review of the care plan for Resident #40 dated 05/01/25 revealed the resident had impaired skin integrity related to a pressure ulcer to the buttock. Interventions included the following: administer treatments as ordered and monitor for effectiveness, educate resident/family/and caregivers as to cause of skin breakdown including transfer/positioning requirements, good nutrition, and frequent repositioning, encourage the resident to offload bony prominences with pillows and positioning devices. Review of the Minimum Data Set (MDS) assessment for Resident #40 dated 05/01/25 revealed the resident had impaired cognition, required staff assistance with activities of daily living (ADLs), and had an unstageable pressure ulcer. Review of the dietary progress note for Resident #40 dated 05/06/25 revealed the resident had an unstageable pressure ulcer to the left buttocks with an increased need for nutrition to promote wound healing. Review of the pressure ulcer risk assessment for Resident #40 dated 05/08/25 revealed the resident was at low risk for developing pressure ulcers, had no limitation of mobility, and made frequent changes in position. Interview on 05/02/25 at 11:04 A.M. with Assistant Director of Nursing (ADON) #366 confirmed she was the facility wound nurse and made rounds weekly with WNP #500. ADON #366 confirmed a nurse first identified the wound to Resident #40's wound on left buttock on 04/30/25 and described the area as MASD but did not complete measurements or a detailed assessment at the time of identification. ADON #366 confirmed the facility failed to complete weekly skin assessments for Resident #40 on 04/14/25, 04/21/25, and 04/28/25 and did not identify Resident #40's wound until it had reached an advanced stage. Interview on 05/20/25 at 11:51 A.M. with WNP #500 confirmed the facility asked her to assess a wound to Resident #40's left buttock which was first identified on 04/30/25. WNP #500 confirmed she assessed Resident #40 on 05/01/25 and found an unstageable pressure ulcer with a wound bed which was covered 100 % with slough tissue to the resident's left buttock. WNP #500 confirmed all wounds should be considered avoidable. Interview on 05/21/25 at 4:05 P.M with Clinical [NAME] President (CVP) #312 confirmed the facility nurses should have completed a weekly skin assessment for Resident #40 and the assessments for 04/14/25, 04/21/25, and 04/28/25 were not completed. Review of the facility policy titled Wound Management Documentation dated 05/07/25 confirmed the facility should complete and document weekly wound and skin assessments. Review of the NPUAP guidelines dated 2014 pages 70-71 at https://npiap.com/general/custom.asp?page=2014Guidelines revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that included the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment.

Based on observation, staff interview, review of pest control documentation, and policy review, the facility failed to maintain effective pest control in the kitchen area. This had the potential to affect all of the residents residing in the facility. The facility census was 68 residents. Findings include: 1. Observation on 05/18/25 at 8:40 A.M. revealed there were several black specs, measuring approximately one quarter inch on the floor between the deep fryer and stove and on the rack below the steamer. Interview on 05/18/25 at 8:57 A.M. with Dietary Staff (DS) #392 confirmed the black specs on the floor between the deep fryer and stove and on the rack below the steamer were mouse droppings. 2. Observation on 05/18/25 at 9:08 A.M. on the floor by the dry storage area revealed there were three cockroaches measuring approximately two inches in length. Interview on 05/18/25 at 9:10 A.M. with DS #392 confirmed there were three dark brown insects on the floor by the dry storage area. Review of pest control documentation revealed the kitchen had been treated for routine monthly services on 01/20/25, 02/14/25, 03/14/25, and 04/11/25 with no issues were noted at the time of the visits. Review of the facility policy titled Sanitation Inspection dated 05/19/25 revealed all food service areas should be kept clean, sanitary, and protected from rodents, roaches, flies, and other insects. .

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure garbage cans in the kitchen were covered. This had the potential to affect all of the residents residing in the facility. The facility census was 68 residents. Findings include: Observation on 05/18/25 at 8:40 A.M. revealed there were two garbage cans in the food preparation area which had no covers Interview on 05/18/25 at 8:52 A.M. with Dietary Staff (DS) # 392 confirmed the garbage cans were not covered. Observation on 05/19/25 at 10:05 A.M. revealed the two garbage cans in the food preparation remained uncovered. Review of the facility policy titled Disposal of Garbage and Refuse dated 05/21/25 revealed garbage and refuse containers should be covered when not in use.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure food was prepared, stored, and served in a manner to protect against foodborne illness. This had the potential to affect all of the residents residing in the facility. The facility identified one (Resident #37) who did not receive food from the kitchen. The facility census was 68 residents. Findings include: 1. Observation on 05/18/25 at 8:36 A.M. of the breakfast tray line revealed Certified Nursing Assistant (CNA) #362 was assisting with food preparation by covering plates, adding drinks to trays, and placing trays on a cart. CNA #362 was not wearing a hair net. Interview on 05/18/25 at 8:50 A.M. with CNA #362 confirmed she was assisting with tray line and was not wearing a hair net. CNA #362 stated she was trying to stay away from the steam table so she wouldn't have to wear a hairnet. 2. Observation on 05/18/25 at 8:40 A.M. revealed there were several black specks, measuring approximately one-quarter of inch on the floor between the deep fryer and stove and on the rack below the steamer. Interview on 05/18/25 at 8:57 A.M. with Dietary Staff (DS) #392 confirmed there were black specks on the floor between the deep fryer and stove and on the rack below the steamer. DS #392 stated the black specks were mouse droppings. 3. Observation on 05/18/25 at 8:40 A.M. revealed there were two windows in the kitchen which were open. Further observation revealed the screen on one of the windows was damaged and had a hole, which measured approximately one inch by one inch. Interview on 05/18/25 at 8:55 A.M. with DS #392 confirmed the windows were open and one of the screens was damaged. 4. Observation on 05/18/25 at 8:48 A.M. with DS #392 revealed the reach-in cooler contained the following items: strips of cooked bacon, wrapped in plastic with no label or date, a ham and cheese sandwich on a plate, wrapped in plastic wrap, with no label or date, four fruit plates with tuna salad, each wrapped in plastic wrap, with no label or date, a large plastic bin of tuna salad, covered, with no label or date, a tray with nine individual cups of Italian dressing with a label which read pears undated, three supplement shake cartons, unopened, dated 04/04/25, a tray with seven individual cups of shredded cheese, with no label or date, six hard-boiled eggs, wrapped in plastic wrap, with no label or date, a bag of shredded cheese, wrapped in plastic wrap, with no date, a pan of hamburgers, covered in foil with no label or date, a pan of olives, covered in plastic wrap dated 05/01-05/07. Interview on 05/18/25 at 8:48 A.M. with DS #392 confirmed the food items in the reach-in cooler were not labeled and/or dated appropriately and the supplement shakes were outdated. 5. Observation on 05/18/25 at 8:53 A.M. with DS #392 revealed the reach-in freezer contained the following opened, unlabeled, undated, and unsealed items: a box of roll dough, box of biscuit dough, and a box of frozen broccoli. Interview on 05/18/25 at 8:53 A.M. with DS #392 confirmed the rolls, biscuits, and broccoli in the reach-in freezer were not sealed, labeled, or dated. 6. Observation on 05/18/25 at 8:58 A.M. with DS #392 revealed there was a foul odor inside the walk-in cooler. There was a large puddle of a reddish-brown liquid on the floor which measured approximately eight by eight inches below an empty cart. Interview on 05/18/25 at 8:58 A.M. with DS #392 confirmed the odor and puddle beneath the cart in the walk-in cooler were due to meat that had recently been thawed and attributed the foul odor to the liquid remaining on the floor. DS #392 was unsure long the puddle of liquid had been there or when the meat had been removed from the cooler. 7. Observation on 05/18/25 at 9:00 A.M. with DS #392 revealed the walk-in freezer contained the following opened, unlabeled, and undated items: a bag of strawberries, a bag of french fries. Interview on 05/18/25 at 9:00 A.M. with DS #392 confirmed the strawberries and the french fries in the walk-in freezer were not labeled or dated appropriately. 8. Observation on 05/18/25 at 9:02 A.M. with DS #392 revealed the dry storage area contained the following items: a box containing a plastic jug of oil, stored directly on the floor, four bags of pasta, opened and wrapped in plastic wrap with no label or date, a bag of cream soup base, opened and wrapped in plastic wrap with no label or date, bins of flour and breadcrumbs with no label or date. Interview on 05/18/25 at 9:02 A.M. with DS #392 confirmed the oil in the dry storage area was stored on the floor and the pasta, cream soup base, flour, and breadcrumbs were not labeled or dated appropriately. 9. Observation on 05/18/25 at 9:08 A.M. with DS #392 revealed there were three dark brown insects each measuring approximately two inches in length on the floor by the dry storage area. Interview on 05/18/25 at 9:10 A.M. with DS #392 confirmed there were three dark brown insects on the floor near the dry storage area. 10. Observation on 05/18/25 at 12:26 P.M. revealed CNA #500 served Resident #19 her lunch and touched the bun of the resident's sandwich with his bare hands. Interview on 05/18/25 at 12:28 P.M. with CNA #500 confirmed he touched Resident #19's food with his bare hand and he should have been wearing gloves when handling resident food. 11. Observation on 05/18/25 at 12:28 P.M. revealed CNA #349 assisted Resident #48 and picked up the resident's sandwich with her bare hands. Interview on 05/18/25 at 12:30 P.M. with CNA #349 confirmed she handled Resident #48's sandwich with her bare hands. 12. Observation on 05/19/25 at 10:05 A.M. with Dietary Manager (DM) #389 revealed the vents of the oven hood were caked with a fuzzy white substance. Interview on 05/19/25 at 10:05 A.M. with DM #389 confirmed the vents of the oven hood were caked with a white and fuzzy substance. 13. Observation on 05/19/25 at 10:09 A.M. revealed DS #321 unloaded clean plates from a plastic rack, which had just been run through the dishwasher and used a rag to dry the plates. Interview on 05/19/25 at 10:09 A.M. with DS #321 confirmed she was drying the plates which had just been washed using a rag. 14. Observation on 05/19/25 at 10:50 A.M. revealed DM #389 prepared pureed chicken for the lunch meal and used a spatula which had a burnt and blackened section which measured approximately one-half to remove the chicken from the blender. There were two additional spatulas hanging in the food preparation area which also had blackened and burnt areas on them. Interview on 05/19/25 at 10:51 A.M. with DM #389 confirmed the spatula utilized to scrape the chicken out of the blender had a burnt and blackened section. Review of the facility policy titled Date Marking for Food Safety dated 05/19/25 revealed food should be clearly marked to indicate the date or day by which the food should be consumed or discarded. The discard date might not exceed the manufacturer's use-by date Review of the facility policy titled Food Safety Requirements dated 05/22/25 revealed food should be stored off the floor, gloves should be used when touching and assisting with ready-to-eat foods, all equipment used in the handling of food should be clean and sanitized, and staff should wear hairnets when cooking, preparing, or assembling food. Review of the facility policy titled Sanitation Inspection dated 05/19/25 revealed all food service areas shall be kept clean, sanitary, and protected from rodents, roaches, flies, and other insects.

Based on review of staffing schedules, staff interview, and review of the facility policy, the facility failed to ensure there was a Registered Nurse (RN) scheduled for at least eight consecutive hours daily. This had the potential to affect all of the residents residing in the facility. The facility census was 68 residents. Findings include: Review of staffing schedules dated 04/13/25 through 05/17/25 revealed on 04/27/25 there was no RN working in the facility. Interview on 05/21/25 at 11:10 A.M. with Clinical Director (CD) #312 confirmed the facility did not have an RN working for eight consecutive hours on 04/27/25. Review of the facility policy titled Nursing Services-Registered Nurse dated 05/01/25 revealed the facility would utilize the services of an RN for at least eight consecutive hours per day, seven days per week.

Based on observation and interview the facility failed to maintain a safe, functional, and sanitary environment in the common areas of the facility. This had the potential to affect all of the residents residing in the facility. The facility census was 68 residents. Findings include: 1.Observation on 05/18/25 at 4:55 P.M. revealed the cove base in the entrance to the rehab hallway was ripped and torn. There were also multiple missing floor tiles. Interivew on 05/18/25 at 4:55 P.M. with Certified Nursing Assistant (CNA) #377 confirmed the cove base to the walls near the entrance to the rehab unit was ripped and torn and there were multiple missing floor tiles. CNA #377 confirmed the floor was in disrepair and presented a trip hazard to residents, staff, and visitors. 2. Observation on 05/21/25 at 3:23 P.M. with Maintenance Supervisor (MS) #307 revealed the ceiling light to the entrance of the rehab unit was not working and the cover to the light fixture was broken. Interview on 05/21/25 at 3:23 P.M. with MS #307 confirmed the ceiling light to the entrance of the rehab unit was in a state of disrepair. 3. Observation on 05/21/25 at 3:25 P.M. with MS #307 revealed the ceiling vents on the Sea Side Lane unit were dusty with debris hanging down from them. Interview on 05/21/25 at 3:37 P.M. with MS #307 confirmed the ceiling vents on the Sea Side Lane unit were dusty with debris hanging down from them. .

7. Review of the medical record for Resident #42 revealed the resident an admission date of 12/28/21 with diagnoses including diabetes, mood disturbance, dementia, and pressure ulcer. Review of care plan for Resident #42 dated 01/14/22 revealed the resident had moisture associated skin damage. Review of the MDS assessment for Resident #42 dated 03/25/25 revealed the resident had severe cognitive impairment, required extensive assistance with ADLs. Review of the monthly physician's orders for Resident #42 dated May 2025 revealed the resident had a treatment order to a stage III pressure ulcer on the coccyx. Interview on 05/21/25 at 2:00 P.M. with Registered Nurse (RN) #312 confirmed Resident #42 had developed a stage III pressure ulcer to the coccyx and the resident's care plan had not been updated to reflect the resident's current skin condition. Review of the facility policy titled Care Planning dated 01/25/25 revealed the facility would make changes to the plan of care as needed. Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure care conferences were completed as required. This affected four (Residents #10, #23, #40, and #56) of five residents reviewed for care conferences. The facility failed to ensure care plans were updated following a change in condition. This affected two (Residents #10 and #48) of 19 residents reviewed for care planning. The facility census was 68. Findings include: 1. Review of the medical record of Resident #10 revealed an admission date of 09/04/21 with diagnoses including congestive heart failure (CHF), type two diabetes mellitus, chronic obstructive pulmonary disease (COPD), depression, and schizoaffective disorder. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 04/07/25 revealed the resident had intact cognition and required staff assistance with activities of daily living. Review of a progress note for Resident #10 dated 10/10/24 revealed the resident and her family were invited to a care conference that was scheduled for the same date as the invitation and both declined to attend. Review of the medical record for Resident #10 revealed no evidence of care conferences being held. Interview on 05/18/25 at 10:15 A.M. with Resident #10 confirmed she had not had any recent care conferences and further stated she did not know what care conferences were. Interview on 05/19/25 at 1:34 P.M. with Clinical Director (CD) #312 confirmed there was no evidence of care conferences being held for Resident #10. CD #312 stated Resident #10 refused, however verified there was no further documentation beyond the progress note dated 10/10/24. 2. Review of the plan of care for Resident #10 dated 01/22/23 revealed the resident was at risk for complications related to the use of antipsychotic medications. The resident had bipolar disorder and major depressive disorder. Further review of the care plan revealed the plan had not been updated regarding Resident #10's diagnosis of schizoaffective disorder. Review of the diagnosis list for Resident #10 revealed the resident was diagnosed with schizoaffective disorder on 01/11/24. Interview on 05/20/25 at 12:20 P.M. with CD #312 confirmed the facility had not updated Resident #10's care plan to address the resident's new diagnosis of schizoaffective disorder on 01/11/24. 3. Review of the medical record for Resident #23 revealed an admission date of 01/25/25 with diagnoses including fracture of the left humerus, post-traumatic stress disorder, depression, and glaucoma. Review of the MDS assessment for Resident #23 dated 05/02/25 revealed Resident #23 was cognitively intact. Review of Resident #23's medical record dated June 2024 to May 2025 revealed a care conference had not been completed for the resident. Interview on 05/19/25 at 03:27 P.M. with CD #312 confirmed that there was no documentation of a care conference being held for Resident #23. 4. Review of the medical record for Resident #56 medical recorded revealed an admissions date of 08/23/23 with diagnoses including benign neoplasm of meninges, pulmonary hypertension, blindness, and arthropathy. Review of the MDS assessment for Resident #56 dated 04/11/25 revealed the resident #23 was moderately cognitively impaired. Review of medical record for Resident #56 dated June 2024 to May 2025 revealed the only care conference held for the resident during this time frame occurred on 11/21/24 and the care conference document for 11/21/24 had not been signed and dated as completed. Interview on 05/19/25 at 3:29 P.M. with CD #315 confirmed the facility only had one care conference documented for Resident #56 from June 2024 to May 2025. CD #312 confirmed the only documented care conference on 11/21/24 had not been signed and dated as complete. 5. Review of the medical record for Resident #40 revealed an admission date of 08/14/24 with diagnoses including peripheral vascular disease, diabetes mellitus (DM), essential primary hypertension, depression, and anxiety disorder. Review of the MDS assessment for Resident #40 dated 05/01/25 revealed the resident had impaired cognition and required staff assistance with ADLs. Review of the care conference note for Resident #40 dated 11/24/24 revealed there no signature or lock date to confirm the conference had been completed. Interview on 05/18/25 at 11:58 A.M. with Resident #40 confirmed he had never had a care conference to discuss his plan of care. Interview on 05/20/25 12:45 A.M. with CD #312 confirmed the care conference note for Resident #40 dated 11/24/24 had not been signed or locked to indicate the conference had been completed. 6. Review of the medical record for Resident #62 revealed as admission date of 04/13/25 with diagnoses including polyneuropathy, CHF, hypertension, and acute respiratory failure with hypoxia. Review of the MDS assessment for Resident #62 dated 05/08/25 revealed the resident was cognitively intact and required staff assistance with ADLs. Review of the medical record for Resident #62 dated June 2024 to May 2025 revealed there was no documentation of a care conference completed for the resident. Interview on 05/18/25 at 10:47 A.M. with Resident #62 confirmed she was not sure if she ever had a care conference to discuss her plan of care. Interview on 05/20/25 12:45 A.M. with CD #312 confirmed Resident #62's record did not include documentation of a care conference completed for the resident from June 2024 to May 2025. Review of the facility policy titled Care Planning-Resident Participation dated 01/25/25 revealed the facility would discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences initially, at routine intervals, and after significant changes. The facility would make an effort to schedule the conference at the best time of day for the resident/resident's representative and obtain a signature from the resident and/or representative after discussion or viewing of the care plan.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure a clean and homelike dining experience. This had the potential to affect the 11 facility-identified residents (#02, #03, #07, #18, #19, #24, #39, #48, #50, #59, #61) who ate their meals in the main dining room. The facility also failed to ensure resident rooms were clean and sanitary. This affected three (Residents #53, #62, #123) of 19 residents sampled. The facility census was 68 residents. Findings include: 1. Observation on 05/18/25 at 8:36 A.M. of breakfast revealed residents were served the meal in Styrofoam containers. Interview on 05/18/25 with Dietary Staff (DS) #392 confirmed residents were being served their meal in Styrofoam containers because another dietary staff member had called off and they were trying to minimize the amount of dishes that needed to be washed. 2. Observation on 05/19/25 at 12:24 P.M. revealed there was a large vent in the ceiling in the middle of the dining room which was caked in a thick dark gray and fuzzy material which was visibly blowing in the air coming from the vent. Further observation revealed the curtains on the double doors from the dining room to the facility smoking area contained a gray and fuzzy coating. The curtain rod above the window in front of the tray line condiment station was caked in a dark gray and fuzzy material and a house fly was stuck to the curtains. Thee sprinkler heads in the dining room were also caked with a gray fuzzy material. There was a string of the gray fuzzy material approximately 12 inches in length dangling from a ceiling tile above a table in the dining area. Interview on 05/19/25 at 12:46 P.M. with Dietary Manager (DM) #389 confirmed the gray fuzzy material throughout the dining area on the vent, ceiling, curtains, and sprinkler heads, and confirmed the fly on the curtains was dead and stuck to the curtains. Review of the facility policy titled Safe and Homelike Environment dated 05/21/25 revealed the facility would provide a safe, clean, comfortable, and homelike environment. 3. Observation on 05/18/25 at 4:15 P.M. with Certified Nurse Aide (CNA) #378 revealed the floor and the walls in Resident #62's room were heavily soiled with an unknown black substance. The bathroom floor was heavily soiled, and there was a black ring inside the toilet bowl. Interview on 05/18/25 at 4:15 P.M. with CNA #378 confirmed the walls, floors, and toilet in Resident #62's room were soiled. 4. Observation on 05/18/25 at 4:16 P.M. with CNA #378 revealed the floor and the walls in Resident #123's room were heavily soiled with an unknown black substance. The bathroom floor was heavily soiled, and there was a black ring inside the toilet bowl. Interview on 05/18/25 at 4:17 P.M. with CNA #378 confirmed the walls, floors, and toilet in Resident #123's room were soiled. 5. Observation on 05/18/25 at 4:19 P.M. with CNA #378 revealed the floor and the walls in Resident #53's room were heavily soiled with an unknown black substance. The bathroom floor was heavily soiled, and there was a black ring inside the toilet bowl. Interview on 05/18/25 at 4:20 P.M. with CNA #378 confirmed the walls, floors, and toilet in Resident #53's room were soiled. 6. Observation on 05/18/25 at 4:45 P.M. with Dietary Manager (DM) #389 confirmed the resident dining room floor was heavily soiled with food debris and liquid stains. Interview on 05/18/25 at 4:45 P.M. with DM #389 confirmed the dining room staff was responsible for cleaning the dining room floor. DM #389 stated the dining staff was short staffed on 05/17/25, and the floor was not mopped after dinner or before breakfast on 05/18/25 and remained soiled throughout the day.

Based on medical record review, resident interview, observation, staff interview, and review of the facility policy, the facility failed to ensure resident meal preferences were honored. This affected one (Resident #23) of 19 residents sampled. The facility census was 68 residents. Findings include: Review of the medical record for Resident #23 revealed an admission date of 01/25/25 with diagnoses including fracture of the left humerus, post-traumatic stress disorder, depression, and glaucoma. Review of the Minimum Data Set assessment for Resident #23 dated 05/02/25 revealed the resident was cognitively intact. Review of the lunch order for Resident #23 dated 05/19/25 revealed the resident ordered a hot dog, mashed potatoes and fruit. Interview on 05/18/25 at 10:08 A.M. with Resident #23 confirmed she often did not receive what was written on the menu and would receive a peanut butter and jelly sandwich instead. Observation service on 05/19/25 at 12:59 P.M. of the lunch service revealed Resident #23 received mashed potatoes, fruit, and a peanut butter sandwich. Interview on 05/19/25 at 12:59 P.M. with Resident #23 confirmed she received a peanut butter sandwich for an entrée instead of the hot dog she had ordered. Interview on 05/19/25 at 1:00 P.M with Director of Nutritional Services (DNS) #389 confirmed Resident #23 had ordered a hot dog as an entrée for lunch but instead received a peanut butter sandwich. DNS #389 confirmed when the kitchen did not have an ordered item available, a staff member should discuss other options with the resident. Further interview with DNS #389 confirmed the kitchen staff were busy, and a staff member had not discussed alternative menu options with the resident since hot dogs were not available. DNS #389 verified that the kitchen staff assumed Resident #23 would want a peanut butter sandwich without verifying this with the resident. Review of the facility policy titled Standardized Menus dated 05/01/25 revealed that the facility would support resident's rights to make personal dietary choices.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to properly store medications in a safe and secure manner. This affected one (Resident #62) of 19 residents sampled. The facility census was 68 residents. Findings include: Review of the medical record for Resident #62 revealed an admission date of 04/13/25 with diagnoses including polyneuropathy, congestive heart failure, hypertension, and acute respiratory failure with hypoxia. Review of the Minimum Data Set (MDS) assessment for Resident #62 dated 05/08/25, revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #62 dated May 2025 revealed no orders for cranberry supplement, probiotic tablets, Refresh Tears eye drops, Replenish eye drops, Ketorolac eye drops, multivitamin capsules, and Tums tablets. Review of the Medication Administration Record (MAR) for Resident #62 dated May 2025 revealed there was no documentation of administration of the following medications: cranberry supplement, probiotic tablets, Refresh Tears eye drops, Replenish eye drops, Ketorolac eye drops, multivitamin capsules, and Tums tablets. Observation on 05/18/25 at 10:52 A.M. with Licensed Practical Nurse (LPN) #400 revealed Resident #62 had the following medications/supplements in bottles on her bedside table: cranberry supplement, probiotic tablets, Refresh Tears eye drops, Replenish eye drops, Ketorolac eye drops, multivitamin capsules, and Tums tablets Interview on 05/18/25 at 10:52 A.M. with LPN #400 confirmed the medications should not be at Resident #62's bedside and should be locked in the medication cart. LPN #400 confirmed Resident #62 did not have orders for the medications and supplements listed. Review of the facility policy titled Medication Storage dated 04/28/25 confirmed the facility would ensure all medications housed on the premises would be stored in medication rooms according to the manufacturer's recommendation and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Further review of the policy revealed all drugs and biologicals would be stored in locked compartments, medication carts, cabinets, drawers, or refrigerators.

Based on medical record review, review of resident fund records, staff interview, and review of the facility policy, the facility failed to transfer funds upon death to a resident's estate within thirty days. This affected one (Resident #127) of five residents reviewed for personal funds. The facility census was 68 residents. Findings include: Review of the medical record for Resident #127 revealed an admission date of [DATE] with diagnoses including anemia, atrial fibrillation, hypertension, dementia, and depression. Resident #127 expired in the facility on [DATE]. Review of the resident fund account records revealed the facility sent a dated [DATE] to the estate of Resident #127 with a check containing the balance of $245.51 from the resident's fund account with the facility. Interview on [DATE] at 11:04 A.M. with Business Office Manager (BOM) #310 confirmed Resident # 127 expired on [DATE] in the facility and the facility did not refund balance of $242.51 from the resident's fund account to the resident's estate within 30 days as required. Review of the facility policy titled Resident Personal Funds dated [DATE] revealed upon the death of a resident with personal funds deposited with the facility, the facility would convey the balance of the funds to the person administering the resident's estate within 30 days of the resident's death.

Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident was free from significant medication error. This affected one (#32) resident out of the three residents reviewed for medication administration. The facility census was 62. Findings include: Review of the medical record for Resident #32 revealed an admitted [DATE] with medical diagnoses of myocardial infarction, cerebral infarctions, diabetes mellitus with neuropathy, spinal stenosis and congestive heart failure. Review of the medical record for Resident #32 revealed a quarterly Minimum Data Set (MDS) assessment, dated 09/24/24, which indicated Resident #32 was cognitively intact and required supervision with toilet hygiene, showers, bed mobility, and transfers. Review of the medical record for Resident #32 revealed a physician order dated 05/12/24 for Insulin Glargine 100 units per milliliter (ml), administer eight units subcutaneous (SQ) daily, an order dated 06/-2/24 for Insulin Lispro 100 units per ml, administer five units SQ before meals daily, and an order dated 11/06/24 for Zoloft 175 milligram (mg) one tablet by mouth daily. Review of the medical record for Resident #32 revealed the November 2024 Medication Administration Record (MAR) did not contain documentation to support Resident #32 was administered Insulin Glargine as ordered on 11/05/24, 11/14/24, 11/15/24, 11/18/24 through 11/21/24. Further review of the November MAR revealed no documentation to support Resident #32 was administered Zoloft as ordered on 11/14/24, 11/25/24, 11/18/24 through 11/21/24 or Insulin Lispro as ordered on 11/05/24, 11/14/24, 11/15/24, 11/18/24 through 11/21/24, or 11/24/24. Interview on 12/04/24 at 2:45 P.M. with Regional Clinical Nurse (RCN) #170 confirmed the medical record for Resident #32 did not contain documentation to support the staff administered Resident #32's Insulin Glargine, Insulin Lispro and Zoloft as ordered in November 2024. RCN #170 confirmed Resident #32 did not experience any negative effects from medications not being administered as ordered. Review of the facility policy titled, Administering Medications, stated medications shall be administered in a safe and timely manner, as prescribed. 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 OH00159826.

Based on medical record review, staff and resident interviews, and policy review, the facility failed to ensure a medication was available for administration as ordered. This affected one (#51) resident out of the three residents reviewed for medications available from pharmacy for administration. The facility census was 62. Findings include: Review of the medical record for Resident #51 revealed an admitted [DATE] with medical diagnoses of acquired absence of left below knee amputation (BKA), peripheral vascular disease, diabetes mellitus, and hypertension. Review of the medical record for Resident #51 revealed an admission Minimum Data Set (MDS) assessment, dated 08/21/24, which indicated Resident #51 was cognitively intact and required substantial/maximum staff assistance with toilet hygiene and transfers and partial/moderate staff assistance with bathing and bed mobility. Review of the medical record for Resident #51 a physician order dated 09/12/24 for Percocet 5-325 milligram (mg) give one tablet by mouth every four hours for pain. Review of the medical record for Resident #51 revealed the October 2024 Medication Administration Record (MAR) which did not have documentation to support Resident #51 received Percocet as ordered on 10/12/24, 10/13/24, 10/18/24, and 10/28/24. Review of Resident #51's December 2024 MAR revealed no documentation to support Resident #51 received Percocet as ordered on 12/04/24. Review of the medical record for Resident #51 revealed a nurses' note dated 10/18/24 at 12:46 P.M. with stated the nurse spoke with the pharmacy and per the representative the Percocet would be delivered in the evening. Review of Resident #51's nurses' note dated 10/19/24 at 12:03 A.M. stated Resident #51 was out of Percocet. The note stated the nurse contacted the pharmacy to get authorization to pull the medication from the Pyxis system, but the nurse did not have access to the Pyxis. The note continued to state the nurse contacted the on-call supervisor who stated she did not have access to the Pyxis system either. Review of the medical record for Resident #51 revealed a nurses' note dated 12/04/24 at 10:47 P.M. which stated Percocet was not given because the medication was not available in the medication cart and the medication was reordered. Interview on 12/04/24 at 11:38 A.M. with Resident #51 confirmed he does not receive his pain medication at times because the medication was not available at the time of administration. Interview on 12/05/24 at 9:40 A.M. with Regional Clinical Nurse (RCN) #170 confirmed the medical record for Resident #51 did not contain documentation to support Resident #51 received his Percocet as ordered on 10/12/24, 10/13/24, 10/18/24, 10/28/24, and 12/04/24. Review of the facility policy titled, Administering Medications, stated medications shall be administered in a safe and timely manner, as prescribed. 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 OH00159826.

Based on medical record review, staff interview, review of the facility policy, and review of guidelines per the National Pressure Injury Advisory Panel (NPIAP), the facility failed to thoroughly assess residents' skin and to implement interventions to prevent the development of pressure ulcers and failed to initiate prompt and timely treatment for a resident with pressure ulcers (a pressure ulcer is a localized injury of the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). This resulted in Actual harm when Resident #14 was admitted to the facility without pressure sores but was at risk for the development of pressure ulcers and subsequently developed an avoidable unstageable pressure ulcer to the right heel (full-thickness tissue loss where the depth of the wound bed was completely obscured by eschar in the wound bed) and a stage II pressure ulcer to the left heel. This affected one (Resident #14) of three residents reviewed for pressure ulcers. The facility census was 64 residents. Findings include: Review of the medical record for the Resident #14 revealed an admitted [DATE] with diagnoses including periprosthetic fracture around internal prosthetic right hip joint, chronic obstructive pulmonary disease, and peripheral vascular disease. Resident #14 was discharged to the hospital on 09/11/24. Review of the admission assessment for Resident #14 dated 8/21/24 revealed the resident had a surgical incision to her right knee with no pressure ulcers. Review of the pressure ulcer risk assessment for Resident #14 dated 08/21/24 revealed the resident was at risk for the development of pressure ulcers. Review of the Minimum Data Set (MDS) assessment for Resident #14 dated 08/28/24 revealed the resident was cognitively intact and required extensive assistance of two staff members for bed mobility. Resident #14 was at risk for the development of pressure ulcers but had no pressure ulcers during the MDS review period. Review of a visit note per wound Certified Nurse Practitioner (CNP) #300 dated 08/29/24 revealed the CNP was treating the resident's surgical incision and did not include documentation regarding the presence or absence of pressure ulcers. Review of the care plan for Resident #14 initiated 08/30/24 revealed the resident was at risk for skin integrity/breakdown related to impaired mobility and incontinence of bowel and bladder. Interventions included the following: assess skin condition with activities of daily living (ADL) care daily and report abnormalities, encourage/assist the resident to turn/reposition at least every two hours or more often as needed or requested, position with pillows daily as needed, pressure relieving mattress to bed, preventative skin treatments as ordered, and weekly skin checks by a licensed nurse. Review of the Treatment Administration Record (TAR) for Resident #14 dated August 2024 revealed there were no orders for heel protection or offloading of heels. Review of the weekly skin check for Resident #14 dated 09/03/24 revealed resident had no pressure ulcers. Review of the occupational therapy note for Resident #14 dated 09/03/24 revealed the resident was in bed and was noted to have reddened areas to both heels. Review of the nurse progress note for Resident #14 dated 09/05/24 revealed new pressure ulcers to the right and left heel were observed during a wound assessment with wound CNP #300. Review of the wound visit note for Resident #14 dated 09/05/24 per wound CNP #300 revealed the resident had an unstageable pressure ulcer to the right heel which measured 5.0 centimeters (cm) in length by 6.0 cm in width with the depth unable to be determined as the wound bed was covered 100 percent (%) with eschar (dead tissue.) and a stage II pressure ulcer to the left heel which measured 2.0 cm in length by 2.0 cm in width. CNP #300 gave orders for treatment of the wound and recommended offloading of the resident's heels. Review of the TAR for Resident #14 dated September 2024 revealed there were no orders for heel protection or offloading of heels. There was a treatment order dated 09/05/24 to cleanse the pressure ulcer to the left heel with wound cleanser, apply skin prep, cover with an ABD pad, and wrap with Kerlix gauze on Tuesday, Thursday, and Saturday which was signed off as completed. There was a treatment order dated 09/05/24 to cleanse the pressure ulcer to the right heel with wound cleanser, apply Betadine, cover with an ABD pad, and wrap with Kerlix gauze on Tuesday, Thursday, and Saturday which was signed off as completed. Interview on 09/30/24 at 11:59 A.M. with CNP #300 confirmed on 09/05/24 she evaluated Resident #14's surgical incision to the right knee and discovered the resident had developed an avoidable unstageable pressure ulcer to the right heel and a stage II pressure ulcer to the left heel. CNP #300 confirmed she identified the pressure ulcers and reported them to the Director of Nursing (DON) and gave orders for wound care for the pressure ulcers and recommended the resident's heels be offloaded. Interview on 10/15/24 at 1:40 P.M. with Occupational Therapist (OT) #305 confirmed she noticed Resident #14's heels were reddened on 09/03/24 but she did not report this to the nursing staff. Interview on 10/15/24 at 2:00 P.M. with the DON confirmed the facility nursing staff did not identify Resident #14's pressure ulcers to the heels. The DON confirmed wound CNP #300 identified the pressure ulcers to Resident #14's heels on 09/05/24. The DON further confirmed the facility did a skin assessment upon admission which revealed Resident #14 had no pressure ulcers. The DON confirmed residents should have a skin assessment completed weekly per a licensed nurse. The DON confirmed the only weekly skin assessment completed for Resident #14 per the facility nursing staff form was completed on 09/03/24 and indicated the resident had no pressure ulcers. Further interview with the DON confirmed Resident #14's care plan did not include interventions to protect the heels from skin breakdown such as floating or offloading heels or applying heel protectors. The DON confirmed Resident #14 had no physician orders for heel protection, and the pressure ulcer to resident's right heel was not identified until it had reached an advanced stage (unstageable with 100% eschar to the wound bed.) Review of the facility policy titled Pressure Injury Prevention and Management dated 10/17/24 revealed the facility was committed to the prevention of avoidable pressure injuries and to providing treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Review of the policy titled Change in Condition and Physician Notification dated 09/25/24 revealed the nursing department was responsible for monitoring residents, conducting assessments, notifying physicians, and documenting all relevant information promptly when significant changes have occurred in a resident's condition. Review of the guidance from the National Pressure Injury Advisory Panel (NPIAP) dated 2014 revealed staff should assess the pressure ulcer upon discovery and at least weekly thereafter and should implement appropriate wound care. Further review revealed with each dressing change, staff should observe the pressure ulcer for signs that indicate if a change in treatment is required (e.g., wound improvement, wound deterioration, signs of infection, or other complications). Wound status could change rapidly. Wound improvement or deterioration indicated by change in wound dimensions, change in tissue quality, an increase or decrease in wound exudate, signs of infection or other complications all provided indications of the effectiveness of the current management plan. The person responsible for dressing changes should be educated regarding signs and symptoms of complications that should be reported to the health professional.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, medical record reviews, review of COVID-19 guidance from the Centers for Disease Control and Prevention (CDC), observation, review of the facility's Coronavirus (COVID-19) policies, and staff interviews, the facility failed to implement effective and recommended infection control practices, including the implementation of appropriate isolation and quarantine procedures to prevent the spread of COVID-19 within the facility. This resulted in Immediate Jeopardy on 07/23/22 when Resident #153, who was mobile and left her room frequently, was not placed under quarantine upon being notified Resident #153's roommate (Resident #01) tested positive for COVID-19 in the emergency room (ER) at the hospital. On 07/26/22, the facility conducted broad-based testing and results confirmed five additional residents (Residents #22, #25, #37, #46, and #153) tested positive for COVID-19. Furthermore, the facility failed to monitor residents for possible signs and symptoms of COVID-19 at least daily, failed to ensure a cognitively impaired COVID-19 positive resident (Resident #46) wore a mask which covered her mouth and nose when outside of her room and did not smoke with residents who were negative for COVID-19, failed to ensure staff properly utilized Personal Protective Equipment (PPE), failed to place new admissions who were unvaccinated under quarantine, and failed to place residents who were not fully vaccinated under quarantine as part of the facility's broad-based testing strategy. The lack of current effective infection control practices and prevalence of continued positive cases in the facility placed all 55 residents currently residing in the facility at potential risk for serious life-threatening harm, negative health outcomes/complications, and/or death related to the facility's failure to control the COVID-19 outbreak. On 07/28/22 at 12:25 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 07/23/22 when the facility was notified that Resident #01 tested positive for COVID-19 in the ER at the hospital and Resident #01's roommate (Resident #153) was not placed under quarantine. On 07/26/22 at 9:38 A.M., Licensed Practical Nurse (LPN) #1005 confirmed Resident #153 was mobile and left her room frequently in her wheelchair. Five additional residents (Residents #22, #25, #37, #46, and #153) tested positive for COVID-19 on 07/26/22. Additionally, on 07/26/22 at 10:55 A.M., 12:01 P.M., 12:57 P.M., and 1:02 P.M. Resident #46, who tested positive for COVID-19 and was cognitively impaired, was observed wandering around the facility while not wearing PPE appropriately and facility staff made no attempts to intervene. On 07/26/22 at 12:57 P.M., Resident #46 was observed outside smoking within six feet of Resident #154 who was unvaccinated. There were no facility staff present to monitor the smoking patio. Resident #154, who was unvaccinated and newly admitted to the facility, was not placed under quarantine upon admission. Six residents (Residents #03, #04, #24, #36, #149, and #154) were unvaccinated or partially vaccinated and were not placed under quarantine as part of the facility's broad-based testing strategy. Finally, observations from 07/25/22 through 07/28/22 revealed multiple facility staff (Cook #731, State tested Nurse Aide [STNA] #787, Cook #719, Dietary Aide #730, and STNA #792) were observed not wearing PPE appropriately. The Immediate Jeopardy was removed on 08/04/22, when the facility implemented the following corrective actions: · On 07/26/22 at 11:00 A.M., all residents were tested for COVID-19 and Residents #22, #25, #37, #46, and #153 were placed under isolation due to positive COVID-19 tests. · On 07/26/22 at 3:00 P.M., the DON was educated by the Administrator on the Admission Policy and CDC guidance summary of changes dated 02/22/22. The facility policy is to place unvaccinated and partially vaccinated residents into a ten-day quarantine upon admission. · On 07/26/22 at 3:00 P.M., the Administrator, DON, and other management staff began education with staff regarding when staff are within six feet of a resident who was on Transmission-Based Precautions (TBP) for COVID-19, the staff member must wear PPE which includes a N95 respirator, isolation gown, gloves, and eye protection. · On 07/26/22 at 4:00 P.M., one-on-one supervision was started with Resident #46 to ensure compliance with infection control procedures such as wearing a mask, maintaining social distancing while smoking, and maintaining isolation protocols. In addition, the facility contacted the Local Health Department (LHD) for further guidance on options for ensuring Resident #46 was following protocol as the resident had behaviors and cognitive deficiencies. The LHD was in agreement with the protocols being implemented by the facility. The one-on-one supervision will continue throughout the duration of Resident #46's isolation. · On 07/26/22 at 4:00 P.M., outside facilities were contacted to find a more appropriate facility who could admit a COVID-19 positive, cognitively impaired resident; however, facilities contacted were not accepting COVID-19 positive residents or were full at that time. The social worker will continue to contact potential placement options. · On 07/26/22 at 5:00 P.M., a policy was developed to address residents that test positive for COVID-19 and are non-compliant with infection control protocols. · On 07/27/22 at 12:00 P.M., Resident #153 was discharged from the facility to home per Resident #153's choice. · On 07/27/22 at 3:00 P.M., the DON reviewed proper infection control procedures with all staff that were assigned to be a one-on-one with Resident #46. The new policy regarding residents that test positive for COVID-19 and are non-compliant with infection control protocols was reviewed with all staff assigned to the one-on-one with Resident #46. · On 07/28/22 at 10:00 A.M., residents who were not fully vaccinated were placed in quarantine. The unvaccinated residents did not have any signs or symptoms of COVID-19 and their COVID-19 tests were negative. The residents who were not fully vaccinated included Residents #03, #04, #24, #25, #36, #149, and #154. Resident #25 tested positive for COVID-19 on 07/26/22 and was placed under isolation precautions on 07/26/22. · On 07/28/22 at 10:45 A.M., PPE audits were initiated to ensure staff were properly wearing PPE and to ensure staff understood the PPE policy and procedures during a COVID-19 outbreak as well as the importance of wearing proper PPE when within six feet of a resident who was on droplet precautions for COVID-19. Audits will be completed every hour, each day for the duration of the COVID-19 outbreak. The audits will be completed by the Administrator, DON, or designee. · On 07/29/22, signs were placed on the door of every quarantined resident's room. The signs included verbiage regarding enhanced droplet contact precautions along with pictures showing N95 respirators, gloves, eye protections, and gowns. · By 08/01/22 at 10:30 A.M., the Administrator, DON, and other management staff educated all staff, except Cook #720, regarding proper infection control procedures, when a resident is exposed to COVID-19, the proper protocols for residents under isolation and quarantine precautions, the protocols for residents who have confirmed or suspected COVID-19, and admission policy procedures regarding quarantine of new residents if partially vaccinated or unvaccinated. Any staff who was not educated would be educated prior to their next working shift. All training will be completed by 08/10/22 for staff. All new employees will be educated during new employee orientation. · On 08/01/22 at 3:00 P.M., vitals and respiratory assessments were taken for all residents during the evening shift to identify any other residents that may be exhibiting signs or symptoms. A protocol was initiated for staff to take vitals on all residents each shift for the duration of the outbreak and testing was to be performed on all staff and residents in accordance with CDC guidance on testing frequency and duration. Vitals would continue to be monitored daily after the outbreak to assess for signs and symptoms of COVID-19. · On 08/02/22 at 3:00 P.M., the DON clarified the COVID-19 quarantine versus isolation orders in the charts by making three separate orders. The orders included COVID-19 Droplet/Contact Quarantine for ten days due to exposure to COVID-19. All resident services will be provided in room. or COVID-19 Droplet/Contact Quarantine for ten days due to being partially vaccinated or unvaccinated for COVID-19. All resident services will be provided in room. or Resident in Contact and Droplet Isolation for positive COVID-19 status. All services provided to resident in a private room. · By 08/03/22 at 12:30 P.M., all agency staff who were currently working had been educated by the Administrator, DON, or other management staff. All agency staff will be educated prior to working next shift. The education included proper infection control procedures, when a resident is exposed to COVID-19, the proper protocols for residents under isolation and quarantine precautions, the protocols for residents who have confirmed or suspected COVID-19, and admission policy procedures regarding quarantine of new residents if partially vaccinated or unvaccinated. · On 08/03/22 at 1:45 P.M., the DON reviewed all current orders and updated them to reflect the difference between quarantine and isolation. · Interviews on 08/04/22 at 11:17 A.M. with agency STNA #851, at 11:19 A.M. with Registered Nurse (RN) #767, and at 1:20 P.M. with LPN #1005, revealed they received education related to infection control policies and procedures. Each staff member was knowledgeable regarding proper infection control procedures. · Observations completed on 08/04/22 from 10:45 A.M. to 4:00 P.M. revealed facility staff were wearing appropriate PPE throughout the facility. Staff were observed donning and doffing PPE correctly, including disinfecting eye protection and N95 masks in between rooms. · The facility policies including the admission policy, non-compliant residents testing positive for COVID-19 policy, COVID-19 resident screens policy, COVID assessment policy, COVID-19 positive resident policy, COVID-19 resident status policy, Respiratory-Hygiene-Cough-Etiquette policy, contact precautions policy, and PPE illustrations, along with current CDC recommendations to prevent the spread of COVID-19 in nursing homes will be reviewed with all staff by 08/10/22. All staff will be trained through scheduled in-services on 08/08/22, 08/09/22, and 08/10/22, and new staff will receive training in orientation. Although the Immediate Jeopardy was removed on 08/04/22, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action and monitoring to ensure ongoing compliance. Findings Include: 1) Review of Resident #01's medical record revealed an original admitted on 10/06/21 and readmitted s on 07/05/22 and 07/29/22. Resident #01's medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment, dated 07/12/22, revealed Resident #01 had intact cognition and required extensive assistance from one staff to complete all Activities of Daily Living (ADLs), except bed mobility and eating. Review of the progress note dated 07/23/22 at 3:28 P.M. revealed Resident #01 was unable to sit up on her own and was lethargic in the morning on 07/23/22. Resident #01 was sweating but did not have a temperature on three different thermometers. Resident #01 was administered a COVID-19 test and Resident #01 was negative for COVID-19. Resident #01 was sent out to the hospital for evaluation and treatment after receiving instructions from Physician Assistant (PA) #852. Resident #01 was sent to the hospital via 911 (emergency medical services) where she was admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Respiratory Infection Screener assessments for Resident #01 revealed no assessments had been completed on Resident #01 prior to Resident #01 being sent to the hospital on 07/23/22. Review of Resident #01's care plan dated 07/07/22 revealed Resident #01 was at risk for an alteration in psychosocial well-being related to medically imposed restrictions related to COVID-19 precautions. Resident #01 was at risk for infection related to the COVID-19 pandemic. Interventions included follow facility protocol for COVID-19 screening/precautions, monitor temperature and respiratory status daily as per facility policy and notify the physician of abnormal findings promptly, and observe for signs and symptoms of COVID-19 and document and report signs and symptoms promptly. Review of Resident #153's medical record revealed an admitted [DATE]. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE] revealed Resident #153 had intact cognition and required extensive assistance from one to two staff to complete ADLs. Resident #153 used a walker and a wheelchair. Review of Respiratory Infection Screener assessments revealed Resident #153 did not have any assessments completed prior to testing positive for COVID-19 on 07/26/22. Review of a progress note dated 07/26/22 at 7:47 P.M. revealed Resident #153 was on a ten-day isolation for COVID-19 with no symptoms. Review of Resident #153's vaccination status revealed Resident #153 was unvaccinated and refused to be vaccinated for COVID-19. Interview on 07/25/22 at 9:38 A.M., with the DON and Business Office Manager (BOM) #717 revealed the facility had four residents (Residents #01, #48, #150, and #156) who tested positive for COVID-19. Resident #48 and Resident #150 tested positive in the facility and remained on isolation droplet precautions. Resident #156 had been sent to the hospital for other medical concerns, tested positive for COVID-19 during the hospitalization , and remained out of the facility. On 07/23/22, Resident #01 displayed possible signs and symptoms of COVID-19 which included lethargy and sweating. The facility sent Resident #01 to the hospital for treatment and Resident #01 tested positive for COVID-19 in the ER upon arrival at the hospital. Observation on 07/25/22 at 12:30 P.M. of Resident #153 (Resident #01's roommate) revealed Resident #153 remained in the room without any evidence of being under quarantine or TBP. Review of the COVID-19 timeline on 07/26/22 at 11:00 A.M., provided by the DON, revealed five residents (Residents #22, #37, #46, #25, and #153) tested positive for COVID-19 on 07/26/22. Interview on 07/26/22 at 2:22 P.M. with the DON, confirmed Resident #153 was not placed under quarantine or TBP due to possible exposure after her roommate (Resident #01) tested positive for COVID-19 on 07/23/22. The DON also confirmed the staff were not expected to monitor residents for signs and symptoms of COVID-19 unless the facility was in an outbreak. Interview on 07/27/22 at 9:38 A.M. with LPN #1005 revealed Resident #153 was mobile, used a wheelchair, and would frequently leave her room in her wheelchair and ambulate around the unit as well as off the unit prior to testing positive for COVID-19 on 07/26/22. LPN #1005 confirmed Resident #153 had not been placed under quarantine or TBP prior to testing positive for COVID-19 on 07/26/22. Interview via telephone on 07/27/22 at 11:08 A.M. with RN/Infection Preventionist (IP) #850 revealed if a resident tested positive for COVID-19 and had a roommate, she would expect the facility staff to separate the residents, isolate the resident who tested positive for COVID-19, and place the roommate under quarantine precautions for monitoring. Both residents under isolation and under quarantine should be cared for by staff wearing full PPE which included an N95 respirator, gloves, gown, and eye protection. Review of the facility policy COVID-19 Routine Resident Screens, revised 03/2019, revealed the policy stated, when a suspected case of COVID-19 was identified in the facility, the facility should do the following: follow COVID-19 precautions for the roommate for 14 days while screening every four hours. Facility to complete the resident screen daily providing no suspected cases are in the facility. Review of the facility policy Cohorting of Residents, revised June 2020, revealed the policy stated, Residents who test positive for COVID-19 will be separated from residents who test negative for COVID-19 using the following strategies: place residents together by COVID-19 status, cohort positive residents in designated COVID-19 area when possible, roommates of residents with COVID-19 will be considered exposed and potentially infected and will not share a room with other asymptomatic or negative residents for 14 days. Roommates of residents with COVID-19 will be quarantined for 14 days in designated COVID-19 area if at all possible, however residents that have been exposed and considered potentially infected will be isolated in place with other potentially exposed or positive residents when space does not permit being moved to a designated area. Then isolation in place guidelines will be followed. In addition, the following steps will be taken: monitoring of residents at least three times daily, initiate COVID-19 precautions, ex: mask, gowns, eye protection and gloves when within six feet and providing care and services and continue COVID-19 precautions for CDC recommended length of time. Review of the Centers for Disease Control (CDC) guidance titled Manage Residents who had Close Contact with Someone with [CONDITION(S)]-CoV-2 Infection, dated 02/02/22, revealed the guidance stated, Residents who are not up to date with all recommended COVID-19 vaccine doses and who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine after their exposure, even if [CONDITION(S)] testing is negative. Healthcare personnel (HCP) caring for them should use full PPE (gowns, gloves, eye protections, and N95 or higher-level respirator). Residents can be removed from Transmission-Based Precautions (TBP) after day ten following the exposure (day zero) if they do not develop symptoms. 2) Review of the medical record for Resident #46 revealed an admitted [DATE]. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] revealed Resident #46 had impaired cognition and scored a six out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #46 displayed inattention, disorganized thinking, verbal behaviors toward others (threatening, screaming, cursing, etc.), rejection of care, and wandering behaviors. Resident #46 required supervision with set up help only or physical help from one staff to complete ambulation/locomotion, eating, transfers, and bed mobility. Resident #46 required extensive assistance from one staff to complete dressing, toileting, and hygiene tasks. Resident #46 used a walker for assistance. Review of Resident #46's physician orders revealed an order dated 07/26/22 for COVID precautions for ten days every shift. Review of the Respiratory Infection Screener assessments revealed Resident #46 did not have a respiratory screening assessment completed prior to the resident testing positive for COVID-19 on 07/26/22. Review of Resident #46's progress notes dated 07/01/22 to 08/01/22 revealed there were no notes related to Resident #46 testing positive for COVID-19 on 07/26/22. Review of Resident #46's care plan, revised 06/24/22, revealed Resident #46 was alert; however, her cognition was impaired. The care plan further revealed Resident #46 was an elopement risk/wanderer with a history of attempts to leave the facility unattended, impaired safety awareness, significantly intrudes on privacy or activities, and walks throughout the facility for a significant amount of time every day. Additionally, Resident #46 was at risk for complications related to actual COVID-19 infection (added 07/26/22). Interventions included administer medications and treatments as ordered and report any adverse effects or ineffectiveness to the physician, coordinate/collaborate with the local health department for alternative placement related to difficulty in maintaining contact/droplet precautions due to impaired cognitive/safety/judgement, maintain droplet/contact isolation per facility policy, monitor for signs and symptoms such as cough, shortness of breath, fatigue, loss of taste, fever, headache, sore throat, nausea, vomiting, or diarrhea, monitor vital signs as ordered, provide education related to hand hygiene, provide one-on-one care to assist in maintaining contact/droplet isolation, and staff to offer/assist with mask placement and reapproach as needed. Observations on 07/26/22 at 10:55 A.M., 12:01 P.M., 12:57 P.M., and 1:02 P.M. of Resident #46 revealed Resident #46 was out of her room with her mask placed below her mouth and nose, ambulating independently down the hallways with her walker. Interview on 07/26/22 at 11:10 A.M. with LPN #753 confirmed Resident #46 had tested positive for COVID-19 and she was not sure how the facility was going to keep Resident #46 isolated because Resident #46 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 07/26/22 at 12:57 P.M., revealed Resident #46 was ambulating down the hall independently with her walker and Resident #46's nose was uncovered. Resident #46 entered the designated smoking area. Resident #154 (who was unvaccinated) was smoking and Resident #46 immediately pulled her mask down and sat within one foot of Resident #154. There were no staff present on the smoking patio. At 1:02 P.M., Resident #46 entered the facility again with her mask around her neck. Resident #46 requested a lighter from Registered Nurse (RN) #767. RN #767 informed Resident #46 she did not have a lighter and Resident #46 continued walking and sat down in the common area with several doctors and interns. RN #767 did not remind Resident #46 to place her mask over her nose and mouth. Interview on 07/26/22 at 1:03 P.M. with RN #767 confirmed she was aware Resident #46 had tested positive for COVID-19 and was not wearing a mask over her nose and mouth while ambulating throughout the building. RN #767 confirmed Resident #46 sat in the common area without a facial covering in place. RN #767 confirmed she did not intervene to remind Resident #46 to place the mask over her nose and mouth. Interview on 07/26/22 at 2:51 P.M. with the DON confirmed Resident #46 tested positive for COVID-19 and wandered throughout the facility without appropriate PPE in place. The DON stated Resident #46 was confused and non-compliant with following isolation protocols. The DON stated, I don't know what to do with her. The DON stated when staff approached Resident #46 constantly, Resident #46 became agitated and aggressive. The DON contacted the local health department (after surveyor intervention) for advice and stated Resident #46 would be placed on one-to-one supervision with a staff member while the facility looked for alternative placement for Resident #46 to complete her isolation period. Interview on 07/27/22 at 11:08 A.M. via telephone with RN/Infection Preventionist (IP) #850 revealed, when a resident tested positive for COVID-19 and was non-compliant with isolation protocols, she would expect the facility staff to encourage the resident to isolate and wear a mask appropriately. If that did not work, the facility should search for alternative placement at a facility with a COVID unit for the resident to complete the isolation period. In the meantime, facility staff should stay with the resident at all times, including when the resident was out on the smoking patio, in order to monitor the resident's movements and try to limit other residents from potentially being exposed. Review of the Centers for Disease Control and Prevention guidance titled Quarantine and Isolation, dated 03/30/22, revealed the guidance stated, if you tested positive for COVID-19 or have symptoms regardless of vaccination status, isolate from others for five days. Wear a well-fitting mask if you must be around others. Take precautions until day ten including wear a well-fitting mask for ten full days any time you are around others and avoid being around people who are more likely to get very sick from COVID-19. In certain high-risk congregate settings that have high risk of secondary transmission and where it is not feasible to cohort people, CDC recommends a ten-day isolation period for residents. 3) Review of the facility matrix on 07/25/22 at 11:30 A.M. revealed Residents #154 and #157 were admitted within the last ten days. Observations on 07/25/22 at 12:45 P.M. revealed Residents #154 and #157 had a sign on their doors which indicated they were under TBP; however, there was no cart with PPE placed near Resident #154 and Resident #157's doors. Review of the COVID Quarantine and COVID Precautions list on 07/25/22 at 4:30 P.M. provided by the DON revealed Residents #154, and #157 were under COVID Precautions. Observation and interview on 07/26/22 at 1:23 P.M. with STNA #851 on the rehabilitation unit confirmed Resident #153, Resident #19, and Resident #25 were under isolation due to testing positive for COVID-19 and staff were required to wear full PPE to care for those residents. STNA #851 stated she was not aware Resident #154 or Resident #157 were under any TBP related to COVID-19. Interview on 07/26/22 at 3:30 P.M. with the DON revealed new admissions and readmissions who were not fully vaccinated were placed under COVID precautions for ten days to monitor for signs and symptoms of COVID-19. The DON stated the staff were only required to wear a N95 respirator and eye protection and were not required to wear a isolation gown or gloves. The DON stated the residents really don't need to be placed under precautions because they have tested negative in the hospital and upon admission to the facility, but the facility has been doing it anyway as an extra precaution. Review of the CDC website community transmission rate on 07/26/22 at 3:40 P.M. revealed the facility's county was in a high transmission area. Review of the facility's vaccination status for all residents on 07/26/22 at 5:00 P.M. revealed the facility had five residents (Residents #03, #04, #24, #36, and #154) who had refused COVID-19 vaccinations and were unvaccinated. The facility also had one resident (Resident #149) who had only received the first vaccination dose of a two-dose primary series and was considered partially vaccinated. Interview on 07/27/22 at 9:00 A.M. with LPN #1005 revealed she would know if a resident was on TBP because she would receive the information in report at the beginning of her shift, a PPE cart would be outside or near the resident's door, and there would be a sign posted on the resident's door. LPN #1005 stated if there was not a sign posted on the door, she would assume the resident was not on any TBP. LPN #1005 stated for new admissions, who were not fully vaccinated, the only PPE required to care for those residents was a N95 respirator and eye protection. Full PPE including an isolation gown and gloves was only required for COVID-19 positive residents. Interview on 07/27/22 at 11:08 A.M. via telephone with RN/IP #850 confirmed if a resident was not fully vaccinated and was a new admission, readmission, or the facility was in an outbreak, then she would expect the resident to be placed under quarantine, tested for COVID-19, and monitored for ten days to make sure they were not positive for COVID-19. Interview on 07/27/22 at 1:00 P.M. with the Administrator revealed the facility did not have a COVID-19 testing policy in place. The facility followed the most recent QSO memo (from the Centers for Medicare and Medicaid Services) related to testing of residents and staff. Interview on 07/27/22 at 2:00 P.M. with the DON revealed the facility was using a broad-based testing approach. All residents and staff were tested twice a week when the facility identified a new COVID-19 positive case. The DON was not aware that all residents who were not fully vaccinated should be placed under quarantine and TBP, even if they tested negative, until the facility reached 14 days without any additional positive COVID-19 cases. Interview on 07/27/22 at 5:24 P.M. with the Administrator and DON confirmed Resident #154, who was a new admission and was not fully vaccinated, was not cared for by staff using full PPE including an isolation gown, gloves, N95 respirator, and eye protection. The DON revealed she was unsure why Resident #157 had been placed under TBP. Resident #157 was a new admission and was fully vaccinated. The DON stated she misunderstood the guidance and thought full PPE was only needed for residents who had a confirmed or suspected case of COVID-19. The DON confirmed all residents who were not fully vaccinated (Residents #03, #04, #24, #36, #149, and #154), even if tested negative for COVID-19, had not been placed under quarantine or cared for by staff using full PPE as a part of the facility's chosen broad based testing strategy. Review of the CDC guidance titled Infection Control for Nursing Homes: Interim Guidelines for Managing Residents and HCP in Nursing Homes, dated 02/02/22, revealed the guidance under the section titled New Admissions and Residents Who Leave the Facility, stated, in general, all residents who are not up to date with all recommended COVID-19 vaccine doses and are new admissions and readmissions should be placed in quarantine, even if they have a negative test upon admission, and should be tested as described in the testing section above; COVID-19 vaccination should also be offered. Furthermore, the guidance under the section titled New Infection in Healthcare Personnel or Residents, stated, Because of the risk of unrecognized infection among residents, a single new case of [CONDITION(S)]-CoV-2 infection in any HCP or a nursing home-onset [CONDITION(S)]-CoV-2 infection in a resident should be evaluated as a potential outbreak. Alternative, broad-based approach: if a facility does not have the expertise, resources, or ability to identify all close contacts, they should instead investigate the outbreak at a facility-level or group-level. Perform testing for all residents and HCP on the affected unit(s), regardless of vaccination status, immediately and, if negative, again five to seven days later. Residents and healthcare personnel (HCP) who are not up to date with all recommended COVID-19 vaccine doses: these residents should generally be restricted to their rooms, even if testing is negative, and cared for by HCP using an N95 or higher-level respirator, eye protection, gloves, and gown. They should not participate in group activities. If additional cases are identified, testing should continue on affected unit(s) or facility-wide every three to seven days in addition to room restriction and full PPE use for care of residents who are not up to date with all recommended COVID-19 vaccin [TRUNCATED]

Based on record review, observation, interview and review of the facilities Self-Reported Incident (SRI) and abuse policy the facility failed to ensure a resident was free from being physically abused by a visitor. This affected one Resident (#1) of four residents reviewed for abuse. This resulted in harm to Resident #1 who received facial and head injuries requiring hospitalization . The facility census was 71. Findings include: Review of the medical record for Resident #1 indicated he was admitted on [DATE]. [DIAGNOSES REDACTED]. His comprehensive assessment dated [DATE] indicated he had no cognitive impairment and required supervision to complete his activities of daily living During an interview with the Administrator and the Director of Nursing (DON) on 11/05/15 at 9:15 A.M., SRI tracking number 6 was discussed. They both stated the incident occurred on 11/03/15 at approximately 6:30 A.M. The Administrator stated the previous visitation policy was seven days a week and 24 hours a day. The doors were locked between 6:00 P.M. and 7:00 A.M. There was a security camera at the door, and staff could buzz someone in if they recognized the person on the camera. The Administrator indicated the perpetrator was the nephew of Resident #3. The Administrator indicated the perpetrator had visited the facility occasionally, and had even brought his children with him to visit. He was known by the staff, and there had not been any issues with him visiting in the past. The perpetrator was buzzed in that night, 11/03/15, at 4:30 A.M., as staff recognized him. He went to his uncle's room on the long term care area of the facility, and also went to the smoking area. The had told his uncle he was waiting at the facility to get picked up for work. The smoking area was a patio, outside the fireside lounge. Those doors were not locked, but there was no access or entrance to the smoking area from the outside as it was a raised patio. The Administrator indicated the perpetrator exited the building through the smoking patio, and jumped over the railing to leave the premises. The Administrator and the DON indicated Resident #1 had resided in the facility approximately six months, and had a history of [REDACTED]. He refused to let them lock his money up, to open an account with the facility, to use a lock box or to use the drawer that locks in his room. They indicated the resident indicated he had carried $10,000 in his pocket all his life, and he wasn't going to stop doing that. He talked about his money a lot, and showed his money to others. The Administrator indicated they had addressed this with him numerous times. An interview was conducted on 11/05/15 at 9:55 A.M. with Registered Nurse (RN) #60 was was working on 11/03/15 at the time of the incident. She stated she was the manager of the rehabilitation unit, where Resident #1 resided She stated at around 6:45 A.M., she was in another resident's room at the opposite end of the hall, when she heard State tested Nursing Assistant (STNA) #10 screaming her name. STNA #10 and STNA #86 told her that Resident #1 had been attacked, and they all ran to him. The perpetrator was no longer in the building. Resident #1 was sitting on the floor, with blood dripping from his face and blood on the floor One of the STNA's called 911 and took the resident's vital signs, while RN #60 applied gauze to the bleeding. RN #60 stated she saw zip ties laying across the bed side table. The resident was shaken up but talking, and he was alert and oriented. He told her the perpetrator hit him in the face with the gun, punched him in the stomach and took his money. He said the perpetrator was trying to put zip ties around his hands. RN #60 stated the blood was mainly coming from the inside of Resident #1's mouth, and she was trying to stop the bleeding until the medics and police arrived. Resident #1 said the perpetrator sounded like a man who he had hired to do work on his house, and he stated the man's name. The resident said the man was wearing a skeleton mask. RN #60 stated Resident #1 has had a lot of money in his pocket before and he had refused for staff to lock his money up. RN #60 said she saw the perpetrator earlier that morning, walking toward the long term care side of the facility. She did not know him, so she called the long term care nursing station and asked about him. They confirmed they knew him and he was visiting a resident. RN #60 stated she had also seen the perpetrator again by the smoking patio. STNA #10 was interviewed by phone on 11/05/15 at 10:12 A.M. regarding the incident on 11/03/15. She stated Resident #4, who resided across the hall from Resident #1, was calling for help. Their rooms were at the end of the rehab hallway. As she approached the room, the perpetrator ran past her. He was wearing a skeleton mask. She saw Resident #1 on the floor with blood coming from his face and blood on the floor, and she immediately went to get RN #60. At that time STNA #86, who was scheduled to work day shift, was walking toward the unit and went with her to get RN #60 and then they all rusted to Resident #1's room. Resident #4 was interviewed on 11/05/15 at 10:38 A.M., regarding the attack of Resident #1 on 11/03/15. He said he was in the room across the hall from Resident #1. He was in bed, and his door was shut, and he heard yelling, help help! He got out of bed and opened the door. He saw the perpetrator in the skeleton mask rush out and say Happy Halloween, and the perpetrator tried to get out a door, but it wouldn't open, so he turned and ran down the hall, and was gone. Resident #4 called out for help as STNA #10 was walking down the hall toward him. Resident #4 looked in Resident #1's room, and Resident #1 was on the floor with blood everywhere. On 11/05/15 at 12:50 P.M., Resident #1 was interviewed at the hospital. He had been moved out of ICU and was in a room on a step-down unit. Resident #1 was observed in his hospital bed. His bottom lip was swollen and he had a large scabbed area above his lip. He stated he was feeling better. He stated he was asleep in bed when the incident occurred the morning of 11/03/15. He said the perpetrator came in and woke him up and told him I'm going to rob you The perpetrator punched Resident #1 in the stomach and he tried to tie Resident #1's hands together with zip ties. Resident #1 said he fought back and kicked the perpetrator. The perpetrator pulled a gun and hit Resident #1 in the head with it. The perpetrator then reached in the resident's pocket and took his money a total of $2800. The resident stated he had just gotten the money out of the bank to have some plumbing work done on his house. He stated he knew of the man who robbed him. He knew the perpetrator was the nephew of another resident (he named Resident #3). He indicated the two of them were introduced in the smoking area at the facility a few months ago. The perpetrator would visit the facility from time to time. Resident #1 stated he needed some work done at his house, and the man who robbed and beat him had done the work, and the resident had paid him. Resident #1 said he would have given the perpetrator money if he needed it. He said he has given money to people before. He stated he wanted to come back to the facility, because it was his home now. He stated he would feel safe there. On 11/05/15 at 2:45 P.M., the Administrator stated the Assistant Director of Nursing visited Resident #1 in the hospital yesterday. During their visit, Resident #1 had agreed that he would lock up his money from now on, after he returns to facility. The Administrator stated the resident will be moved to a room right next to the nursing station upon his return. RN #60 was interviewed again on 11/05/15 at 3:15 P.M., and stated she had been in Resident #1's room, approximately 20 to 30 minutes before the attack giving his room mate a breathing treatment that was scheduled for 6:00 A.M. Review of a facility SRI tracking number 6 and dated 11/03/15, indicated on 11/03/15 at 6:30 A.M., Resident #1 was in his room when a visitor, a relative of another resident in the facility, came into his room and threatened him, demanded his money, punched him the stomach and beat him with a pistol. The Report indicated the resident received lacerations to his face, mouth, and head, and was in an intensive care unit (ICU) with a brain bleed. The SRI was substantiated for abuse. Review of the facility's abuse prevention policy and procedure, dated 02/2010, indicated, All residents have the right to be free from abuse, mistreatment, neglect and misappropriation of resident property. Widows Home will not tolerate abuse, mistreatment, neglect and misappropriation of property by anyone. This deficiency substantiates Complaint Number OH 370.

Based on observation, record review, staff interview and resident interview the facility failed to prevent one resident from acquiring two avoidable pressure areas on her left foot. This affected one Resident #121 of three Residents (#32, #70 and #121) reviewed for pressure. This resulted in harm for Resident #121 when staff continued to place splints on the resident causing the pressure ulcers on her heels to increase in size and causing her pain. There were five residents identified in the facility as having pressure areas. Findings include: Resident #121 was admitted to the facility on [DATE] and was noted to have the [DIAGNOSES REDACTED]. Review of Resident #121's nursing admission assessment dated [DATE] identified two pressure areas, one on the coccyx and an area on the right heel. Record review of the note from the Wound Management Service dated 05/21/13 also identified two pressure areas, an unstageable pressure ulcer on the coccyx and a vascular ulcer on the right heel. Record review of a previous lab reports dated 04/15/13 contained the results of an Ultrasound Venous Doppler Bilateral Lower Extremities noted no deep venous or superficial insufficiency in the right or left leg. The Admission Minimum Data Set completed on 05/22/13 indicated Resident #121 had a Brief Interview for Mental Status score of fifteen which indicated she was cognitively intact. She was assessed under functional status as needing extensive assistance of one staff for bed mobility, dressing, toilet use and personal hygiene. She also needed extensive assistance of two staff for transfers and physical help in part of bathing activity by one staff. Resident #121 was identified as having impairment in range of motion on both sides of the lower extremities. She had an indwelling catheter and was assessed as always being incontinent of bowel. The resident was noted to be at risk for developing pressure ulcers. There was one pressure area identified as being unstageable with slough and/or eschar measuring six and six-tenths centimeters by nine and four-tenths centimeters by an unknown depth. The most severe tissue type identified for an identified pressure area was necrotic tissue (eschar). There was one area identified under venous and arterial ulcers. Review of the care plan initiated on 05/28/13 and last revised 06/14/13 addressing Resident #121's pressure areas stated resident had a pressure ulcer on her coccyx, which was present upon admission and a venous ulcer on her right heel related to immobility and disease process. Has pressure areas on heels. Interventions included: assessing, recording and monitoring wound healing as required. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the Medical Doctor (MD). Review of the care plan that the State tested Nursing Assistants (STNA) referred to for care instructions did not identify any appliances or foot care instructions. Resident #121 was being seen weekly by the wound care center and on 06/11/13 was noted to have two new pressure areas on the left heel. Record review of the wound care center note dated 06/11/13 stated "Patient also has two new wounds to her left lower extremity. Patient has splints that she wears to bilateral lower extremities, splints discontinued due to skin issues. Physical therapy notified." The note identified a stage two pressure area on the left medial heel measuring four centimeters by two centimeters. There was also a stage two pressure ulcer identified on the left lateral heel measuring one and four tenths of a centimeter by two and a half centimeters by thirty-five centimeters. These areas were noted to have produced mild pain. Review of the ulcer tracking tool dated 06/11/13 noted the measurements of the two left heel ulcers, one measuring four centimeters by two centimeters identified as unstageable and one measuring one and four-tenths centimeters by two and a half centimeters with stage not identified in the note. In the comments section of the notes for these areas it stated to "Discontinue foot brace. Float heels while in bed." The Physical Therapy note dated 06/11/13 stated "to order new unna boots secondary to two heel sores, one right heel and one left heel." Review of the Physician's Telephone order sheet also revealed an order written [REDACTED]. Bilateral heels pad and protect with one half abdominal (ABD) pad, secure with fluffy Kerlix, change three times weekly and as needed." Resident #121 was seen again one week later on 06/18/13 by the Wound Management Service who noted the stage two left medial heel pressure area measuring six centimeters by four and a half centimeters by zero depth which showed an increase in size from the previous week. It was also noted that Resident #121 had a left lateral heel stage two pressure area measuring two and a half centimeters by one-tenth of a centimeter with zero depth. The resident was noted to have mild pain in these areas. Review of the facility Ulcer Tracking tool dated 06/18/13 identified two left heel stage two pressure areas one measuring six centimeters by four and a half, and the other area measuring two centimeters by two and a half centimeters by one-tenth of a centimeter. These measurements also showed an increase in size from the previous week. In the comment section it was again noted to "Discontinue foot brace. Float heels while in bed." The Physical Therapy note dated 06/18/13 stated "Discussion with wound specialist regarding patient's bilateral heel ulcers and increased symptoms on right heel. Recommended use of air boots in bed instead of dorsiflexion boots currently used." During review of the Physician's Telephone Orders form dated 06/17/13 noted order stating "Bilateral lower extremities, discontinue current braces use air boots for pressure reduction and float heels when in bed." Record review of Resident #121's Medical Administration Record for June 2013 indicated on the treatment sheet that the resident's order for bilateral Pressure Relief Ankle Foot Orthosis (PRAFO) boots at all times while in bed was being initialed as being in place until discontinued on 06/18/13. It was also noted that the resident was documented as having pain on 06/16/13, 06/20/13 and 06/21/13 with as needed pain medication given. The resident was prescribed [MEDICATION NAME] 5-325 milligram tablets, take two tablets by mouth every four hours as needed for moderate pain. The nursing notes were reviewed with the following entries noted. On 06/13/13 the note stated "Resident in bed resting and voiced complaints of left leg pain and requested a pain pill. This nurse gave PRN (as needed) pain pill." There was also an entry on 06/21/13 which stated "Resident complained of pain in her left leg at 10:00 P.M. Given two as needed [MEDICATION NAME] with positive effect." A staff interview was conducted with Licensed Practical Nurse (LPN) #1 on 06/23/13 at 11:00 AM. She stated she was not sure how the resident ended up wearing the boots (PRAFO boots) again after they had been removed, but thought an aid may have put them back on the resident. An observation was made on 06/23/13 at 4:10 P.M. of LPN #1 and LPN #3 changing Resident 121's dressing on her left heel. Noted the air boots were removed and measurements were taken. The left medial heel measured eight and six tenths centimeters by five and one-tenth centimeters. The left lateral heel measured two and three-tenths centimeters by two centimeters. The areas were covered by one half of an abdominal dressing and wrapped with [MEDICATION NAME]. During an interview conducted on 06/24/13 at 10:00 A.M., the Director of Nursing stated a resident that was wearing a boot or a splint should have their skin assessed weekly During an interview with Resident #121 on 06/24/13 at 10:10 AM, she stated the State tested Nursing Assistants were looking at the skin on the resident's heels every other day, she stated the facility stopped using the PRAFO boots and started using the air boots about one to one and a half weeks ago and said she has some pain with the right heel but takes medication for it which is effective. A staff interview was conducted with the Minimum Data Set nurse #5 on 06/24/13 at 2:25 P.M. When questioned what would constitute more frequent skin assessment as written in the facility policy, she stated when there are increased risk factors. She stated the expectation is that a resident should be monitored during morning and evening care, whenever a splint is removed or before reapplying it to make sure there is no reddened areas. There was not a specific written skin and wound care policy identified. A staff interview was conducted with STNA #1 on 06/24/13 at 4:15 P.M. When this surveyor inquired how she would know what care should be provided for a resident with boots or a splint on she stated she checks with the nurse first and refers to the STNA care plan also. She stated the boots (PRAFO boots) were ordered to stay on Resident #121 at all times and even while in bed. The STNA said the only time she removed them was when the resident took a shower and her showers were only twice weekly. She also stated when questioned about the last time the resident was wearing the boots, she stated last week. During a staff interview with LPN #2 on 06/24/13 at 4:20 PM, she stated that any resident wearing an assistive device such as a boot or splint should be looked at daily by a nurse for skin issues. Review of facility policy on Pressure Ulcer Risk Assessment revised in October 2010 noted under General Guidelines that "pressure can also come from splints, casts, bandages, and wrinkles in the bed linen." It also stated under General Guidelines to "Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure ulcer to the supervisor."Under the area of Assessment in the policy it states "A pressure ulcer risk assessment will be completed upon admission". It also stated that "Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated."