Every finding on record at Willoughby Post Acute

Based on medical record review, interview and review of facility policy, the facility failed to ensure behavioral health services were appropriately provided for one resident (#122) of three reviewed for behavioral health services. The facility census was 121.Findings include:Review of the closed medical record for Resident #122 revealed an admission date of 10/14/25 and discharge date of 04/04/26. Diagnoses included but were not limited to Raynaud's syndrome, liver disease, history of transient ischemic attack (TIA), osteoarthritis, obstructive uropathy, major depressive disorder, generalized anxiety disorder, peripheral vascular disease (PVD), obesity, alcohol abuse, and nicotine dependence. Review of the facility supplemental admission agreement dated 10/15/25 for Resident #122 revealed the resident had signed the form granting permission to receive psych services while at the facility.Review of the physician order dated 10/15/25 for Resident #122 revealed an order for staff to record behavior monitoring each shift . The scale indicated to record zero (0) if no behaviors, record 1 if the resident was afraid, two (2) if the resident was agitated, three (3) if the resident was angry, four (4) if the resident was anxious, five (5) if the resident had a mood change, six (6) if the resident was noisy, seven (7) if the resident was restless, eight (8) if the resident was withdrawn or depressed, nine (9) if the resident was crying, and ten (10) if the resident was combative. Continued review of Resident #122's physician orders revealed medication orders dated 10/15/25 for Fluoxetine Hydrochloride 40 milligrams (mg) once daily for depression, Buspirone Hydrocholoride 15 mg twice daily for anxiety, Mirtazapine 15 mg orally at bedtime for depression, and Seroquel 100 mg once daily for agitation. Review of the 01/07/26 Patient Health Questionaire-9 (PHQ-9), a multipurpose instrument for screening diagnosing, monitoring and measuring the severity of depression, for Resident #122 indicated a level of 15 which indicated moderately severe depression and proposed treatment actions included pharmacotherapy with psychotherapy. Review of the 01/18/26 PHQ-9 for Resident #122 indicated a level of 2 which indicated minimal depression.Review of the progress note dated 01/18/26 timed at 2:43 P.M. written by Social Worker (SW) #324 revealed a PHQ-9 score of 2 which indicated minimal depression.Review of the care plan dated 01/21/26 for Resident #122 revealed resident required anti-anxiety medication related to anxiety disorder. Interventions included but were not limited to administering anti-anxiety medication as ordered by the physician, pharmacy review as indicated and psychiatrist consult as indicated. An additional care plan focus revealed the resident required antipsychotic medication related to agitation. Interventions listed included but were not limited to administering antipsychotic medication as order, psychiatrist consult as indicated and social services visits as indicated. A third care plan focus indicated the resident required antidepressant medication related to a diagnosis of major depressive disorder. Interventions included to obtain a pharmacy review as indicated, a psychiatrist consult as indicated, and social service visits as indicated.Review of 01/27/26 quarterly Minimum Data Set (MDS) 3.0 for Resident #122 revealed a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. Review of activities of daily living (ADLs) revealed Resident #122 required moderate assistance for oral hygiene, personal hygiene, and wheeling 50 feet, maximum assistance for dressing and wheeling 150 feet, and was dependent on staff for toileting, bathing and Hoyer transfers. Resident #122 was noted to have little interest in doing things 12-14 days of the 14-day lookback period, was noted to have a poor appetite 12-14 days and had a total mood severity score of 15 which indicated moderately severe depression. Resident #122 was noted to receive an antipsychotic, antidepressant, and opioid. No behaviors were noted. Review of the physician order dated 03/16/26 for Resident #122 revealed an order for Hydroxyzine 25 mg to be given orally every six hours as needed for anxiety or itching for a duration of 14 days.Review of the progress note dated 03/17/26 timed at 9:30 A.M. written by Nurse Practitioner (NP) #322 revealed Resident #122 was noted to have had a history of anxiety and reported increased anxiety over the last several days due to worrying about finances. The NP note referenced Hydroxyzine was resumed due to increased anxiety.Review of the phone text messages dated 03/23/26 provided by Resident #122's family sent to SW #324 revealed a request for some kind of therapy. Resident #122's son wrote in the message .Is there any chance of getting him (Resident #122) some kind of therapy. He's very depressed and starting to talk about making some very bad decisions. Not like killing himself but he's so bothered by the lack of availability for physical therapy daily and is ready to give up altogether, just when he is making progress. They had at one point prescribed something for him. I don't know what your resources are there, but it would be helpful if someone could talk him through sticking the course out. If he keeps going with the therapy and there's any chance of increasing it (every doctor has written that he needs intensive therapy. I don't know if two days a week meets that). He might just get himself out of there walking. But if he refuses it, he might as well just sign up to stay in that bed. The phone text message indicated it was read on 03/23/26.Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated March 2026 for Resident #122 revealed the as needed Hydroxyzine was given eight days (03/18/26, 03/19/26, 03/20/26, 03/23/26, 03/26/26, 03/27/26, 03/28/26, and 03/29/26) of the 14 days prescribed. No behaviors were indicated on the MAR.Review of the nursing progress notes on 03/18/26, 03/19/26, 03/20/26, 03/23/26, 03/26/26, 03/27/26, 03/28/26, and 03/29/26 revealed Hydroxyzine was administered but there were no corresponding notes to distinguish whether it was given for itching or anxiety.Review of a progress note dated 03/31/26 timed at 8:15 A.M. written by NP #322 revealed Resident #122 stated he had difficulty sleeping and Melatonin was increased from 5 mg to 10 mg at bedtime for insomnia.Review of the nursing progress noted dated 04/04/26 timed at 4:31 P.M. written by Licensed Practical Nurse (LPN) #317 revealed Resident #122's son called the facility and reported concern for a change in resident condition. Resident #122 was noted with change in mental status and behavior, observed with flat affect on assessment. The note indicated Resident #122 was speaking clearly with respiration even and unlabored and no respiratory distress noted. Vital signs were obtained and within resident's baseline. Resident was alert and responsive, denied pain or discomfort, and no emesis was noted at time of the assessment. Due to the change, 911 was activated for further evaluation. Resident #122's physician was notified and the resident was transferred from the facility via emergency medical services (EMS) for further evaluation. Interview on 04/22/26 at 9:21 A.M. with Licensed Practical Nurse (LPN) #314 revealed she was working the day of the incident with Resident #122. LPN #314 stated Resident #122's son called stating his father called stating goodbye. LPN #314 went down to Resident #122's room to assist LPN #317 who had already called 911. Resident #122 was observed to be alert and had a bright yellow substance all down the front of him and on his blanket. Resident #122 admitted to putting antifreeze (a chemical additive commonly used to lower the freezing point of a water-based liquid which is not intended for ingestion) in a coffee cup and was drinking it. LPN #314 asked what he was doing and he responded he could not get a gun. Resident #122 stated he ordered the antifreeze on Amazon the day before. The bottle of antifreeze was on his bedside table in the open amazon box. EMS arrived and Resident #122 went to the hospital.Telephone interview on 04/22/26 at 11:18 A.M. with Resident #122's son revealed he had contacted Social Worker #324 on 03/23/26 via phone text to express concerns that Resident #122 appeared dark and his family was concerned about his mental state and was asking if psychological services could see and evaluate Resident #122. Resident #122's son stated the resident had previously made statements of wanting to harm himself but had not attempted it and stated his depression appeared to intensify a few weeks leading up to the suicide attempt with antifreeze. Resident #122 stated the resident was frustrated and wanted to leave the facility.Telephone interview on 04/22/26 at 12:41 P.M. with LPN #317 revealed she passed meds to Resident #122 between approximately 8:00 and 8:10 A.M. and did not notice anything different and did not notice the box of antifreeze in the resident's room at that time. She stated she checked on him around 9:30 A.M. and again did not notice anything out of the ordinary. Around 11:20 A.M., Resident #122's son called and stated his father had just called him and told him goodbye. She told the son okay and ran to Resident #122's room. When she entered Resident #122's room, she saw the resident with a bottle of antifreeze sitting on his bedside table. Resident #122's gown was saturated with a yellow substance. Resident #122 appeared to be alert and was talking to her and his vitals were stable. Another nurse came in and was taking his vitals while she called 911. LPN #317 was speaking with the family while they were in the room until EMS arrived to transport Resident #122 to a local hospital.Interview on 04/23/26 at 8:58 A.M. with Certified Nursing Assistant (CNA) #326 revealed it was her first day off of training working independently. CNA #326 she checked on Resident #122 upon her arrival and went to get him some water. CNA #326 changed Resident #122 while in the room and he was talking with her. Resident #122's bedside table had a closed box on it when she went back to bring his breakfast. When CNA #326 went back in to pick up his breakfast tray, Resident #122 asked for another cup of coffee which she brought back to him. CNA #326 then went to get a Hoyer (mechanical lift) pad from laundry downstairs to give Resident #122 a bath. When she got off the elevator, she was made aware Resident #122 drank antifreeze and went to his room. LPNs #309, #314 and #317 were in the resident's room to assist. While in the room, staff asked Resident #122 why he drank the antifreeze and he stated he did not have the courage to buy a gun and had researched the fastest ways to kill himself. The staff stayed in the room until EMS arrived.Interview on 04/22/26 at 12:58 P.M. with the Director of Nursing (DON) revealed she received a call at home about the incident with Resident #122 and was told he was speaking clearly and vitals appeared to be normal.Interview on 04/22/26 at 1:47 P.M. with Nurse Practitioner (NP) #322 revealed Resident #122 reported down days but had never reported suicidal ideations and stated he was frustrated he was unable to walk. NP #322 stated she was not aware of any family reported concerns related to his care or mental status.Interview on 04/23/26 at 9:14 A.M. with Social Worker (SW) #324 revealed she did not have a lot of one-on-one interaction with Resident #122 and was aware family was trying to initiate additional physical therapy. SW #322 confirmed she received a text from Marketing #319 stating Resident #122's sister had contacted her about transferring to another facility but did not recall anything about concerns about depression. SW #324 also confirmed she received a text from Resident #122's son on 03/23/26 about increased depression but did not make a referral for psychological services and was unable to provide evidence of Resident #122 was seen or evaluated by psychological services since admitting to the facility.Interview on 04/23/26 at 9:44 A.M. with the DON revealed she was not aware of any family or staff reported concerns of depression for Resident #122. DON confirmed if a resident had a PHQ-9 score of 15, they may have behaviors. The DON confirmed Resident #122 did not receive psychological services while at the facility and confirmed Resident #122 had a signed permission to receive psychological services. The DON confirmed the Hydroxyzine was given and was unable to provide evidence of behaviors or whether it given for anxiety or itchiness for the eight times it was given during the month of March 2026. Telephone interview on 04/23/26 at 3:15 P.M. with Resident #122 revealed he signed the paperwork upon admission but was never offered to have behavioral health services visit him while at the facility.Review of the written witness statement dated 04/04/26 written by NP#325 revealed on Saturday 04/04/26 at roughly 11:30 A.M., LPN #317 received a phone call from Resident #122's son stating his father had just called him and told him goodbye but didn't inform him of what the plan was. LPN #317 notified LPN #309 who informed NP #325 of the emergency at hand. Resident #122 was immediately tended to. The bedside table had a large bottle of antifreeze sitting inside an opened Amazon box. Antifreeze was opened and a large amount was visibly spilled on abdominal area and upper thighs. Resident #122 was questioned as to why he would drink it and resident stated, 'A gun would be harder to get.' Resident #122 continued to state he wanted to go home. He stated he did not want to be alive anymore and he was very depressed. Resident #122's son was on the phone with LPN #309 the entire visit. 911 was called and quickly came to take resident to hospital at roughly 11:50 A.M.Review of the 2001 facility policy called Behavioral Health Services revealed the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with comprehensive assessment and care plan. Behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care. Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care.This deficiency represents non-compliance investigated under Complaint Number 2987748.

Based on closed record review, policy review and interview, the facility failed to provide adequate and timely pain assessment and interventions following a fall with acute injury. This affected one resident (#148) of three residents reviewed for pain. The facility census was 146. Actual Harm occurred on 09/25/25 when Resident #148 was diagnosed with displaced fractures of the left lower leg bones (tibia and fibula) from a fall that had occurred on 09/24/25. Resident #148, who was admitted to the facility on [DATE] for respite care with hospice services was not adequately assessed or provided timely pain interventions following the fall on 09/24/25. During the morning of 09/25/25 it was noted Resident #148 had been up all night the previous night screaming, crying loudly and being aggressive. Resident #148's pain escalated throughout the day on 09/25/25 until an x-ray was ordered. On 09/25/25 at 7:04 P.M. (almost 24 hours after the fall) the radiology report identified the resident's fractures, and the resident was then transferred to the hospital for treatment. The resident did not return to the facility. Findings include: Review of the closed medical record for Resident #148 revealed an admission date of 09/24/25 and discharge date of 09/25/25. Resident #148 had diagnoses including senile degeneration of the brain, vascular dementia, diabetes, anxiety disorder, and unspecified fall-subsequent encounter. Review of the admission Summary note dated 09/24/25 at 12:20 P.M. revealed Resident #148 was admitted for respite care. The family dropped off the resident. The resident was confused but easy to redirect and able to voice his needs. The resident received hospice care, and self-propelled around the second floor in his wheelchair. Medications were verified by the physician. There was no evidence of a pain assessment being completed at the time of admission. Review of the physician orders for Resident #148 revealed an order dated 09/24/25 at 7:45 P.M. for Lorazepam (Ativan) 0.5 milligrams (mg) by mouth every four hours as needed for anxiety or restlessness, and Morphine Sulfate (concentrate), an opioid analgesic used to treat moderate to severe pain (100 mg per 5 milliliters (ml)) give 0.5 ml by mouth every four hours as needed for pain or shortness of breath. On 09/25/25 at 9:30 A.M. there was an order for Lidocaine Pain Relief External Patch 4% to the lower back and ribs once daily for pain. Review of a nurse's note dated 09/24/25 at 8:14 P.M. by Licensed Practical Nurse (LPN) #201 revealed Resident #148 was sitting on the floor of the internet cafe at about 7:30 P.M. The note included vital signs were within normal limits. Skin check and range of motion (ROM) were performed, and the note revealed the resident had no apparent injuries noted. The resident was transferred to his wheelchair. The resident's doctor, ex-wife, and unit manager were notified. There was no evidence of a pain assessment being completed or of hospice being notified of the incident. Review of a nurse's note dated 09/25/25 at 6:44 A.M. by Registered Nurse (RN) #204 revealed Resident #148 was up all-night screaming, crying loudly and was aggressive. The resident was not directable and continued to cry out and moan. Resident #148 complained of knee pain. The resident continued to remove his indwelling urinary catheter from his drainage bag leaving urine on the floor beside the bed. The resident would not keep his gown on, and his gown and bed linens were changed three times. There was no evidence of hospice being notified of the resident's condition throughout the night. Review of the Hospice Visit Summary dated 09/25/25 from 11:16 A.M. to 12:32 P.M. revealed an unidentified hospice aide and nurse visited Resident #148 and upon arrival at the facility the resident was heard screaming down the hallway. The resident was seen in bed covered with urine, so they got him up into a chair, and changed him and the bed, during which Resident #148 screamed in pain again. The resident's left knee was swollen, bruised and red. The resident was unable to bear weight to left hip or straighten his left knee. The facility's Director of Nursing (DON) and Unit Manager (UM) #206 entered the room and stated they did not know the resident was hurt but had reports which indicated Resident #148 fell the previous day with no injuries and neurological checks within normal limits. The summary revealed this was the first hospice was informed of the fall that had occurred on the previous day. The hospice physician was notified and gave an order for an x-ray. The facility was notified of the new order and was obtaining it. The resident's power of attorney (POA) was in agreement, and the facility was to contact hospice with the x-ray results. Review of a nurse's note dated 09/25/25 at 3:12 P.M. by RN #211 revealed an unidentified hospice nurse notified the facility of Resident #148 having swelling to the left knee and it was red and warm to the touch. The resident was medicated with Morphine as ordered and it had positive effects. Additionally, an x-ray was ordered of the left ankle. The resident's mother was updated about the new order. Review of the medication administration record for September 2025 revealed no medication was documented as offered, refused or received to address pain from 09/24/25 until 09/25/25 at 3:40 P.M. when Resident #148 received one dose of Lorazepam for anxiety, and at 3:41 P.M. when the resident received one dose of Morphine for knee pain assessed at a seven out of 10 on a pain scale of one to 10 with 10 being the most severe. On 09/25/25 at 4:26 PM., the Lorazepam and Morphine doses were documented as ineffective as the resident was still in pain assessed at an eight out of 10 on a pain scale. Review of the radiology report dated 09/25/25 at 7:04 P.M. revealed the left ankle x-ray resulted in displaced fractures of the tibia and fibula. There was no evidence of hospice being notified of the results. Review of nurses' notes for September 2025 revealed no documentation of Resident #148's transfer to the hospital including a pain assessment for pain level or his condition at the time of discharge. Interview on 10/15/25 at 4:47 P.M. with LPN #201, who was present at the time of Resident #148's fall, revealed hospice was at the facility when the resident initially arrived (on 09/24/25). LPN #201 stated she had informed hospice of the resident's fall (although this was not noted in the nursing progress note). During the interview, the LPN revealed following the incident, the resident had required one on one care until about 10:00 P.M. at which time she stated staff were able to get him to stay in bed. The LPN did not provide additional information to support the resident's pain following the fall was assessed or adequately managed. Interview on 10/15/25 at 4:19 P.M. with Certified Nursing Assistant (CNA) #214 confirmed Resident #148 fell out of bed on 09/24/25 and broke his (unspecified) leg between the knee and the ankle, but an x-ray was not taken until the next day. CNA #214 stated all staff heard the resident scream throughout the shift and believed the nurse only gave him Tylenol for pain. Interview on 10/15/25 at 4:43 P.M. with RN #204, who cared for Resident #148 during the night of 09/24/25 and documented the resident was up all-night screaming, crying loudly and was aggressive, revealed Resident #148 had allowed the nurse to put ice on his knee after his fall. RN #204 described being in and out of the room because the resident kept sitting up, ready to get up, and his urinary catheter kept leaking so he needed changed and the bed was remade several times. During the interview RN #204 claimed Resident #148 would not take either the ordered Lorazepam or Morphine but verified she failed to document any pain assessments, pain interventions, medication offers or refusals and confirmed she did not contact hospice regarding the resident's condition during the night. Interview on 10/16/25 at 2:35 P.M. with the Director of Nursing (DON) verified Resident #148 had pain following the fall on 09/24/25 as noted in the nursing progress note on 09/25/25 at 6:44 A.M. and in a hospice note on 09/25/25 at 11:16 A.M. The DON verified there were no documented offers or refusals of pain medication, no facility attempts to obtain pain medication and no pain medication provided to the resident until 09/25/25 at 3:40 P.M. The DON stated she recalled seeing the resident's ankle and it was swollen but the DON denied remembering if the resident was acting like he was in pain. Interview on 10/21/25 at 11:48 A.M. with CNA #211, who worked night shift on 09/24/25, revealed Resident #148 screamed once during the night when the CNA staff changed him early in the shift, and she believed it was because he was stiff. When she changed him again later she did not remember him yelling out but reported when the resident screamed the nurse came in to see what was wrong because Resident #148's room was right across from the nurse's station. Review of the nursing schedule for September 2025 revealed two additional staff members, CNA #212 and #213, worked while Resident #148 was at the facility. CNA #212 failed to return the surveyor's call and CNA #213 was no longer an employee and had no working telephone number. Review of the facility policy, Pain Assessment and Management, dated 2001, revealed the facility assessed residents for pain at admission and during ongoing assessments, and monitored residents for the presence of pain and the need for further assessment when there was a change of condition. This deficiency represents non-compliance investigated under Complaint Number 2636783.

Based on observation, interview and facility policy review, the facility did not ensure the carpeting in the hallways of all units was maintained in a clean manner. This had the potential to affect all 136 residents residing in the facility. Findings include: Observation on 07/30/25 from 8:23 A.M. to 9:23 A.M. revealed the carpeting in the hallways of all units were discolored and contained multiple black, brown stains throughout. Interview on 07/31/25 at 9:13 A.M. with Environmental Service Manager #613 revealed she was aware there were multiple stains on the carpeting on all the units. She revealed the facility had a floor technician who cleaned the carpeting routinely, but the carpeting was old, and the stains did not come up even after cleaned. She stated, the carpeting needs to be replaced. She revealed she was unsure if there were any quotes on getting the carpeting replaced or where the facility was at regarding replacing the carpeting. Environmental tour on 07/31/25 from 9:30 A.M. to 9:44 A.M. with Environmental Service Manager #613 and Administrator verified the following findings: A. Med Ridge unit revealed the carpeting near the double doors had approximately two large three feet by four feet black oblong stains. B. Entrance by the door of room [ROOM NUMBER] revealed the carpeting had a large black- brown stain approximately three feet by four feet. C. In front of room [ROOM NUMBER] it was revealed the carpeting had a black stain approximately six feet by four feet and another stain approximately three feet by three feet next to the other stain. D. In front of room [ROOM NUMBER] it was revealed the carpeting had a large brown stain circular in nature approximately three feet by three feet. E. Entrance by the doors of rooms [ROOM NUMBERS] revealed the carpeting contained large black, brown stains. F. Arcadia unit lounge area revealed the carpeting had multiple stains. G. Willow unit outside of elevator revealed the carpeting had dark, brown stains extending in front of both elevators. H. In front of room [ROOM NUMBER] the carpeting had a medium brown circular stain in the center of rug I. Near the double doors on Willow unit revealed the carpeting had approximately five feet by four feet black discolored stain. J. Entrance into the soiled utility, and stair well door entrance on Willow unit revealed the carpeting had large black discolorations K. Entrance by rooms [ROOM NUMBERS] revealed the carpeting had large black discolorations. L. Lakeside unit revealed the carpeting had black discolorations throughout the hallway of unit including the entry to the soiled utility room. M. Entrance by rooms 218, 219, 220, 221, 222, and 223 revealed there were large black discolorations on the carpeting. N. Courtside unit revealed the carpeting had discolorations throughout the hallway including outside the dining room had darker black stains. O. Entrance by rooms [ROOM NUMBER] revealed the carpeting had large black discolorations. P. Ridge unit carpeting contained black stains throughout the hallway including outside of the recreational therapy door entrance, and rooms 209, 210, 214, and 217. Interview with Administrator on 07/31/25 from 9:30 A.M. to 9:44 A.M. verified the above findings and revealed the carpeting does need replaced, and she was going to work on getting quotes. She verified she had not obtained any quotes currently nor did the facility have any active plans in process to replace the carpeting. Review of the facility policy labeled, Homelike Environment, dated 2001, revealed residents were to be provided safe, clean, comfortable and homelike environment. The facility staff and management maximize to the extent as possible a clean, sanitary and orderly environment. This deficiency represents non-compliance investigated under Complaint Number OH001276910 (OH00165788).

Based on observation, interview, review of the medical record, Employee Counseling Form review and review of the facility policy, the facility did not ensure fall interventions were implemented including proper staff assistance with bed mobility and toileting per the Kardex (summary of resident's information for reference) and the care plan. This affected one (Resident #12) out of three residents reviewed for falls. The facility census was 136. Findings include: Review of the medical record for Resident #12 revealed an admission date of 06/27/24 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, congestive heart failure, chronic obstructive pulmonary disease, aphasic (a language disorder affecting resident's ability to communicate), and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had impaired cognition and had impairment on one side to her upper and lower extremities. She was dependent on staff for most of her activities of daily living (ADL) including toileting hygiene and rolling left and right in bed. She was frequently incontinent of urine and always incontinent of bowel. Review of the care plan dated 05/21/25 revealed Resident #12 had bladder and bowel incontinence. Interventions included provide incontinence care on rounds and upon request. Review of the care plan dated 05/21/25 revealed Resident #12 had actual ADL decline and required staff assistance related to hemiplegia, anxiety, weakness and aphasia. Interventions included Resident #12 was totally dependent of two staff for bed mobility and toileting and she utilized a mechanical lift (a device designed to safely transfer a resident) for transfers. Review of the care plan dated 06/27/25 revealed Resident #12 was at risk for falls. Interventions included assistance with transfers, locomotion and mobility, do not leave resident in sitting position in bed, low bed, perimeter mattress, and staff education was provided on 07/28/25. Review of the nursing note dated 07/25/25 at 8:43 P.M. and completed by Registered Nurse (RN) #601 revealed Resident #12 was assessed for injuries, and she complained of right shoulder and jaw pain. Resident #12 and Certified Nursing Assistant (CNA) #611 stated she hit her head. The note revealed the Primary Care Physician (PCP) #900 and hospice were notified and ordered to send the resident to the emergency room (ER) for further evaluation. Review of the nursing note dated 07/26/25 at 12:40 A.M. and completed by RN #601 revealed Resident #12 rolled out of bed during patient care and hit her head. Review of the witness statement dated 07/26/25 that was taken by RN #601 from CNA #611 revealed, I was providing patient care when resident (Resident #12) rolled out of bed on the opposite side of the bed. The statement also revealed Resident #12 hit her head during the fall and CNA #611 yelled for help, and staff came to assist. Review of nursing note dated 07/26/25 at 4:17 A.M. and completed by RN #617 revealed Resident #12 returned from the ER with no injuries, including no fractures. Her vital signs were stable, and she was monitored at frequent intervals. Review of the Interdisciplinary Team (IDT) progress note dated 07/28/25 and completed by Licensed Practical Nurse (LPN)/ Unit Manager #610 revealed on 07/25/25 at approximately 8:00 P.M. Resident #12 had fallen out of bed during patient care. She was assessed and complained of right shoulder and jaw pain. The note revealed that staff stated she hit her head. PCP #900 was notified and ordered Resident #12 to go to the ER for further evaluation. The note revealed the fall intervention included that staff (CNA #611) was educated. Review of the Employee Counseling Form dated 07/28/25 revealed CNA #611 received a disciplinary action form from the Director of Nursing (DON) as he failed to follow a resident's care plan and Kardex resulting in a fall. CNA #611 was re-educated on use of Kardex and would follow the Kardex to ensure resident safety. Review of the Kardex as of 07/30/25 revealed Resident #12 was to be offered toileting on rounds and upon request and provided incontinence care on rounds and upon request. The Kardex revealed Resident #12 required total dependence of two staff for bed mobility and toileting. Observation on 07/30/25 at 3:17 P.M. revealed CNA #607 walked into Resident #12's room to provide incontinence care. She proceeded to don gloves, pulled back the sheet and rolled Resident #12 over towards the window. CNA #12 provided incontinence care and then rolled her back until she was lying flat on her back. Interview on 07/30/25 at 3:25 P.M. with CNA #607 verified she had turned Resident #12 and provided incontinence care by herself. She revealed she always completed Resident #12's care, including bed mobility and toileting hygiene, by herself. Interview on 07/30/25 at 3:31 P.M. and 3:45 P.M. with LPN/ Unit Manager #610 revealed on 07/25/25 at approximately 8:00 P.M. CNA #611 was providing incontinence care and rolled Resident #12 away from him towards the window resulting in Resident #12 falling out of bed onto the floor hitting her head. She revealed RN #601 assessed Resident #12 and she had complained of right shoulder and jaw pain; therefore, RN #601 sent Resident #12 to the ER per PCP #900's order for further evaluation. She revealed she had returned with no injury, including no fractures. She verified Resident 12's Kardex and care plan stated there were to be two staff always assisting Resident #12 with bed mobility, and toileting and that CNA #611 should not have completed her incontinence care by himself. She revealed CNA #611 received disciplinary action for not following the Kardex and care plan resulting in Resident #12's fall out of bed. LPN/ Unit Manager #610 was informed during observation on 07/30/25 at 3:17 P.M. of incontinence care for Resident #12, CNA #607 turned her towards the window away from her and provided incontinence care by herself. LPN/ Unit Manager #610 again verified per Resident #12's care plan and Kardex stated that two staff always were to assist with bed mobility and incontinence care for safety to prevent falls. Interview on 07/30/25 at 3:38 P.M. with RN #601 revealed she was the nurse on duty on 07/25/25 at approximately 8:00 P.M. when CNA #611 yelled up the hall as she was passing medications that Resident #12 had fallen out of bed while he was turning her. She verified CNA #611 turned her by himself to provide incontinence care, and she fell out of bed on the other side landing on her right side. She revealed the bed was approximately waist high as he was changing her. She revealed Resident #12 complained of right shoulder and jaw pain and had hit her head during the incident. She revealed her pain was a seven on a pain scale of zero to ten, ten being the worst pain. She revealed she contacted PCP #900 who ordered to send Resident #12 to the ER for further evaluation. Interview on 07/30/25 at 4:40 P.M. with CNA #611 revealed he had worked at the facility for approximately three months. He revealed on 07/25/25 at approximately 8:00 P.M. he went into Resident #12's room to change her. He revealed he elevated the height of the bed to waist high and rolled Resident #12 away from him towards the window, and her leg went over her other leg causing her to roll off the bed onto the floor. He revealed Resident #12 hit her head on the floor and he yelled for the nurse. He verified he turned her to provide incontinence care by himself, and no other staff was in the room. He revealed he was never previously trained on how to use a Kardex or care plan to know that Resident #12 was to be a two-person assist with bed mobility and toileting. He revealed he always felt she needed to be a two-person assist but when he asked other staff to assist him, they would never help him, so he usually always changed her by himself. He revealed he never reported to management that other staff would not assist him with Resident #12's care. He revealed after the incident he was educated on how to utilize a Kardex. Review of the facility policy labeled, Fall Risk Assessment, dated 2001, revealed the nursing staff in conjunction with the attending physician and others would seek to identify and document risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. Review of the facility policy labeled, Activities of Daily Living (ADL), Supporting, dated 2011, revealed residents who were unable to carry out activities of daily living independently received the services necessary to maintain good nutrition, grooming and personal hygiene. The policy revealed care, and services were provided in accordance with the plan of care including the appropriate support and assistance with including hygiene, and mobility. This deficiency represents non-compliance investigated under Complaint Number OH001276912 (OH00167179).

Based on observation, interview, medical record review, review of manufacture guidelines and facility policy review, the facility failed to ensure residents were free from significant medication error. This affected two (Residents #133, and #137) out of seven residents observed and/or reviewed for medication administration. The facility census was 136. Findings include: 1. Review of the closed medical record for Resident #137 revealed an admission date of 06/28/25, and he was discharged home on [DATE]. His diagnoses included motor-vehicle accident with multiple fractures, diabetes and hypertension. Review of the After Visit Summary revealed on 06/28/25 Resident #137 was discharged from the hospital to the facility with the following medication orders: lispro insulin 100 units per milliliter (ml) inject zero to ten units subcutaneously (SQ) three times a day before meals as directed per insulin instructions. The last dose given at the hospital per the discharge instructions was on 06/28/25 at 1:24 P.M. The orders also included Lantus insulin 100 units per ml inject 10 units SQ once daily at bedtime. The last dose was given at the hospital on [DATE] at 9:15 P.M. Review of the nursing note dated 06/28/25 at 11:36 P.M. and completed by Licensed Practical Nurse (LPN) #606 revealed Resident #137 was admitted at approximately 6:30 P.M. He had an allergy to penicillin and had multiple fractures including to his bilateral femurs and nasal bone. Vital signs were obtained, but there was no documentation a blood sugar was taken. There was no documentation regarding Resident #137's insulin and that the orders were verified with Primary Care Physician (PCP) #900. Review of the blood sugars from admission on [DATE] to discharge on [DATE] revealed the first blood sugar documented for Resident #137 was on 06/30/25 at 9:29 A.M., and it was 165. Review of Nurse Practitioner (NP) #901's progress note dated 06/30/25 at 12:13 P.M. revealed Resident #137 had a diagnosis of diabetes, and she ordered lispro insulin before meals SQ per sliding scale and Lantus 10 units SQ at night. Review of Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #137 had intact cognition, and he received insulin. Interview on 07/30/25 at 1:55 A.M. with the Director of Nursing (DON) verified per the After Visit Summary from the hospital Resident #137 was to be on lispro insulin 100 units per ml inject zero to ten units SQ three times a day before meals as directed per insulin instructions and Lantus insulin 100 units per ml inject 10 units SQ once daily at bedtime. She verified these orders were not transcribed, and there was no documentation in the medical record that PCP #900 was contacted upon Resident #137's admission and verified there was no documentation stating Resident #137's insulin was discontinued. She verified the first documentation Resident #137's blood sugar was checked was on 06/30/25 at 9:29 A.M. and he had not received insulin until 06/30/25 (two days after he was admitted ). Interview on 07/30/24 at 2:08 P.M. and 3:58 P.M. with LPN #606 revealed she did not remember anything regarding Resident #137's admission including if she contacted PCP #900 to verify Resident 137's admission orders, and/or anything regarding his insulin orders from the hospital including what was on the After Visit Summary. LPN #606 revealed she did not know why Resident #137's insulin orders were not transcribed on admission. She revealed she did not remember day to day as she went from unit to unit. She revealed if it was not documented that she contacted PCP #900 then she probably did not. 2. Review of the medical record for Resident #133 revealed an admission date of 08/03/23 with diagnoses including dementia, diabetes, and hypertension. Review of the July 2025 physician orders revealed Resident #133 had an order for metoprolol succinate extended release (ER) give 25 milligram (mg) tablet one time a day for hypertension. There was no physician order to crush her medication. Review of the annual MDS assessment dated [DATE] revealed Resident #133 had impaired cognition. Observation on 07/30/25 at 8:35 A.M. revealed LPN #600 crushed Resident #133's medications including the Metoprolol Extended Release (ER) 25 mg. The only medication she did not crush was her ferrous sulfate which she placed whole in applesauce. She then placed the crushed medications in the applesauce and administered them to Resident #133 at 8:41 A.M. Interview on 07/30/25 at 8:43 A.M. with LPN #600 verified she had crushed Resident #133's metoprolol ER and that it was ER, and there was no order to crush it. She also verified there was nothing in the medical record that the physician had approved Resident #133's metoprolol ER to be crushed. Review of the Federal Drug Administration package insert labeled, Metoprolol Succinate Extended- Release Tablets, dated December 2007, revealed Metoprolol succinate ER were intended for daily administration for the treatment of hypertension and angina (chest pain). Metoprolol succinate ER tablets were scored and can be divided; however, the whole or half tablet should be swallowed whole and not chewed or crushed. Review of the facility policy labeled, Crushing Medications, dated 2001, revealed medications shall be crushed only when it is appropriate and safe to do so, consistent with physician orders. The nursing staff shall notify the attending physician who would give an order to crush a drug that the manufacturer states shall not be crushed, for example long acting or enteric coated medications. The policy revealed the physician must document why crushing the medication would not adversely affect the resident. Review of the facility policy labeled, Administering Medications, dated 2001, revealed medications were administered in a safe and timely manner. Medications were administered in accordance with prescriber orders. Review of the undated facility policy labeled, Nursing admission Assessment and Examination revealed the purpose of the policy was to ensure a comprehensive, timely and person-centered admission assessment was completed. The policy revealed the nurse was to confirm the accuracy of the medication list, names, and dosages of the medications by reconciling all medications promptly using the electronic data confirmation. This deficiency represents non-compliance investigated under Complaint Number OH001276910 (OH00165788) and OH001276912 (OH00167179).

Based on observation, interview, review of medical record and review of facility policy revealed the facility did ensure proper infection control during incontinence care. This affected one Resident (#12) out of five residents reviewed for incontinence care. This had the potential to affect 70 residents (#1, #2, #4, #7. #9, #10, #12, #13, #15, #19, #20, #22, #25, #27, #29, #30, #31, #33, #37, #38, #39, #40, #41, #45, #46, #47, #48, #53, #54, #56, #57, #58, #60, #61, #62, #71, #57, #77, #80, #81, #83, #84, #89, #90, #91, #93, #95, #96, #97, #98, #100, #101, #102, #104, #106, #107, #111, #112, #114, #115, #116, #119, #122, #124, #129, #131, #132, #133, #134, and #125) identified by the facility as incontinent.Review of the medical record for Resident #12 revealed an admission date of 06/27/24 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, congestive heart failure, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had impaired cognition and was dependent on staff for most of her activities of daily living (ADL) including toileting hygiene and rolling left and right in bed. She was frequently incontinent of urine and always incontinent of bowel. Review of the care plan dated 05/21/25 revealed Resident #12 had bladder and bowel incontinence. Interventions included observing for changes in skin integrity and providing incontinence care on rounds and upon request. There was nothing in the care plan regarding staff applying two incontinence briefs at once. Review of the Kardex as of 07/30/25 revealed Resident #12 was to be offered toileting on rounds and upon request and provided incontinence care on rounds and upon request. There was nothing in the Kardex regarding Resident #12 wearing two incontinence briefs. Observation on 07/30/25 at 3:17 P.M. revealed Certified Nursing Assistant (CNA) #607 walked into Resident #12's room to provide incontinence care. CNA #607 revealed she had changed Resident #12 before lunch. She proceeded to don gloves, take one towel and place the towel under the faucet, wetting both ends of the towel. She did not apply soap to the towel. She then pulled back the sheet, and Resident #12 was wearing two white incontinence briefs. The first brief was moderately saturated in urine. CNA #607 denied applying two incontinent briefs when she changed her before lunch but was unable to identify who else would have changed her. CNA #607 proceeded to roll Resident #12 over towards the window and removed both incontinence briefs. She then proceeded to use one end of the towel and cleansed her buttock region which had a small amount of bowel movement. Resident #12 continued to smear bowel movement as CNA #607 wiped; therefore, CNA #607 continued to wipe with the same end of the towel. CNA #607 then, without drying Resident #12's buttocks, proceeded to apply barrier cream with her gloved hand to her buttock and rolled her back until she was lying flat on her back. CNA #607 then proceeded with the same gloved hands to take the same towel but the other end of the towel and wiped the front of her perineal area using three swipes in an upward motion. The other side of the towel that had the smears of bowel movement on it was lying on Resident #12's bilateral thighs. After she wiped the front of her perineal area, she proceeded to take her hand and in a fanning type motion went back and forth in a motion as if she was trying to air dry the area for a few seconds. She then proceeded to take barrier cream and apply to the front of her perineal area, closed her incontinent brief and proceeded to cover her up. She then proceeded to remove her gloves and perform hand hygiene. Interview on 07/30/25 at 3:25 P.M. with CNA #607 verified she used one towel to perform perineal care for Resident #12. CNA #607 was asked why she did not use soap, and she stated, I did. (This was not observed as it was only observed that she stuck the towel under the faucet to wet both ends). She verified she wet both ends of the towel. She was asked how she washed, rinsed and dried if she used the same end of the towel but CNA #607 just looked at the surveyor and did not respond. She later stated, I flipped the towel but would not provide any other details. She verified that she had cleansed her buttock first that had bowel movement then proceeded to clean the front of her perineal area with the same gloved hands. She also verified she had applied barrier cream to her buttocks and then with the same gloved hands proceeded to clean the front of her perineal area and apply barrier cream. Interview on 07/30/25 at 3:31 P.M. and 3:45 P.M. with Licensed Practical Nurse (LPN)/ Unit Manager #610 verified Resident #12 was not to have two incontinence briefs on and to her knowledge CNA #607 was the aide assigned to her so would have been the one that most likely put the two briefs on as she could not think of anyone else who would of changed her. She also verified during perineal care that CNA #607 should not have used only one towel to provide incontinence care as she should have first started with the front and provided perineal care including washing, rinsing and drying with different washcloths and/or towel and then proceeded to cleanse her buttock area in the same manner. Interview on 07/30/25 at 3:38 P.M. with Registered Nurse (RN) #601 revealed she was the nurse for Resident #12, and that CNA #607 was assigned as her aide. To her knowledge, CNA #607 was the only one throughout the day that had performed incontinence care, so she would have been the aide that applied the two incontinence briefs. She verified Resident #12 was to only have one brief on. Review of the facility policy labeled, Perineal Care, dated 2001, revealed the purpose of the policy was to provide cleanliness and comfort to the residents, prevent infection, prevent skin irritation, and observe the resident's skin condition. The policy revealed the following equipment, and supplies were necessary when performing the procedure including wash basin, towels, washcloth, soap, and personal protective equipment. The steps to the policy included fill the wash basin one half full of warm water, wet the washcloth, apply soap and wash the perineal area by wiping front to back. Then staff were to rinse the perineum area thoroughly in same direction using fresh water, clean washcloth and then gently dry the perineum area. After the perineal area was cleansed staff were to turn resident to side and wash, rinse and dry the rectal area. This deficiency represents non-compliance investigated under Complaint Number OH001276910 (OH00165788) and OH001276912 (OH00167179).

Based on review of the Payroll-Based Journal (PBJ) Staffing Data Report, interview with residents and staff and review of the facility assessment, the facility failed to assure sufficient staff to care for residents needs. This had the potential to affect all residents residing at the facility. The facility census was 132. Findings include: Record review of the PBJ Staffing Data Report 1705D Fiscal Year Quarter 3 2024 (April 1 - June 30) revealed Facility ID: OH00603 triggered a one star staffing rating and excessively low weekend staffing. Record review of the Facility assessment dated [DATE] revealed a Certified Bed Capacity of 157. The average daily census the last assessment revealed short stay average census of 19.4 and long stay average census was 105.4; This assessment will inform the facility's staffing decision to ensure that there are a sufficient number of staff with appropriate competencies and skill sets necessary to care for residents needs as identified through resident assessments and plans of care. The facility will consider staffing needs for each resident unit in the facility for each shift and adjust as necessary based on the resident population. Licensed nurses 1.0 -1.3, nurse aids 1.5 - 1.66 and nursing personnel with administrative duties .20 - .26. Review of the daily schedule revealed on 09/21/24 Licensed nurses were 1.05 and nurse aids were 1.4; On 09/22/24 Licensed Nurses were 1.05 and nurse aids were 1.29. Interview on 11/19/24 between 9:02 A.M. and 11:18 A.M. with Certified Nursing Assistant (CNA) #207 and #368 revealed at times when there are call offs, residents are not checked and changed every two hours and some residents don't receive their scheduled showers. Interview on 11/19/24 between 12:55 P.M. and 3:25 P.M. with Resident #118 and Resident Council President Resident #111 revealed at times it takes up to an hour for staff to answer call lights, showers/bathing are not consistently being done, residents are not being changed timely, especially on the weekends. The interview on 11/19/4 at 3:31 P.M. with Administrator revealed the corporate staff review the actual staff punches used to submit the PBJ. This deficiency represents non-compliance investigated under Complaint Number OH00158759.

Based on observation, interview, and review of the facility policy, the facility failed to assure rooms were appropriately cleaned and sanitized prior to admitting a new resident to the room. This had the potential to affect all new admissions. The facility census was 132. Findings include: Interview on 11/19/24 at 12:59 P.M. with Housekeeping Supervisor #221 revealed when a resident is discharged , the room the resident resided in is deep cleaned within 24 hours of the discharge. The deep cleaning included all trash would be pulled, all the contents in the room that belonged to the former resident would be removed and packed, all the drawers and closets would be emptied and cleaned and all surfaces would be cleaned. Observation and interview on 11/19/24 at 1:03 P.M. with Housekeeping Supervisor #221 of room [ROOM NUMBER] bed two revealed the portion of the room was unoccupied. Housekeeping Supervisor #221 confirmed the room had been deep cleaned and ready for a new admission. Observation with Housekeeping Supervisor #221 confirmed the nightstand in the cleaned room had a white brief in the top drawer, oxygen tubing, a used urinal with dried urine in the bottom and on the sides, and a collection canister with dried urine in the bottom. Housekeeping Supervisor #221 revealed those should have been removed when the room was deep cleaned. Observation and interview on 11/19/24 at 1:03 P.M. with Housekeeping Supervisor #221 of room [ROOM NUMBER] bed two revealed the portion of the room was unoccupied. Housekeeping Supervisor #221 confirmed the room had been deep cleaned and ready for a new admission. Observation revealed in the top drawer of the nightstand was several potato chips and crumbs. There were large visible dust piles behind the stand. The bedside stand had dry drips of a fluid on the front of the stand and thick dust on the entire lower rim of the stand. Housekeeping Supervisor #221 revealed the stand should have been moved out to clean the dust behind it, the drawers should have been cleaned out and the stand should have been washed down. Housekeeping Supervisor #221 revealed she had concerns brought to her in the past regarding the room not being deep cleaned before a new resident was admitted to the room. Housekeeping Supervisor #221 revealed that's when she started rotating housekeepers, but it only worked for a while. Interview on 11/20/24 with Resident #136's daughter revealed she was with Resident #136 when she was admitted to the facility. Resident #136's daughter revealed when she was admitted to the room, the room was still dirty, the floors were dirty, and it looked like the room hadn't been cleaned. There was another resident's personal items in the drawers and closet. Record review of the facility Admissions revealed for the months of October and November 2024 there were a total of 45 admissions to the facility. Review of the facility policy titled, Routine Cleaning dated 11/30/23 revealed surfaces in residents rooms/areas will be cleaned and disinfected according to current Centers for Disease Control (CDC) recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard to reduce the risk of infections and transmission of diseases. This deficiency represents non-compliance investigated under Complaint Number OH00158759.

Based on closed record review and interview, the facility failed to collect a urinalysis for one resident, Resident #136 per the physicians orders. This affected one resident (Resident #136) of three residents reviewed for physician orders/labs. The facility census was 132. Findings include: Closed record review for Resident #136 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnosis included type two diabetes mellitus, hydronephrosis, weakness, and retention of urine. Record review of the Medicare five-day Minimum Data Set (MDS) dated [DATE] revealed Resident #136 was cognitively intact. Resident #136 was dependent for toileting and was frequently incontinent of urine. Record review of the Certified Nurse Practitioner (CNP) #369 progress note for Resident #136 dated 09/27/24 at 10:19 A.M. revealed worsening confusion and anxiety, ordered to send urine stat. Record review of the physician orders for Resident #136 revealed an order dated 09/27/24 to collect urine for urinalysis. Record review of the urinalysis lab result for Resident #136 revealed the urine specimen was collected on 09/30/24 and reported to the facility on [DATE]. The results of the urinalysis revealed an abnormal result of three plus leukocytes, six to 20 white blood cells, bacteria and mucous. The urine had mixed flora, so sensitivity was not able to be completed. On 10/02/24 a new physician order was received for Resident #136 to straight cath for urine specimen and send for a urinalysis and culture and sensitivity. Record review for Resident #136 revealed no documentation of the straight cath for the urinalysis with a culture and sensitivity was completed on 10/02/24 or after. Record reviews revealed there was no documentation either to why the urinalysis was not collected for Resident #136. Interview on 11/19/24 with Director of Nursing (DON) revealed the CNP ordered the urinalysis stat for Resident #136 on 09/27/24. DON revealed urinalysis could not be done stat, the lab would not come to the facility to collect a stat urinalysis so she explained that to the CNP. DON confirmed the urinalysis was not collected until 09/30/24 and the results received on 10/01/24 had mixed flora. DON confirmed the physician ordered the straight cath for the urinalysis with a culture and sensitivity on 10/02/24. DON revealed she reviewed the labs collected by the lab company and confirmed the urinalysis was not collected for Resident #136 on or after 10/02/24 per the physicians orders. DON also confirmed there was no documentation in the medical record to why the urinalysis was not completed and confirmed there should have been documentation. DON revealed she did not know why the nurses did not collect the urinalysis per the physicians orders. This deficiency represents non-compliance investigated under Complaint Number OH00158759.

Based on record review ,interview, and policy review, the facility failed to administer the correct medication to the resident. This affected one resident (Resident #136) of one resident reviewed for medication errors. The facility census was 132. Findings include: Record review for Resident #136 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnosis included endocarditis, heart failure, hypertension, vascular dementia, and weakness. Record review of the Medicare five-day Minimum Data Set (MDS) dated [DATE] revealed Resident #136 was cognitively intact. Review of the medical record for September 2024 for Resident #136 revealed there was no documentation of a medication error that occurred or the physician being notified of a medication error. Review of the form titled, Investigative Data Sheet Medication/Treatment Error and Omission Form dated 09/24/24, untimed revealed Resident #136 received an incorrect blood pressure medication. The administration error was the wrong drug. The physician was notified, the responsible party was notified and the order received was to monitor blood pressure. The name of the medication nor the amount of time to monitor the blood pressure was documented on the form. Record review of the Medication Administration Record (MAR) for Resident #136 revealed on 09/24/24 at 9:00 A.M. Resident #136 received medications that included metoprolol succinate ER 12.5 milligrams (mg) for hypertension, spironolactone 25 mg for hypertension, torsemide 20 mg for hypertension, and Entresto 24-26 mg for hypertension (given at 9:00 A.M. and 5:00 P.M.). Interview on 11/19/24 at 3:55 P.M. with Director of Nursing (DON) revealed on 09/24/24 (unsure of the time) Registered Nurse (RN) #201 administered a blood pressure pill and a multivitamin to Resident #136 that was another residents medication. DON confirmed there was no documentation in Resident #136's medical record regarding the medication error, physician notification or if there were any new orders regarding the error. DON revealed RN #201 must have forgotten to document the information. DON confirmed the medication error, resident assessment, MD notification and any new orders should be documented in the resident medical records. DON revealed she discussed the medication error with RN #201 but neither her nor RN #201 wrote down the names of the medication administered in error to Resident #136. DON revealed she did not remember the names of the medications, but remembered it was a blood pressure medication and a multivitamin. Review of a notebook paper provided by DON with handwritten times and dated 09/24/24 - 09/25/24 with Resident #136's name next to the date revealed blood pressures were documented starting on 09/24/24 at 3:45 P.M. and monitored approximately every hour through 09/25/24 at 2:30 P.M.; No abnormal blood pressures were observed in the documentation. Phone interview on 11/20/24 at 6:17 P.M. with Resident #136's daughter revealed she was visiting Resident #136 on 09/24/24 in the evening when the medication error was made. Resident #136's daughter revealed, The nurse gave my mom the pills, they did not look right so I went to get the nurse, I turned around and my mom already took them, there was four of them, at first the nurse denied giving her the wrong pills then she admitted after looking at the records they were supposed to be for another resident, not her, she said don't worry about it, she will be fine. Resident #136's daughter revealed she wrote the name of the pills down that was given to Resident #136 in error. Resident #136's daughter revealed the pills were sodium bicarbonate (used to relieve heartburn), colace (used for constipation), norvasc five mg (used for high blood pressure) and simethicone (used to treat the symptoms of gas). Review of the facility policy titled, Preparation and General Guidelines, Medication Administration dated November 2021 revealed preparation of medication included Five Rights. Right resident, right drug, right dose, right route and right time are applied for each medication being administered. A triple check of these five rights are recommended. Residents are identified before medication is administered using two methods of identification. Medications supplied to one resident are never administered to another resident. This deficiency represents non-compliance investigated under Complaint Number OH00158759.

Based on record review and interview, the facility failed to document a medication error, the name of the medication, and follow up in one resident, Resident #136's medical record. This affected one resident (Resident #136) of one resident reviewed for medication errors. The facility census was 132. Findings include: Record review for Resident #136 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnosis included endocarditis, heart failure, hypertension, vascular dementia, and weakness. Record review of the Medicare five-day Minimum Data Set (MDS) dated [DATE] revealed Resident #136 was cognitively intact. Review of the medical record for September 2024 for Resident #136 revealed there was no documentation of a medication error that occurred or the physician being notified of a medication error. Review of the form titled, Investigative Data Sheet Medication/Treatment Error and Omission Form dated 09/24/24, untimed revealed Resident #136 received an incorrect blood pressure medication. The administration error was the wrong drug. The physician was notified, the responsible party was notified and the order received was to monitor blood pressure. The name of the medication nor the amount of time to monitor the blood pressure was documented on the form. Record review of the Medication Administration Record (MAR) for Resident #136 revealed on 09/24/24 at 9:00 A.M. Resident #136 received medications that included metoprolol succinate ER 12.5 milligrams (mg) for hypertension, spironolactone 25 mg for hypertension, torsemide 20 mg for hypertension, and Entresto 24-26 mg for hypertension (given at 9:00 A.M. and 5:00 P.M.). Interview on 11/19/24 at 3:55 P.M. with Director of Nursing (DON) revealed on 09/24/24 (unsure of the time) Registered Nurse (RN) #201 administered a blood pressure pill and a multivitamin to Resident #136 that was another residents medication. DON confirmed there was no documentation in Resident #136's medical record regarding the medication error, physician notification or if there were any new orders regarding the error. DON revealed RN #201 must have forgotten to document the information. DON confirmed the medication error, resident assessment, MD notification and any new orders should be documented in the resident medical records. DON revealed she discussed the medication error with RN #201 but neither her nor RN #201 wrote down the names of the medication administered in error to Resident #136. DON revealed she did not remember the names of the medications, but remembered it was a blood pressure medication and a multivitamin. Review of a notebook paper provided by DON with handwritten times and dated 09/24/24 - 09/25/24 with Resident #136's name next to the date revealed blood pressures were documented starting on 09/24/24 at 3:45 P.M. and monitored approximately every hour through 09/25/24 at 2:30 P.M.; No abnormal blood pressures were observed in the documentation. Phone interview on 11/20/24 at 6:17 P.M. with Resident #136's daughter revealed she was visiting Resident #136 on 09/24/24 in the evening when the medication error was made. Resident #136's daughter revealed, The nurse gave my mom the pills, they did not look right so I went to get the nurse, I turned around and my mom already took them, there was four of them, at first the nurse denied giving her the wrong pills then she admitted after looking at the records they were supposed to be for another resident, not her, she said don't worry about it, she will be fine. Resident #136's daughter revealed she wrote the name of the pills down that was given to Resident #136 in error. Resident #136's daughter revealed the pills were sodium bicarbonate (used to relieve heartburn), colace (used for constipation), norvasc five mg (used for high blood pressure) and simethicone (used to treat the symptoms of gas). Review of the facility policy titled, Preparation and General Guidelines, Medication Administration dated November 2021 revealed preparation of medication included Five Rights. Right resident, right drug, right dose, right route and right time are applied for each medication being administered. A triple check of these five rights are recommended. Residents are identified before medication is administered using two methods of identification. Medications supplied to one resident are never administered to another resident. This deficiency represents non-compliance investigated under Complaint Number OH00158759.

Based on interview, record review, and facility policy review, the facility failed to administer an antiparkinsonian medication as ordered by the prescriber to ensure Resident #118 was free from significant medication error. This affected one resident (#118) out of three residents reviewed for medication administration. Findings include: Review of the medical record for Resident #118 revealed an admitted [DATE]. Diagnoses included hereditary spastic paraplegia, secondary parkinsonism, degenerative disease of nervous system, contracture of muscle multiple sites, and idiopathic progressive neuropathy. The Quarterly Minimum Data Set (MDS) assessment completed 08/16/24 indicated no cognitive impairment. Review of Resident #118's physician orders effective September 2024 revealed Rytary (antiparkinsonian medication) 48.75-195 milligrams, two capsules four times daily. Review of Resident #118's medication administration record for August 2024 to September 2024 revealed Rytary was scheduled four times daily at 8:00 A.M., 12:00 P.M., 5:00 P.M. and 10:00 P.M. Review of Resident #118's medication administration report from 08/17/24 to 08/24/24 revealed Rytary was administered late. On 08/18/24 the 8:00 A.M. dose was administered at 10:44 A.M. and the 12:00 P.M. dose was administered at 1:20 P.M. On 08/20/24 the 8:00 A.M. dose was administered at 9:36 A.M. On 08/21/24 the 5:00 P.M. dose was administered at 7:25 P.M. On 08/22/24 the 8:00 A.M. dose was administered at 9:40 A.M. and the 12:00 P.M. dose was administered at 1:37 P.M. On 08/23/24 the 8:00 A.M. dose was administered at 10:59 A.M. and the 12:00 P.M. dose was administered at 1:53 P.M. On 08/24/24 the 8:00 A.M. dose was administered at 10:41 A.M. Additional review of the administration report indicated on 08/24/24 both the 5:00 P.M. dose and the 10:00 P.M. dose were administered together at 10:07 P.M. On 09/12/24 at 8:30 A.M. interview with Resident #118 revealed concerns with staff administering his antiparkinsonian medication, which he was to receive four times a day, late. Interview on 09/12/24 at 12:12 P.M. with Director of Nursing (DON) verified the above medication administration findings. The DON stated she believed the nurses were likely not signing off medication administration at the actual time it was given but waiting until later in the shift to do it although that was not the proper procedure for medication administration. The DON revealed the nurses had one hour prior to one hour after the scheduled dose times to complete medication administration as ordered. Review of facility policy, Medication Administration - General Guidelines, revised December 2019 revealed the right resident, right drug, right dose, right route and right time were applied for each medication being administered. Medications were administered within 60 minutes of the schedule time. The individual who administered the medication dose recorded the administration on the medication administration record directly after the medication was given. This deficiency represents noncompliance investigated under Complaint Number OH00157103.

Based on observation, interview and record review, the facility failed to maintain a clean, comfortable, homelike environment for Resident #134 and Resident #109. This affected two residents (#134 and #109) of three residents reviewed for physical environment. The facility census was 128. Findings include: Review of the closed record for Resident #134 revealed an admitted [DATE] with diagnoses including congestive heart failure, anemia, hypertension, hyperlipidemia and glaucoma. Review of the Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #134 had intact cognition. Review of Resident Grievance Concern Log dated 01/15/24 revealed the family of Resident #134 had concerns about a window in Resident #134's room. Interview on 07/23/24 at 3:05 P.M. with Resident #134's family member revealed when the resident was residing in the facility during February 2024 the family member felt the room was not being cleaned thoroughly because there were spider webs formed up the entire right side of the outside of the window sill and underneath the sink in the room there was an exposed sink pipe and a black substance on the wall under the sink and under the sink counter. The family member said she would submit photos as evidence. She said the photos were taken before Resident #134 was discharged in February 2024. Review of photo evidence submitted by Resident #134's family member revealed a photo of spider webs formed up the entire right side of the outside window sill and another picture of the underside of a sink with open pipes and black like substance on the wall and under the sink counter. Observation on 07/23/24 at 4:00 P.M. of the room previously occupied by Resident #134 and at the time of the survey was occupied by Resident #109 revealed spider webs remained up the entire right side of the outside window sill upon looking out the window and the sink pipe was exposed with black like substance on the wall and under the sink counter which were the same details in the pictures submitted by Resident #134's family. Interview on 07/23/24 at 4:12 P.M. with Maintenance Director # 395 verified the spider webs had not been cleaned from the window sill and the pipe under the sink remained exposed with black like substance on the wall and under the counter. Interview on 07/23/23 at 4:15 P.M. with the Administrator revealed the Administrator reviewed the photos and verified that in the photo spider webs formed up the entire right side of the outside window sill and another picture of the underside of a sink with open pipes and black like substance on the wall and under the sink counter. Review of facility policy titled, Routine Cleaning dated 11/30/23, revealed rooms and areas were disinfected according to current Centers for Disease Control recommendation for healthcare facilities. This deficiency represents non-compliance investigated under Complaint Number OH00155736

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, record review and interview the facility failed to ensure Resident #49 was transferred safely between the bed and the wheelchair. Actual harm occurred on 07/02/23 when Resident #49 began complaining of pain in her right leg after her leg got caught between her bed and wheelchair during a staff assisted transfer. X-ray results dated 07/04/23 indicated Resident #49 had a right tibia and fibula fracture. The facility investigation determined this injury was caused from the staff assisted transfer. This affected one resident (#49) of six residents reviewed for accident hazards. The total census was 143. Findings include: Record review for Resident #49 revealed the resident was admitted to the facility on [DATE] and had diagnoses including diabetes, spinal stenosis, and venous insufficiency. A plan of care, dated 11/04/22 revealed staff were to provide assistance with transfers as needed. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 05/04/23 revealed the resident was cognitively intact and required extensive two-person assistance for transfers. Review of a nurse's note dated 07/02/23 at 10:00 P.M. revealed the authoring nurse asked an STNA to assist Resident #49 to bed. The same STNA came to the nurse to tell her Resident #49 was complaining of arthritis pain and wanted some cream for it. The nurse completed a skin check and found no redness, bruising or edema in the right lower extremity. Between 11:00 P.M. to 11:30 P.M. the STNA told the nurse Resident #49 wanted to see her. Resident #49 told the nurse she had pain in her right leg, the nurse completed an assessment, offered Tylenol, and called the physician who ordered a STAT x-ray. The nurse completed another skin check and found no bruising, redness or swelling. Review of a nurse's note dated 07/03/23 at 12:30 A.M. revealed a late entry indicating Resident #49 had told the nurse during the transfer by the STNA she had hurt her leg. The resident declined to go out to the hospital for evaluation at that time but agreed to a STAT x-ray order. The resident was given Tylenol for pain and fell asleep. Further review of nurse's notes revealed the x-ray was documented as completed on 07/03/23 and reported 07/04/23, which identified an acute fracture to Resident #49's right tibia and fibula. She was sent to the emergency roiagnom on [DATE] and returned the same day with orders for follow-up orthopedic appointments. The resident's plan of care was updated on 07/05/23 to include having two staff assisting when providing transfers for Resident #49. Review of the facility investigation documentation into Resident #49's injury revealed an undated statement by STNA #938 stating she transferred Resident #49 to the wheelchair for a visit with family the morning of the event, and she had no complaints of pain. While trying to transfer her to the bed after the visit, the resident said ou so she stopped, sat the resident down in her chair, and retrieved another aide. The resident did not complain of pain until she was in the bed and staff notified the nurse. A documented interview with Resident #49 dated 07/03/23 revealed she stated her leg got caught between the wheelchair and the bed when the aide tried to transfer her and she said ouch. Later while lying down she began having pain again and informed the nurse. Undated documentation of a family interview revealed they denied any events occurred during the visit which could have resulted in injury. Review of physician's orders revealed an order dated 07/06/23 for the resident to be non-weight bearing on her right lower extremity and an order dated 07/11/23 for an immobilizer to her right lower extremity. Interview with Resident #49 on 07/31/23 at 10:06 A.M. revealed around the 4th of July, she suffered a broken leg when a single staff member tried to transfer her from the wheelchair, and her leg became caught between the wheelchair and the bed. She said the aide left after the transfer, and she called the nurse for pain medicine which was given. The next day the facility ordered x-rays and identified the leg had a fracture. Observation of Resident #49 at the time of the above interview revealed her right leg to be in a removable cast. Interview with the Director of Nursing (DON) on 08/02/23 at 8:05 A.M. revealed the facility had previously investigated Resident #49's alleged injury event. The nurse aide (STNA #938) who did the transfer no longer worked at the facility. The DON revealed during the investigation, STNA #938 said the resident complained of pain as soon as she tried to stand up during the transfer on 07/02/23. Resident #49 said her leg got caught between the bed and the wheelchair during the transfer, which STNA #938 denied. Interview with the Administrator on 08/02/23 at 5:11 P.M. confirmed the above findings. He said the facility did not determine the event to be an injury of unknown origin, as the facility concluded the injury occurred during the bedside transfer. Interview with STNA #871 on 08/03/23 at 3:58 P.M. revealed she was called into Resident #49's room on the evening of 07/02/23 to assist STNA #938 with providing positioning care. The STNA indicated Resident #49 did not complain of pain to her during the care. The deficiency was corrected on 07/06/23 when the facility implemented the following corrective actions: o On 07/03/23 an x-ray was completed and reported 07/04/23, which identified an acute fracture to Resident #49's right tibia and fibula. o On 07/04/23 Resident #49 was sent to the emergency room and returned the same day with orders for follow-up orthopedic appointments. o A fall investigation was completed including a statement by Resident #49. o On 07/05/23 Resident #49's plan of care was updated to include having two staff assisting when providing transfers. o On 07/06/23 and 07/11/23 Physician's orders were obtained related to Resident #49's injury. o On 07/06/23 a QAPI Plan was developed including the root cause was identified, education and audits were developed, and the Medical Director was notified. o On 07/06/23 an in-service was completed related to appropriate resident transfers by all State tested Nurse Aides (STNAs) and Nurses. Education was provided by the Director of Nursing and Nursing Scheduler. o On 07/06/23 a house wide audits was completed for all residents' transfer status. o On 07/10/23 audits of transfers continued via observation of three residents three times a week for four weeks. The audits will be completed by the DON/designee. Audit findings will be presented to Quality Assurance and Performance Improvement (QAPI) committee for recommendations. Three weeks of audits (07/10/23, 07/19/23 and 07/26/23) were reviewed with no concerns noted. o On 07/31/23, during the interview with Resident #49, she voiced no current concerns related to inappropriate transfers. o During the course of the survey from 07/31/23 to 08/03/23 no current identified concerns related to inappropriate transfers were identified related to the regulation at F689.

Based on observation, interview, record review and review of facility policy, the facility failed to ensure physician orders were followed, and care planned interventions for oral care were implemented for Resident #109, Resident #112, and Resident #126, and failed to ensure Resident #12, #29 and #94 were provided proper incontinence care timely Actual Harm occurred on 03/19/23 at 4:19 P.M. when Resident #126, who exhibited moderate cognitive impairment and required extensive staff assistance for personal care was assessed (by hospital staff upon transfer from the facility) to have poor oral/denture condition. The resident's upper dentures were stuck in place and coated in thick, white yellow mucous and coating. Resident #126 had dryness of the mouth, dry, cracked lips, teeth, and tongue. There were large amounts of white patches noted to Resident #126's dentures, tongue, and gums. Resident #126's gums were bright red, and her teeth were covered in spots of thick and fuzzy white patches and areas of light yellow. Resident #126's tongue was cracked, hairy, with white plaque. The facility failed to provide evidence of adequate oral/denture care being provided on an ongoing basis prior to the hospitalization to prevent this condition. This affected three residents (Resident's #12, #29 and #94) out of four residents reviewed for incontinence care and three residents (#109, #112 and #126) of four residents reviewed for oral care. The facility census was 122. Findings include: 1. Review of the closed medical record for Resident #126 revealed an admitted [DATE]. Resident #126's diagnoses included traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, chronic pain syndrome, dementia with agitation, and Alzheimer's Disease. Resident #126 was discharged from the facility on 03/19/23. Review of Resident #126's physician orders dated 02/01/23 revealed the resident's overall plan of care and services were approved. Review of Resident #126's progress note, dated 02/02/23 at 4:00 P.M. included Resident #126 was admitted from the local hospital, had Alzheimer's disease, a history of multiple falls and had a pacemaker. Resident #126 wore full dentures. Review of Resident #126's progress notes from 02/03/23 through 03/19/23 did not reveal documented evidence Resident #126 refused to have her dentures removed from her mouth for cleaning, or documentation Resident #126 was missing her lower dentures. There was no documentation the family and responsible party were informed Resident #126's dentures were missing. Review of Resident #126's State tested Nursing Assistant documentation from 02/02/23 through 03/19/23 indicated the opportunity to document personal hygiene three times a day on each shift noted personal hygiene assistance was not completed three times a day, every day as planned. Review of Resident #126's care plan dated 02/04/23, included Resident #126 had an ADL (activity of daily living) self-care deficit related to disease process, dementia. Resident #126 would receive assistance necessary to meet ADL needs. Interventions included to assist with daily hygiene, grooming, dressing, oral care and eating as needed. The care plan noted Resident #126 was resistive, non-compliant with treatment, care, refusing meds, ADL's and showers related to cognitive impairment. Resident #126 would participate in developing a personal schedule of care. Interventions included to allow for flexibility in ADL routine to accommodate mood, preferences, and customary routine. If Resident #126 resisted care, leave (if safe to do so) and return later; provide non-care related conversation proactively before attempting ADL's. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 02/07/23 revealed Resident #126 had moderate cognitive impairment. The assessment revealed Resident #126 required extensive assistance of one staff for personal hygiene (included brushing teeth), bed mobility, transfers, and extensive assistance of two staff for toilet use. Resident #126 did not have broken or loosely fitting full or partial dentures, did not have an abnormal mouth issues such as ulcers, masses, oral lesions, and did not have inflamed or bleeding gums. Resident #126 did not have mouth or facial pain, discomfort or difficulty with chewing. Review of the facility Concern Log dated 03/03/23 and documented by Unit Manager #562 revealed Resident #126 was missing her lower dentures, and the concern type was loss, theft, damage. Review of Resident #126's Periodic Dental Examination and Charting dated 03/12/23, revealed bite registration, full upper and lower. Resident #126 was difficult, and an aide was present at 10:30 A.M., told nurse, kept in contact with Resident #126's spouse, and saw Resident #126 two times. Further review did not reveal documentation under areas of illnesses, medications, existing prostheses, oral hygiene, and ridges upper and lower. Review of Resident #126's progress note dated, 03/19/23 at 4:20 P.M. revealed Resident #126 was lethargic and slow to respond. Resident #126's husband was at bedside and wanted the resident to go to hospital to be evaluated. Resident #126's vital signs were a blood pressure of 109/51, pulse 81, respirations were 16, oxygen saturation was 88%, and her temperature was elevated at 101 degrees Fahrenheit. Resident #126's pupils were pin point and lung sounds were clear in all bases. The note documented mouth was dry, and tongue was dry with no coating noted. Certified Nurse Practitioner (CNP) #633 was notified and Resident #126 was transported via 911 to the local hospital Emergency Department. Review of Resident #126's hospital records revealed she arrived to the Emergency Department on 03/19/23 at 4:19 P.M. for altered mental status, fever, hypoxia and lethargy. Further review of the Emergency Department progress notes assessment at 8:44 P.M. included dryness of mouth, dry, cracked lips, teeth and tongue. Resident #126's upper dentures were stuck in place, coated in thick, white, yellow mucous and coating. There were large amounts of white patches noted to dentures, tongue and gums. Resident #126's gums were bright red, her teeth were covered in spots of thick and fuzzy white patches and areas of light yellow. Resident #126's tongue was cracked, hairy, with white plaque. Resident #126's appearance was disheveled, she was groomed inappropriately, and malodorous. Resident #126 was passive, noncommunicative, and had decreased responsiveness. Interview on 04/26/23 at 2:01 P.M. with Licensed Practical Nurse (LPN) #559 revealed Resident #126 was confused, would become agitated, was a high fall risk and was resistive to care. LPN #559 stated she remembered Resident #126 had dentures and she remembered Resident #126 wore her dentures a couple times. Interview on 04/26/23 at 2:37 P.M. with Unit Manager #562 revealed Resident #126's husband reported the resident's lower dentures were missing. Unit Manager (UM) #562 stated she documented the concern and it was addressed in an interdisciplinary team (IDT) meeting. UM #562 indicated Dentist #632 came to the facility, took impressions and dentures were made. UM #562 stated she did not know if the new dentures were delivered to the facility before Resident #562 was transported to the local Emergency Department, and could not remember if Resident #126's teeth were in the belongings her husband picked up from the facility. UM #562 stated when residents were cognitively impaired their teeth were often thrown in the trash or placed on the meal tray. UM #562 indicated she searched everywhere for Resident #126's teeth and could not find them. UM #562 stated Dentist #632 was contacted to have Resident #126's teeth replaced. UM #562 stated Dentist #632 had a helper when he visited the facility, and UM #562 did not make rounds with him. UM #562 stated she looked in Resident #126's mouth, she was missing her lower dentures, and the upper dentures were in her mouth. Interview on 04/26/23 at 3:10 P.M. with Director of Nursing (DON) revealed resident denture care should be completed in the morning and the evening as needed. The DON stated denture care included taking the dentures out of residents' mouths if the residents would allow it, and brushing the teeth. The DON stated residents would not always allow staff to remove their dentures from their mouth, but staff should reapproach the resident later to give denture care after the resident was comfortable and settled in. Interview on 05/01/23 at 7:08 A.M. with State tested Nursing Assistant (STNA) #549 revealed Resident #126 had no issues with her dentures and did not have sores in her mouth that she was aware of. STNA #549 stated Resident #126 did not like to wear her top dentures because they were too big. STNA #549 indicated Resident #126 would take her dentures out as soon as they were put in her mouth. Interview on 05/01/23 at 7:13 A.M. with STNA #571 revealed she worked day shift, and two to three days a week she worked second shift as well. STNA #571 stated she usually worked in the memory care unit. STNA #571 stated STNA's from a staffing agency often worked second shift in the memory care unit. STNA #571 indicated she often was assigned to care for Resident #126, and she needed someone constantly monitoring her because she was a high fall risk, was combative, restless, and required extensive assistance of one staff with her ADL's. STNA #571 stated if the STNA staff took their time to work with Resident #126, she would allow them to take care of her. STNA #571 stated she was not aware Resident #126 had dentures until one day a man (Dentist #632) allowed her to stay in Resident #126's room while he was fitting her for dentures. STNA #571 stated Resident #126 did not like to have her dentures removed, would resist but eventually would allow dentures to be removed. STNA #571 stated she cleaned Resident #126's dentures and place them in a denture cup when she worked second shift, but she was not always assigned to her. Interview on 05/01/23 at 8:04 A.M. with DON revealed she could not say how long it would take for thick white yellow mucous and fuzz to grow on dentures. The DON stated it would depend on what the resident was eating and drinking and if they ate something that day. The DON stated if a resident was found to have red and inflamed gums it would be addressed right away. The DON stated the resident would probably complain of pain when eating and also when not eating. Interview on 05/01/23 at 8:17 A.M. with Dentist #632 revealed he was commissioned to make a full set of dentures for Resident #126. Dentist #632 stated he took impressions but did not do an oral exam because the facility only wanted dentures made. Dentist #632 stated he did not look underneath Resident #126's tongue and did not look at ridges on the top and bottom of her mouth. Dentist #632 stated he did not remember details of his visit, but Resident #126 was not cooperative. Dentist #632 stated it took four visits to complete a set of dentures and he saw Resident #126 two times. Dentist #126 stated if he only needed to make bottom dentures he might leave top dentures in the mouth when making the impressions. Interview on 05/01/23 at 8:50 A.M. with Licensed Social Worker (LSW) #543 revealed she did not document the missing lower dentures in Resident #126's progress notes and the Concern Form was the only documentation regarding Resident #126's missing dentures. LSW #543 stated if the Concern Form stated Resident #126 was missing her lower dentures then that is what would be replaced. LSW #543 stated upper dentures would not need to be replaced. Interview on 05/01/23 at 8:51 A.M. with Certified Nurse Practitioner (CNP) #633 revealed she examined Resident #126 on 03/19/23 at 9:15 A.M. as a follow up for hypertension medications. CNP #633 stated she examined Resident #126 including PERRLA (pupils equal, round, reactive to light and accommodation), listened to her heart, lungs, abdomen, and checked for edema (swelling) to her lower extremities. CNP #633 stated she did not do an oral exam and would only do an oral exam if needed. CNP #633 stated if the nurses or STNA's brought concerns to her attention then she would complete an oral exam. CNP #633 stated Resident #126 was sitting quietly in a padded wheelchair in the common area, and she did not find anything that concerned her during Resident #126's exam. CNP #633 stated later in the day Resident #126 developed a fever, the family was in the facility and requested Resident #126 to be transported to the local Emergency Department. Interview on 05/01/23 at 8:58 A.M. with Husband #634 revealed he thought Resident #126's care at the facility was terrible, and that was why he did not send her back after she was admitted to the hospital. Husband #634 stated he found Resident #126 drenched in urine, she did not have the correct size incontinence briefs on her even though he bought the correct size and brought them to the facility. Husband #634 stated he found Resident #126 wearing two incontinence briefs at the same time which were the wrong size. Husband #634 stated he would come to the facility at all hours because Resident #126 was unruly and he would help calm her down. Husband #634 stated Resident #126 was transported to the Emergency Department because she had a fever. Husband #634 stated Resident #126's lower dentures were lost and arrangements were made to replace them. Husband #634 stated he never saw any of the staff give Resident #126 mouth care, never saw staff clean her dentures, and never saw her dentures in the cup for cleaning. Husband #634 stated he brought Resident #126's denture cup from home and the staff did not use it, and he did not think it was ever used while Resident #126 was in the facility. Husband #634 stated he never saw Resident #126 take the dentures out of her mouth because she did not like the way they fit. Husband #634 stated Resident #126 only had top dentures because the bottom ones were lost. Husband #634 stated he asked an unidentified nurse about Resident #126's missing lower dentures and the nurse stated she was only in the facility temporarily, was passing medications and did not help him locate her teeth or even act like she cared. Interview on 05/01/23 at 2:23 P.M. with DON regarding Resident #126's denture and oral condition upon arrival to the hospital on 03/19/23 revealed Resident #126 was very combative and might not have allowed staff to remove dentures to clean them. The DON stated Resident #126 was combative when the dentist made impressions for dentures and would probably bite the aide if they tried to take her dentures out for cleaning. Review of the facility policy titled Personal Care and Activities of Daily Living dated, 06/2021, included personal care services included assistance with personal hygiene for example, hair, nails, skin, oral, shaving, eye care, make-up and jewelry, assistance with nighttime care and bathing. 2. Review of Resident #109's medical record revealed an admitted [DATE] and diagnoses included other toxic encephalopathy, weakness, and dementia. Review of Resident #109's care plan dated 11/21/22 included Resident #109 had an ADL (activity of daily living) self-care deficit as evidenced by the need for assistance related to weakness, debility. Resident #109 would receive assistance necessary to meet ADL needs. Interventions included assist with daily hygiene, grooming, dressing, oral care and eating as needed. Review of Resident #109's quarterly MDS 3.0 assessment, dated 02/15/23 revealed Resident #109 had severe cognitive impairment. Resident #109 required extensive assistance of one staff member for bed mobility and personal hygiene (included brushing teeth) and required extensive assistance of two staff members for transfers. Review of Resident #109's physician orders dated 02/28/23 revealed overall plan of care and services approved. Review of Resident #109's State tested Nursing Assistance documentation from 04/13/23 through 05/01/23 revealed Resident #109 required assistance of one staff member for personal hygiene including brushing teeth. Observation on 04/26/23 at 10:10 A.M. of State tested Nursing Assistant's (STNA)'s #508 and #549 revealed they were providing incontinence care and morning care for Resident #109. STNA #508 filled a basin with warm water and had Resident #109 wash her face with a cloth. After Resident #109 washed her face STNA's #508 and #549 did not offer to brush her teeth and give oral care or ask Resident #109 if she would like to brush her teeth. STNA's #508 and #549 proceeded to give her a bed bath and provided incontinence care using appropriate standards of care. When STNA's #508 and #549 were finished with Resident #109's morning and incontinence care they assisted her into a wheelchair, and STNA #549 brushed Resident #109's hair. STNA's #508 and #549 did not offer to brush Resident #109's teeth or assist with brushing her teeth before finishing her morning care and leaving the room. Interview on 04/26/23 at 1:24 P.M. of STNA #549 confirmed Resident #109 did not have mouth care or her teeth brushed during her morning care. STNA #549 stated Resident #109 should have had oral care and her teeth brushed but she forgot to do it. 3. Review of Resident #112's medical record revealed an admitted [DATE] and diagnoses included dementia, major depressive disorder, and hypertension. Review of Resident #112's care plan dated 06/03/22 included Resident #112 had an ADL self-care deficit related to physical limitations, dementia. Resident #112 would be clean, dressed and well groomed daily to promote dignity and psychosocial well-being. Resident #112 would receive assistance as necessary to meet ADL needs. Interventions included Resident #112 required extensive assistance with daily hygiene, grooming, dressing, supervision set-up oral care and eating as needed. Review of Resident #112's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #112 had severe cognitive impairment. Resident #112 required extensive assistance of two staff members for bed mobility and personal hygiene (included brushing teeth) and had total dependence of two staff members for transfers. Interview on 04/26/23 at 11:16 A.M. with STNA #635 revealed he provided morning care for Resident #112 including washing her face and giving her a bed bath without initiating or completing oral care. When asked if he provided any other care during her morning care STNA #635 stated no. 4. Review of Resident #94's medical record revealed an admitted [DATE] and diagnoses included other symptoms and signs involving the musculoskeletal system, dementia, and weakness. Review of Resident #94's care plan dated 12/30/22, included Resident #94 was at risk for alteration in skin integrity related to impaired mobility. Resident #94 would have decreased, minimized skin breakdown risks. Interventions included to provide preventive skin care routinely and as needed. Review of Resident #94's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #94 had moderate cognitive impairment. Resident #94 required extensive assistance of one staff member for bed mobility and toilet use. Resident #94 required extensive assistance of two staff members for transfers, and was frequently incontinent of urine and bowel. Observation on 04/12/23 at 7:50 A.M. of State tested Nursing Assistant (STNA) #579 providing incontinence care for Resident #94 revealed Resident #94's incontinence brief, gown, draw sheet and bed sheet were soaked with urine. Resident #94 stated her incontinence brief did not get changed last night. Observation revealed redness and skin irritation between Resident #94's legs and on her bottom and barrier cream was applied by STNA #579. STNA #579 stated third shift was a problem and often when she came in at 7:00 A.M. the residents were not changed timely, were very wet and needed complete bed changes. STNA #579 stated this happened depending on which staff worked third shift. STNA #579 stated Resident #94 was not a heavy wetter and it looked like it had been a while since Resident #94 had her incontinence brief changed. STNA #579 stated residents told her when she was not working they did not have their incontinence briefs changed timely. 5. Review of Resident #29's medical record revealed an admitted [DATE] and diagnoses included dementia, schizoaffective disorder, and overactive bladder. Review of Resident #29's care plan dated, 03/24/22 included Resident #29 had an ADL (activity of daily living) self-care deficit related to physical limitations and weakness. Resident #29 would be clean, dressed and well groomed daily to promote dignity and psychosocial well being. Interventions included Resident #29 required supervision to limited assistance with daily hygiene, grooming and dressing. Review of Resident #29's Annual MDS 3.0 assessment dated , 02/22/23 revealed Resident #29 had moderate cognitive impairment. Resident #29 required supervision and assistance of one staff member for toilet use. Resident #29 was occasionally incontinent of urine. Observation on 04/12/23 at 8:25 A.M. of STNA #584 providing incontinence care for Resident #29 revealed Resident #29's incontinence brief, draw sheet and sheet were soaked with urine. STNA #584 stated Resident #29 was not a heavy wetter. STNA #584 stated depending on which staff worked third shift determined if residents were changed timely, and as you can see Resident #29 was not changed timely. STNA #584 stated Resident #29 had recently become incontinent of urine more often, and if a staff member was not familiar with Resident #29 report should be given by the outgoing STNA to the new STNA arriving for work. Resident #29 stated the last time she was changed was after dinner sometime. 6. Review of Resident #12's medical record revealed an admitted [DATE] and diagnoses included protein-calorie malnutrition, heart failure and hemiplegia (paralysis) and hemiparesis (weakness) following nontraumatic intracerebral hemorrhage affecting the left non-dominant side. Review of Resident #12's Quarterly MDS 3.0 assessment dated , 03/07/23 revealed Resident #12 had moderate cognitive impairment. Resident #12 required extensive assistance of two staff members for bed mobility and toilet use and had total dependence of two staff members for transfers. Resident #12 was always incontinent of urine and bowel. Observation on 04/12/23 at 8:46 A.M. of STNA #584 providing incontinence care for Resident #12 revealed Resident #12's incontinence brief was soaked with urine. Further observation revealed Resident #12 was wearing two incontinent briefs. STNA #584 stated Resident #12 should not have two incontinence briefs on and the previous STNA probably put two incontinence briefs on Resident #12 on because he was a heavy wetter. Review of the facility policy titled Personal Care and Activities of Daily Living dated, 06/2021 included the community goal was to maintain the resident's routine with personal care and activities of daily living, as specified in the Service Plan. It the resident's routine or changes in the routine present a health or hygiene concern, approaches were developed to address specific concerns. Resident Services staff promoted resident independence and self-care in these areas as practicable. Family involvement was encouraged. Personal care services included assisting with bathing and assisting with toileting, bladder and bowel management. This deficiency represents non-compliance investigated under Master Complaint Number OH00141926 and Complaint Number OH00141329.

Based on observation, record review, facility policy and procedure review, and interview, the facility failed to ensure interventions were implemented to prevent and timely identify the development of Resident #125's pressure ulcer and/or to ensure adequate treatments for Resident #47 were in place to promote healing. Actual Harm occurred on 02/21/23 when Resident #125, who required extensive assistance from two staff for bed mobility, developed a new, in-house acquired deep tissue injury (purple or maroon localized area of discolored, intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) to the sacrum without evidence of adequate preventive interventions including turning and repositioning. The facility failed to identify the pressure ulcer prior to it being identified as a deep tissue injury. This affected two residents (#47 and #125) of three residents reviewed for pressure ulcers. The facility census was 122. Findings include: 1. Review of Resident #125's medical record revealed an admitted [DATE] and diagnoses included two part displaced fracture of surgical neck of right humerus, type two diabetes mellitus, and vascular dementia, mild, without behavioral disturbances, psychotic disturbance, mood disturbance and anxiety. Review of Resident #125's hospital discharge instructions dated 02/14/23, included Resident #125 was discharged to the facility, level of care was skilled, and placement was for rehabilitation for 10 to 30 days. Further review revealed Resident #125 was at risk for developing a pressure ulcer, injury. Resident #125's skin was intact and there were no pressure ulcers, injuries. Review of Resident #125's Braden Scale For Predicting Pressure Sore Risk dated 02/14/23, revealed Resident #125 was at risk for developing a pressure ulcer, injury. Review of Resident #125's Admission Evaluation dated 02/14/23, included Resident #125 was admitted from an acute care hospital. The evaluation revealed Resident #125 had a right great toe diabetic ulcer and measurements were length 0.9 centimeters (cm), width 0.9 cm and depth was unable to be determined. Resident #125 had a callous on the right foot and bruises and scabs to his upper extremities. Further review of the evaluation revealed Resident #125 was not independent with bed mobility, not independent moving supine to sitting, not able to sit on edge of bed with little or no support, not able to independently transfer from sit to stand, and not able to perform a stand pivot transfer with contact guard assist or less. Review of Resident #125's care plan dated 02/15/23 included Resident #125 had an activity of daily living (ADL) self-care deficit as evidenced by right proximal humerus fracture related to physical limitations. Resident #125 would receive assistance necessary to meet ADL needs. Interventions included bed mobility and transfers with extensive assistance of two staff and encourage and, or assist to reposition frequently. Review of Resident #125's physician orders dated 02/14/23 through 02/24/23 did not reveal orders for Resident #125 to be turned and repositioned. Review of Resident #125's Medication Administration Record (MAR) and Treatment Administration Record (TAR) from 02/14/23 through 02/24/23 did not reveal documentation Resident #125 was turned and repositioned. Review of Resident #125's progress notes from 02/14/23 through 02/24/23 did not reveal documentation Resident #125 was turned and repositioned or Resident #125 refused to be turned and repositioned. Review of Resident #125's progress notes dated 02/15/23, included follow up skin assessment following admission to the facility revealed Resident #125 had a fungal rash to the groin, nystatin powder was ordered, healing bruises to bilateral upper extremities from blood draws were scabbed over. Resident #125 had a healed diabetic ulcer to the right great toe. Review of Resident #125's progress notes dated 02/16/23, included Resident #125 had a body audit and no new areas were found. Review of Resident #125's shower sheets dated 02/17/23 did not reveal a new skin area of concern was documented. Review of Resident #125's Admission Minimum Data Set (MDS) 3.0 assessment dated , 02/21/23 revealed Resident #125 was cognitively intact. Resident #125 required extensive assistance of two staff members for bed mobility and toilet use. Resident #125 required extensive assistance of one staff member for transfers, and was frequently incontinent of urine and always incontinent of bowel. Resident #125 was at risk for developing a pressure ulcer, injury and was not on a turning and repositioning program. Review of Resident #125's physician orders dated 02/21/23, revealed treatment to sacrum, cleanse with normal saline solution, pat dry, apply calcium alginate, cover with dry, clean, dressing, and change every day and as needed for wound care. Review of Resident #125's Braden Scale For Predicting Pressure Sore Risk dated 02/21/23 revealed Resident #125 was at moderate risk for developing a pressure ulcer, injury. Review of Resident #125's shower sheet dated 02/22/23, and documented by STNA #502 revealed a new area of concern was reported to the nurse and Resident #125's sacral area was circled on the shower sheet. Review of Resident #125's progress notes dated 02/22/23, included Resident #125 had decreased mobility leaving him at risk for skin alterations. A new area was noted to Resident #125's sacrum. Resident #125 had an unstageable deep tissue injury to the sacrum which measured length 9.0 centimeters (cm), width 7 cm, and depth was 0 cm. The sacrum was deep purple, red. Review of Resident #125's Treatment Administration Record (TAR) dated 02/23/23, revealed there was no documentation Resident #125's treatment to the sacrum was completed. Review of Resident #125's progress notes dated, 02/24/23 at 6:00 P.M. included Resident #125 was lethargic, Resident #125's blood sugar was 439, Resident #125 having large amounts of loose stool. Resident #125 was pallor in color, extremities cool and vital signs were blood pressure 99/58, heart rate 108, respirations 24, temperature 97.9 Fahrenheit and oxygen saturation 96 percent. Physician order to sent Resident #125 to the local hospital Emergency Department. Resident was transported via 911 to the local hospital Emergency Department. Resident #125 was sent to rule out sepsis. Review of Resident #125's Prehospital Care Report Summary dated, 02/24/23, included Emergency Medical Services (EMS) received a call on 02/24/23 at 6:13 P.M. from the facility for a sick person. EMS arrived at the facility at 6:19 P.M. and Resident #125's vital signs were blood pressure 112/62, pulse 110 per minute, respirations 16 per minute, and oxygen saturation was 99 percent. EMS started an intravenous to administer fluids. Staff informed EMS that Resident #125 experienced blood sugars of over 500, had a fracture of the right humeral head, and was likely septic due to a bedsore. Resident #125's blood sugar was 496 and Resident #125 was transported to the local hospital Emergency Department. Interview on 04/10/23 at 9:51 A.M. of Family Member (FM) #500 revealed Resident #125 was discharged from the facility after he was transported to the Emergency Department and admitted to the local hospital, and now resided at a different facility. FM #500 stated on 02/02/23, Resident #125 had a fall at home, sustained a fracture to his humerus and was transported via 911 to the local hospital. FM #500 stated Resident #125 was a patient in the hospital until 02/14/23. FM #500 stated Resident #125 needed skilled care until his arm healed and that was why he was admitted to the facility. FM #500 indicated discharge instructions from the local hospital were to make sure Resident #125 was turned and repositioned every two hours, and Resident #125 could not move his arm due to the fracture. FM #500 stated Resident #125 needed an incontinence brief and when she visited she would check to see if Resident #125's incontinence brief was changed timely. FM #500 revealed she checked Resident #125's incontinence brief and observed dried feces on his legs near his butt and thought to herself what was going on. FM #500 stated she activated the call light, but it took and hour and ten minutes for someone to answer the call light. FM #500 stated an unidentified nurse finally came in the room and assured FM #500 that Resident #125's incontinence brief would be checked every two hours and he would be repositioned every two hours, and an aide changed the incontinence brief and cleaned the feces off Resident #125's legs. A few days after this happened FM #500 saw Licensed Practical Nurse (LPN) #501 in the hall, called her into Resident #125's room, and asked her to examine him because she was his admitting nurse when he arrived at the facility. FM #500 stated LPN #501 did not find any pressure ulcer when Resident #125 was admitted to the facility. FM #500 stated she told LPN #501 she was furious with Resident #125's care and the facility had not been changing his incontinence brief timely, he had dried poop on his thighs, and his lower back hurt him. FM #500 indicated LPN #501 rolled Resident #125 onto his side, and exclaimed oh my god because she noticed a bedsore. FM #500 stated LPN #501 asked her if she had her permission to send Resident #125 to the hospital because the wound needed taken care of. FM #500 stated the wound was approximately three inches by two inches and was flaming red. FM #500 revealed Resident #125 was sent to the hospital via 911, the hospital staff told her he had a severe wound on his lower back and he needed to stay in the hospital. FM #500 stated Resident #125 was seen by a surgeon who told her Resident #125 was a very sick man and needed a wound vac to pull out the bacteria from the wound. FM #500 stated in addition to the wound vac Resident #125 had a PEG (percutaneous endoscopic gastrostomy) tube placed because he needed a lot of protein. FM #500 stated Resident #125 had a swollen right leg, had a blood clot in the leg and was placed on an anticoagulant. FM #500 stated Resident #125 was receiving therapy to help strengthen him while residing at the new facility, but the wound on his bottom was so painful it is getting in the way of the therapy because Resident #125 was unable to sit up. FM #500 indicated Resident #125 resided on the second floor skilled nursing unit when he was at the facility, he was neglected, she trusted the facility to take care of him and they did not take care of him. FM #500 stated Resident #125 was her whole world. Interview on 04/10/23 at 4:27 P.M. with Licensed Practical Nurse (LPN) #501 revealed Resident #125 was admitted to the facility on [DATE], and she completed his admission assessment. LPN #501 stated Resident #125 did not have a wound on his sacrum or buttocks when he was admitted , and developed a wound on his sacrum while residing in the facility. LPN #501 indicated the wound did not look good to her. LPN #501 stated the first day she saw Resident #125's sacral wound was the day he was transported to the hospital Emergency Department. LPN #501 revealed the sacral wound was butterfly shaped, had yellow slough, was purple and had black areas. LPN #501 stated she remembered thinking Resident #125 was not well, stat labwork was not quick in nursing home facilities, and she called Resident #125's physician to have Resident #125 sent to the local hospital. LPN #501 stated Resident #125 was in her assignment routinely when she worked at the facility and no State tested Nursing Assistants (STNA)'s told her his bottom was red. LPN #501 stated Resident #125's wife told her Resident #125 did not activate his call light for help and he was not continent of urine and bowel. Interview on 04/11/23 at 12:00 P.M. with STNA's #502 and #503 revealed they could not remember all the details of Resident #125's wound on his bottom and his care because it was a couple months ago. STNA #503 stated the area on Resident #125's butt was about the size of a quarter, it was black and looked like the skin was ready to fall off. STNA #503 stated she reported the wound to Unit Manager/Registered Nurse (UM/RN) #504 when it was found. STNA #502 and #503 stated they worked together when Resident #125 was provided incontinence care. STNA #503 stated the area on his bottom did get bigger before Resident #125 was transferred to the hospital. Interview on 04/11/23 at 1:56 P.M. with UM/RN #504 revealed all residents should be turned and repositioned if they were not able to do it for themselves. UM/RN #504 stated if a resident required extensive assistance for care and the aides knew the resident needed assistance turning and repositioning then it was automatically initiated. UM/RN #504 stated the facility did not have physician orders for turning and repositioning, and she was not really sure how she could check if residents who need turned and repositioned were getting turned and repositioned because there was no documentation in the resident records regarding turning and repositioning. UM/RN #504 stated she learned of Resident #125's pressure injury on 02/21/23 and charted it on 02/22/23. UM/RN #504 stated Resident #125's deep tissue injury developed quickly. Interview on 04/11/23 at 2:23 P.M. with STNA's #502 and #503 revealed there was nowhere in residents records for the aides to chart turning and repositioning, and the aides knew to do it if a resident was bed bound or had trouble moving about the bed. STNA #502 stated Resident #125 was not always in bed and would sometimes get out of bed with assistance. STNA's #502 and #503 stated Resident #125 was not turned and repositioned before the wound on his sacrum was found, and it was after the wound was found that the aides initiated turning and repositioning. STNA #503 stated Resident #125 was not turned and repositioned before the aides found the wound on his sacrum. Interview on 04/11/23 at 3:21 P.M. with the Administrator revealed turning and repositioning was a standard of care and that was why there were no physician orders or documentation for turning and repositioning in the residents medical records. Interview on 04/12/23 at 10:59 A.M. with Unit Manager/Registered Nurse (UM/RN) #504 confirmed on 02/23/23, Resident #125's treatment to the sacrum was not documented it was completed. UM/RN #504 stated she did not know if the nurse completed the treatment and forgot to document she completed it, or she did not do the dressing change. Review of the facility policy titled Skin Management Guidelines dated, 03/2022 included the purpose was to describe the process steps required for identification of patient's at risk for the development of skin alterations, identify prevention techniques and interventions to assist with the management of pressure injuries and skin alterations. Care plan interventions to consider based upon the Braden risk categories included repositioning, off-loading, heel protection; manage moisture, pressure reduction support surface. If at moderate risk for developing a pressure ulcer, injury add position, maintain 30 degree lateral lying position. 2. Review of Resident #47's medical record revealed an admitted [DATE] and diagnoses included an unstageable right hip pressure ulcer, bipolar disorder, schizophrenia, and multiple sclerosis. Review of Resident #47's care plan dated, 02/10/23 included Resident #47 was at risk for alteration in skin integrity related to impaired mobility, MS (Multiple Sclerosis), and CVA (cerebrovascular accident). Decrease, minimized Resident #47's breakdown risks. Interventions included to encourage to reposition and use assistive devices as needed. Review of Resident #47's Admission MDS 3.0 assessment dated [DATE], revealed Resident #47 had severe cognitive impairment. Resident #47 required extensive assistance of two staff members for bed mobility, transfers, and toilet use. Resident #47 had an indwelling catheter and was frequently incontinent of bowel. Review of Resident #47's Braden Scale For Predicting Pressure Sore Risk dated, 04/01/23 revealed Resident #47 was at moderate risk for developing a pressure ulcer, injury. Review of Resident #47's Mobile Wound Care Provider Program Follow-Up progress notes dated 04/11/23, included Resident #47 had multiple wounds at multiple sites. Wounds were pressure injuries of sacrococcygeal region, unspecified stage, (measurements were length 2.2 centimeters (cm), width 2.8 cm and depth 1 cm), right hip, lateral buttock, Stage 3 (measurements were length of 3.5 cm, width 5 cm, and depth 1.5 cm), left perineal ischial region, Stage 2 (measurements were length 1.5 cm, width 2.5 cm, and depth 0.1 cm). Further review of the progress notes included Resident #47 was previously on a pressure relieving mattress but not at the time of the visit. Staff would obtain another air mattress for Resident #47. The notes stated diligent offloading and repositioning, turning at least every hour. Observation on 04/11/23 at 10:15 A.M. of Resident #47's wound care with Staff Development Coordinator/ Registered Nurse (SDC/RN) #517 and Wound Certified Nurse Practitioner (WNP) #630 revealed Resident #47 had a right hip wound approximately three inches in diameter, a sacral wound about three inches in diameter, and a left ischial wound approximately a half inch by an inch. WNP #630 measured the wounds and a treatment was ordered and completed. Observation revealed Resident #47 was not on a low air loss mattress and this observation was confirmed by WNP #630 and SDC/RN #517. WNP #630 stated Resident #47 was previously in a different room, was transferred to the room she currently resided in temporarily, and was on a low air loss mattress in the original room. WNP #630 stated the low air loss mattress was not transferred to the bed Resident #47 currently was lying in and WNP #630 asked SDC/RN #517 to make sure the low air loss mattress was put on Resident #47's bed. SDC/RN #517 stated Resident #47 went to an appointment recently, and when she returned she was moved to the room she was currently in due to the floor was being waxed. SDC/N #517 stated the bed Resident #47 was lying in did not have a low air loss mattress but this was a temporary bed and Resident #47 would soon be moved back to her original room. WNP #630 stated residents were placed on an air mattress when their pressure wounds were stage three and stage four. Observation on 04/12/23 at 7:45 A.M., 10:38 A.M., and 12:18 P.M. of Resident #47 revealed she was lying in bed, on her back, and the head of the bed was elevated approximately thirty degrees. There was no observation of a low air loss mattress on the bed. There was no observation of staff turning and repositioning Resident #47 or encouraging her to turn and reposition. Interview on 04/12/23 at 12:23 P.M. of State tested Nursing Assistant (STNA) #503 confirmed Resident #47 was lying in bed on her back with the head of the bed elevated, and had been in bed all morning. STNA #503 stated she turned and repositioned Resident #47 while she was in bed with the assistance of STNA #502. Interview on 04/12/23 at 12:21 P.M. with Licensed Practical Nurse (LPN) #501 revealed Resident #47 had an appointment on 04/03/23, she had a procedure where a PEG (percutaneous endoscopic gastrostomy) tube was placed and when she returned on 04/03/23 she was moved to a temporary room due to the floor in her original room was being waxed. LPN #501 was not sure why Resident #47 was not moved back to her original room. LPN #501 confirmed Resident #47 did not have a low air loss mattress on her bed and the air mattress should have been moved to the temporary room. Observation on 04/12/23 at 3:53 P.M. and 4:30 P.M. lying on her back in bed and the head of the bed was elevated about 30 degrees. There was no observation of staff turning and repositioning Resident #47 or encouraging her to turn and reposition. Review of the facility policy titled Skin Management Guidelines dated 03/2022, included the purpose was to describe the process steps required for identification of patient's at risk for the development of skin alterations, identify prevention techniques and interventions to assist with the management of pressure injuries and skin alterations. Care plan interventions to consider based upon the Braden risk categories included repositioning, off-loading, heel protection; manage moisture, pressure reduction support surface. If at moderate risk for developing a pressure ulcer, injury add position, maintain 30 degree lateral lying position. This deficiency represents non-compliance investigated under Complaint Number OH00141200.

Based on interview, record review and review of facility policy, the facility failed to ensure Resident #125's insulin was administered per physician orders. This affected one resident (Resident #125) out of three residents reviewed for insulin administration. The facility census was 122. Findings include: Review of Resident #125's medical record revealed an admitted [DATE] and diagnoses included two part displaced fracture of surgical neck of right humerus, type two diabetes mellitus, and vascular dementia, mild, without behavioral disturbances, psychotic disturbance, mood disturbance and anxiety. Review of Resident #125's Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #125 was cognitively intact. Resident #125 required extensive assistance of two staff members for bed mobility and toilet use. Resident #125 required extensive assistance of one staff member for transfers, and was frequently incontinent of urine and always incontinent of bowel. Resident #125 was administered insulin. Review of Resident #125's care plan dated 02/15/23, included endocrine system related to insulin dependent diabetes. Resident #125's goal would be to minimize, be free of complications related to the disease process. Interventions included to administer medication per physician orders. a. Review of Resident #125's physician orders dated 02/21/23 at 3:07 P.M., revealed orders for Lantus SoloStar (insulin glargine) subcutaneous solution Pen-injector 100 units per milliliter (ml), inject 10 units subcutaneously every morning and at bedtime for diabetes mellitus. Further review of the orders did not reveal orders for blood sugar checks or parameters for blood sugar checks. Review of Resident #125's Medication Administration Record (MAR) revealed on 02/22/23 at 6:00 A.M. there was no documentation Lantus SoloStar Pen-Injector 10 units was administered. Review on 02/23/23 at 9:00 P.M. revealed Resident #125's blood sugar was 467. Review on 02/24/23 at 6:00 A.M. revealed Resident #125's blood sugar was 453. There was no documentation the physician was notified of Resident #125's blood sugars of 467 and 453. b. Review of Resident #125's physician orders dated 02/21/23 at 3:11 P.M., revealed orders for insulin lispro 100 units per milliliter (ml) pen, inject as per sliding scale, if blood sugar was 0 to 150 give 0 units, if blood sugar was 151-200 give 4 units, if blood sugar was 201 to 250 give 6 units, if blood sugar was 251 to 300 give 8 units, if blood sugar was 301 to 350 give 10 units, if blood sugar was 351 to 400 give 12 units, if blood sugar was 401 to 450 give 12 units, if blood sugar was greater than 450 give 14 units and call the physician, inject subcutaneously before meals for diabetes mellitus. Review of Resident #125's blood sugars revealed there were no blood sugar checks before meals on 02/21/23 for the dinner meal, and no blood sugar checks on 02/22/23 before breakfast, lunch, and dinner meal, and on 02/23/23 no blood sugar checks were documented before the breakfast and lunch meal. Review of Resident #125's Medication Administration Record (MAR) dated 02/21/23 through 02/23/23 revealed there was no documentation of insulin administration or blood sugars for the evening meal on 02/21/23, the breakfast, lunch, and evening meal on 02/22/23, and breakfast and lunch on 02/23/23. Review of Resident #125's progress notes dated, 02/23/23 at 5:00 P.M. written by Licensed Practical Nurse (LPN) #501 included Resident #125's blood sugar was 500, insulin not received during the previous shift, physician aware and ordered to administer 14 units insulin lispro 100 units per ml. Interview on 04/12/23 at 3:55 P.M. of LPN #501 revealed LPN #501 remembered Resident #125 did not receive his sliding scale insulin as ordered by the physician. LPN #501 stated she remembered Resident #125 received sliding scale insulin and when it did not pop up to give she started looking into why that occurred, and found Resident #125's sliding scale insulin was not given previously as ordered. LPN #501 stated she confirmed the sliding scale insulin order and called the physician to inform him Resident #125 did not receive his insulin as ordered and she received an order to give insulin 14 units for a blood sugar of 500. Interview on 04/12/23 at 4:00 P.M. with the Director of Nursing confirmed Resident #125's sliding scale insulin was not given according to physician orders. DON confirmed the physician was not notified of blood sugars above 450 when taken before administration of Lantus insulin. Review of facility policy titled Medication Administration: Medication Pass, dated 06/2021, included to administer medication in accordance with frequency prescribed by the physician, within 60 minutes before or after prescribed dosing time. If the resident was not in the room to receive the medication flag the MAR and at the conclusion of the medication pass, roll cart to resident's location and administer medications. Review of Medscape guidance for insulin glargine (Lantus Solostar) undated, revealed to make any changes to a patient's insulin regimen under close medical supervision with increased frequency of blood glucose monitoring. This deficiency represents non-compliance investigated under Complaint Number OH00141329.

Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure a medication error rate of less than 5 percent during the medication observation. This affected three residents (Resident's #7, #27 and #36) out of six residents reviewed for medication errors. The medication error rate was 9.67 percent for three medication errors out of 31 medication observations. The facility census was 97. Findings include: 1. Review of Resident #7's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #7 had moderate cognitive impairment. Resident #7 required the extensive assistance of one staff member for bed mobility and transfers and required the extensive assistance of two staff members for toilet use. Review of Resident #7's care plan dated 05/10/22, included Resident #7 had neurological deficiencies related to spastic [CONDITION(S)], history of [CONDITION(S)] activity, and neuritis. Resident #7 would have reduced risk of [CONDITION(S)] activity or injury. Interventions included to administer medication per physician orders. Review of Resident #7's physician orders dated, 08/08/21 revealed orders for [MEDICATION(S)] 5 mg tablet, give one half tablet by mouth two times a day for muscle spasm. Observation on 06/13/22 at 9:09 A.M. of Licensed Practical Nurse (LPN) #602 administering medications to Resident #7 revealed [MEDICATION(S)] 5 milligram (mg) tablet was not in the medication cart and unavailable to be administered to Resident #7. Interview on 06/13/22 at 3:15 P.M. with LPN #602 revealed [MEDICATION(S)] 5 mg tablet was not available in the automated medication dispensing system. Interview on 06/13/22 at 3:18 P.M. with Resident #7 revealed when she does not receive her [MEDICATION(S)] sometimes and her arms and legs shake. Review of the on-hand medications available in the automated dispensing system did not reveal [MEDICATION(S)] 5 mg tablet. This resulted in one medication error. 2. Review of Resident #27's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #27's Quarterly MDS assessment dated [DATE] revealed Resident #27 had moderate cognitive impairment and required extensive assistance of two staff members for bed mobility, transfers, and toilet use. Review of Resident #27's care plan dated 05/17/22, included Resident #27 had an endocrine system problem related to insulin, dependent diabetes. Resident #27 would have minimized complications related to the disease process. Interventions included to administer medication per physician orders. Review of Resident #27's physician orders dated 10/29/20, revealed orders for [MEDICATION(S)] solution 100 units per milliliter (ml) (insulin [MEDICATION(S)]), inject per sliding scale for blood sugar subcutaneously before meals and at bedtime for diabetes mellitus. Interview on 06/13/22 at 12:25 P.M. with LPN #201 revealed Resident #27 was in the dining room and he would wait for Resident #27 to be transported back to his room before checking his blood sugar and administering insulin if needed. Observation on 06/13/22 at 1:30 P.M. of Resident #27's room revealed he had not returned from the dining room. Interview on 06/13/22 at 3:30 P.M. with State tested Nursing Assistant (STNA) #601, the Administrator and Director of Nursing revealed the lunch meal on 06/13/22 was served at 12:30 P.M. in the resident rooms and at 12:45 P.M. in the dining room. Review of Resident #27's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. was 268 and [MEDICATION(S)] insulin 6 units was administered subcutaneously at 1:45 P. M after lunch. This resulted in one medication error. 3. Review of Resident #36's physician orders dated 07/10/21, revealed orders for [MEDICATION(S)] solution 100 units per milliliter (ml) (insulin [MEDICATION(S)]), inject per sliding scale for blood sugar subcutaneously before meals for diabetes mellitus. Observation on 06/13/22 at 12:57 P.M. of Resident #36 revealed LPN #201 administered 6 units of [MEDICATION(S)] solution insulin subcutaneously for a blood sugar of 297 after lunch. This resulted on one medication error. Review of the facility policy titled, Medication Administration: Medication Pass, dated 03/2010, revealed the purpose was to safely and accurately prepare and administer medications according to physician orders and resident needs. This deficiency substantiates Master Complaint Number OH 162.

Based on interview and record review, the facility failed to ensure the appropriate level of assistance was provided to Resident #27 which result in a fall with minor injury. This affected one resident (Resident #27) of four residents reviewed for falls. Findings include: Review of the medical record for Resident #27 revealed the resident was admitted on [DATE] with diagnoses including type II diabetes, [CONDITION(S)], heart failure and dementia. Review of the Quarterly Minimum Data Set (MDS) 3.0 of 03/27/22 revealed the resident was moderately cognitively impaired, required extensive assist of two for most Activities of Daily Living (ADL), including bed mobility and transferring. Review of Resident #27's care plan of 05/17/22 revealed care areas for risk of falls and assistance with ADL's including two person assist for bed mobility and transfers with a mechanical lift. Review of the fall investigation of 05/29/22 revealed State tested Nursing Assistant (STNA) #100, from a staffing agency, was providing incontinence care to Resident # 27. When the resident was turned onto his left side, he leaned too far and rolled off the bed. He was sent to the hospital for evaluation with minor injuries of a small cut (about 1/2 inch) to his left eyebrow and an even smaller cut to his upper lip. The resident received dissolvable stitches and surgical glue for his cuts. He returned to the facility the same day. A fall intervention added on 05/29/22 by Unit Manager (UM) #300 was to re-educate staff on using two person assist for care while in bed for Resident #27. Interview with on 06/07/22 at 2:51 P.M. with UM #300 revealed STNA #100 was an agency aide, but she should have checked the Kardex binder at the nurse station to see what level of assistance Resident #27 required. All new and agency staff were required to review the Kardex, which detailed what level of assistance residents required, before providing care to residents. The UM verified Resident #27 required assistance of two for bed mobility and STNA #100 should have gotten another staff member to assist her with the resident. Interview and observation on 06/06/22 at 4:35 P. M with Resident #27 revealed a small amount of old surgical glue visible in line with the resident's left eyebrow, with no sign of a scab or open wound and no cut visible on upper lip. Resident #27 reported he fell but suffered no injury other than the small cut above his eye and a small cut to his upper lip. He was in no pain and was unable to provide any details of the fall. Review of the 2011 Fall Practice Guide revealed residents should be assessed for risk of falls with their history of falls and interventions incorporated into the care plan and Carex for staff education and reference. This deficiency substantiates Master Complaint Number OH 162 and Complaint Number OH 860.

Based on observation, interview, record review and review of the facility policy, the facility failed to maintain infection control by ensuring clean, unused mechanical lift slings were used for Resident's #37 and #92 This affected two residents (Resident's #37 and #92) and had the potential to affect all 14 residents (Resident's #4, #9, #17, #22, #27, #33, #35, #37, #41, #66, #82, #86, #92, #98) who required a mechanical lift for transfers. Findings include: Review of Resident #37's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #37's Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #37 was cognitively intact and required the assistance of two staff members for bed mobility, transfers and toilet use. Resident #37 was always incontinent of urine and frequently incontinent of bowel. Review of Resident #37's care plan dated 05/15/22 revealed Resident #37 required assistance to transfer from one position to another related to physical limitations and unsteady balance. Resident #37 would be able to transfer with a mechanical lift and the assistance of two staff members. Interventions included to transfer with a mechanical lift using a large size sling. Resident #37 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #37 would develop no infections. Interventions included to evaluate lung sounds and vital signs as needed and report abnormalities to the physician. Review of Resident #92's medical record revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #92's Quarterly MDS 3.0 assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was not completed due to the resident was rarely or never understood. Resident #92 required the extensive assistance of two staff members for bed mobility, transfers, and toilet use. Resident #92 was always incontinent of urine and bowel. Review of Resident #92 care plan dated 05/05/22, revealed Resident #92 required assistance to transfer from one position to another as evidenced by history of [CONDITION(S)] and weakness. Resident #92 would maintain the ability to transfer self safely. Interventions included to transfer with a mechanical lift with large size sling. Review of the facility list of residents who require the use of a mechanical lift revealed Resident's #4, #9, #17, #22, #27, #33, #35, #37, #41, #66, #82, #86, #92, #98 needed a lift sling. Observation on 06/13/22 at 10:15 A.M. of a mechanical lift in the hallway of the nursing unit with a mechanical lift sling hanging on the lift, and a second mechanical lift was next to the first one in the hallway. Observation of State tested Nursing Assistant (STNA) #600 revealed she removed a mechanical lift sling from underneath Resident #37 after he was transferred to his bed. STNA #600 walked out of the room with the used sling and placed it on the second mechanical lift in the hallway. Observation on 06/13/22 at 11:02 A.M. of STNA #600 and #601 revealed they entered Resident #92's room to transfer her from her bed to a wheelchair. STNA #600 walked to the second mechanical lift with the used sling and pushed the lift into Resident #92's room. After care was provided for Resident #92, STNA #601 picked up the used sling and the pad that was positioned under Resident #92 by STNA's #600 and #601. Resident #92 was transferred to the wheelchair, the sling was removed from underneath her and STNA #600 hung the used sling on the mechanical lift and pushed the lift out of the room into the hall. Interview on 06/13/22 at 11:02 A.M. with STNA's #600 and #601 revealed mechanical lift slings were reused for residents who required a mechanical lift for transfers. STNA #600 confirmed she used the sling for Resident #37 and used the same sling for Resident #92. STNA #600 stated there were not enough mechanical lift slings for each resident to have their own and they did not have a choice but to use the same hoyer pad for more than one resident. STNA #600 stated she knew it was bad for cross contamination to reuse the slings. STNA's #600 and #601 stated they did not know how often the slings were washed, and sometimes when they arrived for work in the morning the slings were hanging on the mechanical lifts and they would be used to transfer the residents that day. STNA's #600 and #601 stated if slings were not hanging on the lifts, the storage room on the nursing unit should have slings in it and if not they could go to the laundry room for the slings. Observation on 06/13/22 at 11:10 A.M. of the storage room for the nursing unit with STNA #601 revealed two clean mechanical lift slings were in the room. STNA #601 stated the slings were sized small and extra large. STNA #601 stated Resident's #37 and #92 required a large sling, and large was the most common size used for the residents and there were none in the storage room. Observation on 06/13/22 at 11:30 A.M. with Environmental Service Manager (ENV) #330 of the laundry area revealed there were a total of three lift pads in the clean area, two small and one large. Further observation did not reveal lift pads in the dirty laundry area. ENV #330 stated more mechanical lift slings were located on the nursing units. Observation on 06/13/22 at 12:30 P.M. of a mechanical lift on a different nursing unit with two slings hanging on it. Licensed Practical Nurse (LPN) #201 confirmed the slings were hanging on the lift. Interview on 06/13/22 at 1:06 P.M. with Unit Manager (UM) #300 and the Director of Nursing (DON) revealed the policy was not to reuse mechanical lift slings for more than one resident. UM #300 stated there are enough slings and the slings had been counted. The DON stated the mechanical lift slings were not to be used for more than one resident, and each resident should have their own sling. The DON stated there were twelve slings in the facility and all sizes were available. The DON stated additional mechanical lift slings had been ordered. Review of the facility policy titled Mechanical Lift revised, 04/2019, included the purpose was to move immobile or obese residents for whom manual transfer poses potential for staff or resident injury.

Based on observation, review of medical records, the facility policy and procedure for skin management, interviews with residents and staff, and interview with Nurse Practitioner (NP) Wound Nurse #621, the facility failed to implement a comprehensive and effective pressure ulcer prevention program to prevent and identify pressure ulcers in a timely manner for Resident's #22, #31, #72, #87 and #102. This resulted in Immediate Jeopardy that was Actual Harm on 03/12/21 when Resident #31, who was a quadriplegic and required two-staff assist with bed mobility and transfers was found with an unstageable (full thickness skin or tissue loss, depth unknown as wound is obscured by slough or eschar) pressure ulcer to his left buttock described with 100 percent slough to the wound bed, a Stage 3 (full thickness tissue loss, with subcutaneous fat may be visible but bone, tendon, or muscle are not exposed) pressure ulcer to his right buttock. Immediate Jeopardy that was Actual Harm occurred on 03/12/21 when Resident #22, who required two-staff extensive assist with bed mobility and transfers, was found to have three Stage three pressure ulcers to her right upper buttock, right lower buttock and left buttock. Immediate Jeopardy that was Actual Harm also occurred on 03/12/21 when Resident #72 who required extensive assist of two staff for bed mobility and transfers was found to have an unstageable pressure ulcer to her coccyx area that was described with 100 percent black eschar (dead tissue) to the wound bed and a stage three pressure ulcer to her left gluteal fold. In addition Immediate Jeopardy occurred on 03/30/21 when Resident #87, who required extensive assist of one staff for bed mobility and extensive assist of two staff for transfers, was found to have a stage three pressure ulcer to her left buttock. Immediate Jeopardy also resulted on 04/09/21 when Resident #102, who required extensive assist of two staff for bed mobility and transfers was found to have a Stage 3 pressure ulcer to her left buttock. This affected five residents (Resident's #22, #31, #72, #87 and #102) of seven residents reviewed for pressure ulcers. The facility identified six current residents (Resident's #22, #31, #32, #36, #72 and #87) with pressure ulcers. On 05/03/21 at 5:00 P.M. the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on 03/12/21 when Resident #31, who was a quadriplegic and required two staff assist with bed mobility and transfers, was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 04/28/21 revealed Resident #31 was not turned or repositioned from 9:32 A.M. to 2:40 P.M. On 03/12/21, Resident #72, who required extensive assist of two staff assist with bed mobility and transfers was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/12/21 Resident #22, who required two-staff extensive assist with bed mobility and transfers, was found to have three Stage 3 pressure ulcers to the upper right buttock, lower right buttock, and left buttock. On 03/30/21 Resident #87, who required extensive assist of one staff with bed mobility and extensive assist of two staff with transfers, was found to have a Stage 3 pressure ulcer to her left buttock. Additionally, on 04/09/21 Resident #102, who required extensive assist of two people for bed mobility and transfers, was found with a Stage 3 pressure ulcer to her left buttock. The Immediate Jeopardy was removed on 05/03/21 when the facility implemented the following corrective actions: · Resident #72 currently has a Stage 3 pressure ulcer to the coccyx that was identified on 03/12/21 with a treatment initiated. A daily body audit is in place that will be completed by a licensed nurse, a support surface (Span Model 5900 air mattress) is in place (the resident does not get out of bed), Medical Doctor (MD) #620 and family are aware, and the resident was assessed by Wound Nurse Practitioner (NP) #621 on 03/16/21 with a change in treatment orders and plan of care. At this time the Stage 3 pressure ulcer remains and is being followed by Wound NP #621 weekly at the facility. Observation on 05/04/21 at 1:36 P.M. verified Resident #72's interventions including the air mattress and daily body audits were in place. · Resident #87 currently has a Stage 3 pressure ulcer to the right buttock that was identified on 03/12/21 as an open area and staged on 03/30/21 by Wound NP #621 at a Stage 3 with a treatment initiated. MD #620 and family were made aware. A daily body audit is in place which will be completed by the licensed nurse, support surfaces are in place (Span Model 5900 air mattress and wheelchair cushion-ROHO), and the resident was assessed by Wound NP #621 on 03/30/21 with new treatment orders written. A care plan is in place. At this time the Stage 3 pressure ulcer remains and is being followed by Wound NP #621 weekly at the facility. Observation on 05/04/21 at 4:05 P.M. verified Resident #87 interventions including the air mattress, ROHO wheelchair cushion and daily body audits were in place. · Resident #31 currently has an unstageable pressure ulcer to the left buttock and a Stage 3 pressure ulcer to the right buttock that merged with the coccyx that were identified on 03/12/21 with a treatment initiated. MD #622 and family were made aware. A daily body audit is in place that will be completed by the licensed nurse. A support surface is in place (Span Model 5900 air mattress), and the resident was seen by Wound NP #621 on 03/16/21 with treatment orders and a plan of care in place. At this time the left buttock and right buttock pressure ulcers remain and are being followed by Wound NP #621 weekly at the facility. Observation on 05/04/21 at 2:04 P.M. verified Resident #31's interventions including the air mattress and daily body audits were in place. · Resident #22 had a right lower buttock Stage 3 pressure ulcer that was identified on 03/12/21 with a treatment initiated. A daily body audit is in place that will be completed by the licensed nurse. Support surfaces are in place (Derma Float LAL air mattress and standard foam wheelchair cushion utilized during family visits when up in chair since her pressure ulcer is now healed as of 05/05/21) utilized during family visits when up in chair). MD #620 and family were made aware. The resident was assessed by Wound NP #621 on 03/16/21 and a plan of care in place. At this time the Stage 3 is healed as of 05/04/21. Observation on 05/04/21 at 1:34 P.M. verified Resident #22 had support surfaces and daily body audits as identified in place. · Resident #102 was discharged from the facility on 04/10/21. · Current residents with pressure ulcers were reviewed by the Quality Assurance (QA) Consultant, Registered Nurse (RN) #623 on 04/29/21 at 2:00 P.M. and reflected on the pressure ulcer audit tool. Observation on 05/04/21 at 1:10 P.M. verified RN #623 completed the pressure ulcer audit tool. · A skin sweep of the current census was completed on 04/29/21 at 2:00 P.M. by the licensed nurses with no new pressure areas identified. Observation on 05/04/21 at 1:15 P.M. verified the facility completed skin sweep on 04/29/21. · On 04/29/21 at 1:00 P.M. the current census was reviewed for orders for body audits, and orders were obtained by the licensed nurses as needed. Observation on 05/04/21 at 1:20 P.M. verified the audit was completed on 04/29/21, and orders were received for identified residents requiring an order to have either a weekly or daily body audit. · On 04/29/21 at 1:00 P.M. the current census was reviewed for Braden completion and accuracy, and new assessments were completed by the licensed nurses as needed on 05/03/21. Observation on 05/03/21 at 1:29 P.M. verified the audit was completed on 05/03/21, and residents requiring a Braden Scale were identified and completed. · A Bed System audit was completed which includes review of the mattress and frame by the Administrator and Environmental Services Supervisor (EVS) Supervisor #624 of the current bed systems in the facility on 05/03/21. No significant findings were identified. Observation on 05/03/21 at 1:40 P.M. verified the audit was completed on 05/03/21. · A wheelchair cushion audit was completed by the Administrator and EVS #624 on current residents who utilize an assistive device (wheelchair, Geri-chair, Broda chair) on 05/03/21. Results of the audit indicated additional cushions were needed for multiple wheelchairs in the center and will be obtained and placed on assistive device which began on 05/03/21 and was completed on 05/04/21 at 2:30 P.M. Reviewed audit that was completed on 05/03/21 that identified no wheelchair cushion for Resident #1, Resident #44, Resident #12, Resident #20, Resident #67, Resident #69, Resident #38, Resident #64, Resident #16, and Resident #76. Observation on 05/04/21 from 3:28 P.M. to 3:42 P.M. revealed wheelchair cushions were in place for the above identified residents. · Quality Assessment and Assurance (QAA) was conducted on 04/29/21 with attendees including Medical Director, Licensed Nursing Home Administrator (LNHA), DON, Quality Assurance Consultant #623, Unit Managers #602, #603 and #618, Licensed Social Service #610, Medical Records #631, Activities Director #617, Minimum Data Set (MDS) Staff #632 and a performance improvement plan discussed and initiated. Observation 05/04/21 at 4:05 P.M. verified QAA meeting was held on 04/29/21 including the above attendees. · Medical Director #622 was notified of a skin concern by the DON on 04/29/21 at 11:00 A.M. Observation on 05/04/21 at 4:10 P.M. verified this was completed on 04/29/21 at 11:00 A.M. · Ad Hoc QAA meeting was conducted on 05/03/21 5:30 P.M. to discuss Immediate Jeopardy findings and plan of correction. Attendees included Administrator, DON, Quality Assurance Consultant #623, Divisional Quality Assurance Consultant #633, Regional Director of Operations #634, General Manager #635, Director of Clinical Services #636, and Assistant Vice President (AVP) of Clinical Services #637. Observation on 05/04/21 at 4:17 P.M. verified QAA meeting was completed on 04/29/21 at 11:00 A.M. · All nursing staff will be educated on the Skin Practice Guide which includes proactive and preventative interventions-support surfaces, positioning devices, turning and repositioning, offloading heels, etc. identification of a new skin alteration- documentation and communication, Weekly and daily body audit completion as ordered, State tested Nurse Aide (STNA) skin observation daily by the DON beginning on 04/30/21 with completion on 05/03/21 11:00 P.M. Any nursing staff member that cannot be educated will be removed from the employee schedule until education has been completed. Observation on 05/05/21 at 10:05 A.M. verified in-services were completed from 04/30/21 to 05/05/21 and 68 nursing staff were educated. The facility has 14 nursing staff remaining that still need in-serviced and they will receive the in-service prior to the next shift they work. Observation and interviews on 05/04/21 from 1:44 P.M. to 3:18 P.M. verified that the following staff were knowledgeable regarding the education: Registered Nurse (RN)/ Unit Manager #618, RN #612, RN #626, RN #607, Licensed Practical Nurse (LPN) # 600, STNA #625, STNA #616, STNA #627, STNA #628 and STNA #629. · A weekly skin sweep will be completed weekly times four weeks by the licensed nurse and reflected on the skin sweep summary. This began on 4/29/2021. Observation 05/04/21 at 4:16 P.M. verified skin sweeps were completed on 04/29/21 with no new findings. · The unit managers will complete random rounds of resident's weekly times four weeks to ensure turning and repositioning is occurring, and this will be reflected on the Skin Quality Assurance and Performance Improvement (QAPI) audit. This began on 05/04/21. · A QAPI meeting will be held weekly times four weeks to review the audits and make further recommendations. After that time, the QAA committee will decide the frequency of the audits. Attendees will include the Administrator, DON, and Medical Director #622 beginning 05/03/21. Although the Immediate Jeopardy was removed on 05/03/21 the deficient practice remained at a severity Level 2 (no actual harm with the potential for minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings included: 1. Review of the medical record for Resident #31 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 11/28/20 revealed Resident #31 had an activities of daily living self-care deficit because he was a quadriplegic with physical limitations. Interventions included extensive assist to total assist required for daily hygiene, grooming and dressing. The resident was totally dependent with bathing and showering as needed. Review of the assessment titled Braden Scale for Predicting Pressure Sore Risk dated 02/13/21 completed by RN #608 revealed Resident #31 was at moderate risk for skin breakdown due to a slight limitation with sensory perception, occasionally moist, completely immobile, and a potential problem with friction and shear. Review of the assessment labeled Pressure Ulcer dated 03/12/21 completed by RN Supervisor #607 revealed Resident #31 had a pressure ulcer to his right buttock that measured 4.0 centimeters (cm) in length by 2.0 centimeters in width by 0.1 cm in depth. The area to his right buttocks was described as red with moist tissue present with scant bleeding. The area to his left buttock measured 2.0 cm in length by 1.2 cm in width by 0.1 cm in depth. The area contained slough with clear yellow drainage. The assessment did not stage the areas. The assessment revealed extrinsic risk factors included Resident #31 required assistance to move, was confined to the bed or chair all or most of the time, required regular schedule for turning, and was persistently wet from incontinence. Review of the nurses note dated 03/12/21 at 2:07 P.M. authored by RN/ Unit Manager #602 revealed during skin audits, the nurse found two open areas to Resident #31's buttocks. Resident #31 had an unstageable pressure ulcer to his left buttock that measured 2.0 cm in length by 1.2 cm in width and the depth was unable to be determined. The wound bed contained 100 percent slough. Resident #31 was also found to have a Stage 3 pressure ulcer to his right buttock that measured 4.0 cm in length by 2.0 cm in width by 0.1 cm in depth. The area contained 100 percent granulation tissue. RN/ Unit Manager #602 notified the physician and obtained treatment orders, notified the family, updated the care plan, and added Resident #31 to weekly wound rounds. Review of the care plan dated 03/15/21 revealed Resident #31 had an unstageable pressure ulcer to his left buttock related to diabetes, friction, impaired mobility, and incontinence. Interventions included encourage and assist as needed to turn and reposition, and pressure reducing surface to bed and wheelchair. Review of the care plan dated 03/15/21 revealed Resident #31 had a Stage 3 pressure ulcer to his right buttock related to diabetes, friction, impaired mobility, and incontinence. Interventions included encourage and assist as needed to turn and reposition, and pressure reducing surface to bed and wheelchair. Review of the Wound NP #621 progress note dated 03/16/21 at 2:31 P.M. revealed Resident #31 was evaluated and had a Stage 3 pressure ulcer to his right buttock measuring 2.5 cm in length by 1.5 cm in width by 0.1 cm in depth. The ulcer to his right buttock was described as full thickness loss with the wound color described as 80 percent red tissue and 10 percent yellow tissue. He also had an unstageable pressure ulcer to his left buttock measuring 1.5 cm in length by 1.0 cm in width, and the depth was unable to be determined. The pressure ulcer to his left buttock contained 100 percent yellow adherent tissue. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #31 had impaired cognition, and he displayed no behaviors including rejection of care. He required extensive assist of two staff for bed mobility, and toileting. He required assistance of two staff to transfer but that activity only occurred once or twice during the seven-day assessment period. He was unable to ambulate. He was at risk for pressure ulcers, and he had one Stage 3 pressure ulcer which was not present on admission and one unstageable pressure ulcer which was also not present on admission. Interview and observation on 04/28/21 at 9:32 A.M. revealed Resident #31 was lying on his back on a pressure reducing mattress. Resident #31 stated he was not turned as he needed to be, and he believed this was why he developed the sores on his bottom. The resident revealed someday's he laid in the same position all day long and if he put his call light on the staff would not come to turn him. Observation on 04/28/21 at 11:19 A.M. revealed Resident #31 remained in the same position lying on his back in bed. Observation on 04/28/21 at 1:10 P.M. revealed Resident #31 remained in the same position lying on his back in bed. Interview and observation on 04/28/21 at 2:40 P.M. revealed Resident #31 remained in the same position lying on his back in bed. Resident #31 stated nobody had been in to turn him like he said this morning, they do not turn me side to side as they should, and it is an everyday thing anymore. He believed this was why he developed the sores on his bottom. Interview on 04/28/21 at 2:47 P.M. with Agency STNA #605 revealed she was assigned as the aide for Resident #31. She stated, he is right, I have not been in there to turn him today. She revealed she was unable to make it to everyone as she did not feel there was enough staff to ensure the residents were turned as they needed to be. She revealed she did not realize he had pressure ulcers. 2. Review of the closed medical record for Resident #102 revealed an admitted [DATE] and discharge date of [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #102 was rarely or never understood and had no behaviors documented. She required extensive assist of two staff to assist with bed mobility and toileting. Resident #102 required two staff to assist with transfers, but this activity only occurred once or twice during the seven-day assessment period. She was at risk for pressure ulcers but had no pressure ulcers at the time of the assessment. Review of the assessment titled Braden Scale for Predicting Pressure Sore Risk dated 04/03/21 revealed Resident #102 was at moderate risk for skin breakdown. Factors included slight limitation in sensory perception, occasionally moist, chair fast, very limited mobility, inadequate nutrition and a potential problem with friction and shearing. Review of the assessment titled Pressure Ulcer dated 04/09/21 and completed by RN/ Unit Manager #602 revealed Resident #102 was found to have a Stage 3 pressure ulcer to her left buttock measuring 3.4 cm in length by 2.0 cm in width by 0.1 cm in depth. The wound contained 30 percent slough and 70 percent granulated tissue. The assessment revealed extrinsic factors that included she required staff assistance to move, confined to a bed or chair most of the time, and required a regular turning schedule. Review of the nurses note dated 04/09/21 at 12:10 P.M. and authored by RN/ Unit Manager #602 revealed Resident #102 was found to have a new pressure ulcer to her left buttock measuring 4.0 cm in length by 2.0 cm in width by 0.1 cm in depth. The wound contained 30 percent slough and 70 percent granulation tissue with scant amount of serosanguinous drainage (thin, pink, watery). The nurses note revealed the resident was to be repositioned every two hours, to be placed back into bed after meals, and pressure reducing mattress and cushion to wheelchair. Review of the care plan dated 04/09/21 revealed Resident #102 had a pressure ulcer to her left buttock related to immobility. Interventions included treatment as ordered, pressure redistributing support surface, and repositioning with all activities of daily living. 3. Review of the medical record for Resident #22 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the assessment titled Braden Scale for Predicting Pressure Sore Risk dated 10/19/20 and completed by RN/ Unit Manager #603 revealed Resident #22 was at moderate risk for skin breakdown due to being moist, chair fast, slightly limited with mobility, probable inadequate nutrition and a problem with friction and shearing. Review of the nurse's notes dated 03/11/21 at 2:20 P.M. and authored by LPN #601 revealed a skin assessment indicating two open areas were noted to her right buttocks that were reddened and moist inside. One area measured 2.5 cm in length by 1.0 cm in width, but no depth was documented, and the other area measured 1.5 cm in length, by 1.0 cm in width and no depth was documented. There was no documentation regarding the stage of the wounds. Review of the assessment titled Pressure Ulcer dated 03/12/21 and competed by RN/ Unit Manager #602 revealed Resident #22 was found with three pressure ulcers. The right upper buttock was a Stage 3 and measured 3.5 cm in length by 2.8 cm in width by 0.1 cm in depth and described as beefy red. A Stage 3 pressure ulcer to her right lower buttock measured 2.2 cm in length by 1.7 cm in width and 0.1 cm in depth and described as dark red. She also had a pressure area to her left buttock which was a Stage 3 that measured 2.0 cm in length by 1.7 cm in width by 0.1 cm in depth and described as beefy red. The assessment revealed extrinsic risk factors including the resident required staff assistance to move, confined to a bed or chair most of time, required regular schedule for turning and persistently wet from incontinence. Review of Wound NP #621's progress note dated 03/16/21 at 2:15 P.M. revealed she evaluated Resident #22, and she had a upper right buttock Stage 3 pressure ulcer measuring 3.0 cm in length by 2.3 cm in width by 0.1 cm in depth and was described as a full-thickness pressure ulcer that was red and moist. She had a Stage 3 pressure ulcer to her lower right buttock measuring 1.7 cm in length by 1.3 cm in width by 0.1 cm in depth and described as a full-thickness pressure ulcer that was red and moist. She also had a Stage 3 pressure ulcer to her left ischial area measuring 2.6 cm in length by 1.0 cm in width by 0.1 cm in depth and described as a full-thickness pressure ulcer that was red and moist. Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #22 had intact cognition. She required extensive assist of two staff with bed mobility, and transfers. She was unable to ambulate. She was at risk for pressure ulcers and had two Stage 3 pressure ulcers which were not present on admission. Interview on 04/28/21 at 9:41 A.M. with Resident #22 revealed she felt she was turned as needed and had no concerns regarding her pressure areas. Observation on 04/28/21 at 11:01 A.M. of a dressing change for Resident #22 revealed RN/ Unit Managers #602 and #603 completed the dressing change as ordered, and no concerns were identified on observation of the dressing change. 4. Review of the medical record for Resident #72 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the assessment titled Braden Scale for Predicting Pressure Sore Risk V2 dated 01/31/21 for Resident #72 revealed she was at risk for skin breakdown with factors including occasionally moist, chair fast, limited mobility, probable inadequate nutrition and had a potential problem with friction and shearing. Review of the care plan dated 12/27/20 revealed Resident #72 had an activities of daily living self-care deficit as evidenced by her needed assistance due to disease process and physical limitation. She required two staff to assist with bed mobility. Review of the care plan dated 02/13/20 revealed Resident #72 was resistive and non-compliant with treatment and care as she refused to get out of bed and refused turning and repositioning related to personal preference. Interventions included if she resisted care leave and return later, provide education about risks of not complying with therapeutic regimen which included risk of pressure ulcers, and allow flexibility in activities of daily living to accommodate preferences. Review of the nurse's note dated 03/12/21 at 2:22 P.M. revealed Resident #72 was discovered with a facility acquired unstageable pressure ulcer to her coccyx and a Stage 3 pressure ulcer to her left gluteal fold. The coccyx pressure area was documented as unstageable and measured 1.5 cm in length by 0.5 cm in width and unable to determine depth as the area had 100 percent eschar. A Stage 3 pressure ulcer to the left gluteal fold measured 6.0 cm in length by 4.0 cm in width and 3.0 cm in depth. The area contained 50 percent slough and 50 percent granulated tissue. The physician and family were notified, and the care plan was updated. Review of the assessment titled Pressure Ulcer dated 03/12/21 revealed Resident #72 had a pressure ulcer to her coccyx area measuring 0.2 cm in length by 0.1 cm in width by less than 0.1 cm in depth and described the area as a dry, black area with no drainage. The assessment revealed a pressure ulcer to the right gluteal fold measuring 7.0 cm in length by 4.0 cm in width by 0.1 cm in depth. The assessment did not stage the pressure ulcers but revealed extrinsic risk factors including staff assistance to move, confined to a bed or chair, and required a regular turning schedule. Review of the care plan dated 03/15/21 revealed Resident #72 had an unstageable pressure ulcer to the coccyx related to friction, impaired mobility, and incontinence. Interventions included encourage and assist as needed to turn and reposition, pressure reducing surface to wheelchair and bed, and administer treatment as ordered. Review of Wound NP #621's progress note dated 03/16/21 at 6:48 P.M. revealed she evaluated Resident #72 due to a Stage 3 pressure ulcer to her left ischial (right gluteal fold) that measured 4.5 cm in length by 5.0 cm in width by 0.1 cm in depth. The wound was described as full-thickness loss and 100 percent red in color. Wound NP #621 also evaluated a pressure ulcer to the coccyx area and described the ulcer as a Stage 2 measuring 4.0 cm in length by 12.0 cm in width by 0.1 cm in depth with 50 percent pink tissue and 50 percent red tissue. Review of the significant change MDS 3.0 assessment dated [DATE] revealed Resident #72 had impaired cognition. She had no behaviors documented including resistance to care. She required extensive assist of two staff for bed mobility and transfers. She was unable to ambulate. She was at risk for pressure ulcers and had two unhealed Stage 3 pressure ulcers that were not present on admission. Attempted interview on 04/30/21 at 9:44 A.M. with Resident #72 was unsuccessful due to impaired cognition. 5. Review of the medical record for Resident #87 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 05/01/20 revealed Resident #87 had an activities of daily living deficit as evidenced by her need for assistance related to weakness and peripheral vascular disease. Interventions included extensive to total assist of one to two staff with bed mobility and a stand-up lift for transfers. Review of the care plan dated 12/10/20 revealed Resident #87 was at risk for alteration in skin integrity related to impaired mobility, history of pressure ulcers, and incontinence. Interventions included encourage to reposition as needed, observe skin condition with activities of daily living, and pressure redistribution mattress on bed and wheelchair. Review of the assessment titled Braden Scale for Predicting Pressure Sore Risk V2 dated 01/12/21 revealed Resident #87 was at risk for developing pressure ulcers due to she was occasionally moist, chairfast, slightly limited with mobility, and had a potential problem with friction and shearing. Review of the quarterly MDS 3.0 assessment dated [DATE] for Resident #87 revealed she had intact cognition. She had no behaviors. She required extensive one staff assist with bed mobility and extensive two staff assist with transfers. She was at risk for pressure ulcers and had no pressure ulcers during the assessment period. Review of the nurse's note dated 03/30/21 at 1:21 P.M. and authored by RN/ Unit Manager #618 revealed a Stage 3 pressure ulcer to her left buttock measuring 0.5 cm in length by 0.5 cm in width by 0.1 cm in depth. The wound was described as 50 percent red and 50 percent yellow. The pressure ulcer to her right buttock she already had on 03/10/21 was assessed and was a Stage 3 measuring 4.0 cm in length by 1.5 cm in width by 0.2 cm in depth. The wound was described as 100 percent red. Review of Wound NP #621's progress note dated 03/30/21 at 10:58 P.M. revealed she evaluated Resident #87 and documented Resident #87 had a Stage 3 pressure ulcer to her right buttock measuring 4.0 cm in length by 1.5 cm in width by 0.2 cm in depth. The right buttock pressure ulcer was described as full-thickness loss, and the tissue color was red and moist. She also documented Resident #87 had a Stage 3 pressure ulcer to her left buttock measuring 0.5 cm in length by 0.5 cm in width by 0.1 cm in depth. She described the left buttock pressure ulcer as full-thickness loss which was red and moist. Review of the care plan dated 03/30/21 revealed Resident #87 had a pressure ulcer to her right and left buttocks related to incontinence, impaired mobility, and resistance of offloading when up in chair. Interventions included administer treatments as ordered, reposition with activities of daily living, specialty mattress and incontinence management. Interview on 04/28/21 at 1:11 P.M. with STNA #604 revealed many residents required two staff assist and residents were not turned every two hours as they should be. Interview on 04/28/21 at 1:30 P.M. with RN/ Unit Manager #602 verified on 03/12/21 Resident #31's pressure area to the left buttock was discovered at unstageable as the wound bed contained 100 percent slough, and the pressure ulcer to the right buttock was discovered at Stage 3. RN/ Unit Manager #602 verified Resident #102 was at an appointment and verified the physician discovered the Stage 3 pressure ulcer to her left buttock during that office visit. RN/ Unit Manager #602 verified Resident #22 was discovered with three Stage 3 pressure ulcers as she documented on 03/12/21. She verified there had been an increase in facility acquired pressure ulcers as she did not feel there was sufficient staff to ensure the residents were turned and repositioned appropriately. She stated, I guarantee the increase based on staffing, we try to hire just nobody to be hired. Interview on 05/03/21 at 8:48 A.M. with STNA #611 revealed she had worked at the facility for two years and felt since COVID-19 the facility did not have enough staff to enable them to turn and reposition residents every two hours or as needed. She revealed

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated [DATE], Nursing Home Guidance from the Centers for Disease Control (CDC), review of the facility's Coronavirus Disease 2019 (COVID-19) policy and procedure, review of the facility's Coronavirus (COVID-19) employee testing report, review of the facility's daily COVID-19 Focused Employee Temperature and Signs/Symptoms Log and Authorized Visitors Screening Temperature and Sign/Symptoms Log, review of daily resident census reports, observations, record review, and staff interview, the facility failed to implement effective and recommended infection control practices, including following CDC guidelines for restricting staff and visitors from the facility for suspected or confirmed COVID-19 positive symptoms or exposure, and failed to ensure the proper use of personal protective equipment (PPE) to prevent the spread of COVID-19 within the facility. This resulted in Immediate Jeopardy on [DATE] when the facility permitted Nurse Practitioner (NP) #500 to enter the building to see residents after indicating on the facility screening tool that they were awaiting COVID-19 test results that were conducted as a result of experiencing symptoms or due to an exposure, and that they were exposed to someone with COVID-19 in the previous 14 days when they were not wearing PPE or a mask. On [DATE], [DATE], and [DATE] the facility continued to permit the entry of Mobile X-Ray Technician (MXT) #501 and MXT #502 into the resident care areas and throughout the facility even though they indicated on the facility screening tool that they had been diagnosed with [REDACTED]. From [DATE] to [DATE], the facility failed to identify 13 staff members who indicated on the facility screening tool that they had symptoms related to COVID-19, and they were permitted to work, as well as four people who did not complete the screening process and were permitted entrance into the facility. This continued between [DATE] and [DATE] when the facility failed to identify 10 staff members who indicated on the facility screening tool that they had signs and symptoms related to COVID-19 and they were permitted to work, and 48 people who did not complete the screening process who were permitted entrance into the facility. In addition, on [DATE] the facility failed to ensure Dietary Staff (DS) #261 and State tested Nursing Assistant (STNA) #203 wore masks as required or personal protective equipment (PPE) appropriately. On [DATE], Lab Technician (LT) #260 also did not wear a mask appropriately as required. According to the facility COVID-19 records, between [DATE] and [DATE], 71 residents tested positive for COVID-19 while residing in the facility: 57 residents recovered, and 14 residents expired after their COVID-19 diagnosis. In addition, between [DATE] and [DATE], 35 staff members tested positive for COVID-19. The lack of implementation of effective facility screening procedures and infection control practices placed all facility residents at risk for serious life-threatening harm, complications, and/or death related to the facilities failure to control the spread of COVID-19. The facility census was 91 residents. The administrator was notified on [DATE] at 4:14 P.M. that an Immediate Jeopardy began on [DATE] when NP #500 was permitted entrance into the facility even though they indicated on the screening tool that they were awaiting COVID-19 test results conducted as a result of experiencing symptoms or due to exposure. In addition, observations on [DATE] and [DATE] revealed the facility failed to ensure a visiting lab technician and staff members wore PPE (masks) appropriately as required in the facility. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE] the Administrator immediately re-educated the facility receptionist who were identified as non-compliant to the screening process. They were also re-educated on [DATE] by Corporate Quality Assurance Consultant (CQAC) #400. · On [DATE], CQAC #400 began educating all facility staff on the COVID-19 Employee Communication with completion planned for [DATE]. Any facility staff member that cannot be educated will be removed from the employee schedule until education has been completed by the Administrator or the Director of Nursing. · On [DATE], Registered Nurse (RN) #262 began educating all facility staff on the facility's screening process upon entry to the facility and upon exit, with completion planned for [DATE]. Any facility staff member that cannot be educated will be removed from the employee schedule until education has been completed by the Administrator or the Director of Nursing. · On [DATE], CQAC #400 began educating all facility staff with return demonstration on the proper donning and doffing of PPE to include masks, both surgical and N95, face shields, gloves, and gowns, with completion planned for [DATE]. Any facility staff member that cannot be educated with return demonstration will be removed from the employee schedule until education and return demonstration has been completed by the Administrator or the Director of Nursing. · On [DATE], the CQAC #400 educated all facility staff assigned to complete employee, visitor and vendor screening on the proper process for screening to include validation of correct application of PPE, and immediate notification to Nursing Home Administrator and/or Director of Nursing when abnormal symptoms are identified or non-compliance to PPE usage is identified. · On [DATE], the facility COVID-19 screening process was revised by the administrator to include 24-hr coverage of the front desk as well as social distance markings on the front lobby floor. If the administrator and/or the director of nursing are unavailable, staff will notify the nurse supervisor on shift who will then notify the administrator and/or director of nursing by phone of any reported symptoms. · On [DATE], the Administrator notified the Medical Director of the Immediate Jeopardy and the corrective action plan. · On [DATE], the Administrator and/or Director of Nursing began monitoring the facility staff assigned to complete employee, visitor and vendor screening. Random monitoring will continue five times a week for four weeks to ensure screening is completed as educated above through [DATE] and will continue randomly on a weekly basis thereafter. · On [DATE] the Administrator and/or the DON will conduct random rounds utilizing the COVID-19 Focused Infection Control Tool, to ensure employees, visitors, and/or vendors are wearing PPE appropriately. These random rounds will be conducted 5 times a week for 4 weeks through [DATE] and will continue randomly on a weekly basis thereafter. · As of [DATE], 11 dietary staff, 10 environmental staff, 21 RNs, 19 licensed practical nurses (LPNs), 47 STNAs, four activity staff, six therapy staff, seven department heads, and four administrative staff were educated regarding the COVID-19 Employee Communication, the facility's screening process, and proper donning/doffing of PPE. There are three PRN (as needed) RNs, one LPN on a leave of absence, one PRN STNA, and six PRN therapy staff yet to be educated. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of facility communication with the local health department revealed an email dated [DATE] that was sent from RN #215 to the nurse at the local health department that listed 12 resident names as new positive COVID-19 cases at the facility. Interview on [DATE] at 10:16 A.M. with RN #222 (who tracks infection control data at the facility) regarding this e-mail revealed a facility COVID-19 outbreak occurred at the facility in [DATE]. RN #222 said she managed the infection control programs at the facility, however, she tested positive for COVID-19 on [DATE], so RN #215 covered for her until she returned on [DATE]. Interview on [DATE] at 2:28 P.M. with the Administrator and Director of Nursing revealed the facility had performed mandatory COVID-19 testing on all residents and staff every two weeks in August (on [DATE] and [DATE]), and then weekly beginning [DATE], except for [DATE] when the staff specimens were not processed as they had expired after being placed in the wrong refrigerator for collection. Review of the resident COVID-19 testing reports from [DATE] to [DATE] revealed 71 facility residents tested positive for COVID-19. Further review revealed 14 of the 71 residents expired after testing positive for COVID-19. Review of the facility employee COVID-19 testing reports revealed 35 staff members tested positive for COVID-19 between [DATE] and [DATE]. Review of the facility screening process and screening tools used for all staff, health care providers, vendors, and visitors revealed the facility did not ensure staff and visitors completed the screening tools as directed on the form instructions. The facility failed to implement an effective process to screen individuals entering the facility in order to identify those with [DIAGNOSES REDACTED]. There was also a lack of evidence that there was a clinical review of the individual who indicated symptoms on the screening tools prior to their entrance into the facility. According to the screening form instructions and interviews with Staff Development (SD) #262 on [DATE] at 1:36 P.M. and RN #263 on [DATE] at 1:32 P.M., if the individual coming into the facility has indicated they have symptoms, the RN Supervisor is to review the symptoms and determine if the individual can enter the facility Review of facility screening tool titled Authorized Visitors Screening Temperature and Sign/Symptoms Log, revealed the following individuals checked the box below or responded Y or Yes under the screening questions. According to the explanation on the form Any visitor who answers yes to any of the screening questions will have visit suspended. · On [DATE], a visiting Nurse Practitioner (NP) #500 checked the boxes beneath the following questions: Are you awaiting COVID-19 test results that were conducted as a result of experiencing symptoms or due to an exposure? and Have you been exposed to anyone with COVID-19 in the previous 14 days when you were not wearing PPE (mask)? · On [DATE], Mobile X-ray Technician (MXT) #501 indicated Yes to Have you ever been diagnosed with [REDACTED]. Record review confirmed MXT #501 had visited Resident #41 on that date. · On [DATE], MXT #501 indicated Yes Last Month to Have you ever been diagnosed with [REDACTED].? Record review confirmed MXT #501visited Residents #18 and #59 on that date. · On [DATE], MXT #501 indicated Y to Have you ever been diagnosed with [REDACTED]. Record review confirmed MXT #501 visited Resident #15 on that date. · On [DATE], MXT #502 indicated Y to Have you ever been diagnosed with [REDACTED]. Review of resident records revealed positive COVID-19 testing results for the following residents: Resident #18 (dated [DATE]); Resident #59 (dated [DATE]); Resident #41 (dated [DATE]); and Resident #15 (dated [DATE]). Record review of Quality Assurance and Performance Improvement Committee Meeting dated [DATE], attended by the Administrator, Director of Nursing (DON), and Medical Director, revealed a facility trend of new positive COVID-19 cases in residents and staff, concerns with PPE guidelines, and inconsistent use of the facility screening logs including staff self-documenting. Interview on [DATE] at 2:11 P.M. with the Administrator confirmed the above findings and verified a quality assurance process was created for facility screening in [DATE] after identifying the receptionist was not actively involved and staff were working without being screened. Review of the facility screening tools dated [DATE] to [DATE] revealed there were 33 staff members who entered the facility after they indicated on the screening tool that they had symptoms of COVID-19. There was no evidence that the RN Supervisor evaluated these staff members prior to their entry into the facility for work. In addition, between [DATE] and [DATE], 21 screening tools were incomplete facility staff and visitors that came into the facility during this time frame. The screening forms did not provide the necessary information for a proper screening of all individuals entering the facility in order to prevent the possible spread of COVID-19 in the facility. Interview on [DATE] at 9:05 A.M. with RN #215 confirmed as interim Director of Nursing she was responsible for the care of the residents who were positive with COVID-19 from [DATE] to [DATE]. RN #215 verified the screening process was completed by supervisors when no receptionist was available but in August and September it was discovered staff were self-screening or not screening at all. RN #215 confirmed when staff indicated symptoms, temperatures were taken twice daily and they continued to work unless they had a temperature, but if there were two or more symptoms or a fever they would not work and one symptom and no fever they would work. RN #215 also verified she had addressed problems with staff on second shift in [DATE] for not wearing PPE as required because they were just not taking it serious. RN #215 confirmed the [DATE] mandatory staff COVID-19 tests were not processed because the agency nurse acting as Director of Nursing mixed up which laboratory to send the specimens, so the specimens were placed into the wrong refrigerator and not picked up. Interview on [DATE] at 1:28 P.M. with Human Resources (HR) #213 verified staff must be symptom free for three days before returning to work or COVID-19 tested after sent home during the screening process for symptoms. HR #213 indicated she does not review the screening sheets and was told about the information on them. Interview on [DATE] at 1:36 P.M. with Staff Development #262 verified staff was trained within the past week on the screening process, and managers review all staff symptoms which would be indicated on the screening sheets and indicate whether the staff are sent home. Interview with the Administrator on [DATE] at 4:11 P.M. and [DATE] at 8:55 A.M. verified the previous findings relative to documentation on the facility screening logs (Focused Employee Temperature and Signs/Symptoms Log and Authorized Visitors Screening Temperature and Sign/Symptoms Log) Observation on [DATE] at 8:35 A.M. revealed the following sign posted on the facility entrance doors of the lobby: Attn:: Staff -Staff must have a mask on when entering the building!! No EXCEPTIONS!!! Observation on [DATE] at 2:35 P.M. revealed Dietary Staff #261 entered the facility lobby without wearing a mask and conducted screening procedures with Receptionist #262 and Receptionist #209. Afterward, Dietary Staff #261 exited the facility through the first set of lobby doors. Interview with Dietary Staff #261 at the time of the observation confirmed Dietary Staff #261 discarded his mask prior to leaving the kitchen and verified he did not wear a mask after leaving the kitchen, during the screening process, and while exiting the facility as required. Interview on [DATE] at 2:41 P.M. with Receptionist #262 and Receptionist #209 confirmed Dietary Staff #261 did not wear a mask while in the facility as required, and further verified it was not addressed during the screening process. Observation on [DATE] at 3:00 P.M. revealed STNA #203 entered the first floor hallway from the secured employee area with a mask positioned underneath his chin and not covering his mouth or nose, and walked toward the facility elevators. Interview on [DATE] at 3:21 P.M. revealed STNA #203 verified he had placed the mask underneath his chin and did not wear it appropriately as required. STNA #203 further verified wearing a mask was required in all areas of the facility except the employee breakroom while eating, and it must cover the mouth and the nose. Observation on [DATE] at 8:33 A.M. revealed Lab Technician (LT) #260 conducted the screening process at the facility front desk with Receptionist #262, while talking on a cell phone with a mask placed underneath their chin. The Administrator was observed monitoring the screening process. LT #260 was observed to complete the screening process with Receptionist #262, and with the mask still placed underneath the chin, LT #260 walked away from the front desk toward the facility elevators. Interview with LT #260 at the time of the observation confirmed the mask was underneath their chin and LT #260 said the mask would be worn as she liked. Interview with Receptionist #262 at the time of the observation verified LT #260's mask was not covering the mouth or nose and Receptionist #262 did not address it during the screening process. Interview on [DATE] 8:50 A.M. with Administrator and DON confirmed LT #260 did not wear the mask as required, responded inappropriately, and was educated to correctly wear a mask while in the facility. Interview on [DATE] at 9:13 A.M. with RN #102 revealed wearing PPE (mask) was required while in the facility, and if staff had symptoms during screening, they must be symptom free for three days or cleared to return to work. Interview on [DATE] at 1:32 P.M. with RN #263 revealed the facility had a COVID-19 outbreak in mid-August and the facility started losing staff and residents. RN #263 verified staff were required to wear PPE (mask) while in the facility, and if staff had symptoms during screening, they were sent home immediately with a note written on the screening sheet. Interview on [DATE] at 2:01 P.M. with STNA #265 revealed PPE (masks) were worn everywhere in the facility except when eating lunch in the break room. STNA #265 was unable to recall the last training on the screening process. Interview on [DATE] at 2:29 P.M. with RN #266 revealed there was a COVID-19 outbreak in [DATE] which made staffing a problem and care took longer. RN #266 verified PPE (masks) were worn while in the facility, training on screening was completed within the last few days, and if staff indicated symptoms, they were sent home and Human Resources approved them to return to work. Interview on [DATE] at 3:04 P.M. with STNA #219 revealed PPE (masks) were worn while in the facility except when eating in the break room. STNA #219 said she had tested positive for COVID-19 and believed she caught it from a resident who was positive and only surgical masks were worn at the time. Interview on [DATE] at 3:17 P.M. with STNA #100 confirmed she had tested positive for COVID-19 in [DATE] and many staff had been off for two weeks, which made work take longer. STNA #100 verified she reported symptoms and was told to work since she had no fever but kept reporting symptoms to the interim Director of Nursing but when her positive COVID-19 test results returned then she was removed from work. STNA #100 indicated training on the screening process was completed on [DATE]. Review of facility policy, Standard Precautions, dated ,[DATE], revealed wear mask, eye protection or face shield to protect mucous membranes of the eyes, nose and mouth. Review of facility policy, Coronavirus Disease 2019 (COVID-19), dated [DATE], revealed employees with symptoms who have confirmed direct exposure to the Coronavirus Disease 2019 (COVID-19) and who were not wearing appropriate PPE at the time of exposure should be referred to their Health Care Provider or COVID-19 testing location for COVID-19 [MEDICATION NAME] testing, and those employees will be placed on a quarantine from the time of their last known exposure until results of their test are known. Review of the Department of Health and Human Services, Centers for Medicare and Medicaid (CMS) Memo QSO ,[DATE]-ALL dated [DATE] revealed CMS is committed to taking critical steps to ensure America's healthcare facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (COVID-19). As part of CMS guidance, the Focused Infection Control Survey was made available to every provider in the country to make them aware of infection control priorities during this time of crisis, and providers may perform a voluntary self-assessment of their ability to meet these priorities. The Quality, Safety and Oversite Group (QSO) Memo included additional instructions to nursing homes. We are disseminating the Infection Control survey developed by CMS and Centers for Disease Control (CDC) so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of COVID-19. We also encourage nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and whom possible incidents of communicable diseases or infections should be reported (42 CFR 483.80 (a) (2) (i) and (ii). Review of the Centers for Disease Control (CDC) Strategies to Mitigate Healthcare Personnel Staffing Shortages, updated [DATE], revealed if healthcare personnel develop even mild symptoms consistent with COVID-19, they must cease patient care activities and notify their supervisor or occupational health services prior to leaving work. These individuals should be prioritized for testing. This deficiency substantiates Complaint Numbers OH 786, OH 716, and OH 238.

Based on interview and record review the facility failed to provide Resident #1 with a two person assist per her care plan for bed mobility during incontinence care and failed to properly position the resident during care. Actual harm occurred when one staff provided incontinence care, rolled the resident away from self and Resident #1 fell out of bed resulting in a closed [MEDICAL CONDITION] end of the tibia, fractures to the nasal bone and a facial laceration. This affected one resident (Resident #1) of three residents reviewed for falls and accidents. The facility census was 138. Findings include: Review of the medical record for Resident #1 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #1's care plan dated 01/04/18 revealed she had an activities of daily living deficit related to limited mobility. Interventions included assist with daily hygiene, grooming, dressing, oral care and eating as needed with extensive assist of two person assist for bed mobility and toileting. Review of the significant change Minimum Data Set 3.0 (MDS) assessment, dated 05/10/19, revealed Resident #1 had a brief interview for mental status (BIMS) score of a 13 indicting she was cognitively intact. She had no behaviors. The resident required extensive assist of one person with bed mobility and toileting. She was totally dependent of two people with transfers. She was unable to ambulate. She was always incontinent of bowel and bladder. Review of a nursing note authored by Registered Nurse (RN) #701 dated 07/21/19 at 9:50 P.M. revealed Resident #1 fell out of bed during hygiene care. The resident complained of pain to her neck, and legs and had cuts to her mouth and bridge of her nose. The resident had range of motion to her arms. The nurse did not attempt range of motion to her legs or neck. The nurse stabilized the resident's neck until the emergency rescue squad arrived and brought her to the local emergency room . Review of a nursing note authored by Licensed Practical Nurse (LPN) #607 dated 07/21/19 at 11:45 P.M. revealed the nurse was notified by the state tested nursing assistant (STNA) that Resident #1 fell out of bed while STNA (#606) was performing care. The nurse entered Resident #1's room and witnessed her on the floor next to the bed with blood coming from her face. She was stabilized on the floor and the emergency rescue squad was notified to transport her to the hospital. She complained of pain to her bilateral legs. Review of an incident report completed by RN #701 dated 07/21/19 at 9:45 P.M. revealed during hygiene care Resident #1 was turned and her leg fell out of the bed and the resident rolled onto the floor. STNA #606 attempted to catch the resident. The resident was sent to the hospital because she complained of pain to her legs. The investigation revealed during care STNA #606 was tucking the resident's brief under the resident. The resident stated her leg was slipping and before STNA #606 could react the resident rolled out of the bed. Review of a witness statement dated 07/21/19 by LPN #607 revealed she was notified by STNA #606 that Resident #1 fell . She revealed she ran to the room and witnessed the resident on the floor next to the bed by the window on her left side. She saw blood coming from the resident's face and called the emergency rescue squad. Review of a witness statement dated 07/24/19 at 2:55 P.M. by STNA #606 revealed on 07/21/19 at 9:30 P.M. the STNA went into Resident #1's room to provide her evening care. The resident's call light was not on; however, she was incontinent of bowel and needed to be changed. STNA #606 had all the supplies and started to change her. The resident was rolled onto her right side and incontinence care was completed. After the resident was cleaned, the STNA was getting ready to tuck the brief underneath her, and she stated the resident's leg was slipping. Before the STNA had a chance to react, the resident rolled off the bed onto the floor. STNA #606 ran to get the nurse. Review of the form labeled, FESA Formula Coaching written by RN #701 and given to STNA #606 on 07/21/19 revealed Resident #1 was rolled away from STNA #606 and the resident fell out of bed. The form included the expectation of STNA #606 was to roll the resident towards him when cleaning the resident unless there was two people performing the care. The solution on the form revealed STNA #606 would roll residents towards him when performing care if unable to get help. The actions on the form revealed failing to meet the expectations would result in further disciplinary action. RN #701 and STNA #606 signed the form on 07/21/19. Review of a nursing note dated 07/22/19 at 3:16 A.M. revealed Resident #1 was admitted to the hospital with [REDACTED]. Review of the discharge hospital record summary of event form for Resident #1 dated 07/24/19 revealed she was admitted to the hospital after a fall at the facility. She had a [DIAGNOSES REDACTED]. Review of nursing note dated 07/25/19 at 4:18 A.M. revealed Resident #1 was readmitted to the facility from the hospital on [DATE] with a nose fracture and right tibia fracture. She had a splint to her right leg and pain was present. Review of nursing note dated 07/26/19 at 10:55 P.M. revealed Resident #1 complained of pain to her nose, left side of face and her lower extremity. She revealed her pain was a seven out of ten with ten being the worst. She was administered pain medication. Review of nursing note dated 07/27/19 at 11:34 P.M. revealed Resident #1 complained of pain to her right knee and her pain level was a ten out of ten. She was provided pain medication. Interview and observation on 08/07/19 at 3:30 P.M. with Resident #1 revealed she had a bruise to her left cheek and a right leg brace in place. She revealed on 07/21/19 in the evening a staff member was standing on the left side of her bed providing incontinence care. She said there was only one staff that assisted with her incontinence care. The staff member rolled her towards the window and her leg slipped off the bed causing her to fall off the bed onto the floor. She revealed she had a large cut on her face because her face hit the waste paper basket. She revealed she had a broken leg and nose because of the fall. Phone interview on 08/07/19 at 5:54 P.M. with STNA #606 revealed he was providing Resident #1 with incontinence care and he rolled her towards the window away from him to apply a clean brief. The resident said her leg was slipping off the side of the bed towards the window and she then fell out of bed before he could catch her. The bed was at his waist level at the time of the incident. He verified he was the only staff that assisted with her bed mobility and incontinence care. STNA #606 verified the resident was in the center of the bed and he did not move her to the edge of the bed prior to turning her per the facility policy. He also verified he turned her away from him towards the window not towards him per the facility policy. Phone interview on 08/07/19 at 6:07 P.M. with LPN #607 revealed she was the nurse on duty the night Resident #1 fell out of bed. She revealed Resident #1 was provided with incontinence care and bed mobility by one staff, STNA #606. She revealed when he rolled Resident #1 towards the window her leg slipped off the bed causing her to fall out of bed. She revealed STNA #606 had stated he was on the other side of the bed when he rolled her away from him towards the window. Interview on 08/07/19 at 8:26 P.M. with the Director of Nursing verified Resident #1's care plan dated 01/04/18 indicated she was to have extensive assist of two people with bed mobility and toileting. She verified there was only one STNA in the room providing incontinence care when Resident #1 fell from the bed on 07/21/19, STNA #606 did not roll the resident towards him during care, and did not follow the facility policy on bed positioning. Review of facility policy titled Bed Positioning, dated (MONTH) 2019, revealed the facility did not implement their policy. The policy revealed staff would verify the resident's transfer assist status per the Kardex. The staff would obtain additional assistance as indicated. When staff were turning a resident from their back to side lying the staff would move the person to the edge of the bed on the side farthest from the staff so that when they were turning the resident would be in the middle of the bed. The staff would position the resident's lower extremity farthest away over the lower extremity closest to the staff. The staff then would reach across the patient and place one hand on the patient's shoulder and the other hand on the resident's hip. The staff would then roll the patient towards them. This deficiency substantiates Complaint number OH 912.

Based on record review and interview the facility failed to ensure a significant medication error was prevented when one resident was given an incorrect dose of [MEDICATION NAME] sulfate on 10/28/18. Actual harm occurred when Resident #51 became unresponsive, respirations declined, the resident required two doses of [MEDICATION NAME] and was sent to the hospital via emergency medical squad. This affected one resident (Resident #51) reviewed for previously administered medications. Findings include: Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #51 developed [MEDICAL CONDITION] in both lower extremities with [MEDICAL CONDITION] (swelling based secondary to water retention) and weeping and oozing open areas. There was a physician order [REDACTED].#51 receiving the [MEDICATION NAME], this was a prn order), (Concentrate) milligrams (mg) per milliliter (ml). Give 5 mg by mouth every two hours as needed for pain. Give 5 mg = 0.25 ml by mouth/sub-lingual. Review of a progress note dated 10/28/18 at 11:52 A.M., written by Licensed Practical Nurse (LPN) #1, revealed an unidentified state tested nursing assistant (STNA) notified LPN #1 that Resident #51 did not want to wake up for breakfast. LPN #1 assessed Resident #51 as lethargic, arousable to voice but could not stay awake. Review of the vital signs sheet for Resident #51 dated 10/28/18 revealed that at 8:32 A.M. blood pressure was 121/82, pulse was 80 and regular. There was no respiratory rate or blood oxygen level documented. Review of the facility Controlled Substance Record Sheet for Resident #5 revealed LPN #5 administered 5 mgs of [MEDICATION NAME] sulfate to Resident #51 on 10/28/18 at 4:00 A.M. A hospice nurse note dated 10/28/18 at 2:47 P.M. documented Resident #51 received a dose of [MEDICATION NAME] last night, no time indicated. Upon arrival, the patient was in bed. Her respirations were five per minute, counted twice. The hospice nurse contacted the physician and a verbal order to administer [MEDICATION NAME] was obtained. The floor nurse administered two doses of [MEDICATION NAME] and 911 was called. In an interview on 11/01/18 at 11:00 A.M. nursing supervisor, Registered Nurse (RN) #2, stated that on 10/28/18 between 11:00 A.M. and 12:00 P.M. she was asked to check the medication bottle of Resident #51's [MEDICATION NAME] (a controlled opioid narcotic pain medication) by LPN #1. There were 27 mls in the bottle. The bottle was new and started with 30 mls. The nurse who gave the [MEDICATION NAME] on night shift documented she gave 0.5 mls so there should have been 29.5 mls in the bottle. RN #2 stated she was sure the amount was 27 mls. RN #2 checked Resident #51 who was arousable and responsive to her name and advised LPN #1 to call the hospice nurse. The hospice nurse came in, assessed Resident #51, called the hospice doctor and obtained an order for [REDACTED].#51 was alert and talking. Emergency medical services (911) was called and Resident #51 was sent to the hospital via emergency squad. RN #2 stated the emergency squad wanted to see the bottle of [MEDICATION NAME] sulfate and the contents were poured into a medication cup to see the amount easier. RN #2 stated the amount was 27 mls. In an interview on 11/01/18 at 11:23 A.M., LPN #1 stated that on 10/28/18 after she received morning report she checked on Resident #51 who was asleep. At around 8:00 A.M. Resident #51 appeared lethargic. LPN #1 checked Resident #51's oxygen level (pulse ox), which was 74% on room air. (The Mayo Clinic defines normal pulse ox levels as between 95% and 100%. A level less than 90% is considered low). LPN #1 placed Resident #51 on supplemental oxygen at 3 liters (L) and the pulse ox went up to 96%. LPN #1 stated that around 11:00 A.M. Resident #51's respirations declined and were about eight per minute. She notified the in house nursing supervisor, (RN) #2, who came and assessed Resident #51. RN #2 advised LPN #1 to notify hospice who came in around 1:30 P.M. [MEDICATION NAME] was administered and Resident #51 was sent 911 to the hospital. On 11/01/18 at 11:23 A.M. facility Director of Nursing (DON) #3 and the surveyor observed the bottle of [MEDICATION NAME] sulfate. There were 27 mls in the bottle. On 11/01/18 at 12:34 P.M. DON #3 stated the facility disciplined LPN #1 for a medication error in regard to the [MEDICATION NAME]. This deficiency substantiates Complaint Number OH 946.

Based on observation, record review, and staff interview, the facility failed to implement pressure ulcer prevention interventions for Resident #302, identified to be at risk for altered skin integrity at the time of admission. This resulted in actual harm for Resident #302 who developed a deep tissue injury to the right heel and a Stage II sacral pressure ulcer after admission to the facility. This affected one of three residents reviewed for pressure ulcers. The facility census was 136. Findings included: Resident #302 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #302 was assessed to require assistance with all mobility. The initial skin assessment date 01/03/14 identified the surgical site to the right leg as the only skin issue at the time of admission. An at risk for alteration in skin integrity care plan related to impaired mobility and incontinence was initiated on 01/03/14. Review of the nurses notes dated 01/14/14 revealed Resident #302 was assessed to have a dark red area to the right heel. On 01/25/14 during morning care, an open area to the sacral area was identified. On 01/27/14 at 12:31 P.M., Licensed Practical Nurse (LPN) #43 confirmed Resident #302 had a deep tissue injury to the right heel and a Stage II sacral pressure ulcer that presented after admission. On 01/28/14 at 10:25 A.M. treatments to Resident #302's right heel and sacral wound were observed. The resident was alert and oriented to person, place, and time and tolerated the treatments without incident. Review of the computer "task" category of the clinical record for Resident #302 revealed that the heel protectors (Prevalon boots) were put in place on 01/16/14 per Employee #44. On 01/27/14 an air mattress was implemented for Resident #302. The facility was unable to provide any documentation of skin assessment sheets or shower sheets for Resident #302 at the time of the survey. On 01/29/14 at 9:14 A.M. an interview was conducted with Registered Nurse, Direct Care Director (DCD) #45. DCD #45 verified that the heel wound was assessed on 01/14/14 and that the Prevalon boots were ordered on [DATE] and implemented on 01/16/14. In addition, DCD #45 confirmed the sacral wound was identified on 01/25/14 and the air mattress was implemented on 01/27/14. DCD #45 reported that Resident #302 was admitted from the hospital after sustaining a fall and had a right [MEDICAL CONDITION] surgically repaired. DCD #45 confirmed Resident #302 had limited mobility following the surgery and was on antibiotics to treat [MEDICAL CONDITION] at the time of admission.