Every finding on record at Winchester Terrace

Based on observation and staff interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect all 56 residents who consumed food from the kitchen. The facility census was 56.Findings include:Observation on 06/29/26 at 9:15 A.M. revealed the dish room revealed multiple broken and chipped tiles. On the left side, the baseboard was coming away from the wall exposing a large area of wall beneath. Additionally, tiles were coming up under the dishwasher, dishwashing area, and around the drain causing water to pool. There were broken tiles underneath the three-compartment sink and the food preparation sink. Underneath the food preparation sink, the tiles were cracked around the drain and there was standing water. Observed throughout the kitchen, the edges of the walls behind and beneath the kitchen equipment were observed to have food and other debris build up.Interview on 06/29/26 at 9:15 A.M. with [NAME] #162 verified the above observations. [NAME] #162 reported they had been told for a long time that the kitchen floor would be replaced; however, that had yet to occur.Interview on 06/29/26 at 2:16 P.M. with Maintenance Supervisor (MS) #202 revealed the facility was replacing all the floors in the facility in phases; however, he was unsure when the kitchen area would be completed. MS #202 reported he was able to replace tiles and baseboards in the kitchen if he was notified, and verified he was not aware of anything that needed fixed in the kitchen at that moment.Interview on 06/30/26 at 10:35 A.M. with the Administrator revealed they had plans to power wash the kitchen soon to address some of the concerns. This deficiency represents non-compliance investigated under Complaint Number 2717578.

Based on observation, review of pest control visit documents, staff interview, and review of a facility policy, the facility failed to ensure an effective pest control program was provided to eradicate pests in the facility. This had the potential to affect all 56 residents residing in the facility. The census was 56.Findings include:Observation on 06/29/26 at 9:15 A.M. revealed there were numerous flying insects (gnats) in the kitchen, with the highest concentration in the dish room. There were floor tiles coming up under the dishwasher, dishwashing area, and around the drain causing water to pool. Noted underneath the food preparation sink the floor tiles were cracked around the drain and there was standing water. Interview on 06/29/26 at 9:15 A.M. with [NAME] #162 verified the above observations and reported the gnats had gotten better since pest control's last visit. Observation on 06/29/26 at 12:00 P.M. of meal service revealed there were many gnats around the kitchen.Review of the pest control visit dated 05/20/26 revealed Maintenance Supervisor (MS) #202 reported small flies near the dishwasher. Pest control noted some spillage remained under the dishwasher, the area was treated; however, it was noted the area needed cleaned and dried better.Review of the pest control visit dated 05/22/26 revealed the facility had several open conditions that needed addressed. Floor tiles were peeling up under the ice machine and vending machine by the break room the cracks and crevices needed sealed. This problem was first noted on 09/14/23 and listed as high severity. Additionally, it was noted there were floor tiles coming up in the dish room under the dishwasher providing habitat for small flies that was first noted on 09/14/23 and listed as high severity. On 01/28/26 it was noted the facility was told new floors were to be installed. It was also documented there was accumulated spillage noted on or under equipment. The debris and spillage under the dishwasher were present and needed removed or cleaned. This was first noted on 05/15/24 and listed as high severity.Interview on 06/30/26 at 10:35 A.M. with the Administrator revealed they had plans to power wash the kitchen soon to address some of the concerns. The Administrator was unaware pest control had recommended changes to the kitchen for several years. She reported they had a six-phase plan to fix all the floors in the facility, had completed three of the phases, and the kitchen and ice machine area were to be fixed during the fifth phase. The Administrator did not have a timeline for when the phases would be completed.Review of the undated pest control policy revealed the purpose was to ensure a clean and safe environment free of pests and rodents.This deficiency represents non-compliance investigated under Master Complaint Number 2960437, Complaint Number 2736361, and Complaint Number 2717578.

Based on medical record review, review of an medication error investigation, and staff interview, the facility failed to ensure medications were administered to residents as ordered, resulting in a significant medication error. This affected one (#90) of three residents reviewed for medication errors. The census was 56.Findings include:Record review for Resident #90 revealed the resident was admitted to the facility on [DATE] with diagnoses including acute metabolic encephalopathy, chronic pain syndrome, and hypertension. Resident #90 was admitted to the facility directly following her hospitalization for decreased consciousness after taking medication, including Lyrica, a medication used to treat nerve pain. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. The resident was assessed to require staff assistance with self-care and mobility.Review of the physician's progress notes dated 02/16/26 revealed, at time of admission, Resident #90 brought Lyrica 200 milligram (mg) tablets from home. The physician advised the resident at that time, the Lyrica should be given to the facility staff to hold because, per the resident's discharge instructions from her hospitalization dated 02/13/26, her Lyrica was to be not administered until further notice by the resident's physician.Review of the facility Medication Error Investigation dated 02/18/26 revealed on 02/17/26 at approximately 9:30 A.M., Licensed Practical Nurse (LPN) #215 administered one 200 mg tablet of Lyrica to Resident #90 due to the resident complaining of leg pain. LPN #215, in a written statement, acknowledged the medication was not listed on Resident #90's medication administration report as ordered. When the facility's Director of Nursing (DON) was alerted about the medication error on 02/18/26, the facility's corporate nurse was notified. The facility's Medical Director assessed Resident #90 on 02/18/26 at 11:10 A.M. and found no ill effects.During an interview with the DON on 06/30/26 at 10:35 A.M., she confirmed LPN #215 was terminated for administering Resident #90 Lyrica on 02/17/26 without and order. This deficiency represents non-compliance investigated under Master Complaint Number 2960437.

Based on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure mechanical lifts were operated safely. This affected one (#21) of one resident reviewed for mechanical lift transfers. The facility census was 53. Findings include:Review of the medical record for Resident #21 revealed an admission date of 10/23/19. Diagnoses included normal pressure hydrocephalus, hemiplegia, and dementia. Review of the annual Minimum Data Set (MDS) assessment, dated 11/01/25, revealed Resident #21 was cognitively impaired and required total (staff) assistance with Activities of Daily Living (ADLs). Resident #21 utilized a mechanical lift for transfers. Review of the care plan dated 10/23/19 revealed Resident #21 had an ADL deficit related to dementia and hemiplegia. Interventions included using a mechanical lift with two staff to transfer Resident #21 in and out of bed.Review of the physician orders revealed an order dated 12/20/22 for Hoyer (mechanical) lift for all transfers.Observation on 12/30/25 at 11:39 A.M. revealed Certified Nursing Assistant (CNA) #200 entered Resident #21's room with a mechanical lift. No other staff were present. Further observation on 12/30/25 at 11:59 A.M. revealed CNA #200 exited Resident #21's room with the mechanical lift. No other staff were present in the room. Interview on 12/30/25 at 11:59 A.M. with CNA #200 verified she transferred Resident #21 utilizing a mechanical lift without a second staff person present. Further interview with CNA #200 confirmed Resident #21 was to be transferred utilizing a mechanical lift with two staff person assistance. CNA #200 confirmed she was trained on how to transfer a resident utilizing a mechanical lift and knew two staff were to assist with the transfer. Review of the facility policy titled, Hoyer Lift Education-Long Term Care, dated 08/20/25, revealed to always use two staff members when transferring a resident using a mechanical lift. This was an incidental finding discovered during the complaint investigation.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on medical record review, staff interview, review of the facility incident and accident log, review of hospital records, review of staff statements, and review of facility policy, the facility failed to ensure staff operated Hoyer lifts in a safe manner to prevent falls. This resulted in Actual Harm on 08/20/25 at approximately 6:30 A.M. when Certified Nursing Assistant (CNA) #236 and Registered Nurse (RN) #252 transferred Resident #03 out of bed with the use of a Hoyer lift and did not ensure the transfer sling straps were secured. During the transfer, the Hoyer lift became stuck and staff forcefully pulled the Hoyer lift, causing the transfer sling strap to disconnect from the lift and Resident #03 fell to the floor. Resident #03 sustained a laceration above the right eyebrow that required sutures, and a laceration to the right wrist. This affected one (Resident #03) of three residents reviewed for falls. The facility census was 46.Findings include:Review of the medical record for Resident #03 revealed an admission date of 04/30/24. Diagnoses included chronic kidney disease, hypertensive heart disease, and venous insufficiency.Review of the significant change Minimum Data Set (MDS) assessment, dated 06/27/25, revealed Resident #03 had severe cognitive impairment and was dependent on staff for transfers and utilized a Hoyer lift.Review of the care plan, dated 06/30/25, revealed Resident #03 had an activities of daily living (ADL) self-care performance deficit and utilized a Hoyer lift and a wheelchair. Interventions included staff to set up equipment and assist as needed for bathing, dressing, and hygiene, monitoring for skin concerns during care, and report all found.Review of the Fall Risk Screen dated 08/20/25 revealed Resident #03 was at high risk for falls and required the use of an assistive device.Review of the facility incident and accident log for August 2025 revealed on 08/20/25 at 6:30 A.M., Resident #03 had a fall in her room. Interventions included emergency room (ER) visit with staff education.Review of the hospital provider notes, dated 08/20/25, revealed Resident #03 presented to the ER at 6:47 A.M. with a chief complaint of a fall and a laceration. Resident #03 had an altered level of mental status, which was chronic, and presented from the nursing home after rolling off a Hoyer lift and falling approximately three feet to the floor. Resident #03 had no loss of consciousness. Resident #03 was awake, alert, and at her baseline, per staff. Resident #03 sustained a two-centimeter (cm) laceration to her right eyebrow, which was repaired with five sutures. Review of the nursing progress note dated 08/20/23 at 12:00 P.M. revealed Resident #03 returned from the hospital with a right forearm open area measuring 1.5 inches (in) by 0.5 in, and right forehead laceration with five sutures. Resident #03 was placed in bed, reoriented to her room and call light, and no other needs were noted.Review of the statement provided by CNA #236, dated 08/20/25, revealed CNA #236 and RN #252 were getting Resident #03 out of bed with the Hoyer lift when CNA #236 thought the wheel of the Hoyer lift had gotten stuck under a cord, but the lift was jammed and began to spin. CNA #236 pulled forward and RN #252 pushed the Hoyer above the chair and the Hoyer pad disconnected, causing the Hoyer lift to stop moving completely. Resident #03 then fell to the floor and hit her head.Review of the statement provided by RN #252, dated 08/20/25 at 2:00 P.M., revealed RN #252 assisted CNA #236 with a Hoyer transfer and the Hoyer became snagged on the wheelchair and bed. When staff attempted to release the Hoyer lift from the snag, the Hoyer strap came off and the resident fell to the floor.Review of the nursing progress note dated 08/25/25 at 11:37 A.M. revealed new orders to clean Resident #03's right forearm skin tear with normal saline and pat dry, apply xeroform and bordered foam three times a week and as needed.During an interview on 09/17/25 at 10:19 A.M., the Director of Nursing (DON) stated CNA #236 and RN #252 were in Resident #03's room to complete a Hoyer lift transfer on 08/20/25. CNA #236 and RN #252 believed the Hoyer lift strap disconnected after they forcefully pulling on the Hoyer lift after it became stuck. The Hoyer lift was immediately pulled from the floor and checked by maintenance, who found no issues with the Hoyer lift. The DON verified Resident #03 sustained a laceration above her right eyebrow that required five sutures and a laceration to the wrist that required wound treatments three times per week. Review of the facility policy titled Activities of Daily Living (ADLs)/ Maintain Abilities, dated 09/03/24, revealed the facility would provide care and services for mobility, transfers and ambulation.The deficiency was corrected on 09/16/25 when the facility implemented the following corrective actions: On 08/20/25 at approximately 6:30 A.M., RN #252 assessed Resident #03 for injury. Resident #03 was transferred to the hospital for further evaluation and treatment. On 08/20/25, Maintenance Director (MD) #244 completed an inspection of all Hoyer lifts, with no concerns identified. Verification was received confirming the inspection was completed. Beginning on 08/26/25, the DON or designee will audit four Hoyer lift transfers weekly for four weeks, then bi-weekly for one month, and then monthly for two months. Results of the audits will be reviewed by the Quality Assurance and Performance Improvement (QAPI) committee to ensure on-going compliance. Review of audit documentation from 08/26/25 through 09/16/25 verified completion of the audits, with no negative findings. On 08/26/25, the DON educated all direct care staff on the safe use of Hoyer lifts. Verification was received verifying the education was completed. On 08/28/25, the DON completed a Hoyer lift competency with all direct care staff to ensure safe use of the lifts. Verification was received verifying the competencies were completed. Interviews on 09/17/25 from 2:38 P.M. through 2:56 P.M. with CNA #230 and CNA #234 confirmed education and competencies were completed on the safe use of Hoyer lifts. Review of two (Residents #6 and #10) additional open residents records, reviewed for Hoyer lift transfers, revealed no related concerns.This deficiency represents non-compliance investigated under Complaint Number 2601158.

Based on observation, staff interview, review of electronic mail (e-mail) correspondence, and review of the facility policy, the facility failed to maintain a clean, safe and sanitary environment. This had the potential to affect all 46 residents residing in the facility. The facility census was 46.Findings include:Observation on 09/17/25 at 3:03 P.M. of the courtyard entrance, located near the front doors, revealed a laminate type flooring that was raised and buckled. The flooring was not secured to the floor and could be lifted off of the floor. Further observation revealed spaces between the flooring slats. Observation on 09/17/25 at 3:10 P.M. of the Malabar Lane Hall revealed large areas of discoloration/stains on the carpeting throughout the hallway. Across from Resident # 33's room was a large tear in the carpet, and the carpet was able to be lifted, exposing the floor underneath.Observation on 09/17/25 at 3:15 P.M. of the Oakhill Hall revealed large areas of discoloration/stains on the carpeting throughout the hallway. Further observation revealed a large tear in the carpeting in front of Resident #1's, which exposed the subflooring. Additional observations revealed in front of room [ROOM NUMBER] (unoccupied) the carpeting was lifted from one wall to the other, and in front of room [ROOM NUMBER] (unoccupied) the carpet was lifted.Observation on 09/17/25 at 3:30 P.M. of the Oakhill Circle Hall revealed large areas of discoloration/stains on the carpeting throughout the hallway. Additionally, the carpeting in front of Resident #44 and Resident #20's room had tears, exposing the subfloor. Observation on 09/17/25 at 3:35 P.M. of the [NAME] Court Hall revealed large brown stains and fraying carpet in front of Resident #42 and Resident #41's room. Observation on 09/17/25 at 3:40 P.M. of the [NAME] Avenue Hall revealed the carpeting in front of the therapy and oxygen room had large tears exposing the subfloor and large areas of discoloration/staining was observed throughout the hallway carpeting. Interview on 09/17/25 at 12:30 P.M. with Maintenance Director (MD) #244 revealed that the courtyard drains clogged with mulch from the flower beds anytime there was a hard rain, causing the rainwater to back up into the facility. MD #244 stated the last time water backed-up into the facility was on 08/20/25. MD #244 stated he came to the facility on [DATE] and tried to clean up the water with a floor scrubber and another machine that extracted water. MD #244 stated fans were used to help dry the flooring. MD #244 stated the dining room had a strong musty odor from water and the facility had to close the dining room temporarily until it could dry and air out. MD #244 confirmed the above observations and stated the carpeting throughout the facility needed to be replaced due to tearing, lifting, and fraying in each of the hallways.Interview with the Director of Nursing (DON) on 09/17/25 at 12:15 P.M. revealed the facility had a flooding issue due to the drains in the courtyard backing up. DON stated that FM #600 had been e-mailed on multiple occasions revealing the need for new flooring, with no response received. The DON confirmed that the carpet throughout the facility had tears, lifting, and fraying. The DON also confirmed stains on the carpeting throughout the facility and stated the facility had professional cleaners come to the facility, without improvement.Review of an electronic mail (e-mail) correspondence dated 08/09/25 from the Director of Nursing (DON) to Facility Manager (FM) #600 confirmed the DON identified the following areas of concern that remained following professional carpet cleaning: large stains on the carpet in the lobby entrance, in the hall by room [ROOM NUMBER], in the hall near room [ROOM NUMBER] and 35, in the hall by room [ROOM NUMBER], and in the hall by room [ROOM NUMBER] and 41. Further review revealed the DON identified that new carpet pieces by the dining room were fraying, the carpet at the entrance of the dining room was rippling, the carpet near room [ROOM NUMBER] was fraying, the carpet by room [ROOM NUMBER] was fraying and had white spots, the carpet by room [ROOM NUMBER] had white/light spots and holes present, the carpet by room [ROOM NUMBER] had fraying, and the carpet by room [ROOM NUMBER] and 79 and staining. Lastly, the carpet at the entrance of the soiled laundry room had a large stain. Review of the facility policy titled, Resident Right- Safe/Clean/Comfortable/Homelike Environment, dated 09/03/24, revealed the facility must provide a safe, clean, comfortable, and homelike environment. Review of the facility policy titled, Safe Environment dated 09/03/24, revealed the facility will maintain the facility premises and conducts its operations in a safe and sanitary manor.This deficiency represents non-compliance investigated under Complaint Number 2601158.

Based on observation, medical record review, Self-Reported Incident (SRI) review, review of hospital records, facility investigation review, personnel file review, staff interview, and review of facility policy, the facility failed to ensure Resident #10 was transferred in a safe manner and as per the resident's assessed/planned needs to prevent an avoidable accident resulting in major injury. Actual harm occurred on 09/08/24 when Certified Nursing Assistant (CNA) #400 attempted to transfer Resident #10, who required the use of a mechanical lift for transfers, out of bed without an additional staff assisting and using the resident's walker. This improper transfer resulted in Resident #10 falling backwards onto the bed, striking her right elbow on the metal bed frame causing pain, a decrease in function of the resident's arm, swelling, redness, warmth and scattered bruising. An x-ray of the right elbow was completed on 09/09/24 and revealed a displaced fracture of the distal humerus (the long bone in the upper arm located between the shoulder joint and the elbow joint. The distal portion of the humerus joins with the bones of the lower arm at the elbow joint). The resident was subsequently transferred to the hospital for treatment and orthopedic consultation. This affected one resident (Resident #10) of two residents reviewed for falls. The facility census was 46. Findings Include: Review of the medical record for Resident #10 revealed admitted [DATE] with diagnoses including heart failure, type two diabetes mellitus, anxiety, depression, and difficulty with ambulation. Review of Resident #10's care plan initiated 02/21/23 revealed an alteration in self - mobility related to heart failure, difficulty in walking, and need for assistance with personal care with interventions to assist with bed mobility, transfers and ambulation. Review of Resident #10's Significant Change Minimum Data Set (MDS) Assessment, dated 08/29/24, revealed the resident had severely impaired cognition and required substantial/maximum (staff) assistance for mobility and bed/chair transfers. Review of hospital records, dated 09/01/24, revealed Resident #10 had been transferred to the emergency room due to a nosebleed which could not be controlled or stopped at the facility. Enroute to the hospital, Resident #10 had several episodes of bloody emesis. Resident #10 returned to the facility on [DATE] with diagnoses of acute upper gastrointestinal (GI) bleed and anemia. Review of the CNA's Information Binder, located at the nurses' station for CNA reference concerning the residents, revealed a list of residents requiring the use of the mechanical lift for transfers. The list was dated 09/01/24 and included Resident #10. Review of Resident #10's re-admission assessment, dated 09/06/24, revealed Resident #10 was dependent of staff assistance for personal care, bed mobility, and transfers. Review of the progress notes, dated 09/08/24, revealed no mention of any incidents involving Resident #10. Review of Resident #10's progress note, dated 09/09/24 at 8:57 A.M. and authored by Registered Nurse (RN) #213, revealed Resident #10 requested to go to the hospital due to complaints of pain in the right arm. Resident #10 was unable to squeeze RN #213's fingers during the assessment and Resident #10's right elbow appeared swollen. Resident #10 was administered Tylenol 325 milligrams (mg) two tablets for the pain. Resident #10 had not complained of right arm pain during the previous shift. Review of Resident #10's progress note, dated 09/09/24 at 12:05 P.M. and authored by RN #233, revealed Resident #10's right elbow was noted to be swollen and warm to touch with redness and scattered bruising to the area. The physician was notified, and an x-ray was ordered. Review of Resident #10's physician orders revealed an order dated 09/09/24 for an x-ray of the right elbow related to bruising and pain. Review of Resident #10's x-ray results of the right elbow, dated 09/09/24, revealed Resident #10 had a displaced fracture of the distal humerus. Review of Resident #10's progress notes, dated 09/09/24 at 1:57 P.M. and authored by RN #233, revealed an X-ray was completed with results reported as a displaced fracture of the distal humerus. The physician was notified with an order obtained for Resident #10 to be transferred to the hospital for orthopedic consultation. Resident #10's family member was notified of the same. Further review of the medical record revealed an order dated 09/09/24 to transfer the resident to the hospital for an orthopedic consultation. Review of Resident #10's hospital discharge paperwork, dated 09/06/24, revealed a diagnosis of a comminuted fracture of the right distal humerus. Discharge orders included the use of a splint and follow up with the orthopedic physician. Further review revealed an order for pain medication Norco 5-325 milligrams (mg) take one tablet by mouth every four hours as needed for pain. Review of Resident #10's progress notes, dated 09/09/24 at 7:42 P.M., revealed Resident #10 returned to the facility with a splint to the right elbow, due to family declining orthopedic surgery. Review of a facility Self-Reported Incident (SRI), tracking number 251667, dated 09/09/24, revealed the facility reported an incident of physical abuse involving Resident #10. The SRI included bruising was noted to the resident's right arm and the resident stated her arm hurt. CNA #400's statement dated 09/10/24 at 9:30 A.M. revealed on 09/08/24 at 8:00 P.M. CNA #400 attempted to assist and transfer Resident #10 to use the restroom by using Resident #10's walker. Resident #10 fell back onto the bed, striking her right elbow on the metal bed frame. CNA #400 assisted Resident #10 back into bed and completed incontinence care via a check and change. CNA #400 stated check and changes were completed for the remainder of 09/08/24's night shift for Resident #10. When CNA #400 was asked if Resident #10 had a fall, CNA #400 stated Resident #10 never hit the floor. Further review of the SRI revealed the CNA did not report the incident to the nurse working because the CNA did not think the resident hitting her elbow on the bedframe resulted in an injury. Review of the facility's investigation, initiated on 09/09/24, included CNA #310's statement dated 09/10/24 revealing assistance was given to CNA #400 with incontinence care for Resident #10 at approximately 8:00 P.M. and again between 1:00 A.M. and 2:00 A.M. Resident #10 was in bed during these times and CNA #400 had stated Resident #10 had been attempting to get out of bed and into the recliner. CNA #310 had updated CNA #400 with Resident #10's new transfer status with the use of a mechanical lift (hoyer). Review of Registered Nurse (RN) #213's statement dated 09/09/24 at 6:00 P.M. revealed RN #213 had been alerted at approximately 7:00 A.M. on 09/09/24 by staff (unidentified) concerning Resident #10's right arm hurting and Resident #10's request to go to the hospital. RN #213 was approached again by staff with Resident #10 reportedly saying he dropped her, and her arm hurt. RN #213 entered Resident #10's room and observed her right arm was elevated on a pillow. When RN #213 asked Resident #10 what had happened, Resident #10 stated he dropped me, picked me up and my arm hurts. RN #213 asked Resident #10 which arm hurt and Resident #10 used her left hand and pointed to her right arm. Review of Resident #10's Medication Administration Record (MAR) dated 09/09/24 to 09/30/24 revealed the pain medication Norco 5-325 mg was administered on 09/11/24 two times, on 09/12/24 three times, and on 09/13/24 one time for pain levels ranging from four to 10 with 10 being considered the worst pain the resident had experienced. The pain medication was documented as being effective in controlling Resident #10's pain. Review of Resident #10's orthopedic follow-up appointment dated 10/24/24 revealed Resident #10 continued to have swelling to the right elbow with a severely displaced humerus fracture continuing. Resident #10's Power of Attorney (POA) had opted to not have surgical intervention due to co-morbidities of Resident #10 and was considering hospice services for the same. Review of CNA #400's personnel file revealed CNA #400 was hired on 08/19/24, completed orientation and received the employee handbook on 08/19/24. CNA #400's employment was terminated on 09/13/24 for company policy violation. An interview on 10/31/24 at 1:10 P.M. was attempted with Resident #10 but the resident was unable to be interviewed due to impaired cognition. An interview on 10/31/24 at 2:20 P.M. with the Director of Nursing (DON) confirmed Resident #10 sustained a fractured right distal humerus when CNA #400 attempted to transfer Resident #10 not using the required mechanical lift and assistance from other staff. CNA #400 attempted to stand the resident, using her walker to transfer the resident from the bed to the chair. The resident fell backward, onto the bed and struck her elbow on the frame of her bed resulting in a humeral fracture. The DON shared CNA #400 was suspended pending an investigation and ultimately terminated on 09/13/24 for violating company policy. A review of the facility's policy titled, Ambulation/Transfer Policy revealed to prevent and/or reduce injury to staff and residents. It was the intent of the facility to provide safe transfers and ambulation for our clients and prevent injury to clients and staff during this process. This deficiency is an incidental finding discovered during the complaint investigation.

Based on observation, record review, interview and facility policy review the facility failed to maintain infection control measures during incontinence care for a resident. This deficient practice affected one resident (Resident #13) of three residents reviewed for incontinence care. The facility census was 46. Findings Include: An observation on 10/20/34 at 11:00 A.M. revealed Certified Nursing Assistant (CNA) #322 and CNA #209 completing incontinence care for Resident #13. CNA #322 had a basin with warm water sitting on the bedside table with a bottle of personal hygiene soap. CNA #322 placed the used washcloth on the bedside table. CNA used one washcloth to wash Resident #13's front peri-area and groin area, once washing was complete CNA #322 placed the used washcloth on the bedside table without a barrier. CNA #322 then took another wet washcloth and rinsed Resident #13's front peri-area and groin area, once completed CNA #322 placed the used washcloth on the bedside table. CNA #322 took a towel and dried the area, placing the towel on the bed sheet at the foot of Resident #13's bed. Resident #13 was rolled onto the left side; CNA #322 then took the two wash cloths which were used to clean the front peri-area and groin area for Resident #13 and washed and rinsed Resident #13's buttocks and was dried with the same towel. Once CNA #322 completed the incontinence care of Resident #13, the used washcloths and towel were placed on the bed sheet at the foot of the bed. CNA #322 removed the left-hand glove to retrieve a trash bag and grabbed the used washcloths and towel with the bare left hand and placed them into the trash bag. CNA #322 then donned a glove on their left hand without washing or sanitizing hands and applied preventative cream to Resident #13's buttocks. CNA #322 then removed the water basin from the bedside table and then returned the bedside table to the end of the bed. Water was observed on the bedside table. CNA #322 wiped up the water with several tissues but did not disinfect the bedside table. A review of the medical record for Resident #13 revealed an admitted [DATE] with diagnoses including stroke, high blood pressure, Bell's Palsy, and right sided weakness. Resident #13 had moderately impaired cognition, was always incontinent of bladder and bowel, and was receiving hospice services. Resident #13 was dependent on staff for personal care and hygiene to be completed. A review of Resident #13's physician orders revealed an order dated 09/24/24 for the application of house barrier cream to peri-area and bilateral buttocks twice daily and as needed (PRN) may keep at bedside, CNA may apply. An interview on 10/30/24 at 11:15 A.M. with CNA #322 confirmed there were only two washcloths used to complete incontinence care for Resident #13, their bare hand removed soiled linens from the bedside table and the foot of the bed, and their hands were not washed or sanitized prior to donning a new glove, and the bedside table was not disinfected after soiled linens placed on the surface without a barrier. An interview on 10/30/24 at 12:15 P.M. with the Director of Nursing (DON) revealed the expectations of the facility staff is to use multiple washcloths while completing incontinence care, the use of gloves, washing hands, and disinfecting the equipment used during the procedure. The DON stated CNA #13 should have followed infection control procedures while completing incontinence care for Resident #13. A review of the facility's policy titled, Handwashing revealed, Handwashing should be performed before and after care is given. Gloving does not replace the need for handwashing. This deficiency is an incidental finding discovered during the complaint investigation.

Based on observation and staff interview, the facility failed to ensure carpeting was maintained in a clean, sanitary and safe condition. This had the potential to affect all 44 residents residing in the facility. Findings Include: 1. Random intermittent observations on 06/30/24 between 8:00 A.M. and 4:00 P.M. revealed large numerous areas of stains on the carpeting through out the facility. Numerous instances of carpet peeling, creating a tripping hazard, were also noted through out the facility. Interview with the Administrator on 07/01/24 at 1:34 P.M. verified the condition of carpeting. The Administrator further stated areas (of the carpeting) were just replaced approximately six months ago. At this point in time, I do not believe it is in the budget to replace. 2. Observation of the dinning room sink on 07/02/24 at 12:00 P.M. revealed significant areas of brown and black discoloration in the sink and around the drain. When wiped with a towel, a thick brown layer of what appeared to be a mixture of brown and black sludge was taken off but the discoloration in the drain and sink remained The Administrator verified the condition of the sink and drain in an interview on 07/02/24 at 12:00 P.M.

Based on record review and staff interview, the facility failed to ensure Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) contained all the necessary information. This affected two (Residents #6 and #8) of three residents reviewed for beneficiary notices. The facility census was 44. Findings include: 1. Review of Resident #6's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including bronchitis, sepsis, and osteoporosis Review of the SNF ABN provided to Resident #6 on 06/14/24 revealed the resident's skilled therapy services were being discontinued due to the resident reaching maximum benefits from therapy services. The notice contained no specific information as to what therapy services were being discontinued and what specific costs the resident would incur if they desired for therapy services to continue. The cost section of the notice was labeled daily cost. Interviewed with the Administrator on 06/30/24 at 3:06 P.M. verified the SNF ABN notice given to Resident #6 did not contain specific information as to what skilled services were ending and information concerning potential costs that would be associated with the resident continuing therapy services 2. Review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including schizophrenia, sepsis and morbid obesity Review of the SNF ABN provided to Resident #8 on 06/26/24 revealed the resident's skilled therapy services were being discontinued due to the resident reaching maximum benefits from therapy services. The notice contained no specific information as to what therapy services were being discontinued and what specific costs the resident would incur if they desired for therapy services to continue. The cost section of the notice was labeled daily cost. Interviewed with the Administrator on 06/30/24 at 3:06 P.M. verified the SNF ABN notice given to Resident #8 did not contain specific information as to what skilled services were ending and information concerning potential costs that would be associated with the resident continuing therapy services

Based on observations, staff, resident and family interviews, record review, and policy review, the facility failed to offer or provide Resident #194, who was dependent on staff for hygiene tasks, assistance with shaving. This affected one (Resident #194) of three residents reviewed for activities of daily living (ADL). The facility census was 44. Findings include: Review of Resident #194's medical record revealed an admitted [DATE]. Diagnoses included malignant neoplasm of the pancreatic duct, type II diabetes mellitus, vertigo, and weakness. Review of Resident #194's admission nursing assessment, dated 06/26/24, revealed the resident was identified to be dependent on staff for bathing, dressing, and hygiene tasks. Review of Resident #194's care plan, revised 07/02/24, revealed the resident had an ADL self-care performance deficit related to an acute illness, impaired mobility, weakness, and history of falls. The resident was identified to require assistance with bathing, hygiene, transfers, toileting, ambulating, and dressing. Listed interventions included Resident #194 required staff assistance to complete bathing, hygiene, and dressing tasks. An observation and interview on 06/30/24 at 9:08 A.M. with Resident #194 and a family member of Resident #194 revealed the resident had unkempt facial hair approximately one quarter inch long. The resident was observed rubbing his face and cheeks and stated he preferred to be clean shaven. The family member of Resident #194 confirmed the resident preferred to be clean shaven and had brought in his personal electric razor, but no staff members had offered to shave him. A subsequent observation on 07/01/24 at 10:10 A.M. of Resident #194 revealed the resident seated in his recliner chair in his room. The resident remained unkempt and unshaved, with the facial hair unchanged from the prior observation. An interview on 07/01/24 at 4:25 P.M. with Licensed Practical Nurse (LPN) #404 confirmed Resident #194 required hands-on assistance with ADLs. LPN #404 confirmed the aides should be completing hygiene tasks on a daily basis, and morning care should consist of changing clothes and shaving male residents if preferred. LPN #404 stated the aides were a good crew, but required reminders to offer and complete certain tasks, such as shaving male residents. An interview on 07/01/24 at 4:52 P.M. with State tested Nurse Aide (STNA) #412 revealed she was assigned to care for Resident #194 from 7:00 A.M. to 7:00 P.M. STNA #412 stated she was unaware of the resident's preferences for shaving. STNA #412 confirmed she had seen shaving supplies in the resident's room that day but verified she did not offer to assist him with shaving. An observation on 07/02/24 at 7:17 A.M. of Resident #194 with the Director of Nursing (DON) revealed the resident was lying in bed. The resident's facial hair appeared unchanged from prior observations, approximately one quarter inch in length. The DON confirmed the resident was unshaved and described him as scruffy and stated he would be offered to be shaved today. Review of the policy titled Activities of Daily Living (ADLs)/Maintain Abilities, undated, revealed it is the policy of the facility to create and sustain an environment that humanizes and individualizes each resident's quality of life. The policy specified care and services provided are person-centered and honor and support each resident's preferences, choices, values, and beliefs. The facility will provide care and services which included hygiene tasks of bathing, dressing, grooming and oral care. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, staff, family, and resident interview, record review, and policy review, the facility failed to provide a program of activities that met the needs and preferences of the residents. This affected three (Residents #3, #8, and #41) of four residents reviewed for activities. The facility census was 44. Findings include: 1. Review of the medical record for Resident #41 revealed an admitted [DATE]. Medical diagnoses included coronary artery disease, atrial fibrillation, and had a fall resulting in a left femur fracture prior to admission to the facility. The record identified Resident #41 had elected to receive hospice services. Review of Resident #41's Minimum Data Set (MDS) 3.0 significant change in status assessment, dated [DATE], revealed the resident had severely impaired cognition. The resident's activity section revealed the resident was interviewed as to activity preferences, and listed having family members involved in her care as very important, and having books and magazines to read and doing her favorite activities as somewhat important. Review of Resident #41's care plan, dated revised [DATE] revealed the resident had a cognitive deficit and the potential for activity or psychosocial deficit. A listed intervention included to engage the resident in simple, structured activities that avoided overly demanding tasks. Review of Resident #41's activity documentation in the electronic medical record under tasks from [DATE] to [DATE] revealed options for staff to record activity attendance and participation at various types of activities which included music, television, radio, family/friend visits, chaplain visits, and room visits. Resident #41's record contained only five entries of Resident #41 receiving any types of activities. These entries, recorded on, [DATE], [DATE], [DATE], [DATE] and [DATE], indicated the resident received family/friend visits and were documented by State tested Nurse Aide (STNA) #412. There was no entries recorded by any activity staff members. Review of Resident #41's interdisciplinary progress notes from [DATE] to [DATE] revealed no indication the resident had been invited to participate in activities, screened for activity preferences, or had any 1:1 room visits, outside of family and friend visits, recorded. An interview on [DATE] at 10:43 A.M. with a family member of Resident #41 revealed the resident had recently declined and was receiving hospice care. Resident #41 was previously more alert and able bodied . The family member identified she visits near-daily and revealed staff had not offered or provided any way for Resident #41 to continue to participate in activities she enjoyed. The family member explained the resident had always enjoyed music, specifically country music, but the facility did not have the television channel that played country music. An interview on [DATE] at 3:21 P.M. with Activity Director (AD) #411 revealed she had been at the facility for approximately one year and knew the residents fairly well. AD #411 confirmed she works Monday through Friday during daytime hours, and was the only activity personnel employed by the facility. AD #411 stated Resident #41 slept a lot and was unsure if she enjoyed music. AD #411 stated she had not talked to the family of Resident #41 to obtain preferences and likes, and had never arranged for or provided music for Resident #41. AD #411 stated she records activity participation in each resident's electronic medical record which would be available under tasks. A review of Resident #41's activity documentation with AD #411 confirmed she did not record any documentation of activities or attempts for Resident #41 for the past 30 days. AD #411 confirmed that even though Resident #41 was mostly in bed, she does not provide any 1:1 or room visits for this resident. 38523 2. Review of the record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Charcot [NAME] Tooth disorder, hereditary motor and sensory neuropathy, and bicipital tendinitis of the left shoulder. Review of Resident #3's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was cognitively intact. She had impairment of both sides of her upper and lower extremities. She used an electric wheelchair. She was dependent on staff for all activities of daily living. Review of Resident #3's record revealed no activity documentation, activity progress or activity summary notes were found for the past 30 days. An interview on [DATE] at 9:12 A.M. with Resident #3 revealed the resident never goes to activities because they do activities she cannot physically do, as they involve using her extremities which she was unable to do. Resident #3 stated sometimes the facility canceled the few activities she did enjoy, such as the once-monthly happy hour. Review of Resident #3's activity documentation with Activity Director (AD) #411 on [DATE] at 3:21 P.M. confirmed she did not record any documentation of activities or attempts for Resident #3 in the past 30 days. 3. Review of the record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including sepsis due to Escherichia Coli (E. Coli), rheumatoid arthritis, and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 has intact cognition. Review of Resident #8's care plan revealed the resident was very active in activities and enjoyed BINGO, cratfing, and cooking activities. Interventions included Resident #8 will attend/participate in activities of choice three to five times per day and invite the resident to scheduled activities. Review of Resident #8's record revealed no activity documentation, activity progress or activity summary notes were found. An interview on [DATE] at 9:37 A.M. with Resident #8 revealed the facility had no activities in the evenings or weekends. There was only one activity staff person, and she works Monday through Friday, only on day shift. An interview on [DATE] at 3:21 P.M. with Activity Director (AD) #411 confirmed she did not record any documentation of activities or attempts for Resident #8 in the past 30 days. AD #411 stated she works Monday through Friday during daytime hours, and was the only activity staff member employed by the facility. AD #411 stated the facility does not offer evening activities and all the residents went to bed right after dinner. AD #411 confirmed she had to cancel certain activities, including the [DATE] happy hour, as she did not receive her monthly budget for that month and had nothing to provide to the residents. AD #411 confirmed there was no designated activity personnel for the weekends, and she believed the STNAs were responsible for completing weekend activities in her absence. Review of the facility policy titled Activities Meet Interest/Needs of Each Resident dated [DATE] revealed it is the facility's responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life and honor and support these principles for each resident and that the care and services provided are person-centered and honor and support each resident's preferences, choices, values and beliefs.

Based on observation, staff interviews, medical record review, review of the Centers for Disease Control and Prevention (CDC) guidance on prevention of Catheter-Associated Urinary Tract Infections, and review of the facility policy, the facility failed to ensure residents urinary catheter bags were not resting on the floor. This affected two (Residents #20 and #28) of seven residents with urinary catheters. The facility census was 44. Findings include: 1. Review of the medical record for Resident #28 revealed an admitted [DATE]. Diagnoses included personal history of urinary tract infections, hydronephrosis with renal and ureteral calculous obstruction and presence of urogenital implants (suprapubic catheter). Review of Resident #28's care plan, undated, revealed the resident was at risk for complications related to her suprapubic catheter. The resident required the use of a suprapubic catheter related to obstructive and reflux uropathy. Listed interventions included to not allow the urinary drainage bag to lie on the floor. Observation on 06/30/24 at 9:46 A.M. revealed Resident #28's catheter bag was hung on the trash can and resting on the floor. Interview on 06/30/24 at 9:54 A.M. with Registered Nurse (RN) #444 verified the catheter bag was hooked on the trash can and resting on the floor. The catheter tubing was caught in the footrest of the recliner she was sitting in. 2. Review of Resident #20's medical record revealed an admitted [DATE]. Medical diagnoses included neuromuscular dysfunction of the bladder and chronic kidney disease. Review of Resident #20's care plan, undated, revealed the resident was at risk for complications related to the use of a Foley (indwelling urinary) catheter. Listed interventions included to provide catheter care every shift and to not allow the urinary drainage bag to lie on the floor. Observation on 06/30/24 at 10:15 A.M. revealed Resident #20's indwelling urinary catheter bag was resting on the floor. Interview on 06/30/24 at 10:15 A.M. with Agency Licensed Practical Nurse (LPN) #450 confirmed the above observation. An interview on 07/02/24 at 10:58 A.M. with the Director of Nursing (DON) confirmed she connected binder-type clips to catheter tubing so they can be more easily secured and will not drag on the floor. Review of the policy titled Infection Prevention and Control and Surveillance Program, dated 10/2023, revealed the infection control program is designed to prevent, report, investigate and control the spread of infections and communicable disease for all residents; provide a safe, sanitary, and comfortable environment; and to help prevent the development and transmission of disease and infection. Review of the CDC's Summary of Recommendations from the Guidelines for Prevention of Catheter-Associated Urinary Tract Infections, last updated 03/25/24, and found out at https://www.cdc.gov/infection-control/hcp/cauti/summary-of-recommendations.html revealed to keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor.

Based on observation, review of survey history, and staff interview, the facility failed to ensure results of complaint investigations by the state survey agency were available as required. This had the potential to affect all 44 residents residing in the facility. Findings include: An observation on 06/30/24 at 12:08 P.M. of the facility's main lobby area revealed a white binder identifying the state survey results. The most recent report contained in the binder was 04/23/23. Review of the previous survey activity for the facility revealed the Ohio Department of Health conducted complaint investigation surveys on 11/03/23, 12/19/23, 02/07/24, and 04/09/24. The results of these surveys were not present in the survey book at the time of the observation on 06/30/24. An interview conducted on 06/30/24 at 1:10 P.M. with the Director of Nursing (DON) verified the survey results binder contained only the results of the last annual survey and were missing the four complaint investigation results reports since the last annual survey. The DON confirmed the survey results books should contain the results of both annual and complaint investigations and stated the book needed to be updated.

Based on record review and staff interview, the facility failed to ensure a representative of the Office of the State Long-Term Care (LTC) Ombudsman were notified of the residents transfers to the hospital. This affected 12 (Residents #14, #21, #40, #41, #42, #43, #145, #146, #147, #148, #149, and #195 ) reviewed for hospitalization and transfers and had the potential to affect all 44 residents currently residing in the facility. Findings include: Review of the list of admission transfers and discharges from April 2024 through July 2024 revealed the following: Resident #14 was discharged to an acute care hospital on 05/02/24. Resident #21 was discharged to an acute care hospital on 05/03/24. Resident #40 was discharged to an acute care hospital on 04/16/24. Resident #41 was discharged to an acute care hospital on 04/16/24. Resident #42 was discharged to an acute care hospital on 05/20/24. Resident #43 was discharged to an acute care hospital on 05/07/24. Resident #145 was discharged to an acute care hospital on 06/12/24. Resident #146 was discharged to an acute care hospital on 05/22/24. Resident #147 was discharged to an acute care hospital on 06/27/24. Resident #148 was discharged to an acute care hospital on 06/29/24. Resident #149 was discharged to an acute care hospital on 04/05/24. Resident #195 was discharged to an acute care hospital on 06/28/24. Review of the medical records for Residents #14, #21, #40, #41, #42, #43, #145, #146, #147, #148, #149, and #195 revealed there were no evidence in their medical record that the LTC Ombudsman was notified of their transfer to a hospital as required. Interview with the Administrator on 07/01/24 at 1:34 P.M. verified the facility did not notify the LTC Ombudsman of any resident transfers to the hospital as required. The Administrator stated notifying the LTC Ombudsman of resident transfers to the hospital had fallen through the cracks, unfortunately.

Based on observation, review of maintenance repair logs, review of Resident Council meeting minutes, staff interview, Ombudsman interview, and review of manufacturer instructions, the facility failed to ensure processes were in place to ensure the resident call light system was tested and maintained in a fully functioning manner, and staff had required equipment to be alerted to resident call lights. This had the potential to affect all 44 residents residing in the facility. The census was 44. Findings include: Review of the facility maintenance repair log for the past three months revealed on 11/12/23 both call lights in room [ROOM NUMBER] were broken, the call light was broken in room [ROOM NUMBER], and the call light in room [ROOM NUMBER] would not go off. On 11/15/23 the call light in room [ROOM NUMBER] and in room [ROOM NUMBER], and in room [ROOM NUMBER]'s bathroom were not working. On 01/03/24 the call light was not working in room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]. Review of Resident Council meeting minutes dated 11/02/23 revealed call light system concerns were voiced, and review of Resident Council meeting minutes dated 12/28/23 revealed the call light system was replaced. Interview with Assistant Director of Nursing (ADON) #45 on 02/07/23 at 7:18 A.M. confirmed the facility call light system used pagers that staff members carried during their shift. The call light signal go to the pager and that was how staff are notified when a resident activated their call light. ADON #45 confirmed when agency staff work they are not provided a pager because as they kept leaving the facility with the pagers. ADON #45 stated there was a computer screen at the Oak Hill nursing station that also listed when call lights were activated. ADON #45 stated the staff can come to the Oak Hill nursing station to see when lights are activated. Interview and observation with Registered Nurse (RN) #31 occurred on 02/07/23 at 7:20 A.M. confirmed she recently started working a the facility a few weeks ago. RN #31 confirmed she was not provided a pager and verified she did not currently have one in her possession. RN #31 confirmed if she was on the other side of the facility there was no way for her to know a resident activated their call light and needed assistance. Interview with State tested Nurse Aide (STNA) #15 was completed on 02/07/24 at 7:23 A.M. and confirmed agency staff members do not receive a pager to be notified if residents call for assistance when they work. STNA #15 was not aware how staff members who worked on the other side of the facility would know when residents activated their call lights. Interview with the facility Ombudsman occurred on 02/07/24 at 9:33 A.M. confirmed there were concerns the facility call light system was not working properly, and there were concerns from residents wondering if staff knew when the residents activated their call lights. Observation of the facility call light system was completed with Maintenance Director (MD) #36 and the Director of Nursing (DON) on 02/07/24 a 1:35 P.M. A random check of the call light functionality was completed and noted room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]'s call lights were not functioning properly. room [ROOM NUMBER] was noted to illuminate the call box located in the room; however, the signal was not going to the pager system. room [ROOM NUMBER]'s call light was pressed and the activation string pulled, but the call light did not activate. The box did not illuminate and no signal was sent to the pager. room [ROOM NUMBER]'s call light was not functioning when tested . The observations were confirmed in interview with MD #36 and the DON. Interview with MD #36 and the DON, at the time of the observation, confirmed the resident room call boxes frequently needed batteries replaced, and the call system should sent alerts to the computer when the boxes are getting low battery signals. Observation of the call light computer screen located at the Oak Hill nursing station on 02/07/24 at 1:53 P.M. revealed the screen was noted to include 23 alerts dating back to 02/02/24. The alerts identified low battery and missing device. The missing device alerts were noted on the screen dated 02/02/24 for Rooms #16, #18, #19, #37, #40, #41, #54, #71, #72, #73, #76, and #79. The computer also listed nine alerts dated 02/07/24 for low batteries for Rooms #18, #19, #20, #33, #37, #40, #41, #76, and #79. Interview with MD #36 and the DON, at the time of the observation on 02/07/24 at 1:53 P.M., stated no one was currently in charge of fixing call light system alerts or checking the status of the alerts. Interview with MD #36 and the DON confirmed they did not really know what some of the alerts on the call system were or what the alerts meant. Observation and interview with MD #36 on 02/07/24 at 1:53 P.M. revealed MD #36 brought the call light box from room [ROOM NUMBER] and opened the box. MD #36 stated sometimes when the boxes were dropped something inside the box breaks loose and will illuminate; however, it will not send a signal to the pagers. MD #36 confirmed residents could think they activated their call light when in reality the signal was not being sent to the pagers. MD #36 confirmed the facility has no documented evidence of any ongoing testing of the call light system. MD #36 stated the issue with the call light boxes not sending a signal occurred a lot, and confirmed he needed to fix the boxes or replace the batteries almost daily. MD #36 stated in December 2023 the computer system for the call light system was replaced, because the entire system went down, but there was no evidence of him being trained on how to maintain the new call light system. Review of the facility call light system manufactures instruction contained an undated form letter that revealed a footprint test of the system was vitally important to be completed at least weekly. The instructions further revealed when using a pendent, send a test alarm from each of your test points and then validate that your call has registered on the Arial(R) computer and/or a pager carried by staff. Also, record your test results so that you will know if any system variances occur. Failure to perform these tests could result in inquiry to, or death of, someone in your care. Staff are to test your Arial(R) system regularly. Test all devices at least monthly as described in the product instructions/documentation for each installed device and be sure that alert and notification signals are received at all Arial PCs and at any other devices your facility uses to communicate alerts, such as pagers, signs, and smart-phones. Additionally, you should test your system after power outages, programming changes or upgrades, or after reconfiguring any system equipment. Failure to regularly test your Arial system could cause you to be unaware of a system failure. Do not ignore low battery alerts on your devices and replace batteries immediately. Failure to replace batteries could result in a call not reaching the Arial system. The Arial system should only be operated by properly trained personnel. This deficiency represents non-compliance investigated under Master Complaint OH00150540.

Based on observation, medical record review, and resident and staff interview, the facility failed to ensure suprapubic urinary catheter dressing changes were completed as ordered. This affected one (#32) of three residents reviewed for dressing changes. The facility census was 44. Findings include: Review of Resident #32's medical record revealed admission to the facility occurred on 06/29/23. Diagnoses included chronic obstructive pulmonary disease (COPD), anxiety, chronic kidney disease (CKD), and obstructive uropathy. Review of Resident #32's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 was assessed as cognitively intact and had a suprapubic urinary catheter in place. Review of Resident #32's February 2023 physician orders revealed nursing staff should clean the urinary catheter site and apply a sponge daily. Interview and observation of Resident #32 on 02/07/23 at 9:45 A.M. stated the dressing to her suprapubic urinary catheter was not changed the previous day. Resident #32 proceeded to lift her shirt and revealed the dressing in place was not dated. Further observation of the dressing revealed there were no staff initials, no time or date when the dressing was applied, and the dressing contained a large amount of brown-colored drainage. Observation of Resident #32's suprapubic urinary catheter dressing was completed with the Director of Nursing (DON) on 02/07/24 at 9:55 A.M. The DON observed the dressing that was in place and confirmed there was no date as to when the dressing was applied. Resident #32 stated to the DON at the time of the observation that her dressing was not changed yesterday. Interview on 02/07/24 at 9:55 A.M., with the DON at the time of the observation of Resident #32's dressing, confirmed all dressings should have the date and nurses initials when it was applied. The DON also confirmed Resident #32's dressing was noted with a large amount of brown drainage and confirmed the dressing was not initialed or dated. This deficiency represents non-compliance investigated under Master Complaint OH00150540.

Based on observations and staff interview, the facility failed to ensure wallpaper was not peeling and/or carpet was maintained in a clean manner/in good repair throughout the hallways of the facility. This had the potential to affect all 46 residents currently residing in the facility. Facility census was 46. Findings include: An environmental tour was conducted on 12/18/23 between 12:19 P.M. and 12:50 P.M. The tour revealed carpet in the hallways throughout the facility leading to resident rooms and other common resident areas contained multiple dark and light stains on dark blue carpet. There were many areas where the carpet fibers were missing. Interview on 12/18/23 at 12:20 P.M. with Housekeeper #103 revealed the sweeper sucks up a string of carpet and it keeps unraveling and [NAME] on the vacuum spool causing a bare spot revealing the carpet backing. The carpet was also noted in numerous areas to be pulling away from the floor in the center of the hallways that lead to resident rooms presenting a significant tripping hazard for any resident while walking, especially those who required an assistive device such as a wheeled walker for ambulation. Observation of Resident #47's room revealed wallpaper torn in three spots, behind the recliner under the chair rail, under the clock but had been glued back in place and by the top corner of the dresser/TV stand. Housekeeper #103 verified the condition of the wall paper in Resident #47's room and the carpet throughout the facility on 12/18/23 at 12:20 P.M. Housekeeper #103 confirmed the condition of the carpet as described in the tour. This deficiency substantiates Complaint Number OH00148581.

Based on review of the facility funds management system, and resident, family and staff interviews, the facility failed to obtain written authorization prior to opening resident personal needs accounts. This affected four (#8, #16, #19, and #28) of four resident personal needs accounts reviewed. The facility identified Resident #8, #16, #19, and #28 as the only residents with personal needs accounts. The census was 37. Findings include: 1. Review of Resident #8's medical record identified admission to the facility occurred on 06/02/22. Review of Resident #8's Minimum Data Set (MDS) dated [DATE] revealed Resident #8 was assessed with severely impaired cognition. Resident #8's payer source was listed as Medicaid. Review of Resident #8's personal needs account (PNA) revealed a balance on 03/31/23 of $700.15. There was no written authorization provided that indicated Resident #8 or a legal representative authorized for personal funds to be deposited in an account with the facility. 2. Review of Resident #16's medical record identified admission to the facility occurred on 06/15/22. Resident #16 was identified as a Medicaid payer source. Review of Resident #16's PNA revealed a balance on 03/31/23 of $600.30. There was no written authorization provided that indicated Resident #16 or a legal representative authorized for personal funds to be deposited in an account with the facility. 3. Review of Resident #19's medical record revealed an admitted [DATE]. Resident #19 was identified as a Medicaid payer source. Review of Resident #19's PNA revealed a balance on 03/31/23 of $951.28. There was no written authorization provided that indicated Resident #19 or a legal representative authorized for personal funds to be deposited in an account with the facility. 4. Review of Resident #28's medical record revealed an admitted [DATE]. Review of the MDS assessment dated [DATE] revealed Resident #28 was assessed with moderately impaired cognition. Resident #28 was identified as a Medicaid payer source. Review of Resident #28's PNA revealed a balance on 03/31/23 of $750.78. There was no written authorization provided that indicated Resident #28 or a legal representative authorized for personal funds to be deposited in an account with the facility. Interview with the Administrator on 04/10/23 at 9:10 A.M. stated the facility did not maintain any residents PNA accounts at the facility, and the corporate office maintained the resident funds. Interview with the Administrator on 04/13/23 at 11:04 A.M. confirmed there was no evidence of any written authorization for the facility to manage any resident funds for Resident #8, Resident #16, Resident #19 and Resident #28.

Based on review of the facility funds management system, and resident, family and staff interviews, the facility failed to provide quarterly statements of account activity and failed to maintain resident fund records in a clear and understandable manner. This affected four (#8, #16, #19, and #28) of four resident personal needs accounts reviewed. The facility identified Resident #8, #16, #19, and #28 as the only residents with personal needs accounts. The census was 37. Findings include: 1. Review of Resident #8's medical record identified admission to the facility occurred on 06/02/22. Review of Resident #8's Minimum Data Set (MDS) dated [DATE] revealed Resident #8 was assessed with severely impaired cognition. Resident #8's payer source was listed as Medicaid. Review of Resident #8's personal needs account (PNA) revealed Resident #8 had a balance of $700.00 on 01/15/23 and on 03/31/23 was given interest brining the balance to $700.15. Further review of the account document revealed no monthly addition of Resident #8's monthly $50.00 PNA allowance or accounting of any deposits or withdrawals. 2. Review of Resident #16's medical record identified admission to the facility occurred on 06/15/22. Resident #16 was identified as a Medicaid payer source. Review of Resident #16's PNA revealed a balance on 10/01/22 of $600.00, on 12/31/22, a balance of $600.15, and on 03/31/23 a balance of $600.30. Further review of the account document revealed no monthly addition of Resident #16's monthly $50.00 PNA allowance. Interview with Resident #16's sister on 04/13/23 at 1:27 P.M. confirmed confirmed any time herself or Resident #16 asked for some of his PNA account funds the facility informed them it was all done at the cooperate office, and the facility had nothing to do with it. Further interview with Resident #16's sister stated she did not get statements that show where all of Resident #16's personal funds deposits and withdrawals. 3. Review of Resident #19's medical record revealed an admitted [DATE]. Resident #19 was identified as a Medicaid payer source. Review of Resident #19's PNA revealed a balance on 06/30/22 of $950.54, a balance on 09/30/22 of $950.78, a balance on 12/31/22 of $951.03, and a balance on 03/31/23 of $951.28. Further review of the account document revealed no monthly addition of Resident #19's monthly $50.00 PNA allowance. 4. Review of Resident #28's medical record revealed an admitted [DATE]. Review of the MDS assessment dated [DATE] revealed Resident #28 was assessed with moderately impaired cognition. Resident #28 was identified as a Medicaid payer source. Review of Resident #28's PNA revealed a balance on 06/30/22 of $750.19, a balance of $750.38 on 09/30/22, a balance of $750.58 on 12/31/22, and a balance of $750.78 on 03/31/23. Further review of the account document revealed no monthly addition of Resident #28's monthly $50.00 PNA allowance. Interview with Resident #28 on 04/13/23 at 11:12 A.M. stated he had no idea if he received a monthly PNA allowance or if it was placed into his account. Further interview with Resident #28 stated he did not remember ever getting any statements for his account. Interview with the Administrator on 04/10/23 at 9:10 A.M. stated the facility did not maintain any residents PNA accounts at the facility, and the corporate office maintained the resident funds. Interview with the Administrator on 04/13/23 at 11:04 A.M. confirmed there was no way to determine when the monthly $50.00 PNA allowances for Resident #8, Resident #16, Resident #19 and Resident #28 were deposited since it was not documented. Interview with Business Office Manager (BOM) #56 on 04/13/23 at 12:29 P.M. stated she started her role at the facility on 02/28/23. BOM #56 confirmed she had to contact the cooperate office if any resident asked for monies from their PNA accounts, and confirmed looking at Resident #8, Resident #16, Resident #19 and Resident #28's PNA account records there was no documentation of when their monthly $50.00 allowance was deposited or located.

Based on medical record review, review of hospital documentation, staff and physician interview and policy review, the facility failed to ensure staff thoroughly assessed a resident who was experiencing unrelieved abdominal pain to ensure the resident received timely treatment. This resulted in actual harm for Resident #8 when staff failed to assess and immediately report increased severe abdominal pain to the physician resulting in delayed emergency room treatment for [REDACTED].#8) of one resident reviewed for a change in condition. The facility census was 43. Findings include: Review of the closed medical record for Resident #8 revealed an admitted d 09/18/14. [DIAGNOSES REDACTED]. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had intact cognition. Review of a nurse's note dated 11/06/19 at 12:04 P.M. revealed a new order for Speech Therapy (ST) was received related to dysphagia. Review of a nutrition note dated 11/14/19 at 4:01 P.M. revealed Resident #8 had experienced a significant weight loss of 18 pounds in the past 90 days and it was likely related to congested heart failure and diuresis. ST trialed a mechanical soft diet for three days but Resident #8 requested to go back on a regular diet on 11/12/19. Resident #8 had no complaints of chewing or swallowing issues. Review of nurse's note dated 11/18/19 at 6:44 P.M. revealed Resident #8's stool was checked times two for occult blood related to recent abnormal laboratory values. The occult stool samples were negative for blood. The nurse practitioner was updated and a gastrointestinal (GI) consultation was recommended related to Resident #8's increased vomiting following medications. Resident #8's Power of Attorney (POA) was notified and the POA stated the consultation would be up to the resident. Resident #8 was informed of the recommendation for the GI consultation and stated not at this time. Review of the nurse's notes revealed no other documentation regarding abdominal distress, pain or other notable concerns from 11/18/19 through 11/22/19. Further review of a nurse's note dated 11/22/19 at 6:24 [NAME]M. revealed the resident had been awake most of the night. The resident complained of nausea and severe abdominal pain. The resident refused Tylenol and stated, It doesn't help. Further review of the progress note revealed the resident took [MEDICATION NAME] at 4:00 [NAME]M. for nausea and it was not effective. The resident was noted as lying in bed unable to sit up without assistance and very shaky. The resident reported she sneezed and felt like she was being ripped apart. The resident stated she could not take the pain much longer, something has to be done. When asked if she wanted to go to the hospital the resident stated, If that's what it takes, then yes I want to go. Continued review of the nurse's note revealed the physician was notified at 6:44 [NAME]M. and an order was given to send the resident to the emergency room . A ambulance service was contacted to transport the resident to the emergency room (ER). Review of a nurse's note for Resident #8 dated 11/22/19 at 7:41 [NAME]M. revealed the squad was here to transport to the ER at 7:40 [NAME]M. Review of a nurse's note dated 11/22/19 at 3:33 P.M. revealed the ER was contacted for an update on the resident. The nurse stated the resident had a bowel perforation and would be admitted for surgical consult. Review of the emergency room documentation dated 11/22/19 at 8:11 [NAME]M. for Resident #8 revealed the resident had ten out of ten suprapubic abdominal pain that began two days ago. The resident had nausea but no vomiting. The resident reported she has not been able to sleep due to the pain. The resident reported her pain as two days in duration. The resident described her pain as new, sudden, severe, constant, and worsening. The resident described the quality of her pain as aching, bloating, burning, cramping, pressure and sharp. Review of the hospital operative note dated 11/22/19 at 4:06 P.M. revealed Resident #8 was diagnosed with [REDACTED]. Resident #8 required a laparoscopic repair of a perforated [MEDICAL CONDITION] with graham patch. Interview on 12/04/19 at 9:56 [NAME]M. with the Director of Nursing (DON) revealed Licensed Practical Nurse (LPN) #69 told her she sent Resident #8 out for increased abdominal pain. The DON revealed LPN #69 should have notified the physician as soon as Resident #8 complained of increased abdominal pain. The DON revealed the nurse should have completed and documented a through assessment in the medical record. The DON verified there was no documented assessment in the resident's medical record. The DON revealed it was out of character for Resident #8 to complain of pain. Interview on 12/04/19 at 10:39 [NAME]M. with LPN #26 revealed she assessed Resident #8 on 11/21/19. LPN #26 revealed the resident had abdominal pain on and off for a couple weeks. LPN #26 revealed Resident #8 had refused a GI consult. LPN #26 revealed Resident #8 had a small bowel movement on 11/21/19. LPN #26 revealed the resident had bowel sound in all four abdominal quadrants. LPN #26 verified there was no documentation of her assessment in the resident's medical record. Interview on 12/04/19 at 1:52 P.M. with LPN #69 revealed Resident #8 had nausea for the past couple weeks. LPN #69 revealed on 11/22/19 at 4:00 [NAME]M. Resident #8 stated her pain was at an eight or nine on a zero to ten scale. LPN #69 revealed Resident #8 was not known to complain of pain. LPN #69 revealed Resident #8 had received her routine Tylenol on 11/21/19 at 8:00 P.M. LPN #69 revealed the resident had not wanted more Tylenol because it did not help with the pain. LPN #69 revealed Resident #8 had nothing else ordered for pain. LPN #69 revealed she administered Resident #8 [MEDICATION NAME] at 4:00 [NAME]M. on 11/22/19. LPN #69 revealed the [MEDICATION NAME] was ineffective. LPN #69 verified she had not notified the physician when the resident complained of increased abdominal pain at 4:00 [NAME]M. Further interview with LPN #69 revealed she went to checks the resident's blood sugar at 5:30 [NAME]M. The resident rated her pain as a nine (indicating severe pain) on a zero to ten scale. LPN #69 revealed she looked at Resident #8's abdomen and did not see anything. LPN #69 revealed the resident had bowel sounds in all four quadrants. LPN #69 verified she had not documented her abdominal assessment or pain assessment of Resident #8. LPN #69 stated she told the resident she would notify dayshift to pass on her concerns to the physician. LPN #69 verified she failed to notify the physician of the resident's severe abdominal pain again at 5:30 [NAME]M. LPN #69 revealed she continued with her work and completed her medication administration pass. LPN #69 revealed she then notified the physician at 6:44 [NAME]M. LPN #69 revealed the physician instructed her to send Resident #8 to the emergency room because it sounded like she could have a bowel obstruction. Interview on 12/04/19 at 10:47 [NAME]M. with Physician #73 revealed the nursing staff should have notified him when Resident #8 voiced increased uncontrolled abdominal pain. Physician #73 revealed he ordered Resident #8 to the emergency room when notified by the nurse. Physician #73 revealed Resident #8 had previously been ordered a GI consult but had refused. Review of the policy Change in Condition-Physician Notification, dated 10/2019 revealed nursing staff would notify the attending physician of any sudden and/or marked adverse changes in signs, symptoms, or behavior exhibited by a resident. Staff should call nine-one-one (911) before the attending physician in any situation in which it is the judgement of the nurse any delay in medical care would not be in the best interest of the resident.

Based on medical record review, staff interview, policy review and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure proper pressure ulcer interventions were in place in accordance with physician orders [REDACTED]. This resulted in actual harm when Resident #66's pressure ulcer worsened and the resident was subsequently admitted to the hospital for pressure ulcer treatment. This affected one (#66) of three residents who were reviewed for pressure ulcers. The facility identified five current residents with pressure ulcers. The facility census was 65. Findings Include: Review of the medical record for the Resident #66 revealed an admission date of [DATE] and a discharge date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #66's discharge Minimum Data Set (MDS) assessment dated [DATE] the resident had an unstageable pressure ulcer and was at risk for pressure ulcers. Review of Resident #66's current comprehensive plan of care revealed the resident was at risk for pressure ulcers related to [MEDICAL CONDITION], dependent for activities of daily living and [MEDICAL CONDITION]. Interventions included pressure reduction perimeter mattress on bed, turn and reposition every two hours and notify physician of any skin changes. Review of Resident #66's Braden Scale (for predicting pressure ulcers) dated 07/06/17 and 09/14/17 revealed the resident to be high risk for pressure ulcers. Review of Resident #66's nurse's note dated 08/22/17 revealed a state tested nursing assistant (STNA) reported the resident had a scabbed area to her right hip and red tissue surrounding the scab. The physician and power of attorney (POA) were notified. Further review of Resident #66's pressure wound documentation revealed on 08/22/17 a scabbed area was noted on right hip. Further review revealed on 08/31/17 a scab was noted on right heel. On 08/30/17 the right hip wound measured 0.7 centimeters (cm) by 2.0 cm by 0.1 cm and was documented as a Stage 2 pressure ulcer. On 09/06/17 right hip wound measured 1.7 cm by 2.8 cm by 0.1 cm. On 09/13/17 the right hip wound measured 5.6 cm by 10.2 cm with no depth being listed and large amount of thick purulent drainage. The right heel wound was healed on 09/13/17. The measurements/assessments of the right hip on 09/06/17 and 09/13/17 did not include a stage of the pressure ulcer; however, the pressure ulcer was assessed as unstageable on the MDS dated [DATE]. Review of Resident #66's nurse's notes dated 09/12/17 revealed the power of attorney (POA) was notified of wound changes, excessive drainage and odor. Review of Resident #66's medical record including physician orders [REDACTED]. Further review of Resident #66's physician orders [REDACTED]. On 08/30/17 promod 30 milliliters three times per day was ordered. On 08/31/17 an order for [REDACTED]. Review of Resident #66's treatment administration record (TAR) dated September 2017 revealed the low flow air mattress on the bed and the cushion to the chair was not implemented until 09/13/17. Further review of the record revealed Resident #66 was discharged to the hospital on [DATE]. Review of Resident #66's discharge summary dated 09/13/17 revealed the resident developed a worsening pressure ulcer, the wound started excessively draining with increased pain and odor. Interview on 10/23/17 at 11:15 A.M. with licensed practical nurse (LPN) #104 stated a right hip wound incident report was made for Resident #66 was related to the area was found sometime in August. LPN #104 stated when she saw the right hip wound it was an unstageable pressure wound and continued to get worse. LPN #104 stated the resident was then send to the hospital due to the wound bleeding. Interview on 10/23/17 at 12:00 P.M. with STNA #100 stated Resident #66 did have a bruised area on her right hip and stated she told the nurses but they just said it was a bruise from her fall. STNA #100 stated the right hip was reddened prior to the fall experienced by the resident and then got worse. Interview on 10/23/17 at 12:15 P.M. with STNA #101 stated Resident #66 had a red circle on her hip and the area got worse. STNA #101 stated she had reported it to the nurse and was told it was due to her fall. STNA #101 stated the resident was on bedrest for six weeks prior to the red area being found and did not have an air mattress on her bed during the time she was on bedrest. Review of facility policy titled Skin Care dated September 2017 revealed residents who's Braden Scale is very high will have interventions initiated. All residents with adverse skin conditions that occur after admission will be placed on an episodic plan of care. treatment for [REDACTED]. Review of information from the NPUAP revealed a Stage 2 pressure ulcer is partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough and may also present as an intact or open/ruptured serum-filled blister. An Unstageable pressure ulcer is full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further review revealed the develop a plan of care is based on the areas of risk, rather than on the total risk assessment score. For example, if the risk stems from immobility, address turning, repositioning, and the support surface. The NPUAP advises to assess pressure points, such as the sacrum, coccyx, buttocks, heels, ischium, trochanters (hips), elbows and beneath medical devices. This deficiency substantiates Complaint Number OH 977.

Based on medical record reviews, review of employee personnel files, review of a facility self-reported incident (SRI), review of facility policy and staff interviews, the facility failed to ensure two (#47 and #59) residents were free from abuse by a staff member. This resulted in actual harm to Residents #47 and #59 when State tested Nurse Aide (STNA) #10 provided rough treatment during morning care and bruised both resident's arms. This action resulted in bruising to Resident #47's right forearm and Resident #59's right forearm. This affected two (#47 and #59) of three resident reviewed for allegations of abuse. The facility census was 68. Findings include: Review of Resident #59's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was intact and required extensive assistance with one person physical assistance from staff for bed mobility and transfers. Review of the nursing notes dated 01/04/16 at 12:30 P.M., indicated the resident was observed to have a fresh new bruise on the right forearm and measured 10.0 centimeter (cm.) wide by 5.5 cm. long. Review of Resident #47's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS assessment dated [DATE] revealed the resident had severe cognition impairment and required extensive assistance with two person physical assistance from staff for bed mobility and transfers. Review of Resident #47's nursing notes revealed an entry dated 01/04/16 at 1:10 P.M., documenting the daughter was present in the room at that time and stated the bruise was not there the night prior because she was there. Resident #47 was observed to have a bruise to the right forearm measured 1.5 cm. wide and 2.0 cm. long. Review of the facility's Self-Reported Incident (SRI) revealed on 01/04/16 at approximately 12:30 P.M. Resident #59 reported to the charge nurse (Registered Nurse #11) that State tested Nursing Aide (STNA) #10 grabbed her by her right arm during morning care, that the STNA #10 was in a hurry, and that she pushed her down in her chair. This resulted in a bruise to her right arm, between her wrist and elbow. Resident #59 also reported the same STNA was rough with her roommate, Resident #47. This resulted in Resident #47 having a small, new bruise to her right forearm. Review of the SRI conclusion revealed the STNA #10 was guilty of not using caution and care, but the STNA #10 did not intentionally or willfully caused the bruising. Review of STNA #10 personnel file revealed a written disciplinary action dated 12/11/15 for being to rushed with care and causing a skin tear to a resident. The file contained documented evidence of STNA #10 being terminated as of 01/04/16 due to misconduct, unsatisfactory work, violation of rules, and improper attitude and was not eligible for rehire. Review of the STNA #10's time sheet reflected she clocked out at 12:11 P.M. on 01/04/16. Interview with the Administrator on 01/14/16 at 4:45 P.M., verified STNA #10 had clocked out on 01/04/16 and was terminated. Interview with Registered Nurse (RN) #11 on 01/15/16 at 2:33 P.M. stated STNA #10 was always in a hurry to complete her work assignments and resident's complained about how she was too fast with her care provided to the residents. The RN #11 stated that Resident #59 told her on 01/04/16 at approximately 12:30 P.M. that STNA #10 was rough with providing care to her prior to breakfast and she grabbed her from the bed and threw her in her chair. The RN #11 stated she observed a fresh new bruise on Resident #59's right forearm. RN #11 stated Resident #59 also stated STNA#10 was rough with her roommate, Resident #47. The daughter of Resident #47 was present in the room at that time and stated the bruise was not there the night prior because she was there. The RN #11 stated she reported it to the Director of Nursing (DON) and when the DON spoke to Resident #59 she told the exact same story to her. The RN #11 also stated the STNA #10 was already fired earlier in the day prior to Resident #59 alleging the STNA #10 was rough with her and her roommate. Review of the facility's policy titled, Resident Abuse Policy with revision date of April 2010, indicated all residents at the facility shall be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. This deficiency is an incidental findings discovered during the course of this complaint investigation.

Based on observations, resident and staff interviews and record review, the facility failed to provide consistent care and monitoring of identified and unidentified pressure areas for one (#79) of two residents reviewed for pressure ulcers. This resulted in harm when Resident 79's pressure ulcer increased in size and worsened from a Stage III to one unstageable pressure ulcer and also failed to identified a Stage II area on 03/25/15. The facility identified a total of five resident who have pressure ulcers. The facility census was 76. Findings include: Review of Resident #79's clinical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #79's comprehensive plan of care dated 12/08/14, revealed the resident was alert and orientated and required extensive assist of two persons for bed mobility, transfers and personal hygiene and extensive assist of one person for dressing and eating. Review of Resident #79's plan of care (POC) dated 12/08/14, revealed the resident was identified with actual alteration in skin integrity related to a Stage III wound on the left buttock, fluid filled blister on right buttock, obesity, impaired mobility, incontinence, diabetes, chronic diarrhea, depression, poor motivation, impaired nutrition, red coccyx and peri-area. Review of Resident #79's skilled daily nurses notes from 12/05/15 to 03/19/15, revealed for 34 days, nurses charted the resident's skin was assessed by nurses as of normal turgor (adequate hydration), dry and intact with preventative measures in place. The assessments documented normal skin, however, other nurses charted on 01/28/15, a new open area on the left posterior inner thigh measuring 5.0 centimeters (cm) by 0.5 cm.; on 02/04/15, there was documentation of an open area to the left inner thigh; on 02/06/15, a pressure ulcer to the left buttocks was documented; and 02/09/15, a pressure ulcer to the coccyx and left buttocks. Review of Resident #79's pressure ulcer assessments dated 12/08/15, documented the staff were to apply antifungal to abdominal folds, underneath bilateral breast. skin repair cream to buttocks, peri area, and inner thigh. On 12/10/14, the assessment documented a treatment was in place, no new skin issues noted at this time, will continue to monitor. On 12/17/14, treatment to the groin will continue. On 12/24/14, no new skin issues noted at this time, will continue to monitor resident. On 12/31/14, a pressure ulcer to the coccyx measuring 1.5 cm's by 1.0 cm and pressure ulcer to coccyx measuring 4.0 cm by 1.0 cm. On 01/07/15, no new skin issues noted at this time, will continue to monitor, the comment section was blank. On 01/14/15, no new skin issues noted at this time, will continue to monitor. The assessment form was blank except for a notation regarding the pressure area to the coccyx. On 02/09/15, interventions were reviewed and updated. A skin tear to the left buttock (no measurements) has worsened into pressure ulcer and low air loss mattress put in place on 1/21/15. Hypergel started on 02/03/15, then changed to Mesalt with dressing daily. Up for therapy only, then in bed with positioning from side to side only. Review of Resident #79's weekly skin measurement tool dated 12/23/14, revealed a skin tear on the residents left buttocks measuring 3.0 cm by 1 cm with no depth with wound pain. On 01/06/15, the "skin tear" increased to 5.5 cm x 1.0 cm by 0.1 cm. with attached wound edges. A second area to the left buttocks measuring 2.0 cm by 2.0 cm by 0.1 cm was discovered. On 01/12/15, the area to the left buttocks increased to 6.0 cm by 2.0 cm by .25 cm with wound pain. On 01/13/15, the left buttock and a new area on the coccyx measured 9.0 cm by 5.5 cm with no depth and a notation of red scar tissue on most of the wound. On 01/21/15, the left buttock measured 7.5 cm by 4.5 cm by 0.1 and edges were irregular, wound bed is dark red and bleeds easily. All areas have merged into one area, the resident does not stay on her side and was incontinent. On 01/27/15, the left buttock measured 7.5 cm x 4.0 cm by 0.1 cm. On 02/03/15, the left left buttock was an unstageable pressure ulcer measuring 9.7 cm by 3.0 cm by 0.1 cm with the notation, treatment changed due to "slough." On 02/09/15, the unstageable left buttock measured 7.5 cm by 3.4 cm by 0.1 cm. On 02/16/15, the unstageable left buttocks area measured 7.5 cm by 4.5 cm 0.1 cm with moderate amount of yellow/tan drainage. On 02/23/15, this same area on the left buttock measured 7.5 cm by 3.5 cm with a decrease in slough drainage, some odor present but area improved. On 03/02/15, the left buttock, a Stage III pressure ulcer measured 5.5 cm by 5.0 cm by 2.0 cm. On 03/09/15, the left buttock Stage III area measured 7.5 cm by 3.7 cm, 2.0 cm decrease in slough and drainage present. 03/16/15, the left buttocks, Stage III measured 6.5 cm by 4.0, 2.0 cm slough decrease remains in area with undermining present and bright red granulation tissue. On 03/23/15, the left buttock, Stage III measured 6.8 cm by 3.9 cm by 1.0 cm. A small amount of slough remains, undermining decreased and red granulation tissue present. Interview with Resident #79 on 03/23/15 at 11:22 A.M., revealed she was very upset that she had developed a Stage III pressure area to the left buttocks. Resident #79 stated she had not been turned due to the facility being short staff and she could not get out of bed due to staffing. Resident #79 stated she came her for rehabilitation due to falling at her home and fracturing her right ankle. She indicated she was to be here for rehabilitation for a couple of months and them was to go home. She further adamantly denied that her "bedsore" was not a skin tear and she developed the area from not being turned. Resident #79 repeated the "bedsore" was caused by the facility being short staffed and not being turned when the dressing change was observed on 03/25/15, with Licensed Practical Nurse (LPN) #93 and the Assistant Director of Nursing (ADON) was present. Observation of Resident #79's dressing change on 03/25/15 at 11:22 A.M. with the Assistant Director of Nursing (ADON), revealed the left buttock area measured 7.5 cm by 4.3 cm with tunneling present. The area was clean, without odor or slough. A new non identified or documented circular Stage II area measured approximately 1.2 cm by 1.2 cm, approximately one inch above the left buttock, Stage III pressure ulcer. The ADON indicated the area was caused by the tape. The Director of Nursing was asked on 03/25/15 at 11:45 A.M., 1:30 P.M. and 3:45 P.M., for documented evidence the facility was aware of the new Stage II area on the resident's left buttock. As of 03/26/15 at 4:30 P.M., the facility provided no documented evidence the facility was aware of Resident #79's Stage II pressure area located near the left buttock. Interview with State Test Nursing Assistant (STNA) #95 on 03/24/15 at 1:30 P.M., revealed Resident #79 was not admitted with the pressure ulcer. Interview with the Director of Nursing (DON) on 03/24/15, verified the skin assessments prior to 02/09/15, were not accurate. Nurses were documenting Resident #79's skin was intact, when in fact, the resident had an open area to the left buttocks. The DON stated there has been a change in wound nurses which occurred in February and a different staff measures the wounds. The DON stated the pressure ulcer protocol was in the process of being changed. When the surveyor asked for the new protocol, the DON stated the protocol, training and inservice's have not been developed or implemented to ensure pressure ulcers were staged, documented and measured correctly. The DON further stated there were pieces and parts that are being put together for the new pressure ulcer protocol but as of 03/24/15, the policy and procedure for the new protocol had not been written or put in place.

Based on medical record review, observations, interviews with facility staff, a Hospice aide and a concerned citizen, review of the facility ' s missing person investigation, review of the facility's "Missing Person" policy and procedure, and the "Weather Underground" report, the facility failed to provide adequate supervision for one (Resident #11) of four residents with exit seeking behaviors of a total of four residents reviewed for elopement. The facility's failure to provide adequate supervision resulted in Immediate Jeopardy for one (#11) cognitively impaired resident with wandering and exit seeking behaviors who successfully eloped from the facility without staff knowledge. On 12/03/14 at 11:30 A.M., the Administrator was notified that Immediate Jeopardy began on 11/22/14 at approximately 3:00 P.M. when Hospice Aide (HA) #101, who was in a car, observed Resident #11 walking down the middle of the road using a walker, approximately one-quarter of a mile away from the facility. The resident was wearing a long sleeve shirt, long pants and a long sleeve sweater. The resident was without a hat or gloves. According to the history report for "Weather Underground", the local weather forecast, the average temperature in the area on 11/22/14 was 46 degrees Fahrenheit (F), with wind gusts up to 33 miles per hour. Resident #11 was confused and unable to verbalize where she was going or where she had come from. HA #101 transported the resident back to the facility. The Immediate Jeopardy was removed on 12/03/14 at approximately 4:00 P.M. when the facility implemented the following corrective actions: ? On 11/22/14 at approximately 4:00 P.M., Resident #11 was returned to the facility, placed on every 15 minute checks and a sensor pad was implemented on the resident's bed and chair to alert staff of attempts to exit the facility. ? On 11/22/14 at 4:00 P.M., the key code touch pad alarm system was installed on the first therapy door to alert staff and prevent Resident #11 from exiting the building. The second door to the therapy room was locked with signs instructing visitors, staff and therapy personnel that the door would be locked 24 hours a day and entrance to the therapy department would be made through the front entrance of the facility. ? On 11/23/14 at 2:00 P.M., the Administrator completed an all staff in-service for each shift, including nursing, activities, dietary, housekeeping and maintenance on the "Missing Person" policy and procedure. This training included assessments of residents on admission and as needed, implementation of care plans and interventions (i.e. supervision of wandering residents, wander-guards and redirection by staff), identification of safe areas for wandering and proper procedures in case of an elopement. ? On 11/23/14, the facility re-assessed all residents in the facility with elopement/wandering behaviors. ? On 12/02/14 and 12/03/14, interviews with three (#100, #108 and #112) Registered Nurses (RN' ), six (#111, #112, #113, #114, #118, and #119) Licensed Practical Nurses (LPN's), nine (#104, #105, #106, #107, #109, #110, #115, #116, and #117) State tested Nursing Assistants (STNA's), Activity Director #1, Housekeeper Staff #3, Dietary Staff #120 and Maintenance Director #1, revealed they were able to describe in detail the facility's "Missing Person" policy and procedure, location of alarmed doors and new interventions in place to prevent Resident #11 from further elopement. Although the Immediate Jeopardy was removed, 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 not enough time has elapsed to ensure the actions taken by the facility were effective and being monitored for on-going compliance. Findings include: Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The resident resides in a facility that required a code to enter and exit the building. Review of the form titled, "Risk for Wandering Behavior", dated 09/15/14, documented the resident was at moderate risk for wandering behavior. On 11/22/14 and 12/02/14, Resident #11 was assessed as being at high risk for wandering behavior. Review of the resident's comprehensive assessment dated [DATE], revealed the resident was severely cognitively impaired, displayed no wandering behavior and required extensive assistance of one staff for bed mobility, transfer, dressing and personal hygiene. Review of the resident's plan of care (POC) dated 12/24/13, revealed the resident was at risk for injury related to dementia with psychosis, anxiety, depression, history of falls and doesn ' t always remember to use her walker. Interventions included a WanderGuard to the wrist, a Secure Care bracelet to the ankle and a tab alarm to the bed and chair at all times. On 11/22/14, the POC was updated to include implementation of a motion detector to alert staff of unassisted attempts to exit the bed and room. Review of Resident #11's medication administration record (MAR) dated 11/01/14 to 11/30/14, revealed nurses signed off on the 11-7 shift that the battery to the Secure Care alarm on the ankle was activated and checked during the shift. The facility provided no documented evidence the WanderGuard on the wrist was checked or monitored for function to ensure the alarming system functioned properly. Review of the nurses' notes dated 11/22/14 at 4:00 P.M., indicated Resident #11 was observed stating she needed to go home. Resident #11 was redirected from 3:00 P.M. to the time just before the incident, as well as being ambulated by staff in the hall. Resident #11 was found walking away from the facility by Concerned Citizen (CC) #103. CC #103 reported seeing the resident get into the vehicle of HA #101, who brought the resident back to the facility. When the resident returned to the facility, she was placed on one-to-one supervision to keep her focused on other tasks as she continued to voice she wanted to go home. Interview with Registered Nurse (RN) #100 on 12/02/14 at 2:55 P.M., revealed Resident #11 had been confused and was pacing at change of shift, which occurred at 3:00 P.M. RN #100 stated the resident was reported missing and returned to the facility around 3:40 P.M. RN #100 estimated the resident had been missing from the facility between 20 to 30 minutes before being brought back to the facility by HA #101. RN #100 stated he did not know how far the resident got from the facility before being brought back by HA #101. RN #100 stated the resident was wearing a long sleeve shirt, sweater and long pants when she returned to the facility. RN #100 stated the resident was not wearing a coat, hat or gloves and was not injured. Interview with HA #101 on 12/02/14 at 4:25 P.M., revealed on 11/22/14 at 3:40 P.M. as she was returning from shopping, she found Resident #11 walking down a hill on a heavily traveled road approximately three blocks from the facility. HA #101 stated it was cold outside and Resident #11 had a terrified look on her face and was not wearing a coat, hat or gloves. Resident #11 was walking with her walker down the middle of the road. HA #101 further stated she was afraid Resident #11 was going to get hit by a car before she could pull her car over to get the resident safe and out of traffic. HA #101 stated she asked the resident if she needed help and the resident responded, "I' m lost." HA #101 stated she called the facility and asked if they had a missing resident. She said she was told yes and she got Resident #11 into her car and took her back to the facility. HA #101 stated when she returned the resident back to the facility, staff were waiting on her and took the resident into the facility and she left. HA #101 stated she saw the WanderGuard on the resident ' s wrist but did not point this out because she did not work for the facility. Interview with CC #103 on 12/02/14 at 5:00 P.M., revealed he was driving to the facility to visit his wife when he saw Resident #11 walking along the side of the road, approximately three blocks from the facility. He stated the woman was dressed in a sweater and pants and looked confused. CC #103 further stated he saw a car drive by, pull over and got the women in the car. Concerned Citizen #103 verified Resident #11 was a woman he recognized from the facility who spent her time walking in the halls with her walker. CC #103 stated at the time of the observation, the women was not wearing a coat, hat or gloves and looked like she might be cold. Interview with Maintenance Director #1 on 12/03/14 at 8:45 A.M. revealed the WanderGuard used on the therapy door had been non-functional prior to Resident #11's elopement. He stated a key pad touch alarming system had been installed on the door when the WanderGuard system failed. Observation of Resident #11 on 12/02/14 at 8:15 A.M. revealed the resident had a WanderGuard bracelet on her right wrist and a Secure Care alarm ankle bracelet on the left ankle. Resident #11 was seated on a sensor pad and her room was equipped with a motion detector that when activated, alarmed at the nurses station. On 12/02/14 at 1:50 P.M., STNA #105 escorted Resident #11 near the front door. The door alarm sounded and staff responded to the alarm. Observation of the therapy doors on 12/02/14 at 10:30 A.M. with the Director of Nursing (DON), revealed the therapy entrance door was 90 feet from Resident #11's room. The therapy room consisted of two glass exit doors leading to the outside parking lot. The first glass door that led to the parking lot had a WanderGuard alarm that was not functional; however, the door had a coded key pad next to the door that alarmed loudly when activated by the DON. The second glass exterior door leading directly outside was locked with a notice that indicated all visitors coming to the facility for therapy had to use the front entrance. All other doors in the facility except the front door had coded key pad alarms next to the doors. The front door was alarmed with a Secure Care alarm system All doors were activated and functional on 12/02/14 between 8:45 A. M and 3:30 P.M. On 12/03/14 at 7:00 A.M., the door to the therapy room was observed to be locked. Review of the facility's policy and procedure, titled, "Missing Person", dated July 2005, revealed when a resident was found missing from the facility, staff would immediately check all areas in the facility as well as the facility grounds and parking area. If a resident was not found in the facility or facility grounds, the charge nurse would assign staff to search the surrounding area until the resident was found. Staff were to notify the police to aide in the search and notify the Administrator, DON and assistant DON. The policy also indicated staff were to notify the responsible party or other family member if the responsible party was not available. The policy also indicated an incident report will be filed and an "Episodic Plan of Care" will be initiated. A full body assessment will be completed by nursing to denote any adverse conditions. This deficiency substantiates Complaint Number OH 134.