Every finding on record at Windsor Health Care Center

THIS DEFICIENCY IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, Self-Reported Incident (SRI) review and interview, the facility failed to ensure residents were free from misappropriation. This finding affected four (Residents #49, #55, #56 and #57) of four residents identified during the investigation of diversion of narcotics. Findings include: Review of Resident #49's medical record revealed the resident was admitted on [DATE] with diagnoses including quadriplegia, chronic pain syndrome and anemia. Review of Resident #49's Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #49's physician orders revealed an order dated [DATE] for Oxycodone 10 milligrams (mg) give one tablet every four hours as needed for pain.Review of Resident #55's medical record revealed the resident was admitted on [DATE] with diagnoses including malignant neoplasm of the left breast, morbid obesity, and generalized anxiety disorder. Review of Resident #55's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #55's physician orders revealed an order dated [DATE] for Oxycodone 4 mg one tablet every four hours as needed for moderate to severe pain. Review of Resident #56's closed medical record revealed the resident was admitted on [DATE], readmitted on [DATE] and discharged on [DATE] with diagnoses including malignant neoplasm of the bronchus, bipolar disorder and disorder of the brain. Resident #56 expired in the facility on [DATE].Review of Resident #56's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem.Review of Resident #56's physician orders revealed an order dated [DATE] for Oxycodone 5 mg one tablet four times a day for moderate to severe pain; and an order dated [DATE] for Oxycodone 10 mg every four hours as needed for increased pain. Review of Resident #57's closed medical record revealed the resident was admitted on [DATE] and discharged on [DATE] with diagnoses including chronic obstructive pulmonary disease, essential hypertension, and muscle wasting. Resident #57 was discharged home on 0721/25.Review of Resident #57's admission MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #57's physician orders revealed an order dated [DATE] for Oxycodone 5 mg give one to tablets by mouth every four hours as needed for pain.Review of the Misappropriation SRI Tracking #263185 dated [DATE] revealed LPN Agency #812 misappropriated narcotics from Residents #49, #55, #56 and #57. The investigation determined Resident #49 was missing an unknown amount of Oxycodone narcotic pain tablets due to LPN Agency #812 forging signatures of other nursing staff on the resident's narcotic flow record; Resident #55 was missing seven Oxycodone narcotic pain tablets; Resident #56 was missing 30 Oxycodone narcotic pain tablets; and Resident #57 was missing an unknown amount of Oxycodone narcotic pain tablets because LPN Agency #812 took the remaining Oxycodone card and narcotic flow record from the facility.Interviews on [DATE] at 12:23 P.M. with Regional Administrator #811 and Registered Nurse (RN) #813 confirmed the above findings.Review of the Resident Abuse Prevention Practices policy revised 10/2022 revealed it was the policy of the company to protect all residents from mistreatment, neglect, abuse, and misappropriation of resident property. This includes protection from verbal, mental, physical, emotional, or financial abuse by staff, families, residents, visitors or outside ancillary service employees or in any situation that would be harmful to the resident.The deficiency was corrected on [DATE] when the facility implemented the following corrective actions:On [DATE], the Administrator and Director of Nursing (DON) immediately removed Licensed Practical Nurse (LPN) Agency #812 from the staffing schedules.On [DATE], SRI tracking #263185 was reported to the State agency by the Administrator and an investigation was conducted which included witness statements and was substantiated for misappropriation of narcotics.On [DATE], the Administrator and DON conducted a Quality Assurance Performance Improvement (QAPI) AD Hoc meeting to review and develop a plan of action for the medication diversion.On [DATE], the DON and/or Designee completed narcotic counts on all residents and determined four residents including Residents #49, #55, #56 and #57 were missing narcotics and/or narcotic flow records.On [DATE], the Administrator contacted the nursing agency concerning LPN Agency #812's involvement in the missing narcotics and narcotic flow records.On [DATE], the Administrator contacted the local police department involving LPN Agency #812's involvement in missing narcotics and narcotic flow records.On [DATE], the Administrator submitted a report with the Ohio Board of Nursing regarding LPN Agency #812's involvement in the missing narcotics and narcotic flow records.On [DATE], the Administrator and DON sent other nursing staff for drug testing including LPNs #814, #815, #816, #817, #818, #819 and #820.On [DATE], the DON/Clinical Designee in-serviced all staff on Abuse, Neglect and misappropriation.Resident #49's oxycodone medication was replaced on [DATE]; and Resident #55's Oxycodone medication was replaced on [DATE]. Residents #56 and #57 were discharged from the facility.From [DATE] to [DATE], the DON/Designee in-serviced all staff on the correct medication administration policy and procedure including narcotic flow records.The DON/Designee conducted Audits daily for one week then three times a week for three weeks.

Based on record review, interview, and review of the facility policy, the facility failed to utilize an effective antibiotic stewardship program that monitored antibiotic use including reducing the risk of adverse effects of the development of antibiotic resistant organisms from unnecessary or inappropriate antibiotic use. This affected 15 residents (#4, #7, #11, #19, #30, #31, #32, #33, #34, #37, #42, #49, #56, #57 and #61) out of 16 residents who were ordered antibiotics during the months of April 2025 and May 2025. The facility census was 57. Findings include: 1. Review of the Monthly Infection Log for April 2025 revealed the facility tracked residents who received antibiotics during the month. It included the resident name, admission date, onset of symptoms, the site of infection, if the infection was healthcare associated (nosocomial), the antibiotic received, and if the infection met McGeer criteria (infection surveillance definitions for long term facilities for antibiotic use). The following nine residents were identified on the log as receiving antibiotic treatment for infections but did not meet McGeer's criteria for infections: A. Resident #30 who was admitted on [DATE] received flagyl, cefepime and vancomycin for a left below the knee amputation; however, the log specified the indication for antibiotic use did not meet McGeer criteria for infections. B. Resident #11 who was admitted on [DATE] received doxycycline for pneumonia; however, the log specified the indication for antibiotic use did not meet McGeer criteria for infections. C. Resident #49 who was admitted on [DATE] received doxycycline for a urinary tract infection (UTI); however, the log specified the indication for antibiotic use did not meet McGeer criteria for infections. D. Resident #56 who was admitted on [DATE] received vancomycin and rocephin for an infection on the head; however, the log specified the indication for antibiotic use did not meet McGeer criteria for infections. E. Resident #4 who was admitted on [DATE] received doxycycline for a chronic infection of the right hip; however, the log specified the indication for antibiotic use did not meet McGeer criteria for infections. F. Resident #32 who was admitted on [DATE] received fluconazole for a UTI; however, the log specified the indication for antibiotic use did not meet McGeer criteria for infections. G. Resident #34 who was admitted on [DATE] received doxycycline and levofloxacin for a UTI; however, the log specified the indication for antibiotic use did not meet McGeer criteria for infections. H. Resident #7 who was admitted on [DATE] received cipro for a UTI; however, the log specified the indication for antibiotic use did not meet McGeer criteria for infections. I. Resident #61 who was admitted on [DATE] received cefepime and vancomycin for a left foot infection; however, the log specified the indication for antibiotic use did not meet McGeer criteria for infections. Review of the medical records for Residents #4, #7, #11, #30, #32, #34, #49, #56 and #61 revealed there was no evidence the physician was made aware of the McGeer criteria results to evaluate for necessary and appropriate antibiotic use. 2. Review of the Monthly Infection Log for April 2025 revealed the following eight residents were identified on the log as receiving antibiotic treatment for infections but did not meet McGeer's criteria for infections: A. Resident #33 who was admitted on [DATE] received ceftin for pneumonia; however, the log specified the indication for antibiotic use did not meet McGeer criteria for infections. B. Resident #4 who was admitted on [DATE] received doxycycline for a chronic infection of the right hip; however, the log specified the indication for antibiotic use did not meet McGeer criteria for infections. C. Resident #57 who was admitted on [DATE] received ceftin for a respiratory infection; however, the log specified the indication for antibiotic use did not meet McGeer criteria for infections. D. Resident #37 who was admitted on [DATE] received acyclovir for a chronic blood infection; however, the log specified the indication for antibiotic use did not meet McGeer criteria for infections. E. Resident #19 who was admitted on [DATE] received cefdinir and flagyl for a gastrointestinal infection; however, the log specified the indication for antibiotic use did not meet McGeer criteria for infections. F. Resident #56 who was admitted on [DATE] received doxycycline for a left head infection; however, the log specified the indication for antibiotic use did not meet McGeer criteria for infections. G. Resident #42 who was admitted on [DATE] received cipro for a genitourinary infection; however, the log specified the indication for antibiotic use did not meet McGeer criteria for infections. H. Resident #31 who was admitted on [DATE] received keflex for a genitourinary infection; however, the log specified the indication for antibiotic use did not meet McGeer criteria for infections. Review of the medical records for Residents #4, #19, #31, #33, #37, #42, #56 and #57 revealed there was no evidence that the physician was made aware of McGeer criteria results to evaluate for necessary and appropriate antibiotic use. 3. Review of the medical record for Resident #11 revealed an admission date of 06/20/15 and diagnoses including quadriplegia, chronic pain syndrome, and epileptic spasms. Review of Resident #11's physician orders revealed an order dated 06/29/18 for the antibiotic cephalexin to be administered every six hours for a spinal abscess. The order had no stop date or duration for the antibiotic use. Review of the medication administration records from June 2024 until June 2025 revealed Resident #11 received the antibiotic cephalexin as ordered. Review of the hospital record dated 11/27/13 revealed an assessment and plan for an antibiotic as Resident #11 would likely need lifelong prophylactic treatment. Review of the hospital record dated 10/14/15 revealed Resident #11 had an order for cephalexin four times daily and would receive it indefinitely due to a history of a spinal abscess. There was no McGeer criteria available for review related to this antibiotic use. Review of Resident #11's nursing and physician progress notes from 06/24/24 to 05/22/25 revealed no evidence the physician reviewed or evaluated the necessity and appropriateness for the ongoing antibiotic use. Interview on 06/17/25 at 2:14 P.M. with Clinical Director #450 and the Director of Nursing confirmed Resident #11's antibiotic order had no stop date or indication of duration and indicated the physician was aware of its ongoing use but was unable to verify or provide evidence the physician had reviewed its appropriateness or continued necessity. 4. Review of the facility policy, Antibiotic Stewardship Program, dated November 2017 revealed the infection preventionist monitored and supported antibiotic stewardship activities, and the Director of Nursing (DON) conveyed expectations to nursing staff and set practice standards for assessing, monitoring and communicating change in resident condition by front line nursing staff. The facility followed McGeer criteria for identification of infections and tracked how and why antibiotics were prescribed, how often and the number of antibiotics prescribed, and adverse outcomes if any from antibiotic use. Antibiotic use, tracking and trending was compiled monthly and results reported to infection control committee and quality assurance team. Clinicians, nursing, staff, residents and families were provided with antibiotic stewardship education. Every dose, duration, route and indication of every antibiotic was documented in the medical record and reviewed monthly to assess compliance. Providers utilized the assessment criteria when considering antibiotic use. There was no evidence on the facility policy of its annual review. Interview on 06/17/25 at 8:54 A.M. with Clinical Director (CD) #450, who was the infection preventionist, verified the above findings. CD #450 confirmed McGeer's criteria was not assessed for any residents who had chronic infections or came from the hospital but were noted on the infection log as not meeting criteria. If a resident was involved with an infection disease specialist, then McGeer's was not completed. Instead, orders were followed and any follow-up completed. The facility did not get involved with assessing or determining appropriateness or necessity of antibiotic use unless the infection started in the facility. CD #450 denied getting involved with any physicians outside of the facility because of being able to communicate with the facility physician, as other physicians were difficult to reach. CD #450 reported talking with the facility physician about antibiotic use but was unable to confirm or provide evidence for reviewing McGeer criteria for the residents unless it was reflected in a progress note. CD #450 stated the facility physician had a tendency to order antibiotics as did the hospitals. Interview on 06/17/25 at 10:56 A.M. with the DON verified being a participant in staff training and confirmed there was no known staff training on antibiotic stewardship. The DON confirmed they lacked documentation for the assessment and evaluation of the necessity and appropriateness for ongoing antibiotic use. During interview on 06/17/25 at 2:14 P.M. with CD #450 and the DON, the DON indicated the antibiotic stewardship policy was reviewed annually despite the policy date being November 2017 but was unable to provide evidence of the last annual review.

Based on observation, interview, review of medical record and review of facility policy the facility failed to ensure passive range of motion (PROM) and splinting restorative programs were completed per therapy recommendations. This affected two residents (#22 and #53) out of two residents reviewed for ROM. The facility identified 21 residents (#4, #6, #8, #10, #11, #12, #14, #15, #18, #19, #22, #23, #25, #26, #30, #32, #34, #35, #43, #51 and #53) with impaired ROM. The facility census was 57. Findings include: 1. Review of medical record for Resident #53 revealed an admission date of 02/14/25 and diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dementia, and heart failure. Review of physician orders and electronic task bar from 02/14/25 to 06/16/25 for Resident #53 revealed there were no orders or documentation for restorative range of motion and/or splints. Review of the Occupational Therapy (OT) Evaluation and Plan of Treatment dated 03/13/25 completed by Occupational Therapist (OT) #478 revealed Resident #53 had a cerebral infarction, muscle wasting and need for assistance with personal care. The evaluation revealed Resident #53 had impaired bilateral upper and lower range of motion and had functional limitation due to contractures to his bilateral upper hands and wrists which he had resting hand splints for. The evaluation recommended OT therapy three times a week for two weeks with a goal to safely wear his resting hand splints on his bilateral hands for up to four hours. The evaluation revealed he was wearing the splints currently less than 30 minutes. Review of the OT Discharge Summary dated 03/24/25 completed by OT #478 revealed Resident #53 was discharged from therapy and recommended a restorative PROM (passive range of motion) program with splint wearing schedule. The summary revealed upon discharge Resident #53 was safely wearing his bilateral hand splints for 30 minutes. Review of the Restorative Nursing Program Communication Form dated 03/24/25 completed by Former Occupational Therapy Assistant (OTA)/ Rehab Director #900 revealed Resident #53 was recommended a PROM to his upper and lower extremities and to be out of bed in a wheelchair three to five times a week. There was nothing on the communication form regarding bilateral hand splints. Review of the care plan dated 03/28/25 revealed Resident #53 had a self-care deficit. Interventions included therapy evaluation and treat as ordered, assisting with toileting as applicable, and encouraging to do as much as possible. There was nothing in the comprehensive care plan regarding contractures to his upper and lower extremities, PROM and/or bilateral hand splints. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 had impaired cognition. Resident #53 had impairment to both upper and lower extremities. Resident #53 was dependent of staff for his activities of daily living (ADLs) including toileting hygiene, bathing, rolling left and right in bed and transfers. There was no restorative ROM and splinting completed during this assessment period. Observation on 06/16/25 at 10:25 A.M. revealed Resident #53 was lying in his bed, and his right hand was in a clenched position with his fingers touching the inside of his palm area in a contracted position. Resident #53's left hand also appeared to have the fingers bent towards his palm area in a contracted position. There were no splints to his bilateral hands. Observation on 06/16/25 at 3:58 P.M. revealed Resident #53 was up in a Broda chair (reclined chair on wheels), and his bilateral hands continued to be clenched with his fingers touching the inside of his palm area in a contracted position. There were no splints to his bilateral hands. Observation on 06/17/25 at 7:29 A.M. revealed Resident #53 was lying in bed and his bilateral hands continued to be clenched with his fingers touching the inside of his palm area in a contracted position. There were no splints to his bilateral hands. Observation on 06/17/25 at 8:55 A.M., 11:05 A.M. and 4:25 P.M. revealed Resident #53 continued to lay in bed with his bilateral hands clenched with his fingers touching the inside of his palm area in a contracted position. There were no splints to his bilateral hands. Interview on 06/17/25 at 11:14 A.M. with Rehab Director #477 and OT #478 verified Resident #53 had significant contractures to his bilateral hands and wrists. OT #478 verified Resident #53 was discharged on 03/24/25 from OT and it was recommended per the discharge summary that Resident #53 receive restorative nursing PROM of bilateral upper extremities and to follow with splint wearing schedule. OT #478 verified a restorative nursing program communication form was provided to nursing for a PROM program to his upper and lower extremities three to five days a week. OT #478 was unsure why the bilateral hand splints were not included in the communication form but felt it was because Resident #53 did not tolerate the splints well in therapy. OT #478 verified documentation on the discharge summary indicated Resident #53 did tolerate wearing the bilateral hand splints safely for 30 minutes and the discharge summary recommended a splint wearing schedule. Interview on 06/17/25 at 11:28 A.M. with Registered Nurse (RN)/ MDS #416 revealed she oversaw the restorative programs at the facility. RN/MDS #416 revealed therapy placed restorative communication forms in her mailbox for anyone that was to be on a program. RN/MDS #416 revealed she did not remember getting a form for Resident #53 to be on a program. RN/MDS #416 verified Resident #53 had not been receiving a PROM and/or splinting program since discharge from therapy on 03/24/25. Review of the nursing note dated 06/17/25 timed 12:35 P.M. completed by RN/ MDS #416 revealed an assessment was completed by Rehab Director #477 and noted bilateral upper and lower contractures which were present on admission. PROM was performed on all extremities and Resident #53 tolerated. The note revealed there was no change in contractures, and a PROM program was initiated. 2. Review of the medical record for Resident #22 revealed an admission date of 10/24/22 and diagnoses including cerebral infarction, muscle wasting, dementia, and diabetes. Review of the care plan dated 02/14/23 revealed Resident #22 required a PROM restorative program due to functional maintenance. Interventions included explaining procedure prior to performing exercises, providing rest periods, and stoping PROM if the resident had any signs of pain. Review of the care plan dated 03/08/24 revealed Resident #22 had a restorative splinting program for contracture prevention. Interventions included explaining procedure, right hand and elbow splints for five hours per day, monitoring for redness, irritation, and/ or open areas, range of motion prior to applying and after removing the splints, and referring to therapy as ordered. Review of the Restorative Nursing Program Communication Form dated 02/20/25 completed by Former Occupational Therapy Assistant (OTA)/ Rehab Director #900 revealed Resident #22 was being discharged from OT on 02/25/25 and it was recommended to have a restorative PROM program to her bilateral upper extremities and left resting hand splint to be worn one to two hours. Review of the Occupational Therapy Discharge Summary dated 02/24/25 completed by OT #478 revealed Resident #22 had received OT therapy from 01/23/25 to 02/24/25 due to cerebral infarction, muscle wasting and need for assistance with personal care. During therapy it was documented Resident #22 had been tolerating wearing the left hand and elbow splint for one and a half hours. The summary revealed Resident #22 was referred to restorative for splint program for contractual management. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #22 had impaired cognition and had impairments to her upper and lower extremities. Resident #22 was dependent on staff assistance with all her activities of daily living (ADLs) including toileting hygiene, bathing, rolling left and right in bed and transfers. There was no restorative range of motion and splinting completed during this assessment period. Review of the task bar per electronic record from 05/21/25 to 06/16/25 revealed Resident #22 had an order for restorative splint program that she was to wear her left hand and elbow splint for five hours per day as tolerated. There was no documentation the splint was applied on 05/23/25, 05/28/25, 05/30/25, 06/01/25, 06/05/25, and 06/10/25. There was also no documentation Resident #22 had refused. Interview on 06/17/25 at 11:14 A.M. with Rehab Director #477 and OT #478 revealed Resident #22 was discharged from OT on 02/24/25 and recommendations at that time were for a restorative splinting program to wear the left elbow and hand splint every day up to four hours. Interview on 06/17/25 at 11:28 A.M. with RN/MDS #416 revealed she oversaw the restorative programs at the facility. RN/MDS #416 revealed the facility used to have specific restorative certified nursing assistants (CNAs) that completed the restorative programs but beginning 05/01/25 there was no longer restorative CNAs; instead, the programs were to be completed per the CNAs on the floor. RN/MDS #416 revealed it had been an issue with the CNAs on the floor ensuring the programs were completed and documented appropriately as ordered. RN/MDS #416 verified Resident #22 had a restorative splinting program to wear her left hand and elbow splint for five hours per day as tolerated. RN/MDS #416 verified the communication form per Former Occupational Therapy Assistant (OTA)/ Rehab Director #900 revealed Resident #22 was to wear the splints one to two hours. RN/MDS #416 also verified per the task bar on the electronic medical record there was no documentation the program was completed six days including 05/23/25, 05/28/25, 05/30/25, 06/01/25, 06/05/25, and 06/10/25 out of the last 30 days. Review of the facility policy labeled, Range of Motion dated December 2022 revealed residents who had or could develop functional limitations in joint movement would be provided with active or passive range of motion to prevent further decline/ contractures and would maintain joint mobility. The policy revealed staff would document date, time, type of activity, resident participation, if any refusal of treatment and reason of refusal.

Based on interview, record review and review of facility policy the facility failed to ensure Resident #4's weights were obtained and the physician notified as ordered. This affected one resident (#4) out of four residents reviewed for nutrition. The facility census was 57. Findings include: Review of medical record for Resident #4 revealed an admission date of 11/20/24 and diagnoses including dysphagia, dementia, gastro-esophageal reflux disease, and hypertension. Review of weight records from 11/22/24 to 06/16/25 revealed on 11/22/24 Resident #4's weight was 119.6 pounds. The record revealed on 03/18/25 her weight was 129.6 pounds (10 pound gain from admission), on 03/23/25 her weight was 131.8 pounds (12.2 pound gain from admission), on 03/25/25 her weight was 132.8 pounds (13.2 pound gain from admission), on 04/03/25 her weight was 143.6 pounds (24 pound gain from admission), on 04/08/25 her weight was 143.4 pounds, 04/17/25 her weight was 121.2 pounds (22.2 pound weight loss in one week), 04/23/25 her weight was 121.2 pounds, 04/24/25 her weight was 121.2 pounds, on 05/01/25 her weight was 134.4 pounds (13.2 pound gain in one week), on 05/28/25 her weight was 138.2, on 06/06/25 her weight was 142.4 pounds, and 06/12/25 her weight was 139 pounds. There were entries documented per the weight record per Dietitian Tech #449 that a reweight was needed 04/02/25, 04/18/25, and 05/02/25. There was no record a weight was obtained from 05/01/25 to 05/28/25 even after a request on 05/02/25 for a reweight until 05/28/25. Review of the care plan dated 12/16/24 revealed Resident #4 had a nutritional problem related to dementia, and heart disease. Interventions included providing diet as ordered, monitoring intake, recording intake every meal, supplements as ordered, and monitoring monthly weights. There was nothing in the care plan regarding weekly weights per order and notifying physician if weight greater or less than three pounds from her admission weight. Review of Physician Significant Weight Notification dated 04/09/25 revealed Resident #4 had a six percent weight loss in one month. The notification revealed her oral intakes widely varied and she had a history of edema with diuretic therapy. The recommendation was to continue weekly weights. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had impaired cognition, and she ate independently. Her weight was recorded as 121 pounds, and she had weight loss that was not prescribed. Review of the Medical Nutrition Therapy Evaluation dated 05/21/25 completed by Dietitian Tech #449 revealed Resident #4's monthly weight was pending as her last weight on 04/24/25 was 121.2 pounds that triggered a significant weight loss for one month of eight percent and three month of 9.8 percent. The evaluation noted that the physician was notified, and a nutritious drink was added at breakfast for additional support. There was no mention of weekly weight not being completed as ordered. Review of the Physician Significant Weight Notification dated 05/28/25 completed by Dietitian Tech #449 revealed Primary Care Physician #475 was notified of Resident #4's significant weight gain of 15.6 percent in six months. The weight change was likely due to drinking 100 percent of nutritional supplements and good intakes. The notification recommended to follow and monitor. Review of June 2025 physician orders revealed Resident #4 was on a regular diet, nutritious juice with meals, two Kcal supplement three times a day and an order dated 03/18/25 for a weekly weight and to notify the physician if greater and/or less than three pounds from admission weight. Interview on 06/17/25 at 1:27 P.M. with Dietitian #476 verified Resident #4 had an order for a weekly weight dated 03/18/25 and that the physician was to be notified if there was a three-pound gain and/or loss from her admission weight. Dietitian #476 verified there was no record a weight was obtained from 05/01/25 to 05/28/25. Dietitian #476 revealed per the record it appeared Dietitian Tech #449 had requested a reweight on 05/02/25 but that a reweight had not been completed until 05/28/25. Dietitian #476 verified Resident #4's weight on 04/24/25 was 121.2 and on 05/01/25 her weight was 133.4 (12.2 pound increase in one week). Dietitian #476 revealed notification to the physician would be by nursing since it was a physician order to notify if the resident gained or lost three pounds from admission. Dietitian #476 was unsure what weight nursing went by but verified her admission weight was 119.6 which was obtained on 11/22/24. Dietitian #476 verified Resident #4's weight increased on 05/01/25 from 133.4 to 138.2 on 5/28/25 which was a 4.8 pound gain, and then increased on 06/06/25 to 142.4 (4.2 pound increase). Dietitian #476 was unsure if the physician was notified of the weight increase as ordered as nursing would complete the notification. Interview on 06/17/25 at 2:00 P.M. with the Director of Nursing and Clinical Director #450 verified Resident #4 had an order dated 03/18/25 for a weekly weight and to notify the physician if greater and or less than three pounds from admission weight. They verified Resident #4 had no record a weight was completed from 05/01/25 to 05/28/25. They thought Dietician #476 or Dietician Tech #449 made notification regarding all weight changes including as ordered. They verified they had no further evidence the physician was notified each time the weekly weight was greater or less than three pounds from the admission weight including on 03/18/25, 04/03/25, 04/17/25, 05/01/25, 06/06/25, and 06/12/25 in which the weight was recorded greater or less than three pounds from her admission weight. Review of the facility policy labeled, Weight Protocol dated February 2025 revealed residents were to be weighed monthly or as ordered by the physician. Reweights would be completed if a five pound or greater variance was noted from the last recorded weight. Reweights would be completed within 24 to 72 hours. The nutrition clinician would send a physician significant weight notification with documentation of residents' weight changes for one, three and six months along with any recommendations. The notification was to be sent even if no recommendations were made.

Based on observation, interview, record review, facility policy review, and review of the memorandum from the Department of Health and Human Services, the facility failed to initiate and use enhanced barrier precautions (EBP) when appropriate for Resident #32. This affected one resident (#32) out of two residents observed for use of enhanced barrier precautions. The facility identified 17 residents (#7, #14, #16, #18, #22, #29, #30, #32, #33, #35, #38, #40, #43, #52, #53, #56, and #57) on enhanced barriers. Facility census was 57. Findings include: Review of medical record for Resident #32 revealed an admission date of 03/27/25 and diagnoses including diabetes, muscle wasting, chronic kidney disease, and peripheral vascular disease. Review of the Medicare Five-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 had intact cognition, required total dependence of staff assistance with toileting and transfers, and was unable to ambulate. Resident #32 required substantial to maximum staff assistance with rolling left and right in bed and putting or taking off footwear and had pressures ulcers present on admission. Review of the Wound Tracking dated 05/12/25 completed by Registered Nurse (RN)/Wound Nurse #403 revealed Resident #32 was found to have an intact non-blanchable (stays red/purple when skin was pushed indicating little or no blood flow to area) purple discoloration to her left medial heel. Review of the care plan dated 05/28/25 revealed Resident #32 was at risk for complications related to the pressure ulcer to her left heel. Interventions included administering treatments as ordered and monitoring for signs of infection. There was nothing in the care plan regarding EBP. Review of June 2025 Physician Orders revealed Resident #32 did not have an order for EBP. Review of Wound Nurse Practitioner (NP) #479's progress note dated 06/02/25 revealed Resident #32's left medial pressure ulcer declined and was classified as unstageable (full- thickness skin and tissue loss in which the extent of the tissue damage within the ulcer could not be confirmed because it was obscured by slough (dead skin) and/or eschar). Wound NP #479 described the wound as having serosanguinous (a combination of watery fluid and blood) drainage with slough. Observation on 06/16/25 at 4:00 P.M. revealed Resident #32 had no signage and/or personal protective equipment (ppe) on or near her door indicating she was on EBP. Observation of wound care on 06/17/25 at 10:40 A.M. completed by RN/Wound Nurse #403 revealed she performed hand hygiene, applied gloves but no gown and proceeded to unwrap the ace wrap and dressing to Resident #32's left foot. RN/Wound Nurse #403 performed hand hygiene and applied new gloves but did not don a gown to cleanse the left medial heel with normal saline. RN/Wound Nurse #403 described the wound as an opened pressure ulcer with serous (clear or pale-yellow fluid) drainage that contained white slough. RN/Wound Nurse #403 then applied mesalt (absorbs drainage from the wound) that was cut to the size of the wound, covered with an ABD pad and wrapped with Kerlix. RN/Wound Nurse #403 then removed her gloves and performed hand hygiene. During the observation RN/Clinical Director #450, who was the infection control preventionist, was also in the room and observed the wound care but did not provide any hands-on care. Interview on 06/17/25 at 10:51 A.M. with RN/Wound Nurse #403 verified Resident #32's left medial heel was opened with drainage and contained slough. RN/Wound Nurse #403 verified Resident #32 did not have a physician order for EBP, and there was no signage in her room indicating to staff that she was on EBP. RN/Wound Nurse #403 verified that she did not follow EBP including wearing a gown during the wound care. RN/Wound Nurse #403 revealed she felt it was an oversight because at first Resident #32's wound was not opened but verified when the wound opened the facility should have obtained an order for EBP and implemented EBP during care including wound care. Interview on 06/17/25 at 2:13 P.M. with the Director of Nursing and RN/Clinical Director #450 they verified staff should have implemented EBP which would included use of a gown during Resident #32's care including wound care. Review of the memorandum, QSO-24-08-NH, entitled Enhanced Barrier Precautions in Nursing Homes, dated 03/20/24, by the Centers for Medicare & Medicaid Services, Department of Health & Human Services revealed enhanced barrier precautions were indicated for residents with wounds and/or indwelling medical devices even if the resident was not known to be infected or colonized with a multi-drug resistant organism (MDRO). The effective date for implementation of enhanced barrier precautions under the guidelines was 04/01/24. Review of facility policy labeled, Enhanced Barrier Precautions (EBP) dated November 2024 revealed EBP was an infection control intervention designed to reduce the transmission/ spread of multidrug resistant organisms. The policy revealed precautions were used in conjunction with standard precautions and expanded to the use of ppe with the donning of a gown and gloves during high contact resident care activities. Indications for EBP use included residents that had indwelling medical devices, or wounds. The policy revealed high contact care activities for which EBP was indicated included wound care and treatments. Communication to staff for the use of EBP was through EBP signage.

Based on interviews, record review and facility policy review, the facility failed to provide trauma-informed care to Resident #28. This affected one resident (#28) out of three residents reviewed for trauma-informed care. The facility reported three residents (#28, #31 and #42) who had trauma related diagnoses. The facility census was 57. Findings include: Review of the medical record for Resident #28 revealed an admission date of 06/05/21 and diagnoses of dementia, major depressive disorder, anxiety disorder, intermittent explosive disorder, alcohol abuse, and post-traumatic stress disorder (PTSD). Review of a psychosocial note dated 06/11/21 revealed Resident #28 related memories of being in a fight where a jealous boyfriend hit him in the head with an object, and also being in the Vietnam War. Review of a psychosocial note dated 06/17/21 revealed Resident #28's family provided clarifying information of the resident getting beat up with a pipe at an apartment. The perpetrator was convicted and sentenced, and since the incident had some memory issues. Review of a psychosocial note dated 03/25/22 revealed Resident #28 voiced stories about being in the military and certain people triggered certain conversations. Review of a psychosocial note dated 07/19/22 revealed Resident #28 talked about what he went through in the military and the stories were very tragic. The resident voiced when seeing a person of authority then he knew it was alright to talk about what he had been through but otherwise kept so much bottled up inside. Review of a psychosocial note dated 10/04/22 revealed Resident #28 started counseling services. Review of the Minimum Data Set (MDS) screening completed on 01/02/24 revealed Resident #28 answered moderately to having repeated, disturbing memories, thoughts or images of a stressful experience from the past and feeling very upset when something reminded of a stressful experience from the past. Review of a psychosocial note dated 06/04/24 revealed Resident #28's counseling services were stopped due to the resident's declined cognition. Review of a psychosocial note dated 07/11/24 revealed Resident #28 had poor cognition and difficulty with forming sentences. The staff had to sometimes guess what the resident was trying to say. Resident #28 had a constant worried expression on the face but would follow another's lead. Review of a psychosocial note dated 10/09/24 revealed Resident #28 was getting combative during hands on care, and had progressing dementia, not always understanding staff's intentions or direction. It was believed the resident's resistance and combativeness might be from frustration. Review of the MDS screening completed on 01/07/25 revealed Resident #28 answered a little bit to having repeated, disturbing memories, thoughts or images of a stressful experience from the past and feeling very upset when something reminded of a stressful experience from the past. Review of a psychosocial note dated 01/28/25 revealed Resident #28 displayed paranoia and hallucinations. Review of the care plan initiated on 06/05/21 and last reviewed on 04/28/25, revealed Resident #28 was dependent on staff for meeting emotional, intellectual, physical and social needs related to cognitive deficits. There was no reference in the care plan relevant to Resident #28's trauma including triggers and trauma-informed care. Review of the Quarterly MDS assessment completed 05/27/25 revealed Resident #28 had severe cognitive impairment and PTSD. Review of Resident #28's Kardex (patient information) for nursing assistants effective June 2025 revealed no information relevant to trauma including triggers and trauma-informed care. Review of nursing progress notes from June 2024 to June 2025 revealed no documentation relevant to Resident #28's trauma or trauma-informed care. Review of assessments for Resident #28 revealed no trauma focused assessments completed since admission. Interview on 06/17/25 at 11:09 A.M. with Licensed Practical Nurse (LPN) #406 revealed Resident #28 had behaviors including wandering, fear with personal care, and resistance during care. LPN #406 was able to identify Resident #28 as a Vietnam veteran but denied knowledge of specific trauma related care or trauma triggers. Interview on 06/17/25 at 11:15 A.M. with Certified Nursing Assistant (CNA) #466 revealed Resident #28 was resistive to care but denied knowledge of specific trauma related care or trauma triggers. Interview on 06/17/25 at 11:26 A.M. with Social Services (SS) #405 revealed there was no specific assessment related to trauma but there was a screening completed upon admission. SS #405 reported if a resident had a trauma diagnosis then psychiatric services were referred, but Resident #28 was now unable to participate in those services due to dementia. Interview on 06/17/25 at 11:40 A.M. with Registered Nurse (RN)/MDS #416 verified there was no trauma assessment used for Resident #28 but two questions for screening were completed last on 04/01/25. RN/MDS #416 reported knowing the resident was in the Vietnam War and had PTSD, but confirmed the care plan did not reflect any specific trauma related care or trauma triggers, including the Kardex because it was generated off the care plan. Review of the facility policy, Trauma Informed and Behavioral Health Care Policy, reviewed January 2025, revealed all residents were assessed on admission and quarterly for behavioral health and trauma related issues. The care plan was reviewed quarterly and with any significant change in condition. Interventions were updated as needed and as recommended or requested by residents, resident representatives, mental health professionals and the interdisciplinary team. The care plan included non-pharmacological interventions to address behaviors and reduce stress, triggers to avoid that would re-traumatize, behavioral health services provided, and cultural and religious preferences. The care plan included monitoring for effectiveness of the interventions with measurable goals.

Based on observation, interview, record review, and facility policy review the facility failed to ensure a low air loss mattress (a specialized therapeutic surface to help redistribute pressure across the body to prevent pressure ulcers) was initiated for Resident #32 as recommended per Wound Nurse Practitioner (NP) #479. This affected one (Resident #32) out of two residents reviewed for wounds. The facility identified 13 residents (#6, #7, #9, #11, #29, #30, #31, #32, #35, #36, #40, #48, #57) with wounds. The facility census was 57. Findings include: Review of medical record for Resident #32 revealed an admission date of 03/27/25 and diagnoses including diabetes, muscle wasting, chronic kidney disease, and peripheral vascular disease. Review of the Braden Scale dated 03/27/25, completed by Registered Nurse (RN) #440, revealed Resident #32 was at risk for developing pressure ulcers as she was very moist and had limited mobility. Review of Wound NP #479's progress note dated 03/27/25 revealed Resident #32 had barriers to wound healing that included immobility, malnutrition, and atrophy (muscle or tissue wasting). Wound NP #479 evaluated Resident #32, who was admitted with pressure ulcers to her left and right buttock. Wound NP #479 recommended Resident #32 to have a low air loss mattress and to be reposition every two hours. Review of the Medicare Five-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 had intact cognition. Resident #32 required total dependence of staff assistance with toileting and transfers and was unable to ambulate. Resident #32 required substantial to maximum staff assistance with rolling left and right in bed and putting or taking off footwear. Resident #32 was at risk for developing pressure ulcers and had pressures ulcers present on admission. Review of Wound NP #479's progress notes dated 04/28/25, and 05/05/25 revealed Wound NP #479 continued to recommend a low air loss mattress. Review of Wound Tracking dated 05/12/25, completed by RN/ Wound Nurse #403, revealed Resident #32 was found to have an intact non-blanchable (stays red/purple when skin pushed indicating little or no blood flow to area) purple discoloration to her left medial heel that measured two centimeters in length and two cm in width. Review of Wound NP #479's progress note dated 05/19/25 revealed Wound NP #479 continued to recommend a low air loss mattress. Resident #32 had a new deep tissue injury (DTI) to her left medial heel that was purple and non-blanchable. Wound NP #479 recommended to clean the wound bed, pat dry, apply skin prep (creates a protective layer on the skin to shield it from adhesive trauma, friction, and moisture damage) cover with ABD (large bulky gauze pad) and wrap with kling daily. Review of Wound NP #479's progress note dated 05/26/25 revealed Wound NP #479 continued to recommend a low air loss mattress. Review of the care plan dated 05/28/25 revealed Resident #32 was at risk for complications related to the pressure ulcer to her left heel. Interventions included administer treatments as ordered, monitor for signs of infection, instruct and assist to shift weight frequently as tolerated, and follow facility policies for the prevention and treatment of skin breakdown including use of pressure reducing mattress to bed. There was nothing in the care plan regarding a low air loss mattress. Review of June 2025 Physician Orders revealed Resident #32 had an order dated 03/27/25 for a pressure reducing mattress. She also had orders dated 04/21/25 to wear heel protectors while in bed and off load her bilateral heels with pillows while in bed. Review of Wound NP #479's progress note dated 06/02/25 revealed Resident #32's left medial pressure ulcer declined and was classified as an unstageable (full- thickness skin and tissue loss in which the extent of the tissue damage within the ulcer cannot be confirmed because it was obscured by slough (dead skin) and/or eschar). Wound NP #479 described the wound as having serosanguinous (combination of watery fluid and bloody) drainage) drainange with slough (dead tissue). Wound NP #479 changed the treatment to clean the wound bed, pat dry, apply mesalt (absorbs drainage from the wound) cut to size, apply ABD pad and wrap with Kerlix daily. Wound NP #479 continued to recommend a low air loss mattress. Review of Wound NP #479's notes dated 06/09/25 and 06/16/25 revealed Wound NP #479 continued to recommend a low air loss mattress. Observation on 06/16/25 at 4:00 P.M. and 06/17/25 at 7:26 A.M. revealed Resident #32 had a pressure reducing mattress, but it was not a low air loss mattress. Observation of wound care on 06/17/25 at 10:40 A.M. completed by RN/Wound Nurse #403 revealed the wound care was completed as ordered. RN/Wound Nurse #403 described the wound as an opened unstageable pressure ulcer with serous (clear or pale-yellow fluid) drainage that contained white slough. Resident #32 did not have a low air loss mattress in place. Interview on 06/17/25 at 10:51 A.M. with RN/Wound Nurse #403 verified Resident #32's left medial heel was opened with drainage and contained slough. RN/Wound Nurse #403 verified per Wound NP #479's weekly progress notes from 03/27/25 to 06/16/25 that Wound NP #479 recommended a low air loss mattress. RN/Wound Nurse #403 verified Resident #32 had not had a low air loss mattress since admission. Interview on 06/18/25 at 10:05 A.M. with Wound NP #479 revealed she evaluated all wounds at the facility including Resident #32 weekly. Wound NP #479 verified she had recommended a low air loss mattress and that was still her recommendation as she felt it would help with wound healing and prevention especially since Resident #32 at times refused to wear her heel protectors. Wound NP #479 revealed the left medial heel was a DTI that was purple and non-blanchable but then declined to an unstageable pressure ulcer. Wound NP #479 said it was hard to say if the low air loss mattress could have prevented the DTI and/or decline as there were several other contributing factors including Resident #32 dangled her feet without elevating most of the day, and bumped into things with her feet while up but that it was possible especially with her noncompliance with the heel protectors. Review of the facility policy labeled, Pressure Ulcer Prevention and Care Protocol dated January 2025 revealed the facility would use the criteria as part of the resident's comprehensive assessment to determine risk of pressure ulcer development and development of resident's plan of care. The policy revealed all facility beds had a pressure redistribution mattress that reduced friction and shear during movement. The facility would select a surface that met the residents' needs based on risk assessment and current skin issues that could include a low air loss mattress. The policy revealed treatment of pressure ulcers would vary depending on orders from the consulting wound specialist and the nurse would carry out the treatment as ordered and implement measures to prevent pressure ulcers.

Based on record review and staff interview, the facility failed to ensure there was a registered nurse ( RN) on duty for at least eight consecutive hours a day and seven days a week as required. This had the potential to affect all 56 residents. The facility census was 56. Findings include: Review of the staff schedule for the week of 12/22/24 to 12/28/24 revealed there was no RN scheduled in the building on 12/22/24, 12/25/24, and 12/28/24. Interview on 12/31/24 at 11:45 A.M. with the Payroll Coordinator (PC) #360 stated an RN was scheduled on 12/22/24 but was pulled to another facility. PC #360 confirmed no RN was scheduled on 12/25/24 or 12/28/24 or present in the facility. Interview on 12/31/24 at 1:00 P.M. with the Director of Nursing ( DON) revealed a Licensed Practical Nurse ( LPN) was called in to cover the call-off of the RN on 12/22/24, therefore, no RN was in the facility 12/22/24. The DON also verified no RN was scheduled or in the facility on 12/25/24 and 12/28/24.

Based on record review and interview, the facility failed to have a Registered Nurse (RN) working in the facility for eight consecutive hours each day of the week. This had to potential to affect all 47 residents in the facility. Findings include: Review of the schedule for 01/22/23 through 02/26/23 revealed the facility did not have an RN working for eight consecutive hours on 01/22/23, 01/28/23, 01/29/23, 02/04/23, 02/05/23, 02/11/23/ 02/12/23, 02/18/23, 02/19/23, 02/25/23 and 02/26/23. Interview on 02/22/23 at 6:52 A.M. with Licensed Practical Nurse (LPN) #409 revealed she had no knowledge of any RN's working for the facility except for the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) #456. Interview on 02/23/23 at 8:09 A.M. with the Administrator confirmed no RN worked eight consecutive hours on the dates listed above.

Based on record review, interview, and facility policy review the facility failed to obtain authorization and a third-party witness to manage their finances for Residents #30 and #41. This affected two residents (#30 and #41) of five reviewed for funds. The facility census was 47. Findings include: 1. Review of the medical record for Resident #30 revealed an admitted [DATE] with diagnoses including heart failure, hypothyroidism, and Alzheimer's disease. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 was severely cognitively impaired. He had a power of attorney for finances. Review of Resident #30's financial records revealed no authorization for resident funds or witness to such authorization available for review. 2. Review of the medical record for Resident #41 revealed an admitted [DATE] with diagnoses including dementia, post-traumatic stress disorder (PTSD), depression, and anxiety. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #41 had moderate cognitive impairment. He had a power of attorney for finances. Review of Resident #41's financial records revealed no authorization for resident funds or witness to such authorization available for review. Interview on 02/27/23 at 1:47 P.M. with the Administrator confirmed no authorization for resident funds or witness to such authorizations were available for Resident's #30 and #41. Review of the facility policy titled Resident Funds, dated January 2017, revealed the facility would not manage resident funds without authorization from the resident, and the authorization would be witnessed by a person not affiliated with the facility in any way.

Based on observation, record review, and interview the facility failed to follow infection control policies and procedures for wound care and medication administration. This affected one resident (#5) of one resident reviewed for wound care and one resident (#34) of one resident reviewed for medication administration. The facility census was 47. Findings include: 1. Review of the medical record revealed Resident #5 was initially admitted to the facility on [DATE] with diagnoses including end stage renal disease, dependence on renal dialysis, type II diabetes mellitus with diabetic neuropathy, hypothyroidism, pleural effusion, acute kidney failure, hyperkalemia, and stage IV pressure ulcer (full-thickness tissue loss with exposed bone, tendon, or muscle. Slough may be present on some parts of the wound bed) as of 09/30/22 with wound infection. Review of the five-day Minimum Data Set (MDS) 3.0 assessment of 01/31/23 revealed Resident #5 was cognitively impaired with periods of confusion, was totally dependent on two staff for activities of daily living, was always incontinent of bowel and bladder, and had developed a Stage IV pressure ulcer after admission to hospital on 09/30/22. Review of the care plan of 01/18/23 revealed a care area for actual impairment to skin integrity related to pressure area to the sacrum. The care plan also noted Resident #5 was at increased risk for further impairment to skin integrity related to impaired cognition, diabetes, incontinence, impaired mobility, and generalized weakness. Interventions included wound care to evaluate and treat as needed, assessing, recording, and monitoring wound healing, turning, air mattress, pressure reducing cushion to wheelchair, monitoring diet as ordered and intake, and repositioning frequently with rounds and as needed. Review of Resident #5's progress notes for wound care from 09/30/22 through 02/26/23 revealed a wound to the sacrum was discovered on admission after hospital stay on 09/30/22. Review of Resident #5's physician's orders dated February 2023 revealed orders for turn an repositioning every two hours and as needed using pillows to offload buttocks, barrier cream to bilateral buttocks after each incontinence episode, weekly skin checks every Tuesday on night shift, cleanse sacral wound with normal saline, pat dry, apply nickel thick layer of Santyl (ointment that removes dead tissue from wounds to aide in healing) to the wound bed, apply Dakin's solution (antiseptic) to dampen sterile gauze, lightly pack wound, and cover with a foam dressing twice a day and as needed due to drainage or incontinence. Observations on 02/27/23 at 9:00 A.M. and 11:30 A.M. revealed Resident #5 was repositioned after two hours, air mattress was in place, resident was lying her left side by using pillows to offload buttocks. Pressure reducing cushion to wheelchair was observed to be in place. Observation on 02/27/23 at 12:00 P.M. of Resident #5's right sacral area revealed a stage IV pressure ulcer. The wound bed was pink in color in the center and was red around the edges. There was a moderate amount of bluish-green drainage on the old dressing. Registered Nurse (RN) #456 stated Resident #5's wound deteriorated after an admission to the hospital with return to the facility on [DATE]. RN #456 gathered wound care supplies and brought them into the resident's room where a floor nurse was checking Resident #5's blood pressure, and there was a break in infection control when RN #456 placed all dressing supplies on tray table without disinfecting surface. There was a glass of water and medication cup that the floor nurse had placed on tray table and other items belonging to Resident #5. RN #456 then placed a protective barrier on the tray table again without disinfecting the tray table and did not put any of the dressing supplies on the barrier. RN #456 proceeded with wound care, repositioned the resident for comfort during wound care, removed the old dressing, completed hand hygiene, cleansed the wound with normal saline, applied Santyl to 0.125 percent Daskins solution-soaked gauze, and covered with foam dressing. Resident was then repositioned again for comfort with pillows for offloading. Interview on 02/27/23 at 12:30 P.M. with Resident #5 revealed she stated wound care was completed as ordered multiple times a day due to drainage or incontinence. 42733 2. Review of Resident #34's medical records revealed an admitted [DATE] with diagnoses including stroke, dysphasia (difficulty swallowing), and altered mental status. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #34 had impaired cognition and required extensive assist with toileting and personal hygiene. Review of the physician orders for February 2023 revealed Resident #34 was ordered Omeprazole (medication used to treat heartburn) 40 milligrams (mg) to be administered via the residents feeding tube. Observation of medication administration on 02/23/23 at 8:05 A.M. with Licensed Practical Nurse (LPN) # 415 for Resident #34 revealed LPN #465 had obtained the residents Omeprazole capsule. LPN #465 proceeded to break open the capsule with an ungloved hand and had poured the contents of the capsule into a medication cup. Interview with LPN #415 at time of observation confirmed she should have been wearing gloves prior to opening the capsule.

Based on observation, interview, record review, and facility policy review the facility failed to ensure narcotic pain medications were properly documented and accounted for. This affected three residents (#16, #47 and #353) of three residents reviewed for narcotics. The facility census was 47. Findings include: 1. Review of Resident #16's medical records revealed an admitted [DATE] with diagnoses including quadriplegia, chronic pain syndrome, contractures, and muscle weakness. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #16 had intact cognition and required extensive assistance with bed mobility, toileting, and personal hygiene. Review of physician orders for February 2023 revealed Resident #16 had an order for Oxycodone (narcotic pain medication) 10 milligrams (mg) every four hours as needed. Review of narcotic sign out sheets for January and February 2023 revealed Oxycodone was signed out on 01/27/23 at 5:30 P.M., 01/29/23 at 5:00 P.M., 01/31/23 at 11:35 A.M., 02/03/23 at 12:00 A.M., 02/03/23 at 11:00 A.M., 02/04/23 at 8:00 A.M., 02/04/23 at 2:00 P.M., 02/05/23 at 12:00 P.M., 02/11/23 at 12:00 P.M., 02/11/23 at 5:30 P.M., 02/12/23 at 12:00 P.M., 02/12/23 at 5:30 P.M., 02/14/23 at 11:00 A.M., 02/18/23 at 12:20 A.M., 02/18/23 at 5:00 A.M., 02/18/23 at 11:35 P.M., 02/19/23 at 10:00 A.M. and 02/19/23 at 8:00 P.M. Review of the Medication Administration Record (MAR) revealed the Oxycodone was not signed off as administered. Interview on 02/21/23 at 12:34 P.M. with Resident #16 revealed she could not recall if she had received all of her doses of pain medication. 2. Review of Resident #47's medical records revealed an admitted [DATE] with diagnoses including cervical cancer and chronic pain. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #47 had intact cognition, was independent for ambulation, and required supervision with toileting and personal hygiene. Review of the physician orders for February 2023 revealed Resident #47 had an order for Oxycodone 20 mg every four hours as needed for pain. Review of the narcotic sign out sheets from January and February 2023 revealed Oxycodone was signed out on 02/05/23 at 5:00 P.M., 02/06/23 at 9:00 A.M., 02/06/23 at 6:42 P.M., 02/08/23 at 6:20 P.M. 02/10/23 at 1:50 P.M., 02/12/23 at 9:00 A.M., 02/13/23 at 9:00 A.M., 02/15/23 at 7:30 P.M., 02/17/23 at 1:50 P.M., 02/18/23 at 9:00 A.M., 02/19/23 at 9:00 A.M., 02/20/23 at 9:00 A.M. and 02/22/23 at 6:45 P.M. Review of the MAR revealed the medication was not signed off as administered. 3. Review of Resident #353's medical records revealed an admitted [DATE] with diagnoses including spinal fusion and chronic pain syndrome. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #353 had intact cognition. Resident #353's functional assessment was in progress. Review of the physician orders for February 2023 revealed Resident #353 had an order for Oxycodone 15 mg every four hours as needed and Methadone (narcotic pain medication) 10 mg every eight hours as needed. Review of the narcotic sign out sheets for February 2023 revealed Oxycodone was signed out on 02/19/23 at 1:00 P.M., 02/19/23 at 7:30 P.M., 02/20/23 at 2:00 P.M., and 02/22/23 at 4:10 A.M. Review of the MAR revealed the Oxycodone was not signed off as administered. Review of the MAR for February 2023 revealed Oxycodone was signed off as administered on 02/17/23 at 4:17 A.M., 02/17/23 at 1:52 P.M., 02/22/23 at 3:24 P.M. and 02/22/23 at 7:46 P.M. Further review revealed no documentation on the narcotic sign out sheet of the medication having been signed out. Review of the narcotic sign out sheet for February 2023 revealed Methadone was signed out on 02/18/23 at 4:30 A.M. and 02/20/23 at 2:00 P.M. Review of the MAR revealed the Methadone was not signed off as administered. Observation of medication administration on 02/22/23 at 8:12 A.M. with Licensed Practical Nurse (LPN) #465 revealed Resident #353 requested pain medication. LPN #465 informed the resident she would look at her orders and see what she was able to have. LPN #465 checked the orders and informed the resident she was able to receive her ordered Oxycodone, and the resident was agreeable. LPN #465 proceeded to obtain the medication from the narcotic drawer, and there was one Oxycodone left in the medication card. LPN #465 removed the medication, and she removed the used medication card. LPN #465 proceeded to document the removal of the medication card on the narcotic sign out sheet. LPN #465 stated the narcotic card count was off by one. LPN #465 stated the narcotic card count sheet stated there were a total of ten medication cards; however, only there were only nine medication cards in the narcotic drawer. LPN #465 was unable to state why the count was off and stated she would inform the Director of Nursing (DON). LPN #465 proceeded to document administering Resident #353's Oxycodone and stated the medication was signed out in the narcotic sign out sheet on 02/22/23 at 4:10 A.M.; however, the MAR stated the medication last administered on 02/21/23 at 4:32 P.M. LPN #465 stated narcotics were to be signed out on the narcotic sign out sheet as well signed off as administered on the MAR. Interview on 02/22/23 at 2:48 P.M. with the DON revealed she was informed of the narcotic discrepancy by LPN #465 and stated she investigate into the situation. The DON denied being aware of concerns related to narcotic discrepancy previously. Interview on 02/23/23 at 9:53 A.M. the DON stated she investigated the situation regarding the narcotic discrepancy. At 10:56 A.M. the DON returned with narcotic sign out sheets; however, she was unable to specify why the narcotic card count was not accurate. Review of the narcotic sign out sheets with the DON at time of interview revealed on 11/01/22 the narcotic count was identified as having six cards; however, the correct number should have been seven. The DON stated a nurse made an error and that had caused the count to be off by one. The DON stated the error should have been caught sooner; however, the nurses who had performed the daily narcotic count did not identify the error. Interview with the DON further revealed the narcotic medications were to be signed out on the narcotic sign out sheets as well as in the MAR. Review of the facility policy titled Controlled Drug Count, dated 11/16, revealed two nurses were to complete a physical inventory of controlled substances at change of each shift, ensure proper record keeping, no more than one prescription for a controlled drug was to be entered on an individual controlled drug sheet and if the count was not accurate, the off going nurse was to remain on duty until the count could be reconciled and all discrepancies were to be reported to the DON immediately. Review of the facility policy titled Medication Administration, revised 05/22, revealed medications were to be charted in the MAR. This deficiency represents non-compliance investigated under Complaint Number OH00136547.

Based on observation, interview, record review, and facility policy review the facility failed to ensure pain assessments were documented prior to and after narcotic pain medications were administered. This affected three residents (#16, #47 and #353) of three residents reviewed for narcotics. The facility census was 47. Findings include: 1. Review of Resident #16's medical records revealed an admitted [DATE] with diagnoses including quadriplegia, chronic pain syndrome, contractures, and muscle weakness. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #16 had intact cognition and required extensive assistance with bed mobility, toileting, and personal hygiene. Review of the care plan dated 02/08/23 revealed Resident #16 was at risk for acute and chronic pain related to medical conditions. Interventions included administer medications as ordered and assess pain type and intensity using a scale of 1-10 before and after intervention and evaluate the effectiveness of pain interventions. Review of the physician orders for February 2023 revealed Resident #16 had an order for Oxycodone (narcotic pain medication) 10 milligrams (mg) every four hours as needed. Review of the narcotic sign out sheets for January and February 2023 revealed Oxycodone had been signed out on the narcotic sheets on 01/27/23 at 5:30 P.M., 01/29/23 at 5:00 P.M., 01/31/23 at 11:35 A.M., 02/03/23 at 12:00 A.M., 02/03/23 at 11:00 A.M., 02/04/23 at 8:00 A.M., 02/04/23 at 2:00 P.M., 02/05/23 at 12:00 P.M., 02/11/23 at 12:00 P.M., 02/11/23 at 5:30 P.M., 02/12/23 at 12:00 P.M., 02/12/23 at 5:30 P.M., 02/14/23 at 11:00 A.M., 02/18/23 at 12:20 A.M., 02/18/23 at 5:00 A.M., 02/18/23 at 11:35 P.M., 02/19/23 at 10:00 A.M. and 02/19/23 at 8:00 P.M. Review of the Medication Administration Record (MAR) revealed the medication had not been signed off as administered and no pain assessment of evaluation for effectiveness was documented. Interview on 02/21/23 at 12:34 P.M. with Resident #16 revealed she could not recall if she had received all of her doses of pain medication. 2. Review of Resident #47's medical records revealed an admitted [DATE] with diagnoses including cervical cancer and chronic pain. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #47 had intact cognition, was independent for ambulation and required supervision with toileting and personal hygiene. Review of the care plan dated 12/26/22 revealed Resident #47 was at risk for chronic and acute pain related to cancer diagnosis. Interventions included administer medications as ordered, evaluate the effectiveness of pain interventions, record and monitor pain characteristics using scale of 1-10. Review of the physician orders for February 2023 revealed Resident #47 had an order for Oxycodone 20 mg every four hours as needed for pain. Review of the narcotic sign out sheets from January and February 2023 revealed Oxycodone had been signed out on the narcotic sheets on 02/05/23 at 5:00 P.M., 02/06/23 at 9:00 A.M., 02/06 23 at 6:42 P.M., 02/08/23 at 6:20 P.M. 02/10/23 at 1:50 P.M., 02/12/23 at 9:00 A.M., 02/13/23 at 9:00 A.M., 02/15/23 at 7:30 P.M., 02/17/23 at 1:50 P.M., 02/18/23 at 9:00 A.M., 02/19/23 at 9:00 A.M., 02/20/23 at 9:00 A.M. and 02/22/23 at 6:45 P.M. Review of the MAR revealed the medication had not been signed off as administered and no pain assessment of evaluation for effectiveness was documented. 3. Review of Resident #353's medical record revealed an admitted [DATE] with diagnoses including spinal fusion and chronic pain syndrome. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #354 had intact cognition. The resident's functional assessment was in progress. Review of the care plan dated 02/16/23 revealed no care plan related to pain. Review of the physician orders for February 2023 revealed Resident #353 had an order for Oxycodone 15 mg every four hours as needed and Methadone (narcotic pain medication) 10 mg every eight hours as needed. Review of narcotic sign out sheets for February 2023 revealed Oxycodone was signed out on 02/19/23 at 1:00 P.M., 02/19/23 at 7:30 P.M., 02/20/23 at 2:00 P.M., and 02/22/23 at 4:10 A.M. Review of the MAR revealed the medication had not been signed off as administered and no pain assessment of evaluation for effectiveness was documented. Review of the MAR for February 2023 revealed Oxycodone had been signed off as administered on 02/17/23 at 4:17 A.M., 02/17/23 at 1:52 P.M., 02/22/23 at 3:24 P.M. and 02/22/23 at 7:46 P.M. Further review revealed no documented evidence on the narcotic sign out sheet of the medication having been signed out. Review of the narcotic sign out sheet for February 2023 revealed Methadone was signed out on 02/18/23 at 4:30 A.M. and 02/20/23 at 2:00 P.M. Review of the MAR revealed the medication had not been signed off as administered and no pain assessment of evaluation for effectiveness was documented. Interview on 02/23/23 at 9:53 A.M. the Director of Nursing (DON) stated a pain assessment as well as follow up for effectiveness of pain medications were to be documented in the MAR before and after a pain medication was administered. Review of the facility policy titled Medication Administration, revised 05/22, revealed medications were to be charted in the MAR. This deficiency represents non-compliance investigated under Complaint Number OH00136547.

Based on observation, interview, record review, and facility policy review the facility failed to ensure residual of a residents continuous tube feeding was checked prior to administering medications. This affected one resident (#34) of two residents observed for tube feeding medication administration. The facility identified six residents (#13, #21, #32, #34, #35, and #356) with a feeding tube. The facility census was 47. Findings include: Review of Resident #34's medical record revealed an admitted [DATE] with diagnoses including stroke, dysphagia (difficulty swallowing), and altered mental status. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #34 had impaired cognition and required extensive assistance with toileting and personal hygiene. Resident #34 was dependent on staff for eating as he received nothing by mouth (NPO) and had a feeding tube. Review of the care plan dated 01/18/23 revealed Resident #34 was NPO and required a feeding tube (tube inserted through the abdomen into the stomach) for nutrition and medication administration. Interventions included check for tube placement and residual volume and prior to use. Review of the physician orders for February 2023 revealed to check tube feeding placement before initiation of formula and medication administration. There were no orders related to a feeding tube dressing or checking for residual. Observation of medication administration for Resident #34 on 02/23/23 at 8:05 A.M. with Licensed Practical Nurse (LPN) #415 revealed the resident had a feeding tube. Observation revealed LPN #415 prepared the residents medications by crushing them to administer via his feeding tube. LPN #415 did check for placement but did not check for residual prior to administering the resident's medications. Interview with LPN #415 revealed she should have checked residual prior to administering the medications. Further observation revealed Resident #34 had a gauze dressing around the feeding tube insertion site that was dated 02/21/23 and was soiled with what appeared to be the tube feed substance. Interview with LPN #415 at time of observation confirmed the soiled dressing and stated the dressing should have been changed when soiled. Review of the facility policy titled Medications trough N/G (nasogastric, feeding tube inserted through the nose into the stomach) or G-Tube (gastrostomy tube, feeding tube inserted through the abdomen into the stomach), Administration Of, revised 06/2017, stated once medications are ready for administration, the nurse will stop the feeding, disconnect the feeding administration tubing and check for placement, then flush briskly with 30 cubic centimeters (cc) of warm water. If the resident has an order to check the residual stomach contents: insert feeding syringe into the feeding tube and aspirate the stomach contents gently. Follow any established physician orders for administration of the feeding. If there are no specific physician orders: For 50 cc's or less of residual, return aspirate to the stomach and administer the feeding as prescribed. For 50-100 cc's of residual, return aspirate to the stomach, subtract the amount from the feeding to be administered. For 100 cc's or more, return the aspirate to the stomach, hold the feeding, and notify the physician.

Based on record review, interview, review of the facility self-reported incident (SRI), and facility policy review the facility failed to thoroughly investigate on incident of staff to resident verbal abuse for Resident #26. This affected one resident (#26) of three residents reviewed for abuse and had the potential to affect all 47 residents in the facility. Findings include: Review of the medical record for Resident #26 revealed an admitted [DATE] with diagnoses including diabetes, anxiety, hypertension, and hyperlipidemia. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #26 was cognitively intact. He required supervision of one staff for bed mobility, hygiene, eating, dressing, and toilet use and was independent for transfers. He had no behavioral concerns. Review of the facility SRI tracking number 231391 dated 01/24/23 revealed Resident #26 reported State tested Nurse Aide (STNA) #479 looked at him with a mean look, told him to leave, asked why he was still at the facility, and would not give him things he asks for. Interview on 02/23/23 at 8:09 A.M. with the Administrator confirmed the investigation revealed other employees reported STNA #479 used rough talk with residents, had a rough tone of voice, and was stern. Her employment was terminated as a result of the investigation for not following the employee Code of Conduct. The Administrator further confirmed the SRI was complete but did not contain all the information necessary for the investigation to be considered thorough. She confirmed non-interviewable residents were not assessed and all staff working at the time of the incident were not interviewed. Review of the facility policy for Resident Abuse Prevention Practices, dated October 2022, revealed the facility would thoroughly investigate all allegations of abuse.

Based on record review, interview, review of the facility self-reported incident (SRI), and facility policy review the facility failed to follow their policy for abuse when they did not thoroughly investigate an incident of staff to resident verbal abuse for Resident #26. This affected one resident (#26) of three residents reviewed for abuse and had the potential to affect all 47 residents in the facility. Findings include: Review of the medical record for Resident #26 revealed an admitted [DATE] with diagnoses including diabetes, anxiety, hypertension, and hyperlipidemia. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #26 was cognitively intact. He required supervision of one staff for bed mobility, hygiene, eating, dressing, and toilet use and was independent in transfers. He had no behavioral concerns. Review of the facility SRI tracking number 231391 dated 01/24/23 revealed Resident #26 reported State tested Nurse Aide (STNA) #479 looked at him with a mean look, told him to leave, asked why he was still at the facility, and would not give him things he asked for. Interview on 02/23/23 at 8:09 A.M. with the Administrator confirmed the investigation revealed other employees reported STNA #479 used rough talk with residents, had a rough tone of voice, and was stern. Her employment was terminated as a result of the investigation for not following the employee Code of Conduct. The Administrator further confirmed the SRI was complete but did not contain all the information necessary for the investigation to be considered thorough. She confirmed non-interviewable residents were not assessed and all staff working at the time of the incident were not interviewed. Review of the facility policy for Resident Abuse Prevention Practices, dated October 2022, revealed the facility would thoroughly investigate all allegations of abuse.

Based on record review and interview, the facility failed to ensure wound treatments were completed for Residents #40 as ordered by the physician. This affected one of three residents reviewed for wound care and treatments. The facility census was 43. Findings include: Review of the medical record revealed Resident #40 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #40's plan of care dated 03/21/22 revealed he had an arterial ulcer of the right fourth toe related to [CONDITION(S)]. Interventions included nursing staff to change the dressing per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included nursing staff to change the dressing per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #40 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was discontinued on 05/24/22 and new order implemented to cleanse the open area to Resident #40's left heel with normal saline solution, apply [MEDICATION(S)] 500 units/gram topically and pad lightly with 4x4 gauze and place two rolled kling wraps on the bottom of the foot leaving the wound covered only by the 4x4 and secure with kling daily and as needed. Review of the treatment administration records (TARs) for May 2022 and June 2022, revealed the physician ordered treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR also revealed Resident #40's left heel treatments were not documented as completed on 05/22/22, 05/28/22, 05/29/22, 05/30/22, 06/12/22 and 06/13/22. Interview on 06/26/22 at 2:55 P.M. with the Director of Nursing verified Resident #40's dressing changes/treatments were not documented as completed by nursing staff as ordered by the physician on the dates listed above.

Based on record review and interviews, the facility failed to complete pressure ulcer wound treatments for Resident #44 as ordered by the physician. This affected one of three residents reviewed for wound care and treatments. The facility census was 43. Findings include: Review of the medical record revealed Resident #44 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's order dated 05/24/22, revealed nursing staff were to cleanse the intact blister on Resident #44's right dorsal foot with normal saline solution and cover with an abdominal pad (ABD) pad and secure with kling wrap daily; cleanse the intact blister to the right inner foot with normal saline solution, cover with ABD pad and secure with kling daily; cleanse the open area (open blister) on the right medial foot with normal saline solution and apply Santyl ointment topically (nickel size thickness) and cover with an ABD pad and secure with kling daily; cleanse the open area (deep tissue injury, a persistent non-blanchable deep red, maroon or purple discoloration of intact or non-intact skin with underlying tissue damage) on the right outer great toe with normal saline solution, cover with calcium alginate and ABD pad and secure with kling daily; cleanse the open area (unstageable pressure ulcer) to the right inner ankle with normal saline solution, apply Santyl topically (nickel size thickness) to eschar and cover with ABD pad and secure with kling daily; cleanse the right heel (unstageable pressure ulcer) with normal saline solution, apply Santyl topically (nickel size thickness) to eschar and cover with ABD pad and secure with kling daily; cleanse the open area (stage two pressure ulcer) on the left ischial tuberosity (which is the curved bone to the bottom of the pelvis) with normal saline solution, cover with calcium alginate and secure with house foam daily; cleanse the right ischial tuberosity (stage two pressure ulcer) with normal saline solution, cover with calcium alginate and secure with house foam daily; and cleanse the open area (unstageable pressure ulcer) on the sacrum with normal saline solution, apply Santyl (nickel size thickness) to eschar and cover with calcium alginate and secure with house foam daily. Review of the treatment administration record (TAR) for May 2022, revealed the physician's orders for Resident #44's treatments/dressing changes to the blister on the right dorsal foot, blister on the right inner foot, open blister on the right medial foot, deep tissue injury to the right outer great toe, unstageable pressure ulcer to the right inner ankle and unstageable pressure ulcer to the right heel were not documented as completed by nursing staff on 05/28/22, 05/29/22 and 05/30/22. The TAR also revealed the treatments/dressings to Resident #44's stage two pressure ulcer to the left ischial tuberosity, stage two pressure ulcer to the right ischial tuberosity and the unstageable pressure ulcer to the sacrum were not documented as completed by nursing staff on 05/29/22 and 05/30/22. Interview on 06/26/22 at 2:55 P.M. with the Director of Nursing verified Resident #44's pressure ulcer treatments were not documented as completed by nursing staff as ordered by the physician on the TAR on the dates listed above. Review of the facility policy titled, Pressure Ulcer Prevention and Care Protocol, revised January 2020, revealed the nurse was responsible to carry out the treatments as ordered by the physician and for implementing the measures to prevent pressure ulcers.

Based on observation, record review and interviews the facility failed to provide routine nail care to Resident #6 and #12, who were dependent on staff for personal care. This affected two of three residents reviewed for nail care. Findings included: 1. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care dated 06/19/19 revealed Resident #6 enjoyed having her hair and nails done. Her goal was to have her nails done weekly. There was also an Activities of Daily Living (ADL) self-care performance deficit care plan for Resident #6 related to her right sided [CONDITION(S)], impaired balance, and limited mobility. Interventions indicated Resident #6 was totally dependent on staff to provide showers twice a week and as needed and required staff assistance for personal hygiene. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 had severely impaired cognition, required extensive assistance of one staff for bed mobility and dressing, total assist of two staff for transfers and bathing, and total staff assistance for personal hygiene. Review of the October 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician orders for November 2021 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the November 2021 MARS and TARS revealed no documentation of Resident #6 having her nails trimmed. Interview on 11/18/21 at 10:55 A.M. with State tested Nursing Assistant (STNA) #101 indicated showers were twice a week. She indicated Resident #6's hair was washed and her nails were trimmed on shower days however most of the residents have activity staff do their nails. Review of the shower schedule revealed Resident #6 was scheduled to receive a shower on Mondays and Thursday on the second shift. Observation on 11/18/21 at 11:45 A.M. revealed Resident #6 had very long, dirty fingernails on her right flaccid hand. Her finger nails were curling under into the palm of her hand. Her nails had chipped red nail polish on them with a half inch of new growth showing on each nail. The fingernails on her left hand were also long but not as long as her right hand and were dirty. They did not have any nail polish on them. Interview on 11/18/21 at 11:45 A.M. was attempted with Resident #6 but she was not able to respond in full sentences. She was able to respond in yes or no answers and shake her head yes or no. Resident #6 was asked if she liked her fingernails as long as they were, she nodded no and said no. When asked if staff ever cut her fingernails, she said no. Resident #6 indicated she received her showers. Interview on 11/18/2 at 1:15 P.M. with Licensed Practical Nurse (LPN) #102 indicated the nurses were supposed to trim Resident #6's finger nails, not the nursing assistants. She stated there was a box to check on the shower sheets to indicate if the resident needed her nails trimmed. If the box was checked, the nurses would need to trim them at that time. LPN #102 said they did not document anywhere in the medical record if they trimmed a resident's nails. Interview on 11/18/21 at 1:18 P.M. with STNA #103 indicated the activity department staff trimmed the residents' nails. Interview on 11/18/2 at 1:20 P.M. with LPN #104 indicated the activity department trimmed the residents' nails, but they could cut them as needed. Interview on 11/18/21 at 2:00 P.M. with the Director of Nursing (DON) verified the fingernails of Resident #6 were long and dirty and they were curling under on her flaccid right hand. The DON stated the nurses were to trim her fingernails. Interview on 11/18/21 at 2:20 P.M. with Activity Director #106 indicated the activity department staff do not trim the nails of residents who are diabetics. The only file their nails. Review of the facility policy titled, Nails, Care of Fingernails, dated 06/11, revealed the purpose of the policy was to ensure the cleanliness, prevent infection, injury, and odors, and to improve appearance, promote self-esteem, and contribute to the resident's sense of well-being. The fingernails of diabetic residents were to be cut by the nurse. Fingernail care would be done during the shower/bath and as needed and could also be done by an STNA during an activity. 2. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care dated 08/06/18 revealed Resident #12 had a ADL self-care performance deficit care plan related to Alzheimer's disease and impaired balance. The care plan indicated Resident #12 could be resistive with care as she was unaware of the staff's intentions and she was totally dependent for personal hygiene Review of the November 2021 physician's orders revealed Resident #12 had an order initiated on 04/17/19 for nursing staff to cut her fingernails every two weeks. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #12 had severely impaired cognition, required total assist of two staff for bed mobility, transfers, dressing, personal hygiene, and bathing. toileting. Interview on 11/18/2 at 1:15 P.M. with LPN #102 indicated the nurses were supposed to trim Resident #6's finger nails, not the nursing assistants. She stated there was a box to check on the shower sheets to indicate if the resident needed her nails trimmed. If the box was checked, the nurses would need to trim them at that time. LPN #102 said they did not document anywhere in the medical record if they trimmed a resident's nails. Observation on 11/18/21 at 1:10 P.M. revealed Resident #12 had long dirty fingernails. Interview on 11/18/21 at 1:18 P.M. with STNA #103 indicated the activity department staff trimmed the residents' nails. Interview on 11/18/2 at 1:20 P.M. with LPN #104 indicated the activity department trimmed the residents' nails, but they could cut them as needed. Interview on 11/18/21 at 2:10 P.M. with the DON verified Resident #12's fingernails were long and dirty. Interview on 11/18/21 at 2:20 P.M. with Activity Director #106 indicated the activity department staff do not trim the nails of residents who are diabetics. The only file their nails. Review of the facility policy titled, Nails, Care of Fingernails, dated 06/11, revealed the purpose of the policy was to ensure the cleanliness, prevent infection, injury, and odors, and to improve appearance, promote self-esteem, and contribute to the resident's sense of well-being. The fingernails of diabetic residents were to be cut by the nurse. Fingernail care would be done during the shower/bath and as needed and could also be done by an STNA during an activity. This deficiency substantiates Complaint Number OH 403.

Based on record review and staff interview, the facility failed to ensure Resident #18 was free from sexual abuse. This affected one (Resident #18) of two residents reviewed for sexual abuse. The facility census was 44 residents. Findings include: Review of the medical record for Resident #18 revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's comprehensive Minimum Data Set (MDS) assessment, dated 06/21/21, revealed the resident had impaired cognition with no behaviors or [CONDITION(S)]. Review of the medical record for Resident #24 revealed an initial admitted [DATE], and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the psychosocial note written on 07/27/21 revealed Resident #24 tended to display more behaviors in the afternoon and nighttime and could be difficult to redirect. In addition, Resident #24 had gone into other resident's rooms to use the toilet. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/20/21, revealed Resident #24 had verbal behaviors and physical behaviors not directed towards others. Review of the nurses notes dated 09/04/21 at 2:50 A.M. revealed Resident #24 was visually supervised at all times when awake and on fifteen-minute checks while in bed. Review of the nurses notes dated 09/04/21 at 6:47 P.M. and at 10:28 P.M. revealed Resident #24 was visually supervised and on fifteen-minute checks. Further review of the 09/04/21 notes revealed the resident had attempted to go into other resident rooms multiple times throughout the day. Review of the nurse notes dated 09/05/21 through 09/09/21 revealed Resident #24 remained on fifteen-minute checks. Further review of 09/05/21 notes revealed Resident #24 had entered the room of a female resident but came right back out. Further interview with staff revealed there were two incidents on 09/03/21: during the first incident staff observed Resident #24 in Resident #18's room touching her upper body, and during the second incident Resident #24 was removing his pants while at Resident #18's bedside. There was no evidence found in the medical record regarding these two incidents. Review of the psychiatry Certified Nurse Practitioner note dated 09/07/21 revealed Resident #24 was found at night on 09/03/21 in a female resident's room taking off his pants. On 09/09/21 at 11:50 A.M., interview with Resident #24 revealed he had no knowledge of entering any other resident rooms. On 09/09/21 at 12:50 P.M., interview with State tested Nursing Assistant (STNA) #114 revealed Resident #24 was routinely observed, and had been observed at a distance entering Resident #18's room. When STNA #114 arrived at the room, Resident #24 was standing over Resident #18 and touching the resident's upper portion of her body near the chest area. Resident #18 was wearing a shirt. Registered Nurse (RN) #130 was immediately notified. On 09/09/21 at 2:30 P.M., Resident #18 was observed sitting in a wheelchair watching television in the common area. Attempted interview with Resident #18 revealed she was unable to participate in the interview. On 09/09/21 at 2:40 P.M., interview with STNA #109 revealed Resident #24 was observed in Resident #18's room walking toward Resident #18's bed, where the resident was lying. STNA #109 redirected the resident. STNA #109 was unable to provide a date and time of this observation. Interview on 09/09/21 at 2:50 P.M. with STNA #100 revealed the STNA went to Resident #24's room when another staff member was heard yelling. STNA #100 was unable to recall the date or time but revealed it had been recent and prior to Resident #18's transfer to another unit. STNA #100 observed Resident #24 with pants and underwear down around his knees and was sitting on the bed beside Resident #18. Resident #18 had a shirt on and a blanket covering the lower portion of the body. Resident #18's eyes were shut with her arms crossed over her chest and was not observed to be in distress. STNA #100 further revealed staff routinely visually observed Resident #24 due to his behaviors. Observation on 09/09/21 at 3:00 P.M. revealed Resident #24's room had been moved the day of the survey and was now closer to the nurses' station and the common area. Interview with the Administrator on 09/09/21 at 3:50 P.M. revealed he received a phone call at home the evening of 09/03/21 from staff informing him Resident #24 had just been found with his pants down in Resident #18's room. The Administrator also said after talking with staff, the incident between Resident #24 and Resident #18 was not considered to be abuse. The administrator further revealed staff were busy with other resident needs and it would be unrealistic to monitor Resident #24 every minute of the day. Interview on 09/10/21 at 9:35 A.M. with Registered Nurse (RN) #130 revealed STNA #101 and STNA #114 notified RN #130 around noon on 09/03/21 that Resident #24 had been in Resident #18's room and had been touching on Resident #18. This was an incident that occurred prior to Resident #24 being found in Resident #18's room with his pants down while at the resident's bedside. RN #130 was unable to determine exactly where Resident #18 had been touched on the upper body, and said it was uncharacteristic of Resident #24. The Administrator came to the unit immediately after notification. Resident #24 remained on visual observation, and had been routinely visually observed by staff due to behaviors of getting into things and being busy. RN #130 said fifteen-minute checks were documented beginning with the evening shift of 09/04/21. There was no evidence of monitoring Resident #24 prior to this. Resident #18 was moved out of the memory care unit on the afternoon of 09/04/21. Review of STNA #114's witness statement to another incident dated 09/03/21 revealed Resident #24 was observed touching the sequins on Resident #18's shirt and Resident #24 was asked to leave Resident #18's room. No additional information was available. Review of the fifteen-minute check sheet revealed checks were started on 09/04/21 at 0015 AM. Review of the Resident Abuse Prevention Practices Policy, dated November 2016, revealed alleged, suspected or observed abuse, neglect and/or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Suspected violations are reported upon investigation to the Department of Health using the online submission of self-reported incidents. This deficiency substantiates Complaint Number OH 592.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of the facility's Coronavirus (COVID-19) policy, and review of the Centers for Disease Control and Prevention (CDC) guidelines, observations, interviews, and record review the facility failed to implement appropriate infection control practices related to inservicing agency staff on facility COVID-19 policies and procedures and use of appropriate personal protective equipment (PPE) for residents on COVID-19 quarantine and isolation precautions. This resulted in Immediate Jeopardy on 09/30/20 after the first resident (Resident #3) tested positive for COVID-19 and was moved to the COVID-19 containment area. As of 10/19/20, Resident #1, Resident #2, Resident #4, Resident #6, Resident #9, and Resident #10 were confirmed positive for COVID-19 and resided in the COVID-19 containment area. The facility did not implement the need to change or discard N95 masks upon exiting the COVID-19 containment area. The lack of effective infection control practices placed all residents at the facility at risk for serious life-threatening harm, complications and/or death related to the facility's failed practice of infection control. The facility census was 49. The Administrator and Director of Nursing (DON) were notified on 10/20/20 at 2:31 P.M. that an Immediate Jeopardy began on 09/30/20 when the facility failed to implement appropriate and recommended infection control practices after moving a COVID-19 positive resident, Resident #3, to the COVID-19 containment area when the facility did not properly educate and monitor staff for removal of contaminated PPE when leaving the COVID positive unit. In addition, observations on 10/19/20 and 10/20/20 revealed all staff were not wearing N95 masks throughout the facility and staff did not change or discard their N95 masks when exiting the COVID-19 containment area. Resident #11, Resident #12, and Resident #13 were new admissions and were quarantined, but the rooms did not identify the residents were in quarantine and staff were not using full PPE (gowns, gloves, face shield, and N95 masks) in quarantine rooms. Interviews on 10/19/20 with State tested Nurse Aid (STNA) #604, STNA #605 and STNA #606 revealed they do not change their N95 masks when exiting the COVID-19 containment area, they were unsure what residents were quarantined, and agency staff were not inserviced on COVID-19 policies and procedures. The facility identified six COVID-19 positive residents (Residents #1, #2, #4, #6, #9 #10) and three quarantined residents (Residents #11, #12, #13). The Immediate Jeopardy was removed on 10/21/20 when the facility implemented the following correction actions: · On 10/19/20 at 5:15 P.M., the Administrator and DON placed stop sign/infection alert signs on the doors of Resident #11, Resident #12, and Resident #13's rooms who were on admission/readmission quarantine. On 10/20/20 at 5:15 P.M. an email was sent to all five staffing agencies used by the facility. The email stated all agency staff must review the education packet prior to providing care. They must also sign an acknowledgement that they have received the information. These will be locked at the application desk in the front lobby, marked with a yellow sign. Management including weekend managers will ensure the agency staff sign before starting their shift. The packet will include hand washing, proper donning/doffing of PPE, Droplet-Plus Isolation Policy, COVID-19 Policy, donning/doffing procedures for COVID-Containment Unit, donning/doffing procedures for new admits, readmits, or those in isolation for possible COVID-19 symptoms. The packet will also include the direct contact information for the Administrator and DON so agency staff may communicate directly with them as needed. DON/designee will maintain a copy of the agency staff's signed acknowledgement and it will be placed with their COVID-19 materials. · On 10/20/20 at 7:30 P.M., the DON/designee reeducated all staff in the building on the use and meaning of the stop sign/infection alert signs. · On 10/20/20 at 7:30 P.M., the DON/designee educated all staff in the building on proper donning/doffing procedures for the COVID-19 unit, proper donning/doffing procedures for admissions, readmissions and residents in quarantine isolation with possible COVID-19 symptoms. Education was completed for all staff on 10/21/20 in person or via phone. · On 10/20/20 at 7:45 P.M. the Medical Director was consulted by DON and made aware of their corrective action plan and audits to monitor compliance. · On 10/20/20, the facility identified for all future admissions, readmissions or residents with possible COVID-19 symptoms; appropriate signs will be placed on their doors by the admission nurse, DON, or designee. · On 10/21/20 at 5:15 P.M. random audits will be completed by DON/designee to ensure stop sign/infection control alert signs are in place three times a day for two weeks. · Starting 10/22/20, random audits will be completed by DON/designee to assure compliance of proper PPE use with quarantine residents and proper use of N95 masks. Audits to be performed every shift for two weeks then daily alternating between every shift by DON/designee for two weeks. · Starting 10/22/20, the DON/designee will audit five times a week for four weeks that all new agency staff have received the educational materials. Results of these audits will be reviewed at November 2020 QAPI meeting to determine any necessary adjustments to the education packet and the schedule of ongoing audits. · Audits and procedure will be reviewed for compliance, any adjustments and further ongoing audits will be scheduled at the November 2020 QAPI meeting. Although the Immediate Jeopardy was removed on 10/21/20, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: 1. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #11's physician orders revealed on 10/14/20 she was ordered droplet plus isolation precautions for 14 days due to being a new admission. Review of the medical record revealed Resident #12 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #12 was sent to the hospital on [DATE] and returned to the facility on [DATE]. Review of Resident #12's physician orders revealed on 10/10/20 the resident was ordered droplet plus isolation precautions for 14 days upon readmission from the hospital. Review of the medical record revealed Resident #13 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #13 was sent to the hospital on [DATE] and returned to the facility on [DATE] with a [DIAGNOSES REDACTED].#13's physician orders revealed on 09/29/20 the resident was ordered droplet plus isolation precautions for 14 days due to readmission from the hospital. Interview on 10/19/20 at 4:05 P.M. with the DON revealed she was working as a floor nurse on the hall where residents were quarantined for unknown COVID-19 status, which was the upper part of South A hall. The DON believed there were five residents on isolation/quarantine. The DON said staff should wear a gown, gloves, N95 mask, a blue surgical mask over the N95 and a face shield when in these isolation/quarantined resident rooms. The DON said staff should discard the blue surgical mask when exiting resident rooms and keep the same N95 mask on and then exit the COVID quarantine area. Observation of the quarantine unit at that time revealed no signs at the entrance to the hall to indicate it was a quarantine unit. Resident #11, Resident #12 and Resident #13, resided on the unit but did not have a stop sign or any signage on or near their room doors to indicate they were on isolation or quarantine precautions including what type of PPE should be worn in caring for these residents. Interview on 10/19/20 at 4:44 P.M. with STNA #604 revealed two residents were in quarantine isolation precautions, Resident #11 and Resident #13. STNA #604 revealed she wears an N95 mask and a face shield in quarantine rooms. STNA #604 revealed she wears the same N95 mask throughout the entire facility and does not change or discard the mask even when leaving quarantine or COVID-19 positive resident rooms. STNA #604 said a lot of times they do not have enough PPE. Observation at that time in the donning room before entering the COVID-19 containment area revealed there was one small box of N95 masks available to use. STNA #604 verified there were enough supplies currently. Interview on 10/19/20 at 4:59 P.M. with STNA #605 revealed she worked at the facility five times through a staffing agency. STNA #605 revealed she received no education on the facility COVID-19 policies and procedures and did not think any of the residents in the quarantine area were on isolation/quarantine precautions. STNA #605 revealed she wears an N95 mask and a face shield in quarantine rooms and wears the same N95 mask throughout the entire facility and does not change or discard the mask when leaving quarantine or COVID-19 positive rooms. On 10/20/20 at 5:07 P.M. interview with the DON confirmed there were no signs posted at the entrance to the quarantine hall or on any of the resident rooms for those residents in quarantine, Resident #11, #12 and #13. Interview on 10/20/20 at 11:01 A.M. with the Administrator revealed most of the agency staff are regulars and are educated with the facility staff. The Administrator indicated agency staff were given verbal education. Review of the facility education provided to facility staff on 10/01/20, titled, Containment, revealed STNA #605 did not sign for receipt of the education. Interview on 10/20/20 at 11:42 A.M. with Registered Nurse (RN) #600 revealed staff had to wear gloves, a mask, and a face shield in quarantine rooms, but staff did not have to wear a gown. She voiced no concerns with having enough PPE available. Interview on 10/20/20 at 2:23 P.M. with the DON revealed the facility has been ordering PPE weekly and they are being sent enough PPE, therefore there was no shortage of PPE. The facility administration indicated they regularly monitor PPE supplies and had 240 N95 masks available for staff. 2. Review of the medical record revealed Resident #1 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. She tested positive for COVID-19 after going to the hospital after a fall on 09/28/20. Resident #1 returned from the hospital on [DATE] with physician orders for droplet plus isolation precautions for 14 days due to COVID-19. Resident #1 resided on the facility COVID-19 containment area. Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #2's progress notes revealed he was sent to the hospital on [DATE] with a change in condition and returned on 10/06/20. Resident #2's laboratory testing results revealed he was tested for COVID-19 on 09/29/20 and the results on 09/29/20 were positive for COVID-19. Resident #2 resided on the facility COVID-19 containment area. Review of the medical record revealed Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's progress notes revealed on 09/30/20 the resident tested positive for COVID-19 and was moved to the COVID-19 containment area for isolation. Resident #3 was the first resident to be moved to the containment area. She later tested negative for COVID-19 on 10/15/20 and was moved off the COVID-19 containment area. Review of the medical record revealed Resident #4 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #4 tested positive for COVID-19 on 09/30/20. Resident #4's progress notes revealed she was sent to the hospital on [DATE] due to abnormal vital signs and altered mental status. Resident #4 returned to the facility on [DATE] and was placed on the COVID-19 containment area. Review of the medical record revealed Resident #6 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #6 was tested for COVID-19 on 09/29/20 and the results on 10/02/20 revealed she was positive for COVID-19. Resident #6 was immediately moved to the COVID-19 containment area. Resident #6's progress note dated 10/09/20 revealed the resident was sent to the hospital due to respiratory distress. Resident #6 returned to the facility on [DATE] to the COVID-19 containment area. Resident #10 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #10's laboratory test results revealed she was tested for COVID-19 on 09/29/20 and results on 10/02/20 revealed she was positive for COVID-19. Resident #10 was moved to the facility COVID-19 containment area. Resident #10's progress notes revealed she was hosptalized on [DATE] after being found unresponsive and returned to the facility on [DATE]. Resident #10 remained on the COVID-19 containment area. Resident #9 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #9's laboratory records revealed on 09/29/20 she was tested for COVID-19 and the results on 10/02/20 revealed she was positive for COVID-19. Resident #9 was moved to the facility COVID-19 containment area. Resident #9 was tested again on 10/07/20 and she was still positive for COVID-19. Resident #9 remained in isolation on the COVID-19 containment area. Observation on 10/19/20 at 4:11 P.M. revealed Resident #1, Resident #2, Resident #4, Resident #6, Resident #9, and Resident #10 were in isolation on the COVID-19 containment area for COVID-19. There was a plastic zip wall that separated the COVID-19 positive area from the rest of the facility. Upon exiting the containment area, interview with the DON revealed staff should change their contaminated N95 mask to a clean mask after exiting this COVID-19 positive area. Interviews with STNA #604 and #605 on 10/19/20, as noted above, revealed they wore the same N95 mask used in the COVID-19 containment unit to provide care to residents who did not have COVID-19. Observation on 10/20/20 at 11:32 A.M. revealed STNA #606 exited the COVID-19 containment area wearing a KN95 mask. STNA #606 did not discard or change her KN95 mask. STNA #606 then entered Resident #14's room to speak with the resident. Resident #14 was not in any type of isolation. Interview on 10/20/20 at 11:34 A.M. with STNA #606 confirmed she wore a KN95 mask on the COVID-19 containment area and did not change her mask after exiting. STNA #606 revealed she was not assigned to the COVID-19 area, but the staff all help back in that area. STNA #606 revealed she should have worn an N95 mask in the COVID-19 containment area but had not been educated on the need to change her mask when exiting the unit. Interview on 10/20/20 at 12:28 P.M. with Administrator revealed facility staff were not educated to change their N95 mask after exiting the COVID-19 containment area because they cannot discard N95 masks due to a PPE shortage. Interview on 10/20/20 at 2:23 P.M. with DON revealed the facility has been ordering PPE weekly and they are being sent enough PPE. The DON confirmed they had no shortage of PPE. The facility administration indicated they regularly monitor PPE supplies and had 240 N95 masks available for staff. Review of the facility policy titled, Droplet Plus Precautions, dated 03/31/20, revealed the facility will use droplet plus precautions to decrease the risk of droplet transmission of infection agents, specifically COVID-10. Residents will be placed in a private room and if not available, the resident may be placed in a room with a resident who has active infection with same organism but with no other infection. A mask should always be worn when in room with the resident. An N95 mask is worn and a KN95 or surgical mask is worn if a N95 mask is not available. Face shields or eye protection/goggles should be worn for droplet plus precautions if available. Isolation gowns should be worn during direct resident care when the staff member has physical contact with the resident. Gloves should be worn for any direct contact with the resident and hand hygiene will be done before and after resident contact. Resident movement and transport will be limited and applying a mask to the patient for transport is required. Review of the facility policy titled, Policy for Suspected of Confirmed Coronavirus (COVID-19), dated 03/2020 revealed all new admissions and readmissions will be placed in dedicated area of facility. They will remain in that area for 14 days with no symptoms and will be placed in droplet plus isolation for those 14 days. PPE will include gloves, gown, masks, face shield/eye protection if available. Under PPE, the policy indicated in the event of supply concerns for PPE, the facility will follow CDC strategies for optimizing the supply of gowns, face masks, N95 respirators and eye protection. Also, facility will allow use of CMS approved industrial N95 masks. With no shortage of PPE, facility will follow droplet precautions policy for those with confirmed COVID-19, suspicion of COVID-19, and those admissions under droplet plus precautions. Disposable N95 masks will be used for positive or suspected COVID-19 residents. N95 masks should be donned prior to entry to a room and removed and discarded after exiting room and closing door. Surgical masks may be used for asymptomatic admissions. Hand hygiene will be completed after discarding. The facility will follow guidance for conservation of PPE as outlined in CDC guidance should PPE supplies be running low. Review of the CDC guidance updated 07/15/20, revealed PPE recommended when caring for a patient with suspected or confirmed COVID-19 includes the following: respirator or facemask. Disposable respirators and facemasks should be removed and discarded after exiting the patient's room or care area and closing the door unless implemented extended use or reuse. If reusable respirators are used, they should be removed after exiting the patient's room or care area. They must be cleaned and disinfected according to manufacturer's reprocessing instructions prior to re-use. Review of the CDC guidance updated 07/15/20 revealed recommended infection prevention and control practices when caring for a patient with suspected, confirmed, or unknown [DIAGNOSES REDACTED]-CoV-2 (COVID-19) infection as a measure to limit healthcare personnel exposure and conserve PPE included to consider designating entire units within the facility, determine how staffing needs would be met as the number of patients with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection increases and if healthcare personnel become ill and were excluded from work. Limit transport and movement of the patient outside of the room to medically essential purposes. Regarding PPE, healthcare personnel who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves and eye protection. Personal protective equipment training, on understanding and demonstrate when to use PPE, what PPE was necessary, how to properly apply (don), use and remove (doff) PPE in a manner to prevent self-contamination, how to properly dispose or disinfect and maintain PPE and the limitations of PPE should be completed. This deficiency substantiates Master Complaint Number OH 244.

Based on staff interview, review of a closed medical record, facility self-reported incident (SRI), police report, Emergency Medical Services (EMS) run report, hospital records the Facility Annual Assessment and the Resident Census and Condition report, the facility failed to provide sufficient staffing to meet the acuity needs of residents in the secured dementia unit. This resulted in Immediate Jeopardy on [DATE] when the licensed practical nurse (LPN) assigned to the secured unit was also assigned to provide resident care off the unit, leaving one state tested nurse aide (STNA) to provide care for 15 residents on the secured unit. Actual Harm occurred when Resident #53 physically abused Resident #52 resulting in Resident #52 sustaining multiple injuries including subdural hemorrhage that required emergent transfer to the local hospital. This affected one of two residents reviewed for physical abuse. The facility identified 13 additional residents residing on the secured unit (Residents #1, #2, #5, #6, #11, #16, #17, #21, #23, #26, #30, #36, and #38). The facility census was 51. On [DATE] at 2:32P.M. the Administrator, Director of Nursing (DON), and Corporate Quality Assurance Registered Nurse (RN) #115 were notified Immediate Jeopardy began on [DATE] when the facility failed to provide sufficient staffing to meet the acuity needs of residents in the secured dementia resulting in physical abuse of Resident #52 by Resident #53. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective action: · Staffing was adjusted to ensure there were a minimum of two staff always present on the secure dementia unit beginning on [DATE] following the incident. The secure unit staffing policy was updated [DATE]. The policy stated the secure unit would always have a minimum of two staff members (two nurses, two STNAs, or one nurse and one STNA) to provide oversight of all residents on the secure unit. The secured unit nurse is responsible to assure two staff members are always present. STNAs will always report to the floor nurse prior to leaving the unit to assure no other staff member has left the unit. No employee will exit the secured unit prior to the presence of the replacement employee. All nurses and STNAs received in-servicing regarding the adjusted minimum staffing on the secure dementia unit on between [DATE] and [DATE] per the DON and Corporate Quality Assurance RN #116. The facility DON or her designee will monitor the daily sign-in/sign-out log for completion to monitor for compliance. · Re-education was completed on [DATE] between 12:10 P.M. and 1:32 P.M. by the DON and Corporate Quality Assurance RN #116. with all midnight staff to re-enforce two staff members will be present on the secured dementia unit. · The facility implemented a sign-in/sign-out binder that is kept at the Secured Unit nursing desk. The following is kept in this binder: Secured Unit Staffing policy; scheduled STNA break times to ensure all STNAs are aware of times that replacements will be needed for lunch and breaks so routines can be adjusted. STNAs coordinate with each other to take their ten-minute breaks opposite each other, during that 30-minute time increment. Nurses take their lunches and breaks at times when the STNAs are not off the unit; North (Secured Unit) sign-in/sign out sheet includes instructions pertaining to signing out at all times and replacement signatures; Secured Unit sign-in/sign-out Daily Review Log. This will be used to verify daily monitoring of the sign-in/sign-out log by the DON or her designee. · The facility Administrator along with members of the facility Quality Assurance and Performance Improvement (QAPI) team met on [DATE] to review and update the Facility Annual Assessment to reflect the changes in staffing policy for the secure dementia unit that was done as part of the immediate action plan on [DATE]. · The facility Medical Director as noted above was made aware of the incident on [DATE] and was involved with the immediate interventions of the facility. He has been updated by the DON and Administrator as part of the QAPI team. He was updated on [DATE], the date of the most recent full QAPI meeting and was updated on [DATE] of the facilities corrective action plan. The facility has a follow-up QAPI meeting scheduled [DATE] to review the corrective action plan and the audits that are in place to monitor for continued compliance. · No further incidents of physical aggression have occurred. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Review of the Resident Census and Condition for the secured dementia unit for [DATE] revealed there were 15 residents on the unit with care needs as follows: - Seven residents required assistance of one to two staff for bathing and seven residents were totally dependent on staff for bathing. - Ten residents required assistance of one to two staff for dressing and four residents were totally dependent on staff for dressing. - Eleven residents required the assistance of one to two staff for transfers and two residents were totally dependent on staff for transfers. - Ten residents required assistance of one to two staff for toileting, and three residents were totally dependent on staff for toileting. - Thirteen residents were occasionally to frequently incontinent of bladder. - Twelve residents were occasionally to frequently incontinent of bowel . - Two residents were noted to have behaviors. Interview on [DATE] at 10:09 [NAME]M. with Corporate Quality Assurance RN #115 verified the night shift assignment for the secured dementia unit in place on the night of [DATE] included one nurse that was split between the secured dementia unit and seven rooms outside of the dementia unit and one STNA on the secured dementia unit. This schedule left one STNA on the secured dementia unit to provide care for the residents with the above listed acuity level while the nurse left the unit to provide for resident care needs of the other assigned area. Telephone interview on [DATE] at 8:16 [NAME]M. with LPN #101, the nurse on duty on the dementia unit on [DATE], revealed the LPN started the shift at 10:30 P.M. By 10:46 P.M she had left the dementia unit to complete her assignments on the other hall. LPN #101 indicated she finished there by 12:45 [NAME]M., later than her usual time. LPN #101 said as soon as she came back, she did rounds on the dementia unit. LPN #101 noted Resident #53's door closed but heard the resident's voice. She went in the room, but Resident #53 was not there. She went into the bathroom and he was not there, but she could still hear him. She noticed Resident #52's door was closed, so she opened door and saw Resident #52 lying on the floor. She could hear ragged breathing and gurgling. Resident #53 was sitting on the bed. He appeared to have something dark and sticky on his hands. LPN #101 stated she kept thinking she had to get Resident #52 up so he could breathe. With STNA #109, they log rolled Resident #52 while supporting his head, got him in the Hoyer lift and onto the bed. She was trying to comfort Resident #52. Resident #53 would not leave the room. He was swearing and muttering about those God (expletive) people, who are they to leave me here, why'd they leave me here, and on and on. LPN #101 called the DON, at 1:00 [NAME]M. CNP #124 at 1:03 [NAME]M., the family member at 1:08 [NAME]M. and then EMS at 1:32 [NAME]M. Review of the facility self-reported incident (SRI) and the facility investigation dated [DATE] revealed on [DATE] at approximately 1:00 [NAME]M., LPN #101 was making rounds on the secured dementia unit. She first entered the room of Resident #53. The resident was not in his room; she checked the bathroom, and he was not in the bathroom, but she could hear his voice. She then entered the neighboring room, Resident #52's room. The door to this room was shut and upon opening the door she observed Resident #53 sitting on the bed. Resident #53 had blood on his hands and stated to LPN #101 I didn't do anything; I am tired of this (expletive). LPN #101 observed blood splashed on the pillow at the head of the bed and then observed Resident #52 lying on the floor face down. There was blood noted around his head and his head was turned to the right. He moaned when she called his name. LPN #101 immediately called for help and assessed Resident #52. The facility guard was walking past the room on his hourly rounds and she asked him to call the other STNAs for assistance. Resident #53 remained on the bed and was wringing his hands. STNA #109 arrived at the room and assisted LPN #101 with log rolling Resident #52. His vital signs blood pressure: ,[DATE], pulse: 82, respirations: 20, temperature: 98.1 degrees Fahrenheit (F), neurological assessment: left pupil reactive to light, right pupil non-reactive to light, both at 1 millimeter (mm). Resident #52 did have movement of his arms and legs. LPN #101 had Resident #53 move to the chair in the room. LPN #101 and STNA #109 then placed the Hoyer sling under Resident #52 and transferred him from the floor to the bed. LPN #101 called EMS and placed a call to CNP #124. LPN #101 cleansed Resident #52's face and head, noted bruising and swelling to the right eye and to the side of the head above the right ear. He had bleeding from the mouth. EMS arrived and transported Resident #52 to the local emergency room (ER). After Resident #52 was transported the other STNA's stayed in the room with Resident #53 and began to clean the room. LPN #101 called the ER to give report and called the guardian of Resident #52 to inform her of his condition and transfer to the hospital. LPN #101 then went back where Resident #53 was still seated in the chair and took him into the bathroom to wash his hands and change his clothes. She noted blood and bruising to both hands/knuckles and blood on his slippers. When she assisted him up off the chair, she noted blood on the chair and on the stand/counter where the television was located. LPN #101 did not note any other injuries other than bruising, some swelling on his hands and knuckles. Review of the Trauma History and Physical dated [DATE] revealed Resident #52 presented to the ER at 1:56 [NAME]M. via ambulance with swelling and bruising of the eyes. He was intubated, due to concerns of aspiration and acute [MEDICAL CONDITION]. The ER physician suctioned bloody secretions from the resident's mouth and a nasogastric tube (a tube that is passed through the nasopharynx and esophagus into the stomach) was placed which yielded 1000 cubic centimeters (cc) of dark bloody output. Computed tomography (CT) scan of the facial bones, without contrast, revealed extensive facial soft tissue injury without acute facial bone fractures. CT scan of the head revealed right cerebral convexity acute subdural hemorrhage (a collection of blood outside the brain usually caused by severe head injuries) measuring up to 11 millimeters (mm). Mild extension along the posterior falx; scattered bilateral acute subarachnoid hemorrhage. Review of the medical record revealed Resident #52 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #52 was totally dependent on staff for all care including bed mobility, transfers, locomotion, dressing, eating, toilet use and personal hygiene. The resident used a mechanical lift (Hoyer) for transfers. The resident had behavioral symptoms not directed toward others and made noises like a loud engine hum and laughed inappropriately. The Brief Interview for Mental Status (BIMS) was unable to be completed because the resident was non-verbal. The staff assessed the resident as severely cognitively impaired. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 14-day MDS 3.0 assessment dated [DATE] revealed Resident #53 required supervision for bed mobility, walking and locomotion. The resident required limited assistance for transfers, dressing, toileting and personal hygiene. Resident #53 did not receive an antipsychotic, antianxiety or antidepressant during the assessment period. The BIMS score of 03 indicated severe cognitive impairment. The resident had behaviors including rejection of care and wandering. A review of the progress notes from [DATE] through [DATE] revealed Resident #53 frequently became agitated at other residents and staff. He would yell and sometimes threaten. He thought they were stealing from him. On [DATE] at 6:10 P.M., Certified Nurse Practitioner (CNP) #124 saw Resident #53. The progress note revealed the resident was having increased agitation, behaviors and depression due to the inability to leave the facility. CNP #124 ordered [MEDICATION NAME] 125 milligrams (mg), a mood stabilizer, twice a day (BID) and 250 mg at bedtime (HS) and a psychiatry consult due to mood lability and agitation. Interview on [DATE] at 9:02 [NAME]M. with RN #102 revealed Resident #53 was easily agitated by others and would escalate. The resident would start telling the noisy person to shut up and escalate to cursing or yelling. Resident #53 never became physical. RN #102 indicated Resident #52 had been at the facility a long time. Resident #52 didn't speak but made constant noises sort of like an engine and would laugh inappropriately. RN #102 stated that agitated Resident #53, but he just would tell him to shut up, never anything more. Interview on [DATE] at 11:36 [NAME]M. with STNA #105 revealed Resident #53 was fairly new but in the last couple of weeks, Resident #53 was becoming more verbally aggressive. He was becoming more agitated but had not struck out at anyone. STNA #105 indicated Resident #53's aggression seemed to come out of nowhere in the last couple weeks. Interview on [DATE] at 11:42 [NAME]M. with STNA #106 revealed Resident #52 was always smiling and laughing, he didn't speak, but would sit and make noises. STNA #106 indicated Resident #53 could be aggressive and had triggers. It was not directed at anyone, but he was still aggressive. STNA #106 said Resident #53 had a few residents he didn't like and Resident #52 was one of them. Interview on [DATE] at 11:54 [NAME]M. with STNA #107 revealed Resident #53 was highly agitated and noise drove him crazy, but anything could set him off. He wouldn't go to sleep at times because of his agitation. STNA #107 said with dementia residents, it was hard to tell when there would be behaviors by one or more residents. The STNA had told administration there always needed to be two aides on the secured dementia unit. She had also told them there shouldn't be a nurse splitting between the secured unit and the center hallway. STNA #107 said she was told the budget would not allow it. Interview on [DATE] at 12:11 P.M. with STNA #108 revealed Resident #53 was verbally abusive in the way he talked. The resident had threatened he was going to beat the crap out of that SOB, referring to Resident #52. Resident #53 constantly complained about Resident #52. The STNA told the nurses that Resident #53 was threatening to do things to Resident #52 due to his constant noises. The STNA stated a couple aides suggested the resident rooms be moved apart. Resident #52 remained hospitalized until [DATE] when he returned to the facility with hospice services. He expired on [DATE]. Review of the Facility Annual assessment dated [DATE] and reviewed by QAPI [DATE] revealed no evidence that specific staffing needs were addressed related to the secured dementia unit to deal with resident behaviors. This deficiency substantiated self-reported incident control number OH 015.

Based on staff interview, review of a closed medical record, facility self-reported incidents (SRI), police report, Emergency Medical Services (EMS) run report, hospital records and the Facility Annual Assessment and the Resident Census and Condition report, the facility administration failed to provide adequate staffing on the secured dementia unit to prevent resident to resident abuse as evidenced by an Immediate Jeopardy in physical abuse. This resulted in Immediate Jeopardy on [DATE] when the licensed practical nurse (LPN) assigned to the secured unit was also assigned to provide resident care off the unit, leaving one state tested nurse aide (STNA) to provide care for 15 residents on the secured unit. Actual Harm occurred when Resident #53 physically abused Resident #52 resulting in Resident #52 sustaining multiple injuries including subdural hemorrhage that required emergent transfer to the local hospital. This affected one of two residents reviewed for abuse. The facility identified 13 additional residents that resided on the secured unit (Residents #1, #2, #5, #6, #11, #16, #17, #21, #23, #26, #30, #36, and #38). The facility census was 51. On [DATE] at 2:32 P.M. the Administrator, Director of Nursing (DON), and Corporate Quality Assurance Registered Nurse (RN) #115 were notified Immediate Jeopardy began on [DATE] when facility administration failed to provide staffing to meet the needs of residents on the secure dementia unit to prevent physical abuse of Resident #52 by Resident #53. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective action: · Staffing was adjusted to ensure there were a minimum of two staff always present on the secure dementia unit beginning on [DATE] following the incident. The secure unit staffing policy was updated [DATE]. The policy stated the secure unit would always have a minimum of two staff members (two nurses, two STNAs, or one nurse and one STNA) to provide oversight of all residents on the secure unit. The secured unit nurse is responsible to assure two staff members are always present. STNAs will always report to the floor nurse prior to leaving the unit to assure no other staff member has left the unit. No employee will exit the secured unit prior to the presence of the replacement employee. All nurses and STNAs received in-servicing regarding the adjusted minimum staffing on the secure dementia unit on between [DATE] and [DATE] per the DON and Corporate Quality Assurance RN #116. The facility DON or her designee will monitor the daily sign-in/sign-out log for completion to monitor for compliance. · Re-education was completed with all midnight staff to re-enforce two staff members will be present on the secured dementia unit on [DATE] between 12:10 P.M. and 1:32 P.M. by the DON and Corporate Quality Assurance RN #116. · The facility implemented a sign-in/sign-out binder that is kept at the Secured Unit nursing desk. The following is kept in this binder: Secured Unit Staffing policy; scheduled STNA break times to ensure all STNAs are aware of times that replacements will be needed for lunch and breaks so routines can be adjusted. STNAs coordinate with each other to take their ten-minute breaks opposite each other, during that 30-minute time increment. Nurses take their lunches and breaks at times when the STNAs are not off the unit; North (Secured Unit) sign-in/sign out sheet includes instructions pertaining to signing out at all times and replacement signatures; Secured Unit sign-in/sign-out Daily Review Log. This will be used to verify daily monitoring of the sign-in/sign-out log by the DON or her designee. · The facility Administrator along with members of the facility Quality Assurance and Performance Improvement (QAPI) team met on [DATE] to review and update the Facility Annual Assessment to reflect the changes in staffing policy for the secure dementia unit that was done as part of the immediate action plan on [DATE]. · The facility Medical Director as noted above was made aware of the incident on [DATE] and was involved with the immediate interventions of the facility. He has been updated by the DON and Administrator as part of the QAPI team. He was updated on [DATE], the date of the most recent full QAPI meeting and was updated on [DATE] of the facilities corrective action plan. The facility has a follow-up QAPI meeting scheduled [DATE] to review the corrective action plan and the audits that are in place to monitor for continued compliance. · No further incidents of physical aggression have occurred. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record revealed Resident #52 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #52 was totally dependent on staff for all care including bed mobility, transfers, locomotion, dressing, eating, toilet use and personal hygiene. The resident used a mechanical lift (Hoyer) for transfers. The resident had behavioral symptoms not directed toward others and made noises like a loud engine hum and laughed inappropriately. The Brief Interview for Mental Status (BIMS) was unable to be completed because the resident was non-verbal. The staff assessed the resident as severely cognitively impaired. Review of the closed medical record revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 14-day MDS 3.0 assessment dated [DATE] revealed resident required supervision for bed mobility, walking, locomotion. The resident required limited assistance for transfers, dressing, toileting and personal hygiene. Resident #53 did not receive an antipsychotic, antianxiety or antidepressant during the assessment period. The BIMS score of 03 indicated severe cognitive impairment. The resident had behaviors including rejection of care and wandering. A review of the progress notes from [DATE] through [DATE] revealed Resident #53 frequently became agitated at other residents and staff. He would yell and sometimes threaten. He thought they were stealing from him. The resident was resistive to showers. On [DATE] at 6:10 P.M., Certified Nurse Practitioner (CNP) #124 assessed Resident #53. The progress note revealed the resident was having increased agitation, behaviors and depression due to inability to leave the facility. CNP #124 ordered [MEDICATION NAME] 125 milligrams (mg), a mood stabilizer, twice a day (BID) and 250 mg at bedtime (HS) and a psychiatry consult due to mood lability and agitation. Interview on [DATE] at 9:02 [NAME]M. with RN #102 revealed Resident #53 was easily agitated by others and would escalate. The resident would start telling the noisy person to shut up and escalate to cursing or yelling. Resident #53 never became physical. Resident #52 had been here a long time, he didn't speak but made constant noises sort of like an engine and would laugh inappropriately. That did agitate Resident #53, but he just would tell him to shut up, never anything more. Interview on [DATE] at 11:36 [NAME]M. with STNA #105 revealed Resident #53 was fairly new. In the last couple weeks, Resident #53 was becoming more verbally aggressive. He was becoming more agitated but had not hit out at anyone. His aggressiveness seemed to come out of nowhere the last couple weeks. Interview on [DATE] at 11:42 [NAME]M. with STNA #106 revealed Resident #52 was always smiling and laughing, he didn't speak, but would sit and make noises. Resident #53 could be aggressive and had triggers. It was not directed at anyone, but he was still aggressive. The resident had a few residents he didn't like and Resident #52 was one of them. Interview on [DATE] at 11:54 [NAME]M. with STNA #107 revealed Resident #53 was highly agitated, noise drove him crazy, but anything could set him off. He wouldn't go to sleep at times because of his agitation. The STNA had told administration there always needed to be two aides on the secured dementia unit because you could not tell with dementia residents what would upset them. She had also told them there shouldn't be nurse splitting between the secured unit and the center hallway. The STNA was told the budget would not allow it. Interview on [DATE] at 12:11 P.M. with STNA #108 revealed Resident #53 was verbally abusive in the way he talked. The resident had threatened he was going to beat crap out of that expletive. Resident #53 constantly complained about Resident #52. The STNA told the nurses that Resident #53 was threatening to do things to Resident #52 due to his constant noises. The STNA stated a couple aides suggested the resident rooms be moved apart. Review of the facility self-reported incident (SRI) and the facility investigation dated [DATE] revealed on [DATE] at approximately 1:00 [NAME]M., LPN #101 was making rounds on the secured dementia unit. She first entered room [ROOM NUMBER], the room of Resident #53. The resident was not in his room; she checked the bathroom, and he was not in the bathroom, but she could hear his voice. She then entered the neighboring room, room [ROOM NUMBER]. The door to this room was shut and upon opening the door she observed Resident #53 sitting on the bed. Resident #53 had blood on his hands and stated to LPN #101 I didn't do anything; I am tired of this (expletive). LPN #101 observed blood splashed on the pillow at the head of the bed and then observed Resident #52 lying on the floor face down. There was blood noted around his head and his head was turned to the right. He moaned when she called his name. LPN #101 immediately called for help and assessed Resident #52. The facility guard was walking past the room on his hourly rounds and she asked him to call the other STNAs for assistance. Resident #53 remained on the bed and was wringing his hands. STNA #109 arrived at the room and assisted LPN #101 with log rolling Resident #52. His vital signs blood pressure: ,[DATE], pulse: 82, respirations: 20, temperature: 98.1 degrees Fahrenheit (F), neurological assessment: left pupil reactive to light, right pupil non-reactive to light, both at 1 millimeter (mm). Resident #52 did have movement of his arms and legs. LPN #101 had Resident #53 move to the chair in the room. LPN #101 and STNA #109 then placed the Hoyer sling under Resident #52 and transferred him from the floor to the bed. LPN #101 called EMS and placed a call to CNP #124. LPN #101 cleansed Resident #52's face and head, noted bruising and swelling to the right eye and to the side of the head above the right ear. He had bleeding from the mouth. EMS arrived and transported Resident #52 to the local emergency room (ER). After Resident #52 was transported the other STNA's stayed in the room with Resident #53 and began to clean the room. LPN #101 called the ER to give report and called the guardian of Resident #52 to inform her of his condition and transfer to the hospital. LPN #101 then went back to room [ROOM NUMBER] where Resident #53 was still seated in the chair and took him into the bathroom to wash his hands and change his clothes. She noted blood and bruising to both hands/knuckles and blood on his slippers. When she assisted him up off the chair, she noted blood on the chair and on the stand/counter where the television was located. LPN #101 did not note any other injuries other than bruising, some swelling on his hands and knuckles. Resident #53 was on Eliquis, a blood thinning medication. After cleaning him up, LPN #101 sat with Resident #53 and talked with him and looked at his picture book to calm him. She sat with him until he fell asleep and then checked on him frequently. He remained in his room and sleeping. LPN #101 called the DON and informed her of the incident. Review of the ambulance run report dated [DATE] revealed EMS arrived at the facility at 1:13 [NAME]M. Upon arrival, staff stated Resident #52 was found lying prone (face down) on the floor at approximately 1:00 [NAME]M. Upon arrival Resident #52 was lying supine (on his back) on the bed with swelling to both eyes, nose and upper lip. He had moderate bleeding from the mouth. Lung sounds: rales were heard on auscultation due to moderate bleeding. They provided suctioning and oxygen and left the facility at 1:47 [NAME]M. to transport the resident to the hospital. They arrived at the hospital at 1:50 [NAME]M. Review of the Trauma History and Physical dated [DATE], Resident #52 presented to the emergency room (ER) at 1:56 [NAME]M. via ambulance with swelling and bruising of the eyes. He was intubated, due to concerns of aspiration and acute [MEDICAL CONDITION]. The ER physician suctioned bloody secretions from mouth and a nasogastric tube (a tube that is passed through the nasopharynx and esophagus into the stomach) was placed which yielded 1000 cubic centimeters (cc) of dark bloody output. Computed tomography (CT) scan of the facial bones, without contrast, revealed extensive facial soft tissue injury without acute facial bone fractures. CT scan of the head revealed right cerebral convexity acute subdural hemorrhage (a collection of blood outside the brain usually caused by severe head injuries) measuring up to 11 millimeters (mm). Mild extension along the posterior falx; scattered bilateral acute subarachnoid hemorrhage. Telephone interview on [DATE] at 8:16 [NAME]M. with LPN #101, the nurse on duty in the dementia unit on [DATE], revealed the LPN started the shift at 10:30 P.M. By 10:46 P.M had left the dementia unit to complete her assignments on the other hall. LPN #101 finished there by 12:45 [NAME]M., later than her usual time. As soon as she came back, she did rounds on the dementia unit. LPN #101 noted room [ROOM NUMBER]'s door closed but heard his voice. She went in the room, but Resident #53 was not there. She went into the bathroom; he was not there, but she could still hear him. She noticed room [ROOM NUMBER]'s door was closed, so she opened door and saw Resident #52 lying on the floor. She could hear ragged breathing and gurgling. Resident #53 was sitting on the bed. He appeared to have something dark and sticky on his hands. She stated she kept thinking she had to get Resident #52 up so he could breathe. With STNA #109, they log rolled Resident #52 while supporting his head, got him in the Hoyer lift and onto the bed. She was trying to comfort Resident #52. Resident #53 would not leave the room. He was swearing and muttering about those expletive people, who are they to leave me here, why'd they leave me here, and on and on. LPN #101 called the DON, at 1:00 [NAME]M. the CNP #124 at 1:03 [NAME]M., the family member at 1:08 [NAME]M because she wanted to give them time to get to the hospital, then the ambulance at 1:32 [NAME]M. Resident #52 remained hospitalized until [DATE] when he returned to the facility with hospice services. He expired on [DATE]. Review of the Facility Annual assessment dated [DATE] and reviewed by QAPI on [DATE] revealed no evidence that specific staffing needs were addressed related to the secured dementia unit to deal with resident behaviors. Interview on [DATE] at 10:09 [NAME]M. with Corporate Quality Assurance RN #115 verified the night shift assignment for the secured dementia unit on [DATE] included one nurse that was split between the secured dementia unit and seven rooms outside of the dementia unit and one STNA on the secured dementia unit. This left one STNA on the secured dementia unit when the nurse was providing care to the residents on his/her assignment off of the unit. Review of the Resident Census and Condition for the secured dementia unit for [DATE] revealed there were 15 residents on the unit the night of the incident with care needs as follows: - Seven residents required assistance of one to two staff for bathing and seven residents were totally dependent on staff for bathing. - Ten residents required assistance of one to two staff for dressing, and four residents were totally dependent on staff for dressing. - Eleven residents required the assistance of one to two staff for transfers and two residents were totally dependent on staff for transfers. - Ten residents required assistance of one to two staff for toileting and three residents were totally dependent on staff for toileting. - Thirteen residents were occasionally to frequently incontinent of bladder and 12 residents were occasionally to frequently incontinent of bowel. - At the time of the incident, two residents were noted to have behaviors. This deficiency substantiated self-reported incident control number OH 015.

Based on staff interview, review of a closed medical record, a facility self-reported incident (SRI), police report, Emergency Medical Services (EMS) run report, and hospital records, the facility failed to prevent the physical abuse of Resident #52 by Resident #53. This resulted in Immediate Jeopardy on [DATE] when Resident #52, who was not mobile, was found on the floor of his room with red drainage around his head and coming from his mouth and nose. Resident #53 was found seated on resident #52's bed with what appeared to be blood on his hands and indicating he could not take this expletive anymore. Actual Harm occurred when Resident #52 was urgently transported to the local hospital and found to have multiple injuries including cerebral hemorrhages. This affected one of two residents reviewed for physical abuse. The facility identified 13 additional residents residing on the secure dementia unit (Residents #1, #2, #5, #6, #11, #16, #17, #21, #23, #26, #30, #36, and #38). The facility census was 51. On [DATE] at 11:29 [NAME]M. the Administrator, Director of Nursing, and Corporate Quality Assurance Registered Nurse (RN) #116 were notified Immediate Jeopardy began on [DATE] when staff failed to provide adequate supervision to prevent Resident #53 from physically assaulting Resident #52, resulting in significant, life threatening injury. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective action: · Resident #53 was transferred to the emergency room for medical clearance and then pink-slipped as a direct admission to the psychiatric unit on [DATE]. Resident #53 will not be returning to the facility. · Body assessments of all residents on the secured dementia unit were completed on [DATE] between 8:00 [NAME]M. and 10:00 [NAME]M. by RN #117 with no further injuries identified. · An in-service on the abuse policy, preventing abuse, care of a resident with dementia, care of a resident who is physically abusive, care of a resident who is verbally abusive, managing aggressive episodes and dealing with difficult behaviors was completed for all staff on [DATE] and [DATE] by the Administrator, STNA/Activity Director #119 and Environmental Director #120. · An in-service on reporting suspected crimes was completed for all staff on [DATE] and [DATE] by the Administrator and LPN #121. · Staffing was adjusted to ensure there are two staff always present on the secure dementia unit at all times beginning on [DATE] following the incident. · A new policy was implemented on [DATE] to maintain two staff members at all times on the secured dementia unit. · Re-education was completed with all midnight staff to re-enforce two-staff members will be present on the secured dementia unit on [DATE] at 12:10 P.M. by the DON and Corporate Quality Assurance RN #116. · Interviews on [DATE] from 9:02 [NAME]M. through 12:11P.M. with Registered Nurse (RN) #102, RN #104, Licensed Practical Nurse (LPN) #103 and State tested Nurse Aides (STNAs) #105, #106, #107 and #108 revealed staff were trained in, and knowledgeable of how to appropriately intervene in situations involving residents who had aggressive reactions. They were knowledgeable regarding what, when, and to whom to report, according to the facility policies. · A form was developed on [DATE] to standardize all questions asked of potential admissions by Licensed Social Worker (LSW) #122 or LPN/ Admissions Director #126. · The facility Administrator along with members of the facility Quality Assurance and Performance Improvement (QAPI) team met on [DATE] to review and update the Facility Annual Assessment to reflect the changes in staffing policy for the secure dementia unit that was done as part of the immediate action plan on [DATE]. · The facility Medical Director as noted above was made aware of the incident on [DATE] and was involved with the immediate interventions of the facility. He has been updated by the DON and Administrator as part of the QAPI team. He was updated on [DATE], the date of the most recent full QAPI meeting and was updated on [DATE] of the facilities corrective action plan. The facility has a follow-up QAPI meeting scheduled [DATE] to review the corrective action plan and the audits that are in place to monitor for continued compliance. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record revealed Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #52 was totally dependent on staff for all care including bed mobility, transfers, locomotion, dressing, eating, toilet use and personal hygiene. The resident required a mechanical lift (Hoyer) for transfers. The resident had behavioral symptoms not directed toward others. Resident #52 made noises like a loud engine hum and laughed inappropriately. Review of the Brief Interview for Mental Status (BIMS) score revealed Resident #52 had severe cognitive impairment. Review of the closed -medical record revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 14-day MDS 3.0 assessment dated [DATE] revealed Resident #53 required supervision for bed mobility, walking and locomotion. He required limited assistance for transfers, dressing, toileting and personal hygiene. Resident #53 did not receive an antipsychotic, antianxiety or antidepressant during the seven-day assessment reference period. Review of the BIMS score revealed Resident #53 had severe cognitive impairment. The resident had behaviors of rejection of care and wandering. A review of the progress notes from [DATE] through [DATE] revealed Resident #53 frequently became agitated at other residents and staff. He would yell and sometimes threaten staff and residents. He thought they were stealing from him. Review of Certified Nurse Practitioner (CNP) #124 progress note dated [DATE] revealed Resident #53 was having increased agitation, behaviors and depression due to the inability to leave the facility. CNP #124 ordered [MEDICATION NAME] 125 milligrams (mg), a mood stabilizer, twice daily and 250 mg at bedtime and a psychiatry consult due to mood lability and agitation. Interview on [DATE] at 9:02 [NAME]M. with RN #102 revealed Resident #53 was easily agitated by others and would escalate. The resident would start telling the noisy person to shut up and escalate to cursing or yelling. RN #102 indicated Resident #52 had been at the facility a long time, he didn't speak but made constant noises sort of like an engine and would laugh inappropriately. The behavior did agitate Resident #53, but he just would tell him to shut up, never anything more. Interview on [DATE] at 11:36 [NAME]M. with STNA #105 revealed Resident #53 was fairly new. In the last couple weeks, Resident #53 was becoming more verbally aggressive. STNA #105 indicated Resident #53 was becoming more agitated but had not struck out at anyone. STNA #105 stated Resident #53's aggressiveness seemed to come out of nowhere the last couple weeks. Interview on [DATE] at 11:42 [NAME]M. with STNA #106 revealed Resident #52 was always smiling and laughing, he didn't speak, but would sit and make noises. The STNA indicated Resident #53 could be aggressive and had triggers. It was not directed at anyone, but he was still aggressive. STNA #106 stated Resident #53 had a few residents he didn't like and Resident #52 was one of them. Interview on [DATE] at 11:54 [NAME]M. with STNA #107 revealed Resident #53 was highly agitated, noise drove him crazy, but anything could set him off. He wouldn't go to sleep at times because of his agitation. STNA #107 stated with dementia residents, it was hard to tell when there would be behaviors by one or more residents. The STNA had told administration there always needed to be two aides on the secured dementia unit. She had also told them there shouldn't be a nurse splitting between the secured unit and the center hallway. The STNA was told the budget would not allow it. Interview on [DATE] at 12:11 P.M. with STNA #108 revealed Resident #53 was verbally abusive. The resident had threatened he was going to beat the crap out of that (expletive). Resident #53 constantly complained about Resident #52. STNA #108 told the nurses that Resident #53 was threatening to do things to Resident #52 due to his constant noises. The STNA stated a couple aides suggested the resident rooms be moved apart. They had rooms next to each other and shared a bathroom in between the rooms. Review of the facility SRI, tracking number 8, initiated on [DATE] revealed on [DATE] at approximately 1:00 [NAME]M., LPN #101 was making rounds on the secure dementia unit. LPN #101 entered the room of Resident #53. Resident #53 was not in his room. The nurse checked the bathroom and he was not in the bathroom, but she could hear his voice. LPN #101 then entered Resident #52's room. The door to the room was shut and upon opening the door she observed Resident #53 sitting on the bed of Resident #52 with blood on his hands and stating I didn't do anything. I am tired of this (expletive). LPN #101 observed blood splashed on the pillow at the head of the bed and then observed Resident #52 lying on the floor face down. There was blood noted around his head, and his head was turned to the right. Resident #52 moaned when the nurse called his name. Resident #52 was sent to the emergency room (ER) for evaluation. Review of the EMS run report dated [DATE] revealed EMS arrived at the facility at 1:13 [NAME]M. Staff stated Resident #52 was found lying prone (face down) on the floor at approximately 1:00 [NAME]M. Upon arrival, the resident was lying supine (on his back) on the bed with swelling to both eyes, nose and upper lip. He had moderate bleeding from the mouth. Lung sounds indicated rales were heard on auscultation due to moderate bleeding. (EMS) provided suctioning and oxygen and left the facility at 1:47 [NAME]M. to transport the resident to the hospital. (EMS) arrived at the hospital at 1:50 [NAME]M. Review of the Trauma History and Physical from the hospital dated [DATE], revealed Resident #52 presented to the ER at 1:56 [NAME]M. via ambulance with swelling and bruising of the eyes. He was intubated, due to concerns of aspiration and acute [MEDICAL CONDITION]. The ER physician suctioned bloody secretions from his mouth and a nasogastric tube was placed which yielded 1000 cubic centimeters (cc) of dark bloody output. Computed tomography (CT) scan of the facial bones, without contrast, revealed extensive facial soft tissue injury without acute facial bone fractures. CT scan of the head revealed right cerebral convexity (curved like the exterior of a sphere) acute subdural hemorrhage (a collection of blood outside the brain usually caused by severe head injuries) measuring up to 11 millimeters (mm). Mild extension along the posterior falx (runs between the two hemispheres of the brain and is designed to protect and insulate the brain); scattered bilateral acute subarachnoid hemorrhage. Review of the police report, incident number 19Y 9, dated [DATE] at 3:32 [NAME]M. revealed when the police arrived at the ER, Resident #52's right eye was swollen shut, his nose was swollen, he was bleeding from the mouth and had bruises to his right shoulder. Officer #127 spoke with the guardian of Resident #52, and the guardian said she received a call from the facility at approximately 1:00 [NAME]M. and was told the resident fell out of bed. The resident's guardian said Resident #52 could not have fallen out of bed because he was totally immobile and unable to move on his own or speak. Due to the severity of Resident #52's injuries, the officer requested a detective/ sergeant, and the detectives and crime lab were notified. Once the detective and crime lab arrived on the scene, they took over the investigation. The hospital ER had made the notification to law enforcement. Telephone interview on [DATE] at 8:16 [NAME]M. with LPN #101, the nurse on duty in the dementia unit on [DATE], revealed she started the shift at 10:30 P.M. By 10:46 P.M. she left the dementia unit to complete her assignments on the other hall. LPN #101 finished there by 12:45 [NAME]M., later than her usual time. As soon as she went back to the dementia unit, she did rounds. LPN #101 noted the door to Resident #53's room was closed but heard the resident's voice. LPN #101 indicated she went in the room, but Resident #53 was not there. She went into the bathroom; he was not there, but she could still hear him. She noticed the door to Resident #52's room was also closed. She opened the door and saw Resident #52 lying on the floor. She could hear ragged breathing and gurgling. LPN #101 said Resident #53 was sitting on the bed. He appeared to have something dark and sticky on his hands. She stated she kept thinking she had to get Resident #52 up so he could breathe. With STNA #109, they log rolled Resident #52 while supporting his head, got him in the Hoyer lift and onto the bed. She was trying to comfort Resident #52. Resident #53 would not leave the room. He was swearing and muttering about those expletive people, who are they to leave me here, why'd they leave me here, and on and on. LPN #101 called the DON, at 1:00 [NAME]M., CNP #124 at 1:03 [NAME]M., and the family member of Resident #52 at 1:08 [NAME]M. LPN #101 then called EMS at 1:32 [NAME]M she indicated because she wanted to give the family time to get to the hospital. Resident #52 remained in the hospital until [DATE] when he returned to the facility on Hospice Services. The medical record contained no assessment of Resident #52 on his return. Resident #52 expired on [DATE]. At the time of this investigation the coroner's report was not available. Interview on [DATE] at 10:12 [NAME]M. with the DON revealed Resident #52 returned under palliative care, he remained non-verbal, and was in a stuporous state, almost entirely unresponsive and only responded to intense stimuli such as pain. She stated he was no longer making the humming noises and did not respond to her as he did prior to the incident. His blood oxygen saturation was 94 percent on 10 liters of oxygen with some use of accessory muscles when breathing. This deficiency substantiates Complaint Number OH 015.