Every finding on record at Woods Edge Rehab and Nursing

Based on observation, staff interview, record review, and review of the facility policy, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect 75 of 77 residents who received food from the kitchen. Two residents received no food by mouth. The facility census was 77 residents.Findings include: 1.Observation on 04/13/26 at 9:06 A.M. of two deep freezers with Dietary Manager (DM) #12 revealed there was debris and scum at the bottom of each deep freezer. In one of the freezers there were 100 unlabeled and undated strawberry shortcakes and 50 unlabeled and undated vanilla pudding cups. One deep freezer did not have a thermometer. Observation of the food preparation area revealed there was no soap in the dispenser at the sink used for staff hand hygiene. A box of hair nets contained a dirty used facemask and two used hair nets. Observation of walk-in freezer revealed it contained two unlabeled and undated pitchers of juice. Observation of the walk-in refrigerator revealed it contained the following unlabeled and undated items: 10 sandwiches, 25 cups of pre-poured cranberry juice, 25 cups of pre-poured water. Interview on 04/13/26 at 9:16 A.M. with DM #12 confirmed the debris in the bottom of the freezers, the freezer without a thermometer, the unlabeled and undated items throughout the kitchen, the lack of soap in the dispenser, and the dirty mask and hairnets discarded in the clean box of hair nets. 2.Observation of breakfast preparation on 04/15/26 at 7:47 P.M. revealed DM #12 made pancakes on the griddle using a ladle to scoop pancake batter onto the griddle and the using a spatula to flip the pancakes. Then DM #12 moved the pancakes to a pan on the tray line with his gloved hands. After moving a stack of pancakes into the pan on the tray line, DM #12 reached over and patted the pancakes down with his gloved hands. Interview on 04/15/26 at 7:57 A.M. with DM #12 confirmed he had touched the pancakes with his gloved hand that had been used to touch the ladle from the pancake batter. 3.Observation on 04/14/26 at 2:44 P.M. of the refrigerator/freezer on C-wing it did not include a thermometer in the freezer compartment and there was a buildup of ice in the freezer approximately three inches in depth. The refrigerator compartment thermometer read 50 degrees Fahrenheit (F.) Both the freezer and refrigerator compartments had food and drink spills throughout. Interview on 04/14/26 at 2:45 P.M. with Licensed Practical Nurse (LPN) #6 confirmed the freezer had spills and needed to be defrosted. She also confirmed the temperature of 50 degrees in the refrigerator was too high and the refrigerator needed to be cleaned of spills. 4. Observation on 04/14/26 at 2:46 P.M. revealed the resident ice cooler on the unit had a can of soda lying on the top of the ice. Interview on 04/14/26 at 2:47 P.M. with LPN #6 confirmed there was a can of pop laying on the ice and confirmed the soda should not be stored in the ice. 5. Observation on 04/14/26 at 3:01 P.M of the medical wing resident refrigerator/ freezer revealed there was ice buildup in the freezer compartment and spills and debris throughout freezer and refrigerator. Interview on 04/14/26 with Certified Nursing Assistant (CNA) #69 confirmed the freezer needed to be cleaned and defrosted and the refrigerator needed to be cleaned. 6. Observation on 04/16/26 at 10:22 A.M. of the men's locked unit resident refrigerator-freezer revealed the refrigerator and freezer had spills and debris throughout. Interview on 04/16/25 at 10:23 A.M. with LPN # 88 confirmed the refrigerator and freezer compartments both had spills and debris and needed to be cleaned. Review of the facility policy titled Food Storage dated August 2018 revealed all refrigerators should be kept clean and in good working condition at all times and refrigerator temperatures should range between 36 and 41 degrees F. Review of the facility policy titled Storage of Frozen Foods dated August 2018 revealed freezer units should be defrosted as frequently as necessary to maintain efficiency.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to properly label and store medications. This affected seven residents (Resident #20, Resident #55, Resident #36, Resident #37, Resident #58, Resident #75, and Resident #7) of 18 residents reviewed for medication storage. The facility census was 77 residents. Findings include: 1. Review of the medical record for Resident #20 revealed an admission date of [DATE] with a diagnosis of type two diabetes. Review of the physician's orders for Resident #20 revealed an order dated [DATE] for insulin glargine 12 units subcutaneously at bedtime. Observation on [DATE] at 10:15 A.M. with Licensed Practical Nurse (LPN) #112 revealed Resident #20's insulin glargine was opened and had not been dated. Interview on [DATE] at 10:16 A.M with LPN #112 confirmed Resident #20's insulin glargine had not been dated upon opening. 2.) Review of the medical record for Resident #55 revealed an admission date of [DATE] with a diagnosis of diabetes mellitus. Review of the physician's orders for Resident #55 revealed an order dated [DATE] for Novolog insulin per sliding scale which was discontinued on [DATE]. Observation on [DATE] at 10:30 A.M with LPN #117 revealed Resident #55's Novolog insulin was opened and had not been dated. Interview on [DATE] at 10:31 A.M. with LPN #117 confirmed Resident #55's Novolog was still in the cart even though it had been discontinued and the Novolog insulin had not been dated upon opening. 3. Review of the physician's orders for Residents #7, #58, and #75 dated [DATE] revealed the residents had orders for multivitamins with minerals tablets. Review of the physician's orders for Residents #36 and #37 dated [DATE] revealed the residents had orders for guaifenesin liquid. Observation on [DATE] at 10:40 A.M of medication storage room one revealed it contained five bottles of multiple vitamin and mineral tablets with expiration dates of [DATE] and four bottles of guaifenesin liquid with expiration dates of [DATE]. Interview on [DATE] at 10:50 A.M with the Director of Nursing (DON) confirmed the five bottles of multiple vitamins-minerals tablet and the four bottles of guaifenesin liquid in medication storage room one were expired and should have been discarded. Review of facility policy titled Medication Administration undated revealed the nurse should verify the expiration date of all medications.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to offer Coronavirus (COVID-19) vaccines to residents upon admission and annually. This affected two residents (Resident #2 and Resident #38) of five residents reviewed for vaccines. The facility census was 77 residents.Findings include: 1.Review of the medical record for Resident #2 revealed an admission date of 03/14/26 with diagnoses including anoxic brain damage, hypertension, and chronic diastolic heart failure. Review of the medical record for Resident #2 revealed the resident was not offered the COVID-19 vaccine upon admission. 2. Review of the medical record for Resident #38 revealed an admission date of 03/13/24 with diagnoses including chronic obstructive pulmonary disease, major depressive disorder, and diabetes mellitus. Review of the medical record for Resident #38 revealed the resident was not offered the COVID-19 vaccine upon admission. Interview on 04/16/26 at 9:30 A.M with the Director of Nursing (DON) confirmed Residents #2 and #38 were not offered the COVID-19 vaccine upon admission. Review of the facility policy titled COVID-19 Protocols dated October 2025 revealed residents would be educated on the risks and benefits of the COVID-19 vaccination and would be offered the vaccination. Vaccination information should be documented in the resident's medical record.

Based on medical record review, observation, resident interview, and staff interview, the facility failed to ensure call lights were within reach. This affected one (Resident #47) of 18 residents reviewed for call lights. The facility census was 77 residents.Findings include: Review of the medical record for Resident #47 revealed an admission date of 04/14/17 with diagnoses including chronic kidney disease, cardiomegaly, peripheral vascular disease, and schizoaffective disorder, Review of the Minimum Data Set (MDS) assessment for Resident #47 dated 03/09/26 revealed the resident was moderately cognitive impaired and was dependent on staff assistance with activities of daily living (ADLs.) Review of the care plan for Resident #47 dated 03/22/26 revealed the resident had an ADL deficit and the staff were to encourage the resident to use the call light to request assistance. Observation on 04/13/26 at 11:47 A.M. revealed Resident #47 was lying in bed and the call light was hanging on the wall out of reach of the resident. Interview on 04/13/26 at 11:50 A.M. with Resident #47 confirmed the resident was concerned about not being able to reach the call light, because she was dependent on staff for help. Interview on 04/13/26 at 11:57 A.M. with Certified Nursing Assistant (CNA) # 46 verified that the call light was out of reach for Resident #47.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure a clean and sanitary environment. This affected one (Resident #38) of 18 residents sampled. The facility census was 77 residents. Findings include: Review of the medical record for Resident #38 revealed an admission date of 02/15/23 with diagnoses including obsessive-compulsive disorder, delusional disorder, psychosis, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment for Resident #38 dated 03/21/26 revealed the resident was cognitively intact and required supervision with activities of daily living (ADLs.) Observation on 04/13/26 at 12:05 P.M. revealed the wall air conditioning unit next to Resident #38's bed was covered with a black substance. Interview on 04/13/26 at 11:45 AM with Resident #38 confirmed he was concerned about the black substance on his air conditioning unit because he thought it could negatively impact his health. Interview on 04/13/26 at 12:05 P.M. with Certified Nursing Assistant (CNA) #111 verified that the wall air conditioning unit next to Resident #38's bed was coated with a black substance and confirmed the unit should be kept clean. Review of facility policy titled Cleaning of Residents' Rooms dated July 2022 revealed walls, blinds, and window curtains in resident areas would be kept clean when those surfaces are visibly contaminated or soiled.

Based on medical record review, review of the facility fall investigation, staff interview, and review of the facility policy, the facility failed to provide adequate the adequate level of supervision and assistance during care to prevent falls. This affected one (Resident #84) of three residents reviewed for falls. The facility census was 77 residents.Findings include: Review of the medical record for Resident #84 revealed an admission date of 12/06/26 with diagnoses including cerebral infarction, hemiplegia and hemiparesis affecting left non-dominant side, and paranoid schizophrenia. Review of the fall risk assessment for Resident #84 completed 12/06/25 revealed the resident was at moderate risk for falls. Review of the Minimum Data Set (MDS) assessment for Resident #84 dated 12/11/25 revealed the resident was moderately cognitively impaired and was dependent on staff for toileting, dressing, bathing, personal hygiene, and turning and repositioning. Review of the care plan for Resident #84 dated 12/08/25 revealed the resident had a self-care deficit, impaired cognition, and was at risk for falls due to hemiplegia and hemiparesis. Interventions included two staff were to assist the resident with daily hygiene, grooming, and dressing. Review of the nurse progress note for Resident #84 dated 03/03/26 at 7:59 A.M. revealed at 6:10 A.M. Certified Nursing Assistant (CNA) #109 called out for assistance. Registered Nurse (RN) #59 ran to the room and observed CNA #109 attempting to assist Resident #84 onto the floor. RN #59 and CNA #109 assisted Resident #84 back into bed using the Hoyer lift. Review of the facility fall investigation for Resident #84 dated 03/03/26 revealed CNA #109 was completing Resident #84's incontinence care and bed bath. CNA #109 began to roll Resident #84 over toward the wall to perform care. When CNA #109 was done performing care the aide cleaned off the bed and turned around to grab dry linens. When CNA #109 turned around Resident #84 started to fall sliding feet first and then to his knees. Interview on 04/14/26 at 10:38 A.M. with CNA #109 confirmed Resident #84 required the assistance of two staff for all ADLs including bed baths. CNA #109 confirmed if they would have had another person assisting them Resident #84 would not have fallen. CNA #109 confirmed Resident #109 slid out of bed during the bed bath when the aide turned away from the resident to grab fresh linens. Interview on 04/14/26 at 2:37 P.M. with the Director of Nursing (DON) confirmed Resident #84 had a witnessed fall without injury on 03/03/26 during a bed bath provided by CNA #109. The DON verified the facility investigation determined Resident #84 required the assistance of two staff with transfers and CNA #109 had not followed the resident's care plan which resulted in the fall. Interview on 04/14/26 at 3:16 P.M. with RN #59 confirmed Resident #84 required the assistance of two staff for bed baths and CNA #109 should have had another staff member in the room. Review of the facility policy titled Accident and Incidents Protocol dated on March 2025 revealed the facility would implement interventions to prevent falls. This deficiency represents noncompliance investigated under Complaint Number 2964143.

Based on observation, staff interview and review of the facility policy, the facility failed to ensure nurses performed appropriate hand hygiene during medication administration. This affected three residents (Resident #11, Resident #76 and Resident # 38) of five residents observed for medication administration. The facility census was 77 residents.Findings include: 1.Observation on 04/15/26 at 8:30 A.M. of medication administration per Licensed Practical Nurse (LPN) #6 revealed the nurse popped Resident #11's medications out of the package into her bare hand and placed the pills in the medication cup. Interview on 04/15/26 at 9:00 A.M. with LPN #6 verified she should not touch resident medications with her bare hand. 2.Observation on 04/15/26 at 9:00 A.M. of medication administration per LPN #6 revealed the nurse did not wash or sanitize her hands before administering medications to Resident #76. Interview on 04/15/26 at 9:40 A.M. with LPN #6 confirmed she had not washed or sanitized her hands prior to medication administration to Resident #76. 3. Observation on 04/15/26 at 2:15 P.M. of medication administration revealed LPN #112 sanitized her hands and administered routine medications to Resident #38. Observation on 04/15/26 between 2:05 PM and 2:15 PM of medication administration revealed LPN # 112 sanitized her hands prior to administering medication to Resident # 38. Resident #38 then requested pain medication. LPN #112 went back to the medication cart to retrieve pain medicine for Resident #38 but did not wash or sanitize her hands between tasks. Interview on 04/15/26 at 2:15 P.M. with LPN #112 confirmed she should have sanitized her hands prior to each medication administration. Review of the facility policy titled Medication Administration undated revealed the first step in medication administration was to wash hands and to wash hands prior to proceeding to the next resident during medication administration.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure that residents were offered the pneumococcal vaccine upon admission and annually. This affected three residents (Resident #22, #38, and Resident #2) of five residents reviewed for vaccines. The facility census was 77 residents.Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 05/21/18 with diagnoses including alcoholic cirrhosis of liver without ascites, unspecified dementia, and schizophrenia. Review of the medical record for Resident #22 revealed the resident received one pneumonia vaccine on 10/17/25 and the facility did not offer additional pneumonia vaccines. 2. Review of the medical record for Resident #2 revealed an admission date of 03/14/26 with diagnoses including anoxic brain damage, hypertension, and chronic diastolic heart failure. Review of the medical record for Resident #2 revealed the resident was not offered the pneumonia vaccine nor the influenza vaccine upon admission. 3. Review of the medical record for Resident #38 revealed an admission date of 03/13/24 with diagnoses including chronic obstructive pulmonary disease, major depressive disorder, and diabetes mellitus. Review of the medical record for Resident #38 revealed the resident was not offered the pneumonia vaccine upon admission. Interview on 04/16/26 at 9:30 A.M with the Director of Nursing (DON) confirmed Resident #22 did not receive nor was offered the pneumonia vaccine after 10/17/25, Resident #2 did not receive nor was offered the pneumonia or influenza vaccines, and Resident #38 did not receive nor was offered the pneumonia vaccine. Review of the facility policy titled Pneumococcal Vaccine dated January 2026 revealed all residents would be offered pneumonia vaccines to aid in preventing infection.

Based on observation, record review, staff interview, and facility policy review, the facility failed to ensure a resident's falls were thoroughly investigated, properly documented in the medical record, a fall risk assessment was completed, a post-fall evaluation completed and assure immediate fall interventions were implemented. This affected one (Resident #39) of the three residents review for falls. The facility also failed to ensure residents were assessed following a fall. This affected one (Resident #49) out of three residents reviewed for falls. The facility census was 75. Findings include: 1) Review of the medical record for Resident #49 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia, delusional disorder, essential primary hypertension, major depressive disorder, hypothyroidism, osteoarthritis, urinary tract infection, and Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #49, revealed the resident was cognitively impaired. Resident #49 was dependent on staff for activities of daily living (ADL). Review of the progress note for Resident #49 dated 09/22/25 at 3:05 P.M., revealed the resident had an unwitnessed fall and was found on the floor near her roommate's bed. There was no documented fall interventions listed, or a post fall evaluation completed. Review of the fall care plan for Resident #49 revised on 10/08/25, revealed the resident was at risk for falls related to confusion, impaired safety awareness, incontinence, and psychoactive medications. The following interventions were listed: non-skid fall strips to the sides of resident's bed, complete a fall risk assessment per facility policy, anticipate the resident's needs, review past falls and attempt to determine contributing factors, promote a safe environment, keep the resident's call light accessible, and non-skid strips to the open side of Resident #49's bed. Review of the progress note for Resident #49 dated 11/21/25 at 3:51 P.M., revealed the resident had a fall on 11/21/25 at 2:30 A.M. There was no documentation related to this fall at the time of the fall. The resident was not acting at her baseline, and the resident was sent to the emergency room (ER) for evaluation. Resident #49 was admitted to the hospital with a diagnosis of UTI. There was no documented evidence of the thorough investigation being completed for this fall. Interview on 11/24/25 at 2:23 P.M., the Director of Nursing (DON) verified Resident #49 had a fall on 11/21/25 at 2:30 A.M. The DON also verified that the facility failed to complete a thorough investigation of fall. The DON stated a fall investigation should have started when the incident occurred at 2:30 A.M. and Licensed Practical Nurse (LPN) #176 failed to document the fall and failed to complete the proper paperwork related to the fall. The DON also verified the fall on 11/21/25 at 2:30 A.M. was not listed on the incident / accident log due to an investigation being completed. The DON stated LPN #176 did not complete the proper documentation and failed to complete a fall risk assessment and a post fall evaluation. The DON stated she did not have very much information to provide related to Resident #49's fall on 11/21/25 at 2:30 A.M. and stated she only knew Resident #49 was found on the floor next to her bed on the night of 11/21/25. Interview on 11/24/25 at 4:03 P.M., LPN #176 stated she was the nurse responsible for Resident #49 on 11/21/25 when Resident #49 was found on the floor around 2:30 A.M. LPN #176 stated Resident #49 was found on the floor with blood coming from her nose and a hematoma over her left eye. LPN #176 stated she called 911 for Resident #49 to be sent to the emergency room. LPN #176 stated when Emergency medical Services (EMS) arrived, they felt Resident #49 was stable and did not need to be taken to the ER for evaluation. LPN #176 verified she did not start an accident/incident investigation, completed a fall risk assessment, properly documented the fall in Resident #49's chart, and put an immediate intervention in place. LPN #176 stated she was behind on charting and focused on other assignments and could not complete the required tasks after Residents #49's fall. A subsequent interview on 12/01/25 at 9:46 A.M., the DON verified Resident #49 had a fall on 09/22/25 and the staff failed to complete a post-fall evaluation and implement any new fall interventions. Observation on 12/01/25 at 10:40 A.M. with Certified Nursing Assistant (CNA) #135, revealed Resident #49 was seated in her wheelchair next to her bed. Resident #49's call light was not within reach and was resting on the wall across the room and there were no non-skid fall strips next to Resident #49's bed per orders. Interview CNA #135 at the same time verified Resident #49's call light was located across the room from Resident #49 and rested on the switch on the wall and stated there should be non-skids strips on the floor. Subsequent interview on 12/01/25 at 11:58 P.M., the DON stated Resident #49 should always have her call light within reach to aid in the prevention of a fall. The DON stated Resident #49 had a room change recently and stated the staff forgot to apply the non- skid strips to the floor when the resident changed rooms. 2) Review of the medical record for Resident #39 revealed the resident was admitted to the facility on [DATE]. Diagnoses included paranoid schizophrenia, essential primary hypertension, peripheral vascular disease, dementia, insomnia, anxiety, anorexia, and chronic kidney disease. Review of the fall care plan for Resident #39 revised on 10/08/25, revealed the resident was at risk for falls related to her dementia diagnoses and diagnosis of anemia. Resident #39's fall interventions included fall risk assessment per facility protocol, anticipate the resident's needs, review falls and attempt to determine contributing factors, promote a safe environment, keep call light accessible, interdisciplinary team (IDT) to review falls for appropriate interventions, and follow the fall protocol if a fall occurs. Review of the MDS assessment dated [DATE], revealed Resident #39 was cognitively intact. Resident #39 was dependent on staff for ADLs and received Hospice services. Review of the progress note for Resident #39 dated 10/28/25 at 12:26 P.M., revealed the resident had an unwitnessed fall and was found on the floor parallel to Resident #39's bed. Resident #39 stated she tried to untangle her blankets on the bed and fell. Resident #39 had blood under right nostril, and the immediate intervention was to remind Resident #39 the importance of utilizing her call light when Resident #39 needed assistance. There was no documented evidence of a post-fall-evaluation completed for the resident after the fall on 10/28/25 at 12:26 P.M. Interview on 12/01/25 at 11:58 A.M., the DON verified the facility failed to complete a post fall evaluation after Resident #39's fall on 10/28/25. Review of the facility policy titled Accident and Incidents Protocol dated 08/2024 revealed the facility determined a fall or suspected fall was considered an incident/accident. A thorough investigation and follow-up would be completed as well as a summary of the accident. Accident/incident reports are initiated by a clinician as soon as the occurrence is discovered or reported. An accident/ incident report is an accurate and objective account of an occurrence. The staff was expected to document in the resident's medical chart the following facts, the date, time, person involved, where the accident/incident occurred, who first noticed the accident/incident, where the patient was positioned, assistance given, physician examination, and response of the family member at notification. This deficiency is a recite to the complaint survey completed 09/30/25.

Based on observation, interview and record review, the facility failed to ensure infection control techniques were properly maintained during wound care. This affected one (Resident #15) of three Residents reviewed for wound care. The facility census was 77. Findings include: Medical record review for Resident #15 revealed he was admitted to the facility on [DATE]. His diagnoses included hemiparesis/hemiplegia, Alzheimer's dementia with associated cognitive and decision-making impairments, peripheral vascular disease, and hypertension. Resident #15 required a guardian for his care. Resident #15 was ordered to be in Enhanced Barrier Precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes). Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 was cognitively impaired and dependent on staff for activities of daily living (ADL). Was assessed to have a stage IV pressure ulcer (a severe, full-thickness wound with extensive tissue loss, exposing muscle, tendon, ligament, or bone) on his left heel. An observation of wound care and dressing change to the left heel of Resident #15 on 11/25/25 at 1:21 P.M. with Licensed Practical Nurse (LPN) #106, LPN#174, and Certified Nursing Assistant (CNA) #120. Resident #15 was noted to be in EBP. Prior to putting on gowns and gloves, all staff washed and dried hands. While LPN #106 was holding Resident #15's left leg up off the bed, LPN #174 used scissors to cut the old dressing, removed the soiled dressing and placed it in the trash with soiled gloves. LPN #174 washed hands and applied new gloves with no hand hygiene. LPN #106 asked where the wound cleanser was, then LPN #174 exited the resident's room with her isolation gown in place and returned with wound cleaner. LPN #174 applied gloves, cleansed the wound with gauze and cleaner, disposed of each gauze used to clean, removed soiled gloves and applied fresh gloves without any hand hygiene between. LPN #174 applied Santyl to gauze, applied gauze to left heel, wrapped the dressing in Kerlix, applied tape to dressing and exited room with her personal protective equipment (PPE) still in place. LPN #174 returned to room still in same gown and gloves, with a black marker, and initialed and dated the dressing. Interview on 11/25/25 at 1:47 P.M., LPN #174 verified she should have removed the gown and gloves prior to exiting resident's room. LPN #174 verified she should have completed hand hygiene after removing the soiled gloves following the wound cleansing and prior to applying new gloves when she applied the wound treatment. Interview on 11/25/25 at 9:21 A.M., DON stated the staff were expected to bring in all supplies prior to beginning any type of care the staff should be following the proper infection control techniques when doing wound care. Subsequent interview on 12/01/25 at 9:47 A.M., the DON stated the facility policy on EBP included the proper use of gloves and gown and the facility policy on Aseptic Dressing Change included the proper hand hygiene. The DON verified it was standard nursing practice to remove a gown prior to exiting a resident's room and applying a clean gown prior to re-entry, washing hands before you start wound care, anytime take your gloves off, touch anything soiled, going to clean dressing wash hands, and after you have completed the treatment. The DON stated the staff were expected to follow policies and procedures for infection control. Review of facility policy for Aseptic Dressing Change dated January 2024, revealed steps that include placing soiled dressing in trash, washing hands, applying clean gloves to cleanse wound, discarding cleansing supplies to trash, wash hands and apply gloves, apply medication and clean dressing, remove gloves and place in trash, tape dressing ion place, date and initial according to facility policy. Review of facility policy on EBP dated March 22, 2024, revealed EBP for residents with wounds regardless of MDRO colonization status should be ordered and followed by staff during high-contact resident care activities including wound care. These precautions include the proper application and removal of gloves and gown.

Based on medical record review, observation, staff interview, review of the facility's investigation, review of witness statements, review of the facility Self-Reported Incidents (SRI), review of emergency medical services (EMS) report, review of hospital records, review of emergency room (ER) notes, review of the local weather report, and review of the facility policy, the facility failed to provide adequate supervision and implement timely interventions for exit-seeking behaviors for Resident #11, to prevent his elopement from the facility. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm and/or death on [DATE] when Resident #11 broke the window and exited the secured building by jumping out of the second story window, approximately 15 feet from the ground level. Resident #11 suffered an open fracture to the left ankle as a result of the jump. This affected one (Resident #11) of three residents reviewed for elopements. The facility identified 18 residents who were at risk for elopement from the facility. The facility census was 74 residents. On [DATE] at 11:35 A.M., the Administrator, the Director of Nursing (DON), and Regional Clinical Officer (RCO) #800 were notified Immediate Jeopardy began on [DATE] at 1:40 P.M. when Resident #11 made threats to jump out a window, and 1:59 P.M. staff found Resident #11 on the ground outside the unit. Staff assessed Resident #11 and transferred Resident #11 to the hospital via emergency medical services. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE], the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) began interviewing staff from the unit to gather statements regarding the incident. Beginning on [DATE], the DON and ADON immediately provided education to current staff on suicidal and threatening behavior protocols and interventions, behavior management, and how to deal with challenging behaviors and the need to immediately respond to resident threats of self-harm. The resident should not be left alone or out of line of sight for their safety. If the nurse does not respond, then they should notify the DON/ADON/ Administrator. On [DATE], the DON and the ADON reviewed the suicidal ideation (SI) risk assessment/questionnaire. The DON and the ADON educated staff on the abuse and neglect policies and procedures. This education was completed for all day and night shift staff working on [DATE] by approximately 7:30 P.M. Employees working on [DATE] received the education prior to their shifts. Education for current staff was completed on [DATE]. On [DATE], the DON notified staff who were not present on [DATE] and [DATE] via online communication, they must report to the DON/ADON for education before their next scheduled shift. Starting [DATE], training will continue ongoing for all employees who have not yet received it due to paid time off (PTO), sick leave, etc., and will also be provided to all new hires. On [DATE], the ADON completed suicide risk assessments and elopement assessments for all current residents on the male secured unit, and no other residents were identified with suicidal ideations or increased/current immediate elopement risk. On [DATE], the Maintenance Director (MD) audited all second-floor windows to ensure they were secured and in place with no further issues noted. Staff secured Resident #11's room to prevent re-entry and cleared glass debris from the courtyard for safety. On [DATE], the facility Administrator opened a Self-Reported Incident (SRI) and reported the incident to the Ohio Department of Health (ODH). On [DATE], the Administrator suspended Licensed Practical Nurse (LPN) #205 who was the unit nurse at the time of the incident, pending the outcome of the investigation. LPN #205 has remained suspended and/or has not worked since the incident due to being on vacation. On [DATE] at 4:30 P.M., the Administrator and the DON notified the Medical Director and a member of the governing body (GB)/Owner of the incident on [DATE] involving Resident #11. The facility then held an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting by phone with the Administrator, the DON, the Medical Director and the Facility Owner. On [DATE], the Administrator and the DON completed a root cause analysis of the incident on involving Resident #11 and determined the root cause was staff did not stay with Resident #11 when the resident verbalized an intent to leave the facility by jumping out a window and LPN #205 failed to assess Resident #11 when notified by staff. On [DATE], the ADON began questioning random staff three times weekly to verify knowledge of resident safety protocols. Results are turned into the Administrator for ongoing monitoring and compliance. The ADON will continue the monitoring three times weekly for three months. Beginning on [DATE], the management team will conduct ongoing education and continue to address any issues related to suicidal and threatening behaviors. Staff have been and will continue to be questioned by the Administrator or designee on appropriate actions to take if a resident expresses an intent to harm themselves. This will be conducted three times per week for three months, and results will be reported to the QAPI committee. On [DATE], the facility Psych Nurse Practitioner (NP) #701 and outside counseling service representatives met with all residents on the secured male unit to provide support. On [DATE] at 3:23 P.M. and on [DATE] from 10:21 A.M. to 3:20 P.M., interviews with Certified Nursing Assistants (CNA) #314, #324, and #326, LPN #205, Activity Assistant (AA) #350, and Housekeeper (HK) #500, revealed all staff were educated and verbalized knowledge of the facility's elopement policies, procedures, and guidelines for monitoring residents who have been placed on one-on-one supervision. On [DATE], RCO #800 provided re-education to the current Administrator and the acting Administrator at the time of the incident on [DATE] on the importance of a thorough investigation and the need to review the accuracy and information provided by staff. On [DATE] the Administrator notified LPN #205 that after investigation LPN #205's employment was terminated. Although the Immediate Jeopardy was removed on [DATE] the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #11 revealed an admission date of [DATE] with diagnoses including traumatic brain injury (TBI), schizoaffective disorder, and severe cognitive impairment and a discharge date of [DATE]. Review of the Preadmission Screening and Resident Review (PASARR) for Resident #11 dated [DATE] revealed the resident was recommend for admission to the facility due to diagnoses of schizoaffective disorder and bipolar disorder with an intervention of one-to-one support from staff as needed. Review of the care plan for Resident #11, updated [DATE] revealed the resident had dementia/history of TBI with memory loss with symptoms including impaired decision making, poor impulse control, poor ability to control anger, resistance to care, apathetic at time, fluctuation in mood behaviors, poor short term and long term memory, alteration in mood and/or behavior as evidenced by feeling down/depressed/hopeless, showing little interest/pleasure in doing things, history of being sexually inappropriate, history of physical aggression with peers, exit seeking behaviors, and impulsivity secondary to anoxic brain injury. The goal of the care plan was Resident #11 would not elope from the facility. Interventions included the following: observe/report any changes in mental status, secured unit placement, allow resident the opportunity to express concerns and feelings through active listening, orient resident to surrounding and ensure understanding of limitations. Resident #11 was also at high risk for elopement and had a care plan for exit seeking behaviors with a goal to not harm self or others, and an intervention to provide one on one supervision as needed. Review of Minimum Data Set (MDS) for Resident #11 dated [DATE] revealed the resident #11 had severe cognitive impairment, and was coded for delusions, hallucinations, and wandering. Resident #11 was independent with mobility and transferring, Resident #11 weighed 219 pounds and was 70 inches tall. Review of the physician order dated [DATE] revealed staff were to monitor the resident every shift for signs and symptoms of self-injury or risk-taking behavior, sleep disturbance, change in appetite and to document on behaviors observed. Review of the physician order dated [DATE] was to increase the resident's dose of Zyprexa (an antipsychotic medication to treat schizophrenia) from 10 milligrams (mg) daily to 15 mg due to increased exit seeking behaviors and other changes in behaviors. Review of a psychiatry progress note for Resident #11 dated [DATE] revealed the resident was evaluated for recent behavioral changes and medication management. Recently Resident #11 had exhibited behaviors including exit-seeking, yelling at staff, threatening to break a window, and grabbing a fire extinguisher. Resident #11's Zyprexa was increased from 10 mg to 15 mg for treatment of schizoaffective disorder. Since the medication adjustment, the resident had continued to display delusions, disorganized thinking, mood swings, and paranoia but no further aggressive behaviors were reported. Review of a progress note for Resident #11 dated [DATE] at 10:07 A.M. revealed the CNA reported Resident #11 wearing nothing but his underwear had entered another resident's room without permission. The other resident yelled for Resident #11 to get out, and the CNA intervened and told Resident #11 to leave and go back to his room. Review of an EMS report for Resident #11 dated [DATE] revealed EMS responded to a call which came in on [DATE] at 1:59 P.M. with EMS arriving at 2:08 P.M. for a male who had jumped out of a window on the second floor. Upon arrival, Resident #11 was lying on the ground with a visible open fracture to left ankle with bleeding controlled. Resident #11 was transported to local hospital. Review of hospital records for Resident #11 dated [DATE] at 3:12 P.M. revealed the resident presented to the emergency room (ER) transported by EMS following a jump from a second story window. Resident #11was in a psychiatric facility in a locked unit and reportedly jumped out of a second story window when he wanted to leave the leave the facility. Resident #11's left ankle fracture required surgical fixation. Review of a written witness statement from HK #500 revealed he was working on the locked second floor unit on [DATE] mopping a resident room when Resident #11 approached him and tried to grab HK #500's nipples. HK #500 asked Resident #11 not to touch him. Resident #11 told HK #500 that all people liked having their nipples pinched. HK #500 told Resident #11 he did not like that and asked the resident not to touch him. Resident #11 then told HK #500 he was going to jump out the window and slammed his door. HK #500 then told an unnamed CNA, later identified as CNA #326 that Resident #11 threatened to jump out the window, but CNA #326 told HK #500 that Resident #11 would not jump. HK #500 then went to the locked unit's outside smoking patio to have a cigarette. Resident #11 then watched HK #500 through the observation window of the smoking patio. Resident #11 told HK #500 that he was watching him which made HK #500 feel uncomfortable, so the housekeeper put out his cigarette and left the unit by the elevator. HK #500 stated later he saw Resident #11 lying outside on the ground. During an interview on [DATE] at 3:23 P.M., AA #350 stated he was on the locked second floor unit on [DATE] from approximately 1:30 P.M. to 2:00 P.M. setting up pizza to be distributed to the residents. Resident #11 tried to take half of a pizza for himself, and AA #350 redirected Resident #11 who walked away from AA #350 but did not leave the common area. Resident #11 reapproached AA #350 and told him he was not afraid of him, and he was going to jump out the window. AA #350 stated he then told LPN #205 about Resident #11's threat to jump out the window. AA #350 then left the secured unit to deliver pizza to other units. AA #350 stated Resident #11 was found outside the building shortly after he left the locked unit, but he was not certain of the exact time. During an interview on [DATE] at 12:03 P.M., HK #500 stated Resident #11 attempted to touch him at approximately 1:40 P.M. Resident #11 then told HK #500 he was going to go out the window. HK #500 confirmed he reported Resident #11's threat to jump out the window to CNA #326. HK #500 said he then went to smoke a cigarette on the secured unit's locked smoke patio, but Resident #11 was staring at him which made the housekeeper uncomfortable, so HK #500 left the unit via the elevator. HK #500 stated as he was leaving the unit he saw LPN #205 in the nursing station, but the nurse was sleeping, and he didn't speak to the nurse about Resident #11's threat to jump out the window. HK #500 stated he reported to the administrative staff that he saw LPN #205 sleeping. During an interview on [DATE] at 12:22 P.M., LPN #205 stated earlier in the morning of [DATE] CNA #314 reported Resident #11 was in the wrong room and only wearing his underwear, which LPN #205 stated he documented. LPN #205 verified AA #350 told LPN #205 about Resident #11 trying to take more pizza and about the resident's statement about jumping out the window. LPN #205 stated Resident #11 made those kinds of statements about leaving the facility and jumping out a window in the past, and also that Resident #11 had broken a window on the unit in the past although he couldn't recall the specific date. LPN #205 confirmed Resident #11 had gone back to his room alone, the nurse did not go to observe and/or assess the resident. LPN #205 stated he was going to let the resident cool off. LPN #205 did not know how much time passed between AA #350 telling the nurse about Resident #11's threat and receiving the call that Resident #11 was found outside the unit. LPN #205 estimated it was about 30 minutes after the threat that Resident #11 was found on the ground outside the unit. LPN #205 denied being asleep at the time of the incident. LPN #205 stated he took his breaks on the unit and sometimes rested his eyes. LPN #205 stated he was written up later for being asleep. Observation on [DATE] at 1:00 P.M. revealed the room where Resident #11 had resided was locked and inaccessible to residents on the unit. Resident #11's window was a large stationary single pane four feet by four feet with two smaller windows, one on each side, that opened by swinging out a few inches to allow air flow, but not wide enough to allow egress. The large stationary window was broken horizontally in half, about two feet up from the lower edge. There was no evidence of a tool or piece of furniture used to break the glass. During an interview on [DATE] at 2:18 P.M., CNA #324 stated she was training CNA #326 on [DATE], because it was CNA #326's first day on the unit. They were providing incontinence care to another resident so she was not in the common area when everything with Resident #11 occurred. CNA #324 stated she felt Resident #11 had been off, and was not himself that day. CNA #324 confirmed she had told LPN #205 earlier in the day about her concerns about Resident #11's demeanor the day of the incident. During an interview on [DATE] at 2:55 P.M., CNA #314 stated he heard a resident yelling at Resident #11 to get out of his room on the morning of [DATE] and the CNA was able to redirect the resident. CNA #314 stated Resident #11 then offered to give the CNA money if he could help the resident to escape the facility. CNA #314 talked with Resident #11 and convinced him to stay at the facility. CNA #314 stated he told LPN #205 about Resident #11's desire to escape from the facility. CNA #314 stated Resident #11 had mentioned leaving the unit through a window before but had never acted on the statements. CNA #314 confirmed on [DATE] Resident #11 had been fixated on leaving the building. CNA #314 confirmed he was at lunch and not on the unit when Resident #11 jumped out the window. During an interview on [DATE] at 3:20 P.M., CNA #326 stated he was working with CNA #324 and went to get items to help a resident get up for the day. CNA #326 stated HK #500 had told him about Resident #11's sexual inappropriateness but had not mentioned Resident #11's threat to jump out the window. CNA #326 stated if he had known about Resident #11's threat to jump out the window, he would have told LPN #205 immediately and stayed with Resident #11 as per the facility training for resident safety. CNA #326 stated he felt the situation was avoidable had LPN #205 not dismissed CNA #324's concerns. CNA #326 could not confirm if LPN #205 was sleeping at the time Resident #11 jumped out the window, but CNA #326 had seen LPN #205 with his head down on the desk in the nursing station. During an interview on [DATE] at 9:00 A.M., NP #700 stated on [DATE] at approximately 1:58 P.M. she found Resident #11 lying on the ground outside the building and it appeared he had fallen from the second story out the window which was broken. NP #700 stated Resident #11 told her that he had been mad and wanted to leave the facility, and he knew the doors would not open, so he decided to go through the window. NP #700 called 911 and the resident went to the hospital. During an interview on [DATE] at 1:05 P.M., RCO #800 stated he felt the investigation of the incident involving Resident #11 could have been more thorough. RCO #800 stated he wasn't in town when the situation occurred, which made it difficult for him to assist the acting Administrator on [DATE] in the investigation. RCO #800 stated the acting Administrator on [DATE] had moved to serve as the Administrator of a sister facility when the current Administrator started working at the facility. RCO #800 felt there was a lack of supervision by LPN #205, which became more apparent with additional review. RCO #800 stated LPN #205 was terminated for failure to provide adequate quality of care to the nursing standard, because the nurse left Resident #11 left alone during a behavioral outburst. RCO #800 stated on [DATE] he re-educated the current Administrator and the acting Administrator at the time of the incident on the importance of a thorough investigation and the need to review the accuracy and information provided by staff. During an interview on [DATE] at 2:00 P.M., the Administrator stated she had not started employment with the facility until after the incident with Resident #11 occurred. The Administrator stated the original investigation which was conducted by the acting Administrator on [DATE] could have been tighter. The Administrator felt LPN #205 changed his story as the surveyor's investigation progressed and the administration asked follow-up questions. LPN #205 left the country on a planned leave of absence within a few days after [DATE] and was not available for questioning again until [DATE]. The Administrator confirmed the incident involving Resident #11 occurred due to to lack of adequate supervision of Resident #11 on [DATE]. The Administrator confirmed the facility did not have a policy regarding supervision of residents threatening to harm themselves or others. However, the facility did have training documents regarding resident safety and supervision during a behavioral emergency. The Administrator confirmed staff were trained upon hire to not leave residents unattended if they threaten to hurt themselves or others and the onboarding training document was used in staff re-education following the incident on [DATE]. Review of the facility SRI regarding the incident with Resident #11 dated [DATE] at 4:44 P.M. revealed the facility initiated an investigation of an allegation of abuse/neglect when the Resident #11 threatened to staff that he was going to break a window and jump out. The brief description of the incident indicated Resident #11 who resides in a secured male unit, who has a history of an anoxic brain injury, schizoaffective disorder, has impulsivity, and poor decision-making impairments threw himself through a plated glass window causing a fall onto the ground. The facility concluded the investigation on [DATE] at 2:09 P.M., but did not substantiate neglect, due to the resident's behaviors and impulsivity. Review of the weather report for [DATE] at 2:00 P.M. revealed a temperature of 79 degrees Fahrenheit (F), mostly clear, with no precipitation. Review of the facility policy titled Elopement Prevention and Management Unsafe Wandering and Exit Seeking Behavior dated [DATE] revealed the facility strives to prevent resident elopement and would develop a care plan and implement individualized interventions to prevent elopement. Review of the facility training document undated and untitled used for onboarding new hires and used again in the facility safety re-education initiated on [DATE] revealed a resident threatening to hurt themselves or others was a mental health crisis requiring immediate intervention. Immediate actions included the following: do not leave the resident alone, maintain continuous observation of the resident, do not leave the resident unsupervised, call for backup immediately, use a code word (Code 4-behavioral emergency) to discreetly alert staff, supervisor, and security. Further review of the document revealed even if staff felt the resident would not commit to hurting themselves or someone else, the threat should be reported immediately to the Administrator and the DON, and the resident should be placed on one-on-one supervision. This deficiency represents noncompliance at investigated under Complaint Number 2614502.

Based on observation, interview and record review, the facility failed to ensure infection control techniques were properly maintained during wound care. This affected one (Resident #15) of three Residents reviewed for wound care. The facility census was 75. Findings include:Medical record review for Resident #15 revealed he was admitted to the facility on [DATE]. His diagnoses included hemiparesis/hemiplegia, Alzheimer ' s dementia with associated cognitive and decision-making impairments, peripheral vascular disease, and hypertension. Resident #15 required a guardian for his care. Resident #15 was ordered to be in Enhanced Barrier Precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes). Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 was cognitively impaired and dependent on staff for activities of daily living (ADL). Was assessed to have a stage IV pressure ulcer (a severe, full-thickness wound with extensive tissue loss, exposing muscle, tendon, ligament, or bone) on his left heel. An observation of wound care and dressing change to the left heel of Resident #15 on 11/25/25 at 1:21 P.M. with Licensed Practical Nurse (LPN) #106, LPN#174, and Certified Nursing Assistant (CNA) #120. Resident #15 was noted to be in EBP. Prior to putting on gowns and gloves, all staff washed and dried hands. While LPN #106 was holding Resident #15 ' s left leg up off the bed, LPN #174 used scissors to cut the old dressing, removed the soiled dressing and placed it in the trash with soiled gloves. LPN #174 washed hands and applied new gloves with no hand hygiene. LPN #106 asked where the wound cleanser was, then LPN #174 exited the resident ' s room with her isolation gown in place and returned with wound cleaner. LPN #174 applied gloves, cleansed the wound with gauze and cleaner, disposed of each gauze used to clean, removed soiled gloves and applied fresh gloves without any hand hygiene between. LPN #174 applied Santyl to gauze, applied gauze to left heel, wrapped the dressing in Kerlix, applied tape to dressing and exited room with her personal protective equipment (PPE) still in place. LPN #174 returned to room still in same gown and gloves, with a black marker, and initialed and dated the dressing. Interview on 11/25/25 at 1:47 P.M., LPN #174 verified she should have removed the gown and gloves prior to exiting resident ' s room. LPN #174 verified she should have completed hand hygiene after removing the soiled gloves following the wound cleansing and prior to applying new gloves when she applied the wound treatment. Interview on 11/25/25 at 9:21 A.M., DON stated the staff were expected to bring in all supplies prior to beginning any type of care the staff should be following the proper infection control techniques when doing wound care. Subsequent interview on 12/01/25 at 9:47 A.M., the DON stated the facility policy on EBP included the proper use of gloves and gown and the facility policy on Aseptic Dressing Change included the proper hand hygiene. The DON verified it was standard nursing practice to remove a gown prior to exiting a resident ' s room and applying a clean gown prior to re-entry, washing hands before you start wound care, anytime take your gloves off, touch anything soiled, going to clean dressing wash hands, and after you have completed the treatment. The DON stated the staff were expected to follow policies and procedures for infection control. Review of facility policy for Aseptic Dressing Change dated January 2024, revealed steps that include placing soiled dressing in trash, washing hands, applying clean gloves to cleanse wound, discarding cleansing supplies to trash, wash hands and apply gloves, apply medication and clean dressing, remove gloves and place in trash, tape dressing ion place, date and initial according to facility policy. Review of facility policy on EBP dated March 22, 2024, revealed EBP for residents with wounds regardless of MDRO colonization status should be ordered and followed by staff during high-contact resident care activities including wound care. These precautions include the proper application and removal of gloves and gown.

Based on medical record review, review medication administration records and controlled drug records, staff interview, and policy review, the facility failed to ensure administration of a narcotic pain medication was documented on the medication administration record. This affected one (#13) of three residents reviewed for medication administration documentation. The facility census was 83. Findings include: Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, osteoporosis, uterine cancer, and chronic pain. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #13 had severe cognitive impairment and was frequently incontinent of bowel and bladder. The resident required supervision with eating and was dependent for oral and personal hygiene, toileting, bathing, dressing, bed mobility, and transfers. Review of the census profile revealed Resident #13 transitioned to hospice services on 08/14/24. Review of physician orders revealed Resident #13 had an order dated from 08/14/24 to 02/27/25 for the administration of the narcotic pain medication morphine sulfate solution 20 milligrams per milliliter (mg/ml) with instructions to give five (5) mg by mouth every four hours as needed for pain/dyspnea (0.25 ml). The order was renewed on 02/27/25. Review of the September 2024 medication administration record (MAR) revealed Resident #13 received one documented dose of morphine administered on 09/27/24 at 10:41 A.M. by Licensed Practical Nurse (LPN) #405. Review of the controlled drug record for Resident #13's physician ordered morphine sulfate solution revealed doses were signed out on 09/15/24 at 9:00 P.M., on 09/27/24 at 12:00 P.M. and 5:00 P.M., on 09/28/24 at 7:20 P.M., and on 09/29/24 at 7:58 P.M. Review of the October 2024 MAR revealed Resident #13 received two documented doses of morphine on 10/03/24 at 5:55 P.M. by LPN #410 and 10/08/24 at 12:35 P.M. by LPN #410. Review of the controlled drug record for Resident #13's physician ordered morphine sulfate solution revealed doses were signed out on 10/01/24 at 6:00 P.M., on 10/03/24 at 6:00 P.M.,on 10/04/24 at 7:20 P.M., on 10/07/24 at 9:00 A.M. and 9:30 P.M., on 10/08/24 at 12:00 P.M., and on 10/09/24 at 9:15 P.M. Review of the December 2024 MAR revealed Resident #13 received two documented doses of morphine on 12/02/24 at 5:40 P.M. by LPN #410 and 12/23/24 at 4:17 P.M. by LPN #420. Review of the controlled drug record for Resident #13's physician ordered morphine sulfate solution revealed doses were signed out on 12/02/24 at 1:00 P.M., on 12/05/24 at 3:00 P.M., and on 12/23/24 at 4:00 P.M. Interview on 04/10/25 at 3:40 P.M. with the Director of Nursing (DON) verified medications must be administered to residents as ordered by the physician and documented in the MAR when given. The DON verified the discrepancies with Resident #13's morphine controlled drug records and MARs for the months of September, October, and December 2024 on the aforementioned dates. Review of the undated policy titled, Medication Administration, revealed medications are to be documented on the medication administration record (MAR) as soon as the medications are given. This deficiency represents non-compliance investigated under Complaint Number OH00163953.

Based on observation, staff interview, and policy review, the facility failed to properly label prepared foods in the refrigerator. This had the potential to affect all residents residing in the facility who receive food from the kitchen. The facility census was 85. Findings include: Observation and interview on 03/18/25 at 8:53 A.M. with Kitchen Supervisor (KS) #43 revealed during a tour of the kitchen, there were two trays of sandwiches, one tray of bowls of mandarin oranges, and three trays of cups of juice that were not labeled or dated inside the refrigerator. KS #43 verified the two trays of sandwiches, one tray of bowls of mandarin oranges, and three trays of cups of juice were not labeled or dated. KS #43 stated they should be labeled and dated. Review of the facilities Dietary/Food Handling policy dated 01/2023 revealed food is to be dated and labeled upon arrival from vendor and/or upon preparation date. This deficiency represents non-compliance investigated under Complaint Number OH00162926.

Based on interview, observations and record review, the facility failed to serve specialized diets as planned by the Registered Dietitian (RD). This affected 15 residents, (#01, #15, #20, #21, #22, #32, #41, #52, #61, #66, #67, #69, #72, #77, and #87) of the 89 residents receiving food from the kitchen. The facility census was 90. Findings Include: Review of the physician orders revealed Residents #01 and #69 had diet orders for puree food texture consistency. Residents #15, #20, #21, #22, #32, #41, #52, #61, #66, #67, #72, #77, and #87 had physician orders for a mechanical soft food texture consistency. Review of the lunch menu diet spreadsheet revealed the puree texture diet was to be served puree green beans. The mechanical foods texture diets were to be served green beans. Observation on 11/04/24 at 11:40 A.M. of the lunch meal service revealed the puree texture diets of Resident #01 and #69 and mechanical soft texture diets for Residents #15, #20, #21, #22, #32, #41, #52, #61, #66, #67, #72, #77, and #87 received no green beans or other like vegetable. Interview on 11/04/24 at 11:40 A.M., [NAME] #41 verified Residents #01, #15, #20, #21, #22, #32, #41, #52, #61, #66, #67, #69, #72, #77, and #87 did not receive green beans or any other like vegetable. The [NAME] #41 stated she did not know the puree and mechanical soft diets were to receive green beans as the planned texture vegetable because she had not reviewed and followed the diet spreadsheet. [NAME] #41 verified the diet menu spreadsheet was available for review during meal preparation for all diets planned by the Registered Dietitian. Interview on 11/04/24 at 12:00 P.M. the RD #600 verified the diet spreadsheet is available for the cooks to prepare the textured diet foods. RD #600 verified Residents #01, #15, #20, #21, #22, #32, #41, #52, #61, #66, #67, #69, #72, #77, and #87 were not served the correct alternate food for the puree and mechanical soft food textures. Review of facility policy Spreadsheet Guidelines for Menu Planning,, dated 2024, revealed spreadsheets are designed to meet therapeutic requirements. The [NAME] is to refer to the spreadsheet for details in preparing therapeutic diet foods as ordered by the physician. This deficiency represents non-compliance investigated under Complaint Number OH00158767 and Complaint Number OH00158338.

Based on staff interviews, observations and record review, the facility failed to provide adequate supervision to prevent the elopement of one (#59) of the three residents reviewed. The facility census was 90. Findings Include: Review of the medical record for Resident #59 revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizophrenia, dementia, chronic obstructive pulmonary disease (COPD), diabetes, drug abuse, and tobacco use. Review of a physician order dated 01/24/24 for Resident #59, revealed the resident was ordered to be on a secured unit due to vascular dementia and schizophrenia. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #59 had moderately impaired cognition and was independent for ambulation. The resident resided on a secured behavior unit. Review of the most recent care plan for Resident #59, revealed the resident resided on a secured unit to promote the resident's safety related to cognitive impairment, elopement risk, exit seeking behaviors, and wandering. Review of an unsigned /unlocked nurse's note dated 11/03/24 at 9:45 P.M. and authored by Licensed Practical Nurse (LPN) #500, revealed she was completing medication administration on A-Wing when she heard a noise coming from the 200-Hall door which leads to the second-floor secured unit. When LPN #500 opened the door, STNA #216 was in the stairwell asking if she had seen Resident #59 come down the stairs. STNA #216 stated Resident #59 was missing from the smoking room. The staff immediately searched inside and outside of the faciity and was unable to locate the resident. STNA #216 reported the police were outside the facility investigating a possible break in when they called the facility about the person they found walking around. The facility described the missing resident, and the police returned the resident within 15 minutes. The resident's assessment revealed no injuries and all vital signs within normal limits. The resident was returned to the secured unit and placed on 15-minutes checks by staff. All notifications were made to the responsible party and the physician, with no new orders. Review of the facility elopement investigation dated 11/03/24 completed by the Assistant Director of Nursing, (ADON) #304, revealed she was called by the staff on 11/03/24 around 10:00 P.M. indicating Resident #59 was missing from the facility. Resident #59 had been observed at 9:30 P.M. by State tested Nurse Aide (STNA) #216 in the smoking area. STNA #216 provided the Resident #59 with an unlit cigarette and upon lighting his cigarette, he was gone from the area. Resident #59 was returned to the facility 40 minutes later by the police after they found him walking around near the facility. When ADON #340 arrived at the facility, the police and Resident #59 were standing outside the facility. he investigation revealed the Resident #59 had taken a stairwell exit to the exterior of the facility while the STNA #216 was in an adjacent resident smoking room. The resident returned to the facility with no injuries upon return. Review of the witness statement by STNA #216 dated 11/03/24, revealed Resident #59 was in the smoking room on the second floor and was given a cigarette. When STNA #216 went to light the resident's cigarette, he was not present in the room. STNA #216 indicated the resident went down a set of stairs to a door at the bottom of the stairs near A-wing which led to the courtyard. Resident #59 exited the courtyard and off the premises. The staff started searching for him and couldn't find him when the authorities brought him back. Review of witness statement by LPN #500 dated 11/03/24, revealed at approximately 9:45 P.M., she heard a pulling noise coming from the 100-hall side door. When LPN #500 got to the door, STNA #216 was in stairwell looking for Resident #59. STNA #216 indicated Resident #59 was not in the smoking room and walked down the stairs. The staff searched the inside and outside of the facility. LPN #500 reported STNA #216 called her and indicated the local police called the facility indicating there was a potential break in next to the facility and inquired about any missing residents . When STNA #216 provided the description of the resident, the police officer verified it was Resident #59. LPN #500 went to the area where Resident #59 was found, and the police returned him to the facility at 10:15 P.M. Interview on 11/05/24 at 11:23 A.M. with the ADON #304 and the Administrator verified on 11/03/24 at 9:30 P.M. Resident #59 eloped from the facility through a stairwell adjacent to the resident smoke room, being supervised by STNA #216. Resident #59 returned to the facility by the policy without injury on 11/03/24 at 10:15 P.M. put on one-on-one increased checks.

Based on observation, record review and interview, the facility failed to ensure menus were followed and residents were notified of menu changes prior to the meal. This had the potential to affect 88 of 89 residents. The facility identified one Resident (Resident #33) who did not receive food from the kitchen. The facility census was 89. Findings include: During observations on 06/03/24 between 10:50 A.M. and 11:10 A.M., the menus posted on each unit indicated the residents were to receive turkey and rice casserole, green peas, and a biscuit for the supper meal on 06/03/24 and were to receive a baked pork chop, stuffing, green beans, and a dinner roll for the supper meal on 06/02/24. Review of the menu for the current week had had turkey and rice casserole, green peas, and a biscuit for the supper meal on 06/02/24. Review of the Daily Menu for 06/02/24 listed a baked pork chop, stuffing, green beans, and a dinner roll for supper The menu for 06/03/24 had turkey and rice casserole, green peas, and a biscuit for the supper meal. During an observation on 06/03/24 at 4:44 P.M., the tray line had shredded pork, potatoes with peas, and a roll for the supper meal. During an interview on 06/03/24 at 4:46 P.M., Dietary Supervisor (DS) #405 stated the residents were not being served the turkey and rice casserole, green peas, and a biscuit as was on the menu. DS #405 stated she ran out of biscuits and the turkey and rice casserole meal was served on 06/02/24 because the meal scheduled for 06/02/24 had not been taken out to thaw. DS #405 stated menus are posted on all units and verified the posted menu did not match what was served on 06/02/24 and 06/03/24 at the supper meals. DS #405 verified the residents had not been notified of the menu changes prior to the meals and further verified residents should be notified of menu changes prior to the meal. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on observation, record review and interview, the facility failed to ensure recipes were followed and that the food was visually appealing. This had the potential to affect 88 of 89 residents. The facility identified one resident (Resident #33) who did not receive meals from the kitchen. The facility census was 89. Findings include: Review of the menu for the current week revealed the residents were to receive an open-faced turkey sandwich with gravy, roasted potatoes, and a California vegetable blend for lunch on 06/03/24. Review of the daily menu for 06/03/24 revealed the residents were to receive an open faced turkey sandwich with gravy, mashed potatoes, and a California vegetable blend. Review of the recipe revealed the open faced turkey sandwich was to consist of a slice of toast with three ounces of sliced turkey, mashed potatoes on top of the turkey, and turkey gravy over the sandwich. During observations on 06/03/24 between 12:10 P.M. and 1:00 P.M., residents on all units received a piece of white bread with a chopped meat with a reddish-brown gravy served on top with mashed potatoes and mixed vegetables on the side. During an interview on 06/03/24 at 12:19 P.M., Resident #66 stated the meal looked like dog food and she was not going to eat it. During an interview on 06/03/24 at 12:22 P.M., Resident #71 looked at the meal she had just been served, and pushed it away and stating it looked awful and she would not eat it. During an interview on 06/03/24 at 12:27 P.M., Resident #80 stated the meal did not look at all appetizing. During an observation on 06/03/24 at 12:42 P.M., Resident #38 looked at the contents of the plate as staff served it. He stated it looked gross and immediately asked for a peanut butter and jelly sandwich. During an interview on 06/04/24 at 9:00 A.M., Dietary Supervisor (DS) #405 verified the recipe for the open face turkey sandwich did not match what was served at lunch on 06/03/24. Meat was cubed instead of sliced and the gravy was dark/red in color and did not appear to be turkey gravy. DS #405 stated the correct food had not been taken out to thaw. This deficiency represents non-compliance investigated under Complaint Number OH00153742.

Based on observation, interview and policy review, the facility failed to ensure employees wore hair nets while preparing and serving food and beverages. This had the potential to affect 88 of 89 residents. The facility identified one resident (Resident #33) who did not receive food from the kitchen. The facility census was 89. Findings include: During an observation on 06/03/24 at 4:28 P.M., Dietary Aide (DA) #415 was standing at the juice machine in the kitchen, pouring drinks, in preparation for the dinner meal. DA #415 was not wearing a hairnet. During interview at the time of the observation, Dietary Supervisor (DS) #405 verified DA #415 was not wearing a hairnet and told DA #415 to go put a hairnet on. During an observation on 06/03/24 at 4:29 P.M., DA #415 put a hairnet on, however his braids were not fully covered. During observation on 06/03/24 at 4:34 P.M., Dietary [NAME] (DC) #430 was standing at the steam table stirring the food that would be served for the dinner meal. DC #430 was wearing a hairnet, however her braids were sticking outside of the hairnet, not fully covered. During an observation on 06/03/24 at 4:42 P.M., DC #430 plated food for the meal and DA #415 placed drinks and silverware on the trays. DA #415 and DC #430 wore hairnets but their braids were not secured beneath the hairnets. During an interview on 06/03/24 at 4:49 P.M., DS #405 verified DA #415 and DC #430 did not have their hair fully covered and affirmed all hair should be contained within the hairnet. Review of the facility policy titled, Dietary/Food Handling, dated 01/2023, revealed hairnets must be worn in food service areas.

Based on observation, staff interview, and policy review, the facility failed to ensure residents were fed in a safe and dignified manner. This affected one (Resident #64) of one resident reviewed for dignity. This had the potential to affect all 89 residents in the facility. Findings include: During an observation on 06/03/24 at 12:21 P.M., State tested Nursing Assistant (STNA) #300 was standing in the hallway at the nurse station on the 400-hall feeding Resident #64. Resident #64 was seated in a reclining geri-chair facing away from the nurse station. STNA #300 was standing behind Resident #64, reaching around him and putting food into his mouth. There was a cart containing trays for the lunch meal approximately three feet away from the resident's geri-chair. There was no chair in the vicinity for STNA #300 to sit on. During an interview at the time of the observation, STNA #300 verified she was standing to feed Resident #64 and was not facing him as she fed him. STNA #300 stated she was standing to feed Resident #64 because the cart was in her way. STNA #300 did not say why she was not facing the resident to feed him. Review of the facility policy titled, Resident Rights and Dignity, undated, revealed all residents should be treated in a dignified manner. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, resident and staff interview, review of hospital records, review of the facility's Self-Reported Incidents (SRI) and investigation, and review of the facility's abuse policy, the facility failed to ensure residents were free from physical abuse. This resulted in Actual Harm when Resident #50 punched Resident #25 in the face several times resulting in Resident #25 sustaining a fracture to his nose, a laceration to his cheek, and swelling in his face. This affected one (Resident #25) of four residents reviewed for abuse. The facility census was 74. Findings include: 1. Review of Resident #25's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had cognition impairment and required supervision with all activities of daily living. Review of the plan of care dated 09/27/21 revealed Resident #25 enjoyed spending time in his room watching television. Resident #25 experienced alteration in mood and/or behavior and shows little interest in activities. Resident #25 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included to have mental health counseling as needed and as determined. Review of the progress notes dated 06/28/22 at 7:02 A.M. revealed Resident #25 was physically attacked by another resident (Resident #50). Resident #25 was hit several times in the face with closed fists. When Resident #25 was asked what happened, Resident #25 stated Resident #50 accused him of stealing his pants and shoes. Resident #25 came out of his room and went to the nurse's station. The nurse documented the residents were immediately separated and head-to-toe assessments were completed on both residents. Resident #25's vital signs were within normal limits. Resident #25 had swelling under both eyes and nose and a laceration measuring 0.5 centimeter (cm.) by 1.5 cm. by 0.1 cm. on the resident's right cheek. The progress note revealed Emergency Medical Services (EMS) and the police were notified. The progress note revealed both Resident #25 and Resident #50's guardians were notified. Resident #25 spoke to the police and was transported to the hospital for evaluation. Review of Resident #25's hospital discharge documentation dated 06/28/22 revealed the reason for visit was facial swelling and facial injury after an assault. Discharge diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Review of Resident #50's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS assessment dated [DATE] revealed Resident #50 had cognition impairment and required set-up help for all activities of daily living. There was no history of physical aggression. Review of the plan of care dated 04/01/22 revealed Resident #50 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included if resident becomes agitated, back off and try later. Resident #50 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no identification of a history of physical aggression. Review of Resident #50's Psychiatry Progress note dated 06/22/22 revealed no risk factors for self-harm, suicidal ideation, homicidal ideation, substance abuse or aggression. The psychiatrist note documented Resident #50 was not currently a danger to self or others. The psychiatric report included history of criminal record including robbery, theft, manslaughter, drugs and driving while intoxicated. Review of the progress note dated 06/28/22 at 4:35 P.M. revealed Resident #50 was transported to a mental health hospital for further evaluation related to the physical aggression toward another resident. Review of Resident #50's Neurological Assessment flowsheet dated 06/28/22 revealed the facility completed every fifteen-minute checks on 06/28/22 from 7:15 A.M. until 4:35 P.M. when Resident #50 was then transferred to a mental health hospital for further mental health evaluation related to the physical aggression. Review of the progress note dated 07/06/22 revealed Resident #50 was readmitted to the facility following a hospitalization on [DATE]. Resident #50 was admitted to the secured men's unit. Resident #50 was provided a closet with lock and key to secure his belongings were safe. Resident #50 was able to demonstrate he could open and lock the closet. Review of the Self-Reported Incident (SRI) dated 06/28/22 at 7:02 A.M., revealed Resident #25 was attacked by Resident #50. The summary of the incident revealed Resident #25 presented to the nursing station with a nosebleed. Resident #50 hit Resident #25 several times in the face with closed fists. When asked what happened, Resident #25 stated Resident #50 said Resident #25 stole his pants and shoes' and then Resident #50 punched Resident #25 in the face. Both residents were separated, and nine-one-one was called. The police stated they were not able to take Resident #50 due to a psychiatric diagnosis. Resident #25 was taken by ambulance to the hospital for further evaluation. The facility's conclusion substantiated abuse was verified by the evidence. Resident #50's history of SRIs revealed Resident #50 was shown as being the physical aggressor on 04/30/15 at a previous facility. There was no other history of SRIs with Resident #50 being the physical aggressor from 04/30/15 to 06/27/22. Review of the facility's investigation dated 06/28/22 included witness statements from the night shift Licensed Practical Nurse (LPN) #70. The statement revealed Resident #25 ran up to the nurse's station and stated, he hit me and said I stole his clothes. LPN #70 asked Resident #25 who hit him, and he replied, Resident #50 hit him. LPN #70's statement revealed multiple cuts on the right side of his face, a swollen left eye and bleeding from his mouth. LPN #70 stated she assisted Resident #25 to the shower room and gave him a towel. Resident #25 stated he wanted Resident #50 prosecuted. The witness statement revealed the Cincinnati police came to the facility and spoke to Resident #25 prior to him being transported to the hospital. Interview on 07/07/22 at 8:30 A.M. with Social Worker Director (SWD) #100 revealed Resident #50 returned last evening on 07/06/22 from the hospital, following an extended evaluation of the resident's mental status. SWD #100 stated Resident #50 was admitted to the men's secured unit on the second floor. SWD #100 stated Resident #50 previously resided on the unsecured-first floor. SWD #100 confirmed Resident #25 was involved in a resident-to-resident incident with Resident #50 and chose to remain in his room on the first floor. SWD #100 stated Resident #25 denied wanting to be moved to a different room. SWD #100 revealed Resident #25 denied the need for counseling and revealed Resident #25 had stated he felt safe at the facility. SWD #100 stated he was familiar with both residents and denied either resident had any previous aggressive behavior. Interview on 07/07/22 at 8:55 A.M. with Resident #25 confirmed he had been injured by Resident #50 on 06/28/22. Resident #25 revealed he was lying in his bed and Resident #50 came into his room. Resident #25 stated he stood up to ask Resident #50 what he wanted. Resident #25 stated Resident #50 accused him of stealing money and his clothes. Resident #25 stated he told Resident #50 he did not steal any money and Resident #50 started punching me. Resident #25 stated he made it out to the hallway to get help. Resident #25 stated LPN #70 handed him a towel and helped him. Resident #25 confirmed the police arrived and he talked to the police officer. Resident #25 stated the ambulance came and took him to the hospital. Resident #25 denied anyone had previously been aggressive or tried to hurt him. Resident #25 denied anyone had tried to hurt him since the incident on 06/28/22. Resident #25 confirmed the facility offered him to move to another room. Resident #25 confirmed the facility offered counseling. Resident #25 confirmed he felt safe at the facility. Interview on 07/07/22 at 9:15 A.M. with LPN #70 confirmed working on 06/28/22 the morning of the incident between Resident #25 and #50. LPN #70 stated he had just walked onto the unit to start work when he turned the corner and saw red liquid running down Resident #25's face. The incident had just occurred at 7:02 A.M. and he had just walked onto the unit at 7:03 A.M. LPN #70 confirmed he had worked with both residents for several years and was not aware of any previous physical aggression by either resident. LPN #70 stated he never saw or anticipated any aggression from either resident. LPN #70 stated several months ago, the two residents were roommates. LPN #70 stated Resident #50 made accusations that Resident #25 was taking some of Resident #50's clothing. LPN #70 stated there was no physical aggression, only an accusation. The two residents were separated and given rooms on opposite ends of the hallway. There was no verbal or physical aggression associated with the previous incident. LPN #70 stated he was not aware of any incidents between Resident #50 and any other resident either before or after the incident on 06/28/22. LPN #70 stated Resident #50 was admitted back to the facility on [DATE] from a mental health evaluation and now resided on the secured men's unit. Interview on 07/07/22 at 9:50 A.M. with the Administrator confirmed she investigated the SRI (06/28/22) which involved the physical aggression of Resident #50 toward Resident #25. The Administrator confirmed Resident #50 returned the evening of 07/06/22 from an extended mental health evaluation at the hospital. The Administrator denied being aware of any previous physical aggression by Resident #50. The Administrator stated she had worked at the facility since 2017. The Administrator stated the police came and spoke to both residents. The Administrator revealed the police could not take Resident #50 due to his psychiatric diagnosis. The Administrator confirmed Residents #50 and #25 were roommates until a couple months ago. The Administrator revealed on 04/09/22, Resident #50 alleged Resident #25 took some of Resident #50's clothes. The Administrator denied any physical aggression had occurred. The Administrator stated Resident #50 was transferred to a room at the opposite end of the hall from Resident #25. The Administrator stated there had been no other concerns since that time. Interview and observation on 07/07/22 at 10:40 A.M. with Resident #50 in his room on the second-floor secured unit revealed the resident was with State tested Nursing Assistant (STNA) #99 assisting Resident #50 in counting his money and working with the resident to ensure he was able to use the lock the facility maintenance staff had installed to keep his personal belongings safe. Observation revealed Resident #50 was a tall, muscular build and spoke clearly and politely. Resident #50 began talking about the incident and confirmed he should not have hit Resident #25. Resident #50 repeated several times Resident #25 was wearing his shoes and his sweatpants. Subsequent interview on 07/07/22 at 11:02 A.M. with the Administrator confirmed Resident #25's clothing and shoes were checked, and the clothing was confirmed to be Resident #25's clothing and shoes. The Administrator stated Resident #25 was short and small frame and Resident #50 was tall and a large frame. The clothing and shoes that Resident #25 had on and in his room belonged to him. There were no personal items belonging to Resident #50 found in Resident #25's room. A request on 07/07/22 was made to the local police department for documentation and the police report for 06/28/22. The report was not received as of the writing of this report. Review of the facility's policy titled Abuse, Neglect, Exploitation, Misappropriation of Resident Property Policy and Procedure, dated 08/17/16 and revised 09/12/18, revealed the definition of physical abuse included but was not limited to hitting, slapping, pinching, and kicking. Willful meant the individual must have acted deliberately not that the individual must have intended to inflict injury or harm. This deficiency substantiates Complaint Number OH 906.

Based on observation, record review, and staff interview, the facility failed to ensure a resident who developed unavoidable pressure ulcers were given the care and treatment to promote healing. This resulted in actual harm to a (Residents #36) as the pressure ulcers worsened due to the lack of treatment and preventative measures. Three residents were reviewed for pressure ulcers. Findings Included: 1. Resident #36 was initially admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #36's Pressure Ulcer Plan of care dated 11/03/11 included the resident had a previous pressure ulcer to the coccyx that was healed as of 08/16/14. On 03/04/15 Stage III pressure ulcer with current treatment and pressure ulcer plan of care did not include any new interventions since 08/06/14, except the updated treatment. Review of the comprehensive assessment dated [DATE] revealed Resident #36 was severely cognitively impaired and was dependent for all activities of daily living and is always incontinent of bowel and bladder. In regards to pain it was noted that Resident #36 indicated pain in the last five days by non-verbal sounds (e.g. whining, moaning, groaning, gasping or crying), and protecting body movements or postures and pain was noted one to two days during the assessment period. Review of Initial Skin grid assessment for Resident #36's pressure ulcer on 01/27/15 included the area was found at a Stage II and measure 2.5 centimeters (cm) by 1.6 cm and a depth of 0.1 cm with a scant amount of drainage. Review of treatment order dated 03/04/15 revealed cleanse wound to coccyx with normal saline pat dry, apply Santyl ointment to the wound bed, cover with dry dressing, change twice a day and as needed. For the month of March 2015, the treatment was not documented as completed 28 of 56 ordered times to be changed. Review of April 2015 TAR revealed five of 16 times the treatment was not documented to be completed. Review of skin grid dated 03/17/15, the grid's narrative description lists the wound as having yellowish (slough) and dark tissue noted. Review of Skin grid dated on 03/24/15, the grid assessment indicated a Stage III pressure ulcer. Review of Most Recent Skin grid assessment for Resident #36's pressure ulcer on 04/07/15, included it is a Stage III and measured at 3 cm by 2.2 cm with a depth of 0.5 cm with a moderate amount of drainage. Observation on 04/08/15 at 3:30 P.M., revealed Registered Nurse (RN) #30 and Licensed Practical Nurse (LPN) #47 changed the resident's dressing. Observation the next day on 04/09/15 after Resident #36 had been transferred from the bed to the wheelchair at 10:36 A.M. with State tested Nurse Aide (STNA) #71 confirmed the treatment was dated 04/08/15 with the initials of LPN #47. LPN #47 was requested to observe the dressing. At 10:48 A.M., LPN #47 confirmed that was the same dressing she had changed yesterday morning. LPN #47 stated she had not changed the dressing other than in the morning on 04/08/15. LPN #47 stated the nurse responsible for changing the dressing on the evening shift, LPN #110, had documented that she had not completed it and the Director of Nursing (DON) was checking with the nurse to find out why she would not change the dressing as ordered. LPN #47 stated there was no order from the physician or documentation that the physician was notified. Interview on 04/09/15 at 10:05 A.M. with STNA #71 revealed Resident #36 gets out of bed by 5:00 A.M. and remains up in her wheelchair until after lunch about 11:30 A.M. or 11:45 A.M. Interview on 04/09/15 at 2:07 P.M. with the DON and RN #30 revealed Resident #36's pressure ulcer treatment was not completed as ordered for night shift on 04/08/15. The DON and RN #30 were unable to answer if the staff were not documenting the pressure ulcer treatments or if staff were not completing the treatments as ordered. Interview on 04/10/15 at 2:41 P.M. with LPN #47 stated the facility believes the source of pressure was a result of Resident #36 being in her chair all day. LPN #47 stated Resident #36 should be up for meals and then lay back down to relieve pressure afterwards. LPN#47 stated that was not documented on the resident's care plan or on the STNA's care card. LPN #47 was unaware of how that was communicated with the aides. Interview on 04/09/15 3:20: P.M. with RN #57 confirmed no new interventions have been put into Resident #36's plan of care since Resident #36's last pressure ulcer was healed in August 2014. RN #57 was unaware of any new non-pharmalogical interventions put into place to promote healing of the pressure ulcer. Interview on 04/09/15 3:27 P.M. with RN #30 interventions felt that the facility only needed to change the medicated treatments as ordered to heal the pressure ulcer, and no other interventions were needed. Interview on 04/10/15 at 4:58 P.M. with Physician #200 revealed Resident #36's source of pressure was from the resident's squirming and being in her wheel chair, in addition to poor nutrition, low protein levels and dementia. Physician #200 also indicated this was the same location of the resident's previous pressure ulcer. She confirmed that Resident #36's pressure ulcer worsened when it went from a Stage II to pressure ulcer to a Stage III in addition to the development of slough. Physician #200 was unaware that the treatment was missed on third shift on 04/08/15 until she entered the facility this date 4/10/15. Physician #200 also was unaware that there were a number of treatments that were missed, and was also unaware that facility staff had not implemented any new interventions other than treatments and changes in tube feeding. Physician #200 stated if appropriate interventions are not in place the pressure ulcer will open back up. This deficiency substantiates complaint number OH 347.

Based on medical record review, observations and staff interviews, the facility failed to ensure that cognitively impaired residents with pressure ulcers were medicated for pain prior to treatments being administered. This resulted in actual harm for Resident #39 and Resident #36, both of who were not medicated for pain prior to the treatments of multiple pressure ulcers and exhibited signs of pain during the treatments. There were 29 residents that were identified as being on a pain management program. Findings included: Resident #39 was most recently admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was started on Hospice services 03/05/15. The comprehensive assessment dated [DATE] revealed the mental status assessment could not be completed. He was totally dependent on staff for all activities of daily living and was always incontinent of bowel and bladder. He was unable to complete the pain assessment screening but at the time of the assessment he was not observed having signs of pain. The resident had a plan of care for pain related to arthritis, wounds and chronic pain. The goal was for the resident to be pain free. Interventions included administering pain medication and note the effectiveness; give "as needed" medications for breakthrough pain and note the effectiveness; acknowledge presence of pain and discomfort and to listen to resident's concerns. Nurse Practitioner progress notes dated 03/11/15 and 03/18/15 documented the resident had a recent significant decline, was enrolled in Hospice and actively dying. The resident was lethargic, unresponsive and unable to verbalize complaints. The assessment was that the resident had discomfort, with a plan to medicate with [MEDICATION NAME], a pain medication, and [MEDICATION NAME], an antianxiety medication. The physician orders [REDACTED]. Licensed Practical Nurse (LPN) #47 was observed completing the pressure ulcer treatment to the resident on 04/08/15 at 2:26 P.M., with Director of Nursing (DON) #29 and DON #30 assisting her. The resident was observed moaning and grimacing in pain upon placement of gauze into his sacral wound. LPN #47 stated she believed Resident #39 had last been medicated with pain medication at 12:00 P.M. (which was 2.5 hours prior to the treatment). Upon completion of the treatments, the pharmacy narcotic count sheet for the [MEDICATION NAME] was reviewed with LPN #47 and DON #30. The last dose of [MEDICATION NAME] was given on 04/08/15 at 4:30 A.M. During review of the pharmacy narcotic count sheet it was discovered that although the resident was ordered to have treatments for his pressure ulcers twice daily, he had not been given any pain medication on 03/08/15, 03/09/15, 03/10/15, 03/12/15, 03/14/15, 03/15/15, 03/18/15, 03/20/15, 03/22/15, 03/26/15, 03/28/15, 03/30/15, 04/01/15, 04/02/15, 04/04/15, 04/05/15 or 04/06/15. LPN #14, who was caring for the resident on 04/08/15, stated during interview at 3:29 P.M. she had not given the resident any pain medication since her shift started at 7:00 A.M. LPN #47 stated during interview on 04/08/15 at 4:38 P.M., she had not heard him speak a word for the past month, but did notice he seemed to be in pain while being repositioned for the multiple pressure ulcer treatments. The resident's physician, Physician #200, stated during interview on 04/10/15 at 11:46 A.M. that Resident #39 is in pain all of the time due to pressure ulcers of his sacrum and buttock. This is why he is ordered to have the [MEDICATION NAME] pain medication every four hours. She stated she was unaware the resident had not been medicated prior to treatment. 2. Resident #36 was initially admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #36's Pressure Ulcer Plan of care dated 11/03/11 documented the resident has a Stage III pressure ulcer and interventions included to administer pain medications as ordered. Review of the comprehensive assessment 01/04/15 revealed Resident #36 was severely cognitively impaired and was dependent for all activities of daily living and was always incontinent of bowel and bladder. The assessment documented the resident had pain in the last five days by non-verbal sounds (e.g. whining, moaning, groaning, gasping or crying), and protecting body movements or postures and pain was noted one to two days during the assessment period. Review of the Initial Skin grid assessment dated [DATE] revealed the pressure ulcer was found at a Stage II and measured 2.5 centimeters (cm) by 1.6 cm and a depth of 0.1 cm with a scant amount of drainage. Review of Most Recent Skin grid assessment for Resident #36's pressure ulcer on 04/07/15 included it is a Stage III and measured at 3 cm by 2.2 cm with a depth of 0.5 cm with a moderate amount of drainage. Review of Medication Administration Record [REDACTED]. Observation of the treatment to the resident's wounds was observed on 04/08/15 at 3:30 P.M. LPN #47 completed the wound treatment and RN #30 assisted. Resident #36 was talking but her speech was unintelligible. The wound was cleaned and when the medication was placed in the wound bed, the resident screamed. Interview at 3:54 P.M. with LPN #47 confirmed the resident screamed out during wound care when the new treatment was applied. On 04/09/15 at 8:38 A.M. LPN #14, who was responsible for giving care to Resident #36 and works regularly on this unit, revealed it is difficult to assess Resident #36 for pain. LPN #14 stated the resident would moan or grimace if she was in pain. LPN #14 stated she has not given the resident any pain medications prior to any dressing changes or treatments completed for Resident #36's pressure ulcer. LPN #14 stated if Resident #36 had screamed out when the dressing was placed to the pressure ulcer, then she would conclude the resident was in pain. Interview on 04/10/2015 at 11:44 A.M. with Physician #200 confirmed that Resident #36 may be in pain during the pressure ulcer treatments, and staff should medicate the resident prior to the pressure ulcer treatments.

Based on record review, review of incident reports, review of facility self reported incidents, observation and interview, the facility failed to ensure residents were transferred safely and had assistive devices used properly to prevent avoidable falls. This involved one sampled resident (#64) who sustained a fractured leg during a transfer and one sampled resident (#61) who sustained repeated falls from bed due to the net bed enclosure not being properly secured. Eleven sampled residents were reviewed for falls. The facility identified seven residents with falls in the past 30 days. Findings include: 1. Review of the medical record Resident #64 revealed the resident was admitted on [DATE] and had [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required extensive physical assistance of two person for activities of daily living including transfers and bed mobility. The MDS further indicated the resident had severely impaired cognitive skills. According to the Kardex (nurse aide information sheet), the resident required a mechanical lift (hoyer) with two staff members for transfers. Review of nurse's notes dated 10/29/10 at 10:50 P.M. revealed the resident was sent to the hospital for evaluation of leg pain. Review of the emergency department report dated 10/29/10 revealed the resident's final [DIAGNOSES REDACTED]. Nurse's notes dated 10/30/10 at 2:35 A.M. stated the resident returned to the facility with an ace wrap on her left lower leg. Nurse's notes dated 10/30/10 at 2:45 A.M. stated the resident was given as needed morphine medication for pain. Review of the Medication Administration Record (MAR) for October 2010 revealed the resident received morphine ER 30 milligrams twice daily. The MAR further revealed an order for [REDACTED]. The MAR indicated the resident received two doses of the as need morphine medication in October prior to fracturing her leg. After returning from the hospital on [DATE] the MAR revealed the resident received the as needed pain medication six times on 10/30/11 and 10/31/11 and 22 times from 11/01/11 until 11/07/11. Review of a facility Self Reported Incident report dated 11/05/10, revealed on 10/29/10 at 9:00 P.M., Resident #64 sustained a fracture of her left tibia (lower leg) during a transfer with a gait belt. The facility's investigation of the incident revealed state tested nurse aide (STNA) #101 had told other staff members the hoyer lift was broken and could not be used to transfer residents. STNA #101 then with the assistance of another STNA, transferred Resident #64 from the chair to her bed with a gait belt and during the transfer the resident's leg got caught on the side rail and was fractured. During interview on 05/17/11 at 2:35 P.M., the Director of Nursing verified Resident #64's leg was fractured during an improper transfer. The DON affirmed STNA #101 told other staff members the hoyer lift was broken when it was not and transferred Resident #64 without the required hoyer lift which resulted in an avoidable fractured leg. 2. Review of the medical record of Resident #61 revealed the resident was admitted on [DATE] and had [DIAGNOSES REDACTED]. The physician order [REDACTED]. Review of Fall Nurses Note dated 03/03/11 at 11:50 P.M. revealed Resident #61 was found on the floor next to his net enclosed bed. The note stated the zipper to the enclosure was broken and open at the bottom of the canopy. Scratch marks were noted on the resident's left foot and right ankle. Review of a facility Quality Assurance Resident Incident Report dated 03/03/11 revealed Resident #61 was found on the floor next to his net enclosed bed. The report stated the incident was a result of a medical device malfunction because the zipper on the bed came apart at the bottom of the bed while zipped up to the top of bed. Review of a facility Incident/Accident report dated 04/25/11 revealed the resident was found on the floor in his room on his back with his legs caught between the red zipper area on the net enclosed bed. The report further stated the suspected cause of the fall based on the investigation was the red zipper on bed net was not secured and locked. The new intervention implemented was to check all zippers on the netting. On 05/16/11 at 8:55 P.M. the resident was observed awake laying in his net enclosed bed with the net zipped up. On 05/18/11 at 2:49 P.M. the resident was observed in his net enclosed bed with the red zipper unsecured and unlocked in place. This was verified by the Director of Nursing. During interview on 05/17/11 at 10:32 A.M., the Director of Nursing (DON) verified there was no new intervention implement with the 03/03/11 fall to prevent Resident #61 from having additional falls out of bed. The DON stated the facility contacted someone to fix the zipper but they were unable to fix it so the facility got the resident a new bed. The DON further stated after the resident's second fall from bed on 04/25/11, the zipper was found unzipped, unsecured and unlocked. Observation of the resident's net enclosed bed on 05/18/11 at 2:49 P.M., revealed the red zipper on the net was unsecured and unfastened.