**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, hospital record review, facility policy review and interviews, the facility failed to ensure timely evaluation, physician notification and treatment following a fall with fracture for Resident #205. Actual Harm occurred for Resident #205 on 10/21/24 at 7:19 P.M. when the facility received results of a STAT (immediate) x-ray indicating the resident had a left elbow fracture but failed to seek medical intervention or treatment for the resident. The nurse practitioner (NP) was notified of the results on 10/22/24 at 8:42 A.M. at which time an order was obtained to transfer the resident to the hospital. The delay in treatment and lack of timely medical intervention resulted in Resident #205 experiencing increased pain and resulted in a delay in the facility identification of additional injuries (the hospital identified the resident also had a left acetabulum fracture, left iliac fossa (bone that is part of the hip) fracture and left retroperitoneal hemorrhage (bleeding in the space located behind the abdominal cavity). Resident #205 was transferred to a level 2 trauma hospital for further treatment. This affected one resident (#205) of one resident reviewed for change in condition. The facility census was 50. Findings include: Review of Resident #205's medical record revealed an admission date of 10/04/24 with diagnoses including vascular dementia with behavioral disturbance, atrial fibrillation, hypotension, hyperlipidemia, alcohol abuse, anxiety, major depressive disorder and insomnia. Resident #205 was transferred to the hospital on [DATE]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #205 was minimally cognitively impaired, was able to ambulate with a wheeled walker and required minimal (staff) assistance for eating and oral hygiene, partial/moderate (staff) assistance for toileting and dressing and maximal (staff) assistance all other activities of daily living (ADLs.) Review of the care plan dated 10/19/24 revealed Resident #205 was at risk for falls related to impaired balance, hypotension, dementia, impaired judgement, incontinence and use of psychotropic medications. Interventions included to re-educate on the use of the call light for assistance with transfers/ambulation, notify therapy for evaluation if applicable, monitor for latent signs/symptoms of pain/injury, notify family/Power of Attorney (POA) of incidents and interventions and notify the physician of incidents. Review of the nursing progress note dated 10/21/24 at 2:00 P.M. revealed the State Tested Nursing Assistant (STNA) reported Resident #205 was lying on his left side on the floor in his room. The resident stated he was getting clothes out of his closet, lost his balance and fell on his left elbow. Range of motion was within normal limits. Tylenol was given. STAT x-ray of the left elbow was ordered. The note revealed the resident was confused at times and ambulatory without assistance. Following the incident, the resident had a room change to be closer to the nurses' station. Vital signs were taken and were as follows: blood pressure 99/56, pulse 90, respirations 20, temperature 97.8 degrees Fahrenheit (F) and oxygen saturation per pulse oximetry at 97 percent on room air. The note documented NP updated. Review of a physician order dated 10/21/24 revealed an order for a STAT x-ray of the left elbow and acetaminophen 325 milligrams (mg), two tablets by mouth every six hours as needed for pain. Review of Medication Administration Record (MAR) for October 2024 revealed acetaminophen 650 mg was administered to Resident #205 by LPN #333 on 10/21/24 at 4:30 P.M. Review of the nursing progress note dated 10/21/24 at 3:22 P.M. revealed an order for a STAT x-ray of the left elbow was submitted to the radiology provider. Review of the pain assessment records revealed Resident #205 had consistent pain levels of 0 out of 10 (on a scale from 0-10) from admission on [DATE] until the date of injury on 10/21/24. Following the fall, Resident #205's pain levels increased to 5 out of 10. Observation on 10/22/24 at 8:19 A.M., during medication administration with Licensed Practical Nurse (LPN) #333, revealed Resident #205 was lying in bed with his left arm resting on his chest and bent at a 90-degree angle. The resident's left elbow was red and swollen. Concurrent interview with Resident #205 revealed his elbow hurt. Coinciding interview with LPN #333 revealed Resident #205 had a fractured elbow due to a fall the previous day. LPN #333 stated she was waiting for the NP to call back with an order to send the resident to the emergency room (ER) for further evaluation. LPN #333 stated the facility did not like to send residents to the ER unless there was an order from the NP. Review of the nursing progress note dated 10/22/24 at 8:46 A.M. revealed a return call was received from the NP and order given to send the resident to the ER for evaluation and treatment of the left elbow per STAT x-ray results. Review of the hospital ER Physician Report dated 10/22/24 at 11:14 A.M. revealed Resident #205 presented to the ER following a fall. The resident had an x-ray that showed an intra-articular fracture of the left ulna. Resident #205 could not provide the physician with specifics and denied pain but had pain when his left elbow was touched or moved and in the left hip with movement. Additional radiological imaging was completed and confirmed Resident #205 had a left olecranon (bony part of the elbow, allows the elbow to move) fracture. Furthermore, imaging indicated Resident #205 also had a left acetabular (socket part of the hip joint where the thigh bone sits) fracture and acute fracture of the posterior right 11th rib. Pre-operative diagnoses included left olecranon fracture, left acetabulum fracture, left iliac fossa (bone that is part of the hip) fracture and left retroperitoneal hemorrhage (bleeding in the space located behind the abdominal cavity). Resident #205 was transferred to a level 2 trauma hospital for further treatment. Interview on 10/24/24 at 4:50 P.M. with LPN #333 revealed she was notified of Resident #205's fall by Staffing Coordinator (SC) #304 after the resident's roommate heard the resident fall and called out for staff assistance. LPN #333 stated Resident #205 was assessed and complained of elbow pain, but no other pain at that time. LPN #333 stated Resident #205 had full range of motion and once he was back in bed, he was able to demonstrate full body mobility buy doing bicycles with his legs. LPN #333 stated the resident told her he tried to break his fall with his left elbow. LPN #333 stated she notified the NP, and an order was received for a STAT x-ray of the left elbow and acetaminophen for pain, which was administered to the resident. The radiology provider was contacted immediately for the x-ray. LPN #333 denied Resident #205 had any swelling at that time. LPN #333 stated she gave report to Registered Nurse (RN) #310, informing her of Resident #205's fall and pending x-ray results. When she arrived for her shift on 10/22/24 at 7:00 A.M., she found the x-ray results, which were faxed to the facility on [DATE] at 7:19 P.M., laying on the nurses' station desk. LPN #333 stated she immediately checked on Resident #205 and received report from RN #310, who indicated the resident's left elbow was swollen and discolored and had ballooned from the previous afternoon. RN #310 did not indicate whether or not he had contacted anyone regarding the x-ray results. LPN #333 stated she administered Tylenol to the resident, elevated his elbow on a pillow and stated that he needs to go (to the hospital). Review of the timeline provided by the Director of Nursing (DON) revealed the STAT left elbow x-ray was completed 10/21/24 at 6:38 P.M. and the results were faxed to the facility on [DATE] at 7:19 P.M. On 10/22/24 at 7:05 A.M., LPN #333 sent a message and the x-ray results to the NP. After receiving no response, LPN #333 called the NP at 7:44 A.M. (left a message) and again at 8:42 A.M. The NP responded with an order to send Resident #205 to the ER. The timeline provided no indication RN #310 notified the NP on 10/21/24 when the results were received. Interview 10/24/24 at 3:03 P.M. with the DON and Assistant Director of Nursing (ADON) #367 revealed Resident #205 was transferred to the ER via 911 emergency squad after receiving the order from the NP on 10/22/24 at 8:42 A.M. The DON indicated she left a message for RN #310 regarding physician notification when the x-ray results were received on 10/21/24 but she had not received a response. The DON verified the NP should have been notified of the x-ray results indicating a fracture immediately for further orders. Additionally, the DON confirmed Resident #205 was in pain and his injuries went untreated from the time of the fall on 10/21/24 at 2:00 P.M. until he was transferred to the ER at approximately 8:45 A.M. on 10/22/24. This deficiency represents noncompliance investigated under Complaint Number OH00158492.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, facility policy review and interview, the facility failed to ensure Resident #99's received assistance with activities daily living (ADLs) to maintain adequate and necessary personal and oral hygiene. Actual harm occurred on 06/21/24 when Resident #99, who was totally dependent on staff assistance for ADLs, did not receive sufficient hygienic care and developed maggots in her mouth and nose, requiring hospitalization. This affected one resident (#99) of three residents reviewed for ADL care. The facility census was 47. Findings include: Review of Resident #99's closed medical record revealed the resident was admitted on [DATE] and discharged to the hospice house on 06/21/24 with diagnoses including amyotrophic lateral sclerosis (ALS), dysphagia and gastrostomy status. Review of Resident #99's ADL Self-Care Performance Deficit Care Plans with an admission date of 04/20/24 revealed the resident required one staff participation with personal hygiene and oral care. Review of Resident #99's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem and was dependent (helper completed all effort and resident did none of the effort to complete the activity). Review of Resident #99's hospice Visit Summary forms from 05/03/24 to 06/21/24 revealed the resident received mouth care and a bed bath on 06/14/24 and on 06/21/24 by hospice staff. No visits from hospice services were conducted between 06/15/24 to 06/20/24. Review of Resident #99's ADL Look Back Report form from 06/14/24 to 06/21/24 revealed the resident was provided oral care on 06/15/24 at 3:56 A.M.; on 06/16/24 at 12:51 A.M.; on 06/17/24 at 12:09 A.M.; and on 06/18/24 at 1:06 P.M. The documentation did not reveal evidence the resident was provided any oral care on 06/19/24 or 06/20/24. The documentation also did not reveal evidence the resident was provided oral care for first and second shifts on 06/15/24; first and second shifts on 06/16/24; first and second shifts on 06/17/24; or second or third shifts on 06/18/24. Review of Resident #99's progress note dated 06/21/24 at 11:00 A.M. authored by Licensed Practical Nurse (LPN) #821 revealed a full body assessment was completed by the nurse and two staff members. Tiny white worms were noted on top of the resident's tongue when mouth care was provided. The resident sneezed and more tiny white worms came out of her nostrils. The concern was reported to the administration and the physician. A call was placed to the hospice nurse who was asked to return to the facility to address. Review of Resident #99's progress note dated 06/21/24 at 12:30 P.M. authored by LPN #821 indicated the hospice nurse returned to the facility to assess the resident. Review of Resident #99's progress note dated 06/21/24 at 2:00 P.M. authored by LPN #821 indicated the hospice nurse collected a tiny white worm specimen to send with the resident to the ER. A call was placed to 911 per hospice and the resident's son was notified via the phone by the hospice nurse and updated on the resident's condition. Review of Resident #99's progress note dated 06/21/24 at 5:17 P.M. authored by the Administrator indicated the hospice nurse informed him that she spoke with the resident's family, and they were aware of the reason for hospitalization and in agreement with the plan. The hospice nurse stated they were going to ensure a head CAT scan (CAT or CT which was a computed tomography scan or medical imaging technique that uses X-rays and computers to create detailed cross-sectional images of the inside of the body) and a chest X-ray were completed, and that the family had already asked about an in-patient hospice house. Review of Resident #99's progress note dated 06/21/24 at 11:27 P.M. authored by LPN #822 indicated a call was placed to the ER to obtain an update on the resident. The resident had been transported by a private ambulance to the hospice center. Review of Resident #99's hospital documentation dated 06/21/24 indicated the resident presented from the skilled nursing facility (SNF) for concerns of larvae in the resident's nose. Nursing was completing oral and mouth care and noted larvae in the nose. The resident had ALS and was nonverbal. She had a percutaneous endoscopic gastrostomy tube (PEG tube which was passed into a resident's stomach through the abdominal wall to provide a means of feeding when oral intake was not adequate). The resident was on hospice services, and they provided care as well. The hospice team was worried about the resident's airway and sent the resident in for an airway assessment. A CAT of the facial area was ordered to evaluate the extent of an intraoral involvement or airway involvement. The CAT of the facial without contrast was obtained per the request of hospice services and there was no evidence of an erosive abnormality noted in the facial region. A reassessment of the resident did not reveal evidence of intraoral larvae or maggots. The resident did have a dry tongue and received all nutrition through the PEG tube. The resident was moved to the hospice care center and would be discharged from the ED for hospice ongoing care. The larvae were sent for an analysis but were most likely consistent with a fly. Review of the Timeline of Events (facility investigative report) for Resident #99 dated 06/21/24 indicated at 9:30 A.M. the facility notified hospice of an intolerance to the current tube feeding regimen and the hospice nurse reported that a tiny white worm was found on the resident's chest when providing a bed bath. At 9:50 A.M., the facility nurse and two staff members completed a full body assessment and noted that white worms were on top of the resident's tongue during oral care. The resident sneezed and more came out of the nasal passages. The Administrator, physician and hospice were notified. At 11:30 A.M., the hospice nurse returned to the facility and obtained a specimen to send to the emergency room (ER). The family was notified at this time. At 2:37 P.M., the facility completed oral assessments on all residents to ensure no other residents were affected. No other concerns were identified. Housekeeping did an audit of rooms and the building, and no other flies were noted. Window screens were audited, and six screens were noted to have holes in them. Tape was applied to the holes until repairs could be made. Audits would be completed three times a week for oral care for five residents per the Director of Nursing (DON) and/or designee. The concern would be reviewed in the quality assurance perform improvement (QAPI) meeting. Information obtained from the resident's family as part of the complaint investigation revealed Resident #100 had been admitted to the facility since late April 2022 and had a diagnosis of ALS. The family revealed they had been contacted by a hospice nurse, (this nurse visited the resident weekly) on Friday 06/21/24 indicating she had some bad news. The family revealed what was reported to them left them horrified and speechless. The nurse informed the family that a nurse's aide found fly larvae in the resident's mouth. The family stated literal fly eggs that had hatched into larvae and were now feeding on my poor mother, while she laid in bed not being able to move or help herself. The resident was transferred to the hospital for a CT scan to determine how deep the bug infestation had made it into her sinuses and lungs. The family indicated the next 24 hours were very rough having to endure multiple bug larvae being extracted from her body. Interview on 07/29/24 at 8:15 A.M. with the Administrator indicated he was aware that the hospice nurse had observed a maggot on Resident #99's shirt/gown on 06/21/24. Interview on 07/29/24 at 8:23 A.M. with State Tested Nursing Assistant (STNA) #814 indicated she assisted STNA #817 with Resident #99's ADL care when the hospice nurse had discovered a maggot crawling across the resident's gown. STNA #814 confirmed she had looked in Resident #99's mouth during oral care and had observed five maggots in the resident's mouth. She stated she also did see a maggot drop out of the resident's left nostril during care. She stated the resident always had her mouth open and could not move independently from the neck down. She stated the resident was dependent on all care. Telephone interview on 07/29/24 at 8:48 A.M. with Licensed Social Worker (LSW) for hospice house #816 revealed Resident #99 was admitted to their facility on 06/21/24 and discharged home on [DATE]. She was aware of maggots in the resident's mouth and nose but unable to provide further details. Telephone interview on 07/29/24 at 9:22 A.M. with Hospice Registered Nurse (RN) #846 and Chief Quality Officer for Hospice #815 confirmed on 06/21/24, she had assessed Resident #99 in the morning and provided a bed bath with the hospice nurse. She stated at that time, a small fly larvae was discovered crawling across the resident's chest on top of the gown. Hospice RN #846 stated she did a body assessment and could not determine the cause of the fly larvae so she notified the shift nurse. She stated she was called by the facility later in the day and was informed by the facility that the resident had sneezed and found maggots in her nose. Hospice RN #846 confirmed she went back to the facility and assessed the resident and identified a maggot in her right nostril which she scooped out and placed in a plastic bag to be sent with the resident to the ER. Hospice RN #846 confirmed Resident #99 was discharged to the hospital and then to the hospice house before discharging home. Interview on 07/29/24 at 11:42 A.M. with the DON confirmed Resident #99's oral care should be completed every shift by the nursing staff and the facility had three shifts per day. The DON also confirmed the resident's oral care was not completed as required as evidenced by the documentation in the resident's medical record. A follow up interview on 07/29/24 at 1:40 P.M. with STNA #814 confirmed she had observed three or four flies flying around Resident #99's room on 06/21/24 when the maggots were discovered in the resident's nose and mouth. Review of the facility ADL policy, reviewed 08/2021, revealed residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADL care. Appropriate care and services would be provided for residents who were unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming and oral care). The deficient practice was corrected on 06/26/24 when the facility implemented the following corrective actions: • Regional Support RN #551 completed staff inservices for ADLs and Oral Care Recommendations in person on 06/21/24 which included RN #810, LPNs #821, #902, #903, STNAs #805, #820, #825, #901. • Regional Support RN #551 and STNA Scheduler #808 completed additional staff inservices for ADLs and Oral Care Recommendations via the telephone for all other nursing staff from 06/21/24 at 3:55 P.M. to 06/23/24 at 12:40 P.M. which included 3 RNs, 10 LPNs and 19 STNAs. • LPN #821 completed Oral Cavity Assessment Audits of all residents on 06/21/24 with no negative findings. • Director of Housekeeping #552 completed an audit of resident rooms for flies on 06/21/24 with no negative findings. • Director of Housekeeping #552 completed an audit for intact window screens on 06/21/24. The facility identified six resident rooms with holes in the screen including rooms 104, 106,108, 111 and 115. Tape was placed over the holes in the screens. • A QAPI Meeting was held on 06/24/24 at 3:45 P.M. with the Administrator, DON via phone and Medical Director via phone. No other staff had signed the form including the Infection Preventionist, Dietitian/Dietary Representative, Pharmacy Representative, Lab Representative, Life Enrichment Representative, Life Enrichment Representative, Environmental Services, Rehabilitation/Restorative Representative, MDS Representative, Safety Representative, Medical Records Representative and Human Resources. • The DON completed Oral Care Audits beginning 06/26/24 for three times a week for five weeks. • Pest control services were provided for flies in the facility with fly baits on 06/17/24, 06/24/24, 07/15/24 and 07/17/24. The facility maintained the use of a contracted company for pest control. This deficiency represents non-compliance investigated under Complaint Number OH00155328.