**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, interview, and policy review the facility failed to ensure Resident #100, a newly admitted resident received hemodialysis services timely and as recommended by the hospital at the time of the resident's hospital discharge and failed to ensure timely and ongoing monitoring of the resident's hemodialysis access site for patency and/or signs of infection. This affected one resident (#100) of three residents reviewed for dialysis services. The facility census was 96. Actual harm occurred on 08/14/24 when the facility failed to ensure Resident #100 received hemodialysis treatments as ordered (between 08/10/24 and 08/14/24) resulting in an acute change in the resident's condition, including a swollen abdomen, generalized edema throughout the resident's body and presence of excessive fluid requiring transfer to the hospital for hemodialysis. The resident did not return to the facility after being transferred to the hospital. Findings include: Review of the closed medical record for Resident #100 revealed the resident was admitted to the facility on Saturday 08/10/24 with diagnoses including acute osteomyelitis, altered mental status, end stage renal disease, type two diabetes mellitus with hyperglycemia requiring long term use of insulin, ascites, hepatomegaly with splenomegaly and chronic kidney disease. Record review revealed the resident received hemodialysis. Review of hospital discharge record from the resident's hospitalization 08/01/24 to 08/10/24 revealed the resident was to follow up with dialysis services with a current dialysis schedule of Tuesday, Thursday, and Friday. Review of communication email dated 08/09/24 to the facility-based dialysis center admissions revealed Admissions Coordinator #170 notified the dialysis center the resident would be admitting on 08/10/24. The facility-based dialysis center performed dialysis treatments on Monday, Wednesday, and Fridays. Review of an admission assessment completed 08/10/24 revealed the resident was admitted due to osteomyelitis and was identified with dialysis access via arteriovenous (AV) shunt with a positive bruit and thrill. Review of the physician's orders with a start date of 08/13/24 (three days after admission) revealed liberal renal/cardiac consistent diet with double protein. There was also an order dated 08/12/24 (two days after admission) for staff to check bruit and thrill to left upper arm. And to observe fistula to left upper arm for thrombosis bleeding, stenosis, infection, steal syndrome and aneurysm. An additional order dated 08/12/24 (two days after admission included an order for the medication Velphoro (for chronic kidney disease). Lastly, an order dated 08/12/24 included the resident was to receive hemodialysis in house Monday, Wednesday and Friday. Review of the medication administration record (MAR) revealed Resident #100's fistula was first assessed beginning on 08/12/24 during night shift and continued until discharge on [DATE]. Review of a plan of care created on 08/12/24 revealed Resident #100 was at risk for complications related to the need for dialysis. A second plan of care revealed the resident was at nutritional and/or dehydration risk related to end-stage renal disease on hemodialysis. Neither care plan included any interventions. Review of an eINTERACT transfer form dated 08/14/24 revealed Resident #100 was exhibiting edema (new or worsening) of the abdomen. The form noted the resident had dialysis treatments on Monday, Wednesday, and Fridays and had a fistula to his left arm with provider recommendation to send to the hospital for evaluation. Review of a progress note dated 08/14/24 revealed Resident #100 ordered to be sent out to a local hospital for dialysis. Abdomen noted to be distended. Review of dialysis schedule for 08/12/24 and 08/14/24 revealed Resident #100 was not on the list to receive dialysis services on these dates. Review of 5-day Minimum Data Set (MDS) 3.0 assessment completed 08/28/24 revealed Resident #100 was cognitively intact and required assistance with activities of daily living. Interview on 09/30/24 at 11:06 A.M. with Admissions Coordinator #170 revealed an email was sent to the dialysis center informing the clinic of Resident #100's admission on [DATE]; however, Admissions Coordinator #170 did not confirm with the clinic the resident had been admitted to the facility on [DATE]. admission Coordinator #170 said the resident was marked as pending during the duration of his stay and due to the pending status, the resident was not placed on the dialysis schedule to receive dialysis treatment. Admissions Coordinator #170 revealed facility staff were expected to notify dialysis of new admissions to put them as active in the system. Interview on 09/30/24 at 11:19 A.M. with Licensed Practical Nurse (LPN) #268 revealed Resident #100 was admitted on [DATE] on her shift. Through review of the hospital record, it was identified the resident required dialysis services. LPN #268 informed the Director of Nursing (DON) who the LPN stated was responsible for dialysis admissions on the weekend, and did not hear an update back. LPN #268 confirmed she was responsible for putting in initial physician orders upon admission for residents to receive dialysis, LPN #268 confirmed she put in all admitting orders including the orders for dialysis on 08/10/12 and called the physician to verify. She did not see that the orders were verified by the physician by the end of her shift and she pass the information on to the oncoming nurse. The oncoming nurse was unable to be reached for interview by the surveyor. LPN #268 confirmed the next on-shift nurse was informed the resident was a dialysis patient. Interview on 09/30/24 at 2:33 P.M. with the DON denied working in the facility from 08/10/24 to 08/13/24. Upon her return (on 08/14/24), she stated she was informed Resident #100 had not received dialysis services as required and would require transfer to the hospital. The DON confirmed facility nursing staff should confirm with the dialysis clinic when a resident was physically in the building so they could remove them as pending in the dialysis system and add them to the schedule. The DON confirmed the resident did not receive two of his scheduled dialysis treatments, on 08/12/24 and 08/14/24 as per the order obtained on 08/12/24 for hemodialysis treatments every Monday, Wednesday and Friday. Interview on 09/30/24 at 11:29 A.M. with the dialysis admissions coordinator revealed the clinic had been informed Resident #100 was planning on admitting to the facility on [DATE]. The Admissions coordinator denied facility staff followed-up to confirm the resident was actually admitted on [DATE] and required dialysis services to begin. Interview on 09/30/24 at 12:58 P.M. with the dialysis nurse revealed she was made aware on 08/14/24 Resident #100 had been admitted to the facility and did not receive scheduled dialysis treatment as ordered. Resident #100 was assessed by the dialysis nurse after notification and was found to have a swollen abdomen and generalized edema throughout his body. The dialysis nurse voiced Resident #100 did not look good due to the excessive fluid, and he would need to go to the hospital to receive dialysis treatment. The dialysis nurse said the resident was marked as pending in the system and facility staff did not notify the clinic he was admitted . Interview on 09/30/24 at 2:35 P.M. with the administrator confirmed the facility provided dialysis services on Monday, Wednesday and Friday when Resident #100 was admitted due to a low number of resident requiring dialysis services. Interview on 09/30/24 at 3:10 P.M. with Registered Nurse #143 revealed facility best practice for when a dialysis resident was admitted to the facility was to walk down to the clinic located in the facility and confirm with staff in-person and ask when the resident could receive treatment. Interview on 09/30/24 at 3:17 P.M. with Unit Manager #149 confirmed facility staff were required to confirm with the dialysis clinic that a resident had been admitted to the facility so they could remove the resident's pending status. Review of hemodialysis policy dated 09/26/23 revealed hemodialysis was a potentially life-saving procedure that removed blood from the body and circulated it through a purifying dialyzer, then returned the blood to the body. Staff were required to obtain a physician's order for hemodialysis upon admission. This deficiency represents non-compliance investigated under Complaint Number OH00156992 and Complaint Number OH00156955.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of hospital medical records, observations, resident and staff interviews, and facility policy review, the facility failed to provide timely treatment and care in response to resident's change in condition resulting in hospitalizations. This resulted in actual harm for Resident #37, who was admitted to the facility on [DATE], was sent to the hospital from an outside appointment on 07/18/23 due to abdominal distention and a concern for a bowel obstruction related to multiple days of having no bowel movements and no treatment. Resident #37 received a computed topography (CT) scan of her abdomen in the emergency department which revealed a bowel obstruction. A gastrointestinal (GI) consult was completed, and Resident #37 received surgery for a loop colostomy to be placed. This resulted in actual harm when Resident #6, who was initially admitted on [DATE] and readmitted to the facility on [DATE], reported to the facility staff he was having a stroke on 02/25/24 and requested to be sent out to the hospital. Registered Nurse (RN) #732 did not send Resident #6 out to the hospital as requested or inform the physician of Resident #6's desire to go to the hospital. Resident #6 had a history of cerebral infarction (CVA) (stroke). Physician Assistant (PA) #620 assessed Resident #6 on 02/26/24 and found the resident presented with dysarthria, significant left facial droop, and significant left side hemiparesis, likely consistent with an acute CVA. Resident #6 was sent to the hospital where a diagnosis of acute CVA was confirmed. This resulted in actual harm for Resident #85, who was initially admitted on [DATE] and readmitted to the facility on [DATE], was transferred to the hospital on [DATE] at approximately 6:45 P.M. due to an altered mental status after the facility was unable to obtain STAT (immediate) laboratory values ordered by the provider. Resident #85 was nearly unresponsive, hypotensive (low blood pressure), tachycardic, and febrile with a temperature of 104.8 degrees Fahrenheit upon arrival at the hospital. Resident #85 was diagnosed with septic shock related to a catheter associated urinary tract infection (CAUTI) and was admitted to the hospital. Resident #85 remained in the hospital for further treatment until 04/22/24. This affected three residents (#37, #6 and #85) of four residents reviewed for changes in condition. The facility census was 101. Findings include: 1. Review of the medical record for Resident #37 revealed an admission date on 03/07/19. Diagnoses include colostomy status (07/21/23), malignant neoplasm of brain (03/07/19), abnormal posture (07/28/23), constipation (03/07/19), and encounter for surgical aftercare following surgery on the digestive system (07/28/23). Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 had impaired cognition and scored an eight out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #37 required setup or clean-up assistance from staff with eating; supervision or touching assistance with oral hygiene; substantial or maximum assistance with upper body dressing; and was totally dependent on staff assistance to complete toileting, bathing, lower body dressing, bed mobility, and transfers. Resident #37 did not have an ostomy and was always incontinent of bowel and bladder. Review of the clinical census for Resident #37 revealed the resident was hospitalized from [DATE] until 07/28/23 (ten days). Review of the Medication Administration Record (MAR) dated July 2023 revealed Resident #37 received Miralax Oral Powder 17 grams (GM) per scoop daily for constipation and Senna Oral Tablet 8.6 milligrams (mg) daily for constipation. Resident #37 had an additional order for Bisacodyl Rectal Suppository 10 mg every 24 hours as needed (PRN) for constipation. The PRN suppository was not administered to Resident #37 in the month of July 2023. Review of the Treatment Administration Record (TAR) dated July 2023 revealed Resident #37 had an order to please schedule abdominal computed tomography (CT) scan related to abdominal distention dated 06/29/23. This order was not marked as completed. An additional order to obtain the results of the abdominal CT scan completed on 07/14/23 and upload to Resident #37's medical record for review by the physician/Certified Nurse Practitioner (CNP) dated 07/18/23. This order was marked as completed on 07/18/23. Review of Toileting Documentation dated July 2023 revealed Resident #37 had normal stools on 07/01/23. No bowel movements were documented from 07/02/23 through 07/05/23 (four days). Loose stools were documented on 07/06/23 and 07/07/23. No bowel movements were documented from 07/08/23 through 07/10/23 (three days). A loose stool was documented on 07/11/23. No bowel movement was documented on 07/12/23. Loose stools were documented on 07/13/23 and 07/14/23. No bowel movements were documented from 07/15/23 through 07/17/23 (three days). A loose stool was documented on 07/18/23. Review of progress notes dated from 07/01/23 through 07/31/23 revealed on 07/13/23 at an unknown time, Resident #37 was seen by CNP #612 for follow up on abdominal distention. A previous kidney, ureter, and bladder (KUB) x-ray showed progressed colonic ileus (a motility disorder that causes a nonmechanical obstruction in the colon) with moderate stool burden. Scheduled Miralax and Senna medications (laxatives) were ordered. Outputs were to be monitored. If no improvement, consider an abdominal CT scan. No worsening of symptoms or issues were noted but not resolved. A CT scan of the resident's abdomen was scheduled for 07/14/23. On 07/14/23 at 6:14 P.M., Resident #37 was noted to have returned from an abdominal CT scan appointment at around 12:00 P.M. with no new orders. On 07/18/23 at 9:00 A.M., Resident #37 was noted to leave the facility to attend an outside appointment. On 07/18/23 at 5:36 P.M., Resident #37 was noted to be sent to the hospital from her appointment. Resident #37 was in the emergency room and was awaiting a bed. Review of the hospital records dated 07/19/23 revealed Resident #37 had a diagnosis of bowel obstruction. Resident #37 presented to the emergency room from her neuro oncology appointment due to abdominal distention and concern for a bowel obstruction. An abdominal CT scan was completed and showed continued sigmoid colon dilation with transition point in the distal sigmoid colon, which may represent partial obstruction. A gastrointestinal (GI) consult was recommended. An abdominal x-ray was completed on 07/18/23 which showed gaseous colonic dilation that had increased compared to the recent CT scan. A large amount of stool burden was found especially in the right hemicolon. A GI consult was completed on 07/19/23. The risk for perforation was too high to perform a flexible sigmoidoscopy (a diagnostic procedure that allows a doctor to examine the lower colon and rectum) and planned for a loop colostomy surgery completed on 07/21/24. On 07/28/23 at 1:35 P.M., Resident #37 returned to the facility from the hospital. Review of the After Visit Summary (AVS) dated 07/28/23 revealed Resident #37 was discharged from the hospital with a colostomy in place. Review of the care plan, (initially dated 10/21/19) and revised 07/29/23, revealed Resident #37 was at risk for constipation related to decreased mobility, medication side effects, and rectal mass on 10/21/19. Interventions included administer medications as ordered, increase fiber and fluid intake, observe for signs and symptoms of bowel obstruction: abdominal distention, decreased appetite, and/or diarrhea with continued feelings of fullness and report findings to the physician, record bowel movement pattern after each occurrence describing amount and consistency. The revised care plan dated 07/29/23 revealed Resident #37 was at risk for complications related to a colostomy in place related to a small bowel obstruction (SBO). Interventions included change colostomy bag as needed, check for proper fit of colostomy bag to stoma, empty colostomy bag every shift and as needed, observe for air in the colostomy bag frequently and release as needed, observe for bowel movement and document, report a lack of bowel movement to nursing and physician, observe for diarrhea, constipation, dehydration, and pain every shift, observe for ostomy functioning, and observe stoma site and surrounding skin during each change for warmth, redness, or tenderness. Review of a follow-up surgical note, dated 08/15/23, revealed Resident #37 had a post-operative visit after creation of a loop transverse colostomy. A follow-up flexible sigmoidoscopy which did not reveal any masses or strictures. Interview on 05/22/24 at 3:33 P.M. with the Director of Nursing (DON) revealed if a resident did not have a bowel movement for three days, the physician or CNP should be notified, and any ordered PRN laxatives or suppositories should be administered. Interview on 05/23/24 at 10:35 A.M. with the DON confirmed Resident #37 had documented normal stools on 07/01/23 followed by not having a bowel movement for several days and then having loose stools until the resident was sent to the hospital on [DATE] from an outside appointment. The DON confirmed loose stools could be a sign of a bowel obstruction when the resident was noted to be able to form normal stools previously. The DON confirmed Resident #37 did not receive a PRN suppository when she was noted without a bowel movement for at least three days in a row. A facility policy related to treatment of constipation and/or treatment for a change in condition was requested at the time of the survey, however, the facility did not have any policies which addressed either area. 2. Review of the medical record for Resident #6 revealed an initial admission date on 12/12/22 and a readmission date to the facility on [DATE]. Diagnoses include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (weakness and paralysis on one side of the body) (03/02/24), cerebral infarction (CVA) (stroke) (03/02/24), dysarthria following cerebral infarction (slurred speech) (03/02/24), and dysphagia following cerebral infarction (difficulty swallowing) (03/02/24). Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #6 had impaired cognition and scored an 11 out of 15 on the BIMS assessment. Resident #6 did not have any impairments in his upper extremities and had an impairment on one side of his lower extremity. Resident #6 required setup or clean-up assistance from staff with eating, upper body dressing, and personal hygiene; substantial or maximal assistance with bathing, bed mobility, lower body dressing, and transfers; and total dependence on staff to complete oral hygiene and toileting. Review of Resident #6's clinical census revealed the resident was hospitalized from [DATE] to 03/02/24 (six days). Review of the MAR dated February 2024 revealed Resident #6 received Aspirin 81 milligrams (mg) daily and Plavix 75 mg daily (an antiplatelet medication). Review of the progress notes for Resident #6 revealed on 02/25/24 at 3:20 P.M., Registered Nurse (RN) #732 noted a change in condition evaluation due to Resident #6 being tired, weak, confused, and drowsy. Resident #6's vital signs were blood pressure 137/76, pulse 72, respiration rate 18, temperature 97.6, pulse oximetry 98%, and blood glucose 181 (on 01/19/23). Resident #6 verbalized that he was having a stroke around 3:20 P.M. Range of motion (ROM) was performed, and the resident was able to raise both arms and legs. Resident #6 denied any pain. The physician was informed and recommended to continue to monitor Resident #6. On 02/26/24 at an unknown time, PA #620 completed an acute visit with Resident #6 with a chief complaint of weakness. PA #620 noted the nursing staff reported that the resident complained yesterday (02/25/24) that he may have had a stroke. On exam today, Resident #6 had dysarthria, had significant left-sided hemiparesis with left-sided facial droop. Resident #6 did have a history of prior CVA and was currently treated with Plavix and Aspirin. It is unclear when Resident #6 was last known well. National Institute of Health (NIH) stroke score is 15. (The scoring range is zero to 42 points, with higher numbers indicating a greater severity. A score of five to 15 represents a moderate stroke). The physical exam noted left sided facial droop and loss of left nasolabial fold (a skin crease that runs from the bottom of the nose to the outer corner of the mouth) with an asymmetric smile, ROM at baseline, left upper and lower extremity weakness, and confusion. Resident #6's presentation was likely consistent with an acute CVA and he would be sent to the emergency department for further management. Resident #6 was sent to the hospital via stretcher at 1:10 P.M. on 02/26/24. Review of the hospital records dated 02/26/24 revealed Resident #6 presented to the hospital at 1:33 P.M. for evaluation of stroke-like symptoms. The resident had dysarthria, facial droop, and left-sided weakness that started yesterday (02/25/24). The resident's wife was at bedside and reported symptoms had started on Thursday, 02/22/24 or Friday, 02/23/24 but worsened on 02/25/24. Deep vein thrombosis prophylaxis with sequential compression devices (SCD's) (shaped like sleeves that wrap around the legs and inflate with air). Resident #6 required admission due to concern of stroke-like symptoms and urinary tract infection (UTI) due to posed a threat to life and organ dysfunction. Review of the After Visit Summary (AVS) dated 03/02/24 revealed Resident #6 had a diagnosis of stroke (cerebrum). Resident #6's medications were changed to stop taking Plavix and start taking Apixaban (Eliquis) (an anticoagulant). Recommended dysphagia (difficulty swallowing) treatment. A regular diet and mildly thickened liquids was recommended. Review of the progress note dated 03/02/24 at 4:15 P.M. revealed Resident #6 returned to the facility. On 03/04/24 at an unknown time, PA #620 completed a follow-up visit with Resident #6 with a chief complaint of urinary tract infection (UTI) and CVA. A magnetic resonance imaging (MRI) of the brain showed a faint area of restricted diffusion in the right aspect of the [NAME] (any obstruction of blood supply to the [NAME], whether or acute or chronic, causes pontine infarction, a type of ischemic stroke) with chronic pontine, cerebellar, and cerebral infarcts and extensive small vessel disease. Resident #6 was alert and oriented but did have dysarthria and dysphagia secondary to CVA. Resident #6 could consume regular solids with thickened liquids. Resident #6 was also noted to have multidrug-resistant Klebsiella and Pseudomonas UTI and had completed antibiotics. Resident #6 still had significant left-sided hemiparesis. Review of the significant change MDS 3.0 assessment dated [DATE] revealed Resident #6 had impaired cognition. Resident #6 had impairments on both sides of his upper extremities and impairment on one side of his lower extremity. Resident #6 required substantial or maximal assistance with upper body dressing and personal hygiene and total dependence on staff with lower body dressing and bathing. Review of the care plan, revised 03/11/24, revealed Resident #6's history of CVA or monitoring for signs and symptoms of a stroke was not addressed in the resident's care plan. Interview on 05/21/24 at 10:23 A.M. with Resident #6 revealed he had a stroke in February 2024. Resident #6 stated he knew he had one and reported it to the facility staff. Resident #6 stated he requested to go to the hospital but the staff did not send him out due to needing approval from the physician and the physician was off. Resident #6 stated he was not sent out to the hospital for two days. Resident #6 stated prior to having the stroke, he was able to do almost everything for himself and now he is way worse. Interview on 05/23/24 at 1:32 P.M. with PA #620 confirmed he had not been notified Resident #6 complained of having a stroke on 02/25/24 until he saw the resident on 02/26/24. PA #620 stated he was not sure which on-call physician had been contacted as there were not any notes entered on 02/25/24. PA #620 stated he could not confirm when exactly Resident #6's symptoms started but confirmed when he did see Resident #6 on 02/26/24, he definitely showed signs of a stroke and that is why he sent the resident to the emergency room. PA #620 stated he educated the DON on the importance of identifying signs and symptoms of a stroke and responding quickly to strokes as they are one of the biggest emergencies that could occur in the facility. PA #620 stated the facility staff reported to him Resident #6 did not have any signs of a stroke on 02/25/24 but he was still thinking about that one. Interview via telephone on 05/23/24 at 4:14 P.M. with RN #732 confirmed Resident #6 complained he was having a stroke and requested to be sent out to the hospital. RN #732 assessed Resident #6, checked his vital signs, and ROM. RN #732 stated Resident #6 was able to raise arms and legs and stuck out his tongue. RN #732 notified the on-call provider of the resident's report of having a stroke, his vital signs, and that his ROM was normal. RN #732 confirmed she did not inform the on-call provider of Resident #6's request to be sent to the hospital. RN #732 stated the on-call provider instructed to continue monitoring Resident #6. RN #732 stated she and State Tested Nurse Aide (STNA) #630 monitored Resident #6 three times during her shift from 7:00 A.M. to 7:00 P.M. RN #732 stated she notified the night-shift nurse on 02/25/24 and PA #620 the following day on 02/26/24. Interview on 05/23/24 at 4:13 P.M. with the DON confirmed PA #620 did have a conversation with her regarding Resident #6's reporting of having stroke symptoms. The DON stated RN #732 informed the on-call provider and did verify with the resident that he could move his arms and legs and took his vital signs. PA #620 suggested providing stroke education to the staff. The DON confirmed she provided RN #732 with a teachable moment. After RN #732 received the additional education, she did show improvement when she noted another resident who had symptoms of a CVA and was sent out to the hospital timely. Interviews with the on-call provider, PA #609, STNA #630, and the night shift nurse, RN #669, were attempted but unsuccessful. Review of the facility policy titled, Notification of Change, dated 02/14/24, revealed the facility must inform the resident, consult with the resident's practitioner, and notify the resident's representative when there was a change in status including a significant change in the resident's physical, mental, or psychosocial status. The policy did not address providing timely treatment when a resident experienced a change in condition. No other facility policies were provided at the time of the survey. 3. Review of the medical record for Resident #85 revealed an initial admission date on 06/08/23 and a readmission date on 04/22/24. Diagnoses include infection and inflammatory reaction due to indwelling urethral catheter (04/22/24), urinary tract infection (04/22/24), benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (06/08/23), neuromuscular dysfunction of bladder (06/08/23), and retention of urine (06/08/23). Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #85 had intact cognition and scored a 15 out of 15 on the BIMS assessment. Resident #85 required total dependence on staff to complete toileting. Resident #85 had an indwelling catheter. Review of the clinic census for Resident #85 revealed the resident was hospitalized from [DATE] to 04/22/24 (five days). Review of the TAR dated March 2024 revealed Resident #85's Foley catheter was changed on 03/28/24 as ordered. Review of the MAR dated April 2024 revealed Resident #85 received Finasteride Oral Tablet five milligrams (mg) daily for BPH as ordered and Tamsulosin Hydrochloride Oral Capsule 0.4 mg daily for BPH as ordered. There was no order to monitor urine outputs from Resident #85's Foley catheter. Review of the TAR dated April 2024 revealed Resident #85 received Foley catheter care every shift (twice a day) as ordered, Resident #85's Foley catheter was noted to be straight draining every shift as ordered. Review of blood pressures (BP's) revealed on 04/16/24 at 7:53 A.M., Resident #85's BP was 116/73. On 04/17/24 at 7:10 A.M., his BP was 112/66 and at 1:49 P.M., Resident #85's BP was 99/81. There were no additional BP's documented. Review of oxygen saturations (O2 sats) revealed on 04/16/24 at 7:53 A.M., Resident #85's O2 saturation was 95% on room air. On 04/17/24 at 7:10 A.M., his O2 saturation was 89% on room air and at 3:56 P.M., Resident #85's O2 saturation was 90% on room air. There were no additional O2 saturations documented. Review of pulse rates revealed on 04/16/24 at 7:53 A.M., Resident #85's pulse was 59 beats per minute (bpm). On 04/17/24 at 7:10 A.M., it was 122 bpm and at 1:55 P.M., Resident #85's pulse was 108 bpm. There were no additional pulse rates documented. Review of meal and fluid intakes dated April 2024 revealed Resident #85 was noted to eat 51-75% of all three meals and drank between 220 and 230 mL of fluid at each meal on 04/16/24. On 04/17/24, Resident #85 ate 26-50% of breakfast and drank 230 milliliters (mL) of fluids. Resident #85 did not eat or drink anything at lunch and refused dinner. Resident #85 did not drink any fluids at dinner. Review of the Change in Condition Evaluation dated 04/17/24 and completed by Registered Nurse (RN) #733 revealed Resident #85 experienced a change in condition which started on the morning of 04/17/24. The resident was lethargic. Vital signs included blood pressure (BP) 99/81, pulse 108, apical heart rate 110, temperature 97.6, and oxygen saturation was 90% on room air. Resident #85 had all of the following: a systolic BP below 100, a heart rate above 100, a temperature above 100, and signs and symptoms suggested possible sepsis. Functional changes indicated included: needed more assistance with Activities of Daily Living (ADL's), decreased mobility, a decline in the ability to perform mobility, bowel and bladder, dressing, and eating. The symptoms were noted as having a recent onset without resolving spontaneously. The symptoms were noted as staying the same. The clinician was notified on 04/17/24 at 12:12 P.M. and ordered complete blood count (CBC) and basic metabolic panel (BMP) labs. Resident #85's wife was notified on 04/17/24 at 1:38 P.M. of the change in condition. Review of the Transfer Form dated 04/17/24 and completed by RN #733 revealed Resident #85 was discharged to the hospital from the facility on 04/17/24 at 7:49 P.M. due to abdominal pain. The resident had a pain level of four out of ten where ten was the worst pain imagined. Resident #85 was not alert. Review of the progress notes revealed on 04/17/24 at 3:48 P.M., a change in condition note was entered for Resident #85 by the DON. Resident #85's BP was 99/81 at 1:49 P.M. and pulse oximetry (ox) was 90% on room air at 3:56 P.M. Resident #85's mental status was noted as other. Resident #85 needed more assistance with completing ADL's and had decreased mobility. CBC and BMP labs were ordered. On 04/17/24 at 4:03 P.M., RN #733 noted Resident #85 was lethargic since this morning and unable to awake after several attempts. Vital signs were taken. BP 99/81, pulse 108, respiration rate 16, temperature 97.6, and oxygen saturation was 90%. The on-call physician was notified and ordered STAT (immediate) CBC and BMP labs. The family was notified and will continue to monitor. The electronic MAR (e-MAR) notes dated 04/17/24 from 7:24 P.M. to 7:27 P.M. revealed Resident #85 was not able to swallow his evening medications and the medications were held. Review of the hospital records revealed Resident #85 presented to the ED on 04/17/24 at 7:49 P.M. with altered mental status after the resident was found fairly unresponsive at the facility. When Resident #85 was seen in the ED, no history could be obtained. Resident #85 was found to have evidence of septic shock and was admitted . Resident #85 was diagnosed with septic shock with an acute UTI (later determined on 04/21/24 to be due to bactermia with E. Coli and Proteus bacteria). Initial assessment and treatment indicated Resident #85 was hypotensive (low blood pressure) with a blood pressure in the 60's and 70's despite adequate volume resuscitation, was fairly febrile with a temperature as high as 104.8 degrees Fahrenheit, and was tachycardic upon arrival at the ED. Vital signs were: BP 74/53, heart rate 121, respiration rate 17, temperature 104.8, O2 sat 97%. Resident #85's Foley catheter was exchanged in the ED and over a liter of urine came out, likely indication Resident #85's Foley catheter was clogged on arrival. Initial treatment included: the resident was started on norepinephrine (or noradrenaline, a neurotransmitter and hormone used for blood pressure support), admitted for further evaluation and treatment, a urinalysis with significant pyuria (contains high levels of white blood cells or pus) was completed, a culture had been obtained and Resident #85 would be started on broad-spectrum antibiotics, and continue vasopressor support. On 04/17/24 at 8:00 P.M., RN #733 noted Resident #85 was sleeping all day which was unusual for him. An assessment was completed. The on-call physician was notified. STAT CBC and BMP labs were ordered. Resident #85's condition continued to decline, and the physician ordered to send the resident to the emergency room (ER) for further evaluation. Resident #85 was transferred to the hospital via Emergency Medical Services (EMS) at 6:45 P.M. The physician, DON, and family were notified. On 04/22/24 at 7:29 P.M., Resident #85 returned to the facility from the hospital at approximately 4:40 P.M. The resident had a Foley catheter in place. On 04/23/24 at an unknown time, Medical Doctor (MD) #750 completed a history and physical visit with Resident #85. The chief complaint was a catheter associated urinary tract infection (CAUTI) with sepsis. Resident #85 was seen for readmission after hospitalization for sepsis related to urinary catheter infection with cystitis (inflammation of the bladder, usually caused by a bladder infection). Resident #85 would complete the course of oral antibiotic therapy for the CAUTI of Cefdinir Oral Capsule 300 mg. Dark amber urine was noted in the Foley bag. On 04/24/24 at an unknown time, PA #620 completed an acute visit for UTI with Resident #85. Resident #85 was receiving Cefdinir (an antibiotic) 300 mg twice daily through 05/01/24 for treatment of his UTI. The Foley catheter was now draining yellow-colored urine. Review of lab results for Resident #85 revealed the STAT labs ordered on 04/17/24 had not been completed. Review of the care plan (originally dated 06/09/23) and revised on 05/07/24 revealed Resident #85 was at risk for UTI and catheter-related trauma due to having an indwelling catheter. Interventions included change catheter and tubing per facility policy, enhanced barrier precautions (added on 05/07/24), may irrigate catheter for occlusion as ordered (added on 05/07/24), observe and document for pain or discomfort due to catheter, observe and document output as per facility policy (added on 05/07/24), observe, record, and report to the physician signs or symptoms of UTI including: pain, burning, red tinged urine, cloudiness, no output, deepening of urine color, increased temperature, foul smelling urine, fever, chills, altered mental status, changes in behavior, or changes in eating patterns, position catheter bag and tubing below the level of the bladder and observe for any kinks each shift, and provide catheter care per policy. Interview via telephone on 05/22/24 at 9:40 A.M. with RN #733 confirmed she first saw Resident #85 at approximately 8:30 A.M. on 04/17/24. RN #733 was able to wake Resident #85 up, the resident took his medications, and then fell back asleep. RN #733 stated Resident #85 did eat breakfast, but not as much as usual. RN #733 next saw Resident #85 around lunch time for his next dose of medications which was around 12:30 P.M. RN #733 stated Resident #85 was not able to be aroused at that time. RN #733 stated the aide then reported Resident #85 had not eaten lunch. RN #733 checked on the resident again around 1:00 P.M. and Resident #85's vital signs were taken and were within normal limits (WNL). RN #733 notified the on-call provider who directed the nurse to continue monitoring Resident #85. RN #733 stated she checked on Resident #85 every two hours and checked the resident's vital signs but did not document them. RN #733 stated she tried to arouse Resident #85 but the resident would not wake up. Around dinner time, Resident #85 still would not wake up to eat dinner and did not take any medications. RN #733 stated Resident #85's vital signs also became abnormal. RN #733 stated the resident's catheter bag had been emptied and the catheter was draining but she could not recall how much it was draining or the color of the urine. RN #733 contacted the on-call provider again around dinner time and at that time, Resident #85 was sent out to the hospital. Interview on 05/22/24 at 4:35 P.M. with the DON and Regional Nurse (RGN) #810 confirmed outputs from Resident #85's Foley catheter had not been monitored prior to the resident being sent out to the hospital on [DATE]. The staff would only monitor outputs if there was a physician order. Interview on 05/23/24 at 1:15 P.M. with PA #620 revealed Resident #85 had a history of UTI's. PA #620 stated signs of possible sepsis may include a sudden, significant change in a resident's vital signs. PA #620 would be particularly interested in the resident's blood pressure, heart rate, and temperature. PA #620 stated when he ordered staff to monitor a resident, he would expect that resident to be checked on every two hours, including checking and documenting vital signs. Interview via telephone on 05/23/24 at 2:46 P.M. with PA #607 confirmed he was the on-call provider for the facility from 1:00 P.M. to 7:00 P.M. on 04/17/24 when Resident #85 was transferred to the hospital. PA #607 stated when RN #733 first contacted him, he ordered STAT (immediate) CBC and BMP labs. PA #607 expected the labs to be completed and resulted within four hours, but he did not receive any results before Resident #85 was sent to the hospital. PA #607 stated RN #733 contacted him again later and reported Resident #85 was still lethargic. At that time, he agreed to have the resident sent to the hospital. PA #607 stated he did not give RN #733 specific instructions on how frequently he wanted Resident #85 to be checked on or vital signs to be obtained. PA #607 stated he felt it was understood the nurse would continue watching the resident because there was clearly a change in his condition that needed to be addressed. Interview via email on 05/28/24 at 12:39 P.M. with the DON confirmed STAT labs were expected to be drawn within four hours and then resulted within another four hours after being drawn. Physicians, PA's, or Certified Nurse Practitioner's (CNP's) who ordered the labs or the on-call provider scheduled depending on when the results are reported to the facility should be notified immediately of any critical or abnormal lab results. The DON confirmed the STAT lab turnaround times had not been communicated to the on-call providers to her knowledge. A facility policy related to responding to a change in condition was requested at the time of the survey, however, the facility did not have a policy. The deficiency represents non-compliance related to allegations contained in Complaint Number OH00153177.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, review of equipment use instructions review of a facility investigation and interviews, the facility failed to ensure Resident #216 was safely transported to prevent a fall with injury. Actual harm occurred on 05/30/23 when State Tested Nursing Assistant (STNA) #241 was transporting Resident #216 while seated on the seat of a wheeled (rollator) walker, the wheels of the walker got caught on the threshold to the shower room, resulting in the walker flipping over and the resident falling backwards onto the floor hitting his head and back. The resident was subsequently transported to the hospital for evaluation and diagnosed with bilateral subdural hematoma and a closed left seventh rib fracture requiring medical interventions. This affected one resident (#216) of five residents reviewed for falls. The facility census was 106. Findings include: Review of the closed medical record for Resident #216 revealed an admission date of 05/26/23 and discharge date of 05/30/23. Resident #216 had diagnoses including syncope and collapse, weakness, abnormalities of gait and mobility, cerebral infarction, and transient cerebral ischemic attack. Review of Resident #216's physician's medication orders for May 2023 revealed an order for Aspirin 81 milligrams (mg) daily for myocardial infarction and Clopidogrel Bisulfate (Plavix), which prevents platelets from sticking together and forming a clot 75 mg tablet, daily for myocardial infarction. Review of the plan of care dated 05/26/23 revealed Resident #216 was at risk for fall related injury and falls. Interventions included to encourage resident to wear appropriate footwear as needed, keep environment as safe as possible with even floors, free from spills and/or clutter, adequate lighting, call light within reach, commonly used items within reach, avoid repositioning furniture and keep the bed in the appropriate position. Provide resident with activities that minimize the potential for falls while providing diversion and distraction, Physical/Occupational therapy to evaluate and treat as ordered and as needed. The care plan was updated on 05/30/23 to reflect the use of a wheelchair as needed for transfers. Review of Resident #216's five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was independent with daily decision making and displayed no memory concerns or behaviors. The assessment revealed Resident #216 required supervision from one staff member for bed mobility, transfers, toilet use, personal hygiene, limited assistance from one staff member for ambulation and dressing. The assessment did not identify any impairment to bilateral upper and/or lower extremities and noted the resident required the use of a wheelchair for mobility. Review of an incident and accident investigation form dated 05/30/23 at 4:50 A.M. revealed Resident #216 was ambulating with his rollator to the shower, his legs felt weak, and he sat on the seat of the rollator. STNA #241 pushed him on the rollator to the shower room. The wheel on the rollator got stuck on the threshold and the resident fell back. An assessment of the resident was completed along with neuro-checks and vital signs. The physician was contacted who gave an order to administer pain medication (Tramadol) every six hours as needed for pain. The investigation noted no orders or recommendations were made to send the resident to the emergency room for evaluation. Review of a nurse's note dated 05/30/23 at 6:00 A.M. created by Licensed Practical Nurse (LPN) #13 revealed, Guest was sitting in the walker and aide was pushing the walker with guest on the hallway to give him a shower. The wheels from the walker got stuck where the floor is connected. [NAME] tipped over and the guest fell on his back and hit his head. Vitals within normal limits. Neuro checks started and continue. Guest able to move all the extremities and walk around with assistance. Guest has an abrasion on the back of the head. Son notified and Medical Director made aware. Review of a summary of staff interview for STNA #241 dated 05/30/23 revealed the resident was walking to the shower room using his rollator, he said he felt weak in the legs and sat down on the rollator seat. The summary revealed we were very close to the shower room, so I pushed him by his rollator into the shower room, the wheels got caught on the threshold and he fell on his back. An addendum was added to the employee's statement during the onsite investigation (dated 06/23/23) which included the resident stated to STNA #241 just push me the rest of the way, while he was seated on the rollator. The employee stated she thought because he requested, then it was his right, he was alert and oriented. On 05/30/23 (exact time unknown) the resident left the facility with his son to go to a pre-scheduled physician appointment. Review of a nurse's note dated 05/30/23 at 2:03 P.M. created by LPN #174 revealed the resident had a scheduled appointment that his son transported him to. At this appointment the resident was sent to hospital on [DATE]. Review of the physician's office progress note dated 05/30/23 revealed Resident #216 was being seen for follow up on recent stay at hospital for a fall. Follow up after two recent hospitalizations on 05/22/23 and 05/24/23 for generalized weakness, multiple falls, urinary tract infection and confusion. He was discharged to a rehab facility for Physical Therapy (PT) and strengthening. States he fell again this morning- was being pushed on the seat of his walker down to the rehab and the walker tipped forward causing him to fall off the front onto the back of his head. The resident reported head pain and left rib pain. He reported headache and denied any loss of consciousness. Due to the severity of his fall and blood thinner usage, it was recommended he be seen at the emergency department for a cat scan (CT) scan and evaluation of his ribs. The resident agreed and was taken to emergency department via wheelchair. Review of the emergency department notes dated 05/30/23 revealed Resident #216 presented with left rib pain as well as posterior head and neck pain. He was being pushed on his walker, it tipped over and he hit the back of his head. No loss of consciousness. He takes Aspirin and Plavix. Impression: Traumatic subdural hemorrhage without loss of consciousness and closed fracture to ribs, left side. X-ray revealed possible sixth and seventh rib fracture and admit for observation. Review of chest x-ray imaging dated 05/30/23 revealed in the result, Probable minimally displaced lateral left 7th rib fractures. No associated effusion or pneumothorax. Review of the CT of the head and C-spine of the left rib dated 05/30/23 revealed bilateral subdural hematoma, worse on the right. Patient was neurologically intact, airway was intact, does not require intubation. X-ray interpreted as no pneumothorax, possible sixth and seventh rib fracture. Review of hospital Discharge summary dated [DATE] at 1:52 P.M. revealed the discharge final diagnoses included acute bilateral subdural hematomas, and acute left 7th rib fracture. The hospital course summary revealed, Patient is an [AGE] year-old male status post ground level fall. Patient states he was being pushed by a staff member at facility in his walker when they hit a bump and patient fell out and hit the back of his head. The patient was taken to hospital for evaluation. CT found bilateral subdural hematoma and CT found left 7th rib fracture. Patient was transferred to another hospital for further trauma evaluation with nursing consulted who managed the patient conservatively. The nurse signed off with a plan for outpatient follow up in 4-6 weeks. Interview on 06/20/23 at 9:30 A.M. with the Director of Nursing (DON) revealed when a resident experiences a fall that is witnessed and the resident is noted to hit their head, no matter what, neuro checks would be completed and it was up to the physician who was notified if the resident was to be sent out to the hospital even if that resident was on blood thinners or not. Continued monitoring would occur. On 06/20/23 at 10:22 A.M. an attempt to call Physician #300 who provided the order for Tramadol for Resident #216 on 05/30/23 after fall was made. The call was unsuccessful and the physician did not call the surveyor back. On 06/20/23 at 10:27 A.M. attempts to call STNA #241 and LPN #13 were also unsuccessful with no return call. On 06/21/23 at 3:30 P.M. interview with Certified Medical Assistant (CMA) #299 revealed CMA #299 worked for the medical group where Resident #216 had a follow up appointment on 05/30/23. CMA #299 revealed she completed the intake for this patient on 05/30/23 and after being told by the resident what occurred (the fall at the nursing home), the decision was made to send him to the emergency room (ER) for evaluation. The resident told her he was sitting on a wheeled walker and the person pushing him hit a bump and he was catapulted out of the chair and hit his back and head. CMA #299 indicated since the patient was on blood thinners, it was best for him to go to the ER for evaluation. Review of user instructions and warranty document for a Basic Steel Rollator with 8 wheels rolling walker revealed under Safety Instructions, General Cautions: Do not self-propel the rollator while seated. Rollators are intended for individual use only and are not to be used as a wheelchair. Serious injury to the user and/or damage to the rollator's frame or wheels may result from improper use. All wheels must be in contact with the floor and/or ground at all times. This will ensure the rollator is properly balanced. Seat Cautions: The brakes must be in the lock position before sitting on the seat. Do not use seat to transport people or objects. This deficiency represents non-compliance investigated under Complaint Number OH00143418.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, policy review and review of the National Pressure Injury Advisory Panel (NPIAP) guidelines, the facility failed to implement an effective pressure ulcer prevention and treatment program for Resident #47 and Resident #63. Actual harm occurred on 01/02/23 when Resident #47, who was mildly cognitively impaired and dependent on staff for turning and repositioning, was identified to have an open area to the buttocks. The area was not staged, and no treatment orders were implemented. On 01/05/23 the resident was assessed to have a Stage III (full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epiboly (rolled wound edges) are often present) pressure ulcer to the buttocks. The facility failed to implement effective preventive pressure ulcer interventions for the resident, failed to implement timely skin assessments, and failed to implement a treatment timely following the identification of the Stage III pressure ulcer following the resident's re-admission to the facility status post an above the knee amputation. This affected two residents (Resident #47 and Resident #63) of four residents reviewed for pressure ulcers. Findings include: 1. Medical record review for Resident #47 revealed an admission date of 06/24/22 with medical diagnoses included diabetes mellitus, chronic kidney disease, peripheral vascular disease, cognitive communication deficit, weakness, severe protein calorie malnutrition, and absence of right leg above the knee amputation. Review of physician's progress note dated 12/09/22 revealed Resident #47 was to go out for elective surgery planned for 12/12/22 for a right above the knee amputation right (AKA). Further review of the notes revealed he left the facility for surgery on 12/12/22 and returned to the facility on [DATE]. Review of care plan dated 12/20/22 revealed the resident had actual impairment to his skin post surgery. Interventions were to apply a pressure reducing mattress, pillows to protect the skin while in bed, encourage good nutrition and hydration in order to promote healthier skin, provide dietary supplements, and to turn and reposition every two hours and as needed. The location of the skin impairment was the right AKA. Review of Medicare 5-day Minimum Data Set (MDS) 3.0 assessment, dated 12/27/22 revealed Resident #47 was moderately cognitively impaired. His functional status was extensive assistance for bed mobility, and toilet use with one-person assistance. He was supervision for eating. He was always incontinent for bowel and bladder. He wasn't coded for any skin issues on this MDS. Review of bed bath for Resident #47 revealed on 12/30/22 he did not have skin impairment to his buttocks. Review of skin assessment dated [DATE] for Resident #47 revealed there was an area that measured 6.0 centimeters (cm) by 4.9 cm with no depth. There was not any description or where this wound was and it was not staged. The wound was later identified as being located on the buttocks. Review of physician orders and Treatment Medication Record (TAR) dated 12/20/22 through 01/02/22 revealed there was not preventive measures in place to prevent a pressure ulcer. There was not any evidence the resident was being turned or repositioned. Review of physician orders and the TAR dated 01/02/23 revealed there was not a treatment implemented for the left and right buttocks wound. Review of wound physician's progress notes dated 01/05/23 revealed it was reported last week Resident #47 needed evaluation and management of the right and left buttocks wound. The resident had been mostly bed bound since his right AKA and has not been able to turn and reposition himself. The buttocks had been treated with Triad Paste. Further review of the wound notes dated 01/05/23 revealed Resident #47's left buttock was a Stage III pressure ulcer that measured 6.2 cm by 0.2 cm with 100% granulation with light serosanguinous drainage peri-wound area was pink and intact, wound edges were attached. There was not any tunneling or undermining, no odor or signs of infection, the new order was to cleanse with normal saline, pat dry, and apply Triad Paste and leave open to air twice a day. New interventions were to place an air mattress to bed, turn and reposition every two hours and provide protein liquid twice a day for wound healing. Further review of the wound notes dated 01/05/23 revealed Resident #47's right buttock was Stage III pressure ulcer that was 3.7 cm by 0.2 cm with 100% granulation, light serosanguinous drainage, peri-wound area was pink and intact and the wound edges were attached. There wasn't any tunneling or undermining and no odor or signs of infection. The treatment was to cleanse with normal saline, pat dry, apply Triad Paste and leave open to air twice a day. New interventions were to place an air mattress to bed, turn and reposition every two hours and provide protein liquid twice a day for wound healing. Observation of a wound care treatment for Resident #47 on 01/11/23 at 10:28 A.M. revealed there was a light amount of drainage and beefy red parts to the left and right buttocks. The skin looked like it had been peeled back on his buttocks. The wound nurse, Licensed Practical Nurse (LPN) #241, cleaned his buttocks with normal saline and placed Triad paste on the areas. Interview with the LPN #241 on 01/11/23 at 10:45 A.M. revealed when Resident #47 came back from the hospital on [DATE] he didn't have any skin impairment on his buttocks. She confirmed there wasn't any preventive orders in place when he returned from the hospital to prevent a buttocks wound. She said on 01/02/23 an aide approached her and said come and take a look at the residents' bottom and it was discovered he had breakdown. She said she measured the area and thought there was a treatment in place for the Triad paste, but she should have done it herself so to be sure it was done. She confirmed she didn't stage the wound because she waited for the nurse practitioner to come in on 01/05/23 to put in the description of the wound and the stage. She said on the skin assessment dated [DATE] she didn't put where the area was but the measurement was for the left and right buttock and then when the wound nurse came into the facility she separated the areas out to different areas. She said the staff were not doing their job with turning and repositioning the resident because he didn't have any skin impairment on his buttocks when he returned back from the hospital. Interview with State Tested Nursing Aide (STNA) #289 on 01/11/23 at 11:23 A.M. revealed turning and repositioning was not getting done due to lack of staff. Review of the physician order for Resident #47 revealed the air loss mattress was not in place until 01/15/23. Interview with LPN #241 on 01/19/23 at 7:50 A.M. revealed the air loss mattress should have been placed on the bed before 01/15/23 since the wound nurse had ordered it on 01/05/23. Interview with Wound Nurse Practitioner (WNP) #501 on 01/19/23 at 7:58 A.M. revealed the first time she saw Resident #47 he had two Stage III pressure ulcers on his left and right buttocks. She stated the facility notified her on 01/02/23 and an order for the Triad Paste was given. She was unaware the Triad Paste was not implemented. She confirmed the air loss mattress should have been ordered on 01/05/23 and placed on the resident's bed. She stated Resident #47 was very compromised after his surgery for his amputation and he had to learn to live without the leg. She stated he could move around really well before the surgery, but after the surgery he needed help with turning and repositioning. She thought his lack of turning and repositioning could be a factor in the development of the wounds on his buttocks. She didn't feel like there was enough staff to do the turns but only knew the aides were always rushing around to complete their tasks. Review of policy entitled, Skin Management, dated 12/15/22, revealed it is the policy that the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries. Residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. A weekly total body skin evaluation was completed for each resident by the licensed nurse. The licensed nurse would document findings of the skin evaluation. Review of the NPIAP guidelines dated 2014 pages 70-71 at https://npiap.com/general/custom.asp?page=2014 Guidelines revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure. Further review revealed Stage 3 Pressure Injury is a full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epiboly (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. 2. Review of the medical record for Resident #63 revealed an admission date of 03/05/2020 with medical diagnoses of right sided hemiparesis following cerebral infarction (CVA), diabetes mellitus (DM), dysphagia, aphasia, hypertensive chronic kidney disease, hyperlipidemia, chronic kidney disease stage 3, and benign prostate hypertrophy. Review of the medical record for Resident #63 revealed a physician order dated 01/20/22 to encourage Prevalon boot (pressure reducing boots) placement to bilateral feet every shift. Review of the medical record for Resident #63 revealed no documentation to support the facility implemented Prevalon boots as ordered. Review of the medical record for Resident #63 revealed an at risk for impaired skin integrity care plan due to decreased mobility, CVA with right hemiparesis, and decreased range of motion (ROM) to bilateral lower extremities (BLE). Interventions included an air mattress, conduct weekly head to toe skin assessments, and skin prep as ordered to left knee, right knee, right foot and second toe. Review of the medical record for Resident #63 revealed a skin and wound assessment dated [DATE] which stated Resident #63 had a diabetic ulcer to great toe on right foot which healed 09/28/22. No other wound areas noted. Review of the medical record for Resident #63 revealed an assessment titled, Skin and wound total body skin assessment, dated 12/01/22, which stated resident had no new wounds. Observation on 01/08/23 at 1:57 P.M. revealed Resident #63 lying in bed, wearing a hospital gown. Resident #63 did not have Prevalon boots to bilateral lower extremities in place. Observation on 01/09/23 at 1:42 P.M. revealed Resident #63 lying in bed, wearing a hospital gown. Resident #63 did not have Prevalon boots to bilateral lower extremities in place. Observation on 01/10/23 at 8:25 A.M. revealed Resident #63 lying in bed, wearing a hospital gown. Resident #63 did not have Prevalon boots to bilateral lower extremities in place. Interview on 01/10/23 at 9:11 A.M. with Registered Nurse (RN) #16 confirmed Resident #63 had an order for Prevalon boots to BLE and to encourage the resident to wear the boots. RN #16 confirmed Resident #63 did not have Prevalon boots to BLE and RN #16 stated she could not recall the last time the resident wore the boots. Review of the policy titled, Skin Management, revised 12/15/22, stated guests/residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated, and provided appropriate treatment to promote prevention and healing. This deficiency represents non-compliance investigated under Master Complaint Number OH00139431 and Complaint Number OH00139427.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff and family interview, and policy review, the facility failed to implement timely interventions to decrease the risk for falls for Resident #256 who was a new admission and identified to have a history of falls and cognitive impairment. Actual harm occurred to Resident #256 when there was not a baseline care plan with fall interventions implemented, resulting in an unwitnessed fall on 12/31/22 and hospitalization where she was found to have a right fibular fracture. This affected one resident (Resident #256) of four residents reviewed for falls. The census was 106. Findings include: Medical record review for Resident #256 revealed an admission date of 12/28/22 with admitting diagnoses including displaced Trimalleolar fracture of right lower leg. Further diagnoses included history of falling, esophageal varices, renal insufficiency, cognitive communication deficit, and cirrhosis of the liver. Review of Nursing Comprehensive Evaluation upon admission dated 12/28/22 revealed it was not completed. Review of 48 hours baseline care plan for Resident #256 revealed there wasn't any evidence of a care plan within 48 hours of admission. Review of progress note dated 12/31/22 at 3:05 A.M. revealed Resident #256 was found on the floor sitting with legs facing backwards and she stated she was trying to go to the bathroom and slid from the bed. The staff were unable to pick her up off the floor due to the position she was sitting and called emergency services to come and pick her up off the floor and took her to the hospital for evaluation. Review of the hospital records dated 12/31/22 for Resident #256 revealed she had an unwitnessed fall at the facility and a right knee x-ray showed Proximal Fibular Fracture. It was agreed to place a knee immobilizer since she had a cast on this same leg from a recent operation. Review of the fall investigation, not dated, revealed Resident #256 was observed on the floor in her room and said she was trying to get up out of bed to go to the bathroom and slid off the side of the bed. She was sitting on the floor with legs facing backwards. She was a new admission and her mental status was the same as on admission which was alert and slightly confused. She was bare footed at the time of the fall. The last time she was toileted was at 11:00 P.M. and she was continent when she was found on the floor. Her vital signs were within normal limits. There wasn't a root cause analysis for the fall. Review of Medicare five-day Minimum Data Set (MDS) dated [DATE] revealed Resident #256 was moderately cognitively impaired. She was an extensive assistance for bed mobility, total dependence for transfers, and toilet use. She was independent for eating. She was always incontinent for bladder and bowel. She was coded for not steady for surface o surface transfers and required stabilization with staff and used a wheelchair. Observation and attempted interview with Resident #256 on 01/08/23 at 10:00 A.M. revealed she was lying in bed and was confused and couldn't answer appropriately to the questions for the interview. Interview with family at the time of the observation revealed the resident fell and had a major injury on the early morning of 12/31/22 and broke her leg and was sent out to the hospital. He stated this fracture was to the same leg that had a fracture fixed before coming to the facility. He revealed she was confused and was on Lactulose because of her ammonia levels, which was an ongoing problem for the resident. He stated ever since the resident fell at the facility he has stayed 24/7 to ensure she stayed safe. Review of physician notes dated 01/10/23 revealed Resident #256 sustained an open right trimalleolar ankle fracture (prior to admission) on 12/06/22 and on 12/21/22 there was a planned orthopedic procedure for the right ankle. Interview on 01/17/23 at 11:03 A.M. with Director of Nursing (DON) revealed they placed the resident on one on one when she came back from the hospital following the fall on 12/31/22 because of her confusion and didn't want her to get back out of the bed and fall. She confirmed there wasn't a 48 hour care plan initiated, no fall interventions in place, and no fall assessment was completed. She further confirmed the resident had metabolic encephalopathy and was on Lactulose for it and had periods of confusion and admitted this was an unsafe practice for the resident. She admitted there wasn't a root cause analysis determined for the fall and she would have to change her fall investigation report form to reflect this. Interview with the admitting Licensed Practical Nurse (LPN) #229 on 01/17/23 at 3:40 P.M. revealed she admitted Resident #256 on 12/28/22. She said she was on orientation on the evening of 12/31/22 but couldn't remember the nurse who was her mentor. She stated she didn't put in the baseline care plan for Resident #256 on this night. She admitted the resident wasn't alert and oriented and should have put in a care plan and assessment at the very least for falls. Interview with LPN #17 on 01/17/23 at 3:53 P.M. revealed she cared for Resident #256 on 12/31/22. She stated she only saw her between 7:00 P.M. to 8:00 P.M. that evening for a medication administration until she had the fall around 3:05 A.M. She stated the resident was slightly confused when she administered her medication. Interview with State Tested Nursing Aide (STNA) #500 on 01/17/23 at 3:59 P.M. revealed she cared for Resident #256 on 12/31/22 at the time of her fall. She said she saw her around 11:00 P.M. and changed her. She stated the resident's husband stated he was tired and wanted to go home for some rest and wasn't going to stay the night with the resident. The aide said she received in report the resident was confused and may want to keep a close eye on her. She said she checked on the resident but didn't know what time and didn't have documentation of it either. She stated she heard a loud boom at about 3:00 A.M. and found the resident was barefooted and slid off of the bed on to the floor and had to be sent out to the hospital. She stated she had the bed in low position. Attempted to interview Registered Nurse (RN) #502 on 01/19/23 at 10:30 A.M. who was the trainer on 12/31/22 but she wasn't available. Review of policy entitled, Fall Management, dated 08/18/22, revealed each resident is assisted in attaining/maintaining his or her highest practical level of function by providing the resident adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk for falls. Residents will be evaluated by the interdisciplinary team for their risk for falls. A plan of care is developed and implemented based on this evaluation with ongoing review. If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls. 1. The licensed nurse will evaluate residents for fall risk upon admission and re-admission, quarterly, annually and with a significant change in condition. 2. Residents identified at risk for falls will have an initial plan of care developed to meet each guest/resident's needs. Interventions should be related to the risk factors as well as incorporating resident choice to help minimize the risk of a fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, review of facility policy, review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), and review of an online resources regarding pain in dementia residents, the facility failed to ensure Resident #15's pain was managed during a dressing change to a Stage III pressure ulcer. Actual Harm occurred on 01/09/23 when Resident #15 was not medicated for pain prior to wound care which resulted in the resident exhibiting signs (yelling out, moaning and grimacing) of severe pain. This affected one resident (#15) of one resident reviewed for pain management. Findings include: Review of Resident #15's medical record revealed she was admitted to the facility on [DATE] with diagnoses including heart failure, respiratory failure, lack of coordination, dysphagia following nontraumatic intracerebral hemorrhage, attention and concentration deficit following nontraumatic intracerebral hemorrhage, memory deficit following nontraumatic intracerebral hemorrhage, epilepsy, chronic obstructive pulmonary disease, anxiety, depression, pressure ulcer of sacral region, Stage III, attention to gastrostomy. Review of the care plan dated 10/21/22 revealed Resident #15 was at risk for pain related to Stage III pressure ulcer on her coccyx which she was unable to verbalize. Interventions included to anticipate resident's need for pain relief as needed and respond immediately to any complaint of pain. Observe and report any signs or symptoms of non-verbal pain: changes in breathing (noisy, deep/shallow, labored, fast/slow); vocalizations (grunting, moans, yelling out, silence); mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); eyes (wide open/narrow slits/shut, glazed, tearing, no focus); face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing), and report abnormal findings to the physician. Review of Resident #15's physician orders dated 11/27/22 revealed an order to cleanse sacrum wound with normal saline, pat dry, lightly pack with Dakin's soaked gauze, cover with clean dressing every day shift. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had impaired cognition. Her functional status was listed as totally dependent on staff for all activities of daily living. The MDS also revealed Resident #15 had one Stage III pressure area to her coccyx upon admission. Review of the physician orders dated 01/2023 revealed orders for Oxycodone HCl Tablet five milligrams (mg), give 0.5 tablet via percutaneous endoscopic gastrostomy tube every four hours for pain. Review of the Medication Administration Record (MAR) for Resident #15 revealed no pain medication was given on 01/09/23 prior to 12:10 P.M. Observation of a dressing change to Resident #15's coccyx wound on 01/09/23 from 12:10 P.M. through 12:25 P.M., revealed Licensed Practical Nurse (LPN) #241 started to undress the coccyx wound when Resident #15 started moaning, yelling out and grimacing in pain. The surveyor asked the LPN if she had medicated the resident for pain before starting and LPN #241 revealed she had not. During the wound dressing change Resident #15 continued to moan and grimace and yell out for staff to stop. Review of Resident #15's medical record revealed no evidence the resident's pain was assessed from the wound observation. Interview on 01/09/23 at 12:10 P.M. with LPN #241 confirmed Resident #15 had not been given any pain medication before her first dressing change. She revealed it was her responsibility to make sure the resident received her pain medication prior to wound care so the pain was more tolerable. LPN #241 confirmed Resident #15 was in pain during her procedure and she did not stop the dressing change. Review of the facility policy titled, Pain Management, dated 07/09/23, revealed the staff would implement the care plan, monitor the guest/resident, and administer therapeutic interventions for pain control. The nursing staff would identify any situations or interventions where an increase in the resident's pain may be anticipated, for example, wound care, ambulation, or repositioning. Review of the NPUAP guidelines dated 2014 page 161 at https://npiap.com/general/custom.asp?page=2014Guidelines in the section regarding Pain Management for Residents with Pressure Ulcers revealed staff should organize care delivery to ensure that it is coordinated with pain medication administration and that minimal interruptions follow. Set priorities for treatment. Pain management includes performing care after administration of pain medication to minimize pain experienced and interruptions to comfort for the individual. Review of online resource at https://www.mdapp.co/pain-assessment-in-advanced-dementia-painad-scale-calculator-550/ revealed the Pain Assessment in Advanced Dementia Scale (PAINAD) scale was a reliable tool for pain evaluation in dementia patients. The original study defines scores between zero and 10, where zero means no pain and 10 means severe pain. The scale administrator is asked to observe the patient for five minutes, either at rest, during a relaxing activity, during caregiving activities or administration of pain medication. PAINAD items include descriptions of breathing (independent of vocalization), negative vocalization, facial expression, body language, and consolability.