**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital record review, staff interview, and facility policy review, the facility failed to ensure residents received the necessary treatment and services to promote healing and prevent infections for a pressure ulcer. This resulted in Actual harm when Resident #20 ' s weekly skin assessments were not completed and subsequently led to hospitalization for a wound infection and possible osteomyelitis. This affected one (Resident #20) of three residents reviewed for pressure ulcers. The facility census was 132. Findings include: Review of the medical record for Resident #20 revealed an admission date to the facility on [DATE] and a discharge date to the hospital on [DATE], and as of 04/16/24 Resident #20 is still hospitalized . Resident #20 had a hospital diagnosis of right large heel pressure ulcer with wet necrosis with suspected superimposed infection/osteomyelitis. The resident had pertinent diagnoses of cellulitis of right upper limb, atherosclerotic heart disease of native coronary artery, type two diabetes mellitus with diabetic neuropathy, atrial fibrillation, hypertensive heart disease with heart failure, congestive heart failure, anxiety disorder, asthma, chronic kidney disease stage three, attention deficit hyperactivity disorder, restless legs syndrome, hyperlipidemia, syncope and collapse, sleep apnea, left bundle branch block, hemiplegia and hemiparesis following cerebral infarction affecting left nondominant side, insomnia, depression, and gastroesophageal reflux disease. Review of a [NAME] scale for predicting pressure sore risk assessment dated [DATE] revealed the resident had a score of 18 and was categorized as at risk for pressure ulcers. Review of a plan of care dated 01/02/24 revealed Resident #20 had impaired skin integrity to right heel with a goal of tissue injury will heal and be free from complications. Interventions included: Assess and document skin condition, notify doctor of signs of infection (redness, drainage, pain, fever), assess for pain and treat as indicated, notify physician of worsening or no improvement in wound, pressure reducing/redistributing mattress on bed, wound location: right heel and wound treatment as ordered. Review of the 03/26/24 quarterly Minimum Data Set (MDS) assessment revealed Resident #20 was cognitively intact and rejected care one to three days during the look back period. Resident #20 used a walker and wheelchair to aid in mobility and was dependent for toileting hygiene, and showering. Resident #20 required substantial to maximal assist for rolling left to right, sit tolying and lying to sitting, and sit to stand. Resident #20 had treatments in place to include pressure reducing device for chair and bed, and applications of ointments and dressings. Review of outside wound clinic assessment notes dated 03/05/24 revealed multiple wounds including an unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed) right calcaneus pressure ulcer injury that was open and was acquired 12/31/23 with wound measurements of 6.5 centimeters (cm) in length, 6.5 cm in width with a depth of 0.3 cm. Review of a Physician Order dated 03/06/24 revealed to cleanse right heel wound with normal saline, apply Exufiber dressing (no silver), cover with abdominal pad and wrap with kerlix every other day and as needed per wound clinic every night shift, every other day for wound care, and as needed for wound care. Review of the outside wound clinic assessment notes dated 03/12/24 revealed an unstageable right calcaneus pressure ulcer injury with wound measurements of 6.5 cm in length, 6 cm in width, with a depth of 0.3 cm. The next appointment date was scheduled for 03/26/24. Review of the medical record revealed there were no wound measurements or assessments from 03/13/24 until a wound assessment was completed on 04/08/24. Review of the medical record revealed there was no information on the appointment for the date of 03/26/24. Review of a progress note dated 04/02/24 revealed tried to get resident ready for wound care appointment, resident too weak to sit up straight in bed, bed bath and sheets changed by aide, and educated resident on needing a stretcher for appointments. Review of the wound assessment report from the in-house wound nurse practitioner dated 04/08/24 revealed the right heel wound was unstageable 8 cm in length, by 6.5 cm in width, with a depth of 0.5 cm. There was slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy, and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed) from 1-24% with a moderate amount of seropurulent exudate. Review of the Nurse Practitioner progress note dated 04/08/24 at 11:37 A.M. revealed spoke with nurse to confirm appointment at outside wound clinic for 04/09/24. Updated her on concerns for possible wound infection. Review of a progress note dated 04/09/24 at 5:45 P.M. revealed Resident #20 was being admitted to the hospital for wound infection per emergency room nurse. Interview with Registered Nurse (RN) #10 on 04/10/24 at 3:00 P.M. revealed Resident #20 did not go out to his wound clinic appointment on 03/26/24 and 04/02/24 because he was not feeling well. Interview with Director of Nursing (DON) on 04/15/24 at 12:05 P.M. verified there were no wound measurements or wound assessments from 03/13/24 until 04/08/24. Interview with Licensed Practical Nurse (LPN) #11 on 04/15/24 at 12:18 P.M. revealed she was wound certified and rounded with the wound Nurse Practitioner on Mondays. She stated they see patients weekly if they are on the caseload on her rounds. She stated she was notified on 04/08/24 that Resident #20 had missed the 04/02/24 wound appointments and was not notified of missing the 03/26/24 wound appointment. Residents usually have an order to measure wounds weekly. She verified she had not measured Resident #20 ' s wound from 03/13/24 to 04/08/24. LPN #11 stated if a new wound pops up and whoever does the treatment would measure it and assess the wound. She stated they quit following Resident #20 ' s wound back in February when they realized he was going out to a podiatrist at a wound clinic, and then switched over to a different wound provider. She revealed they called the wound clinic on 04/08/24 and talked to a nurse and the doctor, because the Nurse Practitioner was thinking the right heel had osteomyelitis and it had an odor. Review of the hospital records from admission date on 04/09/24 revealed Resident #20 had a wound culture that showed Methicillin Resistant Staphylococcus Aureus, Escherichia coli, and possibly extended spectrum beta lactamase. A fungus culture grew Candida Albicans. There was a right heel pressure ulcer with wet necrosis with suspected superimposed infection/osteomyelitis. The right foot x-ray showed erosion of the posterior right calcaneus compatible with osteomyelitis. Resident #20 was receiving intravenous daptomycin antibiotic. The MRI (Magnetic Resonance Imaging) for osteomyelitis was still pending. Review of the facilities skin management policy dated 10/01/19 revealed residents will have a skin assessment completed upon admission and no less than weekly by the licensed nurse in an effort to assess overall skin condition, integrity, and skin impairment. This deficiency represents non-compliance investigated under Complaint Number OH00152801.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident and staff interview, review of facility documents and review of the facility policy titled Abuse Prevention Program, the facility failed to ensure residents were protected from abuse during an investigation and failed to conduct a thorough abuse investigation. This resulted in psychosocial harm for Resident #94 after the facility failed to protect and thoroughly investigate Resident #94's allegation of emotional and verbal abuse resulting in Resident #94 being afraid to leave her room, was agitated, and tearful. This affected one (Resident #94) of three residents reviewed for abuse. The facility census was 148. Findings include: Review of the medical record for Resident #94 revealed an admission date of 03/01/22. Diagnoses included chronic pain syndrome, bipolar disorder, and chronic respiratory failure (CRF) with hypoxia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 was cognitively intact and required extensive assistance of one staff with activities of daily living (ADLs.) Review of the nursing progress note for Resident #94 dated 05/01/23 written by Unit Manager (UM) #236 revealed resident refused care when resident's call light was answered. The Director of Nursing (DON) and Social Worker (SW) #347 were made aware. Review of the concern form dated 05/02/23 revealed Resident #94 did not want UM #236 to answer her call light or be part of her care team. Further review of the form revealed the resident's request was granted and UM #236 would not be part of resident's care team. The form was signed by SW #347 and Resident #94. Review of interview statements of residents on the unit where Resident #94 resided dated 05/02/23 revealed the residents were asked if they ever had a negative encounter with a staff member, and if they had any issues regarding the nurses' approach. All residents interviewed answered no to the questions. Observation and interview on 05/17/23 at 10:13 A.M. revealed Resident #94's door was shut upon arriving to her room. Resident #94 was alert and oriented to person, time and place. Resident #94 became tearful during the interview. Resident #94 stated she stayed in her room and kept her door shut so she would not have to interact with UM #236. Resident #94 stated she was afraid of UM #236, and she thought she was a bully, that she was aggressive in her approach and that she talked to her like she was a child. Resident #94 confirmed things got worse between her and UM #236 when the nurse came into her room sometime back in April 2023 and told her that she wasn't allowed to have a catheter and that she didn't need it. Resident #94 stated she felt the nurse was disrespectful to her and she told the nurse to get out of her room and that she didn't want the nurse to ever come into her room again. Resident #94 confirmed that early in May 2023, UM #236 came into her room to answer her call light and she asked her to leave. Resident #94 confirmed UM #236 argued with her about how she had to answer the call light and the resident told UM #236 to leave and to get someone else to help her. Resident #94 reported her concerns to Licensed Practical Nurse (LPN) #356. Resident #94 confirmed she was afraid UM #236 might retaliate against her for complaining and she was upset UM #236 did not honor her request to stay out of her room. Resident #94 confirmed she could still hear UM #236 talking in the hallway, so she knew she was around, and it made her uneasy. Resident #94 confirmed SW #347 and the DON met with her and told her they would move UM #236 to another unit. Interview on 05/17/23 at 10:27 A.M. with LPN #356 confirmed early in May 2023, Resident #94 reported to her that she was afraid of UM #236, and Resident #94 called UM #236 a bully. Resident #94 had asked UM #236 back in April 2023 to never come in her room again. LPN #356 confirmed Resident #94 was upset because UM #236 did not honor her request and came in her room anyway when Resident #94 put her call light on. UM #236 said she had to answer the light. LPN #356 confirmed she reported Resident #94's concerns to the DON. LPN #356 confirmed Resident #94 did not accuse UM #236 of verbal or emotional abuse, but calling someone a bully could be considered an allegation of possible abuse. Interview on 05/17/23 at 11:54 A.M. with the DON confirmed LPN #356 reported to her by phone on 05/01/23 that Resident #94 complained she didn't want UM #236 to be part of her care team anymore and she didn't like her personality or her customer service approach. The DON confirmed LPN #356 did not use the word abuse nor did she share that the resident called UM #236 a bully. The DON confirmed if a resident reported a staff member was a bully, she would consider it an abuse allegation and would handle the situation per the facility's abuse protocol. The DON confirmed SW #347 and the DON met with Resident #94 on 05/01/23 or 05/02/23. The DON confirmed Resident #94 told them she did not want UM #236 to enter her room again for any reason and if her call light was on, someone else should answer it. The DON stated the facility made the decision to move UM #236 to be manager of a different unit in the facility and the switch was made a week ago. The DON confirmed as the facility was coordinating the switch, UM #236 continued to work on Resident #94's unit, but LPN #229 was asked to respond to any nurse management needs for Resident #94 which involved direct interaction with the resident. The DON confirmed she had not obtained written statements from the resident and/or staff who may have had first-hand knowledge of the incident. The DON confirmed the facility had not initiated an abuse investigation and UM #236 was not suspended at any time in April or May of 2023. Interview on 05/17/23 at 1:51 P.M. with SW #347 confirmed the DON and herself interviewed Resident #94 on 05/01/23 or 05/02/23. SW #347 stated Resident #94 was agitated during the interview and said she didn't like UM #236's personality towards her and didn't feel comfortable with her providing care and didn't want the nurse to enter her room for any reason. SW #347 confirmed Resident #94 was reluctant to elaborate any further but said she felt UM #236 was gruff in her mannerisms and speech. Interview on 05/17/23 at 2:24 P.M. with UM #236 stated her relationship with Resident #94 was fine until she went into her room and told her she needed to stop refusing her diuretics and the risk this could cause to her health. UM #236 confirmed Resident #94 was unhappy with her because she got her indwelling catheter discontinued. In April 2023, Resident #94 told her she thought her approach was aggressive and she didn't want UM #236 to answer her call light, come in her room, or even speak to her. UM #236 confirmed she went to Resident #94's room sometime in May 2023 and the resident was very upset and told her to leave the room. UM #236 confirmed she told Resident #94 she was obligated to answer call lights, and Resident #94 told her to find someone else to assist. UM #236 confirmed she was not suspended at any time in April or May of 2023. Review of the facility policy titled Abuse Prevention Program, dated March 2021, revealed the facility should protect residents during abuse investigations. The facility would ensure timely and thorough investigation of all reports and allegations of abuse. Abuse included verbal abuse-oral or written or gestured language that willfully includes disparaging and derogatory terms to residents or their families and mental abuse which included humiliation, harassment, and threats of punishment or withholding treatments or services. The facility should also ensure the reporting and filing of accurate documents relative to incidents of abuse. Employees of the facility who have been accused of resident abuse shall be suspended from duty immediately until the results of the investigation have been reviewed by the Administrator. This deficiency represents non-compliance investigated under Complaint Number OH00142514.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, review of Emergency Medical Services (EMS) run report, review of hospital records, review of facility investigation, and review of facility policy, the facility failed to provide necessary supervision for Resident #108, who was assessed by the facility to be a moderate fall risk. Actual harm occurred on 12/03/22 when Resident #108 sustained an unwitnessed fall with injury. Facility staff failed to provide adequate supervision during the overnight hours, resulting in Resident #108 not being found on the floor until 12/04/22 (EMS arrived on 12/04/22 at 6:35 A.M.). Subsequently, the resident was transferred to a local emergency department (ED) where she was diagnosed with acute fractures of her thoracic (T-7) (vertebrae in back) and cervical (C-7) (vertebrae in neck) areas. This affected one resident (#108) of three residents reviewed. The facility census was 151. Findings include: Review of the medical record for Resident #108 revealed an admission date of 07/21/22 with a hospital stay from 11/30/22 to 12/03/22. The resident had diagnoses including, but not limited to, Crohn's Disease, wedge compression fracture of T-7 and T-8 vertebra, wedge compression fracture of lumbar (L-4) vertebra, diverticulosis of intestine, anemia, hyperlipidemia, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #108 dated 11/11/22, revealed resident was cognitively intact. Resident #108 required supervision with transfers and bed mobility. The resident was noted to be independent with walking in her room. Review of the Morse Fall Scale assessment for Resident #108 dated 07/21/22, revealed the resident was at moderate risk for falling. Review of the plan of care for Resident #108 dated 07/22/22, revealed the resident was at risk for falls or fall related injuries related to weakness, Crohn's disease, and pain. Interventions included assisting resident with transfers, encouraging resident to use call light for assistance, and keeping the pathways clear and well lit. Review of the Morse Fall Scale assessment for Resident #108 dated 11/19/22, which was completed after a previous fall, revealed the resident was assessed to be at a high risk for falling. Review of the hospital paperwork for Resident #108, revealed the resident was admitted to the hospital on [DATE] related to stomach pain and bloating and released back to the facility on [DATE]. Review of the nursing notes for Resident #108 dated 12/03/22 at 6:43 P.M., revealed the resident returned to the facility from the hospital via private transportation and resident reported she felt a lot better. Notes indicated Resident #108 reported she had pain in her shoulder and back, was noted to have eaten her dinner in her room and orders were verified with the physician as well as admission vital signs and weight were obtained. Review of the aide charting for Resident #108 dated 12/03/22, revealed no documented entries from 7:00 P.M. to 7:00 A.M. Review of the EMS run report for Resident #108 dated 12/04/22 at 6:35 A.M., revealed EMS responded to the nursing home related to injuries from a fall for Resident #108. EMS report indicated resident stated she had been on the floor since 12/03/22 at 9:45 P.M. after falling while turning off her lights. EMS report indicated Resident #108 reported tenderness to her neck region, denied back pain and had a laceration to the back of her which was difficult to visualize due to matted hair. The resident was able to stand with assistance from EMS staff and Resident #108 was taken to a local emergency room for further evaluation. Review of the hospital paperwork for Resident #108 dated 12/04/22 at 6:56 A.M., revealed the resident arrived at the hospital ED after a fall at the nursing home. Notes indicated Resident #108 stated she fell on [DATE] around 10:00 P.M. and remained on the floor until she was checked on the next morning. Notes indicated the resident fell while trying to turn off her Christmas lights. Notes indicated the resident reported she turned too quickly, lost her balance, and fell on the floor. Notes indicated resident had an acute closed wedge compression fracture of the T-7 vertebra and a compression fracture of the C-7 vertebra. Review of the nursing notes for Resident #108 dated 12/04/22 at 8:11 A.M., revealed the resident was found in the supine position on the floor of her room and next to her couch with her walker next to her. Notes indicated the resident stated she fell trying to walk to bed from the window area and there was blood was noted to the back of resident's head. Resident was sent to a local hospital via EMS and the physician and family were notified of the incident. Review of the nursing notes for Resident #108 dated 12/04/22 at 11:47 A.M., revealed the facility received a report from the hospital stating the resident would be returning to the facility. Notes indicated resident had T-7 lumbar compression fracture, head injury, and a cervical collar was to be worn at all times except during bathing. Notes indicted resident was ordered to follow up with neurosurgeon. Notes indicated there were orders to cleanse head wound daily and apply antibiotic ointment daily until healed. Review of the Interdisciplinary Team (IDT) notes for Resident #108 dated 12/04/22 at 1:09 P.M., revealed the resident was observed on the floor during night shift and sent to the ED. Notes indicated resident reported she was turning her Christmas tree lights off and when she turned around and lost her balance. Notes indicated the resident reported she did not get dizzy or lightheaded and she had her gym shoes on. Notes indicated staff would encourage the resident to allow staff members to turn off Christmas lights or they could remain on if the resident wishes. The Family was made aware of all new orders. Review of the nursing notes for Resident #108 dated 12/04/22 at 3:26 P.M., revealed the resident returned from the hospital after the fall. Notes indicated the resident had cervical collar in place related to her compression fracture and the cervical collar was to stay in place at all times until the resident saw the neurologist. Notes indicated Resident #108 was re-educated about the use of call light and resident voiced her understanding. The resident continued on neurological (neuro) checks per facility policy. Review of the nursing notes for Resident #108 dated 12/04/22 at 6:20 P.M., revealed the nursing staff spoke with family to notify them the resident would be placed on frequent checks throughout the night. Review of the untitled facility documentation for Resident #108 revealed the resident was placed on 15-minute checks from 12/04/22 at 7:00 P.M. through 12/05/22 at 7:00 A.M. Review of the facility interviews dated 12/05/22 with Licensed Practical Nurse (LPN) #35 confirmed she was the nurse taking care of Resident #108 on 12/03/22 from 7:00 P.M. to 7:00 A.M. Notes indicated LPN #35 reported she gave the resident her nighttime medication around 9:30 P.M. and the nurse reported she did not go back into resident's room until around 6:00 A.M. on 12/04/22 when State Tested Nursing Aide (STNA) #23 alerted her that Resident #108 was on the floor at which time LPN #35 called 911. Notes indicated LPN #35 confirmed she did not do rounds that evening and thought the aide was completing rounds. Additionally, LPN #35 verified she knew Resident #108 had just returned from the hospital and the resident was feeling weak. Notes indicated LPN #35 did not check on resident because she had said before that she did not want to be disturbed during nighttime hours because she liked her sleep. Notes indicated resident was usually self-sufficient. Review of the updated care plan dated 12/14/22 for Resident #108, revealed new interventions to allow staff to turn off Christmas lights or leave them on and encouraging the resident to use the call light for assistance. Care plan revealed no documentation regarding checking on the resident at night. The surveyor attempted to call LPN #35 on 02/11/23 at 10:45 A.M. and 11:30 A.M. with no success. The mailbox to the phone number was full and no call back was received. Review of the facility witness statement provided by STNA #23 dated 12/05/22 at 9:36 A.M. confirmed that she was taking care of Resident #108 on 12/03/22 from 7:00 P.M. to 7:00 A.M. The statement indicated STNA #23 last observed Resident #108 on 12/03/22 around 10:00 P.M. when resident took her nighttime medications. Notes indicate the resident said goodnight and was going to bed. Notes indicated the resident had reported in the past, she did not like to be disturbed in the middle of the night, because she does everything for herself. Notes indicated STNA #23 went into the room on 12/04/22 at 6:00 A.M. to get the residents morning weight and Resident #108 was lying on the floor next to her wardrobe and couch. The statement went on to say the resident's walker was near her, and resident said she was turning off her Christmas lights when she fell. Notes indicated the resident reported she could not reach her call light or phone for help. Notes indicated the nurse called 911. Review of an additional interview dated 02/10/23 and completed by the Director of Nursing (DON) with STNA #23, confirmed she he went into resident's room on 12/04/22 at around 6:00 A.M. to get resident's weight when she found Resident #108 on the floor. Notes indicated STNA #23 reported she knew about rounding two hours, but the resident had told her before that she did not want to be disturbed during the night. Phone interview on 02/11/23 at 10:50 A.M. with STNA #23 confirmed she was the aide taking care of Resident #108 on the night shift of 12/03/22 from 7:00 P.M. to 7:00 A.M. STNA #23 confirmed the last time she saw Resident #108 was on 12/03/22 at 10:00 P.M. and she did not see the resident again until 12/04/22 at 6:00 A.M. when she was going to obtain the residents weight. STNA #23 indicated she never heard any yelling or crying from the resident's room while taking care of other residents around Resident #108's room. STNA #23 also confirmed she never opened the door to Resident #108's room from 10:00 P.M. to 6:00 A.M. because resident would hit the call light if she needed anything. Review of the call light logs dated 12/03/22 and 12/04/22 for Resident #108, revealed the call light was never activated during the night shift on 12/03/22 from 7:00 P.M. to 7:00 A.M. Interview on 02/11/23 at 6:30 A.M. with the Director of Nursing (DON), confirmed there was no aide charting for Resident #108 on 12/03/22 from 7:00 P.M. to 12/04/22 at 7:00 A.M. The DON also confirmed there was no documentation of the resident being checked on from 12/03/22 at approximately 10:00 P.M. until 12/04/22 at about 6:00 A.M. The DON stated that staff were expected to make regular rounds on each resident regardless of how much assistance they needed. The DON additionally stated the resident had stated in the past, she did not want to be bothered at night, however, also verified this reported information was not documented anywhere in resident's medical records. Review of the facility policy titled Fall Management dated 01/2023, revealed the resident would be assessed immediately and necessary treatment would be provided. Policy indicated the physician would be contacted immediately to receive any orders, This deficiency was an incidental finding discovered during the complaint investigation completed on 02/21/23.