**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, facility policy and procedure review, self-reported incident (SRI) review, and facility investigation review the facility failed to prevent an incident of neglect when Resident #42 was not properly assisted with activities of daily living (ADL) including bed mobility, bathing, and incontinence care according to the resident care card to prevent an injury. Actual Harm occurred on 10/27/23 during the 7:00 P.M. to 7:00 A.M. shift when Resident #42, who was dependent on staff for ADLs, including two-person assistance for bed mobility, bathing, and toileting, was found with significant bruising including deep purple bruises on her forehead, under her left and right eyes, and on the outside of her left eye. The injuries were determined by the facility to be the result of Agency State Tested Nursing Assistant (STNA) #611 providing care without another staff member assisting on 10/27/23 during the 7:00 P.M. to 7:00 A.M. shift for the resident including a bed bath, changing all of the resident's bed linen while she was in bed, and providing incontinence care. The resident's injuries were assessed to be consistent with the resident's face being hit against the half side rail of the bed with no other explanation of the injuries provided. This affected one resident (#42) of three residents who were dependent on two staff for their ADL care, including bed mobility. The facility identified 28 residents (#1, #3, #4, #5, #7, #11, #12, #14, #17, #18, #24, #26, #31, #34, #36, #37, #39, #41, #42, #44, #46, #52, #55, #56, #57, #58, #60, and #61) who were dependent on two-staff assistance with bed mobility. The facility census was 62. Findings Include: Review of the medical record for Resident #42 revealed an admission date of 03/03/16 with diagnoses including Alzheimer's disease, psychotic disturbance, and diabetes. Review of the care plan dated 03/10/16 revealed Resident #42 had an ADL self-care performance deficit related to weakness, decreased mobility, and alteration in cognition. Interventions included bed mobility and transfer with staff assistance (refer to resident care card). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. Resident #42 rejected care one to three days during the seven-day assessment reference period. She was dependent on staff for ADL, including rolling left and right, transfers, and toileting. She was always incontinent of bowel and bladder. Review of the resident care card dated 10/23/23 revealed Resident #42 was oriented to self only. She required a turn schedule with two-staff assistance with bed mobility, a mechanical lift (a machine that transfers a resident from surface such as wheelchair to bed) with two-staff assistance for transfers, and two-staff assistance with toileting. She was unable to ambulate. She was incontinent of bowel and bladder and was to be checked and changed every two hours. Review of the nursing note dated 10/28/23 at 10:08 A.M. and completed by Registered Nurse (RN) #607 revealed he was notified by staff that Resident #42 had bruising to her facial area. She was assessed and had deep purple bruises on her forehead, under her left and right eyes, and on the outside of her left eye. She was confused when asked how it happened and stated, it happened outside the school. Nurse Practitioner (NP) #902 was notified and ordered the resident to be sent to the emergency room (ER) for an evaluation. The Administrator and Resident #42's Power of Attorney (POA) were notified. Review of the After Visit Summary dated 10/28/23 revealed Resident #42 was seen by ER Physician #701 due to fall and closed head injury. The summary report revealed a computed tomography (CT) scan was completed of her cervical spine, facial bones, head, and left hip. She also had a chest and pelvis x-ray. All testing was essentially negative, and he recommended no new orders. Review of the nursing note dated 10/28/23 at 11:08 A.M. and completed by RN #607 revealed he received a call from the hospital, and Resident #42 would be returning to the facility as all x-rays and CT scans were negative. Review of the facility SRI tracking number 240643, dated 10/29/23 revealed the Administrator reported (to the State agency) an injury of unknown source for Resident #42. The report indicated on 10/28/23 at 8:40 A.M. STNA #608 and Agency STNA #609 notified RN #607 that Resident #42 had bruising to her face. RN #607 assessed and noted purple/red bruising to her forehead, under both eyes, and surrounding tissue of her left eye. When interviewed, Resident #42 stated, it happened outside of the school. NP #902 was notified and ordered her to be sent to the hospital for evaluation. The SRI revealed all staff were interviewed that worked from 10/27/23 7:00 A.M. to 10/28/23 at 8:40 A.M. The investigation revealed STNA #700 was assigned to Resident #42 on 10/27/23 from 7:00 A.M. to 7:00 P.M. and had not noticed any bruising. The investigation revealed the Administrator interviewed Agency STNA #611, and she had stated she noticed a bump on Resident #42's forehead and her right eye was purple when she provided her with a bed bath on 10/27/23 at 8:20 P.M. without any other staff assistance. Agency STNA #611 revealed STNA #613 was providing Resident #11 (Resident #42's roommate) a bed bath at the same time, but she had not reported the bruising to STNA #613 or RN #612 (nurse on duty) as she stated, I assumed everyone knew. Agency STNA #611 revealed she checked and changed Resident #42 throughout the rest of the night providing her care without any other staff assistance. The facility investigation concluded that it appeared the resident was turned and repositioned by Agency STNA #611 and hit her face on the half upper side rail. The SRI was substantiated, and Agency STNA #611 was not to return to the facility. As an intervention, the facility padded the residents side rails. Observation on 11/16/23 at 8:57 A.M. revealed Resident #42 had bruising of all different colors (yellow, green, blue, light purple, and dark purple) in the middle of her forehead, under and above her bilateral eyes, and on the outside (temple region) of her left eye. Attempts to interview Resident #42 were unsuccessful due to cognitive ability as she was unable to provide any details regarding how the bruises occurred. She denied pain. Interview on 11/16/23 at 2:20 P.M. with RN #607 revealed on 10/28/23 around breakfast time STNA #609 stated Resident #42 had bruising to her face. He revealed he went and assessed, and she had raccoon eyes as she had bright red to dark red to purple bruising to her bilateral eyes, forehead, and on the outside of her left eye (temple region). He stated he felt they were fresh new bruises by the appearance. He revealed he had not received anything in the report and/or seen anything in her medical record regarding the bruising. He contacted NP #902 who ordered the resident to be sent to the emergency room. He revealed there was no way the resident fell as she would have been unable to get back up unless two staff assisted with a mechanical lift as she was heavy as well as dead weight. He revealed the resident was fully dependent on two staff for her ADL care, including bed mobility, bathing, and toileting as she was difficult to roll over. He revealed he did not feel one person could safely provide ADL care to the resident. Interview on 11/16/23 at 2:38 P.M. with STNA #608 revealed she remembered collecting breakfast trays on 10/28/23 with STNA #609 and noticed Resident #42 had two huge black eyes. She revealed she had purple and black bruises all around both eyes (under and above) and on her forehead. She revealed Resident #42 required two-person assistance with her ADL care as she did not assist with rolling over. Interview on 11/16/23 at 2:49 P.M. with Agency STNA #609 revealed on 10/28/23 at approximately 8:40 A.M. when she went in with STNA #608 to change Resident #42, she noticed the resident had bruising all over her face: both eyes, bridge of her nose, and forehead. She stated she asked Resident #42 what had happened, and she stated she fell going to school but was unable to provide any other information. She stated she reported the bruises to RN #607. She revealed she did not believe the resident fell as two staff would have had to assist her up with a mechanical lift as she does not bear any weight. She stated she required two staff to assist with bed mobility and provide incontinence care as she does not roll herself and would be very hard to do alone. Interview on 11/16/23 at 5:26 P.M. with Agency STNA #611 revealed on 10/27/23 she worked 7:00 P.M. to 7:00 A.M. and the aide she was working with (STNA # 613) stated that Resident #42 and her roommate, Resident #11, were scheduled for bed baths. She stated between 7:00 P.M. and 9:00 P.M. they both went into the room at the same time. She stated STNA #613 completed the bed bath for Resident #11, and she completed the bed bath and incontinence care for Resident #42. She revealed the resident required a complete linen change during the bed bath. She verified she did not ask STNA #613 for assistance in providing the care as she completed it by herself. She stated she had never received information in report that Resident #42 required two staff assist with her ADL care and was not aware of the facility had resident care cards indicating the type of care the residents required. She stated during Resident #42's bed bath she had noticed a bruise to the middle of her forehead and underneath one of her eyes (was not sure which eye). She revealed she asked Resident #42 what happened, and she stated, she rolled out of bed. She revealed STNA #613 was on the other side of the room, and she told her about the bruise and what Resident #42 said. She revealed she told a nurse but was not sure of the nurse's name. She revealed the next day a man from the facility (unsure who) contacted her, and she told him that Resident #42 stated she rolled out of bed. She revealed throughout the night she checked and changed Resident #42, and each time she did not have any assistance. Interview on 11/16/23 at 3:33 P.M. with RN #612 revealed she worked on 10/27/23 from 7:00 A.M. to 11:30 P.M. and completed several assessments approximately every four hours on Residents #42 as she had COVID-19. She revealed she last checked her at approximately 9:30 P.M. and that Resident #42 did not have any bruising to her face. She stated Agency STNA #611 never reported to her that Resident #42 had bruising to her forehead and/or her eye. She also never reported that Resident #42 stated that she rolled out of bed. Interview on 11/16/23 at 4:50 P.M. with STNA #613 revealed on 10/27/23 from 4:00 P.M. to 10:00 P.M. Resident #42 and her roommate (Resident #11) were scheduled for bed baths. She stated she and Agency STNA #611 went into the room together, and Agency STNA #611 gave Resident #42 a bed bath at the same time she gave Resident #11 a bed bath. She stated she had not seen Resident #42 as the curtain was pulled, but she did not hear anything that appeared unusual. She stated she did not assist Agency STNA #611 with the bed bath, changing of linens, incontinence care, and/or turning Resident #42. She revealed Agency STNA #611 never told her anything about Resident #42 having bruising to her face and/or the resident stating that she rolled out of bed. Interview on 11/16/23 at 2:17 P.M. with the Administrator and Director of Nursing (DON) verified Resident #42 required two-person assistance with bed mobility, incontinence care, and bed baths. They stated staff were to check the resident care cards for what assistance a resident needed and verified Resident #42's care card stated she required two-staff assistance for the above ADL. They stated through the investigation it was determined beginning the evening of 10/27/23 Agency STNA #611 provided Resident #42 a bed bath, changed her linen, and provided incontinence care without any other staff assistance. They revealed that was the reason they concluded that the bruising to Resident #42's face most likely occurred; from Agency STNA #611 turning the resident into the side rail. They revealed as an intervention they padded the resident's half side rails. They revealed they did not feel Resident #42 fell as she was pretty heavy (her weight was 160 pounds), and she required a mechanical lift with two persons assist to transfer her. They also revealed they believed if she had fallen, she would have had bruises and/or injuries on other parts of her body, not only on her face. They stated Agency STNA #611 also verified throughout the rest of the night that she checked and changed Resident #42 also using only one person assist. Observation on 11/19/23 at 9:25 P.M. revealed Licensed Practical Nurse (LPN) #615 and STNA #617 transferred Resident #42 with a mechanical lift from her wheelchair to her bed to provide incontinence care. Resident #42 was totally dependent on the staff to roll her side to side as she did not assist. They both confirmed that they would not be able to complete her care by themselves as they stated, she was very heavy and fully dependent on care. Interview on 11/19/23 at 10:40 A.M. with Administrator revealed he had contacted Agency STNA #611 on 10/28/23 at approximately 1:00 P.M. as part of the investigation and Agency STNA #611 had stated during the bed bath she had noticed bruising to Resident #42 forehead and small purple mark by her right eye. He revealed he asked her if she reported the bruising, and she stated she had not stating, she assumed everyone knew. He revealed Agency STNA #611 had never told him that Resident #42 had stated she rolled out of bed. Interview on 11/19/23 at 12:58 P.M. with Resident #11 (Resident #42's roommate) revealed she did not know what happened to Resident #42 as she just knew one day her face was all bruised up. She denied seeing or hearing anything. Review of the facility policy labeled Activities of Daily Living, dated June 2015, revealed the purpose of the policy was to provide assistance as necessary. The policy revealed all resident functional status would be assessed and supervised as needed to assist in achieving and maintaining maximum functional ability. Review of the facility policy labeled Abuse, Alleged and/ or Actual, Neglect and Misappropriation, dated September 2016, revealed the purpose of the policy was to assure residents right to be free of verbal, physical, sexual, and mistreatment. The policy stated no employee and/or agency serving the residents would knowing abuse, mistreat, or neglect any resident of the facility. The policy revealed neglect was the reckless failing to provide a resident with treatment, care, goods, or services necessary to maintain the health and safety of the resident when the failure results in serious physical harm to the resident. This deficiency represents non-compliance investigated under Self-Reported Incident, Control Number OH00147913.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the facility policy and interview the facility failed to ensure timely assessments were completed and adequate interventions were implemented to prevent the development of a pressure ulcer for Resident #14. Actual Harm occurred on 10/03/23 when Resident #14, who was totally dependent on staff for activities of daily living (ADL) including bed mobility, toileting, and transfers was found to have an unstageable (full thickness tissue loss in which the actual depth of the ulcer was obscured by slough/ dead skin) pressure ulcer to his left gluteal (buttock) area. There was no documented evidence of adequate intervention(s) or monitoring to prevent the development of this wound or to ensure the pressure ulcer was identified prior to being unstageable. This affected one resident (#14) of two residents reviewed for pressure ulcers. The facility census was 62. Findings include: Review of the medical record for Resident #14 revealed an admission date of 06/28/23 with diagnoses including osteomyelitis of vertebra sacral region, cerebral infarction, congestive heart failure, and diabetes. Review of the care plan dated 06/29/23 revealed Resident #14 had the potential for and/or actual skin breakdown related to decreased mobility, incontinence, friction, and diabetes. Interventions included keeping the resident's skin clean and dry, positioning him properly using devices such as pillows as needed, pressure reducing device to bed and wheelchair, and preventing skin to skin contact as much as possible. Review of the care plan dated 07/05/23 revealed Resident #14 had a self-care deficit in ADL related to weakness, decreased mobility, and cerebral vascular accident. Interventions included assisting with all transfers, assisting with bed mobility, and anticipating and meeting all needs in a timely manner. Review of the Braden scale for predicting pressure sore risk dated 09/14/23 and completed by Licensed Practical Nurse (LPN) #620 revealed Resident #14 was at risk for developing pressure ulcers because he was chair fast, very limited with mobility, and had a problem with friction and shearing. Review of the resident care card dated 09/14/23 revealed Resident #14 required two-staff assistance and was on a turn schedule for bed mobility, two-staff assistance with a mechanical lift for transfers, and two-staff assistance with toileting. Review of the significant change Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #14 had impaired cognition. He was totally dependent on two staff with bed mobility, transfers, and toileting. He was unable to ambulate. He was at risk for pressure ulcers. Review of the weekly skin assessment dated [DATE] and completed by Assistant Director of Nursing (ADON)/ LPN/ Wound Nurse #620 revealed no new areas of concern, including Resident #14's left gluteal area. Review of nursing note dated 10/02/23 at 8:03 P.M. and completed by LPN #615 revealed he found a new area on Resident #15's left buttock and compromised tissue on his hip. The note revealed new orders were in place. There was no other description of the wound including stage and/or measurements. Review of the provider consultation dated 10/03/23 revealed Wound Nurse Practitioner (NP) #901 consulted, and Resident #14 had a new pressure wound to his left gluteal area which was in-house acquired. The wound was classified as unstageable and measured 7.0 centimeters (cm) in length by and 11.0 cm in width. The wound had a moderate amount of serosanguinous (thin and watery fluid that is pink in color due to the presence of small amounts of blood) drainage. The wound contained 20 percent (%) slough and 10 percent deep tissue injury (an injury to the soft tissue under the skin due to pressure and was usually over a boney prominence). She ordered a treatment for the area. Review of the skin grid dated 10/03/23 and completed by ADON/ LPN/ Wound Nurse #620 revealed Resident #14's left gluteal area originated as a facility acquired unstageable pressure ulcer on 10/03/23. The wound measured 7.0 cm in length by 11.0 cm in width, and the wound contained slough. Review of the November 2023 physician's orders revealed Resident #14 had an order dated 10/03/23 to cleanse the lower left buttock wound with normal saline, apply Medihoney (promotes a moist wound environment that aids and supports autolytic debridement), calcium alginate (dressing for moderately to heavily draining wounds), and cover with a dressing twice a day and as needed. Review of the skin grid dated 11/14/23 and completed by ADON/ LPN/ Wound Nurse #620 revealed Resident #14's left gluteal unstageable pressure ulcer continued and measured one cm in length, 7.5 cm in width and 0.1 cm in depth. The wound bed contained slough. Review of the provider consultation dated 11/14/23 revealed Wound NP #901 consulted, and the unstageable pressure ulcer was now classified as a Stage three (involved full-thickness skin loss potentially extending into the subcutaneous tissue layer) and measured a 1.0 cm in length by 7.5 cm in width by 0.1 cm in depth. The wound continued to have moderate serosanguinous drainage with 10% percent slough. The wound was debrided to remove the slough at the bedside, and Resident #14 tolerated the procedure well. Interview on 11/19/23 at 10:30 A.M. with the Director of Nursing (DON) and ADON/ LPN/ Wound Nurse #620 revealed Resident #14's wound to his left gluteal area was noted per nursing notes on 10/02/23 by LPN #615 but there was no description including stage and/or measurements of the wound. They verified the first measurements and staging of the wound was on 10/03/23 identified as facility acquired unstageable pressure ulcer that contained 20% slough per Wound NP #901's assessment on 10/03/23. They verified Resident #14 required total dependence from staff for his ADL, including for bed mobility, transfers, and toileting. Observation of the wound care on 11/19/23 at 1:06 P.M. completed by LPN #601 and LPN #615 revealed Resident #14 continued to have a pressure ulcer to his left gluteal area. LPN #615 described the wound as having small amount of white slough to the center of the wound bed with blanchable healthy skin surrounding the wound. The treatment was completed as ordered. Interview on 11/19/23 at 1:29 P.M. with LPN #615 as he was the nurse who first found the wound on 10/02/23 revealed he had to be honest stating, it had been a hot minute since the wound was found and could not recall and/or describe how the wound looked when he found it. He verified he did not include a description, and/or measurements in the nursing notes and/or on another assessment form. Review of the facility policy labeled Pressure Ulcers identification and Suggested Treatment Protocols, dated June 2015, revealed pressure ulcers would be identified and treatments would be ordered for proper healing of the wound. Review of the facility policy labeled Pressure Ulcers, Prevention and Care of, dated June 2015, revealed the purpose of the policy was to prevent impairment in the skin integrity. The protocol would be followed when a resident had a decubitus ulcer or was at high risk for developing an ulcer including care to prevent the alteration in skin integrity in all residents. This deficiency represents non-compliance investigated under Complaint Number OH00147676.