**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, interview and facility policy review, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent, accurately and timely assess, promote healing and prevent pressure ulcer/wound infection from occurring. This affected one (Resident #95) of three residents reviewed for pressure ulcers. The facility census was 93. Actual Harm occurred on 07/03/25 when Resident #95 was assessed to have an acute change in condition requiring hospitalization. Upon hospital assessment, the resident was assessed to have a Stage II pressure ulcer to the sacrum with extensive gas forming soft tissue infection at the lower back extending to the tip of the coccyx measuring 9.0 centimeters (cm) by 2.3 cm by 16.1 cm. Prior to the development of the pressure ulcer infection, the facility failed to ensure effective ongoing monitoring and adequate interventions were in place to prevent the wound infection and subsequent hospitalization for treatment. Findings include:A review of Resident #95's closed clinical record revealed an admission date of 05/08/25 with diagnoses including left above the knee amputation, severe protein-calorie malnutrition, acute respiratory failure with hypoxia, pleural effusion, necrotizing fasciitis (Bacterial infection that rapidly destroys the skin, fat, and soft tissues surrounding muscles.), diabetes mellitus, hypothyroidism, high blood pressure, and gastroesophageal reflux disease. Resident #95 was discharged from the facility on 07/25/25. A review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #95 was cognitively intact. The assessment revealed the resident had no behaviors and she was assessed to be dependent on staff for toileting hygiene, transfers, and showers. The assessment revealed the resident required partial to moderate assistance with bed mobility, was always incontinent of urine and frequently incontinent of bowel. The resident was assessed to be at risk for pressure ulcer development, had no pressure ulcers, and had moisture associated skin damage (MASD). The assessment included the resident had pressure reducing devices to the bed and chair. A review of Resident #95's plan of care initiated on 05/19/25 revealed Resident #95 was at risk for the development of pressure ulcers related to limited mobility, left below the knee amputation with noted episodes of refusing boots to offload pressure to the heels and moisture associated buttocks/sacrum, thin fragile skin, and multiple bony prominences. The plan of care indicated on 05/20/25 Resident #95 frequently chose not to be repositioned, removed pillows when used to assist with side positioning, removed pressure reduction boots and informed the staff I move around plenty. The goal of the plan of care was for Resident #95 to have intact skin, free of redness, blisters or discoloration. Interventions on the plan of care included administering medications/treatments as ordered by the physician and monitor for side effects and effectiveness. Follow the facility policies/protocols for the prevention of skin breakdown, including the use of pressure reducing mattress to the bed, inform family/caregivers of any new area of skin breakdown, monitor nutritional status, serve diet as ordered, monitor food intake and record, monitor/document/report as needed any changes in skin appearance, color, wound healing, signs and symptoms of infection, wound size measurements and stage of wound, obtain and monitor laboratory/diagnostic work as ordered and report results to the physician, and treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. A review of Resident #95's physician's orders revealed an ordered dated 05/19/25 to cleanse coccyx with normal saline, pat dry, apply Allevyn Life dressing (dressing for the prevention and treatment of pressure injuries and other wounds) to the coccyx to pad and protect the area every other day and as needed for preventative treatment every night shift (11:00 P.M. to 7:00 A.M.). The order was noted due to the resident's history of a healed pressure ulcer to this area. The order indicated to sign and date the dressing when completed. A review of Resident #95's medical record revealed a skin evaluation assessment dated [DATE]. The assessment included the area was cleaned with normal saline, pat dried and a dry dressing was applied as ordered to pad and protect. The assessment note included the resident's skin was intact and the dressing remained dry and intact. A review of Resident #95's weekly skin evaluation/assessment dated [DATE], completed by Licensed Practical Nurse (LPN) #100, documented the resident had no new areas of skin breakdown identified, and dressing was intact to the coccyx. The evaluation included the resident's skin was intact with no new issues. The assessment indicated Resident #95 was at risk for the development of pressure ulcers. (However, there was no evidence the dressing that was in place at the time of the assessment on this date (used to pad and protect) was actually removed during this skin evaluation to determine if the resident had skin breakdown to the coccyx). This was the last weekly skin evaluation documented prior to the resident being transferred 07/03/25 hospitalization. A review of Resident #95's progress note dated 07/03/25 revealed at 9:06 A.M. the nurse found Resident #95 moaning in pain and lethargic. Resident #95's blood sugar was obtained, and the result was 36 milligrams/diluent (mg/dL). Orange juice was provided, blood sugar was re-checked, and the reading was 27 mg/dL. Glucagon was administered, the blood sugar was checked and the glucometer read low. The physician was notified and 911 was called. While waiting for emergency medical services (EMS) Resident #95's blood sugar was checked, and the result was 51 mg/dL and moments later was 24 mg/dL. Resident #95 was transferred to the hospital. A review of Resident #95's hospital emergency room documentation dated 07/03/25 revealed the resident had a Stage II pressure ulcer (the top layer of skin (epidermis) is broken; it looks like a shallow open sore. There may be mild swelling, oozing or pus.) the size of a quarter with surrounding erythema (redness), warmth, induration (a hardening or thickening of the tissue surrounding the wound.). A computerized tomography (CT) scan with contrast was obtained which revealed the presence of extensive gas forming soft tissue infection at the lower back extending to the tip of the coccyx measuring 9.0 centimeters (cm) by 2.3 cm by 16.1 cm pressure ulcer at the sacrum with no definitive osteomyelitis. Resident #95's blood sugar continued to drop, and she was administered dextrose 10 percent, antibiotics were started, and the hospital nurse informed the facility Resident #95 would be admitted to the hospital with diagnoses of sepsis with acute hypoxic respiratory failure without septic shock, necrotizing soft tissue infection, acute respiratory failure with hypoxia, pneumonia of the right lower lobe due to infectious organism, acute cystitis without hematuria. The hospital documentation did not state if there was a dressing to Resident #95's sacrum/coccyx upon arrival to the hospital. Resident #95 was hospitalized until 07/12/25, at which time she returned to the facility. The resident was discharged to the hospital again on 07/25/25 due to a low hemoglobin level with no active sign of bleeding and did not return to the facility. An interview with Wound Registered Nurse (WRN) #103, the facility wound nurse, on 09/09/25 at 1:41 P.M. revealed she had assessed the resident upon admission and the resident did not have any pressure ulcers. WRN revealed the floor nurses were then responsible to complete weekly skin assessments/evaluations and should notify her if a resident developed or had a pressure ulcer develop following admission. During the interview, WRN #103 verified the skin evaluation/assessments dated 06/16/25 and 06/30/25 were incomplete as they failed to include evidence the staff completed the assessments had actually looked at the resident's skin under the dressing that was in place. WRN #103 was unable to provide any information as to when the pressure ulcer had actually developed. WRN #103 agreed the weekly skin assessment dated [DATE] indicated the coccyx dressing was intact but there was no actual skin assessment of the area underneath the dressing documented in Resident #95's medical record. WRN #103 verified on 07/03/25 the resident was admitted to the hospital and the hospital first identified the resident had an infected Stage II pressure area. She stated the nurses should have removed the dressing to assess the resident's skin prior to have identified this ulcer sooner. WRN #103 revealed staff were documenting they were changing the resident's dressing every other day as ordered; however, there was no documentation of an actual description of the resident's coccyx under the pad and protect dressing during the resident's stay in the facility. During the interview, WRN #103 revealed she did not personally see Resident #95 for wound care because the facility staff had not identified the resident had a Stage II pressure ulcer or that the ulcer was infected prior to the resident being transferred to the hospital on [DATE]. An interview with Physician #102 (Infectious Disease Physician) on 09/09/25 at 4:05 P.M. revealed Resident #95 had a pressure ulcer located on the coccyx upon her arrival to the hospital. Surgery was performed to debride the coccyx area. The physician revealed the pressure ulcer had become infected during the resident's stay at the extended care facility. An interview with LPN #100 on 09/09/25 at 4:25 P.M. revealed she had completed the most recent weekly skin evaluation on 06/30/25 prior to Resident #95's admission to the hospital on [DATE]. During the interview, LPN #100 stated she did not actually remove the pad and protect dressing to Resident #95's coccyx to inspect the area for skin breakdown. LPN #100 stated she was unable to say if Resident #95's coccyx area had developed a pressure ulcer at the time the assessment was completed. An interview with LPN #101 on 09/11/25 at 7:40 A.M. revealed he had completed Resident #95's preventative wound treatment on 06/30/25. During the interview, LPN #101 stated he was unable to remember what the resident's coccyx area looked like at the time. An interview with Quality Assurance Nurse (QAN) #104 on 09/09/25 at 3:00 P.M. verified the above findings and agreed the facility staff failed to ensure adequate and ongoing assessments were being completed for Resident #95. QAN #104 also verified the assessment/evaluation documented on 06/30/25 was not comprehensive or complete to ensure the resident's skin had actually be assessed under the pad and protect dressing that was in place. The facility policy and procedure titled Pressure Ulcer Prevention and Care Protocol revised 1/2025 revealed the licensed nursing staff would use the following criteria as part of the resident's comprehensive assessment to determine risk of pressure ulcer development and development of the resident's plan of care. Risks and complications unique to the resident would be documented on the resident's individualized plan of care. The prevention and care interventions developed through the assessment would be noted on the plan of care and followed by the direct care staff. The risk assessment criteria included: A head-to-toe examination of the skin for Stage I or greater pressure ulcer, scar over a bony prominence (healed pressure ulcers), or non-removable dressing/device and any alteration in skin condition. Review of medical history/medical record for co-morbid conditions Assessment of oxygen transport/tissue perfusion and BP Advanced Age Ability to move, turn, transfer and ambulate Presence of Trauma, Tremors, Spasticity Incontinence/skin moisture Medication review Treatments such as Chemotherapy, Radiation, Dialysis Nutritional status and hydration Hygiene Review laboratory data Cognitive status Psychosocial status Behaviors Refusal of care This deficient practice represents noncompliance investigated under Master Complaint Number 2608745 and Complaint Numbers 2604131 and 1334558 (OH00167327).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of video recorded evidence, review of the facility self-reported incident, review of facility policy, observation and interview, the facility failed to ensure Resident #16 was free from humiliation, intimidation and verbal and physical abuse by staff. Using the reasonable person concept, actual harm occurred on 07/14/24 when Resident #16, who was cognitively impaired and dependent on staff for all activities of daily living (ADL), was forcefully rolled onto his right side for incontinence care by State Tested Nursing Assistant (STNA) #434 causing Resident #16's face to go into a pillow requiring him to move his head to yell let me breathe. STNA #434 repeatedly poked him in his ear with his dirty gloves he used to provide incontinence care causing Resident #16 to become agitated and yell get out of here. STNA #435 and #436 were present in the room and did not stop the abuse nor report it. This affected one resident ( Resident #16) of the three residents reviewed for abuse. The total census was 103. Findings include: Review of the medical record for Resident #16 revealed an admission date of 06/29/23 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting non-dominant side, dysphagia, anxiety, obstructive hydrocephalus, palmar fascial fibromatosis, muscle wasting, difficulty walking, transient cerebral ischemic attack, epileptic seizure, major depression, and chronic obstructive pulmonary disease. The resident was receiving hospice services. Review of the Minimum Data Set (MDS) 3.0 annual assessment dated [DATE] revealed Resident #16 was cognitively impaired , hearing impaired and needed a hearing aid. Resident #16 had clear speech and was able to make self-understood and sometimes understood others. Physical and verbal behavior symptoms were present one to three days but did not interfere with resident care, and there was no behavior impact on others. Rejection of care occurred one to three days. Resident #16 was dependent for feeding, oral hygiene, toilet hygiene, bathing and dressing. Resident #16 was dependent on staff to roll left to right in bed, sit on side of the bed, lay back in bed and did not sit to stand. Resident #16 was dependent of staff for transfers and was always incontinent of urine and bowel. Review of the plan of care dated 07/05/24 revealed Resident #16 could be verbally aggressive. Interventions included administer medication, anticipate resident needs, assess resident coping skills, assess understanding of the situation, allow time for resident to express self and feelings towards situation, give resident choices, positive feedback for good behavior, engage calmly in conversation, and staff to walk away calmly and approach later. Review of a progress note dated 07/15/24 at 12:45 P.M. authored by the Administrator revealed Resident #16's Power of Attorney (POA) was notified by the Administrator that the Ombudsman's office had sent the Administrator a video (date sent was not in this note) and it was reviewed. The employees in the video were suspended, the Ohio Department of Health ( ODH) was notified, a head-to-toe assessment was done on Resident #16, the Nurse Practitioner ( NP) and Hospice were notified. The NP assessed the resident, and a full staff education was completed. Review of the facility SRI and related investigation dated 07/15/24 revealed on 07/15/24 at 12:06 P.M. the Ombudsman office called the Administrator and said the family of Resident #16 had sent them a video showing abuse. The Ombudsman office sent the video to the Administrator and the video was seven minutes long and time stamped for 07/14/24 at 3:30 P.M. The video showed events that would be investigated as verbal/emotional abuse. Three State Tested Nurse Assistants (STNA) #434, #435 and #436 were immediately suspended from work pending investigation. The facility immediately completed a head-to-toe assessment of the resident, notified the physician and the resident would be seen by the NP on 07/15/24. The Administrator and Director of Nursing (DON) spoke to the family about the allegation. The DON attempted to ask the resident about the events of the allegation, and he was unable to articulate how he felt or answer questions which was in line with his usual state of mind. Review of the video showed STNA #434 roll the resident on his side in a way that caused the resident to groan and become upset. STNA #434 was shown touching the resident's face repeatedly causing the resident to become agitated. One of the other STNA in the room stated where the (expletive) is his hearing aid and the third STNA in the room was a witness to the incident and did not report it. STNA #434 was heard making statement you know I don't play with him, (expletive) and speaking disrespectfully to the resident. The facility substantiated abuse and terminated the employment of all three STNA on 07/17/24. Further review of the facility investigation revealed a statement written by the DON dated 07/15/24 indicating Hospice was notified on 07/15/24 at 3:30 P.M., of the incident and that the investigation process was explained to Hospice. Review of a Weekly Skin Evaluation dated 07/15/24 at 1:01 P.M. revealed Resident #16 had no new skin areas identified, and no new open areas identified. Review of a progress note dated 07/15/24 authored by Nurse Practitioner (NP) #438 revealed Resident #16 did not appear to be in any acute distress, his behaviors had been stable and Resident #16 denied pain. Review of a written statement dated 07/17/24 obtained from STNA #434 revealed STNA #434 stated he did not need to see the video, as the facility already fired him. STNA #434 gave his badge to the Administrator. Review of a written statement from STNA #436 on 07/17/24 revealed on 07/14/24 she entered Resident #16's room with a Hoyer lift. STNA #436 confirmed she stated, where the (expletive) is his hearing aid. STNA #436 indicated she was not aware verbal or emotional abuse had happened. Review of a witness statement by STNA #435 on 07/17/24 revealed she confirmed she worked on 07/14/24 with Resident #16 and made no further comment after watching the video of care Resident #16 received that day of the incident. Interview on 08/22/24 at 9:30 A.M. with Ombudsman #429 revealed Resident #16's family contacted the Ombudsman office on 07/15/24 regarding video footage they witnessed on 07/14/24. The Ombudsman stated Resident #16 was upset when STNA # 434 continued to poke the resident in the ear. STNA # 435 laughed when STNA #434 poked his finger in the resident's ear. The Ombudsman stated STNA # 434 cleaned Resident #16's peri area with a gloved hand and used the same gloved hand to poke the resident's nose and ear. The Ombudsman state the female aids in the room dismissed the behavior of STNA #434. The Ombudsman stated a reasonable person would be upset by the actions of the staff members. The Ombudsman also stated during the video a female aid stood in front of the camera and it was possible, but not certain, a slap sound was heard, and after that Resident #16 went quiet. Interview on 08/22/24 at 10:14 A.M. with Resident #16's POA revealed the family had a camera in the resident's room because Resident #16 was too cognitively impaired to speak up for himself. The POA stated Resident #16 was visibly upset STNA #434 was rough with changing Resident #16 diaper and STNA #434 put his fingers in resident's ear to get the resident's attention. The POA stated it looked like Resident #16 was visibly upset and did not like how rough STNA # 434 was after changing his brief. POA stated she observed STNA #434 use the same gloved hand to wipe the resident's peri-area then put his finger in the resident's ear and by the mouth. POA stated they heard a smack at the end of the video. The POA stated other staff that entered the room did not stop STNA #434's treatment of the resident. Interview on 08/22/24 at 10:37 A.M. with Resident # 16's family member #432 revealed it appeared STNA #434 antagonized her brother by putting their finger in the resident's ear twelve to thirteen times. Family member # 432 stated Resident #16 was uncomfortable with his care. Interview on 08/22/24 at 11:38 A.M. with STNA #435 confirmed they watched the video of STNA #434 poke Resident #16 in the ear and the care Resident #16 received and realized it was abuse. STNA #435 stated they regretted not reporting the incident. Observation on 08/22/24 at 12:45 P.M. with The Administrator and the DON of the video submitted by the Ombudsman revealed camera footage of Resident #16 in his room and the video captured footage on 07/14/24. The Administrator and the DON confirmed STNA #434 poked Resident #16 in the ear twelve times. Resident #16 would yell get out of here when poked in the ear. STNA #434 put his finger in Resident #16's left ear multiple times for unknown reasons which appeared to upset Resident #16. STNA #434 did not explain care that was done. STNA #434 opened Resident #16's brief and provided peri area care and continued to poke Resident #16 in the ear with the same gloved hand. It was verified by The Administrator STNA #434 forcefully rolled Resident #16 onto his right side with his face in a pillow. Resident #16 had to move his head to speak. STNA #434 made a comment to Resident #16 I ain't playing with you, you know that. and you want to be real? Guess what. Resident #16 yelled out let me breath. STNA #434 stated you breath with your mouth not with your back and made a comment you ain't gonna be rude to me. S*** Resident #16 asked STNA #434 not be tough when rolling him, STNA stated I am tough A female STNA entered Resident #16 room ( STNA # 435 ) and stated, we have to be though when you don't listen STNA #435 laughed when STNA # 434 would stick his finger in Resident #16's ear and face. Another female STNA # 436 entered Resident #16 room with a Hoyer lift. Female STNA #436 was in front of the camera when more yelling continued by Resident #16, the resident went quiet after STNA # 434 stated don't play with me the video ended. There was no slapping noise evidenced in the video as was reported by Resident #16's family and the Ombudsman. Interview with The Administrator on 08/22/24 at 12:45 P.M. revealed the facility was notified by the Ombudsman on 07/15/24 at 12:09 P.M. regarding an incident that happened 07/14/24. STNA # 434 was immediately suspended and after review of the video submitted by the Ombudsman STNA # 435 and # 436 were suspended. The Administrator stated this was not appropriate treatment towards a resident and verified because of the investigation the abuse was substantiated. Interview on 08/22/24 at 2:21 P.M. with Resident #16 was conducted to determine if he remembered anything about the incident on 07/14/24. Resident #16 stated he did remember and said he felt shaky and stated, I never know what he was going to do and stated he did not like to be poked in the ear. Observation of the room at the time of the interview revealed a camera was fixed to the wall. Resident #16 was resting in his bed and had no behaviors at the time of the observation. Interview on 08/22/24 at 2:40 P.M. with STNA #434 confirmed he worked 07/14/24 with Resident #16. STNA #434 verified his behavior was not appropriate towards Resident #16. STNA #434 stated he had no reason to poke Resident #16's ear as much as they did. STNA #434 also stated he was frustrated with Resident #16 on 07/14/24. Interview was attempted with STNA #436 on 08/22/24 at 11:07 A.M. and 5:00 P.M. but the phone was no longer in service. Review of the facility policy titled Resident Abuse Prevention Practices, dated 11/2023, revealed abuse was defined as knowingly causing physical harm to the resident and included the willful infliction of intimidation and mental anguish by a caretaker. Physical abuse included hitting, slapping, pinching or kicking and rough corporal punishment. Verbal abuse included any use of oral disparaging and/or derogatory terms to the residents regardless of their ability to comprehend or their disability. Mental abuse included but was not limited to humiliation, harassment, threats of punishment or deprivation. Mistreatment was defined as to inappropriately treat or exploit a resident. Staff must report suspicion of abuse immediately to a supervisor. The deficient practice was corrected on 07/15/24 when the facility implemented the following corrective actions: • Protection of immediate resident safety by suspending STNA # 434, # 435 and #436 following appropriate abuse prohibition on 07/15/24. Termination of employment on 07/17/24. • The Physician and Nurse Practitioner (NP) were notified. The NP was in the facility and performed a bedside evaluation on Resident #16 and the Registered Nurse performed a physical assessment on 07/15/24 without any findings of physical injuries. • All residents with a Brief Interview for Mental Status (BIMS) score of eight or less were assessed for signs of abuse without findings on 07/15/24. • All residents with a BIMS of nine for greater were interviewed for concerns of abuse without findings on 07/15/24. • Staff re-education by the Administrator for abuse prevention and reporting was completed on 07/15/24 or prior to next working shift for all 164 staff. • The facility Director of Nursing held an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting with QAPI members to develop a plan on 07/15/24. • The facility filed an SRI with ODH on 07/15/24. • Hospice was notified of the findings on 07/15/24 for coordination of care. • Additional re-education for behaviors and combative care was initiated on 07/17/24 with all staff and will be completed on 07/24/24. • The facility Director of Nursing/Designee began random staff competencies on 07/17/24 and will continue twice weekly for three weeks. Findings will be reviewed in scheduled QAPI meetings. • The facility Director of Nursing/Designee began random observations of staff to resident interactions on 07/17/24 to ensure dignity and respect was provided and will continue twice weekly for three weeks. Findings will be reviewed in scheduled QAPI meetings. • Weekly ongoing audits on staff abuse competencies began on 07/17/24 and would continue twice weekly for three weeks. Findings would be reviewed in scheduled QAPI meeting. • Random observation by the DON/designee of all staff to resident interactions began on 07/17/24 to ensure dignity and respect and abuse prohibition and would continue twice weekly for three weeks. Findings would be reviewed in scheduled QAPI meetings. As of the date of the survey on 08/29/24 no other instances of abuse had been identified. This deficiency represents noncompliance investigated under Complaint Number OH00156377

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and facility policy review the facility failed to ensure Resident #77 was free of an accident hazard during a staff assisted transfer. Actual Harm occurred on 01/30/24 when Resident #77 suffered a second-degree burn (a burn that involves the first two layers of skin which may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin) that measured 15 centimeters (cm) in length by 7.5 cm width to her left lower leg from a portable oxygen tank that had been placed on her bed while staff were transporting the resident from her room to the shower room. The improper transport of the oxygen caused the tank to freeze to the resident's leg causing pain/discomfort and the burn. The burn required treatment with Silvadene cream (medication used to help prevent and treat wound infections for serious burns) and Kerlix gauze to the area daily. This affected one resident (#77) of three residents reviewed for accidents. The facility census was 97. Findings include: Review of the medical record for Resident #77 revealed an admission date of 04/07/23. Diagnoses included Amyotrophic Lateral Sclerosis (ALS) a progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord, arthritis, depression, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77 was cognitively intact. She required set up help for eating, oral hygiene, and personal hygiene, substantial or maximum assistance for showing or bathing, and was dependent on staff for toileting. Review of the progress note dated 01/30/24 at 3:03 P.M. revealed a State Tested Nursing Assistant (STNA) informed the nurse that another STNA mistakenly left Resident #77's portable oxygen lying on its side next to Resident #77's left lower leg. The resident obtained a burn that measured 15 centimeters (cm) in length by 7.5 cm in width. The resident reported some discomfort and was medicated with Tylenol (analgesic). The area was slightly pink with no open areas or drainage. The nurse aide supervisor was notified and educated staff on proper handling of portable oxygen tanks. The physician, power of attorney (POA), and clinical director were notified. Review of the facility incident report dated 01/30/24 at 4:08 P.M. revealed the oxygen tank was removed from Resident #77 after discovery of the injury. Two witnesses were noted to have been involved; however, there were no witness statements included on the investigation. Review of the physician's orders for February 2023 revealed an order to cleanse the left lower leg burn and apply Silvadene cream (medication used to help prevent and treat wound infections for serious burns) and Kerlix gauze to the left lower calf daily. Review of a facility provided document titled Wound Tracking Grid - Initial assessment dated 02/05/24 revealed the resident's calf wound measured 6.0 cm in length by 2.0 cm in width. The skin tone was normal with an intact scab. Interview on 02/06/24 at 10:28 A.M. with the Administrator revealed on 01/30/24 an oxygen tank was placed on the bed while Resident #77 was being transported to the shower. The oxygen tank collected ice and froze to the resident's leg. The Administrator reported the tank was immediately disconnected and staff were in-serviced on safe transport of portable oxygen. He confirmed there should have been a hook for caddy available for transporting the oxygen. The Administrator revealed the nurse assessed the injury, and the resident's mother was notified. STNA #203 did not sign the in-service sign in sheet. Interview on 02/06/24 at 10:51 A.M. with Resident #77 revealed she told STNA #203 her leg hurt while being transported to the shower, but STNA #203 told her they were almost there and did not stop to look at the source of the pain. Interview on 02/06/24 at 12:40 P.M. with STNA #202 revealed on 01/30/24 STNA #203 placed the resident's oxygen tank on its side on the bed and it had ice on the outside. She confirmed oxygen should always be upright and never on its side. She revealed Resident #77 suffered a burn on her leg as a result of the oxygen tank touching her leg. Interview on 02/06/24 at 12:49 P.M. with STNA #203 revealed on 01/30/24 she was transporting Resident #77 to the shower and needed to take the resident's oxygen with her. She revealed the tank was hooked to the bed and stated she did not know it was touching her leg. She stated Resident #77 said her leg felt warm, but she did not see anything at the time. After the residents' shower she saw a burn on the resident's leg. She could not describe the size, shape, or color. She stated she let the nurse know immediately. Observation on 02/07/24 at 8:05 A.M. of wound care for Resident #77 revealed Licensed Practical Nurse (LPN) #207 provided appropriate care and treatment to Resident #77's left lower leg. The wound was scabbed over with no odor or drainage observed. Interview at the time of the observation with both LPN #207 and the resident confirmed the wound looked better and was healing well. The resident denied any pain as of this time. Review of the in-service titled OSHA - Environmental Safety dated 07/01/23 revealed staff were educated prior to the incident on proper oxygen use including oxygen tanks were to be stored in a stand or cart to prevent tipping or falling, portable tanks were to be kept in an upright position, and any frosted parts or connections were not to be touched. STNA #203 did not sign the in-service sign in sheet (hire date was 03/14/23). Review of the facility policy titled Oxygen, liquid dated January 2023 revealed portable oxygen tanks were to be kept in an upright position and should be carried by a shoulder strap, hung on the back of a wheelchair, or placed in a wheeled cart. No frosted parts or connectors were to be touched. This deficiency represents noncompliance investigated under Complaint Number OH00150765.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to ensure therapy discharge recommendations were implemented in order to maintain a resident's mobility and range of motion (ROM) capabilities. This affected one (Resident #5) of 24 residents observed for limitations in range of motion. Actual harm occurred on 01/31/23 when Resident #5 presented with limitations in ROM after the facility failed to implement therapy recommendations for restorative nursing programs. Prior to 01/31/23, no ROM impairment had been identified and the resident was noted to be able to ambulate. On 01/31/23 an assessment noted a decrease in range of motion to the resident's right knee and bilateral ankles. An Occupational Therapy (OT) note, on 03/21/23 revealed Resident #5 had a significant decline in mobility and participation with activities of daily living with significant bilateral lower extremity contractures. Findings include: Review of Resident #5's medical record revealed diagnoses including Alzheimer's disease, peripheral vascular disease, and generalized muscle weakness. A nursing admission assessment dated [DATE] indicated Resident #5 ambulated with two or more assistants. No impairment in ROM was noted. Resident #5 received OT from 07/21/22 to 08/31/22. An OT Discharge summary dated [DATE] did not reveal limitations in ROM. The discharge summary indicated recommendation for a restorative nursing program (RNP) for upper extremity strengthening and ROM. Resident #5 received Physical Therapy (PT) from 07/21/22 to 08/31/22. A PT Discharge summary dated [DATE] indicated at the time of discharge Resident #5 was able to ambulate 75 feet with a wheeled walker with contact guard assistance but not consistently. A restorative ambulation program was established with the restorative nursing program for upper extremity exercises using a two pound dowel/fine motor tasks and gait training with a wheeled walker inconsistent for 75 feet with contact guard assistance. Resident #5 received OT from 11/01/22 to 12/02/22. The discharge summary indicated Resident #5 was trained on strategies and positioning maneuvers to improve independence with mobility, training on upper extremity strengthening to improve upper extremity strength needed for functional activities and transfers and training on wheelchair mobility to improve participation within environment. Resident #5 had self-limiting behaviors at times and required maximal encouragement for participation in therapy. Resident #5 was discharged to the restorative nursing program for upper extremity strengthening. Resident #5 received PT from 11/04/22 to 12/02/22. Resident #5 was discharged with a recommendation for a restorative ROM program including bilateral upper extremity therapeutic exercise using two pound dowel in all functional directions and wheelchair mobility. Resident #5 received PT from 01/31/23 to 03/06/23. When PT was started on 01/31/23 it was noted there had been a decrease in ROM to the right knee and both ankles compared to prior function. The discharge summary indicated Resident #5 was making consistent progress before being sent to the hospital. Resident #5 was evaluated by OT on 03/21/23 after being admitted to the hospital on [DATE] after a fall out of bed. The evaluation indicated Resident #5 had a significant decline in mobility and participation with activities of daily living with significant bilateral lower extremity contractures. Resident #5 was evaluated by PT on 03/17/23 with contractures of bilateral lower extremities more prominent due to prolonged bed rest. On 03/30/23 at 12:31 P.M., interview with Corporate Quality Assurance (QA) Nurse #577 revealed Resident #5 never had a restorative nursing program initiated. On 03/30/23 at 12:33 P.M., interview with Therapy Manager #598 indicated therapists made recommendations for restorative nursing programs when residents were discharged from therapy. Restorative recommendations were written on a restorative form and provided to the restorative nurse. On 03/30/23 at 1:54 P.M., interview with Licensed Practical Nurse (LPN) #812 (the facility restorative nurse) verified once residents were discharged from therapy she was provided with a referral form for restorative programs. LPN #812 verified Resident #5 never had a restorative nursing program initiated. LPN #812 indicated the reason the programs were not initiated was due to the number of residents already receiving programs and lack of enough staff to complete the recommended programs. Restorative aides would get reassigned to take an assignment on the unit or to provide showers. While reviewing the history of Resident #5 receiving therapy services then being discharged with no restorative programs initiated, Resident #5 had a history of experiencing declines and having to be added back to therapy caseload, LPN #5 reiterated the programs could not be initiated due to staffing and stated she had a list of resident on a waiting list for restorative programs. LPN #5 stated when she decided not to initiate restorative programs she would sometimes initiate a program for aides on the floor to complete. At 2:29 P.M., LPN #812 verified she had not initiated a program for floor aides to complete to prevent declines for Resident #5 between therapy sessions. This deficiency represents non-compliance investigated under Complaint Number OH00141011.