Every finding on record at Altercare Cambridge Inc.

Based on closed medical record review, hospital record review, Self-Reported Incident (SRI) review, facility policy review, and interviews, the facility failed to timely identify and address a resident's change in condition following a mechanical lift transfer. This affected one resident (#55) of three residents reviewed for hospitalizations. The facility census was 47. Actual harm occurred on 11/16/25 when Resident #55, who was severely cognitively impaired and required staff assistance for activities of daily living, slammed her body down into a sit-to-stand (mechanical lift) device on her right side and back due to an episode of increased weakness. The facility staff failed to notify the resident's medical provider of the change in condition including the episode of weakness and slamming of the right side of her body and back down into the sit-to-stand device. The resident was assessed at the time with no injuries noted. Following the initial assessment, there was no documented evidence of ongoing monitoring of the resident's right side and back for bruising or injury. The resident was admitted to the hospital on [DATE] (two days later) with diagnoses including traumatic hematoma of the right gluteal region, acute kidney injury likely due to hypovolemia as a result of extravasation (the accidental leakage of fluid from a blood vessel into surrounding tissue) of blood into the tissue, acute blood loss anemia, and severe anemia as a result of the sit-to-stand incident on 11/16/25. Findings include: Closed record review revealed Resident #55 was admitted to the facility on [DATE] with diagnoses including infection following a procedure surgical site, cellulitis of left lower limb, dementia, anemia, muscle weakness, dysphagia, cognitive communication deficit, repeated falls, fracture of left femur, and acute respiratory failure with hypoxia. Review of the admission Minimum Data Set (MDS) 3.0 revealed Resident #55 was severely cognitively impaired and required physical assistance from staff with activities of daily living (ADLs) and substantial/maximal assistance with sit-to-stand and chair/bed-to-chair transfer. Review of the care plan dated 10/21/25, revealed Resident #55 had anemia and was at risk for fatigue, weakness, and confusion. Interventions included observing the resident for the following signs and symptoms associated with anemia: pale skin, fatigue, shortness of breath, headaches, insomnia, dizziness, leg cramping, increased heartbeat and altered blood values such as low hemoglobin. Further review of the care plan revealed the resident was at risk for falls/injury related to confusion, history of falls, and incontinence of bowel and urine. Interventions included with device use, to observe for potential mental and physical side effects such as lethargy, mood changes, mobility changes, skin integrity changes, and toileting changes; and to report side effects to the physician or nurse practitioner (NP). Review of a facility Self-Reported Incident (SRI) tracking number 267738 submitted to the Ohio Department of Health (ODH) on 11/19/25 revealed an investigation was initiated by the facility following an allegation of possible physical abuse. The SRI revealed Resident #55 was discharged to the hospital on [DATE] following a non-SRI related critical lab finding. Resident #55's daughter contacted the facility on 11/19/25 to report the resident had bruising on her right hip and possibly small bruises on her back. There was no alleged perpetrator. Staff were interviewed and it was revealed that over the weekend, 11/15-11/16/25, staff had attempted to utilize a mechanical lift known as a sit-to-stand to safely transfer the resident. Staff stated Resident #55 demonstrated a noticeable right-side lean during this time and had to be highly encouraged to keep her feet in place. Staff stated the resident had rubbed her right hip area against the device on multiple occasions and leaned in the back support brace with most of her body weight. The night shift nurse and aide noticed a small quarter-sized reddened/pink area located on the right hip while providing care on the night of 11/17/25. On the morning of 11/18/25 preceding the resident's transfer to the hospital, the certified nursing assistant (CNA) notified the nurse on duty of the area as well, however, before she could be examined, the resident was sent to the hospital. The SRI included at no time did the resident voice concerns of pain or issues with the area. It was reported by staff that the resident demonstrated a right-side lean multiple times while transferring, causing the resident's hip to come into contact with the assistive device. The resident also put her full weight into the supportive sling that was wrapped around her back, which is the most likely explanation for the alleged bruising. The facility unsubstantiated the allegation of abuse. Review of a nursing progress note, 11/16/25 at 12:31 P.M., (authored by Licensed Practical Nurse (LPN) #318) revealed she was alerted by the CNA that Resident #55 appeared weak while utilizing the sit-to-stand device. Respirations were even and unlabored with respiratory rate of 18, pulse was 88, blood pressure was 124/75, oxygen saturation was 87% on room air. The resident was alert and oriented to self and surroundings and did mention to her spouse while visiting that she fell and was running around the facility all night, which she did not. She was easily reoriented and able to answer questions and express needs. She stated she just feels tired today. Review of a Treatment Administration Record (TAR), dated November 2025, revealed routine daily vital signs were ordered twice daily, on each shift. On 11/16/25 between 7:00 A.M. and 7:00 P.M., Resident #55's oxygen saturation level was 87%. Further review revealed the preceding daily oxygen saturation levels were between 94%-99%. There was no evidence documented in the medical record of physician notification of the change/abnormally low oxygen saturation level. Review of a nursing progress note dated 11/18/25 at 11:23 P.M., (authored by the Director of Nursing (DON) and recorded as a late entry on 11/24/25 at 10:39 A.M.) revealed per licensed practical nurse (LPN) interview, Resident #55 slammed her body down into sit-to-stand on her right side and her back during an episode of weakness. There were no noted injuries. The resident was safely transferred into bed and assessed thoroughly with no major obvious and/or findings. Upon documentation review it was noted that night shift LPN observed new bruising to the right hip area on 11/17/25. The area was identified as a clustered, small area of newer looking discoloration to the right side of hip area through the night by both CNA and LPN per completed pink man form. The area is consistent per interview with staff of resident bumping off sit-to-stand on Sunday evening. Further review of the medical record revealed no documentation of Resident #55 slamming into the sit-to-stand on 11/16/25 until 11/18/25 (recorded as late entry on 11/24/25 at 10:39 A.M.) when a nursing progress note was entered by the DON. Review did not reveal a nursing progress note regarding the newly identified bruising to the right hip on 11/17/25, described as a clustered small area of newer looking discoloration to the right side of hip area, as referenced in the 11/18/25 nursing progress note authored by the DON. Review of the Illustration of Documentation and Measurements of Skin Areas (Pink Man Form), dated 11/17/25, revealed a small circle drawn on the posterior right hip area. There was no documentation of measurements. Review of Resident #55's laboratory results collected on 11/17/25 revealed an abnormally low hemoglobin level of 6.9 grams per deciliter (g/dL) (normal range 11.7-15.8 g/dL). The Nurse Practitioner (NP) was notified on 11/18/25 and gave the order for the resident to be transferred to the emergency department (ED). Review of Resident #55's preceding hemoglobin levels were 9.2 g/dL on 10/31/25; 9.0 g/dL on 10/13/25; and 8.8 g/dL on 10/10/25. Review of Resident #55's hospital records revealed she arrived at the emergency department on 11/18/25 at 9:14 A.M. with diagnoses of acute blood loss, severe anemia, traumatic hematoma of hip, and acute kidney injury. The resident was found to have a hemoglobin of six (6) and was transfused with one unit of packed red blood cells. Her hemoglobin the next morning was 7.2 and therefore she was scheduled for two more units of packed red blood cells. The record noted a repeat computed tomography (CT) scan of the pelvis would be completed to assess for any further worsening of the hematoma, which may warrant a transfer for angiogram and embolization if indicated. The plan was to transfuse to maintain hemoglobin above 8 and monitor hemoglobin and hematocrit every six hours. Surgery would be involved if there is no improvement after the transfusions, and/or the resident may be transferred out to have angiography for subsequent embolization if there was a persistent bleed. Acute kidney injury was noted to be likely due to hypovolemia as a result of the extravasation of blood into the tissue. The hospital record noted would avoid all nephrotoxins and maintain patient on intravenous (IV) fluid hydration to get off the blood transfusion and would be repeating labs in the morning to assess for correction of the renal function. The patient has Alzheimer's dementia and is disoriented with her surroundings. The hospital records revealed fall precautions would be maintained. Interview on 12/29/25 at 2:01 P.M. with Resident #55's daughter (Family Member #401) confirmed her mother had sustained traumatic bruising (in November 2025) to her entire right buttock area requiring the transfusion of three units of blood. The resident subsequently had fluid overload and was transferred to a Columbus area hospital to receive a higher level of care and received diuretics and treatment for congestive heart failure likely caused from the blood transfusions. The resident did not require surgical intervention. Interview on 12/23/25 at 4:33 P.M. with the DON revealed she first became aware of an issue after Resident #55's daughter called her on 11/19/25. The resident had been transferred to the hospital on [DATE] due to a very low hemoglobin level. Resident #55's daughter reported her mom had a large, bruised area to the right buttock and back. After interviews with staff, the DON concluded during an episode of weakness on 11/16/25 while being transferred with a sit-to-stand, Resident #55 sustained an injury/bruising. The DON stated following this incident, a Sara Steady Sit-to-Stand was utilized to transfer the resident due to increased weakness. The DON confirmed following the incident on 11/16/25 which was identified as the root cause of the resident's injury, there was no evidence of ongoing monitoring of the resident's right side or back, nor physician notification of the episode of weakness/incident. The DON revealed she believed a small bruise was initially identified on night shift, 11/17/25, but there was no evidence of physician notification. The DON further confirmed the facility did not investigate the resident's allegation made on 11/16/25 of a fall the night before as documented in the nursing progress note. Interview on 12/23/25 at 12:31 P.M. with Nurse Practitioner (NP) #400 revealed she did not recall being notified at the time of the incident on 11/16/25 when Resident #55 had an episode of weakness and slammed into the sit-to-stand; however, she was notified of the incident later in the week when the resident had an episode of weakness/pallor and slurred speech. NP #400 stated at this time she ordered lab work including a hemoglobin level to be obtained. Interview with Licensed Practical Nurse (LPN) #318 on 12/23/25 at 5:08 P.M. revealed she was notified by CNA #363 that Resident #55 was weak during a transfer with a sit-to-stand and fell against the device bumping her right side. The LPN revealed the resident's vital signs were stable other than her oxygen saturation which was 87% on room air. LPN #318 stated Resident #55 did not complain of pain or injury. LPN #318 confirmed she did not notify the physician of the incident or of the low oxygen saturation level of 87%. LPN #318 stated she believed she rechecked the oxygen saturation level later and it had come up, however, she did not document this reading. Review of the facility's policy titled, Change in the Residents Condition or Status, dated 05/01/25, revealed it was the facility's policy to ensure the resident's attending physician and the resident's authorized representative or interested family member were notified of changes in the resident's physical, mental, or psychosocial status. The nurses would immediately notify the resident, consult with the resident's attending physician, on-call physician, nurse practitioner, physician assistant, or clinical nurse specialist and notify resident's authorized representative when there was an accident or incident involving the resident, which resulted in an injury and had the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status. Procedure for documentation of changes in the medical record: the nurse would record in the resident's medical record information relative to changes in the resident's medical/mental condition or status (e.g. assessment, appropriate notifications, interventions, and responses).

Based on observation, medical record review, hospital record review, policy review and interview, the facility failed to implement a comprehensive and individualized pressure ulcer program to timely identify, treat and/or prevent a decline of pressure ulcers. This affected two residents (Resident #42 and #07) of three residents reviewed for pressure ulcers. Actual Harm occurred on 12/06/25 when Resident #42, who had been identified at risk for pressure ulcer development and required maximum staff assistance for bed mobility, returned from the hospital with a red and blanchable area to his (unidentified) buttock without evidence of a comprehensive skin assessment or implementation of pressure relieving interventions or wound treatment to prevent decline in the pressure ulcer. On 12/11/25, a skin assessment identified a new Stage III (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed) pressure ulcer to the coccyx without implementation of pressure relieving intervention until 12/15/25 (a low air loss mattress). Findings include: 1. Medical record review revealed Resident #42 was admitted to the facility on [DATE] with diagnoses including muscle weakness, polymyalgia rheumatica, atrial fibrillation, heart failure, chronic obstructive pulmonary disease, peripheral vascular disease, chronic ulcer of lower leg, venous insufficiency, hypothyroidism, type 2 Diabetes Mellitus, malnutrition and cognitive communication deficit. Review of Resident #42's Minimum Data Set (MDS) assessment completed on 10/21/25 revealed a Brief Interview for Mental Status score of 14 out of a possible 15 points, indicating the resident had intact cognition. The resident used a walker for mobility. Resident #42 was dependent on staff for toileting, lower body dressing, and transfers. He required substantial/ maximal (staff) assistance for bed mobility, including rolling in bed, showering, and dressing. The resident was frequently incontinent with bowel and bladder. Under Section M for skin conditions it was noted the resident had unhealed pressure ulcers/injuries. The resident required pressure reducing devices for bed, applications of ointments/ medications other than to the feet and dressings applied to the feet. The resident had one unstageable deep tissue injury noted on the assessment. Review of the resident's care plan dated 10/21/25 revealed Resident #42 has a pressure injury to his left heel with shearing and friction concerns, and poor sensory perception. The goal developed was for the resident's wound to show progressive signs of healing by target date of 01/21/26. Interventions included continuing with preventative care plan (there was no preventative care plan located as part of the medical record) measures to prevent further skin breakdown, nutritional status assessments as needed, observe wound for any redness, warmth, drainage, odor, and report to physician as needed. Further review of the medical record revealed the resident was admitted to the hospital on [DATE] with a diagnosis of weakness. The resident returned to the facility on [DATE]. Review of the hospital records revealed no mention of wounds to the resident's coccyx or buttocks. Chronic wounds to the right extremity and left heel were noted.Further review of Resident #42's medical record revealed a progress note authored by Licensed Practical Nurse (LPN) #344 on 12/06/25 at 4:04 P.M. and edited on 12/07/25 at 11:23 A.M. which documented the resident returned to the facility from the hospital. Assistant Director of Nursing (ADON) was made aware of the resident's arrival at the facility. Skin assessment completed upon arrival and noted resident had an area to his upper right shin and left heel (previously identified before hospitalization) and redness to his (unidentified) buttock but was blanchable with scattered bruising to all his body from recent hospital stay. The progress note revealed to See wound grids for noted areas (however, there were no skin grids completed by LPN #344 for the buttock). There was no mention of additional wounds to the buttocks or coccyx.Further review of the medical record revealed no documentation of physician notification related to the resident's red, blanchable area to his coccyx or buttocks. In addition, there was also no notification in the on-call physician notification notebook (kept at the nurses' station).Further review of the medical record revealed no evidence of any risk for pressure ulcer development care plan or mention of the resident's pressure ulcers/injuries to his buttocks or coccyx.Review of weekly skin checks for Resident #42 revealed a skin check completed on 12/11/25 by LPN #344 stating a new area to the coccyx was identified. Assistant Director of Nursing (ADON) notified. No additional assessment was provided.Review of Resident #42 orders revealed an order dated 12/11/25 to cleanse the sacrum with soap/water, pat dry, apply Triad Paste (a zinc oxide based, sterile, hydrophilic wound dressing used for mild to moderate exudate (drainage) that creates a moist wound environment that facilitates natural debridement and protects the skin, especially in areas difficult to apply a dressing) twice a day (BID) and as needed (PRN) every shift.Review of Resident #42's wound management detail report revealed an assessment created and completed by the ADON on 12/13/25 and made a late entry for 12/06/25 (a seven day delay) revealed a wound to the sacrum measuring 4.2 centimeters (cm) in length, 5 cm in width, 0.1 cm in depth., Stage III (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough (dead tissue) may be present but does not obscure the depth of tissue loss. May include undermining and tunneling (pockets or narrow passages under the skin)). Review of Wound Care Physician #404s progress note dated 12/11/25 revealed a stage III pressure wound to the sacrum, full thickness, measuring 8.5 cm by (x) 9 cm x 0.2 cm. Open ulceration area of 45.9 cm squared, light serous drainage, no pain, no signs of infection.Review of Resident #42's wound management detail report revealed an assessment created and completed by ADON on 12/13/25 and made a late entry for 12/11/25 (three-day delay) revealed a wound to the sacrum measuring 8.5 cm in length, 9 cm in width, 0.2 cm in depth., Stage III.Review of the Treatment Administration Record (TAR) for December 2025 revealed the Triad Paste treatment was initiated on 12/11/25.Review of Resident #42 orders revealed an order placed on 12/15/25 for a low air loss mattress, check functioning each shift three times a day (TID).Review of the December 2025 TAR revealed the low air loss mattress was implemented on 12/15/25.Review of Resident #42's wound management detail report revealed an assessment created and completed by ADON on 12/18/25 revealed a wound to the sacrum measuring 0.5 cm in length, 1.2 cm in width, 0.2 cm in depth., Stage III. The wound had light, clear drainage with pink, well defined wound edges. Review of Resident #42's record revealed no documentation of the resident refusing interventions including weight shifts, turning and repositioning, or treatments.Observation of wound care on 12/23/25 at 3:02 P.M. with ADON and Registered Nurse #403 revealed Resident #42 had an open area to his right buttock measuring 7.5 cm in length and 2.5 cm in width. The wound had no drainage and the wound bed was pink. The ADON stated that the wound had moved down further (the wound increased in size) since last Thursday (12/18/25). The ADON cleansed the area with soap and warm water, patted dry, and applied Triad Paste. Interview with the resident revealed he was unable to recall how long he had the pressure wound but he was currently getting treatment to the wound. The resident provided no additional information. Interview with Registered Nurse #314 on 12/24/25 at 7:36 A.M. revealed when a resident returns from the hospital, whether it's an admission or re-admission, it is always treated like an admission. First the nurse checks their medications, gets a second nurse to check off the medications, contacts the provider, asks the resident questions and completes a head-to-toe assessment which includes a skin assessment. Everything the nurse does was to be documented such as assessments of new wounds, skin changes even if it's bruising from Intravenous catheters (IV's), everything was documented. Skin assessments when a resident was admitted or returned can be found in the body of the admission note, which was in the progress notes. Any new skin abnormalities were measured, and a wound grid was created. If a resident's skin was red and blanchable, they would initiate interventions immediately to prevent it from deteriorating and opening. Wound rounds were completed once a week; the nurse should assess skin changes and document them. Wounds may be assessed more frequently, depending on the order, severity, changes in the wound, etc With any new skin issues, you are to notify the physician. If there was a new skin issue, for example red and blanchable but not open, med one (on-call physician notification) would be notified. Immediate interventions were initiated such as Triad paste and border foam dressing. Skin interventions to prevent new or worsening areas begin on admission, and/or readmission.Interview with Wound Care Physician #404 on 12/24/25 at 10:03 A.M. revealed. Wound Care Physician #404 sees patients at the facility on Fridays and takes measurements but he was not aware of any open areas to the resident's skin until 12/11/25. Wound Care Physician #404 stated he recommended a low air loss mattress for Resident #42 on 12/11/25 because one was not already in place. Further interview revealed he was unsure of the resident's additional pressure prevention interventions but due to the resident already having one pressure ulcer and a wound to his leg, in addition to the resident's impaired mobility, he would have expected the resident to have had interventions in place.Interview on 12/24/25 at 12:46 P.M. with the ADON revealed she was responsible for overseeing pain management, restorative nursing services, wounds, and bowel and bladder incontinence. If a resident had (skin) redness, depending on where the redness was located, the resident should have preventatives (interventions) like extra protective cream (EPC) or a foam dressing, floating their heels, pressure reduction (devices) or Triad paste. The ADON further stated the treatment would depend on the location of the pressure area and the resident's mobility patterns (requiring staff assistance) with pressure and diabetic wounds being referred to the wound physician (Wound Care Physician #404).Further interview revealed Resident #42 was a re-admission and the admitting nurse completed a skin assessment, and she (the ADON) did a follow up skin assessment to the admission skin assessment. The ADON stated Resident #42 returned to the facility on [DATE] (Saturday) but she was not working that day and did not assess the wound until 12/08/25. The ADON verified the wound assessment for this wound was created by the ADON on 12/13/25 but back dated to reflect it was completed on 12/06/25, however, the ADON did not work on 12/06/25. The ADON did not provide additional information as to why the assessment was incorrectly dated 12/06/25 or why it was not consistent with LPN #344's findings (the hospital record also did not indicate the resident had any pressure ulcers or injuries to his coccyx or buttocks at the time of discharge back to the facility). The ADON shared the resident had two areas on his buttock that were red and open and she documented the areas were a Stage II (please note, the ADON did not identify the resident had two areas on his buttock and identified the area as a Stage III on the initial assessment). Wound Care Physician #404 evaluated the resident on 12/11/25 and determined the wound to the resident's sacrum was a Stage III. The ADON confirmed she only had her paper wound documentation for 12/08/25 that was for her personal tracking and not part of the resident's medical record. The ADON also confirmed there were no treatments ordered until the resident was seen by the wound physician on 12/11/25 despite her knowledge of the wound on 12/08/25 because she knew the physician would give orders when he visited on 12/11/25. The ADON verified she did not enter the order for the low air loss mattress that the wound physician ordered on 12/11/25 because she forgot and said looking back she should have gotten orders to start treatment to the resident's wound before the wound physician visited and per the documentation, the resident's wound declined without evidence of appropriate treatment and timely interventions.Interview on 12/24/25 at 1:03 P.M. with Regional Nurse #400 and #403 verified there were no interventions ordered or implemented until 12/11/25 for Resident #42's altered skin integrity. The Regional Nurses verified two skin grids were dated 12/06/25, one for the red and blanchable area and one for the Stage III pressure ulcer/injury to the sacral/coccyx area.Interview on 12/24/25 at 1:10 P.M. with the Director of Nursing (DON) confirmed Wound Care Physician #404 recommended a low air loss mattress on 12/11/25 for Resident #42; however there was no documentation or evidence the resident received the low air loss mattress until 12/15/25.Four unsuccessful interview attempts were made to contact LPN #344 by phone during the time of the survey from 12/22/25 through 12/24/25. Review of facility policy titled pressure injuries: assessment, prevention, and treatment revised 5/01/25 revealed it was the facilities policy to identify residents at risk for developing pressure injuries, implement interventions to prevent the development of pressure injuries and provide care for existing pressure injuries. A pressure injury risk assessment would be completed upon admission, quarterly, annually, and with significant change period skin would be assessed routinely for the presence of developing pressure injuries and documented on the nursing skin tool. Interventions for prevention based on risk factors can include checking the residents for incontinence at least every two hours, cleaning the skin when soiled, using a moisture barrier, encouraging residents to shift weight every 15 minutes while sitting in a chair, use the pressure redistribution mattress, and use pillows or wedges and other devices for positioning. A Stage 3 pressure injury was defined as a full thickness skin loss in which adipose is visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough or eschar may be visible. The depth of the 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 if slough or eschar obscures the extent of tissue loss this is an unstageable pressure injury. For provisions orders treat the wound per physician orders, protect the wound, manage drainage, promote A moist wound healing, and manage pain.2. Record review revealed Resident #07 admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left side, flaccid hemiplegia affecting left side, muscle weakness, abnormal posture, muscle wasting, diabetes mellitus, insomnia, hyperlipidemia, anxiety, vascular dementia, wheelchair dependent, bipolar disorder, contracture of left lower extremity and left upper extremity, and vascular dementia. Review of resident #07 quarterly Minimum Data Set (MDS) completed 10/28/25 revealed a BIMS score of 05, indicating severe cognitive impairment. The resident used a wheelchair and was dependent of staff for activities of daily living. The resident was also identified at risk for pressure ulcer development and required a pressure relieving device to the bed and chair.Review of Resident #07 skin tool completed on 12/20/25 completed by Registered Nurse #309 revealed the resident had no new areas of concern. Review of the resident's medical record revealed no current wound care orders.On 12/23/25 at 2:12 P.M. incontinence care was observed being performed on Resident #07 with the assistance of Regional Registered Nurse (RN) #403. Observation revealed scattered areas on Resident #07 bilateral buttock with scabbing, open areas, and blanchable tissues. All areas confirmed by Regional RN #403 on 12/23/24 at 2:15 P.M.Interview on 12/24/25 at 1:03 P.M. with Regional Nurse #400 and #403 confirmed Resident #07 had areas of impaired skin integrity that were not timely identified by staff resulting in delayed treatment to the wounds.Review of facility policy titled change in resident condition or status revised on 05/01/25 revealed it was policy to ensure the resident's attending physician, representative were notified of changes in the residence physical, mental, or psychosocial status. Nurses would immediately notify the resident, consult with resident's attending physician, or on call physician, nurse practitioner when there is a significant change in the residence physical, mental, or psychosocial status such as a deterioration health, mental, or echo social status and either life threatening condition or clinical complications. Documentation of changes in the medical record include the nurses recording in the resident's medical record information relative to changes in the resident's medical or mental condition or status such as assessments, appropriate notification, interventions, and response.

Based on observation, review of the facility policy, and interview with the staff, the facility failed to ensure the facility was cleaning the floors in the residents' rooms and hallways with a disinfectant. This had the potential to affect all 47 residents in the facility. The facility census was 47.Findings include:Observation of the gallon container of orange neutral cleaner on 12/23/25 at 9:30 A.M. with Environmental Service Coordinator #313 revealed there was no documentation on the bottle indicating it was a disinfectant. On 12/23/25 at 9:33 A.M. an interview with Environmental Service Coordinator #313 confirmed the facility used bleach wipes for the hard surfaces in the room and an orange neutral cleaner on the floors in the resident rooms. Review of the product properties guide on the website revealed the orange neutral cleaner was not a disinfectant. Further review of the ingredients revealed no disinfectant ingredients; the main ingredient was sodium cocoamphoacetate which was a coconut oil surfactant used in shampoos and soaps. Review of the United States Environmental Protection Agency website for approved disinfectants revealed the orange neutral cleaner was not listed as an approved disinfectant. Review of the facility policy titled, Environmental Service, dated 07/01/25 revealed it was the facility policy to maintain the resident's environment in a clean and sanitary condition. The floors would be dust mopped then mopped with a disinfectant solution.

Review of the medical record, review of the facility policy, and interview with staff the facility failed to ensure as needed psychotropic medications were not used beyond 14 days without rationale. This affected two residents (#1, #51) reviewed for unnecessary medications. Findings include:1.Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included sepsis, pneumonia, dysphagia, end stage renal disease, chronic respiratory failure with hypoxia, congestive heart failure, hypertension, rheumatoid arthritis, macular degeneration, vitamin D deficiency, exocrine pancreatic insufficiency, depression, hypertensive heart, chronic kidney disease, osteoarthritis, and atrial fibrillation. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition, had no behaviors, and was not on any antipsychotic medications. Review of the December 2025 physician's orders revealed Resident #1 had an order for lorazepam (benzodiazepine used to treat anxiety) 0.5 milligram twice daily for anxiety as needed dated 11/20/25 with no rationale. Review of the Note to the Attending Physician (pharmacy recommendation) dated 12/10/25 revealed Resident #1 was currently receiving lorazepam 0.5mg twice daily as needed for longer than 14 days. If the medication was needed to be extended please document the rationale for the extended period in the medical record and indicate a specific duration. The note was signed by the nurse practitioner on 12/22/25. On 12/22/25 at 2:43 P.M. an interview with the Director of Nursing )DON) verified Resident #1 was receiving lorazepam for longer than 14 days without a stop date or rationale. Review of the facility policy titled, Psychoactive Medication, dated 05/01/25 revealed it was the policy of the facility to utilize psychoactive medication therapy to assist a resident to reach his/her highest practicable level of well-being. The facility would limit psychoactive medication use to circumstances in which the resident had a medical diagnoses and/or symptoms that warrant the use of therapeutic psychoactive medication. As needed orders for psychotropic drugs were limited to 14 days. If the practitioner believed that it was appropriate for the as needed order to be extended beyond 14 days he or she should document their rationale in the resident's medical record and indicate the duration of the as needed order. 2. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, streptococcal infection, contusion of left thigh, dysphagia, cognitive communication deficit, congestive heart failure, urinary tract infection, chronic obstructive pulmonary disease, atrial fibrillation, chronic kidney disease, atherosclerotic heart disease, hypothyroidism, depression, hyperlipidemia, hypertension, panic disorder anxiety disorder, goiter, fracture of right pubis, and low back pain. Review of the December 2025 Physician's orders revealed Resident #51 had an order for lorazepam 0.5 milligrams every four hours as needed for terminal restlessness dated 12/01/25. Resident #51 was not receiving hospice services. On 12/22/25 at 2:43 P.M. an interview with the Director of Nursing verified Resident #51 was on lorazepam for longer than 14 days without a stop date or rationale.

Based on medical record review, self-reported incident (SRI) review, facility investigation review, facility policy review, and interview, the facility failed to complete a thorough investigation following an allegation of abuse. This affected one (#55) of one resident reviewed for abuse. The facility census was 47.Findings include: Review of the Self-Reported Incident (SRI) #267738 submitted to the Ohio Department of Health (ODH) on 11/19/25 revealed an investigation was initiated by the facility for an allegation of physical abuse. The SRI revealed Resident #55 was discharged to the hospital on [DATE] following a non-SRI related critical lab finding. Resident #55's daughter contacted the facility on 11/19/25 to report the resident had bruising on her right hip and possibly small bruises on her back. There was no alleged perpetrator. Staff were interviewed and it was revealed that over the weekend 11/15-11/16/25 staff had attempted to utilize a mechanical lift known as a sit-to-stand to safely transfer the resident. Staff stated Resident #55 demonstrated a noticeable right-side lean during this time and had to be highly encouraged to keep her feet in place. Staff stated the resident had rubbed her right hip area against device on multiple occasions and leaned in the back support brace with most of her body weight. The night shift nurse and aide noticed a small quarter-sized reddened/pink area located on the right hip while providing care on the night of 11/17/25. On the morning of 11/18/25 preceding the resident's transfer to the hospital, the certified nurse aide (CNA) notified the nurse on duty of the area as well, however, before she could be examined, she was sent to the hospital. At no time did the resident voice concerns of pain or issues with the area. It was reported by staff that the resident demonstrated a right-side lean multiple times while transferring, causing the resident's hip to come into contact with the assistive device. The resident also put her full weight into the supportive sling that was wrapped around her back which is the most likely explanation for the alleged bruising. The facility unsubstantiated the allegation of abuse. Review of the medical record for Resident #55 revealed an admission date of 09/24/25 with diagnoses including infection following a procedure surgical site, cellulitis of left lower limb, muscle weakness, dysphagia, cognitive communication deficit, repeated falls, fracture of left femur, acute respiratory failure with hypoxia, anemia, and anxiety. Review of the Minimum Data Set (MDS) 3.0 revealed the resident was severely cognitively impaired and required physical assistance from staff with activities of daily living (ADLs). Review of the facility's investigation revealed Licensed Practical Nurse (LPN) #334, Certified Nursing Assistant (CNA) #303 and CNA #358's witness statements did not indicate dates or times of the referenced incident in their statements; CNA #358's witness statement (conducted via phone by the Director of Nursing) did not contain her last name or title; there was no witness statement obtained from CNA #367 who was identified by the DON as one of the two staff present during Resident #55's sit-to-stand incident; and no physical assessments for abuse were conducted of non-interviewable residents. Interview on 12/29/25 at 9:51 A.M. with the Director of Nursing (DON) confirmed the investigation of SRI #267738 did not contain witness statements for LPN #334 and CNA (#303 and #358) with a date of the incident referenced in the statements; and CNA #358's witness statement (conducted via phone by the Director of Nursing) did not contain her last name or title. The DON further confirmed there was no witness statement obtained from CNA #363 who was present during the identified incident which resulted in Resident #55's injury; and there were no observations or physical assessments for abuse of non-interviewable residents. Interview on 12/29/25 at 10:55 A.M with the Administrator confirmed the investigation for SRI #267738 did not contain witness statements with complete names and titles of all staff interviewed and dates of the information referenced in the witness statements. The Administrator further confirmed there was no evidence or documentation of non-interviewable residents having been physically assessed for abuse. Reviewed facility policy, Abuse, Mistreatment, Neglect, Misappropriation of Resident Property and Exploitation, undated, revealed the facility will not tolerate abuse, neglect, misappropriation of resident property or exploitation of its residents. Once the Administrator and ODH are notified, an investigation of the allegation or suspicion will be conducted. Investigation protocol: interview the resident, the accused, and all witnesses. Witnesses generally include anyone who witnessed or heard the incident; came in close contact with the resident the day of the incident; and employees who worked closely with the accused employee and/or alleged victim the day of the incident. Obtain written statements from the resident, if possible, the accused, and each witness.

Review of the medical record, review of the notification of bed hold forms, review of the facility policy, and interview with the staff, the facility failed to ensure a resident was notified in writing the amount of the bed hold routine daily charge. This affected two residents (#1, #51) of three residents reviewed for bed hold notices. Findings include:1.Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included sepsis, pneumonia, dysphagia, end stage renal disease, chronic respiratory failure with hypoxia, congestive heart failure, hypertension, rheumatoid arthritis, macular degeneration, Vitamin D deficiency, exocrine pancreatic insufficiency, depression, hypertensive heart, chronic kidney disease, osteoarthritis, and atrial fibrillation. Review of the progress note dated 10/26/25 at 12:02 P.M. revealed Resident #1 was sent to the emergency room for left lower lobe consolidation collapse. Review of the Notification of Bed Hold Days form dated 10/27/25 revealed the notice did not specify the amount it would cost the resident per day. On 12/24/25 at 10:36 AM an interview with the Administrator revealed he had been doing the bed hold notices and did not indicate the daily per diem charge on the bed hold notices Review of the facility policy titled, Bed Hold Days, dated 10/21 revealed the facility would provide to the resident and the resident representative at the time of the transfer of a resident for hospitalization or therapeutic leave, a written notice which specified the duration of the bed hold policy. 2.Review of the medical record revealed Resident #51 was admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, streptococcal infection, contusion of left thigh, dysphagia, cognitive communication deficit, congestive heart failure, urinary tract infection, chronic obstructive pulmonary disease, atrial fibrillation, chronic kidney disease, atherosclerotic heart disease, hypothyroidism, depression, hyperlipidemia, hypertension, panic disorder anxiety disorder, goiter, fracture of right pubis, and low back pain. Review of the Progress Note dated 11/07/25 at 8:48 P.M. revealed the physician was notified of Resident #51's laboratory results and gave the order to send the resident to the emergency room for evaluation. Review of the Notification of Bed Hold Days dated 11/07/25 revealed the notice did not specify the amount it would cost the resident per day. Review of the Progress note dated 11/10/25 at 12:39 P.M. revealed Resident #51 was lethargic and confused. The Nurse Practitioner was notified and gave an order for the resident to go to the emergency room for evaluation. Review of the Notification of Bed Hold Days form dated 11/10/25 revealed the notice did not specify the amount it would cost the resident per day.Review of the Progress note dated 11/26/25 at 1:39 P.M. revealed the power of attorney for Resident #51 was in the facility and wanted the resident sent to the emergency room due to her change in condition. Review of the Notification of Bed Hold Days dated 11/26/25 revealed the notice did not specify the amount it would cost the resident per day. On 12/24/25 at 10:36 AM an interview with the Administrator revealed he had been doing the bed hold notices and did not indicate the daily per diem charge on the bed hold notices. Review of the facility policy titled, Bed Hold Days, dated 10/21 revealed the facility would provide to the resident and the resident representative at the time of the transfer of a resident for hospitalization or therapeutic leave, a written notice which specified the duration of the bed hold policy.

Based on record review, observation and interview, the facility failed to provide a person-centered, comprehensive care plan, developed and implemented to meet the preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. This affected two residents (#37, #48) of five residents reviewed for care plans. The facility census was 47.Findings include:1. Review of the medical record for Resident #37 revealed she was admitted to the facility on [DATE]. Diagnoses included osteomyelitis; muscle weakness; need for assistance with personal care; methicillin resistant staphylococcus aureus; bacteremia; noncompliance with other medical treatment and regimen; Type 2 diabetes mellitus with diabetic polyneuropathy; depression; chronic obstructive pulmonary disease; anxiety disorder; hyperlipidemia; hypokalemia; anemia; acute kidney failure; hyperglycemia; and gastroesophageal reflux disease without esophagitis. Review of a Minimum Data Set (MDS) version 3.0, dated 11/18/25, for Resident #37 revealed a Brief Interview for Mental Status (BIMS) assessment score of 12 on a 0-15 scale. A score of 12 would indicate moderate problems with thinking and memory. The resident was to be non-weight bearing on the right foot, and required assistance with activities of daily living. Review of a care plan for Resident #37, dated 12/18/25, indicated the resident had an infection related to osteomyelitis of the right ankle. Interventions included providing medications as ordered. The care plan revealed the resident had a wound vacuum (or wound vac, a device which used negative pressure to accelerate wound healing and improve outcomes), which she frequently changed the rate on as a concern for healing of the chronic wound. There was a problem listed on care plan for behavioral symptoms. This problem included non-adherence to care/services which included noncompliance with changing settings on a wound vac, pulling tubes out of the wound vac, blaming the cat for changing the wound vac settings, noncompliance with keeping clothes on, constantly picking at wound vac dressing, yelling and cussing on phone and crawling around on the floor. Interventions for this included obtaining a psychological consult as needed and providing alternatives to refusals of care. Further review of the care plan for Resident #37 failed to reveal a problem statement or interventions for care and maintenance of a peripherally inserted central catheter (PICC). It also failed to reveal a problem for behavioral concerns regarding illegal drug use or mental health concerns. On 12/22/25 at 12:28 P.M., an observation of Resident #37 revealed a PICC line inserted into her right arm. The resident did not have a wound vac in place. This was confirmed by Registered Nurse (RN) #314 on 12/23/25 at 3:30 P.M. On 12/23/25 at 3:30 P.M., an interview with Registered Nurse (RN) #314 revealed the resident was no longer receiving intravenous antibiotics, however she still had a PICC line, which had been used for lab work and kept in place until the resident went to the Infectious Disease practitioner to see if she would require further intravenous antibiotics. She confirmed there had been no orders to discontinue use or care of PICC line. She further confirmed the resident no longer had orders for use of a wound vac. She reported the resident had been caught a few times with drug paraphernalia, and other smoking implements in her room, and was very disruptive to the entire hall. Review of a progress note, dated 12/13/25 at 7:30 A.M., was entered into Resident #37's chart on 12/15/25 at 1:58 P.M. The note indicated the staff found three pipes with an unknown substance in them wrapped in tissue in the resident's recliner. The resident was noted to appear under the influence of drugs or over medicated. The police were called and took the pipes and a report was filed. This was confirmed by Registered Nurse (RN) #336 on 12/24/25 at 10:48 A.M. An interview with RN #336 on 12/24/25 at 10:48 A.M., revealed Resident #37 had brought what they believed to be drugs into the facility or would sit with significant other across the street from the facility for long periods of time, smoking and possibly using other drugs. The facility had drug tested her and these tests came back positive. Because of this, her pain medications had been adjusted to non-narcotic pain medications. An interview with Registered Nurse (RN) #400 on 12/29/25 at 1:00 P.M. revealed Resident #37 had a care plan which did not address PICC line maintenance, drug use, or other behavioral issues which could be detrimental to her health and well-being. She also confirmed the care plan continued to list a wound vac as a problem, however the wound vac had been discontinued. 2. Review of medical record for Resident #48 revealed she was admitted on [DATE]. She had diagnoses of metabolic encephalopathy, sepsis, muscle weakness, acute on chronic diastolic congestive heart failure, chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, hypothyroidism, unspecified bilateral hearing loss, anemia, and depression. Review of a Minimum Data Set (MDS) version 3.0 for Resident #48 dated 11/05/25 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10 on a 0-15 scale. A score of ten indicated moderate problems with thinking and memory. Review of a care plan dated 12/22/25 revealed Resident #48 had an alteration in hearing but did not wear any hearing aides. There was no evidence in the review of the care plan to address Hospice or palliative care for the resident. Review of the medical record for Resident #48 failed to reveal an order for Palliative Care to begin. The first progress note from palliative care was noted on 01/02/25 and continued through 12/05/25. An interview with Registered Nurse (RN) #400 on 12/29/25 at 1:00 P.M. revealed Resident #48 was active with a Palliative Care agency. She confirmed the resident's record did not have orders or care plan for Palliative care. Review of a facility policy, dated 05/01/25, titled Care Planning-Comprehensive, revealed the facility's interdisciplinary team was responsible for care planning. The team would develop an individualized, comprehensive plan for each resident. Per the policy, care plans were to be updated as a resident condition changed. These plans were reviewed quarterly or when a significant change in condition in which a Minimal Data Set (MDS) assessment was completed.

Based on observation, staff interview, medical record review and review of facility policy, the facility failed to ensure medications were properly stored. This affected one resident (#27) of one resident reviewed for medication storage. The facility census was 47.Findings include:Review of the medical record for Resident #27, revealed an admission date of 08/19/21. Diagnoses included: spinal stenosis, lumbar region without neurogenic claudication, Alzheimer's disease, dementia and major depressive disorder.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14. Observation on 12/22/25 at 10:23 A.M. revealed a medicine cup containing four pills on Resident #27's bedside table. Resident #27 stated she does not know how long they have been there.Review of the physician orders revealed Resident #27 did not have an order to self-administer medications or for medications to be left at bedside.Interview on 12/22/25 at 10:25 A.M. with Licensed Practical Nurse (LPN) # 361 revealed she administered Resident #27's medications, confirmed she left the medications on the bedside table and further confirmed Resident #27 does not have an order for self-administration or for medications to be left at bedside.Review of facility policy titled, Medication Storage in the Facility dated May 2020, revealed medications are stored safely, securely, and properly, following manufacturers' recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on record review, self reported incident review, and interview the facility failed to ensure the incident log was complete and accurate for a resident fall and failed to ensure a resident's medical record was complete. This affected one resident (#55) of two residents reviewed for accidents. The facility census was 47.Findings include:Review of the medical record for Resident #55 revealed an admission date of 09/24/25. Diagnoses included infection following a procedure surgical site, cellulitis of left lower limb, muscle weakness, dysphagia, cognitive communication deficit, repeated falls, fracture of left femur, acute respiratory failure with hypoxia, anemia, and anxiety. Review of a Minimum Data Set (MDS) version 3.0, dated 10/13/25, revealed a Basic Interview for Mental Status (BIMS) of seven on a 0-15 scale. A BIMS score of seven would indicate severe problems with thinking and memory. It also indicated the resident needed assistance with all activities of daily living (ADLs).Review of a Care Plan, dated 10/21/25, revealed Resident #55 had anemia and was at risk for fatigue, weakness, and confusion. Interventions included observing the resident for the following signs and symptoms associated with anemia: pale skin, fatigue, shortness of breath, headaches, insomnia, dizziness, leg cramping, increased heartbeat and altered blood values such as low hemoglobin. Further review of the Care Plan revealed the resident was at risk for falls/injury related to confusion, history of falls, and incontinence of bowel and urine. Interventions included with device use, to observe for potential mental and physical side effects such as lethargy, mood changes, mobility changes, skin integrity changes, and toileting changes; and to report side effects to the physician or nurse practitioner (NP).Review of Self-Reported Incident (SRI) #267738 submitted to the Ohio Department of Health (ODH) on 11/19/25 revealed an investigation was initiated by the facility following an allegation of possible physical abuse. The SRI revealed Resident #55 was discharged to the hospital on [DATE] following a non-SRI related critical lab finding. Resident #55's daughter contacted the facility on 11/19/25 to report the resident had bruising on her right hip and possibly small bruises on her back. There was no alleged perpetrator. Staff were interviewed and it was revealed that over the weekend, 11/15-11/16/25, staff had attempted to utilize a mechanical lift known as a sit-to-stand to safely transfer the resident. Staff stated Resident #55 demonstrated a noticeable right-side lean during this time and had to be highly encouraged to keep her feet in place. Staff stated the resident had rubbed her right hip area against device on multiple occasions and leaned in the back support brace with most of her body weight. The night shift nurse and aide noticed a small quarter-sized reddened/pink area located on the right hip while providing care on the night of 11/17/25. On the morning of 11/18/25 preceding the resident's transfer to the hospital, the certified nursing assistant (CNA) notified the nurse on duty of the area as well, however, before she could be examined, the resident was sent to the hospital. At no time did the resident voice concerns of pain or issues with the area. It was reported by staff that the resident demonstrated a right-side lean multiple times while transferring, causing the resident's hip to come into contact with the assistive device. The resident also put her full weight into the supportive sling that was wrapped around her back, which is the most likely explanation for the alleged bruising. The facility unsubstantiated the allegation of abuse.Review of a nursing progress note, dated 11/16/25 at 12:31 P.M., (authored by Licensed Practical Nurse (LPN) #318) revealed she was alerted by CNA that Resident #55 appeared weak while utilizing the sit-to-stand device. Respirations were even and unlabored with respiratory rate of 18, pulse was 88, blood pressure was 124/75, oxygen saturation was 87% on room air. The resident was alert and oriented to self and surroundings and did mention to her spouse while visiting that she fell and was running around the facility all night, which she did not. She was easily reoriented and able to answer questions and express needs. She stated she just feels tired today. Review of a progress note for Resident #55, dated 11/17/25 at 12:55 P.M. revealed a nurse was called to Resident #55's bathroom. Upon entering bathroom, resident was noted to be sitting on the toilet. Face noted to be pale but resident alert. Speech noted to be slurred at this time but appropriate responses. Staff assist resident off the toilet and to her wheelchair. Noted that resident had a large formed BM in the toilet. Noted that once in wheelchair, resident regained color to her face and was alert and oriented and stated that she felt better. Able to carry a conversation with this nurse. Noted that when this nurse left the room resident was eating a donut prior to going to her appointment. Husband at bedside. Call light and fluids within reach. The resident record failed to reveal communication with the resident's primary care provider regarding a change in her condition. This was confirmed by Nurse Practitioner (NP) #401 on 12/23/25 at 5:02 P.M.An Interview on 12/23/25 at 5:02 P.M. with NP #401 confirmed she did not recall being notified of incident on 11/17/25, but was notified later in the week when the resident had an episode of weakness/pallor and slurred speech at which time she ordered a hemoglobin level to be checked. Review of a progress note for Resident #55, dated 11/18/25 at 11:23 A.M., revealed a note from IDT (interdisciplinary team). This note was noted to actually be documented on 11/24/25 at 10:39 A.M. as a late entry. The note indicated on chart review it had been found the night shift LPN (Licensed Practical Nurse) noted new bruising to the right hip area on 11/17/25 , which had been identified as a clustered small area of newer looking discoloration to right side hip area through the night by both STNA (state tested nurse assistant) and LPN per completed pink man form, area is consistent per interview with staff with resident bumping off sit to stand on Sunday evening. Per LPN interview when resident during a weak episode slammed body down into sit to stand on right side and her back, at the time of incident there were no noted injuries per interview with staff resident was educated after incident and safely transferred into bed and assessed thoroughly with no major obvious and/or finding's. Review of the facility incident and accident log failed to reveal an incident regarding Resident #55 on 11/16/25. This was confirmed by the Director of Nursing (DON) on 12/29/25 at 9:51 A.M. On 12/29/25 at 9:51 A.M., an interview with the Director of Nursing (DON) confirmed the nursing progress notes failed to contain documentation of 11/16/25 transfer incident and incidents of ongoing weakness. The DON confirmed the incident and accident log did not reflect the incident on 11/16/25 regarding Resident #55.

Based on review of the job descriptions, review of the employee handbook, review of a self-reported incident investigation, review of timed stamped and dated photographs, review of Centers for Disease Control (CDC) and the National Institute for Occupational Safety and Health (NIOSH) report, review of the facility assessment, review of time sheets, interviews, and policy review the facility failed to have systems in place to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to prevent staff sleeping while on duty and monitor to ensure licensed staff do not pre-pour medications for residents prior to administration. This had the potential to affect all 48 residents residing in the facility. Findings include: 1. Review of Licensed Practical Nurse (LPN) #133's timecard dated 11/06/25 and 11/07/24 revealed LPN #133 clocked in at 11:54 P.M. on 11/06/25 and clocked out at 6:12 P.M. on 11/07/24. The LPN worked 17.75 hours.Review of photographs dated 11/07/24 at 4:33 A.M., revealed LPN #133 standing in front of medication cart with the card drawer open. There were approximately nine medication cups with several loose pills in the cups and five clear cups set up in a line with no medication in them yet were on top of the medication cart. Interview on 08/25/26 at 9:25 A.M., with Certified Nursing Assistant (CNA) #888 confirmed LPN #133 pre-pouring medication and groups medication administration times (morning and afternoon medication times) together so she only has one medication pass. Residents will question their medication and LPN #133 would tell residents the medication was correct and just take them. Administration staff were aware, and several staff had reported LPN #133, but nothing was addressed and the nurse continued to pre-pour medications. Several staff ended up resigning due to the nurse's negligence. Interview on 08/25/25 at 1:06 P.M., with LPN #133 and the Director of Nursing (DON) revealed LPN #133 confirmed she was the nurse in the photo dated 11/07/24 at 4:33 A.M. pre-pouring medications for administration. The LPN reported she had occasionally pre-poured medication to get a jump start on the day. The DON reported she was not aware the LPN was pre-pouring medications and staff should not be pre-pouring medications (for a later administration). Interview and review of LPN #133's timecard on 08/26/25 at 11:16 A.M., with Registered Nurse (RN) #100 verified the nurse worked 17.75 hours on 11/07/24.Review of LPN #133's job description dated 09/19/23 revealed the LPN would administer scheduled medications to residents in a timely manner, ensuring proper and correct dosages were given. Properly records administration on the Medication Administration Records (MAR). Follows the facility's policy and procedures for administrating medications. Review of the facility's policy titled Medication Administration-General Guideline dated 05/2020 revealed when medications are administered by mobile cart the cart is taken to the resident location and administered at the time they are prepared. Medication is not pre-poured either in advance of the medication pass or for more than one resident at a time. 2. Review of a photograph of a Facebook post dated 06/23/25 revealed Resident #50 had posted two pictures of LPN #133 asleep on the couch in the common area. The post indicated this was the dayshift nurse (nurses name posted) at (facility's name posted) sleeping on night shift at 3:30 A.M. The nurse picks up all the hours, now we know how she does it. Feel sorry for the residents that need help, like me. I have been waiting for my pain medication for almost six hours. Review of pictures/videos dated 06/23/25 at 1.38 A.M, 1:45 A.M., 2:29 A.M., and 4:03 A.M., revealed LPN #133 on the couch in the common area, asleep. Review of Self-Reported Incident (SRI) Tracking Number 261941, dated 06/23/25, revealed Resident #50 alleges she went too long without pain medication. Review of the investigation revealed a statement authored by Registered Nurse (RN) #152 that indicated on 06/22/25 into 06/23/25 she had walked over to the other unit approximately midnight to get medication and asked the Assistant Director of Nursing (ADON) for the medication room keys. The ADON stated she had given the keys to LPN #133. RN #152 went to ask LPN #133 for the medication keys, and she was observed on the couch in the day area covered up with a blanket, sleeping. RN #152 woke her up and she stated she didn't have the keys and went back to sleep. RN #152 told the ADON that LPN #133 stated she didn't have the keys. The ADON stated LPN #133 had the keys and they just had counted the narcotic drawer. RN #152 stated she returned to her unit and thought she would get the medication she needed later. The lab technician came over at approximately 3:30 A.M. and asked if there were labs on the other unit due to there being no log and the nurse was asleep, and she could not wake her. Both CNAs were present during the conversation. RN #152 had gone back to LPN #133's unit at 5:30 A.M. to get medication out of the medication room and LPN #133 had asked if lab had been there. LPN #133 reported she was unable to print the labs off the computer. RN #152 told LPN #133 she could have called her over and she could have printed them. LPN #133 stated I'm allowed to take a break. RN #152 returned to her unit. Review of a statement authored by Physical Therapist (PT) #999 dated 06/24/25 revealed Resident #50 had reported to PT #999 that LPN #133 had been sleeping for six hours, and she had to wait on her pain medication. Review of a statement authored by the Administrator via phone with CNA #503 on 06/25/25 at 12:14 P.M., revealed CNA #503 was called over to the 200 unit by CNA #888 to help with resident care around 3:00 A.M., on 06/23/25 and she had seen LPN #133 on the couch. CNA #503 returned to her unit. Sometime around 3:30 A.M. the lab tech reported to CNA #503 and #888 she saw someone sleeping on the couch and a resident was taking pictures. Review of CNA #144's statement dated 06/25/25 revealed the CNA had come in early around 1:30 A.M., the RN went over to the other unit to get some medication and reported she couldn't get LPN #133 up and the CNA had asked for help to pull a couple resident up because she couldn't get the LPN awake. Around 3:00 A.M., the lab tech asked if there were any labs because the nurse was asleep and she could not wake her up and there was a resident on the unit taking pictures. The CNA went back over to see what was going on. Review of LPN #133's timecard dated 05/25/25 to 08/25/25 revealed the LPN worked 10.75 hours on 05/26/25, 3.75 hours on 05/27/28, 9.5 hours on 05/28/25, 17.25 hours on 05/29/25, 17.25 hours on 05/30/25, and 05/31/25 2.25 hours. The LPN has no hours record on 06/01/25, 9.0 hours on 06/02/25, 7.5 hours on 06/03/25, 17.00 hours on 06/05/25 and 16.5 hours 06/06/25, 11.75 hours on 06/07/25, 15.5 hours on 06/08/25, 0.0 hours on 06/09/25, 10.75 hours on 06/10/25, 0.0 on 06/11/25, 17.25 hours on 06/12/25, 14.25 hours on 06/13/25, 5.5 on 06/14/25, 6.0 hours on 06/15/25, 17.0 hours on 06/16/25, 0.0 hours on 06/17/25 and 06/18/25, 18.0 hours on 06/19/25, 12.75 hours on 06/20/25, 17.58 hours on 06/21/25, 11.75 hours on 06/22/25, 10.0 hours on 06/23/25. Interview on 08/25/25 at 1:06 P.M., with LPN #133 and the Director of Nursing (DON) revealed LPN #133 confirmed she was the nurse in the photos dated 06/23/25 at 1.38 A.M, 1:45 A.M., 2:29 A.M., and 4:03 A.M. LPN #133 reported she took her break from 3:30 A.M. to 4:00 A.M. The LPN #133 reported staff don't lock out for their 30-minute break. The time clock just asked if you took a break when you clock out and you enter yes or no. Interview on 08/26/25 at 6:43 A.M., with Licensed Practical Nurse (LPN) #148 revealed about four or five months ago she had observed LPN #133 sleeping on the unit. Interview on 08/26/25 at 12:06 P.M., with Assisting Director of Nursing (ADON) #131 confirmed LPN #133 had confirmed LPN #133 had worked over 16 hours on 05/29/25, 05/30/25, 06/05/25, 06/06/25, 06/12/25, 06/16/25, 06/19/25, and 06/21/25.3. Review of the staffing schedule dated, and time sheets dated 08/14/25 to 08/25/25 revealed 08/14/25 LPN #133 worked 12.25 hours, 08/15/25 6.0 hours, 08/16/25 12.75 hours, 08/17/25 11.5 hours, 08/18/25 5.75 hours, 08/20/25 4.75 hours, 08/21/25 15.75 hours, 08/22/25 15.75 hours, 08/23/25 15.50 hours, 08/24/25 15.5 hours, and was scheduled 16 hours (6:00 A.M. to 10:00 P.M.) on 08/25/25. Interview on 08/25/25 at 1:33 P.M., with the DON, revealed staff don't always communicate with administration changes in schedule but LPN #133 picks up a lot of shifts. There was one other incident 7-8 months ago staff had reported LPN #133 sleeping, however she was not able to verify, nor did she document the incident or investigation. After the incident in June staff are not permitted to work over 16 hours. The DON confirmed LPN #133 had worked several 16-hour shifts in the last few days. The DON confirmed several staff had resigned due to the incident in June. Interview on 08/28/27 at 2:11 P.M., with Registered Nurse (RN) #600 revealed LPN #133 had been reported numerous times to Administration staff for sleeping, not administering medication as ordered, and not assessing residents. RN#600 reported she had a text message from a nurse who reached out to the DON due to LPN #133 had forgot to administer a Xanax and during reconciliation LPN #133 popped the pill out of the bubble card and threw it in the sharps container and then signed the medication off. The nurse texted the concern to the DON and she asked the nurse to call her. The DON didn't want anything in writing. RN #600 shared she had personally reported LPN #133 and wrote a statement and the DON gave the written statement directly to LPN #133. Residents have voiced and reported concerns. LPN #133 was bragging a few months ago because she worked 154 hours in two weeks and her check with bonuses and over time was $7,000.00. The DON and ADON tolerate her behavior because LPN #133 comes into work, so they don't have to. There was another time LPN #133 was working as the aid on her hall and was asleep and snoring at the nurse's station. The RN reached out to the Administration, and they asked if she was answering call lights and she responded yes and that was it nothing was done. Every time someone reports her sleeping they say its her break times. The DON and Administrator have been good to her, and she thought they were good people but covering up neglect was the last straw. RN #600 reported she had called the Administrator regarding her concerns before she gave her notice. The DON is related to LPN #133 and reported she doesn't show favoritism, but they are always together. Review of the employee handbook dated 01/2018 revealed employees were expected to act as a neighborhood watch for the compliance program. Therefore, if you observe any conduct that you suspect may be a violation of the Code of Conduct, you are required to report that conduct to your immediate supervisor. The potential violation would be investigated and action taken. Review of the job description of the Licensed Nursing Home Administrator dated 10/16/23 revealed the administrator would be responsible for the overall management and leadership of the facility. Ensures that the services offered meet or exceed federal, state, local, and company standards. Operation profitably within corporate budgetary guidelines. The Administrator would manage and evaluate designated departments leaders through ongoing performance management, timely constructive feedback, and professional development plans. Promotes positive employee relations by facilitating an atmosphere of open communication and problem-solving. Effective use of Employee Satisfaction surveys to action plan addresses any employee concerns. Review of the job description of the Director of Nursing (DON) dated 10/17/23 revealed the DON required the professional knowledge, skills necessary to plan, organize, develop, and direct the overall operation of the Nursing Department in accordance with current state and federal standards to ensure the highest degree of quality of care was maintained at all times. The DON ensures the nursing department awareness of potential hazards and unsafe conditions to the appropriate department to maintain a safe environment for residents, visitors, and staff. The DON maintains effective and appropriate staffing within as required by facility policy/procedure and regulatory guidelines. Adjust employees ' hours of work and assignments as necessary. Monitors resident care on regular basis to determine quality and customer service was maintained. Ensures medication and treatments were administered and documented as ordered by the physician. Review of the CDC and NIOSH risk associated with shift work and long work hours for nurses dated 03/31/20 revealed research indicated shift work and long work hours were associated with somewhat higher risks for errors and injuries. Getting less sleep than needed is called sleep deprivation. Not only do people feel tired and sleepy when they are sleep deprived, but they can show declines on tests of brain function such as response rate, thinking, remembering, and concentration. Sleep deprivation influences work performance and while driving home. Both short-term recall and working memory decline. Thus, it becomes difficult for you to perform tasks that require information to be accurately held in memory for brief periods such as remembering a drug dose from chart to medication room or remembering a list of tasks when interrupted, or dialing a phone number you just looked up. Your learning is impaired, reducing information retained during activities such as patient handovers and in-service training. Sleep deprivation impairs your performance. Divergent thinking, innovation, and insight decrease. Risk assessment is poor and risk-taking behaviors increase. As sleep deprivation increases, activities judged to be nonessential are neglected because awareness of surroundings and circumstances decreases. For example, you may misjudge how much time has passed or may not recognize signs that a patient's condition was deteriorating. Communication skills decrease. You may fumble for the right word, say the wrong word, or misinterpret another person's words. People often think the effects of sleep deprivation can be overcome through motivation, professionalism, training, or experience. However, recent research provided evidence against this idea. Several studies show similarities between fatigue-related impairment in cognitive and physiological functioning, and impairments due to alcohol intoxication were similar. Being awake for 17 hours is similar to having a blood alcohol concentration (BAC) of 0.05%, which is the legal intoxication for purpose of driving as a BAC of 0.08%. However, driving impairments are seen at a BAC of 0.05%. Nurses are at risk for making a very serious mistake, and as a nurse this could be fatal. Evidence is growing that long work hours are linked to patient care errors and dissatisfaction. Shifts greater than 13 hours were linked to patient dissatisfaction. Specifically, patients reported that their nurses were not communicating well, their pain was not controlled, and they did not get help as soon as they wanted. Studies showed nurses had over three times the odds of making an error when working 12 or more hours, compared to 8.5 hours shifts. Employers and workers have been penalized when a fatigue-related error led to a person's death. Shift work and long work hours can reduce productivity, increase work errors, increase absenteeism, increase turnover, increase healthcare cost, and loss of nurses who leave the job. Review of LPN #133 job description dated 09/19/23 revealed the LPN would ensure quality resident care. Review of the facility assessment undated revealed the average daily census was 47.3. The facility provides care and services to individuals with certain medical and cognitive disabilities. The facility care team reviews all referrals prior to admission to determine needed staff, equipment and supply resources to care for the potential admission. The facility's daily staffing was based on the resident's population and acuity taking into consideration staffing needs for each resident unit and shift. The facility has the following personnel (Administration staff, nursing services, food and nutrition, therapy, physician services, pharmacy services, support staff) available to provide care and services to residents. This deficiency represents non-compliance investigated under Complaint Numbers 2568688, 1274323, 1274309, and 1274308.

Based on review of the job descriptions, review of the employee handbook, review of a self-reported incident investigation, review of timed stamped and dated photographs, review of the facility assessment, review of time sheets, interviews, policy review, and review of the Nurse Practice Act, the facility failed to ensure care and services were provided within acceptable standards of quality when Licensed Practical Nurse (LPN) #133 was observed pre-pouring resident medications and also observed sleeping multiple times throughout the shift. This had the potential to affect the residents residing on the Rodeo Unit where LPN #133 was working. The facility census was 48.1. Review of Licensed Practical Nurse (LPN) #133's timecard dated 11/06/25 and 11/07/24 revealed LPN #133 clocked in at 11:54 P.M. on 11/06/25 and clocked out at 6:12 P.M. on 11/07/24. The LPN worked 17.75 hours.Review of photographs dated 11/07/24 at 4:33 A.M., revealed LPN #133 standing in front of medication cart with the card drawer open. There were approximately nine medication cups with several loose pills in the cups and five clear cups set up in a line with no medications in them yet were on top of the medication cart. Interview on 08/25/26 at 9:25 A.M., with Certified Nursing Assistant (CNA) #888 confirmed LPN #133 pre-pouring medication and groups medication administration times (morning and afternoon medication times) together so she only has one medication pass. Residents will question their medication and LPN #133 would tell residents the medication was correct and just take them. Administration staff were aware, and several staff had reported LPN #133, but nothing was addressed and the nurse continued to pre-pour medications. Interview on 08/25/25 at 1:06 P.M., with LPN #133 and the Director of Nursing (DON) revealed LPN #133 confirmed she was the nurse in the photo dated 11/07/24 at 4:33 A.M. pre-pouring medications for administration. The LPN reported she had occasionally pre-poured medication to get a jump start on the day. The DON reported she was not aware the LPN was pre-pouring medications and staff should not be pre-pouring medications (for a later administration). Review of LPN #133's job description dated 09/19/23 revealed the LPN would administer scheduled medications to residents in a timely manner, ensuring proper and correct dosages were given. Properly record administration on the Medication Administration Records (MAR). Follows the facility's policy and procedures for administrating medications.Review of the facility's policy titled Medication Administration-General Guideline dated 05/2020 revealed when medications are administered by mobile cart the cart is taken to the resident location and administered at the time they are prepared. Medication is not pre-poured either in advance of the medication pass or for more than one resident at a time. 2. Review of a photograph of a Facebook post dated 06/23/25 revealed Resident #50 had posted two pictures of LPN #133 asleep on the couch in the common area. The post indicated this was the dayshift nurse (nurses name posted) at (facility's name posted) sleeping on night shift at 3:30 A.M. The nurse picks up all the hours, now we know how she does it. Feel sorry for the residents that need help, like me. I have been waiting for my pain medication for almost six hours. Review of pictures/videos dated 06/23/25 at 1:38 A.M., 1:45 A.M. and 4:03 A.M., revealed LPN #133 on the couch in the common area, asleep. Review of Self-Reported Incident (SRI) Tracking Number 261941, dated 06/23/25, revealed Resident #50 alleges she went too long without pain medication. Review of the investigation revealed a statement authored by Registered Nurse (RN) #152 that indicated on 06/22/25 into 06/23/25 she had walked over to the other unit approximately midnight to get medication and asked the Assistant Director of Nursing (ADON) for the medication room keys. The ADON stated she had given the keys to LPN #133. RN #152 went to ask LPN #133 for the medication keys, and she was observed on the couch in the day area covered up with a blanket, sleeping. RN #152 woke her up and she stated she didn't have the keys and went back to sleep. RN #152 told the ADON that LPN #133 stated she didn't have the keys. The ADON stated LPN #133 had the keys and they just had counted the narcotic drawer. RN #152 stated she returned to her unit and thought she would get the medication she needed later. The lab technician came over at approximately 3:30 A.M. and asked if there were labs on the other unit due to there being no log and the nurse was asleep, and she could not wake her. Both CNAs were present during the conversation. RN #152 had gone back to LPN #133's unit at 5:30 A.M. to get medication out of the medication room and LPN #133 had asked if lab had been there. LPN #133 reported she was unable to print the labs off the computer. RN #152 told LPN #133 she could have called her over and she could have printed them. LPN #133 stated I'm allowed to take a break. RN #152 returned to her unit. Review of a statement authored by Physical Therapist (PT) #999 dated 06/24/25 revealed Resident #50 had reported to PT #999 that LPN #133 had been sleeping for six hours, and she had to wait on her pain medication. Review of a statement authored by the Administrator via phone with CNA #503 on 06/25/25 at 12:14 P.M., revealed CNA #503 was called over to the 200 unit by CNA #888 to help with resident care around 3:00 A.M., on 06/23/25 and she had seen LPN #133 on the couch. CNA #503 returned to her unit. Sometime around 3:30 A.M. the lab tech reported to CNA #503 and #888 she saw someone sleeping on the couch and a resident was taking pictures. Review of CNA #144's statement dated 06/25/25 revealed the CNA had come in early around 1:30 A.M., the RN went over to the other unit to get some medication and reported she couldn't get LPN #133 up and the CNA had asked for help to pull a couple resident up because she couldn't get the LPN awake. Around 3:00 A.M., the lab tech asked if there were any labs because the nurse was asleep and she could not wake her up and there was a resident on the unit taking pictures. The CNA went back over to see what was going on. Review of LPN #133's timecard revealed the LPN worked 18.0 hours on 06/19/25, 12.75 hours on 06/20/25, 17.58 hours on 06/21/25, 11.75 hours on 06/22/25, 10.0 hours on 06/23/25.Interview on 08/25/25 at 1:06 P.M., with LPN #133 and the Director of Nursing (DON) revealed LPN #133 confirmed she was the nurse in the photos dated 06/23/25 at 1:38 A.M., 1:45 A.M. and 4:03 A.M. LPN #133 reported she took her break from 3:30 A.M. to 4:00 A.M. LPN #133 reported staff don't lock out for their 30-minute break. The time clock just asked if you took a break when you clock out and you enter yes or no. Interview on 08/26/25 at 6:43 A.M., with Licensed Practical Nurse (LPN) #148 revealed about four or five months ago she had observed LPN #133 sleeping on the unit. Interview on 08/26/25 at 12:06 P.M., with Assisting Director of Nursing (ADON) #131 confirmed LPN #133 had worked over 16 hours on 06/19/25 and 06/21/25.Interview on 08/25/25 at 1:33 P.M., with the DON, revealed staff don't always communicate with administration changes in schedule but LPN #133 picks up a lot of shifts. There was one other incident 7-8 months ago staff had reported LPN #133 sleeping, however she was not able to verify, nor did she document the incident or investigation. After the incident in June staff are not permitted to work over 16 hours. The DON confirmed LPN #133 had worked several 16-hour shifts in the last few days. The DON confirmed several staff had resigned due to the incident in June. Interview on 08/28/27 at 2:11 P.M., with Registered Nurse (RN) #600 revealed LPN #133 had been reported numerous times to Administration staff for sleeping, not administering medication as ordered, and not assessing residents. The DON and ADON tolerate her behavior because LPN #133 comes into work, so they don't have to. Review of the facility assessment undated revealed the average daily census was 47.3. The facility provides care and services to individuals with certain medical and cognitive disabilities. The facility care team reviews all referrals prior to admission to determine needed staff, equipment and supply resources to care for the potential admission. The facility's daily staffing was based on the resident's population and acuity taking into consideration staffing needs for each resident unit and shift.Review of LPN #133 job description dated 09/19/23 revealed the LPN would ensure quality resident care. Review of the Nurse Practice Act revealed it does not address employment matters, such as work schedules, nor does it establish limits on the number of hours a licensee may practice within a given period of time. However, nurses must be knowledgeable of the standards of nursing practice in Rule 4723-4-03, OAC (related to RN practice), and Rule 4723-4-04, OAC (related to LPN practice). These rules require RNs and LPNs to demonstrate competence and accountability in all areas of practice in which the nurse is engaged, which includes but is not limited to 1) consistent performance of all aspects of nursing care; and 2) appropriate recognition, referral or consultation and intervention when a complication arises. In addition, all nurses are required to maintain a safe environment for the patient. Rule 4723-4-06(H), OAC. Working under conditions of fatigue may not be safe for the nurse or the patient. A nurse who fails to demonstrate competence or does not provide consistent performance within his or her nursing practice as a result of excessive work hours, or for any other reason, will not have met standards of safe practice. This deficiency represents non-compliance investigated under Complaint Numbers 2568688, 1274323, 1274309, and 1274308.

Based on interview and record review the facility failed to ensure residents received timely pain management. This affected one (Resident #50) of three residents reviewed for pain management. The census was 48. Findings include: Record review revealed Resident #50 admitted to the facility on [DATE] with diagnoses including anemia, hypertension, thyroid atrophy, hypomagnesemia, anxiety, and femur fracture with surgical intervention.Review of Resident #50 admission Minimum Data Set (MDS) section C for cognition revealed a Brief Interview for Mental Status Score of 15, indicating Resident #50 was cognitively intact.Review of MDS section J for health conditions revealed Resident #50 was receiving a scheduled pain medication regimen, and received as needed (PRN) pain medication.Review of Resident #50 care plan completed on 06/11/25 revealed Resident #50 has a left hip surgical wound. Goals include resident will have controlled pain and a level of comfort maintained daily. Interventions include to administer pain medications per physicians orders, remind the resident that reporting pain early may improve effectiveness of pain medication, try non medication relief measures such as repositioning pillows, pad, support, diversion, and observe and report if resident is experiencing breakthrough pain with current medication.Review of Resident #50 orders revealed an order starting 06/19/25 and ending on 06/23/25 for Oxycodone tablet 5 milligrams (mg) orally (PO) every four hours (q.4h) PRN.Review of grievance filed by Resident #50 on 06/23/25 with the Director of Nursing (DON) revealed Resident #50 wanted her pain medications more frequently.Review of event statement form completed on 06/24/25 by physical therapy assistant (PTA) #999 revealed Resident #50 had reported to her on the night of 06/22/25 into 06/23/25 she had waiting six hours for pain medicationReview of Resident #50 Narcotic log sheet for Oxycodone 5mg PO q.4h PRN starting 06/20/25 at 4:00 A.M. revealed from 06/20/25 until 06/22/25 Resident #50 received pain medication approximately every four hours for pain, until 06/22/25 when there was a six and a half hour time without medication from 1:13 P.M. until 7:47 P.M. and an eight and a half hour time from 7:47 P.M. until 5:21 A.M. on 06/23/25.Review of Resident #50 Medication Administration Record (MAR) for June of 2025 revealed Oxycodone 5mg PO q.4h PRN administered on 06/22/25 at 12:32 A.M., 4:28 A.M., 9:09 A.M., 1:13 P.M., and 7:47 P.M Resident #50 pain medication was given q.4h until 1:13 P.M. when there was a six and a half hour time between doses.Review of Resident #50 progress notes revealed a note dated 06/22/25 at 8:00 P.M. authored by assistant director of nursing (ADON) stating certified nurse ' s aides (CNA ' s) alerted this nurse that resident was upset, upon entering room Resident #50 demanded a pain pill stating it was due several hours ago. Let the resident know she was just then due to be able to get her PRN dose.Review of Resident #50 Narcotic log, MAR, and progress notes revealed they were due for their PRN dose on 06/22/25 at 5:13 P.M., not 8:00 P.M Review of Resident #50 Narcotic log sheet for Oxycodone 5mg PO q.4h PRN starting 06/20/25 at 4:00 A.M. revealed from 06/20/25 until 06/22/25 Resident #50 received pain medication approximately every four hours for pain, until 06/22/25 when there was a six and a half hour time without medication from 1:13 P.M. until 7:47 P.M Record review revealed no documentation of non-pharmacological pain interventions attempted or implemented to address Resident #50 pain between the hours of 1:13 P.M. 7:47 P.M. on 06/22/25.Review of Resident #50 June 2025 MAR revealed Oxycodone 5mg PO q.4h PRN was given on 06/22/25 at 7:47 P.M. and was not administer again until eight and a half hours later on 06/23/25 at 9 and a half hours later at 5:21 A.M.Review of Resident #50 Narcotic log sheet for Oxycodone 5mg PO q.4h PRN starting 06/20/25 at 4:00 A.M. revealed from 06/20/25 until 06/22/25 Resident #50 received pain medication approximately every four hours for pain, until 06/22/25 when there was an eight and a half hour time without pain medication from 7:47 P.M. until 5:21 A.M. on 06/23/25. After this time Resident #50 began receiving her pain medication every four hours as previous until discontinuation of the order. Record review revealed no documentation of non pharmacological pain interventions attempted or implemented to address Resident #50 pain between the hours of 7:13 P.M. on 06/22/25 and 5:21 A.M. on 06/23/25. Interview on 08/25/25 at 9:25 A.M. with certified nursing assistant (CNA) #888 revealed staff was telling Resident #50 her pain medication was due every eight hours however Resident #50 pain medication was due every four hours at that time. CNA #888 stated on 06/22/25 on night shift into 06/23/25 Resident #50 was upset because she had asked for pain medication several hours prior and still had not received any.Interview on 08/26/25 at 8:41 A.M. with ADON revealed Resident #50 wanted pain medication on 06/22/25, stated Resident #50 is very consistent with timing of her pain medication and knows when they are due.Interview on 08/26/25 at 12:36 P.M. with Resident #50 revealed on 06/22/25 on night shift she had requested pain medication, she had fell and broke something and had surgery on a couple weeks prior so she had been in a lot of pain. Resident #50 stated she requested the pain medication on night shift on 06/22/25, she waited several hours and no one brought her pain medication. Their pain continued to get worse as she waited and it got pretty bad due to how long they had been waiting. Resident #50 stated it was not until early morning sometime on 06/23/25 that she received her pain medication.Interview on 08/26/25 at 12:40 P.M. with ADON revealed on 06/22/25 at 8:00 P.M. she authored a note which stated Resident #50 pain medication was just then due. ADON confirmed on 06/22/25 Resident #50 pain medication was actually due at 5:13 P.M. approximately three hours prior to the resident being told it was due. ADON stated she did not get to the building until about 7:00 P.M. on 06/22/25. ADON confirmed after Resident #50 received pain medication from her on 06/22/25 at 7:47 P.M. Resident #50 did not receive pain medication again until 06/23/25 at 5:21 A.M., ADON stated she was not on the floor the entire night shift of 06/22/25. ADON stated Resident #50 was very on top of her pain medication, she always knew when it was due, and she took it right when it was due.Interview on 08/26/25 at 12:55 P.M. with PTA #999 revealed PTA #999 was assisting Resident #50 with therapy on 06/24/25 when Resident #50 had stated on the night of 06/22/25 into 06/23/25 she requested pain medication and had been waiting a long time, at least six hours. PTA #999 stated she immediately went to administration and filed a statement reporting what she had been told by resident #50.Review of Facility policy named Pain Medication Administration revised 05/21/25 revealed It is the facilities policy to administer pain medications in accordance with professional standards of practice. Review the residence care plan to assess for any special needs of the resident. The residents ' experience of pain is highly individual and subjective. Pain is whatever the resident says it is. Intense pain can result from even minor procedures or surgery. Not attempt nonpharmacological interventions as per the residence plan of care prior to administering pharmacological interventions if possible. Administer as needed pain medication as ordered.This deficiency represents non-compliance investigated under Complaint Numbers 2568688, 1274323, 1274309, and 1274308.

Based on observation, medical record review, policy review and interview, the facility failed to maintain resident dignity for Resident #100. This affected one resident (#100) of three sampled residents. The facility census was 49. Findings include: Medical record review revealed Resident #100 was admitted to the facility on [DATE] with a history of urinary tract infections and discharged to the hospital on 12/16/24. The resident returned to the facility on [DATE] with diagnoses including neurocognitive disorder with Lewy bodies, dementia, prostate cancer, obstructive uropathy, and an indwelling urinary catheter. Review of the 5-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #100 was cognitively intact for daily decision-making and utilized an indwelling urinary catheter. Review of the Physician Orders dated 12/30/24 revealed Resident #100 was ordered a suprapubic catheter to straight drainage. On 12/30/24 at 9:19 A.M., observation revealed Resident #100 and Resident #83 were sitting in wheelchairs in the lobby/TV area across from the nursing station. The resident's indwelling urinary catheter tubing was observed lying on the floor without a barrier under the resident's wheelchair. Yellow urine was observed in the uncovered collection drainage bag. Assistant Director of Nursing (ADON) #200 verified the above at the time of the observation and stated the drainage bag should be covered. Review of the policy titled Resident Rights, revised October 2016, revealed employees shall treat all residents with kindness, respect, and dignity. This deficiency is an incidental finding investigated under Complaint Number OH00160178.

Based on observation, BIPA (Benefits Improvement and Protection Act) Report review, daily census report review, and interview, the facility failed to post accurate nurse staffing information as required. This had the potential to affect all 49 residents residing within the facility. Findings include: On 12/30/24 at 9:07 A.M., observation of the reception area revealed a BIPA Report dated 12/30/24 indicating the current census was 46. At 9:09 A.M., an interview with the Administrator stated he would need to double-check the census as the BIPA Report could change due to, he received this report from the corporate office. The Administrator stated the BIPA report currently posted had been printed out on 12/27/24 to cover through the weekend, including this one. BIPA Report postings were observed at the reception desk and both nursing stations. On 12/30/24 at 4:15 P.M. observation of the posted BIPA Reports dated 12/30/24 at two nursing stations and the reception area revealed the facility census was 46. Review of the Daily Census Report dated 12/30/24 revealed the facility census was 49. On 12/31/24 at 7:30 A.M., observation of the reception area revealed the posted BIPA Report was dated 12/30/24 with a census of 46. On 12/31/24 at 7:30 A.M., interview with Receptionist #215 verified the above posting. On 12/31/24 at 9:05 A.M., the interview with the Administrator verified the facility census on 12/30/24 was 49 and the BIPA Reports posted did not accurately reflect the daily census. This deficiency is an incidental finding investigated under Complaint Number OH00160178.

Based on medical record review and staff interview, the facility failed to ensure a Pre-Admission Screening and Resident Review (PASRR) document accurately reflected medications and a psychiatric hospitalization . This affected one (Resident #37) of four residents reviewed for PASRR documents. The census was 46. Findings Include: Medical record review revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, Alzheimer's disease, major depressive disorder, delusional disorder, dementia with psychotic disturbance, and panic disorder. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 07/19/24, revealed the resident was severely cognitively impaired and received an anti-anxiety medication. Review of Resident #37's PASRR document, dated 08/26/24, revealed under Section E, no anti-anxiety medication. Review of the resident's physician orders, dated 03/29/24, revealed the order for Xanax 0.5 milligrams (mg) to be administered three times per day. Review of the medication administration record (MAR), dated August 2024, revealed the resident received this medication as ordered. Further review of the PASRR document under Section E, incorrectly indicated the resident had not been hospitalized for inpatient psychiatry. Review of Resident #37's medical record revealed the resident was hospitalized on [DATE] due to increased confusion, paranoia, believing he was breaking up a prostitution ring, making sexual comments to staff, delusions, grandiosity, and having trouble sleeping. During interview on 09/03/24 at 4:41 P.M., Social Services Designee (SSD) #194 confirmed Resident #37's PASRR document was not accurate and did not indicate the use of an anti-anxiety medication nor the inpatient psychiatric hospitalization on [DATE].

Based on observation, resident interview, record review, policy review and staff interview, the facility failed to ensure oxygen tubing was changed weekly and documented as administered in the medical record. This affected one (Resident #8) of two residents reviewed for supplemental oxygen use. The facility census was 46. Findings include: Observations of Resident #8 on 09/03/24 at 9:26 A.M. revealed the resident lying in bed. Supplemental oxygen was supplied by an oxygen concentrator (machine that separates nitrogen from atmospheric air delivering 95% pure oxygen) via a nasal cannula. No evidence of any date to the tubing and nasal cannula was observed. Additional observations of Resident #8 on 09/03/24 at 3:58 P.M., 09/04/24 at 7:38 A.M. and 09/04/24 at 12:05 P.M. revealed supplemental oxygen in use by Resident #8 with no date on the tubing. Observation on 09/05/24 at 9:50 A.M. revealed Resident #8 sitting in her recliner and supplemental oxygen lying on her bed with the tubing undated. Interview with Resident #8 on 09/05/24 at 9:50 A.M. revealed that she uses the supplemental oxygen when in bed every day. She could not recall when the oxygen tubing was replaced. Review of Resident #8's medical record revealed an admitted [DATE] with diagnoses that included chronic obstructive pulmonary disease, Parkinson's disease and cerebrovascular accident. Further review of the medical record including Minimum Data Set (MDS) 3.0 significant change assessment with a reference date of 08/09/24 indicated Resident #8 had an independent and intact cognition level and used supplemental oxygen therapy. Physician's orders for Resident #8 indicated on 08/03/24 an order for two liters of supplemental oxygen as needed for a blood oxygen saturation level lower than 89%. No order was found related to replacing the oxygen tubing routinely. Progress notes revealed as needed supplemental oxygen was utilized by Resident #8 on 08/03/24, 08/05/24, 08/06/24, 08/07/24, 08/11/24, 08/12/24, 08/18/24, 08/20/24, 08/24/24, 08/25/24, 08/26/24, 08/27/24, 08/30/24 and 09/02/24. An additional progress note dated 08/11/24 indicated Resident #8 uses the supplemental oxygen every night while sleeping. No evidence of changing the oxygen tubing was found in the progress notes. Review of the Medication Administration Record (MAR) revealed documentation of supplemental oxygen administered as ordered on 08/03/24, 08/05/24, 08/17/24 and 09/01/24. No evidence of changing oxygen tubing was found on the MAR. On 09/03/24 at 3:20 P.M. interview with Licensed Practical Nurse (LPN) #133 indicated residents on supplemental oxygen therapy have tubing changed weekly on Fridays by a contracted oxygen supply company. On 09/05/24 at 9:55 A.M. interview with the Director of Nursing verified Resident #8's oxygen tubing and nasal cannula were not dated and unknown when last replaced. The DON also verified supplemental oxygen use was not consistently documented as administered on the MAR. Review of the facility policy titled Respiratory Treatment Oxygen dated 05/19/21 indicated to change oxygen tubing, nasal cannula every seven days.

Based on record review, review of a meal ticket, observation, resident interview, staff interview, and policy review, the facility failed to ensure there was consistent communication between the facility and the dialysis center regarding a resident's hemodialysis treatments. They also failed to ensure the medical record accurately reflected the resident's current order for a fluid restriction and staff were knowledgeable about the resident's need for a fluid restriction as ordered for end stage renal disease. This affected one (Resident #19) of one resident reviewed for dialysis. Findings include: 1 a.) Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included end stage renal disease, dependence on renal dialysis, pulmonary hypertension, and congestive heart failure. Review of Resident #19's physician's orders revealed the resident had an order for dialysis treatments every Monday, Wednesday, and Friday. The order originated on 08/19/23. Review of Resident #19's active care plans revealed she had a care plan in place for an alteration in renal function, as the resident was receiving renal dialysis. The care plan was initiated on 06/28/23 and indicated the facility was to encourage the dialysis center to forward dialysis treatment notes to the facility. Review of Resident #19's medical record revealed it was absent for most of the dialysis visit notes for the resident's dialysis treatments she received in the past 30 days. Out of the 14 times the resident was sent out of the facility for a dialysis treatment, 13 of those visits did not have a dialysis visit note to indicate what the resident's pre-weight and dry weight (weight after dialysis) were, what her vital signs were, what medications she had been given, and how the resident tolerated the dialysis treatment during each visit. On 09/03/24 at 2:22 P.M. an interview with Resident #19 revealed she did not believe the facility was sending her to the dialysis center with any paperwork. She also denied the dialysis center had sent her back to the facility with any dialysis visit notes. She did not feel the facility and the dialysis center were communicating as well as they should. On 09/04/24 at 3:02 P.M., an interview with LPN #133 revealed the facility's nurses completed dialysis observation assessments on Resident #19 before and after she had her dialysis treatments. She denied those dialysis observation forms that were completed were sent with the resident to dialysis. She further denied the resident was sent back to the facility with any dialysis visit notes. Any communication made between the dialysis center and the facility would be done by the dialysis center calling them. She indicated they may get a call from the dialysis center on occasion, if there was a new order or a change in the resident's condition. She denied the facility would know what the resident's weights and vital signs were pre and post-dialysis. They would also not know what medications the resident received while at dialysis, or how she tolerated the treatment. On 09/05/24 at 10:10 A.M., findings were verified by the Director of Nursing (DON) and RN #220 that Resident #19's electronic medical record (EMR) did not show evidence of consistent and adequate communication occurring between the facility and the resident's dialysis center. They acknowledged the dialysis center was not sending a dialysis visit note for the resident that let them know what the resident's pre-weight and dry weight was when the resident received hemodialysis. There was also no communication of any medications that may have been administered to the resident or how she tolerated the dialysis treatment while there. They acknowledged their policy and the resident's plan of care indicated the facility was to receive a dialysis visit note from the dialysis center when the resident received her treatments three days a week. The facility's dialysis policy updated 2024 was reviewed and revealed it was the policy of the facility that all residents utilizing renal dialysis receive comprehensive interdisciplinary monitoring to ensure resident safety and support of dialysis services. The dialysis center would send reports from the resident's dialysis treatments to the facility after each visit. 1 b.) Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included end stage renal disease (ESRD), dependence on renal dialysis, pulmonary hypertension, and congestive heart failure. Review of Resident #19's physician's orders revealed the resident had an order in place for a 1,500 milliliter (ml)/ day fluid restriction with directions for dietary to provide 1,000 ml and nursing to provide 500 ml to equal the 1,500 ml/ day. The 500 ml allotted to nursing was further broke down to 250 ml on the day shift and 250 ml on the night shift. The order had been in place since 04/26/24. Review of Resident #19's active care plans revealed the resident had a care plan in place for an alteration in renal function, as the resident was receiving renal dialysis for ESRD. The care plan was initiated on 06/28/23 and indicated the resident was on a 1,200 ml/ day fluid restriction with nursing and dietary dividing fluids with meals and daily care including medication passes. The care plan intervention was not consistent with what was specified in the physician's orders. That intervention for the 1,200 ml/ day fluid restriction had been in place since 06/28/23. Further review of Resident #19's care plans revealed she had another care plan in place for being at risk for altered nutrition related to ESRD and being on hemodialysis. That care plan indicated the resident was on a 1,500 ml/ day fluid restriction, which was not consistent with what was indicated on the alteration in renal function care plan. The care plan for the resident's risk for altered nutrition was last revised on 08/15/24. Review of Resident #19's meal ticket for 09/05/24 revealed the resident was identified as being on a 1,200 ml fluid restriction. It did not break it down on the meal ticket to specify how much fluid the resident should be given for each meal. On 09/03/24 at 2:22 P.M. an observation of Resident #19 noted her to be in her room. She was noted to have a can of pop in her room and a full Styrofoam cup of water. The resident was not sure if she was on a fluid restriction or not for her dialysis. On 09/05/24 at 8:06 A.M., an interview with State tested Nursing Assistant (STNA) #144 revealed she was not aware of Resident #19 being on a fluid restriction. She indicated they gave the resident the same amount of water in her Styrofoam cup as the other residents received. She indicated the resident usually did not drink all of what was given to her in her Styrofoam cup and thought she only drank about 240 ml from it. She usually did drink what they sent on her meal trays. She then indicated, since the resident was on dialysis, she likely was on a fluid restriction, as most of them were. She did not know what amount of fluids the resident could have, if she was on a fluid restriction. She felt the resident probably drank what she was able to, but did not know for sure, as they did not know what she drank when out of the facility with her family. On 09/05/24 at 10:10 A.M., findings were verified by the DON and RN #220 that Resident #19's care plans, physician's orders, and meal ticket were unclear on the amount of the fluid restriction the resident was to be on. They acknowledged the discrepancy in the amount of fluids that the resident could have as documented on her two care plans, physician's orders, and meal ticket. They confirmed the resident's current order was for a 1,500 ml/ day fluid restriction and the care plans and meal ticket should all reflect such. They further acknowledged the STNA interviewed, who was caring for Resident #19, was unaware she was on a fluid restriction and was providing the resident water in a Styrofoam cup just like they did with all the other residents.

Based on observation, medical record review and staff interview, the facility failed to follow appropriate transmission based precautions for a resident on contact precautions. The affected one (Resident #253) of two residents identified on transmission based precautions. The facility census was 46. Findings include: Review of Resident #253's medical record revealed an admitted [DATE] with diagnoses that included enterocolitis due to clostridium difficile, sepsis, pneumonia and chronic obstructive pulmonary disease. Physician's orders upon admission indicated Resident #253 required contact transmission based precautions and resident to remain in his room related to signs of symptoms of a highly transmissible disease or epidemiologically significant pathogen. Observation on 09/04/24 at 2:20 P.M. revealed Activity Coordinator (AC) #192 in Resident #253's room. A sign was posted on Resident #253's door frame indicating he was on contact precautions and a cart containing personal protective supplies was noted below the sign and outside the resident's room door. AC #192 was sitting on the edge of Resident #253's bed and was wearing a protective gown and gloves. The gown was tied twice in the back but was open with approximately a three to four inch opening with AC #192's pants contacting the linens of Resident #253's bed. Resident #253 was observed sitting in a recliner next to the bed. Resident #253 was observed in the bed earlier in the day. On 09/04/24 at 2:22 P.M. interview with AC #192 indicated she was completing an activity assessment for Resident #253. She verified the resident had contact precautions in place for C-Diff and should not have been sitting on the residents bed with her personal clothing exposed and contacting the bed linens. On 09/04/24 at 2:40 P.M. AC #192 indicated she changed into new nursing scrubs after informing the Director of Nursing and Administrator of the incident.

Based on observation , review of the medical record and interview with the staff the facility failed to ensure that private identifiable medical information for Resident #10 was not visible on the computer screen and left unattended by staff. This affected one resident ( Resident #40) of four residents observed for medication administration. The facility census was 49. Findings included: Review of the medical record revealed Resident #40 was admitted to the facility on [DATE]. Diagnoses included muscle weakness, chronic obstructive pulmonary disease, diabetes, hypertension, rheumatoid arthritis, major depressive disorder, anxiety disorder, respiratory failure, polyneuropathy, glaucoma, vitamin D deficiency, congestive heart failure, low back pain, irritable bowel syndrome, ulcerative colitis, diverticulitis, intervertebral disc degeneration, chronic pain syndrome, and adult failure to thrive. Observation on 04/16/24 at 7:22 A.M. revealed the facility medication cart was sitting outside room [ROOM NUMBER] with resident information for Resident #40 up on the screen unattended and where any passerby could view the information. On 04/16/24 at 7:25 A.M. an interview with Registered Nurse #110 came out of the room [ROOM NUMBER] and verified she had left Resident #40's private health information up on her computer screen while she went into the resident's room. Review of the undated facility policy titled, HIPAA, revealed protected health information may not be used or disclosed for reasons other than treatment, payment, or health care operations without resident authorization. Do not leave written documents with resident health information in a location that could be seen by unauthorized individuals and keep unattended medical records behind the nurse's station. This deficiency represents noncompliance identified as an incidental finding during the investigation of Complaint Number OH00152284.

Based on observation, review of the medical record and interview with staff the facility failed to ensure medications were not left unattended on top of the medication cart and failed to ensure the medication cart was locked while unattended. This had the potential to affect three residents ( Resident #33, #41, and #43) out of 21 who were cognitively impaired and independently mobile on the Rodeo Unit. The facility census was 49. Findings included: Observation on 04/16/24 at 7:22 A.M. revealed the facility medication cart was sitting outside room [ROOM NUMBER] unlocked and with a plastic medicine cup with 12 tablets in it on the top of the cart. The medication in the medication cup was for Resident #40 and contained; one tablet of aspirin (analgesic) 81 mg, one tablet of Buspar (anti-anxiety) 15 mg, one tablet of Carafate (gastrointestinal agent) 1 gram, one tablet of vitamin D 3 ( vitamin) 5000 units, one tablet of Dicyclomine (anti-cholinergic) 20 mg, one tablet of Duloxetine (anti-depressant) 60 mg, one tablet of Hydroxychloroquine (immune-suppressant) 200 mg, one tablet of Lasix (diuretic) 20 mg, one tablet of Leflunomide (immunosuppressant) 20 mg, one tablet of Lyrica (pain medication) 75 mg, one tablet of Pantoprazole heartburn medication) 40 mg, and one tablet of Sulfasalazine (amino acid) 500 mg. On 04/16/24 at 7:25 A.M. an interview with Registered Nurse #110 came out of the room [ROOM NUMBER] and verified she had left the cart unlocked and left medication unattended on the top of her medication cart. She stated the resident wanted to take the medication after she ate. Review of the facility policy titled, Medication Administration, dated 05/20 revealed during medication administration the medication cart was to be kept closed and locked when out of sight of the medication nurse or aide. No medication was to be kept on top of the cart . In addition, privacy was to be maintained for all resident information when not in use. This deficiency identified noncompliance as an incidental finding during the investigation of Complaint Number OH00152284.

Based on observation, record review, resident and staff interview, and review of the policies for Pain Management and Skin and Wound Management the facility failed to implement an effective pain management program, including the timely administration of as needed pain medication for Resident #73. The facility also failed to comprehensively assess and monitor a bruise to Resident #58's hand. Harm occurred when Resident #73, who was admitted with multiple fractures and an order for [REDACTED]. This affected one resident (Resident #73) of two residents reviewed for pain and affected one resident (Resident #58) of three residents reviewed for skin conditions that was non pressure. Findings include: 1. Resident #73 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Nursing Admission assessment dated [DATE] revealed she was alert and oriented with an intact memory and was independent with her decision making. She required physical assistance of one staff member for activities of daily living. Review of Resident #73's admission orders [REDACTED]. Review of Resident #73's pain assessment completed with the admission nursing assessment dated [DATE] at 2:54 A.M. revealed she rated her pain a level six out of ten (with ten being the worst pain). The resident described the pain as moderate in intensity. The assessment revealed she had indicators of pain daily, the pain was relieved by medication management, and she required medication multiple times a day. Review of Resident #73's electronic Medication Administration Record [REDACTED]contingency/stock. Review of Resident #73's nurse's progress notes, eMAR general notes, and daily skilled notes revealed no evidence that the resident received any pharmacological or non- pharmacological interventions for pain until 04/06/16 at 1:30 P.M. Review of Resident #73's abbreviated skilled nursing note dated 04/06/16 at 3:30 P.M. revealed Resident #73 was provided skilled services for pain control. Review of Resident #73's April, 2016 MAR indicated [REDACTED].M. at which time her pain level was assessed as an eight out of ten on a pain scale of ten. There was no evidence of Tylenol administration until 04/08/16. Review of Resident #73's care plan initiated on 04/06/16 revealed an intervention to administer and monitor for effectiveness of pain medication. Interview on 04/11/16 at 11:31 A.M. with Resident #73 revealed she stated her [MEDICAL CONDITION] had been in remission and now she was in pain all the time. She revealed she did not receive any pain medication that she had requested and needed until the afternoon after she was admitted . She stated she went almost a whole day without any medication for pain. Observation on 04/11/16 at 11:31 A.M. of Resident #73 at the time of the interview revealed no non-verbal indicators of pain. Interview on 04/13/2016 at 9:17 A.M. with Resident #73 revealed the first night of admission when she hadn't received her pain medication she could not move easily and her arm was thumping. She had tossed and turned all night because she was in pain. Interview on 04/13/2016 at 9:55 A.M. with Registered Nurse (RN) #42 revealed that pain medication was often not available to the residents upon admission. The prescriptions (script) from the hospital had to be written well and then faxed to the pharmacy. If the prescription was written correctly the pharmacy gave the nurse an authorization to pull medication from the facility's contingency stock. If the script was not written well then the nurse had to call the hospital to have it rewritten. If the nurse was unable to obtain that prescription then the nurse would send a request to the house doctor to write a script and that took longer. The prescription was then sent to the pharmacy with a drop ship order. The drop ship had a 4-6 hour delivery window. Resident #73 was ordered liquid pain medication and the facility did not have liquid in the contingency box. She confirmed the Director of Nursing (DON) was notified the day after Resident #73's admission about the pain medication. The DON called the doctor to obtain a different pain medication order that was available in the contingency box until the liquid came in. RN #42 confirmed Resident #73 had not received any pain medication before that and was in pain. RN #42 stated she believed Resident #73 received the ordered pain medication on 04/06/16 around 1:45 P.M. RN #42 confirmed she did not give any Tylenol to Resident #73 on her shift. Interview on 04/13/16 at 10:16 A.M. with Resident #73 revealed her usual pain level was between two and three on a scale from one to ten with ten being the worst pain she had ever experienced. She confirmed an acceptable level of pain was two to three on that same scale. She stated she could not tolerate pain past a level five. She revealed if her pain level went past five she shook and was uncomfortable. The shaking made her muscles hurt because of her [MEDICAL CONDITION] and she stated it was a double whammy. She confirmed that when she didn't receive her ordered pain medication the pain was unbearable. Interview on 04/15/16 at 12:20 P.M. with the DON revealed Resident #73 was admitted on the evening of 04/05/16 at 8:16 P.M. She revealed the admitting physician orders [REDACTED]. She confirmed Resident #73 had admitting orders for pain medication upon admission. The DON revealed it was brought to her attention the day after admission that the pain medication for Resident #73 was not available. She revealed she called the doctor to get an order for [REDACTED].#73 received her first dose of pain medication on 04/06/16 at 1:30 P.M. She confirmed there was no evidence in the record of doctor notification prior to 04/06/16 at 1:30 P.M. She confirmed Resident #73 had an order for [REDACTED]., and confirmed Tylenol was available. The DON confirmed that Resident #73's medical record contained no evidence of non drug interventions used for pain prior to 04/06/16 at 1:30 P.M. and confirmed the care plan stated to administer pain medication. Review of the facility pain management policy revised 11/17/2012 revealed all residents in the facility had the right to adequate pain management to ensure their quality of life was maintained at the highest practicable level. The guidelines included the hospital liaison would communicate to the hospital that incoming residents must be discharged with the required hard scripts. Licensed nursing staff were responsible for communicating with the physicians regarding pain signs and symptoms, initiating treatment for [REDACTED]. 2. Review of the medical record revealed Resident #58 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the state tested nurse aide (STNA) Task List dated April ,2016 revealed Resident #58's skin was observed every shift with no documentation of skin impairment. Review of the Weekly Skin Integrity Review dated 04/12/16 revealed no evidence the resident had any bruises. Review of the care plan for Impaired Skin Integrity revised 04/11/16 revealed interventions including protect hands and body parts from excessive moisture, monitor location, size and treatment of [REDACTED]. On 04/11/16 at 4:32 P.M., observation of Resident #58 revealed a black/purple bruise to the back of her right hand and fingers. On 04/14/16 at 3:35 P.M., observation revealed a dark black/purple bruise covering the back of the resident's right hand and fingers. On 04/11/16 at 4:48 P.M., interview with Resident #58 stated she thought the bruise on her hand was from [MEDICAL TREATMENT]. On 04/14/16 at 3:43 P.M., interview with the DON verified Resident #58's right hand was bruised a deep black/purple extending to four of five fingers, and the weekly skin assessment by licensed nurses and the STNAs did not reflect the resident had any new skin impairments or bruises. Review of the Skin and Wound Process policy revised June, 2015 revealed it was the standard of the facility to provide skin/wound care to members to assist in maintaining or achieving optimal skin integrity including completion of weekly skin checks.

Based on observation, medical record review, policy review and interview, the facility failed to ensure pressure relieving interventions were implemented to prevent the development and deterioration of facility acquired pressure ulcers. This affected one resident (Resident #58) of three residents reviewed for pressure ulcers. Actual harm resulted when the facility failed to implement pressure relieving interventions for Resident #58 who was admitted to the facility with no pressure ulcers. The resident developed a facility-acquired, right heel suspected deep tissue injury (SDTI) that deteriorated to an unstageable pressure ulcer on 02/19/16 and a SDTI to the left heel on 03/31/16. On 04/11/16, Resident #58 was observed sitting in a wheelchair with her heels pressed against the foot rests with no pressure relief. On 04/11/16, observation of the pressure ulcers revealed the right heel was a Stage III (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed) pressure ulcer and the left heel was unstageable measuring 2.8 centimeters (cm) in length (l) by 2.7 cm in width (w) with 75 percent of the wound covered with thick, leathery black eschar. Findings include: Review of the medical record revealed Resident #58 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Skin assessment dated [DATE] revealed the resident was at risk for pressure ulcers and her skin was intact. Review of the care plan titled Impaired Skin Integrity dated 10/19/15 revealed a facility acquired pressure area SDTI on 11/03/15 that deteriorated to a Stage III pressure ulcer as of 03/10/16, and a SDTI to the left medial heel as of 03/31/16. Interventions included the use of moon boots at all times when Resident #58 was in bed as allows, assist/encourage to float heels in bed, turn and reposition every two hours and as needed; monitor location, size and treatment of [REDACTED]. Review of the care plan revealed no evidence of pressure relief interventions for when the resident was up in a chair or wheelchair. Review of care plan titled At Risk for Developing a Pressure Ulcer dated 10/19/15 revealed interventions including to minimize pressure over boney prominence's. Review of the admission Minimum Data Set 3.0 (MDS) assessment dated 10/23/15 revealed Resident #58 was moderately impaired for daily decision- making and had no pressure ulcers. Review of the progress note dated 11/03/15 revealed a blackened area to the right heel measuring 4.0 cm with an approximate 1.0 cm reddened area surrounding the heel that was discovered during bathing. Pressure relieving interventions icluded to encourage and assist to elevate heels, turn every two hours and apply pre-fit/bunny boots at bedtime. Review of the 30-day MDS assessment dated [DATE] revealed Resident #58 had one unstageable pressure ulcer. Review of the progress note dated 03/31/16 revealed a 3.6 cm in (l) by 3.6 cm in (w) SDTI was discovered on the resident's left heel that was described as brown with soft boggy tissue. Resident #58 sits in a geri-chair while at [MEDICAL TREATMENT] and heels typically were not floated during [MEDICAL TREATMENT]. The note indicated the facility educated [MEDICAL TREATMENT] and was to send heel float boots to [MEDICAL TREATMENT] for pressure relief. Review of Resident #58's Wound Progress Report revealed the following: On 04/04/16, the right heel Stage III pressure ulcer measured 2.0 cm in (l) by 1.8 cm in (w) by 0.2 cm in depth (d) with red granulation tissue. The left heel was a SDTI measuring 3.6 cm in (l) by 3.6 cm in (w). The wound was closed with no necrotic tissue. On 04/11/16, the right heel Stage III pressure ulcer measured 2.2 cm in (l) by 2.2 cm in (w) by 0.2 cm in (d) with pink granulation tissue. The left heel was unstageable and measured 2.8 cm in (l) by 2.7 cm in (w) with brown eschar firmly adherent. Review of the physician orders [REDACTED]. On 04/11/16, observations of Resident #58 revealed the following: At 10:31 A.M. and 4:47 P.M., Resident #58 was sitting in a wheelchair with bilateral heels pressed against the foot rests with no pressure relief interventions observed. At 4:54 P.M., Resident #58 was sitting in a wheelchair with bilateral heels pressed against the foot rest with no pressure relief interventions observed. Interview with Licensed Practical Nurse (LPN) #18 verified the observation. LPN #18 proceeded to take the resident to the dining room without implementing any pressure relief interventions and Resident #58's bilateral heels remained pressed against the foot rests. Between 4:54 P.M. and 6:18 P.M., Resident #58 remained in a wheelchair with bilateral feet pressed against the foot rests with no pressure relief. [MEDICAL CONDITION] was noted to the left foot/ankle extending over the resident's socks. Between 6:22 P.M. and 6:48 P.M., observation of Resident #58's pressure ulcer dressing change revealed LPN #18 applied normal saline to the right heel without removing the calcium alginate, measured the wound, and prepared to apply a new calcium alginate dressing. The surveyor questioned the calcium alginate that remained in the wound bed and LPN #18 stated it was adhered to the wound and was not sure whether to pull it off. LPN #18 applied normal saline to the old dressing and it was removed without difficulty. A necrotic area to the periwound was observed. LPN #18 removed her gloves, did not wash her hands, grasped a contaminated wound measuring grid and placed the grid to the wound holding it with ungloved hands. LPN #18 verified there was a 0.4 cm in (l) by 0.5 cm in (w) necrotic area at the periwound at one o'clock that had not been assessed prior and the Stage III pressure ulcer measured 2.2 cm in (l) by 2.2 cm in (w) by 0.2 cm in (d). At 6:45 P.M., LPN #18 lifted the resident's left heel revealing an open area measuring 2.8 cm in (l) by 2.7 cm in (w) with the lower aspect of the wound covered with thick, leathery black eschar and the remainder of the wound was red/yellow. LPN #18 measured the eschar to be 2.0 cm in (l) by 2.0 cm in (w). LPN #18 stated the left heel pressure ulcer did not have eschar the previous day when the treatment was completed. On 04/13/16 at 7:06 A.M., observation revealed Resident #58 was sitting in a chair in her room. Her right foot was observed pressed into the foot rest of the chair and a pressure relieving boot was observed on the floor. The DON verified the position of the resident at the time of the observation. On 04/11/16 at 10:31 A.M., interview with LPN #18 verified Resident #58 had a right heel Stage III pressure ulcer and a left heel SDTI, and the resident did not have pressure relief interventions implemented while up in chair except the facility sends bunny boots with the resident to [MEDICAL TREATMENT] to be worn. On 04/11/16 at 4:48 P.M., interview with Resident #58 verified her feet were pressed against the foot rests, she did not have much feeling in her feet and only had to wear boots at night. Resident #58 stated the staff put them on her at night and took them off when she gets up for the day. Resident #58 stated she sat in the wheelchair the majority of the day. On 04/14/16 at 10:00 A.M., interview with the DON verified Resident #58 developed two facility acquired pressure ulcers to bilateral heels that both deteriorated, pressure relief interventions were not implemented when the resident was up in the wheelchair, and continued pressure on the heels could have contributed to the deterioration of the pressure ulcers. Review of the Evaluation Wound Care Standards of Practice policy dated 10/07/04 revealed evaluation of wounds was to include location, measurements, appearance, drainage, odor, presence of undermining/tunneling, healing, stage, pain and [MEDICAL CONDITION]. Evaluation results were to be communicated to the members of the interdisciplinary team through documentation, weekly wound reports, case conferences and care planning.

Based on observation, record review, interview and policy review, the facility failed to implement interventions to maintain and prevent the decline in urinary function for Resident #17. This affected one resident (Resident #17) of one resident reviewed for urinary incontinence. One resident was identified with a decline in urinary status during the annual survey. Harm occurred when Resident #17, who was admitted to the facility with occasional urinary incontinence deteriorated to being frequently/totally incontinent of urine without interventions implemented to maintain or restore bladder function. Resident #17 was not provided any type of formal retraining plan and deteriorated to where she required a check and change program every two hours and as needed to check for incontinence and provide incontinence care. Findings include: Review of Resident #17's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the urinary incontinence program screen information dated 12/05/15 revealed the resident had no trouble controlling her bladder and did not wear pads to control urine leakage. The resident was without signs of incontinence. Review of the physician's orders [REDACTED]. Review of the admission (12/05/15 admitted ) Minimum Data Set 3.0 (MDS) assessment revealed the resident had moderate cognitive impairment and required extensive assistance of two staff members with activities of daily living. The resident was assessed to be occasionally incontinent of urine without a bladder program. Review of the urinary incontinence program screen information dated 02/17/15 revealed unchanged information from the screen form dated 12/05/15. Review of the quarterly MDS 3.0 dated 02/28/16 revealed the resident was cognitively intact and required extensive assistance of two staff members with activities of daily living. The resident was not on a toileting program and was assessed to be frequently incontinent of urine. Further review of the medical record revealed no plan of care related to urinary incontinence had been developed for the resident. Review of the nurse's progress notes revealed the resident was sent to the hospital on [DATE] and returned on 02/17/16 after a colon resection due to [MEDICAL CONDITION]. On 04/14/16 at 4:38 P.M. interview with the Director of Nursing (DON) verified the resident had a decline in urinary status from occasionally incontinent to frequently incontinent without interventions to maintain or restore bladder function. Further interview verified the lack of a plan of care for incontinence. The DON shared the resident was placed on every two hour check and changes after her bowel surgery in February and no further attempts were made to assist the resident with her urinary status. The DON indicated the resident was incontinent of urine and the facility attributed her incontinence to her bowel surgery in February. The DON verified the resident, at present time was totally incontinent of urine. On 04/14/16 at 5:20 P.M. Resident #17 was observed lying in bed wearing a disposable incontinence brief. Interview with the resident revealed she was continent of urine when she was admitted to the facility but now wore an incontinence brief and the staff would just come in and change her. During the interview, while discussing the decline in urinary status, the resident was observed to become visibly upset and tearful. Review of the urinary incontinence program process, dated 09/2004 and revised 02/2015 revealed urinary incontinence was not a normal aging process even though aging affects the urinary tract and increases the potential for urinary incontinence. Review of the urinary incontinence programs policy, dated 09/04 and revised 02/2015 revealed a urinary incontinence program will be put into effect with the goal of restoring continence, decreasing the number of incontinent episodes and/or assisting the resident to manage the incontinence.

Based on review of medical records, facility investigation reports, facility policy and interviews with staff, the facility failed to protect Resident #4 and Resident #5 from physical abuse by a state tested nursing assistant (STNA) employed by the facility. This affected two of 46 residents residing in the facility. On 08/11/14 at 4:35 P.M. the Director of Nursing (DON) and Registered Nurse (RN) #50 were notified that Immediate Jeopardy began on 07/17/14 at 6:45 P.M. when STNA #25 roughly forced Resident #5 back down in her chair causing a skin tear to Resident #5 ' s right lower leg. STNA #26 observed and reported the incident to RN #22, but RN #22 did not remove STNA #25 from resident care immediately. Immediate Jeopardy continued on 07/17/14 at 7:15 P.M. when STNA #25 forcefully held Resident #4 down in bed by placing her knee over the chest of Resident #4. RN #22 removed STNA #25 from the building on 07/17/14 at 7:15 P.M. and, as a result of the investigation, STNA #25 was terminated by the facility on 07/18/14. The Immediate Jeopardy was removed on 07/22/14 at 2:00 P.M. when the facility implemented the following actions: ? On 07/18/14 STNA #25 was terminated from employment. ? On 07/22/14 at 2:00 P.M. the facility began to educate all permanent staff. Thirty of 52 staff members received training on Abuse Prevention and Reporting Protocol. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) because the facility did not provide all staff members training on Abuse Prevention and Reporting Protocol but a plan was in place to have all staff educated by 08/13/14. Findings include: Review of the closed medical record for Resident #5 revealed an admission to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Resident #5 was discharged to an Assisted Living facility on 07/28/14. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was cognitively impaired. Review of Resident #4 ' s medical record revealed Resident #4 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] revealed Resident #4 was severely cognitively impaired. Review of a self-reported incident (SRI) dated 07/18/14 revealed on 07/17/14 at 6:45 P.M. an allegation of physical abuse was reported. The SRI indicated STNA #25 physically abused Resident #4 and Resident #5. The report revealed STNA #25 was observed to have roughly sat Resident #5 back down in her chair. STNA #25 was also witnessed putting her knee on Resident #4's chest to prevent movement. The allegation was substantiated and STNA #25 was immediately walked out of the facility and terminated. Review of the resident abuse report form dated 07/17/14 at 6:45 P.M. revealed STNA #26 witnessed STNA #25 slam Resident #5's leg into a recliner foot rest when sitting the resident down. There was a skin tear noted to Resident #5's right lower leg. Review of the resident incident report dated 07/17/14 at 6:45 P.M. revealed Resident #5's leg was bumped when STNA #25 sat her down in a recliner which resulted in a skin tear. Resident #5 stated "that girl did it. " Review of a nurses progress note dated 07/17/14 at 8:00 P.M. revealed Resident #5 cut her leg on the recliner and had an open area that measured 0.1 centimeter (cm) by 1.0 cm to the right lower leg. Review of one written statement completed by STNA #26 and dated 07/17/14 (no time) revealed Resident #5 attempted to get out of her recliner. STNA #25 made Resident #5 sit back, swung Resident #5's legs up on the chair and cut Resident #5's leg. Review of the written statement dated 07/17/14 (no time) completed by STNA #25 revealed STNA #25 found an open cut bleeding "more like a skin tear" on the leg of Resident #5. STNA #25 notified RN #22 and RN #22 "took care of it." Review of the resident abuse report form dated 07/17/14 (no time) revealed STNA #26 observed STNA #25 using her knee and pushing against Resident #4's chest after the resident became combative. Review of a second written statement completed by STNA #26 and dated 07/17/14 (no time) revealed when STNA #26 and STNA #25 assisted Resident #4 to bed, Resident #4 "became stubborn and was fighting staff. " STNA #25 placed her knee on Resident #4's chest to keep her arms back from hitting STNA #25. Review of a written statement completed by RN #22 and dated 07/17/14 at 6:45 P.M. revealed STNA #25 approached RN #22 and reported that Resident #5's leg was bleeding. When RN #22 assessed Resident #5's leg, the resident stated "That girl did it." It was not noted who Resident #5 met by " that girl. " STNA #25 told RN #22 that another resident caused the injury to Resident #5 ' s leg. STNA #26 approached RN #22 and stated "Don't let STNA #25 lie to you." STNA #26 explained that she had observed STNA #25 sit Resident #5 down and slam her legs onto the footrest of the recliner. Resident #5 hit her leg on the corner of the recliner foot rest. After STNA #25 sat her down in the recliner, Resident #5 yelled out "ouch, my leg". STNA #26 told RN #22 that Resident #5's leg was bleeding. STNA #26 also stated that she had observed STNA #25 using her knee to hold down Resident #4 after the resident became combative. Review of the incident report dated 07/17/14 at 7:15 P.M. revealed STNA #26 informed RN #22 that STNA #25 was observed placing her knee on the chest of Resident #4 to hold her down when she became combative. There was no injury noted to Resident #4. STNA #25 was immediately escorted out of the building. Resident #4 was unable to provide a statement as she was confused and disoriented. Review of a written statement completed by RN #22 on 07/18/14 at 9:30 P.M. revealed an addendum to the statement completed on 07/17/14 at 6:45 P.M. RN #22 added that on 07/17/14 she was informed STNA #25 had placed her knee over the chest of Resident #4 while she was in the process of investigating the incident that was reported when STNA #25 treated Resident #5 roughly. Interview with the DON on 08/06/14 at 1:15 P.M. revealed the first allegation of abuse occurred on 07/17/14 at 6:45 P.M. when STNA #26 observed STNA #25 handle Resident #5 roughly. STNA #26 reported the incident immediately to RN #22. STNA #25 stated to RN #22 that another resident caused the skin tear. Resident #5 stated "that girl did it. " RN #22 had two versions of what occurred. One version was that STNA #25 treated Resident #5 roughly. The second version was that another resident caused the skin tear to Resident #5. RN #22 telephoned the DON to report the incident and took statements from both of the STNA's. While RN #22 was on the phone reporting the incident to the DON, STNA #25 and STNA #26 assisted Resident #4 to bed. STNA #26 reported immediately to RN #22 that while STNA #25 and STNA #26 were assisting Resident #4 to bed, STNA #25 placed her knee on the chest of Resident #5 to hold her down. At that time, RN #22 walked STNA #25 out of the building and STNA #25 was terminated. Interview on 08/06/14 at 1:45 P.M. with RN #22 revealed on 07/17/14, STNA #25 approached her and stated Resident #5 was bleeding. RN #22 revealed as she assessed Resident #5, STNA # 25 stated another resident caused the injury to Resident #5. However, Resident #5 stated "that girl did it." RN #22 revealed the other STNA (STNA#26) indicated STNA #25 was too rough when she had sat Resident #5 down in the recliner and caused the injury. RN #22 stated she had two different versions of what had occurred. RN #22 stated she went directly to the phone and notified the DON. The DON advised her to remove STNA #25 from the building. At this time, STNA #26 approached her again and reported that STNA #25 placed her knee over Resident #4's chest to hold her down as she had become combative during care. RN #22 stated she had already been in route to walk STNA #25 out of the building just before the last incident was reported to her. She and another staff member immediately walked STNA #25 from the building. On 08/06/14 at 3:00 P.M., RN #22 verified when STNA #26 informed her of the allegation of physical abuse to Resident #5; she did not remove STNA #25 from the building immediately following the alleged abuse. RN #22 verified that she should have walked STNA #25 from the building immediately after Resident #5 was injured, which may have prevented Resident #4 from additional abuse. On 08/11/14 at 4:45 P.M. a second interview with the DON revealed the facility currently had 56 total employees. The DON stated 30 of the employees were provided training on abuse on 07/22/14. The DON verified that 22 employees had not been provided training on abuse since the incident had occurred on 07/17/14. A telephone interview with STNA #26 on 08/11/14 at 5:10 P.M. revealed on 07/17/14 at 6:45 P.M. she witnessed STNA #25 roughly transfer Resident #5 back into her recliner chair, which caused a skin tear to Resident #5 ' s right lower leg. STNA #26 stated STNA #25 reported the incident to RN #22 and indicated another resident caused the injury. STNA #26 revealed as soon as STNA #25 walked away she told RN #22 that STNA #25 treated Resident #5 roughly and caused the skin tear. STNA #26 stated as she and STNA #25 were assisting Resident #4 into bed, Resident #4 become combative. STNA #25 placed her knee over Resident #4 ' s chest to hold her down. STNA #26 stated as she and STNA #25 were leaving the room of Resident #4, RN #22 was at the doorway to the room to walk STNA #25 out of the building. Review of the Abuse Prevention/Reporting Protocol dated as last revised on 07/29/13, revealed the purpose of the policy was to provide an effective method of preventing, detecting, and reporting abuse. The policy stated upon a report of alleged abuse, employees of the facility who are suspected of the alleged abuse would immediately be placed on suspension, until the investigation was completed. This deficiency was an incidental finding to complaint #OH 702.

Based on resident and family interview, record review, observation, physician interview and staff interview, the facility failed to respect resident and family wishes during the insertion of an indwelling urinary catheter which did not maintain the resident's mental and psychosocial well being which resulted in actual harm when the resident experienced prolonged emotional distress. This affected one of three residents reviewed for urinary catheters (Resident #41). The facility census was 46. Findings include: Interview with Resident #41 and her daughter on 10/30/13 at 10:30 A.M. revealed the resident had been experiencing [MEDICAL CONDITION]. After alerting staff, the daughter was notified by Registered Nurse (RN) #1 by telephone, of the need for an indwelling urinary catheter to remove the urine. The daughter informed RN #1 the insertion of the urinary catheter was fine, but expressed that RN #2 (male )was not to complete the insertion of the urinary catheter. During the interview, observation of Resident #41 and the daughter revealed both were visibly upset and tearful discussing the event. Review of Resident #41's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment with a reference date of 10/02/13 identified the resident as having an independent cognition level. Hospital records indicated that on 09/28/13 the resident was evaluated in the emergency room (ER) due to the inability to urinate and abdominal pain. The resident was evaluated and diagnosed with [REDACTED]. An indwelling urinary catheter was inserted with instructions to follow up with a urologist. On 10/07/13 the resident was seen by a urologist, the indwelling urinary catheter was left in place with instructions to remove the urinary catheter on the morning of 10/08/13. Additional instructions included to reinsert the urinary catheter if necessary and to return in one week. Review of the nurse's notes revealed on 10/08/13 the facility staff removed the urinary catheter as ordered without incident. On 10/14/13 at 2:45 P.M., RN #1 attempted to insert an indwelling urinary catheter for Resident #41 due to complaints of [MEDICAL CONDITION] per the physician's orders [REDACTED]. On 10/14/13 at 2:45 P.M., RN #2 attempted to insert an indwelling urinary catheter for Resident #41 but was also unsuccessful and would have another nurse attempt the insertion. On 10/14/13 at 3:15 P.M., RN #3 successfully inserted the indwelling urinary catheter for Resident #41. On 10/14/13 at 8:45 P.M., a nurse's note revealed that both the resident and her daughter were both very upset regarding the catheter insertion process. On 10/15/13, Resident #41 was evaluated as scheduled by the urologist. A note was made that an indwelling urinary catheter was reinserted on 10/14/13 due to complaints of [MEDICAL CONDITION]. A cystoscopy (test to visually assess the bladder) was to be completed in one week. On 10/22/13, Resident #41 was evaluated again by the urologist to complete the cystoscopy. Review of the consultation notes revealed that the cystoscopy was unable to be completed as the the "patient was not able to handle it" per the physician's documentation. On 10/31/13 at 8:35 A.M., per phone interview with the urologist office, Office Manager (OM) #4 on behalf of the physician stated the cystoscopy was unable to be completed due to Resident #41 being emotionally upset by the catheter insertion at the facility on 10/14/13. Phone interview with RN #1 on 10/30/13 at 12:15 P.M. revealed that on 10/14/13 Resident #41 was unable to urinate. She contacted her daughter by phone to inform her of the need to insert an indwelling urinary catheter. At the time of the phone conversation with Resident #41's daughter, RN #1 was instructed RN #2 was not permitted to attempt the insertion. RN #1 then unsuccessfully attempted the catheter insertion. After the unsuccessful attempt she notified RN #2, who then also attempted to insert the catheter despite the family informing them that RN #2 was not to attempt the insertion. Phone interview with RN #2 on 10/30/13 at 12:25 P.M. revealed that he did attempt to insert an indwelling urinary catheter for Resident #41 on 10/14/13 despite being asked by the family to not do so. This deficiency substantiates Complaint Number OH 241.