Every finding on record at Altercare of Bucyrus Center Fo

Based on medical record review, review of the facility's internal investigation, facility document review, facility policy review, and interviews, the facility failed to conduct a complete and thorough investigation of allegations of abuse. This affected one residents, (#69) of three residents reviewed for abuse. The facility census was 66. Findings include:Record review for Resident #69 revealed the resident was admitted to the facility following hospitalization for left-foot cellulitis and osteomyelitis requiring amputation of the left third toe. Diagnoses included Type II Diabetes Mellitus, chronic kidney disease, hypertension, major depressive disorder, anxiety disorder, chronic pain, and fibromyalgia.Review of Resident #69's Minimum Data Set, dated [DATE] revealed the resident had intact cognition, as evidenced by a Brief Interview for Mental Status score of 15. The resident was not coded to have verbal behaviors, physical behaviors, rejection of care, wandering, or other behavioral symptoms.Review of Resident #69's medical record reveaeld there was no documentation of an unplanned medication administration, medication error, adverse reaction, behavioral episode, or medication administered by Registered Nurse (RN) #125 at approximately 4:30 A.M. on 06/08/26.Review of the facility's internal investigation dated 06/08/26 revealed the facility received a complaint indicating Registered Nurse #125 said she provided medication to Resident #69 that was not hers just to shut her up and said she wishes she would just kill herself. The facility's investigation revealed Resident #69 was interviewed and denied concerns regarding medication administration. A medication audit for 06/07/26 through 06/08/26 identified no discrepancy. The facility concluded the medication allegation was not substantiated. The investigation revealed most staff interviewed denied hearing RN #125 make the alleged comments. However, one certified nursing assistant stated she previously heard RN #125 jokingly state a resident should just kill themselves. The certified nursing assistant could not recall the exact wording or identify the resident involved. The facility investigation had no documentation the facility identified or interviewed the resident who may have been the subject of the statement, and there was no documentation the facility interviewed additional residents who received care from RN #125 regarding inappropriate comments, mistreatment, or medication concerns. The facility provided documentation of staff training after the incident, however it did not identify education was provided to staff regarding abuse prevention, resident rights, improper medication administration, or mandatory reporting of alleged violations.Review of RN #125's employee file reveaeld no corrective-action documentation to address the allegations involving improper medication administration or inappropriate comments regarding residents.During an interview on 07/24/26 at 2:19 P.M., the Administrator confirmed the facility did not interview additional residents who received care from RN #125. The Administrator stated the alleged comments were not considered abuse because they were reportedly made privately and were not directed toward a resident.Review of the facility policy titled Abuse, Mistreatment, Neglect, Misappropriation, and Exploitation, undated, revealed the facility was required to investigate all allegations and suspicions involving abuse, neglect, exploitation, mistreatment, or misappropriation, protect residents during the investigation, and take corrective action based on the investigation findings.This deficiency represents non-compliance investigated under Complaint Number 3037060.

Based on record review, review of the facility's internal investigation, facility document review, facility policy review, and interviews, the facility failed to report an allegation of abuse to the state agnency for one resident, (#69) of three revewed for abuse. The facility census was 66. Findings Include:Record review for Resident #69 revealed the resident was admitted to the facility following hospitalization for left-foot cellulitis and osteomyelitis requiring amputation of the left third toe. Diagnoses included Type II Diabetes Mellitus, chronic kidney disease, hypertension, major depressive disorder, anxiety disorder, chronic pain, and fibromyalgia.Review of Resident #69's Minimum Dat Sat (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15, indicating intact cognition. The MDS assessment did not identify verbal behaviors, physical behaviors, rejection of care, wandering, or other behavioral symptoms.Review of Resident #69's June 2026 Medication Administration Record (MAR), Treatment Administration Record (TAR), physician orders, nursing progress notes, and point-of-care documentation revealed there was no documentation was present for any type of medication error, or of Resident #69 having medication administered for agitation or yelling.Review of the facility's internal investigation dated 06/08/26 revealed the facility received a complaint indicating Registered Nurse (RN) #125 said she provided medication to Resident #69 that was not hers just to shut her up and said she wishes she would just kill herself. The facility investigated the concern by talking with the RN, other staff, the resident involved and performing a drug screen on the resident. The facility concluded the allegations involving improper medication administration and inappropriate comments were not substantiated.Review of the Facilities Self-Reported Incidents (SRI) revealed there was no submission regarding Resident #69 being provided medication to just shut her up that was not her medication. There was no SRI for the reported statement the nurse wished the resident would just kill herself.During a telephone interview on 07/24/26 at 11:35 A.M., Resident #69 denied receiving medication that was not prescribed for her or medication intended to make her quiet. Resident #69 stated staff generally treated her kindly and respectfully.During an interview on 07/24/26 at 2:19 P.M., the Director of Nursing (DON) and Administrator confirmed the facility did not submit a Self-Reported Incident to the state agency. The DON and Administrator stated they did not believe the allegations met the reporting requirements because the comments made to Resident #69 were reportedly not made directly to a resident. The Administrator confirmed the decision not to report the allegations was based on the conclusions reached through the facility's internal investigation.Review of the facility policy titled Abuse, Mistreatment, Neglect, Misappropriation, and Exploitation, undated, revealed staff were required to immediately report allegations or suspicions involving abuse, neglect, exploitation, mistreatment, or misappropriation to the Administrator and the Ohio Department of Health in accordance with the facility's reporting procedures. The policy further required the facility to protect residents and investigate all allegations. This deficiency represents non-compliance investigated under Complaint Number 3037060.

Based on record review, interview and facility policy review the facility failed to ensure staff timely documented a resident's fall. This affected one resident, (#45) of three reviewed for falls. The facility census was 66.Findings Include:Review of Resident #45's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included vascular dementia with behavioral, psychotic, mood, and anxiety disturbances; generalized muscle weakness; difficulty walking; coronary artery disease; hypertension; Type II Diabetes Mellitus; major depressive disorder; insomnia; and a history of transient ischemic attack and cerebral infarction.Review of Resident #45's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had cognitive and functional impairments and required staff assistance or supervision with transfers, toileting, dressing, ambulation, and other mobility-related activities.Review of Resident #45's care plan revealed the resident was at risk for falls related to impaired mobility, cognitive impairment, weakness, and the need for assistance with activities of daily living. Interventions included staff assistance or supervision with mobility and transfers, use of assistive devices, fall-prevention measures, education to request assistance, and review of interventions following a fall.Review of an event report for Resident #45 revealed the resident experienced an incident in his room on 06/08/26 at approximately 4:30 A.M. The report date was recorded as 06/09/26 at 3:56 P.M. and was completed on 06/11/26 and recorded Registered Nurse (RN) #125 as the creator and documented the resident fell without injury while transferring. The report included vital signs and physical and neurological assessment findings. The report documented the physician was notified on 06/09/26 at 6:30 A.M.Review of Resident #45's progress notes revealed there was no nursing progress note related to the to the incident which occurred on 06/08/26. Review of the facility's internal investigation packet revealed management received a complaint on 06/08/26 at 8:18 A.M. which indicated Resident #45 was on the floor at 4:30 A.M. with feces covering him. The report documented the Nurse caring for the resident said we were in the room when he fell which would create less work and then said this never happened and left the room. The complaint documented no paperwork was created and also there was no report to the State agency completed. The facility's internal investigation revealed the facility identified RN #125's failed to document Resident #45's incident. The facility provided staff education regarding fall reporting and documentation on 06/09/26, and issued corrective action to RN #125 on 06/11/26.During an interview on 07/24/26 at 12:08 P.M., Resident #45 stated he partially recalled being on the floor on 06/08/26 and recalled certified nursing assistants assisting him with cleaning. Resident #45 was unable to recall whether he struck his head or whether a nurse evaluated him before staff assisted him from the floor. Resident #45 denied concerns with his overall care.During an interview on 07/24/26 at 2:19 P.M., the Director of Nursing and Administrator confirmed RN #125 did not complete the required documentation for Resident #45's 06/08/26 incident at the time it occurred.

Based on observation, medical record review, staff interview, review of the resident room bathrooms quote, and policy review, the facility failed to ensure a safe, clean, and homelike environment. This affected one (#60) of three residents reviewed for a safe, clean, homelike environment. The facility census was 64. Findings include:Review of the medical record for Resident #60 revealed an admission date of 06/15/21. Diagnoses included Alzheimer's disease, type two diabetes mellitus, pseudobulbar affect, unspecified dementia, and chronic kidney disease.Review of Resident #60's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 had a memory problem and was dependent for showering/bathing and toileting hygiene.Observation on 03/16/26 at 8:14 A.M. of Resident #60's bathroom in room [ROOM NUMBER] revealed a black substance to be around the base of the toilet. Furthermore, the wood at the bottom of the vanity below the sink appeared to have water damage. The wood had a large hole in which you could see the floor of the facility through. The wood also had a black substance on it in multiple areas. Concurrent interview with the Maintenance Coordinator (MC) #114 verified the black substance around the toilet and under the sink, in the vanity and stated he did not think it was mold. Interview on 03/16/26 at 12:30 P.M. with Certified Nurse Aide (CNA) #152 revealed she had worked at the facility for a little over a year and a half and the wood at the bottom of the vanity below the sink had been damaged and discolored since she began working at the facility.Review of the 100/200 Resident Room Bathrooms email documentation revealed on 03/12/26 an email was sent to the [NAME] President of Property Management that stated attached is the information for the Bucyrus resident room bathroom project from 2016. The project was quoted at $142,805 for 25 resident rooms.Review of the facility policy last updated on 07/01/25 titled Environmental Service revealed it was the facilities policy to maintain the resident's environment in a clean and sanitary condition.This deficiency represents non-compliance investigated under Complaint Number 2800297.

Based on closed medical record review, staff interview, and review of facility policy, the facility failed to ensure enabler bars were implemented for mobility as assessed by the facility. This affected one (#100) of three residents reviewed for side rails. Findings include:Review of the closed medical record for Resident #100 revealed an admission date of 10/13/25. Diagnoses included cellulitis of both great toes with gangrene, peripheral vascular disease (PVD), bacteremia (infection of a bacteria in the blood), significant coronary artery disease, heart failure with preserved ejection fraction (type of heart failure where the hearts main pumping chamber is stiff and does not fill and pump efficiently), end stage renal disease (ESRD) requiring hemodialysis (kidney failure where dialysis is required to sustain life), chronic combine systolic and diastolic congestive heart failure (CHF) (where both the right and left side of the heart is not functioning properly), angina (chest pain), and multiple coronary stent placement (this is required to open the heart vessels following blockage to maintain adequate blood flow to the heart muscle). Resident #100 discharged to the hospital on [DATE].Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 had moderate cognitive impairment. Review of the Enabler assessment dated [DATE] revealed Resident #100 was ordered half enabler bars to both sides of the bed for weakness. Benefits included to aid in maintenance of proper body alignment, aid in proper body posture for eating, breathing, and appearance, and assist the resident with Activities of Daily Living (ADL). Review of the care plan dated 10/26/25 revealed Resident #100 was care planned for bilateral enabler bars for bed mobility.Review of the physician orders for January 2026 revealed Resident #100 had an order for bilateral assist bars/siderails to aid in bed mobility.Observation on 02/04/26 at approximately 8:15 A.M. of Resident #100's former room revealed the room was vacant and clean. Further observation revealed the bed did not have any side rails or enabler bars in place.Interview on 02/05/26 at 1:54 P.M. with Licensed Practical Nurse (LPN) #340 revealed Resident #100 did not have enabler bars on his bed when he resided at the facility. Interview on 02/05/26 at 2:10 P.M. with Maintenance Director (MD) #330 revealed he did not have a work order for enabler bars to be applied to Resident #100's bed once he transferred from the skilled unit to the long-term care unit. MD #330 confirmed he did not apply enabler bars to the bed for Resident #100.Interview on 02/05/26 at 2:20 P.M. with Registered Nurse (RN) #335 revealed Resident #100 transferred from the skilled unit to the long term care unit on 11/01/25.Review of the facility policy titled, Side Rails-Proper Use, revised May 2025, revealed it was the facility's policy to ensure side rails were only utilized for residents to assist in bed mobility that enabled the resident to function at their highest functional level that their condition would allow. Side rails may be used to assist in mobility and transfer of residents. An assessment would be made to determine the resident's symptoms or reason for using side rails. When used for mobility, the residents' bed mobility and transfer ability would be taken into consideration. The use of side rails as an assist device would be addressed in the resident's plan of care.This deficiency represents non-compliance investigated under Complaint Number 2733940.

Based on record review, resident interview, staff interview, review of the facility investigation, and policy review, the facility failed to ensure Resident #18 was provided adequate supervision to prevent an elopement without staff knowledge. This resulted in Actual harm on 10/22/25 at 2:00 A.M. when Resident #18 was left unattended, eloped from the facility, fell in the parking lot, required Emergency Medical Service (EMS) transport to the hospital, and was diagnosed with a nondisplaced fracture of the nasal bones and a right humerus fracture. This affected one (#18) of three residents reviewed for elopement and falls. The facility census was 71.Review of Resident #18 ' s medical record revealed an admission date of 09/19/22. Diagnoses included unspecified dementia with mood disturbances, schizoaffective disorder bipolar type, delusional disorders, anxiety disorder, major depressive disorder, and insomnia.Review of Resident #18 ' s quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had moderately impaired cognition. Resident #18 utilized a walker and wheelchair for mobility, required partial or moderate assistance for sitting to standing and could ambulate 50 feet with supervision or touching assistance, and required substantial or maximal assistance to ambulate 150 feet.Review of Resident #18 ' s admission elopement assessment dated [DATE] revealed Resident #18 was a moderate elopement risk. Factors identified putting Resident #18 at moderate risk for elopement included the diagnosis of dementia, ability to ambulate, propel self in wheelchair, and being seen near windows or exit doors.Review of Resident #18 ' s elopement assessment dated [DATE] revealed Resident #18 was a moderate elopement risk. Factors identified putting Resident #18 at moderate risk for elopement included Resident #18 ' s ability to ambulate, propel self in wheelchair, a diagnosis of dementia, and hallucinations.Review of Resident #18 ' s admission fall risk assessment dated [DATE] revealed Resident #18 was not at risk for falls.Review of Resident 18 ' s fall assessment dated [DATE] revealed Resident #18 was a high fall risk. Risk factors identified were Resident #18 ' s disorientation, required assistance for elimination, balance problems while standing or walking, required use of a walker, use of antidepressants, antihypertensives, antipsychotics, and cathartic drugs, and a neuromuscular/functional decline.Review of Resident #18 ' s care plan dated 10/01/25 revealed Resident #18 was a high fall risk. Interventions included a sign placed in room to remind Resident #18 to ask for assistance when getting up, clipping call light to Resident #18 ' s clothing while in the wheelchair, anti-rollbacks to wheelchair, and a sign placed on the resident ' s walker to remind her to use the walker for ambulation. The care plan contained no interventions related to Resident #18 ' s elopement risk.Review of the facility incident and fall log from 08/01/25 to 10/27/25 revealed Resident #18 suffered a fall with a major injury on 10/22/25.Review of the care plan updated 10/22/25 revealed Resident #18 had eloped and was at risk for elopement. Interventions included for the resident to be checked on frequently, re-direct from exit doors as needed, inform facility staff including the interdisciplinary team and the receptionist of any potential for elopement, staff to report immediately to the nurse any statements by the resident for the need to leave, to go to the bank, home, or work, attempt to determine what the resident wants or is searching for and try to convince the resident there is no need to look outside, and the resident can be outside only with staff one to one supervision and with instruction of the nurse.Review of the facility staffing for the night shift on 10/22/25 revealed the facility had two nurses and five aides scheduled to care for 68 residents. Staff assigned to the Memory Care Unit and Hall 300, located at one end of the building, were Licensed Practical (LPN) #189, and Certified Nursing Assistants (CNA) #144 and #189. At the opposite end of the building, covering Halls 100, 200 and 500 were LPN #122, CNA #102, CNA #146, and CNA #106.Review of the facility investigation dated 10/22/25 beginning at 6:15 A.M. revealed at 12:00 A.M. on 10/22/25 Resident #18 was assisted to the bathroom by CNA #144 at approximately 1:35 A.M. CNA #144, assigned to Hall 300 went to the Memory Care Unit to relieve CNA #189 for a break, leaving LPN #193 on Hall 300. At approximately 2:00 A.M., CNA #144 heard the door alarm from the employee entrance near Hall 300 and when CNA #189 returned at 2:05 A.M. from break, CNA #144 responded to the door alarm and when looking outside, found LPN #193 and CNA #146 attending to Resident #18. An assessment was performed by LPN #193, Resident #18 had no complaints of pain, LPN #193 requested CNA #144 get a wheelchair as LPN #193 and CNA #146 assisted Resident #18 back into the facility. Resident #18, once inside the building, was placed in a wheelchair and covered with a bath blanket. LPN #193 performed a second assessment and Resident #18 was bleeding from her face but denied any pain. Appropriate notifications were made, and Resident #18 remained in the wheelchair at the nurse ' s station with direct monitoring until Emergency Medical Services (EMS) arrived and transported Resident #18 to the hospital for evaluation at 2:52 A.M.Further review of the facility investigation revealed Resident #18 was found lying outside on the ground wearing a gown, brief, and slipper socks by LPN #193 and CNA #146 when they were returning from their breaks. The temperature outside was noted to be 45 degrees.Review of the hospital documentation dated 10/22/25 and printed at 5:54 A.M. revealed Resident #18 had a subtle deformity of the nasal bones on the right without bony displacement, consistent with a nondisplaced fracture. Resident #18 had an impacted, comminuted proximal right humeral fracture.Interview on 10/28/25 at 7:32 A.M. with CNA #189 revealed she was working in the Memory Care Unit on 10/22/25 and at 1:35 A.M. CNA #144 came to the unit to relieve her for break. CNA #189 stated she returned from break around 2:05 A.M. CNA #189 stated she took her break in an empty resident ' s room on the Memory Care Unit and denied hearing the door alarm until she came out of the room at the end of her break.Interview on 10/28/25 at 8:06 A.M. with Resident #18 revealed she had gotten a black eye and broken arm from a fall outside. Resident #18 could not recall how she got outside or why she was outside. When asked if she had any pain, Resident #18 stated she remembered she had pain in her right arm and in her head at the time of the incident on 10/22/25 and continues to have right arm pain. Resident #18 verified staff provide her with pain medication if she asks.Interview on 10/28/25 at 11:07 A.M. with CNA #129 revealed she had been in the activities room when the incident occurred on 10/22/25. CNA #129 stated she would come to work early on the days she was scheduled to see if extra help was needed, if not she would go into the activities room until the start of her shift. CNA #129 verified she heard the door alarm at the employee entrance going off for around five minutes but was not clocked in, so she did not respond. She thought the alarm may have been from LPN #193 and CNA #146 returning from their break.Interview on 10/28/25 at 11:11 A.M. with CNA #144 revealed she went to the Memory Care Unit to relieve CNA #189 for break when she heard the employee entrance door alarm near Hall 300. CNA #144 stated when she heard the door alarm, she could not leave the Memory Care Unit because she was the only staff member present on the unit. CNA #144 stated the door had been alarming for about five minutes when CNA #189 returned from break, at which time she went to investigate and when looking outside found LPN #193 and CNA #146 assisting Resident #18 inside the building. LPN #193 asked her to get a wheelchair and once Resident #18 was inside the building she was seated in the wheelchair. CNA #144 stated she assisted LPN #193 in cleaning up Resident #18 ' s face and remained with Resident #18 until EMS arrived while LPN #193 made multiple calls. CNA #144 stated the last time she saw Resident #18 was at 12:15 A.M. when she assisted the resident to the bathroom. CNA #144 stated LPN #193 did not tell her she was going on a break. CNA #144 stated she was unaware of the residents on Hall 300 being left unattended.Interview on 10/28/25 at 3:36 P.M. with LPN #193 verified she worked on 10/22/25 and was the nurse assigned to the Memory Care Unit and Hall 300. LPN #193 said she could not recall what time she left the facility, but it was when CNA #146 approached her and asked if she wanted to go outside to smoke. LPN #193 verified when she left the building CNA #144 was on the Memory Care Unit and no other staff were present to monitor Hall 300. LPN #193 stated while outside, she asked CNA #146 to take her to a local restaurant, approximately a six minute drive from the facility. They got into CNA #146 ' s car and by the time they got to the end of the parking lot they decided they would not have enough time, so they turned around. When driving back to the staff parking lot, LPN #193 noticed Resident #18 laying on the ground in the parking lot, approximately 25 steps from the employee entrance, near the Memory Care Unit courtyard gate. LPN #193 stated Resident #18 was lying on the ground with her knees up to her chest. LPN #193 verified Resident #18 did not have her walker or her wheelchair, adding she did not know how Resident #18 could have made it outside. LPN #193 stated Resident #18 was repeatedly apologizing, saying she was on her way home. LPN #193 stated she and CNA #146 assisted Resident #18 back into the building after assessing the resident, placed Resident #18 into a wheelchair, cleaned her face, called the Director of Nursing, the resident ' s daughter, and EMS for transportation to the emergency room (ER).Review of the facility policy titled Elopement - Missing Resident with a last revision date of 05/01/25 revealed an elopement is when a resident leaves the nursing facility unattended without the facilities knowledge.Review of the facility policy titled Hours of Work with a last revision date of May 2024 revealed staff may have two ten-minute breaks during an eight-hour shift and no employee is permitted to leave company property during their breaks without special permission of the immediate supervisor.Review of the facility policy titled Routine Resident Checks with a last revision date of 05/01/25 revealed routine resident checks shall be made every two hours to ensure that the resident ' s safety and well-being are maintained.This deficiency represents non-compliance investigated under Master Complaint Number 2651195 and Complaint Number 2650725.

Based on observation, staff interview and facility policy review, the facility failed to provide a safe smoking area for all residents. This affected all residents in the facility. The census was 66.Observation on 07/30/25 at 10:55 A.M. revealed smoking shack did not have designed smoking times posted to enable nonsmokers to avoid the area during the posted times. There were also numerous cigarette butts on the ground outside the smoke shack, on the concrete and in the landscaping mulch, and one half smoked cigarette beside the ashtray receptacle in the smoke shack. Interview with Director of Nursing (DON) on 07/30/25 at 11:00 A.M. confirmed no smoking times were posted and numerous cigarette butts were on the ground.Review of the undated policy titled Smoking-Resident policy revealed the designated smoking area will be posted with proper signage designated the area as a smoking area and include the designated smoking times to enable nonsmokers to avoid the are during the posted times.

Based on observation, staff interview, review of facility water temperature logs, and review of the facility policy, the facility failed to maintain safe water temperatures. This had the potential to affect all residents residing on the 300-hall (Resident #6, #8, #9, #19, #21, #22, #26, #30, #34, #35, #50, #55, #56, #58, #60, #62, #65, #67, and #71), all residents residing on the 400-hall (#5, #12, #13, #14, #20, #23, #27, #32, #68, and #69) and residents residing in room [ROOM NUMBER]. The facility census was 66.Review of the facility's hot water temperature logs for 07/02/25 through 07/24/25, revealed on 07/09/25 the hot water temperature in room [ROOM NUMBER] was 127 degrees Fahrenheit, the hot water temperature in room [ROOM NUMBER] was 128 degrees Fahrenheit, and the hot water temperature in room [ROOM NUMBER] was 124 degrees Fahrenheit. On 07/24/25, the hot water temperature in room [ROOM NUMBER] was 123 degrees Fahrenheit, the hot water temperature in room [ROOM NUMBER] was 122 degrees Fahrenheit, the hot water temperature in room [ROOM NUMBER] was 124 degrees Fahrenheit, and the hot water temperature in room [ROOM NUMBER] was 123 degrees Fahrenheit. On 07/28/25, the hot water temperature in room [ROOM NUMBER] was 128 degrees Fahrenheit, the hot water temperature in room [ROOM NUMBER] was 125 degrees Fahrenheit, the hot water temperature in room [ROOM NUMBER] was 130 degrees Fahrenheit, and the hot water temperature in room [ROOM NUMBER] was 128 degrees Fahrenheit. Observations on 07/28/25 from 11:47 A.M. through 12:38 P.M. of the facility's secured memory care unit (400-hall) revealed hot water temperatures were taken for all bathrooms located in all resident rooms. Hot water temperatures in resident bathrooms ranged from 130 degrees Fahrenheit to 132 degrees Fahrenheit.Observations on 07/28/25 from 12:40 P.M. to 12:50 P.M. of rooms located near each end of the 300-hall revealed hot water temperatures in resident bathrooms were 130 degrees Fahrenheit.An interview on 07/28/25 at 1:17 P.M. with Maintenance Director #530 verified hot water temperatures on the 300-hall and 400-hall had been running high for several weeks and were supposed to be below 120 degrees Fahrenheit. Maintenance Director #530 reported the facility had some plumbing work completed on 07/02/25 and the hot water temperatures in resident rooms located on the aforementioned halls began running high following that work. Maintenance Director #530 reported they had contacted the plumbing company who completed the work, but the company had not been able to come back and did not always show up when they said they were going to. Maintenance Director #530 reported they had not contacted a second plumbing company regarding the hot water temperatures that had been running too high and had not implemented any measures to protect residents while water temperatures remained high. Maintenance Director #530 was asked several times and reported there was no way for the facility to physically turn the temperatures down in the facility.On 07/28/25 from 1:27 P.M. through 1:35 P.M., Maintenance Director #530 used the facility's digital thermometer to test the hot water temperature in the bathrooms of room [ROOM NUMBER], #312, and #405, and obtained a reading of 132 degrees Fahrenheit for each room. On 07/28/25 from 1:31 P.M. through 1:50 P.M., Maintenance Director #530 checked the hot water temperature in the bathroom of room [ROOM NUMBER] and #501 and obtained a reading of 130 degrees Fahrenheit for each room.Interviews on 07/28/25 with Maintenance Director #530 at the time of each observation verified the hot water temperatures in each resident bathroom.A follow-up interview on 07/28/25 at 3:03 P.M. revealed Maintenance Director #530 spoke with a regional maintenance worker and was informed and instructed to turn the hot water temperature down on hot water tanks located in the facility. Maintenance Director #530 reported the hot water tanks were previously set to 140 degrees Fahrenheit and were just turned down to 125 degrees Fahrenheit.Observation on 07/28/25 at 3:03 P.M. of two hot water tanks located in the facility revealed each hot water tank had a separate gage with the ability to be adjusted. Both hot water tanks were set to approximately 125 degrees Fahrenheit.Review of the facility policy titled Water Temperature Policy, not dated, revealed staff were to check with their regional support staff on whether temperature locations applied to the specific type of facility, and to ensure patient room temperatures were between 105 and 120 degrees in Ohio.

Based on observation, record review, facility staff interview, and facility policy review, the facility failed to follow physician's order for oxygen administration. This affected two residents (#34 and #28) out of nine residents identified to received oxygen at the facility. The facility census was 66.Review of medical record for Resident #34 revealed admission date of 04/03/25. The resident was admitted with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), bipolar disorder and neuromuscular dysfunction of bladder.The Minimum Data Set (MDS) dated [DATE] revealed Resident #34 had a Brief Interview Mental Status (BIMS) score of 13 indicating no impaired cognition. Resident #34 was dependent for meals, dependent with toileting hygiene, bed mobility and transfers.Review of the physician orders dated 05/30/25 revealed continuous oxygen at 1 liter per minute via nasal cannula. Indicated for COPD exacerbation. Keep Resident #34's oxygen saturation level above 90 percent (%) and check twice a day.Observation on 07/29/25 at 11:56 A.M. revealed Resident #34 was wearing nasal cannula with oxygen running at a rate of 0.5 liters of oxygen per minute.Interview with Licensed Practical Nurse (LPN) #512 on 07/29/25 at 12:44 P.M. confirmed Resident #34's oxygen was set at 0.5 liter of oxygen per minute and the physician's order was for one liter of oxygen per minute.2. Review of medical record for Resident #28 revealed an admission date of 12/04/21. The resident was admitted with diagnoses of post polio, Type II Diabetes, rheumatoid arthritis, non-pressure chronic ulcer of unspecified part of right lower leg, wedge compression fracture of first lumbar vertebra, and sequela.The Minimum Data Set (MDS) dated [DATE] revealed Resident #28 had a Brief Interview Mental Status (BIMS) score of 15 indicating no impaired cognition. Resident #28 was set up for meals, dependent with toileting hygiene, bathing, and transfers.Review of the physician orders revealed an order dated 04/16/25 for oxygen at 2 liter per nasal cannula for resident comfort. Check twice a day.Observation on 07/29/25 at 3:37 P.M. revealed Resident #28 was wearing nasal cannula with oxygen running at a rate of one liters of oxygen per minute.Interview with Director of Nursing on 07/29/25 on 12:44 P.M. confirmed Resident #28's oxygen was set at one liter of oxygen per minute and the physician's order was for two liter of oxygen per minute.Review of policy titled Oxygen Administration, dated 05/01/25, revealed: verify there is physician's orders for service.

Based on observation, facility staff interview, and facility policy review, the facility failed to ensure infection control standards were implemented and maintained during medication administration. This affected one (Resident #62) of four residents observed for medication administration. The facility census was 66.Observation of medication pass on 07/29/25 at 8:59 A.M. revealed Licensed Practical Nurse (LPN) #512 was observed entering Resident #21 room, placed right hand on resident's shoulder, then returned to the medication cart to pull medication for Resident #62. LPN #512 did not sanitize hands between tasks. Interview with (LPN) #512 at 9:10 A.M. confirmed no hand sanitization was complete in between medication pass between Resident #21 and Resident #62.Review of policy titled Medication Administration-General Guidelines, dated May 2020, revealed hand sanitation is to be completed when returning to medication cart and regular intervals during medication pass such as after each room.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of the fall investigation and witness statements, review of the hospital records, review of facility lift inspections, review of the manufacturer recommendations for use, and review of facility policy, the facility failed to ensure a resident was safely transferred by a mechanical lift that was not inspected per manufactures instructions or identified as defective by facility staff. This resulted in Actual Harm on 01/31/25 when Resident #70 was transferred from the bed to her recliner with the mechanical (Hoyer) lift when the lifts shoulder bolt fell out and Resident #70 dropped to the floor landing on top of the lift legs, from approximately four feet in the air. Resident #70 complained of pain in the right leg and right knee. Subsequently, Resident #70 was sent to the local hospital where she was diagnosed with a tibia fracture. This affected one (#70) of three residents reviewed for accident hazards. The facility census was 66. Findings include: Review of the medical record for Resident #70 revealed an admitted [DATE]. Diagnoses included cerebral palsy, heart failure, hypercapnia, hypoxemia, esophageal stenosis, contracture of muscle in right lower leg, and on 01/31/25 she was diagnosed with a displaced bicondylar fracture of the right tibia. Review of the care plan dated 02/17/22 revealed Resident #70 was at risk for falls and injuries with interventions to utilize a stand-up lift for transfers. Review of the Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #70 was cognitively intact and was dependent upon staff for activities of daily living. Resident #70 was also dependent on staff for transfers from bed to chair, tub/shower, and rolling left and right. Review of the progress note dated 01/31/25 at 2:35 P.M., revealed Resident #70 was being lifted by the mechanical (Hoyer) lift when the part that the sling attached to snapped off. Resident #70 fell to the floor on top of the mechanical lift legs. A red area was observed across Resident #70's lower abdomen. Resident #70 complained about her right leg hurting and stated that it hurt a little before the incident. Resident #70 was assisted by five people and placed back into bed. The intervention in place was for a Hoyer lift audit per the Director of Nursing (DON). Review of the fall investigation revealed on 01/31/25 at 2:35 P.M. Resident #70 fell while staff were transferring her via Hoyer lift from her bed to recliner. Two staff members were present, but during the transfer, the hang bar fell off of the Hoyer lift and the resident fell to the floor. An assessment showed a light red area across her lower abdomen and the resident was alert after the fall. Resident #70 was medicated for pain, an X-ray was ordered, and Resident #70 was subsequently sent to the emergency room . The resident's health care provider and resident representative were notified. The immediate safety measure taken was a post fall assessment that revealed the need to audit the Hoyer lifts. Hoyer lift audits were to be added to Resident #70's care plan. Review of the fall investigation timeline revealed on 01/31/25 at 2:35 P.M. two staff members were maneuvering the mechanical (Hoyer) lift, and the hanger bar became detached from the boom which resulted in Resident #70 landing on the floor in front of the recliner. Certified Nursing Assistant (CNA) #44 notified the charge nurse and Medical Director (MD) #222 immediately. The charge nurse and MD #222 responded to Resident #70's room and completed an assessment of the resident. A red area was noted to the resident's abdomen and Resident #70 stated her right knee was hurting a little prior to the incident. MD #222 did not identify any injuries at the time. Resident #70 was assisted into bed by MD #222 and five other staff members with the sling that was still under the resident. The DON removed the Hoyer lift from service. Staff provided care to Resident #70 and Resident #70 requested to be placed in her recliner. She was transferred to the reclining chair via a different and operational Hoyer lift with the assistance of two staff members. On 01/31/25 at 3:16 P.M., Resident #70 was medicated with Tylenol for a complaint of right knee pain. On 01/31/25 at approximately 4:00 P.M. to 4:15 P.M., the DON checked on Resident #70 and asked if she was hurting. Resident #70 patted her right knee and stated it was sore, along with her left side. The DON assessed the resident's left side with no abnormal findings. The DON assessed the resident's right knee, and no bruising, deformities, or swelling was identified. Resident #70 was able to lift her right leg off the chair at that time. On 01/31/25 at 4:30 P.M., the DON verified that all other mechanical lifts were in proper working order. On 01/31/25 at 4:50 P.M., Resident #70 complained of increased right knee pain. Orders were received for X-rays of the right knee, right rib, and thoracic lumbar. The mobile X-ray company was notified of the new X-ray orders. On 01/31/25 at 5:57 P.M. a new order was received to discontinue Tylenol 350 milligrams (mg) daily and initiate Tylenol 1,000 mg three times a day and Oxycodone 5 mg every four hours as needed. On 01/31/25 at 9:17 P.M. Resident #70 was given Tylenol 1,000 mg. On 01/31/25 at 9:18 P.M. Resident #70 was given Oxycodone 5 mg for right knee pain. On 01/31/25 at 10:30 P.M. Resident #70 was sent to the ER due to an increase in knee pain and medications were not effective. On 02/01/25 at 7:09 P.M., Resident #70 returned to the facility. Review of the witness statement of CNA #14 dated 01/31/25 revealed she and CNA #44 were using the weighted Hoyer lift to place Resident #70 back in her recliner. The lift was raised safely enough to clear the bed. The bolt holding the weight box and metal loops snapped off and Resident #70 fell to the floor but did not hit her head. Resident #70 revealed only her left leg/knee was hurting. When Resident #70 fell , CNA #14 was getting into position to pull her back into her recliner. CNA #44 was positioning the lift to approach the recliner, and the Hoyer was in front of the recliner. Review of the witness statement of CNA #44 dated 01/31/25 revealed CNA #44 and another aide [CNA #14] were using the Hoyer to transfer Resident #70 to her chair. In the process, CNA #44 heard a loud noise and Resident #70 fell to the floor and landed on the legs of the Hoyer. Review of the witness statement of Resident #70 transcribed by the DON dated 01/31/25 revealed the lift broke apart and she fell . Resident #70 stated she had soreness to her left side and right leg. Review of the progress note dated 01/31/25 at 4:50 P.M., revealed Resident #70 complained of pain in the right knee becoming more intense. A new order was received for an X-ray of the right knee, right rib, and thoracic lumbar area. Review of the progress note dated 01/31/25 at 5:57 P.M., revealed Resident #70 received a new order for Tylenol 1,000 mg three times a day and Oxycodone 5 mg every four hours as needed. The resident and her emergency contact were notified. Review of the progress note dated 01/31/25 at 11:00 P.M., revealed Resident #70 was sent to the hospital at approximately 10:30 P.M. Resident #70 complained of severe pain to her right knee related to her fall that occurred earlier. An X-ray was ordered, but Resident #70 stated she could not wait any longer for the X-ray. The nurse administered Tylenol and the as-needed Oxycodone 5 mg. The medications were not effective for Resident #70. The resident's physician, power of attorney (POA) and DON were notified. Review of the progress note dated 02/01/25 at 9:34 A.M. revealed the emergency room (ER) called to update the facility on Resident #70's status. Resident #70 was noted in the ER with a fractured tibia. Resident #70 was to see orthopedic services. Review of the hospital notes dated 02/01/25 revealed Resident #70 had a right medial tibial plateau fracture. The notes further revealed the resident received an orthopedic consult on 02/01/25 and they recommended nonoperative treatment due to her non-ambulatory status. Review of the progress note dated 02/01/25 at 7:09 P.M. revealed Resident #70 returned to the facility from the hospital. Resident #70 was to be non-weight bearing and was to wear a brace to the right leg for six weeks. Review of the care plan updated 02/03/25 revealed Resident #70 was at risk for falls and injuries with a new intervention for Hoyer lift audits. Interview on 03/18/25 at 3:15 P.M. with CNA #14 revealed Resident #70 needed to use her bed pan and like normal, she was safely lifted with the Hoyer into her bed, and it was also the Hoyer that weights were taken with. She then was going to be lifted back to her recliner. Resident #70 was pulled up by the lift and the button was pressed to open up the lift's legs. CNA #14 stated the bolt that holds up the straps that they hooked everything to, snapped. She revealed the lift unit had been working all day and first shift did not have issues with the lift. Telephone interview on 03/18/25 at 4:05 P.M. with CNA #44 revealed she did not think the facility kept lift equipment maintained, and she did not see a maintenance man that often. CNA #44 revealed the day the fall occurred, Resident #70 was being transferred to her chair. As CNA #44 was opening the legs to the hoyer she heard a snap and saw Resident #70 fall to the floor. After this occurred, a bunch of people came and transferred her to her bed. Telephone interview on 03/20/25 at 12:51 P.M. with Licensed Practical Nurse (LPN) #199 revealed she was called into Resident #70's room after the fall. Resident #70 was on the floor on top of the Hoyer lift legs and the part that everything hooked up to, broke off of the machine. LPN #199 assessed Resident #70 and asked if she was in pain and Resident #70 said no. LPN #199 immediately went and got MD #222. LPN #199 asked MD #222 to assess Resident #70 before she touched her. MD #222 assessed Resident #70 and stated they could get her up. LPN #199 wanted to send Resident #70 out, but MD #222 said they could get her up. LPN #199 did not know how far the fall from the Hoyer lift was and she would have been more comfortable sending Resident #70 out. Interview on 03/19/25 at 11:28 A.M. with the DON revealed that maintenance looked at the lift units monthly. Since the incident happened, the lifts had been evaluated weekly. She stated floor staff only looked at basics of the lift, like if anything was loose or not working properly. The DON revealed the U-shaped piece with a bolt in it, failed and the shoulder bolt and mounting bracket were bent out. She stated the hanger bar with the weight box fell off too. The DON reiterated that the shoulder bolt and mounting bracket was what failed and the hanger bar was still fine. Interview on 03/19/25 at 5:13 P.M. with the DON revealed a medical company came in every six months and evaluated the mechanical lifts. The DON also revealed maintenance was looking at them weekly for the next four weeks and then they would go back to monthly. The DON revealed she was leading an all staff meeting when the Hoyer fall incident occurred with Resident #70. The DON revealed staff were transferring the resident with the Hoyer lift and as they were opening the legs, the shoulder bolt fell out and Resident #70 fell to the floor in her sling along with the hanger bar, as the hanger bar fell on top of her. An aide came out and got a nurse and MD #222 to assess the resident, and the lift was taken out of commission immediately. The DON revealed she went and checked all the other lifts for loose bolts, bent metal or anything not working properly and there were no issues with the other lifts. The DON revealed staff received training on lifts as part of their orientation and lifts were discussed at almost every staff meeting. She stated for example, the 04/04/24 agenda was related to proper use of mechanical lifts and Hoyer pads, the 05/23/24 agenda was related to proper lift use, the 09/05/24 agenda was related to how Resident Council talked about the use of Hoyer lifts and the guidelines were discussed as well as Hoyer pad issues, the 11/25/24 agenda was related to using a mechanical lift properly, the 12/03/24 agenda was related to proper mechanical lift procedure, and the 01/31/25 agenda was related to a discussion on proper use of a Hoyer lift. Interview on 03/20/25 at 11:06 A.M. with the Administrator revealed monthly inspections on lifts were completed by maintenance coordinators. Observation 03/19/25 at 11:46 A.M. of the Invacare Reliant 600 Hoyer lift that failed, with the Administrator and DON present, revealed the shoulder bolt itself was not cracked or broken, but the mounting bracket was observed severely bent. Review of the manufacturer's Invacare Reliant 600 RPL600-2 user manual revealed regular maintenance of patient lifts and accessories were necessary to assure proper operation. Review of the maintenance safety inspection checklist in the user manual revealed the institution was to conduct monthly inspections/adjustments to the hardware, hanger bar supports, bolted joints, pivot joints, and hardware on the mast, boom, and base as well as checking for bends or deflections. Further review of the manual revealed casters and axle bolts, the hanger and eye of the boom, pivot points and fasteners, lubrication, hanger bar hooks and mounting brackets, and the mast pivot bolt required inspections every six months. The user manual also stated that all parts of the patient lift were made of the best grades of steel, but metal to metal contact would wear after considerable use. Review of the resident lift work history report from January 2024 to March 2025 revealed resident mobile lifts were inspected every month, except for January 2025. The inspection prior to the incident was dated 12/31/24 and it revealed that the mobile lifts were inspected. The documentation did not mention if there were issues or if the lift passed or failed the inspection, just that they were inspected. Review of the contracted medical equipment company lift evaluation on 02/13/25 revealed two lifts passed the evaluations and four lifts failed the calibration and safety tests. The lifts that failed were taken out of commission. The contract company also performed the same evaluation on 05/29/24 where four lifts passed the safety and calibration tests and on 11/13/24 where five lifts passed the evaluation. Review of the Administrator email correspondence sent to the DON, Maintenance Coordinator #80, [NAME] President of Nursing Operations #225, Regional Plant Maintenance Director #226, and Regional Nurse Consultant #227, after a conversation with their contracted lift company, dated 02/26/25 at 3:37 P.M. revealed, Here is what I received from Medical Equipment. While here, he stated it is common for the screws to come loose. The lift is poorly designed, and the screws need tightened all the time. It only takes 5 threads for the screw to come loose. Based on his observation, the screw came loose, and the pressure from the scale, and resident being moved in the Hoyer, the screw gave way, and the bolt fell out causing the resident to fall. Review of the Hoyer Lift policy dated 2024 revealed it was the facility's policy to utilize a Hoyer lift when transferring a resident in accordance with professional standards of nursing practice. As a result of the incident, the facility took the following actions to correct the deficient practice as of 03/14/25: On 01/31/25, the DON placed the broken lift out of commission. On 01/31/25, the DON checked all of the other facility lifts for loose bolts, bent metal or anything not working properly. No issues were noted. On 01/31/25, the DON educated all staff during the all staff meeting on Hoyer lifts and proper use. The education discussed the amount of staff it takes to operate a lift, that the emergency power button is for emergencies, and the new process to wash and clean the slings as well as assessing the lifts for damage prior to use. On 02/04/25, a new maintenance man [Maintenance Coordinator #80] was hired. On 02/05/25 the facility rented two lifts. On 02/06/25, 02/09/25, and 02/10/25, the DON provided all direct care staff education on identifying possible safety hazards with mechanical lifts specifically regarding breaks, casters, the boom, sling clips, bolts, and [NAME] pins. The education also included for staff to look for any potential hazards in the sling such as frayed edges and ripping in the material and being aware of how to respond if any hazard was identified. On 02/10/25, the Administrator provided education to all leadership regarding how the mechanical lifts would be audited weekly for four weeks and as needed to check for hazards and ensure they were in working order. Once the weekly audits were completed, mechanical lifts would be checked monthly and as needed. Processes were reviewed for auditing lifts, the use of checklists, hazards to look for, and what to do when/if hazards were found. On 02/10/25, the DON provided education to Maintenance Coordinator #80 regarding how the lift audits would be completed weekly for four weeks, then monthly and as needed. On 02/13/25, an outside contracted medical equipment company audited the facility's lifts. Five lifts failed the evaluation. The lifts were taken out of commission and removed from use. One of the five lifts was a sit-to-stand machine which the facility stated they did not use. On 02/13/25, Regional Plant Maintenance Director #226 was educated regarding the requirement for monthly lift inspections. On 02/26/25, the Quality Assurance Performance Improvement (QAPI) Committee met and discussed safety and monitoring for all lifts and lifts being audited weekly for safety for four weeks and then monthly. The committee also discussed that a new lift was purchased and delivered on this day. On 02/11/25 and 02/28/25, the facility purchased two new lifts. The lifts were received on 02/26/25 and 03/05/25. On 03/07/25, the Maintenance Director or designee completed the weekly audits of all mechanical lifts for four weeks and as needed to ensure that all mechanical lifts were in proper working order on 02/13/25, 02/20/25, 02/28/25, and 03/07/25. On 03/14/25, the DON, or designee(s), completed interview audits with staff on identifying possible safety hazards with a mechanical lift on all shifts three times a week on alternating shifts for four weeks then as needed on 02/17/25, 02/19/25, 02/21/25, 02/24/25, 02/26/25, 02/28/25, 03/03/25, 03/05/25, 03/07/25, 03/10/25, 03/12/25, and 03/14/25. This deficiency represents non-compliance investigated under Master Complaint Number OH00162693 and Complaint Number OH00162620.

Based on observation, staff interview, and policy review, the facility failed to store refrigerated food properly. This had the potential to affect all 69 residents in the facility who received food from the kitchen. Findings include: Observation of the walk-in refrigerator on 01/22/24 at 8:00 A.M. revealed there was a large metal tray labeled meat loaf that was uncooked on the top shelf over the drinks stored in carafes. There was also observed a small metal rectangle pan of brown liquid that was unlabeled and undated, a small metal rectangle pan of what appeared to be cooked meat with grease on top that was not dated or labeled, and a large metal tray of what appeared to be meatloaf that had been served but was not labeled or dated. Interview with Dietary Manager (DM) #177 on 01/22/24 at 8:15 A.M. confirmed there was meatloaf thawing that was on the top shelf and over drinks, DM #177 stated the meatloaf should be on the bottom shelf and not over other food/drink items. DM #177 also verified the three undated unlabeled metal containers not labeled or dated. DM #177 stated these three metal containers were gravy, cooked hamburger, and meatloaf that was previously served. DM #177 verified the the containers were not labeled or dated. Review of the facility's undated policy titled Refrigerated Storage revealed refrigerated food shall be stored in a manner that optimizes food safety and quality. The procedure included the refrigerated items shall bear a label indicating product name and date (month, day and year) product was received, used or first opened. Discard date may be included on labels per facility preference. Meat shall be stored on bottom shelf. Cooked meat shall not be stored along with frozen meat items that are being thawed (e.g., cooked ham in tray with raw ground beef). Cross-contamination of food shall be prevented by: Storing raw meat on shelves below fruits, vegetables or other ready-to-eat food.

Based on observation, family and staff interview, and record review, the facility failed to ensure funds were accessible seven days a week. This affected one (Resident #14) of five residents reviewed for Personal Needs Accounts (PNA). The facility identified 36 residents with PNA. The facility census was 69. Findings include: Review of the medical record for Resident #14 revealed an admitted [DATE]. Diagnoses included dementia without behavioral disturbances. Resident #14's granddaughter was listed as the emergency contact, responsible party, resident representative, and primary financial contact for Resident #14. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 12/01/23, revealed Resident #14 had severely impaired cognition. Review of Resident #14's Personal Needs Account (PNA) revealed Resident #14's granddaughter had signed an authorization on 12/05/22 for the facility to manage funds for Resident #14. Resident #14 had a balance of $149.58 as of 01/16/24. Observation of an undated sign posted on the desk of the business office manager and visible from the main lobby revealed a sign which stated Personal Needs Account (PNA) information and funds are available during office hours Monday to Friday 9:00 A.M. until 3:00 P.M. An interview on 01/22/24 at 9:32 A.M. with the granddaughter of Resident #14 revealed the facility did not provide access to PNA funds on the weekend. The granddaughter of Resident #14 had attempted to retrieve funds on a weekend day in mid-December 2023 to have a birthday party for Resident #14, but the office was closed with no one at the facility being able to access funds. The granddaughter additionally stated she likes to take Resident #14 on outings on weekend days and had been unable to access Resident #14's funds for the outings. An interview on 01/22/24 at 10:16 A.M. with Lead Receptionist #159 revealed she was responsible for the management of PNA funds at the facility. Lead Receptionist #159 verified the signage on the desk was correct, PNA funds were only available Monday through Friday from 9:00 A.M. until 3:00 P.M. Lead Receptionist #159 stated the change was made a few months ago to limit access to PNA funds and verified residents and their families were not all notified of the change.

Based on medical record review, review of the Ohio board of nursing licensure verification system, review of a personnel file, review of the facilities policies, resident and staff interviews, and review of the facility's Self-Reported Incidents (SRI), the facility failed to timely report allegations of misappropriation of resident's narcotic medications. This affected one (Resident #22) of 24 residents reviewed for abuse. The facility census was 69. Findings include: Review of Resident #22's medical record revealed an admission to the facility occurred on 12/04/21. Diagnoses included post polio syndrome, arthritis, high blood pressure, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was cognitively intact. Interview with Resident #22 on 01/23/24 at 10:29 A.M. confirmed he used to work in the medical field and had a concerning incident with Licensed Practical Nurse (LPN) #140. Resident #22 stated LPN #140 had attempted one evening to give him night time medications that included a Tylenol (treats mild pain, over the counter medication) instead of his ordered and scheduled Vicodin (narcotic pain medication to treat moderate to severe pain), in his cup of pills. Resident #22 stated he believed LPN #140 was trying to steal the Vicodin and put the Tylenol in his medications thinking he would not catch it. Resident #22 stated he took a picture on his cell phone, dated 11/24/23, of the Tylenol and shared this with the Director of Nursing (DON) at that time. Resident #22 stated requested for a written report regarding this incident however none was ever provided to him. Subsequent review of Resident #22's Controlled Drug Receipt, Proof of Use/Disposition Form, dated 11/24/23, revealed LPN #140 did sign out of the controlled records Vicodin 5/325 mg at 9:23 P.M. Interview with the DON on 01/23/24 at 4:17 P.M. confirmed Resident #22 had reported an incident of almost medication error. The DON confirmed Resident #22 had told her LPN #140 had attempted to give him Tylenol in place of Vicodin on 11/24/23 and that he made the nurse get the Vicodin to administer to him. The DON stated she did not think this was an attempt at narcotic drug diversion and therefore did not investigate the incident as such or report this to the Pharmacy Board, Board of Nursing, or to State Survey Agency, Ohio Department of Health. The DON stated LPN #140 was coached on 11/24/23 to ensure she was verifying medications prior to administration. The DON confirmed the facility has not reported any possible narcotic drug diversion to their pharmacy, board of nursing and/or law enforcement. Interview with Registered Nurse (RN) #102 on 01/23/24 at 11:22 A.M. confirmed she has been concerned that LPN #140 seems to sign out many more narcotics than anyone else and was suspicious she was diverting narcotics. RN #102 confirmed she has reported her concerns to management. Interview with Resident #22 and the Administrator on 01/25/23 at 3:18 P.M. confirmed Resident #22 was suspicious that LPN #140 was attempting to divert Vicodin and replace the pill with Tylenol. Review of the facility's SRI from 11/24/23 to 01/22/24 revealed there was no SRI reported involving Resident #22 and/or LPN #140. Review of LPN #140's personal file revealed she was hired at the facility on 05/30/23, with the facility performing a check on her nursing license. LPN #140's licensed did not have any actions at the time of hire. LPN #140 had coaching on 11/24/23 to ensure verification of five rights for medication administration. LPN #140 received a personal action form dated 12/08/23 at which time multiple doses of Oxycodone (Narcotic) had been signed out on controlled log but not signed out on the Medication Administration record (MAR). The form did not list which resident/residents the 12/08/23 coaching had occurred from. Review of the Ohio Board of Nursing current licensure on 01/23/24 revealed LPN #140 had a nursing license. Under board action, it stated pending. Review of the facilities undated abuse policy revealed the facility will not tolerate Mistreatment, Abuse, Neglect of its residents or Misappropriation of resident property by anyone. It is the facility's policy to investigate all allegations, suspicions and incidents of Abuse, Mistreatment, Neglect, Misappropriation of resident property, and injuries sustained by its residents. Facility staff should report all such allegations to the Administrator and the Ohio Department of Health (ODH) in accordance with the procedures in this policy. The policy defined misappropriation of resident property as; the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. All allegations Abuse, Neglect, Mistreatment, Injuries of Unknown Source, and Misappropriation of Resident Property must be reported immediately to both the Administrator and to the Ohio Department of Health. For the purposes of this policy, immediately means as soon as possible, but ought not to exceed twenty-four (24) hours after the incident or discovery of the injury. Review of the facility's Discrepancies, Loss and or Diversion of Medications policy, dated May 2020, revealed all discrepancies, suspected loss and/or diversion of medications. irrespective of drug type or class. are immediately investigated and reported. Immediately upon the discovery or suspicion of a discrepancy, suspected loss, or diversion, the Administrator. Director of Nursing (DON), and Pharmacy (i.e., Consultant Pharmacist) are notified and an investigation conducted. The DON or designee leads the investigation; The information is not to be discussed with other individuals.

Based on observations, medical record review, review of the facility policy, and resident and staff interviews, the facility failed to ensure the residents who were dependent on staff for activities of daily living (ADL) received the assistance with shaving. This affected two (Residents #22 and #52) of three residents reviewed for ADL care. The facility census was 69. Findings include: 1. Review of Resident #22's medical record revealed an admission to the facility occurred on 12/04/21. Diagnoses included post polio syndrome, arthritis, high blood pressure, and diabetes mellitus. Review of Resident #22's plan of care, dated 03/23/22, revealed the staff were to provide assistance with all ADL care and mobility as needed/ anticipate resident needs as able and to assist with and/or shave facial hairs everyday or per resident preference. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was cognitively intact. Resident #22 was dependent on staff for ADLs, including shaving and bathing. Observation and interview with Resident #22 on 01/22/24 at 9:18 A.M. revealed it has been a week since he was shaven and preferred to be clean shaven everyday. Observation of Resident #22 on 01/24/23 at 7:59 A.M. revealed Resident #22 remained unshaven and again stated he preferred to be shaven daily. Resident #22 stated he moved rooms recently and was not getting shaved everyday. Interview with the Director of Nursing (DON) on 01/24/23 at 8:06 A.M. confirmed Resident #22 does need shaven and that it appeared to be several days of facial hair growth. The DON provided documentation on 01/24/24 at 1:20 P.M. stating Resident #22 refused to be shaved and bathed on 01/21/24. There was no other documentation to show Resident #22 refused to be shaven on a daily basis. 36297 2. Review of Resident #52's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia with mood disturbance, rhabdomyolysis, metabolic encephalopathy, weakness, depression, and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #52 had short and long term memory problems, had physical, verbal and behaviors directed towards others one to three days of the review period, and the resident had rejection of care six days of the review period. Resident #52 was dependent n staff with showering, dressing, and personal hygiene. Review of Resident #52's shower documentation revealed Resident #52 was given a bed bath or shower on 01/04/24, 01/07/24, 01/10/24, 01/15/24, 01/18/24, and 01/23/24. The forms did not address if Resident #52 was shaven or had refused shaving. Review of the progress notes from 01/01/24 to 01/23/24 revealed there was no documentation of refusal of care by Resident #52. Review of the behavior documentation forms for Resident #52 for January 2024 revealed the resident was documented to refuse shaving on 01/05/24. The documentation indicated the goal was to have resident's daily care needs met within limitations of resistance to care with date of 01/06/24. Interventions attempted were documented as watching television, 15 minute checks, and approach in a calm manner. The interventions were documented as ineffective. There were no other behavior forms completed for Resident #52 from 01/01/24 to 01/23/24. Review of the behavior analysis report completed by the state tested nursing aides (STNAs) in the electronic medical record from 11/18/23 to 01/25/24 revealed the staff documented Resident #52 rejected care on 12/30/23 and 01/25/24. No other refusals of care were documented on the behavior analysis report. Observation of Resident #52 on 01/23/24 at 7:19 A.M. revealed the resident had several long hairs on her chin. Observation of Resident #52 on 01/24/24 at 7:22 A.M. revealed the resident was sitting in the lounge with a lidded cup in her hand watching television. The resident had several long hairs on her chin. Interview with STNAs #123 and #112 on 01/24/24 at 10:00 A.M. (who were observed to be providing incontinent care to Resident #52) revealed Resident #52 did not refuse care or have behaviors for them when they were providing care to her. STNAs #123 and #112 verified they document refusals of care in the electronic medical record, and they let the nurse know if the resident will not allow the staff to complete some part of daily care after re-approaching the resident at another time. Interview with the Director of Nursing (DON) on 01/24/24 at 1:20 P.M. confirmed shaving should be daily with morning care to residents. Interview with Registered Nurse (RN) #152 on 01/24/24 at 1:31 P.M. confirmed Resident #52 had several long hairs on her chain that had not just occurred in the past few days. RN #152 stated Resident #52 can be combative with care at times but not always. Review of the facility's undated policy titled Shaving the Resident revealed it is the facility's policy to promote cleanliness and to provide skin care. The following information should be recorded in the resident's medical record: the date and time that the procedure was performed.; The name and title of the individual{s) who performed the procedure; If and how the resident participated in the procedure or any changes in the resident's ability to participate in the procedure.; and if the resident refused the treatment, the reason{s) why and the intervention taken. The staff were to report to the supervisor if the resident refuses the procedure and report other information in accordance with facility policy and professional standards of practice.

Based on observations, medical record review, and staff interviews, the facility failed to ensure a resident received oxygen therapy as physician ordered. This affected one (Resident #22) of one resident reviewed for respiratory services. The facility census was 69. Findings include: Review of Resident #22's medical record revealed an admission to the facility occurred on 12/04/21. Diagnoses included with post polio syndrome, high blood pressure, and pneumonia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was cognitively intact. Review of Resident #22's current physician orders for 01/2024 revealed an order for oxygen to be administered at two liters via nasal cannula, and have humidifier placed on oxygen. Observations of Resident #22 on 01/22/24 at 9:37 A.M. and 12:13 P.M. revealed Resident #22 was receiving oxygen from a concentrator that the tubing was plugged directly into. The observation identified there was no humidification bottle as ordered by the physician. The observation at 12:13 P.M. revealed an Oxygen Supply Person #900 had a cart and was going resident-to-resident changing their oxygen tubing, humidification bottles and breathing equipment. Interview with Oxygen Supply Person #900 stated he was just replacing what was current in each resident's room and had no idea what their physician's orders state. Subsequent observations of Resident #22 on 01/23/24 at 3:06 P.M. and on 01/24/23 at 7:59 A.M. revealed Resident #22 was receiving oxygen from a concentrator that the tubing was plugged directly into. The observation identified there was no humidification bottle as ordered by the physician. Observation and interview with the Director of Nursing (DON) on 01/24/24 at 8:06 A.M. confirmed Resident #22's physician order does state to administer oxygen with humidification. The DON confirmed Resident #22 does not have a humidification bottle on his oxygen concentrator. The DON confirmed the oxygen company changes the tubing and bottles on Monday and confirmed the person doing this does not have any nursing license.

Based on staff and resident interview, record review, and policy review, the facility failed to ensure controlled medications were accurately recorded as being received by Residents #30 and #66. This affected two (Resident #30 and #66) of nine residents reviewed for medications. The facility census was 69. Findings include: 1. Review of the medical record for Resident #66 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included a trochanteric fracture of the left femur (hip fracture), a fracture of the lower end of the left radius (wrist), osteoarthritis, and anxiety. Review of the Minimum Data Set (MDS) 3.0 discharge return anticipated assessment, dated 01/05/24, revealed Resident #66 had intact cognition. Resident #66 experienced pain rating of an eight out of ten on a frequent basis, and the pain frequently made it difficult to sleep at night. Review of Resident #66's physician's orders revealed an order dated 12/27/23 for Hydrocodone-acetaminophen (APAP) 5-325 mg (a schedule II, controlled narcotic medication) give one tablet three times daily routine for five days (12/27/23 to 12/31/23) for pain. Resident #66 had an order dated 01/01/24 for Hydrocodone-APAP 5-325 mg, one tablet twice daily routine for five days (01/01/24 to 01/05/24) for pain. Resident #66 had an order dated 12/16/23 for tramadol 50 mg (a schedule IV, controlled narcotic medication) one tablet every four hours as needed (PRN) for pain. On 12/27/23, Resident #66's tramadol order was changed to Tramadol 50 mg one tablet three times daily PRN for pain. Review of the controlled drug receipt log for Hydrocodone/APAP 5-325 revealed the following doses were documented as removed from the narcotic drawer but there was no documentation on the Medication Administration Record (MAR) indicating the medication was administered to the resident on the following eight dates and times: 12/29/23 at 3:15 A.M.; 12/29/23 at 5:30 P.M.; 12/30/23 at 5:30 A.M.; 12/31/23 at 2:25 A.M.; 12/31/23 at 6:00 P.M.; 01/01/24 at 2:55 A.M.; 01/03/24 at 3:50 A.M.; and on 01/15/24 at 2:00 A.M. Review of the controlled drug receipt log for Hydrocodone/APAP 5-325 mg for Resident #66 revealed following a dose was signed as removed from the narcotic drawer on 12/28/23 at 5:30 A.M. but the time the medication was documented on the MAR as administered to Resident #66 was between 7:00 A.M. and 11:00 A.M. Review of the controlled drug receipt log for Tramadol 50 mg revealed the following doses were documented as removed from the narcotic drawer but there was no documentation on the Medication Administration Record (MAR) indicating the medication was administered to Resident #66 on the following 23 dates and times: 12/17/23 at 5:00 P.M. 12/18/23 at 5:00 P.M. 12/19/23 at 2:35 A.M. 12/19/23 at 6:00 P.M. 12/19/23 at 10:45 P.M. 12/20/23 at 4:30 P.M. 12/21/23 at 3:15 A.M. 12/21/23 at 4:00 P.M. 12/21/23 at 10:30 P.M. 12/22/23 at 3:00 A.M. 12/22/23 at 2:40 P.M. 12/22/23 at 6:20 P.M. 12/23/23 at 7:30 A.M. 12/23/23 at 11:00 P.M. 12/24/23 at 3:25 A.M. 12/24/23 at 4:30 P.M. 12/26/23 at 4:00 P.M. 12/27/23 at 4:30 P.M. 12/27/23 at 10:40 P.M. 01/01/24 at 8:00 A.M. 01/01/24 at 7:00 P.M. 01/02/24 at 12 A.M. 01/03/24 at 11:30 P.M. Additionally, the MAR for Resident #66's Tramadol medication had doses signed as given, but with no corresponding entries on the controlled drug receipt log, on the following six dates and times: 12/23/23 at 4:03 A.M.; 12/28/23 at 6:33 A.M.; 12/28/23 at 5:41 P.M.; 12/29/23 at 4:49 P.M.; 12/30/23 at 5:45 A.M.; and 12/31/23 at 4:32 A.M. Telephone interview on 01/23/24 at 4:49 P.M. with Resident #66 revealed she did experience pain while a resident of the facility, and she recalled the nurses administering her pain medication, though she could not recall which medication she took at which times. An interview on 01/29/24 at 10:45 A.M. with the Director of Nursing (DON) verified the above discrepancies between the controlled drug receipt logs and the medication administration records. The DON confirmed that all PRN doses of the medication signed out from the controlled drug receipt logs should also be recorded on the MAR. The DON verified that after reviewing the medical record for Resident #66, two nurses, Licensed Practical Nurse (LPN) #140 and Registered Nurse (RN) #174, were suspended pending investigation into potential misappropriation of Resident #66's narcotic medications. The DON confirmed the investigation remained ongoing, but stated LPN #140 would not be returning to the facility. 36297 2. Review of Resident #30's record revealed the resident was admitted to the facility on [DATE] and discharged home on 01/20/24. Diagnoses included pyelonephritis,, type two diabetes mellitus, and obesity with a body mass index of 50-59. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 was alert and oriented and had no behaviors. Resident #30 was coded as not receiving any scheduled or as needed pain medication and no non medication intervention was required for pain intervention the past five days. Resident #30's pain interview revealed the resident denied having any pain or hurting at any time in the past five days. Review of the physician orders dated 12/24/23 revealed Resident #30 had the following medications orders during her stay at the facility: Tylenol (antipyretic/analgesic) 650 milligrams (mg) every four hours as needed for pain and Oxycodone (Opioid) 5.0 mg every four hours as needed. On 01/10/24, an order for Hydrocodone/APAP (Opioid) 5/325 mg half tablet or whole tablet twice daily as needed for pain ordered. Review of the Controlled drug receipt log for Hydrocodone/APAP 5-325 for Resident #30 revealed the 28 doses that were documented as removed from the narcotic drawer were all removed by Licensed Practical Nurse (LPN) #140. Review of the controlled drug receipt log for Hydrocodone/APAP 5-325 mg revealed the following doses were documented as removed from the narcotic drawer but there was no documentation on the Medication Administration Record (MAR) indicating the medication was administered to the resident on the following four dates and times: 01/10/24 at 11:44 P.M.; 01/14/24 at 3:00 P.M.; 01/16/24 at 8:30 P.M.; and 01/18/24 at 2:50 P.M. Review of the controlled drug receipt log for Hydrocodone/APAP 5-325 mg for Resident #30 revealed following doses were signed as removed from the narcotic drawer but the time the medication was documented on the medication administration record as administered to the resident was drastically different on the following four dates and times: On 01/17/24, medication was documented on the controlled drug receipt as removed from the narcotic drawer at 1:40 A.M. and the MAR documented the medication was provided to the resident at 01/17/24 at 3:21 A.M. On 01/18/24, medication was documented on the controlled drug receipt log as removed from the narcotic drawer at 9:00 P.M. and the MAR documented the medication was provided to the resident on 01/18/24 at 10:35 P.M. On 01/19/24, medication was documented on the controlled drug receipt log as removed from the narcotic drawer at 11:15 P.M. and the MAR documented the medication was provided to the resident on 01/19/24 at 10:35 P.M. On 01/20/24, medication was documented on the controlled drug receipt log as removed from the narcotic drawer at 4:00 A.M. and the MAR documented the medication was provided to the resident on 01/20/24 at 8:05 A.M. Telephone interview with Resident #30 on 01/23/24 at 4:12 P.M. revealed the resident had no concerns with the nurses who provided care to her at the facility. Resident #30 denied having pain at the facility and stated she did not think she had any pain medication at the facility. Resident #30 was asked if she requested any medication for pain while a resident at the facility and she stated, I did not request any pain pills while at the facility. Resident #30 stated the facility provided her a prescription for Vicodin when she discharged home and stated, I am not going to fill it. Interview with the Director of Nursing (DON) on 01/29/24 at 10:22 A.M. confirmed the controlled drug receipt log for Resident #30's Hydrocodone/APAP 5/325 mg and MAR did not match as documented above. The DON confirmed LPN #140 was the only nurse who had removed narcotic medication and documented narcotic medication as administered to Resident #30. Review of the facility's Medication Administration - General Guidelines policy, dated May 2020, revealed medications should be administered within 60 minutes of the scheduled time frame. The individual who administers the medications should record the administration on the MAR immediately after the medication is given. In no case should the individual who administered medications report off-duty without first recording the administration of any medications. Review of the facility's policy titled Discrepancies, loss and or Diversion of Medications, dated May 2020, revealed the policy identified all discrepancies, suspected loss and/or diversion of medications. irrespective of drug type or class. are immediately investigated and reported. Immediately upon the discovery or suspicion of a discrepancy, suspected loss, or diversion, the Administrator, Director of Nursing (DON), and Pharmacy (i.e., Consultant Pharmacist) are notified and an investigation conducted. The DON or designee leads the investigation; The information is not to be discussed with other individuals; During the process, the Consultant Pharmacist will verify suspected loss. This deficiency represents non-compliance investigated under Complaint Number OH00149667.

Based on observations, staff interview, review of the facility water temperature log and policy, the facility failed to maintain safe hot water temperatures between 105 degrees Fahrenheit (F) and 120 degrees F. This had the potential to affect four (#45, #58, #31 and #16) randomly observed residents room with elevated hot water temperature readings. Facility census was 67. Findings include: Observation of water temperatures in a public bathroom on in south side of the facility on 05/11/21 at 9:10 A.M. revealed the water temperature was 125 degrees F`. Temperature checks were completed with the Housekeeping Supervisor #500 with a facility thermometer on 05/12/21 between 9:55 A.M. and 10:23 A.M. Water temperatures proved to be elevated with a water temperature reading of 126.9 degrees F in Resident #45 and #58's room. The water temperature in Resident #31 and #16's room was 125.3 degrees F. These temperatures were taken and verified by Housekeeping Supervisor #500. Interview with Housekeeping Supervisor #500 on 05/13/21 at 8:55 A.M. revealed she took over the position temporary position of Maintenance Director after the permanent director took a leave of absence. Housekeeping Supervisor #500 stated at times the water temperatures in the facility, including resident rooms, were as high as 130 degrees F. Housekeeping Supervisor #500 stated she did attempted to turn the hot water heater down, but the temperatures fluctuated often. Review of the facility water temperature logs dated November 2020 through April 2021 revealed water temperatures were with in safe limits of 105 degrees F and 120 degrees F. Review of the facility policy titled F-323 - Accidents and Supervision - Water Temperatures revealed F323 is typically regulated by the State Department of Health. Each State will have it's own regulation on maximum water temperature allowed, but it typically falls between 105 and 115 degrees Fahrenheit.

Based on medical record review, observation, resident and staff interviews and review of the facility policy, the facility failed to ensure oxygen tubing was labeled and dated. This affected three (#34, #41, #61) of three residents reviewed for oxygen therapy. Facility census was 67. Findings included: 1. Review of Resident #34's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #34's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a high cognitive function. The resident also received oxygen therapy. Review of Resident #34's most recent care plan revealed the resident had the potential for alteration in respiratory function related to [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]. Interventions included to administer oxygen as ordered. Review of Resident #34's medical record revealed a physician's order dated 04/15/19 for continuous oxygen at two to three liters per minute. Observation on 05/11/21 at 10:42 A.M. of Resident #34 revealed the oxygen tubing and the humidifier attached to the oxygen concentrator were not dated or labeled. On 05/11/21 at 9:23 A.M. Licensed Practical Nurse (LPN) #250 verified Resident #34's oxygen tubing nor concentrator humidification were labeled nor dated. The nurse also verified that it was facility policy to date the tubing and humidification when replaced. Interview with Assistant Director of Nursing (ADON) #100 on 05/13/21 at 10:50 A.M. revealed a local company provided the oxygen tubing, humidification and concentrators for the facility residents. The company personnel was to change the tubing and humidification when making their weekly stops and were expected to label and date the equipment. ADON #100 verified the company and facility staff failed to label and date the oxygen tubing and concentrator humidification. 2. Review of Resident #41's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #41's quarterly MDS assessment dated [DATE] revealed the resident had a high cognitive function. The residents had shortness of breath on exertion and required oxygen therapy. Review of Resident #41's most recent care plan revealed the resident had a potential for alteration in respiratory function related to [CONDITION(S)], [CONDITION(S)], respiratory failure and being a smoker. Interventions included to deliver oxygen as ordered. Review of Resident #41's medical record revealed a physician's order dated 02/13/21 for continuous oxygen at one to two liters per nasal cannula and to check placement and record oxygen saturation every shift. Special Instructions: every shift Observation on 05/11/21 at 10:43 A.M. of Resident #41 revealed the oxygen tubing and the humidifier attached to the oxygen concentrator were not dated or labeled. On 05/11/21 at 9:23 A.M. an interview with LPN #250 verified Resident #41's oxygen tubing nor concentrator humidification were labeled nor dated. The nurse also verified that it was facility policy to date the tubing and humidification when replaced. 3. Review of the Resident #61's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment, dated 04/13/21, revealed the resident had impaired cognition. The resident also received oxygen therapy. Review of Resident #61's care plan dated 04/19/21 revealed the resident has potential for alteration in respiratory function related to [CONDITION(S)]. Administer oxygen as ordered and auscultate lung sounds as needed. Observation on 05/10/21 at 10:24 A.M., of Resident #61's revealed the oxygen tubing and humidifier attached to the oxygen concentrator were not labeled or dated. Interview on 05/11/21 at 3:10 P.M., with LPN #200 verified Resident #61's oxygen tubing and humidification were not labeled nor dated. Interview on 05/11/21 at 3:12 P.M. with Resident #61 reports does not know when the oxygen tubing was last changed. Resident #61 further stated the oxygen tubing is starting to have a weird smell. Interview with Assistant Director of Nursing (ADON) #100 on 05/13/21 at 10:50 A.M. revealed a local company provided the oxygen tubing, humidification and concentrators for the facility residents. The company personnel were to change the tubing and humidification when making their weekly stops and were expected to label and date the equipment. ADON #100 verified the company and facility staff failed to label and date the oxygen tubing and concentrator humidification. Review of facility policy titled Departmental Respiratory Therapy Prevention of Infection, dated 11/19, revealed it is the facility's policy to guide prevention of infection associated with respiratory therapy tasks and equipment among residents and staff. Steps in procedure infection control in consideration related to oxygen therapy change the oxygen cannula and tubing every seven days, or as needed.

Based on medical record review, observation, staff interview and policy review, the facility failed to ensure soiled linens were properly placed in a bag or container and transferred to the laundry. This had the potential to affect one (#6) out of 32 residents sampled during the survey. Facility census was 67. Findings include: Review of the medical record for Resident #6 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 05/10/21 at 11:24 A.M., of Resident #6's bathroom floor with soiled towels, wash clothes and bed pad laying on the bathroom floor and not placed in a container or plastic bag. The soiled linens on the bathroom floor was verified with the Housekeeping Supervisor #505. Interview on 05/12/21 at 1:48 P.M. with the Assistant Director of Nursing (ADON) #100 revealed are not to be on the floor they are to be placed in a plastic bag and sent to the laundry. Review of the facility policy titled Laundry and Bedding, Soiled, undated, revealed it is the facility's policy that soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen. Soiled laundry and bedding (personal clothing, scrubs sits, gowns, bed sheets, blankets, towels, etc.) contaminated with blood or other potentially infectious materials must be handled as little as possible and with a minimum of agitation. Place contaminated laundry in a bag or container at the location where it is used and do not sort or rinse at the location of use.

Based on medical record review, interviews with residents, facility staff, Laboratory Technician #300, and Medical Director (MD) #05, review of laboratory (lab) testing results, review of the facility policy titled, Anticoagulation-Clinical Protocol and review of Medscape Guidelines 2019, the facility failed to ensure adequate monitoring was completed for two (#22 and #58) residents who received the oral anticoagulant (blood thinning) medication, [MEDICATION NAME]. The failure to monitor the anticoagulant therapy resulted in Immediate Jeopardy and the potential for serious-life threatening harm to Resident #22 and Resident #58, who required administration of Vitamin K (antidote) following critically elevated International Normalized Ratio (INR) levels of greater than 14 (used to monitor therapeutic levels of blood clotting). This affected two (#22 and #58) of four residents reviewed who received anticoagulant medication. The facility census was 74. On 05/08/19 at 2:17 P.M., the Administrator, Regional Consultant #310 and #320, and the Director of Nursing (DON) were notified Immediate Jeopardy began on 02/25/19, when the facility failed to obtain a physician ordered lab (INR) test on 02/25/19 to monitor Resident 22's [MEDICATION NAME] level. Resident #22 continued to receive [MEDICATION NAME] five milligrams (mg) daily without any INR monitoring until 03/06/19. The lab results on 03/06/19 at 12:28 P.M. revealed Resident #22 had a critically elevated INR level of greater than 14 (normal therapeutic range 2.0 to 3.0). MD #05 was notified on 03/06/19 at 2:31 P.M. and ordered Resident #22 to receive one dose of Vitamin K five mg, to attempt to reverse the effects of the [MEDICATION NAME] medication. The Immediate Jeopardy continued 04/21/19 at 10:40 P.M. when Resident #58 was identified bleeding from his nose and the physician was not notified until 04/23/19, two days later. Resident #58 continued to receive [MEDICATION NAME] 11.25 mg on Monday, Wednesday, Friday and [MEDICATION NAME] 7.5 mg on Tuesday, Thursday, Saturday and Sunday. Review of the lab INR results dated 04/23/19 at 7:10 A.M., revealed a critical INR level of greater than 14. MD #05 was notified and ordered to hold the [MEDICATION NAME] and administer Vitamin K five mg immediately and repeat the PT/INR on 04/24/19. The resident continued to have critical levels of [MEDICATION NAME] on 04/24/19 of 6.21 and 04/25/19 at 5.21. On 04/25/19, MD #05 again ordered Vitamin K five mg immediately and to repeat the INR on 04/29/19. The Immediate Jeopardy was removed on 05/08/19 when the facility reviewed the medical records of all four residents receiving anti-coagulant medications, care plans were reviewed and updated as appropriate, and licensed nurses and State tested Nurse Aides (STNA) were in-serviced on the facility's policies and procedures related to adequate monitoring of residents on anti-coagulant medications, facility protocols, and changes in condition, and the facility implemented the following corrective actions: · On 05/08/19, Registered Nurse (RN) #36 completed a care plan review to ensure signs and symptoms of bleeding were addressed for all residents receiving anti-coagulants, anti-platelets and Aspirin. · On 05/08/19, the facility reviewed the records of all four residents receiving [MEDICATION NAME] (#07, #19, #22 and #58) and no concerns were identified. · On 05/08/19 at 4:35 P.M. and continuing on 05/09/19, in-service education for licensed nurses began on the following topics: change in resident condition related to anticoagulant medications; anticoagulation policy and [MEDICATION NAME] protocol; and change in resident condition or status which included abnormal labs, telephone order transcription protocol, and [MEDICATION NAME] log protocol. No nurses will be permitted to work until they have received education on the above topics. · On 05/08/19, STNAs began receiving in-service education on the signs and symptoms of bleeding that must be reported to the charge nurse. As of 05/08/19, no STNA's will be permitted to work until the education is completed. · All nurses and nursing assistants working on 05/09/19 were interviewed from 3:00 P.M. through 3:10 P.M. and included RNs #32 and #35, Licensed Practical Nurse (LPN) #45, and STNAs #50, #68, #76, #79, #88 and #110. Nurses and nursing assistants verified they had been in-served and were able to indicate the topics and provided information related to the in-service as stated above. · On 05/09/19, the facility began daily audits for two weeks, then three times a week for two weeks, then weekly for two weeks and then as needed. The audits were to ensure PT/INR labs were obtained per order, notification to physician was timely and to ensure any signs and symptoms of bleeding were noted and reported to the physician timely. Although the Immediate Jeopardy was removed on 05/08/19, 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) as the facility is still in the process of implementing their corrective action plan to ensure on-going monitoring. Findings include: 1. Review of Resident #22's medical record revealed he was admitted to the facility on [DATE] and re-admitted on [DATE]. [DIAGNOSES REDACTED]. Review of the admission comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #22 was cognitively intact. Review of the re-admission physician orders dated 02/19/19 revealed Resident #22 was receiving [MEDICATION NAME] 5 mg daily. The record indicated a lab was completed on 02/20/19, which revealed a therapeutic INR level of 2.4. The 02/20/19 lab indicated to recheck the INR in one week. A physician order dated 02/21/19 revealed to change the INR checks to Mondays, along with additional weekly labs. There was no evidence the INR was completed on Monday 02/25/19 or 03/04/19. Further review of the INR lab results dated 03/06/19 for Resident #22 revealed an INR level of greater than 14. There was a documented note on the lab results that verified the laboratory notified the facility on 03/06/19 at 12:28 P.M. of the critical results. Review of the progress notes dated 03/06/19 at 2:31 P.M. revealed the physician was updated on the labs, ordered an INR recheck on 03/08/19, continue to monitor for signs and symptoms of bleeding and give Vitamin K for one dose. Review of the Medication Administration Record [REDACTED]. Review of the INR dated 03/08/19 revealed an INR level of 1.4 and an alternate anticoagulant was started ([MEDICATION NAME]). Resident #22 was in the hospital for a planned surgery from 03/12/19 through 03/14/19. Review of the nursing progress notes from 03/14/19 to 05/08/19 revealed no negative findings of the effects of the anticoagulant medication. Review of the anticoagulant plan of care dated 03/18/19 revealed interventions to give medications as ordered and to monitor and document for side effects. Additional interventions included to monitor laboratory values as ordered by the physician and observe for signs of active bleeding. 2. Review of Resident #58's medical record revealed an admitted to the facility on [DATE] following hospitalization for a [MEDICAL CONDITION]. [DIAGNOSES REDACTED]. Review of the admission physician orders revealed the resident was to receive [MEDICATION NAME] 11.25 mg Sundays and Thursdays and 7.5 mg on Monday, Tuesday, Wednesday, Friday and Saturday and to check the INR on 04/12/19. Resident #58 was also receiving [MEDICATION NAME] (blood thinner) daily from 04/09/19 through 04/30/19. Review of a lab test dated 04/10/19 indicated Resident #58 had a hemoglobin (protein in the blood that carries oxygen/can identify blood loss) level of 12.4 (normal range is 14.0 - 18.0). Review of the INR lab results dated 04/12/19 revealed a subtherapeutic level of 1.69. There was no evidence Physician #500 was notified until 04/16/19 at 3:36 P.M., when he ordered an increase in [MEDICATION NAME] of 11.25 mg on Monday, Wednesday and Friday and [MEDICATION NAME] 7.5 mg on Tuesday, Thursday, Saturday and Sunday. The physician order did not include any INR orders for continued monitoring. Review of the progress notes dated 04/21/19 at 10:40 P.M. documented the resident complained of nasal congestion, was unable to get oxygen in his lungs, had a pulse oximetry (ox) of 94% and was on 3.0 liters of oxygen. Dried blood was visible at the base of his nares and he asked the nurse to clean out his nares. He was educated regarding his order for [MEDICATION NAME] and that nose bleeds could be a concern regarding his [MEDICATION NAME] medication. The resident had standing orders for saline nasal spray one to two sprays each nostril as needed (PRN). The nurse sprayed two sprays in each nostril and documented dark dry blood ran out. Will continue to monitor. The notes identified Physician #500 was not notified. Review of the progress notes dated 04/22/19 at 2:30 P.M. documented the resident complained of being tired, had a poor appetite, and was lethargic. Lungs sounds were diminished at bilateral bases, oxygen was in place as ordered, and will update the physician. The notes indicated Physician #500 was notified on 04/22/19 at 3:06 P.M. of the decreased appetite, lethargy and complaints of increased tiredness. There was no documented evidence of any notification of the bloody nose that occurred on 04/21/19. Review of the INR lab results dated 04/23/19 revealed the resident had a critical INR level of greater than 14. The lab report indicated they called the facility to report the level on 04/23/19 at 7:10 A.M. Further review of the progress notes dated 04/23/19 at 7:25 A.M. revealed the lab called with the critical INR level of greater than 14 and Physician #500 was notified. Physician #500 ordered to hold the [MEDICATION NAME], administer Vitamin K 5 mg immediately and repeat the PT/INR on 04/24/19. The notes identified no active bleeding during this time. Review of the INR lab results dated 04/24/19 revealed a critical INR level of 6.21. The lab report identified the lab called the facility to report the result on 04/24/19 at 9:17 A.M. The lab test had physician orders (no time listed) to continue to hold [MEDICATION NAME] and recheck INR on 04/25/19. Additionally, Resident #58 was ordered an antibiotic ([MEDICATION NAME]) at that time. Review of the INR lab results dated 04/25/19 revealed a critical INR level of 5.41. The lab report identified the lab called the facility on 04/25/19 at 7:04 A.M. to report the critical result. The progress notes identified the notification to MD #05 did not occur until 04/25/19 at 2:50 P.M. The physician ordered Vitamin K 5 mg immediately and to repeat the INR on 04/29/19. The lab results dated 04/25/19 also identified a hemoglobin (hgb) of 9.6 (normal 14.0 - 18.0). Interview with Resident #58 on 05/08/19 at 12:24 P.M. revealed he fired Physician #500 due to not monitoring his [MEDICATION NAME] levels and started using MD #05. Resident #58 confirmed his nose was bleeding and identified the bleeding as pretty steady for several days. Resident #58 confirmed he does not usually have nose bleeds and has utilized oxygen for a long time. During an interview with MD #05 on 05/08/19 at 11:50 A.M. she stated she took over Resident #58's care starting on 04/24/19 and was not concerned about the bloody nose due to being associated with dryness and pollen counts. The physician stated Resident #58 could not lose that much blood from a nose bleed when informed of the drop in the resident's hemoglobin levels. The physician identified Resident #58 was seen by the Certified Nurse Practitioner (CNP) on 04/23/19 and his nose was oozing. The physician revealed Vitamin K was ordered when the INR level was greater than 10. Review of the undated facility policy titled, Anticoagulation-Clinical Protocol revealed adverse reaction of [MEDICATION NAME] Therapy (or signs of possible toxicity) may include: Abnormal bleeding (e.g., blood or black tarry stools, blood in sputum, emesis or urine, nose bleeds, bleeding gums and easy bruising or bleeding from wound that will not stop); changes in mental status; jaundice; unexplained swelling; and skin tissue necrosis. The policy indicated if a resident on anticoagulant therapy exhibited side effects or adverse reactions as identified above, the nurse shall assess the resident and document the assessment in the medical record; notify the physician and resident representative in accordance with the change in resident condition. Review of the medication information titled, Medscape Guidelines 2019, revealed [MEDICATION NAME] was an anticoagulant and used as treatment of [REDACTED]. Under the black box warning, it indicated [MEDICATION NAME] can cause major or fatal bleeding; bleeding was more likely to occur during the starting period and with a higher dose (resulting in a higher INR). Risk factors for bleeding included high intensity of anticoagulation (INR greater than 4), and age sixty-five years or older. Regular INR monitoring should be performed on all treated patients; those at high risk for bleeding may benefit from more frequent INR monitoring, careful dose adjustment to desired INR and a shorter duration of therapy was recommended.

Based on medical record review, policy review, staff interview and review of a fall investigation, it was determined that the facility failed to ensure one resident was transferred properly to prevent an avoidable fall. This resulted in actual harm for Resident #18 who fell and sustained a fractured left hip that required surgical intervention. This affected one (#18) of three residents reviewed for falls with fractures. The facility identified a total of six residents who experienced falls with fractures in the past year while in the facility. Findings include: Review of Resident #18's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The minimum data set (MDS) assessment dated [DATE] indicated the resident had short and long term memory deficits with moderately impaired decision making skills. The resident required the extensive assistance of two staff members for transfers. Review of the MDS assessment dated [DATE] revealed the resident required the extensive assistance of one staff member to transfer from one surface to another. Review of the fall risk assessment dated [DATE] revealed the resident was at high risk for falls. Review of the initial plan of care dated 03/26/10 and revised June of 2010 indicated the resident was at risk for falls due to a history of falls, confusion, incontinence and unsteady gait. Interventions to reduce the resident's risk for falls and injury included; assistance and the use of a gait belt to support the resident when ambulating. Review of the nurses' notes dated 07/01/10 at 9:30 P.M. revealed Licensed Practical Nurse (LPN) #6 was called to the resident's room by a state tested nurse aide (STNA) who stated the resident fell . The resident was found in her room by her recliner on her back. The resident was complaining of severe left hip pain and was unable to move her left leg. The physician was notified and the resident was sent to the emergency room . The medical record revealed the resident was admitted to the hospital with [REDACTED]. Review of the fall investigation, dated 07/02/10 completed by the Director of Nursing (DON), revealed the resident sustained [REDACTED].M. in her room. The fall investigation noted the investigation was based on a witness statement. The circumstances of the fall indicated the STNA stated she was in the resident's room helping her get ready for bed. She awakened the resident and gave her a few minutes to wake up and then stood the resident up with her walker in front of her. While the resident was standing, the STNA took the sensor pad alarm from the resident's chair and put it in her bed. While the STNA was turned putting the alarm in the resident's bed, the resident yelled. When the STNA turned to look at the resident she observed the resident falling, landing on her left side. The STNA stated the lights were on in the room, the pathway to the bathroom was clear and the resident's shoes were on and tied. On 12/21/10 at 10:30 A.M. the fall investigation was reviewed with the DON. She verified the nurse note entry dated 07/01/10 at 9:30 P.M. and the fall investigation dated 07/02/10 revealed no documented evidence that a gait belt was utilized at the time of Resident #18's fall. The DON stated STNA #10 was in the room caring for the resident at the time of the fall. The DON further indicated she counseled and educated STNA #10 on the use of a gait belt following the incident. Review of STNA #10's personnel file revealed she was hired on 04/08/10. At the time of hire, STNA #10 received the policy and procedure entitled "Gait Belt". On 04/08/10, she read and signed the document which indicated she had read and understood the facility's gait belt policy. Further review of STNA #10 personnel file revealed no documented evidence that she received additional education or was counseled on the use of gait belts for transfers and ambulation following the 07/01/10 incident. Further review of Resident #18's medical record revealed a "Tinetti Balance Tool" dated 06/29/10 completed by Physical Therapy Assistant (PTA) #30 and cosigned by Physical Therapist #35, that noted the resident scored a 17 out of 28 on the balance and gait test. The interpretation located at the bottom of the tool indicated residents who score below 19 are at high risk falls. On 12/21/10 at 2:35 P.M., PTA #40 verified Resident #18 scored a 17 on the "Tinetti Balance Tool". She stated that with a score of 17, residents are considered to be at high risk for falls and should not be left alone without hands on assistance for transfers and ambulation. During interview on 12/21/10 at 4:30 P.M. with STNA #10, the STNA caring for Resident #18 at the time of her fall, she stated that on 07/01/10 at approximately 9:30 P.M. she went into Resident #18's room to get her ready for bed. She stated the resident was sitting in her recliner sleeping. She woke the resident up and talked to her for a little while then stood her up in front of her recliner with her walker. She indicated the resident had a gait belt on at the time of the incident. STNA #10 stated she tuned to remove the sensor alarms from the resident's recliner and when she turned around, the resident was falling and landed on her left side. She verified she was not holding onto the resident's gait belt and was unable to grab it to lower the resident to the floor prior to the resident landing on the floor. Review of the facility's undated policy entitled "Gait Belt" indicates nursing staff will utilize gait belts on residents that require one or more staff for transfer or ambulation. The policy notes that a gait belt provides a firm grasping surface for staff and protects the resident from accidental trauma. The policy for ambulating a resident from a stationary surface versus pivoting from one surface to another is to stand slightly behind the resident, grasping the gait belt with an underhand grip from the back. The policy instructs staff to lock the resident's knee with their knee if the resident begins to slide. If the resident begins to fall, pull the resident close to your body with the gait belt and slowly lower him/her to the floor allowing the resident to slide down your leg.