Every finding on record at Altercare of Louisville CTR for Rehab & NSG Care

Based on observations, review of the medical record, interviews, and review of facility policy, the facility failed to accurately assess, document, and initially treat an unstageable pressure ulcer for Resident #54 and failed to ensure hand hygiene was performed during wound care for Resident #54. This affected one resident (#54) of three reviewed for pressure ulcers/wounds.Findings Include:Review of the medical record revealed Resident #54 was admitted to the facility on [DATE]. Diagnoses included acute kidney failure, urinary tract infection, weakness, dysphagia, diabetes, hypothyroidism, hypertension, atrial fibrillation cerebral infarction, congestive heart disease major depressive disorder, atherosclerotic heart disease, chronic kidney disease dehydration, adult failure to thrive, and adjustment disorder. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #54 had moderately impaired cognition, required maximum assistance with bed mobility, and had one unstageable pressure ulcer upon admission. Review of the Progress note dated 07/14/26 at 9:58 P.M. revealed Resident #54 arrived at the facility and was oriented to the room, call light, mealtimes and television. Resident #54 was noted to be confused; she also refused her tuberculous test or signing anything without her son present. Vital signs were within normal limits but reported pain when attempting to lay on her back and refused to lay in the supine position. Resident #54 was only able to tolerate lying on her right side due to discomfort. She had no acute distress noted while in this position. Skin was observed to be diffusely reddened with scattered rash like areas present over multiple areas of her body.Review of the admission wound grid dated 07/14/26 revealed Resident #54 was admitted with an unstageable 2.0 centimeter (cm) by 3.3 cm by undetermined depth to the left flank. The wound was pink with no drainage, no odor, and no pain. There was no treatment initiated. Review of the Nurse Practitioner Wound note dated 07/16/26 revealed Resident #54 had an unstageable wound to the left flank. The wound measured 2.0 cm by 3.3 cm by indetermined depth. The wound had slough (fibrous dead tissue) covering 70 percent of the wound with a light amount of serosanguinous drainage. The wound was documented as stable.Review of the physician's orders dated 07/16/26 revealed Resident #54 had a new order to cleanse the left flank with normal saline, pat dry, apply Medi honey and cover with bordered gauze every day and as needed. Review of the July 2026 Treatment Administration record revealed there was no documentation of a treatment being done to the left flank of Resident #54 from admission on [DATE] until 07/16/26.On 08/10/26 at 12:55 P.M. an interview with Wound Nurse #121 revealed she had completed the admission assessment on Resident #54 and documented the wound incorrectly. She stated Resident #53 had slough covering her wound however she stated it was just pink and unstageable on the document. She stated the slough was why she staged the wound as unstageable.Observation of wound care for Resident #54 on 08/10/26 at 2:20 P.M. with the Director of Nursing (DON) and Wound Nurse #121 revealed Wound Nurse #121 had gloves on and wiped the over-the-bed table down with bleach wipes, placed a barrier on the table, picked up her supplies (which were out of their packaging) from a second over-the-bed table, and placed them on the barrier without changing her gloves or washing her hands. The surveyor stopped her and she verified she had touched the clean opened dressing supplies with her soiled/bleached gloved hands. She stated she would get more supplies. She came back with more supplies and completed the dressing change with no further concerns.On 08/11/26 at 8:40 A.M. an interview with Wound Nurse #121 confirmed again she had documented in error the initial wound assessment for Resident #54. She stated she did have slough and that was why she documented it was unstageable but verified she had not documented there was slough in the wound bed. She stated she did not know why she did not obtain a treatment order initially. The DON was in the room and stated they would have to look into it.On 08/11/26 at 8:57 A.M. an interview with Regional Director of Clinical Services #202 verified there was no treatment order put into place for Resident #54 for two days after admission, from 07/14/26 through 07/16/26.Review of the facility policy titled, Pressure Injury: Assessment, Prevention, and Treatment, dated 05/01/25 revealed it was the facility's policy to identify residents at risk for developing pressure injuries, implement interventions to prevent the development of pressure injuries and provide care for existing pressure injuries. A pressure injury risk assessment would be completed upon admission, quarterly, annually and with a significant change.This deficiency represents non-compliance investigated under Complaint Number 3075471.

Based on review of the medical record, interviews, and review of facility policy, the facility failed to ensure timely monitoring for a change in condition for Resident #1 and failed to ensure appropriate interventions were in place to prevent Moisture Associated Skin Damage (MASD) to Resident #1. This affected one resident (#1) of three residents reviewed for change in condition and wounds. Findings include:1. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included spinal stenosis, chronic pain syndrome, presence of a neurostimulator, benign neoplasm of meninges, hypertensive heart and chronic kidney disease, congestive heart failure, atrial fibrillation, diabetes, depression, and anxiety disorder. Resident #1 was a full code and was discharged to the hospital on [DATE]. Review of the Social Service Note for Resident #1 dated 07/02/26 at 11:37 A.M. revealed the Brief Interview for Mental Status was 13 indicating she had intact cognition.Review of the Social Service Note dated 07/07/26 at 12:09 P.M. revealed the Social Service Designee (SSD) was called to the room of Resident #1 to speak to the family as the daughter and spouse were requesting the resident be discharged to home. The SSD notified nursing to reach out to the nurse practitioner (NP) for a discharge order. The family was notified that the NP did not give the order as there were concerns for safe discharge planning. The family expressed concerns that the resident was not receiving enough therapy, and they stated they could take better care of her at home. Education was provided on a safe discharged plan versus leaving Against Medical Advice (AMA). Nursing was notified of the concerns, and the SSD would continue to monitor for a safe discharge.Review of the Progress Note dated 07/07/26 at 12:57 P.M. revealed the family was at the bedside of Resident #1 and were expressing concerns with resident care. The family was requesting the resident be discharged . The NP and therapy were not agreeable at this time. Review of the Progress Note dated 07/07/26 at 5:37 P.M. revealed the daughter of Resident #1 approached the nurse and a second nurse stating they needed to come see her mother because the resident was unresponsive and she had to slap her in the face to arouse her. Both nurses rushed to the room. Resident #1 was in the wheelchair, awake, alert and an appeared to have tics and twitching, her face appeared to be dusky. Her daughter indicated her mother was displaying periods of apnea. Resident #1 stated that her neck hurt. Both nurses transferred her to bed. The neurological assessment was within normal limits, and vital signs were blood pressure 160/96 millimeters of Mercury (mmHg) (normal ranges around 120/80 mmHg), pulse 68 beats per minute (bpm) (normal ranges from 60 to 100 bpm), oxygen saturation 97 percent (%) (normal ranges from around 95% to 100%), and blood sugar was 156 milligrams per deciliter (mg/dL) (normal ranges from around 70 to 100 mg/dL). There was no documentation of additional monitoring related to the residents change in condition and no documentation that the physician was notified of her change in condition, except there was a new order written for ceftriaxone (Rocephin, an antibiotic). Review of the physician's orders revealed Resident #1 had an order for ceftriaxone with instructions to inject 1 gram for seven days dated 07/07/26. Review of the Progress note dated 07/07/26 at 10:27 P.M. revealed the vital signs for Resident #1 were oxygen saturation 94% on room air, pulse 82 bpm, respirations 14 breaths per minute, blood pressure 114/82 mmHg, temperature 98 degrees F. She was having 14-23 second apnea and was lethargic and hard to arouse. The NP was notified and 911 was called. The family was notified and they came to the facility and followed the ambulance.Review of the Discharge Minimum Data Set assessment dated [DATE] revealed no cognition was coded; the resident had no pressure ulcers and was frequently incontinent of bladder and bowel. There was no other Minimum Data Set information available.Review of the Concern Log/Customer Alert form completed by Social Service Designee #125 dated 07/07/26 revealed the daughter of Resident #1 stated she made several concerns over the weekend and her mother was getting worse and had not received much therapy. The resolution was therapy had been seeing Resident #1 five times a week since admission, the NP was aware of the residents decline and ordered laboratory tests and intravenous fluids. The family requested Resident #1 be sent to the emergency department. On 08/10/26 at 4:30 P.M. an interview with the Director of Nursing (DON) confirmed Resident #1 had a change in condition that was not timely addressed as almost 5 hours had passed before the next documented monitoring of the resident, when she was documented as unresponsive and sent to the hospital. She stated the NP was called initially and ordered Rocephin, but when they went to give it to her, she refused and then she was sent to the hospital. She verified there was no documentation of her refusing the medication or the NP or physician being notified. On 08/10/26 at 4:42 P.M. an interview with Licensed Practical Nurse #201 revealed she did not work at the facility anymore. She stated she had been working the day Resident #1 had a change in condition. She stated it was her first time working with Resident #1, so she did not know her or her baseline condition. She stated around suppertime the resident's daughter came to her and stated her mother was unresponsive. She stated when she went to the room the resident was not acting the same as she had been when she gave her medication earlier in the day. She stated she did not have the tics and twitching earlier in the day. She stated she did not know why she did not send her out and she did not remember anyone calling the physician. However, she did remember her vital signs were good and so were her neuro checks but she was twitching and her color was pale. She stated her shift was done at 6:00 P.M. and they did not send her out until later that evening. On 08/11/26 at 10:20 A.M. with Family Member #200 stated another family member was at the facility the day Resident #1 went totally unresponsive and would not open her eyes. She stated the other family member went and got the nurse, and they came down to assess Resident #1. She stated it took several hours before they would send her to the hospital even after they had requested she be sent to the hospital. She stated her father got a call around 11:00 P.M. stating they were sending the resident out to the hospital. She stated she had told the social worker earlier in the day she was unhappy with the care Resident #1 was receiving, that she was declining at the facility and she wanted to take her home because they could provide better care, but the social worker stated she was getting therapy and she was doing better.Review of the facility policy titled, Change in the Resident's Condition or Status, dated 05/01/25 revealed it was the facility's policy to ensure the resident's attending physician and the residents authorized representative or interested family member were notified of changes in the resident's physical, mental, or psychosocial status. A Significant Change in Condition would not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (was self-limiting), impacted more than one area of the resident's health status; and required interdisciplinary review and/or revision to the plan of care.2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included spinal stenosis, chronic pain syndrome, presence of a neurostimulator, benign neoplasm of meninges, hypertensive heart and chronic kidney disease, congestive heart failure, atrial fibrillation, diabetes, depression, and anxiety disorder. Resident #1 was a full code and was discharged to the hospital on [DATE]. Review of the Progress Note dated 06/26/26 at 2:51 P.M. revealed Resident #1 arrived at the facility and was assisted to bed with two staff. A skin check was completed and was noted to have two surgical sites. The left flank had 14 staples and the right mid back had 17 staples, the edges were well approximated and there was no drainage. The wounds were to be open to air per the hospital and there were no other wounds documented.Review of the Braden Scale completed with the Clinical admission Documentation dated 06/26/26 at 10:27 A.M. revealed Resident #1 was at risk for pressure ulcer development.Review of the admission Skin assessment dated [DATE] revealed Resident #1 had no pressure injuries or skin issues. Review of the Baseline Care Plan dated 06/30/26 revealed wound prevention and treatment approaches were to check skin with daily care and weekly with bathing, report any skin concerns to the nurse or physician, and monitor for pain. The Baseline Care plan also noted the resident was incontinent of urine with interventions to maintain dignity, check for incontinence and provide care, observe skin for redness and open areas and observe for burning, pain, fever, odor and increased confusion. There was no comprehensive plan of care or documentation related to specific interventions, such as barrier cream, repositioning, or specialty mattress/cushions for MASD or wound prevention.Review of the Progress note dated 07/07/26 at 12:57 P.M. revealed a family member of Resident #1 observed redness on her buttocks. The area was assessed and Moisture-Associated Skin Damage (inflammation or erosion of the skin caused by prolonged exposure to moisture from bodily fluids) was observed. A new order was received to cleanse with normal saline, pat dry, apply Triad cream and leave open to air. Review of the Initial Wound Grid documentation dated 07/07/26 revealed Resident #1 had in-house MASD to the bilateral buttocks which measured 2.0 centimeters (cm) by 9.5 cm by less than 0.1 cm. The wound surface was pink.Review of the July 2026 physician's orders revealed Resident #1 had orders to float heels in bed and to cleanse the bilateral buttock with normal saline, pat dry, apply Triad cream and leave open to air dated 07/07/26. There were no orders for pressure relieving devices, barrier cream, or repositioning prior to 07/07/26. Review of the Discharge Minimum Data Set assessment dated [DATE] revealed no cognition was coded; the resident had no pressure ulcers and was frequently incontinent of bladder and bowel. There was no other Minimum Data Set information available.On 08/10/26 at 11:28 A.M. an interview with Wound Nurse #121 confirmed Resident #1 developed MASD in house. On 08/11/26 at 10:20 A.M. an interview with Family Member #200 revealed someone was at the facility with her mother daily, her father or sister were at the facility all day long. She stated the staff never came in to change or turn her mother. She stated the staff would come in maybe once when they were there, place her on the bed pan and then they would leave her on the bedpan for a long period of time. She stated therapy would come in, get her up and walk her to the bathroom as part of her therapy, but nobody came into the room and change her brief or turned her side to side. She stated she did not feel it was MASD, but it was an open area to her bottom.On 08/11/26 at 10:53 A.M. an interview with the Administrator revealed the facility used pressure redistribution mattresses and cushions, applied barrier cream during incontinence care and resident's skin was assessed during showers, but verified none of these interventions were documented for Resident #1 and she had developed MASD.This deficiency represents non-compliance investigated under Complaint Number 3075471.

Based on observation, interview, and policy review the facility failed to ensure proper hand hygiene was maintained during medication administration for Resident #46 and Resident #61 and during incontinence care for Resident #59. This affected three residents (#46, #59, #61) out of six residents reviewed for hand hygiene practices. The facility census was 78.Findings include:1. Observation on 04/09/26 between 8:40 A.M. and 9:17 A.M. of medication administration revealed the following: Licensed Practical Nurse (LPN) #363 dispensed and administered medications to Resident #41 and did not utilize hand hygiene upon exiting the room; LPN #363 then immediately dispensed and administered medications to Resident #61 and did not utilize hand hygiene upon exiting the room; LPN #363 then went to the medication storage room before returning to the medication cart; LPN #363 did not utilize hand hygiene after returning to the mediation cart from the medication storage room and then immediately dispensed and administered medications to Resident #46; LPN #353 then assisted Resident #46 with inserting and adjusting her nasal cannula for oxygen administration, and then LPN #363 washed her hands.An interview on 04/09/26 at 9:15 A.M. with LPN #363 verified the above findings.Review of the facility policy titled Medication Administration-General Guidelines, dated 01/2028 revealed medications were to be administered in accordance with good nursing principles and practices, hand hygiene was to be done prior to handling medications and after direct resident contact.Review of the undated facility policy titled Hand Washing-Hygiene, revealed hand hygiene would aid in the prevention and transmission of disease, hand hygiene was to be performed before direct resident contact, hand hygiene was to be performed before handling medications, after contact with objects near the resident, and after removing gloves.2. Review of the medical record revealed Resident #59 was admitted to the facility on [DATE] with a re-entry date of 11/11/25 with diagnoses that included epilepsy, physical debility, Type 2 diabetes, muscle weakness, and major depressive disorder.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #59 was cognitively intact, did not reject care, was dependent on staff for toileting hygiene, required maximal assistance to turn side to side, and was frequently incontinent of urine.Review of the care plan revealed Resident #59 was incontinent of urine with a goal dated 02/23/26 that the resident would not have skin breakdown, interventions included provide incontinence care as needed and assist with toileting.An observation on 04/09/26 at 11:12 A.M. of incontinence care for Resident #59 with Nurse Aid in Training (NAIT) #371 and LPN #328 revealed the following: NAIT #371 was providing perineal care to Resident #59 and after the resident was cleansed of the skin cleaner NAIT #371 removed her gloves and then immediately put on a new pair without utilizing hand hygiene; NAIT #371 then dried Resident #59 with a towel; Resident #59 was assisted to her left side by NAIT #371 and LPN #328; incontinence care continued when NAIT #371 asked LPN #328 to get an incontinence brief from the bathroom; LPN #328 went to the resident bathroom, removed her gloves, came back into the room, handed NAIT #371 the incontinence brief and then immediately put on new gloves without utilizing hand hygiene, and then continued assisting with Resident #59 positioning; and then incontinence care was completed and Resident #59 made comfortable and repositioned.An observation on 04/09/26 at 11:23 A.M. revealed a hand sanitizer dispenser was not located in Resident #59's bathroom.An interview on 04/09/26 at 11:25 A.M. with NAIT #371 verified her gloves were changed without utilizing hand hygiene.An interview on 04/09/26 at 11:35 A.M. with LPN #328 verified hand hygiene was not completed before new gloves were applied.Review of the facility policy titled Perineal Care, dated 05/01/25 revealed after gloves are removed hand hygiene was to be utilized before new gloves were applied.Review of the undated facility policy titled Hand Washing-Hygiene, revealed hand hygiene would aid in the prevention and transmission of disease, hand hygiene was to be performed before direct resident contact, hand hygiene was to be performed before handling medications, after contact with objects near the resident, before applying gloves, after removing gloves, after contact with intact resident skin, and after contact with contaminated objects.

Based on observation, record review, interview, and review of facility policy, the facility failed to ensure Resident #17's oxygen therapy was administered as ordered and Residents #55 and #87's aerosol masks were stored in a protective barrier to prevent cross contamination of the masks. This affected three residents (Resident#17, #55 and #87) of four residents reviewed for respiratory care. The facility census was 77.Findings include:1. Review of Resident #17's medical record revealed the resident was readmitted on [DATE] with diagnoses including chronic diastolic congestive heart failure, muscle weakness and chronic obstructive pulmonary disease. Review of Resident #17's Alteration in Respiratory Function Care Plan revealed an intervention dated 12/10/23 to administer oxygen as ordered. Review of Resident #17's physician orders revealed an order dated 03/10/25 for continuous oxygen at two liters per nasal cannula and check placement every shift for shortness of breath. Review of Resident #17's Quarterly Minimum Data Set (MDS) 3.0 Assessment revealed the resident exhibited moderate cognitive impairment. Review of Resident #17's medication administration record (MAR) and treatment administration record (TAR) from 07/01/25 to 07/22/25 revealed the oxygen therapy was implemented as ordered. An observation on 07/21/25 at 9:39 A.M. revealed Resident #17's oxygen tubing via nasal cannula was wrapped up and in a protective plastic bag hanging on the bedside dresser drawer knob. The oxygen tubing was dated 07/18/25. Interview on 07/21/25 at 9:45 A.M. with Licensed Practical Nurse (LPN) #211 confirmed Resident #17's oxygen therapy was not administered as ordered. LPN #211 stated it was hard to keep the oxygen on the resident and that was why it was not implemented. 2. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE]. Diagnoses included chronic obstruction pulmonary disease, chronic respiratory failure, dysphagia, dementia, peripheral vascular disease, major depressive disorder, hypothyroidism, chronic kidney disease, bipolar disorder, hypertension, Alzheimer's disease, osteoarthritis of the knees, generalized anxiety disorder, and chronic pain syndrome. Review of the July 2025 physician orders revealed Resident #55 had an order for ipratropium albuterol 0.5 milligrams/3.0 milligrams solution for nebulization in a 3.0 milliliters unit twice daily. Review of the Significant Change MDS 3.0 assessment dated [DATE] revealed Resident #55 had severely impaired cognition. An observation on 07/21/25 at 9:44 A.M revealed the aerosol mask for Resident #55 was lying directly on the bedside table without a protective barrier. An interview on 07/21/25 at 9:49 A.M. with LPN #209 verified the aerosol mask of Resident #55 was lying directly on the bedside stand and it should be stored in a protective barrier to prevent contamination. 3. Review of the medical record revealed Resident #87 was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure with hypoxia, pneumonia due to coronavirus disease, chronic obstructive pulmonary disease, obstructive sleep apnea, insomnia, anxiety disorder, bipolar disorder, pulmonary embolism, congestive heart failure, chronic pain syndrome, Barrett's esophagus, ulcerative colitis, irritable bowel syndrome, osteoarthritis, shortness of breath, chest pain, and chronic kidney disease. Review of the physician orders revealed Resident #87 had an order for albuterol sulfate solution 2.5 milligrams/3.0 milligrams solution for nebulization in a 3.0 milliliters unit every four hours as needed. Observation on 07/21/25 at 9:59 A.M. revealed the aerosol mask for Resident # 87 was lying directly on the bedside stand. An interview on 07/21/25 at 10:01 A.M. with LPN #209 verified the aerosol mask of Resident #55 was lying directly on the bedside stand and it should be stored in a protective barrier to prevent contamination. Further observations on 07/21/25 at 10:04 A.M. revealed LPN #209 picked the aerosol mask up off the bedside stand placed medication in the reservoir and placed it on the residence face without getting a new one or cleaning the contaminated one. LPN #209 verified at this time she had not obtained a new aerosol mask or cleaned the contaminated one prior to placing it on the resident. Review of the facility policy titled, Oxygen Equipment-Change, dated 05/01/25 revealed it was the facility policy that professional standards were followed to reduce the risk of transmission of infection when utilizing respiratory equipment.

Based on observation, record review, and interview, the facility did not ensure the call light was kept within reach for Resident #27. This affected one resident (Resident #27) of 23 residents reviewed for accommodation of needs. The facility census was 77. Findings include: Review of the medical record revealed resident #27 was admitted to the facility on [DATE]. Diagnoses include senile degeneration of the brain, dementia, chronic kidney disease, depression, Alzheimer's disease, impulsiveness, repeated falls, generalized anxiety disorder, psychotic disorder, insomnia, and sundowning. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #27 had severely impaired cognition and had two or more falls with no injuries.Observation on 07/22/25 at 10:42 A.M. revealed Resident #27 was up in the Broda chair (reclining wheelchair) in the middle of the room and his call light was tucked up under the blanket on his bed and out of his reach. An interview at this time with Certified Nursing Assistant (CNA) #218 verified the call light for Resident #27 was not within his reach.Observation on 07/23/25 at 9:55 A.M. revealed Resident #27 was up in the Broda chair in the middle of the room and his call light was tucked under the blanket on the bed out of his reach. An interview at this time with the Director of Nursing verified the call light for Resident #27 was not within his reach.

Based on record review, interview and review of facility policy, the facility failed to immediately notify the physician and responsible parties of a fall incident involving Resident #8. This affected one resident (Resident #8) of five residents reviewed for accidents. The facility census was 77. Findings include:Review of the medical record for Resident #8 revealed an admission date of 02/27/25 with diagnoses including acute and chronic respiratory failure, multiple sclerosis, unsteadiness on feet and diabetes.Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #8 had no cognitive impairment and required extensive assistance with toileting. Review of the incident log revealed Resident #8 had a fall on 07/06/25 at 8:00 A.M.Review of the STNA Event Witness Statement dated 07/06/25 and timed for 8:00 A.M. authored by Registered Nurse (RN) #205 revealed Resident #8 was reported by a Certified Nursing Assistant (CNA) to have had a fall during the night while transferring to the toilet. It did not disclose the name of the CNA who reported the incident nor did it specify what time during the night the resident fell.Review of a progress note dated 07/06/25, timed 8:45 A.M. and authored by RN #205 revealed it was reported to her Resident #8 fell in her bathroom while transferring to the toilet. Resident #8 was complaining of left knee pain. RN #205 notified the Nurse Practitioner (NP). Review of the fall investigation dated 07/06/25 and authored by RN #205 revealed there were two different times listed as the time of incident: 5:00 A.M. and 8:30 A.M. It stated Resident #8 slipped off the toilet. No injuries were noted. The immediate intervention was to use the call light.An interview on 07/22/25 at 3:52 P.M. with Resident #8 revealed she had fallen on 07/06/25 around 5:00 A.M. Resident #8 stated an agency nurse was assigned to her that shift. An interview on 07/23/25 at 2:00 P.M. with RN #205 revealed she did not witness the fall on night shift. She stated a CNA told her about the fall. RN #205 stated the agency nurse did not tell her in report that Resident #8 fell, and she did not remember the name of the agency nurse. RN #205 stated she was not sure why she wrote 8:00 A.M. for the time of the incident because the CNA told her that the fall occurred during the night shift around 5:00 A.M. RN #205 confirmed there was no documentation in the medical record about the fall from the agency nurse nor any record of notification to the NP until she completed a progress note on 07/06/25 at 8:45 A.M. An interview on 07/23/25 at 2:04 P.M. with Licensed Practical Nurse (LPN) #216 revealed the agency nurse who worked nights did not report to anyone Resident #8 had a fall on 07/06/25. LPN #216 said it was expected a nurse whose resident had a fall would be responsible to complete the investigation report, write a progress note, notify the physician and responsible party as well as share in report to the next shift.An interview on 07/23/25 at 4:45 P.M. with the Director of Nursing and Regional Nurse revealed the dayshift nurse found out about Resident #8's fall after the nightshift agency nurse left. The nightshift agency nurse was expected to complete the investigation report and the notifications to the physician and responsible party, chart in the progress notes and relay in report but did not. Review of the facility policy titled Change in the Resident's Condition or Status, dated 05/01/25, revealed the facility would ensure the resident's attending physician and the resident's authorized representative or interested family member were notified of changes in the resident's physical, mental or psychosocial status. The nurse would immediately notify the resident, consult with their attending physician, on-call physician or nurse practitioner and notify the authorized representative when there was an accident or incident which resulted in injury and had the potential for requiring physician intervention. The nurse would record in the resident's medical record information relative to changes in the resident's medical/mental condition or status (e.g. assessment, appropriate notifications, interventions and response).

Based on observation, record review, interview and review of facility policy, the facility failed to ensure personal privacy and confidentiality of records for Resident #42 and #85. This affected two residents (Residents #42 and #85) of 23 residents reviewed for privacy/confidentiality. The facility census was 77.Findings include:1. Review of the medical record for Resident #85 revealed an admission date of 07/18/25. Diagnoses included stroke, weakness, atrial fibrillation, diabetes and heart disease. An observation on 07/23/25 at 10:36 A.M. of the medication cart on the 100 hall revealed the computer on the medication cart was open to the electronic medical record (EMR) of Resident #85 and his picture, personal demographic information and list of medical orders was visible to anyone passing by the cart which was unattended by facility staff. An interview on 07/23/25 at 10:39 A.M. with Licensed Practical Nurse (LPN) #216 verified the EMR of Resident #85 was open on the medication cart in the hallway and his private information was in view of passersby. Review of the facility policy titled Matrix: Medical Record Policy and Procedure, dated 08/16/10, revealed the facility would monitor and protect health information including but not limited to care plans, nursing information, dietary, social service, activity, therapy and progress notes. 2. Review of the medical record for Resident #42 revealed an admission date of 05/19/25. Diagnoses included malignant neoplasm of the bone, malignant neoplasm of the breast, congestive heart failure, radiculopathy, diabetes, atrial fibrillation glaucoma, and chronic kidney failure. Review of the July 2025 physician orders revealed Resident #42 had an order to cleanse the right heel with normal saline, pat dry, apply skin prep, cover with an abdominal dressing and wrap in kerlix once a day. An observation of wound care on 07/23/25 at 1:07 P.M. revealed the Director of Nursing (DON) provided wound care to the right heel of Resident #42 without maintaining privacy during the treatment. Resident #42 was in bed during the treatment. The DON did not close the door or draw the blinds to the room which exposed the resident to anyone outside or in the hallway. An interview on 07/23/25 at 1:07 P.M. with the DON at the time of the observation of the wound care verified privacy during treatment was not maintained for Resident #42.

Based on observation, record review, interview and review of facility policy, the facility failed to ensure a physician order was obtained for Resident #7's right lower arm skin tear. This affected one resident (#7) of one resident reviewed for general skin conditions. The facility census was 77.Findings include: Review of Resident #7’s medical record revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia, aphasia and chronic systolic congestive heart failure. Review of Resident #7’s care plan for skin care revealed an intervention dated 04/15/25 to perform treatments as per the physician orders. Review of Resident #7’s Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #7’s Wound Information form dated 07/07/25 revealed the resident had a right lower arm skin tear which measured one centimeter (cm) length by 0.8 cm width. Review of Resident #7’s Wound Information form dated 07/21/25 at 7:33 P.M. revealed the resident had a right lower arm skin tear first identified on 07/02/25 at 10:28 P.M. which measured 1.2 cm length by 1.2 cm width. Review of Resident #7’s physician orders for July 2025 revealed no treatment orders for the resident’s right lower arm skin tear. Observation on 07/21/25 at 9:07 A.M. revealed Resident #7 was lying in bed and had a dressing on the right arm. The dressing was dated 07/19/25. An interview on 07/21/25 at 9:18 A.M. with Certified Nursing Assistant (CNA) #223 verified Resident #7 had a dressing on the right arm dated 07/19/25. An interview on 07/22/25 at 2:59 P.M. with the Director of Nursing (DON) revealed Resident #7 did not have an active physician order for treatment to the skin tear on the right arm. A follow-up interview on 07/22/25 at 4:30 P.M. with the DON revealed a treatment plan was obtained on 07/02/25 for Resident #7 to receive treatment to the right lower arm skin tear including cleanse the right forearm with normal saline, pat dry, and cover with a clean dressing every other day. The DON verified it had not been written as a physician order. Review of the Clean Technique Wound Care policy updated 05/01/25 revealed it was the facility policy to provide wound care to residents using professional standards of practice.

Based on observation, record review, interview and review of facility policy, the facility failed to ensure Resident #5's left lower leg/foot dressing was administered as ordered. This affected one resident (Resident #5) of three residents reviewed for pressure ulcers/injury. The facility census was 77.Findings include:Review of Resident #5's medical record revealed the resident was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including end stage renal disease, cellulitis of the right and left lower limbs and chronic pain.Review of Resident #5's Pressure Ulcer Care Plan revealed an intervention dated 01/29/25 to perform current treatment as ordered and observe treatment for effectiveness.Review of Resident #5's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #5's physician orders revealed an order dated 07/17/25 to flush the left medial ankle and posterior Achilles with normal saline, pat dry, pack with iodoform and cover with a dry dressing daily; an order dated 07/17/25 to apply betadine wet to dry to bilateral heels once a day; an order dated 07/22/25 to cleanse the left heel and right heel with normal saline, pat dry, apply xeroform gauze into the wound, cover with an abdominal dressing, wrap with kerlix and secure with tape once a day.Review of Resident #5's medication administration record (MAR) and treatment administration record (TAR) from 07/01/25 to 07/22/25 revealed on 07/20/25 Licensed Practical Nurse (LPN) #213 documented the wound care was on hold and wound rounds were the next day and on 07/21/25 the betadine was unavailable to be administered to the resident's right and left heel per the physician's order.Review of Resident #5's progress notes from 07/01/25 to 07/22/25 did not reveal evidence that the resident's left medial ankle and posterior Achilles wound care were on hold by the physician.An observation including interview was conducted on 07/21/25 at 2:56 P.M. with Physical Therapist (PT) #293 of Resident #5's left foot and ankle's dressing that was observed with a date mark of 07/19/25. PT #293 verified Resident #5's left foot and ankle dressing was dated 07/19/25. An observation on 07/22/25 at 3:45 P.M. with the Director of Nursing (DON) of wound care treatment for Resident #5 revealed the nurse removed the dressing to Resident #5's right heel, removed her gloves, washed her hands, put on gloves, cleaned the right heel with normal saline, removed gloves, washed hands, put on gloves, applied xeroform non-stick dressing, an abdominal dressing and kerlix to the right heel. Betadine was not applied to the right heel.An observation on 07/22/25 at 4:00 P.M. with the DON of wound care treatment for Resident #5 revealed the nurse removed the dressing to Resident #5's left heel, removed her gloves, washed her hands, put on gloves, cleansed the left heel with normal saline, removed her gloves, washed her hands, put on gloves, placed a xeroform non-stick dressing, an abdominal dressing and kerlix to the left foot. Betadine was not applied to the left heel.An observation on 07/23/25 from 10:35 A.M. to 10:42 A.M. with the DON of the treatment administration cart and treatment storage rooms did not reveal evidence of betadine in the facility.An interview on 07/23/25 at 10:42 A.M. with the DON revealed she had called the Nurse Practitioner (NP) to change the order for Resident #5 to have betadine applied to bilateral heels once a day because the facility ran out of betadine. The DON confirmed Resident #5 had not received wound care treatment as ordered. Review of the Pressure Injuries: Assessment, Prevention and Treatment policy updated 05/01/25 revealed the facility should identify the residents at risk for developing pressure injuries, implement interventions to prevent the development of pressure injuries and provide care for existing pressure injuries. This deficiency represents non-compliance investigated under Complaint Number OH00167333 (1373385).

Based on observations, record review, interview and review of facility policy, the facility failed to ensure fall interventions were in place for Resident #27. This affected one resident (Resident #27) of five residents reviewed for accidents. The facility census was 77.Findings include: Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses include senile degeneration of the brain, dementia, chronic kidney disease, depression, Alzheimer's disease, impulsiveness, repeated falls, generalized anxiety disorder, psychotic disorder, insomnia, and sundowning. Review of the July 2025 physician orders revealed Resident #27 had orders for a defined perimeter mattress to the bed to alert resident of bed boundaries, maintain the bed in the lowest position when occupied by the resident, and the resident was a high risk for falls. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #27 had severely impaired cognition and had two or more falls with no injuries. Review of the care plan dated 10/02/22 revealed Resident #27 was at risk for falls/injury related to behavior, confusion, antidepressants, antihypertensives, and unsteady gait. Interventions included a defined perimeter mattress to the bed provided by hospice, Ativan at bedtime, medication review, staff to offer and encourage toileting approximately every two hours, provide the urinal and encourage use during the night, offer and assist resident to bed to rest between meals, assess the resident for bowel and bladder program needs, maintain the bed in the lowest position when occupied by the resident, gripper socks/shoes when out of bed, call light for assistance sign in room, bed against the wall to help define bed boundaries, encourage common areas while awake, encourage resident to use call light and observe resident in their room, dining room, and meal services for safety needs. Observation on 07/22/25 at 10:42 A.M. revealed Resident #27 was up in the Broda chair (reclining wheelchair) in the middle of the room and his call light was tucked up under the blanket on his bed and out of his reach. An interview at this time with Certified Nursing Assistant (CNA) #218 verified the call light for Resident #27 was not within his reach. Observation on 07/22/25 at 2:19 P.M. revealed Resident #27 was in bed on his right side towards the wall and his bed was not in the lowest position. CNA #240 was observed entering the room, walked to the bed and lowered it to the floor. CNA #240 verified the bed had not been in the low position until the CNA entered the room. Observation on 07/22/25 at 5:00 P.M. revealed Resident #27 was up in the Broda chair in the main dining room with regular nonslip socks on both his feet. An interview at this time with Agency CNA #333 verified Resident #27 did not have gripper sock or shoes on at the time of the observation. Observation on 07/23/25 at 9:55 A.M. revealed Resident #27 was up in the Broda chair in the middle of the room and his call light tucked under the blanket on the bed out of his reach. An interview at this time with the Director of Nursing verified the call light for Resident #27 was not within his reach.Review of the facility policy titled, Fall Investigation, dated 05/01/25 revealed the policy was to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. A member of the team would review current intervention and implement additional fall interventions based on the residents risk factors and results of the root cause analysis.

Based on observation, record review, interview, and review of facility policy, the facility failed to ensure Resident #7's percutaneous endoscopic gastrostomy (PEG) tube dressing was administered as ordered. This affected one resident (Resident #7) of one resident reviewed for tube feeding. The facility identified one resident (#7) as ordered a tube feeding. The facility census was 77.Findings include:Review of Resident #7's medical record revealed Resident #7 was admitted on [DATE] with diagnoses including aphasia following a cerebral infarction, gastrostomy status and chronic pain syndrome.Review of Resident #7's physician orders revealed an order dated 03/26/25 to cleanse the PEG tube site with normal saline (NS) and apply a t-sponge dressing to the site daily.Review of Resident #7's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment.Review of Resident #7's care plan for skin care revealed an intervention dated 04/01/25 to administer the skin treatment to the PEG tube site as ordered.Review of Resident #7's medication administration record (MAR) and treatment administration record (TAR) from 07/01/25 to 07/21/25 revealed Licensed Practical Nurse (LPN) #213 documented she completed the care for Resident #7's PEG tube dressing.An observation was conducted on 07/21/25 at 9:07 A.M. of Resident #7 lying in bed with his body exposed from the hip line up to his head. The PEG tube site was visible and there was no dressing on the PEG tube site. The resident had one dressing on his right arm dated 07/19/25. An observation was conducted on 07/21/25 at 9:18 A.M. with Certified Nursing Assistant (CNA) #223 of Resident #7 lying in his bed. CNA #223 confirmed Resident #7 did not have a dressing on the PEG tube site.Review of the Enteral Feeding Site Care policy, updated 05/01/25 revealed it was the policy of the facility to provide ostomy site care for residents with enteral tubes in accordance with professional standards.

Based on observations, interview and review of facility policy, the facility failed to ensure staff performed hand hygiene during medication administration for Resident #21. This affected one resident (Resident #21) of five residents (Resident #7, #21, #22, #30, and #71) observed for medication administration. The facility census was 77.Findings include:Observation of medication administration on 07/23/25 at 9:45 A.M. revealed Registered Nurse (RN) #205 pushed the medication cart from the nurses station down to the room of Resident #21. RN #205 went into Resident #21's room, obtained his blood pressure, walked back out to the medication cart, prepared his medication, took the medication to Resident #21 and administered the medication all without performing any hand hygiene. After she administered the medications to Resident #21, RN #205 walked back out to the medication cart and started to push the medication cart up the hall way to continue the medication administration. An interview on 07/23/25 at 9:50 A.M. with RN #205 verified she had not washed hands before going into Resident #21's room, obtaining his blood pressure, before administering his medication or after coming out of the room. Review of the undated facility policy titled, Hand Hygiene, revealed it was the facility policy for employees to conduct proper hand hygiene that would aid in the prevention and transmission of infectious diseases.

Based on record review and interview the facility did not ensure pre and post dialysis assessments were completed as required for Resident #5. This affected one resident (Resident #5) of one resident reviewed for dialysis services. The facility identified one resident (#5) as receiving dialysis services. The facility census was 77.Findings include:Review of the medical record for Resident #5 revealed an admission date of 05/05/25 with diagnoses including end stage renal disease, sepsis, diabetes and chronic pain.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 was cognitively intact. Review of the June 2025 orders for Resident #5 revealed he had hemodialysis scheduled for Tuesday, Thursday and Saturdays at 5:00 A.M. Review of the Pre/Post Dialysis Assessments dated 06/01/25 through 07/01/25 revealed the following dates were missing at least one of the two (pre/post) assessments: 06/05/25, 06/07/25, 06/14/25, 06/17/25, 06/21/25, 06/24/25, 06/28/25 and 07/01/25. An interview on 07/23/25 at 2:21 P.M. with Licensed Practical Nurse (LPN) #216 revealed she noticed when agency nurses worked at the facility the pre and post dialysis assessments did not get done as required for Resident #5. LPN #216 verified multiple dialysis assessments were not completed. An interview on 07/23/25 at 4:47 P.M. with the DON and Regional Nurse revealed there was no other place staff documented pre/post dialysis assessments except on the assessment. Both the DON and Regional Nurse verified the missing assessments for Resident #5. Review of the facility policy titled Dialysis Policy, dated 05/01/25, revealed residents utilizing renal dialysis will complete pre/post dialysis observations.

Based on record review and interview, the facility did not ensure Resident #81 was administered medication according to physician orders. The affected one resident (#81) of five residents reviewed for medication administration. The facility census was 77.Findings include: Review of the medical record revealed Resident #81 was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus. Resident #81 discharged from the facility on 04/09/25.Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #81 had intact cognition, had lower extremity impairment on one side, required substantial assistance with turning in bed, urinary continence was not rated, and he was frequently incontinent of bowels. Resident #81 was at risk of developing pressure injuries however he was not admitted with any unhealed pressure injuries. Review of the physician orders revealed Resident #81 had an order for Mounjaro (diabetic medication)15 milligrams subcutaneous one a week on Monday dated 02/26/25 and discontinued on 03/24/25 (changed to Tuesday on 03/24/25 so they could give him the injection after it came in from the pharmacy)Review of the March 2025 Medication Administration Record (MAR) revealed Resident #81 was not administered his once weekly Mounjaro on 03/03/25, 03/17/25, and 03/24/25. The comment section of the MAR indicated on 03/03/35 the medication was discontinued, on 03/17/25 it was on hold, and on 03/24/25 it was on hold. Resident #81 was administered the medication on 03/10/25. Review of the pharmacy delivery sheet dated 02/27/25 revealed Resident #81 received one 15 milligram injection of Mounjaro.Review of the pharmacy delivery sheet dated 03/25/25 revealed Resident #81 received four-15 milligram injections of Mounjaro.An interview on 07/23/25 at 10:45 A.M with Regional Nurse #292 revealed on 03/03/25 the nurse working had inadvertently put in the comment section of the MAR that the Mounjaro for Resident #81 was discontinued because she had discontinued his Lantus insulin and she wrote that in error for his Mounjaro. RN #292 verified the nurse never administered the Mounjaro on 03/03/25. RN #292 stated Resident #81 was given one dose of the Mounjaro on 03/10/25 which had been delivered on 02/26/25 however, the pharmacy had not sent any more doses and no one in management was aware the facility had not received any more doses from the pharmacy and Resident #81 had missed several doses until 03/24/25 when they reached out to the pharmacy and had them deliver the medication and it was administered the next day. RN #292 stated the facility had not realized pharmacy had not sent it. RN #292 stated Resident #81 had not received the 03/17/25 and 03/24/25 dose because it was not available from the pharmacy and it was then given on 03/25/25.

Based on record review, interview and review of facility policy, the facility did not ensure gradual dose reduction recommendations pertaining to anti-anxiety medications for Resident #58 were addressed by the physician. This affected one resident (Resident #58) of five residents reviewed for unnecessary medications. The facility census was 77.Findings include:Review of the medical record for resident #58 revealed an admission date of 04/28/23. Diagnoses included senile degeneration of the brain, difficulty walking, muscle weakness, dementia, depression and anxiety. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #58 was severely cognitively impaired, required supervision for eating, substantial assistance for oral hygiene, dressing and personal hygiene and was totally dependent for toileting and showering. Review of the physician orders for September 2024 revealed an order for Ativan (for anxiety) one milligram every two hours (mg) as needed (prn) for anxiety. The order began on 09/02/24 with a stop date of 01/28/25. Review of the facility document for gradual dose reduction (GDR) recommendations by pharmacy, dated 09/09/24, revealed a request by pharmacy to the physician to address the use of as needed Ativan for longer than 14 days. There was no evidence the form had been reviewed by the physician. An interview on 07/23/25 at 9:16 A.M. with the Administrator confirmed the September 2024 GDR recommendation for Resident #58 was not addressed by the physician. Review of the facility policy titled Psychoactive Medication dated 05/01/25 revealed the facility would report irregularities with medications to the physician. The facility would comply with federal and state regulations regarding the use of psychopharmacological medications to include regular review of continued need, appropriate dosage, side effects and risk or benefits.

Based on medical record review, resident interview, and staff interview, the facility failed to ensure Resident #29's pain medication was reordered timely. This affected one resident (#29) out of three (Resident #18, Resident #29, and Resident #54) reviewed for medication administration. The facility census was 64. Findings include: Review of the medical record for Resident #29 revealed an admitted [DATE]. Diagnoses included malignant neoplasm of head, face and neck, malignant neoplasm of tongue, dysphagia, oropharyngeal phase, and gastrostomy status. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #29 was mildly impaired with a Brief Interview for Mental Status (BIMS) of 12. Review of Resident #29's February 2025 physicians orders revealed an order for Gabapentin 12 milliliters (ml) to equal 600 milligrams (mg) to be administered orally twice daily. Review of Resident #29's Medication Administration Record revealed the resident did not receive his Gabapentin 600 mg on 02/10/25 for the scheduled dose from 1:00 P.M. to 2:30 P.M. or on 02/11/25 from 6:30 A.M. to 10:30 A.M. The reason/comment section for the missed medication dates showed the rational as not administered, on hold, awaiting pharmacy. Review of Resident #29's nurse progress notes from 02/10/25 through 02/11/25 revealed no evidence where the physician was made aware of the missed doses of pain medication. Interview on 02/26/25 at 3:25 P.M. the Director of Nursing verified Resident #29's Gabapentin was not reordered timely by the facility nurses resulting in the resident missing two doses of his pain medication. Interview on 02/27/25 at 9:07 A.M. with Resident #29 revealed the facility did not always order his pain medication timely. He reported he had to wait for the pharmacy to bring in his medication and had also missed doses because the facility had not ordered the medications timely. This deficiency represents non-compliance investigated under Complaint OH00162436.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, self-reported incident review (SRI), interview, and facility policy review the facility failed to ensure Resident #21 was free from staff-to-resident physical abuse. This finding affected one resident (#21) of five residents reviewed for Abuse, Neglect and Misappropriation of Resident Property. The facility census was 70. Findings include: Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including vascular dementia, muscle weakness and need for assistance with personal care. Review of Resident #21's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of physical abuse SRI Tracking #244568 dated 02/26/24 revealed Resident #21 became behavioral when State tested Nursing Assistant (STNA) #833 and STNA #904 attempted to provide care to the resident on 02/24/24 at approximately 10:30 P.M. Resident #21 ended up biting down on STNA #904's forearm and drew blood. STNA #904 reacted by slapping Resident #21 which caused him to release her forearm. The allegation was unsubstantiated. Review of Resident #21's Illustration of Documentation and Measurements of Skin Areas form dated 02/24/24 at 10:40 P.M. revealed the resident had a red area (handprint) on the right side of the face. Review of Resident #21's Event Statement Form dated 02/26/24 authored by the Administrator revealed she interviewed STNA #904 over the phone. The statement indicated STNA #833 and STNA #904 went into the resident's room around 10:00 P.M. on 02/24/24. The resident was transferred using a Hoyer mechanical lift from the wheelchair to the bed. He was fine and did not seem agitated. After the transfer, the staff started taking off his pants to provide care at which point he became agitated. The staff told him exactly what was happening and he started hitting and kicking the staff. STNA #904 rolled him towards her so that peri care could be completed for a bowel movement when the resident lifted his head and bit into the STNA #904's right forearm very hard until it drew blood. Resident #21 eventually released STNA #904's arm, and the nurse was notified. STNA #904 stated she did not slap the resident, but he must have been lying on one side of his cheek which must have caused some redness. Review of Resident #21's undated witness statement authored by STNA #833 indicated both STNA #833 and STNA #904 went into Resident #21's room to lay the resident down for incontinence care. He was becoming irritated with the transfer and became combative while doing peri care. He was hitting and kicking and ended up biting STNA #904's arm. As Resident #21 bit her, STNA #904 slapped the resident on the cheek. After she did it, STNA #904 stated it was a reflex. The peri care was completed, and STNA #833 notified the nurse. Interview on 08/20/24 at 1:20 P.M. with the Administrator indicated STNA #904 hit Resident #21 as a reaction to the resident biting down on her arm. The Administrator confirmed the red mark went away quickly. She confirmed education and audits were completed following the incident. Review of the Abuse, Neglect and Misappropriation Policy, dated 2016, indicated it was the facility's policy to investigate allegations, suspicions and incidents of Abuse, Neglect and Misappropriation of Resident Property. Facility staff should immediately report all allegations to the Administrator and State in accordance with the procedures. As a result of the incident, the facility took the following actions to correct the deficient practice as of 02/27/24: On 02/24/24 at approximately 10:38 P.M. (immediately following the incident), STNA #904's (agency staff) shift had ended. She left the building, and the agency STNA was not allowed to return. On 02/24/24 at approximately 10:39 P.M., STNA #833 immediately reported Resident #21's alleged abuse to Licensed Practical Nurse (LPN) #871. On 02/24/24 at 10:40 P.M., LPN #871 assessed Resident #21 for injuries following the witnessed event. A reddened hand mark was identified on the right side of the resident's face. No blood was observed, and the skin was not broken. On 02/24/24 (unknown time), STNA #833's written incident statement was obtained by the Director of Nursing (DON). On 02/24/24 at 11:00 P.M., the DON interviewed Certified Medication Aide (CMA) #868 and LPN #871 regarding Resident #21's alleged abuse allegation. Negative findings were not identified. On 02/24/24 from 11:40 P.M. to 11:47 P.M., the DON completed skin assessments of Residents #703, #704, #705. Negative findings were not identified. On 02/24/24 at 11:45 P.M., a second skin assessment was completed for Resident #21 by the DON, and no marks were noted on the resident's skin, and no new areas were observed. On 02/26/24 (unknown time), the DON and Administrator contacted STNA #904 (specified perpetrator) to obtain a witness statement. On 02/27/24 at varied times, the Administrator interviewed Residents #4, #11, #44, #701 and #702 for abuse, dignity, and respect. Negative findings were not identified. The Assistant Director of Nursing (ADON) #839 and the Administrator conducted audits on 02/27/24, 03/01/24, 03/04/24, 03/07/24, 03/13/24, 03/15/24, 03/18/24, 03/21/23. Negative findings were not identified. On 02/27/24, the DON completed staff education for all registered nurses (RNs), LPNs, and STNAs. Review of the Abuse, Neglect and Misappropriation policy, dated 2016, and no changes were made. This deficiency is an incidental finding identified during the complaint investigation.

Based on observation, record review, interview, and facility policy review the facility failed to ensure Resident #46 was provided timely incontinence care. This finding affected one resident (#46) of three residents reviewed for incontinence care. The facility census was 70. Findings include: Review of Resident #46's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with early onset, altered mental status, and adult failure to thrive. Review of Resident #46's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment and was always incontinent of bowel and bladder Review of Resident #46's physician orders revealed an order dated 05/14/21 for miconazole powder (antifungal powder) twice daily and an order dated 05/19/21 for zinc oxide 20% (cream used to treat or prevent skin irritation) twice daily to affected areas. Review of Resident #46's physician's orders revealed an order dated 05/01/24 which indicated the resident was dependent to shower/bathe and upper body dressing, and dependent on eating, oral hygiene, and toileting hygiene. Review of Resident #46's physician's orders revealed an order dated 05/01/24 which indicated the resident was dependent on a Hoyer mechanical lift, was incontinent of bowel and bladder, dependent to roll left and right and dependent on lower body dressing and putting on and taking off footwear. Interview on 08/19/24 at 6:25 A.M. with State tested Nursing Assistant (STNA) #801 revealed she provided morning care to Resident #46 and then had Licensed Practical Nurse (LPN) #804 assist her in transferring the resident from the bed to a Broda (reclining) chair using a Hoyer mechanical lift. She denied concerns. She stated Resident #46 was assisted out of bed prior to 6:00 A.M. Interview on 08/19/24 at 6:27 A.M. with LPN #804 confirmed she assisted STNA #801 with Resident #46's transfer from the bed to a Broda chair using the Hoyer mechanical lift. She denied concerns with timely incontinence care. Observation on 08/19/24 at 6:52 A.M. revealed Resident #46 was in the common television lounge with other resident's watching television. She appeared clean and no odors were evident. The resident was not interviewable. Observation on 08/19/24 at 8:00 A.M. revealed staff removed Resident #46 from the television lounge and took her down to the main dining room for the breakfast meal which consisted of scrambled eggs, cheerios, bacon, juice, milk, and toast. Observations on 08/19/24 at 8:14 A.M. revealed Resident #46 was assisted with the breakfast meal. Observation on 08/19/24 at 9:08 A.M. revealed Resident #46 was placed back into the television lounge and was sitting in front of the television in her modified Broda chair following the breakfast meal. Observation on 08/19/24 at 9:25 A.M. revealed STNAs #809 and #810 removed Resident #46 from the common lounge, took her into her room, used the Hoyer mechanical lift and transferred the resident from the Broda chair to the bed. Incontinence care was provided at this time. The skin on the resident's coccyx and sacrum was intact. No fungal infections were observed on the resident's perineum. The resident's bilateral heels appeared intact. Observation on 08/19/24 at 9:38 A.M. revealed Resident #46's husband was sitting in the common television lounge waiting on the resident to return to the lounge. He stated he usually arrives in the building around 9:30 A.M. daily and sometimes the resident would have scrambled eggs on her clothing and one time she was slumped over the chair. He stated his niece installed a camera in the resident's room. Observation on 08/19/24 at 9:40 A.M. revealed staff returned Resident #46 to the television lounge where the resident's husband was waiting. Observation on 08/19/24 at 10:41 A.M. revealed Resident #46's husband was observed to leave the building. Observation on 08/19/24 at 10:42 A.M. revealed Resident #46 was in the television lounge sitting in the Broda chair watching television. Observation on 08/19/24 at 11:56 A.M. revealed Resident #46 was taken into the dining room for the lunch meal. Telephone interview on 08/19/24 at 1:31 P.M. with Resident #46's niece revealed the family had concerns with showers, nail care, one staff member transferring the resident using the Hoyer mechanical lift or two staff members in the room and one of them not helping with the transfer. She also had concerns with the resident having a touch pad for a call light. She stated she brought up the concern on 07/24/24 and again on 08/14/24. She stated she paid for the installation of the surveillance camera and felt someone with a hat removed the SanDisk (SD) card from the camera. She indicated she was able to view live feed from the surveillance camera, but the camera did not save video surveillance, so she had to use her personal phone to take screen shots or tape the live feed with her personal phone. She indicated she observed Resident #46 was being provided incontinence care during the conversation at approximately 2:00 P.M. with two staff assistance. The telephone call lasted 48 minutes. Interview on 08/19/24 at 2:21 P.M. with STNA #810 confirmed the resident was provided incontinence care at 2:00 P.M. and placed in bed for a nap. Further interview confirmed from 6:30 A.M. to 2:00 P.M., Resident #46 was provided incontinence care at 9:30 A.M. and again at 2:00 P.M. She confirmed Resident #46 was a check and change and was to be provided care every two hours. She indicated the resident's husband was in to visit and then lunch occurred which was why the resident was not provided incontinence care check and changes every two hours. Review of the undated Routine Resident Checks policy indicated it was the facility's policy that routine resident checks shall be made to assure that the resident's safety and well-being were maintained. To ensure the safety and well-being of the residents, a resident check would be made at least every two (2) hours throughout each 24-hour shift by nursing service personnel. Review of the Dressing and Undressing the Resident policy, dated 08/2010, indicated the purpose of the procedure was to assist the resident as necessary with dressing and undressing and to promote cleanliness. This deficiency represents non-compliance investigated under Complaint Number OH00156416.

Based on observation, record review, staff interview, and review of the facility policy the facility failed to ensure smoking assessments were completed with a quarterly according to the facility's smoking policy. This affected three residents (#10, #25, and #29) of three residents reviewed for smoking. The facility identified six residents (#10, #25, #26, #29, #36, and #37) who smoked at the facility. The facility census was 65. Findings include: 1. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including sepsis, acute kidney failure, chronic obstructive pulmonary disease, and personal history of nicotine dependence. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 was cognitively intact. Further review of Resident #10's medical record revealed that smoking assessments were not done quarterly. Smoking assessments were completed on 12/13/22 and then another smoking assessment was completed on 11/16/23 after an incident with another smoker (Resident #29). 2. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and tobacco use. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #25 was cognitively intact. Further review of Resident #25's medical record revealed that smoking assessments were not completed quarterly. Smoking assessments were completed on 12/13/22 and then another smoking assessment was completed on 11/16/23 after an incident with another smoker (Resident #29). 3. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and tobacco use. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #29 was cognitively intact. Interview on 11/29/23 at 11:04 A.M. with MDS Nurse #210 verified that quarterly smoking assessments were not completed for Residents #10, #25, and #29. Review of the undated facility policy titled, Resident Smoking Policy revealed that licensed nursing staff or designee will conduct a smoking assessment on residents wishing to smoke, upon admission, readmission, with a significant change in condition, and at minimum quarterly. This deficiency represents non-compliance investigated under Self-Reported Incident, Control Number OH00148659.

Based on closed record review and interview, the facility failed to provide adequate assistance to Resident #63, who had cognitive impairment and required two staff to transfer using a mechanical (Hoyer) lift to prevent an injury. Actual Harm occurred on 10/06/23 when State tested Nursing Assistant (STNA) #804 failed to ensure a second staff member was present (as care planned) to reposition and then transfer Resident #63 from her wheelchair to bed using a Hoyer lift. At the time of the transfer, STNA #804 identified the Hoyer lift pad was not properly under the resident and instead of obtaining a second staff member to properly reposition the resident, required the resident to push up and scoot herself in the wheelchair. The resident complained of pain to her arm during this time. STNA #804 proceeded to transfer the resident (without a second staff person present) to bed using the Hoyer lift. On 10/07/23 the resident requested an x-ray due to continued pain to her arm. The resident was diagnosed with an acute proximal humeral fracture requiring medical intervention. This affected one resident (#63) of three residents reviewed for accidents and hazards. The facility census was 62. Findings include: Review of the closed medical record revealed Resident #63 was admitted on [DATE]. Resident #63 had diagnoses including bipolar disorder, pain in the left shoulder, and obsessive-compulsive disorder. Review of Resident #63's activities of daily living (ADL) care plan dated 04/26/22 revealed the resident required a Hoyer lift transfer with the assistance of two staff members. Review of Resident #63's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of a witness statement form authored by STNA #804 dated 10/06/23 at 9:30 P.M. indicated she went into the resident's room on 10/06/23 at 7:15 P.M. for bedtime care. Resident #63 was in the wheelchair and the Hoyer lift pad was not underneath the resident properly. STNA #804 had Resident #63 put her hands on the armrest of the wheelchair and push up to scoot back in her chair. STNA #804 pulled the Hoyer lift pad down. The resident said ouch and the STNA told her that if it hurt, they should not continue. STNA #804 proceeded to hook up the Hoyer lift to the Hoyer lift pad that was underneath the resident and put her in bed. When Resident #63 was up in the air, she complained of left arm pain, and she was placed in bed. STNA #804 called for the nurse. Resident #63's progress notes dated 10/06/23 had no documented evidence the resident was assessed and monitored when the resident complained of left arm pain during the resident's nighttime care and subsequent transfer using a Hoyer lift to transfer the resident from the wheelchair into the bed. Review of Resident #63's progress notes dated 10/07/23 at 9:47 A.M. indicated the resident stated she wanted an x-ray done on her left arm due to pain. The Nurse Practitioner (NP) was notified and a new order for an x-ray was obtained due to pain. Review of Resident #63's x-ray of the left shoulder dated 10/07/23 revealed a moderately displaced proximal humeral fracture. An old impacted humeral neck fracture and humeral head fracture was also seen. Gleno-humeral and AC joint space loss and spurring were noted. The impression was an acute proximal humeral fracture. Review of Resident #63's progress note dated 10/07/23 at 11:57 A.M. indicated the NP was updated on the x-ray results and a new order was obtained to send the resident to the emergency room (ER) for evaluation and treatment was obtained. The Power-of-Attorney (POA) and Director of Nursing (DON) were made aware. Review of Resident #63's hospital documentation dated 10/07/23 indicated the resident had a non-comminuted obliquely oriented fracture of the midshaft of the humerus. There was approximately 2.0 centimeters (cm) of lateral displacement of the midshaft fracture and a moderate amount of soft tissue edema was present in the upper extremity. The care instructions from the hospital indicated to wear the left arm sling as instructed and follow-up with the orthopedic department within the next few days. Take Percocet (opioid pain medication) as needed for pain. Review of Resident #63's progress note dated 10/07/23 at 5:20 P.M. indicated the resident returned to the ER and was assisted into bed with the call light in reach. New orders were obtained and implemented. Review of Resident #63's progress note dated 10/09/23 at 5:00 P.M. indicated the resident returned from an appointment with orders for a computerized tomography scan or CAT scan (a series of cross-sectional x-ray images of the body). Review of Resident #63's progress note dated 10/19/23 at 9:06 A.M. indicated a follow-up x-ray was completed of the resident's left arm. Review of Resident #63's progress note dated 10/20/23 at 1:50 P.M. indicated the resident had an appointment with the surgery center. Review of Resident #63's progress note dated 10/23/23 at 11:10 A.M. revealed the resident would be kept overnight after the procedure. However, the resident did not return to the facility and was transferred to another facility. Interview on 11/06/23 at 2:40 P.M. with Registered Nurse (RN) Assistant Director of Nursing (ADON) #802 indicated she reported to the Ombudsman that Resident #63 was pulled back in her wheelchair by the Hoyer lift sling by STNA #804. Interview on 11/06/23 at 2:51 P.M. with the Administrator indicated Resident #63's transfer using the Hoyer lift occurred on 10/06/23 and the resident complained of pain on 10/07/23. Telephone interview on 11/06/23 at 2:54 P.M. with STNA #806 with the Administrator, RN ADON #802, and RN Regional #809 in attendance revealed she worked with STNA #804 on 10/06/23 from 2:00 P.M. to 10:00 P.M. and was not in the room when STNA #804 transferred Resident #63 from the wheelchair to the bed using a Hoyer lift. STNA #806 indicated there were only two STNAs working on that unit along with the nurse, and STNA #804 transferred Resident #63 by herself using the Hoyer lift. STNA #806 stated STNA #804 reported that something was wrong with Resident #63's arm and Licensed Practical Nurse (LPN) Agency #808 was obtained to assess the resident. Telephone interview on 11/06/23 at 3:05 P.M. with STNA #804 with the Administrator, RN ADON #802, and RN Regional #809 in attendance revealed she went into Resident #63's room to put the resident to bed, and the Hoyer lift pad was not under the resident's thighs properly. STNA #804 indicated she had Resident #63 put her hands on the arms of the wheelchair and scoot backwards. STNA #804 indicated at that point Resident #63 said ouch. She stated she asked the resident if she would like to continue and then proceeded to using the Hoyer lift to transfer Resident #63 from the wheelchair to the bed. STNA #804 stated when she laid Resident #63 down in the bed, the resident started complaining of pain in her left shoulder and arm. STNA #804 confirmed the incident occurred on 10/06/23 around 8:45 P.M. to 9:00 P.M. and confirmed she transferred Resident #63 using the Hoyer mechanical lift by herself because she could not find another staff member to assist her even though the transfer required a two-person assist using the Hoyer lift. Interview on 11/07/23 at 9:40 A.M. with RN Regional #809, RN ADON #802, the Administrator, and the DON (team) stated Resident #63 was high risk for skin breakdown and they could not leave the resident for a long period of time in the wheelchair. The team also stated the resident would have needed to be transferred back to the bed regardless of the resident's transfer status, and one staff member transferred the resident. RN Regional #809 confirmed Resident #63 complained of pain prior to the actual transfer when she stated ouch and the team stated they felt the resident's left arm fracture occurred when the resident pushed herself back in the wheelchair. RN Regional #809 also confirmed Resident #63's medical record did not have evidence the resident was assessed after her complaints of pain on 10/06/23. Interview on 11/07/23 at 10:17 A.M. with the DON indicated she worked on the floor and provided care to Resident #63 on 10/06/23 from 10:00 P.M. to 2:00 A.M. and she did a pain scale for the resident who reported a pain scale of two out of ten. She confirmed she did not conduct a physical assessment of Resident #63 during this timeframe. Review of the undated Invacare Manual/Electric Portable Patient Lift manufacturer guidelines stated although Invacare recommended two assistants be used for all lifting preparation, transferring from, and transferring to procedures, the equipment would permit proper operation by one assistant. Review of the undated Safe Lifting and Movement of Residents policy indicated the staffing for all shifts would include sufficient numbers of staff members who had been trained in the use of mechanical lifting devices. Mechanical lifts should be operated per the manufacturer guidelines. This deficiency represents non-compliance investigated under Complaint Number OH00147346.