Every finding on record at Arbors at Pomeroy

Based on record review, interview, and policy review, the facility failed to ensure a resident's comprehensive care plans addressed the resident's known problem with constipation related to a malignant neoplasm of the colon, use of opioid pain medication, and receiving stool softeners/ laxatives on a scheduled basis for constipation. This affected one (Resident #55) of 23 residents reviewed for care plans. Findings include:Review of Resident #55's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a malignant neoplasm of the colon, morbid obesity, chronic pain, and muscle weakness. Review of Resident #55's active physician's orders revealed the resident had orders in place to receive Colace (a stool softener) 100 milligrams (mg) with directions to give two capsules by mouth (po) two times a day for constipation. The order originated on 03/28/26. She was also to receive Lactulose (a laxative) 10 grams/ 15 milliliters (ml) with directions to receive 15 ml po once daily for constipation. That order originated on 03/23/26. She also had an order for Norco (narcotic pain medication) 7.5- 325 mg po every six hours as needed (prn) for chronic pain. She had been receiving that medication on a prn basis, since 07/07/26. Review of Resident #55's medication administration record (MAR) for July 2026 revealed the resident was receiving her Colace and Lactulose on a scheduled basis, as ordered for constipation. She was receiving Norco 7.5- 325 mg prn for pain, as ordered. Review of Resident #55's active care plans revealed she did not have a care plan in place to address her known constipation, despite the use of stool softeners/ laxatives on a scheduled basis for the treatment of constipation, her known diagnosis of malignant neoplasm of the colon that put her at risk for constipation, or the use of an opioid pain medication that had constipation as a potential side effect of the medication. On 07/15/26 at 10:30 A.M., an interview with Registered Nurse (RN) #184 confirmed Resident #55's active care plans did not address constipation, as one of the resident's medical problems. She acknowledged, with the resident's medical diagnoses and the use of medications to treat constipation on a scheduled basis, the resident should have had an active care plan addressing that medical problem. Review of the facility's policy on Comprehensive Care Plans revised 06/30/22 revealed it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the resident's comprehensive assessment (Minimum Data Set assessment). The comprehensive care plan would describe, at a minimum, the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The comprehensive care plan would be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment.

Based on record review, resident interview, and staff interview, the facility failed to ensure a resident received the appropriate medications, in accordance with his physician's orders, to properly manage/ treat his known chronic diarrhea. This affected one (Resident #9) of one residents reviewed for constipation/ diarrhea. Findings include:Review of Resident #9's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included a malignant neoplasm of the prostate and the need for assistance with personal care. He was hospitalized on [DATE] and readmitted to the facility on [DATE], after being treated for pneumonia and a urinary tract infection. Review of Resident #9's physician's orders revealed the resident was receiving Lomotil (an antidiarrheal used to treat severe or chronic diarrhea) 2.5 milligrams (mg)- 0.025 mg by mouth (po) three times a day for chronic diarrhea. He had been on that medication since 01/28/26. He was also receiving Glycolax (an osmotic laxative used to treat occasional constipation) 17 grams po once daily for constipation. That order originated on 07/05/26. He also had an order for Imodium (an antidiarrheal) 2 mg with directions to given one tablet by mouth prn for loose stools with directions to take one tablet after each loose stool, maximum of eight tabs/24 hours. Review of Resident #9's medication administration record (MAR) for July 2026 revealed the resident was receiving Lomotil 2.5 mg- 0.025 mg po three times a day on a scheduled basis, as ordered for chronic diarrhea. He was also receiving Glycolax 17 grams po once daily on a scheduled basis for constipation, since his return from the hospital on [DATE]. He had not received any doses of Imodium that was ordered to be given on an as needed basis for loose stools/ diarrhea. Review of Resident #9's Discharge Instructions included in his hospital paperwork for his hospitalization between 07/02/26 and 07/05/26 revealed he was to start taking Clearlax (another brand name for Glycolax/ Miralax) 17 grams one packet by mouth once daily as needed (prn) for constipation. He was not to receive the Clearlax 17 grams once daily on a scheduled basis, as was written and being administered to the resident since his return from the hospital on [DATE]. Review of Resident #9's bowel movement (BM) report for the past 30 days (06/17/26- 07/16/26) revealed the resident was documented as having diarrhea 13 times in the past 30 days. Since his return from the hospital on [DATE], the resident was documented as having diarrhea on 07/05/26, 07/06/26, 07/10/26, 07/11/26, 07/12/26, 07/13/26, 07/15/26, and 07/16/26. On 07/13/2026 at 10:23 A.M., an interview with Resident #9 revealed he has been having diarrhea that he felt the facility was not adequately addressing. He reported they have been giving him something for diarrhea but it did not seem to be helping. He was not sure what all medications he was receiving for that but confirmed he continued to have diarrhea, since returning from the hospital. On 07/16/26 at 10:55 A.M., findings were verified by RN #184 that Resident #9 was receiving both Lomotil three times a day on a scheduled basis for chronic diarrhea and also Glycolax 17 grams po daily for constipation. She agreed it did not make sense for the resident to be receiving one medication for chronic diarrhea and the other for constipation. She confirmed Resident #9's hospital discharge orders for 07/05/26 intended the Glycolax to be used once daily prn for constipation and not on a scheduled basis, as erroneously transcribed upon his return from the hospital. She acknowledged the resident was complaining of loose stools and his BM report showed he was still having loose stools/ diarrhea on multiple days, since returning from the hospital on [DATE]. She further confirmed the facility's MAR for July 2026 did not show the resident had been given any prn doses of Imodium that was ordered to be given as needed for diarrhea.

Based on record review, observations, and interview, the facility failed to ensure fall prevention interventions were in place per the plan of care for Resident #8 and #33. The facility also failed to ensure additional safety interventions were in place for seizure precautions and hot beverages for Resident #8. This affected two (#8 and #33) of three residents reviewed for accidents. The facility census was 66. Findings include: 1. Record review revealed Resident #8 admitted to the facility on [DATE] with diagnoses including dementia, epilepsy, and difficulty in walking. Review of the minimum data set (MDS) dated [DATE] revealed Resident #8's cognition was moderately impaired and she had no falls. a. Review of orders revealed Resident #8 had an order in place dated 02/17/25 to encourage lids to hot liquids. Review of a care plan updated on 06/18/26 revealed Resident #8 was at risk for falls/injury related to unsteady gait and difficulty with coordination. The goal was to reduce the risk of injury through the next review date. Interventions included but were not limited to encourage resident to use a cup with lid when handling hot liquids and visual cue to ask for assistance. Observation on 07/13/26 at 3:26 P.M. revealed Resident #8 was resting in bed and had a cup of coffee on her bedside table. There was no lid on the coffee. Observation on 07/16/26 at 8:03 A.M. with Registered Nurse (RN) #163 confirmed Resident #8 was in bed having breakfast and there was no lid on her cup of coffee. RN #163 confirmed there was an order in place for Resident #8 to be encouraged to use a lid with hot beverages. Observation on 07/16/26 at 2:30 P.M. revealed there was no sign in Resident #8's room as a visual cue to ask for assistance. Interview during this time with Certified Nursing Assistant (CNA) #180 confirmed there was no visual cue in Resident #8's room. CNA #180 stated Resident #8 had a room change a couple weeks ago and the sign was likely left behind. b. Review of an orders revealed an order for Resident #8 dated 07/12/26 to have padding to enabler rails related to seizure precautions. Observation on 07/13/26 at 3:26 P.M. revealed Resident #8 was resting in bed and there was no padding to her enabler rails. Observation on 07/14/26 at 2:40 P.M. revealed Resident #8 was resting in bed and had no padding to her enabler rails for seizure precaution. Interview with Activity Director (AD) #116 and RN #129 confirmed there was no padding to the enabler rails. 2. Review of Resident #66's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included dementia, anxiety disorder, a history of a stroke, adult-onset diabetes mellitus, hypertension, age-related osteoporosis, muscle weakness, unsteadiness on feet, and irritable bowel syndrome. Review of Resident #66's active care plans revealed the resident had a care plan in place for being at risk for falls and injury related to her history of a stroke, impaired cognition, and impulsiveness. The care plan originated on 12/01/25. The goal was to reduce the risk of injury through the next review date. The interventions included the need for a low bed when not providing care and for the use of floor mats at bedside. The intervention for the low bed had been in place since 12/15/25. Review of Resident #66's active physician's orders revealed the resident had an order to be in a low bed while in bed and staff were to check every shift. That order originated on 02/10/26. On 07/14/2026 at 9:02 A.M., an observation of Resident #66 noted her to be lying in bed with her upper torso leaning to the left side of the bed. She had fall mats on the floor on each side of the bed, but her bed was not in it's lowest position. On 07/14/26 at 4:15 P.M., a follow up observation of Resident #66 noted her to be again, in bed, after she had been previously observed up in her wheelchair in the dining room for lunch. She had her fall mats on the floor on both sides of the bed, but her bed was raised and not in it's lowest position and she was not receiving any care by staff. The resident's bedframe was approximately 14 inches off the floor and the top level of the mattress was approximately 22 inches off the floor. On 07/14/26 at 4:33 P.M., an interview with RN #129 revealed Resident #66 was considered to be at risk for falls. She denied the resident had any recent falls, but had fallen in the past when trying to self-transfer. She reported the resident's fall prevention interventions included the use of fall mats on the floor, when in bed, and the resident was to be in a low bed. She confirmed the resident was lying in bed and her bed was not in it's lowest position. She lowered the resident's bed so the bedframe was only approximately eight inches off the floor and the level of the top of the mattress was only 16 inches off the floor. She acknowledged several observations had been made of the resident being in bed, without the bed being in it's lowest position, and would be at greater risk of injuries from a fall, if she rolled out of bed. Review of the facility's Fall Prevention Program policy revised 10/26/23 revealed each resident would be assessed for the risks of falling and would receive care and services in accordance with the level of risk to minimize the likelihood of falls. The nurse would indicate the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of fall risk. Each resident's risk factors and environmental hazards would be evaluated when developing the resident's comprehensive plan of care. Interventions would be monitored for effectiveness.

Based on interview and record review the facility failed to ensure medications were not administered outside of physician ordered parameters. This affected one Resident (#4) of five sampled for unnecessary medication use. The facility census was 66.Findings include: Review of Resident #4's medical record revealed an admission date of 12/27/21 with diagnoses including transient cerebral ischemic attack (mini-stroke), and hypertension (high blood pressure).Review of Resident #4's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment and hypertension.Review of Resident #4's physician orders revealed an order dated 05/01/26 for metoprolol succinate tablet extended release 50 milligrams give 0.5 tablet by mouth one time a day for hypertension. Hold for systolic blood pressure (SBP) (the top number of the blood pressure reading) less than 100 millimeters (mm) of mercury (Hg) or diastolic blood pressure (the bottom number of the blood pressure reading) less then 80 mm Hg, or a heart rate (HR) less than 60 beats per minute. Review of Resident #4's July 2026 medication administration record (MAR) revealed the medication was administered despite a diastolic blood pressure reading of less than 80 mm Hg on 07/04/26 BP 144/77 mmHg, 07/06/26 BP 134/68 mmHg, 07/07/26 BP 130/75 mmHg, 07/08/26 BP 140/72 mmHg, 07/12/26 BP 140/76 mmHg, 07/13/26 BP 116/70 mmHg, 07/14/26 BP 141/72 mmHg and 07/15/26 BP 146/77 mmHg.In an interview on 07/15/2026 at 3:55 P.M. Regional Nurse #184 confirmed the metoprolol was not held according to the ordered parameters, when the diastolic blood pressure was less than 80 mmHg on 07/04/26, 07/06/26, 07/07/26, 07/08/26, 07/12/26, 07/13/26, 07/14/26 and 07/15/26.The Regional Nurse confirmed the metoprolol should not have been administered.

Based on record review, observation, review of the facility's spreadsheet for therapeutic menus, interview, and policy review, the facility failed to ensure a resident received all food items included on the menu for their ordered therapeutic diet. This affected one (Resident #71) of one residents, who the facility identified as being on a renal diet. Findings include:Review of Resident #71's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included end stage renal (kidney) disease and dependence on renal dialysis (life saving medical treatment that filters waste, excess salt and fluid from a person's blood when the kidneys no longer function properly). Review of Resident #71's active physician's orders revealed the resident was on a renal (chronic kidney disease 5) diet. The order originated on 07/14/26, when the resident was readmitted from the hospital. On 07/15/26 at 12:02 P.M., an observation of the tray line process for the lunch meal served revealed Resident #71's meal ticket came through that identified the resident as being on a renal diet. The cook (Dietary [NAME] #138) and the dietary aide (Dietary Aide #152) used the meal ticket to identify what food items the resident was to receive for that meal. The cook substituted a baked potato that was given to the majority of residents with buttered noodles, as per the renal diet menu. The resident was not provided a piece of cornbread that the majority of other residents received. Dietary Aide #152 was observed to initially place a piece of cornbread on Resident #71's tray but then removed it, without putting any other type of bread item on her tray. There was a bowl that contained pre-wrapped cornbread in it and there were no other bread options available for the meal service, as part of the tray line. Review of the facility's spreadsheet for all diets (including the therapeutic diets) revealed the residents on a renal diet were to have buttered noodles substituted in place of a baked potato, which Resident #71 did receive. The renal diet menu also indicated the residents on that diet were not to receive cornbread, but should have been provided with a dinner roll or a slice of bread in place of the omitted cornbread from their diet. On 07/15/26 at 1:25 P.M., an interview with Dietary Manager #101 confirmed Resident #71 was on a renal diet at the time of the meal service being observed. She acknowledged Resident #71 was not provided with a dinner roll or a slice of bread in place of cornbread, as specified on the renal diet spreadsheet. She further acknowledged Dietary Aide #152 initially put a piece of cornbread on Resident #71's tray that was not permitted before removing it and not replacing it with any other bread source (dinner roll/ slice of bread) that was permitted based on the resident's diet menu. On 07/15/26 at 1:45 P.M., an interview with Resident #71 confirmed she did not receive a dinner roll or a slice of bread with her lunch, as was included on the renal diet menu. She stated she would have liked to have had a dinner roll to help fill her up. She did not like the noodles that were provided to her and did not care for the chicken that was served. The dinner roll would have allowed her something to eat, if it had been offered. Review of the facility's policy on Therapeutic Diet Orders revised 07/01/25 revealed the facility was to provide all residents with food in the appropriate form and/ or the appropriate nutritive content as prescribed by a physician, and/ or assessed by the interdisciplinary team to support the resident's treatment/ plan of care, in accordance with his/ her goals and preferences. A therapeutic diet was defined as a diet ordered by a physician, or delegated registered or licensed dietitian, as part of treatment for a disease or clinical condition. It also may be ordered to eliminate, decrease, or increase specific nutrients in the diet. Therapeutic diets would be based on the resident's individual needs as determined by the resident's assessment. Dietary and nursing staff were responsible for providing therapeutic diets in the appropriate form and/ or the appropriate nutritive content as prescribed.

Based on record review, observation, interview and policy review, the facility failed to ensure residents had assistive devices in place for meals. This affected one (#33) of one resident reviewed for assistive devices. The facility census was 66. Findings include:Record review revealed Resident #33 admitted to the facility on [DATE] with diagnoses including Parkinsonism, dementia, and need for assistance with personal care.Review of a Minimum Data Set (MDS) Assessment completed 05/07/26 revealed Resident #33's cognition was mildly impaired.Review of physician orders revealed Resident #33 had an order in place dated 05/15/26 for a regular diet with level three texture, regular fluid, thin consistency, drink one electrolyte daily, weighted utensils and plate guard to be used with each meal, Sippy cup (a spouted lid to aid in drinking) with each meal, and double bread for breakfast.Review of a care plan revised on 07/13/26 revealed Resident #33 was at risk for altered nutritional status related to mechanically altered diet, medical diagnosis of Parkinsonism, hypotension, dementia, hypertension, hyperlipidemia, depression, and a history of weight loss. Resident #33 required a sippy cup and weighted utensils. The goal was to maintain nutritional status as evidenced by stable weight without significant changes through the next review. Interventions included but were not limited to provide adaptive equipment.Observation on 07/16/26 at 8:02 A.M. revealed Certified Nursing Assistant (CNA) #177 was in Resident #33's room assisting him with breakfast. CNA #177 stated Resident #33 had a glass of juice with a straw to make it easier because he is shaky. There was no sippy or spouted cup observed for use during the meal.Interview on 07/16/26 at 8:03 A.M. with Registered Nurse (RN) #163 confirmed Resident #33 had an order in place for a sippy cup/cup with spouted lid for all meals as an assistive device during meals.Review of a policy titled Use of Assistive Devices dated 10/26/23 revealed assistive devices are tools, products, types of equipment, or technology to help individuals perform tasks and activities to help move around, see, communicate, eat, or get dressed. The facility will provide assistive devices for residents who need them. Assistive devices helps to maintain or improve function and/or dignity.

Based on interview, record review, policy review, and review of narcotic log the facility failed to ensure narcotic medication and insulin were administered by a licensed qualified staff member. This affected two residents (#18, #64) of 32 residents who had narcotic and/or insulin orders. The census was 71. Findings include: 1.Record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus, cerebrovascular disease, asthma, dysphagia, peripheral vascular disease, lymphedema, cognitive impairment, restless leg syndrome, major depressive disorder, hypertension, and hyperlipidemia. Review of Resident #18's quarterly Minimum Data Set (MDS) completed 07/11/25 revealed a brief interview for mental status (BIMS) score of 14. Record review of Resident #18's orders revealed an order placed on 04/28/25 for hydrocodone-acetaminophen oral tablet 5-325 milligram (mg), give one tablet by mouth every 12 hours as needed for severe pain. Review of Resident #18's electronic medication administration record progress notes revealed a note authored by Certified Medication Aide/Tech #3 on 08/02/25 at 8:51 P.M. stating as needed hydrocode acetaminophen oral tablet 5-325mg was administered by Certified Medication Aide/Tech #3. Review of Resident #18's electronic medication administration record progress notes revealed a note authored by Certified Medication Aide/Tech #3 on 08/03/25 at 9:10 P.M. stating as needed hydrocode acetaminophen oral tablet 5-325mg was administered by Certified Medication Aide/Tech #3.Review of Resident #18's Medication Administration Record (MAR) revealed Certified Medication Aide/Tech #3 administered hydrocode acetaminophen oral tablet 5-325mg on 08/02/25 and 08/03/25. Review of Resident #18's controlled drug receipt/record/disposition form revealed Certified Medication Aide/Tech #3 signed off they had administered hydrocode acetaminophen oral tablet 5-325mg on 08/02/25 and 08/03/25. Review of MedScape medication formulary revealed hydrocode acetaminophen is a class level II narcotic medication with a warning of serious, life-threatening, or fatal respiratory depression. 2. Record review revealed Resident #64 was admitted to the facility 04/02/18 with diagnoses including type two diabetes mellitus, chronic obstructive pulmonary disease, spastic hemiplegia affecting left side, cerebral infarction, myocardial infarction, dysphagia, dementia, schizoaffective disorder, hypertension, and major depressive disorder. Review of Resident #64's orders revealed an order for NovoLog (insulin aspart) Flex pen subcutaneous pen injector 100 unit/ milliliter (ml) inject per sliding scale ordered on 01/23/24. Review of Resident #64's August 2025 MAR revealed on 08/02/25 Certified Medication Aide/Tech #3 administered four units of insulin aspart to Resident #64. Review of Resident #64's August 2025 MAR revealed on 08/03/25 Certified Medication Aide/Tech #3 administered eight units of insulin aspart to Resident #64. On 08/12/25 at 1:31 PM interview with Administrator #74 confirmed Certified Medication Aide/Tech #3 had not completed her training at her time of termination on 08/06/25 (termination due to attendance reasons), therefore would have been unqualified to administer narcotics and insulin to residents. On 08/12/25 at 1:31 PM interview with Registered Nurse (RN) #136 confirmed on 08/02/25 and 08/03/25 Certified Medication Aide/Tech #3 administered insulin to Resident #64 and narcotics to Resident #18 while un-qualified to do so. Review of Certified Medication Aide/Tech #3 personnel file revealed no documentation or evidence they were qualified or trained to administer insulin and/or narcotics to residents. Review of facility policy titled Medication Administration (implemented 10/30/20 and revised 01/17/23) revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. This deficiency represents non-compliance investigated under Complaint Number 2583769.

Based on observation, medical record review, review of Emergency Medical Service (EMS) reports, review of hospital records, review of National Weather Service website, review of a facility investigation, and resident and staff interviews, the facility failed to ensure adequate and proper interventions were provided to prevent resident heat stroke during an outside activity. The facility also failed to ensure outdoor activities were planned and provided to meet the safety and total care needs of residents. This resulted in Immediate Jeopardy and actual harm and/or adverse health outcomes on 06/21/25 when facility staff took 13 residents to the zoo with the outside temperature reaching 88 degrees with a heat index of 90. The residents were at the zoo from approximately 12:00 P.M. to 6:00 P.M. Residents complained of not feeling well and being hot at the zoo. After leaving the zoo, the residents loaded a bus that had not been pre-cooled and drove to a local fast-food restaurant where they were provided meals while remaining on the bus. The bus was noted to be warm inside at that point. After leaving the restaurant, Resident #41 became unresponsive requiring 911 be called. Emergency Medical Services (EMS) arrived and assessed residents. Resident #41 had a temperature of 105.7 degrees Fahrenheit and was transferred to the hospital where he was place on a ventilator and treated for heat stroke. Resident #35 was also noted by EMS to be unresponsive with a temperature of 104 degrees Fahrenheit. Resident #35 was transported to the hospital where she was admitted for treatment of heat stroke. This affected 13 residents (#4, #23, #28, #29, #30, #33, #35, #41 #47, #52, #57, #60, and #68) of 13 residents who went on the outing to the zoo. The facility was 69. On 06/26/25 at 3:40 P.M. the Administrator, Regional Clinical Support Nurse (RCDSN) #6, Director of Nursing (DON) #153, and Regional Administrator were notified of Immediate Jeopardy began on 06/21/25 when the facility proceeded with a planned outdoor activity outing despite outside temperatures reaching 88 degrees Fahrenheit with a heat index of 90 resulting in residents complaints of being hot and suffering heat stroke. The Immediate Jeopardy was removed on 06/23/25 when the facility implemented the following corrective actions: • On 6/21/25 at approximately 8:05 P.M. Certified Nursing Assistant (CNA) #117 identified Resident #41 had a change in level of consciousness (during a facility planned outing). 911 was called by CNA #80 and arrived on scene. Residents, including Resident #41 were assessed. Resident #41 and Resident #35 were transported to the hospital for treatment of increased (body) temperature and lethargy. • On 6/21/25 at around 9:00 P.M. Regional Director of Operations (RDO) #3 instructed the Administrator and DON that outdoor outings were suspended until heat advisories or increase in temperature had been removed for the health and safety of residents. However, no outdoor outings were scheduled at the time, so no outdoor activities were canceled. Education was provided to the Administrator and DON on 6/21/25. The facility implemented a plan for all outdoor activities to be reviewed individually to determine if weather was appropriate for outdoor activity based on resident ' s status with final approval by the Administrator. • On 06/21/25 at 9:46 P.M. Medical Director #1 was notified by RCDSN #6 with orders obtained for skin assessment and vital sign monitoring for residents who returned to the facility from the outing on this date. • On 6/21/25 around 11:50 P.M. upon return from the outing, Licensed Practical Nurse (LPN) Unit Manager #156 assessed Resident 4, #23, #28, #29, #30, #33, #47, #52, #57, #60, and #68 for signs and symptoms of heat stroke. • Between 06/21/25 at 11:00 P.M. and 06/22/25 at 1:00 A.M. LPN #156 notified the responsible parties of Resident 4, #23, #28, #29, #30, #33, #35, #41, #47, #52, #57, #60, and #68, who were on the outing of the situation and of any negative outcomes. • On 06/22/25 LPN #156 re-assessed Resident 4, #23, #28, #29, #30, #33, #47, #52, #57, #60, and #68. • On 06/23/25 Senior DON #163 and RDCNS #6 re-assessed Resident 4, #23, #28, #29, #30, #33, #47, #52, #57, #60, and #68. The assessment included vital signs, skin assessments and psychosocial assessments. • On 06/23/25 at around 2:00 P.M. an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, DON, and Medical Director #1 and discussed plan of correction and root cause analysis. During QAPI, the facility identified the root cause of the incident was that the facility took residents to the zoo when they were then exposed to high heat for an extended period of time. Interventions including increase fluid intake, sunblock, periods of time in air-conditioned facilities or shaded areas, and umbrellas and fans, were ineffective. • On 06/23/25 RDCSN #6 provided education to all staff that if the temperature increased outside or there was a heat advisory then all outings would be placed on hold and re-scheduled for a later date with Administrator final approval. • On 06/23/25, all staff education was completed by RDCSN #6 related to signs and symptoms of heat stroke and prevention of heat stroke. Education was also provided related to heat advisories/increased temperature for prevention with the following; appropriate actions should be in place for residents that go outside to include the use of sunscreen with frequent reapplication, residents to be dressed in light clothing, limit time outdoors, and avoid being in direct sun light as much as possible, with increased fluids being offered and encouraged. As of 06/23/25 all staff had been education with the exception of two staff members, one of which was on medical leave and the other staff member on vacation. These staff would be educated prior to their next working shift. • The facility implemented a plan for RDCSN #6/designee to provide staff training to all new hires related to heat stroke, heat advisories/increased temperature. • Beginning 06/25/25 the facility implemented a plan for the DON/Designee to conduct audits five times per week (Monday-Friday) of three random residents who spend time sitting outside to ensure no sunburn occurred and no signs or symptoms of heat stroke occurred as well. During a heat advisory the DON/designee would then assess all residents who spend time outside. • Beginning on 06/25/25 (Monday-Friday) the facility Administrator/designee would review to see if any resident outings were scheduled and if appropriate based on weather conditions. • The facility would complete weekly Ad Hoc QAPI meetings for four weeks to review audits and ensure effectiveness of plan. Although the Immediate Jeopardy was removed on 06/23/25 the deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of the medical record for Resident #41 revealed an admission date of 08/10/25 with diagnoses including cerebral infarction with hemiplegia, chronic obstructive pulmonary disorder, congenital hydrocephalus, hypertension and gastroesophageal reflux disease. Resident #41 ' s brother was listed as his power of attorney (POA). Review of the care plan dated 9/28/23, revealed Resident #41 was at risk for altered activity patterns/pursuits related to frequent naps/sleeping during the day. Interventions included 1:1 visit from staff and volunteers, allow the resident to make choices/decisions about their preferred activity pursuits, encourage activities that assure success and are non-threatening. The care plan revealed the resident enjoyed outside activities and pets/animals. Review of the care plan dated 01/31/24 revealed Resident #41 had an activities of daily living (ADL) self-care performance deficit related to generalized weakness, hemiplegia, poor coordination, age-related cognitive decline, developmental delay, chronic obstructive pulmonary disorder, difficulty walking, cerebral infarction and history of falls. Interventions included providing resident with set up for meals, set up/clean up assist with toileting hygiene and transfers. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 had cognitive impairment. The assessment revealed Resident #41 used a wheelchair for mobility and required (staff) set up assistance with meals, toileting hygiene and transfers. Review of a nursing note authored by DON #153 dated 06/21/25 at 9:33 A.M. revealed Resident #41 left the facility with staff for an outing at Columbus Zoo. Review of a nursing note authored by Registered Nurse (RN) #73 dated 06/21/25 at 8:25 P.M. revealed this nurse received a phone call from the facility staff (on the outing) stating Resident #41 was being sent to the emergency room. The physician was notified, and a message was left on voice mail for the POA. RN #73 called report to the Emergency Room. Review of the Emergency Medical Services (EMS) run sheet dated 06/21/25 revealed Medic #204 responded to address for emergency status. Upon arrival the medic crew were greeted by nursing home staff that were driving the bus. The staff stated (Resident #41) had been unconscious for roughly 15 minutes and they had nowhere to stop so they drove to the nearest rest stop. The medic crew assessed Resident #41 who had no response to any stimuli and presented red, dry and hot. A 12 lead ECG was obtained with baseline vitals. The ECG showed normal sinus rhythm and vital signs within normal ranges. With the assistance from the local fire department the resident was extracted from the bus via mega mover and placed on the cot. The Medic crew established intravenous access in the left antecubital space. A rectal temperature was obtained at 105.7 degrees Fahrenheit. Ice packs were placed on the groin area of the resident due to the high rectal temperature and need for passive cooling. Resident #41 began to vomit, and medic crew suctioned as needed to keep the airway clear. Resident #41 was transported to the local hospital as emergent status and turned over to the nursing staff and physicians at the emergency room. Review of the hospital documentation revealed Resident #41 presented to the emergency department on 06/21/25 with altered mental status from heat exposure and initial temperature of 105.5 degrees Fahrenheit. The resident was cooled and the temperature dropped to 95.5 degrees Fahrenheit. The resident was currently on a Bair Hugger (a convective temperature management system used in a hospital to maintain a person ' s core body temperature) and intubated. Magnesium had been replaced, and phosphate had been ordered. The resident was awaiting transport to a Columbus hospital Intensive Care Unit (ICU). Attempted to contact family, however, no contacts were available in the chart and no decision maker present at the bedside. Resident #41 was admitted to Ohio Health Hospital in Columbus on 06/22/25 from an outlying hospital with diagnosis of severe sepsis, bronchitis and heat stroke. Review of the medical record revealed Resident #41 was re-admitted to the facility on [DATE] at 4:16 P.M. Observation on 06/30/25 at 11:01 A.M. of Resident #41 revealed the resident was up in his wheelchair, dressed appropriately, clean, dry with no wetness or odors noted. He was pleasant but difficult to understand. 2. Review of the medical record for Resident #35 revealed an admission date of 02/09/24 with diagnoses including cerebral infarction, hemiplegia, hypertension and legal blindness. Review of the care plan dated 01/12/24 revealed Resident #35 was at risk for altered activity patterns/pursuits related to impaired mobility and lack of interest in activities. Interventions included 1:1 visit from staff and volunteers as resident would allow, encourage activities that assure success and were non-threatening. The care plan revealed the resident enjoyed group activities, outside activities, religious activities and pets/animals. Review of the care plan dated 02/22/25 revealed Resident #35 had an ADL self-care performance deficit related to weakness, cerebral infarction and hemiplegia. Interventions included supervision with eating, one to two persons for assistance with toileting, and bed mobility, and one person assistance with transfers, and hygiene. Review of the most recent MDS assessment dated [DATE] revealed Resident #35 had intact cognition. The assessment revealed Resident #35 was independent with eating, dependent upon staff for toileting and hygiene and needed substantial to maximum assistance with transfers. Resident #35 received hospice care and services. Review of a nursing note authored by DON #153 dated 06/21/25 at 8:27 A.M. revealed Resident #35 left the facility with staff to go to the Columbus Zoo. Resident #35 received all morning medications and early evening medications were given to the staff to be administered during the outing. Review of a nursing note authored by RN #73 on 06/21/25 at 8:36 P.M. revealed Resident #35 was being sent to the local emergency room. The physician was notified, and a message was left for the resident ' s POA. RN #73 called report to the local emergency room. Further review revealed at 9:37 P.M. the POA called back and was made aware of the situation with Resident #35. Review of a nursing note authored by RN #73 dated 06/22/25 at 12:00 A.M. revealed the nurse called the local hospital to get a report on Resident #35. Resident #35 was up and talking. Resident #35 was going to be admitted to an outside hospital related to diagnosis of heat stroke. The physician was notified. Review of the Emergency Medical Services (EMS) run sheet dated 06/21/25 revealed Medic #201 was dispatched to the rest stop on Route 33 in Rockbridge for a mass casualty. On arrival at the scene, the Incident Commander (IC) instructed this medic to join Medic #203 with their patient. The patient (Resident #35) was on hospice per the nursing home staff. The EMS report included Resident #35 was on a bus with nursing home staff after a trip to the zoo when the bus overheated and the driver pulled off into the rest area. Resident #35 had signs and symptoms of heat stroke, sun stroke, altered mental status and fever. The resident was responsive to verbal stimuli and went in and out of responsiveness. The resident had altered mental status due to heat emergency, was unable to walk and was unable to get off of the bus. Resident #35 had an oral temperature of 104 degrees Fahrenheit and there was a missed intravenous attempt in the left hand. Resident #35 had ice packs under her armpits and a patent airway, breathing unlabored, skin hot to the touch and pulses were rapid. Resident #35 opened eyes to verbal stimuli then goes unresponsive intermittently and intravenous access successful in resident ' s right antecubital and a 1000 milliliter bag of fluids started wide open and approximately 500 milliliters of fluids was given by arrival to emergency room. The decision not to intubate was related to the residents ' hospice status. A 12 lead ECG was completed showing sinus tachycardia. Review of the hospital documentation for Resident #35 revealed the resident presented to the emergency department with altered mental status. The resident was traveling from Columbus in a bus from a nursing home after visiting the zoo. Several residents were noted to become overheated and altered. Resident #35 ' s temperature was noted to be 104 degrees Fahrenheit by the EMS. The resident required immediate attention upon arrival. Cooling measures were initiated with ice packs to neck/axilla/groin areas with intravenous fluids infusing. Also cooling fans and misting were initiated. The resident had improvement in temperature as well as mental status. The troponin blood level was elevated to 497 with no complaints of chest pain, likely demand related. The hospital records included the resident ' s daughter would like a full work up including cariology evaluation and would pursue intervention if it was deemed appropriate despite her hospice status. Impression was a heat stroke, sepsis and non-ST elevated myocardial infarction. Review of the discharge hospital documentation dated 06/22/25 revealed a discharge diagnosis of heat stroke likely due to no air conditioning while being transported to the zoo. The resident returned to normal at the time of discharge. Elevated troponin levels likely secondary to dehydration with no cardiac etiology indicated. Resident #35 was admitted to the hospital from [DATE] through 06/23/25 with diagnoses of heat stroke and elevated troponin level likely secondary to dehydration. Review of a nursing note authored by RN #62 dated 06/23/25 at 10:00 P.M. revealed Resident #35 was re-admitted to the facility. Observation on 06/25/25 at 10:17 A.M. revealed Resident #35 was lying in bed with the television on. An interview with the resident at the time of the observation revealed Resident #35 stated she went to the zoo and got overheated. Resident #35 stated she went to the hospital but stated she did not remember much about the day. The resident did not recall eating a sack lunch at the zoo or eating at a fast-food restaurant on the way home. The resident was unable to recall when she got too hot. Review of the EMS run sheets revealed Resident #30, #23, #57, #29, and #28 refused to be assessed or provided care and treatment when EMS were on scene on 06/21/25. Residents #33, #47, #60 #52, #4 and #68 were assessed with recommendations for emergency room visit for care and treatment but refused. Interview on 06/25/25 at 8:00 A.M. with the Administrator revealed the facility had a zoo trip/outing on 06/21/25 of 13 residents, Resident #4, #23, #28, #29, #30, #33, #35, #41, #47, #52, #57, #60, and #68, six staff members (Administrator, DON, Activity Director #178, Activity Assistant #109, Housekeeping Supervisor #101 whom was also Certified Nursing Assistant (CNA), and two additional CNAs #80 and #117 ) and four volunteers. All 13 residents and two CNAs rode the facility bus; the rest of the staff/volunteers followed in their own cars. During the outing, two of the residents, Residents #35 and #41 were transported to the hospital. The Administrator stated on the way home from the Columbus Zoo, the bus overheated-meaning the temperature inside the bus was hot. The residents and staff had eaten fast food while on the bus, about 10 minutes from the zoo. Resident #41 started complaining of his stomach hurting and the two CNAs on the bus thought he was upset after eating. Resident #41 started to get restless, jerking on other people ' s seats and opened the emergency window on the bus. The staff pulled the bus over to fix the window, and the Administrator kept going down the road to the roadside rest. When they started back on the road, Resident #41 started getting worse. Resident #41 was lethargic and not talking to staff. The staff pulled over again at the roadside rest in Rockbridge and the Administrator, who is also a registered nurse, got on the bus to assess the resident. Resident #41 was not good enough to drink and had a strong fast pulse at 120 beats per minute. The Administrator poured room temperature water on him. The Administrator stated the van was really hot inside (all the doors and windows were open at that time) and she did not know why it was so hot. One of the CNAs called 911 and she continued to try to cool the resident off. The local EMS and fire department arrived. The person seated behind Resident #41, Resident #35, was flushed. The medics checked everyone ' s temperature and asked if they wanted to go to the hospital. Residents #35 and #41 were taken to local hospital emergency rooms. All the residents were removed from the bus and five sat in her car with the air conditioning on. The Administrator stated again she did not know why the bus was so hot; stating it usually takes about 15 minutes to cool down. When she was getting off the bus, she felt heat coming from under the driver ' s seat. She then called the Maintenance Director #90, and he was able to reach the sister facility close by who came and transported the residents back to the facility on their bus. Once the residents arrived back at the facility they were assisted inside, provided care and got ready for bed. The Administrator revealed the temperature that day was 88 degrees Fahrenheit, and she stated they stayed indoors most of the time while at the zoo. The Administrator stated they entered the zoo about 12:00-12:30 P.M. and around 4:00 P.M. she prompted the residents to wrap it up. Some of the residents wanted to go home and some wanted to see one more animal. They left the zoo about 6:00 P.M. The Administrator stated residents did complain about being hot at the zoo. The staff would take them to cool areas and give them cool wet wash cloths. The residents did not want to drink water because they did not want to go to the bathroom. The Administrator stated they had umbrellas, sunscreen, portable fans, sunglasses, cold wet wash cloths and six cases of water in coolers. Review of the facility provided investigation timeline authored by the Administrator, dated 06/26/25 at 1:00 P.M. revealed 13 residents and six staff arrived at the Columbus Zoo (on 06/21/25) at 11:40 A.M. and entered the zoo at 12:35 P.M. The residents were provided with a sack lunch to eat under the umbrellas at the tables in the front of the zoo. At 1:10 P.M. the residents went to an indoor exhibit, at 2:00 P.M. the residents went into the air-conditioned conservation education rooms, and at 2:15 P.M. back outside to see the polar bear exhibit. At 2:30 P.M. the residents went inside to the air-conditioned polar bear exhibit and at 3:45 P.M. went to the Kudu-Shaded area. At 4:30 P.M. the Administrator informed the group they were going to wrap things up. The residents requested to see at least one animal of their choice. One group went to the kangaroos and the other group went to the aquarium. At 5:30 P.M. the groups were told to go to the front and get ready to board the bus. The residents left the zoo at 6:12 P.M. and arrived at fast food restaurant at 6:30 P.M. All residents were provided with a meal and drink. The Administrator asked why the windows were open and the residents replied they wanted air blowing. At that time the residents verbalized all were okay, just tired. At 6:50 P.M., they left the fast-food restaurant. At 7:35 P.M. the van pulled over onto an exit in Canal [NAME] due to Resident #41 ' s complaints of stomach pain and was restless (which was common when he needed to use the restroom). Resident #41 pulled open the emergency window and the van stopped to close it. At 8:01 P.M. Resident #41 was lethargic and the CNA on the bus called the nurse (Administrator who was driving her personal car and was near the roadside rest and also a Registered Nurse). At 8:05 P.M. the bus pulled over to the roadside rest in Rockbridge. The nurse (Administrator) attempted to apply oxygen, and the resident refused. Resident #41 was lethargic and tried to drink water. Resident #41 was not flushed or clammy. Resident #41 then slumped over to his right side, called his name and did a sternal rub and the resident would groan. Resident #41 respirations were regular, and pulse was strong at 120 beats per minute. The nurse applied room temperature water over the resident multiple times and called 911. All residents were assessed by the Emergency Medical Services (EMS). Residents #35 and #41 were taken to local emergency rooms. The van was extremely hot with the windows and doors open during the EMS assessments and care. Residents were evacuated from the bus during and after assessments were completed. Five residents were placed in a vehicle with air conditioning and six were placed in the shade. At 9:00 P.M. a call was placed for alternate transportation from sister facility. At 11:50 P.M. the residents arrived back at the facility. Interview on 06/25/25 at 3:03 P.M. with Maintenance Director #90 revealed the facility van had monthly inspections and was inspected by the State Highway Patrol in May 2025 and passed. Maintenance Director #90 stated he was not aware of any issues with the air conditioning prior to the residents going to the zoo. He and the Administrator took the van out the day before the trip for an approximate 12-mile drive and he believed the air conditioning was working fine. He stated he had the air conditioner checked on 06/23/25 and it was slightly low on freon in the back of the bus unit. The Maintenance Director stated he installed two thermometers on the bus, one in the front and one in the back. Interview on 06/25/25 at 3:20 P.M. with Housekeeping Supervisor #101 revealed she was involved in the zoo trip with the residents. She stated the trip was discussed a couple weeks prior as to whether the date should be changed due to how hot it was. This was discussed with CNA #117 and Activities Director #178 and Housekeeping Supervisor #101 revealed she thought the Activities Director had discussed this with the Administrator. Housekeeping Supervisor #101 stated she was told if the state called her for an interview (related to the incident) to only say nice things and not be negative. She also stated she wrote out a statement of what happened, but it was re-written by the DON due to the things she had written. Housekeeping Supervisor #101 revealed the group left the facility around 8:30-9:00 A.M. for the zoo with no stops on the way there. They arrived at the zoo around 12:30 P.M. and the residents ate their lunch outside at tables with umbrellas. Housekeeping Supervisor #101 stated she had Resident #41 in her group and each group went to different parts of the zoo. She stated they took rest breaks in the shade and drank water. The Housekeeping Supervisor revealed a lot of the residents had asked to leave at 2:00 P.M. but they did not leave, and were told they would leave at 4:00 P.M. At 5:00-5:30 P.M. the Administrator texted and said they were leaving. They loaded up the bus and left. The bus stopped at a fast-food restaurant. The residents stayed on the bus and the staff went in to get the food. The bus air conditioning was left running, but the doors were left open. When she stepped up on the bus to give the food to the residents the heat hit you in the face. Housekeeping Supervisor #101 did not ride the bus as she followed in a personal car. She stated after leaving the restaurant, the bus pulled off on an exit and the CNA driving called and stated that Resident #41 had opened an emergency window latch, but they were okay. About 20 minutes later the CNA called again to tell the Administrator that they needed her and that something was wrong with Resident #41. She called the CNA back and stated the Administrator was at the roadside rest and the CNA stated they did not need her to stop. They drove back to the facility and waited on the residents to return. The residents returned about 11:30 P.M. and staff helped them exit the bus. The residents were tired. Interview on 06/25/25 at 3:45 P.M. with Activity Assistant #109 revealed the Administrator planned the trip to the zoo after the residents mentioned they wanted to go in Resident Council. The Administrator scheduled the date to go. Activity Assistant #109 stated she did not hear anyone discussing the temperature prior to going on the trip. The residents left the faciity on the bus (on 06/21/25) around 8:30-9:00 A.M. and she drove her own car. The bus did not stop on the way there. Once at the zoo, they unloaded the residents, applied sunscreen, and stayed in the shade while the Administrator purchased the tickets. They went inside the park, toileted the residents and sat at tables with umbrellas and at lunch. Activity Assistant #109 stated she had different residents with her at different times. The plan was to leave around 2:00 P.M. but they arrived late so they stayed until 5:00-5:30 P.M. She stated if a resident stated they were hot they took them to the shade. Activity Assistant #109 did not stop at the fast-food restaurant with the bus nor was she at the roadside rest area. She went back to the facility and waited for the residents to return. She stated she was not aware of any problems with the air conditioning on the bus prior to the trip. The temperature that day was in the 80 ' s to 90 ' s. Interview on 06/25/25 at 4:20 P.M with the DON #153 revealed the Administrator planned the zoo trip and the DON did not know if there was any discussion about going on a day with temperatures as high as they were. The DON stated on 06/21/25 it was in the mid 80 ' s with a decent breeze. DON #153 stated she did not discuss with the physician to see if it was okay for those residents to go on the trip. There were 13 residents and two CNAs on the bus, and she met them at the zoo around 11:30 A.M. (The DON stated she lived nearby) They started unloading residents while the Administrator went to purchase the tickets. They entered the zoo and ate lunch under the umbrella covered tables just inside the zoo. All the residents were given water. The DON stated she was with Residents #47, #52, #4, #35, #33 and #29 and Activity Director #178, the Administrator, CNA #80 and a volunteer. The DON revealed incontinence care was provided at least two times while at the zoo. There was not a specific or set time to leave, it was to be based on how well the residents did. Around 4:00 P.M. the residents started towards the front of the zoo to the shaded umbrella area. They then loaded the residents back on the bus. Resident #47 stated she did not feel good while in the zoo and they used wet wash cloths, encouraged her to drink fluids, put a fan on her and took her to an air-conditioned area. After about 10 minutes she felt better, and we went back out. When the bus left the zoo, the DON returned to her home. Interview on 06/26/25 at 5:18 A.M. with RN #103 revealed she was working as an aide on 06/21/25 night shift when the residents returned from the zoo around 11:00 P.M. RN #103 stated she helped unload residents off the bus and the Unit Manager/LPN #156 assessed the resident including vital signs. None of the residents complained about anything, however, their faces were red. When toileting and changing Resident #68, the resident smelled of urine, but her skin was intact. RN #103 stated she felt bad for the residents that went because they wanted to go but did not feel like it was a good idea for them to be out in the hot temperatures all day due to their medical conditions. Interview on 06/26/25 at 5:33 A.M. with CNA #170 revealed she was working on 06/21/25 when the residents returned from the zoo trip. The residents returned around 12:30 A.M. CNA #170 revealed upon their return, staff started providing care for the residents. Resident #68 had bowel movement on her and was changed. Resident #47 was also changed, and the resident ' s skin was red and the open area she had prior was worse and bleeding. Resident #47 reported the aides changed her at the zoo, but she was up all day in a wheelchair. Resident #47 was slumped over and sweaty and seemed to be lethargic from exhaustion. Resident #68 was very distressed

Based on observation, record review, interview and facility policy review, the facility failed to develop and implement a baseline plan of care related to Resident #116's orthotic splint. This affected one resident (#116) of 19 sampled residents. Findings Include: Review of the medical record for Resident #116 revealed an initial admitted [DATE] with the diagnoses including but not limited to osteoarthritis right wrist, osteonecrosis of right carpus, severe protein calorie malnutrition, Kienbock's disease of adults, major depressive disorder, alcohol dependence with withdrawal delirium, altered mental status, confusional arousals, anxiety disorder, Wernicke's encephalopathy, repeated falls, anemia, abnormal weight loss, gastro-esophageal reflux disease, disorders of plasma protein metabolism, metabolic acidosis, seasonal allergic rhinitis, hypertension and allergy to mammalian meats. Review of the plan of care dated 01/20/25 revealed the resident is at risk for impaired skin integrity related to splint to right hand. Interventions included administer medications as ordered, apply protective barrier cream after incontinent episode, assist resident with turning and repositioning as needed, complete skin inspection weekly and as needed, consult Dietitian as needed, labs as ordered, notify nurse of any new areas of skin impairment noted during bathing or daily care, notify the physician of any new areas of skin impairment and therapy to screen/evaluate/treatment as needed. Review of the resident's nursing admission evaluation dated 01/20/25 revealed the resident had limited range of motion in the right hand. The resident's right orthotic brace was not addressed on the admission evaluation. Review of the February 2025 monthly physician orders identified orders dated 01/20/25 monitor scab to first digit to right hand daily until resolved, 01/21/25 maintain splint to right wrist, check placement and skin integrity every shift, non-weight bearing to right wrist, circulatory checks to right hand every shift, On 02/04/25 at 10:01 A.M., observation/interview with the resident revealed he had a black orthotic splint to his right hand/wrist. He reported he fell on the ice at home and the hospital said it wasn't broken but he felt it was. He said his fingers bent back and touched his forearm. His right hand was noted to be edematous around the the brace. The resident reported the brace felt tight. The resident denied having the brace adjusted. On 02/05/25 at 11:20 A.M., interview with Senior Director of Nursing (SDON) #210 confirmed a baseline plan of care was not developed containing the physician ordered instructions to care for the orthotic splint to the resident's right hand/wrist. Review of the facility policy titled, Baseline Care Plan, (last revised 12/28/23) revealed the facility will develop and implement a baseline plan of care for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care.

Based on record review, interview and facility policy review, the facility failed to review and revise two residents (#5, #46) in the area of activities of daily living (ADL) and palliative care. This affected two residents (#5, #46) of 19 sampled residents. Findings Include: 1. Review of the medical record for Resident #5 revealed an initial admitted [DATE] with the latest readmission of 12/26/23 with the diagnoses including but not limited to cerebrovascular accident (CVA) with right sided hemiplegia, chronic obstructive pulmonary disease (COPD), aphasia, mild intellectual disabilities, dysphagia, idiopathic peripheral autonomic neuropathy, vertigo, protein calorie malnutrition, schizophrenia, bipolar disorder, osteoporosis, hyperlipidemia, peripheral vascular disease, cerebellar ataxia, hypertension, malignant neoplasm of prostate, solitary pulmonary nodule, dementia with agitation, major depressive disorder, benign prostatic hyperplasia, alcohol abuse and nicotine dependence. Review of the plan of care dated 10/30/23 revealed the resident had an activities of daily living (ADL) self-care performance deficit related to intellectual disability, lack of coordination, muscle weakness, hemiplegia, COPD and pain. Interventions included assist/grab bars to aide with bed mobility, the resident was independent with ambulation, bed mobility, dressing, transfers, toileting, required supervision with personal hygiene and dependent with eating, encourage participation in daily care and provide positive reinforcement for activities attempted and/or partially achieved, encourage resident to use call light when assistance is needed, honor resident's choices and preferences whenever possible, observe for pain during ADL tasks and report to nurse if observed, place assistive devices within reach, place call light within reach, therapy screen/evaluation/treatment as needed, report changes in ADL abilities to Nurse, Physician/NP/PA, and/or therapy, bent utensils at all meals and encourage resident to allow staff to shave them. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the mood and behavior revealed the resident displayed no behaviors. Review of the monthly physician orders for February 2025 identified orders dated 11/26/24 regular diet, level one texture thin liquids, staff to feed, encourage to be upright with meals for fortified pudding with lunch/diner. Review of the resident's ADL documentation from 01/05/25 to 02/06/25 revealed the resident required extensive assistance with ADL. On 02/06/25 at 10:34 A.M., interview with Senior Director of Nursing (SDON) verified the lack of revision of the ADL plan of care to reflect the resident's current ADL status of extensive assistance with ADL. 2. Review of the medical record for Resident #46 revealed an initial admitted [DATE] with the latest readmission of 04/02/24 with the diagnoses including but not limited to acute and chronic respiratory failure, severe morbid obesity, chronic obstructive pulmonary disease (COPD), hypothyroidism, depression, diabetes mellitus, pain in foot, sleep disorder, liver disease, fatty liver and gout. Review of the plan of care dated 10/17/23 revealed the resident had a terminal prognosis with admit to Compass Palliative Care with diagnoses of COPD. Interventions included administer medications as ordered and observe for effectiveness, allow resident to express fears and concerns related to terminal diagnosis, notify hospice/palliative team for additional emotional support services as needed, collaborate with the palliative/hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met, involve resident, family, clergy and other team members as needed, evaluate for verbal and non-verbal signs and symptoms relating to pain, honor preference related to hospitalization s, notify hospice/palliative team for additional family support services if needed, notify hospice/palliative team if current pain medications is ineffective, provide care based on resident/family/responsible party's preferences related to end-of-life comfort measures, provide space and privacy for the family to spend time with the resident and provide time for the family/responsible party to express feelings about end-of-life prognosis for their loved one. Review of the resident's monthly physician orders for February 2025 identified orders dated 04/02/24 admit to Compass Palliative Care with diagnoses of COPD. On 02/05/25 at 4:25 P.M., interview with Registered Nurse (RN) #111 verified the resident's current hospice company was Buckeye Hospice. Review of the facility policy titled, Comprehensive Care Plan, (last revised 06/30/22) revealed it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessments.

Based on observation, record review, interview and facility policy review, the facility failed to provide ensure one resident (#24) who was dependent on staff assistance with nail care as physician ordered. This affected one resident (#24) of three residents reviewed for activities of daily living (ADL). Findings Include: Review of the medical record for Resident #24 revealed an initial admitted [DATE] with the latest readmission of 12/05/24 with the diagnoses including diabetes mellitus, polyneuropathy, spondylosis, disease of pancreas, gastro-esophageal reflux disease, osteoarthritis, disorders of urethra, obstructive and reflux uropathy, noncompliance with medical treatment and regimen, calculus of kidney, congestive heart failure, dysphagia, hypertension, anxiety disorder, atrial fibrillation, adjustment disorder with mixed disturbance of emotions and conduct, chronic pain syndrome, insomnia, major depressive disorder, basal cell carcinoma of skin of unspecified eyelid, acanthosis nigricans, hypothyroidism and hyperlipidemia. Review of the resident's plan of care dated 09/27/23 revealed the resident had self-care performance deficit related to muscle weakness, lack of coordination, need for assistance with personal care, stiffness of joints, atrial fibrillation and anxiety. Interventions included bilateral enables to bed, resident is to be upright for all meals, the resident requires two person assist with bathing, dressing, personal hygiene, toileting, transfers and supervision with eating, encourage participation in daily care and provide positive reinforcement for activities attempted and/or partially achieved, encourage resident to use call light when assistance is needed, honor resident's choices and preferences whenever possible, observe for pain during ADL tasks and report to nurse if observed, place assistive devices within reach, place call light within reach, provide cues and assist as needed to accomplish daily tasks, therapy to screen/evaluate/treat as needed, report changes in ADL abilities to Nurse, Physician/NP/PA, and/or Therapy and resident may utilize tilt and space wheelchair for locomotion. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. Review of the mood and behavior revealed the resident displayed verbal behaviors directed towards others. Review of the resident's February 2025 monthly physician orders identified orders dated 12/06/24 nurse to trim nails every Monday. Review of the resident's February 2025 Medication Administration Record (MAR) revealed the order was initialed on 02/03/25 indicating the resident's nails were trimmed. On 02/03/25 at 10:55 A.M., observation of the resident's fingernails revealed they were long, jagged with a brown substance under the nail. On 02/05/25 at 12:55 P.M., interview with the resident revealed her nails were not cut on 12/03/25 but are due for a cutting. On 02/05/25 at 1:02 P.M., interview with Regional Director of Clinical (RDC) #220 confirmed the resident's nails were long, jagged and dirty. Review of the facility policy titled, Nail Care, (last revised 08/20/24) revealed the purpose of this procedure is to provide guidelines for the care of a resident's nails for good grooming and health. Routine cleaning and inspection of nails will be provided during activities of daily living (ADL) care on an ongoing basis. Routine nail care includes trimming and filing, will be provided on a regular basis and as the need arises.

Based on observation, record review, interview and facility policy review, the facility failed to ensure one resident (#46) received routine palliative care visits. Additionally, the facility failed to monitor one resident's (#116) orthotic splint causing increased edema. This affected two residents (#46, #116) of 19 sampled residents. Findings Include: 1. Review of the medical record for Resident #46 revealed an initial admitted [DATE] with the latest readmission of 04/02/24 with the diagnoses including but not limited to acute and chronic respiratory failure, severe morbid obesity, chronic obstructive pulmonary disease (COPD), hypothyroidism, depression, diabetes mellitus, pain in foot, sleep disorder, liver disease, fatty liver and gout. Review of the plan of care dated 10/17/23 revealed the resident had a terminal prognosis with admit to Compass Palliative Care with diagnoses of COPD. Interventions included administer medications as ordered and observe for effectiveness, Allow resident to express fears and concerns related to terminal diagnosis, notify Hospice/Palliative team for additional emotional support services as needed, collaborate with the Palliative/Hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met, involve resident, family, clergy and other team members as needed, evaluate for verbal and non-verbal signs and symptoms relating to pain: grimacing, guarding, crying, moaning, increased anxiety, honor preference related to hospitalization s, notify Hospice/Palliative team for additional family support services if needed, notify Hospice/Palliative team if current pain medication(s) is ineffective, provide care based on resident/family/responsible party's preferences related to end-of-life comfort measures, provide space and privacy for the family to spend time with the resident and provide time for the family/responsible party to express feelings about end-of-life prognosis for their loved one. Review of the resident's monthly physician orders for February 2025 identified orders dated 04/02/24 admit to Compass Palliative Care with diagnoses of COPD. Review of the resident's hospice documentation revealed the resident had not had a visit from the contracted palliative care service since 12/14/24. On 02/06/25 at 8:42 A.M., interview with the Director of Nursing (DON) revealed the resident's palliative care company was scheduled but with the snow storm and sickness at the providers company she was not seen in the month of January 2025. Review of the facility policy titled, Hospice, (last revised 10/26/23) revealed when a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff in order to promote the resident's highest practicable physical, mental and psychosocial well-being. 2. Review of the medical record for Resident #116 revealed an initial admitted [DATE] with the diagnoses including but not limited to osteoarthritis right wrist, osteonecrosis of right carpus, severe protein calorie malnutrition, Kienbock's disease of adults, major depressive disorder, alcohol dependence with withdrawal delirium, altered mental status, confusional arousals, anxiety disorder, Wernicke's encephalopathy, repeated falls, anemia, abnormal weight loss, gastro-esophageal reflux disease, disorders of plasma protein metabolism, metabolic acidosis, seasonal allergic rhinitis, hypertension and allergy to mammalian meats. Review of the plan of care dated 01/20/25 revealed the resident is at risk for impaired skin integrity related to splint to right hand. Interventions included administer medications as ordered, apply protective barrier cream after incontinent episode, assist resident with turning and repositioning as needed, complete skin inspection weekly and as needed, consult Dietitian as needed, labs as ordered, notify nurse of any new areas of skin impairment noted during bathing or daily care, notify the physician of any new areas of skin impairment and therapy to screen/evaluate/treatment as needed. Review of the resident's nursing admission evaluation dated 01/20/25 revealed the resident had limited range of motion in the right hand. The resident's right orthotic splint was not addressed on the admission evaluation. Review of the progress note dated 02/04/25 revealed the physician examined the resident due to edema and pain to the right hand/wrist. A new order was received for a two view x-ray of the right wrist and hand to rule out a fracture. The facility contracted x-ray company was notified of the need for the x-ray. Review of the progress note dated 02/05/25 at 7:11 P.M. revealed the radiology results were received revealing no gross osseous abnormality. Limited study for which fracture is not excluded. The Radiologist recommended a repeat study with diagnostic views. The conclusion of the two view x-ray for right wrist was no definite acute fracture, consider more sensitive imaging evaluation with CT as clinically directed. The physician was made aware with no new orders. Review of the February 2025 monthly physician orders identified orders dated 01/20/25 monitor scab to first digit to right hand daily until resolved, 01/21/25 maintain splint to right wrist, check placement and skin integrity every shift, non-weight bearing to right wrist, circulatory checks to right hand every shift, Review of the resident's progress notes revealed no documentation related to the increased edema and adjustment of the brace to the right wrist. On 02/04/25 at 10:01 A.M., observation/interview with the resident revealed he had a black orthotic splint to his right hand/wrist. He reported he fell on the ice at home and the hospital said it wasn't broken but he felt it was. He said his fingers bent back and touched his forearm. His right had was noted to be edematous around the the brace. The resident reported the brace felt tight. The resident denied having the brace adjusted. On 02/04/25 at 3:02 P.M., interview with Registered Nurse (RN) #111 confirmed the resident's orthotic splint to his right hand/wrist was too tight causing the swelling. Observation of the resident's right hand at the time of the interview revealed his right hand had doubled in swelling leaving indents of the orthotic brace in the back of his hand.

Based on observation, record review, interview and facility policy review, the facility failed to ensure residents (#24, #50) were provided routine podiatry services. This affected two residents (#24, #50) of three residents review for activities of daily living (ADL). Findings Include: 1. Review of the medical record for Resident #24 revealed an initial admitted [DATE] with the latest readmission of 12/05/24 with the diagnoses including diabetes mellitus, polyneuropathy, spondylosis, disease of pancreas, gastro-esophageal reflux disease, osteoarthritis, disorders of urethra, obstructive and reflux uropathy, noncompliance with medical treatment and regimen, calculus of kidney, congestive heart failure, dysphagia, hypertension, anxiety disorder, atrial fibrillation, adjustment disorder with mixed disturbance of emotions and conduct, chronic pain syndrome, insomnia, major depressive disorder, basal cell carcinoma of skin of unspecified eyelid, acanthosis nigricans, hypothyroidism and hyperlipidemia. Review of the resident's plan of care dated 09/27/23 revealed the resident had self-care performance deficit related to muscle weakness, lack of coordination, need for assistance with personal care, stiffness of joints, atrial fibrillation and anxiety. Interventions included bilateral enables to bed, resident is to be upright for all meals, the resident requires two person assist with bathing, dressing, personal hygiene, toileting, transfers and supervision with eating, encourage participation in daily care and provide positive reinforcement for activities attempted and/or partially achieved, encourage resident to use call light when assistance is needed, honor resident's choices and preferences whenever possible, observe for pain during ADL tasks and report to nurse if observed, place assistive devices within reach, place call light within reach, provide cues and assist as needed to accomplish daily tasks, therapy to screen/evaluate/treat as needed, report changes in ADL abilities to Nurse, Physician/NP/PA, and/or Therapy and resident may utilize tilt and space wheelchair for locomotion. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. Review of the mood and behavior revealed the resident displayed verbal behaviors directed towards others. Review of the podiatry list for 11/01/24 and 01/08/25 revealed the resident was not seen by the podiatrist. Review of the resident's medical record revealed no documented evidence the resident refused podiatry care. On 02/03/25 at 10:55 A.M., observation of the resident's fingernails revealed the resident's right great toenail was long and curving under. On 02/05/25 at 12:55 P.M., interview with the resident revealed her left great toenail fell off while in the hospital and the right great toenail needed trimmed. On 02/05/25 at 1:02 P.M., interview with Regional Director of Clinical (RDC) #220 confirmed the resident was in need of podiatry of care. Review of the facility policy titled, Nail Care, (last revised 08/20/24) revealed the purpose of this procedure is to provide guidelines for the care of a resident's nails for good grooming and health. Routine cleaning and inspection of nails will be provided during activities of daily living (ADL) care on an ongoing basis. Routine nail care includes trimming and filing, will be provided on a regular basis and as the need arises. 28923 2. Review of Resident #50's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included neurocognitive disorder with Lewy Bodies, malignant neoplasm of unspecified breast, mood disorder, generalized anxiety disorder, depression, osteoarthritis of the bilateral hips, age-related cognitive decline, difficulty in walking, dementia, muscle weakness, lack of coordination, and need for assistance with personal care. Review of Resident #50's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had unclear speech. She was usually able to make herself understood and was usually able to understand others. Her cognition was severely impaired. She was not known to display any behaviors, nor was she known to reject care. She required partial/ moderate assist for personal hygiene. Review of Resident #50's care plans revealed the resident had a care plan in place for a self care performance deficit for activities of daily living (ADL's) related to neurocognitive disorder with Lewy bodies. There was nothing in the care plan regarding podiatry care. The resident's other active care plans did not address the need to provide podiatry services or assistance with trimming her toenails in any of the care plans in place for the resident. Review of Resident #50's physician's orders revealed there was not an order in place for the resident to receive any ancillary services to include podiatry services. Her physician's orders indicated she was placed under the care and services of hospice on 10/25/24 for senile degeneration of the brain. Further review of Resident #50's medical record revealed it was absent of any consents for ancillary services to include podiatry services. It was not clear if the resident and/ or her resident representative had been offered podiatry services, as one of the ancillary services offered by the facility, and had been declined. The medical record was absent of any podiatry consults that showed any podiatry services had been provided since the resident's admission to the facility on [DATE]. Review of facility provided lists of the contracted podiatrists prior visits revealed the podiatrist had been in the facility on 11/01/24 and again on 01/03/25. Resident #50 was not on either of those two lists to show podiatry services had been provided to the resident. On 02/03/25 at 10:52 A.M. an observation of Resident #50 noted her to be lying in bed with her feet uncovered. She was not wearing any socks or shoes and her toes were visible. The resident was noted to have a thick, long toenail on the great toe of the left foot. Her toenail on the right great toe was long as well but was not as thick as what the left side was. The toenails extended past the end of her digits and were growing out diagonally in the direction of her other toes. On 02/06/25 at 8:20 A.M., an interview with Regional Director of Clinical Operations #220 revealed they had contacted the podiatrist that was contracted by the facility to see if Resident #50 had been seen by the podiatrist since her admission to the facility on [DATE]. They were waiting to hear back to see if the resident had been seen by the podiatrist during any of his previous visits. She was not able to obtain any additional information to show the resident had been seen. On 02/06/25 at 8:23 A.M., an interview with Registered Nurse (RN) #210 (who was the corporate office's senior DON assisting during the annual survey) revealed they were not able to find an ancillary service consent form for Resident #50 to determine if the resident/ resident representative wanted the resident to receive podiatry services while in the facility. They had no evidence that service was offered and declined by the resident or her representative. On 02/06/25 at 8:43 A.M., an interview with Certified Nursing Assistant (CNA) #145 revealed Resident #50 was a total assist for ADL's. The staff had to provide her with all personal hygiene care. She reported the resident liked to get her fingernails done. She was asked who was responsible for toenail care and indicated they were done by the podiatrist. She was asked if she had seen the resident's toenails lately and stated that she had not noticed them when she took care of her yesterday. She went to the resident's room and removed her socks. She confirmed the resident's toenails on both the great toes of her bilateral feet were long and growing out and sideways. She noted the toenail on the left great toe was also thick and her toenails were in need of being trimmed.

Based on record review, observation, staff interview, and policy review, the facility failed to ensure fall prevention interventions were implemented for residents with a history of falls and another resident known to have non-pressure skin injuries had a footboard padded as per their plan of care. This affected three residents (#29, #37, and #50) of seven residents reviewed for accidents. Findings include: 1. Review of Resident #29's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included dementia with behavioral disturbances, unspecified psychosis, schizo-affective disorder, age-related cognitive decline, unsteadiness on her feet, lack of coordination, difficulty walking, and muscle weakness. Review of Resident #29's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and her cognition was moderately impaired. Hallucinations and delusions were noted. The resident had other behaviors director at others and was known to reject care. Substantial/ maximum assist was needed for bed mobility and transfers. She was identified as having had a fall since the last assessment that was without injury. Review of Resident #29's active care plans revealed she had a care plan in place for being at risk for falls related to bladder incontinence, bowel incontinence, functional problems, generalized weakness, impaired cognition with decreased safety awareness, needs assistance with activities of daily living (ADL's), and poor communication/comprehension. The care plan originated on 10/03/23. The goal was to reduce the risk of injury through the next review. Interventions included non-skid footwear to reduce the risk of slipping, as the resident allows (initiated 01/30/24), and for the bed to be in low position (initiated on 04/22/24). Review of Resident #29's physician's orders revealed the staff were to ensure the resident's bed was in low position unless providing care or when the resident was out of bed. That order was last ordered on 07/25/24. On 02/04/25 at 10:27 A.M., an observation of Resident #29 noted her to be in bed. Her bed was not in the lowest position as ordered or per her plan of care. On 02/05/25 at 1:20 P.M., further observations of Resident #29 noted her to be in bed resting on her side. Staff were not in her room providing care to the resident. Her bed frame was noted to be about 14 inches off the floor. The resident was also noted not to be wearing any non-skid socks for fall prevention as per her plan of care. On 02/05/25 at 1:25 P.M., an interview with Registered Nurse (RN) #147 revealed she did not consider Resident #29 to be at risk for falls due to the resident not getting up much anymore. She reported the resident was difficult to care for due to behaviors. She was usually more active at night, as she had her days and nights turned around. The resident had recent medication changes as they increased her Vistaril (an anti-anxiety medication) and put her back on Seroquel (an anti-psychotic medication). She was asked what fall prevention interventions were in place for the resident. She was not able to state what any of those were and indicated she would have to check the physician's orders and the resident's plan of care in the computer. She acknowledged the resident's fall prevention interventions included her bed to be in the lowest position and the resident was to have the use of non-skid socks to prevent her from slipping. She confirmed the resident's bed was not in its lowest position and the resident was not wearing non-skid socks. She was able to lower the bed about eight inches, until the bed frame was only six inches off the floor. She obtained a pair of non-skid socks from the resident's drawer under her wardrobe and put them on the resident's bare feet. 2. Review of Resident #50's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included history of a displaced intertrochanteric fracture of the right femur, neurocognitive disorder with Lewy Bodies, malignant neoplasm of unspecified breast, mood disorder, generalized anxiety disorder, osteoarthritis of the bilateral hips, age-related cognitive decline, difficulty in walking, dementia, muscle weakness, lack of coordination, age-related osteoporosis, and need for assistance with personal care. Review of Resident #50's significant change MDS assessment dated [DATE] revealed the resident had unclear speech. She was usually able to make herself understood and was usually able to understand others. Her vision was impaired with the use of corrective lenses. Her cognition was severely impaired, but she was not known to have any behaviors or rejection of care. Supervision or touching assist was needed with bed mobility and partial/ moderate assistance was needed with transfers. She was identified as having one fall with no injury that had occurred since her last assessment. Review of Resident #50's active care plans revealed she had a care plan in place for being at risk for falls/injury related to unspecified lack of coordination, dementia, and a history of a fracture to her right hip. The goal was to reduce the risk of injury through the next review. The interventions included the use of anti-rollbacks to her wheelchair (initiated on 10/25/24) and for gloves to be removed from the resident's room (07/11/24) related to a fall she had on 06/28/24. Review of Resident #50's progress notes revealed a nurse's note dated 06/28/24 at 3:05 P.M. that indicated the resident was heard yelling from her room and was found sitting on the floor on her buttocks. She was noted to have a glove on her left foot. Further review of Resident #50's progress notes revealed the resident suffered another fall on 10/14/24 at 5:25 P.M. when the staff noted the resident lying on the floor on her left side. She complained of bilateral hip pain and low back pain following the fall and was sent to the emergency room for an evaluation. She returned to the facility on [DATE] and anti-rollbacks were to be placed onto her wheelchair when available. On 02/05/25 at 11:00 A.M., Resident #50 was observed up in her wheelchair in the dining room attending an activity. The resident's wheelchair was noted to be missing the anti-rollback bar behind the right wheel of the wheelchair. On 02/05/25 at 11:05 A.M., an interview with Certified Nursing Assistant (CNA) #145 revealed Resident #50 was totally dependent on staff for care. She reported the resident had really went downhill, as of late. She was normally up in her wheelchair, but had been sleeping a lot lately. She considered the resident to be at risk for falls. The resident used to try to get up a lot and has fallen. When asked what fall prevention interventions were in place for the resident, she stated the resident had the use of a low bed. Fall mats were not being used at the bedside as they were more of a tripping hazard to the resident. She confirmed the resident had the use of a wheelchair and she was currently up in the dining room for an activity. She knew the resident had the use of a cushion when in her wheelchair but did not mention the use of an anti-rollback bars to her wheelchair. CNA #145 was asked to accompany the surveyor to the dining room to check to see what interventions were in place on the resident's wheelchair. She verified the resident only had one anti-rollback bar to her wheelchair and was missing the one on the right side of the wheelchair. Verification was made on 02/05/24 at 11:09 A.M. On 02/05/25 at 11:10 A.M., an interview with RN #147 revealed she was aware the resident was up in her wheelchair and in the dining room for an activity. She denied she was aware the resident's wheelchair was missing one of the two anti-rollback bars to the back of her wheelchair. She knew the resident was supposed to have those on the back of her wheelchair. She was asked to clarify the care plan intervention for no gloves in the resident's room. She stated she was unaware of that being a fall prevention intervention for the resident. She did recall the resident had a fall in the past that involved her putting a disposable glove over her foot that was deemed to be a contributing factor to one of her falls. She verified the resident had two boxes of disposable gloves in her room that were above the sink. She asked where that was in the resident's record that indicated she was not to have gloves in her room. She was made aware that was one of the fall prevention interventions on her plan of care. She removed the two boxes from the resident's room at that time. Review of the facility's policy on Fall Prevention Program (revised 01/01/22) revealed each resident would be assessed for the risk of falling and would receive care and services in accordance with the level of risk to minimize the likelihood of falls. Each resident's risk factors and environmental hazards would be evaluated when developing the resident's comprehensive plan of care. Interventions would be monitored for effectiveness and the plan of care would be revised as needed. 32654 3. Review of the medical record for Resident #37 revealed an initial admitted [DATE] with the latest readmission of 08/01/24 with the diagnoses including but not limited to cerebrovascular accident with right sided hemiplegia, diabetes mellitus, anxiety disorder, hypertension, dysphagia, insomnia, schizoaffective disorder, constipation, hyperlipidemia, gastro-esophageal reflux disease, hearing loss, depression, peripheral vascular disease, and idiopathic peripheral autonomic neuropathy. Review of the plan of care dated 09/27/23 revealed the resident had impaired skin integrity as evidenced by scabs to right dorsum foot second digit and scabs to rear right thigh. Interventions included padded foot board, circulation checks as ordered, encourage resident to keep arms inside wheelchair when going through doorways, encourage resident to wear pants before getting out of bed, resident/family education provided for safe transfers, administer medication/treatments as ordered, apply protective barrier cream after incontinent episode, assist resident with turning and repositioning as needed, complete skin inspection weekly and as needed, consult Dietitian as needed, encourage good nutrition and hydration, assist as needed, encourage/assist as needed to elevate heels off the mattress as tolerated, if resident refuses interventions/treatments, encourage compliance to minimize further skin impairment, labs as ordered, notify nurse of any new areas of skin impairment noted during bathing or daily care, notify Physician/NP/PA of noted worsening skin condition or any new areas of skin impairment, notify Physician/NP/PA of signs/symptoms of infection, pressure redistribution mattress to bed and therapy screen/evaluation/treat as needed. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. Review of the mood and behavior revealed the resident rejected care. The assessment indicated the resident was at risk for skin breakdown and had no skin issues. Review of the monthly physician orders for February 2025 identified an order dated 08/01/24 padded footboard to prevent further skin injuries. On 02/04/25 at 9:36 A.M., observation of the resident's footboard was not padded as physician ordered. On 02/05/25 at 2:26 P.M., interview with Licensed Practical Nurse (LPN) #144 confirmed the resident's footboard was not padded as physician ordered.

Based on record review, interview and facility policy review, the facility failed to address a pharmacy recommendation timely for one resident (#24). Additionally, the physician failed to provide a rationale for the decline of a pharmacy recommended gradual dose reduction (GDR) for Resident #5. This affected two residents (#5, #24) of five residents reviewed for unnecessary medications. Findings Include: 1. Review of the medical record for Resident #5 revealed an initial admitted [DATE] with the latest readmission of 12/26/23 with the diagnoses including but not limited to cerebrovascular accident (CVA) with right sided hemiplegia, chronic obstructive pulmonary disease (COPD), aphasia, mild intellectual disabilities, dysphagia, idiopathic peripheral autonomic neuropathy, vertigo, protein calorie malnutrition, schizophrenia, bipolar disorder, osteoporosis, hyperlipidemia, peripheral vascular disease, cerebellar ataxia, hypertension, malignant neoplasm of prostate, solitary pulmonary nodule, dementia with agitation, major depressive disorder, benign prostatic hyperplasia, alcohol abuse and nicotine dependence. Review of the plan of care dated 12/01/23 revealed the resident took psychotropic/mood stabilizer medication as evidenced by antidepressant use, antipsychotic use and Mirtazapine use. Interventions included administer medications as ordered, consult with Pharmacist/Physician/NP/PA for gradual dose reduction if appropriate, observe PHQ-9 score for indication of worsening signs/symptoms of depression, refer to psychologist/psychiatrist as needed, review with resident/family/responsible person the risks vs. benefits of psychotropic medication use, observe for and report to Physician/NP/PA adverse effects of antidepressant medication use, observe for and report to Physician/NP/PA adverse effects of antipsychotic/mood stabilizer medication use and periodically complete the AIMS evaluation for extrapyramidal symptoms. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the mood and behavior revealed the resident displayed no behaviors. The assessment indicated the dementia, depression, bipolar disorder and schizophrenia were current diagnoses. The resident received antipsychotic and opioid medications. The resident received antipsychotic medication on a routine basis, a GDR had not been attempted and and the physician had not documented the GDR was not clinically contraindicated. Review of the resident's AIMS scale dated 12/25/24 revealed a score of zero indicating the resident had no abnormal involuntary movements. Review of the monthly physician orders for February 2025 identified orders dated 01/03/24 Depakote Sprinkles 375 mg by mouth twice daily, 01/15/24 Risperdal 0.25 milligrams (mg) by mouth two times a day and Risperdal 0.5 mg by mouth daily and 01/23/24 Remeron 7.5 mg by mouth daily at bedtime for appetite stimulant. Review of the pharmacy recommendation dated 06/26/24 revealed the pharmacist recommended a GDR for the medication Remeron used as an appetite stimulant. The physician addressed on 07/02/24 and documented continue as ordered. No explanation for the continued use of the medication was documented. Review of the pharmacy recommendation dated 01/27/24 revealed the pharmacist recommended a GDR on the medications Depakote Sprinkles 375 mg by mouth twice daily, Remeron 7.5 mg by mouth daily at bedtime for appetite stimulant and Risperdal 0.25 mg twice daily and Risperdal 0.5 mg by mouth daily. The physician addressed the recommendation on 02/03/25 and checked the resident had a good response, maintain the current dose and to see the physician progress note. Review of the resident's medical record revealed no progress note dated 02/03/25 indicating a rationale to decline the recommended GDR. On 02/06/25 at 1:52 P.M., interview with the Director of Nursing (DON) confirmed no rationale for the decline for the 06/26/24 and 01/27/25 pharmacy recommendations. 2. Review of the medical record for Resident #24 revealed an initial admitted [DATE] with the latest readmission of 12/05/24 with the diagnoses including diabetes mellitus, polyneuropathy, spondylosis, disease of pancreas, gastro-esophageal reflux disease, osteoarthritis, disorders of urethra, obstructive and reflux uropathy, noncompliance with medical treatment and regimen, calculus of kidney, congestive heart failure, dysphagia, hypertension, anxiety disorder, atrial fibrillation, adjustment disorder with mixed disturbance of emotions and conduct, chronic pain syndrome, insomnia, major depressive disorder, basal cell carcinoma of skin of unspecified eyelid, acanthosis nigricans, hypothyroidism and hyperlipidemia. Review of the plan of care dated 02/01/24 revealed the resident takes psychotropic/mood stabilizer medication as evidenced by antianxiety use. Interventions included administer medications as ordered, consult with Pharmacist/Physician/Nurse Practitioner (NP)/Physician Assistant (PA) for gradual dose reduction if appropriate, observe PHQ-9 score for indication of worsening signs/symptoms of depression, refer to psychologist/psychiatrist as needed, review with resident/family/responsible person the risks vs. benefits of psychotropic medication use and Monitor for and report to Physician/NP/PA adverse effects of antianxiety medication use. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. Review of the mood and behavior revealed the resident displayed verbal behaviors directed towards others. The assessment indicated anxiety disorder and depression were current diagnoses. The resident received daily insulin injections, antianxiety, antidepressant, anticoagulant, diuretic, antiplatelet, opioid and hypoglycemic medications. Review of the resident's monthly physician orders for February 2025 identified orders dated 12/04/24 Buspar 5 mg by mouth two times a day for anxiety Review of the medical record revealed the facility contracted pharmacist reviewed the resident's drug regimen monthly and made recommendations as applicable. Review of the pharmacy recommendation dated 03/12/24 revealed the pharmacist recommended a reduction on the medication Omeprazole 20 mg twice daily. The physician agreed with the recommendation on 05/01/24 and decreased the medication to 20 mg daily. On 02/05/25 at 12:42 P.M., interview with Regional Director of Clinical (RDC) #220 verified the recommendation was addressed more than 30 days after the recommendation was made and should have been addressed within 30 days. Review of the facility policy titled, Addressing Medication Regimen Review Irregularities, (last revised 12/28/23) revealed it was the policy of the facility to provide a medication regimen review (MRR) for each resident to identify irregularities and respond in a timely manner to prevent the occurrence of an adverse drug event.

Based on medical record review and interview the facility failed to obtain physician ordered laboratory testing for one resident (#45) of five sampled for unnecessary medications. The facility census was 66. Findings include: Review of Resident #45's medical record revealed an admitted [DATE] and diagnoses including Alzheimer's disease, Crohn's disease, dementia, delusional disorders, hallucinations, unspecified psychosis, anxiety disorder, and depression. Review of Resident #45's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status score of 03 indicating a severe cognitive deficit. Further review revealed Resident #45 had hallucinations in the seven days prior to the MDS date of 10/29/24. Further review of the MDS revealed Resident #45 had received antipsychotic and antidepressant medications in the seven days prior to the MDS date of 10/29/24. Review of the pharmacy recommendation note to attending physician/prescriber dated 07/25/24 revealed Resident #45 was receiving respiridone and quentiapine and that these medications had a risk of causing adverse metabolic effects. The pharmacy recommended checking a fasting lipid panel, a fasting glucose level and an A1C (a blood test that measures a persons average blood sugar/glucose levels over the past two to three months) yearly. Review of Resident #45's physician's orders revealed an order dated 07/29/24 to check Resident #45's A1C yearly. Further review of Resident #45's medical record revealed no A1C results. Interview on 02/06/25 at 10:30 A.M. the facility Director of Nursing, Registered Nurse #151 confirmed the facility did not have A1C results for Resident #45.

Based on record review, review transfer notices, staff interview, and policy review, the facility failed to ensure the local Ombudsman was notified of resident transfers as required. This affected two residents (#57 and #65) of two residents reviewed for hospitalization s. Findings include: 1. Review of Resident #57's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included acute on chronic respiratory failure with hypoxia, history of a tracheostomy (removed), seizures, adult onset diabetes mellitus, heart failure and cerebellar stroke disorder. Review of Resident #57's census tab and Minimum Data Set assessments under the electronic medical record (EMR) revealed the resident was hospitalized on [DATE] and did not return to the facility until 12/10/24. Review of Resident #57's progress notes revealed a nurse's note dated 11/30/24 at 8:57 P.M. that indicated the resident was transferred from the facility via local emergency medical services (EMS). The progress note did not specify the reason for the transfer or where the resident was being transferred to. A bed hold policy was indicated to have been provided to the resident at the time of his transfer. Subsequent progress notes indicated the resident was sent to the emergency room Review of an SBAR (Situation, Background, Assessment, and Request) communication form for Resident #57 dated 11/30/24 at 8:40 P.M. revealed the resident was noted to have seizure activity with a low oxygen saturation of 83% (92-100% normal) on 4 liters per minute (LPM) and possible aspiration. His pulse was 123 and his respirations were 18 with a blood pressure of 136/96. The resident was also found to be unresponsiveness and his respirations were indicated to be labored. He was found to be clammy, cool to touch, awake but not responding, and was noted to be wheezing when taking a breath. The physician was notified and a new order was received to send the resident out to the emergency room . The resident then began actively seizing and the staff assisted the resident to his side safely with the seizure lasting 1 minute and 45 seconds. The resident's breathing remained labored with his oxygen saturation starting at only 80% on room air. Oxygen was placed on the resident at 4 LPM raising his oxygen saturation to 83% by the time the squad arrived to transfer the resident to the emergency room . The surveyor requested the facility provide all transfer notices that had been provided to the Resident #57 and/ or to his resident representative and the local Ombudsman. They provided a transfer notice and a bed hold notice that had been provided to the resident/ resident representative, but did not have evidence of the local Ombudsman being notified of the resident's transfer to the hospital as required. Findings were confirmed with Regional Director of Operations #200. On 02/05/25 at 2:30 P.M., Regional Director of Operations #200 reported the facility had reached out to the local Ombudsman's office and left a message on two separate voicemails to see if they had any documentation to support they had been notified of Resident #57's transfer to the hospital on 11/30/24. They were not able to get any confirmation from the Ombudsman's office to show the facility had notified them of the resident's transfer as required. Review of the facility's policy on Transfer and Discharge (revised 10/30/23) revealed it was the policy of the facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents were endangered. Transfer was defined as the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expected to return to the original facility. For an emergency transfer, the social service director or designee should provide notice of the transfer to a representative of the State Long-Term Care Ombudsman via a monthly list. 50538 2. Review of Resident #65's medical record revealed an admitted [DATE], a re-entry date of 11/08/24 and a discharge date of [DATE]. Further review revealed diagnoses including multiple sclerosis, right femur fracture, cellulitis of the right lower limb, osteoarthritis and anemia. Review of Resident #65's progress notes revealed he was sent to the local emergency roiagnom on [DATE] at 5:55 P.M. for an infection in his right lower extremity and that a copy of the bed hold policy was sent with him. In an interview on 02/06/25 at 2:15 P.M. Senior Director of Nursing #210 and Regional Director of Operations #200 confirmed the facility had no proof the ombudsman had been notified of Resident #65's transfer to the local emergency room .

Based on observation, record review, review of the facility's fall investigation, staff interview, and policy review, the facility failed to ensure Resident #55 was provided the assistance needed to prevent an avoidable fall from occurring that resulted in major injury to the resident and failed to ensure Resident #44's room was free of a safety hazard (an electrical heated curling iron). This affected two residents (#55 and #44) of three residents reviewed for accidents. The facility census was 65. Actual harm occurred on 09/26/23 when Resident #55, who was severely cognitively impaired was observed ambulating in the hall, without the use of her walker, and was only educated by a staff member that she needed her assistive device when ambulating. At the time of the incident, Resident #55 was encouraged to return to her room, without being provided the appropriate staff assistance needed and fell fracturing her left hip requiring surgical repair Findings include: 1. A review of Resident #55's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia, muscle weakness, unsteadiness on her feet, lack of coordination, and need for assistance with personal care. Her diagnoses list was updated to reflect she had a displaced fracture of the base of the left femur that was added on 10/02/23. A review of Resident #55's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was assessed as being severely impaired. She was sometimes able to understand others and was sometimes able to make herself understood. She required supervision with the physical assist of one for ambulation in her room and in the corridor. Balance issues were indicated to be present with transfers and ambulation but the resident was able to stabilize herself without the assistance of staff. A walker was listed as the only mobility device being used at that time. A review of Resident #55's care plans revealed she was at risk for falls related to unsteadiness on her feet, lack of coordination, and a closed fracture of the left femur. Interventions included visual cues in room to remind the resident to use call light, educate resident on safety interventions, encourage the resident to keep needed items within reach, encourage the resident to use her call light, and to place call light in reach. A review of Resident #55's progress notes revealed a nurse's note dated 09/26/23 at 10:06 P.M. by Registered Nurse (RN) #120 that indicated she was walking up from the back hall of B unit to go answer a phone call. On her way up, she saw Resident #55 fall. Resident #55 landed on her left hip. The resident was ambulating without the use of her walker. She was sent out to the emergency room for an evaluation and was transported to another local hospital with the diagnosis of a left hip fracture. She remained in the hospital until her return to the facility on [DATE]. A review of the facility's fall investigation for Resident #55's fall that occurred on 09/26/23 revealed the fall occurred on 09/26/23 at 8:05 P.M. She resided on the front hall of the B unit at the time the fall occurred. The nurse's description of the fall revealed the same information the nurse documented in her progress note on 09/26/23 at 10:06 P.M. In addition, the nurse further indicated an aide was present speaking to another resident when Resident #55 walked up. The aide gave Resident #55 a verbal cue and encouraged the resident that she needed to have her walker. Resident #55 walked off while the aide's back was turned towards her as the aide continued to speak with the other resident. Resident #55 then fell . When assessed for injuries, Resident #55 complained of left hip pain. The physician was notified and an order was received to send the resident to the emergency room . Injuries observed at the time of the incident was a fracture of the left hip. Predisposing factors of the fall included confusion, impaired memory, gait imbalance, and weakness. Predisposing situational factors included ambulating without assistance. Witnesses to the incident included RN #120 and State tested Nurse Aide (STNA) #125. STNA #125's statement regarding the fall revealed Resident #55 had walked up to her while she was talking to another resident. She reminded the resident that she needed her walker. The resident then went walking towards her room. She turned around from talking to the other resident and observed Resident #55 on the floor by the nurse's station. She further indicated on a statement given on 09/29/23 that Resident #55 brought her bowl from her snack while she was talking with another resident. She asked the resident where her walker was because she needed to use it. She told the resident she needed to have it. The aide then reported she turned around to finish with the other resident for maybe two seconds and turned back around seeing Resident #55 on the floor. A review of Resident #55's hospital records for her hospital stay between 09/26/23 and 10/02/23 revealed a history and physical from the hospitalist revealed the resident presented to the emergency room for complaints of a fall. She was noted to have fallen from a standing position onto the floor and complained of left hip pain that was worse with movement. A CT scan of her left hip revealed a left femoral neck fracture with superior and anterior displacement of the distal components with compaction. Morphine had been given twice in the ER for pain. Her diagnosis was as indicated on the CT scan. An orthopedic follow up was ordered. The plan was for her to have a left hemiarthroplasty performed on 09/27/23 pending medical clearance and surgical risks were acceptable. On 11/22/23 at 3:00 P.M., an interview with STNA #125 confirmed she was on duty 09/26/23 when Resident #55 had her fall. She reported the resident resided on the front hall of B unit at the time the fall occurred. They had passed her a snack and the resident came walking out of her room to take the bowl back to the snack cart. The snack cart was on the back hall of B unit just past the nurse's station (approximately 65 feet from the resident's room). The aide was on the back hall of B unit talking to another resident when she observed Resident #55 walking without a walker. She reminded the resident she needed to have her walker when ambulating. The resident fell while she was walking back to her room. The aide had her back to the resident when she fell as she continued to talk to the other resident she had previously been engaged in a conversation with. She denied she stopped talking with the other resident to immediately assist Resident #55, after she observed her walking without her walker. She received education from the facility's administrative staff (after the incident occurred) informing her she should have intervened and assisted the resident when she noted her to be walking without her assistive device. The facility's administrative staff also told her she should not have continued talking with the other resident while failing to assist Resident #55 with returning safely to her room. On 11/22/23 at 3:25 P.M., an interview with the Director of Nursing (DON) confirmed Resident #55 did have a fall on 09/26/23 that resulted in a hip fracture. The fall investigation showed Resident #55 fell while ambulating without the use of her walker. STNA #125 observed the resident ambulating without her walker and did not provide the immediate assistance needed to prevent the fall from occurring. They provided education to the aide, as well as all other staff. The education provided included the following: If they see a resident ambulating without an assistive device that was needed, they were to wait with the resident while someone else went to get the assistive device. They were not to tell the resident that they needed to go get the assistive device and leave them unattended. Safety was to come first. A review of the facility's Fall Prevention Program policy (revised 10/26/23) revealed each resident would be assessed for the risks of falling and would receive care and services in accordance with the level of risk to minimize the likelihood of falls. Each resident's risk factors and environmental hazards would be evaluated when developing the resident's comprehensive plan of care. 41271 2. Review of the medical record for Resident #44 revealed an initial admitted [DATE] and a re-entry date of 07/16/23. Diagnoses included Bipolar disorder with current episode manic severe with psychotic features, schizoaffective disorder, bipolar type, dementia with other behavioral disturbance, psychotic disorder with delusions, lack of coordination, and need for assistance with personal care. Review of the plan of care (dated 09/14/23) revealed Resident #44 was at risk for falls and/or injuries related to a lack of coordination. Interventions included to encourage to allow staff to carry items when walking, the use of a call light, and to ensure room is free from accident hazards. Review of Resident #44's quarterly Minimum Data Set (MDS) 3.0 assessment (dated 10/16/23) revealed a Brief Interview for Mental Status (BIMS) score of 04 indicating a severely impaired cognition for daily decision making abilities. Resident #44 was also noted to experience hallucinations. Observation of Resident #44 on 11/20/23 at 10:45 A.M. revealed the resident was using an electrical curling iron in private room to curl her own hair with no assistance from facility staff. Continued observation revealed STNA #300 entering Resident #44's room, observing resident in bathroom using electrical curing iron to curl her hair, telling the resident her hair looked nice, and exiting the resident's room. Interview with STNA #300 on 11/20/23 at 10:50 A.M. revealed she didn't know Resident #44 had a curling iron but she thinks one of her family members brought it in for her to use. Interview on 11/20/23 at 11:00 A.M. with the DON revealed no knowledge of the resident having a curling iron but someone would check on this. Observation on 11/20/23 at 11:05 A.M. revealed STNA #302 entering Resident #44's room and shortly after wards exiting the resident's room with the electrical curling iron in his hand. Review of the progress note dated 11/20/23 at 5:06 P.M. created by the DON revealed, Resident noted to have curling iron in room this morning and curling hair. Removed curling iron from room and educated resident we would leave at nurses station and she can come get it daily to curl hair and to have staff help her with this task to prevent any injury. Resident feels she can curl her hair by self and appropriately. Resident did agree to letting us keep the curling iron. Resident was assessed and no injury or anything noted from having curling iron. Medical Director (MD) and responsible party made aware.

Based on medical record review, policy review, and staff interview, the facility failed to ensure the accuracy of a resident's advance directives. This affected one of 24 sampled residents (#7). The facility census was 65. Findings include: Review of the medical record for Resident #7 revealed an admitted [DATE]. The resident was out to the hospital from [DATE] to [DATE]. The resident was readmitted on [DATE]. Review of physician's orders revealed an order dated [DATE] for do not resuscitate in the event of cardiac arrest. However, review of a binder at the nurses station titled code status revealed a paper dated [DATE] which was signed by Resident #7 expressing a desire to have cardiopulmonary resuscitation (CPR) be done in the event of cardiac arrest. Interview with Licensed Practical Nurse (LPN)# 100 on [DATE] at 2:45 P.M. revealed that she puts the code status information in the binder at the nurses station for reference by the nurses. She confirmed the paper in the binder desiring CPR be done for Resident #7 did not match the physician's order for do not resuscitate. She stated the order for do not resuscitate must have been written after the resident returned from the hospital. However, the facility did not have any documentation to confirm that the resident wanted do not resuscitate instead of requesting CPR be done. On [DATE] at 3:00 P.M. LPN #100 stated she just talked with Resident #7 and the resident requested to have CPR done in the event of a cardiac arrest. She stated the physician's order would have to be changed so that the resident would receive CPR as requested in the event of cardiac arrest. Review of the facility policy titled Resident Rights Regarding Treatment and Advance Directives (dated [DATE] and revised [DATE]) revealed it was the policy of the facility to support and facilitate a resident's right to request, refuse, and/or discontinue medical or surgical treatment and to formulate an advance directive.

Based on record review, observation and interview, facility failed to maintain a homelike environment in resident rooms. This affected two residents (#18 and #55) of four residents reviewed for homelike environment. The census was 65. Findings include: 1. Record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, chronic obstructive pulmonary disease, hypertension, gastro-esophageal reflux disease, dysphagia, schizoaffective disorder, major depression, and acute kidney failure. Observation on 11/29/23 at 10:44 A.M. revealed Resident #18 in his room. The bathroom door in his room had three holes on the bottom, each approximately the size of a golf ball. Interview on 11/29/23 at 10:46 A.M. with Registered Nurse (RN) #145 confirmed the holes in Resident #18's bathroom door. During the course of the annual survey, Resident #18 was not available for interview. 2. Record review revealed Resident #55 was admitted to the facility on [DATE] with diagnoses including type II diabetes, hypertension, hyperlipidemia, dysphagia, and cognitive communication disorder. Resident #55 was cognitively impaired and was not able to be interviewed. Observation on 11/29/23 at 10:42 A.M. revealed Resident #55 was resting in her room. The walls did not have any decorations, very few personal items were noted in the room, paint was peeling off the walls in areas, and multiple nail or screw holes were scattered across the wall to the right of the residents' bed. Observation of her bathroom revealed a dirty toilet with bowel movement in it, a putrid smell, and a rattling exhaust fan. Interview on 11/29/23 at 10:46 A.M. with RN #145 confirmed the findings in Resident #55's room and bathroom.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on observation, record review, review of a facility Self-Reported Incident (SRI) and investigation including witness statements, review of the facility Abuse policy and staff and resident interviews, the facility failed to ensure Resident #27 was free from staff to resident physical and verbal abuse. This resulted in Immediate Jeopardy and actual psychosocial and physical harm on 07/05/23 at approximately 11:00 A.M. when State tested Nursing Assistant (STNA) #50 and STNA #60 witnessed Licensed Practical Nurse (LPN) #30 scream at Resident #27, grab the resident by the arm, and forcibly moving the resident from her wheelchair to a shower chair in the shower room. Resident #27 was observed by both STNAs to be sobbing uncontrollably and hyperventilating during the incident. STNAs #50 and #60 did not intervene appropriately or immediately report the abuse incident to the Administrator. LPN #30 continued to work on the floor for an additional two hours and 15 minutes following the incident before being relieved of her duties. This affected one resident (#27) of three residents reviewed for abuse and placed an additional 19 residents (#33, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, and #71) at risk for potential harm when LPN #27 had unrestricted access and continued working following the abusive incidents. The facility census was 70. On 07/13/23 at 11:55 P.M., the Administrator was notified the Immediate Jeopardy began on 07/05/23 at approximately 11:00 A.M., when Resident #27 was witnessed being physically and verbally abused by LPN #30. On 07/05/23 at 11:00 A.M., STNA #50 and STNA #60 observed LPN #30, enter the facility shower room after being asked for assistance with Resident #27. LPN #30 entered the shower room and pointed her finger at the resident and stated, You will be getting a shower today or you will be going to psych. The nurse then stated, You are either going to psych or getting the needle, I've done it before, and I'll do it again. At this point, Resident #27 began crying and physically swung her arm at LPN #30. The nurse then forcibly grabbed the resident by the arm and pulled it up to place her other arm under the resident. The nurse then transferred the resident to a nearby shower chair with enough force to knock several items off a nearby shelf which scattered all over the floor. At this point, Resident #27 was observed by both STNAs to be sobbing uncontrollably and hyperventilating. LPN #30 then left the shower room to return to her duties as the floor nurse. STNA #50 and #60 did not report the physical and verbal abuse immediately. Both STNAs then completed the shower for Resident #27 and finished at approximately 11:55 A.M., at which time the resident was noted to be calm. Both STNAs then reported the incident to Registered Nurse (RN) #90 after assisting the resident to her bed. The facility did not immediately suspend LPN #27 and she continued to work over two hours and 15 minutes providing care to the residents and passing medications following the incident, until 1:15 P.M. which placed the other residents at risk for potential further abuse. The Immediate Jeopardy was removed, and the deficiency corrected on 07/06/23 when the facility implemented the following corrective actions: On 07/05/23 at 11:55 A.M., Resident #27 was assessed by RN #90 with no negative findings on skin assessment. On 07/05/23 at 3:54 P.M., RN #90 completed a pain assessment for Resident #27 with no issues noted. The Administrator completed a Patient Health Questionnaire (PHQ-9) for depression with the resident scoring at baseline. On 07/05/23 at 4:09 P.M., LPN #190 interviewed Resident #27 with no concerns. The resident agreed she was okay with receiving her shower. On 07/05/23 at 4:20 P.M., Resident #27 was evaluated by Psychologist #1 with no concerns. On 07/05/23 at 1:15 P.M., the Administrator removed LPN #30 from her work duties to complete an interview and obtain a statement. The LPN was removed from the facility on 07/05/23 at 2:28 P.M. and remained off work until being terminated on 07/10/23 at 4:00 P.M. On 07/05/23 at 3:30 P.M., an AD HOC Quality Assurance and Performance Improvement (QAPI) meeting was held with the Administrator, Director of Nursing (DON), Medical Director #5, RN #90, RN #110, LPN #190, Admissions Director #10, Maintenance Director #15, Business Office Manager #20, Medical Records #888 and Rehabilitation Director #8. The meeting was held to ensure the facility would comply with the abuse policy and timely reporting to ensure all staff were educated on the abuse policy. On 07/05/23 at 5:08 P.M., the Administrator submitted an initial SRI to the State agency related to the abuse incident involving Resident #27. On 07/05/23 at 5:30 P.M. a skin sweep of all non-alert residents was completed by RN #90 and RN #110 and interviews with alert and oriented residents were completed by RN #90, RN #110, and Housekeeping Supervisor #79. All alert and oriented residents were interviewed with no complaints of abuse and no concerns were found on the skin sweeps of all non-alert residents. On 07/05/23, RN #90, RN #110, and Housekeeping Supervisor #79 completed education for all 77 facility staff on the facility's abuse policy including reporting abuse. On 07/05/23, employee questionnaires were initiated to ensure competency and to be completed weekly for four weeks and will run with Quality Plan for two months with Medical Director involvement. On 07/06/23, RN #90 completed a skin assessment, pain assessment, and follow up interview with Resident #27. No complaints or signs of distress were noted. On 07/07/23 at 10:10 A.M., Nurse Practitioner #300 assessed Resident #27 with no physical or psychosocial effects noted related to shower incident. From 07/08/23 through 07/10/23, LPN #190 assessed Resident #27 each day for skin assessment and for psychosocial effects following the incident with no new concerns noted. Beginning on 07/06/23, online education was assigned to all staff titled Abuse Prevention, Dealing with Difficult Behaviors. All 77 staff members completed the education by 07/12/23. On 07/11/23 at 4:36 P.M., the Administrator reported LPN #30 to the Ohio Board of Nursing related to the physical and verbal abuse of Resident #27. On 07/12/13 and 07/13/23, interviews were conducted with facility staff including LPN #190, LPN #619, STNA #200, STNA #620, and RN #313 which revealed they had received abuse/neglect training and could verbalize information regarding abuse prevention and proper procedures to follow reporting abuse. On 07/12/13 and 07/13/23, the records of two additional residents (#23 and #32) were reviewed for abuse. There were no additional concerns noted. Findings include: Record review for Resident #27 revealed the resident was admitted to the facility on [DATE] with diagnoses including lack of coordination, muscle weakness, schizophrenia, and cataracts. Review of the Facility Activities of Daily Living (ADL) and Cognitive Impairment assessment dated [DATE] revealed Resident #27 had severe cognitive impairment and required staff assistance with bathing, dressing, continence, and toileting. Review of a facility SRI dated 07/05/23 revealed the facility reported an allegation of verbal and physical abuse involving Resident #27. The allegation concluded LPN #30 grabbed Resident #27 on the bicep and transferred the resident to the shower chair while verbally stating that behaviors exhibited by the resident get people the needle or sent to psych. This incident allegedly took place in the shower room. This incident was reported by two STNAs (#50 and #60) who witnessed the event. Statements were obtained by all involved parties, with LPN #30 being suspended following the events. The responsible party and Medical Director were notified on 07/05/23 of the incident. LPN #30's personnel file was reviewed with no previous infractions of this kind. Law Enforcement was notified of the allegation on 07/07/23. As a result of the investigation, the facility substantiated the allegation of abuse. Review of Resident #27's medical record revealed it did not include any documentation regarding the witnessed physical and verbal abuse towards the resident on 07/05/23. Review of Resident #27's skin assessment completed on 07/05/23 at 11:55 A.M. by RN #90 revealed no documented skin issues. Review of STNA #50's witness statement dated 07/05/23 revealed she witnessed LPN #30 yell at Resident #27 in the shower room stating, You will be getting a shower today. The nurse also stated, I've given you the needle before, and I'll do it again or you'll be sent to psych. The statement included LPN #30 then grabbed the resident by the arm and roughly transferred the resident to the shower chair. STNA #50 stated Resident #27 was sobbing uncontrollably during this incident. Both STNAs (#50 and #60) then completed the shower and brought the resident back to her room and put her into bed. The incident was reported to RN #90. Review of STNA #60's witness statement dated 07/05/23 revealed STNA #60 witnessed LPN #30 being verbally and physically abusive towards Resident #27. STNA #60 told Resident #27 that she was getting a shower today, and I've given you the needle before and I'll do it again. The statement also indicated LPN #30 then forcibly grabbed the resident by the arm and transferred her to the shower chair. Further review of the facility's investigation revealed a statement completed on 07/05/23 from LPN #30 indicating she had responded to the shower room due to the resident not wanting to stand for a transfer to the shower chair. LPN #30 stated Resident #27 swung at her, and she informed the resident she could not be hitting staff. The statement reflected that she told the resident she could not hit staff as residents have been sent to psych for doing so. The statement also revealed she told the other staff that she had to give the resident an injection in the past for hitting while in another medical facility. Review of LPN #30's timecard sheets dated 07/12/23 revealed LPN #30 worked in the facility on 07/05/23 from 7:00 A.M. to 2:28 P.M. Observation and attempted interview with Resident #27 on 07/12/23 at 11:00 A.M. revealed the resident was alert and responded to her name. Resident #27 had no memory of the incident but did answer yes when asked if staff treated her good and she did he feel safe. No observations of injuries were noted at the time. On 07/12/23 at 11:20 A.M., interview with STNA #50 revealed on 07/05/23 she had taken Resident #27 to the shower room for a shower around 11:00 A.M. with STNA #60. She stated she was told by LPN #30 to give the resident a shower, even though the resident preferred a bed bath at times. She stated the resident would not stand to be transferred to the shower chair, so another STNA was asked to go and get the nurse. She stated the nurse (LPN #30) entered the room and pointed at Resident #27 stating, she would send her to psych, or she would get the needle as she had done it before. She stated the resident began crying and swung her arm at LPN #30, who then grabbed the resident's arm while saying you're getting a shower now. She stated the nurse then jerked the resident out of her wheelchair and put her in the shower chair very hard. She stated the resident was crying so hard that her nose was running. STNA #50 verified she didn't attempt to intervene when observing LPN #30 abuse Resident #27. She stated STNA #60 and herself then calmed the resident down and proceeded to give her a shower without further incident. She stated the resident was assisted back to bed after the shower, and she went to RN #90 to report the incident, who got her statement and took her to the Administrator. STNA #50 verified she continued with the shower as directed by LPN #30 and did not report the allegation of abuse until after the shower was given to Resident #27, which was approximately around 11:55 A.M. On 07/12/23 at 12:40 P.M., interview with STNA #60, revealed there was a meeting one day (date note provided) by RN #90 when education was provided to promote more showers and less bed baths to residents. She stated on 07/05/23, Resident #27 was having a difficult time and not wanting to stand for her transfer in the shower room. LPN #30 was called to the shower room by another STNA. She stated the nurse immediately pointed at the resident and said, You are getting a shower today and further stating she would send her to psych, or she would get the needle. She had done it before, and she would do it again. She stated the resident and LPN #30 had previous knowledge of each other from a previous psychiatric facility. She stated the nurse then roughly grabbed the resident by the right bicep and pulled her up to standing. She then placed her arm under the resident's arm. She stated the resident was crying and hyperventilating at this point when the nurse roughly put her in the shower chair. She stated that during the transfer, supplies had been knocked over and scattered all over the floor including shampoo and soap. STNA #50 verified she didn't attempt to intervene when observing LPN #30 abuse Resident #27. She stated STNA #50 and herself calmed the resident down, finished the shower, and took the resident back to bed with no further incident. She stated she reported the incident to RN #90 at approximately 11:55 A.M. Interview with the Administrator on 07/12/23 at 10:10 A.M. verified the events from 07/05/23 involving Resident #27 and LPN #30 which the Administrator revealed were investigated beginning on the same date. He stated all findings during the investigation were accurate which substantiated (the incident of abuse) as reported to the State agency in the SRI. The Administrator stated LPN #30 was terminated on 07/10/23 following the facility investigation. The Administrator verified he was informed of the incident at approximately 1:00 P.M. on 07/05/23. He also verified the incident should have been reported right then at the time it occurred. Interview with RN #90 on 07/12/23 at 2:00 P.M. revealed during the in-service she conducted with staff prior to 07/05/23, information was given to provide showers to all residents who did not refuse. She stated this was entirely based on resident preference. She verified both STNA #50 and #60 came to her on 07/05/23 at 11:55 A.M. and informed her of an incident in the shower room. She stated that while taking statements, she informed the Administrator of the allegations. Review of the LPN #30's floor assignment for 07/05/23 revealed Residents #33, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, and #71 were assigned to LPN #30. LPN #27 had unrestricted access to these residents for two hours and 15 minutes after she physically and verbally abused Resident #27 in the shower room. Review of the facility's policy titled Abuse, Neglect, and Exploitation, dated July 2020, revealed it is the policy of the facility, the resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This included but not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical condition. Section 6 Resident Protection actions included: Efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. One example included responding immediately to protect the alleged victim and integrity of the investigation. This deficiency represents non-compliance investigated under Control Number OH00144391.

Based on review of a self reporting incident (SRI), medical record review, resident interview, staff interview and policy review, the facility failed to ensure one resident (Resident #65) was free from physical abuse. This affected one of six residents reviewed for abuse. Actual Harm occurred to Resident #65 when Resident #1, who was known to be aggressive and wander throughout the facility, entered her room and struck the resident with a closed fist multiple times resulting in a hematoma to her left forehead, a bloody nose and a black eye. Findings include: 1. A review of self reporting incident (SRI) # 1 revealed an allegation of physical abuse was reported on 11/12/22. The initial source of the investigation was a staff member and the alleged perpetrator was another resident. The involved residents were identified as Resident #1 (alleged perpetrator) and Resident #65 (alleged victim). Resident #1 was not able to provide any meaningful information when interviewed. Her relevant conditions included unspecified [CONDITION(S)], major depressive disorder, and schizo-affective disorder. Resident #65 was indicated to have been able to provide meaningful information when interviewed. The date/time and location of the occurrence was on 11/12/22 at 2:09 P.M. in a resident's room. The narrative summary of the incident revealed staff heard residents yelling. When staff went into Resident #65's room, they noted her to be grabbing Resident #1's shirt. The staff also noted blood on Resident #65's face and on Resident #1's hand. The staff immediately separated and removed Resident #1 from the room and placed her on one on one supervision. Resident #1 had a BIMS score of 3 (cognition severely impaired) and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #65 stated that Resident #1 came into her room and was attempting to take the remote control and a sandwich that were located on her bed. Resident #65 was in her wheelchair by her bed and attempted to redirect Resident #1. She was struck in the face by Resident #1. Both residents' skin was assessed and no injuries were noted to Resident #1. Resident #65 was noted to have a hematoma to the left upper eye brow, an abrasion under her left eye, a small abrasion to the left chest, and a bloody nose. Neuro checks were completed immediately on Resident #65 and continued for 72 hours with no adverse reaction noted. Resident #65 was indicated to have a BIMS of 15 (cognitively intact). She was indicated to not be fearful, afraid or tearful when the incident occurred. Resident #65 had been followed by social services and had not voiced any concerns since the incident occurred. Resident #1 was placed on one on one supervision until she was sent to the emergency room for a psychiatric evaluation. Resident #1 was admitted to the hospital for inpatient geri-psych services. Skin assessments were completed on all residents with a BIMS score under 10 (cognition moderately to severely impaired) and all residents with a BIMS score above 10 (high end of cognition being moderately impaired to being cognitively intact) were interviewed. No additional issues were noted as a result of those skin assessments and interviews. The physician and responsible parties for both residents were made aware. The facility unsubstantiated the allegation of abuse as Resident #1 was deemed to lack the capacity to understand consequences to her actions. The facility's DON was identified as the facility's investigator and the incident was reported to the local sheriff's department. As a result of it's investigation, the facility indicated they placed Resident #1 on one on one supervision and she was sent to the emergency room for a psychiatric evaluation. She was later admitted . Treatments were ordered and ice was applied to Resident #65's new areas. Social services was following Resident #65 for any concerns. Neuro checks were started immediately and continued for 72 hours with no adverse reactions noted. The facility's investigation included an incident report completed by Licensed Practical Nurse (LPN) #7 for an incident involving Resident #65 that occurred on 11/12/22 at 2:09 P.M. The incident report included an incident description which indicated the resident (Resident #65) was hit by another female resident (Resident #1) on the left forehead causing a large hematoma that was raised and purple in color. She was also indicated to have sustained a small abrasion under her left eye, a small abrasion on the right chest, and moderate bleeding from the nose. Cold compresses were applied to stop the bleeding and ice was applied to the hematoma to the head. The resident's description of the incident revealed the other resident was trying to take her sandwich and remote control. When Resident #65 started to stop her, the other resident started hitting her with her first. Immediate action taken included staff entering the room and redirecting the other resident out of the room. She (other resident/Resident #1) was angry and yelling at the staff while trying to hit them. She was assisted over to B- Hall, where she resided, and passed to the staff on that hall. Witnesses identified on the incident report included State tested Nurse Aide (STNA) #11 and Resident #60 (roommate of Resident #65). STNA #11 reported in her statement that she overheard residents yelling so she went into Resident #65's room. She saw Resident #65 have a hold of Resident #1's shirt. Resident #1 was taking objects from Resident #65. Resident #65 had blood on her face, arms, and clothing and there was blood on the floor. Resident #65 stated Resident #1 hit her multiple times in the face with her hand when she told her not to take her belongings. A statement from Resident #60 (as documented on the incident report) revealed she was the only witness to the incident. She reported the other resident (Resident #1) came in the room and attempted to take a sandwich and TV remote. The other resident then started to hit Resident #65 with her fist when she tried to stop her. The incident report indicated the Director of Nursing (DON) was notified of the incident on 11/12/22 at 2:09 P.M. An incident note on behalf of Resident #1 dated 11/12/22 at 2:09 P.M., as completed by the Director of Nursing (DON) revealed she was alerted by staff that Resident #1 had hit Resident #65 while Resident #65 was in her room. Resident #65's sandwich and remote were in place on her bed. Resident #1 was not able to give a description of the incident. Immediate action taken included immediately removing Resident #1 from the room and returning her back to her room while being placed on one on one supervision. The physician was notified and an order was received for her to be sent to the emergency room for an evaluation and treatment. The hospital called at 8:06 P.M. and reported Resident #1 was being admitted to the psychiatric unit. Witnesses were indicated to be Resident #65 and STNA #11. Resident #65 indicated in her statement (as documented on the incident report) she (Resident #1) was trying to take her (Resident #65's) stuff and when she told Resident #1 to stop, Resident #1 started to hit her. STNA #11's statement was the same that was on the incident report completed on behalf of Resident #65. She also indicated she removed Resident #1 from the room and notified the nurse. The facility's investigation file included written statements from STNA #11 and STNA #15. Both were assigned to work Resident #65's hall the afternoon of 11/12/22, when the incident between Resident #1 and Resident #65 occurred. A written statement from STNA #11 dated 11/12/22 revealed she overheard residents yelling so she went into Resident #65's room. She saw Resident #65 have a hold of Resident #1's shirt. Resident #1 was taking objects from Resident #65. Resident #65 was noted to have blood on her face, arms, clothing and floor. Resident #65 stated Resident #1 hit her multiple times in the face with her hand when she told her not to take her belongings. A written statement from STNA #15 dated 11/12/22 revealed he heard screaming from Resident #65's room. He went into the room and the other aide (STNA #11) broke them up. He didn't see any behaviors leading up to that before the incident happened. Additional written statements were obtained from STNA #11 and STNA #15 on 11/16/22. The statement from STNA #11 revealed she was asking Resident #65 how she was feeling since the incident with the other resident (Resident #1). At that time, she alleged Resident #65 told her she grabbed the other resident's (Resident #1) shirt first because she was taking her sandwich. That was when the other resident hit her in the face. The second written statement from STNA #15 revealed Resident #65 told him, when he was getting her up that morning, that she (Resident #65) grabbed her (Resident #1's) shirt first. 1 (a). A review of Resident #65's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #65's quarterly Minimum Data Set (MDS) assessment completed 09/07/22 revealed the resident did not have any communication issues and her vision at that time was moderately impaired. Her cognition was moderately impaired with a BIMS score of 11. She was not known to have displayed any behaviors. She required an extensive assist of two for transfers. Ambulation did not occur. She required a limited assist of one for locomotion on the unit and a wheelchair was listed as a mobility device used. A review of Resident #65's progress notes revealed a nurse's note dated 11/12/22 and documented at 3:34 P.M. that indicated the resident was sitting in her room when another resident came in. The other resident was trying to take her sandwich and remote. The resident's roommate yelled and Resident #65 tried to stop her. The other resident started hitting Resident #65 with her fist. The staff responded and assisted the other resident out of her room. A large hematoma was noted to the left forehead, she was noted to have a bloody nose and abrasions were noted under her left eye and to her right chest. 1 (b). A review of Resident #1's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's quarterly MDS dated [DATE] revealed the resident had clear speech and her cognition was severely impaired. She was known to have delusions but not indicated to have any other behaviors. She required an extensive assist of two for transfers. Ambulation did not occur. She required supervision with one person assist for locomotion on and off the unit and a wheelchair was listed as a mobility device used. A review of Resident #1's active care plans revealed she had a care plan in place for having the potential to be physically aggressive or agitated related to dementia. The care plan had been in place since 07/11/22. The goal was for her to not harm herself or others. Interventions included administer medications as ordered, analyze times of day/ places/ circumstances/ triggers/ and what de-escalates behaviors and document, monitor/document/report as needed any signs or symptoms of the resident posing a danger to herself and/or others, and obtain psychiatric consult as indicated. Resident #1 also had a care plan for exhibiting inappropriate social behavior of impulsiveness, at times difficult to redirect, careless in wheelchair, wanders throughout hallways, argumentative with staff and physical aggression towards staff and residents. The care plan was updated 11/15/22 to reflect a resident to resident altercation. The goal was for the resident's inappropriate behaviors would be managed. The interventions included during episodes of socially inappropriate behavior, redirect by staff, observe for change or increase in agitation, one on one (11/15/22), send to emergency room for inpatient psychiatric stay (11/15/22), and separate from others when demonstrating socially inappropriate behaviors (05/22/20). Resident #1 also had a care plan for being disoriented to place, impaired safety awareness, and wanders aimlessly. The goal was for her safety to be maintained. The interventions included distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, maintain consistent daily routine and consistent bedtime routine, and use of a wander alert as ordered. A review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She was to be one on one until she was able to be sent to the ER. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's progress notes revealed the facility had been seeking alternate placement at other nursing facility's following the resident's return from the hospital on 11/16/22. Her family was in agreement for seeking alternate placement and referrals had been made. On 11/17/22 at 12:53 P.M., an interview with Resident #60 (roommate of Resident #65) revealed she was witness to the alleged incident that occurred between Resident #1 and Resident #65 on 11/12/22. Resident #1 came into their room while Resident #65 was sitting in her wheelchair by her bed. Resident #1 grabbed a hold of Resident #65's sandwich and wouldn't listen when she was told to let go of it. Resident #1 then hit Resident #65. She denied Resident #65 grabbed Resident #1 and claimed Resident #65 just told her to leave her alone. She reported Resident #1 had a closed fist when hitting Resident #65 and Resident #65's nose was bleeding. Resident #1 had been known to come in their room before, but she had not known her to hit anyone before. On 11/17/22 at 12:58 P.M., an interview with Resident #65 confirmed Resident #1 came into her room on 11/12/22. She reported she was blind and could not see but her roommate told her that woman (Resident #1) was in there. She stated she pushed Resident #1 away in her wheelchair. She denied touching her when pushing her wheelchair away. She was asked if she had grabbed Resident #1's shirt during the incident. She admitted that she had, but it was after trying to push her away. When she pushed Resident #1 away, that was when Resident #1 began beating her with her fist. She then stated she grabbed Resident #1's shirt after Resident #1 started hitting her. She just wanted the resident to go away as the resident was hurting her. She claimed she was hit six times and her nose and mouth was bleeding. She pulled down her shirt to reveal the abrasion that remained on her right chest. Her left eye was still black/ blue around the eye. She denied she was afraid since Resident #1 left the facility but it was still shocking to her. She stated she would be afraid if the resident returned. She had not been informed of the other resident's return and kept asking if she had. She reported Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She claimed the other resident has pushed her before but that was the first time she had beat her. She denied that she recalled telling staff on 11/16/22 that she grabbed the other resident's shirt first. She said again she did grab her shirt at one point but was not exactly sure when it occurred as it all happened so fast. On 11/17/22 at 1:12 P.M., an interview with STNA #15 revealed he was there on 11/12/22, when the incident occurred between Resident #1 and Resident #65. He was assigned to Resident #65's hall that night. He stated he heard screaming from Resident #65's room. His coworker (STNA #11) was the first in the room and had already separated them. He stated he grabbed Resident #1 and took her back to her hall. He noticed Resident #65 was bleeding. He stated Resident #65 told him she grabbed Resident #1 first by her shirt. He thought the other resident had a trigger about being grabbed. If she would not have grabbed Resident #1, then Resident #1 would not have hit her. He then stated there would be no way to know that for sure. He confirmed he did write up statements on the incident at the time of the incident but had given a second statement four days when Resident #65 told him she grabbed Resident #1 first. He claimed the conversation about Resident #65 grabbing Resident #1 first was brought up by Resident #65 when they were providing her with care. She told him she grabbed the other resident first. He was asked about his initial statement he gave indicated that Resident #65 told him when he entered the room on 11/12/22 that she had grabbed Resident #1 first. He denied saying that and indicated he must have been misunderstood as it was not until four days later (11/16/22) that Resident #65 told him that. He denied he was asked to provide the second written statement given on 11/16/22 by anyone else. On 11/17/22 at 1:20 P.M., an interview with STNA #11 confirmed she was working A- Hall when the incident between Resident #1 and #65 took place. She reported she was the first one there and separated the residents. She recalled being down the hall when she heard screaming. She heard Resident #65 say give me my sandwich back. When she got there, Resident #65 had blood all over her and had a hold of Resident #1's shirt. Resident #1 had Resident #65's sandwich and remote control in her hand. She stated she told Resident #65 to let go of Resident #1's shirt. She then told Resident #1 to give Resident #65 her remote control. She reported, at that point, the sandwich was already on the floor. Resident #1 was yelling back at her and was saying that was her sandwich. After the residents were separated, she stepped out in the hall and called for the nurse (LPN #7). Her coworker (STNA #15) took Resident #1 out of the room. A nurse from B- Hall came and got Resident #1 and LPN #7 assessed Resident #65. She began assisting with cleaning up Resident #65. She asked Resident #65 to remove her dentures as she had blood coming from her mouth. Resident #65 reported being hit four to five times but her roommate had said she was hit only twice. Resident #1 was known to wander into rooms and take things. It was mainly remote controls that she tried to take but had been known to try to take other things such as candy too. She had known Resident #1 to be aggressive. She was known to grab staff during care and run her wheelchair into other residents. She confirmed she had been known to hit staff before but couldn't recall her hitting other residents. She (Resident #1) was aggressive though. She confirmed Resident #1 had been in Resident #65's room in the past. They were usually able to catch her first and redirect her. She confirmed she wrote a statement the day of the incident and wrote another statement after that on 11/16/22. She stated they were asking Resident #65 about how she was doing after the incident and Resident #65 reported she grabbed Resident #1's shirt after she took her sandwich. She denied she was prompted by anyone to write the second statement. She denied that grabbing Resident #1's shirt first justified Resident #1's action or Resident #65 being hit. She stated she would consider what happened to Resident #65 to be abuse. She knew Resident #65 felt she was abused too. Resident #65 told her that was the first fight she had been in her entire life. She confirmed Resident #1 had been on one on one supervision since her return from the hospital. On 11/17/22 at 3:40 P.M., an interview with the Administrator and DON revealed most of the facility's investigation for SRI # 1 was completed by DON as the Administrator was out of the building that week and only participated via FaceTime. He was involved in the latter part of the investigation, when he returned on Monday (11/14/22). He stated the facility unsubstantiated the allegation of physical abuse based on Resident #1's inability to understand the consequences of her actions. They felt since she was cognitively impaired there was no willful intent. They reviewed the definition of abuse and willful intent as defined in their Abuse policy. They acknowledged the definition of willful meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. They were not aware that abuse could come from a cognitively impaired resident and the resident did not have to have an understanding of what they were doing to make it abuse. The act just needed to be deliberate and Resident #1 hitting Resident #65 in the face was a deliberate act. A review of the facility's Abuse, Neglect, and Exploitation policy revised 10/24/22 revealed it was the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which could include staff to resident abuse and certain resident to resident altercations. Willful was defined as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. This deficiency represents non-compliance investigated under Complaint Number OH 556.

Based on observation, record review, facility policy and procedure review and interview the facility failed to develop and implement comprehensive and individualized restorative nursing services to ensure interventions and treatments were provided to prevent a decline in range of motion or maintain current range of motion (ROM) status for all residents. Actual Harm occurred for Resident #49, who was admitted with no limitations to range of motion, when the facility failed to timely identify and implement effective interventions to prevent and treat contractures to the resident's bilateral lower extremities. Although the facility was unable to determine an exact date when the resident started to exhibit decreased ROM of the lower extremities, staff reported they had noticed a change in the resident in the last year. There was no documented evidence the resident had received any type restorative or ROM services to the lower extremities to prevent the contractures or prevent them from worsening resulting in the resident experiencing increased pain and immobility. Hospice notes indicated the resident was badly contracted and had pain with transfers due to the contractures requiring an increase in his pain medication. Actual Harm occurred for Resident #7, who was cognitively impaired and dependent on staff for care, when the facility failed to identify and implement effective interventions to prevent and treat a contracture to the resident's left hand resulting in increased pain and decreased mobility. Although the facility was unable to determine an exact date when the resident started to exhibit decreased range of motion/contracture to the left hand one staff member reported she had noticed the contracture about a month ago. The facility failed to provide ROM services to prevent the development of the contracture and to properly treat once it was first identified. The resident was observed to exhibit increased pain during passive range of motion. Actual Harm occurred for Resident #22, when the facility stopped applying ordered splinting devices ordered for the left elbow and leg because they were lost during a room change which resulted in an identified decline in the resident's functional abilities. In addition, the facility failed to provide range of motion services as ordered resulting in a decline in range of motion for the resident. This affected five Residents (#7, #22, #41, #49, and #59) of six residents reviewed for mobility. The facility census was 74. Findings include: 1. Record review revealed Resident #49 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed the resident was admitted to Hospice services on 11/13/19. Review of Resident #49's admission assessment, dated 07/30/18 revealed the resident had no limitations in range of motion. The resident ambulated independently, however liked to sit and crawl around on the floor. Record review revealed a plan of care, initiated on 08/01/18 and revised 11/18/21 related to limitations in physical mobility. The goal developed was for the resident to maintain current level of mobility. Interventions included staff would monitor, document, report as needed any signs or symptoms of immobility including contractures forming or worsening, thrombus formation, skin-breakdown or fall related injuries. Review of Resident #49's medical record revealed the last documented evidence the resident received any type of range of motion (ROM) services was from 05/15/20 to 06/2020 with ROM being provided to the resident's bilateral upper extremity. However, the documentation revealed the services were discontinued because the resident did not meet goal. There was no evidence the resident received any type of restorative treatment or ROM services since 06/2020. Review of Resident #49's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/15/22 revealed the resident had functional impairment on both sides of the lower extremities. The assessment revealed walking did not occur during the assessment reference period and the resident required a wheelchair for mobility with extensive physical assistance from one or two staff (for mobility). Review of Resident #49's Hospice notes revealed a note, dated 12/28/21 indicating the resident was dependent on the nursing facility for all activities of daily living (ADL) care. The note indicated the resident was badly contracted to the upper and lower bilateral extremities which made measuring circumferences difficult as the resident's limbs become more drawn up. The contractures were worse on the left side. The resident's neck needed significant support and repositioning or it stayed strained and fallen over towards the left side. The resident required a sizing up in briefs because the contractures were making care and repositioning more difficult. The sizing up in the briefs was NOT due to weight gain. On 03/09/22 a Hospice note revealed the resident's pain medication, [MEDICATION(S)] was increased to three times daily because the facility nurse reported the resident had pain with transfers and positioning. There was no evidence the facility had Hospice care plan for the resident reflecting pain management, positioning or contracture issues. Further review of Resident #49's progress notes, including physician's notes dated 01/01/22 to 04/12/22 revealed no evidence or mention of contractures. From 04/04/22 to 04/08/22 during the annual survey random intermittent observations made revealed during every observation the resident was in bed with his legs observed to be pulled up at the hip level toward his chest. On 04/06/22 at 2:55 P.M. interview with Therapy Coordinator #130 revealed the resident had been in Hospice for over two years and had not received any therapy services or quarterly screenings during that time period. On 04/08/22 at 2:28 P.M. Resident #49 was observed in bed lying on his side. The resident's legs were observed to be contracted up to his waist. On 04/08/22 at 2:30 P.M. interview with State tested Nursing Assistant (STNA) #720 revealed the resident's contractures had worsened in the last year. The STNA reported the resident was not on any type of restorative program and did not use any type of splinting devices because he was on Hospice. During the interview, the STNA confirmed the resident's legs would not straighten/extend out and they had been drawn up to his waist for a while. The STNA confirmed Hospice had to change size of briefs (to a larger size) because it was difficult to put the briefs on due to the resident's contractions. On 04/08/22 at 3:38 P.M. interview with Registered Nurse (RN) #850 verified Resident #49 was admitted to the facility on [DATE] with no functional impairment or range of motion impaired. The RN confirmed Hospice documented the resident was badly contracted in their note on 12/28/21. RN #850 confirmed according to the resident's medical record there was no evidence the resident had been provided any restorative nursing services including range of motion services to prevent or address the development of contractures and limitations in functional ability since 06/13/20. RN #850 confirmed the resident was not currently receiving any type of ROM services. Resident #49 sustained increased pain and decreased functional mobility related to the lack of services being provided. Review of the facility policy titled Range of Motion, dated 01/01/21 revealed the facility in collaboration with the medical director, director of nursing and as appropriate physical/occupational consultant shall establish and utilize a systematic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventive care. Range of motion (such as current extent of movement of his/her joints and the identification of limitation) would be assessed on admission/readmission, quarterly and upon a significant change. Review of facility policy titled Restorative Nursing Programs, dated 01/01/21 revealed residents could benefit from a restorative program to prevent contractures. 2. Record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence of left hand/wrist contractures on admission. A plan of care, dated 09/15/21 revealed Resident #7 required activity of daily living assistance for personal care. The care plan revealed physical therapy, occupational therapy and speech therapy were to evaluate and treat resident as needed. Review of Resident #7's Nursing Admission Evaluation Part 2 document, dated 09/16/21, revealed Resident #7 had limited range of motion (ROM) to the left lower extremity (LLE). There was no documented evidence of limited ROM to the left upper extremity. Review of Resident #7's admission Minimum Data Set (MDS) 3.0 assessment, dated 09/22/21 revealed the resident had moderate cognitive impairment and had functional limitations in ROM in both upper extremities and one lower extremity. Review of Resident #7's physician's orders, dated 10/20/21 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's quarterly therapy screens, dated 11/16/21 and 03/02/22 revealed no evidence of quarterly screenings for physical or occupational therapy were completed. Review of Resident #7's quarterly MDS 3.0 assessment, dated 01/05/22 revealed the resident was severely cognitively impaired and had functional limitation in ROM with upper extremity and lower extremity impairment on one side. Further review of Resident #7's medical record revealed no evidence the resident was receiving therapy or a restorative program. On 04/05/22 at 9:48 A.M. Resident #7 was observed lying in bed with her left hand in a tight fist. The resident's left elbow was observed at a 90-degree angle with her fist positioned on her abdomen. The resident did not move her left hand or the fingers on her left hand freely. On 04/06/22 at 9:00 A.M. interview with Certified Nursing Assistant (CNA) #240 revealed she was not aware of any therapies or restorative programs for Resident #7. On 04/06/21 at 12:52 P.M. observation of Resident #7's left hand with Registered Nurse (RN) #100 present revealed RN #100 attempted to place her finger inside the fist of Resident #7 and passively move Resident #7's fingers. Resident #7 cried in pain. RN #100 immediately stopped the attempt. On 04/06/22 at 3:05 P.M. interview with RN #100 revealed she had spoken with occupational therapy staff and they were not aware of Resident #7's left hand being tightly closed and an inability to do passive ROM on the hand and fingers due to the resident crying out in pain. On 04/06/22 at 4:53 P.M. interview with CNA #660 revealed she wasn't sure how long Resident #7's left hand had been in a fist (contracted). CNA #660 reported she hadn't worked on the resident's hall very long and hadn't care for Resident #7 very much. The CNA then added, I know it takes a while for a hand to get in a tight fist like that. On 04/06/22 at 4:54 P.M. interview with CNA #380 verified she usually worked the unit where Resident #7 resided. CNA #380 reported she wasn't sure how long Resident #7's left hand had been in a tight fist and then indicated it had been that way for approximately one month. Review of an occupational therapy evaluation noted, dated 04/07/22 revealed Resident #7's left upper extremity ROM was impaired. The document also identified a functional limitation in the left arm due to contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Review of the facility policy titled Range of Motion, dated 01/01/21 revealed the facility in collaboration with the medical director, director of nursing and as appropriate physical/occupational consultant shall establish and utilize a systematic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventive care. Range of motion (such as current extent of movement of his/her joints and the identification of limitation) would be assessed on admission/readmission, quarterly and upon a significant change. Review of facility policy titled Restorative Nursing Programs, dated 01/01/21 revealed residents could benefit from a restorative program to prevent contractures. 3. Review of the medical record for Resident #22 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an occupational therapy discharge summary, dated 09/03/21 revealed the resident was tolerable of her soft, left elbow and knee splints without sign of skin breakdown to decrease her risk of further contracture for up to four hours. Further review of the discharge summary revealed the resident was able to demonstrate left shoulder abduction of 52 degrees which had improved from 48 degrees on 08/09/21. The resident was also able to demonstrate left shoulder flexion of 74 degrees which had improved from the 70 degrees she was previously able to do on 08/09/21. She was also able to demonstrate 52 degree left shoulder abduction on 09/03/21 which improved from 48 degrees on 08/09/21. She was able to demonstrate a left shoulder flexion of 74 degrees on 09/03/21 which improved from 70 degrees on 08/09/21. She was discharged from OT with the recommendations for staff to maintain range of motion (ROM) and splinting tolerance. Review of the therapy quarterly screen by Physical Therapy (PT), dated 10/05/21 revealed restorative staff indicated the left lower extremity (LLE)/knee brace was too tight to apply to the resident. The therapy quarterly screen, dated 10/07/21 by PT #210, revealed the resident was added to the physical therapy caseload for contracture management to the LLE/knee. Review of a physical therapy discharge summary, dated 11/04/21 by PT #210 revealed the resident was able to safely wear her knee extension splint on her left knee for up to four hours with minimal signs or symptoms of redness, swelling, discomfort or pain. Further review of the discharge summary revealed the resident's demonstrated left knee extension was -42 degrees on 11/04/21 which had improved from her baseline of -95 degrees on 10/07/21. Review of the quarterly MDS 3.0 assessment, dated 01/19/22 revealed the resident had moderately impaired cognition with a Brief Interview of Mental Status (BIMS) score of 12 of 15 and no documented behaviors. The resident required extensive to total assistance from one to two or more staff members for all activities of daily living (ADL) care. Review of the plan of care, dated 01/26/22 revealed the resident would benefit from a restorative active range of motion (AROM) for impaired physical mobility of her right upper extremity (RUE). Interventions included AROM over 15 minutes, one to two times daily, six to seven days a week, and AROM to her RLE for 15 minutes each. Further review of the care plan revealed the resident would benefit from a passive range of motion (PROM) restorative program related to cerebral vascular accident ([CONDITION(S)]). Interventions included PROM to the resident's affected joints for LLE and LUE, one to two times daily for 15 minutes, and six to seven days a week. Continued review of the resident's care plan revealed she would benefit from splint/brace program for impaired physical mobility to left knee and LUE related to [CONDITION(S)]. Interventions included left knee extension brace two to four hours daily, skin checks before and after brace use, resting hand splint to the left hand to be on for two hours and off for two hours, and soft elbow splint to her left elbow to be on for two hours and off for two hours. Review of the progress note, dated 02/04/2022 at 10:55 A.M. by the Director of Nursing revealed the resident's family was called to inform of the resident being positive for COVID-19 and being moved to the facility Covid unit. Review of the progress note, dated 2/06/2022 at 1:57 P.M. by Licensed Practical Nurse (LPN) #860 revealed the resident was moved to the COVID unit. Review of an occupational therapy (OT) evaluation and plan of treatment, dated 03/27/22 by Occupational Therapist (OT) #1000 revealed the resident would be treated daily, three to five times per week for four weeks from 03/26/22 through 04/24/22. Further review of the evaluation revealed one of the goals for the resident was to tolerate two hours of orthotic wear time with no signs or symptoms of skin integrity issues with a baseline of zero hours on 03/26/22. Another listed goal on the evaluation was for the resident to tolerate her left upper extremity orthotic for six hours with no signs or symptoms of skin integrity issues with a baseline of zero hours on 03/26/22. Further review of the evaluation revealed prior therapy treatment outcome was for the resident to be on restorative nursing program for daily wear of her left resting hand splint. Her prior levels of function (PLOF) for eating, oral hygiene, toileting hygiene, shower/bathing, upper body dressing was substantial/maximal assistance and she was dependent for lower body dressing and putting on/taking off footwear. The resident utilized a left upper extremity orthotic in the past but was no longer wearing the orthotic for unlisted reasons. Further review of the OT evaluation revealed the resident was dependent for eating, hygiene, bathing and dressing and resulted a self-care score of zero out of 12 (12 being the highest function) in the initial assessment/current level of function and underlying impairments section. She was initially assessed on 03/26/22 and determined to have Active Range of Motion (AROM) in the left shoulder that allowed her to have a zero-degree flexion and zero-degree extension. The resident was determined to have passive range of motion (PROM) in the left shoulder that allowed her to have a 45-degree flexion which was a decline from the occupational therapy discharge summary, dated 09/03/21. The resident demonstrated AROM of her left elbow flexion of 110 degrees and -90-degree extension. The resident demonstrated PROM of her left wrist extension of -50 degrees. Her left upper extremity strength was not treated due to contractures and pain. There were functional limitations present due to contracture, but functional limitations were not because of contractures since there was no functional use of her Left upper extremity (LUE) and her current orthotic device would be further assessed and ordered/fabricated. The reason for therapy revealed the resident reported pain in the shoulder and increased pain in the LUE with attempts at PROM, the resident required skilled treatment intervention for manual treatment to increase PROM and utilization of LUE orthotic to decrease upper extremity pain and decrease the opportunity for skin integrity issues. On 04/04/22 at 8:52 P.M. observation and interview with Resident #22 revealed her left elbow and wrist were in a bent condition (flexion) and she was unable to extend the joints upon request. The resident confirmed she was supposed to wear a resting hand splint (which was not in place) but denied wearing any type of elbow splint or leg brace. The resident's hand splint was observed on a dresser in between the resident and her roommate's bed. On 04/05/22 at 3:15 P.M. observation revealed Resident #22 she did not have any braces or splints in place and she continued to have left elbow and wrist flexion. The resident's hand splint remained in the same place on the dresser in between the resident and her roommate's bed. On 04/05/22 at 3:22 P.M. interview with Resident #22 revealed her hand splint had been applied and removed by therapy earlier on this date. The hand splint was not visible in the resident's room at the time of the observation and the resident denied being provided any type of leg brace or elbow splint. On 04/06/22 at 12:18 P.M. observation and interview with Resident #22 revealed her hand splint was not in place and the resident revealed staff had not applied the splint on this date. The resident denied any leg brace or elbow splint being applied. On 04/06/22 at 12:24 P.M. interview with Registered Nurse (RN) #650 revealed nursing was not responsible for the application of splints and denied Resident #22 having any current orders for splints/braces although the RN thought the resident might have had a hand splint at one point. RN #650 revealed therapy staff were responsible to apply ordered splints and nursing did not apply any braces or splints to any residents on her assignment, including Resident #22. Review of a Quality Assistance Form, dated 04/06/22 revealed staff informed Unit Manager #850 Resident #22 was missing her splints and the Laundry and Housekeeping Supervisor #999 was assigned to look for them. On 04/06/22 at 12:48 P.M. interview with Occupational Therapy Assistant (OTA) #160 revealed Resident #22 was being seen by occupational therapy for left arm splinting and the resident was on the physical therapy (PT) list to screen for a left leg brace. OTA #160 confirmed Resident #22 moved rooms when she tested positive for COVID-19 and again after her quarantine period which resulted in her elbow and leg brace being lost/misplaced. OTA #160 revealed a new elbow splint was ordered on 04/06/22 (after surveyor intervention) by central supply staff, she was unsure of the exact date the splint and brace were lost but confirmed it was during the COVID outbreak when the resident was moved from room to room approximately one month ago. She confirmed the resident's leg brace and elbow splint had not been applied since moving rooms approximately one month ago. On 04/06/22 at 12:52 P.M. interview with State tested Nursing Assistant (STNA) #720 confirmed she ordered an elbow brace on 04/06/22 (after surveyor intervention), after searching for the splint and being unable to locate it. She revealed the brace and splint went missing about one month ago during the COVID outbreak and when the resident was moved from room to room. There was no evidence the facility looked to find the brace or re-ordered it timely. On 04/06/22 at 5:46 PM interview with Registered Nurse (RN) #100 confirmed Resident #22's missing brace/splints and confirmed the resident was ordered therapy intervention as a result of a decline in functional mobility associated with the lack of splinting. On 04/07/22 at 8:37 A.M. interview with Physical Therapy Assistant (PTA) #140 and Director of Rehabilitation #130 revealed Resident #22 had been seen by occupational (OT) and physical Therapy (PT) on several occasions for decline in condition. They confirmed the resident was recently placed on PT and OT services for a decline in her functional abilities and confirmed she had a decline in range of motion (ROM) as a result of lack of restorative care. They both confirmed the resident's elbow splint and leg brace were also missing and had not been used since at least the resident's room changes during a COVID outbreak last month. On 04/07/22 at 8:54 A.M. interview with RN #230 revealed she was still learning restorative care and was unsure who was to provide restorative services. She stated she would think an STNA, nurse, therapy or anyone could apply a brace. RN #230 denied applying any braces or splints to residents' on her assignment which included Resident #22. On 04/07/22 at 10:00 A.M. interview with Regional Support RN #100 confirmed there was no policy for splints/braces or missing items. Review of the facility policy titled Range of Motion, dated 01/01/21 revealed the facility in collaboration with the medical director, director of nursing and as appropriate physical/occupational consultant shall establish and utilize a systematic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventive care. Range of motion (such as current extent of movement of his/her joints and the identification of limitation) would be assessed on admission/readmission, quarterly and upon a significant change. Review of facility policy titled Restorative Nursing Programs, dated 01/01/21 revealed residents could benefit from a restorative program to prevent contractures. 4. Review of the medical record for Resident #41 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an OT Evaluation and Plan of Treatment, by OT #4000 dated 06/08/21 revealed the resident had no contractures and no upper extremity impaired strength. The summary did not include any information about the resident's left hand. Review of the quarterly MDS 3.0 assessment, dated 01/03/22 revealed the resident had severe cognitive impairment with a Brief Interview of Mental Status (BIMS) score of three of 15 and no documented behaviors. The assessment revealed the resident required extensive to total assistance from one to two or more staff members for all activities of daily living (ADL) care. Further review of the MDS revealed the resident did not have any functional impairment of the upper or lower extremities. Review of the plan of care dated 01/17/22 revealed the resident had an alteration in musculoskeletal status. Interventions included education of the resident/family/caregivers on joint conservation techniques, monitor for fatigue and plan activities during optimal times when pain and stiffness was abated. There was no specific care plan for contractures or contracture prevention and no physician's orders related to any contractures, contracture prevention, or the resident's left hand. The facility was unable to provide any physical therapy (PT) discharge summary for the resident following attempts on several occasions to request the information through the Administrator and RN #100 during the survey. The facility was unable to provide any documented PT discharge summary. Review of the statement, dated 04/07/22 by Director of Therapy Services #130 revealed she contacted the resident's power of attorney (POA) to address questions and concerns related to Resident #41's hands and hand contractures offering the option for therapy intervention. Further review of the statement revealed the resident's POA, in the past, had adamantly declined therapy services for any reason prior to verbal authorization from her and consent was given. On 04/07/22 at 2:05 P.M. Resident #41 was observed being assisted back to bed. The resident's left hand was observed to be clenched and she was intermittently holding onto her left wrist during care. The resident opened and moved her right hand and fingers and held onto things such as her wheelchair and bed rail with her right hand, but her left hand remained clenched. Upon an attempt to request the resident open her hand, she stated no. STNA #760 and STNA #450 denied the resident opening her hand, using a splint or that the resident received any type of restorative program. On 04/07/22 at 2:21 P.M. interview with Physical Therapy Assistant (PTA) #140 revealed Resident #41 had no contractures that she was aware of. The PTA did confirm the resident tended to keep her left hand clenched but on assessments she was able to open her hand. She confirmed the resident was not receiving therapy services at this time and as far as she remembered the resident did not have a splint for her left hand. On 04/07/22 at 2:28 P.M. interview with Unit Manager #850 revealed she was responsible for the restorative programs and Resident #41 was not receiving restorative therapy for contractures or contracture prevention to her knowledge. Unit Manager #850 revealed she was unsure if Resident #41 was able to open her left hand or if her hand was contracted. She was also unable to report if the resident had a decline in ROM. On 04/07/22 at 2:33 P.M. interview with UM #850 revealed Resident #41 kept her left hand clenched and did not open her fingers despite several attempts for AROM and PROM. On 04/08/22 at 9:47 A.M. Resident #41 was observed up in her wheelchair in the hallway, being assisted to activities. The resident's left hand remained in the a fist position. On 04/08/22 at 9:51 A.M. interview with RN #100 revealed she was unfamiliar with Resident #41 but stated a progress note from 2018 revealed the resident's family did not want therapy services. She was unsure if the care plan reflected the family's choice for no therapy services but stated she would check. She revealed since the family declined therapy the resident should have been receiving ROM services through a restorative nursing program. RN #100 did not dispute the restorative services were not being provided to Resident #41. On 04/08/22 at 12:17 P.M. interview with RN #100 confirmed there was no care plan for Resident #41 family's refusal of therapy services. On 04/08/22 at 12:45 P.M. interview with RN #100 revealed the resident was able to open her left hand and extend her fingers but would pull her hand away and grimace and when asked if her hand hurt, the resident stated yes, hurt, hurt, hurt and continued to pull her hand away. RN #100 also identified the resident's nails were long, extended past the tips of her fingers and jagged. The resident had a tight grip with her left hand but did not have resistance when opening her hand nor did it appear the resident had tightened muscles although the resident immediately balled her fingers back into a fist when she removed her hand. RN #100 confirmed restorative care was needed to ensure the resident maintained ROM, did not experience a functional decline and should have been receiving restorative nursing services for ROM. During the survey, it could not be determined if the resident's functioning of her left hand was her baseline or if there had been a decline in ROM. Review of the facility policy titled Range of Motion, dated 01/01/21 revealed the facility in collaboration with the medical director, director of nursing and as appropriate physical/occupational consultant shall establish and utilize a systematic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventive care. Range of motion (such as current extent of movement of his/her joints and the identification of limitation) would be assessed on admission/readmission, quarterly and upon a significant change. Review of facility policy titled Restorative Nursing Programs, dated 01/01/21 revealed residents could benefit from a restorative program to prevent contractures. 5. Review of Resident #59's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #59's admission Minimum Data Set (MDS) 3.0 assessment, dated 12/30/2021 revealed the resident had clear speech, understands others, made self-understood and her cognition was intact. Resident #59 had minimum depression, no indicators of [CONDITION(S)], no behaviors and did not reject care. Resident #59 required extensive staff assistance from staff for bed mobility, [TRUNCATED]