Every finding on record at Arbors at Stow

Based on observation, interview and review of the facility policy, the facility failed to discard expired food timely. This had the potential to affect all 131 residents receiving food from the kitchen. Facility census was 131.Findings include: Observation on 03/16/26 from 9:25 A.M. to 10:03 A.M. with Food and Nutrition Services Director (FNSD) #642 revealed in the second dry storage room there was a case of bottled water that expired 01/30/24, a case of potato pearls that expired 04/04/24, three expired cases of bottled water that expired 11/30/24, one case of cream of potato soup cans that expired 12/07/24, two two-gallon jugs of water that expired 07/16/25, five cans of corned beef hash that expired 08/23/25, one can of diced green chiles that expired 10/03/25, three cans of mixed fruit that expired November 2025, one case of peanut butter jars that expired 11/21/25, one can of Manwich sandwich filling that expired 11/25/25, six cans of black beans that expired December 2025, one can of mixed fruit that expired December 2025, one case of expired Saltine crackers that expired 12/18/25 and three cans of beets that expired 12/28/25. Interview on 03/16/26 at 9:32 A.M. with FNSD #642 verified the observed food items were expired and should have been discarded prior to the observation.Review of the facility policy, Food Storage: Dry Goods, dated February 2023 revealed all dry goods will be appropriately stored in accordance with the food code. All packaged and canned food items will be kept clean, dry and properly sealed. Storage areas will be neat, arranged for easy identification and date marked as appropriate. The policy did not address discarding expired foods.

Based on observation, interview and review of the facility policy, the facility failed to ensure call lights were functional as required. This affected four residents (#20, #47, #49 and #52) reviewed out of 16 resident rooms observed for call light functionality. Facility census was 131.Findings include: Observation on [DATE] from 9:42 A.M. to 10:40 A.M. with Director of Maintenance (DOM) #584 revealed the following concerns:-Resident #20 and Resident #49's call lights were tested and did not activate (light up) outside of the room. Interview with DOM #584 at the time of observation confirmed the lights did not activate outside of the room and DOM #584 thought the light bulb went bad. -Continued observation of Resident #47 and Resident #52's call lights revealed when pressed, they did not activate outside of the room and also did not ring at the nurses' station. Interview with Registered Nurse (RN) #586 and DOM #584 verified the call lights did not activate outside of the room or at the nurses' station.Interview on [DATE] at 10:22 A.M. Maintenance Assistant (MA) #520 revealed call lights not working was an on-going issue at the facility and he was sure some were outstanding.Interview on [DATE] at 10:40 A.M. with DOM #584 during review of electronic work orders revealed the call lights for Residents #20, #47, #49 and #52 had not been reported as broken and needing repair.Review of Work Orders as of [DATE] for [DATE] to [DATE] did not reveal any of the identified rooms for call lights not working had been reported.Review of the facility policy, Call Lights: Accessibility and Timely Response, revised [DATE] revealed staff are educated in the proper use of the resident call system, including how the system works and ensuring resident access the call light .staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and provides immediate or alternative solutions until the problem can be remedied.This deficiency represents non compliance investigated under Complaint Number 2807675.

Based on observation, interview, recipe review and review of the facility policy, the facility failed to ensure pureed foods were prepared appropriately. This affected 22 residents (#13, #14, #18, #21, #30, #31, #32, #37, #38, #45, #54, #57, #60, #61, #63, #65, #72, #91, #103, #107, #153 and #154) that received pureed cabbage during the lunch meal on 03/17/26. Facility census was 131.Findings include: Observation on 03/17/26 from 9:50 AM to 10:45 A.M. revealed [NAME] #654, District Manager (DM) #643 and Food and Nutrition Services Director (FNSD) #642 were present for puree preparation. [NAME] #654 stated she needed 27 cabbage portions pureed for the lunch meal and would make 33 portions to allow for some extra. [NAME] #654 took the cabbage out of the oven and temped it with the facility's self-calibrating electronic thermometer which read 205.2 degrees Fahrenheit (F) and portioned 33 four-ounce portions of cabbage along with all of the liquid (not measured out) that was in the pan from the oven into the Robo Coupe (food processor). Over the course of the observation, [NAME] #654 added four tablespoons of thickener and reblended the mixture multiple times before the puree was placed into the steamer for hot holding until the lunch meal.Observation on 03/17/26 starting at 11:25 A.M. revealed [NAME] #654 temped the foods to be served using the facility's self-calibrating electronic thermometer, including puree cabbage, 181 degrees F. The puree cabbage was served using a gray #8-scoop (four ounces). Tray line started at 11:35 A.M. The first cart to Pod F ended at 11:40 A.M., the cart to Pod C ended at 11:52 A.M, the cart to Pod D ended at 12:05 P.M and the cart to Pod E ended at 12:20 P.M. Continued observation throughout trayline revealed when the pureed cabbage was scooped onto the plate, the puree spread across the plate and did not hold its shape.Interview on 03/17/26 at 11:53 A.M. with DM #643 revealed the residents on puree or mechanical soft diets received the puree cabbage at lunch this date. DM #643 confirmed the puree cabbage spread across the plate which was not an appropriate consistency.Observation on 03/17/26 at 12:42 P.M. of a test tray with DM #643 revealed in addition to the main entree in regular consistency, a bowl of the pureed cabbage was sampled. The consistency of the pureed cabbage was still runny and did not hold its shape. Interview with DM #643 at the time of the observation confirmed the puree had broken down while on the steam table and lost some of its consistency.Follow-up interview on 03/17/26 at 1:04 P.M. with DM #643 verified the provided puree recipe recommended to drain off the water/liquid off the cabbage which was not done during the puree preparation observed earlier this date.Review of the facility recipe, Cabbage, Braised, no date revealed a procedure including 1) chop cabbage and steam or boil until tender and 2) drain off excess water and toss lightly with margarine. For pureed, measure out desired number of servings into a food processor.Review of the facility policy, Therapeutic Diets, revised October 2022 revealed diets are prepared in accordance with the guidelines in the approved diet manual and the individualized plan of care.This deficiency represents noncompliance investigated under Complaint Number 2807687.

Based on observation, review of medical record, review of facility fall investigation, review of hospital records, review of facility policy and interview, the facility failed to provide comprehensive interdisciplinary monitoring (including input from hospice and Resident #71's son) following an incident on 02/07/26 when the resident was lowered to the floor resulting in a delay in identification and treatment of a left femur fracture, failed to ensure medication parameters were followed per the physician's orders and physician was notified medication was being held for Resident #131, failed to ensure the dressing was changed for Resident #75 per the physician's order, and failed to have a perimeter mattress in place for Resident #12 and #75 per the physician's order. This affected one resident (Resident #71) of nine residents reviewed for change in condition, one resident (Resident #131) of six reviewed for medications, one resident (#75) of two residents reviewed for dressing changes, and two residents (#12 and #75) of three residents observed for perimeter mattresses. Findings include:1.Review of the medical record revealed Resident #71 was admitted to the facility on [DATE] with diagnoses including cerebral atherosclerosis, psychosis, diabetes, diabetic neuropathy, hallucinations, hypertension, dry eye syndrome, macular degeneration, atherosclerotic heart disease, dementia, major depressive disorder, vitreous hemorrhage, and feeding difficulties. Record review revealed Resident #71 was receiving Hospice services. Review of the plan of care with a revision date of 02/13/26 with interventions from 10/04/23 revealed Resident #71 was at risk for pain related to diabetes with diabetic neuropathy, history of rib fractures and left hip fracture. Interventions included administer medication as ordered and observe for side effects and effectiveness (10/04/23), encourage resident to request pain medication prior to pain becoming too intense or prior to activities the resident knows was a potential for increased pain (10/04/23), observe for changes in activity (10/04/23), observe for changes in behavior and mood (10/04/23), observe for changes in sleeping patterns (10/04/23), observe for verbal and non-verbal signs and symptoms relating to pain (10/04/23), and therapy services as needed (10/04/23). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 had severely impaired cognition, was independent for mobility and did not have pain. Review of the Alert Note dated 02/07/26 at 4:30 A.M. revealed there was yelling from the room and Resident #71 was attempting to get out of bed. A blanket was under her buttocks and the resident was sliding off the side of the bed. The resident was assisted to the floor onto the left side due to attempts to turn away from the bed. She stated, help me, the flames, put out the flames! The resident was informed there was no smoke, flames, bright lights or heat present. The room was luminated and bed linens removed. The resident was assisted up from the floor and back into bed once she was reoriented and completely awake. Vital signs were obtained and included temperature 97.9, pulse 90, respirations 20, blood pressure 147/82. The resident denied the need for the toilet and asked if her roommate was awake while smiling and pointing across the room. The bed was placed in the low position and call light was within reach. The nurse practitioner and responsible party were notified. There was no evidence Hospice was notified. Review of the Initial Fall assessment dated [DATE] at 4:30 A.M. documented Resident #71 had no pain, no change in range of motion, and no injury or suspected injury. Review of the Fall During Assist incident report dated 02/07/26 at 4:30 A.M. revealed following the incident, the resident would be monitored for pain and bruising for three days. Review of an Administration Note dated 02/07/26 at 6:57 P.M. revealed Resident #71 reported soreness to the left lower extremity with no change in transfers or range of motion. Review of Resident #71's Fall-Follow-Up Report dated 02/08/26 revealed the resident's most recent pain level was rated a five (on a scale from zero to 10) at 11:19 A.M. with no documented change in acute pain level related to the incident. The note included the resident's left leg, knee, and hip were more sore than usual but the resident had no change in range of motion. The note included there was not a suspected injury related to the incident identified. Review of Resident #71's February 2026 Medication Administration Record (MAR) and Administration note revealed on 02/09/26 at 5:20 A.M. Resident #71 was administered Acetaminophen 650 milligrams (mg) for mild to moderate pain for a pain level of six out of ten. Review of the Administration note dated 02/09/26 at 12:47 P.M. revealed the Acetaminophen 650 mg for mild to moderate pain for Resident #71 was effective and her pain level was zero. Review of a Pertinent Charting Note dated 02/09/26 at 1:58 P.M. revealed Resident #71 had discoloration noted under the left buttock. The note included there were no signs or symptoms of pain or discomfort noted. Range of motion was at baseline. The nurse practitioner (NP) was notified and gave an order to monitor the area twice a day until healed. Review of Resident #71's MAR and Administration note dated 02/09/26 at 7:21 P.M. revealed Resident #71 was administered Acetaminophen 650 milligrams for mild to moderate pain for complaint of left lower leg pain status post fall on 02/07/26 for pain level rated nine out of ten. Review of the Administration Note dated 02/09/26 at 8:57 P.M. revealed the medication was effective and the resident's pain decreased to zero. Review of an NP note written by NP #649 dated 02/09/25 revealed Resident #71 was seen resting in the common area eating lunch in the dining room. The note referenced the resident had been lowered to the floor by nursing staff on 02/07/26 at approximately 4:20 A.M. The resident thought her bed was on fire and was attempting to escape the flames. Staff noted the resident was yelling out and immediately assessed the resident at her bedside. The resident was noted to have a blanket under her buttocks which was causing her to slide off the side of the bed. The staff assisted the resident by lowering her to the floor to avoid her from falling. The resident was noted to have a discoloration to the left buttock about a quarter sized bruise. On examination the resident denied uncontrolled pain, reported her hip was sore with a five out of ten-pain level. The staff denied any reports of uncontrolled pain. She had been utilizing Acetaminophen as need which had been effective. The resident did have an order for Morphine per hospice care; however, she was declining to utilize the Morphine at this time. The resident was ambulating with her walker and was bearing full weight on the left lower extremity. She endorsed mild pain on palpitation to the left hip. Review of the MAR and Administration Note dated 02/10/26 at 11:47 A.M. revealed Resident #71 was administered Acetaminophen 650 milligram for mild to moderate pain for pain rated an eight out of ten. Review of the Administration note dated 02/10/26 at 2:22 P.M. revealed the medication was effective and the resident's pain decreased to zero. Review hospice visit note dated 02/10/26 revealed upon arrival Resident #71 was awake sitting in a wheelchair in the room. The nurse indicated the resident had fallen out of bed early Monday morning and had a bruise to her left buttock. Upon assessment a small bruise was noted on the back of the resident's left upper leg buttock area. The resident was able to rise from the wheelchair but was noticeably favoring her left leg, a small bruise was also noted on the side of her left knee as well. The resident stated she fell early Saturday morning after she woke up and thought the room was on fire she stated when she tried to get up she got tangled in her sheets and fell out of bed. She stated her pain was an eight out of ten. The Hospice physician was notified and ordered x-rays of the left hip and knee, the resident's son was updated and stated his mother seemed to be in a lot of pain when he visited her on Sunday. The facility was also reminded to call Hospice with any falls or changes in condition. Review of Resident #71's Fall-Follow-Up Report dated 02/10/26 revealed there was no change in the resident's pain level. Review of NP #649's note dated 02/11/25 revealed Resident #71 was sitting on the side of her bed. Her family was at the bedside and expressed no concerns. The NP was contacted by the Hospice Registered Nurse (HRN) the day before and notified Resident #71 had complained of an eight out of ten left hip pain and left knee pain. It was discussed with the hospice nurse that the resident had been lowered to the floor on 02/07/26 and had a quarter size bruise but the resident had not complained of uncontrolled pain to the staff. Hospice requested x-rays which the NP had initially ordered; however, after discussion with the staff the x-rays were discontinued due to clarification the resident had not fallen but was lowered to the floor and there were no complaints to the NP or the staff of uncontrolled pain. Prior to the visit today hospice staff had contacted the NP and stated the family was requesting x-rays due to the resident complaining of pain. A left hip and left knee x-ray was ordered at this time. The NP spoke with the resident's son via telephone call and he explained his mother had been complaining of increased left hip pain since Saturday. He stated he knew she had not fallen but was lowered to the floor and the NP explained to him the resident had not had any complains of severe or uncontrolled pain to the NP or staff; however, she apparently expressed pain to the hospice nurse. The son stated he understood some residents expressed pain differently. The NP explained to him why the x-rays were cancelled and explained again the resident had not had any uncontrolled pain thus the goal was to avoid unnecessary radiation and imaging. The NP explained she had a low suspicion of there being a fracture but had ordered for the x-rays to be completed due to his request to have them done. The son had no further concerns at the end of the telephone call. Upon examination the resident was unable to specify her pain on a numeric scale. She reported Acetaminophen was effective. Hospice and the NP both offered as needed Morphine and the resident refused. Her family stated the resident had concern of becoming addicted to the pain medication. The NP reassured the resident and family the Morphine was appropriately ordered and when taken in the appropriate setting the risk of addition was very low. The resident's left hip was palpated, and the resident expressed moderate pain with more pain to the left knee. The resident was ambulating with her walker per her usual per staff and family. After the visit the x-ray results were negative for a left knee fracture. The left hip x-ray findings indicated there was an irregularity of the subcapital region, suspicious for subcapital fracture possibly with slight displacement. Conclusion probable subcapital fracture and recommend follow up studies for confirmation. The NP contacted the radiologist, and she was unable to accurately assess the image due to the glare. The NP contacted the orthopedic surgeon, and he recommended the resident be sent to the emergency room (ER) for an evaluation. The son wanted the resident sent to the ER. Review of the February 2026 Medication administration record revealed on 02/11/26 at 11:26 A.M. Resident #71 was administered Acetaminophen 650 milligrams for mild to moderate pain for pain rated an eight out of ten. Review of the Interdisciplinary Progress note dated 02/11/26 at 12:04 P.M. revealed the team reviewed Resident #71 following the recent fall with complaint of pain to the left knee and hip. Her range of motion was at baseline, as needed Acetaminophen was administered and was effective. The resident was offered as needed Morphine and declined. Hospice was at bedside and requested an x-ray immediately of her left knee and hip per the family's request. Review of the Interdisciplinary Progress note dated 02/11/26 at 2:08 P.M. revealed the x-rays were obtained and there was an irregularity of the subcapital region, suspicious for subcapital fracture. Conclusion probable subcapital fracture and recommend follow up studies for confirmation. The NP was aware and placed orders to send the resident to the emergency room for further evaluation and treatment. No sign or symptoms of pain or discomfort expressed from the resident and she continues to attempt to ambulate at baseline. Review of the hospital history and physical dated 02/12/26 revealed Resident #71 was a direct admit to the hospital from another emergency room for a fracture of the neck of the left femur after she presented there for left leg pain. Resident #71 stated she fell in her room after being woken up thinking there was a fire in her room. She stated she got her legs tangled up in the blanket causing her to fall landing on her left side. She denied striking her head or loss of consciousness, but she had been having ongoing left leg pain since that time. She was brought to the emergency room by her son after she was unable to ambulate. A cat (CT) scan of the pelvis, abdomen and chest revealed an acute impacted, intracapsular, subcapital fracture involving the neck of the left femur. The resident had pain upon palpitation of the left hip. Resident #71 required surgical intervention which included a left closed reduction and percutaneous screw fixation of the left femoral neck fracture. Review of the nurse's note dated 02/15/26 at 4:25 P.M. revealed Resident #71 returned to the facility and via stretcher. Observation on 03/16/26 at 3:20 P.M. revealed Resident #71 was in bed with a shoe and sock on the right foot and just a regular sock on the left foot. On 03/19/26 at 10:15 A.M. an interview with the Director of Nursing revealed the facility was addressing Resident #71 pain with the use of Acetaminophen and she believed there was not a need to order x-rays because the resident's pain was controlled and she was ambulating on her own. She did verify the resident's pain increased following the incident on 02/07/26 with her pain gradually worsening but indicated the use of Acetaminophen remained effective to address the pain. The resident refused Morphine for her pain. The DON also acknowledged the resident did have severely impaired cognition. Observation on 03/19/26 at 10:45 A.M. revealed Resident #71 was in bed with regular socks on both feet. On 03/24/26 at 10:00 A.M. an interview with Family Member #700 revealed his mother fell at 4:00 A.M. on 02/07/26. He was told by the nurse working that his mother was lowered to the floor. He stated he was told his mother had the blankets wrapped around her and she was sliding out of the bed and the nurse had to go get some else to help her lower her to the floor; however, his mother told him she had fallen out of the bed. He stated the main problem was his mother told him about the fall and the facility never called him until morning on 02/09/26 to tell him about the fall. He stated his mother was on hospice and the hospice nurse went to see his mother on 02/10/26 and called him to tell him they needed to get x-rays because his mother was in pain, but the hospice nurse was told by the director of nursing that his mother did not need any x-rays because she was up walking around. He stated the hospice nurse went back into the facility on [DATE] and was upset because his mother was still complaining of pain in her left leg and it was five days since the fall. He stated the facility and the NP was still saying it was not broken after the x-rays were taken because fracture was not clear in the x-ray, so the hospice nurse called the hospice physician and he ordered her sent to the emergency room to get a better x-ray. He stated his mother had complained of pain the whole time and would wince when she moved in the wheelchair. He stated his mother has always had a high tolerance for pain and did not like to take medications. He stated she had a bruise the size of an orange to her left hip. During the interview, the resident's son reported the surgeon stated he did not want to get involved but that someone did not get that type of fracture from being lowered to the floor. On 03/25/26 at 11:30 A.M an interview with Hospice Nurse #701 revealed she had received a call from the hospice aide that Resident #71 was not standing for her shower and was favoring her left leg, so she went right over to the facility to see the resident. She stated the resident told her she had fallen out of bed. She stated she was favoring her left side and was having pain rated an eight out of ten, so she had reached out to the hospice physician, and he ordered an x-ray. She stated the order for the x-ray was placed mid-morning so she should have received the results by the afternoon but she did not receive them, so she called Nurse Practitioner #649 and was told the Director of Nursing said no the x-rays did not need completed because Resident #71 had been lowered to the floor and they were unnecessary. She stated she then went to the facility on [DATE] to check on the resident. She stated she went to speak to the nurse assigned to Resident #71 that day to see how she was doing and she knew nothing about the x-rays or that Resident #71 had even fallen. She stated the nurse indicated she had never been medicated for pain and had not been given Morphine for pain that she had requested be given the day before for pain rated an eight out of 10 pain. She stated the x-ray still had not been completed so she called NP #649 again and asked her why it had not been done and NP #649 stated she told the nurse manger working to put the order in but she must not have done it so she would put the order in herself at that time. She stated the x-ray was finally completed at around 11:30 A.M. on 02/11/26 and they had the results back around 2:00 P.M. showing the resident's left hip was fractured. She stated the resident complained of pain rated an eight out of 10, was not putting any weight on the left leg and she was trying to not put any pressure on the left hip even in bed. Review of the facility policy titled, Notification of Change, dated 01/01/22 revealed the purpose of the policy was to ensure the facility promptly informed the resident, consulted the resident physician and notified the resident's representative when there was a change in the resident's condition. Review of the facility policy titled, Pain Management, dated 10/20/20 revealed the facility would ensure pain management was provided to resident who required such services, consistent with professional standards of practice the comprehensive person-centered care plan, and the residents' goals and preferences. They would recognize when the resident was experiencing pain and identify circumstances when the pain was anticipated. 2. Review of the closed medical record revealed Resident #131 was admitted to the facility on [DATE] with diagnoses included vascular dementia, dementia, chronic obstructive pulmonary disease, mild protein-calorie malnutrition, chronic kidney disease, atherosclerotic heart disease, congestive heart failure, anxiety disorder, peripheral vascular disease, pain, hypertension, osteoarthritis, diverticulosis, cognitive communication deficit, and major depressive disorder. Resident #131 was transferred to the hospital on [DATE] and did not return to the facility. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #131 had severely impaired cognition. Review of the August 2025 physician's orders revealed Resident #131 had orders for Amlodipine 10 milligrams one tablet in the morning hold if systolic blood pressure (BP) was less than 120, Hydrochlorothiazide 25 milligrams one tablet in the morning hold if systolic BP was less than 120 and Lisinopril 40 milligrams one tablet every morning hold if systolic BP was less than 120. Review of the August 2025 Medication Administration record revealed the blood pressures for Resident #131 were 110/61 on 08/05/25, 105/65 on 08/08/25, 114/72 on 08/09/25, 103/65 on 08/10/25, 110/71 on 08/15/25, 108/48 on 08/17/25, 118/62 on 08/19/25, 118/62 on 08/19/25, 110/58 on 08/22/25, 98/61 on 08/28/25 resulting in Amlodipine, Lisinopril and Hydrochlorothiazide were all held. There was no documentation that a physician or nurse practitioner was notified of Resident #131 having numerous blood pressure requiring her medications to be held. Further review of the August 2025 Medication Administration Record revealed on 08/27/25 the blood pressure for Resident #131 was 115/67 and her the Amlodipine, Lisinopril and Hydrochlorothiazide were not held but administered to the resident. On 03/19/26 at 11:40 A.M. an interview with the Director of Nursing verified the facility did not notify the physician of the medication being held 10 times for the month out August 2025 or the three days in a row it was held from 08/08/25, 08/09/25 and 08/10/25 as the order did not indicate the physician needed to be contacted. She verified the medications should have been held on 08/27/25 but were administered to Resident #131. 3. Review of Resident #75's medical records revealed an admission date of 11/24/25. Diagnoses included surgical amputation of right toes, muscle weakness and dementia. Review of care plan dated 12/29/25 revealed Resident #75 was at risk for skin impairments related to diabetes. Interventions included administer medications as ordered, preventive treatments as ordered and notify physician or any signs or symptoms of infection. Review of MDS assessment dated [DATE] revealed Resident #75 had impaired cognition. Resident #75 required moderate assistance with toileting, and bed mobility and was dependent with transfers. Review of current physician orders dated 03/14/26 revealed orders to cleanse Resident #75's left dorsal foot with normal saline, apply Medihoney (antibacterial wound ointment), calcium alginate (absorbent wound dressing) cover with an absorbent pad and wrap with kerlex every day shift. Review of Treatment Administration Record (TAR) for March 2026 revealed Resident #75's wound care orders dated 03/14/26 had been documented as being completed daily. Observation of wound care on 03/18/26 at 10:28 A.M. for Resident #75 with Licensed Practical Nurse (LPN) #621 revealed a kerlex dressing that was dated 03/16/26. LPN #621 confirmed the date on Resident #75's dressing and stated she believed the dressing was to be done daily and as needed. 4. Review of Resident #75's medical records revealed an admission date of 11/24/25. Diagnoses included surgical amputation of right toes, muscle weakness and dementia. Review of MDS assessment dated [DATE] revealed Resident #75 had impaired cognition and required moderate assistance with bed mobility and was dependent with transfers. Review of physician orders dated 01/05/26-March 2026 revealed Resident #75 was ordered an air perimeter mattress to further assist with defining bed boundaries. Observation on 03/16/26 at 9:47 A.M. revealed a clear bag on Resident #75's reclining chair next to his bed that appeared to have mattress pads inside. Resident #75 stated he was unsure what was in the bag. Observation on 03/17/26 at 8:35 A.M. revealed bag remained on Resident #75's reclining chair. Observation of wound care on 03/18/26 at 10:18 A.M. with LPN #621 confirmed the bag of padding on Resident #75's chair. LPN #621 stated she was unsure what was inside the bag and stated it appeared to be some type of perimeter padding. Interview on 03/19/26 at 6:37 A.M. with DON revealed she had not been aware of a bag of possibly padding in Resident #75's room. Observation at time of interview with DON revealed bag had contained a perimeter mattress topper. DON stated hospice may have brought it in and had not informed staff it needed to be applied. Interview on 03/19/26 at 10:13 A.M. with DON confirmed Resident #75's physician orders for a perimeter mattress had been in place since January 2026 and DON stated she was not sure how long the perimeter mattress pad had been in Resident #75's room and it should have been in place. 5. Review of Resident #12's medical records revealed an admission date of 11/03/25. Diagnoses included dementia and cognitive deficits. Review of MDS assessment dated [DATE] revealed Resident #12 had no cognition score due to resident was rarely understood. Resident #12 required moderate assistance with bed mobility and was independent with transfers. Review of care plan dated 02/10/26 revealed Resident #12 was at risk for falls. Interventions included Bari-bed with perimeter mattress. Review of physician orders dated 02/26/26 revealed Resident #12 was ordered a perimeter mattress to bed to further assist with bed boundaries. Interview on 03/19/26 at 10:13 A.M. with DON revealed Resident #12's care plan from February 2026 had included the use of perimeter mattress. DON stated she was unsure when Resident #12 had received the mattress and physician orders had not been put into place until 03/10/26. Observation on 03/23/26 at 11:58 A.M. revealed Resident #12 was resting in bed and had a perimeter mattress. Interview with Resident #12 revealed he was confused and unable to answer questions appropriately. Interview with LPN #634 revealed some residents had recently been given new perimeter mattresses and stated she was unsure if Resident #12 had received one and stated she was unable to recall if Resident #12 had a perimeter mattress previously. This deficiency represents noncompliance investigated under Complaint Number 2611622, 2723634, and 1295325.

Based on record review, interview and review of the facility policy, the facility failed to timely report allegations of abuse to the State Agency (SA) as required. This affected five residents (#8, #77, #131, #155 and #157) out of 21 residents reviewed for abuse. Facility census was 131.Findings include:1. Review of Resident #8's closed medical record revealed an admission date of [DATE] and diagnoses including Alzheimer's disease, dementia with mood disturbance, diabetes, bipolar disorder, anxiety, depression and obesity. Resident #8 expired in the facility on [DATE] on hospice services. Review of Resident #8's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #8 had a memory problem, knew the location of his own room, displayed disorganized thinking and inattention, wandered one to three days in the look-back period, showed verbal and other behavioral symptoms one to three days in the look-back period and displayed physical behavioral symptoms four to six days in the look-back period. Review of Resident #8's plan of care initiated [DATE] and revised [DATE] revealed Resident #8 had behaviors related to dementia as evidenced by verbally aggressive toward other residents, verbally aggressive toward staff, physically aggressive toward other residents, physically aggressive toward staff, verbally aggressive toward other residents, grabbing/hitting/kicking/scratching/anger/screaming towards others, wanders in co-resident rooms, rummaging, throwing furniture, agitated/anxious/restless, and takes others' belongings. Review of a nurses' note dated [DATE] at 1:15 P.M. revealed this writer returned to pod from receiving medications from pharmacy shipment and certified nursing assistants (CNAs) reported that Resident #8 hit a co-resident [Resident #155]. CNAs stated that co-resident [Resident #155] slammed a dining room chair into the table and then Resident #8 pushed co-resident [Resident #155] on abdomen. Co-resident [Resident #155] then hit Resident #8 on the back of his head. CNAs stated they separated residents. Resident #8 was assessed with no bruising/redness/skin alterations noted. Vitals obtained. Unit manager (UM) notified, nurse practitioner (NP) notified with new orders to monitor for pain and bruising for three days. Review of a nurses' note dated [DATE] at 1:53 P.M. revealed Resident #8 was observed by staff hitting co-resident [Resident #155] who was attempting to push Resident #8's wheelchair and Resident #8 turned around and struck [Resident #155] in his abdomen. Co-resident [Resident #155] then hit Resident #8 back on the back of his head. Residents immediately separated by staff. Review of an internal risk report [not part of the medical record] revealed an incident audit report dated [DATE] at 1:15 P.M. Resident #8 struck a co-resident [Resident #155] in the abdomen and the co-resident [Resident #155] struck Resident #8 on the back of his head. No injuries were observed. Residents were separated and notifications were made. Resident #8 was sent to the hospital on [DATE] for treatment for behavioral disturbance. Review of Resident #155's closed medical record revealed an admission date of [DATE] and diagnoses including Alzheimer's disease, chronic obstructive pulmonary disease, dementia with agitation, depression, anxiety and dysphagia. Resident #8 expired in the facility on [DATE] on hospice services. Review of Resident #155's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #155 had a memory problem, displayed inattention and disorganized thinking, and wandered and had verbal and physical behaviors one to three days in the lookback period. Review of Resident #155's plan of care initiated [DATE] revealed Resident #155 had behaviors related to Alzheimer's dementia as evidenced by wandering/exit seeking, physical aggression, verbal aggression and resisting care. Review of a nurses' note dated [DATE] at 7:35 P.M. revealed upon return to unit from receiving medications from pharmacy CNAs reported that Resident #155 slammed a chair into the table near a co-resident [Resident #8] and co-resident [Resident #8] pushed Resident #155 and he hit co-resident [Resident #8] on the back of his head. CNAs reported they separated residents immediately. No skin alterations/discolorations observed and Resident #155 denied pain or discomfort at this time. UM notified and NP notified with new orders to monitor for pain/bruising for three days. Review of an interdisciplinary team (IDT) note dated [DATE] at 3:03 P.M. revealed Resident #155 was observed pushing chairs loudly into the dining room table when nearby co-resident [Resident #8] became agitated by Resident #155's behaviors. Per witness statements of nursing staff present on unit, Resident #155 walked away briefly but returned to the table and began pushing co-resident's [Resident #8's] wheelchair. Co-resident [Resident #8] expressed agitation towards Resident #155 and began to push him and struck him in the abdomen twice. Resident #155 became agitated and struck at the back of co-resident's [Resident #8's] head. Nursing staff present on unit immediately separated residents. Resident #155 was assessed by nurse with no injuries observed at time of incident. Resident #155 interviewed with no changes in daily routine or signs of distress related to incident. Psych NP and UM made aware of incident. Responsible party updated. Resident was monitored for pain/bruising post incident for three days with no documented pain or bruising. Resident without any further documented behaviors or resident to resident altercations at this time. Review of an internal risk report [not part of the medical record] revealed an incident audit report dated [DATE] at 1:15 P.M. Resident #155 was observed striking a co-resident [Resident #8] in the back of his head after co-resident [Resident #8] pushed Resident #155 away and pushed Resident #155 back with his hand to his abdomen. No injuries were observed. Residents were separated and notifications were made. Interview on [DATE] at 3:04 P.M. with the Administrator and the Director of Nursing (DON) revealed while an internal investigation was done with the resident-to-resident altercation involving Resident #8 and Resident #155, they confirmed a self-reported incident (SRI) was not filed as no injury occurred and the residents involved did not have the ability to intend to harm or cause mental anguish. During an interview on [DATE] at 3:36 P.M. Registered Nurse (RN)/Vice President of Clinical (VPOC) #644 provided the surveyor with the abuse flow chart the provider used to help guide their abuse reporting. RN/VPOC #644 was made aware during the interview that applying the reasonable person concept to the above scenario (i.e being punched in the abdomen or the head) could cause injury thus the resident-to-resident altercation should have been reported to the State Agency (SA) as required per the facility's policy. 2. Review of Resident #8's closed medical record revealed an admission date of [DATE] and diagnoses including Alzheimer's disease, dementia with mood disturbance, diabetes, bipolar disorder, anxiety, depression and obesity. Resident #8 expired in the facility on [DATE] on hospice services. Review of Resident #8's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #8 had a memory problem, knew the location of his own room, displayed disorganized thinking and inattention, wandered one to three days in the look-back period, showed verbal and other behavioral symptoms one to three days in the look-back period and displayed physical behavioral symptoms four to six days in the look-back period. Review of Resident #8's plan of care initiated [DATE] and revised [DATE] revealed Resident #8 had behaviors related to dementia as evidenced by verbally aggressive toward other residents, verbally aggressive toward staff, physically aggressive toward other residents, physically aggressive toward staff, verbally aggressive toward other residents, grabbing/hitting/kicking/scratching/anger/screaming towards others, wanders in co-resident rooms, rummaging, throwing furniture, agitated/anxious/restless, and takes others' belongings. Review of a nurses' note dated [DATE] at 6:47 P.M. revealed staff had responded to another resident's [Resident #77's] room after hearing, Hey! Get out of my room! Noted co-resident [Resident #77] sitting in wheelchair facing towards the wall eating dinner beside his bed and Resident #8 sitting on the bed. Co-resident [Resident #77] had told this nurse that Resident #8 had just punched him in the face and further stated that Resident #8 had come into his room, got onto his bed and then just punched him in the face. Residents were immediately separated. No injuries noted. NP, Administrator and DON were notified. Resident #8 was put on 15-minute checks. Review of an internal risk report [not part of the medical record] revealed an incident audit report dated [DATE] at 5:55 P.M. Staff had responded to another resident's room [Resident #77] after hearing, Hey, get out of my room! Noted co-resident [Resident #77] was sitting in wheelchair facing towards the wall eating dinner beside his bed and Resident #8 was sitting on the bed. Co-resident [Resident #77] told this nurse Resident #8 had just punched him in the face and stated Resident #8 had come into his room, got into his bed and just punched him in the face. No injuries were observed. Residents were separated and notifications were made. Resident #8 was placed on 15-minute checks. Review of Resident #77's medical record revealed an admission date of [DATE] and diagnoses including Alzheimer's disease with late onset, unspecified psychosis, vascular dementia, type two diabetes, personality disorder, anxiety disorder and hyperlipidemia. Review of a quarterly MDS 3.0 assessment dated [DATE] revealed Resident #77 had moderate cognitive impairment and wandered, displayed verbal behaviors, displayed physical behaviors and other behaviors one to three days in the seven-day lookback period. Review of Resident #77's plan of care initiated [DATE] and revised [DATE] revealed Resident #77 had behaviors related to Alzheimer's disease as evidenced by physically aggressive toward staff, verbally aggressive toward staff and wandering throughout facility with no sense of direction. Review of a nurses' note dated [DATE] at 6:54 P.M. revealed staff had responded to Resident #77's room after hearing, Hey! Get out of my room! Noted Resident #77 sitting in his wheelchair facing towards the wall eating dinner beside his bed. Co-resident [Resident #8] was sitting on the bed. Resident #77 had told this nurse that co-resident [Resident #8] had just punched him in the face and had further stated that co-resident [Resident #8] had come into his room, got onto his bed and then just punched him in the face. Residents were immediately separated. No injuries noted. Notified Administrator, DON, NP and emergency contact. Review of an internal risk report [not part of the medical record] revealed an incident audit report dated [DATE] at 5:55 P.M revealed staff responded to Resident #77's room after hearing, Hey, get out of my room. Resident #77 was seated in his wheelchair facing towards the wall eating dinner beside his bed. Co-resident [Resident #8] was sitting on the bed. Resident #77 stated co-resident [Resident #8] had just punched him in the face. No injuries were observed. Residents were separated and notifications were made. Interview on [DATE] at 3:04 P.M. with the Administrator and the DON revealed while an internal investigation was done with the resident-to-resident altercation involving Resident #8 and Resident #77, they confirmed a SRI was not filed as no injury occurred and the residents involved did not have the ability to intend to harm or cause mental anguish. During an interview on [DATE] at 3:36 P.M. RN/VPOC #644 provided the surveyor with the abuse flow chart the provider used to help guide their abuse reporting. RN/VPOC #644 was made aware during the interview that applying the reasonable person concept to the above scenario (i.e being punched in the face) could cause injury thus the resident-to-resident altercation should have been reported to the SA as required per the facility's policy. Review of the facility policy, Abuse, Neglect and Exploitation, revised [DATE] revealed the facility would provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prevent and prevent abuse, neglect, exploitation and misappropriation of resident property .the facility will have written procedures to assist staff in identifying the different types of abuse; possible indicators of abuse include but are not limited to physical abuse of a resident observed. The facility will have written procedures that include reporting of alleged violations to the state agency within specified timeframes as required by state and federal regulations: immediately but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Review of an undated abuse flow sheet titled Examples of Physical Altercations revealed resident to resident physical altercations that must be reported include any willful action that results in physical injury, mental anguish or pain. Willful action had a notation stating having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. Mental anguish had a notation there may be some situations in which the psychosocial outcome to the resident may be difficulty to determine or incongruent with what would be expected. In these situations it is appropriate to consider how a reasonable person in the resident's circumstances would be impacted by the incident. 3. Review of the medical record revealed Resident #157 was admitted to the facility on [DATE] with diagnoses including hearing loss, cerebral ischemia, asthma, major depressive disorder, generalized anxiety disorder, and dementia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #157 had severely impaired cognition. Resident #157 had delusions, physical and verbal behaviors, rejection of care, and wandering. Review of the plan of care dated [DATE] revealed Resident #157 had behaviors related to dementia as evidence by exit seeking, physical aggression towards staff, resistant to care verbally aggressive towards staff, wondering in other resident rooms wandering through facility with no sense of direction lower self on the floor, grabbing, kicking, hitting, pushing, cursing at others, anger towards others, screaming, disruptive sounds, wandering in resident rooms, repetitive motion, agitation, anxiety and restlessness, sad and tearful. Interventions included administer medication as ordered and observe for effectiveness and side effects, approach resident in a calm manner to avoid frustration and behavior escalation, communicate care to resident before starting task, if the resident resist with activities of daily living reassure the resident leave and then return later to try again, observe and document episodes of inappropriate behavior, notify the physician or nurse practitioner when behaviors persist or will not deescalate, observe and report any provide positive feedback to the resident when behaviors or changes in mental status caused by situational stressors, observed behavior episodes and attempt to determine underlying cause, offer psychologist and psychiatric services as needed offer resident choices whenever possible provide a calm safe environment when the residents frustrations escalate and allow time to voice feelings, provide a structured schedule for daily care when possible. Review of the medical record revealed Resident #131 was admitted to the facility on [DATE] with diagnoses included vascular dementia, dementia, chronic obstructive pulmonary disease, mild protein-calorie malnutrition, chronic kidney disease, atherosclerotic heart disease, congestive heart failure, anxiety disorder, peripheral vascular disease, pain, hypertension, osteoarthritis, diverticulosis, cognitive communication deficit, and major depressive disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #131 had severely impaired cognition. Review of the Incident Audit Report dated [DATE] at 2:15 P.M. revealed a nursing assistant called the nurse over and stated Resident #157 hit Resident #131 in the left side of her chest with her hand. The other resident was redirected immediately from Resident #131. The nurse assessed Resident #131 and there was no redness or bruising noted to the area, vital signs were blood pressure (B/P) 125/76, pulse (AP) 72, respirations (R) 16, oxygen level 97 percent (%) on room air (RA). The physician and family were notified with a new order to monitor the area for pain or bruises for three days. Resident #131 stated it did hurt but she did not know why the other resident had hit her. Review of the Physical Aggression Form dated [DATE] at 2:15 P.M. revealed there was a section for witness statements. Certified Nursing Assistant #625 stated she was discarding trash and heard yelling, she looked out in the common area and saw Resident #157 hit Resident #131 in the chest, and she immediately stepped in to move Resident#157 away. On [DATE] at 3:25 P.M. an interview with the Director of Nursing revealed they did not do a Self-Reported Incident because she did not believe Resident #131 sustained an injury which needed to be reported. Review of the facility policy, Abuse, Neglect and Exploitation, revised [DATE] revealed the facility would provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prevent and prevent abuse, neglect, exploitation and misappropriation of resident property. Physical Abuse included but was not limited to hitting, slapping, punching, biting and kicking, The facility will have written procedures to assist staff in identifying the different types of abuse; possible indicators of abuse include but are not limited to physical abuse of a resident observed. The facility will have written procedures that include reporting of alleged violations to the state agency within specified timeframes as required by state and federal; regulations: immediately but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. This deficiency represents non compliance investigated under Complaint Number 1295325 and 2611622.

Based on record review, interview and review of the facility policy, the facility failed to implement their abuse policy to timely report allegations of abuse. This affected five residents (#8, #77, #131, #155 and #157) out of 21 residents reviewed for abuse. Facility census was 131.Findings include:1. Review of Resident #8's closed medical record revealed an admission date of [DATE] and diagnoses including Alzheimer's disease, dementia with mood disturbance, diabetes, bipolar disorder, anxiety, depression and obesity. Resident #8 expired in the facility on [DATE] on hospice services. Review of Resident #8's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #8 had a memory problem, knew the location of his own room, displayed disorganized thinking and inattention, wandered one to three days in the look-back period, showed verbal and other behavioral symptoms one to three days in the look-back period and displayed physical behavioral symptoms four to six days in the look-back period. Review of Resident #8's plan of care initiated [DATE] and revised [DATE] revealed Resident #8 had behaviors related to dementia as evidenced by verbally aggressive toward other residents, verbally aggressive toward staff, physically aggressive toward other residents, physically aggressive toward staff, verbally aggressive toward other residents, grabbing/hitting/kicking/scratching/anger/screaming towards others, wanders in co-resident rooms, rummaging, throwing furniture, agitated/anxious/restless, and takes others' belongings. Review of a nurses' note dated [DATE] at 1:15 P.M. revealed this writer returned to pod from receiving medications from pharmacy shipment and certified nursing assistants (CNAs) reported that Resident #8 hit a co-resident [Resident #155]. CNAs stated that co-resident [Resident #155] slammed a dining room chair into the table and then Resident #8 pushed co-resident [Resident #155] on abdomen. Co-resident [Resident #155] then hit Resident #8 on the back of his head. CNAs stated they separated residents. Resident #8 was assessed with no bruising/redness/skin alterations noted. Vitals obtained. Unit manager (UM) notified, nurse practitioner (NP) notified with new orders to monitor for pain and bruising for three days.Review of a nurses' note dated [DATE] at 1:53 P.M. revealed Resident #8 was observed by staff hitting co-resident [Resident #155] who was attempting to push Resident #8's wheelchair and Resident #8 turned around and struck [Resident #155] in his abdomen. Co-resident [Resident #155] then hit Resident #8 back on the back of his head. Residents immediately separated by staff. Review of an internal risk report [not part of the medical record] revealed an incident audit report dated [DATE] at 1:15 P.M. Resident #8 struck a co-resident [Resident #155] in the abdomen and the co-resident [Resident #155] struck Resident #8 on the back of his head. No injuries were observed. Residents were separated and notifications were made. Resident #8 was sent to the hospital on [DATE] for treatment for behavioral disturbance. Review of Resident #155's closed medical record revealed an admission date of [DATE] and diagnoses including Alzheimer's disease, chronic obstructive pulmonary disease, dementia with agitation, depression, anxiety and dysphagia. Resident #8 expired in the facility on [DATE] on hospice services. Review of Resident #155's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #155 had a memory problem, displayed inattention and disorganized thinking, and wandered and had verbal and physical behaviors one to three days in the lookback period.Review of Resident #155's plan of care initiated [DATE] revealed Resident #155 had behaviors related to Alzheimer's dementia as evidenced by wandering/exit seeking, physical aggression, verbal aggression and resisting care.Review of a nurses' note dated [DATE] at 7:35 P.M. revealed upon return to unit from receiving medications from pharmacy CNAs reported that Resident #155 slammed a chair into the table near a co-resident [Resident #8] and co-resident [Resident #8] pushed Resident #155 and he hit co-resident [Resident #8] on the back of his head. CNAs reported they separated residents immediately. No skin alterations/discolorations observed and Resident #155 denied pain or discomfort at this time. UM notified and NP notified with new orders to monitor for pain/bruising for three days.Review of an interdisciplinary team (IDT) note dated [DATE] at 3:03 P.M. revealed Resident #155 was observed pushing chairs loudly into the dining room table when nearby co-resident [Resident #8] became agitated by Resident #155's behaviors. Per witness statements of nursing staff present on unit, Resident #155 walked away briefly but returned to the table and began pushing co-resident's [Resident #8's] wheelchair. Co-resident [Resident #8] expressed agitation towards Resident #155 and began to push him and struck him in the abdomen twice. Resident #155 became agitated and struck at the back of co-resident's [Resident #8's] head. Nursing staff present on unit immediately separated residents. Resident #155 was assessed by nurse with no injuries observed at time of incident. Resident #155 interviewed with no changes in daily routine or signs of distress related to incident. Psych NP and UM made aware of incident. Responsible party updated. Resident was monitored for pain/bruising post incident for three days with no documented pain or bruising. Resident without any further documented behaviors or resident to resident altercations at this time.Review of an internal risk report [not part of the medical record] revealed an incident audit report dated [DATE] at 1:15 P.M. Resident #155 was observed striking a co-resident [Resident #8] in the back of his head after co-resident [Resident #8] pushed Resident #155 away and pushed Resident #155 back with his hand to his abdomen. No injuries were observed. Residents were separated and notifications were made.Interview on [DATE] at 3:04 P.M. with the Administrator and the Director of Nursing (DON) revealed while an internal investigation was done with the resident-to-resident altercation involving Resident #8 and Resident #155, they confirmed a self-reported incident (SRI) was not filed as no injury occurred and the residents involved did not have the ability to intend to harm or cause mental anguish.During an interview on [DATE] at 3:36 P.M. Registered Nurse (RN)/Vice President of Clinical (VPOC) #644 provided the surveyor with the abuse flow chart the provider used to help guide their abuse reporting. RN/VPOC #644 was made aware during the interview that applying the reasonable person concept to the above scenario (i.e being punched in the abdomen or the head) could cause injury thus the resident-to-resident altercation should have been reported to the State Agency (SA) as required per the facility's policy.2. Review of Resident #8's closed medical record revealed an admission date of [DATE] and diagnoses including Alzheimer's disease, dementia with mood disturbance, diabetes, bipolar disorder, anxiety, depression and obesity. Resident #8 expired in the facility on [DATE] on hospice services. Review of Resident #8's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #8 had a memory problem, knew the location of his own room, displayed disorganized thinking and inattention, wandered one to three days in the look-back period, showed verbal and other behavioral symptoms one to three days in the look-back period and displayed physical behavioral symptoms four to six days in the look-back period. Review of Resident #8's plan of care initiated [DATE] and revised [DATE] revealed Resident #8 had behaviors related to dementia as evidenced by verbally aggressive toward other residents, verbally aggressive toward staff, physically aggressive toward other residents, physically aggressive toward staff, verbally aggressive toward other residents, grabbing/hitting/kicking/scratching/anger/screaming towards others, wanders in co-resident rooms, rummaging, throwing furniture, agitated/anxious/restless, and takes others' belongings. Review of a nurses' note dated [DATE] at 6:47 P.M. revealed staff had responded to another resident's [Resident #77's] room after hearing, Hey! Get out of my room! Noted co-resident [Resident #77] sitting in wheelchair facing towards the wall eating dinner beside his bed and Resident #8 sitting on the bed. Co-resident [Resident #77] had told this nurse that Resident #8 had just punched him in the face and further stated that Resident #8 had come into his room, got onto his bed and then just punched him in the face. Residents were immediately separated. No injuries noted. NP, Administrator and DON were notified. Resident #8 was put on 15-minute checks. Review of an internal risk report [not part of the medical record] revealed an incident audit report dated [DATE] at 5:55 P.M. Staff had responded to another resident's room [Resident #77] after hearing, Hey, get out of my room! Noted co-resident [Resident #77] was sitting in wheelchair facing towards the wall eating dinner beside his bed and Resident #8 was sitting on the bed. Co-resident [Resident #77] told this nurse Resident #8 had just punched him in the face and stated Resident #8 had come into his room, got into his bed and just punched him in the face. No injuries were observed. Residents were separated and notifications were made. Resident #8 was placed on 15-minute checks. Review of Resident #77's medical record revealed an admission date of [DATE] and diagnoses including Alzheimer's disease with late onset, unspecified psychosis, vascular dementia, type two diabetes, personality disorder, anxiety disorder and hyperlipidemia. Review of a quarterly MDS 3.0 assessment dated [DATE] revealed Resident #77 had moderate cognitive impairment and wandered, displayed verbal behaviors, displayed physical behaviors and other behaviors one to three days in the seven-day lookback period. Review of Resident #77's plan of care initiated [DATE] and revised [DATE] revealed Resident #77 had behaviors related to Alzheimer's disease as evidenced by physically aggressive toward staff, verbally aggressive toward staff and wandering throughout facility with no sense of direction. Review of a nurses' note dated [DATE] at 6:54 P.M. revealed staff had responded to Resident #77's room after hearing, Hey! Get out of my room! Noted Resident #77 sitting in his wheelchair facing towards the wall eating dinner beside his bed. Co-resident [Resident #8] was sitting on the bed. Resident #77 had told this nurse that co-resident [Resident #8] had just punched him in the face and had further stated that co-resident [Resident #8] had come into his room, got onto his bed and then just punched him in the face. Residents were immediately separated. No injuries noted. Notified Administrator, DON, NP and emergency contact. Review of an internal risk report [not part of the medical record] revealed an incident audit report dated [DATE] at 5:55 P.M revealed staff responded to Resident #77's room after hearing, Hey, get out of my room. Resident #77 was seated in his wheelchair facing towards the wall eating dinner beside his bed. Co-resident [Resident #8] was sitting on the bed. Resident #77 stated co-resident [Resident #8] had just punched him in the face. No injuries were observed. Residents were separated and notifications were made. Interview on [DATE] at 3:04 P.M. with the Administrator and the DON revealed while an internal investigation was done with the resident-to-resident altercation involving Resident #8 and Resident #77, they confirmed a SRI was not filed as no injury occurred and the residents involved did not have the ability to intend to harm or cause mental anguish.During an interview on [DATE] at 3:36 P.M. RN/VPOC #644 provided the surveyor with the abuse flow chart the provider used to help guide their abuse reporting. RN/VPOC #644 was made aware during the interview that applying the reasonable person concept to the above scenario (i.e being punched in the face) could cause injury thus the resident-to-resident altercation should have been reported to the SA as required per the facility's policy.Review of the facility policy, Abuse, Neglect and Exploitation, revised [DATE] revealed the facility would provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prevent and prevent abuse, neglect, exploitation and misappropriation of resident property .the facility will have written procedures to assist staff in identifying the different types of abuse; possible indicators of abuse include but are not limited to physical abuse of a resident observed. The facility will have written procedures that include reporting of alleged violations to the state agency within specified timeframes as required by state and federal regulations: immediately but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Review of an undated abuse flow sheet titled Examples of Physical Altercations revealed resident to resident physical altercations that must be reported include any willful action that results in physical injury, mental anguish or pain. Willful action had a notation stating having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. Mental anguish had a notation there may be some situations in which the psychosocial outcome to the resident may be difficulty to determine or incongruent with what would be expected. In these situations it is appropriate to consider how a reasonable person in the resident's circumstances would be impacted by the incident.3. Review of the medical record revealed Resident #157 was admitted to the facility on [DATE] with diagnoses including hearing loss, cerebral ischemia, asthma, major depressive disorder, generalized anxiety disorder, and dementia.Review of the quarterly MDS assessment dated [DATE] revealed Resident #157 had severely impaired cognition. Resident #157 had delusions, physical and verbal behaviors, rejection of care, and wandering. Review of the plan of care dated [DATE] revealed Resident #157 had behaviors related to dementia as evidence by exit seeking, physical aggression towards staff, resistant to care verbally aggressive towards staff, wondering in other resident rooms wandering through facility with no sense of direction lower self on the floor, grabbing, kicking, hitting, pushing, cursing at others, anger towards others, screaming, disruptive sounds, wandering in resident rooms, repetitive motion, agitation, anxiety and restlessness, sad and tearful. Interventions included administer medication as ordered and observe for effectiveness and side effects, approach resident in a calm manner to avoid frustration and behavior escalation, communicate care to resident before starting task, if the resident resist with activities of daily living reassure the resident leave and then return later to try again, observe and document episodes of inappropriate behavior, notify the physician or nurse practitioner when behaviors persist or will not deescalate, observe and report any provide positive feedback to the resident when behaviors or changes in mental status caused by situational stressors, observed behavior episodes and attempt to determine underlying cause, offer psychologist and psychiatric services as needed offer resident choices whenever possible provide a calm safe environment when the residents frustrations escalate and allow time to voice feelings, provide a structured schedule for daily care when possible.Review of the medical record revealed Resident #131 was admitted to the facility on [DATE] with diagnoses included vascular dementia, dementia, chronic obstructive pulmonary disease, mild protein-calorie malnutrition, chronic kidney disease, atherosclerotic heart disease, congestive heart failure, anxiety disorder, peripheral vascular disease, pain, hypertension, osteoarthritis, diverticulosis, cognitive communication deficit, and major depressive disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #131 had severely impaired cognition.Review of the Incident Audit Report dated [DATE] at 2:15 P.M. revealed a nursing assistant called the nurse over and stated Resident #157 hit Resident #131 in the left side of her chest with her hand. The other resident was redirected immediately from Resident #131. The nurse assessed Resident #131 and there was no redness or bruising noted to the area, vital signs were blood pressure (B/P) 125/76, pulse (AP) 72, respirations (R) 16, oxygen level 97 percent (%) on room air (RA). The physician and family were notified with a new order to monitor the area for pain or bruises for three days. Resident #131 stated it did hurt but she did not know why the other resident had hit her.Review of the Physical Aggression Form dated [DATE] at 2:15 P.M. revealed there was a section for witness statements. Certified Nursing Assistant #625 stated she was discarding trash and heard yelling, she looked out in the common area and saw Resident #157 hit Resident #131 in the chest, and she immediately stepped in to move Resident#157 away.On [DATE] at 3:25 P.M. an interview with the Director of Nursing revealed they did not do a Self-Reported Incident because she did not believe Resident #131 sustained an injury which needed to be reported. Review of the facility policy, Abuse, Neglect and Exploitation, revised [DATE] revealed the facility would provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prevent and prevent abuse, neglect, exploitation and misappropriation of resident property. Physical Abuse included but was not limited to hitting, slapping, punching, biting and kicking, The facility will have written procedures to assist staff in identifying the different types of abuse; possible indicators of abuse include but are not limited to physical abuse of a resident observed. The facility will have written procedures that include reporting of alleged violations to the state agency within specified timeframes as required by state and federal; regulations: immediately but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.This deficiency represents non compliance investigated under Complaint Number 1295325 and 2611622.

Based on observation, interview, record review and review of the facility policy the facility failed to ensure air temperatures remained in required ranges and failed to maintain wheelchairs in a clean and sanitary manner. This affected 48 residents (Resident #5, #18, #27, #47 and #52), all 21 residents on D pod (Residents #2, #8, #14, #15, #17, #22, #25, #33, #38, #44, #58, #61, #78, #83, #84, #88, #92, #97, #115, #149 and #150), and all 22 residents on E pod (Residents #10, #24, #35, #41, #43, #48, #53, #54, #56, #63, #66, #71, #72, #81, #86, #87, #89, #93, #95, #96, #114, #118 and #148). Facility census was 131.Findings include: 1. Observation on 03/19/26 from 9:42 A.M. to 10:40 A.M. with Director of Maintenance (DOM) #584 revealed the following air temperatures were obtained with the facility's laser thermometer:-Resident #47 and Resident #52's room had a temperature of 68.2 degrees F.-Resident #5 and Resident #18's room had a temperature of 69.3 degrees F.-Resident #27's room had a temperature of 69.1 degrees F.-Resident #2 and Resident #58's room had a temperature of 68.9 degrees F.-The main area on Pod D had a temperature of 70 degrees F.-Resident #14's room had a temperature of 67.6 degrees F.-The main area on Pod E had a temperature of 68 degrees F.-Resident #56 and Resident #71's room had a temperature of 70.3 degrees F.-Resident #148's room had a temperature of 69.8 degrees F.The above temperatures were verified by DOM #584 at the time of observation, who also confirmed the acceptable range within the facility was between 71 degrees F and 81 degrees F.Interview on 03/19/26 at 10:22 A.M. with Maintenance Assistant (MA) #520 revealed he had been recording the air temperatures with the facility's orange laser thermometer used this date for the last two months and denied recent concerns with the temperatures being outside of the required range, including under 71 degrees F.Interview on 03/19/26 at 10:40 A.M. with DOM #584 during review of electronic work orders and temperature logs revealed there were no open work orders for the observed low temperatures identified during the observational tour. DOM #584 acknowledged he questioned the accuracy of the temperature logs as they all said 75 degrees F with no variation across the facility. Review of work orders as of 03/18/26 for 12/01/25 to 03/19/26 revealed none of the identified rooms for lower temperatures had been reported.Review of temperature logs from 03/09/26 to 03/13/26 revealed each sampled temperature was documented as 75 degrees F consistently with no variation across the facility.Review of the facility policy, Safe and Homelike Environment, revised 01/01/22 revealed the facility will provide a safe, clean, comfortable and homelike environment Comfortable and safe temperature levels means that the ambient temperature should be in a relatively narrow range and minimize resident' susceptibility to the loss of body heat and risk of hypothermia/hyperthermia and is comfortable for the residents the facility should strive to keep the temperature in common resident areas between 71 and 81 degrees Fahrenheit. If and a resident prefers his or her room temperature be kept below 71 degrees F or above 81 degrees F, the facility will assess the safety of this practice on the resident and the resident's roommate.2. Observation on 03/19/26 at 10:00 A.M. on Pod D revealed Resident #14 was seated in his wheelchair near the nurses' station. The wheelchair was covered in different colors of debris and was noticeably dirty. Interview on 03/19/26 at 10:00 A.M. with Therapy Program Director (TPD) #648 verified the observed condition of Resident #14's wheelchair. TPD #648 stated Resident #14's wheelchair was supposed to be cleaned on Monday [03/16/26] on night shift and confirmed it did not appear that this was completed.Interviews on 03/19/26 at 12:01 P.M. and 12:40 P.M. with Unit Manager (UM)/Licensed Practical Nurse (LPN) #521 revealed nurses and unit managers were to oversee the initiation and completion of the Pod's wheelchair cleaning schedule by Certified Nursing Assistants (CNAs) and if this was not done, staff were to be disciplined. UM/LPN #521 verified the facility did not have a policy relative to cleaning wheelchairs. Review of the D-Pod Wheelchair Cleaning Schedule, no date, revealed that Resident #14 was to have his wheelchair cleaned on Mondays and Fridays.This deficiency represents non compliance investigated under Complaint Number 2807675, 2807687, and 1295320.

Based on record review, interview and review of the facility policy, the facility failed to notify residents when their resident funds accounts were within $200.00 of the Medicaid resource limit as required. This affected three residents (#17, #38 and #49) of five residents reviewed for personal funds. Facility census was 131.Findings include: 1. Review of Resident #17's medical record revealed an admission date of 09/30/24 and diagnoses including dementia with agitation, depression, unspecified psychosis and anemia. Review of Resident #17's resident funds statement revealed a balance of $3957.67 on 01/02/26, $3939.23 on 02/02/26 and $4353.05 on 03/02/26. One spend-down letter was provided to Resident #17 and his representative on 03/16/26 and no other letters were available for review. Interview on 03/20/26 at 1:30 P.M. with Business Office Manager (BOM) #511 revealed she only had the last month of spend-down letters to provide for Resident #17 as she was not keeping historical ones. Interview on 03/20/26 at 1:45 P.M. with the Administrator verified he expected spend down letters to be provided each month a resident was within or over the Medicaid resource limit and confirmed there was no evidence this was done for Resident #17. 2. Review of Resident #38's medical record revealed an admission date of 10/17/25 and diagnoses including Alzheimer's disease with late onset, adjustment disorder, dysphagia, depression and emphysema. Review of Resident #38's resident funds statement revealed a balance of $3497.12 on 12/29/25, $2663.05 on 02/02/26 and $2813.57 on 03/02/26. One spend-down letter was provided to Resident #38 on 03/16/26 and no other letters were available for review. Interview on 03/20/26 at 1:30 P.M. with BOM #511 revealed she only had the last month of spend-down letters to provide for Resident #38 as she was not keeping historical ones. Interview on 03/20/26 at 1:45 P.M. with the Administrator verified he expected spend down letters to be provided each month a resident was within or over the Medicaid resource limit and confirmed there was no evidence this was done for Resident #38. 3. Review of Resident #49's medical record revealed an admission date of 05/13/25 and diagnoses including dementia with mood disturbance, Alzheimer's disease, depression, anxiety and post-traumatic stress disorder. Review of Resident #49's resident funds statement revealed a balance of $6006.82 on 01/02/26, $5143.98 on 02/02/26 and $5174.97 on 03/02/26. One spend-down letter was provided to Resident #49 and his representative on 03/16/26 and no other letters were available for review. Interview on 03/20/26 at 1:30 P.M. with BOM #511 revealed she only had the last month of spend-down letters to provide for Resident #49 as she was not keeping historical ones. Interview on 03/20/26 at 1:45 P.M. with the Administrator verified he expected spend down letters to be provided each month a resident was within or over the Medicaid resource limit and confirmed there was no evidence this was done for Resident #49. Review of the facility policy, Resident Trust Fund Policies and Procedures, revised 02/01/18 revealed the resident trust fund (RTF) designee will review month-end balances each month to identify resident trust balances at or exceeding the state asset limit. For Ohio, the limit was $2000.00 so notification was to occur when the resident reached $1800.00. The Medicaid Asset Limit Notification letter will be generated by the Business Office/Accounts Receivable Manager and mailed to the resident and/or responsible party monthly for any residents that have reached the threshold. A copy of the letter will be maintained either hardcopy or electronic file by the RTF designee.

Based on observation, interview and record review the facility failed to follow proper infection control techniques for residents on Enhanced Barrier Precautions (EBP). This affected one resident (#75) of three observed for EBP. The facility failed to maintain hand hygiene during medication administration and disinfect a glucometer meter after use. This affected one resident (#9) of four observed for infection control techniques during medication administration. The facility census was 131.1.Review of Resident #75's medical records revealed an admission date 11/24/25. Diagnoses included surgical amputation of the right toes, muscle weakness and dementia. Review of care plan dated 12/29/25 revealed Resident #75 required EBP related to diabetic foot ulcer. Interventions included use gown and gloves when providing direct resident care and utilize EBP when providing high contact resident care that included wound care. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #75 had intact cognition. Resident #75 required moderate assistance with toileting, bed mobility and was dependent with transfers. Review of Resident #75's current physician orders for March 2026 revealed to use EBP while performing high contact activity. Observation of wound care on 03/18/26 at 10:28 A.M. with Licensed Practical Nurse (LPN) #621 for Resident #75 revealed signs posted on the door that indicated EBP and a Personal Protective Equipment (PPE) bin outside of the room. LPN #621 had entered Resident #75's room and had proceeded to provide wound care and had not donned PPE prior. LPN #621 had completed wound care and had exited Resident #75's room. Interview with LPN #621 after completion of wound care confirmed an EBP sign posted and a bin of PPE and LPN #621 stated she was unaware she was to donn PPE to perform wound care. Review of facility policy titled Enhanced Barrier Precautions (EBP) revised 03/26/24 revealed PPE was necessary when performing high contact care and high contact resident activities included wound care. 3. Observation on 03/17/26 at 9:00 A.M. revealed Licensed Practical Nurse (LPN) #591 had obtained blood sugar reading from Resident #9 using a glucometer. She then proceeded to place the glucometer in the top drawer of the medication cart without properly sanitizing the glucometer after use. On 03/17/26 at 9:29 A.M. LPN #591 verified she had not sanitized the glucometer after use. Review of the facility policy titled, Blood Glucose Machine Disinfection, dated 12/12/23 revealed the purpose of the procedure was to provide guideline for disinfection od capillary blood sampling devices to prevent transmission of blood born disease to resident and employees. The facility would ensure blood glucose machines would ne disinfected after each use and according to manufacturer's instructions for multi-resident use. 4. Observation on 03/17/26 at 9:10 A.M. revealed a resident had fallen on the floor out of the wheelchair in front of the medication cart. Licensed Practical Nurse (LPN) #591 went to assist Unit Manager #521 with the resident. She obtained his vital signs, assessed the resident ,and help assist him up off of the floor. LPN #591 then came back to the medication cart and proceed to administer medication to Resident #9 without washing her hands after assisting with the fall. On 03/17/26 at 9:29 A.M. LPN #591 verified she had not washed her hands after assisting with the resident who had fallen. Review of the facility policy titled, Hand Hygiene, dated 12/13/23 revealed all staff would preforms proper hand hygiene procedures to prevent the spread of infection to other personal, resident and visitors. This applied to all staff working in all location within the facility. Alcohol-based hand rub was not allowed to be used in the kitchen or other food preparation.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review and staff interview, the facility failed to ensure individualized behavioral health interventions were implemented to meet Resident #77's mental health needs tp prevent suicidal ideation with suicidal attempt. This deficient practice affected one (Resident #77) of two residents reviewed for mood and behavior. The facility census was 131.Findings include: Resident #77 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, personality disorder, and major depressive disorder.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #77 was cognitively intact and required hands-on assistance of one staff person for activities of daily living.Review of Resident #77's admission documentation revealed he was admitted from a psychiatric hospital, where he had been transferred from an assisted living facility following a suicide attempt involving placing a garbage bag over his head.Review of a nursing progress note dated 06/20/26 at 6:33 P.M. revealed Resident #77's assigned Certified Nursing Assistant (CNA) alerted nursing staff after observing the resident with a plastic bag placed over his head and face while staff were preparing to escort him to dinner. The CNA immediately removed the bag and notified nursing.Upon assessment, Resident #77 stated, I don't want to be here. I can't go on like this, and expressed active suicidal ideation, including a stated plan to attempt self-harm if left unsupervised. The resident repeatedly stated, I should have done it later in the night. If you leave me, I will do it again.Resident #77 was immediately moved to a common area and placed under one-to-one supervision. A safety check was conducted to ensure no potentially harmful items (e.g., sharp objects, strings, or other ligature risks) were in the resident's possession. The physician and guardian were notified. The guardian reported a history of similar behaviors at previous facilities. Resident #77 was subsequently admitted to an inpatient psychiatric hospital for further evaluation and treatment.Review of the care plan for Resident #77 prior to 06/20/25 revealed a problem related to a history of suicidal behaviors. Interventions included general behavioral approaches such as medication administration as ordered, redirection, non-judgmental support, environmental calming strategies, and monitoring/documentation of behaviors. The care plan failed to include specific, measurable interventions to mitigate risk, such as increased supervision levels and/or environmental safety precautions (e.g., restriction or removal of potentially harmful items).Interview with the Director of Nursing (DON) on 03/18/26 at 9:30 A.M. confirmed the care plan did not include measurable interventions to address Resident #77's suicidal ideations and behaviors prior to 06/20/26.Review of the facility policy titled Comprehensive Care Plans, dated 01/01/21, revealed, It is the policy of this 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, mental, and psychosocial needs identified in the comprehensive assessment.The deficient practice was corrected on 06/24/25 through the following corrective actions:-On 06/24/25, Resident #77 was readmitted from the psychiatric hospital. A room change was completed to relocate the resident closer to the nurse's station. The resident was placed on one-to-one supervision upon return until cleared by the physician.-On 06/24/25, the care plan was revised to include specific interventions, including 15-minute safety checks, room sweeps every two hours, storage of the resident's cell phone charger at the nurse's station, use of a bell in place of a traditional call light, and provision of preferred activities (e.g., coloring books) daily.-On 06/24/25, the social services department reviewed residents with a known history of suicidal ideation and/or attempts to ensure appropriate care-planned interventions were in place. Four residents were identified and had appropriate care plans in place.-On 06/24/25, a root cause analysis was completed by the Administrator and Director of Nursing.-On 06/24/25, the Director of Nursing educated the social services department on timely identification and care planning for residents with suicidal ideations and behaviors.-On 06/25/25, the Director of Nursing and designee conducted facility-wide nursing education on Resident #77's behavioral health needs and principles of person-centered care.-On 06/25/25, an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was conducted to address the incident.-On 06/25/25, the Director of Nursing completed a 30-day look-back review of new admissions to identify any residents admitted with suicidal ideations or attempts. No additional concerns were identified.This deficiency represents noncompliance investigated under Complaint Number 1295322.

Based on record review and interview the facility failed to adequately manage Resident #6's pain following a fall. This affected one resident (#6) of three reviewed for pain management. The facility census was 131. Findings include:Record review revealed Resident #6 admitted on [DATE] with diagnoses including anxiety, personality disorder, depression, violent behavior, paranoid schizophrenia, polyneuropathy (nerve pain).Review of care plan dated 11/17/25 revealed Resident #6 was at risk for falls related to generalized weakness, history of falls and impaired cognition with decreased safety awareness with intervention to encourage the resident to use the call light. Resident #6 was at risk for pain related to polyneuropathy with intervention to administer medications per orders and monitoring for effectiveness.Review of physician's orders dated 11/17/25 revealed orders for Tramadol 50 milligrams (mg) every 12 hours as needed for pain, Acetaminophen 325 mg every six hours as needed for pain and Lyrica 50 mg three times a day for pain.Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had moderate cognitive impairment. Resident #6 required moderate assistance for bed mobility and maximum assistance for transferring and toileting.Review of nurse's note dated 11/18/25 at 3:28 A.M. authored by Licensed Practical Nurse (LPN) #650 revealed physician had been contacted regarding Resident #6's fall and orders were received for x-ray of right hip and ankle.Review of nurse's note dated 11/18/25 timed at 4:16 A.M. and authored by LPN #650 revealed at approximately 2:45 A.M. Resident #6 was seen lying on the bathroom floor and stated she had to go to the bathroom. Resident #6 stated se had walked herself to the bathroom without her wheelchair unassisted and fell. Resident #6 was checked for injuries with none noted and reported a pain rated nine out of ten. Further review of progress note revealed facility Unit Manager and family were notified.Review of nurse's note dated 11/18/25 and timed 11:21 A.M. authored by Registered Nurse (RN) #586 revealed abnormal x-ray results were received and Resident #6 was to be transferred to the hospital.Review of nurse's note dated 11/18/25 at 2:58 P.M. and authored by RN #632 revealed update was received and Resident #6 was being admitted to the hospital for hip fracture.Review of Medication Administration Record (MAR) for November 2025 revealed Resident #6 was medicated with Acetaminophen on 11/18/25 at 3:05 A.M. Further review revealed a pain reassessment timed 3:35 A.M. that medication was ineffective. Additionally, MAR revealed Resident #6 had been medicated with Tramadol on 11/18/25 at 8:51 A.M. and an untimed reevaluation revealed medication effectiveness was unknown.Interview with Resident #6 on 03/16/26 at 9:35 A.M. revealed she had fallen on the morning of 11/18/25. Resident #6 further stated she had used her call light for toileting assistance, however, staff had not responded and she had taken herself to the bathroom and had fallen.Interview with Director of Nursing (DON) on 03/18/26 at 1:56 P.M. confirmed Resident #6 was administered Acetaminophen on 11/18/25 at 3:05 A.M. and reassessment at 3:35 A.M. was ineffective. DON confirmed Tramadol administered on 3/18/25 at 8:51 A.M. had a pain reassessment of unknown. DON further confirmed no other pain management interventions had been administered or attempted. DON further stated pain management was not appropriate, and other attempts should have been implemented.Review of facility policy titled Pain Management revised 10/26/23 revealed when the resident's pain is not controlled the physician should be notified. If reassessment indicates pain has not been adequately controlled, the pain management regimen and care plan should be revised as indicated.

Based on observation, interview, record review and review of the facility policy the facility failed to ensure Resident's #7 care planned fall interventions were implemented. This affected one resident (Resident's #7) out of three residents reviewed for falls. The facility census was 131.Findings include:Review of Resident #7's medical record revealed an admission date of 02/19/26 and diagnoses included unspecified dementia, quadriplegia, delusional disorders, Alzheimer's Disease with early onset, anxiety disorder, major depressive disorder and epilepsy. Review of Resident #7's Nursing admission Evaluation dated 02/19/26 included Resident #7 was at risk for falls.Review of Resident #7's care plan dated 02/19/26 and revised 02/27/26 included Resident #7 was at risk for falls/injury related to impaired cognition and decreased safety awareness. Reduce the risk of injury through the next review. Interventions initiated on 02/19/26 included to ensure Resident #7's room was free from accident hazards; place a mat to the floor next to the bed, and the floor mat was changed on 03/09/26 to place a mattress on the floor at bedside. Review of Resident #7's care plan dated 02/19/26 and revised on 02/23/26 included Resident #7 had behaviors related to her diagnoses as evidenced by verbal aggression, yelling out at staff, throwing her legs out of bed, resisting care, being socially disruptive, attention seeking, a history of yelling fire, and pretending to have a seizure and other behaviors to get attention per her Power of Attorney. Resident #7 would remain injury free related to her behaviors through the next review. Interventions included to approach Resident #7 in a calm manner to avoid frustration and behavior escalation and if Resident #7 became agitated and showed signs of escalation, re-approach later.Review of Resident #7's care plan dated 02/19/26 and revised on 03/06/26 included Resident #7 had an ADL self-care performance deficit related to quadriplegia, dementia, fluctuating ADL's, Alzheimer's Disease and cognitive impairment. Resident #7's ADL needs would be met through the next review. Interventions included Resident #7 required the assistance of one person for ADL's and was a two person assist and used a mechanical lift for transfers.Review of Resident #7's physician orders dated 02/20/26 revealed the resident received tube feedings of Jevity 1.5 cal/fiber oral liquid (nutritional supplement), give 65 ml per hour enterally one time a day for supplement tube feed, run at 65 ml per hour for 12 hours, start at 7:00 P.M.Review of the facility incident log revealed Resident #7 had an unwitnessed fall on 02/24/26 at 11:45 P.M.Review of Resident #7's progress notes dated 02/25/26 at 12:13 A.M. revealed Resident #7 was found on the floor next to the bed after reportedly throwing herself out of bed. The fall was unwitnessed. Resident #7 had a hematoma to the left side of the head by the eye and an active nosebleed. 911 was activated and EMS arrived at 12:00 A.M. Resident #7 was transported to the local hospital. All parties were notified.Review of Resident #7's progress notes dated 02/25/26 at 4:15 A.M. revealed Resident #7 returned to the facility following an evaluation at the hospital for her fall. No new physician orders were received and Resident #7 was negative for injuries. Resident #7 would be monitored and neuro checks were in place.Review of Resident #7's admission Minimum Data Set (MDS) assessment dated [DATE] included Resident #7 was cognitively intact. Resident #7 had no impairment of the upper and lower extremities, and was dependent for Activity of Daily Living's (ADL)'s. Resident #7 was dependent for the ability to roll from lying on her back to the left and right side, and return to lying on her back on the bed and for transfers to and from a bed to a chair or wheelchair. Observation on 03/17/26 at 4:27 P.M. with Resident #7 revealed she was sitting in a wheelchair in the common area, steri-strips and a bruise were observed on her forehead, and greenish-yellow with some purple bruising was noted under both eyes. Resident #7 was pleasant but unable to answer questions appropriately.Interview on 03/17/26 at 4:35 P.M. with Registered Nurse (RN) #505 revealed Resident #7 was absolutely confused. RN #505 stated Resident #7 had dementia with psychoses and was able to buck herself out of bed and throw herself on the floor. RN #505 stated it was her idea to use the mattress instead of the floor mat because the floor mat was not enough. Interview on 03/18/26 at 10:31 A.M. with Power of Attorney (POA) #660 revealed Resident #7 was recently admitted to hospice services, had terrible anxiety and hospice could provide the right medications and care Resident #7 needed. POA #660 indicated Resident #7 could not move her legs, but she could raise her arm and it would fall after she raised it. POA #660 revealed Resident #7 was able to scoot herself to the edge of the bed and roll off onto the floor. POA #660 indicated Resident #7 did this because she liked the attention she received when she rolled onto the floor and she liked the attention she received at the hospital. POA #660 revealed sometimes Resident #7 hit her head on the floor when she rolled off the bed and had to be transported to the hospital. POA #660 stated the floor mat was not enough protection and now there was a mattress on the floor next to the bed. POA #660 revealed Resident #7 yelled, screamed, put her arms and legs over the side of the bed and she was moved to the facility so her behaviors could be better managed. Interview on 03/19/26 at 6:30 A.M. with Director of Nursing (DON) revealed Resident #7 had not resided in the facility very long and quadriplegia was suspected. The DON stated Resident #7's referral from another facility revealed she had quadriplegia but she was not a quadriplegic, and at times Resident #7 tried to stand up but was unable to. The DON stated at times Resident #7 could move herself and could throw herself out of bed, and at other times she could not. The DON indicated it was unable to be determined what caused Resident #7's quadriplegia. Resident #7's mother wanted her at the facility because the facility had more psych services than most places.Observation on 03/19/26 at 7:53 A.M. of Resident #7 with Certified Nursing Assistant/Central Supply/Transportation (CNA/CS/T) #563 revealed Resident #7 was lying in bed and was leaning over the side of the bed. Next to her head was an oxygen concentrator, a wastebasket and a bedside table. CNA/CS/T #563 immediately moved the oxygen concentrator, the wastebasket and bedside table away from Resident #7's head and stated these things were an accident hazard, Resident #7 was a fall risk and could hit her head on them if she fell out of bed. CNA/CS/T #563 indicated she picked Resident #7 up from her previous facility, was told Resident #7 fell often and she was immediately placed on a low bed with a fall mat next to the bed when she arrived at the facility. CNA/CS/T #563 revealed Resident #7 reached over the bed a lot and grabbed and pulled on the floor mat, she grabbed her tube feeding pole, although now she wasn't getting tube feeding, and she grabbed anything else that was close. Resident #7 often yelled out, calling for people who were not in the facility, and she spent a lot of time in the common area.Interview on 03/19/26 at 10:48 A.M. with Nurse Practitioner (NP) #649 and Unit Manager #633 revealed Resident #7 had a diagnosis of quadriplegia when she was a patient in the hospital and at one point was fully quadriplegic. NP #649 stated she was not sure what caused the diagnosis of quadriplegia and no one really knew what happened to her. NP #649 indicated she felt there was a major psych component related to the quadriplegia. NP #649 revealed she was not able to elicit reflexes of Resident #7's lower extremities, and she felt Resident #7's upper body strength was more than she would present when asked. NP #649 revealed she saw Resident #7 scoot herself to the side of the bed, get leverage, and pushed with one hand to push herself off the bed. NP #649 indicated she asked Resident #7 why she did it and she denied that she did it. NP #649 revealed Resident #7's mother told her Resident #7 pushed herself off the bed and onto the floor at her previous facility. NP #649 stated Resident #7 faked seizures, said she had chest pain, threw herself from her bed, yelled fire and was told by Resident #7's mother that she liked the attention and that was why she did these things. NP #649 indicated she felt Resident #7 was sometimes confused and sometimes had moments of clarity and felt she was terminal because she had quite a few physical ailments. Interview on 03/23/26 at 7:41 A.M. with DON revealed Resident #7 probably hit the cement floor when she rolled off the bed. The DON stated Resident #7 now had a thicker mattress by the side of her bed. The DON was made aware of the observation of a bedside table, a waste basket and an oxygen concentrator by Resident #7's head while she was lying in bed. Interview on 03/23/26 at 10:56 A.M. with Licensed Practical Nurse (LPN) #623 revealed she was working on 02/24/26 when Resident #7 experienced a fall. LPN #623 indicated Resident #7 was assisted into bed for the evening and sometime after she was helped into bed the cleaning lady heard screaming. When LPN #623 entered Resident #7's room she found that Resident #7 had thrown herself off the bed and was face down on the floor and was bleeding. LPN #623 indicated Resident #7 had a feeding tube pole next to the bed with the tube feeding machine attached to it. LPN #623 stated Resident #7 might have hit her head on the tube feeding pole but was not sure because the fall was unwitnessed. Resident #7 had a fall mat on the floor and she was lying on the floor mat. Review of the facility policy titled Falls-Clinical Protocol revised 11/02/23 included as part of an initial and ongoing resident assessment, the staff would help identify individuals with a history of falls and risk factors for subsequent falling. The falls section included history of falls, cognitive status/behavioral symptoms, mobility, balance, medications. Based on the assessment an initial plan of care would be developed and implemented to address identified risk. This would be revised as necessary. Goals of the plan of care included reduction of falls, minimize injury from falls and/or prevent falls while maintaining and/or improving resident abilities and quality of life.This deficiency represents non-compliance investigated under Complaint Number 2794898, 1295318, 1295325, and 1295312.

Based on review of the medical record, review of the Self-Reported Incident and interview with the staff the facility failed to ensure an incident of potential abuse was documented in the medical record of Resident #31. This affected one resident (Resident #31) of 21 residents reviewed for abuse.Findings include:Review of the medical record revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including vascular dementia anxiety disorder, psychosis, cerebral infarction, hemiplegia of the left side, contractures of the right hip, left hip, right knee, left knee, peripheral vascular disease, mood disorder, tremors, pain, insomnia, epilepsy and hypertension.Review of the Annual Minimum Data Set assessment dated [DATE] revealed Resident #31 had severely impaired cognition. Review of the facility's Self-Reported Incident dated 09/17/25 revealed Resident #31 had reported to the nurse and aide on duty that during care on the previous night, an aide allegedly held a towel up to her face. The description provided by Resident #31 did not match any staff assigned to the unit, and her statements have been inconsistent. In addition, the entire F Pod unit received skin assessments and psychosocial assessments, with no findings. The resident was assessed by the nurse and found to have no signs of injury. Psychosocial support was offered, and witness statements were obtained from all staff, none indicated anything out of the ordinary in the last few days. The resident's care plan updated to reflect a two person assist for care. Review of Resident #31's medical record revealed there was no documentation of the incident in the medical record. On 03/23/26 at 9:14 A.M. an interview with the Director of Nursing verified there was no documentation of the incident in the medical record of Resident #31.

Based on review of the medical record review, facility incident report review, interview with staff, and review of the facility's abuse policy the facility failed to provide adequate supervision to prevent physical abuse of a cognitively impaired resident (Resident #131) by another resident identified by the staff to have aggressive behaviors. This affected one resident ( Resident #131) of 21 residents reviewed for abuse.Findings include:Review of the medical record revealed Resident #157 was admitted to the facility on [DATE] with diagnoses including hearing loss, cerebral ischemia, asthma , major depressive disorder, generalized anxiety disorder, and dementia.Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #157 had severely impaired cognition. Resident #157 had delusions, physical and verbal behaviors, rejection of care, and wandering. Review of the plan of care dated 04/02/25 revealed Resident #157 had behaviors related to dementia as evident by exit seeking, physical aggression towards staff, resistant to care, verbally aggressive towards staff, wondering in other resident rooms, wandering through facility with no sense of direction, lower self on the floor, grabbing, kicking, hitting, pushing, cursing at others, anger towards others, screaming, disruptive sounds, wandering and co-resident rooms, repetitive motion, agitation, anxiety and restlessness, sad and tearful. Interventions included administer medication as ordered and observe for effectiveness and side effects, approach resident in a calm manner to avoid frustration and behavior escalation, communicate care to resident before starting task, if the resident resist with activities of daily living reassure the resident leave and then return later to try again, observe and document episodes of inappropriate behavior, notify the physician or nurse practitioner when behaviors persist or will not deescalate, observe and report any, provide positive feedback to the resident when behaviors or changes in mental status caused by situational stressors, observed behavior episodes and attempt to determine underlying cause, offer psychologist and psychiatric services as needed offer resident choices whenever possible, provide a calm safe environment when the residents frustrations escalate and allow time to voice feelings, provide a structured schedule for daily care when possible.Review of the medical record revealed Resident #131 was admitted to the facility on [DATE] with diagnoses including vascular dementia, dementia, chronic obstructive pulmonary disease, mild protein-calorie malnutrition, chronic kidney disease, atherosclerotic heart disease, congestive heart failure, anxiety disorder, peripheral vascular disease, pain, hypertension, osteoarthritis, diverticulosis, cognitive communication deficit, and major depressive disorder. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #131 had severely impaired cognition.Review of the Incident Audit Report dated 08/23/25 at 2:15 P.M. revealed a nursing assistant called the nurse over and stated Resident #157 hit Resident #131 in the left side of her chest with her hand. The other resident was redirected immediately from Resident #131. The nurse assessed Resident #131 and there was no redness or bruising noted to the area, vital signs were blood pressure (B/P) 125/76, pulse (AP) 72, respirations (R) 16, oxygen level 97 percent (%) on room air (RA). The physician and family were notified. New order was implemented to monitor the area for pain or bruises for three days. Resident #131 stated it did hurt but she did not know why the other resident had hit her. Review of the Physical Aggression Form dated 08/23/26 at 2:15 P.M. revealed there was a section for witness statements. Certified Nursing Assistant #625 stated she was discarding trash and heard yelling, She looked out in the common area and seen Resident #157 hit Resident #131 in the chest, and she immediately stepped in to move Resident#157 away. Review of the Nurse's note dated 08/25/26 at 2:59 P.M. revealed Nurse Practitioner (NP) #652 was in the facility to see Resident #131 and order a two-view chest x-ray due to an increase in pain from resident-to-resident altercation a few days ago to rule out rib fractures. Review of the Chest X-ray report dated 08/25/25 revealed Resident #131 had no fractures however she did have left side opacites (haziness/whiter tissue).Review of the August 2025 Medication Administration Report (MAR) dated 08/25/25 at 10:25 A.M. revealed Resident #131 was administered Acetaminophen 1000 milligrams (mg) for left breast pain for a pain level six out of ten. There was no documentation of the medication being effective. Review of the Acute Visit Note from NP #652 dated 08/25/25 at 1:48 P.M. revealed the reason for the visit was due to a follow up for cellulitis and left breast pain secondary to trauma. Resident #131 was stuck by another resident on 08/23/25 on the left side of the chest and breast. She reports mild intermittent pain localized to the side of the left breast with no involvement of the chest. She denied shortness of breath. Physical examination revealed no bruising or visible injury to the left side of the chest or breast. Ordered a one-time dose of Tylenol 100 milligrams and monitor for any late onset signs of injury. Review of the Triage on call note dated 08/25/25 at 10:24 P.M. revealed the on-call Nurse Practitioner #653 was told by the staff, Licensed Practical Nurse #512, that Resident #131 had a chest x-ray for complaint of pain from a resident-to-resident altercation and the resident had discoloration to the left chest. Review of the August 2025 MAR dated 08/26/25 at 5:00 A.M. revealed Resident #131 was administered Acetaminophen 650 milligrams for complaint of nine out of 10 left breast pain. Review of the Administration note dated 08/26/25 at 6:07 P.M. revealed the Acetaminophen was effective with a follow up pain level of six out of ten. Review of the August 2025 MAR dated 08/26/25 at 7:37 P.M. revealed Resident #131 was administered acetaminophen 650 milligrams for complaint of three out of 10 left breast pain which was later documented as effective.Review of the Acute Visit note written by NP #652 dated 08/26/25 at 1:07 P.M. revealed the reason for the visit was Resident #131 was being evaluated for left side chest pain following a resident-to-resident altercation. Resident #131 sustained a contusion to the left front wall of the thorax following an alternation with another resident. Resulting in pain that was initially rated an eight out of 10 by nursing staff. She was administered 1,000 milligrams of Acetaminophen without relief. Due to her multiple allergies an advanced age further pain medication was not administered. Biofreeze was applied, which Resident #131 reported provided some relief. Review of the August 2025 MAR dated 08/27/25 at 12:11 P.M. revealed Resident #131 was administered Acetaminophen 650 milligrams for complaint of six out of 10 left breast pain which was later documented as effective. Review of the Nurse's note dated 08/27/25 at 2:19 P.M. revealed Resident #131 was anxious. The NP was notified an ordered to increase the Depakote to 125 milligrams to twice daily as well as Vistaril 25 milligrams every six hours as needed for 14 days for anxiety. The family was notified. There was no further documentation as to why the resident was anxious. Review of the August 2025 MAR dated 08/27/25 at 3:40 P.M. revealed Resident #131 was administered Vistaril 25 milligrams for anxiety. Review of the Acute Visit notes dated 08/28/25 at 2:29 P.M revealed over the weekend Resident #131 was struck on the left side of her chest by another resident and has since been experiencing mild pain in the area. The family was expressing concern which lead to the initiation of Prednisone by the on-call NP and additionally her Doxycycline was extended three more days and an order for Biofreeze was put into place until 09/02/25. Resident #131 was also started on Vistaril 25 milligrams every six hours as needed by psychiatric services for a two-week trial until 09/10/25 to address anxiety related symptoms. Review of the Nurse's note dated 08/30/25 at 9:09 P.M. revealed Resident #131 complained of left chest aching pain. Acetaminophen was given but was ineffective. Vital signs were B/P 155/68, AP 115, R 16, and oxygen lever 92 % on RA. The on-call service was called, and new orders were received to discontinue the prednisone, apply a Lidoderm patch to the rib cage daily and to be taken off at night and on during the day for seven days, stated levofloxacin 750 milligrams every 48 hours chest pain for five doses. The family was to be notified by the on-call service. And second note dated the same indicated the resident received a new order for complete blood count and basic metabolic panel. Review of the Nurse's note dated 08/30/25 at 10:38 P.M. revealed Resident #131 received a new order for a chest x-ray and the family was aware. Review of the Chest X-ray report dated 08/31/25 revealed Resident #131 had no acute pulmonary disease. Review of the August 2025 MAR dated 08/31/25 at 7:53 A.M. revealed Resident #131 was administered Acetaminophen 650 milligrams for complaint of four out of 10 left breast pain which was later documented as effective.Review of the August 2025 MAR dated 08/31/25 at 9:12 A.M. revealed Resident #131 was administered Vistaril 25 milligrams for anxiety.Review of the August 2025 MAR dated 08/31/25 at 12:15 P.M. revealed Resident #131 was administered Acetaminophen 650 milligrams for complaint of nine out of 10 left breast pain which was documented as ineffective. Review of the Nurse's note dated 08/31/25 at 12:38 P.M. revealed Resident #131 was still complaining of pain in the left chest and the nurse reached out to the on-call service and received a new order for an immediate (STAT) 12 led Electrocardiogram (EKG) and troponin level (heart protein level), DuoNeb aerosols every six hours as needed for three days. The resident and daughter were aware of the new orders.Review of the Administration note dated 08/31/25 at 12:45 P.m. revealed the Acetaminophen was ineffective and the pain lever for Resident #131 was now a 10 out of 10. Review of the Nurse's note completed by Unit Manager #633 dated 08/31/25 at 1:58 P.M. revealed Resident #131 complained of chest pain this shift. Vital signs and assessment were completed by the floor nurse as charted, as needed Acetaminophen was administered, and a Lidocaine patch was in place per orders. The on-call service NP was notified and gave new orders for a STAT 12-lead EKG, Troponin level to be drawn, and DuoNeb treatments every six hours as needed for three days. The EKG service was contacted and reported the EKG could not be performed STAT, and they would contact the facility with an estimated time of arrival, STAT chest X-ray had been completed the night before with negative results. The on-call NP was aware. The resident's sister was at bedside and induced panic by yelling and repeatedly stating the resident could not breathe and was still in pain. This behavior increased resident distress, and resident demonstrated labored breathing patterns and episodes of emesis. The nurse attempted to reassure the resident and redirect to help calm the situation. Vital signs were oxygen level 98% on RA, AP 84, R 18, Temperature 97.7, and BP 98/54. The on-call NP was updated, Acetaminophen was given, and Nitroglycerin 0.4 milligrams sublingual was administered for one dose. The resident's daughter got to the facility and contacted the on-call service herself and demanded her mother be transferred to the emergency room (ER) for further evaluation and treatment. Emergency Medical Services (EMS) were contacted per the on-call orders. EMS conducted an EKG at bedside, which showed no acute abnormalities. Resident #131 was transferred to the ER for further evaluation. Report called to ER by the nurse.Review of the emergency room report dated 08/31/25 revealed Resident #131 was presented to the ER for evaluation of chest and abdominal pain. The family indicated the resident was punched by another resident at the facility about a week ago and since had been experiencing chest wall tenderness on the left side and had recently been treated for pneumonia. CT scan of abdomen and pelvis indicated of evidence of pulmonary embolism, no acute rib fractures however there were some chronic right sided rib fractures, there was dilation of pancreatic duct, mild hydronephrosis related to greatly distended bladder, dissection of the abdominal aorta. The plan was for no acute interventions for the aortic dissection just continue with BP medications. On 03/18/26 at 9:38 A.M. an interview with the Director of Nursing (DON) revealed the facility did not complete a Self-Reported Incident between Resident #131 and #157 because Resident #131 was not injured.On 03/19/26 at 9:40. A.M. an interview with Family Member #661 revealed Resident #131 was punched in the chest by another resident. She stated her mother was complaining of chest pain, so the facility did a chest x-ray which showed pneumonia but not broken ribs. She stated her aunt was visiting her mother and her mother was having trouble breathing and complaining of chest pain and the facility would not send her out to the hospital. She stated she went to the facility and had to call the on-call service herself to have her sent out to the Emergency room. She stated mother had a tear in her aorta and the emergency room physician asked her if her mother was in a car accident because the type of injury she had was from trauma however they could not prove it was from being punched in the chest. She stated her mother had a slight discoloration to her chest from being hit. She stated the hospital took pictures.On 03/23/26 at 1:10 P.M. an interview with NP #652 revealed she did not have access to her notes because she did not work for the on-call service any longer but would answer question the best she could. She stated she remembered Resident #131 had been hit by another resident . She stated the resident has been complaining of chest discomfort and muscular skeletal pain, so she had diagnosed her with a chest contusion even though she did not have any visible bruises at that time. She stated it was appropriate to diagnoses her as such because she had a blunt force trauma to the area. She stated the resident had dementia, so it was difficult to get appropriate information from her but if she remembered correctly the resident daughter was highly involved with her care. She stated she had ordered two separate chest x-rays and started her on an antibiotic and the facility NP had extended that antibiotic. She stated she only worked at the facility Monday through Friday, so she was not called during the weekend. She stated she only physically seen the resident right after she was hit on that Monday (08/25/25).Review of the facility policy, Abuse, Neglect and Exploitation, revised 01/10/24, revealed the facility would provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prevent and prevent abuse, neglect, exploitation and misappropriation of resident property. Physical Abuse included but was not limited to hitting, slapping, punching, biting and kicking, The facility will have written procedures to assist staff in identifying the different types of abuse; possible indicators of abuse include but are not limited to physical abuse of a resident observed. The facility will have written procedures that include reporting of alleged violations to the state agency within specified timeframes as required by state and federal; regulations: immediately but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.This deficiency represents non compliance investigated under Complaint Number 1295325, and 2611622.

Based on review of the personnel files and staff interviews, the facility failed to ensure its Certified Nursing Assistants (CNAs) had regular performance evaluations at least annually as required. This affected two of four CNA personnel files reviewed and had the potential to affect all residents. The facility census was 131. Findings Include:Review of the personnel record for CNA #999 revealed the last yearly performance evaluation was completed on 10/18/16.Review of the personnel record for CNA # 514 revealed the last yearly performance evaluation was completed on 04/25/22.Human Resources Director (HRD) # 998 verified the above lack of evaluations in an interview on 03/20/26 at 12:45 P.M.

Based on observation, record review, policy review and interview the facility failed to ensure residents received adequate fluids to prevent dehydration. This affected Resident #73 and had the potential to affect 17 residents (#19, #28, #36, #49, #59, #63, #67, #70, #71, #72, #81, #84, #87, #88, #91, #99, and #109) who resided on the C pod nursing unit and 19 residents (#5, #31, #33, #41, #44, #46, #64, #66, #73, #77, #90, #92, #94, #100, #101, #108, #112, #121 and #224) who resided on the D pod nursing unit. The facility also failed to ensure diets were followed as ordered. This affected one resident (Resident #93) of five reviewed for nutrition. The facility census was 125. Findings include: Actual harm occurred on 11/16/24 when Resident #73, who had severe cognitive impairment was noted to have an acute change in condition/altered mental status with slurring/mumbling words, an inability to perform hand grasps and equal but fixed pupils. The resident was transferred to the hospital and admitted with dehydration with elevated sodium, acute kidney injury which required intravenous fluids to treat. The resident returned to the facility on [DATE]. Findings include: 1. Clinical record review revealed Resident #73 was admitted on [DATE] with diagnoses including Alzheimer's disease, chronic kidney disease (stage 3), hyperlipidemia, atherosclerotic heart disease, anemia delusional disorders, dementia with behaviors, vitamin D deficiency, osteoarthritis, gastroesophageal reflux disease, depression, paranoid personality disorder, high blood pressure, cardiac murmur, benign prostatic hyperplasia with lower urinary tract symptoms, hyperosmolality, heart attack, mood disorder, irritable bowel syndrome, anxiety, and dysphagia (trouble swallowing). Review of Resident #73's plan of care dated 12/21/23 revealed Resident #73 was at risk for fluid volume deficit related to cognitive impairment. Interventions on the plan of care included to encourage Resident #73 to drink fluids of choice unless contraindicated (i.e., fluid restriction) and assist as needed; offer fluids during activities; offer fluids of choice; ensure all beverages offered complied with diet/fluid restrictions and consistency requirements, and review and report to physician/certified nurse practitioner abnormal laboratory results and any signs of dehydration. Review of the change of condition nursing progress note dated 11/16/24 indicated the nurse was on another nursing unit when an unnamed certified nursing assistant (CNA) notified the nurse that Resident #73 was previously alert at baseline and then was observed sitting at common area table slumped forward and unresponsive for a few seconds. The nurse immediately went to the unit and assessed Resident #73 and obtained his vital signs. The nurse obtained a blood pressure of 176/56, heart rate of 74 beats per minute, respirations 18 per minute, oxygenation level was 97 percent on room air, and temperature was 97.2 degrees Fahrenheit (F). Resident #73 appeared to have a decrease in alertness, was observed slurring/mumbling words, and unable to grasp hands. Resident #73's pupils appeared equal but fixed. The nurse called emergency medical services (911) and waited with Resident #73 until emergency medical personnel arrived. Resident #73 was transported to the hospital for evaluation and treatment. A review of Resident #73's fluid intake documentation dated 11/01/24 to 11/30/24 revealed Resident #73 had consumed only between 850 milliliters (ml) and 900 ml of fluid on 11/14/24 and 11/15/24 prior to his hospitalization on [DATE] for a diagnosis of dehydration. Review of the nursing progress note dated 11/17/24 revealed the nurse contacted the hospital and was informed Resident #73 was admitted with a diagnosis of altered mental status. Review of the nursing progress note dated 11/19/24 revealed Resident #73 was readmitted to the facility from the hospital. A review of Resident #73's discharge summary from the hospital dated 11/19/24 indicated Resident #73 was discharged from the hospital in fair condition. The reason for Resident #73's admission to the hospital was altered mental status, dehydration, and high blood pressure. The discharge summary indicated Resident #73 who had a history of Alzheimer's disease, and hypertension (high blood pressure) presented with concern of altered mental status, decreased arousability from the (facility) memory care unit. Upon arrival his mentation slowly improved and Resident #73 was found to be dehydrated with elevated sodium, acute kidney injury and was started on intravenous fluids. Neurology was consulted and found Resident #73 was negative for seizure but demonstrated encephalopathy. Neurology did not feel encephalopathy was central neurologic in nature and signed off the case. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73's had severe cognitive impairment. An interview on 01/08/25 at 7:30 A.M. with Licensed Practical Nurse (LPN) #494 revealed when a resident returned from the hospital LPN #494 completed a head to toe assessment and obtained vital signs and reviewed the medication list. LPN #494 verified the medication list and obtained other orders from the physician. LPN #494 stated he readmitted Resident #73 back to the facility on [DATE] and had received report by phone from the nurse at the the hospital prior to Resident #73's arrival to the facility. LPN #494 did not document what the nurse had told him during the report and was unable to remember what the nurse had told him during the phone call. LPN #494 did not remember the hospital's diagnoses during Resident #73's admission to the hospital and could not state what was being done to prevent Resident #73 from being readmitted to the hospital (related to concerns with dehydration). LPN #494 was unable to state where information from the hospital could be located in Resident #73's clinical record. LPN #494 did not know what care planned interventions were in place to prevent Resident #73 from returning to the hospital for the altered mental status symptoms/dehydration. LPN #494 verified most of the residents on the D pod nursing unit were cognitively impaired which made them at risk for dehydration but was unable to state where he would need to look on the residents' plan of care for interventions to implement to ensure the residents had adequate hydration. An interview with CNA #509 on 01/08/25 at 8:31 A.M. revealed CNA #509 was unaware Resident #73 was at risk for dehydration or had been admitted to the hospital recently for a diagnosis of dehydration. CNA #509 stated the residents (including Resident #73) were not provided water unless they asked for water and could request water from the staff. An interview with the Director of Nursing on 01/09/25 at 10:25 A.M. verified Resident #73 was hospitalized with a diagnosis of dehydration as noted on the hospital discharge summary dated 11/19/24. An interview with Registered Dietitian (RD) #902 on 01/09/25 at 10:45 A.M. revealed Resident #73's calculated fluid need was 1, 650 ml of fluid per day to prevent dehydration. RD #902 stated residents (including Resident #73) should be offered two cold beverages and one hot beverage of choice with each meal. Review of facility policy Hydration, revised 10/26/23, revealed the facility would offer each resident sufficient needs and preferences to maintain proper hydration and health. 2. An observation on 01/07/25 at 9:00 A.M. revealed there was no cup of water present in the residents' rooms on the D pod. An interview with CNA #509 revealed the residents could request water and the staff would provide them water upon request. CNA #509 verified the residents did not have water within their reach at all times and needed to make a request for water which would be provided. There were 19 residents, Resident #5, #31, #33, #41, #44, #46, #64, #66, #73, #77, #90, #92, #94, #100, #101, #108, #112, #121 and #224 who resided on the D pod nursing unit. An observation of the breakfast meal on 01/08/25 between 7:30 A.M. and 9:00 A.M. on the D pod nursing unit revealed the meal cart arrived with a one gallon pitcher of orange juice, one gallon pitcher of water and a carafe of hot coffee. The residents were seated in the dining room and encouraged to get out of bed to eat their breakfast. All the residents were served one cup of orange juice filled 2/3 to 3/4 full. There were three more meal trays to be served when the gallon of orange juice was empty. The staff had to return to the kitchen to obtain additional orange juice to finish serving all the residents a beverage. An interview with CNA #509 on 01/08/25 at 8:31 A.M. revealed one resident (name not provided) out of the 19 residents residing on the D pod nursing unit were at risk for dehydration. CNA #509 stated the activity personnel brought fluids and a snack to the unit daily but was unable to state where the activity staff documented the amount of fluid the residents consumed to ensure they were well hydrated. CNA #509 stated the residents were not provided water unless they asked for water and could request water from the staff. Review of the facility's Week at a Glance for the facility's four week 2024-2025 menus revealed for breakfast eight ounces milk, six ounces of coffee or tea, and four ounces of juice would be offered, for lunch six ounces of coffee or hot tea would be offered, and for dinner eight ounces of milk and six ounces of coffee or hot tea would be offered. Review of facility policy Hydration, revised 10/26/23, revealed the facility would offer each resident sufficient needs and preferences to maintain proper hydration and health. 46195 3. Observation on 01/08/25 at 8:38 A.M. of the residents in the common area of the C Pod revealed the residents had a half glass full (four ounces or 120 milliliters) of orange juice on their breakfast tray. A gallon pitcher of juice on the beverage cart was empty. Interview on 01/08/25 at 8:36 A.M. and on 01/09/25 at 10:07 A.M. with Certified Nursing Assistant #444 revealed the residents on C Pod preferred juice over water, but there was not enough juice to provide a full glass for each resident. The CNA stated when they would call down to the kitchen to get more juice, it would take too long for the kitchen to bring the extra juice, and by the time the kitchen brought the extra juice to the pod, the residents no longer wanted the juice. Interview on 01/09/25 at 10:07 A.M. with Registered Nurse #488 revealed residents were receiving 120 milliliters (four ounces) of fluid for each meal. Interview on 01/08/25 at 4:22 P.M. with Dietitian #902 confirmed that residents were not receiving enough fluids with meals per her observations, and the aides had been provided a lot of education on the importance of providing adequate fluids. She went on to state there should be multiple pitchers of each of the cold fluids on the beverage carts, so they didn't run out. There were 17 residents, Resident #19, #28, #36, #49, #59, #63, #67, #70,#71, #72, #81, #84, #87, #88, #91, #99, and #109 who resided on the C pod nursing unit. Review of the facility's Week at a Glance for the facility's four week 2024-2025 menus revealed for breakfast eight ounces milk, six ounces of coffee or tea, and four ounces of juice would be offered, for lunch six ounces of coffee or hot tea would be offered, and for dinner eight ounces of milk and six ounces of coffee or hot tea would be offered. Review of undated facility document C Pod revealed the beverage cart for C Pod, which housed 19 residents, would consist of one hot water carafe, two coffee carafes, one gallon (128 ounces) pitcher of juice, one gallon pitcher of water and one-half gallon of milk. Twelve coffee cups and nineteen regular cups were to be sent on each cart. Review of facility policy Hydration, revised 10/26/23, revealed the facility would offer each resident sufficient needs and preferences to maintain proper hydration and health. 35765 4. Review of the medical record revealed Resident #93 was admitted to the facility on [DATE]. Diagnoses included diabetes, vascular dementia, traumatic brain injury (TBI). major depression disorder, hypertension, anxiety, sexual dysfunction, osteoarthritis, magnesium deficiency, atherosclerotic heart disease, hyperlipidemia, mild cognitive impairment, insomnia, hypothyroidism, persistent mood disorder, low back pain, and dementia. Review of the Dietary Progress note dated 02/20/24 timed 12:34 P.M. revealed the family of Resident #93 requested he have double portions. Review of the physician's orders revealed Resident #93 had an order for regular diet with double entrees dated 03/15/24. Review of The Dietary Progress note dated 09/13/24 timed 11:13 A.M. revealed the staff informed the dietician Resident #93 was still hungry after meals so double portions were added. However, he already had an order for double portions. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #93 had severely impaired cognition and was independent with eating. Resident #93 weighed 261 pounds, had no swallowing concerns and did not have a weight loss or gain. Review of the Dietary Progress note dated 12/10/24 timed 3:58 P.M. revealed Resident #93 triggered for a significant weight loss of 10.9 percent in 180 days. His current body weight was 247.2 pounds and the weight loss was desirable. Resident #93 was on a regular diet with double portions. Review of the plan of care with a revision date of 12/13/24 revealed Resident #93 was at risk for nutrition/hydration related to advanced age, history of significant weight changes, diabetes, dementia, TBI, depression, hypertension, anxiety, vitamin D deficiency, hypothyroidism, low mobility, mood disorder, and magnesium deficiency. Interventions included to provide diet as ordered, regular diet, regular fluids, regular texture, thin consistency with double entrees per his request dated 02/19/24. Observation of dining on the 200 unit on 01/06/25 at 11:55 A.M. revealed the residents were having chicken gravy over biscuits (the facility called the meal chicken pot pie) and fruit salad. Further observation revealed Resident #93 only received one serving of chicken gravy and one biscuit on his plate. On 01/06/25 at 12:11 P.M. an interview with Certified Nursing Assistant #432 verified Resident #93 only received one serving of his entree. Review of the facility policy titled, Resident Food Preferences, dated 01/01/22 revealed the nutritional assessment would include an evaluation of individual's food preferences. When admitted the Dietary Manager or designee would identify a resident's food preferences. The Dietary Manger or designee would visit residents periodically to determine if revisions were needed regarding food preferences. The nursing staff would inform the kitchen about resident's requests. This deficiency represents non-compliance investigated under Complaint Number OH00161030 and OH00160414.

Based on observation, interview, review of completed cleaning schedules, and review of facility policies, the facility failed to ensure the kitchen was clean and sanitary and food items were properly stored, which had the potential to affect all residents who received food from the kitchen. The facility identified no residents as receiving nothing by mouth. The facility census was 125. Findings include: Observation of the kitchen on 01/06/25 from 8:40 A.M. to 9:20 A.M. with Dietary Manager (DM) #900 revealed the following concerns: -The wall mounted fan, which was off but pointed toward the tray line, had a visible buildup of black dirt and dust on the blades and on the front and back of the metal guards. -The vents in the commercial hood had an accumulation of black dirt and debris. -The six gas burner cooktop had dried food and debris around the burners. -The left side of the double convection oven, which was next to the six burner cooktop, had dried food splatters on the outside of the unit. -The base of the bottom oven of the double convection oven had six large black areas of burnt on food residue. -The square clear plastic storage container located on the stainless steel work station next to the toaster, which was storing stainless [NAME] lids, had a buildup of food crumbs throughout the bottom of the container, and three of the lids being stored in the container had dried food particles on them. -The white tiled wall next to the plate warmer and a trash can had numerous food splatter marks. -The plate warmer had numerous food spattered marks down the side of the unit. -The proofing pan bun rack, sitting next to the three-compartment sink, had a build up of dried food particles on the tiers. -The dry storage area had debris around the perimeter of the floor which included eight single serve packets of graham crackers, one individual saltine packet, two single serve ketchup packets, one single serve jelly packet, and one single serve sugar packet. -The walk-in freezer had one box with a factory bag of 13 sausage patties open to air, one box with a factory bag of 13 vegetable patties open to air, and one box with a factory bag one fourth full of cinnamon rolls open to air. -The trash can next to the three-compartment sink had a buildup of food splatter marks down the outside of the trash can. At the time of observation, DM #900 confirmed the areas of concern. Review on 01/07/25 at 9:46 A.M. of the kitchen's completed cleaning schedules from 12/01/24 to 01/06/25 with District Manager (DM) of Healthcare Services Group (HSG) #901 on 01/17/25 revealed there was no completed day shift cleaning schedules, and Sunday 12/08/24 was the only night shift cleaning schedule completed. At the time of observation, DM of HSG #901 confirmed the cleaning schedules were not consistently being filled out. Additional observation on 01/07/25 at 10:41 A.M. of the kitchen revealed a wall mounted fan, which was on and blowing towards the dish machine, had an accumulation of visible black dirt and dust on the front and back guards and the blades. At the time of observation DM #900 confirmed the fan was dirty and was potentially blowing dirt toward the dish machine. Review of facility policy Environment, revised September 2017, revealed all food preparation and service areas would be maintained in a clean and sanitary condition. Review of facility policy Equipment, revised September 2017, revealed all foodservice equipment would be clean and sanitary. Review of facility policy Food Storage: Cold Foods, revised February 2023, revealed all foods would be stored wrapped or in covered containers to prevent cross contamination. This deficiency represents non-compliance investigated under Complaint Number OH00160433.

Based on observation, record review and interview the facility failed to maintain acceptable infection control practices to prevent the spread of infection during wound care for Resident #37 and failed to ensure staff performed hand hygiene to prevent cross contamination of germs during Resident #2's, Resident #9's, Resident #87's and Resident #120's medication administration. This affected one resident (#37) out of three residents (Resident #37,#27,#49) reviewed for wound care and four out of ten residents observed for medication administration. The facility census was 125 residents. Findings include: 1. Clinical record review revealed Resident #2 was admitted on [DATE] with diagnoses including respiratory, cerebral and heart disease, bipolar disorder with psychotic features, depression, diabetes mellitus and gastroesophageal reflux disease. A review of Resident #2's physician orders indicated to administer the following medications orally between 7:00 A.M. and 11:00 A.M.: - Tagamet 200 milligrams (mg) 200 mg administer two tablets. - Divalproex 125 mg, administer four capsules. - Eliquis 5 mg - escitalopram 10 mg - Metoprolol 25 mg administer one half a tablet. - mag-oxide 400 mg An observation of Registered Nurse (RN) #405 on [DATE] at 7:10 A.M. revealed RN #405 obtained a cup and picked up the cup by placing her bare finger inside of the cup lip and then filled the cup of water to administer the above listed medications to Resident #2. While dispensing the Divalproex 125 mg medication from the punch card packaging, one capsule dropped on the cart. RN #405 picked up the capsule with her bare hand and placed the Divalproex 125 mg capsule in the medications cup with the other medications. Interview on [DATE] at 7:43 A.M. with RN #405 verified the above findings. 2. Clinical record review revealed Resident #9 was admitted on [DATE] with diagnoses including cerebral palsy, diabetes mellitus, chronic obstructive pulmonary disease, morbid obesity, and hypothyroidism. A review of Resident #9's physician orders dated [DATE] to [DATE] indicated to administer two tablets of acetaminophen 325 mg orally every four hours as needed for pain. An observation on [DATE] at 7:29 A.M. of RN #405 administer two 325 mg acetaminophen tablets orally to Resident #9 revealed she dispensed the acetaminophen tablets in a medication cup. RN #405 proceeded to obtain a cup by touching the inside of the cup with her bare hand. RN #405 then filled the cup with water and carried the cup of water to Resident #9 who consumed the water to swallow the acetaminophen tablets. Interview on [DATE] at 7:43 A.M. with RN #405 verified the above findings. 3. Clinical record review revealed Resident #87 was admitted on [DATE] with diagnoses including dementia with behaviors, atherosclerotic heart disease, hyperlipidemia, high blood pressure, gastroesophageal reflux disease, anemia, vitamin D deficiency, psychosis, depression, anxiety, and insomnia. Resident #87's physician orders dated [DATE] to [DATE] indicated to administer the following medications orally between 7:00 A.M. and 11:00 A.M. every day: - senna 8.6 mg by mouth - rivastigmine 3 mg by mouth - quetiapine fumerate 12.5 mg by mouth - sertraline 25 mg by mouth - sertraline 50 mg by mouth An observation on [DATE] at 8:13 A.M. of RN #504 administer the above listed medications to Resident #87 revealed a failure to perform hand hygiene prior to dispensing the above listed medications in a medication cup and then RN #504 proceeded to administer the medications to Resident #87. While dispensing the above listed medications for Resident #87, RN #504 obtained the sertraline 25 mg and sertraline 50 mg capsules and pulled each capsule apart with her bare hands and emptied the contents of the capsules with the rest of Resident #87's crushed medications in the medication cup. RN #53 failed to perform hand hygiene after administering the medications to Resident #87. An interview with RN #504 on [DATE] at 8:20 A.M. verified the above findings. 4. Resident #120 was admitted on [DATE] with diagnoses including dementia with behaviors, neurocognitive disorder, chronic bronchitis, post-traumatic stress disorder, atherosclerotic heart disease, high blood pressure, depression, anxiety, osteoporosis, and diverticulosis of intestine. A review of Resident #120's physician orders dated [DATE] to [DATE] indicated to administer the following medication orally between 7:00 A.M. to 11:00 A.M. every day: - clopidigrel 75 mg - donepizil 10 mg - memantidine 5 mg - metoprolol 50 mg - sertraline 50 mg An observation on [DATE] at 7:49 A.M. of Medication Technician (MT) #522 administer the above listed medications to Resident #120 revealed she obtained a cup by touching the inside lip of the cup with her bare hand. MT #522 then proceeded to fill the cup with water and handed the cup of water to Resident #120. Resident #120 drank the water to assist her with swallowing the medications. Interview on [DATE] at 7:55 A.M. MT #522 and Licensed Practical Nurse (LPN) #422 verified the above finding. The facility policy and procedure titled Hand Hygiene revised [DATE] indicated all staff would perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applied to all staff working in all locations within the facility. The policy indicated staff should perform hand hygiene before preparing or handling medications and between resident contacts and listed additional guidance for performing had hygiene during other circumstances. The facility policy and procedure titled Medication Administration revised on [DATE] indicated the policy explanation and compliance guidelines included: 1. Keep medication cart clean, organized, and stocked with adequate supplies. 2. Cover and date fluids and food. 3. Identify resident by photo in the medication administration record. 4. Wash hands prior to administering medication per facility protocol and product. 5. Knock or announce presence. 6. Explain purpose of visit. 7. Provide privacy. 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. 9. Position resident to accommodate administration of medication. 10. Review medication administration record to identify medication to be administered. a. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects. b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. c. If other than by moth route, administer in accordance with facility policy for the relevant route of administration (i.e., injection, eye, ear, rectal, etc.). 12. Identify expiration date. If expired, notify nurse manager. 13. Remove medication from source, taking care not to touch medication with bare hand. 14. Administer medication as ordered in accordance with manufacturer specifications. a. Provide appropriate amount of food and fluid. b. Shake well to mix suspensions. c. Crush medications as ordered. Do not crush medications with do not crush instructions. 15. Observe resident consumption of medication. 16. Wash hands using facility protocol and product. 17. Sign medication administration record after administered. For those medications requiring vital signs, record the vital signs onto the Medication Administration Record (MAR). 18. If medication is a controlled substance, sign narcotic book. 19. Report and document any adverse side effects or refusals. 20. Correct any discrepancies and report to nurse manager. 51072 5. Review of Resident #37's medical record revealed the resident was admitted to the facility on [DATE] with primary diagnosis of Alzheimer's disease. Resident #37 developed an in-house unstageable area to his left heel on [DATE] and a treatment order at that time, dated [DATE], indicated to cleanse left heel with Normal Saline, and apply foam dressing every day. Review of the most recent wound measurements dated [DATE] revealed the wound to Resident #37's left heel measured 0.22 centimeters squared (cm2) x 0.4 centimeters (cm) in length x 0.65 cm in width. There was no exudate, the wound edges were attached, the tissue surrounding the wound was dry and flaky, and the wound was 100 percent eschar (dead tissue) and no slough. On [DATE] at 10:29 A.M., an observation of a dressing change for Resident #37, with Licensed Practical Nurse (LPN) #403 and LPN #481, revealed LPN #403 opened the foam dressing, removed it from its packaging, dated and initialed the dressing, and then the dressing on the bed sheet next to Resident #37. After cleansing the wound, LPN #403 retrieved the foam dressing from the bed sheet and applied the dressing to Resident #37's left heel. Interview at the time of observation with LPN #403 verified she placed the foam dressing on the bed sheet without a barrier. LPN #403 also verified a barrier was not placed under the resident's wound prior to the wound care. LPN #403 stated that was how she always did it. When asked if LPN #403 ever used a barrier between the bed sheet and the foam dressing or the wound, LPN #403 replied I can. Review of the facility Clean Dressing Change policy, revised on [DATE], revealed staff were to place a barrier cloth or pad next to the resident, under the wound to protect the bed linen and other body sites. This deficiency represents non-compliance investigated under Complaint Number OH00160414.

Based on observation, review of the facility policy, and interview with staff the facility failed to ensure the water temperature on the 200 unit was maintained at a comfortable temperature. This affected seven residents (Resident #17, #29, #40, #51, #74, #83, and #110) who resided on the 200 hall and had the potential to affect all 23 residents on the 200 unit ( #17, #29, #30, #34, #35, #40, #45, #47, #50, #51, #54, #58, #65, #74, #79, #83, #93, #86 #97, #98, #103, #110, #117). The facility census was 125. Findings include: On 01/07/25 at 9:30 A.M. an interview with Certified Nursing Assistant #520 revealed the 200 unit never had enough hot water for showers and the water never really got hot. Observation on 01/07/25 at 10:00 A.M. revealed the hot water temperature in the central bathing room on the 200 unit was 105 degrees Fahrenheit (F), the hot water in Resident #17 and 51's room was 98 degrees F, and the hot water in Resident 40 and 83's Room was 88 degrees F. Observation of water temperatures with Maintenance Director #472 on the 200 unit on 01/07/25 at 11:40 A.M. revealed the hot water temperature in the central bathing room was 114.1 degrees F, the hot water in Resident #17 and #51's room was 104.1 degrees F, the hot water in Resident #40 and #83's room was 95.4 degrees F, and in Resident #29 and #110's room the water temperate was 99.1 degrees F. Maintenance Director #472 verified the water temperatures were below 105 degrees F. Review of the facility water temperature log from 10/01/24 to 01/01/25 revealed the proper water temperature was 105 degrees Fahrenheit (F) to 120 degrees F. The temperatures documented for the 200 Unit were 111-112 degrees F. On 01/09/25 at 11:40 A.M. an interview with Resident #74 revealed there was never enough hot water for showers. He stated he usually received his shower around 11:00 A.M. and the water was cold. On 01/09/25 at 11:45 A.M. an interview with Resident #110 revealed the hot water was not very hot and he did not like to get a shower because it was too cold. He stated the water in his room never got hot. Review of the facility policy titled, Safe Water Temperatures, dated 01/01/22 revealed it was the policy of the facility to maintain appropriate water temperatures in resident care areas. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE]. Diagnoses included severe dementia, hypertension, osteoarthritis, hallucinogen use, anxiety disorder, dysphagia, major depressive disorder, and peripheral vascular disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 17 had severely impaired cognition and required maximum assistance with bathing. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE]. Diagnoses included severe dementia, diabetes, heart failure, anxiety disorder, major depressive disorder, chronic pain, dysphagia, osteo arthritis, hypertension, gout, and alcohol abuse. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #29 had severely impaired cognition and required moderate assistant for bathing. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, vascular dementia, moderate protein-calorie disturbance, emphysema, adult failure tot thrive, history of adult neglect, sexual disorders, atherosclerotic heart disease, psychosis, transient ischemic attack, anemia, osteoarthritis, insomnia, major depressive disorder, atopic dermatitis, anxiety disorder, hydrocele, dysphagia, and dermatophytosis. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE]. Diagnoses included severe dementia, diabetes, benign prostatic hyperplasia, delusional disorder, aortic aneurysm, emphysema, psychosis, congestive heart failure, anxiety disorder, insomnia. major depressive disorder, and amnesia. Review of the Modification to the Annual MDS assessment dated [DATE] revealed Resident #51 had severely impaired cognition and required supervision for bathing. Review of the medical record revealed Resident #74 was admitted to the facility on [DATE]. Diagnoses included right side hemiplegia, extended-spectrum beta-lactamases, chronic obstructive pulmonary disease, asthma, diabetes, protein-calorie malnutrition, anemia, dysphagia, benign prostate hyperplasia, malignant neoplasm of the prostate, restless leg syndrome, hypertension, obstructive sleep apnea, dementia, anxiety disorder, cerebral infarction, gout, insomnia, major depressive disorder, and osteoarthritis. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #74 had severely impaired cognition. Review of the medical record revealed Resident #83 was admitted to the facility on [DATE]. Diagnoses included dementia, hypertension, celiac disease, polyneuropathy, generalized anxiety disorder, and depression. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #83 had severely impaired cognition and required moderate assistant for bathing. Review of the medical record revealed Resident #110 was admitted to the facility on [DATE], Diagnoses included dementia, chronic obstructive pulmonary disease, diabetes, moderate protein-calorie malnutrition, major depressive disorder, hypertension, traumatic brain injury, anxiety disorder, insomnia, benign prostatic hyperplasia, and chronic kidney disease. Review of the Admission MDS dated [DATE] revealed Resident #110 had intact cognition and he refused bathing. This deficiency represents non-compliance investigated under Complaint Number OH00160780, OH00160433, and OH00160414.

Based on observation, review of the medical record, review of the facility policy and interview with staff the facility failed to ensure hair care was provided to Resident #35 and Resident #40. This affected two residents ( Resident #35 and #40) out of five reviewed for activities of daily living (ADL). The facility census was 125. Findings include: 1. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE]. Diagnoses included dementia, diabetes, aphasia, cerebral infarction, atrial fibrillation, intracerebral hemorrhage, psychosis, peripheral vascular disease, congestion heart failure, osteoarthritis, allergic rhinitis, insomnia, hyperlipidemia, major depressive disorder, generalized anxiety disorder, over active bladder, and vitamin D deficiency. Review of the plan of care dated 08/29/23 revealed Resident #35 had an ADL self care performance deficit related to anxiety, cognitive impairment, congestive heart failure, cerebral vascular accident, pain, dementia, depression, and lack of coordination. Interventions indicated Resident #35 required one person assistance for personal hygiene. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #35 had severely impaired cognation and was dependent for personal hygiene. Observations on 01/06/25 at 9:30 A.M., 11:56 A.M. and 2:30 P.M. revealed Resident #35 was sitting out in the lounge area in a chair and his hair was sticking up everywhere. On 01/07/25 at 2:30 P.M. an interview with Certified Nursing Assistant (CNA) #452 verified Resident #35 had not had his hair combed. Observation on 01/07/25 at 10:11 A.M. revealed Resident #35 was being walked out of the central bathing room after his shower with CNA #454. CNA #454 sat him down in a recliner with his hair not combed. CNA #454 went back into the central bathing room, came back out with her jacket and took her jacket into the janitor's closet. CNA #454 never attempted to comb the hair of Resident #35. On 01/07/25 at 10:14 A.M. an interview with CNA #454 confirmed she had not combed/brushed the hair of Resident #35. Observation on 01/09/25 at 8:40 A.M. revealed Resident #35 was sitting out in the lounge and his hair was not combed and was sticking up everywhere. An interview at this time with Licensed Practical Nurse #443 confirmed the hair of Resident #35 had not been combed and she instructed a CNA to comb his hair. Review of the facility policy titled, Activities of Daily Living, dated 12/28/23 revealed the facility took measures to minimize the loss of residents' functional abilities including ADLs. ADLs included the ability to bathe, dress, groom, transfer, ambulate, toilet, and eat. A resident who was unable to carry out ADLs was to receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 2. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), vascular dementia, moderate protein-calorie disturbance, emphysema, adult failure tot thrive, history of adult neglect, sexual disorders, atherosclerotic heart disease, psychosis, transient ischemic attack, anemia, osteoarthritis, insomnia, major depressive disorder, atopic dermatitis, anxiety disorder, hydrocele, dysphagia, and dermatophytosis. Review of the plan of care dated 02/02/24 revealed Resident #40 had an ADL self-care performance deficit related to anxiety, dementia, depression, COPD, fluctuating ADLs, and a history of falls. Interventions indicated Resident #40 required one person assistance for personal hygiene. Review of the Annual MDS assessment dated [DATE] revealed Resident #40 had severely impaired cognation and was dependent on staff for persona hygiene. Observation on 01/06/25 at 11:59 P.M. and 2:33 P.M. revealed Resident #40 was sitting in the lounge area in his wheelchair. His hair was not combed. On 01/06/25 at 2:33 P.M. an interview with CNA #454 confirmed she had not combed the hair of Resident #40. Review of the facility policy titled, Activities of Daily Living, dated 12/28/23 revealed the facility took measures to minimize the loss of residents' functional abilities including ADLs. ADLs included the ability to bathe, dress, groom, transfer, ambulate, toilet, and eat. A resident who was unable to carry out ADLs was to receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This deficiency represents non-compliance investigated under Complaint Number OH00160433.

Based on observation, record review, facility policy and procedure review and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention and treatment program for Resident #44 to prevent the development of in-house pressure ulcers within 30 days of admission. Actual harm occurred on 11/01/24 when Resident #44, who was cognitively impaired, had a history of skin impairment, was at risk pressure ulcer development, and dependent upon staff for bed mobility, was assessed by facility staff to have deep tissue injury (DTI) (persistent non-blanchable deep red, maroon or purple discoloration due to underlying damage to soft tissue) pressure ulcers to the left heel and sacrum. The resident reported pain associated with the pressure ulcers. Prior to the development, there was no evidence comprehensive skin monitoring and/or effective interventions were in place to prevent the development of these ulcers. This affected one resident (#44) of three residents reviewed for pressure ulcers. Findings included: Review of the medical record revealed Resident #44 was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, dementia, right femur fracture, diabetes, transient ischemic attack, cerebral infarction, Alzheimer's dementia, hypothyroidism, major depressive disorder, post-traumatic stress disorder, adjustment disorder, heart failure, and pulmonary embolism. Review of the Admission Skin Assessment, dated 10/03/24, revealed Resident #44 had Moisture Associated Skin damage (MASD) to the coccyx and four stitches to the right upper leg. Review of the Admission Braden Scale (a tool used to assess a resident's risk for developing pressure ulcers), dated 10/03/24, revealed Resident #44 was assessed as being at moderate risk for pressure injuries. Review of the progress note dated 10/03/24 timed 1:56 P.M. revealed Resident #44 had two MASD areas noted to the coccyx with one being 1.0 centimeters (cm) and the other being 1.5 cm. Zinc oxide was applied as ordered by the nurse practitioner. Resident #44 had four steri-strips to the surgical incision on the right upper leg. Review of the admission physician's orders dated 10/03/24 revealed Resident #44 had orders for a pressure redistribution mattress to the bed (discontinued on 11/05/24), a redistribution cushion in the wheelchair, weekly skin assessments every Thursday, weight bearing as tolerated to the right hip, monitor the area to sacrum twice a day until healed (discontinued on 10/09/24), monitor MASD to the sacrum twice daily until healed (discontinued on 10/09/24), and apply zinc oxide ointment to the sacrum twice daily and as needed (discontinued on 10/18/24). Review of the plan of care, dated 10/03/24, with a revision date of 10/17/24, revealed Resident #44 was as risk for impaired skin integrity related to Alzheimer's disease, dementia, depression, diabetes, impaired cognition, incontinence of bladder and bowel and the need for assistance with activities of daily living. Interventions included apply protective barrier cream after each incontinent episode, assist the resident in turning and repositioning, complete Braden Scales, complete weekly skin assessment, encourage the resident to reposition self, and encourage and assist as needed to elevate the resident's heel off the mattress as tolerated (dated 10/18/24). Review of the Skin and Wound Evaluation, dated 10/09/24, revealed the MASD to the sacrum for Resident #44 was healed. Review of the Weekly Skin assessment dated [DATE] revealed Resident #44 had no new skin issues. However, the assessment included the resident had existing MASD to the sacrum as of this time even though the skin and wound evaluation dated 10/09/24 noted the area had healed. Review of the Admission Minimum Data Set assessment dated [DATE] revealed Resident #44 had moderately impaired cognition, required substantial (staff) assistance for turning side to side, was at risk for pressure injuries and did not have any unhealed pressure injury. The assessment included Resident #44 did have MASD. Review of the Weekly Skin assessment dated [DATE] revealed Resident #44 had no new skin issues, but had existing MASD to the sacrum. Review of the plan of care dated 10/18/24 revealed Resident #44 had impaired musculoskeletal status related to a fracture of the neck of the right femur. Interventions included to provide assistance with turning and repositioning as the resident would allow. Review of the physician's orders revealed Resident #44 had an order to apply house moisture barrier cream to the buttocks twice daily for prophylaxis, dated 10/18/24. Review of the Weekly Skin assessment dated [DATE] revealed Resident #44 had no new skin issues, but had existing MASD to the sacrum. Review of the October 2024 Nursing Assistant Task documentation revealed there was no documentation of Resident #44's heels being floated on 10/04/24 on the evening shift, on 10/06/24 on the evening shift, on 10/07/24 on the evening and night shifts, on 10/09/24 on the evening shift, on 10/11/24 on the day shift, on 10/14/24 on the evening shift and night shifts, and on 10/21/24 on the night shift. Review of the October 2024 Nursing Assistant Task documentation revealed there was no documentation of Resident #44 being turned or repositioned from 10/03/24 to 10/27/24. Review of the wound measurements and comprehensive wound assessments revealed there was no documentation from 10/10/24 to 11/01/24 of the MASD to the sacrum of Resident #44, though the nurses were documenting on the Weekly Skin Assessments the resident still had MASD to the sacrum. Review of a progress note dated 11/01/24 at 5:06 P.M. revealed Resident #44 had new skin areas. She had reddish discoloration to the left heel and sacrum. New orders were received for Skin prep (topical barrier), abdominal dressing (ABD), and Kerlix to the left heel daily, and to clean and apply a border foam dressing to the sacrum daily. Review of the Skin and Wound Evaluation, dated 11/01/24, revealed Resident #44 had an in-house acquired DTI to the left heel which measured 1.6 cm in length, by 2.1 cm in width, by an undetermined depth. The wound was described as an intact blister. A new order was received to cleanse the heel with normal saline, apply Skin prep, allow it to air dry, then pad and protect it with an ABD and Kerlix. The care plan was reviewed and updated for frequent turning and repositioning, and floating the heels. Review of the Skin and Wound Evaluation, dated 11/01/24, revealed Resident #44 had an in-house acquired DTI to the sacrum which measured 8.8 cm in length, by 6.1 cm in width, by no depth. The wound was described as maroon/purple in the center and the surrounding area was noted with erythema and non-blanchable. A new order was received to cleanse the sacrum with normal saline and pad and protect with border foam daily. Review of the plan of care dated 11/01/24 revealed Resident #44 had impaired skin integrity as evidenced by the deep tissue injury (DTI) to the sacrum and left heel. Interventions included administer treatments as ordered, barrier cream after incontinence episodes, staff assistance with turning and repositioning as needed, dietitian consultation, encourage good nutrition and hydration, encourage/assist as needed to elevate the residents heels off of the mattress as tolerated, hospice services, notify the nurse of any new skin impairment noted during care, an air mattress ordered on 11/05/24, and Prevalon (pressure relieving) boots as tolerated ordered on 11/04/24. Review of the physician's orders revealed Resident #44 had an order for Prevalon boots to be worn as tolerated, dated 11/04/24 and an order for an air mattress to her bed, dated 11/05/24. Review of the Skin and Wound Evaluation, dated 11/08/24, revealed Resident #44 had an in-house acquired DTI to the left heel which was measuring larger at 3.3 cm in length, by 3.7 cm in width, by an undetermined depth. The heel was described as soft/mushy/boggy and with an intact blister. The physician ordered staff to continue the treatments as ordered. Review of the Skin and Wound Evaluation, dated 11/08/24, revealed Resident #44 had an in-house acquired DTI to the sacrum which measured 0.8 cm in length, by 0.7 cm in width, by no depth. The staff described the wound as improving. Review of the Skin and Wound Evaluation, dated 11/13/24, revealed Resident #44 had an in-house acquired DTI to the left heel which measured 2.9 cm in length, by 3.6 cm in width, by an undetermined depth. The heel was described as an intact blister, it was less soft/boggy, and it was dark reddish-brown in color. The note indicated the wound was improving. Review of the Skin and Wound Evaluation, dated 11/13/24, revealed Resident #44 had an in-house acquired DTI to the sacrum which measured 0.4 cm in length, by 0.3 cm in width, by no depth. The skin was noted as intact and normal in color. Observations of the pressure ulcers to Resident #44 on 11/19/24 at 8:45 A.M. with Registered Nurse (RN) #307 revealed the coccyx wound was a small open area the size of a pencil eraser with 100 percent (%) granulation tissue present and the would bed was pink. The left heel was a very large blister that covered the whole heel. The blister was still partially fluid filled and the wound was soft/boggy. The outer edge of the blister was dark purple in color and the blister was white/light pink in color. Resident #44 was wearing Prevalon boots and an air mattress was on the bed at the time of the observation. During interview on 11/19/24 at 8:45 A.M. with Resident #44, at the time of the wound observation, Resident #44 stated it (insinuating the wound) hurt her badly and she did not know why. On 11/19/24 at 11:15 A.M. an interview with RN #307 verified Resident #44's current pressure injuries were in-house acquired. On 11/19/24 at 2:27 P.M. an interview with the Director of Nursing (DON) confirmed both of Resident #44's pressure wounds were in-house acquired. During the interview, the DON stated she was not sure why the Prevalon boots were not ordered until 11/04/24 and the air mattress until 11/05/24 (after the ulcers were identified). The DON revealed the Prevalon boots had to be ordered because they were not kept in stock. On 11/19/24 at 3:12 P.M. a second interview with the DON revealed she was mistaken, staff had implemented the air mattress and Prevalon boots on 11/01/24 (the day the DTI ulcers were identified); the DON stated she did not know why the physician order was not written until days later. The DON confirmed the measurements showed a decline in the left heel wound from 11/01/24 to 11/08/24 however she did not believe the floor nurse assessed it properly on 11/08/24 when she noted the wound as stable. On 11/20/24 at 4:38 P.M. an interview with the Administrator confirmed the nurses were not measuring/assessing the affected areas to Resident #44's sacrum once the skin was intact. Staff continued to reflect the MASD to sacrum on the Weekly Skin assessments, but confirmed there were no measurements of the area documented (and staff had noted the MASD had healed on 10/09/24). On 11/20/24 at 4:50 P.M. an interview with the Administrator verified direct care/nursing assistant staff did not include written evidence of turning and repositioning as per the resident's plan of care until 10/27/24. Review of the facility policy titled, Pressure Injury Prevention Guidelines, dated 03/20/24, revealed the facility would prevent the formation of avoidable pressure injuries and promote healing of existing pressure injuries. It was the policy of the facility to implement evidence-based interventions for residents who were assessed as being at risk or for residents who had a pressure injury present. This deficiency represents non-compliance investigated under Complaint Number OH00159238.

Based on closed medical record review, hospital record review, pharmacy regimen review, policy review, resident representative interview and staff interviews, the facility failed to prevent a significant medication error for Resident #150. This resulted in Immediate Jeopardy and serious life-threatening harm when Resident #150, who had a known history of hypothyroidism and myxedema coma (a life-threatening condition caused when the level of thyroid hormones become very low or hypothyroidism which causes lethargy, confusion, weakness, and difficulty breathing) in 2021 and 2022, was not ordered or administered, Synthroid, used to treat hypothyroidism from admission on 09/07/23 through 04/20/24 when the resident was transferred to the hospital due to a deterioration in the resident's condition. On 04/20/24 the resident was transferred to the hospital with decreased consciousness, weakness, decreased appetite and trouble swallowing. The resident's heart rate was bradycardic at 46 beats per minute. The resident was admitted to the intensive care unit (ICU) for treatment of acute toxic metabolic encephalopathy likely myxedema coma and elevated thyroid stimulating hormone (TSH) of 59.9 (normal 0.5 and 5 microunits per milliliter). The hospital noted a concern for medication non-compliance at the nursing home due to no recent fill history and the medication/Synthroid not being listed on the resident's nursing home paperwork. Information obtained during the investigation revealed following the incident, the resident never walked again, developed a pulmonary embolism, and subsequently passed away on 07/24/24. This affected one resident (Resident #150) of five residents reviewed for medication errors. The census was 128. On 09/19/24 at 10:08 A.M., the Administrator, Director of Nursing (DON), Regional Nurse (RN) Regional #815, Administrator in Training (AIT) #816 and Licensed Practical Nurse (LPN) Unit Manager (UM) #860 were notified Immediate Jeopardy began on 04/20/24 when Resident #150 was transferred to the emergency room and subsequently diagnosed with acute toxic metabolic encephalopathy likely myxedema coma and elevated thyroid stimulating hormone (TSH). At the time of admission (09/07/23) the resident's admission order for Synthroid was not transcribed accurately by the nursing staff and the resident's Synthroid (hypothyroidism medication) was not administered from 09/07/23 until the resident's discharge to the hospital on 04/20/24. The facility failed to identify the lack of Synthroid medication for Resident #150 with a history of myxedema coma in 2021 and 2022. The Immediate Jeopardy was removed on 09/19/24 when the facility implemented the following corrective actions: On 04/20/24 at 7:41 P.M. Resident #150 was transferred to the hospital and did not return to the facility. The resident was subsequently discharged to an alternate facility post-hospitalization . On 09/18/24 from 12:30 P.M. to 12:40 P.M. the facility completed an ADHOC Quality Assurance and Performance Improvement (QAPI) meeting with the Administrator, Physician #825 (medical director), the DON, RN #937 (staff development coordinator), LPN UM #906, Admissions #969, LPN UM #860, Social Service Designee (SSD) #884, Licensed Social Worker (LSW) #820, LPN Minimum Data Set (MDS) #809, Human Resources (HR) #872 to discuss the survey concern and to develop an immediate plan of correction/action that was approved by the Medical Director. On 09/18/24 at 12:30 P.M., RN Regional #815 educated the DON and RN #937 on a new Medication Reconciliation Addendum which included two nurse verification at the time of admission, speaking directly with the provider Certified Nurse Practitioner (CNP)/physician via phone (no texting, faxing or picture taking) and included orders that were discontinued (on admission) must be noted in the admission progress notes. On 09/18/24 from 12:40 P.M. to 4:00 P.M., RN #937 educated 37 of 37 licensed nurses on a new Medication Reconciliation Addendum as well as transcribing physician orders and notifying the physician/CNP when a new admission/readmission entered the facility and verifying medications with two nurses and with the provider as well as entering a progress note reflecting verification of medications and any medications that were discontinued at the time of the verification. All nurses were educated prior to working their next shift. On 09/18/24 from 2:00 P.M. to 3:15 P.M., RN MDS #982 conducted care plan audits for all residents with diagnoses of hypothyroidism and hyperthyroidism to ensure care plans were addressed for their specific health needs. Care plans were revised and updated as needed. On 09/18/24 from 2:00 P.M. to 3:15 P.M., LPN UM #860 and LPN UM #906 audited all admissions/readmissions in the last two weeks to verify medications were transcribed correctly and verified with the physician/CNP timely. On 09/18/24 from 2:00 P.M. to 3:00 P.M. the DON completed chart audits on all residents with a diagnosis of hypothyroidism and all residents receiving Synthroid (Levothyroxine) to ensure the orders were transcribed properly, and the medications was administered as ordered. On 09/18/24 from 2:34 P.M. to 2:44 P.M., RN Regional #815 completed one-to one education for the two nurses who admitted Resident #150, LPN #822 and LPN #823, on medication reconciliation to include two nurse verification at the time of admission, speaking with the provider CNP/physician via telephone (no texting, no faxing and no picture taking) and any orders that were discontinued must be noted in the admission progress note. On 09/19/24 from 1:45 P.M. to 1:50 P.M., Regional RN #815 educated CNP #824 and Physician #825 regarding progress notes and the need for a plan (of care) for diagnosis present in each resident's medical records. On 09/19/24 from 1:50 P.M. to 1:55 P.M., Regional RN #815 educated Pharmacist #840 on ensuring pharmacy reviews included all diagnoses having an appropriate plan of care in place including medications administered to the residents. Beginning 09/19/24 the facility implemented a plan for the DON/designee to review CNP and physician notes weekly for four weeks to ensure the diagnosis of hypothyroidism has an appropriate plan in place. Beginning on 09/19/24 the facility implemented a plan for the DON/designee to review pharmacy recommendations monthly for three months to ensure residents with a diagnosis of hypothyroidism have been reviewed and have an appropriate plan of care in place to address the diagnosis of hypothyroidism. Beginning 09/19/24, the DON/designee would complete daily chart audits, Monday through Sunday for three months on all new admissions/readmissions to ensure the orders were transcribed properly, medications were verified with two nurses and with the provider and the progress note entered in the medical record reflected verification of orders as well as any changes made during the verification progress. The audits would continue until compliance could be maintained for three consecutive months. The facility would complete weekly QAPI meetings for four weeks to review all audits regarding this action plan. Although the Immediate Jeopardy was removed on 09/19/24, the facility remains out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #150's previous skilled nursing facility (SNF) discharge paperwork (used for the resident's 09/07/23 facility admission) revealed the resident was receiving the thyroid medication, Synthroid 125 micrograms (mcg) one tablet by mouth one time a day for hypothyroidism. The medication order had been in place since 04/12/22. Review of Resident #150's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including unspecified dementia, anxiety and hypothyroidism. Resident #150 was transferred to the emergency roiagnom on [DATE] and did not return to the facility. Review of Resident #150's progress note dated 09/07/23 at 6:39 P.M. and authored by LPN #822 revealed the resident arrived at the facility from another SNF around 5:00 P.M. The resident was alert and oriented to self. Resident #150's medical record revealed Guardian/Conservator #801 was listed as the resident's responsible party and included responsibility for financial, clinical and legal needs. Review of Resident #150's History and Physical form dated 09/11/23 authored by CNP #824 indicated on 09/07/23, the resident was admitted to the SNF from another SNF for continuation of care. Per the previous facility records, the resident became increasingly agitated, exit-seeking, and was wandering in and out of other resident's rooms. At times, the resident would also become combative with staff and refuse care. The power-of-attorney (POA) requested the resident's transfer to a secured nursing facility. The resident's past medical problems included hypertension, anemia, dementia, psychosis, malnutrition, depression, anxiety, insomnia, hypothyroidism, myxedema coma. There was no plan or information related to treatment or monitoring of the resident's hypothyroidism/myxedema coma conditions contained in the history and physical. Review of Resident #150's lab work form dated 09/11/23 revealed the resident's TSH 3 (thyroid stimulating hormone) level was 4.98 (normal 0.340 to 5.50). (TSH levels below 0.4 indicate hyperthyroidism, while levels of about 4.0 and above indicate hypothyroidism.) Review of Resident #150's care plans dated 09/19/23 revealed the resident had impaired metabolic status related to hypothyroidism, malnutrition, hyperlipidemia and myxedema coma with an intervention (dated 09/19/23) to administer medications and treatments as ordered; and an intervention dated 09/19/23 to observe for and report to the physician, CNP changes in signs/symptoms of hypothyroidism (fatigue, increased sensitivity to cold, constipation, dry skin, unplanned weight gain, muscle weakness, elevated cholesterol levels, muscle aches/tenderness, stiffness, joint pain/swelling, thinning hair, slowed heart rate, depression, goiter, decline in memory). Encourage the resident to report onset of new or worsening symptoms to the nurse. A second plan of care related to activities of daily living (ADL) revealed the resident had ADL self-care performance deficits related to dementia, depression, fluctuating ADLs, generalized weakness and hypothyroidism with an intervention dated 09/19/23 to report changes in ADL abilities to the nurse, physician, CNP and/or therapy. Review of Resident #150's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #150's medication administration records (MARS) and treatment administration records (TARS) from 09/07/23 through 05/03/24 revealed no evidence the resident's Synthroid medication for hypothyroidism was ordered or administered from admission (09/07/23) through discharge (04/20/24). Review of Resident #150's monthly pharmacy reviews authored by Consultant Pharmacist #839 and completed from 10/01/23 to 04/20/24 revealed no evidence Consultant Pharmacist #839 identified the resident's hypothyroidism, addressed the resident's lack of medication to treat the hypothyroidism and/or addressed the lack of laboratory testing related to the resident's hypothyroidism during this time period. Review of Resident #150's progress note dated 04/20/24 at 7:41 P.M. and authored by LPN #826 revealed the resident was observed with a decreased heart rate and increased confusion. The resident had decreased consciousness, weakness, decreased appetite and trouble swallowing. The resident's vital signs included: 110/68 blood pressure, heart rate (HR) of 46 (bradycardic), oxygen level of 94% on room air. New orders were obtained to send the resident to the emergency room (ER). The resident's power of attorney (POA)/(guardian) was notified. The CNP gave new orders to send the resident out via emergency services squad (EMS) to the hospital and the EMS arrived and transferred the resident to the hospital via a cot at 7:40 P.M. Review of Resident #150's progress note dated 04/21/24 at 8:04 A.M. (interdisciplinary progress note or IDT) authored by LPN Unit Manager #827 indicated the resident was admitted to the intensive care unit (ICU) with hypotension and acute metabolic encephalopathy. The CNP and guardian were made aware. Review of Resident #150's hospital History and Physical Progress Note dated 04/21/24 at 12:29 A.M. revealed the resident had a past medical history (PMH) of hypothyroidism, history of myxedema coma in 2022, depression and recurrent admissions related to medication non-compliance. She presented from the SNF to the ER for changes in mental status and after being found on the floor. She had hypotension, hypothermia and multiple lab abnormalities. Review of Resident #150's hospital Initial Consult Endocrinology note dated 04/21/24 at 1:43 P.M. revealed the resident had a known history of hypothyroidism since 2016 according to prior records. The resident was not able to give any history herself. She was admitted on [DATE] for obtundation (state of mild to moderate alertness reduction), felt to be in part due to myxedema coma. She had two previous admissions for myxedema coma in 2021 and 2022. The resident's TSH level on 04/20/24 was 59.9 (normal range 0.270 to 4.200 mIU/L or milli-international units per liter), free T3 was less than 0.4 (normal 2.3 to 4.1 pg/ml or picograms per milliliter) and free T4 was less than 0.1 (normal 0.9 to 1.7 ng/dl or nanograms per deciliter). The assessment impression indicated the resident had myxedema coma because the labs appeared that she had not been receiving Levothyroxine (Synthroid) or it may have been administered incorrectly. Review of Resident #150's hospital Progress Note form dated 04/22/24 at 6:48 A.M. revealed the resident had a PMH of hypothyroidism and major depressive disorder presented from a SNF with altered mental status after being found on the floor. She was not alert or awake and would grimace to painful stimuli but could not arouse her fully to have a conversation. When she presented initially to the ED, she would say only her name but not answer any other questions. In the ED, her blood pressure was 95/60 (hypotensive) with a heart rate of 53 (bradycardic). The resident's TSH level was 59.9 with a T4 blood level of less than 0.1 and a T3 blood level of less than 0.4. She was administered intravenous (IV) Solumedrol 100 mg and 500 cc of dextrose 5% half normal saline (NS) and 200 mcg of IV Levothyroxine. The Assessment and Plan section of the form indicated the resident presented to the ER from the SNF with altered mental status after being found on the floor. She was found to have elevated TSH, low T3-T4 and a concern for central nervous system (CNS) infection given the resident's neck rigidity on presentation. The resident was admitted for treatment of acute toxic metabolic encephalopathy likely myxedema coma and elevated TSH of 59.9. The concern for medication non-compliance at the SNF was identified due to no recent fill history and (no Synthroid) being on the NH paperwork. On 09/18/24 at 12:01 P.M., LPN #822 was contacted by telephone by the Administrator, Regional RN #815 and surveyor and the nurse indicated she could barely remember admitting Resident #150 but felt the resident came at shift change so she probably started the admission, and the next nurse (LPN #823) would have finished the admission. On 09/18/24 at 12:07 P.M., LPN #823 was contacted by telephone by the Administrator, Regional RN #815 and surveyor and the nurse stated he was new to his nursing role when Resident #150 was admitted , and he felt he had faxed the admission orders to the physician or CNP for review and they would have text him back with any changes. He could not remember if Resident #150 was ordered Synthroid. He stated the morning manager would have helped him with this admission, and he could not remember the details. LPN #823 indicated he had deleted the messages from the physician from his phone. Telephone interview on 09/18/24 at 12:15 P.M. with CNP #824 revealed she did not have a fax machine, and the facility would have to call her for resident admission orders. CNP #824 revealed the standards of practice for new admissions was to draw labs upon admission including a comprehensive metabolic panel which indicates the sodium, potassium, creatinine, calcium and albumin levels; lipid profile which indicates the cholesterol and triglyceride levels; magnesium level; Vitamin B12 level; and TSH level. During the interview, CNP #824 stated she could not remember if she gave admission orders for Resident #150. Telephone interview on 08/18/24 at 12:32 P.M. with Physician #825 indicated the CNP usually handled admission orders, and he did not remember the specifics about Resident #150's admission. Physician #825 stated he would review the resident's chart and return the phone call. Interview on 09/18/24 at 12:54 P.M. with the DON revealed Resident #150's Synthroid was not transcribed accurately during the resident's admission from the previous SNF by the admitting nurse and the resident did not receive the Synthroid (hypothyroidism medication) as ordered (during her stay in the facility). Attempted interviews on 09/18/24 and 09/19/24 with Resident #150's guardian (Guardian #801) revealed the guardian was not available. Interview on 09/19/24 at 8:45 A.M. with the Administrator, DON and AIT #816 confirmed LPN #822 was the nurse who had admitted Resident #150, and the nurse did not transcribe the physician (medication) order (for the resident's Synthroid) correctly. The Administer revealed the facility revised their Medication Reconciliation policy on 09/18/24 (following surveyor investigation) to reflect new procedures on admission orders including the facility must speak to the physician or CNP on the phone (no texting, no faxing etc); two nurses must verify admission orders and any orders that were discontinued by the provider must be put in the admission progress note (spelling out each medication that was discontinued). A second telephone interview on 09/19/24 at 10:42 A.M. with Physician #825 revealed he remembered Resident #150 and stated her heart rate decreased, and she was sent to the hospital with a change in condition in 04/2024. At the time of the interview, Physician #825 stated he was under the impression two nurses always reviewed the resident medication list for accuracy and per the revised policy going forward, the facility would ensure two nurses verified resident orders on admission. Telephone interview on 09/19/24 at 2:37 P.M. with Client Services Manager #400 revealed he worked with Consultant Pharmacist #839, who was the facility pharmacist, but this pharmacist was on vacation. Client Services Manager #400 stated he was unsure how Resident #150's Synthroid hypothyroidism medication was missed for several months. Interview on 09/19/24 at 3:04 P.M. with RN Regional #815 revealed the consultant pharmacist should have caught during the monthly pharmacy reviews that Resident #150's Synthroid was not reordered per the prior facility's physician orders or identified the resident had a diagnosis of hypothyroidism and questioned where the medication was to correct the hypothyroidism. RN Regional #815 stated the facility reviewed the consultant pharmacist recommendations for several months following Resident #150's admission and no recommendations were made regarding the resident's diagnosis of hypothyroidism or the use of Synthroid medication for the hypothyroidism. Review of the Admissions to the Facility policy revised 02/01/22 revealed prior to or at the time of the admission, the resident's Attending Physician must provide the facility with information needed for the immediate care of the resident, including orders covering at least the type of diet; medication orders including a medical condition or problem associated with each medication; and care orders to maintain or improve the resident's function until the physician and care planning team can conduct a comprehensive assessment and develop a more detailed Interdisciplinary Care Plan. Review of the Medication Administration policy revised 01/17/23 revealed medications were administered by licensed nurses, or other staff who were legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review of the Medication Reconciliation policy revised 01/30/24 revealed medication reconciliation involved the collaboration with the resident/representative and multiple disciplines including admission liaisons, licensed nurses, physicians and pharmacy staff. Resident identifiers would be verified on all medication labels and documents containing medication information to verify the correct person and that the documents were placed in the correct resident's medical record. Review of the Medication Reconciliation policy revised 09/18/24 revealed the facility must speak to the physician or CNP on the phone (no texting, no faxing etc) for admission orders. Two nurses must verify admission orders and any orders that were discontinued by the provider must be put in the admission progress note (spell out each medication that was discontinued). This deficiency represents non-compliance investigated under Master Complaint Number OH00157684 and Complaint Number OH00157142.

Based on record review, facility Self-Reported Incident (SRI) review, policy review, and interview, the facility failed to ensure Resident #200 was transferred safely using a Hoyer mechanical lift to prevent an injury. Actual harm occurred on 05/14/24 when Resident #200, who required assistance of two people during transfers, was transferred with one staff member using a Hoyer mechanical lift and sustained a displaced fracture of the right distal humerus. This affected one resident (#200) of three residents reviewed for falls and accidents. The facility census was 129. Findings include: Review of Resident #200's medical record revealed the resident was readmitted on [DATE] and discharged on [DATE] with diagnoses including Alzheimer's disease, heart failure, osteoarthritis, and essential hypertension. Review of Resident #200's diagnoses list revealed the resident did not have a diagnosis of osteoporosis. Review of Resident #200's Activities of Daily Living (ADL) self-care care plan revealed an intervention, dated 10/12/23 to transfer the resident with a two person assist and the use of a Hoyer mechanical lift. Review of Resident #200's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem. The MDS did not reflect Resident #200 had any type of impairment to either upper extremities and was not coded to have a diagnoses of osteoporosis. Review of Resident #200's progress note dated 05/14/24 at 10:47 A.M. revealed during resident care, the resident injured herself with a Hoyer mechanical lift bar. The State tested Nursing Assistant (STNA) was getting ready to get the resident up when the incident happened. The nurse did an assessment and observed a minor skin tear above the resident's right eye lid. The area was cleansed with normal saline, pat dry and triple antibiotic ointment. A band aide was applied. The nurse practitioner (NP) and power-of-attorney (POA) were made aware. Review of Resident #200's progress note dated 05/14/24 at 3:30 P.M. revealed the resident's right arm was edematous compared to the left with red, raised area to the antecubital area and small purple discoloration to the back of the right hand. The note indicated the resident's arm was flaccid, and the resident showed signs of pain to the entire upper extremity. The NP, hospice and POA were notified. X-rays were ordered. Review of Resident #200's progress note dated 05/14/24 at 9:16 P.M. revealed the resident's x-ray results identified a displaced fracture of the right distal humerus. There was no evidence this was a chronic/old injury or that the fracture appeared pathological in nature (evidence of osteoporosis). The NP and POA were notified of the x-ray results. Record review revealed the facility submitted a self-reported incident (SRI), dated 05/14/24 and coded as unusual source involving Resident #200. The SRI noted Resident #200 was treated in house for a distal humerus fracture and continued under hospice care. The investigation revealed the resident was removed from the bed via a mechanical lift by STNA #702 at approximately 4:00 A.M. on 05/14/24. STNA #702 admitted to self-transferring the resident, who was slightly resistive to morning care. Evidence collected was inconclusive in determining a definitive cause of injury. However, the SRI noted it was suspected Resident #200 bumped her arm on the mechanical lift bar during the morning care. Review of Resident #200's Statement of Witness form dated 05/14/24 authored by STNA #702 indicated he was doing the last round and was preparing Resident #200 to get her ready for the Hoyer mechanical lift when the resident grabbed the Hoyer strap bar and hit herself above the right eye. The resident was resistant to care. Review of Resident #200's progress note dated 05/15/24 at 12:27 P.M. revealed new orders were obtained from the NP for a sling to the right arm for comfort measures. Interview on 05/21/24 at 8:35 A.M. with Licensed Practical Nurse (LPN) #813 revealed LPN #920 had reported to her during the shift report that Resident #200 sustained an injury to her right eyebrow during a Hoyer mechanical lift transfer. The nurse stated at around 3:30 P.M., STNA #703 told her that the resident complained of right arm pain. She said the resident's right arm was flaccid (different from baseline) and she called and obtained an x-ray which showed evidence of a fracture. Telephone interview on 05/21/24 at 9:10 A.M. with STNA #703 revealed she worked day shift on 05/14/24 and was told in report Resident #200 had bumped her face on the Hoyer mechanical lift bar and caused an injury. Interview on 05/21/24 at 9:29 A.M. with NP #807 revealed she was aware of Resident #200's right arm fracture and felt it was pathological in nature due to a diagnosis of osteoporosis. The NP indicated the osteoporosis diagnosis was within her NP records, but the facility did not provide evidence of this diagnosis upon request. Interview on 05/21/24 at 9:31 A.M. with STNA #702 indicated on 05/14/24 before the end of his shift, Resident #200 was in bed and he provided incontinence care to the resident. The Hoyer mechanical lift was over the resident. He stated that he had turned to throw the soiled incontinence brief into the trash when the resident had become antsy and had grabbed the bottom of the Hoyer mechanical lift and hit herself in the head with the lift causing an injury to the face above the right eye. He stated he proceeded to transfer the resident by himself using the Hoyer mechanical lift from the bed to the Broda chair. When questioned, he stated it was common practice to use a Hoyer mechanical lift with only one staff member even though he was provided education that Hoyer mechanical lifts required two staff members. He stated STNA #843 worked on the unit with him and was in the process of using a Hoyer mechanical lift to transfer his own people and he did not think to ask for assistance. Interview on 05/21/24 at 10:11 A.M. with STNA #843 stated he could not remember if he worked with STNA #702 on 05/14/24 but verified he did not assist STNA #702 in transferring Resident #200 from the bed to a wheelchair on this date. Telephone interview on 05/21/24 at 1:34 P.M. with LPN #920 indicated he was doing his morning medication administration when STNA #702 reported Resident #200 had an injury with a Hoyer mechanical lift bar. He stated he cleansed the resident's right eye but was unaware of a fracture to the right arm. He stated he was unaware STNA #702 had transferred the resident by himself using a Hoyer mechanical lift. During the onsite complaint investigation, the faciltiy was unable to provide any other explanation as to the cause of the resident's fracture that occurred on 05/14/24. The facility investigation/SRI documentation reflected while being transferred by only one staff member (instead of two as per care plan and policy) it was suspected Resident #200 bumped her arm on the mechanical lift bar during the morning care. The resident's injury/fracture was identified following this resident care interaction. Review of the Safe Lifting and Movement of Residents policy, revised 01/01/22 revealed each resident was assessed to determine lifting and movement assistance needs. At times, it was necessary to include the use of mechanical lifts to protect the safety and well-being of staff and residents, and to promote quality of care. Two staff shall be present to assist during all patient lifts utilizing a mechanical lift. This deficiency represents non-compliance investigated under Complaint Number OH00154089 and Complaint Number OH00154066.

Based on observation, open and closed medical record review, hospital medical record review, Self-Reported Incident (SRI) review, facility incident report review, staff schedule review, review of the facility Abuse policy and interviews, the facility failed to ensure Resident #119 was free from an incident of resident-to-resident physical abuse. This resulted in Immediate Jeopardy, serious life-threating injuries, and subsequent death beginning on [DATE] when Resident #119, who was cognitively impaired and had a history of wandering, wandered into Resident #40's room and Resident #40, who had a history of physical aggression toward other residents when entering her room, willfully pushed Resident #119 causing Resident #119 to fall to the ground. Resident #119 was assessed to have a quarter-sized red bump to her upper right forehead, an acute right femoral neck fracture and was in severe pain (shaking and crying) requiring hospitalization as a result of the fall with injury. Resident #119 was transferred to the local hospital where she was admitted , diagnosed to have additional fractures to the superior and inferior pubic rami and a mild T11 compression deformity, underwent surgery for fixation of the right hip but subsequently expired four days after the resident-to-resident abuse incident. On [DATE] at 4:08 P.M., the Administrator, Director of Nursing (DON), and [NAME] President of Clinical Operations (VPCO) #11 were notified Immediate Jeopardy began on [DATE] at approximately 7:00 P.M. when Resident #119 was observed being physically abused/assaulted by Resident #40. Licensed Practical Nurse (LPN) #2 witnessed Resident #40 willfully push Resident #119 resulting in Resident #119 falling to the ground after Resident #119 wandered into Resident #40's room without staff knowledge or evidence of adequate and individualized interventions being in place as ordered. Resident #40 had a physician order and was care planned to have a stop sign across her private doorway entrance to deter other residents from wandering into her room which was not in place at the time of the incident. Resident #119 had a physician order and was care planned to have hand-held assistance during ambulation from one staff member which was not in place at the time of the incident. As a result of the incident, Resident #119 was transferred to the hospital for treatment of an acute right femoral neck fracture, superior and inferior pubic rami fractures and severe pain as evidenced by the resident shaking and crying. The resident underwent surgery for the right hip fracture but subsequently expired on [DATE] at 9:57 A.M. Resident #119's preliminary cause of death was respiratory failure after trauma. This affected one resident (#119) and had the potential to affect seven additional residents (#2, #28, #34, #39, #52, #54, #112 and #113) who the facility identified as residents who wandered and resided on C-Pod (the same pod as Resident #40). The facility census was 119. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at approximately 7:00 P.M., LPN #2 immediately assessed Resident #119, administered pain medication, and an x-ray was ordered by Certified Nurse Practitioner (CNP) #10. Upon results of right hip fracture, Resident #119 was transferred to the local hospital for evaluation and treatment. The resident's responsible party and physician were notified post incident by LPN #2 on [DATE] at approximately at 7:00 P.M. On [DATE] at approximately 7:00 P.M., Resident #40 was placed on one-to-one supervision post incident and was to remain with staff one-to-one supervision. The responsible party and physician were notified post incident on [DATE] by LPN #2 at approximately 7:00 P.M. On [DATE] at 8:48 P.M., the DON notified the police department of the resident-to-resident abuse incident. On [DATE] at 8:00 A.M., Staff Development Coordinator (SDC) #12 educated nursing staff on residents with orders for stop signs to ensure signs were in place at all times. On [DATE] at 12:13 P.M., the DON educated all nursing staff to notify the DON or designee immediately if an assigned one-to-one staff member did not arrive for their shift. On [DATE] at 12:54 P.M., Unit Managers (LPN #12, Registered Nurse (RN) #14 and LPN #15) audited resident orders to identify residents who wandered and needed assistance with ambulation. Resident orders, interventions, and care plans were reviewed and updated as needed. The facility implemented a plan to review audits at monthly Quality Assurance and Performance Improvement (QAPI) meetings. On [DATE] at 2:00 P.M., Unit Managers (LPN #12, RN #14, and LPN #15) began auditing five residents daily, five times a week on various shifts for four weeks to ensure residents were receiving the appropriate assistance with ambulation, according to their plan of care. The audits would be reviewed at monthly QAPI meeting. On [DATE] at 5:02 P.M., LPN #13, RN #14 and LPN #15 educated all in-house staff on the facility abuse policy and procedure and following resident plan of care interventions for ambulation. On [DATE] at 5:27 P.M. an Ad-hoc QAPI meeting was held with the Administrator, DON, VPCO #11, Medical Director #16, RN #9, LPN #12, RN #14, Director of Maintenance (DOM) #17, LPN #18, Licensed Social Worker (LSW) #19, Social Services Assistant (SSA) #20 and Registered Dietitian (RD) #21. On [DATE] at 7:00 P.M., residents known to have a history of aggression with other residents entering their room had a stop sign placed on their door to deter residents who wander from entering their room. On [DATE] at 7:00 P.M., VPCO #11 educated the Administrator and DON on the facility abuse policy and procedure. On [DATE] at 7:00 P.M., SDC #12, LPN #13, RN #14 and LPN #15 educated all staff on the facility abuse policy and following resident plan of care interventions for assistance with ambulation. The facility implemented a plan that no further staff would work until education was provided/completed. On [DATE] at 7:00 P.M., Unit Managers (LPN #12, RN #14, and LPN #15) or designee began auditing five residents per day for four weeks with orders for stop signs in doorway to ensure placement. The audits would be reviewed at the monthly QAPI meeting. On [DATE] at 8:00 A.M., the DON/designee began auditing/interviewing five staff members a week on various shifts for four weeks to ensure their knowledge of the process to location residents' ambulation plan of care. The audits will be reviewed at the monthly QAPI meeting. On [DATE] at 11:15 A.M., Resident #40 was moved to another Pod where there weren't any residents who wander. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #119 revealed an admitted [DATE] and a discharge date to the hospital on [DATE]. Resident #119 had diagnoses including Alzheimer's disease, conversion disorder with seizures or convulsions, and need for personal care. Resident #119 resided on C-Pod, a secured memory care unit. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #119 had short and long-term memory problems, had severely impaired cognitive skills for daily decision making, had inattention and disorganized thinking, wandered that significantly intruded on the privacy and activities of others and received supervision of one-person physical assistance when walking in the corridor. Review of a wandering care plan dated [DATE] revealed Resident #119 was a wanderer related to disease process (Alzheimer's), was disoriented to place, and had impaired safety awareness. Resident #119 wandered aimlessly with eyes closed with an intervention to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, and music. Review of the activities of daily living (ADL) care plan updated [DATE] revealed Resident #119 needed ADL assistance related to dementia, Alzheimer's disease and indicated ADL's might fluctuate day to day due to cognitive deficits with an intervention for the resident to transfer and ambulate with hand-held assistance of one staff. Review of the physical therapy discharge summary dated [DATE] revealed Resident #119 was discharged from physical therapy services due to reaching maximum potential. Continued recommendations for Resident #119 included to transfer and ambulate with hand-held assistance (HHA). Resident #119's prognosis was good with consistent staff follow-through. Review of the [DATE] physician orders revealed an order (dated [DATE]) for Resident #119 to transfer and ambulate with hand-held assist of one staff. Review of a facility SRI, tracking number 238142 dated [DATE] and created at 8:58 P.M. revealed the facility reported an incident of resident-to-resident physical abuse. The SRI revealed on [DATE] a nurse heard Resident #40 yelling, get out of my room then heard a loud noise. Upon entering the room, the nurse saw Resident #40 in her wheelchair and Resident #119 on the floor. Resident #119 was assessed to have a small bump on her head, was medicated with Tylenol for pain and was ordered a right hip x-ray. The final facility SRI investigation, reported to the State agency on [DATE] at 6:01 P.M. revealed the facility substantiated the physical abuse incident involving Resident #119. Review of a witness statement dated [DATE] and authored by State tested Nursing Assistant (STNA) #3 included the following information: I stepped off the unit to use the restroom. When I came back, I was informed that the incident occurred. We were getting everyone ready for bed before this. I redirected Resident #119 away from Resident #40's room earlier. After everything happened, I was sitting with Resident #40. She said she didn't like anyone coming in her room. She told me that she didn't push her. She said she grabbed her hand and was trying to get her out of her room. I also heard her tell the nurse that she hated the resident that was in her room. Review of a witness statement dated [DATE] and authored by STNA #4 included the following information: during this incident, I was in another room with another resident when the nurse called for me and another aide. The nurse asked me to remove Resident #40 from her room. When Resident #40 was removed, she stated she didn't want anyone in her room. She wanted Resident #119 out of her room that she is not allowed. Review of a nursing note dated [DATE] at 8:20 P.M. revealed Resident #119's husband was notified of the resident's fall and interaction with another resident (Resident #40). The resident's husband was notified an x-ray was ordered of the right hip. Review of a radiology report, dated [DATE] revealed Resident #119 had an acute right femoral neck fracture with mild displacement. Review of a nursing note dated [DATE] at 10:06 P.M. revealed Resident #119's husband was notified of the x-ray results of an acute right femoral neck fracture with mild joint displacement. Resident #119 was to be sent to the local hospital. Review of a facility incident report for a physical incident involving Resident #119 (on [DATE]) dated [DATE] at 2:58 A.M. and authored by LPN #2 revealed this nurse was at medication cart outside of Resident #40's room when she heard resident (Resident #40) yell, hey, get out of my room! This nurse turned to enter Resident #40's room and saw Resident #40 push Resident #119 to the ground. Resident #119 fell to her right side. Resident #40 rolled towards Resident #119 with her wheelchair. This nurse was unable to tell if Resident #40 made contact with Resident #119 with the wheelchair. Predisposing factors included on the incident report noted (Resident #119) was confused, gait imbalanced, had impaired memory, was ambulating without assistance, and was a wanderer. The incident report also indicated Resident #40 was to be placed on one-to-one supervision for aggressive behaviors (following the incident) and indicated a physician ordered stop sign to Resident #40's door was not in place at the time of the incident. Review of a nurse's note (for the incident that occurred on [DATE]) dated [DATE] at 3:21 A.M. and authored by LPN #2 revealed this nurse was at medication cart outside of Resident #40's room when this nurse heard another resident (Resident #40) yell, hey, get out of my room, this nurse turned to enter the room and saw resident (Resident #40) push Resident #119 to the ground. Resident #119 fell to her right side. Resident #40 rolled towards Resident #119 with her wheelchair. This nurse was unable to tell if Resident #40 made contact with Resident #119 with the wheelchair. The residents were separated immediately. Resident #119 was assessed for injury. Resident #119 was guarding the right side of her head; a quarter-sized red bump was observed to the upper right forehead. Resident #119 winced upon palpation of the of the right hip. Resident #119 tolerated minimum range of motion of the right extremity. Resident #119 was shaking and crying. Resident #119 was assisted to the wheelchair via two staff assist then to bed. CNP #10 was notified. A new order was received for a two-view x-ray to the right hip STAT and an order to administer Vistaril 25 mg. As needed Tylenol was administered per order. During the x-ray, this nurse observed Resident #119's right hip beginning to swell and redden. The x-ray results were positive for an acute right femoral neck fracture. A new order was received to send Resident #119 to the local hospital via 911. Resident #119 was transported to the local hospital. Review of the nurse's note dated [DATE] at 3:21 A.M. revealed a call was placed to the hospital for follow-up. Resident #119 was admitted was a diagnosis of bilateral pubic rami fracture. Review of the hospital palliative nurse practitioner progress note dated [DATE] revealed Resident #119, a [AGE] year-old female with a past medical history of dementia (non-verbal at baseline) presented from nursing facility after being pushed by another resident. She presented as a Level 2 trauma. Computed tomography with arterial portography (CTAP) showed mild T11 compression deformity and subacute superior and inferior pubic rami fractures. She was taken to the operating room on [DATE] for open reduction and internal fixation (ORIF) of right femoral neck. Post-operative complications included bradycardia, altered mental status and acute hypoxic respiratory failure with CO2 (carbon dioxide) retention. Rapid Response Team (RRT) was called, and patient was transferred to the intensive care unit (ICU) for possible non-invasive ventilation. Husband presented with paperwork for patient's wishes. Palliative care had been consulted to assisted with goals of care. Discussed option to focus on Hospice with comfort as the main priority at this time. Given resident's current clinical status, resident could acutely decompensate to where she may pass quickly. Review of the hospital physician expiration summary dated [DATE] revealed Resident #119 was admitted (to the hospital) after fall with hip fracture. She underwent fixation of her hip the second day of her hospital stay. This was complicated by a delayed extubation in the post-anesthesia care unit (PACU), but patient returned to regular nursing floor (RNF). Then was transferred to surgical intensive care unit (SICU) for respiratory failure and hypotension, which improved with noninvasive care. Discussions with family at this time prompted change in code status to Do Not Resuscitate Comfort Care Arrest (DNR CCA) and they also talked to Hospice at this time. The resident transferred to a RNF but continued to decline. She returned to ICU for progressive respiratory failure and family opted to avoid escalating care. The resident passed away due to hypoxic respiratory failure at 9:57 A.M. Preliminary cause of death was respiratory failure after trauma. Interview on [DATE] at 3:03 P.M. with STNA #1 revealed Resident #119 passed away a week ago. STNA #1 stated Resident #40 wasn't normally aggressive; however, Resident #40 didn't like when people were in her room. STNA #1 was aware Resident #40 was to have one-to-one staff monitoring. Interview on [DATE] at 3:50 P.M. with LPN #2 revealed on [DATE] around 8:00 P.M., LPN #2 had completed Resident #40's skin assessment, taken her in the bathroom, got her ready for bed, administered her medications and then the resident was in bed. Resident #40 had then gotten out of bed, was in her wheelchair and was going in and out of her room retrieving towels and blankets. LPN #2 was outside of Resident #40's room at the medication cart doing medication pass when LPN #2 heard, hey, get her out of my room. LPN #2 stated there was stuff on top of the medication cart that LPN #2 had to put away since other residents were around, and LPN #2 stated, Hey [Resident #40], I'm on the way. There were two STNAs on the unit; one STNA was in the bathroom, and the other STNA was in another resident's room. LPN #2 saw Resident #40, was seated in a wheelchair, saw her reach up with her right hand and push Resident #119's left shoulder/arm while standing. Resident #119 fell to the ground, and LPN #2 heard a crack. LPN #2 attempted to get in-between the residents because Resident #40 was trying to wheel her wheelchair toward Resident #119. Resident #40 stated, Good, I'm glad she's hurt. LPN #2 assisted Resident #40 outside of the room, and one of the STNA staff then took Resident #40 to the common area to calm her down. LPN #2 stated Resident #119 was wearing her helmet and had hipsters on at the time of the incident. Resident #119 had a small red bump on her right temple below the helmet. LPN #2 touched Resident #119's hip and the resident winced. LPN #2 lifted the resident's right leg, and the leg didn't move well. Resident #119 was inconsolable, crying, shaking and in pain. The STNA staff transferred Resident #119 into a wheelchair which the LPN stated the resident tolerated well. LPN #2 administered Resident #119 Tylenol and Vistaril. During the x-ray, Resident #119's right hip was red and swollen. The x-ray results came back showing Resident #119 had a femoral neck fracture. Resident #119 was sent to the hospital. LPN #2 revealed she did not believe the Velcro stop sign was across Resident #40's doorway before Resident #119 wandered into Resident #40's room because Resident #40 was going in and out of her room. LPN #2 also revealed that Resident #119 was quiet, so Resident #119 likely wandered into Resident #40's room without LPN #2 seeing or hearing Resident #119 walking into the room. Observation on [DATE] at 4:25 P.M. revealed Resident #40 was sitting in the common area in a recliner with her feet propped up on a seat of a wheelchair. STNA #1 was sitting next to her. Interview, during the observation, with Resident #40 was attempted, however unsuccessful due to the resident's cognitive impairment. A follow-up interview with STNA #1 during the observation revealed Resident #40 did not have one-to-one monitoring from 6:00 A.M. to 10:00 A.M. that morning ([DATE]). STNA #1 stated she was the only STNA assigned to the unit from 6:00 A.M. to 10:00 A.M. so she was in and out of other resident rooms completing resident care and the nurse was covering another unit, so the nurse was on and off the unit. STNA #6 arrived at 10:00 A.M. for the one-to-one monitoring of Resident #40. Interview on [DATE] at 4:28 P.M. with LPN #2 verified there wasn't a staff member assigned to Resident #40 for one-to-one monitoring this morning ([DATE]). LPN #2 also revealed she was assigned two units (A-Pod and C-Pod) until 10:30 A.M. so LPN #2 was on and off the C-Pod unit. Interview on [DATE] at 4:40 P.M. with STNA #4 revealed on [DATE] around 8:00 P.M. or 9:00 P.M., Resident #119 walked into Resident #40's room and Resident #40 pushed Resident #119. STNA #4 did not observe the incident because of being in another resident's room; however, the nurse called STNA #4 to assist with the incident. When STNA #4 entered the room, Resident #119 was on the floor, and the nurse was trying to obtain the resident's vital signs. Observation on [DATE] at 8:15 A.M. revealed Resident #40 was sitting in the recliner in the common area. STNA #1 and STNA #8 had their backs turned away from Resident #40, and LPN #8 was standing at the medication cart at the nursing station looking at the computer screen. Resident #28 walked over to Resident #40 and sat beside Resident #40 in another chair. Resident #40 did not have one-to-one monitoring by staff during the observation. Interview on [DATE] at 8:32 A.M. with RN #9 revealed Resident #119's physician's order to transfer and ambulate with hand-held assistance by one staff member was a result of a recommendation from physical therapy. Interviews on [DATE] at 4:13 P.M. and [DATE] at 9:50 A.M. were attempted with STNA #3 (who worked the C-Pod on the evening of [DATE]); however, unsuccessful via telephone. Interview on [DATE] at 8:45 A.M. and 10:25 A.M. with the DON revealed she requested Resident #40 have the one-to-one monitoring order after the resident-to-resident incident (with Resident #119) from CNP #10. The DON verified Resident #40 had a history of being aggressive towards other residents who entered her room, verified Resident #119 was known to wander and verified the incident of resident-to-resident abuse resulting in the injury to Resident #119. There were seven additional residents, Resident #2, #28, #34, #39, #52, #54, #112 and #113 who the facility identified as residents who wandered and resided on C-Pod (the same pod as Resident #40), placing these residents also at risk of a resident to resident altercation with Resident #40, should they have wandered into the resident's room. Interview on [DATE] at 8:48 A.M with Director of Rehabilitation #22 revealed when ambulating with Resident #119, it was the expectation for a staff member to hold one of Resident #119's hands while the other hand of the staff member was on Resident #119's gait balance. Interview on [DATE] at 8:50 A.M. with LPN #7 revealed Resident #119 had a known history of wandering into other resident's rooms. A follow-up interview on [DATE] at 12:30 P.M. with the DON verified Resident #40 was not monitored one-to-one by a staff member on [DATE] from 6:00 A.M. to 10:00 A.M. nor was a staff member scheduled for one-to-one monitoring of Resident #40 on [DATE] from 6:00 A.M. to 10:00 A.M. The DON also verified Resident #119 was ordered to have hand-held assistance by one staff member while ambulating which did not occur at the time of the resident-to-resident incident. Interview on [DATE] at 12:45 P.M. with Resident #119's husband/Power of Attorney revealed he received a call from the facility that a resident had pushed Resident #119 down. The nurse notified him Resident #119 sustained a knot to her head and a broken hip. At that point, he rushed to the hospital to meet Resident #119. Interview on [DATE] at 2:45 P.M. with CNP #10 revealed the nurse had called CNP #10 (on [DATE]) stating a resident-to-resident altercation had occurred between Resident #40 and #119 when Resident #119 entered Resident #40's room, Resident #40 got mad and pushed Resident #119 causing Resident #119 to fall. Resident #119 was complaining of hip pain, so CNP #10 ordered an x-ray which was positive for an acute fracture. Resident #119 was sent to the hospital. CNP #10 also revealed Resident #119 was a known wanderer and had a history of taking items off the nurses' cart and taking other resident's food. Resident #40 was known to be very territorial over her room and would display verbally aggressive behaviors. CNP #10 verified she ordered the one-to-one staff monitoring of Resident #40 after the resident-to-resident altercation. Review of the nurse and STNA staff schedule from [DATE] revealed STNA #1 was scheduled to work on C-Pod from 6:00 A.M. to 2:00 P.M., LPN #2 was scheduled to work C-Pod from 6:00 A.M. to 2:00 P.M. There wasn't a nurse assigned to A-Pod from 6:00 A.M. to 2:00 P.M., and there wasn't a staff member assigned for one-to-one monitoring on C-Pod until 10:00 A.M. when STNA #6 was scheduled to arrive. Review of the medical record for Resident #40 revealed an admitted [DATE] with diagnoses of paranoid schizophrenia, severe vascular dementia with behavioral and mood disturbance, delusional disorders, and anxiety. Resident #40 resided on C-Pod, a secured memory care unit. Review of a nurse's note dated [DATE] at 4:33 P.M. revealed the STNA notified this nurse Resident #52 was in Resident #40's room and Resident #40 punched Resident #52 in the stomach while staff was attempting to remove the resident from the area. Review of the interdisciplinary team (IDT) progress note dated [DATE] revealed the IDT team met to discuss the previous incident. Resident (Resident #52) was wandering and entered into resident (Resident #40's) room. Resident #40 hit Resident #52 in the stomach. A stop sign was placed on resident's door to deter coresidents from wandering. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 was severely cognitively impaired, had disorganized thinking and inattention that fluctuated, displayed physical behaviors towards others during one to three days of the seven-day assessment reference period, displayed verbal behaviors towards others during four to six days of the seven-day assessment reference period, and displayed other behavioral symptoms not directed towards others during four to six days of the seven-day assessment reference period. Review of the physician's orders for [DATE] revealed Resident #40 had an order (dated [DATE]) to have a stop sign on the door to her room to deter coresidents from entering the room. Review of a nurse's note dated [DATE] at 8:35 P.M. revealed Resident #40's daughter was notified of an altercation with Resident #119. Review of the nurse's note dated [DATE] at 4:08 A.M. (for the incident that occurred on [DATE]) and authored by LPN #2 revealed this nurse was at medication cart outside of Resident #40's room when this nurse heard Resident #40 yell, hey, get out of my room. This nurse turned to enter room and saw resident push Resident #119 to the ground. Resident #119 fell to ground in front of Resident #40. Resident #40 rolled towards Resident #119 with the wheelchair. This nurse was unable to tell if Resident #40 made contact with Resident #119. The residents were separated immediately. Resident #40 was yelling, Good! I'm glad she's hurt. I hate her. Resident #40 was removed from the room until Resident #119 could be safely transferred and removed from the room. A new order for one dose of Vistaril 25 milligrams (mg), an antihistamine used to treat anxiety was noted. Resident #40 was to be placed on one-to-one supervision for aggressive behaviors and staff education regarding stop sign to door. Review of Resident #40's physical aggression care plan updated [DATE] revealed Resident #40 was physically aggressive or agitated related to anger and dementia. Resident #40 would strike staff when agitated. Resident #40 stuck coresident after wandering into her room on [DATE]. Resident #40 pushed coresident, causing her to fall on [DATE]. Interventions of a stop sign to the resident's door to deter coresidents wandering into her room, monitor and signs or symptoms of resident posing danger to self and/or others, and one-to-one supervision. Review of the facility's Abuse, Neglect and Exploitation policy, revised [DATE], revealed the facility would implement policies and procedures to prevent and prohibit all types of abuse, neglect, and misappropriation of resident property and exploitation that achieves identifying, correcting, and intervening in situations in which abuse, neglect, exploitation and/or misappropriation of resident property was more likely to occur with the deployment of trained and qualified, registered, licensed and certified staff on each shift in sufficient numbers to meet the needs of residents, and assure the staff assigned had the knowledge of the individual residents' care needs and behavioral symptoms and the identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. The facility would make efforts to ensure all residents were protected from physical and psychosocial harm, as well as additional abuse, during and after investigation and increased supervision of the alleged victim and residents. This deficiency represents non-compliance investigated under Complaint Number OH00145778.

Based on observation, record review, review of a facility self-reported incident (SRI), review of a police report, review of the facility Abuse policy, and interviews with facility staff and Police Officer #642 the facility failed to ensure Resident #5 was free from an incident of staff to resident physical abuse. This resulted in Immediate Jeopardy on 04/22/23 at approximately 4:00 P.M. when Resident #5 was attempting to take the phone from the nurse's station to dial 911 and State tested Nursing Assistant (STNA) #576 attempted to remove the phone from Resident #5's hands. Resident #5 became combative with STNA #576 and STNA #576 physically pushed Resident #5 and the resident fell to the floor and hit his head. This resulted in serious life-threatening harm and injury as Resident #5 experienced profuse bleeding from this left ear without loss of consciousness requiring medical intervention. The resident was assessed to have aphasia (difficulty speaking/communicating) and a subdural hematoma as a result of the incident. The resident was readmitted to the facility on [DATE] following hospital intervention. This affected one resident (#5) of three residents reviewed for abuse and neglect. The facility census was 123. On 04/28/23 at 2:25 P.M. the Administrator, Director of Nursing (DON), Administrator in Training (AIT) #570, Regional Director of Clinical Operations #643, and Regional Director of Human Resources #644 were notified Immediate Jeopardy began on 04/22/22 at approximately 4:00 P.M. when STNA #576 physically abused Resident #5. The resident sustained an acute injury as a result of the incident requiring hospital intervention. The Immediate Jeopardy was removed on 04/28/23 when the facility implemented the following corrective actions. On 04/22/23 following the incident STNA #576 was immediately suspended pending investigation. The STNA subsequently resigned his position (on 04/22/23). On 04/22/23 the Administrator notified police an incident occurred between STNA #576 and Resident #5; police report number 23-07196. On 04/22/23 at 4:50 P.M. Resident #5's physician and daughter were notified by the floor nurse and weekend nurse supervisor with new orders obtained to send Resident #5 to the hospital. The resident returned to the facility on [DATE] with additional interventions including Speech Therapy (ST), Occupational Therapy (OT), Physical Therapy (PT) evaluation and treat orders. A psychological services evaluation on 04/24/23 with medications reviewed with an increase in Depakote (mood stabilizer) to 250 milligrams (mg) three times daily (TID). On 04/24/23 the resident's behavior care plan was reviewed and updated by Minimum Data Set (MDS) Registered Nurse (RN) #542. On 04/23/23 skin sweeps were completed for residents on B pod by LPN #523 and RN #627 with no negative findings. On 04/23/23 LPN #591 conducted resident interviews for residents on the B pod with no negative findings. On 04/23/23 LPN #591 and RN #622 conducted all staff education related to the facility Abuse policy and dealing with residents with behaviors. The staff educated included ten administrative staff, 23 LPNs, 65 certified nursing assistants (CNAs), two restorative aides, three facility support advocates, nine registered nurses (RNs), five activities staff, two social services staff; eight nursing administrative staff (three LPNs, three RNs, DON, scheduler), two maintenance staff, four hospitality aides, one Med Tech, one non-cert, one medical record staff, 16 dietary staff, and 11 housekeeping staff. On 04/23/24 MDS RN #542 reviewed the care plans for B pod residents with behaviors for appropriate interventions. Residents #5, #7, #19, #20, #22, #24, #26, #44, #53, #54, #55, #61, #62, #71, #73, #79, #83, #93, #96, #100, #102, #103, #105, and #107 were reviewed. On 4/24/23 9:30 A.M., the nursing station phone was placed out of resident sight/camouflaged under a monitor riser/platform. On 04/24/23 Licensed Practical Nurse (LPN) #617 contacted Resident #5's daughter to inquire about different types of activities the resident might enjoy including, but not limited to, activities done prior to facility admission. Magazines were acquired and given to the resident on 04/25/23. On 04/24/23 an Ad hoc Quality Assessment and Performance Improvement (QAPI) meeting was held with the Medical Director, Administrator, DON, Administrator in Training (AIT) #570, two LPN Unit Manager (LPN #528 and #617), Scheduler #606, Licensed Social Worker (LSW) #537, Social Service Assistant (SSA) #639, MDS LPN #622, Business Office Manager (BOM) #546, Registered Dietitian #646, Maintenance #583, Activities Director #604, Certified Nurse Practitioner (CNP) #647 and MDS RN #542. Topics discussed included but were not limited to alleged abuse, skin sweeps, interviews, education approach and abuse and the State agency SRI. Beginning on 04/25/23, the facility implemented a plan to audit five staff/week by unit managers and/or night and weekend supervisor/manager regarding approach with residents with increased behaviors. Beginning on 04/25/23, the facility implemented a plan for facility management staff (unit managers, MDS, DON, weekend and night nurse supervisor/manager) to observe the staff interaction on the unit with residents to ensure redirection is appropriate five times a week for four weeks on different shifts. On 04/27/23 LPN #528, LPN #516 and LPN #622 completed skin assessments for all facility residents. As a result of the of the assessments new treatment orders were implemented for two residents, Resident #24 and #100. Resident #24 had area that was ordered Dimethicone (cream) and Resident #100 had healing scabbed area on shin. On 04/27/23 the facility implemented a plan to discuss residents with new or increased behaviors during morning clinical meetings. Staff present for meetings would include the Administrator, DON, Unit Managers (LPNs #528, #615, and #622), Registered Dietitian (RD) #646, Activities #603, Social Services #637. On 04/28/23 Regional Directors of Operations #645 and Clinical Services RN # 643 educated/reviewed with the DON and the Administrator the facility Abuse Neglect Policy to include having a proper investigation including conclusion/disposition. The facility SRI was updated with an addendum to change the disposition on 05/01/23 to a substantiated abuse. On 04/28/23 an Ad hoc QAPI meeting was held with the Medical Director to discuss the facility Immediate Jeopardy Abatement Plan. Staff present included the Administrator, DON, Medical Director, CNP #647, Infection Control Preventionist (ICP) DON, Weekend Supervisor/Managers LPN #591, LPN Unit Managers #528 and #617, LPN MDS #622, LSW #537, SSA #639, RN MDS #642, AIT #570, Activity Director #604 and Scheduler #606. Interviews on 05/01/23 from 8:40 A.M. to 8:50 A.M. with HA #619, STNA #605, and Registered Nurse (RN) #594 confirmed the facility had completed further training on abuse and neglect. They were also educated on resident behaviors and how to deescalate resident behaviors safely. Although the Immediate Jeopardy was removed on 04/28/23, 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 were monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #5 revealed an admitted [DATE]. Resident #5 had admission diagnoses including alcohol dependence with alcohol induced dementia, chronic obstructive pulmonary disease, type two diabetes mellitus, and hypertensive chronic kidney disease. The resident's diagnosis list was updated on 04/22/23 with a diagnosis of traumatic subdural hemorrhage without loss of consciousness. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 03/23/23 revealed Resident #5 had mild cognitive impairment. The assessment revealed Resident #5 required supervision with (staff) set-up help only for bed mobility, transfers, eating, and toilet use, supervision with one person assistance for dressing, and limited one person assistance for personal hygiene. Review of the care plan, dated 04/03/23revealed Resident #5 was at risk for falls. Interventions included to anticipate the resident's needs, be sure his call light was in reach and encourage him to use it. The care plan also revealed a focus area indicating Resident #5 exhibited behaviors related to the diagnosis of dementia with psychosis. Interventions included to provide an opportunity for a positive interaction, intervene as necessary to protect the rights and safety of others and to divert the resident's attention. In addition, the care plan also had a focus indicating Resident #5 was an elopement wandering risk related to the resident stating he would call a cab and go home. Interventions included to distract resident by offering pleasant diversions such as structured activities, food, conversation, television, or a book. Review of nursing progress note, dated 04/22/23 at 4:29 P.M. revealed Resident #5 fell in the communal area in front of the nurse's station. The note indicated STNA #576 attempted to redirect Resident #5 away from the telephone. Resident #5 hit STNA #576. During the struggle Resident #5 lost his balance and fell . Resident #5 never lost consciousness. The note indicated before the fall Resident #5 was exit seeking and becoming increasingly agitated with staff and his surroundings by threatening to call the police. Resident #5 had socks and shoes on when he fell . Resident #5 was not incontinent during the fall. This nurse stayed with Resident #5 until the paramedics arrived. Resident #5 was assessed and found to have bleeding coming from his left ear. The area was cleaned, and no lacerations were found. Approximately five minutes after the fall Resident #5 showed symptoms of aphasia. Resident #5 was sent out to the hospital. Review of the facility hospital transfer form dated 04/22/23 revealed Resident #5 was being transferred after suffering a fall. Resident #5 was observed bleeding profusely from the left side of his ear. The family and the nurse practitioner were notified with an order to send Resident #5 to the hospital for evaluation. Review of the facility SRI, tracking number 234266 dated 04/22/23 revealed the facility reported an incident of alleged abuse involving Resident #5. A witness statement from HA #619 reported STNA #576 pushed Resident #5 after STNA #576 removed the phone from Resident #5's hands and Resident #5 had begun hitting STNA #576. The SRI also revealed a witness statement from LPN #591 stating STNA #576 informed her he had pushed Resident #5 after he had removed the nurse's station phone from the resident and Resident #5 began punching him. STNA #576 also informed her Resident #5 lost his footing after the push and fell on his back hitting his head. Review of nursing progress note dated 04/23/23 at 4:43 P.M. revealed Resident #5 returned to the facility at this time. Review of hospital discharge paperwork dated 04/23/23 for Resident #5 revealed the resident had been diagnosed with a subdural hematoma. Review of local police reported, dated 04/22/23 revealed Police Officer #642 returned to the facility to review video surveillance from the incident involving Resident #5. He saw Resident #5 approach the nurse's station and grab the phone from the desk. Hospitality Aide (HA) #619 then approached Resident #5 and began talking with him. STNA #576 then came to the desk a few moments later and took the phone from Resident #5. Immediately upon getting the phone from Resident #5 he was observed striking STNA #576 with his right hand and it did appear to be a clenched fist. STNA #576 was then observed pushing Resident #5 away from him. From being pushed backwards, Resident #5 fell with his right shoe falling off. Resident #5 landed backwards and hit his head on the floor. On 04/28/23 at 10:02 A.M. interview with HA #619 confirmed he did witness the incident with Resident #5 and STNA #576 on 04/22/23. He reported he was sitting at the nurse's station when Resident #5 approached the desk and grabbed the telephone and was attempting to dial 911. HA #619 reported he was requesting Resident #5 give him back the telephone when STNA #576 approached the desk on the side Resident #5 was standing and removed the phone from the resident's hands. HA #619 then reported Resident #5 began hitting STNA #576 and STNA #576 pushed Resident #5 causing him to lose his balance and fall. HA #619 confirmed Resident #5 fell on his back and hit his head. He confirmed seeing blood when STNA #576 informed him to get the nurse. HA #619 then proceeded to get the nurse. On 04/28/23 at 10:08 A.M. an attempted interview with Resident #5 revealed no additional information was provided by the resident. At the time of the interview, the resident was observed to be sleepy and stated he was OK when asked. The resident was unable to provide any additional information related to the incident that occurred on 04/22/23. On 04/28/23 at 10:28 A.M. information obtained via an email interview with Police Officer (PD) #642 revealed the police report was still being finalized and the case was referred to the local prosecutor's office. PD #642 denied charges being filed against STNA #576. On 04/28/23 at 10:43 A.M. interview with the Administrator revealed the facility did at one time have camera footage of the incident on 04/22/23 and it had been given to the police. The Administrator indicated the facility was no longer able to retrieve the video to provide to the surveyor for review. On 04/28/23 at 11:43 A.M. interview with Licensed Practical Nurse (LPN) #591 confirmed she was the nurse HA #619 came to get the day of the incident on 04/22/23 involving Resident #5. She reported when she arrived on the unit, Resident #5 was observed on the floor bleeding from his left ear. LPN #591 asked STNA #576 what happened, and he stated to her Resident #5 was attempting to get the phone to dial 911 when he removed it from the resident's hands. Resident #5 began hitting STNA #576 and STNA #576 pushed Resident #5 off him causing him to lose his footing and fall backwards hitting his head. LPN #591 reported Resident #5 did not lose consciousness while she was assessing him, but he did suffer from aphasia which was not his baseline. LPN #591 also reported she cleaned the resident's left ear to see where the bleeding was coming from, but she was unable to locate it. LPN #591 then called 911 and notified Resident #5's nurse practitioner and family. Resident #5 was sent to the hospital for evaluation. On 04/28/23 at 12:31 P.M. interview with the Administrator and AIT #570 revealed the Administrator was notified of the incident on 04/22/23 and she immediately came into the facility. The Administrator reported she was informed Resident #5 was attempting to take the phone from the nurse's station to dial 911 when STNA #576 came over and removed the phone from Resident #5's hands. She reported Resident #5 then began hitting STNA #576 and STNA #576 moved Resident #5 away from him causing him to lose his footing and fall backwards hitting his head. The Administrator confirmed STNA #576 was removed from the unit immediately and suspended pending an investigation. She reported the staff were educated on abuse and neglect and the police were notified. The Administrator revealed English was a second language to HA #619 and STNA #576 so they might have stated Resident #5 was pushed but they really intended on stating he was moved. The Administrator reported when the investigation first started, she informed STNA #576 she would be notifying the police and the State agency of the incident and if he returned to work, he would have to answer those investigations. STNA #576 immediately resigned his position. Review of the facility policy titled Abuse, Neglect, and Exploitation, revised 10/24/22, revealed abuse was defined as the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Physical abuse was defined as including but was not limited to hitting, slapping, punching, biting, and kicking. It also included controlling behavior through corporal punishment. This deficiency represents non-compliance investigated under Complaint Number OH00142289.

Based on interview and record review the facility failed to ensure the plan of care for falls was followed for one Resident (Resident #1) resulting in a fall with fracture. This affected one of three residents reviewed for accidents (Resident #1). Harm occurred to Resident #1 when the facility failed to provide the required assistance needed for the resident during incontinence/personal care and additionally failed to place the resident's bed in the lowest position resulting in the resident's fall from bed and the resident sustained [REDACTED]. Findings include: Record review revealed Resident #1 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the nurse's progress notes dated 2/25/17 along with a review of the facility form titled: Fall Investigation, dated 02/27/17, revealed Resident #1 sustained a witnessed fall on 02/25/17 when staff assisted the resident with ambulation to the bathroom and with the use of a wheeled walker as per plan of care. After becoming agitated, it was noted that Resident #1 had fallen backwards while in her room, landing on her buttocks after hitting the right side of her head and body on the corner of a bedside table. She sustained a laceration to the right side of her head and was sent out to the hospital on [DATE]. Resident #1 returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. The care plan for falls was updated on 03/01/17 revealing the following interventions to be initiated: weight bearing as tolerated, low bed when not providing care, and floor mat next to resident's bed when resident is in bed. The activities of daily living care plan dated 3/01/17 was as follows: the resident requires assistance from two (2) staff for personal hygiene, bed mobility to turn and reposition in bed every two hours and as necessary, along with transferring, toilet use, bathing/showering and dressing. A review of the facility form titled: Fall Risk dated 03/31/17 revealed Resident #1 was assessed to have a score of 26 indicating a high risk for falls and the need for an appropriate plan of care with interventions to be communicated to all direct care staff members to maintain safety. A review of the quarterly minimum data sets (MDS) assessment dated [DATE] revealed Resident #1 was assessed to be alert to self only, with short and long term memory problems, along with moderate difficulty with cognitive decision making skills for activities of daily living. Resident #1 was assessed to require extensive assistance of two staff members for most activities of daily living including bed mobility, transfers and personal care. A review of the nurse's progress notes dated 04/29/17 at 3:35 P.M. written by the unit manager, Registered Nurse (RN)#25 revealed staff heard Resident #1 yelling, and she was observed lying on her left side with her legs crossed on the floor mat next to her bed. Resident #1 had facial grimacing and was unable to state where her pain was coming from, although her right leg appeared to be dislocated. The physician was notified along with her daughter, an order was obtained, and Resident #1 was sent out to the hospital for evaluation and treatment. A review of the nurse's progress notes dated 05/01/17 along with the admission [DIAGNOSES REDACTED]. A review of the facility self- reported incident (SRI) form # 6 dated 04/29/17 revealed there was no indication or documentation regarding what exactly had occurred to Resident #1 at the time of the fall. An interview was conducted with State tested Nurse Aide (STNA) #10 on 5/08/17 at 4:00 P.M. along with a review of her written witness statements documented after Resident #1 sustained the fall on 4/29/17. STNA #10 documented the following written statement: I had the bed up and not down to the ground. STNA #10 verified during the interview that she forgot to put the bed down to the lowest position prior to leaving the room to dispose of soiled items and get another staff member to help transfer the resident out of bed and to the chair. STNA #10 stated that she also did not check the POC for Resident #1's fall interventions or ADL care needs because she thought she knew what they were, indicating that she would not make that same mistake again. A review of the facility form titled: Fall Investigation dated 4/29/17 revealed the following: The investigation indicated the specified perpetrator, (STNA #10) had been providing incontinence care to Resident #1 prior to her falling out of bed and into the floor. Appropriate staff were interviewed including STNA#10 who verified that she was alone caring for Resident #1 and had forgotten to put the bed down to the lowest position after providing personal care, then left the room with the bed in the neutral (high height) position to get help to transfer Resident #1 out of bed into the chair. She stated that she was aware that Resident #1 required extensive assistance of two staff members to transfer her, that is why she left to get help, but verified that she had not checked Resident #1's plan of care (POC) for fall prevention interventions or ADL assistance needs prior to providing personal care. She stated that only after Resident #1 had rolled out of bed and fallen that the POC did indicate a need for the assistance of two staff for most ADL care, including for personal care and bed mobility and turning and repositioning in bed. An interview was conducted with the director of nursing, (DON) on 5/15/17 at 3:30 P.M. verifying that she did not accurately document the actual events that had taken place per her investigation into Resident #1's fall on 04/29/17. She verified the root cause of the fall was that STNA #10 left the bed in the neutral position, did not lower it to the ground when she left the room, and she also failed to provide the required assistance with Resident #1's care by only one staff member being present during incontinence care. This deficiency substantiates Complaint Number OH 059.