Every finding on record at Arc at Cincinnati

Based on medical record review, staff interview, review of facility Self-Reported Incidents (SRI), review of facility email, and policy review, the facility failed to report an alleged abuse to the State Agency. This affected one (#60) of three residents reviewed for abuse. The facility census was 52. Findings include: Review of the medical record revealed Resident #60 was admitted to the facility on [DATE] and discharged on 04/13/26. Diagnoses included chronic obstructive pulmonary disease, major depressive disorder, and epilepsy.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #60 was cognitively intact and independent with personal hygiene.Review of the progress notes for Resident #60 dated 04/13/2026 at 1:08 A.M. revealed the resident physically assaulted Certified Nurse Aide (CNA) #58. He pulled her hair, closed fist repeatedly punched her, dragged her to the ground, and repeatedly called this writer and other staff racial slurs in front of the local police department. The Night Supervisor notified the Director of Nursing (DON). The police did remove Resident #60 from facility due to CNA #58 pressing charges against the resident. Review of the staff statements provided to the Administrator on 04/21/26 at 8:47 A.M. via an email from Registered Nurse (RN) #50 revealed Resident #60 agreed he did hit CNA #58. But Resident #60 stated he did that as a retaliation because CNA #58 started hitting him first. Review of the facility SRIs revealed the facility had not submitted a SRI regarding the allegation of abuse from Resident #60. Review of the facility Interview on 07/27/26 at 1:59 P.M. the Administrator revealed Resident #60 hit a staff member. The Administrator stated no staff had done anything to Resident #60. The Administrator stated the allegation was not reported to the State Survey Agency. Interview on 07/27/26 at 2:08 P.M. with CNA #60 stated she witnessed CNA #58 come down the hall and yelled at Resident #60 saying Call me bitch one more time and Resident #60 did. Then CNA #58 hit Resident #60 they started fighting and had to be broken up. CNA #60 stated they told to the Administrator and the DON.Interview on 07/28/26 at 9:45 A.M. RN #50 confirmed Resident #60 had reported CNA #58 hit him first. RN #50 also confirmed the DON and Administrator were notified. Interview on 07/28/26 at 2:09 P.M. the Administrator confirmed the statement from RN #50 did have the Resident #60's allegation of abuse. The Administrator stated that part of the statement must have been missed. Review of the policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 01/25/25, revealed it is the community's policy to investigate all alleged violations involving abuse, in accordance with this policy. Community staff should immediately report all such allegations to the Executive Director/Administrator who will in turn make notifications to appropriate state reporting agency in accordance with the procedures in this policy. If abuse is alleged, if any form of abuse is alleged the Administrator or his/her designee will notify the Ohio Department of Health (ODH) immediately, but not later than two hours after the allegation is made. This deficiency represents non-compliance investigated under Master Complaint 3110930, Complaint Number 3106006, and 3110765.

Based on medical record review, staff interview, review of facility email, and policy review, the facility failed to investigate an allegation of resident abuse. This affected one (#60) of three residents reviewed for abuse. The facility census was 52. Findings include: Review of the medical record revealed Resident #60 was admitted to the facility on [DATE] and discharged on 04/13/26. Diagnoses included chronic obstructive pulmonary disease, major depressive disorder, and epilepsy.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #60 was cognitively intact and independent with personal hygiene.Review of the progress notes for Resident #60 dated 04/13/2026 at 1:08 A.M. revealed the resident physically assaulted Certified Nurse Aide (CNA) #58. He pulled her hair, closed fist repeatedly punched her, dragged her to the ground, and repeatedly called this writer and other staff racial slurs in front of the local police department. The Night Supervisor notified the Director of Nursing (DON). The police did remove Resident #60 from facility due to CNA #58 pressing charges against the resident.Review of the staff statements provided to the Administrator on 04/21/26 at 8:47 A.M. via an email from Registered Nurse (RN) #50 revealed Resident #60 agreed he did hit CNA #58. But Resident #60 stated he did that as a retaliation because CNA #58 started hitting him first. Review of the facility Interview on 07/27/26 at 1:59 P.M. the Administrator revealed Resident #60 hit a staff member. The Administrator stated no staff had done anything to Resident #60. The Administrator stated an investigation was not completed for Resident #60's alleged abuse on 04/13/26. Interview on 07/27/26 at 2:08 P.M. with CNA #60 stated she witnessed CNA #58 come down the hall and yelled at Resident #60 saying Call me bitch one more time and Resident #60 did. Then CNA #58 hit Resident #60 they started fighting and had to be broken up. CNA #60 stated they told to the Administrator and the DON.Interview on 07/28/26 at 9:45 A.M. RN #50 confirmed Resident #60 had reported CNA #58 hit him first. RN #50 also confirmed the DON and Administrator were notified. Interview on 07/28/26 at 2:09 P.M. with the Administrator confirmed the statement from RN #50 did have the Resident #60's alleged abuse. The Administrator stated that part of the statement must have been missed. Review of the policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 01/25/25, revealed it is the community's policy to investigate all alleged violations involving abuse, in accordance with this policy. Once the Administrator is notified, an investigation of the allegation violation will be conducted. This deficiency represents non-compliance investigated under Master Complaint 3110930, Complaint Number 3106006, and 3110765.

Based on medical record review, review of the hospital records, staff interview, and policy review, the facility failed to ensure timely treatment of a left leg fracture. This resulted in Actual Harm when Resident #91 complained of a new onset of left leg pain on 12/18/25. After examination, Nurse Practitioner (NP) #235 ordered X-rays for the wrong limb. Upon realizing the error, NP #235 ordered X-rays for the correct limb on 12/19/25; however, the X-rays were not completed until 12/21/25, revealing Resident #91 had a suspected bicondylar fracture of the left distal femur. Resident #91 was sent to the hospital for evaluation and treatment on 12/22/25 where the resident required surgery for an Open Reduction and Internal Fixation (ORIF) on 12/24/25. This affected one (#91) of three residents reviewed for care post fall. The facility census was 89.Findings include:Review of the medical record revealed Resident #91 was admitted to the facility on [DATE] and was discharged on 01/06/26. Diagnoses included unspecified nutritional deficiency, displaced fracture of the lateral condyle of the left femur, other fracture to the lower end of the left femur, major depressive disorder, ischemic cardiomyopathy, unspecified cerebral infarction of the right middle cerebral artery, type II diabetes, and unspecified heart failure.Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition, had verbal behaviors, did not reject care, and did not wander. Resident #91 was dependent on staff for toileting, mechanical lift transfers, and bed mobility.Review of the care plan dated 10/04/24 revealed Resident #91 was at risk for pain. Interventions included evaluating the effectiveness of pain interventions.Review of a progress note dated 12/18/25 at an unspecified time revealed NP #235 documented she acutely evaluated Resident #91 for reports of a possible fall out of bed prior to the current shift. Resident #91 reported he rolled out of bed onto the floor on his right side with knees colliding together. There was no nursing documentation reflecting a fall or change-in-plane status. Notes pertaining to the left leg evaluation were contradictory. The documentation read, no crepitus or difficulty with range of motion (ROM) in the knee or the ankle with passive motion. Resident #91 reported pain with passive ROM and does not participate in active ROM. Completed adduction and abduction of left hip with continued complaints of discomfort. Left leg is stiff with upper leg muscle contractions. The assessment and plan included a possible fall occurring within the last 24 hours without supporting documentation from nursing staff. Resident #91 reported pain in the left leg with no participation in active ROM. No abnormalities with passive ROM. STAT (at once) imaging ordered. Verbal orders were given to the nursing staff for the resident to receive one gram of acetaminophen (pain reliever) now and apply Lidocaine (pain reliever) patch. Will re-evaluate Resident #91 in the morning.Review of a progress note dated 12/18/25 at 4:10 P.M. revealed Resident #91 reported an unwitnessed fall occurring on the previous shift. Resident #91 complained of pain to the left knee which upon assessment appeared swollen. Registered Nurse (RN) #104 notified NP #235 who assessed and found Resident #91 was unable to participate in ROM to the left leg due to pain. New orders were placed and entered by NP #235 for an X-ray to the left leg, a one-time dose for Tylenol (acetaminophen) and a lidocaine patch to the left leg. Pain medications were administered and were effective.Review of the medical record revealed Resident #91 had physician orders dated 12/18/25 for an X-ray of the right hip two views STAT for pain, acetaminophen 500 milligrams (mg) give two tablets by mouth for pain now, and Lidocaine External four percent patch topically to the right posterior hip for twelve hours and remove for twelve hours.Review of the X-ray results dated 12/18/25 revealed Resident #91 had an X-ray to the right knee completed at 9:00 P.M. and reported on 12/18/25 at 10:13 P.M. which revealed modest arthritis of the right knee. Additionally, on 12/18/25 Resident #91 had an X-ray completed of the right hip at 9:03 P.M., and reported at 9:32 P.M., which showed modest osteoarthritis of the right hip.Review of the progress note dated 12/19/25 and untimed, revealed Resident #91 had left knee swelling for an unwitnessed fall on 12/18/25 was treated topically. Review of an X-ray of the right hip noted osteoarthritis. New orders were placed for medications including oral anti-inflammatory twice daily and a muscle relaxer for seven days and X-rays of the left hip and knee.Review of the medical record revealed Resident #91 had physician orders dated 12/19/25 for an X-ray of the left hip two views for pain and an X-ray of the left knee two views for pain. Additionally, the physician discontinued the ordered Lidocaine patch to the posterior right hip. New orders for Lidocaine four percent topical patch to the left posterior hip for pain (on 12 hours, off 12 hours), Ibuprofen 600 mg by mouth three times daily for osteoarthritis of the knee for seven days, and methocarbamol (a muscle relaxer) 750 mg by mouth twice daily for osteoarthritis of the knee for 10 days.Review of the X-ray results dated 12/21/25 revealed Resident #91 had X-rays of the left knee and the left hip at 12:51 P.M. Results reported on 12/21/25 at 6:00 P.M. revealed the left knee was highly suspicious for a minimally displaced distal femoral metaphyseal fracture only seen in the lateral view. The X-ray of the left hip showed mild degenerative changes without acute fracture or dislocation.Review of a progress note dated 12/22/25 at 10:27 A.M. revealed NP #235 reviewed the X-ray results for the left side as previously ordered post fall. Resident #91 was sent to the hospital due to a suspicious, non-confirmed fracture of the left leg.Review of a progress note dated 12/22/25 at 1:22 P.M. revealed therapy notified nursing that Resident #91 was being transferred to the hospital for further evaluation for suspicion of a left leg fracture. Emergency Medical Services (EMS) personnel transported Resident #91 to the hospital where he was admitted for evaluation of a possible left distal femur fracture and bradycardia.Review of hospital documentation dated 12/26/25 revealed Resident #91 was admitted on [DATE] and treated for a closed bicondylar fracture of the left distal femur with Open Reduction and Internal Fixation (ORIF) on 12/24/25. The fracture was of unknown morphology. The resident stated he had fallen out of his bed on the left side while at the facility but was unable to provide more information due to baseline dementia. The hospital was unable to contact the nursing facility staff for further information.During an interview on 01/28/26 at 8:35 A.M., NP #235 said she arrived at the facility on 12/18/25 around 8:35 A.M., Resident #91 was seated in his wheelchair in the dining room and had not complained of pain or appeared to be in any pain. Around 4:00 P.M., RN #104 reported Resident #91 was complaining of pain and needed to be assessed. Upon arrival in the room, Resident #91 was already in bed. He was complaining of pain in the left leg. NP #235 stated she placed the orders for him to have X-rays of the right hip by mistake and had not realized the mistake until she saw the results the next day. On Friday, 12/19/25, she ordered X-rays to the left hip and knee, and routine oral pain medications including Ibuprofen and Robaxin for pain. NP #235 stated when she arrived at the facility on Monday morning. She checked the facsimile (fax) machine; Resident #91's X-ray results, dated 12/21/25, were on the fax machine and indicated he had a fracture. Resident #91 had not appeared to have uncontrolled pain on Monday morning when she saw him. NP #235 stated she sent Resident #91 to the hospital for further evaluation and treatment.During an interview on 01/29/26 at 11:50 A.M., the facility Medical Doctor (MD) #245 stated he was not informed of Resident #91's alleged fall, fractured leg requiring ORIF, or of NP #235's incorrect orders until 01/29/26.During an interview on 02/10/26 at 12:14 P.M., Regional Consultant #242 stated she had spoken with NP #235's direct supervisor, no specified date, and asked her to educate NP #235 regarding professional standards related to the delay in care.During a telephone interview on 02/10/26 at 1:37 P.M. Regional Director of Med Elite of Ohio #255 stated she spoke with NP #235 in December 2025, date not specified, regarding errors in physician orders which resulted in a delay of care for Resident #91. She stated they discussed how important accuracy of orders was related to patient safety and care. The regional director stated they spoke about having the appropriate practices in place to ensure orders were created for correct limb. The NP #235 acknowledged her error and owned up to her mistake. The regional director stated she might have some notes written down in her office about the conversation, but she was unable to provide more details as she was out of town at a medical conference.During a follow-up interview on 02/10/26 at 2:49 P.M., Regional Consultant #242 stated she was unaware of any additional corrective actions the facility had taken regarding the delay of care which affected Resident #91.Review of a policy titled Attending Physician Responsibilities dated August 2014 revealed attending physicians were responsible for providing appropriate and timely medical orders and treatments to enable safe, effective continuing care and to support facility compliance with regulations and care standards.This deficiency represents noncompliance investigated under Complaint Number 2716105.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure fall prevention interventions were implemented as care planned. This affected one (#74) of three residents sampled for falls. The facility census was 89.Findings include:Review of the medical record revealed Resident #74 was admitted to the facility on [DATE]. Diagnoses included multiple fractures of ribs (09/24/25), unspecified bipolar disorder, recurrent major depressive disorder, unspecified anxiety disorder, chronic pain syndrome, repeated falls, and stage IV chronic kidney disease.Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander.Review of the care plan dated 08/14/24 revealed Resident #74 was at risk for falls related to the resident refusing to have environmental modifications in room to reduce falls, self-medicating, using alcohol, using mobility devices, and having clutter in the room. Interventions included cushion in wheelchair, anti-roll backs to wheelchair, encourage to use call light, new bed/mattress, educating on appropriate footwear, encouraging the resident to keep bed in lowest position, non-skid strips to floor next to the bed (09/24/25), and family to declutter room.Observation on 01/27/26 at 12:07 P.M. revealed Resident #74 did not have nonskid strips on the floor beside her bed.During an interview on 01/27/26 at 12:07 P.M. Certified Nursing Assistant (CNA) #151 verified Resident #74 had no non-skid strips on the floor beside her bed.During an interview on 01/27/26 at 3:54 P.M. Maintenance #204 verified Resident #74 did not have non-skid strips on the floor in her room and stated they would have to be ordered because there were none available in the facility.During an interview on 01/28/26 at 1:52 P.M. the Director of Nursing (DON) verified Resident #74 did not have non-skid strips on her floor at the bedside as care planned.Review of policy titled Comprehensive Person-Centered Care Plans dated March 2022 revealed each resident had a comprehensive care plan developed and implemented to meet the resident's physical, psychological, and functional needs.This deficiency represents noncompliance investigated under Complaint Number 2716105 and is a recite to the annual survey completed 12/23/25.

Based on medical record review, staff and resident interviews, review of the hospital record, and policy review, the facility failed to ensure ordered pain medication was available for administration. This resulted in Actual Harm, when Resident #39 missed three days of methadone (a medication to treat severe pain) a total of nine doses, had increased pain, called nine-one-one (911), and went to the emergency room. This affected one (Resident #39) of two residents reviewed for pain medication use. The facility census was 92. Findings Include:Based on medical record review, staff and resident interviews, review of the hospital record, and policy review, the facility failed to ensure ordered pain medication was available for administration. This resulted in Actual Harm, when Resident #39 missed three days of methadone (a medication to treat severe pain) a total of nine doses, had increased pain, called nine-one-one (911), and went to the emergency room. This affected one (Resident #39) of two residents reviewed for pain medication use. The facility census was 92. Findings Include:Review of the medical record revealed Resident #39 admitted on [DATE]. Diagnoses included unspecified pain, low back pain, and chronic pain syndrome with opioid dependence. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/01/25, revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident received scheduled pain medication and had pain occasionally over the last five days of the assessment period that occasionally limited their participation in rehabilitation therapy sessions and day-to-day activities. Review of Resident #39's Care Plan Report included a focus area revised 11/10/25, indicating the resident was at risk for pain related to recent surgeries, major depressive disorder (MDD), gastroesophageal reflux disease (GERD), and chronic pain syndrome. Interventions directed staff to administer analgesics as per orders, initiated 04/17/25, and evaluate the effectiveness of pain interventions with each administration, revised 10/24/25. Review of Resident #39's Care Plan Report included a focus area revised 12/02/25, indicating the resident was at risk for fluctuations in mood and behaviors related to diagnoses of depression, chronic pain, immobility with potential side effects of medications with a history of opioid dependence. Interventions directed staff to administer medications and observe for adverse effects, and if noted, document and report to the physician; contact Social Services as needed; discuss with the resident ways to utilize present coping skills to deal with situations that arise; provide emotional support; and investigate the need for psychological support. During an interview on 12/18/25 at 12:57 P.M., Resident #39 stated there had been many times when the facility had not been able to get their prescribed methadone and the resident had to call 911 to go to the emergency room due to increased pain. The resident stated the facility would tell them that it was due to insurance issues. During a follow-up interview on 12/18/25 at 2:47 P.M., Resident #39 stated when they went without their methadone, their whole body cramped up, their stomach cramped up, and they would get nauseated and nervous. The resident stated they would call 911 even if they only missed a few doses because they were worried they would end up going into withdrawal. Review of Resident #39's physician orders revealed an order dated 09/30/25 for methadone five milligrams (mg) by mouth three times a day related to chronic pain syndrome. Review of Resident #39's October 2025 Medication Administration Record (MAR) and Controlled Drug Record for methadone revealed the following: On 10/01/25, the 12:00 A.M. dose of methadone was signed out on the MAR as being administered; however, there was not a Controlled Drug Record to indicate the medication was available to administer; the 8:00 A.M. and 4:00 P.M. doses of methadone were coded with the number 9 indicating to see the Nurses Notes. Resident #39's Progress Notes dated 10/01/25 at 11:31 A.M. and 7:25 P.M. indicated the facility was waiting on the pharmacy to dispense the resident's methadone and the physician was aware. The MAR indicated the residents' pain level for the day and evening shifts on 10/01/2025 was zero. On 10/02/25 and 10/03/25, the 12:00 A.M. doses of methadone were signed out on the MAR as being administered but were not signed out on the Controlled Drug Record. The pain level indicated zero. On 10/05/25 at 4:00 P.M. and 10/06/25 8:00 A.M. and 4:00 P.M., the methadone was coded with the number 9. Resident #39's Progress Notes dated 10/05/25 at 5:16 P.M. indicated the facility was waiting on the pharmacy to dispense the resident's methadone and the physician was aware. The Progress Notes dated 10/06/25 at 11:58 A.M. and 5:42 P.M. indicated the methadone would be administered when available from the pharmacy. The pain level indicated zero. On 10/06/25, the 12:00 A.M. dose of methadone was signed out on the MAR as being administered; however, there was not a Controlled Drug Record to indicate the medication was available to be administered. The pain level indicated zero. From 10/10/25 to 10/12/25, Resident #39 missed three days (nine doses) of their ordered methadone. Pain levels were documented as zero on the MAR on these dates. On 10/10/2025 and 10/11/2025, the 12:00 A.M. dose of methadone was signed out on the MAR as being administered; however, there was not a Controlled Drug Record to indicate the medication was available to be administered. On 10/10/2025, 10/11/2025, and 10/12/2025 the 8:00 A.M. and 4:00 P.M. doses of methadone were coded as the number 9 on the MAR. Resident #39's Progress Notes dated 10/10/25 at 9:53 A.M. and 5:58 P.M. indicated the facility was waiting on the pharmacy for the methadone to be dispensed and the physician was aware. Progress Notes dated 10/11/25 at 8:31 A.M. and 3:49 P.M. indicated the methadone was not available. Progress Notes dated 10/12/25 at 9:07 A.M. and 3:08 P.M. revealed no documentation of why the medication was not administered. On 10/12/2025, the space on the MAR for the scheduled 12:00 A.M. dose of methadone was blank. Review of Resident #39's Progress Notes dated 10/12/25 at 6:05 P.M. indicated the resident called 911 to be sent to the emergency room for complaints of pain. Review of an Emergency Department After Visit Summary (AVS) dated 10/12/25 indicated Resident #39 was seen for methadone withdrawal and was given a one-time dose of methadone 20 mg to help with withdrawal symptoms and Zofran for nausea. The summary indicated the larger dose of methadone was to help the resident until the care facility could address the delivery of the methadone. Review of Resident #39's October 2025 MAR was coded the number 9 for the 8:00 A.M. dose due on 10/13/25, and a Progress Note dated 10/13/25 at 9:22 A.M. indicated the methadone would be administered when available from the pharmacy and the Nurse Practitioner (NP) was aware. Review of Resident #39's Progress Notes dated 10/13/25 at 10:57 A.M. revealed the resident was transferred to the hospital for a colorectal procedure. Progress Note dated 10/24/25 revealed the resident was readmitted to the facility, and the orders were verified and sent to the pharmacy. Review of a hospital Discharge summary dated [DATE] indicated Resident #39 was admitted to the hospital on [DATE] underwent an open-end colostomy (surgical procedure to take the end of the colon and bring it through the abdominal wall to allow stool to exit the body) and a simple cystectomy with colonic creation (surgical procedure to remove the urinary bladder and create a new pathway for urine to exit the body) on 10/20/2025. The Discharge Summary indicated medications at discharge included methadone five mg by mouth three times a day. Review of Resident #39's October 2025 MAR and Controlled Drug Record for methadone revealed that after returning from the hospital following the surgical procedures, the resident missed two days (six doses) of their methadone: On 10/25/25 at 12:00 A.M., the scheduled dose of methadone was coded the number 5 which indicated to hold/see nurses notes. The 8:00 A.M. and 4:00 P.M. doses were coded the number 9. Resident #39's Progress Notes dated 10/24/25 at 11:59 P.M. revealed no documentation to indicate why the medication was not administered. Progress Notes dated 10/25/25 at 8:31 A.M. and 4:51 P.M. indicated the methadone was not available. There was no documentation of follow up with the physician or the pharmacy. On 10/26/25 the 12:00 A.M., the scheduled dose of methadone was signed out on the MAR as administered; however, there was not a Controlled Drug Record to indicate the medication was available to be administered. The 8:00 A.M. and 4:00 P.M. methadone doses were coded the number 9 on the MAR. The resident's pain level was documented as five on a scale of one to 10 with 10 being the worst pain, on the MAR for the day shift on 10/26/25. Resident #39's Progress Notes dated 10/26/25 at 3:27 P.M. indicated the methadone was not available; the pharmacy was contacted, and the medication was to be sent out immediately. A Progress Note dated 10/26/25 at 5:04 P.M. indicated the methadone was not available; the pharmacy was contacted and informed the facility a new prescription was required. Review of Resident #39's Progress Notes revealed a note dated 10/27/25 indicated the resident called an ambulance and requested to be taken to the hospital around 8:30 P.M. on 10/26/25 for withdrawal since the resident had not received several doses of methadone. Review of the Emergency Department (ED) Provider Notes dated 10/27/25 indicated Resident #39's chief complaint was drug withdrawal, leg pain, and nausea. The note indicated the resident presented with vague symptoms of pain and some mild nausea but had a clinical opiate withdrawal scale (COWS) score of 6, with a score of 5 to 12 indicating mild withdrawal. Review of Resident #39's October 2025 MAR revealed the methadone doses were coded the number 9 on 10/27/25 at 8:00 A.M. and 4:00 P.M. Resident #39's Progress Notes dated 10/27/25 at 6:09 P.M. indicated the methadone would be administered when available from the pharmacy and the NP was aware. The resident's pain level on the morning of 10/28/25 was documented as an eight. During an interview on 12/19/25 at 5:12 P.M., the Nurse Practitioner (NP) #45 stated when she took over Resident #39's care on 07/01/25, she found out Resident #39 was supposed to be on a weaning process from their methadone, so some of the time, because of the changes, there was an issue with receiving the up-to-date prescription from the pharmacy. She stated when the facility changed pharmacies in September 2025, the weaning process had to be thoroughly explained to the new pharmacy, and the new pharmacy had an issue with dispensing the methadone because it had an opioid addiction diagnosis on the prescription. She stated it had to be changed to chronic pain. She stated when she was notified, she would change the diagnosis on the prescription and resend it to the pharmacy. She stated she worked in the facility Monday through Friday from 8:00 A.M. until 5:00 P.M. and after that, there was an on-call service available. She stated she checked for all prescription renewals before she left on Fridays. During an interview on 12/20/25 at 12:07 P.M., the Pharmacy Case Manager #44 stated on 10/01/25 and 10/06/25, the pharmacy sent nine tablets of methadone each day with a note that said they could not fill the prescription with the opioid-dependent diagnosis. She stated per the pharmacist, they could not fill a prescription with an opioid dependency diagnosis, and the resident would have to go to a methadone clinic as part of their treatment. She stated when the facility sent the prescription with the appropriate diagnosis, they were able to fill the prescription. During an interview on 12/20/25 at 1:10 P.M., Licensed Practical Nurse (LPN) #09 stated she only worked as needed (PRN) at the facility but did remember once when she went to get Resident #39's methadone it was not in the cart. She stated she called the pharmacy and was told the resident needed a new prescription. She stated when she told the resident, they refused all their medications and then called 911 to be sent to the emergency room before she was able to follow-up on the prescription. She stated she was not aware the resident called 911 until emergency medical services arrived. During an interview on 12/20/25 at 7:40 P.M., Registered Nurse (RN) #14 stated if a medication was not available to administer, then he would call the pharmacy to find out about it. He stated if they needed a prescription, he would contact the physician to get the prescription and would fax it to the pharmacy. He verified he signed that the methadone was given on 10/11/25, 10/26/25 and 11/22/25, but if there was not a narcotic sheet, then he must have signed off the MAR in error. During an interview on 12/20/25 at 8:00 P.M., RN #23 stated if Resident #39's methadone was not available, he would call the pharmacy, and if a prescription was needed, he would call the physician, notify the medication was not available, and have them send the prescription to the pharmacy. He stated this should be documented in a progress note. During an interview on 12/20/25 at 8:10 P.M., RN #11 stated she worked at the facility PRN. She stated if medication was not available, she would contact the pharmacy and the physician. She stated if it was a narcotic and a prescription was needed, then they would need to call the physician and they would send the prescription to the pharmacy. She stated she remembered that the previous nurse had told her that Resident #39's methadone was going to be delivered on the next pharmacy run that night, but before she knew it, the resident called 911. She stated she thought that the resident had complained of back pain but could not remember.During an interview on 12/21/25 at 8:05 A.M., RN #11 stated she would reorder a resident's medication when there were five pills or less unless it was something that the resident took more often, like every four hours, then the nurse should use common sense and order before there were only 10 pills left. She stated she only worked PRN at the facility, and medications not being available happened a lot when she worked. She stated the previous nurse either did not order or follow-up on the medication and then the resident would get upset and call 911. She stated the NP only worked Monday through Friday until 5:00 PM, so if it happened on the weekend, they would have to call the on-call provider, but the on-call provider would not refill narcotic prescriptions and would say that it had to be done by the primary provider on Monday. She stated sometimes, they were able to get an emergency prescription for a few tablets to pull from the emergency kit, but the on-call provider usually said they had to wait until Monday. She further stated methadone was not available in the emergency kit. During an interview on 12/21/25 at 2:22 P.M., Certified Nursing Assistant (CNA) #26 stated she had been working in the building with Resident #39 when the resident called 911 to be sent out because their medications were not available. She stated the resident would tell the nurses they were in pain so that they would take them to the emergency room, but the resident did not complain of pain to her and the resident had not appeared to be in pain. During an interview on 12/22/25 at 11:24 A.M., LPN #22 stated Resident #39 ran out of methadone a couple of times when she worked. She stated she would call the pharmacy and was told it was an insurance issue. She stated she did not witness Resident #39 with any adverse effects from not getting the methadone, but he would get aggravated and upset. She stated the Nurse Practitioner (NP) was aware when the resident was out of methadone. During a telephone interview on 12/22/25 at 11:52 A.M., RN #25 stated the reason they had trouble getting Resident #39's methadone was because the insurance would not pay, and they needed the Director of Nursing (DON) to authorize it. He stated he would always text the DON when there was an issue with Resident #39's methadone. During a telephone interview on 12/22/25 at 2:20 P.M., the Pharmacy Director of Clinical Services #46 stated their pharmacy started providing services at the facility on 09/08/25. She stated Resident #39 was taking different doses of the methadone, and the facility did not get them all refilled at once since they had them previously filled at a different pharmacy, so they would have to wait for a new prescription to come in before they could fill it. She stated they would send a small amount of pills after receiving the new prescription in order to get the resident by for a few days until the facility could change the diagnosis on the prescription, since it said opioid dependence they legally could not fill the prescription with that diagnosis, but the resident did have a diagnosis of chronic pain that could be used. During an interview on 12/22/25 at 2:40 P.M., LPN #02 stated it was the pharmacy's fault that they could not get Resident #39's methadone. She stated it would take them a long time to send the medication out due to insurance reasons, needing prior authorization, or needing a new prescription. She stated when a new prescription or preauthorization was needed, she would call the NP, and the NP would send a prescription to the pharmacy. During a follow-up interview on 12/23/25 8:20 A.M., the NP #45 stated she had not been able to assess Resident #39 when they had gone without their methadone. She stated the nurses should reorder narcotic medication a minimum of three to five days before the medication ran out. She stated she did final rounds at 3:00 P.M. on Fridays and had the nurses check their narcotic cards to make sure that they had enough medications for the weekend. She stated part of the problem with getting the methadone from the pharmacy was the nurses would reorder the methadone off an older prescription that had the wrong diagnosis, and it would stall the delivery of the medication. During an interview on 12/23/25 at 9:24 A.M., the DON stated the nurse and the pharmacy were responsible to ensure medications were available for administration and if they were not available, then the nurse should reorder the medication, get it from the emergency kit if available, and notify the physician if the resident missed a dose. She stated if it was a routine medication, the resident should not miss more than one dose. She stated she was not sure why they were not getting Resident #39's methadone timely but knew that one of the issues was the diagnosis of opioid dependence. She stated that when a resident was on routine medication, the nurse should order the medication three to five days before the medication was gone. During an interview on 12/23/25 at 10:44 A.M., the Administrator stated the pharmacy filled the medication and the nurse checked it. If they were missing a medication, then they should check the emergency kit and if it was not available, then the nurse should notify the pharmacy so they could send it and call the provider if needed. She stated if they did not get a resolution, then the nurse should call the DON. She stated if the resident was taking a routine narcotic, an acceptable time for the resident to go without it would depend on the reason for the medication. She stated she knew there were issues with getting Resident #39's methadone but she did not remember the details. Review of the facility policy titled, Pain Assessment and Management, revised 04/2025, indicated Implementing Pain Management Strategies 6. The medication regimen is implemented as ordered. Results of the interventions are documented and communicated directly to the provider when appropriate. Ongoing communication between the prescriber and the staff is necessary for the optimal and judicious use of pain medications. The policy also specified, Monitoring and Modifying Approaches 4. If the resident is prescribed opioid analgesics, monitor for the following side effects: b. Physical dependence which causes symptoms of withdrawal when opioid medication is stopped, or a dose is held or missed. 5. Contact the provider immediately if the resident's pain or medication side effects are not adequately controlled.This deficiency represents non-compliance investigated under Complaint Number 2618734.

Based on medical record review, observation, staff and resident interview, review of facility investigation documents, and policy review, the facility failed to provide adequate supervision and assistance for a resident who was dependent on two staff for bathing. This resulted in Actual Harm when Resident #97 was being bathed by one staff member, had a spasm in one leg, fell out of the bed, and sustained fractures in both legs. This affected one (Resident #97) of three residents reviewed for falls. Additionally, the facility failed to ensure the environment was free of accident hazards. This affected four (Residents #80, #86, #45, and #13) of 37 sampled residents. The facility census was 92.Findings Included:Based on medical record review, observation, staff and resident interview, review of facility investigation documents, and policy review, the facility failed to provide adequate supervision and assistance for a resident who was dependent on two staff for bathing. This resulted in Actual Harm when Resident #97 was being bathed by one staff member, had a spasm in one leg, fell out of the bed, and sustained fractures in both legs. This affected one (Resident #97) of three residents reviewed for falls. Additionally, the facility failed to ensure the environment was free of accident hazards. This affected four (Residents #80, #86, #45, and #13) of 37 sampled residents. The facility census was 92.Findings Included:1. Review of the medical record revealed the facility admitted Resident #97 on [DATE]. Diagnoses included absolute glaucoma, binge eating disorder, abnormal posture, bariatric surgery status, muscle weakness, difficulty in walking, and the need for assistance with personal care. Review of an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #97 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident was dependent on staff with toileting, showering/bathing, lower body dressing, rolling left and right, going from sitting on the side of the bed to lying flat on the bed, going from laying on their back to sitting on the side of the bed, going from sitting to standing, chair/bed-to-chair transfers, and with tub/shower transfers. Review of Resident #97's Care Plan Report included a focus area revised on [DATE], indicating the resident had a behavior problem related to impaired cognition, depression, dependence on others for care, anxiety, insomnia, and mood disorder. Interventions directed two staff to be in the residents' room for all care (initiated [DATE]). Resident #97's Care Plan Report included a focus area revised on [DATE], indicating the resident had a self-care/mobility deficit. Interventions initiated [DATE] indicated the resident was dependent on staff for care related to bathing/showering and bed mobility. Review of Resident #97's Progress Notes dated [DATE] at 1:19 P.M. and electronically signed by Licensed Practical Nurse (LPN) #09, revealed LPN #09 was notified by an aide that Resident #97 had fallen while they were providing care. Upon entering the room, LPN #09 observed the resident lying on the floor. Emergency services were called, and the resident was transported to the local hospital. Review of the facility's investigation document related to Resident #97's fall on [DATE], indicated while Certified Nursing Assistant (CNA) #36 provided personal care to the resident, the resident's legs slipped off the bed in a jerking motion and went off to the side of the bed, resulting in the resident sliding off the bed onto their buttocks, with their legs bent outward. The investigation indicated after initial assessment, the resident was transferred back to bed. Resident #97 complained of pain in their right leg and requested to go to the emergency room. Emergency services were contacted, and the resident was taken to the emergency room. During a telephone interview on [DATE] at 9:32 A.M., CNA #36 stated that while providing Resident #97 a bed bath, the residents' legs went to the side and caused the resident to fall onto the floor in the split-like position. She stated Resident #97 screamed out in pain. CNA #36 stated she yelled for help, and approximately five staff members assisted the resident back to bed. CNA #36 stated Resident #97 required assistance from two staff members but stated she always provided care to Resident #97 by herself. CNA #36 stated no one there would help her. CNA #36 stated Resident #97 sustained fractures to both legs and never returned to the facility. During a telephone interview on [DATE] at 8:07 P.M., Resident #97 stated they were receiving a bed bath from CNA #36 when their leg kind of spasmed, went off the side of the bed, and caused them to fall onto the floor. The resident stated that it hurt and they were screaming. Resident #97 stated CNA #36 provided the bed bath without any other staff assistance. Resident #97 stated they were transferred to the local hospital following the incident and was diagnosed with fractures in both legs. Resident #97 stated they had not returned to the facility following the incident. During an interview on [DATE] at 10:12 A.M., LPN #09 stated they only worked at the facility as needed. LPN #09 stated they could not remember the specifics surrounding the incident involving Resident #97 but confirmed the resident was dependent on staff, requiring total assistance for all care. During an interview on [DATE] at 10:32 A.M., the MDS/Care Plan Coordinator (MDS Coordinator) stated based on Resident #97's care plan and MDS, the resident was dependent on staff and required assistance from two staff for all care. The MDS Coordinator stated she expected staff to follow the care planned interventions. During an interview on [DATE] at 8:50 A.M., the Director of Nursing (DON) stated dependent care meant the resident was not able to participate in assisting with their care. The DON stated Resident #97 required assistance from two staff for all care, and it was her expectation that all staff followed resident care planned interventions. Review of the facility policy titled, Falls-Clinical Protocol, revised 03/2018, indicated Treatment/Management included, 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. 2. Review of the medical record revealed the facility admitted Resident #80 on [DATE]. Diagnoses included hemiplegia and hemiparesis following a stroke affecting the dominant right side, anxiety disorder, paranoid schizophrenia, and absolute glaucoma. Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed Resident #80 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident had intact cognition. The MDS indicated Resident #80 rejected care four to six days during the assessment look-back period. The MDS indicated Resident #80 had no functional limitation in range of motion of the lower extremities or the upper extremities. Resident #80 required set up or clean up assistance from staff for eating and supervision or touching assistance from staff for completion of all other activities of daily living. The MDS indicated Resident #80 required set up or clean-up assistance from staff with rolling left and right in bed, moving from sitting to lying, moving from lying to sitting on the side of the bed, moving from sitting to standing, toilet transfers, and chair/bed-to-chair transfers. Review of Resident #80's Care Plan Report included a focus area revised on [DATE], revealed Resident #80 had a behavior problem related to refusing medications and care. Interventions directed the staff to intervene as needed to protect the rights and safety of others, approach/speak in a calm manner, divert attention, and remove from the situation and take to an alternate location as needed. Resident #80's Care Plan Report did not include a focus area for small electrical appliances in the resident's room. Observation of Resident #80's room on [DATE] at 9:57 A.M., revealed a small electric coffee pot on the counter that was plugged into the electrical outlet, and the resident was not in the room. Interview on [DATE] at 10:38 A.M., Resident #80 stated the electric coffee pot had been in the room for a while, and the resident offered no information about where the electric coffee pot came from. During a concurrent observation and interview on [DATE] at 3:11 P.M., Registered Nurse (RN) #06 stated residents were not allowed to have coffee pots or pots to heat water. RN #06 stated these appliances were forbidden because the resident may burn themselves or leave the appliance on and cause a fire. RN #06 stated she had not seen any electrical appliances in a resident's room. RN #06 went to Resident #80's room and saw that the electric coffee pot plugged in. The coffee pot was observed heavy when lifted and made a sloshing sound as if fluid were inside. RN #06 stated she was unaware Resident #80 had the coffee pot in their room since the resident met her in the hall for medications and would not allow staff in the room. RN #06 stated Resident #80 was independent with care and the CNAs did not go into the resident's room. The RN #06 stated Resident #80 broke facility rules. An interview was held with the DON on [DATE] at 10:00 A.M. The DON stated residents were not allowed to have coffee pots or electrical appliances to heat water in their rooms. The DON stated this policy was reviewed on admission and she expected staff to notify her if an electrical appliance was seen in a resident's room. The DON stated no one had reported Resident #80's coffee pot. The Administrator was interviewed on [DATE] at 3:28 P.M. and stated Resident #80 should not have had the coffee pot in their room because the electrical coffee pot could be a hazard or the resident could burn themselves. 3. Review of the medical record revealed the facility admitted Resident #86 on [DATE] and readmitted the resident on [DATE]. Diagnoses included age related macular degeneration of the left eye, bipolar disorder, generalized anxiety, Parkinson's disease, and unspecified allergic rhinitis (inflammation of nose, throat, and/or eyes). Review of the quarterly MDS, with an ARD of [DATE], revealed Resident #86 had a BIMS score of nine which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #86 used corrective lenses. The MDS indicated Resident #86 had impaired vision and was able to see large print but not regular print in newspapers or books. The MDS indicated Resident #86 had no functional limitation in range of motion. Review of Resident #86's Care Plan Report included a focus area initiated [DATE], indicating the resident had impaired safety awareness. Interventions directed staff to administer medications as ordered. Review of Resident #86's Kardex (a form used by the CNAs to guide care for the resident), dated [DATE], revealed in the section Safety that staff was to cue, reorient, and supervise as needed and ensure/provide a safe environment. Review of Resident #86's Physician Order Summary Report, with active orders as of [DATE], included orders for fluticasone propionate nasal suspension (Flonase, a nasal steroid) 50 micrograms per actuation spray, one spray in each nostril in the morning for allergies and ketoconazole external shampoo 2 percent (an antifungal) to be applied to the resident's face, ears, nose topically every Monday and Thursday for dry skin. Review of the 12/2025 Medication Administration Record (MAR), revealed fluticasone had been administered on [DATE] and [DATE] at 9:00 A.M. by the assigned nurse. The MAR indicated ketoconazole was administered on [DATE] at 6:00 A.M. and 8:00 P.M. and on [DATE] at 6:00 A.M. A concurrent observation and interview on [DATE] at 11:16 A.M., revealed an opened bottle of Flonase at the resident's bedside with a dispense date of 2023 and a clear medication cup containing a creamy white substance. Resident #86 stated the white creamy substance was for the moles on their face. Observation of Resident #86's room on [DATE] at 11:52 A.M. revealed a clear medication cup containing a creamy white substance and a bottle of Flonase. A concurrent observation and interview on [DATE] at 8:48 A.M. revealed a nurse took Resident #86's morning medication into the resident's room but did not remove a clear medication cup with a creamy substance. Resident #86 stated he was unsure where the nasal spray went, and the nurses applied the white cream to their face. Registered Nurse (RN) #06 was interviewed on [DATE] at 3:19 P.M. RN #06 stated she had seen the bottle of nasal spray in Resident #86's room and had thrown the bottle away since the medication had expired. RN #06 stated she had seen the bottle of nasal spray in Resident #86's room before and could give no reason why she had not removed the nasal spray sooner. RN #06 stated she had not taken the cup of white cream into Resident #86's room and had no idea what the cream was. RN #06 stated the cream should not be stored in an unlabeled cup. An observation on [DATE] at 8:46 A.M. revealed a clear medication cup of white cream on Resident #86's bedside table. RN #04 was interviewed on [DATE] at 12:23 P.M. and stated medication should not be taken out of the original container and placed in an unlabeled clear medication cup. RN #04 went to Resident #86's room and removed a medication cup containing a creamy substance. The DON was interviewed on [DATE] at 10:06 A.M. and stated medications were not allowed to stay on bedside tables because of safety concerns, and medications should be stored securely. The DON stated a few residents may have rescue inhalers kept by their beds, but those residents had to have orders for the self-administration of medication, orders for the medication to be kept at the bedside, and have been assessed and care planned for medication self-administration. The DON stated medications should not be removed from the original containers and placed at a resident's bedside in a clear medication cup because there would be no way to know what the medication was. The DON stated Resident #86 had no orders to keep medications at their bedside or self-administer medications. The Administrator was interviewed on [DATE] at 3:28 PM. The Administrator stated medication should not be left at the resident's bedside, and nurses should remove medication left at the bedside. The Administrator stated ointments and creams should not be removed from original containers and left in the resident's room with no name and instruction as there would be no way to know who the medication was for, what it was, or what it was for. 4. Review of the medical record revealed the facility admitted Resident #13 on [DATE]. Diagnoses included unspecified encephalopathy and hypertension. Review of the admission MDS, with an ARD of [DATE], indicated Resident #13 had a BIMS score of 14, which indicated the resident had intact cognition. The MDS revealed Resident #13 had adequate vision and hearing and had no functional limitations in range of motion of the upper extremities or lower extremities. The MDS indicated Resident #13 was independent with oral hygiene and needed set up or clean up assistance from staff for eating. Review of Resident #13's Care Plan Report, with an initiation date of [DATE], revealed no documentation related to self-administration of medication. Review of Resident #13's Physician Order Summary Report with active orders as of [DATE], revealed no evidence of a physician's order allowing Resident #13 to keep medication at the bedside or to self-administer medication. Review of Resident #13's 12/2025 MAR indicated Resident #13 had medications scheduled to be given at 8:00 A.M. and 9:00 A.M. The MAR revealed there were no medications scheduled for the timeframe from 9:45 A.M. to 10:45 A.M. The MAR indicated that on [DATE] medications had been administered to Resident #13 by Licensed Practical Nurse (LPN) #02. During an observation and interview on [DATE] at 10:43 A.M., Resident #13 had medication in their room in a clear medication cup. Resident #13 sat up in bed, took the medications, and stated it was usual for the nurses to leave the medication in the room for them to take when they woke up. Resident #13 stated they were okay with the practice of leaving the medications to be taken upon waking up. During an interview on [DATE] at 3:09 P.M., LPN #02 stated she left the medication in Resident #13's room and walked out because Resident #13 had the medication cup in their hand and was ready to take the medication as she walked out. LPN #02 stated she knew she was not supposed to leave medication in a resident's room and knew she was supposed to make sure the resident had taken the medication before leaving the room. LPN #02 stated that the resident must have placed the medication back on the table and laid down again. During an interview on [DATE] at 10:06 A.M., the DON stated for residents that self-administered medications there had to be physician's orders to keep the medications at bedside, residents had to be assessed for self-administration, and care planned for self-administration. The DON stated medications were not allowed to sit at bedside tables because of safety concerns. The DON stated that nurses were not expected to leave medications at bedside for residents to take when they awoke. The nurse reviewed the physician's orders for Resident #13 and stated that the resident had no orders for self-administration of medication. The Administrator was interviewed on [DATE] at 3:18 PM and stated she was unaware of any resident in the facility that had been approved for self-administration of medications, and she expected medications not to be left in residents' rooms. The Administrator stated she expected the nurse to stay in the resident's room until medications were taken. Review of a facility policy titled, Self-Administration of Medications, dated 2001, indicated As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident.5. Review of the medical record revealed the facility admitted Resident #45 on [DATE]. Diagnoses included traumatic subdural hemorrhage with loss of consciousness, cerebral infarction (stroke) due to unspecified occlusion or stenosis of an unspecified cerebral artery, and aphasia (a language disorder from brain damage that impaired speaking understanding, reading, or writing). Review of an annual MDS, with an ARD of [DATE], revealed Resident #45 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. Review of Resident #45's Care Plan Report included a focus area, initiated [DATE], indicating the resident had impaired cognitive function due to a non-traumatic subdural hematoma, craniotomy, medications, and depression. An observation of Resident #45's room on [DATE] at 10:25 A.M. revealed a metal chair rail on the wall to the right side of Resident #45's bed was loose from the wall and left an approximate two-inch gap between the wall and the edge of the metal chair rail. The observation revealed the metal chair rail had sharp edges extending from the lower edge and other areas of the wooden wainscoting were splintered, including an approximate two-inch splinter. The Maintenance Director #55 was interviewed on [DATE] at 10:15 AM. The Maintenance Director stated the danger of a board being loose from the wall or a splintered board in a resident's room would be access to electrical lines in the wall. The Maintenance Director #55 stated he had not been notified about any splintered wood or loose boards in a resident's room. The Maintenance Director #55 went to Resident #45's room and stated no one had reported the metal chair rail was loose from the wall and added that the edge was pointed and sharp. The Maintenance Director #55 further stated no one had reported how rough the wood was in Resident #45's room or the large splinter sticking out from the wood. The DON was interviewed on [DATE] at 9:57 A.M., and stated because the metal chair rail was loose in Resident #45's room, the resident could cut themself. This deficiency represents non-compliance investigated under Complaint Numbers 2614070, 2621620, and 2618734.

Based on medical record review, interviews, review of facility investigation documents, and policy review, the facility failed to implement person-centered care planned interventions. This resulted in Actual Harm when Resident #97 was being bathed by one staff member, had a spasm in one leg, fell out of the bed, and sustained fractures in both legs. This affected one (Resident #97) of three residents reviewed for falls. The facility census was 92.Findings Included: Review of the medical record revealed the facility admitted Resident #97 on 07/04/19. Diagnoses included absolute glaucoma, binge eating disorder, abnormal posture, bariatric surgery status, muscle weakness, difficulty in walking, and the need for assistance with personal care. Review of an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/25/25, revealed Resident #97 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident was dependent on staff with toileting, showering/bathing, lower body dressing, rolling left and right, going from sitting on the side of the bed to lying flat on the bed, going from laying on their back to sitting on the side of the bed, going from sitting to standing, chair/bed-to-chair transfers, and with tub/shower transfers. Review of Resident #97's Care Plan Report included a focus area revised on 11/21/24, indicating the resident had a behavior problem related to impaired cognition, depression, dependence on others for care, anxiety, insomnia, and mood disorder. Interventions directed two staff to be in the residents' room for all care (initiated 11/21/24). Resident #97's Care Plan Report included a focus area revised on 11/21/24, indicating the resident had a self-care/mobility deficit. Interventions initiated 11/21/24 indicated the resident was dependent on staff for care related to bathing/showering and bed mobility. Review of Resident #97's Progress Notes dated 09/05/25 at 1:19 P.M. and electronically signed by Licensed Practical Nurse (LPN) #09, revealed LPN #09 was notified by an aide that Resident #97 had fallen while they were providing care. Upon entering the room, LPN #09 observed the resident lying on the floor. Emergency services were called, and the resident was transported to the local hospital. Review of the facility's investigation document related to Resident #97's fall on 09/05/25, indicated while Certified Nursing Assistant (CNA) #36 provided personal care to the resident, the resident's legs slipped off the bed in a jerking motion and went off to the side of the bed, resulting in the resident sliding off the bed onto their buttocks, with their legs bent outward. The investigation indicated after initial assessment, the resident was transferred back to bed. Resident #97 complained of pain in their right leg and requested to go to the emergency room. Emergency services were contacted, and the resident was taken to the emergency room. During a telephone interview on 12/19/25 at 9:32 A.M., CNA #36 stated that while providing Resident #97 a bed bath, the residents' legs went to the side and caused the resident to fall onto the floor in the split-like position. She stated Resident #97 screamed out in pain. CNA #36 stated she yelled for help, and approximately five staff members assisted the resident back to bed. CNA #36 stated Resident #97 required assistance from two staff members but stated she always provided care to Resident #97 by herself. CNA #36 stated no one there would help her. CNA #36 stated Resident #97 sustained fractures to both legs and never returned to the facility. During a telephone interview on 12/19/25 at 8:07 P.M., Resident #97 stated they were receiving a bed bath from CNA #36 when their leg kind of spasmed, went off the side of the bed, and caused them to fall onto the floor. The resident stated that it hurt and they were screaming. Resident #97 stated CNA #36 provided the bed bath without any other staff assistance. Resident #97 stated they were transferred to the local hospital following the incident and was diagnosed with fractures in both legs. Resident #97 stated they had not returned to the facility following the incident. During an interview on 12/19/25 at 10:12 A.M., LPN #09 stated they only worked at the facility as needed. LPN #09 stated they could not remember the specifics surrounding the incident involving Resident #97 but confirmed the resident was dependent on staff, requiring total assistance for all care. During an interview on 12/19/25 at 10:32 A.M., the MDS/Care Plan Coordinator (MDS Coordinator) stated based on Resident #97's care plan and MDS, the resident was dependent on staff and required assistance from two staff for all care. The MDS Coordinator stated she expected staff to follow the care planned interventions. During an interview on 12/22/25 at 8:50 A.M., the Director of Nursing (DON) stated dependent care meant the resident was not able to participate in assisting with their care. The DON stated Resident #97 required assistance from two staff for all care, and it was her expectation that all staff followed resident care planned interventions. Review of the facility policy titled, Falls-Clinical Protocol, revised 03/2018, indicated Treatment/Management included, 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. This deficiency represents non-compliance investigated under Complaint Numbers 2614070.

Based on medical record review, resident interview, staff interview, and facility policy review, the facility failed to ensure staff provided verbal reports to one another in a manner to protect the residents' health information. This had the potential to affect all 92 residents residing in the facility. The census was 92.Findings include:A Resident Council meeting was held on 12/16/25 beginning at 3:00 P.M. During the meeting Resident #68 stated he knew diagnoses and medications of other residents and had been accused of, knowing too much; however, Resident #68 stated he knew these things due to overhearing the nurses and nurse aides talking. Resident #68 stated he had told staff it was a violation of the Health Insurance Portability and Accountability Act (HIPAA). During the meeting, Resident #27 stated she also knew medical information about other residents, including some of the medications other residents were taking. Resident #27 further stated another resident (Resident #32) also heard information about other residents through her open door.Review of Resident #68's annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 11/13/25, revealed Resident #68 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Review of Resident #27's quarterly MDS assessment, with an ARD of 10/01/25, revealed Resident #27 had a BIMS score of 15, which indicated the resident had intact cognition. During an interview on 12/20/25 at 10:24 A.M., Resident #32 stated when staff gave report to one another, the resident was able to hear other residents' health information. Resident #32 further stated she knew what protected heath information included since she was a former nurse. Review of Resident #32's quarterly MDS, with an ARD of 11/21/25, revealed Resident #32 had a BIMS score of 15, which indicated the resident had intact cognition. Licensed Practical Nurse (LPN) #3 was interviewed on 12/20/25 at 1:19 P.M. and stated shift report was held at the nurses' station, and she was sure residents overheard protected health information. LPN #3 stated she knew it was a HIPAA violation all day long. The Director of Nursing (DON) was interviewed on 12/21/25 at 10:28 A.M. and stated nurses completed shift report at the nurses' stations, but stated each nurses' station had an office area or a medication room that allowed the nurses to meet privately. The DON stated she would not have expected the nurses to discuss residents' illnesses or medications where the information could be overheard by other residents. The DON stated if other residents' information was overheard, it was a HIPAA violation. The Administrator was interviewed on 12/21/25 at 3:46 P.M. and stated she expected staff to keep medical information about residents confidential. Review of a facility policy titled, Dignity, revised 02/2021, indicated staff are to protect confidential clinical information. Examples included verbal staff-to-staff communication (e.g. [exempli gratia, for example], change of shift reports) are conducted outside the hearing range of residents and the public.This deficiency represents non-compliance investigated under Complaint Number 2650678.

Based on observation, interview, and facility document review, the facility failed to ensure essential kitchen equipment was maintained in safe operating condition for one of one dishwasher. This had the potential to affect all residents. The facility census was 92. A tour of the kitchen conducted on 12/15/2025 at 9:09 A.M. with [NAME] (CK) #34, revealed an area of standing water that was approximately four feet wide by 12 feet long by one inch deep was covering an area of the floor near the dishwasher. During an interview on 12/15/2025 at 9:11 A.M., CK #34 stated the dishwasher had been broken for over a year. CK #34 stated that there was a problem with the drain and every time the dishwasher drained, it flooded the whole floor. CK #34 stated that management was aware and had repeatedly informed staff that they were going to have it repaired. During an interview on 12/15/2025 at 9:13 A.M., CK #35 stated the dishwasher had been broken for the entire duration of their 6-month employment and management was aware of the issue. Per CK #35, every time the dishwasher drained, it flooded the floor. CK #35 stated there was always standing water on the floor. A follow-up observation of the kitchen was conducted on 12/16/2025 at 10:41 A.M. with the Dietary Manager (DM) #60. During the observation water was observed pouring from the dishwasher and/or drain line onto the floor. Approximately one to two inches of water was observed covering one-half of the floor in the dishwashing area. During an interview on 12/16/2025 at 10:41 A.M., DM #60 revealed the dishwasher drain had been backed up since their promotion to the management position seven months prior. Per the DM #60, numerous vendors had attempted to clear the line, but it had never resolved the issue. During a follow-up interview on 12/19/2024 at 4:24 P.M., DM #60 stated that they had been having issues with the dishwasher properly draining for the past 18 months. DM #60 stated that they had voiced concerns regarding the dishwasher during facility morning meetings as recently as two weeks prior. She stated that she had also directly reported the issue to the Maintenance Director #55 since being promoted to the management position seven months prior. During an interview on 12/19/2025 at 5:02 P.M., the Maintenance Director #55 revealed that the facility had been having issues with the dishwasher for a while, but the most recent issue had been going on for approximately four to six weeks. Maintenance Director #55 stated the dishwasher was not draining correctly due to a collapsed/clogged pipe and when the dishwasher drained, the water covered the floor. Maintenance Director #55 also revealed that they had discussed and provided estimates for repairs to the facility Administrator. During an interview on 12/22/2025 at 9:11 AM, the Administrator stated she was unaware of any current dishwasher concerns and believed that all previous issues had been resolved. The Administrator stated that it was their expectation that staff would utilize the facility work order management system or communicate concerns directly to Maintenance Director #55. Per the Administrator, all kitchen equipment should be properly maintained and working at all times. The Administrator stated that any issues that could not be resolved should be communicated to them immediately for resolutionDuring an interview on 12/22/2025 at 8:50 P.M., the Director of Nursing (DON) revealed she was aware that there were problems with drainage in the kitchen. The DON stated that the DM had voiced concerns about the dishwasher during the facility morning meetings. A bill to the facility dated 10/29/2025 revealed a plumbing company found significant issue with [the facility] floor drain that services your dish machine. The drain is severely clogged, and our initial attempts to clear it using a jetting hose were only partially successful. During this process we observed considerable amounts of sand and cast-iron debris coming from the drain, indicating deterioration of the existing plumbing system. The bill also revealed an estimate for removing a section of the floor around the drain, excavating approximately four feet from the floor drain to locate and replace the damaged section, and inspecting the line to ensure proper flow. There was no documented evidence that the facility authorized the service to repair the drain line. A letter to the facility, dated 11/21/2025, from a mechanical contractor regarding the dishwasher hub drain, revealed an estimate was provided to excavate the concrete around the hub drain down to the P-trap to determine where the piping issue was for the dishwasher drain line. Again, there was no documented evidence that the facility accepted the proposal.

Based on employee file reviews, staff interview and policy review, the facility failed to ensure four (Registered Nurse (RN) #4, RN #6, Licensed Practical Nurse (LPN) #9, and LPN #15) of eight sampled employees received training on abuse, neglect, and exploitation during orientation and annually as required by facility policy. This had the potential to affect all residents. The facility census was 92.A review of employee files revealed the facility hired Registered Nurse (RN) #4 on 04/12/2023, RN #6 was hired on 03/18/2024, and Licensed Practical Nurse (LPN) #9 on 02/15/2023. The employee files and in-service trainings revealed no documented evidence of abuse/neglect training within the past 12 months for RN #4, RN #6, or LPN #9.Review of LPN #15's employee file revealed the facility hired the LPN on 06/02/2025. There was no documentation in LPN #15 ' s employee file or in-service trainings that the facility had provided abuse neglect training for the LPN. During an interview on 12/22/2025 at 8:50 A.M., the Director of Nursing (DON) stated they expected all staff to attend and complete all required in-services. The DON further stated that they expected the facility management team to monitor employee files to ensure compliance with the requirements. During an interview on 12/22/2025 at 9:11 A.M., the Administrator stated they expected all staff to complete all required in-services and trainings. During an interview on 12/22/2025 at 1:53 P.M., Human Resources Director (HRD) #61 revealed she was responsibility for ensuring all required employee trainings were completed. HRD #61 revealed the required abuse training for the four nurses were missing, and she could not explain why they were not completed. A facility policy titled, Abuse Prevention/Reporting Policy and Procedure, updated 05/09/2018, revealed abuse prevention procedures included training which indicated:1. All new employees will receive training on the abuse policy.2. All employees will attend training during orientation, mandatory annual training and more often as determined by the facility.3. Training classes include at a minimum: a. Definitions of abuse, neglect, exploitation, and misappropriation of resident property. b. Reporting requirements regarding allegations of abuse, without fear of reprisals from any other individual whether they are staff, management, residents or visitors. c. Appropriate interventions to deal with aggressive and catastrophic reactions to residents. d. Recognition of and appropriate interventions for burnout, frustration and stress that could lead to reactions resulting in abusive situations.This deficiency represents non-compliance investigated under Complaint Number 2656167 and Complaint Number 2618734.

Based on observation, staff interview, medical record review, and facility policy review, the facility failed to maintain resident equipment in good repair, specifically, a fall mat used for one (#3) of 37 sampled residents was torn and stained and a shower bench located in one (Willow Unit) of two shower rooms was observed with a worn, cracked surface. The census was 92.Findings include:1. Review of the medical record revealed Resident #3 admitted to the facility on [DATE]. Diagnoses included altered mental status, muscle weakness, vascular dementia, syncope and collapse, and history of falling. Review of a quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 11/21/25, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of seven (7), which indicated the resident had severe cognitive impairment. An observation of Resident #3's room on 12/15/25 at 9:43 A.M. revealed the resident's fall mat was torn across the middle, which exposed foam with black stains. An observation of Resident #3's room on 12/16/25 at 11:57 A.M. revealed the resident's fall mat was torn with black stains. An observation of Resident #3's room on 12/18/25 at 9:00 A.M. revealed the resident's fall mat was torn with black stains. During an interview on 12/18/25 at 2:15 P.M., Certified Nurse Aide (CNA) #31 stated Resident #3's fall mat had been in the same condition for the two weeks she had worked in the facility, but she had not reported the mat to anyone. During an interview on 12/18/25 at 2:43 P.M., Registered Nurse (RN) #6 stated she noticed Resident #3's fall mat and stated the resident needed a new mat, but she had not requested a new mat for the resident. During an interview on 12/19/25 at 12:05 P.M., CNA #19, who also served as the central supply manager, stated as the central supply manager, he oversaw distribution of fall mats. CNA #19 stated he had replaced Resident #3's fall mat on 12/18/25 and described the mat that was previously in the resident's room as tattered and ripped. CNA #19 stated the mat should have been replaced sooner. During an interview on 12/21/25 at 9:45 A.M., the Director of Nursing (DON) stated she expected staff to report the condition of Resident #3's fall mat with the split and exposed foam because she wanted all equipment to function properly. During an interview on 12/21/25 at 3:16 P.M., the Executive Director (ED) stated she expected staff to notify someone when a fall mat was torn or had exposed foam. 2. During a concurrent observation and interview on 12/21/25 at 11:15 A.M., Maintenance Director (MD) #55 observed the [NAME] Unit shower room and described the shower bench as having cracked vinyl and exposed foam. MD #55 further stated the cushion of the bench needed to be replaced, but no one had reported the condition of the shower bench to him. During a concurrent observation and interview on 12/21/25 at 11:27 A.M., Licensed Practical Nurse (LPN) #15 observed the [NAME] Unit shower room and described the shower bench as torn and tattered. LPN #15 stated she had not been notified of the condition of the shower bench and acknowledged she would not want to sit on it in its current condition. During an interview on 12/22/25 at 1:39 P.M., CNA #31 stated she noticed the shower bench on the [NAME] Unit was worn and had cracked vinyl; however, CNA #31 stated the bench had been in that condition for two years, so she assumed someone else had reported it. She stated she had not personally reported the condition of the shower bench. During an interview on 12/22/25 at 1:06 P.M., the DON stated she expected staff to report any issues with equipment used for residents, such as the tattered and torn shower bench, to the maintenance department for replacement. During an interview on 12/21/25 at 4:04 P.M., the Administrator stated she expected staff to report a shower bench with the torn vinyl or exposed foam. Review of a facility policy titled, Assistive Devices and Equipment, revised 01/2020, revealed device condition- devices and equipment are maintained on schedule and according to manufacturer's instructions. Defective or worn devices are discarded or repaired.

Based on medical record review, staff interview, facility document review, facility policy review, and review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices and Ohio Secretary of State Certification, the facility failed to ensure intravenous (IV) therapy was administered in accordance with professional standards of practice and Ohio state requirements, as evidenced by failure to ensure criteria to determine medical necessity for the provision of IV hydration with micronutrients was established, monitored, and documented and failure to ensure the contracted ancillary provider (IV Therapy Company #1) had the appropriate State of Ohio-required credentials for the provision of such services for three (#82, #39, and #1) of three residents reviewed for IV therapy provided by IV Therapy Company #1. Based on a review of all residents' physician orders, the failed practice had the potential to affect 21 current residents and three discharged residents including but not limited to Resident #14, Resident #26, Resident #56, Resident #64, and Resident #94 received services from IV Therapy Company #1. The facility census was 92.Findings include: 1. Review of an admission Record indicated the facility admitted Resident #82 on 09/16/15. According to the admission Record, the resident had a medical history that included diagnoses of anoxic (absence of oxygen) brain damage, paraplegia (partial or complete paralysis of the legs and lower body), diabetes mellitus (DM), and congestive heart failure (CHF). Review of a quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 09/29/25, revealed Resident #82 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS assessment indicated the resident had intravenous (IV) access, received parenteral (IV) feeding, and received an average fluid intake of 500 cubic centimeters (cc) or less per day via IV or tube feeding. Review of Resident #82 's Care Plan Report, included a focus area initiated 08/22/25, that indicated the resident was participating in IV Therapy Company #1 ' s program to promote IV infusion as evidenced by paraplegia, major depression, and DM. Interventions directed staff to monitor for adverse reactions to IV therapy and if noted, notify the physician, monitor the IV access site for redness, swelling, hot to touch, etc., and report adverse findings to the physician, provide aroma therapy, provide IV therapy as ordered, provide music therapy, and provide a relaxing environment. Review of a provider progress note dated 06/20/25 indicated IV hydration was medically indicated for Resident #82 to support fluid balance and prevent dehydration-related complications in the context of limited oral intake and ongoing risk factors. The note indicated to see the Physician Order Form for IV Hydration Therapy. This form was requested but not provided by the facility for the month of June 2025. Review of Resident #82's June 2025, Documentation Survey Report, revealed the resident's average fluid intake with meals was 573 milliliters (mL) per day. This documentation did not include information as to what the resident received between meals or with medications. The report indicated Resident #82's June 2025 urinary catheter output revealed an average output of 1,258 mL per day. Review of Resident #82's laboratory reports revealed no laboratory testing completed during the month of June 2025. Resident #82's Order Recap Report revealed the following orders for June 2025: - May enter peripheral IV insertion during scheduled infusions one time only for IV infusions until 06/26/2025, enter site insertion in supplementary documentation, ordered 06/25/2025. - Hydration + [and] Skin Infusion - one time (500 milliliters) 0.9% normal saline at 500 milliliters (mL) an hour, (total additive volume 14.4 mL) Vitamin C 5 grams (gm), B Complex (B1-Thiamine 200 milligrams [mg], B2-Riboflavin 4 mg, B3-Niacin 200 mg, B5-Pantothenic Acid 4 mg, B6-Pyridoxine 4 mg), Biotin 10 mg, Zinc 10 mg, B-12 methyl-cobalamin 2 mg intravenous hydration at next scheduled clinic - medically necessary given standard interventions being insufficient to address clinical indications of hydrational deficit one time only for micronutrient hydration therapy until 09/25/2025, one time only for hydration and nutritional wellness secondary to wounds, administration time may vary based on clinic, ordered 06/25/2025. - 72-hour post monitoring evaluation for scheduled infusion every shift for three days and enter a progress note for any signs and symptoms of infection or adverse reactions, ordered 06/26/2025. Review of Resident #82's progress notes revealed a nursing note dated 06/26/25 that indicated a peripheral IV was inserted to the right antecubital (front of the elbow) space using a 24-gauge needle. Pre-infusion vital signs were taken, and the registered nurse (RN) initiated the IV Therapy Company #1's IV therapy micronutrient infusion per provider order. The note indicated the infusion started at 8:10 AM and was completed at 9:15 A.M. Post-infusion vital signs were obtained. The IV was discontinued, and a pressure dressing was applied per protocol. Review of Resident #82's, IV Hydration Resident Risk Screening Tool, signed by the previous Director of Nursing (DON) on 07/20/25, indicated the resident had persistent low fluid intake despite efforts to support adequate oral hydration due to diagnoses of paraplegia, major depression, and diabetes. The standard interventions implemented were to ensure the availability and accessibility of fluids and identify and provide the resident ' s preferred beverage. Conditions present that reduced the resident ' s capacity to maintain adequate fluid balance included difficulty communicating needs, functional/activities of daily living (ADL) impairment, depression or anxiety, malnutrition or at risk for malnutrition, and medications such as diuretics and laxatives. Factors that could be caused by, contribute to, or be complicated by chronic fluid deficit included recent or recurrent urinary tract infection (UTI) or other infection, and new/existing pressure ulcer/chronic wounds. The tool indicated the resident had no special considerations for IV fluid administration. The Physician Order Form: IV Hydration Therapy section of the tool was signed by the physician on 07/21/2025 and included an order for IV hydration for prevention of dehydration as indicated in the assessment above. The orders indicated, Fluid type: Normal Saline 0.9%; Fluid Volume: 500 mL; Infusion rate: 500 mL/hr.; Start peripheral IV; Hydration + [and] B-complex: (B1) 200 mg, (B2) 4 mg, (B5) 4 mg, (B6) 4 mg, (B3) 200 mg; vitamin C 5,000 mg; methyl-cobalamin B12 2,000 mcg [microgram]; zinc 10 mg with skin support (biotin B7 10 mg). Review of Resident #82's July 2025, Documentation Survey Report, indicated the resident ' s average fluid intake with meals was 700 mL per day. The report did not reflect fluid taken between meals or with medications. The report indicated Resident #82 ' s July 2025 urinary catheter output averaged 1,255 mL per day. Review of Resident #82's laboratory reports revealed no laboratory testing completed during the month of July 2025. Review of Resident #82's Order Recap Report revealed the following orders for July 2025: - (IV Therapy Company #1) - May enter peripheral IV insertion during scheduled infusions one time only for IV infusions until 07/24/25, enter site insertion in supplementary documentation, ordered 07/23/25. - Hydration + skin infusion - one time (500 milliliters) 0.9% normal saline at 500 milliliters (mL) an hour, (Total additive volume 14.4 mL) vitamin C 5 gm, B complex (B1-thiamine 200 milligrams, B2-riboflavin 4 mg, B3-niacin 200 mg, B5-pantothenic acid 4 mg, B6-pyridoxine 4 mg), biotin 10 mg, zinc 10 mg, B-12 methyl-cobalamin 2 mg intravenous hydration at next scheduled clinic - medically necessary given standard interventions being insufficient to address clinical indications of hydrational deficit one time only for micronutrient hydration therapy until 09/25/25, one time only for difficulty communicating needs, functional ADL impairment, depression/anxiety, malnutrition, medications such as diuretics and laxatives, etc., ordered 07/23/25. - (IV Therapy Company #1) IV - 72-hour post monitoring evaluation every shift for three days and enter a progress note for any signs and symptoms of infection or adverse reactions, ordered 07/23/25. Review of Resident #82's progress notes revealed a nursing note dated 07/24/2025 that indicated a peripheral IV was inserted to the right hand using a 24-gauge needle. Pre-infusion vital signs were taken, and the RN initiated IV Therapy Company #1 ' s IV therapy micronutrient infusion per provider order. The note indicated the infusion started at 8:10 A.M. and was complete at 9:10 A.M. Post-infusion vital signs were obtained. The IV was discontinued and a pressure dressing was applied per protocol. Review of Resident #82's, IV Hydration Resident Risk Screening Tool, indicated the resident had persistent low fluid intake despite efforts to support adequate oral hydration due to paraplegia, major depression, and diabetic diagnoses. Standard interventions were to ensure the availability and accessibility of fluids and identify and provide the resident's preferred beverage. Conditions present that reduced the resident ' s capacity to maintain adequate fluid balance included difficulty communicating needs, functional/ADL impairment, depression or anxiety, malnutrition or at risk for malnutrition and medications such as diuretics and laxatives. Factors that could be caused by, contribute to, or be complicated by chronic fluid deficit included recent or recurrent UTI or other infection, and new/existing pressure ulcer/chronic wounds. The tool indicated the resident had no special considerations for IV fluid administration. This section was not signed or dated by facility nursing staff. The Physician Order Form: IV Hydration Therapy section of the tool was signed by the nurse practitioner on 08/27/25 and included an order for IV hydration for prevention of dehydration as indicated in the assessment above. The tool indicated the orders as follows: Fluid type: Normal Saline 0.9%; Fluid Volume: 500 mL; Infusion rate: 500 mL/hr.; Start peripheral IV; Hydration + B-complex: (B1) 200 mg, (B2) 4 mg, (B5) 4 mg, (B6) 4 mg, (B3) 200 mg; vitamin C 5,000 mg; methyl-cobalamin B12 2,000 mcg; zinc 10 mg; magnesium chloride 600 mg; calcium chloride 100 mg with skin support (biotin B7 10 mg). Review of Resident #82's August 2025, Documentation Survey Report, indicated the resident ' s average daily fluid intake with meals was 728 ml. The report did not indicate the resident ' s fluid intake between meals or with medications. The report indicated the resident's urinary catheter output averaged 1,241 mL per day. Review of Resident #82's laboratory reports revealed no laboratory testing completed during the month of August 2025. Review of Resident #82's Order Recap Report revealed the following orders for August 2025: - May enter peripheral IV insertion during scheduled infusions one time only for IV infusions until 08/28/2025, enter site insertion in supplementary documentation, ordered 08/28/25. - Hydration + skin infusion-one time (500 milliliters) 0.9% normal saline at 500 mL an hour, (total additive volume 14.4 mL) vitamin C 5 grams (gm), B complex (B1-thiamine 200 milligrams [mg], B2-riboflavin 4 mg, B3-niacin 200 mg, B5-pantothenic acid 4 mg, B6-pyridoxine 4 mg), biotin 10 mg, zinc 10 mg, B-12 methyl-cobalamin 2 mg intravenous hydration at next scheduled clinic - medically necessary given standard interventions being insufficient to address clinical indications of hydrational deficit one time only for micronutrient hydration therapy until 09/25/2025, one time only for hydration and nutritional wellness secondary to wounds, administration time may vary based on clinic, ordered 08/27/25. - (IV Therapy Company #1) IV - 72-hour post monitoring evaluation every shift for three days and enter a progress note for any signs and symptoms of infection or adverse reactions, ordered 08/28/25. Review Resident #82's progress notes revealed a nursing note dated 08/28/25 that indicated a peripheral IV was inserted to the left hand using a 24-gauge needle. Pre-infusion vital signs were taken, and the RN initiated IV Therapy Company #1's IV therapy micronutrient infusion per provider order. The note indicated the infusion started at 9:00 A.M. and was completed at 10:00 A.M. Post-infusion vital signs were obtained. The IV was discontinued and a pressure dressing was applied per protocol. Review of Resident #82's IV Hydration Resident Risk Screening Tool indicated the resident had persistent low fluid intake despite efforts to support adequate oral hydration due to paraplegia, major depression, and diabetic diagnoses. Standard interventions were to ensure the availability and accessibility of fluids and identify and provide the resident ' s preferred beverage. Conditions present that reduced the resident ' s capacity to maintain adequate fluid balance included difficulty communicating needs, functional/ADL impairment, depression or anxiety, malnutrition or at risk for malnutrition, and medications such as diuretics and laxatives. Factors that could be caused by, contribute to, or be complicated by chronic fluid deficit included recent or recurrent UTI or other infection, and new/existing pressure ulcer/chronic wounds. The tool indicated the resident had no special considerations for IV fluid administration. This section of the assessment was not signed or dated by a nurse. The Physician Order Form: IV Hydration Therapy section of the tool was signed by the Nurse Practitioner on 09/22/2025 and included an order for IV hydration for prevention of dehydration as indicated in the assessment above. The orders indicated: Fluid type: Normal Saline 0.9%; Fluid Volume: 500 mL; Infusion rate: 500 mL/hr.; Start peripheral IV; Hydration + B-complex: (B1) 200 mg, (B2) 4 mg, (B5) 4 mg, (B6) 4 mg, (B3) 200 mg; vitamin C 5,000 mg; methyl-cobalamin B12 2,000 mcg; zinc 10 mg; magnesium chloride 600 mg; calcium chloride 100 mg with skin support (biotin B7 10 mg). Review of Resident #82's, Documentation Survey Report, for September 2025 indicated the resident ' s fluid intake with meals averaged 766 mL per day. This did not include fluids taken between meals or with medications. The report indicated the resident ' s urinary catheter output averaged 1,149 mL day. Review of Resident #82's laboratory reports revealed no laboratory testing completed during the month of September 2025. Review of Resident #82's Order Recap Report revealed the following orders for September 2025: - (IV Therapy Company #1) - May enter peripheral IV insertion during scheduled infusions one time only for IV infusions until 09/25/25, enter site insertion in supplementary documentation, ordered 09/24/25. - Hydration + skin Infusion-one time (500 milliliters) 0.9% normal saline at 500 milliliters (mL) an hour, (total additive volume 14.4 mL) vitamin C 5 grams (gm), B complex (B1-thiamine 200 milligrams [mg], B2-riboflavin 4 mg, B3-niacin 200 mg, B5-pantothenic acid 4 mg, B6-pyridoxine 4 mg), biotin 10 mg, zinc 10 mg, B-12 methyl-cobalamin 2 mg intravenous hydration at next scheduled clinic - medically necessary given standard interventions being insufficient to address clinical indications of hydrational deficit one time only for micronutrient hydration therapy until 09/25/25, one time only for hydration and nutritional wellness secondary to wounds, administration time may vary based on clinic, ordered 09/24/25. - There was no order for 72-hour post monitoring evaluation after the infusion in September 2025. Review of Resident #82's progress notes revealed a nursing note dated 09/25/25 that indicated a peripheral IV was inserted to the left wrist using a 24-gauge needle. Pre-infusion vital signs were taken, and the RN initiated IV Therapy Company #1's IV therapy micronutrient infusion per provider order. The note indicated the infusion started at 9:48 AM and was completed at 11:48 AM. Post-infusion vital signs were obtained. The IV was discontinued and a pressure dressing was applied per protocol. During an interview on 12/19/25 at 5:12 P.M., Nurse Practitioner (NP) #45 stated IV Therapy Company #1 had their own protocol, so she was not sure why they changed what Resident #82 was getting. She stated she was minimally involved and that she signed the orders monthly but that was all. 2. Review of the medical record indicated the facility readmitted Resident #39 on 04/10/25. According to the record, the resident had a medical history that included diagnoses of paraplegia (partial or total paralysis of the legs and lower body), chronic hepatitis C, and stage 4 pressure ulcer of the sacral region. Review of a quarterly MDS assessment, with an ARD of 07/01/25, revealed Resident #39 had a BIMS score of 15, which indicated the resident had intact cognition. The MDS assessment indicated that the resident had IV access, received parenteral/IV feeding, and received an average fluid intake of 500 cubic centimeters (cc) or fluid or less per day via IV or tube feeding. Review of Resident #39's, Care Plan Report, did not include a focus area that indicated the resident participated in IV Therapy Company #1 ' s program. Review of Resident #39's progress notes revealed a nurse practitioner ' s note dated 06/19/25 that indicated the resident would be receiving IV hydration with supplemental micronutrients due to a prior medical history of pressure ulcers, a wound to the lower back and pelvis, and neurogenic bladder with frequent UTIs, making the resident susceptible to dehydration. Review of Resident #39's June 2025, Documentation Survey Report, revealed the resident's fluid intake with meals averaged 700 mL per day. This did not include the fluids the resident received between meals or with medications. The report revealed Resident #39's urinary catheter output was not monitored and documented for the month of June 2025. Review of Resident #39's laboratory reports revealed no laboratory testing completed during the month of June 2025. Review of Resident #39's, Order Recap Report, revealed the following orders for June 2025: - May use existing peripherally inserted central catheter (PICC) line during scheduled infusions, one time only for IV infusions until 06/26/25 and enter site insertion in supplementary documentation, ordered 06/25/25. - Hydration + skin infusion-one time (500 milliliters) 0.9% normal saline at 500 mL an hour, (Total additive volume 14.4 mL) vitamin C 5 gm, B complex (B1-thiamine 200 mg, B2-riboflavin 4 mg, B3-niacin 200 mg, B5-pantothenic acid 4 mg, B6-pyridoxine 4 mg), biotin 10 mg, zinc 10 mg, B-12 methyl-cobalamin 2 mg intravenous hydration at next scheduled clinic - medically necessary given standard interventions being insufficient to address clinical indications of hydrational deficit one time only for micronutrient hydration therapy until 06/26/25, one time only for hydration and nutritional wellness secondary to wounds, administration time may vary based on clinic, ordered 06/25/25. - 72-hour post monitoring evaluation for scheduled infusion every shift for three days and enter a progress note for any signs and symptoms of infection or adverse reactions, ordered 06/25/25. Review of Resident #39's progress notes revealed a nursing note dated 06/26/25 that indicated the resident's right upper arm PICC line was accessed and that the RN initiated IV Therapy Company #1 ' s IV therapy micronutrient infusion per provider order. The note indicated pre-infusion vital signs were obtained and the infusion started at 8:05 AM and was completed at 9:00 A.M. Post-infusion vital signs were obtained and the PICC line was de-accessed per protocol. Review of Resident #39's, IV Hydration Resident Risk Screening Tool, signed by the previous DON on 07/20/25, indicated the resident had persistent low fluid intake despite efforts to support adequate oral hydration due to paraplegia, hepatitis C, and a stage 4 wound. Standard interventions were to ensure the availability and accessibility of fluids and identify and provide the resident ' s preferred drink. Conditions present that reduced the resident ' s capacity to maintain adequate fluid balance included functional/ADL impairment. Factors that could be caused by, contribute to, or be complicated by chronic fluid deficit included headaches and new/existing pressure ulcer/chronic wounds. The tool indicated the resident had no special considerations for IV fluid administration. The Physician Order Form: IV Hydration Therapy section of the tool was signed by the physician on 07/21/2025 and included an order for IV hydration for prevention of dehydration, as indicated in the assessment above. The orders indicated: Fluid type: Normal Saline 0.9%; Fluid Volume: 500 mL; Infusion rate: 500 mL/hr.; Start peripheral IV; Hydration + B-complex: (B1) 200 mg, (B2) 4 mg, (B5) 4 mg, (B6) 4 mg, (B3) 200 mg; vitamin C 5,000 mg; methyl-cobalamin B12 2,000 mcg; zinc 10 mg with skin support (biotin B7 10 mg). Review of Resident #39's July 2025, Documentation Survey Report, revealed the resident ' s fluid intake with meals averaged 588 mL per day. This did not include the fluids the resident received between meals or with medications. The report revealed Resident #39's urinary catheter output was not monitored and documented for the month of July 2025. Review of Resident #39's laboratory results dated as completed on 07/21/25 revealed no comprehensive micronutrient panel to measure the resident ' s vitamin and mineral levels. Review Resident #39's Order Recap Report revealed the following orders for July 2025: - May enter peripheral IV insertion during scheduled infusions one time only for IV infusions until 07/24/2025, enter site insertion in supplementary documentation, ordered 07/23/25. - Hydration + Skin Infusion-one time (500 milliliters) 0.9% normal saline at 500 mL an hour, (Total additive volume 14.4 mL) vitamin C 5 gm, B complex (B1-thiamine 200 mg, B2-riboflavin 4 mg, B3-niacin 200 mg, B5-pantothenic acid 4 mg, B6-pyridoxine 4 mg), biotin 10 mg, zinc 10 mg, B-12 methyl-cobalamin 2 mg intravenous hydration at next scheduled clinic - medically necessary given standard interventions being insufficient to address clinical indications of hydrational deficit one time only for micronutrient hydration therapy until 06/26/2025, one time only for functional and ADL impairment, ordered 07/2/325. - 72-hour post monitoring evaluation for scheduled infusion every shift for three days and enter a progress note for any signs and symptoms of infection or adverse reactions, ordered 07/23/25. Review of Resident #39's progress notes revealed an electronic Medication Administration Record (eMAR)-Medication Administration Note dated 07/24/25 that indicated the resident ' s vein was not able to be accessed for IV therapy. Review of Resident #39's progress notes revealed a Nursing Note dated 07/24/25 that indicated a peripheral IV was inserted to the right forearm using a 24-gauge needle. Pre-infusion vital signs were taken, and the RN initiated IV Therapy Company #1 ' s IV therapy micronutrient infusion per provider order. The note indicated the infusion started at 10:10 A.M. and, at 10:25 A.M., the IV site was noted to be infiltrated. The note indicated a second attempt to place a peripheral IV line was unsuccessful and a warm compress and pressure dressing were applied. 3. Review of an admission Record indicated the facility admitted Resident #1 on 08/08/25. According to the admission Record, the resident had a medical history that included diagnoses of diabetes mellitus (DM), hemiplegia (paralysis on one side of the body), major depressive disorder, and epilepsy. Reviwe of an admission MDS assessment, with an ARD of 11/18/25, revealed Resident #1 had a BIMS score of 12, which indicated the resident had moderative cognitive impairment. Review of Resident #1's, Care Plan Report, included a focus area initiated 09/17/25, that indicated the resident was participating in IV Therapy Company #1 ' s program to promote IV infusion as evidenced by recent sepsis, diabetes mellitus, depression, history of urinary tract infection (UTI), history of a stroke, hemiplegia, and epilepsy. Interventions directed staff to monitor adverse reactions to IV therapy and, if noted, notify the physician, monitor the IV access site for redness, swelling, hot to touch, etc., and report adverse findings to the physician, provide IV therapy as ordered, and provide a relaxing environment. Review of Resident #1's, IV Hydration Resident Risk Screening Tool, indicated the resident had persistent low fluid intake despite efforts to support adequate oral hydration due to recent sepsis, diabetes mellitus, depression, history of UTI, history of stroke, hemiplegia, and epilepsy. Standard interventions were to ensure the availability and accessibility of fluids and identify and provide the resident ' s preferred drink. Conditions present that reduced the resident ' s capacity to maintain adequate fluid balance included functional/ADL impairment, malnutrition or at risk for malnutrition and medications such as diuretics and laxatives, psychotropic medications, or polypharmacy (>5 medications). Factors that could be caused by, contribute to, or be complicated by chronic fluid deficit included recent falls or increased fall risk. The tool indicated the resident had no special considerations for IV fluid administration. This section of the assessment was not signed or dated by a nurse. The Physician Order Form: IV Hydration Therapy section of the tool was signed by the Nurse Practitioner on 09/22/2025 and included an order for IV hydration for prevention of dehydration as indicated in the assessment above. The orders indicated: Fluid type: Normal Saline 0.9%; Fluid Volume: 1,000 mL; Infusion rate: 500 mL/hr.; Start peripheral IV; Hydration + B-complex: (B1) 200 mg, (B2) 4 mg, (B5) 4 mg, (B6) 4 mg, (B3) 200 mg; vitamin C 5,000 mg; methyl-cobalamin B12 2,000 mcg; zinc 10 mg. Review of Resident #1's September 2025, Documentation Survey Report, revealed the resident ' s fluid intake with meals averaged 676 mL per day. This did not include the fluids the resident received between meals or with medications. The resident ' s urinary catheter output was not monitored or documented on the form. Review of Resident #1's laboratory report dated as completed 09/24/25 did not include a comprehensive micronutrient panel to measure the resident ' s vitamin and mineral levels. Review of Resident #1's Order Recap Report revealed the following orders for September 2025: - (IV Therapy Company #1) - May enter peripheral IV insertion during scheduled infusions one time only for IV infusions until 09/25/25, enter site insertion in supplementary documentation, ordered 09/24/25. - Hydration + Skin Infusion-one time (1,000 mL) 0.9% normal saline at 500 mL an hour, (total additive volume 13.4 mL) vitamin C 5 grams (gm), B complex (B1-thiamine 200 milligrams [mg], B2-riboflavin 4 mg, B3-niacin 200 mg, B5-pantothenic acid 4 mg, B6-pyridoxine 4 mg), biotin 10 mg, zinc 10 mg, B-12 methyl-cobalamin 2 mg intravenous hydration at next scheduled clinic - medically necessary given standard interventions being insufficient to address clinical indications of hydrational deficit one time only for micronutrient hydration therapy until 09/25/25, one time only for hydration, ordered 09/24/25. - There was no order for 72-hour post monitoring evaluation after the infusion in September 2025. Review of Resident #1's progress notes revealed a nursing note dated 09/25/25 that indicated a peripheral IV was inserted to the left wrist using a 24-gauge needle. Pre-infusion vital signs were taken, and the RN initiated IV Therapy Company #1 ' s IV therapy micronutrient infusion per provider order. The note indicated the infusion started at 8:30 AM and was completed at 10:30 AM. Post-infusion vital signs were obtained. The IV was discontinued and a pressure dressing was applied per protocol. Review of the, IV Therapy Services Agreement, signed by IV Therapy Company #1's Chief Operating Officer and the facility ' s corporate Chief Reimbursement Officer on 04/28/25, revealed IV Therapy Company #1 had not yet filed with the Ohio Secretary of State at the time the contract was signed. Additionally, the name of the IV therapy company on the agreement did not match the company name listed on the Ohio Board of Pharmacy License to Distribute Dangerous Drugs provided by the facility. During an interview on 12/19/25 at 5:12 P.M., Nurse Practitioner (NP) #45 stated IV Therapy Company #1 had their own protocol. She stated she was not sure why they were not doing the program for the facility's residents anymore. She stated she was minimally involved and that she signed the orders monthly but that was all. During an interview on 12/22/25 at 11:03 A.M., Chief Reimbursement Officer (CRO) #70, who signed the contract with IV Therapy Company #1, stated she did not have any information to provide regarding the contract and suggested the surveyor speak to Corporate Nurse Consultant (CNC) #71 in Ohio to get more information. She stated she could not say whether IV Therapy Company #1 was licensed to work in the state of Ohio. During an interview on 12/22/25 at 3:58 P.M., CNC #71 stated IV Therapy Company #1 informed them that they had an IV therapy service they wanted the facilities to start using, so they had the regional consultant go through the charts to determine who would benefit from the services. She stated if the resident had a wound, increased falls, or a change of condition, then a list was sent to the Medical Director or physician, and the physician would determine if the resident would benefit from increased hydration. She stated the order form would be filled out, and the orders placed into the electronic health record system. She stated when the clinic day was set, the physician would document the reasons for the hydration, and then they would have the clinic. She stated the residents were allowed to have three consecutive treatments monthly. She stated the residents signed a consent, and the physician or nurse practitioner would determine what the orders would be and what micronutrients were added, and then they provided monitoring after the treatment. She stated they were no longer providing the services because they were told the services were considered experimental treatment in Ohio. She stated she was not aware of any issues with the contract. During an interview on 12/23/25 at 8:20 A.M. NP #45 stated again that she had minimal involvement with IV Therapy Company #1's program. She stated she never got to see the staff or talk to them about the services and never saw any policies or procedures related to the services. She stated the assessments and orders were already filled out when she received them, and she signed the orders, but that was the extent of her involvement. She stated she did feel the residents would benefit from extra hydration and nutrition but could not say what protocols or criteria were used to make that determination. During an interview on 12/23/25 at 9:24 A.M, the DON stated she did not have any information about IV Therapy Company #1. She stated she did help with obtaining consents for the treatments in September 2025, but she did not fill out the screening or the orders. She stated she was not sure who completed those. She stated she did not know the criteria for determining the necessity for the treatments but did know that there were different standards for different diagnoses, such as a resident with wounds would get different nutrients. Copies of the signed consents for IV Therapy Company #1's services were requested from the facility but were not provided by the end of the survey. During an interview on 12/23/25 at 10:44 A.M., the Administrator stated the facility used IV Therapy Company #1's services to help residents who had wounds and other issues because, depending on what the resident had going on, it could help their healing. She stated she was not familiar with all the details of the program and she was not aware of any issues with t[TRUNCATED]

Based on medical record review, staff interview, facility document review, and review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescribed Practices and Ohio Secretary of State certification, the facility failed to develop intravenous (IV) therapy procedures that were compliant with state requirements and accepted standards of practice. Specifically, the facility failed to ensure IV hydration products with vitamin/mineral additives were provided by a source that had the appropriate state-required credentials and was licensed by the State of Ohio as a Terminal Distributor of Dangerous Drugs (TDDD) (which allows a business entity to purchase, possess, and/or distribute dangerous drugs at a specific location) for three (Residents #82, #39, and #1) of three residents reviewed for IV medications provided by IV Therapy Company #1. Based on a review of all residents' physician orders, the failed practice had the potential to affect 21 current residents and three discharged residents including but not limited to Resident #14, Resident #26, Resident #56, Resident #64, and Resident #94 received services from IV Therapy Company #1. The facility census was 92.Findings include: 1. Review of an admission Record indicated the facility admitted Resident #82 on 09/16/15. According to the admission Record, the resident had a medical history that included diagnoses of anoxic (absence of oxygen) brain damage, paraplegia (partial or complete paralysis of the legs and lower body), diabetes mellitus (DM), and congestive heart failure (CHF). Review of a quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 09/29/25, revealed Resident #82 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS assessment indicated the resident had intravenous (IV) access, received parenteral (IV) feeding, and received an average fluid intake of 500 cubic centimeters (cc) or less per day via IV or tube feeding. Review of Resident #82's Care Plan Report, included a focus area initiated 08/22/25, that indicated the resident was participating in IV Therapy Company #1's program to promote IV infusion as evidenced by paraplegia, major depression, and DM. Interventions directed staff to monitor for adverse reactions to IV therapy and if noted, notify the physician, monitor the IV access site for redness, swelling, hot to touch, etc., and report adverse findings to the physician, provide aroma therapy, provide IV therapy as ordered, provide music therapy, and provide a relaxing environment. Review of a provider progress note dated 06/20/25 indicated IV hydration was medically indicated for Resident #82 to support fluid balance and prevent dehydration-related complications in the context of limited oral intake and ongoing risk factors. The note indicated to see the Physician Order Form for IV Hydration Therapy. This form was requested but not provided by the facility for the month of June 2025. Review of Resident #82's June 2025, Documentation Survey Report, revealed the resident's average fluid intake with meals was 573 milliliters (mL) per day. This documentation did not include information as to what the resident received between meals or with medications. The report indicated Resident #82's June 2025 urinary catheter output revealed an average output of 1,258 mL per day. Review of Resident #82's laboratory reports revealed no laboratory testing completed during the month of June 2025. Resident #82's Order Recap Report revealed the following orders for June 2025: - May enter peripheral IV insertion during scheduled infusions one time only for IV infusions until 06/26/2025, enter site insertion in supplementary documentation, ordered 06/25/2025. - Hydration + [and] Skin Infusion - one time (500 milliliters) 0.9% normal saline at 500 milliliters (mL) an hour, (total additive volume 14.4 mL) Vitamin C 5 grams (gm), B Complex (B1-Thiamine 200 milligrams [mg], B2-Riboflavin 4 mg, B3-Niacin 200 mg, B5-Pantothenic Acid 4 mg, B6-Pyridoxine 4 mg), Biotin 10 mg, Zinc 10 mg, B-12 methyl-cobalamin 2 mg intravenous hydration at next scheduled clinic - medically necessary given standard interventions being insufficient to address clinical indications of hydrational deficit one time only for micronutrient hydration therapy until 09/25/2025, one time only for hydration and nutritional wellness secondary to wounds, administration time may vary based on clinic, ordered 06/25/2025. - 72-hour post monitoring evaluation for scheduled infusion every shift for three days and enter a progress note for any signs and symptoms of infection or adverse reactions, ordered 06/26/2025. Review of Resident #82's progress notes revealed a nursing note dated 06/26/25 that indicated a peripheral IV was inserted to the right antecubital (front of the elbow) space using a 24-gauge needle. Pre-infusion vital signs were taken, and the registered nurse (RN) initiated the IV Therapy Company #1's IV therapy micronutrient infusion per provider order. The note indicated the infusion started at 8:10 AM and was completed at 9:15 A.M. Post-infusion vital signs were obtained. The IV was discontinued, and a pressure dressing was applied per protocol. Review of Resident #82's, IV Hydration Resident Risk Screening Tool, signed by the previous Director of Nursing (DON) on 07/20/25, indicated the resident had persistent low fluid intake despite efforts to support adequate oral hydration due to diagnoses of paraplegia, major depression, and diabetes. The standard interventions implemented were to ensure the availability and accessibility of fluids and identify and provide the resident's preferred beverage. Conditions present that reduced the resident's capacity to maintain adequate fluid balance included difficulty communicating needs, functional/activities of daily living (ADL) impairment, depression or anxiety, malnutrition or at risk for malnutrition, and medications such as diuretics and laxatives. Factors that could be caused by, contribute to, or be complicated by chronic fluid deficit included recent or recurrent urinary tract infection (UTI) or other infection, and new/existing pressure ulcer/chronic wounds. The tool indicated the resident had no special considerations for IV fluid administration. The Physician Order Form: IV Hydration Therapy section of the tool was signed by the physician on 07/21/2025 and included an order for IV hydration for prevention of dehydration as indicated in the assessment above. The orders indicated, Fluid type: Normal Saline 0.9%; Fluid Volume: 500 mL; Infusion rate: 500 mL/hr.; Start peripheral IV; Hydration + [and] B-complex: (B1) 200 mg, (B2) 4 mg, (B5) 4 mg, (B6) 4 mg, (B3) 200 mg; vitamin C 5,000 mg; methyl-cobalamin B12 2,000 mcg [microgram]; zinc 10 mg with skin support (biotin B7 10 mg). Review of Resident #82's July 2025, Documentation Survey Report, indicated the resident's average fluid intake with meals was 700 mL per day. The report did not reflect fluid taken between meals or with medications. The report indicated Resident #82's July 2025 urinary catheter output averaged 1,255 mL per day. Review of Resident #82's laboratory reports revealed no laboratory testing completed during the month of July 2025. Review of Resident #82's Order Recap Report revealed the following orders for July 2025: - (IV Therapy Company #1) - May enter peripheral IV insertion during scheduled infusions one time only for IV infusions until 07/24/25, enter site insertion in supplementary documentation, ordered 07/23/25. - Hydration + skin infusion - one time (500 milliliters) 0.9% normal saline at 500 milliliters (mL) an hour, (Total additive volume 14.4 mL) vitamin C 5 gm, B complex (B1-thiamine 200 milligrams, B2-riboflavin 4 mg, B3-niacin 200 mg, B5-pantothenic acid 4 mg, B6-pyridoxine 4 mg), biotin 10 mg, zinc 10 mg, B-12 methyl-cobalamin 2 mg intravenous hydration at next scheduled clinic - medically necessary given standard interventions being insufficient to address clinical indications of hydrational deficit one time only for micronutrient hydration therapy until 09/25/25, one time only for difficulty communicating needs, functional ADL impairment, depression/anxiety, malnutrition, medications such as diuretics and laxatives, etc., ordered 07/23/25. - (IV Therapy Company #1) IV - 72-hour post monitoring evaluation every shift for three days and enter a progress note for any signs and symptoms of infection or adverse reactions, ordered 07/23/25. Review of Resident #82's progress notes revealed a nursing note dated 07/24/2025 that indicated a peripheral IV was inserted to the right hand using a 24-gauge needle. Pre-infusion vital signs were taken, and the RN initiated IV Therapy Company #1's IV therapy micronutrient infusion per provider order. The note indicated the infusion started at 8:10 A.M. and was complete at 9:10 A.M. Post-infusion vital signs were obtained. The IV was discontinued and a pressure dressing was applied per protocol. Review of Resident #82's, IV Hydration Resident Risk Screening Tool, indicated the resident had persistent low fluid intake despite efforts to support adequate oral hydration due to paraplegia, major depression, and diabetic diagnoses. Standard interventions were to ensure the availability and accessibility of fluids and identify and provide the resident's preferred beverage. Conditions present that reduced the resident's capacity to maintain adequate fluid balance included difficulty communicating needs, functional/ADL impairment, depression or anxiety, malnutrition or at risk for malnutrition and medications such as diuretics and laxatives. Factors that could be caused by, contribute to, or be complicated by chronic fluid deficit included recent or recurrent UTI or other infection, and new/existing pressure ulcer/chronic wounds. The tool indicated the resident had no special considerations for IV fluid administration. This section was not signed or dated by facility nursing staff. The Physician Order Form: IV Hydration Therapy section of the tool was signed by the nurse practitioner on 08/27/25 and included an order for IV hydration for prevention of dehydration as indicated in the assessment above. The tool indicated the orders as follows: Fluid type: Normal Saline 0.9%; Fluid Volume: 500 mL; Infusion rate: 500 mL/hr.; Start peripheral IV; Hydration + B-complex: (B1) 200 mg, (B2) 4 mg, (B5) 4 mg, (B6) 4 mg, (B3) 200 mg; vitamin C 5,000 mg; methyl-cobalamin B12 2,000 mcg; zinc 10 mg; magnesium chloride 600 mg; calcium chloride 100 mg with skin support (biotin B7 10 mg). Review of Resident #82's August 2025, Documentation Survey Report, indicated the resident's average daily fluid intake with meals was 728 ml. The report did not indicate the resident's fluid intake between meals or with medications. The report indicated the resident's urinary catheter output averaged 1,241 mL per day. Review of Resident #82's laboratory reports revealed no laboratory testing completed during the month of August 2025. Review of Resident #82's Order Recap Report revealed the following orders for August 2025: - May enter peripheral IV insertion during scheduled infusions one time only for IV infusions until 08/28/2025, enter site insertion in supplementary documentation, ordered 08/28/25. - Hydration + skin infusion-one time (500 milliliters) 0.9% normal saline at 500 mL an hour, (total additive volume 14.4 mL) vitamin C 5 grams (gm), B complex (B1-thiamine 200 milligrams [mg], B2-riboflavin 4 mg, B3-niacin 200 mg, B5-pantothenic acid 4 mg, B6-pyridoxine 4 mg), biotin 10 mg, zinc 10 mg, B-12 methyl-cobalamin 2 mg intravenous hydration at next scheduled clinic - medically necessary given standard interventions being insufficient to address clinical indications of hydrational deficit one time only for micronutrient hydration therapy until 09/25/2025, one time only for hydration and nutritional wellness secondary to wounds, administration time may vary based on clinic, ordered 08/27/25. - (IV Therapy Company #1) IV - 72-hour post monitoring evaluation every shift for three days and enter a progress note for any signs and symptoms of infection or adverse reactions, ordered 08/28/25. Review Resident #82's progress notes revealed a nursing note dated 08/28/25 that indicated a peripheral IV was inserted to the left hand using a 24-gauge needle. Pre-infusion vital signs were taken, and the RN initiated IV Therapy Company #1's IV therapy micronutrient infusion per provider order. The note indicated the infusion started at 9:00 A.M. and was completed at 10:00 A.M. Post-infusion vital signs were obtained. The IV was discontinued and a pressure dressing was applied per protocol. Review of Resident #82's IV Hydration Resident Risk Screening Tool indicated the resident had persistent low fluid intake despite efforts to support adequate oral hydration due to paraplegia, major depression, and diabetic diagnoses. Standard interventions were to ensure the availability and accessibility of fluids and identify and provide the resident's preferred beverage. Conditions present that reduced the resident's capacity to maintain adequate fluid balance included difficulty communicating needs, functional/ADL impairment, depression or anxiety, malnutrition or at risk for malnutrition, and medications such as diuretics and laxatives. Factors that could be caused by, contribute to, or be complicated by chronic fluid deficit included recent or recurrent UTI or other infection, and new/existing pressure ulcer/chronic wounds. The tool indicated the resident had no special considerations for IV fluid administration. This section of the assessment was not signed or dated by a nurse. The Physician Order Form: IV Hydration Therapy section of the tool was signed by the Nurse Practitioner on 09/22/2025 and included an order for IV hydration for prevention of dehydration as indicated in the assessment above. The orders indicated: Fluid type: Normal Saline 0.9%; Fluid Volume: 500 mL; Infusion rate: 500 mL/hr.; Start peripheral IV; Hydration + B-complex: (B1) 200 mg, (B2) 4 mg, (B5) 4 mg, (B6) 4 mg, (B3) 200 mg; vitamin C 5,000 mg; methyl-cobalamin B12 2,000 mcg; zinc 10 mg; magnesium chloride 600 mg; calcium chloride 100 mg with skin support (biotin B7 10 mg). Review of Resident #82's, Documentation Survey Report, for September 2025 indicated the resident's fluid intake with meals averaged 766 mL per day. This did not include fluids taken between meals or with medications. The report indicated the resident's urinary catheter output averaged 1,149 mL day. Review of Resident #82's laboratory reports revealed no laboratory testing completed during the month of September 2025. Review of Resident #82's Order Recap Report revealed the following orders for September 2025: - (IV Therapy Company #1) - May enter peripheral IV insertion during scheduled infusions one time only for IV infusions until 09/25/25, enter site insertion in supplementary documentation, ordered 09/24/25. - Hydration + skin Infusion-one time (500 milliliters) 0.9% normal saline at 500 milliliters (mL) an hour, (total additive volume 14.4 mL) vitamin C 5 grams (gm), B complex (B1-thiamine 200 milligrams [mg], B2-riboflavin 4 mg, B3-niacin 200 mg, B5-pantothenic acid 4 mg, B6-pyridoxine 4 mg), biotin 10 mg, zinc 10 mg, B-12 methyl-cobalamin 2 mg intravenous hydration at next scheduled clinic - medically necessary given standard interventions being insufficient to address clinical indications of hydrational deficit one time only for micronutrient hydration therapy until 09/25/25, one time only for hydration and nutritional wellness secondary to wounds, administration time may vary based on clinic, ordered 09/24/25. - There was no order for 72-hour post monitoring evaluation after the infusion in September 2025. Review of Resident #82's progress notes revealed a nursing note dated 09/25/25 that indicated a peripheral IV was inserted to the left wrist using a 24-gauge needle. Pre-infusion vital signs were taken, and the RN initiated IV Therapy Company #1's IV therapy micronutrient infusion per provider order. The note indicated the infusion started at 9:48 AM and was completed at 11:48 AM. Post-infusion vital signs were obtained. The IV was discontinued and a pressure dressing was applied per protocol. During an interview on 12/19/25 at 5:12 PM, Nurse Practitioner (NP) #45 stated IV Therapy Company #1 had their own protocol, so she was not sure why they changed what Resident #82 was getting. She stated she was minimally involved and that she signed the orders monthly but that was all. 2. Review of the medical record indicated the facility readmitted Resident #39 on 04/10/25. According to the record, the resident had a medical history that included diagnoses of paraplegia (partial or total paralysis of the legs and lower body), chronic hepatitis C, and stage 4 pressure ulcer of the sacral region. Review of a quarterly MDS assessment, with an ARD of 07/01/25, revealed Resident #39 had a BIMS score of 15, which indicated the resident had intact cognition. The MDS assessment indicated that the resident had IV access, received parenteral/IV feeding, and received an average fluid intake of 500 cubic centimeters (cc) or fluid or less per day via IV or tube feeding. Review of Resident #39's, Care Plan Report, did not include a focus area that indicated the resident participated in IV Therapy Company #1's program. Review of Resident #39's progress notes revealed a nurse practitioner's note dated 06/19/25 that indicated the resident would be receiving IV hydration with supplemental micronutrients due to a prior medical history of pressure ulcers, a wound to the lower back and pelvis, and neurogenic bladder with frequent UTIs, making the resident susceptible to dehydration. Review of Resident #39's June 2025, Documentation Survey Report, revealed the resident's fluid intake with meals averaged 700 mL per day. This did not include the fluids the resident received between meals or with medications. The report revealed Resident #39's urinary catheter output was not monitored and documented for the month of June 2025. Review of Resident #39 laboratory reports revealed no laboratory testing completed during the month of June 2025. Review of Resident #39's, Order Recap Report, revealed the following orders for June 2025: - May use existing peripherally inserted central catheter (PICC) line during scheduled infusions, one time only for IV infusions until 06/26/25 and enter site insertion in supplementary documentation, ordered 06/25/25. - Hydration + skin infusion-one time (500 milliliters) 0.9% normal saline at 500 mL an hour, (Total additive volume 14.4 mL) vitamin C 5 gm, B complex (B1-thiamine 200 mg, B2-riboflavin 4 mg, B3-niacin 200 mg, B5-pantothenic acid 4 mg, B6-pyridoxine 4 mg), biotin 10 mg, zinc 10 mg, B-12 methyl-cobalamin 2 mg intravenous hydration at next scheduled clinic - medically necessary given standard interventions being insufficient to address clinical indications of hydrational deficit one time only for micronutrient hydration therapy until 06/26/25, one time only for hydration and nutritional wellness secondary to wounds, administration time may vary based on clinic, ordered 06/25/25. - 72-hour post monitoring evaluation for scheduled infusion every shift for three days and enter a progress note for any signs and symptoms of infection or adverse reactions, ordered 06/25/25. Review of Resident #39's progress notes revealed a nursing note dated 06/26/25 that indicated the resident's right upper arm PICC line was accessed and that the RN initiated IV Therapy Company #1's IV therapy micronutrient infusion per provider order. The note indicated pre-infusion vital signs were obtained and the infusion started at 8:05 AM and was completed at 9:00 A.M. Post-infusion vital signs were obtained and the PICC line was de-accessed per protocol. Review of Resident #39's, IV Hydration Resident Risk Screening Tool, signed by the previous DON on 07/20/25, indicated the resident had persistent low fluid intake despite efforts to support adequate oral hydration due to paraplegia, hepatitis C, and a stage 4 wound. Standard interventions were to ensure the availability and accessibility of fluids and identify and provide the resident's preferred drink. Conditions present that reduced the resident's capacity to maintain adequate fluid balance included functional/ADL impairment. Factors that could be caused by, contribute to, or be complicated by chronic fluid deficit included headaches and new/existing pressure ulcer/chronic wounds. The tool indicated the resident had no special considerations for IV fluid administration. The Physician Order Form: IV Hydration Therapy section of the tool was signed by the physician on 07/21/2025 and included an order for IV hydration for prevention of dehydration, as indicated in the assessment above. The orders indicated: Fluid type: Normal Saline 0.9%; Fluid Volume: 500 mL; Infusion rate: 500 mL/hr.; Start peripheral IV; Hydration + B-complex: (B1) 200 mg, (B2) 4 mg, (B5) 4 mg, (B6) 4 mg, (B3) 200 mg; vitamin C 5,000 mg; methyl-cobalamin B12 2,000 mcg; zinc 10 mg with skin support (biotin B7 10 mg). Review of Resident #39's July 2025, Documentation Survey Report, revealed the resident's fluid intake with meals averaged 588 mL per day. This did not include the fluids the resident received between meals or with medications. The report revealed Resident #39's urinary catheter output was not monitored and documented for the month of July 2025. Review of Resident #39's laboratory results dated as completed on 07/21/25 revealed no comprehensive micronutrient panel to measure the resident's vitamin and mineral levels. Review Resident #39's Order Recap Report revealed the following orders for July 2025: - May enter peripheral IV insertion during scheduled infusions one time only for IV infusions until 07/24/2025, enter site insertion in supplementary documentation, ordered 07/23/25. - Hydration + Skin Infusion-one time (500 milliliters) 0.9% normal saline at 500 mL an hour, (Total additive volume 14.4 mL) vitamin C 5 gm, B complex (B1-thiamine 200 mg, B2-riboflavin 4 mg, B3-niacin 200 mg, B5-pantothenic acid 4 mg, B6-pyridoxine 4 mg), biotin 10 mg, zinc 10 mg, B-12 methyl-cobalamin 2 mg intravenous hydration at next scheduled clinic - medically necessary given standard interventions being insufficient to address clinical indications of hydrational deficit one time only for micronutrient hydration therapy until 06/26/2025, one time only for functional and ADL impairment, ordered 07/2/325. - 72-hour post monitoring evaluation for scheduled infusion every shift for three days and enter a progress note for any signs and symptoms of infection or adverse reactions, ordered 07/23/25. Review of Resident #39's progress notes revealed an electronic Medication Administration Record (eMAR)-Medication Administration Note dated 07/24/25 that indicated the resident's vein was not able to be accessed for IV therapy. Review of Resident #39's progress notes revealed a Nursing Note dated 07/24/25 that indicated a peripheral IV was inserted to the right forearm using a 24-gauge needle. Pre-infusion vital signs were taken, and the RN initiated IV Therapy Company #1's IV therapy micronutrient infusion per provider order. The note indicated the infusion started at 10:10 A.M. and, at 10:25 A.M., the IV site was noted to be infiltrated. The note indicated a second attempt to place a peripheral IV line was unsuccessful and a warm compress and pressure dressing were applied. 3. Review of an admission Record indicated the facility admitted Resident #1 on 08/08/25. According to the admission Record, the resident had a medical history that included diagnoses of diabetes mellitus (DM), hemiplegia (paralysis on one side of the body), major depressive disorder, and epilepsy. Reviwe of an admission MDS assessment, with an ARD of 11/18/25, revealed Resident #1 had a BIMS score of 12, which indicated the resident had moderative cognitive impairment. Review of Resident #1's, Care Plan Report, included a focus area initiated 09/17/25, that indicated the resident was participating in IV Therapy Company #1's program to promote IV infusion as evidenced by recent sepsis, diabetes mellitus, depression, history of urinary tract infection (UTI), history of a stroke, hemiplegia, and epilepsy. Interventions directed staff to monitor adverse reactions to IV therapy and, if noted, notify the physician, monitor the IV access site for redness, swelling, hot to touch, etc., and report adverse findings to the physician, provide IV therapy as ordered, and provide a relaxing environment. Review of Resident #1's, IV Hydration Resident Risk Screening Tool, indicated the resident had persistent low fluid intake despite efforts to support adequate oral hydration due to recent sepsis, diabetes mellitus, depression, history of UTI, history of stroke, hemiplegia, and epilepsy. Standard interventions were to ensure the availability and accessibility of fluids and identify and provide the resident's preferred drink. Conditions present that reduced the resident's capacity to maintain adequate fluid balance included functional/ADL impairment, malnutrition or at risk for malnutrition and medications such as diuretics and laxatives, psychotropic medications, or polypharmacy (>5 medications). Factors that could be caused by, contribute to, or be complicated by chronic fluid deficit included recent falls or increased fall risk. The tool indicated the resident had no special considerations for IV fluid administration. This section of the assessment was not signed or dated by a nurse. The Physician Order Form: IV Hydration Therapy section of the tool was signed by the Nurse Practitioner on 09/22/2025 and included an order for IV hydration for prevention of dehydration as indicated in the assessment above. The orders indicated: Fluid type: Normal Saline 0.9%; Fluid Volume: 1,000 mL; Infusion rate: 500 mL/hr.; Start peripheral IV; Hydration + B-complex: (B1) 200 mg, (B2) 4 mg, (B5) 4 mg, (B6) 4 mg, (B3) 200 mg; vitamin C 5,000 mg; methyl-cobalamin B12 2,000 mcg; zinc 10 mg. Review of Resident #1's September 2025, Documentation Survey Report, revealed the resident's fluid intake with meals averaged 676 mL per day. This did not include the fluids the resident received between meals or with medications. The resident's urinary catheter output was not monitored or documented on the form. Review of Resident #1's laboratory report dated as completed 09/24/25 did not include a comprehensive micronutrient panel to measure the resident's vitamin and mineral levels. Review of Resident #1's Order Recap Report revealed the following orders for September 2025: - (IV Therapy Company #1) - May enter peripheral IV insertion during scheduled infusions one time only for IV infusions until 09/25/25, enter site insertion in supplementary documentation, ordered 09/24/25. - Hydration + Skin Infusion-one time (1,000 mL) 0.9% normal saline at 500 mL an hour, (total additive volume 13.4 mL) vitamin C 5 grams (gm), B complex (B1-thiamine 200 milligrams [mg], B2-riboflavin 4 mg, B3-niacin 200 mg, B5-pantothenic acid 4 mg, B6-pyridoxine 4 mg), biotin 10 mg, zinc 10 mg, B-12 methyl-cobalamin 2 mg intravenous hydration at next scheduled clinic - medically necessary given standard interventions being insufficient to address clinical indications of hydrational deficit one time only for micronutrient hydration therapy until 09/25/25, one time only for hydration, ordered 09/24/25. - There was no order for 72-hour post monitoring evaluation after the infusion in September 2025. Review of Resident #1's progress notes revealed a nursing note dated 09/25/25 that indicated a peripheral IV was inserted to the left wrist using a 24-gauge needle. Pre-infusion vital signs were taken, and the RN initiated IV Therapy Company #1's IV therapy micronutrient infusion per provider order. The note indicated the infusion started at 8:30 AM and was completed at 10:30 AM. Post-infusion vital signs were obtained. The IV was discontinued and a pressure dressing was applied per protocol. Review of the, IV Therapy Services Agreement, signed by IV Therapy Company #1's Chief Operating Officer (#71) and the facility's corporate Chief Reimbursement Officer (#70) on 04/28/25, revealed IV Therapy Company #1 had not yet filed with the Ohio Secretary of State at the time the contract was signed. Additionally, the name of the IV therapy company on the agreement did not match the company name listed on the Ohio Board of Pharmacy License to Distribute Dangerous Drugs provided by the facility.During an interview on 12/22/25 at 11:03 A.M., Chief Reimbursement Officer (CRO) #70, who signed the contract with IV Therapy Company #1, stated she did not have any information to provide regarding the contract and suggested the surveyor speak to Corporate Nurse Consultant (CNC) #71 in Ohio to get more information. She stated she could not say whether IV Therapy Company #1 was licensed to work in the state of Ohio. During an interview on 12/22/25 at 3:58 P.M., CNC #71 stated IV Therapy Company #1 informed them that they had an IV therapy service they wanted the facilities to start using, so they had the regional consultant go through the charts to determine who would benefit from the services. She stated they were no longer providing the services because they were told it was considered experimental treatment in Ohio. She stated she was not aware of any issues with the contract. During an interview on 12/23/25 at 8:20 A.M., Nurse Practitioner (NP) #45 stated that she had minimal involvement with IV Therapy Company #1's program. She stated she never got to see the staff or talk to them about it and never saw any policies or procedures. She stated the assessments and orders were already filled out when she received them, and she signed the orders, but that was the extent of her involvement. During an interview on 12/23/25 at 9:24 A.M., the Director of Nursing (DON) stated she did not have any information about IV Therapy Company #1's program. She stated she did help with obtaining consents for the treatments in September, but she did not fill out the screening or the orders. She stated she was not sure who completed those. She stated she did not know the criteria for determining the necessity for the treatments but did know that there were different standards for different diagnoses, such as a resident with wounds would get different nutrients. During an interview on 12/23/25 at 10:44 A.M., the Administrator stated the facility used IV Therapy Company #1's services to help residents who had wounds and other issues because, depending on what the resident had going on, it could help their healing. She stated she was not familiar with all the details of the program. She stated she was not aware of any issues with the contract and was not aware of the issues with the company's failure to provide the appropriate certification documentation. Review of the State of Ohio Terminal Distributor Licensure of Prescriber Practices document located at https://www.pharmacy.ohio.gov/ and dated 08/24/2023, indicated, A Terminal Distributor of Dangerous Drugs (TDDD) license allows a business entity to purchase, possess, and/or distribute dangerous drugs at a specific location. Terminal distributors of dangerous drugs include, but are not limited to, hospitals, pharmacies, EMS [Emergency Medical Services] organizations, laboratories, nursing homes, and prescriber practices. Distribution includes the administration of drugs on-site to patients as well as providing medications to patients to take away from the facility for later use. The document also specified, Dangerous drugs are defined in the Ohio Revised Code [ORC] as any drug that meets any of the following: 1. Requires a prescription; 2. Bears on the label a Federal Legend (Rx [prescription] Only or Caution: Federal law prohibits dispensing without a prescription); 3. Is intended for injection into the human body; or 4. Any drug that is a biological product as defined in section 3715.01 of the Revised Code. The document indicated, ORC 4729.51 states that no licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor shall sell dangerous drugs to anyone ot[TRUNCATED]

Based on observation, interview, and facility document and policy review, the facility failed to ensure expired medications were discarded. In addition, the facility failed to ensure a thermometer was available to monitor the temperatures of one of two medication refrigerators and the facility failed to ensure staff monitored the temperatures of two of two medication refrigerators daily. This had the potential to affect all residents residing on the [NAME] and Elm units. The facility was census was 92. An observation of the [NAME] Unit medication room on 12/16/2025 at 10:40 A.M. revealed 25 expired heparin lock flush solutions 50 United States Pharmacopoeia (USP) per 5 milliliters (ml); 12 had expiration dates of 07/2022, nine had expiration dates of 04/2023, and four had expiration dates of 03/2023. All items were unopened but available for use during the observation. Additional observation of the [NAME] Unit medication refrigerator on 12/16/2025 at 11:00 A.M. revealed there was no thermometer available to monitor the medication refrigerator temperatures. The following medications were observed stored in the medication refrigerator: nine Lantus SoloStar 100 units/ml flex pens, nine insulin aspart 100 units/ml flex pens, four Bonsity (medication to treat osteoporosis) injection pens, three Trulicity (an injectable diabetic medication) 0.75 milligram (mg)/0.5 ml flex pens, and five Basaglar (a type of long-acting insulin) 100 units/ml flex pens. An observation of the medication cart located on the Elm Unit on 12/16/2025 at 11:25 AM revealed one house-stock tube of Solosite wound gel that expired on 09/01/2025, one enema saline laxative box that expired 11/2025, and one zinc oxide ointment 20 percent (%) that expired 10/2025. Review of the 11/2025 Medication Refrigerator Temperature Log for the [NAME] Unit specified, to be documented every shift. The log revealed the temperature was documented as checked on 11/08/2025 at 8:00 A.M. and 11/09/2025 at 9:00 A.M. The 12/2025 Medication Refrigerator Temperature Log for the [NAME] Unit contained no documented temperature monitoring for the timeframe from 12/01/2025 through 12/15/2025. The 11/2025 Medication Refrigerator Temperature Log for the Elm Unit revealed staff documented temperature monitoring on 11/01/2025 through 11/19/2025; however, the document revealed there was no documentation of temperature monitoring for the timeframe from 11/20/2025 through 11/30/2025. The 12/2025 Medication Refrigerator Temperature Log for the Elm Unit revealed there was no documentation of temperature monitoring for the timeframe from 12/01/2025 through 12/15/2025 or 12/18/2025 through 12/23/2025. During an interview on 12/16/2025 at 11:10 A.M., Licensed Practical Nurse (LPN) #1 stated the night shift was responsible for checking the medication refrigerators nightly to ensure the medication refrigerators contained a thermometer and to document the temperatures on the temperature logs. She stated all nurses were responsible for monitoring for expired medications. During an interview on 12/16/2025 at 3:55 P.M., the Director of Nursing (DON) stated the night shift nurses were responsible for checking the medication refrigerator temperatures and documenting on the logs each day. She further stated each night, staff should check to ensure a thermometer was located inside the medication refrigerators. The DON stated she was unsure whether staff were trained on who was responsible for checking the medication refrigerators and medication rooms for expired items. During an interview on 12/18/2025 at 7:35 A.M., LPN #33 stated the responsibility to check the medication refrigerators had previously been a joint effort shared by the dayshift and nightshift nurses; however, she was recently notified that night shift nurses would be responsible for the monitoring. Review of a facility policy titled, Medication Labeling and Storage, revised 02/2023, revealed , the facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls and the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. The policy continues to read, if the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

Based on medical record review, staff interview, and review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, the facility's governing body failed to ensure a contracted intravenous (IV) therapy provider (IV Therapy Company #1) had the appropriate State of Ohio-required credentials for the provision of services for three (Resident #82, #39, and #01) of three sample residents reviewed for services provided by IV Therapy Company #1. Based on review of physician orders, 21 current facility residents and three discharged residents including but not limited to Resident #14, Resident #26, Resident #56, Resident #64, and Resident #94 received services from IV Therapy Company #1. The facility census was 92.Findings include: 1. An admission record indicated the facility admitted Resident #82 on 09/16/2015. According to the admission record, the resident had a medical history that included diagnoses of anoxic (absence of oxygen) brain damage, paraplegia (partial or complete paralysis of the legs and lower body), diabetes mellitus, and congestive heart failure. Review of Resident #82's order recap reports dated June 2025 through September 2025 included orders for peripheral IV insertion and scheduled infusions of IV hydration with vitamins and minerals per the contracted IV hydration company as follows: - June 2025: May enter peripheral IV insertion during scheduled infusions one time only for IV infusions until 06/26/2025, hydration skin infusion - one time (500 milliliters) 0.9% normal saline at 500 milliliters (ml) an hour, (total additive volume 14.4 ml) vitamin C 5 grams (gm), B complex (B1-thiamine 200 milligrams [mg], B2-riboflavin 4 mg, B3-niacin 200 mg, B5-pantothenic acid 4 mg, B6-pyridoxine 4 mg), biotin 10 mg, zinc 10 mg, B-12 methyl-cobalamin 2 mg intravenous hydration at next scheduled clinic. - July 2025: May enter peripheral IV insertion during scheduled infusions one time only for IV infusions until 07/24/2025. Hydration skin infusion - one time (500 milliliters) 0.9% normal saline at 500 milliliters (mL) an hour, (total additive volume 14.4 mL) vitamin C 5 gm, B complex (B1-thiamine 200 mg, B2-riboflavin 4 mg, B3-niacin 200 mg, B5-pantothenic acid 4 mg, B6-pyridoxine 4 mg), biotin 10 mg, zinc 10 mg, B-12 methyl-cobalamin 2 mg intravenous hydration at next scheduled clinic. - August 2025: May enter peripheral IV insertion during scheduled infusions one time only for IV infusions until 08/28/2025. Hydration skin infusion-one time (500 milliliters) 0.9% normal saline at 500 mL an hour, (total additive volume 14.4 mL) vitamin C 5 grams (gm), B complex (B1-thiamine 200 mg, B2-riboflavin 4 mg, B3-niacin 200 mg, B5-pantothenic acid 4 mg, B6-pyridoxine 4 mg), biotin 10 mg, zinc 10 mg, B-12 methyl-cobalamin 2 mg intravenous hydration at next scheduled clinic. - September 2025: May enter peripheral IV insertion during scheduled infusions one time only for IV infusions until 09/25/2025. Hydration skin infusion-one time (500 milliliters) 0.9% normal saline at 500 milliliters (mL) an hour, (total additive volume 14.4 mL) vitamin C 5 grams (gm), B complex (B1-thiamine 200 mg, B2-riboflavin 4 mg, B3-niacin 200 mg, B5-pantothenic acid 4 mg, B6-pyridoxine 4 mg), biotin 10 mg, zinc 10 mg, B-12 methyl-cobalamin 2 mg intravenous hydration at next scheduled clinic. 2. Review of the admission record indicated the facility readmitted Resident #39 on 04/10/2025. According to the admission record, the resident had a medical history that included diagnoses of paraplegia (partial or total paralysis of the legs and lower body), chronic hepatitis C, and stage 4 pressure ulcer of the sacral region. Review of Resident #39's order recap reports dated June 2025 and July 2025 included orders for scheduled infusions of IV hydration with vitamins and minerals per the contracted IV hydration company as follows: - June 2025: May use existing peripherally inserted central catheter (PICC) line during scheduled infusions, one time only for IV infusions until 06/26/2025. Hydration skin infusion-one time (500 milliliters) 0.9% normal saline at 500 milliliters per hour (mL/hr), (total additive volume 14.4 mls) vitamin C 5 gm, B complex (B1-thiamine 200 mg, B2-riboflavin 4 mg, B3-niacin 200 mg, B5-pantothenic acid 4 mg, B6-pyridoxine 4 mg), biotin 10 mg, zinc 10 mg, B-12 methyl-cobalamin 2 mg intravenous hydration at next scheduled clinic. - July 2025: May enter peripheral IV insertion during scheduled infusions one time only for IV infusions until 07/24/2025. Hydration skin infusion-one time (500 milliliters) 0.9% normal saline at 500 mL/hr, (total additive volume 14.4 mL) vitamin C 5 gm, B complex (B1-thiamine 200 mg, B2-riboflavin 4 mg, B3-niacin 200 mg, B5-pantothenic acid 4 mg, B6-pyridoxine 4 mg), biotin 10 mg, zinc 10 mg, B-12 methyl-cobalamin 2 mg intravenous hydration at next scheduled clinic. Review of Resident #39's progress notes revealed a nursing note dated 07/24/2025 that indicated a peripheral IV site was obtained to the right forearm using a 24-gauge needle. Pre-infusion vital signs were taken, and the registered nurse (RN) initiated the IV therapy micronutrient infusion per provider order. The note indicated the infusion started at 10:10 A.M. and at 10:25 A.M., the IV site was noted to be infiltrated. The note indicated a second attempt to place a peripheral IV line was unsuccessful and a warm compress and pressure dressing were applied. 3. Review of the admission record indicated the facility admitted Resident #01 on 08/08/2025. According to the admission record, the resident had a medical history that included diagnoses of diabetes mellitus, hemiplegia (paralysis on one side of the body), major depressive disorder, and epilepsy. Review of Resident #01's order recap reports dated for September 2025 revealed orders for insertion of a peripheral IV and scheduled infusion of IV hydration with vitamins and minerals per the contracted IV hydration company as follows: - May enter peripheral IV insertion during scheduled infusions one time only for IV infusions until 09/25/2025. Hydration skin infusion - one time (1,000 mL) 0.9% normal saline at 500 mL/hr, (Total additive volume 13.4 mL) vitamin C 5 grams (gm), B complex (B1-thiamine 200 milligrams (mg), B2-riboflavin 4 mg, B3-niacin 200 mg, B5-pantothenic acid 4 mg, B6-pyridoxine 4 mg), biotin 10 mg, zinc 10 mg, B-12 methyl-cobalamin 2 mg intravenous hydration at next scheduled clinic. The State of Ohio Terminal Distributor Licensure of Prescriber Practices document located at https://www.pharmacy.ohio.gov/ and dated 08/24/2023, indicated, A Terminal Distributor of Dangerous Drugs (TDDD) license allows a business entity to purchase, possess, and/or distribute dangerous drugs at a specific location. Terminal distributors of dangerous drugs include, but are not limited to, hospitals, pharmacies, EMS [Emergency Medical Services] organizations, laboratories, nursing homes, and prescriber practices. Distribution includes the administration of drugs on-site to patients as well as providing medications to patients to take away from the facility for later use. The document also specified, Dangerous drugs are defined in the Ohio Revised Code [ORC] as any drug that meets any of the following: 1. Requires a prescription; 2. Bears on the label a Federal Legend (Rx [prescription] Only or Caution: Federal law prohibits dispensing without a prescription); 3. Is intended for injection into the human body; or 4. Any drug that is a biological product as defined in section 3715.01 of the Revised Code. The document indicated, ORC 4729.51 states that no licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor shall sell dangerous drugs to anyone other than the following: (1) a licensed terminal distributor of dangerous drugs; (2) Any person exempt from licensure as a terminal distributor of dangerous drugs under section 4729.541 of the Revised Code; (3) a licensed manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor; or (4) A terminal distributor, manufacturer, outsourcing facility, third-party logistics provider, repackager, or wholesale distributor that is located in another state, is not engaged in the sale of dangerous drugs within this state, and is actively licensed to engage in the sale of dangerous drugs by the state in which the distributor conducts business. The document listed several scenarios that would be considered exemptions from the requirements, then indicated, The exemptions above DO NOT apply to the following: Any prescriber practice that engages in drug compounding [customized preparation of medications by combining, mixing, or altering ingredients to accommodate the specific needs of a patient], including hazardous drug compounding. Review of the IV Therapy Services Agreement, signed by IV Therapy Company #1 ' s Chief Operating Officer and the facility ' s corporate Chief Reimbursement Officer on 04/28/2025, revealed IV Therapy Company #1 had not yet filed with the Ohio Secretary of State at the time the contract was signed. Additionally, the name of the IV therapy company on the agreement did not match the company name listed on the Ohio Board of Pharmacy License to Distribute Dangerous Drugs provided by the facility. The facility provided two different certificates from the Ohio Secretary of State with documentation of Articles of Organization for a Domestic Limited Liability Company. Neither certificate matched the name of the IV therapy company listed on the IV Therapy Services Agreement between the facility and IV Therapy Company #1.During an interview on 12/22/2025 at 11:03 A.M., the Chief Reimbursement Officer (CRO) who signed the contract with IV Therapy Company #1, stated she did not have any information to provide regarding the contract and suggested the surveyor speak to the Corporate Nurse Consultant (CNC) in Ohio to get more information. She stated she could not say whether the company was licensed to work in the state of Ohio. During an interview on 12/22/2025 at 3:58 P.M., the CNC stated IV Therapy Company #1 informed them that they had an IV therapy service they wanted the facilities to start using, so they had the Regional Consultant go through the charts to determine who would benefit from the services. She stated they were no longer providing the services because they were told it was considered experimental treatment in Ohio. She stated she was not aware of any issues with the contract. During an interview on 12/23/2025 at 10:44 AM, the Administrator stated she was not familiar with all the details of IV Therapy Company #1's program and was not aware of the issues with the contract. She stated she was also not aware of the issues with the company's failure to provide the appropriate certification documentation. A copy of the facility's governing body policy was requested from the Administrator on 12/22/2025 but was not provided.

Based on medical record review, observation, and interview, the facility failed to ensure staff did not discard used towels on the shower room floor or designate bath/shower items for individual resident use in one (Willow Unit) of two shower rooms observed. In addition, the facility failed to store respiratory equipment properly when not in use. This affected two (Resident #06 and #37) of four residents reviewed for respiratory care. The facility census was 92.Findings Included:1. During an observation of the [NAME] Unit shower room on 12/19/25 at 9:12 A.M., multiple dirty towels were observed on the floor, and large bottles of shower supplies and brushes were not designated for individual resident use. During an interview on 12/19/25 at 10:32 A.M., Housekeeper #05 stated the Certified Nursing Assistants (CNAs) were responsible for cleaning the shower rooms between residents; however, Housekeeper #05 stated she cleaned the shower room daily. She stated when towels were left on the floor, she picked them up before she cleaned the shower room. Housekeeper #05 stated any unlabeled shower items, such as soaps, deodorants, and shampoo, were placed in the cabinet in the shower room and she returned labeled items to the correct residents' rooms. During a concurrent observation and interview on 12/21/25 at 11:21 A.M., CNA #30 stated she had not utilized the shower room during the current week. CNA #30 then observed the shower room and stated she was unsure to whom the two unlabeled hairbrushes belonged. CNA #30 stated all the bottles of shower products labeled with the name of the unit were used by the CNAs for all of the residents. CNA #30 stated she was not sure which resident the unlabeled shower items belonged to and stated she had been taught that using the same soaps, shampoos, body washes, deodorants, and hairbrushes on multiple residents posed an infection control concern. During a concurrent observation and interview on 12/21/25 at 11:27 A.M., Licensed Practical Nurse (LPN) #15 observed the [NAME] Unit shower room and stated she had no idea who the unlabeled hairbrushes belonged to and she was unable to verify if the brushes had been used for more than one resident. LPN #15 stated the facility expected each resident to have their own bath supplies labeled with their name. LPN #15 stated several residents using the same bottles of shower/bath supplies was an infection control concern. LPN #15 also verified there was a towel on the floor and stated the last person that used the shower room should not have thrown the towel on the floor. During an interview on 12/22/25 at 1:39 P.M., CNA #31 stated most of the residents she was assigned to care for could shower themselves, but she did go in the shower room to set up the shower and turn the water on. CNA #31 stated she had noticed all the bottles of bath accessories and the brush and tried to move them into a cabinet. She stated that staff were always throwing towels on the floor and leaving them and she would pick them up. During an interview on 12/22/25 at 1:06 P.M., the Director of Nursing (DON) stated she expected each resident to have their own bottle of body wash, deodorant, shampoo, and their own hairbrush labeled with their name. During an interview on 12/21/25 at 4:04 P.M., the Administrator stated items in the shower room should be labeled with a resident's name. The Administrator stated if all residents used the same deodorant, hairbrush, or body wash it could spread infection. 2. Review of the medical record revealed the facility admitted Resident #06 on 10/28/22. Diagnoses included persistent vegetative state (brain injury where the patient may seem awake but shows no signs of awareness to self or surroundings), chronic obstructive pulmonary disease (COPD), chronic respiratory failure with tracheostomy (an opening in the neck to facilitate breathing) status. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/15/25, revealed Resident #06 was in a persistent vegetative state with no discernible consciousness. The MDS indicated the resident received oxygen therapy, suctioning, and tracheostomy care. Review of Resident #06's Care Plan Report included a focus area initiated 12/10/24 and revised 07/21/25, indicating the resident had a potential for respiratory infection. Review of Resident #06's physician's orders included an order dated 02/27/25 for albuterol sulfate 0.083 percent (%) nebulization solution 2.5 milligrams (mg)/3 milliliters (mL) via nebulizer every six hours and an order dated 07/18/24 for sodium chloride 3% (4 mL) via nebulizer every 12 hours. Review of Resident #06's December 2025 Medication Administration Record (MAR) revealed the resident was scheduled to receive the albuterol sulfate every six hours at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M. and the sodium chloride every 12 hours at 6:00 A.M. and 6:00 P.M. During observations on 12/15/25 at 11:15 A.M., 12/16/25 at 9:36 A.M., 12/17/25 at 2:47 P.M., 12/18/25 at 8:45 A.M. and 12:36 P.M., and 12/19/25 at 11:35 A.M., revealed a nebulizer machine on Resident #06's over-the-bed table with the medication cannister and connectors lying on top of the table not stored in a bag. During an interview on 12/19/25 at 1:26 P.M., Licensed Practical Nurse (LPN) #02 stated nebulizer equipment should be stored in a plastic bag when not in use. She said there was not a plastic bag in the room, and she meant to get one to put the resident's nebulizer equipment in but got busy with something else and forgot. During an interview on 12/23/25 at 9:24 A.M., the DON stated respiratory equipment should be covered when not in use. She stated the nurses should have covered the nebulizer equipment and not set it on the table for infection control reasons. During an interview on 12/23/25 at 10:44 A.M., the Administrator stated respiratory equipment should be stored in a bag when not in use, and she expected Resident #06's nebulizer equipment to be stored properly. 3. Review of the medical record revealed the facility admitted Resident #37 on 06/19/23. Diagnoses included chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, and moderate persistent asthma. Review of a quarterly MDS, with an ARD of 11/10/2025 revealed Resident #37 had a Brief Interview for Mental Status (BIMS) score of seven, which indicated the resident had severe cognitive impairment. Review of Resident #37's Care Plan Report included a focus area initiated 07/05/24, indicating the resident had a history of altered respiratory status related to COPD, asthma, congestive heart failure (CHF), history of smoking, and obstructive sleep apnea, and use of a continuous positive airway pressure (CPAP) machine. An observation on 12/15/25 at 12:01 P.M. , revealed Resident #37's CPAP mask was not stored in a plastic bag. An observation on 12/20/25 at 1:30 P.M. revealed Resident #37's CPAP mask was lying on the resident's dresser. The mask was not stored in a plastic bag. An observation on 12/21/25 at 1:22 P.M. revealed Resident #37's CPAP mask was lying on the resident's dresser and the mask was not stored in a plastic bag. During an interview on 12/21/25 at 1:30 P.M., CNA #29 verified he just placed CPAP masks on top of the dresser when they were not in use. During an interview on 12/22/25 at 1:55 P.M. CNA #31 verified CPAP masks were to be stored in a plastic bag when not in use. During an interview on 12/21/2025 at 1:39 P.M., LPN # 10 stated CPAP masks should be stored inside a plastic bag when not in use. During an interview on 12/22/25 at 6:10 P.M., the DON stated the facility did not have a policy for storage of CPAP masks. The DON stated she expected staff to store CPAP masks in a plastic bag and not on top of a dresser or in a drawer. During an interview on 12/21/25 at 2:54 P.M., the Administrator stated she expected staff to store CPAP masks in a bag when not in use.

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure residents were taken to outside appointments when scheduled. This affected one (#98) of six residents reviewed for medical appointments. The census was 92.Findings include: Review of a medical record revealed the facility admitted Resident #98 on 07/09/25 and discharged the resident on 08/17/25. Diagnoses included unspecified paraplegia (paralysis to legs/lower body), autonomic dysreflexia (abnormal overreaction of nervous system to painful sensory input), neuromuscular dysfunction of the bladder, anxiety disorder, chronic pain syndrome, and recurrent major depressive disorder. Review of an admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 07/16/25, revealed Resident #98 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS assessment indicated the resident often needed someone to help when reading instructions, pamphlets, or other written material from the physician or pharmacy. The MDS assessment revealed Resident #98 required partial assistance from another person when planning regular tasks such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury. The MDS assessment revealed Resident #98 used a motorized wheelchair and had functional limitation in range of motion to both lower extremities. The MDS assessment indicated Resident #98 was dependent on staff for all aspects of mobility. Review of Resident #98's care plan report included a focus area, initiated 07/10/25, indicated the resident wanted to remain in the facility permanently. Interventions directed staff to arrange transportation as needed to medical appointments, initiated 07/10/25. Review of Resident #98's hospital continuity of care form dated 07/09/25, indicated the resident required stretcher transportation due to being bedbound. The form indicated Resident #98 was discharged from the hospital with two appointments scheduled, on 07/14/25 and 09/30/25. The form indicated the facility should call the orthopedic surgery office to schedule an appointment. Review of a prescriber-written order, dated 07/11/25 at 2:37 P.M., revealed an order to refer Resident #98 to physical medicine and rehabilitation with instructions to, Please arrange transportation. Registered Nurse (RN) #6 was interviewed on 12/18/25 at 3:23 P.M. and stated when a resident was admitted with appointments already made, she faxed the appointment information to the transportation manager and the transportation manager handled everything from there. RN #6 stated if a resident was admitted with orders to schedule an appointment, the admitting nurse was responsible for scheduling the appointment, and then the same process of faxing the appointment information to the transportation manager was followed. RN #6 stated there had been conflicts between what the nurse scheduled and what the transport manager scheduled, causing residents to miss appointments or resulting in appointments that needed to be rescheduled. RN #6 stated when transportation was scheduled, the transportation manager sent a fax to the nurse's station with the transportation information. RN #6 stated two different people setting up appointments and transportation caused residents to miss appointments. Transportation Coordinator (TC) #62 was interviewed on 12/20/25 at 12:42 P.M. and stated she was not responsible for scheduling appointments and was only responsible for scheduling transportation. TC #62 stated nurses were responsible for scheduling appointments, and after the appointment was made, the nurse sent an Appointment Communication sheet that included the resident's name, the location of the appointment, the date and time of the appointment, and who was the payor source for transportation. TC #62 stated she used the information to make transportation arrangements. TC #62 stated when transportation arrangements had been made, she faxed the information back to the nurse to be placed in a log at the nurse's station. TC #62 stated it was up to the nursing staff to make sure the resident was ready for the appointment; she added that while transportation showed up, the residents sometimes refused to get out of bed or refused to go to the appointment. TC #62 reviewed Resident #98's orders and stated it would have been up to the nurse to make the appointments listed and to complete the transportation communication sheet for all the appointments listed on the continuity of care form. The Director of Nursing (DON) was interviewed on 12/21/25 at 10:38 A.M. and described the process for arranging residents' transportation and appointments. The DON stated if a resident was admitted with an appointment already scheduled, the nurse would complete a transportation communication form and send it to TC #62. The DON stated if the residents' orders included appointments to be made, the nurse would make the appointment and then send a transportation communication form to TC #62. The DON reviewed the admission note for Resident #98 and identified the admission nurse as LPN #1, who worked on day shift; the DON noted that Resident #98 had arrived close to shift change. The DON stated in this instance, the night shift nurse would have been responsible for sending the communication form to TC #62. The DON stated any day shift nurse could have scheduled the appointments that needed to be scheduled for Resident #98. The DON reviewed Resident #98's records and stated appointments for the resident had not been signed off, indicating the appointments were not made. During a follow-up interview on 12/21/25 at 11:47 A.M., TC #62 stated she had been unable to find any documentation that Resident #98 had attended appointments or that transportation was arranged. TC #62 stated that she knew Resident #98 had refused to get out of bed for a couple of appointments but knew it was not documented. The Administrator was interviewed on 12/21/25 at 3:28 P.M. and stated any appointments that were scheduled when a resident admitted to the facility were entered into the facility's electronic medical records system, and a transportation communication sheet was given to the transportation coordinator. The Administrator stated if there were orders for appointments to be made, that it was the primary responsibility of the nurses to make the appointments and then request transportation. On 12/22/25 at 8:52 A.M., the Administrator reported there was no information found regarding Resident #98's appointment for 07/14/25 or of an appointment with physical medicine and rehabilitation. The Administrator stated the different physicians' offices had been called, and there was no documentation Resident #98 had appointments scheduled with those providers. Licensed Practical Nurse (LPN) #1 was interviewed on 12/22/25 at 1:16 P.M. and stated that even though nurses faxed requests for transportation to TC #62, TC #62 stated the requests were not received, even with a fax confirmations that indicated faxes were successfully sent. LPN #1 stated TC #62 seemed to miss so many faxes requesting transportation that she placed a copy of the requests under the DON's door. Nurse Practitioner (NP) #45 was interviewed on 12/22/25 at 2:21 P.M. and stated there had been concerns with residents missing appointments. NP #45 identified the problems as transportation falling through or staff not answering phone calls, and stated she was unaware of any negative consequences of missed appointments. Review of a facility policy titled, Transportation, Social Services, revised 12/2008, revealed the facility shall help arrange transportation for residents as needed. This deficiency represents non-compliance investigated under Complaint Number 2618734.

Based on medical record review, observation, staff interview, resident representative interview, and policy review, the facility failed to ensure a residents tube feeding was administered according to physician orders. This affected one (Resident #06) of one resident reviewed for tube feedings. The facility census was 92.Findings Included:Review of the medical record revealed the facility admitted Resident #06 on 10/28/22 and readmitted the resident on 04/11/23. Diagnoses included persistent vegetative state, unspecified severe protein-calorie malnutrition, and gastrostomy status. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/15/25, revealed Resident #06 was in a persistent vegetative state with no discernible consciousness. The MDS indicated the resident had a feeding tube and received 51 percent or more of their total calories via tube feedings and 501 cubic centimeters (cc) or more of fluid per day via the tube. Review of Resident #06's Care Plan included a focus area initiated 11/10/25, indicating the resident required tube feeding related to chewing and swallowing problems. Interventions directed staff to have the Registered Dietitian (RD) evaluate the resident quarterly and as needed, monitor caloric intake, estimate needs, and make recommendations for changes to the tube feeding as needed. Review of Resident #06's Physician Order Recap Report revealed an order dated 12/17/25 for enteral feedings via enteral tube of Fibersource HN (high nitrogen) at 45 milliliters per hour (mL/hr) continuously over 24 hours. Observations on 12/18/25 at 8:45 A.M. revealed Resident #06 was sitting in a Geri-chair and there was no tube feeding hanging in the room or infusing. At 12:36 P.M., Resident #06 was lying in bed, and there was no tube feeding hanging in the room or infusing. During an interview on 12/18/25 at 12:57 P.M., Registered Nurse (RN) #04 stated he forgot that he was supposed to hang the tube feeding for Resident #06 at 12:00 P.M. He stated he had not read the orders and did not know the rate had changed. He stated he was not aware that the feeding should have been running all morning. He stated it was usually hung at 12:00 P.M., until the next morning at a rate of 60 mL/hr. He stated he should have been told about the rate change during report but should have also checked the orders himself. Observations on 12/19/25 at 11:35 A.M. revealed Resident #06 lying in bed with no feeding hanging or infusing. At 1:17 P.M., Resident #06 was lying in bed, and the tube feeding was hanging and infusing at 60 mL/hr instead of 45 mL/hr as ordered. Resident #06's responsible party was in the room and stated the resident was not supposed to be on continuous tube feedings and the reason it was not hanging yesterday morning was because it was supposed to run from 12:00 PM to 6:00 AM at 60 mL/hr. The responsible party stated the resident could not tolerate continuous feeding, and they were not aware of any changes to the orders. During an interview on 12/19/25 at 1:26 P.M., Licensed Practical Nurse (LPN) #02 stated she hung Resident #06's feeding at noon, since it ran from 12:00 P.M. until 6:00 A.M. the next day at 60 mL/hr. She stated she was not aware of any changes or that it was supposed to be administered continuously. She stated she had not had a chance to read all the orders or treatments yet. She stated she should have checked the orders when she hung the bag to verify them but then said she should have been told in report that the rate was different. During an interview on 12/23/25 at 9:24 A.M., the Director of Nursing (DON) stated it was her expectation that the nurses follow the current and active orders for tube feedings. During an interview on 12/23/25 at 10:44 A.M., the Administrator stated tube feedings should be administered according to the orders. A facility policy titled Enteral Nutrition, dated 11/2018, indicated Adequate nutritional support through enteral nutrition is provided to residents as ordered. The policy also indicated, 11. The nurse confirms that orders for enteral nutrition are complete. Complete orders include: a. the enteral nutrition product; b. delivery site (tip placement); c. the specific enteral access device (nasogastric, jejunostomy tube, etc. [et cetera]); d. administration method (continuous, bolus, intermittent); e. volume and rate of administration; f. the volume/rate goals and recommendations for advancement toward these; and g. instructions for flushing (solution, volume, frequency, time and 24-hour volume).

Based on medical record review, resident responsible party interview, staff interview, and facility policy review, the facility failed to ensure a resident's responsible party was notified and approved of a change in treatment, specifically a change in the tube feeding rate for one (#6) of two residents reviewed for a change of condition/treatment. The census was 92.Findings include: Review of the medical record revealed the facility admitted Resident #6 on 10/28/22 and readmitted the resident on 04/11/23. Diagnoses included persistent vegetative state, unspecified severe protein-calorie malnutrition, and gastrostomy status. Review of a quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 10/15/25, indicated Resident #6 was in a persistent vegetative state with no discernible consciousness. The MDS assessment indicated the resident had a feeding tube and received 51 percent (%) or more of their total calories through a feeding tube and 501 cubic centimeters (CC) or more of fluid per day through the tube. Review of Resident #6's care plan included a focus area initiated 11/10/25 which indicated the resident required tube feeding related to chewing and swallowing problems. Interventions directed staff to have the Registered Dietitian (RD) evaluate the resident quarterly and as needed, monitor caloric intake, estimate needs, and make recommendations for changes to the tube feeding as needed. Review of Resident #6's progress notes revealed a dietary note dated 12/17/25 which indicated the resident took nothing by mouth and was tube-feeding dependent. The note indicated the current tube feeding order was for Fibersource high nitrogen (HN) at 60 milliliters per hour (mL/hr) for 18 hours per day, to be turned on at 12:00 P.M. and turned off at 6:00 A.M. daily. The note indicated recommendations were made to switch to a continuous feeding over 24 hours for ease of administration and to continue to provide the flushes and Prostat (protein supplement) as ordered, and change the tube feeding regimen to Fibersource HN at 45 mL/hr continuous feedings over 24 hours, which would provide the same nutrition as the current regimen. There was no documentation that the resident's responsible party was notified of the change in the resident's tube feeding regimen. Review of Resident #6's order summary report revealed an order dated 06/13/25 to start Fibersource HN at 65 ml/hr for 18 hours per day, to be turned on at 12:00 P.M. and off at 6:00 A.M. The report indicated the order was discontinued on 12/17/25 and changed to Fibersource HN at 45 mL/hr over 24 hours continuously. During an interview on 12/19/25 at 1:17 P.M., Resident #6's responsible party stated the resident was not supposed to receive continuous tube feeding and the tube feeding was only supposed to run from 12:00 P.M. until 6:00 A.M. the next day because the resident could not tolerate a continuous feeding. The responsible party stated they were not aware of any changes. During an interview on 12/20/25 at 2:58 P.M., Resident #6's responsible party stated they were not notified of the change in the tube feeding rate and would not have approved it because the resident was not able to tolerate continuous feedings, and the facility should know that. Resident #6's responsible party indicated the Director of Nursing (DON) stated she was going to investigate to see why the feeding order was changed. During an interview on 12/23/25 at 9:24 A.M., the DON stated the facility's regular dietitian was not present and the facility had an alternate dietitian come in who thought it made more sense to change Resident #6's tube feeding to continuous. The DON stated the dietitian did not communicate this with the Resident #6's responsible party but should have. During an interview on 12/23/25 at 10:44 A.M., the Administrator stated any time there were changes to the resident's orders, notifications should be made, either by the dietitian, the nurse, or the supervisor. Review of a facility policy titled, Change in a Resident's Condition or Status, revised 02/2021, revealed the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g. [for example], changes in level of care, billing/payments, resident rights, etc. [et cetera]).

Based on observation, resident and staff interview, medical record review, and facility policy review, the facility failed to provide activities of daily living (ADL) assistance for dependent residents. This affected one (#56) of four residents reviewed for ADLs. The census was 92.Findings include:Review of the medical record revealed the facility admitted Resident #56 on 10/13/23. Diagnoses included legal blindness and multiple sclerosis. Review of a quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/03/25, revealed Resident #56 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS assessment indicated the resident required substantial/maximal assistance for personal hygiene. Review of Resident #56's care plan included a focus area, revised 12/11/24, which indicated the resident had an activities of daily living (ADL) self-care deficit related to needing extensive to dependent assistance with ADLs and mobility. Interventions directed staff to assist the resident with personal hygiene. An observation on 12/17/25 at 3:45 P.M. revealed Resident #56 was observed to have long, dirty fingernails. During an interview on 12/18/25 at 10:55 A.M., Resident #56 stated he had a bed bath and staff had not offered to trim or clean his fingernails or to shave his facial hair. Resident #56 stated he wanted his fingernails to be cleaned, trimmed, and wanted his facial hair to be trimmed. During an interview on 12/18/25 at 11:00 A.M., Certified Nurse Aide (CNA) #12 stated when a resident received their shower/bath, the staff should have offered to trim and clean the resident's fingernails and shave the resident. CNA #12 stated Resident #56 received a bed bath that day, and the resident was dependent on staff for cleaning and trimming their fingernails and shaving. During an observation on 12/18/25 at 11:08 A.M., CNA #12 and Licensed Practical Nurse (LPN) #7 went to Resident #56's room and with the resident's permission, observed the fingernails and face of the resident. During a concurrent interview, CNA #12 and LPN #7 both confirmed the resident's nails were dirty, jagged, long, and needed to be trimmed and confirmed the resident needed to be shaved. During an interview on 12/18/25 at 11:10 A.M., CNA #12 stated Resident #56 had long dirty fingernails and untrimmed facial hair. CNA #12 stated she should have cleaned and trimmed the resident's fingernails and should have trimmed the resident's facial hair or shaved the resident depending on what the resident wanted her to do. CNA #12 stated she should have asked the resident if he wanted to be shaved or have his nails trimmed, but she did not ask the resident; she just gave the resident a bed bath. During an interview on 12/18/25 at 11:15 A.M., LPN #7 stated on the resident's shower days and as needed, the CNAs should offer to trim the non-diabetic resident's fingernails and facial hair. She stated CNAs could clean all residents' fingernails, but the nurses trimmed the diabetic residents' fingernails. During an interview on 12/18/25 at 11:45 A.M., Resident #56 stated he was dependent on staff to clean and trim his fingernails and to shave them. During an interview on 12/22/25 at 6:10 P.M., the Director of Nursing (DON) stated she expected the staff to clean and trim the resident's fingernails and to shave them on their shower/bath days or as needed. During an interview on 12/21/25 at 2:54 P.M., the Administrator stated she expected the staff to offer to clean and trim the resident's fingernails and to shave the residents. Review of a facility policy titled, Activities of Daily Living (ADL), Supporting, revised 04/2025, revealed residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

Based on medical record review, staff interview, observations, review of facility policy, and review of the guidelines from the National Pressure Injury Advisory Panel (NPIAP) website, the facility failed to adequately assess residents' skin, initiate prompt and timely treatment for residents' with pressure ulcers (a pressure ulcer is a localized injury of the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), provide ongoing monitoring of pressure ulcers and failed to timely implement physician ordered interventions to prevent the development of pressure ulcers and/or aid in the healing of existing pressure ulcers. This resulted in Actual Harm when a resident who was at risk for development of pressure ulcers and subsequently developed avoidable, facility acquired pressure ulcers which were not identified until they had reached an advanced stage. Resident #11 developed a pressure ulcer on the coccyx which was first identified as a stage IV pressure ulcer on 01/31/25 and a pressure ulcer on the left buttock which was first identified as unstageable on 01/31/25. This affected one (#11) of the three residents reviewed for pressure ulcers. The facility census was 92. Findings include: Review of the medical record for Resident #11 revealed an admitted [DATE]. Diagnoses included diabetes mellitus type 2, cerebral infarction, vascular dementia, and major depressive disorder. Review of the care plan dated 09/27/24 revealed Resident #11 had a potential for skin breakdown related to impaired mobility, diabetes, incontinence, and impaired cognition. Interventions included barrier ointment applied after incontinent care, instruct and assist the resident in shifting weight in wheelchair frequently, monitor nutritional status, and a pressure reduction mattress with a low-air loss mattress (LALM) to the bed. Review of a physician order dated 10/14/24, revealed Resident #11 was ordered a skin assessment weekly on Mondays every night shift (7:00 P.M. to 7:00 A.M.). Review of the January 2025 Certified Nursing Assistant (CNA) documentation survey report for Resident #11, revealed there was no documentation for rolling the resident from left to right on the following dates: 01/01/25 (day and night shifts); 01/02/25 (day and night shifts); 01/03/25 (day and night shifts); 01/04/25 (day shift); 01/05/25 through 01/14/25 (day and night shifts); 01/15/25 and 01/16/25 (night shift); 01/17/25 (day shift); 01/18/25 through 01/19/25 (day and night shifts); 01/20/25 (night shift); 01/21/25 through 01/24/25 (day and night shifts); 01/25/25 through 01/26/25 (night shift); 01/27/25 through 01/29/25 (day and night shifts); 01/30/25 (night shift); and 01/31/25 (day and night shifts). Review of the weekly skin assessments for Resident #11, revealed no documented evidence of any weekly skin assessments being completed for the month of January 2025. Review of the January 2025 Medication Administration Record (MAR) revealed all weekly skin assessments ordered for 01/06/25, 01/13/25, 01/20/25, and 01/27/25 were recorded with a nine, which indicated to see progress note. Review of the progress notes for Resident #11 dated 01/06/25, 01/13/25, 01/20/25, and 01/27/25, revealed there was no progress note related to the weekly skin observations. Review of the shower sheets for Resident #11 dated 01/21/25 and 01/24/25, revealed the shower sheets were not accurately completed and did not identify if the resident's skin was intact. Review of a progress note for Resident #11 dated 01/25/25 at 2:45 P.M., revealed the resident had a new skin concern located on the sacrum. The measurements were 5.0 centimeters (cm) in length by 4.0 cm in width. A second wound on the left buttock measured 3.0 cm in length by 2.5 cm in width. Treatments included cleaning with normal saline, pat dry, apply wound gel and cover with dry dressing. Resident #11 did not complain of pain. The physician and family were notified. Review of a physician order for Resident #11 dated 01/25/25, revealed the resident was ordered to have coccyx and left gluteal cleansed with normal saline, patted dry, wound gel applied, and covered with a dry dressing twice daily. Review of the January 2025 Treatment Administration Record (TAR) revealed Resident #11 had a nine marked on the morning treatments for 01/28/25 and 01/29/25. There was no documentation on 01/29/25 (evening treatment), 01/30/25 (morning and evening treatments), and 01/31/25 (morning treatment). Review of the progress notes for Resident #11 dated 01/28/25 and 01/29/25, revealed no documentation regarding the wound treatments marked with a nine. Review of a Wound Nurse Practitioner (WNP) progress note for Resident #11 dated 01/31/25 revealed the resident was assessed for a new skin impairment and a wound consultation. The findings included: Wound one was on the resident's coccyx and was categorized as a new, stage IV pressure ulcer. Measurements were 4.0 cm in length and 3.3 cm in width, with 50 percent (%) granulation (the formation of new connective tissue and tiny blood vessels on a wound's surface during the healing process) and 50 % slough (a layer of dead, yellow or gray tissue that separates from the underlying healthy skin), subcutaneous, adipose, and muscle tissue exposed, attached wound edges, with ecchymosis (bruising), scant amount of purulent and serosanguineous (a fluid that contains both blood and serum) drainage. Treatment plan consisted of cleansing the wound with normal saline, Dakins moistened gauze applied to the base of the wound and secured with a bordered foam twice daily and as needed. Wound two was on the resident's left buttock and was categorized as a new, unstageable pressure ulcer. Measurements were 6.2 cm in length by 0.3 cm in width by 0.5 cm in depth, with 20 % slough (a soft, yellow or white, dead tissue that accumulates on the surface of a wound or ulcer) and 80 % eschar (a thick, dry crust of dead tissue that forms over a wound), wound edges attached, erythema (redness), with scant amount of serosanguineous drainage. Treatment plan was to cleanse with normal saline, Hydrogel Calcium alginate applied to the base of wound, secured with bordered foam, and change daily as needed. Recommended ongoing and new interventions included: ongoing pressure reduction and turning/repositioning precautions per protocol, pressure reduction to the heels and all bony prominences, LALM for pressure reduction, and floating heels in bed with use of heel boots. Recommend washing peri-area with soap and water and pat dry thoroughly. Keep areas clean and dry, prevent skin to skin contact, prevent excessive moisture and apply barrier protections as needed. Review of the Five-Day Medicare Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 was not able to complete a Brief Interview for Mental Status (BIMS) because she was rarely/never understood. The resident was assessed to require substantial assistance with Activities of Daily Living (ADLS). Observation on 03/27/25 at 10:41 A.M., revealed Licensed Practical Nurse (LPN) #22 performed wound care with the assistance of Registered Nurse (RN) #30 to Resident #11's sacral and left buttock wounds. Wound bed of the sacral wound was about a softball in size with granulation tissue and slough present. LPN #22 cleansed the wound with normal saline, applied a layer of Santyl to the wound bed covered with Dakins moistened gauze to base of wound, covered with bordered foam and secured with tape. The wound bed of the left buttock was approximately the size of a quarter. LPN #22 cleansed the wound with normal saline, applied a layer of Santyl to the wound bed, covered with Dakins moistened gauze to base of wound, covered with bordered foam and secured with tape. Interview on 04/01/25 at 11:43 A.M. with the Director of Nursing (DON), verified the weekly skin assessments for Resident #11 were not completed as ordered. The DON also verified the lack of documentation for turning and repositioning a dependent resident (Resident #11). Interview on 04/01/25 at 3:19 P.M. with Wound Nurse Practitioner (WNP) #60, verified she was consulted to see Resident #11. WNP #60 stated she assessed the resident on 01/31/25 with a stage IV pressure ulcer on the resident's sacral region and an unstageable pressure ulcer to the left buttock. WNP #60 reported the wounds were pressure related and should have been avoided with proper turning and repositioning and timely incontinence care. Review of the facility policy titled, Skin Condition Assessment and Monitoring - Pressure and Non-Pressure, dated October 2024 revealed guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure injuries, and other non-pressure skin conditions and assuring interventions were implemented. Residents identified would have a weekly skin assessment by a licensed nurse. Each resident would be observed for skin breakdown daily during care and on the assigned bath day by the certified nursing assistant (CNA). Changes shall be promptly reported to the charge nurse who will perform the detailed assessment. Review of the NPIAP guidelines dated 2014 pages at https://npiap.com/general/custom.asp?page=2014Guidelines revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that included the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. Review of the NPIAP website (https://npiap.com/page/PressureInjuryStages), revealed skin and soft tissue assessment is the basis of pressure injury prevention and treatment. Skin and tissue assessment is an essential component of any pressure injury risk assessment and should be conducted as soon as possible after admission and as a component of a full risk assessment. Each time the individual's clinical condition changes, a comprehensive skin and tissue assessment should be conducted to identify any alterations to skin characteristics or integrity, and to identify any new pressure injury risk factors. A comprehensive skin and soft tissue assessment consists of a head-to-toe assessment with particular focus on skin overlying bony prominence's including the sacrum, ischial tuberosities, greater trochanters and heels. In addition to comprehensive skin assessment, a brief skin assessment of the pressure points should be undertaken during repositioning. Stage 4 Pressure Injury: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury is an obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. This deficiency represents non-compliance investigated under Complaint Number OH00161929.

Based on record review, observation, staff and resident interviews, review of facility policy and review of guidelines from the National Pressure Injury Advisory Panel (NPIAP), the facility failed to adequately assess residents' skin, initiate prompt and timely treatment for residents' with pressure ulcers (a pressure ulcer is a localized injury of the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), provide ongoing monitoring of pressure ulcers and failed to timely implement physician ordered interventions to prevent the development of pressure ulcers and/or aid in the healing of existing pressure ulcers. This resulted in Actual Harm when two Residents (#75 and #05) were admitted to the facility without pressure ulcers but were at risk for the development of pressure ulcers and subsequently developed avoidable, facility acquired pressure ulcers which were not identified until they had reached an advanced stage. Resident #75 developed a pressure ulcer on 06/04/24 which was first identified as a stage III (full-thickness skin loss in which adipose [fat] is visible) pressure ulcer on his right heel. Resident #75 developed another pressure ulcer on 08/20/24 which was first identified as a stage III pressure ulcer on his right flank. Resident #75 developed a third avoidable pressure ulcer on 09/11/24 which was first identified as a stage III pressure ulcer on the resident's sacrum. Additionally, Resident #05 was noted with skin breakdown by the licensed nurses on 07/13/24 and 07/16/24, and was not evaluated by the wound physician until 07/30/24 when Wound Care Physician (WCP) #198 diagnosed the resident with a stage III pressure ulcer on the resident's sacrum. This affected two (#75 and #05) of three residents reviewed for pressure ulcers. The facility identified six residents with pressure ulcers. The facility census was 84. Findings include: 1) Review of the medical record for Resident #75 revealed the resident was admitted on [DATE]. Diagnoses included dementia, chronic kidney disease stage IV, diabetes mellitus type II and protein-calorie malnutrition. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] for Resident #75, revealed the resident was cognitively impaired, was dependent on staff for all activities of daily living (ADLs), Section M (Skin Conditions) revealed Resident #75 did not have a pressure ulcer/injury, was at risk of developing pressure ulcers/injuries and needed pressure relieving devices for the chair and bed. Review of the medical record for Resident #75 from 03/05/24 through 06/01/24, revealed no documentation of a plan of care, any skin risk assessments completed, and physician or Non-Physician Provider (NPP) visits completed for the resident. Review of a nurse progress note dated 06/01/24 for Resident #75 and authored by Licensed Practical Nurse (LPN) #410, revealed the resident had an area to the right heel measuring 7 centimeters (cm) in length by 4 cm in width by no depth. The area was dark brown in color and the surrounding tissue was red and blanchable with no warmth. The Medical Director (MD) #199 and Wound Care Nurse (WCN) #490 were notified. An order was received to apply skin prep to the resident's right heel two times a day and the doctor would be in on Monday. WCN #490 relayed the resident would be placed on the next weekly wound physician rounds. Treatment was applied, the resident was repositioned, and the family was notified. Review of a handwritten physician order dated 06/03/24 for Resident #75, located in the hard/paper chart, revealed the resident was ordered to wear bilateral heel protectors while in the bed or wheelchair. Review of a nurse progress note dated 06/04/24 for Resident #75 and authored by LPN #491, revealed the resident was seen by Wound Care Physician (WCP) #198 for a facility acquired stage III pressure injury to resident's right heel with an onset date of 06/01/24. Measurements were 2.7 centimeters (cm) in length by 2.7 cm in width by 0.1 cm in depth and minimal exudate (drainage) was present with no signs or symptoms of infection. WCP #198 gave orders for daily treatment of the wound and recommended the use of a low air loss (LAL) mattress and consult with physical therapy/occupational therapy for wound offloading needs of the resident's heels while in a wheelchair. Review of a physician order in the electronic medical record (EMR) dated 06/14/24 for Resident #75 by MD #199, revealed an order for Resident #75 to have an LAL mattress. Review of the June 2024, July 2024, August 2024 and September 2024 medication administration records (MAR) and treatment administration records (TAR) for Resident #75, revealed the daily dressing changes on the right heel were being completed as ordered. The MAR and TAR revealed no documented evidence that the heel protectors ordered on 06/03/24 and the LAL mattress ordered on 06/14/24 were ever implemented. Review of the weekly wound round visits by WCP #198, revealed Resident #75 was not assessed again by WCP #198 until 08/20/24, when the resident was evaluated for a newly acquired pressure ulcer. Review of a Wound Assessment and Plan visit note dated 08/20/24 for Resident #75 and authored by WCP #198, revealed the resident developed a new facility acquired Stage III pressure injury on his right flank which measured 21 cm in length by 14.2 cm in width by an unable to determine depth. There was 40 percent (%) granulation (new tissue), five % slough (peeling skin) and 55 % eschar (blackened/dead skin) with a moderate amount of exudate (drainage) and no signs and symptoms of infection. WCP #198 performed a sharp debridement (a medical procedure that involves removing dead, infected, or damaged tissue from a wound to help it heal) procedure to remove the eschar and slough. WCP #198 gave orders for daily treatment of the wound, weekly visits and ordered for physical therapy/occupational therapy to consult for wound offloading needs (to offload the resident's right upper extremity off of the right flank). Review of a Wound Assessment and Plan visit note dated 09/03/24 for Resident #75 and authored by WCP #198, revealed the stage III pressure ulcer on the resident's right flank pressure injury measured 11.5 cm length by 8.5 cm width by 0.1 cm depth (a decrease in size). WCP #198 gave orders for daily treatment of the wound, weekly visits and ordered a LAL mattress for wound off-loading. Review of a Wound Assessment and Plan visit note dated 09/11/24 for Resident #75 and authored by WCP #198, revealed the resident developed a new facility acquired stage III pressure injury on his sacrum which measured 7.5 cm in length by 3.3 cm in width by 0.1 cm in depth. WCP #198 gave orders for daily treatment of the wound, weekly visits and recommended a LAL mattress for wound off-loading. The right flank stage III pressure injury measured 8.6 cm in length by 6.2 cm in width by 0.1 cm in depth (a decrease in size). WCP #198 gave orders for daily treatment of the wound, weekly visits and ordered for physical therapy/occupational therapy to consult for wound offloading needs (to offload the resident's right upper extremity off of the right flank). Review of Resident #75's only documented Braden Scale - for Predicting Pressure Sore Risk, dated 09/15/24, revealed the resident was at very high risk for developing pressures ulcers. Review of a Wound Assessment and Plan visit note dated 09/17/24 for Resident #75 and authored by WCP #198, revealed the resident's right flank stage III pressure ulcer measured 3.9 cm in length by 4.4 cm in width by 0.1 cm in depth (a decrease in size). WCP #198 gave orders for daily treatment of the wound, weekly visits and recommended for physical therapy/occupational therapy to consult for wound offloading needs (to offload the resident's right upper extremity off of the right flank) and for the resident to have a LAL mattress. The sacrum pressure injury measured 3.2 cm in length by 4.9 cm in width by 0.1 cm in depth (a decrease in size). WCP #198 gave orders for daily treatment of the wound. The resident had a new diabetic ulcer on her right heel which measured 0.6 cm in length by 0.6 cm in width by 0.1 cm in depth. WCP #198 gave orders for daily treatment of the wound, weekly wound care visits and recommended for the resident to have a LAL mattress. Review of a Wound Assessment and Plan visit note dated 09/24/24 for Resident #75, and authored by WCP #198, revealed the resident's right flank pressure injury measured 6.9 cm in length by 1.3 cm in width by 0.1 cm in depth (an increase in size). WCP #198 gave orders for daily treatment of the wound, weekly visits and ordered for physical therapy/occupational therapy to consult for wound offloading needs (to offload the resident's right upper extremity off of the right flank) and for the resident to have a LAL mattress. The resident's right heel diabetic ulcer measured 3.6 cm in length by 3.4 cm in width by 0.1 cm in depth (an increase in size). WCP #198 gave orders for daily treatment of the wound, weekly visits and recommended the resident to have a LAL mattress. The sacrum pressure injury measured 6.3 cm in length by 1.3 cm in width by 0.1 cm in depth (an increase in size). WCP #198 gave orders for daily treatment of the wound, weekly visits and recommended the resident to have a LAL mattress. Review of a Wound Assessment and Plan visit dated 10/01/24 for Resident #75 and authored by WCP #198, revealed the resident's right flank pressure injury measured 4.9 cm in length by 1.6 cm in width by 0.2 cm in depth (a decrease in size). WCP #198 gave orders for daily treatment of the wound, weekly visits and ordered for physical therapy/occupational therapy to consult for wound offloading needs (to offload the resident's right upper extremity off of the right flank) and for the resident to have a LAL mattress. The right heel diabetic ulcer measured 2.1 cm in length by 1.5 cm in width by 0.1 cm in depth (a decrease in size). WCP #198 gave orders for daily treatment of the wound, weekly visits and recommended for the resident to have an LAL mattress. The sacrum pressure ulcer measured 6.3 cm in length by 1.3 cm in width by 0.1 cm in depth (no changes). WCP #198 gave orders for daily treatment of the wound, weekly visits and recommended the resident to have a LAL mattress. Review of a Wound Assessment and Plan visit dated 10/08/24 for Resident #75 and authored by WCP #198, revealed the resident's right flank pressure injury measured 4.5 cm length by 1.7 cm width by 0.2 cm depth (a decrease in size). WCP #198 gave orders for daily treatment of the wound, weekly visits and recommended for physical therapy/occupational therapy to consult for wound offloading needs (to offload the resident's right upper extremity off of the right flank) and for the resident to have a LAL mattress. The right heel diabetic ulcer measured 2.3 cm length by 0.7 cm width by 0.1 cm depth (an increase in size). WCP #198 gave orders for daily treatment of the wound, weekly visits and recommended the resident to have a LAL mattress. The sacrum wound was healed. A preventative wound recommendation was for the resident to have a LAL mattress. Review of a Wound Assessment and Plan visit dated 10/15/24 for Resident #75 and authored by WCP #198, revealed the resident's right flank pressure injury measured 4.1 cm in length by 1.4 cm in width by 0.2 cm in depth (a decrease in size). WCP #198 gave orders for daily treatment of the wound, weekly visits and recommended for physical therapy/occupational therapy to consult for wound offloading needs (to offload the resident's right upper extremity off of the right flank) and for the resident to have a LAL mattress. The right heel diabetic ulcer was healed. Review of a physician order dated 10/17/24 for Resident #75, revealed the resident was ordered to have weekly skin assessments every Wednesday and notify the physician for any new impairments. Review of a Wound Assessment and Plan visit note dated 10/22/24 for Resident #75 and authored by WCP #198, revealed the resident's right flank pressure injury measured 2.1 cm in length by 1.1 cm in width by 0.2 cm in depth (decrease in size). WCP #198 gave orders for daily treatment of the wound, weekly visits and recommended for physical therapy/occupational therapy to consult for wound offloading needs (to offload the resident's right upper extremity off of the right flank) and for the resident to have a LAL mattress. Review of a Wound Assessment and Plan note dated 11/05/24 for Resident #75 authored by WCP #198, revealed the resident's right flank pressure injury measured 2.0 cm in length by 1.0 cm in width by 0.1 cm in depth (decrease in size). WCP #198 gave orders for daily treatment of the wound, weekly visits and recommended for physical therapy/occupational therapy to consult for wound offloading needs (to offload the resident's right upper extremity off of the right flank) and for the resident to have a LAL mattress. Interview with MDS Coordinator #395 on 11/06/24 at 10:35 A.M., revealed she assisted in updating the residents' care plans. MDS Coordinator #396 verified she never placed any specific off-loading interventions on Resident #75's plan of care and if the staff needed to know of any specific interventions for Resident #75, they would have to go into the physician's orders to view them. MDS Coordinator #395 indicated the facility did not utilize any type of quick reference Kardex system. MDS Coordinator #395 verified there was no LAL mattress, or bilateral heel protectors assessed on the MDS. Interview with LPN #420 on 11/06/24 at 11:35 A.M. who reported being Resident #75's regular nurse, revealed she had no knowledge of the order dated 06/14/24 for Resident #75 to have a LAL mattress. LPN #420 stated she was aware of the bilateral heel protectors for the resident because the order was reflected on the MAR. LPN #420 verified the LAL mattress was not in place on Resident #75's bed when the resident developed the stage III pressure ulcers. Observation of Resident #75's room on 11/06/24 at 11:45 A.M. with CNA #575, revealed the resident was seated in a wheelchair with no heel protectors in place and the resident's bed did not have a LAL mattress in place. Interview with CNA #575 at the same time revealed she was unaware Resident #75 had physician orders for a LAL mattress and bilateral heel protectors. Interview with the Interim Director of Nursing (DON) on 11/06/24 at 1:33 P.M., revealed Resident #75 was ordered to have bilateral heel protectors on 06/03/24 and there was no documented evidence that the bilateral heel protectors were ever implemented. The Interim DON verified the resident was ordered to have a LAL mattress on 06/14/24 which wasn't implemented until 11/06/24 when the surveyor questioned it. The Interim DON verified Resident #75 developed an avoidable facility acquired stage III pressure ulcer on the right heel on 06/04/24 and was not assessed again by WCP #198 until 08/20/24 when the resident developed another facility acquired stage III pressure ulcer on the resident's right flank. The Interim DON verified Resident #75 developed a third stage III pressure ulcer on the resident's sacrum on 09/11/24. The Interim DON acknowledged Resident #75's pressure ulcers should have been identified before they had reached an advanced stage. The Interim DON stated the facility did not have a Kardex type system in place for the staff to use as a quick reference for any physician ordered care interventions for the residents. The Interim DON stated the staff would have to access the physician orders in order to find out if there were any ordered interventions in place for the residents. The Interim DON stated the CNAs did not have access to the physician orders and would have no way of knowing about any specific interventions unless the nursing staff relayed the information. Observation of Resident#75's room on 11/06/24 at 3:45 P.M., revealed the resident was in bed and had a LAL mattress on the bed and was wearing bilateral heel protectors. Review of a Wound Assessment and Plan visit note dated 11/27/24 for Resident #75 and authored by WCP #198, revealed the resident's right flank pressure injury wound measured 2.7 cm in length by 11.3 cm in width by 0.1 cm in depth (decrease in size). WCP #198 gave orders for daily treatment of the wound, weekly visits and recommended for physical therapy/occupational therapy to consult for wound offloading needs (to offload the resident's right upper extremity off of the right flank). Attempted interview with WCP #198 on 12/02/24 at 3:23 P.M. and again on 12/04/24 at 9:05 A.M. with no success. Interview with Regional Director of Rehabilitation (RDR) #800 on 12/04/24 at 1:04 P.M. revealed the facility had been through three different therapy providers since June 2024 with the most recent change in therapy providers taking place on 11/11/24. RDR #800 verified WCP #198 had ordered physical therapy/occupational therapy to be consulted for Resident #75's wound offloading needs. RDR #800 verified there was no documented evidence Resident #75 had been evaluated by therapy for the off-loading needs. Follow-up interview with the Interim DON on 12/04/24 at 4:42 P.M., verified Resident #75 was ordered to have a therapy consultation for off-loading needs on 08/20/24 by WCP #198. Interim DON verified the facility did not have any therapy records for Resident #75 prior to the 11/11/24 transition because the therapy records did not transition over to the new therapy provider. The Interim DON stated the facility recently parted ways with WCP #198 due to several issues and it was not an amicable departure. 2) Review of the medical record for Resident #05 revealed the resident was admitted on [DATE]. The resident was discharged to the hospital on 06/19/24 and readmitted to the facility on [DATE]. Diagnoses included cerebral infarction (stroke) with hemiplegia affecting dominant side, left femur fracture, and displaced fracture of second cervical vertebrae. Review of the admission History and Physical dated 06/14/24 for Resident #05 revealed the only identified skin impairment was a surgical incision for a repaired left femur fracture. Review of the MDS five-day assessment dated [DATE] for Resident #05, Section M (Skin Conditions) revealed the resident did not have a pressure ulcer/injury, was at risk of developing pressure ulcers/injuries and needed pressure relieving devices for the bed and chair due to a surgical incision. Review of the plan of care dated 06/20/24, revealed Resident #05 had a focus area for skin impairments due to impaired mobility, recent left hip replacement, and osteoarthritis. Interventions included, but not limited to, pressure reduction cushion to wheelchair per facility protocol, apply moisture barrier cream after incontinent care, turn and reposition frequently, follow facility policies/protocols for the prevention/treatment of skin breakdown, instruct/assist to shift weight in wheelchair frequently, and LAL mattress to bed and check placement and function per facility protocol. Review of the June 2024, July 2024, August 2024 and September 2024 MARs and TARs revealed no documented evidence Resident #05 had an order for a LAL mattress or had one in place. Review of a nurse progress note dated 07/05/24 at 6:00 P.M. for Resident #05 and authored by LPN #499, revealed the resident readmitted to the facility from the hospital at 1:30 P.M. There was an area to the resident's coccyx, pink in color, measured 3.0 cm in length by 1.5 cm in width by 0 cm in depth. A dry dressing was applied after cleaning with normal saline. There is no documented evidence that the physician or other provider was notified of the new area identified on the resident's coccyx. Review of the hospital Continuity of Care discharge form dated 07/05/24, revealed when Resident #05 was discharged from the hospital, the only wound present was a surgical incision to the left hip. Resident #05 was hospitalized from 06/19/24 to 07/05/24 due to acute respiratory failure with hypoxia. Review of the re-admission History and Physical dated 07/08/24 for Resident #05, revealed the only documented skin impairment, was a surgical incision for the repaired left femur fracture. Review of a nurse progress note dated 07/13/24 at 7:00 A.M. for Resident #05 authored by RN #397, revealed Resident #05 was alert, oriented, had normal breathing with no shortness of breath reported and no other complaints. Dressing to left hip continued with no breakthrough drainage noted. Resident #05 noted with skin breakdown to coccyx area which measured 5 cm in length by 3 cm in width and a dressing was applied. The Foley catheter was patent and draining dark colored urine. Review of a nurse progress note dated 07/16/24 for Resident #05 authored by RN #396 revealed the resident was resting in bed with normal vital signs. The nurse was called to the resident's room to observe the skin breakdown on the resident's coccyx area. The color was pink and dark/scabbed in some places which were noted on admission. The area was cleansed with normal saline. The resident reportedly had three episodes diarrhea. Nurse Practitioner (NP) called and ordered for the resident to have a one-time dose of Imodium (anti-diarrhea). The resident's daughter was notified of the diarrhea and the medication. There was no documented evidence of the NP being notified of the skin breakdown. Review of the nurse progress notes from 07/17/24 to 07/30/24 for Resident #05, revealed no additional documentation of the resident's skin breakdown on his coccyx. Review of the weekly skin assessments from 07/17/24 to 07/30/24 for Resident #05 revealed no documented evidence of any skin assessments being completed. Review of a physician order dated 07/17/24 for Resident #05, revealed the resident was ordered to have weekly skin assessments and to notify physician if a new skin impairment developed. Review of a Wound Assessment and Plan note dated 7/30/24 for Resident #05 and authored by WCP #198 revealed the resident was evaluated and diagnosed with a new facility acquired stage III pressure ulcer on his sacrum. The new pressure ulcer measured 3.4 cm in length by 2.0 cm in width and unable to determine depth. The wound had 20 % granulation, 70 % slough, 10% eschar, minimal exudate, and no signs and symptoms of infection. The resident's wound was debrided to remove excess eschar and slough tissue. Post debridement wound bed had 35 % slough and eschar remaining and post debridement wound bed measurement 3.3 cm in length by 2.2 cm in width by 0.5 cm in depth. WCP #198 gave orders for daily treatment of the wound, weekly visits and recommended the resident to have a LAL mattress. Review of a nurse progress note dated 07/31/24 for Resident #05 and authored by WCN #490, revealed the resident was seen by WCP #198 during the weekly wound care rounds on 07/30/24. The resident had a stage III sacrum pressure injury which measured 3.4 cm in length x 2.0 cm in width and unable to determine depth. Resident was ordered to have his sacrum cleansed with normal saline, hydrogel gauze applied, covered with dry dressing and changed daily and as needed. The resident and family are aware of the new orders and voiced understanding. Review of the physician orders dated 07/31/24 for Resident #05, revealed an order to cleanse the resident's sacral wound with normal saline, apply hydrogel gauze to wound bed, cover with dry dressing, change daily every night shift and as needed. Review of a Wound Assessment and Plan for Resident #05 dated 08/06/24, 08/13/24 08/20/24 08/27/24, 09/03/24, 09/11/24, 09/17/24, 09/24/24, 10/01/24, 10/08/24, 10/15/24, 10/22/24, and 11/05/24 and authored by WCP #198, revealed the resident was ordered to have a LAL mattress. Review of a physician order dated 10/22/24 for Resident #05, revealed the resident was ordered a LAL mattress due to resident being a high-risk for skin breakdown. Interview with the Interim DON on 11/06/24 at 3:00 P.M., revealed the staff had to look at the physician orders or the MARs and/or TARs to view any specific resident care interventions which was not practical. The Interim DON stated the CNAs did not have access to the physician's orders to view any specific interventions ordered for the residents. Observation on 11/18/24 at 12:10 P.M. revealed Resident #05 was in bed and had an LAL mattress in place. Interview with the Interim DON on 11/18/24 at 12:16 P.M. verified Resident #05 was at risk for developing pressure ulcers and was diagnosed with a facility acquired stage III pressure injury located on the resident's sacrum on 07/30/24. The Interim DON verified the pressure ulcer was not identified until it had reached a stage III. The interim DON verified Resident #05's LAL mattress was ordered on 07/30/24 by WCP #198 and not put in place until 10/22/24. Interview with WCN #490 on 11/18/24 at 12:33 P.M., verified Resident #05 was at risk for developing pressure ulcers when the resident developed a facility acquired pressure ulcer on his sacrum and it was not identified until it reached a stage III. WCN #490 verified WCP #198 ordered a LAL mattress on 07/30/24 and it was not put in place until 10/22/24. Interview via phone with RN #396 on 12/02/24 at 7:51 P.M. verified there was no documented evidence that the physician or the facility administration was notified when she observed Resident #05's skin breakdown on the coccyx. RN #396 stated she had no recollection of the resident's wounds. Interview via phone with LPN #499 on 12/02/24 at 8:03 P.M. verified there was no documented evidence that the physician or the facility administration was notified when she observed Resident #05's skin breakdown on the coccyx. LPN #499 stated she had no recollection of the resident's wounds. Interview via phone with RN #397 on 12/03/24 at 2:28 P.M. verified there was no documented evidence that the physician or the facility administration was notified when he observed Resident #05's skin breakdown on the coccyx. RN #397 stated he had no recollection of the resident's wounds. Review of the facility policy titled, Skin Condition Assessment and Monitoring-Pressure and Non-Pressure, last updated October 2024, revealed the purpose of the policy is to establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are implemented. Guidelines include pressure and other ulcers (diabetic, arterial, venous) will be assessed and measured at least weekly by licensed nurse and documented in the resident's clinical record. The facility policy also states that residents identified will have a weekly skin assessment completed by a licensed nurse. Review of the NPIAP, 2019 edition, pages 75 to 81, indicate skin and soft tissue assessment is the basis of pressure injury prevention and treatment. Skin and tissue assessment is an essential component of any pressure injury risk assessment and should be conducted as soon as possible after admission, as a component of a full risk assessment (see the guideline chapter on Risk Factors and Risk Assessment). Each time the individual's clinical condition changes, a comprehensive skin and tissue assessment should be conducted to identify any alterations to skin characteristics or integrity, and to identify any new pressure injury risk factors. Finally, a comprehensive skin and soft tissue assessment should be conducted on discharge, to ensure that an appropriate pressure injury prevention and treatment plan is in place. A comprehensive skin and soft tissue assessment consists of a head-to-toe assessment with particular focus on skin overlying bony prominence's including the sacrum, ischial tuberosities, greater trochanters and heels. In addition to comprehensive skin assessment, a brief skin assessment of the pressure points should be undertaken during repositioning. Check the pressure points on which the individual has been positioned to identify any alterations in condition and to evaluate the effectiveness of the repositioning regimen. Presence of persistent erythema can indicate a need to increase frequency of repositioning. Check pressure points onto which the individual will be repositioned to ensure that the skin and tissue has fully recovered from previous loading. The NPIAP Pressure Injury Stages, revealed if necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). This deficiency represents noncompliance investigated under Complaint Number OH00158062 and Complaint Number OH00160225.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on medical record review, staff interview, local police department detective interview, Sexual Assault Nurse Examiner (SANE) interview, local Ombudsman interview, review of the facility Abuse Prevention/Reporting policy, review of the facility employee handbook, review of the outside hospital records, review of the facility Self-Reported Incident (SRI), review of the local law enforcement report, review of the local county inmate search, review of the Ohio Revised Code (ORC) 2907-02 (11A), review of the personnel record, review of the facility personnel time punches, review of the acknowledgement of receipt of the employee handbook, review of the facility investigation, and review of the witness statements, the facility failed to ensure residents were free from employee to resident sexual abuse. This resulted in Immediate Jeopardy when Resident #100 reported, on 07/31/22 in the early morning hours, State tested Nursing Assistant (STNA) #335 entered her room, barricaded the door with the wheelchair, ripped her adult brief, had difficulty penetrating, used his hands to separate her labia, and then penetrated the resident. STNA #335 retrieved paper towels, cleaned himself off, moved the wheelchair, and left the room. Resident #100 was taken to the local emergency room (ER) where a SANE testing was completed. This affected one resident (#100) of five residents reviewed for abuse. The facility census was 93. On 09/07/22 at 12:18 P.M., the Administrator, the Assistant Administrator (AA) #355, the Director of Nursing (DON), the Regional Vice President of Operations (RVPO) #350, and the Regional Nurse (RN) #360 were notified that Immediate Jeopardy began on 07/31/22 in the early morning hours when Resident #100 reported STNA #335 entered her room, barricaded the door with Resident #100's wheelchair, and sexually assaulted her. Review of the [NAME] County Justice Services Inmate Search revealed STNA #335 was arrested on 09/01/22 at 11:42 A.M. for rape of an impaired person Ohio Revised Code (ORC) 2907-02A1C. Interview on 09/08/22 at 8:51 A.M., the SANE Registered Nurse (RN) #345 stated she received notification on 09/08/22 of the results of the SANE test and STNA #335's semen was found in Resident #100's vagina. The Immediate Jeopardy was removed on 08/03/22, when staff education was provided regarding the abuse policy and procedures, maintaining the residents' rights to be free from sexual abuse and all other forms of abuse and the facility completed interview and assessments on all residents to ensure no further sexual abuse was identified. The deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 08/23/22 when the facility implemented the following corrective actions: On 07/31/22 at approximately 10:00 A.M., Licensed Practical Nurse (LPN) #365 attempted to complete a medical assessment; however, Resident #100 refused. On 07/31/22 at approximately 10:00 A.M., Resident #100's daughter called nine-one-one (911). The local police and paramedics arrived at Resident #100's room at approximately 10:15 A.M. On 07/31/22 at approximately 10:20 A.M., LPN #365 notified the DON of Resident #100's allegation of sexual assault. On 07/31/22 at approximately 10:30 A.M., the DON notified the Administrator of Resident #100's allegation of sexual assault. On 07/31/22 at approximately 10:30 A.M., LPN #365 notified Resident #100's physician (Physician #400) of Resident #100's allegation of sexual assault. On 07/31/22 at approximately 10:45 A.M., paramedics from the local fire department transported Resident #100 to the local Emergency Department (ED). On 07/31/22 at 11:00 A.M., the Administrator contacted STNA #335 and notified him he was suspended immediately pending the outcome of the investigation and was not to return to the facility. On 07/31/22 at approximately 11:15 A.M., the Administrator and LPN #365 began interviewing all residents on STNA #335's assignment. Residents #48, #86, #35, #82, #74, #02, #88, and #09 were interviewed with no negative findings. The Administrator and LPN #365 then interviewed the remaining residents (#54, #97, and #72) on the same hallway where STNA #335 had worked who were able to be interviewed. On 07/31/22 at approximately 12:00 P.M., RVPO #350 submitted a SRI to the State Agency regarding the sexual abuse allegation. On 07/31/22, LPN #365 began skin assessments on all residents on STNA #335's assignment (Residents #48, #86, #35, #82, #74, #02, #88, #09, #45, and #25) and the remaining residents on the unit (Residents #54, #58, #96, #97, #55, #71, #51, and #72). All skin assessments on the unit were completed on 07/31/22 and no concerns were identified. On 07/31/22, the Administrator and LPN #365 initiated staff education regarding the facility abuse policy and residents were to be free from sexual abuse. All staff education was completed on 08/01/22. On 07/31/22, RVPO #350 began conducting employee interviews with LPN #370, STNA #164, STNA #315, LPN #206, STNA #172, LPN #365, STNA #335 (who was the alleged perpetrator and denied the allegations via telephone), STNA #155, LPN #209, and STNA #104, who provided care to Resident #100 and worked the current and/or prior shift. Interviews were completed by 08/03/22. No concerns were identified. No employee had any knowledge or denied knowledge of having sexual contact with Resident #100. On 07/31/22 at approximately 1:00 P.M., a Quality Assessment Performance Improvement (QAPI) meeting was held via a conference call. Those in attendance included the Administrator, the DON, RVPO #350, RN #360, and Physician #400. The plan of correction was developed, and initial wellness audits for the abuse were created for the on-going monitoring in the facility. On 08/01/22, the facility expanded the resident sample by interviewing the remainder of all residents in the facility and completed skin assessments for residents who were cognitively impaired. No concerns were identified. Interviews and skin assessments were completed by 08/03/22. On 08/01/22, the Ombudsman was notified of the incident. On 08/02/22, wellness audits of two residents, three times per week were initiated. Following the two weeks, the facility began wellness audits on three residents weekly for three months. On 09/02/22 at approximately 1:15 A.M., the DON was notified of STNA #335's arrest by a personal acquaintance. On 09/02/22 at approximately 1:30 A.M., the DON notified the Administrator of STNA #335's arrest. On 09/02/22 at approximately 6:30 A.M., the Administrator arrived at the facility to meet with staff at shift change and offer support to residents and staff. Additional safety measures were implemented to ensure facility security, including securing exterior doors, and limiting entrance/exit to the main entrance. On 09/02/22, the DON initiated resident interviews for all residents and skin assessments were completed on those residents with cognitive impairments. Interviews and skin assessments were completed by 09/02/22. No negative findings were identified on this second round of interviews and assessments. On 09/02/22, the Administrator, RVPO #350, and Social Services (SS) #405 were available to answer questions from the residents and families regarding the news report. On 09/02/22 at approximately 2:20 P.M., RVPO #350 notified the State Agency of STNA #335's arrest via an addendum to the original SRI submission. Interviews on 09/06/22 between 11:00 A.M. and 11:30 A.M., Housekeeper (HK) #305, STNA #310, STNA #315, HK #300, and LPN #320 revealed all staff verified they were recently educated on the facility's abuse policy. All staff verbalized concerns relating to abuse would be reported immediately. Interviews and observations on 09/06/22 between 11:00 A.M. and 5:30 P.M. with Residents #29, #89, #94, #49, #102, #92, #39, #100, #98, #56, #03, #83, #66, #46, #91, #34, #96, #36, #08, #04, #15, #86, #29, #74, #48, #88, #42, #09, #45, #97, #31, #51 revealed no additional resident concerns relating to the allegation. Resident #31 was tearful and stated she was raped when she was a teenager and the incident involving STNA #335 brought back bad memories. The facility ensured Resident #31 continued to see her counselor and offered her support from social services. On 09/07/22, the facility became aware STNA #335 had confessed to the alleged crime and STNA #335's employment status was terminated. Findings include: Review of the medical record for the Resident #100 revealed an admitted [DATE] and discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 had intact cognition. The resident required extensive assistance of two staff for bed mobility and transfers. Review of the nurse progress notes dated 07/31/22 at 1:57 P.M. revealed at approximately 10:00 A.M., Resident #100's daughter stated to the writer (LPN #365) her mom was raped. LPN #365 went into Resident #100's room to speak with the resident and to further assess the resident. When LPN #365 asked Resident #100 when this occurred, the resident stated at 8:00 A.M. Resident #100's daughter then stated, mom you told me this happened last night. LPN #365 was unable to perform a physical assessment due to Resident #100 refused. LPN #365 looked in the residents ' adult brief and only observed urine. LPN #365 advised Resident #100 not to wash the genital area based on allegation. At this time the daughter of Resident #100 notified the local police. LPN #365 notified the DON, the Administrator, and the on-call physician. Resident #100 was transferred to the local hospital for an evaluation. Review of the plan of care revealed Resident #100 had potential for difficulty making decisions due to history of depressive diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #100 had potential for declined mood related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included to observe for change in mental status, encourage verbalization, approach resident warmly and positively. Review of the SRI dated 07/31/22 and timed 12:11 P.M., revealed LPN #370 went into Resident #100's room at approximately 9:00 A.M. to give Resident #100 her medications. Resident #100 told LPN #370 she had a bad night and was crying. LPN #370 told the Nurse Supervisor, LPN #365, the resident was upset. LPN #365 went to Resident #100's room to find out why she was upset and offer support. Resident #100 told LPN #365 that her daughter was on her way to inform the facility staff of what happened last night, and her daughter would let them know what was going on. Resident #100's daughter arrived at the facility at approximately 10:00 A.M. and reported to LPN #365 that her mom (Resident #100) was raped last night. LPN #365 asked her what happened, and the resident reported it happened at 8:00 A.M. and STNA #335 forced himself into her, her private areas hurt, and she was too embarrassed to talk about it. Resident #100's daughter called the local police, and the local police came to the facility and opened an investigation. LPN #365 attempted to complete a full body skin inspection; however, Resident #100 refused. Resident #100 allowed LPN #365 to look in her brief, and the brief was wet with urine. STNA #335 worked from 7:52 P.M. on 07/30/22 and clocked out and left the facility at 7:00 A.M. on 07/31/22. LPN #365 made notifications to the physician and Resident #100 was sent to the hospital for a rape examination. The Administrator completed staff interviews and obtained written interviews from other staff who were present. The Administrator also ensured interviews and skin assessments were completed with all other residents on STNA #335's assignment. Review of the facility investigation dated 07/31/22 and timed 12:11 P.M., with RVPO #350 revealed ten residents on STNA #335's assignment were interviewed, with skin assessments completed, male and female. Review of the documentation revealed the ten residents voiced no concerns, and skin assessments were negative. STNA #335's assignment included Rooms #148 through #162. RVPO #350 stated the Administrator came in on 07/31/22 to help interview the residents. RVPO #350 interviewed dayshift staff on 07/31/22 who would have encountered Resident #100. She also interviewed the night shift nursing staff. She stated she spoke with everyone assigned to Resident #100. She stated STNAs #155, #335, #164, #104, #310, #315, #172, LPNs #209, #206, #370, #120 and RN #153 had been interviewed. No one had any knowledge of the alleged rape. Review of the witness statement dated 07/31/22 by STNA #335 denied having any contact with Resident #100 other than passing ice to her around 8:00 P.M., on the shift and no other interaction. Review of the time punch card dated 07/31/22 revealed STNA #335 clocked out of the facility on 07/31/22 at 7:00 A.M. and was not in the facility when the allegation was made. Review of the personnel record for STNA #335 revealed a hire date of 09/22/15. The STNA's license was in good standing with an original application date of 09/19/07. Disciplinary action included July 2019 for attendance, July 2020 for tardiness, on 03/03/20 he had not taken his break in the break room, and on 04/05/21 he received a written warning for attendance. Review of the local hospital record dated 07/31/22 revealed the patient (Resident #100) presented to the ED with an alleged sexual assault. Resident #100 stated that a [AGE] year-old nurse aide at her Skilled Nursing Facility (SNF) assaulted her last night. She stated he came into the room, closed the door, and then put her wheelchair behind the door to block it while locking the wheelchair wheels. The aide then allegedly took and manipulated her legs and proceeded to sexually assault her. Vaginal penetration occurred per the patient. He then went to the sink and cleaned up. The patient endured vaginal pain during the assault. Currently endorses some emotional distress over the events of the night. Her daughter calls her every morning, and when she called that morning, the patient told the daughter the details of what allegedly occurred. The daughter then arrived at the SNF and contacted the authorities. Emergency Medical Services (EMS) and the police arrived at the scene and the patient was transported to the ED. With the exception of the above, there were no aggravating or alleviating factors. A full ten-point review of systems was completed and was otherwise negative unless noted above in the history and physical. Sexual Assault Nurse Examiner (SANE) nurse was at the bedside for examination. Based on shared decision making declined prophylactic [CONDITION(S)] medications but moved forward with gonorrhea and chlamydia prophylaxis. The local police and an investigation unit were at the bedside and took a statement. The alleged perpetrator was allegedly in custody. The patient stated she felt comfortable going back to the nursing facility. The social work note documented the facility feels okay to receive the patient back. The daughter does not feel this is advised when talked to her on the phone. She was going to return to the ED to talk with the patient and come to an agreement in terms of what would be an optimal geographic location for her. Review of the ED attending attestation note dated 07/31/22 revealed the patient was awake and appropriate. A local police officer spoke with her, an investigator spoke with her, the SANE nurse completed the examination. The family was not comfortable with her going back to the nursing facility given the issue that happened and other issues that happened previously. Therefore, she was admitted to the hospital for placement. Interview on 09/06/22 at 11:59 A.M., Detective #330 stated STNA #335 was arrested on 09/01/22 on one count of rape, which was determined over the course of the investigation and STNA #335's admission. Detective #330 stated the official results of the Sexual Assault Nurse Examiner (SANE) report had not yet been received. Interview on 09/07/22 at 11:09 A.M., the Ombudsman stated he opened a case regarding sexual assault on Resident #100 and closed the case on 08/31/22, after Resident #100 relocated to another facility. The Ombudsman stated he visited the facility multiple times during his investigation and no residents in the facility ever expressed any concern or knowledge about the incident. The Ombudsman stated he was in telephone contact with Detective #330 while investigating the case and suspected a turning point was coming in the Detective's investigation due to a decrease in responsiveness from the Detective. Interview on 09/08/22 at 8:51 A.M., the SANE RN #345 stated she received notification the same date of the results of the SANE test and STNA #335's semen was found in Resident #100's vagina. A follow-up interview on 09/08/22 at 9:45 A.M. with Detective #330 revealed the results of the SANE test were received on 09/08/22 and confirmed STNA #335's DNA in Resident #100. Review of the local police report dated 07/31/22 revealed the local police were called to the facility for a forceable rape. The victim reported the suspect came into her room and engaged in sexual conduct with her by force and without her permission to do so. Review of the [NAME] County Justice Services Inmate Search revealed STNA #335 was arrested on 09/01/22 at 11:42 A.M. for rape of an impaired person Ohio Revised Code (ORC) 2907-02A1C. Review of the Ohio Revised Code 2907-02 (11A) revealed No person shall engage in sexual conduct with another who is not the spouse of the offender or who is the spouse of the offender but living separate and apart from the offender when the other person's ability to resist or consent is substantially impaired because of a mental or physical condition or because of advanced age, and the offender knows or has reasonable cause to believe that the other person's ability to resist or consent is substantially impaired because of a mental or physical condition or because of advanced age. Review of the facility Employee Standards of Conduct, undated, from the Employee Handbook, revealed the following types of conduct were grounds for corrective action, up to and including termination: willfully disregarding the ethical standards of the medical profession, failing to deliver services/care as documented, engaging in lewd or obscene conduct, or indecency on company property, violating residents ' rights, failing to report known or suspected resident abuse or neglect, finding that an allegation of resident abuse or neglect is substantiated as the result of an investigation, and engaging in any action that endangers the life or safety of another person. Review of the Acknowledgment of Receipt of Your Guide to Employment at the facility revealed STNA #335 electronically signed to acknowledge the receipt of the team members guidebook on 09/22/15. Review of the facility policy titled Abuse Prevention/Reporting Policy and Procedure, updated 05/09/18, revealed every resident has the right to be free from abuse and residents must not be subjected to abuse by anyone, including employees. Sexual abuse is defined as touching the resident in an intimate or suggestive manner and non-consensual contact of any type with a resident. This deficiency substantiates Complaint Number OH 564.

Based on medical record review, staff interview, physician interview, and review of the hospital records, the facility failed to monitor a resident's lack of bowel movements, implement interventions to prevent a fecal impaction, and assess a resident with signs of fecal impaction. This resulted in Actual Harm when Resident #16 had no bowel movements for four days, no assessment of the resident was completed, no interventions were provided, physician ordered as needed laxatives were not administered, and the physician was not notified. Subsequently, Resident #16 experienced abdominal pain, vomiting, and was admitted to the hospital with a large fecal impaction which required treatment with medications, enemas, and a nasogastric tube. This affected one (#16) of two residents reviewed for hospitalization . In addition, the facility failed to ensure timely treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The census was 90. Findings include: 1. Review of the medical record review revealed Resident #16 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change Minimum Data Set (MDS) assessment, dated 03/17/22, revealed Resident #16 had severely impaired cognition. Resident #16 required extensive assistance for bed mobility with two staff members and total assistance for transfers, toilet use and eating. Resident #16 had an indwelling urinary catheter and was always incontinent of bowel. Resident #16 has a gastrostomy tube and received nutritional support daily. Review of the plan of care, dated 11/22/21, revealed Resident #16 was at risk for constipation related to impaired mobility, history of constipation, medications, diabetes mellitus, and [CONDITION(S)] neurological disorder. Interventions included administer laxatives/stool softeners as ordered, dietary consult as needed, encourage physical activity as tolerated, follow facility bowel protocol for bowel management, monitor medication for side effects of constipation, keep physician informed of any problems, monitor bowel movement patterns, and monitor/document/report as needed signs and symptoms of complications related to constipation such as: change in mental status, new onset of confusion, sleepiness, inability to maintain posture, agitation, [CONDITION(S)], abdominal distention and vomiting, new onset of small loose stools, fecal smearing, bowel sounds, diaphoresis, abdomen tenderness, guarding, rigidity, and fecal compaction. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was also an order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility look back summary for bowel movements, dated 12/01/21 through 01/07/22, revealed Resident #16 had a large bowel movement on 12/23/21. There was no recorded bowel movements on 12/24/21 and the summary had no entries on 12/25/21, 12/26/21, 12/27/21. An entry dated 12/28/21 revealed a medium soft formed bowel movement occurred at 2:57 P.M. Resident #16 had a small bowel movement on 12/30/21 was recorded at 2:19 A.M. No bowel movement was recorded on 12/31/21. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the department notes on 12/31/21 at 11:35 A.M. revealed Resident #16 was complaining of abdominal pain. The physician was notified and advised to send the resident to the emergency room for further evaluation. Review of the department notes on 12/31/21 at 5:51 P.M. revealed Resident #16 was admitted to the hospital for a fecal impaction. Review of the emergency room note for Resident #16 dated 12/31/21, revealed the reason for the visit was altered mental status. History and physical noted the resident complaining about some pain on the side of his head, abdominal pain and difficulty pooping. Physical examination revealed abdomen diffusely firm with some tenderness to palpation. Resident #16 was admitted to the hospital for further evaluation and management of altered mental status and stercoral [CONDITION(S)] (chronic constipation leading to fecal impaction). Review of the hospital imaging studies report, dated 12/31/21, revealed a computed tomography (CT) scan was administered with contrast (dye to highlight areas of the body being examined). The CT scan results revealed Resident #16 had a large amount of stool present with the greatest amount in the rectum. Additionally, a large rectal stool ball was evident measuring up to nine centimeters (cm) in diameter with mass effect on the bladder. The impression listed a large amount of stool with a large rectal stool ball and possible stercoral [CONDITION(S)]. Study impression and plan of care revealed a large stool burden. Recommendation included saline, mineral oil, and [MEDICATION(S)] (SMOG) enema two times a day and start [MEDICATION(S)] if able to take by mouth. Review of hospital progress notes, dated 01/01/22, revealed Resident #16 presents to the hospital with worsening abdominal pain. Resident #16 has increasing nausea, emesis, abdominal pain and distention. In emergency room department the resident was found to have severe stool overload from unclear reasons. The resident was given SMOG enemas with placement of nasogastric tube (NG) and [MEDICATION(S)] prep. The resident had massive results with extensive bowel movements and decompression. Resident #16 was diagnosed with stercocral [CONDITION(S)], severe constipation, and positive for Covid-19. Review of the hospital progress notes, dated 01/04/22, for revealed no acute events overnight and the resident continued to have large explosive bowel movements. Review of the physical exam revealed mildly distended abdomen with bowel sounds diminished. Review of the hospital progress notes, dated 01/05/22, revealed no acute events overnight and Resident #16 continued to have large explosive bowel movements. Review of the physical exam revealed mildly distended abdomen with bowel sounds diminished. Interview on 05/24/22 at 12:33 P.M., Licensed Practical Nurse (LPN) #178 stated nurses should check the electronic health record and review the residents on the assignment to ensure no laxatives were needed. LPN #178 verified residents with no bowel movements in three days should have received a [MEDICATION(S)] per the bowel protocol. Interview on 5/25/22 at 10:24 P.M., State tested Nursing Assistant (STNA) #152 stated when a resident has a bowel movement the aides record it in the electronic health record. STNA #152 stated she did not know how to look back to see if a resident had a bowel movement on any other shift other than the one she was entering. STNA #152 stated the nurse will look up a resident's bowel movements if we have any problems. Interview on 05/25/22 at 3:17 P.M., the Regional Registered Nurse (RN) #225 stated the facility does not have a policy related to constipation. The expectation was if a resident did not have a bowel movement after three days a [MEDICATION(S)] was given. RN #225 verified there were multiple days on the look back assessment for bowel movement monitoring that was blank during the 12/01/21 through 01/07/22 time period for Resident #16 and no as needed [MEDICATION(S)] medication given. Interview on 06/02/22 at 12:09 P.M., LPN #227 stated she was assigned to care for Resident #16 on 12/31/21. LPN #227 verified she did not complete any abdominal assessment for the resident on the day that he was discharged . Resident #16 was yelling out in pain, vomiting, and wanted to go to the hospital. LPN #227 stated she got his vital signs and called 911 for the transfer. LPN #227 stated she was working as an agency nurse for the facility and was unable to access the electronic health record at that time. The STNAs would let her know if a resident needed a [MEDICATION(S)] and no one had said anything. LPN #227 stated she did not have access to the bowel monitoring at the time of Resident #16's transfer and was not told by staff that he needed a [MEDICATION(S)]. Interview on 06/03/22 at 4:45 P.M., the facility Medical Director #251 stated she was not notified Resident #16 did not have a bowel movement for four days in December 2021 prior to being hospitalized for a fecal impaction. Medical Director #251 stated if she had been notified she would have ordered an abdominal radiography (x-ray) test to determine if the resident had a problem. The results of the x-ray would determine the next step in treatment. Interview on 06/06/22 at 8:40 A.M., Dietician #206 stated Resident #16 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Dietician #206 was not aware of any problems since he had been in the facility and there were no specific dietary interventions in place. Dietician #206 stated he was not asked to consult on any dietary interventions for Resident #16. Interview on 06/06/22 at 8:53 A.M., LPN #177, who was assigned to care for Resident #16 on 12/26/21, stated she would have charted a [MEDICATION(S)] on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The agency staff working at the facility have had difficulty documenting in the electronic health record. 2. Medical record review for Resident #57 revealed an admitted d 04/28/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated [DATE] revealed Resident #57 was cognitively intact. The resident required extensive assistance for bed mobility, transfers, and toilet use. The resident was independent for eating. She was frequently incontinent for bowel and bladder. Review of the physician note dated 04/28/21 revealed no mention for a treatment to Resident #57's toe. Review of progress notes dated 04/29/21 revealed there was an area to the right foot second toe. Review of the Treatment Administration Record (TAR) for Resident #57 from 04/28/21 through 04/30/21 revealed the TAR was missing from the chart. Review of the progress notes dated 05/03/21 revealed Resident #57 was admitted with a diabetic ulcer to the right second toe dorsal surface. New order was for [MEDICATION(S)] moistened gauze to ulcer and cover with dry gauze, twice daily and Aquaphor, to left toes daily, wound specialist visit weekly at the facility. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Resident #57 on 05/23/22 at 10:29 A.M. revealed she didn't get her dressing changes on her right foot second toe like she should have been Interview with Licensed Practical Nurse (LPN) #118 on 05/26/22 at 11:05 A.M. revealed she was the admitting nurse for Resident #57 and admitted she did not put a treatment in place for the resident's toe. She said normally when a new admission came into the facility the unit manager would look at the wound the next day and call the physician for a treatment. She said the unit manager no longer worked at the facility.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, observation, staff interview, family interview, review of written statements by staff, review of a police report and review of a facility policy, the facility failed to provide adequate supervision to prevent the elopement of a resident. This resulted in Immediate Jeopardy when one resident (Resident #18) was placed at risk for potential serious harm and injury when the resident eloped from the facility, without staff knowledge, and was missing for approximately two and a half hours. The resident was found across the street from the facility by the police about 200 feet from the facility. The resident was walking back to the facility with a 35 mile per hour speed limit, and two lanes of moving traffic with a blind turn. This affected one (#18) of three residents reviewed for risk of elopement. Additionally, the facility failed to prevent the elopement of another cognitively impaired resident (Resident #10) from a secured care unit placing the resident at risk for potential harm that did not rise to the level of Immediate Jeopardy when she left the secured unit and eloped from the facility, unknown to staff, and fell out of her wheelchair and onto the curb in the facility parking lot. The facility identified eight (#10, #18, #50, #55, #68, #70, #90 and #131) residents at high risk for elopement. The facility census was 99. On 09/02/20 at 2:51 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 07/20/20 at 7:00 P.M. when Resident #18 left his room, went through a double door and a sliding glass door and eloped from the facility, unknown to staff. At approximately 8:57 P.M., the resident was located walking back to the facility across the street. The Immediate Jeopardy was removed on 07/24/20 when the eight residents at risk for elopement were reassessed, their Wanderguard alarms were checked for functionality, and staff were educated on the facility's elopement policy. The deficiency was corrected on 07/24/20 when the facility implemented the following corrective actions: · On 07/20/20, Resident #18 was moved to the secured memory support unit. · On 07/20/20, all Wanderguard alarms for Residents #10, #18, #50, #55, #68, #70, #90 and #131 were checked for functionality by the DON. · On 07/20/20, the status of the locking systems on all doors were checked daily by Plant Supervisor (PS) #639 and Plant Maintenance Staff (PMS) #637 and #642. · On 07/20/20, all new hires were being provided education during orientation. The facility's Elopement Policy as well as a course entitled Wandering: Elopement Prevention will be provided by Human Resource Director #408. · On 07/21/20, an elopement drill was completed by the DON and PS #639 with no identified concerns. · On 07/21/20, a meeting with the interdisciplinary team was directed by the DON to discuss safety compliance requirements and steps that were immediately implemented for the safety of the residents who were at risk for elopement in the facility. · On 07/22/20, elopement risks were completed. Registered Nurse (RN) #634, who was involved in the incident with Resident #18, was counseled by the Assistant Director of Nursing (ADON) #200. · On 07/24/20, all staff were inserviced on the facility's elopement policy. · On 07/24/20, all residents were assessed for elopement by ADON #200 and Care Team Managers (CTM) #641 and #102. Findings include: Medical record review for Resident #18 revealed an admission date of [DATE]. The resident had medical [DIAGNOSES REDACTED]. Review of the Elopement/Unsafe Wandering Risk Assessment, dated 07/17/20, revealed Resident #18 was at risk for elopement/or unsafe wandering. Review of the baseline care plan, dated 07/17/20, for Resident #18 revealed he was admitted with behavior concerns related to wandering. The interventions were to place a Wanderguard and maintain the current alarm as ordered. Review of Resident #18's admission Minimum Data Set (MDS) assessment, dated 07/24/20, revealed the resident's cognitive status was moderately impaired. He required limited supervision for bed mobility, transfers, and toileting. He required supervision for eating, and locomotion on and off the unit with one-person assistance. He used a Wanderguard daily, because he was at a significant risk of getting to a potentially dangerous place and the wandering significantly intruded on the privacy of others. Review of the exit door checks documentation dated 07/20/20 at 4:00 P.M. revealed the Terrace Unit double sliding glass doors were unlocked. Review of the facility's incident summary, dated 07/20/20, revealed it was reported at 6:00 P.M. that Resident #18 was missing from the facility. A search began inside and outside the facility grounds. The Administrator, DON, ADON #200, Licensed Social Worker (LSW) #629 and Activity Director (AD) #01 responded to the call. Family was notified. The police were notified and within minutes the resident was found across the street. He was assessed for injuries and none were found. The resident was wearing the Wanderguard. The physician was notified of the incident and agreed to place the resident on a secured unit. The evening maintenance staff checked the egress doors and adjusted the alarm to make it more sensitive. Resident #18 was moved to the secured unit and the Wanderguard remained on the resident. All door alarms were checked with no fault noted. All Wanderguards were checked, all were in place and were functioning. Review of the interview statement with RN #634 on 07/20/20, no time documented and typed by the DON, revealed when making rounds towards the end of her shift, RN #634 could not locate Resident #18. The DON explained the elopement procedure over the phone. RN #634 stated she and State tested Nursing Assistant (STNA) #252 looked on the unit but couldn't find him. They alerted other units and they joined in the search. She reported that neither she nor STNA #252 heard a door alarm. RN #634 called the resident's family and reported the incident. The police were called when staff could not find the resident. The statement stated the resident was returned to the facility by the police and had been across the street from the facility. Review of the interview statement with STNA #252, no date or time documented and typed by the DON, revealed she was notified by RN #634 that Resident #18 could not be found. She proceeded to check all rooms, closets, bathrooms, and offices and could not locate him. She reported back to the charge nurse. Review of the 911 incident detail report dated 07/20/20 for Resident #18 revealed RN #634 called 911 on 07/20/20 at 8:47 P.M. and reported Resident #18, with [DIAGNOSES REDACTED]. He was wearing a brown brimmed straw hat, peach colored shirt, and a blue short sleeved shirt underneath, gray pants, and white gym shoes. According to the report, Resident #18 was found across the street from the facility at a business, walking back to the facility at 8:57 P.M. Review of a late entry progress note, dated 07/21/20 at 8:56 P.M. and written by RN #634, revealed Resident #18 was observed in the facility on 07/20/20 at 6:30 P.M. eating in the common area. The note revealed he was not present in his room on walking rounds. Room checks were initiated along with a search of the facility grounds. The facility supervisor, the resident's Power of Attorney (POA), and physician were notified. The resident was found by STNA #252 and redirected back to his room without difficulty. The resident was placed on a memory care unit at 9:00 P.M. Observation of the street in front of the facility on 08/27/20 at 12:13 P.M. revealed it was a 35 mile per hour speed zone on the street. There was a blind turn before you pass the facility. A half a block from the entrance to the facility, there was a building that was part of the facility. Two hundred feet across the street was an industrial building with a parking lot. The traffic was light, and the cars came quickly around the blind turn by the facility entrance. Interview with the DON on 08/27/20 at 1:15 P.M. revealed Resident #18 was reported missing on 07/20/20 at around 6:00 P.M. He was wearing a Wanderguard at the time. She said either the staff didn't hear the Wanderguard alarm because they were busy, the system malfunctioned, or the alarm could have been possibly turned down. She stated interviews with the staff said they didn't hear the alarm. She said a search was done as soon as possible inside the building and when they didn't find him, the search began outside. She stated it was dry and warm and Resident #18 was found across the street. It only took about 20 minutes to find him and he was not injured. She said the police were with the resident but since he was found so quickly, they didn't write a report about it. Interview with PS #639 on 08/27/20 at 1:33 P.M. revealed it was about 6:00 P.M. or so when Resident #18 eloped from the facility. He stated he had just arrived at the facility and the resident was in the lobby and was not injured. He stated he walked Resident #18 in and out of the doors but when he walked him out of the doors, the alarms didn't sound. When he walked him into the facility, the alarms sounded. He stated he adjusted the sensitivity of the alarm and walked the resident in and out and the alarm sounded every time. Observation of Resident #18 on 08/27/20 at 2:19 P.M. revealed he was lying in bed and said hello. During observation on 08/27/20 at 2:43 P.M., Resident #18's prior room was examined with the DON. He lived on the Terrace Unit at the time of the elopement. He walked approximately 500 feet to a set of double doors. There was a posting on the door stating the alarm would sound if the door was opened longer than 15 seconds. When tested , the door alarmed after being opened for 15 seconds. To the immediate left, there was a set of sliding double doors that were not locked. According to the DON, the staff wouldn't be able to hear those doors alarm. She said it was discovered the doors were pried open and off the track. Across the street, adjacent to the doors of the facility, about 200 feet away, was the parking lot of an industrial building where Resident #18 was found. During an interview on 08/31/20 at 12:29 P.M., RN #634 stated the incident happened on 07/20/20 in the evening. She charted a late entry on 07/21/20. She stated Resident #18 was sitting in the common area by the nursing station eating dinner about 6:40 P.M. and she was asked by an STNA, who she couldn't remember the name, to help check and change a resident. She stated she felt like Resident #18 eloped when she was in the other resident's room. She stated she did not hear the door alarm sound. At 7:00 P.M. she was doing walking rounds and went into the resident's room and he wasn't there. She said she alerted staff to search for the resident and alerted the DON, POA and physician. She stated he wasn't found in the facility and so the search ensued outside. He was found at 7:30 P.M. across the street because he thought he worked there. She assessed him and he was uninjured. During an interview on 08/31/20 at 2:55 P.M., STNA #252 stated they noticed about 6:40 P.M. Resident #18 wasn't in his room. She stated she did not hear an alarm sound. They did a search, and everyone was looking for him. They couldn't figure out how he got out of the facility. She said it was at shift change and everyone was looking for him in the facility and moved to the outside of the facility too. She stated she was walking to her car about 7:30 P.M. and the officers had a man detained across the street in the parking lot. She remembered what clothes the resident was wearing. She walked over and discovered it was Resident #18. She said she handed Resident #18 over to the nurse. Review of STNA #252's timecard revealed on 07/20/20 she punched out at 8:40 P.M. Interview with Police Officer #300 on 09/01/20 at 11:15 A.M. revealed there wasn't an officer's report filed for the elopement for Resident #18. She revealed there was a call that came into the precinct of a trespasser in the parking lot of a business across the street from the facility, which was identified as Resident #18. She stated the call came in at 8:29 P.M. and he was located at 9:02 P.M. Interview with the DON on 09/01/20 at 3:42 P.M. revealed she thought the incident with Resident #18 happened around 6:00 P.M., even though the documentation stated he was last seen at 6:30 P.M. in the common area. The DON was informed of the time frame that was received from the police department did not match what the facility documented. She stated, I guess the police would be correct on the timing of the incident. She stated she instructed RN #634 to call the police when the nurse informed her the resident was missing but didn't know what time that was. She said she left the faciity on [DATE] at 9:00 P.M. and the resident was in the facility safe. Subsequent interview with the DON on 09/02/20 at 10:29 A.M. revealed RN #634 called 911 on 07/20/20 past the time she stated to the DON. The DON stated she was out in her car looking for the resident and perhaps the nurse was waiting to hear from her if he was found, to determine if she needed to call 911. When asked why she reported in her investigation he was found within 20 minutes of eloping, she said she didn't know why. When asked why she put in her investigation the incident happened at 6:00 P.M. when it was clearly documented in the medical record he was last seen at 6:30 P.M., she said it was an error. 2. Medical record review for Resident #10 revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 07/15/20, revealed Resident #10 was severely cognitively impaired. She required extensive assistance for bed mobility, transfers and toileting. She required supervision for eating. She used a Wanderguard daily. Review of the Elopement/Unsafe Wandering Risk assessment dated [DATE] revealed Resident #10 was at risk for elopement/or unsafe wandering. Review of the care plan for Resident #10, dated 06/22/20, revealed she was an elopement risk as evidenced by history of resident wandering aimlessly and impaired safety awareness. Interventions were for resident to wear identification bracelet at all times, utilize and check Wanderguard placement as indicated, redirect resident from exit doors, maintain calm attitude when redirecting the resident during a behavior, make sure all staff are aware of elopement risk and the resident resided on the secured unit. Review of the investigation for Resident #10 revealed on 07/18/20 it was reported to the charge nurse Resident #10 had attempted to leave the property. The nurse reported she last saw Resident #10 at 6:45 P.M. Staff were alerted, and the resident was found in the front of the building on facility property. The resident stated she was going home. Resident #10 was assessed and there were no injuries found. She had her Wanderguard on. The physician and family were notified of the incident and one-on-one supervision was initiated. Review of a witness statement from STNA #180, dated 07/18/20, revealed on that date at 6:50 P.M., she pulled into the facility parking lot and saw Resident #10 just outside the Newberry Unit exit door. She immediately called the supervisor's phone and reported the resident was on the sidewalk. Review of the witness statement from STNA #437, dated 07/18/20, reported she was working on the unit for Resident #10 but was with another resident and didn't see or hear anything. Review of the witness statement from Licensed Practical Nurse (LPN) #651, dated 07/18/20, revealed she notified the DON of Resident #10 being outside on this date a little before 7:00 P.M. She stated she saw the resident 15 minutes prior to her being found outside. She was exit seeking all day. There were four nurses and STNA's outside when LPN #651 arrived at the resident. She stated the wheelchair was on the sidewalk and the resident was sitting on the curb. No injuries were noted, and vital signs were within normal limits. Three nurses helped assist the resident to her wheelchair. The Wanderguard was working and setting off the alarms on the way back in the facility. The resident had no complaints of pain. Neurological checks were initiated, and a full body assessment was completed with no abnormal findings. On 07/19/20, Licensed Social Worker (LSW) #629 documented a conversation with the resident's family regarding placement on the secured unit. The family declined to move her at that time and one-on-one continued. On 07/22/20, she was moved to the secured unit. Observation of Resident #10 on 08/27/20 at 2:22 P.M. from the hallway revealed she was lying in bed asleep. Interview with LSW #629 on 09/01/20 at 4:15 P.M. revealed Resident #10 was admitted to the skilled unit on admission, because she came from another facility and had to be in 14-day quarantine because of Covid-19. She stated the family of the resident did mention the resident may need to be placed on a more secured unit. LSW #629 said the facility didn't see any behaviors when she came in and there were no conversations with the family that would suggest elopement. During interview on 09/02/20 at 7:08 A.M., STNA #180 revealed as she was pulling into the driveway of the facility at the Transitional Care Unit emergency door in front of the building on 07/18/20 at about 6:25 P.M., Resident #10 was sitting sideways in her wheelchair on the curb right outside of the facility. She said since the resident was a large woman, she ran into the building to get help from another staff member and both went back outside. The resident had fallen out of the wheelchair and was sitting on her buttocks and was not injured. She stated the resident said she was going home and was angry with staff for trying to help her. She stated the resident had her Wanderguard on and the staff members couldn't figure out how she got out of the facility. Interview with LPN #651 on 09/02/20 at 10:34 A.M. revealed Resident #10 had a history of [REDACTED]. She said on 07/18/20 the resident was exit seeking all day and had set off the alarm earlier in the day and the nurse wheeled her back to her room. She stated at 6:30 P.M. she saw the resident and at approximately 6:45 P.M., a nurse came to get her and said the resident was out in the parking lot. She stated she went to assess the resident and she had fallen out of her wheelchair and was sitting on her buttocks with her legs out straight and was up against the curb and the wheelchair was on the curb. She said she didn't have any injuries and the nurse had staff help her get the resident back to her room and called the physician and the POA. She said the POA had voiced to her she wanted the resident to be placed on the secured unit upon admission and was told the facility would have to see the behaviors for themselves before placing her on a secured unit. She stated the POA told her she had a history of [REDACTED]. Review of the facility policy titled Missing Residents, no date, stated if an employee discovers a resident missing from the facility, he/she shall determine if the resident is out on an authorized leave; if not, initiate a search of the buildings and premises. If the resident is not located, notify the Administrator and the Director of Nursing, the resident's legal representative, the attending physician, law enforcement officials and as necessary, volunteer agencies. Provide search teams with resident identification information and initiate an extensive search of the surrounding areas. When the resident returns to the facility, the DON or Charge Nurse shall examine the resident for injuries, contact the attending physician and report findings, notify the resident's legal representative, notify search teams the resident has been located, complete and fill and incident report and document relevant information in the resident's medical record. This deficiency substantiates Complaint Number OH 310.

Based on medical record review, observation, staff and resident interview, review of e-mail communication, review of a witness statement, review of the hospital discharge summary, review of the facility's Abuse, Neglect and Exploitation policy, the facility failed to ensure a cognitively impaired resident (#50) was free from sexual abuse from Resident #12, who had a history of [REDACTED].#12's room and he had Resident #50's breast in his mouth. This resulted in Immediate Jeopardy for one (#50) of five residents reviewed for abuse. Additionally, this placed 14 (#02, #03, #05, #07, #08, #10, #13, #14, #15, #16, #17, #18, #20 and #21) other cognitively impaired female residents, who reside on the Fountains Unit where Resident #12 has unrestricted access, at risk for potential abuse. The facility census was 99. On 08/18/20 at 3:01 P.M., the Administrator and the Director of Nursing (DON) were notified that Immediate Jeopardy began on 07/31/20 when Resident #12, who had a history of [REDACTED].#50 and he had her breast in his mouth. The Immediate Jeopardy was removed on 08/18/20 at 8:00 P.M., when the facility implemented the following corrective actions: · On 08/18/20, following the Immediate Jeopardy notification, Resident #12 was placed on one-to-one (1:1) staff supervision until appropriate placement could be found. Licensed Social Worker (LSW) #411 and Care Team Manager (CTM) #102 began actively pursing alternative placement for Resident #12 to a specialized unit. · On 08/18/20 at 4:30 P.M., the Administrator and the DON conducted a meeting with the Interdisciplinary Team (IDT). Those in attendance included LSW #411, Registered Nurse (RN) #255, CTMs #102 and #641 and Human Resource Director (HRD) #408. The IDT members discussed allegations of compliance requirements and steps they needed to immediately implement for resident safety on the Fountains Unit. · On 08/18/20 by 7:30 P.M., RN #255 and CTM #102 completed a physical assessment on all female residents who resided on the Fountains Unit. The assessment included assessing for any unexplained redness, bruising and/or wounds. There were no negative findings or concerns identified. · On 08/18/20 by 7:30 P.M., LSW #411 completed a psychosocial assessment on all female residents who resided on the Fountains Unit. The assessment included unexplained agitation, crying for no reason and fear of other residents. There were no negative findings. LSW #411 also completed Patient Health Questionnaire (PHQ-9) assessments at the same time. This questionnaire is used to determine depression. There were no negative findings identified. · On 08/18/20 by 8:00 P.M., the DON and HRD #408 completed in-service education to the staff who worked on the Fountains Unit to include seven Licensed Practical Nurses (LPNs) and 12 State tested Nursing Assistants (STNAs). The education included a review of the abuse regulation, review of the facility Abuse Program including policies, procedures and reporting responsibilities. The DON and HRD #408 also reviewed the issues with Resident #12 and #50 and the corrective action the facility was implementing. · On 08/18/20, the Administrator and DON implemented an audit tool to ensure staff could define and identify abuse as well as explain the immediate actions and reporting structure requirements. These audits will be conducted randomly on the Fountains Unit three times a week for four weeks and then monthly for two months. The Quality Assurance Committee will review the audits to determine if further monitoring is needed. Although the Immediate Jeopardy was removed on 08/18/20 at 8:00 P.M., 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 is still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the medical record revealed Resident #50 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #50's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and never or rarely made decisions. Resident #50 required extensive assistance with bed mobility, transfers, and dressing. Review of Resident #50's behavior care plan dated 08/01/18 revealed the resident was noted to refuse care at times. Resident #50's mood fluctuated related to decreased cognition and she had a history of [REDACTED]. Resident #50 wandered throughout the unit daily and had a history of [REDACTED]. Resident #50's behavior care plan also indicated the resident had sought out intimacy with another resident, (unable to verify when this was added to the care plan). On 08/01/20 an approach was added for staff to honor the resident's right for initiating a relationship with other residents and provide privacy during periods of intimacy. Review of a nurse's progress note dated 07/31/20 at 9:08 P.M. revealed LPN #105 documented Resident #50 was found in a male resident's (#12) room and the male resident had Resident #50's breast in his mouth while urinating on himself. STNA #01 immediately called for help and removed Resident #50 from the male's room. The physician, DON, supervisor and responsible party were notified. Review of STNA #01's witness statement dated 07/31/20 revealed STNA #01 was looking for Resident #50 to give her a shower and found her in Resident #12's room and he had his mouth on Resident #50's breast. Resident #12's hand was on Resident #50's other breast while he was urinating on himself. STNA #01 immediately assisted Resident #50 out of harm's way and reported it to the nurse at 6:50 P.M. Further review of Resident #50's progress notes revealed a late entry by CTM #102 dated 08/13/20 that indicated on 07/31/20, Resident #50 was found in Resident #12's room in the midst of a sexual act. Resident #50 was in a pleasant mood in enjoyment. The residents were immediately separated and both families were notified. Resident #50's representative laughed and stated, well I hope she enjoyed it, that's probably the most enjoyment she's had in a while. Observation of Resident #50 on 08/13/20 from 12:45 P.M. to 1:05 P.M. revealed the resident was wandering the hallway on the Fountains Unit. On 08/13/20 at 1:00 P.M., an interview was attempted with Resident #50, but she was unable to be interviewed due to her cognition. Interview with STNA #01 on 08/13/20 at 1:05 P.M. revealed STNA #01 observed Resident #12 with Resident #50's breast in his mouth. STNA #01 stated it looked consensual, but she reported the incident to the nurse and filled out a witness statement. On 08/19/20 at 7:32 A.M., care plan revision dates were requested from the Administrator and DON. Review of e-mail communication dated 08/19/20 at 2:52 P.M. from the Administrator indicated the facility could not provide edit date history for Resident #50's behavior care plan for the issue of the resident seeking out intimacy with another resident. Review of the medical record revealed Resident #05 was admitted on [DATE] and had a pertinent [DIAGNOSES REDACTED]. Review of Resident #05's MDS assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with dressing. Review of Resident #05's progress notes revealed on 05/02/20 at around 4:00 A.M. the night shift STNAs were doing rounds and observed the resident in a room with another resident (#12) and the resident was undressed. Review of Resident #05's care plan revealed Resident #05 was care planned on 05/15/20 for recent undressing with another resident. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE]. Pertinent [DIAGNOSES REDACTED]. Review of Resident #20's MDS assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with dressing. Review of Resident #20's progress notes dated 07/05/20 revealed Resident #20 was noted lying in bed with her bottoms off in a male resident's (#12) room. Resident #20 was asked what happened and the resident replied Thank god you came and got me. I was ready to go. Resident #20 was assessed with [REDACTED]. Review of Resident #20's care plan revealed Resident #20 was care planned on 07/07/20 for undressing in public and frequently taking her pants off. Closed medical record review revealed Resident #115 was admitted to the facility on [DATE]. Pertinent [DIAGNOSES REDACTED]. The resident discharged from the facility on 08/01/20. Review of Resident #115's MDS assessment dated [DATE] revealed the resident was severely cognitively impaired and rarely or never made decisions. Resident #115 required extensive assistance with bed mobility and dressing. Review of Resident #115's progress notes dated 06/14/20 at 6:50 P.M. revealed a resident (#12) was discovered coming out of Resident #115's room by STNAs. The incident was immediately reported to the nurse. Resident #115 was immediately checked on and was in bed with her eyes closed. The resident was easily aroused by voice and denied anyone being in her room. Review of the medical record of Resident #12 revealed he was admitted to the facility on [DATE]. Pertinent [DIAGNOSES REDACTED]. Review of Resident #12's MDS assessment dated [DATE] revealed the resident was severely cognitively impaired and required limited assistance with bed mobility, transfers, and personal hygiene. Review of Resident #12's acute care plan for alternation in behavior related to symptoms of seeking out intimacy with female residents revealed on 05/02/20 an intervention was added for the resident's rooms to be shut at night and staff were to observe the residents nightly. On 05/19/20 the intervention to provide redirection when attempting to enter another resident's room was added. On 06/09/20 the intervention of [MEDICATION NAME] (an [MEDICATION NAME] that has anti-androgen effects and reduces sexual desire in both sexes and affects arousal and orgasm), initiated by psychiatry, was added. On 07/14/20 the intervention of [MEDICATION NAME] (a mood stabilizer that is used to reduce compulsive sexual behavior) was initiated and Resident #12's [MEDICATION NAME] was discontinued. On 08/06/20 the intervention of [MEDICATION NAME] increased to 250 milligrams (mg) twice a day was added. On 08/07/20 the intervention of a door alarm to Resident #12's door was added. Review of Resident #12's care plan dated 08/05/20 revealed Resident #12 desired intimacy and a possible relationship with women. Interventions included to administer medication as ordered per the physician, communicate with the physician as needed for any increase in anxiety or discomfort, refer to mental health for evaluation and treatment, a motion activated door bell was in place to notify staff when anyone goes in or out of the resident's room, provide non pharmaceutical interventions as needed for increased anxiety, monitor resident's relationships and offer emotional support, honor the resident's right for privacy and relationships and provide privacy during periods of intimacy and communicate with resident's family as needed in regards to relationship status. Review of Resident #12's progress notes dated 04/29/20 at 6:08 A.M. revealed Resident #12 was noted to be making sexual comments towards residents and staff. On 05/02/20 around 4:00 A.M., unnamed night shift STNAs were doing rounds and observed Resident #12 in the room with a female resident (#05) who was undressed. Resident #12 was also undressed, and he stated nothing sexual had occurred. The STNAs separated the residents from each other. On 05/04/20 (two days later) Resident #12's physician was made aware of the resident's sexual behaviors. On 05/19/20, Resident #12 was in a dark room with another female resident (#50), who was fully clothed. Resident #12 was reaching out to Resident #50 attempting to touch her. The residents were separated from each other. On 06/03/20 Resident #12 was making inappropriate remarks to staff and the resident was educated. Review of Resident #12's physician's orders [REDACTED].#100 prescribed [MEDICATION NAME] 300 mg twice a day for sexually inappropriate behaviors. Review of progress notes dated 06/10/20 at 5:03 A.M. revealed Resident #12 was noted watching a sexual movie on his personal television and stated, I could watch this movie over and over again. On 06/14/20 at 7:17 P.M., Resident #12 was noted coming out of a female resident's (#115) room by STNAs #180 and #181. Resident #115 was in her bed with her eyes closed. Resident #115 was easily aroused and denied anyone ever being in the room and she appeared in no emotional distress. A physical examination was completed on Resident #115 and the physical was negative. On 07/05/20 at 6:00 A.M., Resident #12 was noted to have another female resident (#20) in his room with her bottoms off underneath the covers. Resident #12 was reported to move away from the bed when nursing staff entered the room. Resident #12 was educated on inappropriate behavior and his routine [MEDICATION NAME] was given. Review of Resident #12's psychiatric progress note dated 07/14/20 revealed the resident was seen by Psychiatric Nurse Practitioner (PNP) #101. The progress note indicated Resident #12 was followed by psychiatry for a history of dementia with behavioral disturbances (his list of active [DIAGNOSES REDACTED]. PNP #101 was requested to follow up for two reasons including a report that Resident #12's insurance would not cover the cost of [MEDICATION NAME] and a female resident was found in resident's room with her pants off. The progress note documented a unit manager indicated this female resident was known for disrobing and wandering into the other resident's rooms. There was no report that the resident was witnessed to have acted inappropriately in this instance. Review of the physician order [REDACTED]. Review of Resident #12's psychiatric progress note dated 07/29/20 revealed the resident was seen by PNP #101. The progress note indicated Resident #12 was followed by psychiatry for a history of dementia with behavioral disturbances, depression and sexual inappropriate behavior. The note indicated PNP #101's last contact with Resident #12 occurred on 07/14/20 and at that time Resident #12 was noted with continued inappropriate sexual behavior despite trial of [MEDICATION NAME]. [MEDICATION NAME] was discontinued and [MEDICATION NAME] 125 mg two times a day was started for management of sexual behavior. There was no report of the resident in any inappropriate sexual behavior since starting [MEDICATION NAME] on 07/14/20. Review of progress notes dated 07/31/20 at 7:25 P.M. revealed Resident #12 was found in his room with another female resident's (#50) breast in his mouth while urinating on himself. STNA #01 immediately called for help and removed Resident #50 from the room. The physician, DON, supervisor and responsible party were notified of the incident. Further review of the progress notes revealed transportation was contacted, and the resident was sent to the hospital around 8:30 P.M. to 9:00 P.M. Resident was being closely monitored on 1:1. Review of Resident #12's hospital discharge summary dated 08/01/20 revealed the resident was seen for increased agitation and being hypersexual with another resident. The summary indicated nursing home staff reported the resident was more agitated and hypersexual. Staff reported Resident #12 was normally sexual with staff, but it was getting worse. Staff at the nursing facility reported Resident #12 had another resident's breast in his mouth and was peeing on himself. Resident #12 was provided with community resources for counseling and psychiatry. Medically acute reasons for mental status were ruled out and the resident was evaluated by the physician, social work and psychiatry. Resident #12 was recommended to follow up with primary care physician and psychiatry in the outpatient setting for further assessment and management. Review of Resident #12's one-on-one monitoring log revealed it had blocks for 30 minute checks. The 30 minute checks were initiated on 08/01/20 at 1:00 P.M. and continued until 08/06/20 at 6:30 P.M. There were no 30 minute checks documented as being completed beginning 08/06/20 from 6:30 P.M. until 08/07/20 at 6:30 A.M. Resident #12's 30 minute checks were documented as being completed on 08/07/20 at 7:00 A.M. until 08/12/20 at 11:00 A.M. Review of progress notes dated 08/05/20 at 4:40 P.M. revealed the resident on 1:1 care, an STNA walked in and found the resident standing in front of the television jacking off. Review of progress notes dated 08/06/20, revealed CTM #102 spoke with PNP #101 regarding Resident #12's increased sexual desires. PNP #101 recommended an increase in Resident #12's [MEDICATION NAME] from 125 mg to 250 mg two times a day. Review of physician orders [REDACTED]. Review of progress notes dated 08/07/20 at 11:26 A.M., as an addendum, CTM #102 documented the resident's daughter informed CTM #102 that her father had been a Gigolo all his life. CTM #102 educated the daughter for the safety of the other residents and himself the increase in medication ([MEDICATION NAME]) was needed. CTM #102 also brought up the possibility the resident might need the services of a men's unit due to behaviors. Review of progress notes dated 08/10/20 revealed Resident #12 had a motion sensor alarm placed on his door on 08/07/20 which was used as an intervention to notify staff of residents or fell ow residents entering and exiting the residents' room. Review of Resident #12's psychiatry progress note dated 08/11/20 revealed the resident was seen by Psychiatrist #100. Resident #12 was seen due to a history of dementia with behavioral disturbance, depression and sexually inappropriate behavior. The note indicated Resident #12 was given a trial of [MEDICATION NAME] and more recently was started on [MEDICATION NAME]. The [MEDICATION NAME] dose was increased to 250 mg twice daily on 08/06/20. The note also indicated Resident #12 was currently on 15 minute checks in order to limit the potential for contact with female residents on the unit (the facility was only completing 30 minute checks). Review of the late entry progress note dated 08/17/20 indicated Resident #12's physician and family were notified of Resident #12's sexual behavior on 05/02/20, 06/14/20 and 07/05/20. Further review of the late entry progress note also indicated on 07/05/20 a large name plate was placed on Resident #12's door to alert residents not to enter and on 08/06/20, 30 minute checks were completed on third shift. Interview with Resident #12 on 08/13/20 at 1:11 P.M. revealed the resident denied having any sexual relationships or participating in any sexual acts at the facility. Interview with STNA #02 on 08/13/20 at 1:15 P.M. revealed Resident #12 had a history of [REDACTED]. Interview with the DON and Administrator on 08/13/20 at 1:25 P.M. revealed Resident #50 was found in Resident #12's room on 07/31/20. Resident #12 had Resident #50's breast in his mouth at that time. The DON stated the facility separated the residents and called Resident #12 and Resident #50's family. The DON reported Resident #12's representative stated the resident had always been a gigolo and Resident #50's resident representative stated that she was glad Resident #50 was having fun. The DON stated the facility did not suspect abuse and a Self-Reported Incident (SRI) was not completed. The DON stated Resident #12 and Resident #50 were seeking out each other. The DON stated Resident #50's cognition varied at times. The DON and the Administrator did not report any other sexual behaviors in the facility at that time. On 08/17/20 at 4:28 P.M., capacity to consent assessments for Resident's #05, #20, #50 and #115 were requested from the administrative staff but were never provided. After the surveyor reviewed Resident #12's medical record and found other instances of possible inappropriate behavior, a telephone interview with the DON and CTM #102 was conducted on 08/17/20 at 4:29 P.M. to discuss the instances. On 05/02/20 the unnamed night shift STNAs were doing rounds and observed Resident #12 in the room with Resident #50. Both residents were undressed with their shirts off and Resident #12 stated nothing sexual had occurred, but he was separated from Resident #50. On 05/02/20 redirection was implemented, and a care plan was put in place to ensure resident rooms were shut at night and to observe residents nightly. On 05/19/20 Resident #12 was in a dark room with Resident #50 whom was fully clothed. Resident #12 was noted to be reaching out to Resident #50 and attempting to touch her. Resident #12 and Resident #50 were separated. They stated redirection was provided at the time. On 06/03/20 Resident #12 had made inappropriate sexual remarks to staff and on 06/08/20 the resident was prescribed [MEDICATION NAME] 300 mg two times a day for sexual behaviors. On 06/10/20 Resident #12 was watching a sexual movie. On 06/14/20 Resident #12 was noted coming out of Resident #115's room by STNAs. Resident #115 was in her bed with her eyes closed. Resident #115 denied anyone ever being in the room and appeared in no emotional distress and her physical exam was negative. The DON stated redirection was provided at that time. On 07/05/20 Resident #12 was noted to have another female resident (#20) in his room with her bottoms off underneath the covers. Resident #12 was noted to move away from the bed when staff entered the room. They verified education was provided to Resident #12 on inappropriate behavior. On 07/14/20 Resident #12's [MEDICATION NAME] was initiated. On 07/31/20 Resident #12 was found with Resident #50 in his room with his mouth on her breast while urinating on himself. CTM #102 stated Resident #12 was sent to the hospital and 30 minute checks were initiated upon his return from the hospital. The DON verified that 30 minute checks were not documented on third shift on 08/06/20 but she would check with staff to see if the checks were completed or documented in another area. On 08/05/20 Resident #12 had a care plan implemented for desiring intimacy and a possible relationship with women and on 08/06/20 his [MEDICATION NAME] was increased. On 08/07/20 Resident #12 also had a door alarm installed. Both the DON and CTM #102 were unable to verify if any other interventions were attempted or if the physician or responsible parties were notified for any of the above occurrences. Telephone interview with the Administrator on 08/18/20 at 8:28 A.M. revealed the resident actions were often misperceived by the direct care staff and that no one had any intent with any of the sexual incidents that occurred with Resident #12. The Administrator stated that some of the females had sought out companionship. The Administrator stated she was new at the facility and was not able to speak for what the former Administrator did regarding the above incidents. Review of an undated list of residents with sexual behaviors received on 08/13/20 revealed Resident #12 and Resident #50 were listed to exhibit sexual behaviors. Review of the facility's Abuse, Neglect and Exploitation policy dated 11/26/16 revealed the facility will protect its residents from abuse, neglect, mistreatment, exploitation and misappropriation of property. The policy also indicated sexual abuse was nonconsensual sexual contact of any type with a resident. Further review of the policy revealed a prompt and thorough investigation would be conducted. The investigation would include but not be limited to securing resident and witness interviews, gathering tangible evidence and documenting all information gathered. Any suspicions of a crime against a resident shall be reported to the appropriate state agencies. The policy also indicated the facility would monitor the resident for signs of mental, emotional, or physical abuse and notify the resident's physician and resident representatives. This deficiency substantiates Complaint Number OH 874.

Based on observation, medical record review, staff interview, and resident weight policy review, the facility failed to provide timely nutrition interventions for one resident who experienced actual harm as evidenced by additional unintended weight loss from the time the weight loss was detected until the physician was notified and additional nutritional interventions to deter additional weight loss was implemented. This involved one Resident (#203) of three residents reviewed for Nutrition, out of 30 Stage II sampled residents. The facility census was 140. Findings include: Review of the medical record revealed Resident #203 was originally admitted to the facility on [DATE], was sent to the hospital and readmitted back to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the minimum data set (MDS) assessment dated [DATE] identified Resident #3 as having short and long term memory problems with moderately impaired cognitive skills, having unclear speech, usually understanding others, sometimes understood by others, having altered level of consciousness at times, hallucinations, occasional verbal symptoms, and requiring the physical assistance of at least one staff person to complete all activities of daily living including eating. The resident was assessed as standing 67 inches tall, with no weight recorded on the assessment, the area where a weight was to be record was left blank. Resident #203 was assessed as being on a mechanically altered, therapeutic diet. Review of Resident #203's current September 2017 physician orders revealed the resident had orders for a pureed no concentrated sweets, large portion diet with nectar thick liquids. The consistency for the liquids was changed to 09/26/17 to honey thick liquids. In addition, the resident had an order effective 07/05/17 for 120 milliliters (ml) of a commercial nutritional supplement yielding 1.8 calories per ml three times a day. On 09/26/17 Resident #203's physician wrote an order for [REDACTED]. supplement receive 240 cubic centimetre (cc's) of Nepro (nutritional supplement) four times a day. Review of Resident #203 weight history revealed the following weights with corresponding dates: 03/03/17 206 pounds (#) 03/09/17 205 # 03/16/17 207 # 03/25/17 196 # 04/03/17 185 # 05/03/17 186 # 09/19/17 128 # 09/27/17 125 # Review of Resident #203's progress notes, completed by unit manager Registered Nurse (RN) #115, and Registered Dietitian (RD) #146 revealed the resident was identified as being at nutritional risk On 07/03/17 RN #115 documented in the residents medical recorded the resident was taking food and fluids poorly due to cognition, unable to process swallowing fluids. RN #115 noted the resident's physician was notified of the resident's change in status, and asked if she could talk to the wife about options with the resident's care. The resident remained a Full Code per the wife's wishes. The nurse documented when she spoke with the wife to discuss options including hospice and possible gastrostomy tube placement for nutrition, she explained the dementia process. RN #115 noted the wife wanted the resident to have a modified [MEDICATION NAME] swallow (MBS) to see if he was safe for oral diet and fluids. On 07/05/17 RD #146 documented in the resident's progress note the resident's food/fluid intakes were variable and poor, and noted the resident's ongoing weight loss. He noted no recent weight was available related to the resident's combativeness and agitation. RD #146 noted he suspected continued weight loss related to hospitalization , decline, dysphagia, and increased dementia. The dietitian documented the resident was fed by staff, eats better for some meals based on alertness, and spits out food at times. The MBS today (07/05/17) showed the resident was okay for thin liquids though he continues to cough. Nursing will fax the physician for desired fluid thickness, and will start supplements Nepro 120 cc's three times a day. RN #146 noted nursing discussed hospice versus a tube feeding with the wife of the resident, and wife was to make a decision regarding hospice shortly, as hospice was appropriate per the physician. The MBS completed on Resident #203 on 07/05/17 at a nearby hospital was reviewed. The speech and language pathologist completing the study recommended a dysphagia (pureed) diet with thin liquids, small bites and sips, alternate pureed food with liquids one to one, assist with all oral intake, and recommended treatment for [REDACTED]. On 09/26/17 at 4:45 P.M. Resident #203 weight history was reviewed, and the 58# weight change for the resident from 05/03/17 to 09/19/17 was found. At that time RD #146 was interviewed regarding the weight loss and he reported he was aware of the documented weight change and had requested a reweigh to affirm the weight recorded on 09/19/17 was correct, but the re-weight had not yet occurred. On 09/26/17, at 5:48 P.M., Resident #203 was observed sitting upright in bed being spoon fed by State tested Nurse Aide (STNA) #126. The resident was alert to himself, with some confusion. The resident was served a large portion pureed diet with honey thick liquids, he consumed 100% of all food and fluids left. On 09/27/17 at 8:19 A.M., RN #115 documented in the resident's record staff re-weighed the resident on 09/26/17; weight 125.8. She noted the residents appetite ranged from poor to good, and appetite depends on mood and behaviors. Resident at times sleeps most of the day, and the supplement (nutritional) was taken by the resident most of the time. RN #115 documented RD #146 was made aware of the weight loss with new orders noted to increase the Nepro (supplement) to 240 cc's four times a day. On 09/27/17, at 8:56 A.M., Resident #203 was observed sitting up in bed with a towel under his chin. The resident was alert, and talkative at this time. When asked if he had eaten breakfast he reported that he had, but stated he was still hungry. STNA #126 nearby in the hall was alerted that the resident was stating that he was hungry. She reported that he had eaten breakfast, and had eaten 100% of a double portion pureed diet and his thickened liquids. STNA #126 pointed to the resident's meal tray with tray card that she had just put on the tray cart. All of the food and fluids had been consumed. STNA #126 then went to the kitchen and returned with a bowl of oatmeal and 4 ounces of honey thick liquids and fed the resident, who ate the additional food items offered. On 09/27/17, at 12:51 P.M., Resident #203 was observed sitting up in bed, and STNA #126 was getting ready to feed the resident. The resident was served a large portion pureed diet with honey thickened liquids. When asked if he was hungry, Resident #203 stated yes. STNA #126 fed the resident all of his lunch On 09/27/17 at 4:03 P.M., RD #146 reported the resident was reweighed the evening of 09/26/17, and the residents re-weigh weight was lower than expected as he had lost an additional three pounds. RD #146 stated the problem was the resident would not let staff weigh him due to combativeness, did not know how often nursing attempted to weigh him after refusals, and the resident's intake was variable due to hepatic [MEDICAL CONDITION]. The nutrition progress note dated 09/27/17, completed by RD #146 was reviewed. RD #146 documented the resident had sustained a 37.4% weight loss over a six month period related to decline, dysphagia, and increased dementia. He noted the resident was fed by staff but would refuse to be fed at times. RD #146 noted the resident was being treated by speech therapy and down graded liquids to honey thick. He documented the supplement would be increased as follows: Nepro 240 cc's four times a day and four ounces of a frozen nutritional supplement with lunch and supper daily. RD #146 noted though hospice care was appropriate, his wife has declined tube feeding and hospice services in the past. An interview was conducted on 09/28/17 at 11:40 A.M. with unit manager, RN #115 who was responsible for coordinating Resident #203's care at the facility. When RN #115 was asked about the resident's significant weight loss she stated when the resident's weight was taken on 09/19/17, and his weight was low, she alerted RD #146 via email or told him verbally but did not recall exactly which. When asked about the omissions on the resident's weight record in June, July, and August of 2017 she reported the resident had been difficult to weigh, as they use a mechanical lift scale, and the resident becomes combative. She reported the resident's appetite fluctuated from not being awake enough to eat, to refusing to eat, to consuming 100%. RN #115 stated they tried to weigh the resident weekly, but did not have any documentation of this. She communicated when nursing detects a significant change in weight the dietitian was notified. RD #146 will request a reweigh, to confirm the weight loss. RN #115 was asked specifically if the resident's physician and family were notified of the 58# weight loss on 09/19/17 when the weight loss was first noted. She reported she was unsure if the physician and family of the resident were notified when the first low weight on 09/19/17 was taken, but they were notified when the resident was reweighed. There was no nursing progress note on 09/19/17 through 09/26/17 acknowledging the 58# weight loss, or notification of RD #146, or the resident' physician or family. On 09/28/17, at 1:22 P.M., a follow-up interview was conducted with RD #146 regarding when and how he was notified regarding Resident #203's significant weight loss. He stated he monitors all weights weekly on a routine basis. When a significant weight loss is entered into the computer, it will be flagged for review when he pulls them up to look at them. He shared he was not made aware personally of the weight loss of Resident #203 until he reviewed the weights, at which time he requested the re-weight on 09/26/17. He shared as soon as the resident was re-weighed and further weight loss was found, new interventions were initiated to attempt to prevent further weight loss. RD #146 affirmed the Resident Weights policy and procedure was to obtain re-weights immediately on any resident when a significant weight loss was found. Review of the facility Policy and Procedure titled Resident Weight reveled re-weights were to be obtained immediately on any resident with a weight change greater than five pounds for residents over 100 pounds, and greater than two pounds for residents less than 100 pounds.

Based on closed clinical record review, observation, staff interview, hospital record, policy review and information from the Mayo Clinic regarding dehydration the facility failed to timely address a resident's poor fluid consumption with an accompanying change in health status. This resulted in actual harm when the resident developed dehydration and required hospitalization for Intravenous (IV) re-hydration. This affected one (#184) of three residents reviewed for hydration status. The facility identified 60 residents who were at risk for dehydration. The facility census was 161. Findings include: Closed clinical record review revealed Resident #184 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nursing admission assessment dated [DATE] documented the resident was admitted to the facility for short term care, he was alert and oriented to person and situation, no height or weight was documented, skin turgor was noted without tenting, mucous membranes were dry and appetite was listed as fair. The Minimum Data Set (MDS) admission assessment dated [DATE] documented Resident #184 was cognitively impaired and he had an acute onset of mental changes. He required extensive assistance of two staff for bed mobility and transfer, one staff assistance with eating and he was always incontinent of bowel and bladder. Review of the physicians orders dated June 2015 documented Resident #184 was taking [MEDICATION NAME] (a diuretic) 40 milligrams daily. Review of the Nutritional assessment dated [DATE] documented Resident #184 had fluid needs calculated at 2500 cc based on the 06/02/15 weight of 219.6. There was no other recalculation of the fluid needs documented in the medical record. Resident #184 was downgraded to nectar thick liquids due to increase coughing. Review of the vital sign chart revealed weights were documented as follows: 06/02/15 219.6 06/03/15 170.6 06/03/15 166.4 06/04/15 160.7 06/05/15 165.6 06/07/15 165.6 06/07/15 162.3 There was no documentation in the medical chart that addressed the weight loss, the multiple weights for each day and/or the errors later brought up by the facility. Review of the Speech Therapy (ST) notes dated from 06/01/15 to 06/05/15 documented Resident #184 was seen on 06/01/15 due to increased coughing at this time and Resident #184 was downgraded to nectar liquids. On 06/03/15 nursing was notified of the increased drooling, inappropriate use of silverware, more lethargic and was to be up for all meals. On 06/05/15 he was more lethargic, no motivation to consume, no initiation of consumption and nursing staff was educated on the total assist with meals. Resident #184 would only accept three drinks of four offered to him and by this time he would gag after three swallows and he was holding fluids in his mouth. A severe swallowing decline was noted. Review of the Plan of Care (POC) dated 06/02/15 documented alteration in nutrition and hydration status secondary to the following contributing factors recent pneumonia, [MEDICAL CONDITION] stage III, dementia and diuretic use. The goal for Resident #184 included: will exhibit no signs and symptoms of dehydration, decreased voiding, poor skin turgor, dry mucous membranes and elevated Blood Urea Nitrogen (BUN). Interventions were listed as encourage intake with food and fluids, monitor for signs and symptoms of dehydration and document negative findings, encourage preferred fluids between meals, cue resident at mealtimes, offer greater than or equal to 1000 ml per day on the meal tray and at least 240 ml with medications. Review of the Medication Administration Record [REDACTED]. Total daily fluids documented were as follows: 06/01/15 total fluids 720 ml 06/02/15 total fluids 1,020 ml 06/03/15 total fluids 920 ml 06/04/15 total fluids 700 ml 06/05/15 total fluids 960 ml 06/06/15 total fluids 720 ml 06/07/15 total fluids 480 ml 06/08/15 total fluids 360 ml Review of the Medication Administration Record [REDACTED] 06/01/15 146/68 06/02/15 152/86 06/03/15 110/57 06/04/15 126/69 06/05/15 125/62 06/06/15 107/59 06/07/15 99/56 06/08/15 Not Available Review of the nurse notes dated 06/07/15 timed 2:39 P.M., indicated the resident was drowsy this shift and staff spoon fed him his meals with a fair appetite noted. On 06/07/15 at 4:09 P.M., the residents daughter was in and voiced concerns due to the resident being more lethargic. The residents daughter also stated the resident gets resistant Urinary Tract Infections [MEDICAL CONDITION] frequently. New orders were obtained to discontinue the antibiotic [MEDICATION NAME], start a different antibiotic [MEDICATION NAME] and obtain an Urinalysis and culture and sensitivity (UA with C&S). On 06/08/15 at 12:09 A.M., the resident continued with lethargy. On 06/08/15 at approximately 11:10 A.M., the resident was very lethargic, staff had difficulty waking him, skin was cool and clammy, blood sugar reading was HIGH, vitals signs were: temperature 99.1, pulse 63-130, respirations 18-28 and blood pressure was 105/61. The Medical Doctor (MD) was called and the resident was sent to the local emergency room . Review of the laboratory values dated 06/08/15 documented a critical high sodium level of 163 with a normal range being 135-145 meq/l, BUN 63 with a normal range being 7-25 mg/dl. Review of the local hospital record dated 06/08/15 documented due to his severe [MEDICAL CONDITION] (increased sodium level), acute [MEDICAL CONDITION] and nursing home acquired infection, intravenous (IV) fluids and high dose of antibiotics were started. He was admitted for aggressive treatment of [REDACTED]. Physical exam revealed dry mucous membranes and a consult was made to nephrology. Plan for acute or [MEDICAL CONDITION] secondary to poor oral intake while being septic, continue IV fluids. [MEDICAL CONDITION] secondary to total body water deficit of eight liters (L), continued IV fluids and check sodium levels every two hours. Review of the nephrology consult dated 06/08/15 documented acute kidney injury and very dry mucous membranes due to severe dehydration after the resident had received two liters of fluids, continue with IV fluids slowly. Review of the nephrology consult dated 06/09/15 documented the sodium level was improving according to the plan and the acute kidney injury due to the severe dehydration was better after IV fluids. During an interview on 08/31/15 at 12:39 P.M., Resident #184's daughter said every time she came into the facility the nurses were always complaining about not having enough staff. She stated she was told by staff her father was eating and drinking 100% of his meals. However she doesn't believe that because the hospital told her he was dehydrated and he needed eight liters of fluid at the hospital. She said she was also not notified about his change in condition. She visited him on 06/07/15 and he was very lethargic, she alerted the nurse and asked them to call the on call Certified Nurse Practitioner (CNP) who she thought was very nasty towards her, she could not recall which CNP it was. CNP #47 did finally listen to her about changing the antibiotic order to cover a possible urinary infection. The daughter indicated she was not aware of the elevated blood sugars without any intervention from the physician. During an interview on 08/31/15 at 3:15 P.M., State tested Nursing Assistant (STNA) #48 said she did not remember much about Resident #184 except he was not wanting to eat or drink a lot when she took care of him. During an observation on 09/01/15 at 11:40 A.M., the dietary staff were observed preparing the hall trays for the facility and only one 240 ml fluid milk was placed on some of the residents meal trays. Other trays were noted with empty coffee cups and no milk for the residents. During an interview on 09/01/15 at 3:31 P.M., Registered Nurse (RN) #49 said some of the signs of dehydration were lethargy, low urinary output and just not acting like themselves. During a telephone interview on 09/02/15 at 11:36 A.M., RN #46 said Resident #184 had episodes of lethargy on the weekend of 06/06/15 - 06/07/15, but by Sunday, 06/07/15 he was more lethargic. RN #46 confirmed the residents daughter expressed concerns the resident was more lethargic. RN #46 indicated she did speak to CNP #47 about changing the antibiotic order. During an interview on 09/02/15 at 11:57 A.M., CNP #47 said on 06/08/15 she was in the facility to see residents and Resident #184 was on her list to see in order to provide additional information to his insurance company. When she arrived to the unit Resident #184 was in the lounge across from the nurses station, he was slumped over and she could not get him to respond to her. Resident #184's vital signs were fluctuating and she was thinking he needed IV fluids. She called for RN #49 who informed her the resident had labs drawn earlier that day. CNP #47 indicated she went to the computer to review his labs and they were abnormal. She further indicated she did not feel comfortable initiating IV fluids in the nursing home so she consulted with the MD. CNP #47 gave an order to send Resident #184 to the local emergency room after consulting with the MD. During an interview on 09/02/15 at 12:24 P.M., Speech Therapist (ST) #51 said Resident #184 had a significant swallowing decline. On 06/05/15 he was gagging with only three swallows and was holding fluid in his mouth. She further said he would not consume all of his meals or fluids but she was only with him for one meal per day. She indicated she reported the significant swallowing decline to nursing. She did not notify the family because the nurses normally completed this task. During an interview on 09/02/15 at 12:55 P.M. RD #36 and Diet Technician #52 said they were not aware of Resident #184's weight changes, but his calculated fluid needs were 2500 ml. RD #36 indicated she was not aware of the error in the residents weight prior to this investigation. RD #36 said if she had calculated his fluid needs from the corrected weight of 170 pounds he would have needed 1900 ml per day. DT #52 said dietary was to provide 680 ml plus two soups daily. During an interview on 09/03/15 at 10:15 A.M., MD #50 said she was not called by the nursing staff over the weekend (06/07/15 - 06/08/15), but was aware the staff had called the on call to request a change in Resident #184's antibiotic order. She was not aware of the increased lethargy until she was notified by CNP #47 on 06/08/15. She had the residnet sent out that day (06/08/15) due to his abnormal laboratory values. She did not confirm nor deny the laboratory values showed dehydration but kept saying he had chronic kidney failure and he was a sick man. Review of the policy titled Notification of Change revised 02/01/13 documented the purpose of the policy was to ensure resident, family and physician are kept informed of significant changes in condition that may alter care and/or treatment. The resident and physician and/or family member will be notified of the following conditions: The residents physical, communicative, psychosocial, or functional status changes unexpectedly (significant weight loss, change in vital signs, brief loss of consciousness, etc.) Information from the Mayo Clinic found at www.mayoclinic.com was reviewed regarding dehydration. According to the Mayo Clinic dehydration occurs when you lose more fluids than you are taking in, and your body does not have enough water and other fluids to carry out its normal function. If you do not replace lost fluids you can become dehydrated. Anyone can become dehydrated but older adults and people with chronic illnesses are at most risk. You can usually reverse mild to moderate dehydration by drinking more fluids, but severe dehydration needs immediate medical treatment. The safest approach is prevention of dehydration. Monitor your fluid loss and drink enough fluids to replace what is lost. This deficiency substantiates Complaint Number OH 525 and OH 391.