Every finding on record at Astoria Place of Waterville

Based on medical record review, staff interview, hospice interview, review of the local weather conditions, emergency medical services (EMS) interview, review of the EMS run report, and review of hospital records, the facility failed to adequately assess, monitor, document, and address a decline in a resident's mental health. This resulted in Actual harm to Resident #09 when on the evening of 01/01/26, the resident did not sleep, appeared to be experiencing hallucinations, and was aggressive toward staff. Facility staff failed to notify the physician or implement any interventions throughout the night. Subsequently, on 01/02/26 at approximately 7:50 A.M., Resident #09 was found outside of the facility, after exiting from his room window and without appropriate clothing for the cold temperatures, in the snow. Consequently, Resident #09 was transferred to the hospital due hypothermia (body temperature falls below 95 degrees Fahrenheit [F]) and placed on an Emergency Application (an involuntary emergency evaluation for someone believed to be a danger to themselves or others due to acute mental illness). This affected one (#09) of three residents reviewed for behavioral health services. The facility census was 60. Findings include:Review of the medical record revealed Resident #09 was admitted on [DATE] and transferred to the hospital on [DATE]. Diagnoses included localization-related symptomatic epilepsy and epileptic syndromes with simple partial seizures, chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), bipolar disorder (a serious mental illness characterized by periods of intense highs [mania] and lows [depression]), schizoaffective disorder (a serious mental illness blending symptoms of schizophrenia [psychosis like hallucinations, delusions] with symptoms of a mood disorder [depression, bipolar mania]), and major depressive disorder. Further review revealed Resident #09 received hospice services.Review of the Minimum Data Set (MDS) assessment, dated 12/26/25, revealed Resident #09 was moderately cognitively impaired. Further review of the assessment revealed Resident #09 did not have mood concerns or behaviors.Review of the physician orders revealed on 10/28/25, Resident #09 was ordered Abilify (antipsychotic medication) 10 milligrams (mg) one time daily. On 11/11/25, Resident #09's Abilify was decreased to five mg in the morning.Review of the behavior tasks documentation from 12/07/25 through 01/02/26 revealed Resident #09 had no documented behaviors.Review of a psychology follow-up visit note, dated 12/10/25, revealed Resident #09 endorsed depression related to his health. Resident #09 was calm, attentive, and in no acute distress. Judgement, insight, and impulse control were intact. Resident #09's speech was coherent with normal rate and volume, thought processes were organized with normal associations, no delusions, paranoia, hallucinations, or other perceptual disturbances. Resident #09 denied suicidal ideation and had good sleep and concentration.Additional review of the physician orders revealed on 12/11/25, Resident #09's Abilify was decreased from five mg to 2.5 mg in the morning.Review of a nursing progress note dated 12/18/25 revealed Resident #09 admitted to hospice with a diagnosis of metabolic encephalopathy with prognosis of six months or less if disease continued natural progression.Review of a nursing progress note dated 12/22/25 revealed Resident #09 was noted to have symptoms of low energy, inability to sleep, quiet, and flat affect. No other behaviors were observed.Review of a behavior note dated 12/22/25 revealed Resident #09 was experiencing anhedonia (persistent inability or reduced capacity to experience pleasure or joy in activities). The behavior was described as sadness.Review of a Patient Health Questionnaire (PHQ)-9 interview progress note, dated 12/23/25, revealed questions for little interested/pleasure in doing things and feeling down, depressed, or hopeless symptoms present were documented as no. Further review revealed the question related to whether the staff mood interview should be conducted was answered no.Review of a psychology follow-up visit progress note dated 12/24/25 revealed Resident #09 presented with depressed affect with low energy and poor concentration observed. Resident #09 reported lack of motivation, interest in activities, and felt sad. Resident #09 was in no acute distress and had poor concentration. Judgment, insight and impulse control were intact. Thought processes were organized and the resident had no delusions, paranoia, hallucinations or other perceptual disturbances. Mood was depressed. Resident reported good sleep.Review of a nursing progress note, dated 12/30/25, revealed the hospice nurse was advised of increased aggression. The nurse stated she would bring it up in the meeting on him (Resident #09) tomorrow. The PNP was also in to see the resident and informed the writer she would be adjusting the resident's medications.Additional review of Resident #09's progress notes and behavior charting revealed no evidence of documentation related to Resident #09's aggression or other behaviors. There was also no documentation that the PNP was in to see Resident #09 on 12/30/25 or that any medication changes occurred.Review of a behavior charting progress note, dated 01/02/26 at 5:59 A.M., revealed when the staff approached (Resident #09) to assess, the resident became verbally aggressive, yelling profanities and instructing staff to leave the room and not shut the door. The resident got out of bed and displayed aggressive gestures toward staff, including shaking hands in a threatening manner. The resident was unapproachable and appeared highly agitated. The resident remained awake throughout the night and did not sleep. Resident #09 was observed talking very loudly and using aggressive, profane language to himself. The physician and on-call provider were notified of the resident's behaviors and lack of sleep. The resident remained in the room and no physical altercations occurred. Review of a nursing progress note, dated 01/02/26, revealed the writer was notified the resident was outside, nine-one-one (911) was called. The writer stayed with the resident until emergency services arrived and had control of the situation. All parties were notified.Review of the EMS run report revealed a call was received on 01/02/26 at 8:09 A.M. and EMS arrived on scene at 8:18 A.M. The resident was noted to be kneeling in the snow with a cold wet blanket. The facility staff were standing approximately 20 feet from the resident. Drag marks in the snow gave the impression the resident ostensibly rolled down the hill. It was reported by facility staff the resident's last known well check was during 7:00 A.M. rounds. The resident presented with an altered mental status, psychosis, aggressive/combative behaviors, injuries from a fall, and hypothermia. The skin was pale with extremities purple and abrasions to the left forehead and bilateral lower extremities with oozing bleeding. The resident was aggressive and attempted to bite and hit responders. Soft restraints were applied with assistance from law enforcement. Unable to obtain reliable pulse oxygen and oxygen was applied at six liters per minute (lpm). Due to combative behavior, five mg of Versed (benzodiazepine used as a sedative) was administered. Resident #09 had multiple brief (less than four seconds) focal seizures.Review of the hospital records, dated 01/02/26, revealed Resident #09 presented to the hospital with a suicide attempt, reportedly jumping from a window at his facility, and remained in the snow/low 20-degree F weather. Upon arrival to the emergency department (ED), Resident #09 was cold to the touch with scattered abrasions. His core body temperature was 95.6 degrees F via rectal thermometer. He had nonblanchable (does not fade or turn white when pressed, indicating blood had leaked under the skin) skin overlying the heels and knees. Dorsalis Pedis (DP) pulses (checks for blood flow to the foot, weak or absent pulses indicate reduced circulation to the lower limbs) were difficult to obtain and only the left was found via Doppler (ultrasound). The resident was in four-point restraints upon arrival with reports of him being extremely violent in route. When asked his name the resident responds, you tell me, and reported that he was pregnant. Wet clothing was removed and active rewarming was initiated with blanket, warm intravenous (IV) fluids, and Bair Hugger (forced air warming blanket that circulates warm air to maintain stable body temperature) was initiated. The resident exhibited paranoia. Psychiatry was consulted for a suspected suicide attempt and Resident #09 was placed on an Emergency Application and Abilify was increased to 10 mg one time daily. Resident #09 was admitted to a medical unit with diagnoses including hypothermia due to exposure, stage one frostbite to the bilateral heels, and delusions, with a plan to transfer to inpatient psychiatry once the resident's medical condition was stabilized. Interview on 01/07/26 at 8:30 A.M. with Licensed Practical Nurse (LPN) #131 revealed he arrived to work on 01/02/26 at approximately 7:45 A.M. and about 20 minutes later, was notified a resident was outside in the snow. Observation on 01/07/26 at 9:06 A.M. of Resident #09's room revealed the room was located on the unsecured unit on the first floor, near the nurses' station. Further observation revealed the side of the facility that the room was on faced the backyard area. The facility sat on a hill, with some of the first-floor rooms being elevated from ground level. Continued observation revealed Resident #09's room window measured 77 inches (approximately 6.5 feet) from the bottom of the window to the ground below. The window screen was folded in half and on the floor. Concurrent interview with Maintenance Director (MD) #146 verified the measurement of 77 inches from the bottom of Resident #09's window to the ground below.Interview on 01/07/26 at 9:47 A.M. with the Director of Nursing (DON) revealed she received a call at approximately 6:00 A.M. on 01/02/26 from the hall nurse (LPN #137) reporting that Resident #09 was having behaviors throughout the shift (nursing shift was from 6:00 P.M. to 6:00 A.M.) of talking to himself and talking to people who were not there. The DON stated she instructed the nurse to call hospice. The DON reported she arrived at the facility at approximately 7:00 A.M. to work in the hall Resident #09 resided on. The DON stated she was told Resident #09 was sleeping and she did not check on him. At approximately 8:00 A.M., Transportation Driver (TD) #120 informed her there was a resident outside. The DON stated she found Resident #09 outside in the snow. The DON reported the resident would not allow any care or treatment, stating that he was dead and to leave him alone. The DON reported Resident #09 was trying to roll into the bushes and the road and was very combative. The DON stated Resident #09 was wearing shorts, a t-shirt, socks and slippers. The DON was unable to assess him but observed scratches on his forehead and right leg and his skin was red. After EMS arrived, the DON stated it took six EMS personnel to get Resident #09 on the stretcher (due to his combativeness).Interview on 01/07/26 at 10:10 A.M. with TD #120 revealed on 01/02/26, he arrived at that facility at approximately 7:50 A.M. and saw something in the snow a little distance from the building. TD #120 stated he discovered Resident #09 outside, approximately 100 feet from the resident's window, and it appeared he had crawled to the area where he was found. TD #120 stated he checked on the resident, and Resident #09 was agitated and stated he wanted to die. TD #120 noted the resident had abrasions to his forehead, saw dried blood, and the resident's skin was bright red. TD #120 stated the resident was wearing a t-shirt, pajama bottoms, and slippers. TD #120 stated he went into the facility to get nursing staff and 911 was called. TD #120 stated staff took blankets outside to Resident #09, which he refused, but they were able to get one on his shoulders. TD #120 stated Resident #09 was on his knees and trying to get into the brush area near the road to get away from EMS staff.Observation on 01/07/26 at 10:18 A.M. of the outdoor area where TD #120 found Resident #09 revealed the resident was located approximately 100 feet from the resident's room window.Interview on 01/07/26 at 10:31 A.M. with Certified Nursing Assistant (CNA) #170 revealed she worked from 7:00 P.M. on 01/01/26 until 7:00 A.M. on 01/02/26 on the hall Resident #09 resided on. CNA #170 stated on that night, Resident #09 was not right, adding that it was actually scary. CNA #170 stated that during the night, Resident #09 was laying in his bed, talking quietly to himself, and when she walked by his room he would shout out (profanity) you! CNA #170 reported it was very out of character for him, and she started to approach him to ask if he was alright, but he only became more agitated and acted like he was going to get out of bed. At approximately 5:00 A.M., CNA #170 stated the resident settled and appeared to be asleep. CNA #170 stated she reported her concerns with the resident's behavior to the nurse, who was floating between two units. CNA #170 stated in the two or three years she had cared for Resident #09; she had never seen him like that. CNA #170 reported the last time she checked on him was shortly after 7:01 A.M., at which time he was calm, lying in bed, and appeared to be asleep. CNA #170 stated the residents' window was not open.A telephone interview on 01/07/26 at 11:06 A.M. with Hospice Executive Director ([NAME]) #200 verified the facility did not contact the hospice agency regarding Resident #09's change in condition. [NAME] #200 stated hospice became aware of the change in the resident's mental status when the hospice nurse arrived at the facility for a routine visit on 01/02/26 at 8:47 A.M. and saw the resident being assisted by EMS. A telephone interview on 01/07/26 at 11:34 A.M. with LPN #137 revealed she was the nurse assigned to provide care for Resident #09 during the night shift on 01/01/26 into 01/02/26. LPN #137 verified CNA #170 reported concerns with Resident #09's behaviors during the shift. LPN #137 stated on 01/01/26 at approximately 7:30 P.M., she attempted to provide the resident his night medications, but he refused. LPN #137 stated they kept his door open to keep an eye on him. LPN #137 stated she sent a text on 01/02/26 at 6:07 A.M. to the physician (not hospice as instructed to do by the DON) to notify him of the concerns, but she did not hear anything back and clocked out at 6:36 A.M.A telephone interview on 01/07/26 at 3:47 P.M. with Hospice Care Manager (HCM) #201 revealed on 12/30/25, she spoke with facility staff, including the facility's PNP, and was informed Resident #09 did best when he was on five to 10 mg of Abilify; however, he was only ordered Abilify 2.5 mg. HCM #201 reported she reviewed the hospice Medication Administration Record (MAR) and, according to their records, Resident #09 was to receive five mg of Abilify. HCM #201 stated she planned to address this with the facility during her visit on 01/02/26.Interview on 01/08/26 at 9:15 A.M. with PNP #300 revealed a gradual dose reduction (GDR) was implemented for Resident #09 on 12/11/25, reducing Ability from five mg to 2.5 mg one time daily. PNP #300 had not seen Resident #09 since October 2025. PNP #300 revealed she had received no reports of increased psychiatric symptoms until 12/30/25, when the hospice nurse stated she planned to discuss increasing the resident's medication (Abilify) with the hospice physician. PNP #300 stated she typically assessed a resident within 30 days of a GDR, and he was on her schedule to be seen on 01/08/26 (Resident #09 was not seen on 12/30/25 as indicated in the nursing progress note). PNP #300 stated the facility staff did not always document behavioral concerns and she was only aware of potential concerns because the hospice nurse reached out to her on 12/30/25.A telephone interview on 01/08/26 at 11:08 A.M. with Fire Chief (FC) #301 revealed he was onsite at the facility for Resident #09 on the morning of 01/02/26. FC #301 stated Resident #09 was combative and potentially hypothermic due to the windchill temperatures being lower than 20 degrees F and there was snow on the ground. FC #301 stated EMS was unable to get an accurate body temperature reading for the resident but, in addition to medication administered to calm the resident, EMS administered warm IV fluids to address potential hypothermia. A telephone interview on 01/08/26 at 1:15 P.M. with Registered Nurse (RN) #158 revealed she authored the nursing progress note on 12/30/25 that indicated Resident #09 had increased aggression. RN #158 stated the resident had been arguing with a roommate, refusing medications, and throwing things in his room. Interview on 01/08/26 at 4:10 P.M. with the Administrator and [NAME] President of Clinical Operations (VPCO) #500 revealed the facility did not have a policy related to meeting residents' behavioral or psychological needs.Review of the local weather information, located at https://www.wunderground.com/history/daily/us/oh/[NAME]/KTOL/date/2026-1-1, revealed the temperature on 01/02/26 at 7:52 A.M. was 21 degrees F.Review of the facility policy titled, Notification of Change in Condition, reviewed June 2025, revealed the intent of the policy was to maintain open communication and continuity of care between nursing staff, resident and/or resident representative, and the resident's physician as it relates to the change in the resident's medical condition. The nurse would inform the resident and consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status or when there was a need to alter treatment significantly (for example, discontinue an existing form of treatment or to commence a new form of treatment). This deficiency represents non-compliance investigated under Complaint Number 2707548.

Based on medical record review, review of the Certification, Licensure, and Survey (CALS) system (system for maintaining healthcare provider information), staff interview, and review of facility policy, the facility failed to notify the Ohio Department of Health (ODH) of a resident elopement. This affected one (#09) of three residents reviewed for elopement. The facility census was 60.Findings include: Review of the medical record revealed Resident #09 was admitted on [DATE] and transferred to the hospital on [DATE]. Diagnoses included localization-related symptomatic epilepsy and epileptic syndromes with simple partial seizures, chronic obstructive pulmonary disease, chronic kidney disease, bipolar disorder, schizoaffective disorder, morbid obesity, and major depressive disorder.Review of the Minimum Data Set (MDS) assessment, dated 12/26/25, revealed the resident was moderately cognitively impaired. Resident #09 did not have mood concerns or behaviors. Review of a nursing progress note, dated 01/02/26, revealed the writer was notified the resident was outside, nine-one-one (911) was called. The writer stayed with the resident until emergency services arrived and had control of the situation. All parties were notified.Review of the CALS system from 01/01/26 to 01/07/26, revealed no evidence the facility notified the ODH of Resident #09's elopement from the facility. Interview on 01/07/26 at 8:40 A.M. with the Administrator verified Resident #09 exited the building through his window on 01/02/26 and was located outside of the facility. The Administrator confirmed the facility did not notify the ODH. The Administrator stated hospice informed her they were required to report the incident to ODH but she was not aware that she was required to. Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property, dated 01/02/25, revealed all incidents and allegations of abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and all injuries of unknown source must be report immediately to the Administrator or designee. If abuse was alleged or serious bodily injury was identified, the Administrator/designee would notify ODH immediately but not later than two hours after the allegation was made or the serious bodily injury identified.

Based on medical record review, staff interview, review of the facility investigation, review of emergency medical service (EMS) and police reports, review of the county coroner case documentation, and review of facility policy, the facility failed to prevent resident to resident abuse. Actual harm occurred on 09/23/25 when Resident #29 was discovered in a resident room behind a closed door and Resident #53 was discovered in the same room behind a drawn privacy curtain laying supine on a sheet on the floor with towels secured tightly around the neck. Resident #53's head was purple in color, skin was cool to touch, with blood in her mouth, petechia to her skin, and no respirations or pulse were present. Resident #29 later admitted strangling Resident #53. The county coroner case documentation listed the cause of Resident #53's death as a homicide by means of strangulation. This affected one (#53) of three residents reviewed for abuse in a facility census of 71. Findings include:1. Review of the medical record revealed Resident #29 admitted to the facility on [DATE]. Diagnoses included schizophrenia, chronic obstructive pulmonary disease, hypertension, and brief psychotic disorder. Review of the resident census revealed Resident #29 was initially admitted to the secured dementia unit and then moved to the secured second floor behavior unit on 07/17/25. Review of the Minimum Data Set (MDS) assessment dated [DATE] the resident was assessed with clear speech, usually understood and understands others, moderate cognitive impairment, no recorded behaviors, no range of motion impairment, and independent with ambulation. Review of the resident's care plan dated 07/25/25 revealed a the nursing plan of care was revised to address Resident #29's cognitive loss/disorientation/impaired judgement related to diagnosis of schizophrenia. Interventions included: Follow doctor's orders for appropriate treatment, review the medication regimen with the physician to assess and rule out possible side effects or contraindications related to medications or food products, verbalize you will help him/her Stay in control, assure the resident he is protected, safe, and secure and in a protected environment. On 08/21/25 Resident #29 was evaluated by psychiatry services. Resident #29 was documented to be pleasant, calm and engaged throughout the entire evaluation. Psychoactive medications were reviewed and no behaviors were documented. Review of Resident #29 medical record lacked documentation indicated he exhibited aggressive behaviors towards staff or residents while residing at the facility. Review of the resident census revealed Resident #29 was returned to the dementia unit on 09/05/25. 2. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE]. Diagnoses included major depression, bipolar disorder, muscle weakness, cognitive communication deficit, insomnia, anxiety disorder, polyneuropathy, and anemia. Resident #53 resided on the secured dementia unit since 01/24/25. Review of the MDS assessment dated [DATE] revealed Resident #53 had clear speech, usually understood and understands, severe cognitive impairment, no recorded behaviors, and was independently ambulatory. On 08/28/25 a quarterly secure unit admission assessment noted Resident #53 to be appropriate for the dementia unit due to a mental health condition. The unit would benefit the resident due to a smaller unit that allowed for staff interventions Review of a facility investigation revealed on 09/23/25 at approximately 9:30 P.M. Registered Nurse (RN) #400 attempted to locate Resident #29 for medication administration. RN #400 was unable to locate Resident #29 in his room or common area and requested Certified Nurse Aide (CNA) #301 to assist in finding him. RN #400 and CNA #301 proceeded to walk down the unit corridor and discovered Resident #55's room door closed. CNA #301 opened the door. Resident #29 was observed standing inside the door rocking from side to side with perspiration on his forehead. CNA #301 observed the curtain pulled around the first bed in the room and proceeded to open the curtain. Resident #53 was observed lying on the floor placed on a sheet in the supine position. Her face was deep purple with blood coming from her mouth. A bath towel and pillowcase were wrapped tightly around her neck. RN #400 yelled for help and Licensed Practical Nurse (LPN) #500 responded to the room. CNA #302 was located at the nursing station and responded to the room. Once CNA #302 observed Resident #53 on the floor she immediately returned to the nurses' station and called Emergency Medical Services (EMS). LPN #500 directed staff to stay with Resident #29 and take him to the unit dining room. LPN #500 assessed Resident #53 and checked her for a radial pulse with no pulse palpable. Resident #53's skin was noted to be cold and clammy, and no respirations were detected. LPN #500 and RN #400 determined the room was a crime scene. LPN #500 stood outside the room until EMS and Police arrived while RN #400 contacted the Director of Nursing (DON) to inform her of the incident. EMS assessed Resident #53, pronounced the resident deceased , and police assumed control of the scene. Resident #29 was placed in police custody. Preliminary autopsy results were obtained and revealed Resident #53's cause of death was a homicide due to strangulation. The incident remains under police investigation and Resident #29 remains in police custody. Review of CNA #302's written stated dated 09/23/25 at 9:00 P.M. noted CNA #302 was at the nurses' station when she heard RN #400 and CNA #301 yelling for help. CNA #302 got up to see what was wrong and saw Resident #53 was lying on the floor. CNA #302 ran back to the nurses' station and RN #400 yelled Call the police. RN #400 took Resident #53's vitals and confirmed she did not hear Resident #53's heart and felt for a pulse. Resident #29 was completely calm standing in the room and was saying he had to do it. Review of EMS report dated 09/23/25 noted at 9:41 P.M. and EMS call was received. Injury was listed as suffocation/asphyxiation. EMS was on scene at 9:51 P.M. Narrative notes document the EMS was dispatched to the facility for an unconscious person. Notes stated someone was possibly strangled. The crew confirmed with dispatch that law-enforcement was on scene. Upon arrival the crew was led to room [ROOM NUMBER] (Resident #55's room). This room was reported to belong to someone not involved in the incident. There was a police officer at the door to the room where the incident occurred. Crew entered the room to find a [AGE] year-old female on the floor in the prone position with her arms under her body and a towel around her neck. With law-enforcement standing nearby the law enforcement officer was notified that we needed to remove the towel. It took great effort to remove this as it was extremely tight. The knot being in the back at the base of her head. Once it was loosened it was noted there was also part of a sheet tied around her neck with this knot more to the side near her right ear. This also took great effort to loosen as it was pulled very tight. Once loosened a carotid pulse was checked noting it to be absent. Signs of obvious death were present. Interview with CNA #300 on 09/25/25 at 6:35 A.M. revealed he went to the dementia unit on 09/23/25 at approximately 9:15 P.M. to ask RN #400 if she wanted some food for lunch. RN #400 was at the dementia unit nurses' station obtaining medications from behind the nurses' station. RN #400 was then walking in the hall to look for Resident #29. CNA #300 remained at the nurses' station talking with LPN #500, CNA #302, and Floor Technician (FT) #700. RN #400 and CNA #301 yelled for help from Resident #55's room door entry. CNA #300 and LPN #500 ran to the room. CNA #300 observed Resident #29 standing inside the room and next to the entry door. Resident #53 was on the floor near bed one. Resident #53 had towels around her neck, her face was purple, her lips were dark purple, her eyes were closed, and CNA #300 saw veins coming out of her head. CNA #300 stayed by the room while RN #400 instructed a CNA to be 1:1 with Resident #29. LPN #500 entered the room to check Resident #53's pulse. CNA #300 heard RN #400 yell Call 911. CNA #302 was at the nursing station and called 911 from the station. CNA #300 heard LPN #500 state Resident #53 was with no pulse and her skin was cold. CNA #300 went out to open the facility door for police and EMS. Interview with RN #400 on 09/25/25 at 7:10 A.M. revealed on 09/23/25 at approximately 8:45 P.M. she was at the dementia unit nurses station gathering Resident #29's medications for administration. RN #400 stated she had seen Resident #29 ambulating in the hall 30 to 35 minutes prior to gathering medications. Resident #53 was last observed in the hall approximately 20 to 25 minutes prior to gathering medications. RN#400 proceeded to Resident #29's room and Resident #29 was not in the room. RN #400 looked in the dementia unit dining room and Resident #29 was not in the dining room. RN #400 observed CNA #301 in front of the dementia unit nurses' station and requested her to assist in looking for Resident #29. Both RN #400 and CNA #301 walked together down the hall. When RN #400 and CNA #301 reached Resident #55's room they noted the room door was closed. RN #400 stated the room door was usually open. CNA #301 opened the door. Resident #29 was standing inside the door rocking side to side with perspiration dripping from his face and a washcloth in his hand. CNA #301 noticed the privacy curtain to bed one was pulled around the bed and proceeded to pull the curtain back. Resident #53 was observed on the floor lying on a bed sheet. Her head was deep purple and thick towels were wrapped around her neck. RN #400 immediately yelled for help. RN #400 listened to Resident #53's back with a stethoscope and was unable to hear lung sounds or a heartbeat. Resident #53 appeared deceased and RN #400 considered the incident a crime scene. LPN #500 and CNA #300 arrived at the room. RN #400 yelled for CNA #302 to call 911. RN #400 told CNA #303 to take Resident #29 to the dining room and stay with him providing one on one observation. RN #400 then notified the DON via phone. Resident #29 was later observed calmly seated in the dementia unit dining room with a flat affect. RN #400 stated the police arrived at the facility within minutes. One officer stayed with Resident #29 and CNA #303. On 09/29/25 at 12:41 P.M. an additional interview with RN #400 revealed EMS arrived 10-15 minutes after the initial notification. CNA #301 called initially and was informed later the call was disconnected. 911 returned a call to the facility and LPN #500 took the second call. Telephone interview on 09/25/25 at 10:42 A.M. with CNA #301 revealed she last observed Resident #29 walking in the dementia unit corridor with Resident #53, Resident #55 and Resident #70 on 09/23/25 at 8:20 P.M. CNA #301 proceeded to go on break and leave the dementia unit. Between 8:30 and 8:40 P.M. CNA #301 returned to the dementia unit nursing station. RN #400 asked CNA #301 if she had seen Resident #29. CNA #301 walked with RN #400 down the dementia unit hall and discovered Resident #55's room door was closed. CNA #301 opened the door and observed the first bed privacy curtain pulled, which was unusual due to no current resident residing in this bed. From under the curtain the CNA saw a cover (sheet) on the floor. The CNA pulled the curtain and stated Oh my God twice. RN #400 was behind CNA #301 and asked what was wrong and entered the resident room. CNA #301 stated Resident #53 was on the floor. She observed Resident #29 to be sweaty. CNA #301 recalled a CNA #303 from a different unit stayed with Resident #29 in the dining room after the incident. Interview on 09/29/25 at 6:40 A.M. LPN #500 stated on 09/23/25 at approximately 8:50 P.M. the received a staff call off so he went to the dementia unit to report the call off to RN #400. He observed RN #400 gathering Resident #29's medications at the nurses' station and she proceeded to look for the resident. LPN #500 did not see either Resident #29 or Resident #53. At 9:05 P.M. while standing at the nurses' station LPN #500 heard RN #400 yell out for help. LPN #500 responded to the room RN#400 was yelling from. LPN #500 entered the room and observed Resident #29 standing inside the door and rocking side to side. Resident #29 appeared to have sweat on his face. Resident #53 was observed on the floor laying supine on a sheet. LPN #500 told RN #400 to take Resident #29 from the room and have someone sit with him until police arrived. LPN #500 proceeded to assess Resident #53. Resident #53's skin was cold and clammy with petechiae on her skin. She had what appeared to be a towel tightly wrapped around her neck with blood coming from her mouth. Her face and head were deep purple in color. LPN #500 stated he thought it was a different resident at first due to her appearance. The resident was also covered with a blanket from her mid back to her feet. LPN #500 stated he attempted to obtain a radial pulse and could not. He also observed no respirations were present. LPN #500 proceeded to exit the room, close the door, and remain outside the room until EMS and police arrived. Review of Police incident report dated 09/23/25 documented the incident occurrence from 9:10 P.M. to 9:44 P.M. on 09/23/25. Time of arrival to the scene was 9:46 P.M. Offense description was listed as Murder and Nonnegligent Manslaughter with weapon/force used coded as asphyxiation. Arrestee recorded on 09/23/25 at 11:39 P.M. and listed Resident #29. Victim listed Resident #53. Offense was murder and strangulation. Narrative notes documented when the officer arrived on scene he saw a group of nurses and aids in Resident #55's room. Upon entering the room Resident #53 was unresponsive, lying face down on the floor, with a towel wrapped around her neck. The nurse told officers the room where the incident happened belonged to Resident #55. Resident #55 was not in the room at the time of the incident. She said the door was closed and when the nurses opened it, Resident #29 was standing in the room rocking back and forth. They pulled back the privacy curtains and found Resident #53 unresponsive on the floor. The suspect, Resident #29, was sitting with one of the nurse aides and a resident at a table in the lounge area. The officer asked Resident #29 what happened today and he responded I don't know, she was down and choked me, stabbed me, then took off. The officer repeated Resident #29's statement questioning who choked and stabbed him. Resident #29 stated, No she didn't choke me, he choked me and stuck me. I don't know his name. The officer asked him if he was hurt at all. Resident #29 said No I'm alright, she was breathing when I was in there. I couldn't do anything to her. One of the residents sitting at the table asked Resident #29 if he was going home after this. Resident #29 responded No, I am going to prison, death row. The officer asked him why Resident #53 was on the floor right now. Resident #29 said She's dead, I guess. She wasn't dead. The officer questioned Resident #29 if he touched Resident #53. He responded Oh yeah. The officer asked him where and Resident #29 said Around the neck. The DON walked into the room and introduced herself to the officer. Resident #29 turned around and said to the DON You see, I killed her. The DON mentioned to me that Resident #29 was in jail for a long time, but she didn't know for what kind of crime. Review of the local county coroner case summary of death of Resident #53 dated 09/24/25 revealed anatomic diagnoses included: petechial hemorrhages involving the face and forehead, bilateral upper and lower petechial conjunctival hemorrhages, facial congestion, faint shallow ligature [NAME] on the anterior neck consistent with cloth ligature, deep right-sided strap muscle hemorrhage, anterior cervical soft tissue hemorrhage, cerebral vascular congestion, and faint purple contusion on right anterolateral neck, distally. Cause of death: Strangulation (minutes). Cause of injury noted as strangled with cloth ligature. Manner of death Homicide. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, last reviewed 05/2025, revealed residents have the right to be free from abuse. The policy defines abuse as the willful infliction of injury resulting in physical harm. The policy defines serious bodily injury as an injury involving extreme physical pain; involving substantial risk of death. The policy defines willful to mean the individual must have acted deliberately. This deficiency represents non-compliance investigated under Master Complaint Number 2627173 and Complaint Number 2626970, Complaint Number 2626838, Complaint Number 2626237. Review of the medical record revealed Resident #29 admitted to the facility on [DATE]. Diagnoses included schizophrenia, chronic obstructive pulmonary disease, hypertension, and brief psychotic disorder. Review of the resident census revealed Resident #29 was initially admitted to the secured dementia unit and then moved to the secured second floor behavior unit on 07/17/25. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed with clear speech, usually understood and understands others, moderate cognitive impairment, no recorded behaviors, no range of motion impairment, and independent with ambulation. Review of the resident's care plan dated 07/25/25 revealed the nursing plan of care was revised to address Resident #29's cognitive loss/disorientation/impaired judgement related to diagnosis of schizophrenia. Interventions included: Follow doctor's orders for appropriate treatment, review the medication regimen with the physician to assess and rule out possible side effects or contraindications related to medications or food products, verbalize you will help him/her Stay in control, assure the resident is protected, safe, and secure and in a protected environment. On 08/21/25 Resident #29 was evaluated by psychiatry services. Resident #29 was documented to be pleasant, calm and engaged throughout the entire evaluation. Psychoactive medications were reviewed, and no behaviors were documented. Review of Resident #29 medical record lacked documentation indicating he exhibited aggressive behaviors towards staff or residents while residing at the facility. Review of the resident census revealed Resident #29 was returned to the dementia unit on 09/05/25. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE]. Diagnoses included major depression, bipolar disorder, muscle weakness, cognitive communication deficit, insomnia, anxiety disorder, polyneuropathy, and anemia. Resident #53 resided on the secured dementia unit since 01/24/25. Review of the MDS assessment dated [DATE] revealed Resident #53 had clear speech, usually understood and understands, severe cognitive impairment, no recorded behaviors, and was independently ambulatory. On 08/28/25 a quarterly secure unit admission assessment noted Resident #53 to be appropriate for the dementia unit due to a mental health condition. The unit would benefit the resident due to a smaller unit that allowed for staff intervention. Review of a facility investigation revealed on 09/23/25 at approximately 9:30 P.M., Registered Nurse (RN) #400 attempted to locate Resident #29 for medication administration. RN #400 was unable to locate Resident #29 in his room or common area and requested Certified Nurse Aide (CNA) #301 to assist in finding him. RN #400 and CNA #301 proceeded to walk down the unit corridor and discovered Resident #55's room door closed. CNA #301 opened the door. Resident #29 was observed standing inside the door rocking from side to side with perspiration on his forehead. CNA #301 observed the curtain pulled around the first bed in the room and proceeded to open the curtain. Resident #53 was observed lying on the floor placed on a sheet in the supine position. Her face was deep purple with blood coming from her mouth. A bath towel and pillowcase were wrapped tightly around her neck. RN #400 yelled for help and Licensed Practical Nurse (LPN) #500 responded to the room. CNA #302 was located at the nursing station and responded to the room. Once CNA #302 observed Resident #53 on the floor she immediately returned to the nurses' station and called EMS. LPN #500 directed staff to stay with Resident #29 and take him to the unit dining room. LPN #500 assessed Resident #53 and checked her for a radial pulse with no pulse palpable. Resident #53's skin was noted to be cold and clammy, and no respirations were detected. LPN #500 and RN #400 determined the room was a crime scene. LPN #500 stood outside the room until EMS and Police arrived while RN #400 contacted the Director of Nursing (DON) to inform her of the incident. EMS assessed Resident #53, pronounced the resident deceased , and police assumed control of the scene. Resident #29 was placed in police custody. Preliminary autopsy results were obtained and revealed Resident #53's cause of death was a homicide due to strangulation. The incident remains under police investigation and Resident #29 remains in police custody. Review of CNA #302's written statement dated 09/23/25 at 9:00 P.M. noted CNA #302 was at the nurses' station when she heard RN #400 and CNA #301 yelling for help. CNA #302 got up to see what was wrong and saw Resident #53 was lying on the floor. CNA #302 ran back to the nurses' station and RN #400 yelled Call the police. RN #400 took Resident #53's vitals and confirmed she did not hear Resident #53's heart and felt for a pulse. Resident #29 was completely calm standing in the room and was saying he had to do it. Review of the EMS report dated 09/23/25 noted at 9:41 P.M. an EMS call was received. Injury was listed as suffocation/asphyxiation. EMS was on scene at 9:51 P.M. Narrative notes document the EMS was dispatched to the facility for an unconscious person. Notes stated someone was possibly strangled. The crew confirmed with dispatch that law-enforcement was on scene. Upon arrival the crew was led to room [ROOM NUMBER] (Resident #55's room). This room was reported to belong to someone not involved in the incident. There was a police officer at the door to the room where the incident occurred. Crew entered the room to find a [AGE] year-old female on the floor in the prone position with her arms under her body and a towel around her neck. With law-enforcement standing nearby the law enforcement officer was notified that we needed to remove the towel. It took great effort to remove this as it was extremely tight. The knot being in the back at the base of her head. Once it was loosened it was noted there was also part of a sheet tied around her neck with this knot more to the side near her right ear. This also took great effort to loosen as it was pulled very tight. Once loosened a carotid pulse was checked noting it to be absent. Signs of obvious death were present. Interview with CNA #300 on 09/25/25 at 6:35 A.M. revealed he went to the dementia unit on 09/23/25 at approximately 9:15 P.M. to ask RN #400 if she wanted some food for lunch. RN #400 was at the dementia unit nurses' station obtaining medications from behind the nurses' station. RN #400 was then walking in the hall to look for Resident #29. CNA #300 remained at the nurses' station talking with LPN #500, CNA #302, and Floor Technician (FT) #700. RN #400 and CNA #301 yelled for help from Resident #55's room door entry. CNA #300 and LPN #500 ran to the room. CNA #300 observed Resident #29 standing inside the room and next to the entry door. Resident #53 was on the floor near bed one. Resident #53 had towels around her neck, her face was purple, her lips were dark purple, her eyes were closed, and CNA #300 saw veins coming out of her head. CNA #300 stayed by the room while RN #400 instructed a CNA to be one-on-one with Resident #29. LPN #500 entered the room to check Resident #53's pulse. CNA #300 heard RN #400 yell Call 911. CNA #302 was at the nursing station and called 911 from the station. CNA #300 heard LPN #500 state Resident #53 had no pulse and her skin was cold. CNA #300 went out to open the facility door for police and EMS. Interview with RN #400 on 09/25/25 at 7:10 A.M. revealed on 09/23/25 at approximately 8:45 P.M. she was at the dementia unit nurses station gathering Resident #29's medications for administration. RN #400 stated she had seen Resident #29 ambulating in the hall 30 to 35 minutes prior to gathering medications. Resident #53 was last observed in the hall approximately 20 to 25 minutes prior to gathering medications. RN#400 proceeded to Resident #29's room and Resident #29 was not in the room. RN #400 looked in the dementia unit dining room and Resident #29 was not in the dining room. RN #400 observed CNA #301 in front of the dementia unit nurses' station and requested her to assist in looking for Resident #29. Both RN #400 and CNA #301 walked together down the hall. When RN #400 and CNA #301 reached Resident #55's room they noted the room door was closed. RN #400 stated the room door was usually open. CNA #301 opened the door. Resident #29 was standing inside the door rocking side to side with perspiration dripping from his face and a washcloth in his hand. CNA #301 noticed the privacy curtain to bed one was pulled around the bed and proceeded to pull the curtain back. Resident #53 was observed on the floor lying on a bed sheet. Her head was deep purple, and thick towels were wrapped around her neck. RN #400 immediately yelled for help. RN #400 listened to Resident #53's back with a stethoscope and was unable to hear lung sounds or a heartbeat. Resident #53 appeared deceased , and RN #400 considered the incident a crime scene. LPN #500 and CNA #300 arrived at the room. RN #400 yelled for CNA #302 to call 911. RN #400 told CNA #303 to take Resident #29 to the dining room and stay with him providing one on one observation. RN #400 then notified the DON via phone. Resident #29 was later observed calmly seated in the dementia unit dining room with a flat affect. RN #400 stated the police arrived at the facility within minutes. One officer stayed with Resident #29 and CNA #303. On 09/29/25 at 12:41 P.M. an additional interview with RN #400 revealed EMS arrived 10-15 minutes after the initial notification. CNA #301 called initially and was informed later the call was disconnected. Nine-one-one (911) returned a call to the facility and LPN #500 took the second call. Telephone interview on 09/25/25 at 10:42 A.M. with CNA #301 revealed she last observed Resident #29 walking in the dementia unit corridor with Resident #53, Resident #55 and Resident #70 on 09/23/25 at 8:20 P.M. CNA #301 proceeded to go on break and leave the dementia unit. Between 8:30 and 8:40 P.M. CNA #301 returned to the dementia unit nursing station. RN #400 asked CNA #301 if she had seen Resident #29. CNA #301 walked with RN #400 down the dementia unit hall and discovered Resident #55's room door was closed. CNA #301 opened the door and observed the first bed privacy curtain pulled, which was unusual due to no current resident residing in this bed. From under the curtain the CNA saw a cover (sheet) on the floor. The CNA pulled the curtain and stated Oh my God twice. RN #400 was behind CNA #301 and asked what was wrong and entered the resident room. CNA #301 stated Resident #53 was on the floor. She observed Resident #29 to be sweaty. CNA #301 recalled CNA #303 from a different unit stayed with Resident #29 in the dining room after the incident. Interview on 09/29/25 at 6:40 A.M. LPN #500 stated on 09/23/25 at approximately 8:50 P.M. they received a staff call off so he went to the dementia unit to report the call off to RN #400. He observed RN #400 gathering Resident #29's medications at the nurses' station and she proceeded to look for the resident. LPN #500 did not see either Resident #29 or Resident #53. At 9:05 P.M. while standing at the nurses' station LPN #500 heard RN #400 yell out for help. LPN #500 responded to the room RN #400 was yelling from. LPN #500 entered the room and observed Resident #29 standing inside the door and rocking side to side. Resident #29 appeared to have sweat on his face. Resident #53 was observed on the floor laying supine on a sheet. LPN #500 told RN #400 to take Resident #29 from the room and have someone sit with him until police arrived. LPN #500 proceeded to assess Resident #53. Resident #53's skin was cold and clammy with petechiae on her skin. She had what appeared to be a towel tightly wrapped around her neck with blood coming from her mouth. Her face and head were deep purple in color. LPN #500 stated he thought it was a different resident at first due to her appearance. The resident was also covered with a blanket from her mid back to her feet. LPN #500 stated he attempted to obtain a radial pulse and could not. He also observed no respirations were present. LPN #500 proceeded to exit the room, close the door, and remain outside the room until EMS and police arrived. Review of Police incident report dated 09/23/25 documented the incident occurrence from 9:10 P.M. to 9:44 P.M. on 09/23/25. Time of arrival to the scene was 9:46 P.M. Offense description was listed as Murder and Nonnegligent Manslaughter with weapon/force used coded as asphyxiation. Arrestee recorded on 09/23/25 at 11:39 P.M. and listed Resident #29. Victim listed Resident #53. Offense was murder and strangulation. Narrative notes documented when the officer arrived on scene, he saw a group of nurses and aids in Resident #55's room. Upon entering the room Resident #53 was unresponsive, lying face down on the floor, with a towel wrapped around her neck. The nurse told officers the room where the incident happened belonged to Resident #55. Resident #55 was not in the room at the time of the incident. She said the door was closed and when the nurses opened it, Resident #29 was standing in the room rocking back and forth. They pulled back the privacy curtains and found Resident #53 unresponsive on the floor. The suspect, Resident #29, was sitting with one of the nurse aides and a resident at a table in the lounge area. The officer asked Resident #29 what happened today and he responded, I don't know, she was down and choked me, stabbed me, then took off. The officer repeated Resident #29's statement questioning who choked and stabbed him. Resident #29 stated, No she didn't choke me, he choked me and stuck me. I don't know his name. The officer asked him if he was hurt at all. Resident #29 said No I'm alright, she was breathing when I was in there. I couldn't do anything to her. One of the residents sitting at the table asked Resident #29 if he was going home after this. Resident #29 responded No, I am going to prison, death row. The officer asked him why Resident #53 was on the floor right now. Resident #29 said She's dead, I guess. She wasn't dead. The officer questioned Resident #29 if he touched Resident #53. He responded, Oh yeah. The officer asked him where and Resident #29 said Around the neck. The DON walked into the room and introduced herself to the officer. Resident #29 turned around and said to the DON You see, I killed her. The DON mentioned to me that Resident #29 was in jail for a long time, but she didn't know for what kind of crime. Review of the local county coroner case summary of death of Resident #53 dated 09/24/25 revealed anatomic diagnoses included: petechial hemorrhages involving the face and forehead, bilateral upper and lower petechial conjunctival hemorrhages, facial congestion, faint shallow ligature [NAME] on the anterior neck consistent with cloth ligature, deep right-sided strap muscle hemorrhage, anterior cervical soft tissue hemorrhage, cerebral vascular congestion, and faint purple contusion on right anterolateral neck, distally. Cause of death: Strangulation (minutes). Cause of injury noted as strangled with cloth ligature. Manner of death Homicide. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, last reviewed 05/2025, revealed residents have the right to be free from abuse. The policy defines abuse as the willful infliction of injury resulting in physical harm. The policy defines serious bodily injury as an injury involving extreme ph

Based on medical record review, observation, staff interview, county coroner interview, review of the Emergency Medical Services (EMS) run report, review of the death certificate, and review of the facility self-imposed action plan, including in-service records and audits, the facility failed to provide residents food in the correct texture to meet individual needs, failed to ensure residents were provided feeding assistance/supervision as required, and failed to put monitoring systems in place to prevent the same actions, situations, and/or practices from reoccurring. This resulted in Immediate Jeopardy for one (#83) resident who experienced serious life-threatening harm and negative health outcomes resulting in death when served the incorrect food item at snack time, subsequently choked, lost consciousness, and collapsed, requiring staff intervention to perform cardiopulmonary resuscitation (CPR), and an emergency medical service response in an effort to remove the food bolus from the trachea where it was preventing air flow to and from the lungs. Additionally, a second resident (#07) was placed at risk for potential serious life-threatening adverse outcomes when Resident #07 who was observed eating alone in his room, coughing with urgency, with a purple/red discoloration to his face, requiring facility staff to be alerted by a surveyor, and staff intervention to dislodge food. This affected one (#83) of three residents reviewed for mechanically altered diets and one (#07) of three residents reviewed for activities of daily living who required assistance/supervision with eating. The facility identified 17 residents (#14, #20, #46, #03, #49, #53, #55, #56, #57, #01, #07, #62, #79, #82, #64, #65, and #72) who were ordered mechanically altered diets, and seven residents (#05, #07, #33, #41, #53, #64 and #78) who required feeding assistance/supervision. The facility census 74. On 08/06/25 at 4:02 P.M., Corporate Chief Nursing Officer (CCNO) #401, [NAME] President of Clinical (VPC) #400, Regional Director of Operations (RDO) #402, and the Director of Nursing (DON) were notified Immediate Jeopardy began on 09/30/24 at 9:26 P.M. when Resident #83 was served a peanut butter sandwich, sometime around 8:00 P.M., as an evening snack by Certified Nursing Assistant (CNA) #320, contrary to the resident's physician order for a regular diet, mechanical soft, thin consistency, no bread, and no straws. Sometime later, CNA #320 responded to Resident #83's roommates call light and found Resident #83 on the floor, and unresponsive. CNA #320 summoned Registered Nurse (RN) #366 for help. RN #366 began CPR as Resident #83 had no pulse or respirations. Emergency Medical Services (EMS) were called and arrived at 8:47 P.M., EMS took over CPR. Resident #83 remained without a pulse or respirations. At 8:53 P.M., EMS attempted to place a breathing tube, and a foreign body was noted in Resident #83's mouth, the foreign body appeared to be chewed food. Resident #83 was suctioned and about five milliliters (ml) of product was removed. Continued efforts to resuscitate Resident #83 were unsuccessful and Resident #83's death was pronounced at 9:26 P.M.The Immediate Jeopardy was removed on 08/07/25 at 2:12 P.M. when the facility implemented the following corrective actions: On 08/06/25 at 4:30 P.M., a root cause analysis was conducted by the following team members: the Administrator, DON, RDO #402, and CCNO #401 and VPC #400 to determine why residents were not provided with food prepared in a form designed to meet individual needs and why residents were not provided the level of supervision when eating as ordered. On 08/06/25 at 4:45 P.M., a Quality Assurance Assessment (QAA) meeting was held which included the Administrator, Executive Director, DON, RDO #402, and the Medical Director. The team discussed a plan to mitigate resident choking incidents. The plan outlined included the following: - Identifying on the resident's meal ticket, the diet ordered, and the resident's required level of assistance with eating, including supervision. Resident diet orders and level of assistance with eating will be managed by the clinical team, with any changes to the diet order or a resident's level of assistance communicated to the Dietary Manager by the clinical team at the time of the change. - The Dietary Manager, on a daily basis, will ensure resident meal tickets are up to date with the resident's current diet and level assistance or need for supervision with eating. The Dietary Manager will also place a list of resident diet orders, including diet texture, level of assistance or supervision needed on the snack carts, and all snacks will be labeled to identify the diet texture type. On 08/06/25 at 5:00 P.M., the Department Managers initiated education with the staff on-duty; five Registered Nurses (RN), 15 Licensed Practical Nurses (LPN), three laundry aides, five housekeepers, nine dietary staff, four activities staff, one Executive Director (ED), one DON, one Assistant Director of Nursing (ADON), five therapy staff, one receptionist, one social service employee, 23 CNAs, and one transportation person, on the meal ticket containing the resident's diet ordered, and the required level of assistance with eating, including supervision, each snack on the snack cart labeled with appropriate diet texture, the snack cart containing a list of resident's current diet orders, including texture, required level of supervision or feeding assistance needed with snacks. Staff are to refer to the diet order list prior to offering a snack to each resident. The education with on-duty staff was completed on 08/06/25 at 10:04 P.M. Staff who were not present for the education on 08/06/25 were sent education via text message, with a requirement to send confirmation of the education received. Staff were to respond to the text with a Y for yes, indicating the staff had received and understood the education. Employees would not be able to work until education was completed. Education for all facility staff was completed on 08/07/25 at 2:12 P.M. On 08/06/25 at 6:00 P.M., CCNO #401 and VPC #400 completed a review of all resident diet orders and made sure resident care plans reflected diet and functional status (level of assistance/supervision with eating). On 08/06/25 at 6:00 P.M., the Dietary Manager updated all meal tickets to reflect the correct diet and level of assistance or supervision with meals a resident needed. On 08/07/25 at 2:12 P.M., the education for all facility staff was completed. On 08/07/25, the Administrator completed an audit of three meals and a snack with no negative findings. Continued random meal and snack audits will be conducted by the Administrator or designee, three times a day for five days for one week, then one meal and a snack will be audited five days a week for three weeks. Results of audits will be reviewed in Quality Assurance meetings. Any identified non-compliance will be addressed immediately by the Administrator or DON. Although the Immediate Jeopardy was removed on 08/07/25, 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 action plan and monitoring to ensure on-going compliance.Findings include: 1. Review of the medical record for Resident #83 revealed an admission date of 03/10/20. Diagnoses included paranoid schizophrenia, major depressive disorder, obstructive and reflux uropathy, dysphagia, type II diabetes mellitus, bipolar disorder, histrionic personality disorder, psychophysical visual disturbances, and auditory hallucinations. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #83 was cognitively intact, independent for eating with set-up, had no signs or symptoms of a swallowing disorder and received a mechanically altered diet. Review of care plan dated 09/12/23 for Resident #83 revealed the resident was a full code status (CPR should be initiated with the absence of pulse, respirations, and/or blood pressure). The care plan also revealed a swallowing problem related to a diagnosis of dysphagia with interventions that included for all staff to be informed of the resident's special dietary and safety needs, follow diet as prescribed, instruct the resident to eat in an upright position, to eat slowly and chew food thoroughly, to monitor for shortness of breath and choking, and due to Resident #83 having no natural teeth, staff were to monitor for chewing or swallowing difficulties. Review of the current physician orders revealed a diet order dated 11/10/23 for Resident #83 to receive a regular diet with mechanical soft texture, thin consistency, no bread, and no straws. Review of the modified barium swallow study completed 03/14/24 at 2:00 P.M. revealed Resident #83 had lingual weakness resulting in lateral stasis for liquids. Recommendations and treatment plan included supervised feeding with a mechanical soft diet, thin liquids. Resident #83 was to eat small bites and sit in an upright, 90 degrees, position when eating or drinking. Review of quarterly nutrition assessment dated [DATE] revealed Resident #83 had a diet order of mechanical soft, no bread, and no straws. The assessment also recommended Resident #83 to have a modified barium swallow study in conjunction with speech therapy in order to rule out aspiration secondary to oropharyngeal dysphagia. Review of the medical record from 08/24/24 to 08/07/25 revealed the medical record lacked evidence of a modified barium swallow study or speech consult as recommended. Review of the nursing progress note dated 09/30/24 at 11:22 P.M. revealed on 09/30/24 RN #366 heard a call light and yelling coming from the other end of hall. CNA #320 was yelling for help as she found Resident #83 on the floor, face down between the nightstand and bed with the wheelchair behind him when she responded to Resident #83's roommate call light. RN #366 went into Resident #83's room to find the resident unresponsive. RN #366 rolled Resident #83 onto his back, felt for a pulse, not finding one, RN #366 initiated CPR and directed CNA #320 to call emergency services. CNA #386 went and got another nurse, LPN #335, to help. RN #366 and LPN #335 continued CPR until EMS arrived at approximately 8:36 P.M. EMS took over CPR and attempted multiple interventions unsuccessfully and called time of death at 9:26 P.M. Review of the EMS run report dated 09/30/24, revealed an arrival time of 8:46 P.M., Resident #83 was on the floor and nursing home staff were performing CPR. EMS reported they found former Resident #83 unresponsive, pulseless, and apneic (without respirations) laying supine on the floor. EMS placed defibrillator pads on Resident #83 and began CPR with a manual mechanical device. At 8:47 P.M., EMS placed a fluid line in Resident #83's left tibia and started to provide fluids, at 8:49 P.M. when attempting to insert an artificial airway, Resident #83 vomited, and at 8:53 P.M. a foreign body, that appeared to be chewed food was noted in Resident #83's mouth. Resident #83's airway was suctioned numerous times with approximately five milliliters of what appeared to be chewed food was returned. Advanced Cardiac Life Support (ACLS) protocols were followed, and after five rounds of epinephrine (an emergency adrenaline medication), one milligram (mg) was given through the fluid line, Resident #83 continued to show asystole. At 9:25 P.M., EMS contacted Medical Control at a local hospital for a termination of efforts order. Former Resident #83 was pronounced deceased at 9:26 P.M. Review of the Certificate of Death dated 10/15/24 revealed Resident #83 was pronounced deceased at 9:26 P.M. on 09/30/24, with an accident identified as the manner of death, and a description of the injury as, choked-on food. The certificate of death also indicated Resident #83 had a history of dysphagia as another significant factor contributing to the resident's death. Interview on 08/06/25 at 8:21 A.M. with LPN #335 revealed that CNA #386 indicated there was a code blue upstairs, LPN #335 went to assist and found RN #366 performing CPR on Resident #83. LPN #335 stated he and RN #366 traded off with performing CPR until EMS arrived and took over. LPN #335 did not see any evidence of food around Resident #83 but was informed Resident #83 was given a peanut butter sandwich just before the choking incident. Interview on 08/06/25 at 9:10 A.M. with the County Coroner confirmed Resident #83's cause of death was from choking on food. Furthermore, the County Coroner stated, looking at the pictures from the autopsy, there appears to be food, more specifically food resembling bread, about the size of a baby's fist, seen completely obstructing Resident #83's airway. Interview on 08/11/25 at 10:35 A.M. with RN #366 revealed that on 09/30/24 at approximately 8:30 P.M. Resident #83 was found on the floor with no pulse or respirations. RN #366 stated CPR was initiated with another nurse switching back and forth performing CPR until EMS arrived. RN #366 stated they worked on Resident #83 for about 45 minutes before pronouncing his death. RN #366 was told by CNA #320 that Resident #83 was given a sandwich by CNA #386. RN #366 confirmed Resident #83 was not to receive bread and had a physician order for no bread. Interview on 08/12/25 at 6:26 A.M. with CNA #386 revealed that on 09/30/24 at approximately 8:30 P.M. the call light was going off in Resident #83's room and when she got there, RN #366 was performing CPR. CPR was performed by nursing staff until EMS showed up. About 30 minutes prior to the call light CNA #386 confirmed that Resident #83 was given a peanut butter sandwich by her. CNA #386 indicated she always checks with whatever nurse is on duty before passing any food but does not remember if she checked that night. Review of the facility self-imposed action plan initiated 10/01/24 revealed the following: On 10/01/24 at 9:00 A.M., a Quality Assurance Assessment (QAA) meeting was held which included the Administrator, DON, RDO #402 and the Medical Director. The team discussed a plan to mitigate the choking incident. The plan implemented included a list of diet textures on the snack cart. Staff education was completed communicating the diet texture list would be placed on the snack cart. On 10/01/24, the DON, Assistant Director of Nursing (ADON), and Unit Manager completed audits on all current resident records, including resident observations during snack pass to ensure residents received the appropriate textured snacks. Observations started at 9:30 A.M. and finished at 11:00 A.M. On 10/01/24 at 11:30 A.M., the Dietary Manager printed a list of the residents' diets and verified the list matched the resident's current diet order. The list would be sent with the snack carts so the CNAs could identify what diet each resident was on. Diet orders were to be up to date at all times with the Dietary Manager verifying each day when printing the list. On 10/01/24 at 11:30 A.M., seven RNs, 15 LPNs, 36 CNAs, nine dietary employees, eight housekeeping and laundry employees, three activities employees, two receptionists, one scheduler, one Human Resources person, one Social Service employee, one admission staff, one maintenance employee, and one medical record staff member were educated by the DON, ADON and Unit Manager to ensure the diet list printed was being referenced prior to serving a resident a snack from the snack cart. Education was completed at 12:45 P.M. On 10/02/24, ongoing audits were started and completed by way of staff interview to ensure staff reviewed the resident diet list prior to snacks offered to the resident, and that the current diet list was available on the snack tray. Audits were completed three times a week for four weeks by the ADON. Compliance was determined on 10/28/24. 2. Review of the medical record revealed Resident #07 was admitted on [DATE]. Diagnoses included chronic kidney disease, epilepsy, and overactive bladder. Review of Resident #07's physician orders, dated 04/04/25, revealed the physician prescribed a regular diet, pureed texture, and nectar consistency. Review of the quarterly MDS assessment, dated 07/11/25, revealed the resident had severe cognitive impairment and required substantial assistance for feeding. Review of the nutritional assessment, dated 07/17/25, indicated Resident #07 was to be supervised while eating. Observation on 08/06/25 at 8:07 A.M. while confirming environmental issues in the residents' rooms with Regional Director of Maintenance #403 revealed coughing coming from Resident #07's bedroom. No staff were present during this time. Resident #07's cough began to sound more urgent, the surveyor went into Resident #07's room and noted Resident #07 with a food tray in front of him. Resident #07 was coughing and had a purple/red discoloration to his face. The surveyor went into the hallway and yelled for help. LPN #381 and CNA #323 went into Resident #07's bedroom and assisted him in clearing the food by sitting him up in the bed manually due to the bed not working. Resident #07 was sitting at approximately a 60-degree angle. Interview on 08/06/25 with LPN #381 revealed herself and CNA #323 had to sit Resident #07 up in bed because the bed position was stuck. LPN #381 further stated with repositioning that the food was able to be dislodged and Resident #07 spit the food into a towel. Interview on 08/06/25 at 10:28 A.M. with ADON #370 revealed Resident #07 coughed up his food and spit it in a towel. ADON #307 confirmed that the most recent nutritional assessment on 07/17/25 stated Resident #07 was to be supervised while eating. Furthermore, the ADON confirmed the MDS indicates Resident #07 requires substantial assistance for feeding. Interview with CNA #323 on 08/06/25 at 10:45 A.M. revealed Resident #07 had choked on his oatmeal on 08/04/25 and was able to clear it himself. Furthermore, CNA #323 stated typically Resident #07 is left unsupervised when eating in his room. Interview on 08/06/25 at 11:18 A.M. with Dietetic Technician #415 stated there are varying levels of set up and supervision that Resident #07 may need; however, if Resident #07 had a choking episode on 08/04/25, then the episode should have been reported, and Resident #07 should have been evaluated by speech therapy. Review of the Facility Assessment, dated 06/17/25, indicated the facility will meet individualized dietary requirements, including specialized diets to ensure the resident's nutritional requirements are met. The staff training and education provided annually and as needed to ensure the level of support and care needed for the resident population included nutritional promotion in older adults, diets in long term care, and feeding and eating assistance. Review of the undated facility policy titled Therapeutic Diets, identified therapeutic diets shall be prescribed by the attending physician. Mechanically altered diets are identified as therapeutic. The Dietician and Dietary Manager are responsible to record in the resident's medical record significant information related to the resident's therapeutic diet. A tray identification system is utilized to ensure each resident receives the correct diet. Review of the undated facility policy titled Reading Meal Tickets/Cards, revealed all staff will read and review the meal ticket/card, including any meal alteration for consistency, to ensure residents are served the correct meal or snack. Review of the facility policy titled Activities of Daily Living, revised January 2022, stated ADL services are directed toward the goal of promoting the highest practicable physical, mental and psychological functioning of the resident. ADL care plans are developed by a nurse and may be delivered by the designated staff members as part of routine care with a facility goal that a resident's abilities do not diminish. ADL care areas include bathing, dressing/grooming, toileting, mobility, transfers and eating. Staff are to follow the resident's care plan when carrying out the ADL task and inform the nurse when there is a refusal or significant decline in the resident's abilities. This deficiency represents non-compliance investigated under Complaint Number OH00166789 (1260025).

Based on observation, medical record review, staff interview, review of a job description, and policy review, the facility failed to provide adequate administration over the facility when a resident died from a choking incident as a result of being provided unapproved food items. The facility subsequently put a corrective action plan into place that was not fully followed to prevent further episodes of resident's choking and prevent residents from receiving restricted food and drinks. This had the potential to affect all 74 residents residing in the facility. The facility census was 74.Findings Include:Interview on 08/12/25 at 1:47 P.M. with the Administrator, Chief Nursing Officer (CNO) #401, and [NAME] President of Clinical Services (VPCS) #400 revealed after a choking incident on 09/30/24 that resulted in a resident's (#83) death when the resident was give food items that were restricted, the facility immediately implemented a self-imposed action plan (SIAP) to correct the deficiencies that contributed to the event. Part of the SAIP included an entry dated 10/01/24, that the Dietary Manager (DM) would put a diet list on each snack tray so staff are aware of the current diet order prior to offering a snack. Additionally, the SAIP included on 10/01/24 staff education on the diet list would be completed by the Director of Nursing (DON)/Assistant Director of Nursing (ADON) #370/Clinical Manager (CM) with audits being done to observe staff were utilizing the cards. The SIAP also indicated the results of the audits will be reported to the Quality Assurance (QA) committee.Random observations made throughout the survey revealed staff not utilizing diet order cards on snack trays during snack pass times; and additional observations made throughout the annual survey revealed on 08/06/25 at 10:27 A.M. Resident #7 was choking on food while eating in bed and staff came to assist with the resident ultimately coughing up food into a towel. Resident #7 was eating alone at the time of the choking incident and review of a nutritional assessment dated [DATE] revealed the resident was to be supervised while eating. Interview on 08/06/25 at 10:28 A.M. with ADON #370 revealed Resident #07 coughed up his food and spit it in a towel. ADON #307 confirmed that the most recent nutritional assessment on 07/17/25 stated Resident #07 was to be supervised while eating. Further observation on 08/11/25 at approximately 9:05 A.M. revealed Resident #38 eating bacon from another resident's meal tray off the unattended hallway cart, and review of Resident #38's physician order dated 01/16/25 revealed the resident a regular diet with pureed texture and thin liquids. Interview on 08/11/25 at approximately 9:07 A.M. with VPCS #400 confirmed Resident #38 had bacon. Interview on 08/11/25 at 9:08 A.M. with Certified Nurse Aide (CNA) #404 confirmed Resident #38 regularly took food from other residents' plates. Staff had to monitor Resident #38 closely because of this behavior. Further interview revealed CNA #404 was in the dining room during the observation at approximately 9:05 A.M. when Resident #38 removed bacon from the tray cart. CNA #404 confirmed Resident #38 was on a pureed diet. Further, CNA #404 confirmed the tray Resident #38 removed the bacon from was an untouched tray for a resident who was hospitalized .Review of the undated Executive Director (Administrator) job description listed essential job functions and responsibilities included to develop and maintain written policies and procedures that govern the operation of the facility, and assume the administrative authority, responsibility, and accountability of directing the activities and programs of the facility. Additionally, the primary purpose of job description was to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern long-term care facilities to assure that the highest degree of quality of care can be provided to our residents at all times.Review of the Quality Assurance Performance Improvement (QAPI) policy, dated 03/2023, revealed governance and leadership will operate under the direction of the QAPI Governing Chairpersons who are considered subject matter experts; Executive Director, Director of Nursing, Medical Director, and Infection Preventionist. Further, the policy revealed the object of the QAPI Governing was to develop a continuous pro-active approach to self-discovery to decrease the likelihood of issues/concerns and test new approaches to correct underlying potential causes of those issues/concerns.This deficiency represents non-compliance investigated under Complaint Number 2562969.

Based on review of water flushing logs, review of water monitoring logs, review of water temperature logs, staff interview, review of a water pH level reading document, and policy review, the facility failed to accurately and adequately conduct water monitoring for the prevention of Legionella within the facility. This had the potential to affect all 74 residents in the facility. The census was 74.Findings include: Review of the water flushing logs from January 2025 through August 2025 revealed no water lines were flushed in January, February, and March 2025. A comment written on the log for March 2025 revealed, all rooms in use 03/14/25. Further review revealed room [ROOM NUMBER] was flushed on 05/06/25 (marked as completed late for April 2025), room [ROOM NUMBER] was flushed on 05/16/25, 06/05/25, and 07/22/25, and room [ROOM NUMBER] was flushed on 08/04/25. Further review revealed no specifics regarding the faucet that was flushed or the duration of the flush.Review of the chlorine and pH monitoring levels in drinking water, dated 04/11/25, revealed A-hall and C-hall had pH levels of five (5) and B-hall had a pH level of four (4). Review of the chlorine and pH monitoring levels in drinking water, dated 06/06/25 and 06/18/25, revealed A-hall, B-hall, and C-hall had pH levels of 4.0 and chlorine levels of 1.0. Review of the water temperature logs from 05/01/25 through 08/12/25 revealed no water temperatures were obtained and documented between 06/21/25 and 07/17/25 and between 07/19/25 and 08/04/25.Interview on 08/12/25 at 7:36 A.M. with Regional Director of Maintenance (RDM) #403 revealed the facility had no assigned maintenance director and RDM #403 was covering the facility until someone was hired for the position. RDM #403 stated and he expected staff to monitor water temperatures by checking at least two rooms from each hall, preferably one room at each end, and to vary the rooms. Further interview revealed unused water sources were flushed for ten (10) minutes, once monthly, to deter Legionella growth. Additionally, RDM #403 stated the facility tested pH and chlorine levels once monthly.Interview on 08/12/25 at approximately 8:00 A.M. with the Administrator revealed the facility had no empty rooms on 08/12/25 and often did not have empty rooms. Follow-up interview on 08/12/25 at 10:25 A.M. with RDM #403 confirmed he should be flushing unused faucets once weekly to deter the growth of Legionella rather than only once monthly as had been his practice at the facility. Further, RDM #403 confirmed water temperatures should be checked daily and confirmed no water temperatures were completed between 06/21/25 and 07/17/25 and between 07/19/25 and 08/04/25. Follow-up interview on 08/12/25 at 10:53 A.M. with RDM #403 confirmed a pH of 4.0 or 5 was not appropriate for drinking water and RDM #403 verified drinking water should have a pH of 6.5 to 8.5. RDM #403 provided a printed internet search regarding the average pH of drinking water and verified it could be used as the facility's policy regarding the appropriate pH range of drinking water.The facility was unable to provide any guidance regarding the optimal level of chlorine in drinking water.Review of the document titled, Standards for water pH readings, printed from the internet on 08/12/25 at 10:50 A.M., revealed the standard range for pH in drinking water, as recommended by the Environmental Protection Agency, was between 6.5 and 8.5. Review of the undated policy titled, Legionella Policy - Environmental, revealed the implement measures to reduce the potential for the growth and spread of Legionella. Control measures would include, but were not limited to routine testing of chlorine levels, routine testing of water temperature levels, and monitoring and flushing pipes in rooms and/or areas of the building that were not in use.

Based on employee file review and staff interview, the facility failed to ensure employees completed Quality Assurance and Performance Improvement (QAPI) training. This had the potential to affect all 74 residents residing in the facility. The facility census was 74.Findings include:Review of the employee file for Certified Nurse Aide (CNA) #320, CNA #306, CNA #305, Licensed Practical Nurse (LPN) #383, and Registered Nurse (RN) #365 revealed none of the employees received training on the facility's QAPI program.Interview on 08/12/25 at 8:00 A.M. with CNA #371, LPN #381 on 08/12/25 at 10:10 A.M., and CNA #219 on 08/12/25 at 10:12 A.M. revealed none of the three staff members were aware of what QAPI was and had not been trained on it.Interview on 08/12/25 at 2:00 P.M. with Human Resource Manager #379 confirmed employees should have QAPI training upon hire and confirmed CNA #320, CNA #305, CNA #306, LPN #383, and RN #365 had no evidence of QAPI training in their employee files.

Based on observation and staff interview, the facility failed to ensure the facility maintained a homelike environment. This affected eight (#35, #82, #22, #36, #12, #81, #7, and #29) of eight residents reviewed for environment. The facility census was 74.Findings include:1. Observation on 08/05/25 at 1:43 P.M. behind Resident #12's bedroom door revealed a large hole in the drywall at the door handle height. Also noted in the coinciding area behind the door right below the ceiling was a small hole in the drywall. In Resident #12's shared bathroom there was a waste basket under the sink, approximately one-quarter full of water.2. Observation on 08/05/25 at 1:43 P.M. of Resident #81's bedroom revealed a light above his bed with no cord to turn the light on. Resident #81 shared a bathroom with Resident #12 which had a waste basket under the sink, approximately one-quarter full of water.3. Observation on 08/05/25 at 1:49 P.M. of Resident #7 and Resident #35's room revealed large brown-colored areas of a substance throughout the entire ceiling.4. Observation on 08/05/25 at 1:51 P.M. of Resident #29's bedroom revealed a light above the bed with no pull cord.5. Observation on 08/05/25 at 1:52 P.M. of Resident #36 and Resident #22's room revealed large brown-colored areas of a substance throughout the entire ceiling.6. Observation on 08/05/25 at 1:53 P.M. of Resident #82's bedroom revealed a light above the bed with a broken cover that was hanging from the light.Interview and observation on 08/06/25 at 8:07 A.M. with Regional Director of Maintenance (RDM) #403 confirmed Resident #12 had two holes behind the door and a waste basket under the bathroom sink shared by Resident #12 and Resident #81 that was approximately one-quarter full of water. RDM #403 stated he was going to get a part to fix the sink. RDM #403 also confirmed Resident #81 and Resident #29 did not have pull cords for their lights over their bed. RDM #403 confirmed the ceilings in the room shared by Resident #7 and Resident #35 and the room shared by Resident #36 and Resident #22 had water pipes that burst and were fixed; however, the brown-colored spots on the ceiling were not. Additionally, RDM #403 confirmed Resident #82's light was broken.This deficiency represents non-compliance investigated under Complaint Number 2562969 and Complaint Number OH00166789 (1260025).

Based on medical record review, staff interview, and policy review, the facility failed to timely develop comprehensive care plans. This affected two (#6 and #16) of 31 residents reviewed for comprehensive care plans. The facility census was 74.Findings include:1. Review of the medical record for Resident #16 revealed an admission date of 07/09/25 with diagnoses of schizoaffective disorder, chronic obstructive pulmonary disease, and unspecified psychosis. Review of the comprehensive admission Minimum Data Set (MDS) assessment, dated 07/16/25, revealed Resident #16 had intact cognition and used tobacco. Review of the admission packet, dated 07/09/25, revealed Resident #16 smoked, required supervision during smoking, and needed the facility to store his lighter and cigarettes. Further review revealed a care plan for safety revealed Resident #16 was at risk for injury. Goals were to maintain a safe environment during smoking and Resident #16 would comply with facility smoking policy. Review of the facility's list of smokers revealed Resident #16 smoked. Review of the comprehensive care plan for Resident #38, on 08/06/25, revealed no care area for smoking. Interview on 08/06/25 at 5:02 P.M. with the Social Services Designee #392 confirmed care area for smoking was in Resident #16's care plan. SSD #392 stated Resident #16 was a relatively new admission and she had not yet completing adding all care areas to his care plan. 2. Review of the medical record revealed Resident #6 had an admission date of 04/02/25. Diagnoses included conversion disorder with seizures or convulsions, dementia, Alzheimer's disease, and depression. Review of the significant change MDS assessment dated [DATE] revealed Resident #6 had impaired cognition. Review of a physician order dated 04/03/25 revealed Resident #6 was ordered Lexapro ten milligrams in the morning daily for depression. Review of a psychiatry progress note dated 06/19/25 revealed Resident #6 had depressive disorder with recommendations to encourage increased physical activity to improve mood and overall well-being, good sleep hygiene, balanced diet, sunlight exposure, and to practice relaxation techniques Review of Resident #6's care plan, last revised 06/20/25, revealed the resident required psychoactive medication due to alteration in mood and behavior related to behavioral disturbance, and depression. Further review of the care plan revealed there was no care plan in place for the depression diagnosis with individualized interventions. Interview on 08/06/25 at 1:47 P.M. MDS Licensed Practical Nurse (MDS LPN) #315 verified Resident #6 had no care plan in place for depression with individualized interventions. Review of the facility policy titled, Care Plan Policy, revised 10/2022, revealed a comprehensive care plan would be developed within 21 days after admission upon completion of the appropriate assessments by the Interdisciplinary Team. Overall, care plans would address diagnoses, physician orders, dietary needs, medications, treatments, general care, devices and interventions, behaviors, advanced directives, choices, cultural preferences, and other needs and preferences specific to the resident. The care plan would be used by the care team to coordinate and manage the resident's goals, preferences, choices, past trauma care, and services that would be provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, medical record review, staff interview, resident interview, physician interview, and policy review, the facility failed to ensure a resident urinary tract infection was timely and appropriately treated; and failed to ensure a urinary catheter was patent and functioning properly. This affected two (#69 and #81) of two residents reviewed for bowel and bladder concerns. The facility identified three residents with urinary tract infections and six residents with urinary catheters. The facility census was 74. Findings include:1. Review of the medical record for Resident #69 revealed an admission date of 03/29/21. Diagnoses included type two diabetes mellitus, depression, schizoaffective disorder, peripheral vascular disease, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 had intact cognition. The resident was occasionally incontinent of bowel and bladder. The resident required substantial/maximal assistance of staff for toileting. Review of a physician order dated 07/22/25 revealed an order for a urinalysis with culture if indicated for dysuria. The nurse was to collect the urine and place in the specimen in the laboratory refrigerator and follow up with results in three days. Review of a nurses note dated 07/24/25 at 9:01 A.M. revealed the nurse was unable to collect a urinary specimen as Resident #69 was unable to produce enough specimen. The nurse would continue to try and collect it. Review of Resident #69's nurses notes dated 07/24/25 through 07/29/25 revealed no documentation of further attempts to obtain a urine specimen for the resident. There was no documentation the resident had been monitored for continued and further signs of infection. Review of Resident #69's nurses note dated 07/30/25 at 6:22 P.M. revealed an order was placed for a urinalysis and the resident had possible symptoms (of a urinary tract infection) and a specimen was placed in the refrigerator that was caught via clean catch (a midstream sample collection of urine). Review of a urinalysis laboratory report dated 08/02/25 revealed a urine specimen was collected on 07/30/25 and received by the laboratory on 07/31/25 for Resident #69. Further review of the laboratory report revealed the facility was notified on 08/02/25 of the culture and sensitivity laboratory results showing the resident had greater than 100,000 Klebsiella Pneumonia bacteria. The bacteria was resistant to the antibiotic nitrofurantoin (Macrobid) and susceptible to nine other antibiotics including ciprofloxacin. Review of Resident #69's nurses note dated 08/04/25 at 9:46 A.M. revealed the physician was notified of results. Interview on 08/04/25 at 2:12 P.M., Resident #6 revealed she had signs and symptoms of a urinary tract infection including weakness, burning, and lethargy for a few weeks and had not received any antibiotic. Resident #6 revealed a urine sample had been collected but she had not heard anything back about the results or treatment. Resident #6 revealed the nursing staff never followed up with her regarding her symptoms which continued to increase. Review of Resident #69's nurses notes from 08/05/25 through 08/06/25 revealed there was no follow up with the physician or resident until after surveyor intervention. Review of a nurses note dated 08/06/26 at 12:33 P.M. revealed the resident was reporting dysuria and lower back pain. The physician was updated with new orders to recheck the urine and start the medication Pyridium (used to treat pain, burning and discomfort of urinary tract infections but does not treat the infection) were given. Interview on 08/07/25 at 4:15 P.M., Registered Nurse (RN) #370 revealed the physician should have been notified when the staff were unable to obtain a urine specimen from 07/24/25 through 07/30/25. RN #370 revealed it should not have taken six days to obtain a urine sample. RN #370 also verified there was no documentation of the resident's signs and symptoms of infection and no documentation the resident had been properly monitored for signs and symptoms of infection and the physician updated of the resident's continued signs and symptoms of a urinary tract infection. Review of a nurses note dated 08/08/25 at 10:07 P.M. revealed the physician wanted Resident #69 started on the antibiotic Macrobid 100 milligrams (mg) twice daily for seven days. Review of the medication administration record (MAR) dated 08/01/25 through 08/31/25 revealed Resident #69 was administered Macrobid 100 mg twice on 08/09/25, and twice 08/10/25, and once on 08/11/25. Interview on 08/11/25 at 2:30 P.M., [NAME] President Clinical Services (VPCS) #400 verified the laboratory report culture and sensitivity results indicated the Klebsiella Pneumonia bacteria was resistant to Macrobid (nitrofurantoin). VPCS #400 verified the physician had ordered the one antibiotic the bacteria was resistant to. VPCS #400 revealed she would notify the physician. Review of Resident #69's nurses note dated 08/11/25 at 3:12 P.M. revealed the physician was notified regarding the urinalysis results and a new order was received to change the antibiotic to Cipro (ciprofloxacin). Review of a physician order dated 08/11/25 at 7:00 P.M. revealed Resident #69 had an order for ciprofloxacin 500 milligrams by mouth two times a day for urinary tract infection for ten days. Interview on 08/12/25 at 2:24 P.M., Physician #410 revealed he was notified of Resident #69's laboratory results and should have followed up to ensure the resident was ordered the right antibiotic. Review of the undated facility policy titled, Laboratory Order Processing, revealed if a laboratory could not be drawn the same day then the physician would be notified for new orders and guidance. The physician would be notified of laboratory results as appropriate with new orders processed at this time. Review of the, Antibiotic Stewardship Policy, last revised 05/2025, revealed the facility would implement an Antibiotic Stewardship Program which would promote appropriate use of antibiotics while optimizing the treatment of infections and to limit antibiotic resistance in the post-acute care setting, while improving treatment efficacy and resident safety, and reducing treatment-related costs. Further policy review revealed the facility would use diagnostic testing to optimize tracking and treatment of infections. 2. Review of the medical records for Resident #81 revealed an admission date of 07/31/25 with diagnoses of unspecified dementia, retention of urine, and diabetes insipidus. Review of the admission care plan dated 08/15/25 revealed Resident #81 had an activities of daily living (ADL) self-care performance deficit related to dementia and schizoaffective disorder. Staff were to assist with toileting and was provide supportive care as needed. Further review of the care plan revealed Resident #81 had an indwelling suprapubic catheter. Resident #81 was to remain free from catheter related trauma by monitoring pain and discomfort, providing catheter care per physician orders, and notifying the physician of any abnormalities. Review of the physician orders for Resident #81 dated 08/01/25 revealed suprapubic catheter #16 French (Fr) to straight drain, and suprapubic catheter care every shift. Observation on 08/05/25 at 2:01 P.M. in Resident #81's bedroom revealed Resident #81 ambulating out of the bathroom behind his bedroom curtain. Resident #81 had his pants off and began urinating on the floor from his penis. Resident #81 had a suprapubic catheter with a leg bag attached to his left leg that was empty. Interview on 08/05/25 at 2:02 P.M. with Resident #81 revealed he reported his catheter not working to the nurse, and the nurse stated there was nothing they could do. Interview on 08/05/25 at 2:04 P.M. with Licensed Practical Nurse (LPN) #383 revealed that was the first time she had taken care of Resident #81 and was told he took care of himself. LPN #383 stated she was unaware the catheter was not functioning and furthermore did not know Resident #81 had a suprapubic catheter. Interview on 08/05/25 at 2:10 P.M. with Assistant Director of Nursing (ADON) #370 revealed the nurse should monitor Resident #81's suprapubic catheter and notify the physician of any abnormal findings. ADON #370 stated Resident #81 pulled on his catheter when taking his pants on and off. Interview on 08/06/25 at 10:05 A.M. with ADON #370 revealed a new suprapubic catheter was placed in Resident #81 on 08/05/25 due to the other catheter not draining properly. Review of the facility policy titled, Foley Catheter Care Policy, dated 01/09/25, revealed the nurse will perform catheter care with soap and water every shift and as needed.

Based on medical record review, staff interview, and policy review, the facility failed timely notify the physician of abnormal laboratory results. This affected one (#69) of two residents reviewed for bowel and bladder concerns. The facility census was 74.Findings include:Review of the medical record for Resident #69 revealed an admission date of 03/29/21. Diagnoses included type two diabetes mellitus, depression, schizoaffective disorder, peripheral vascular disease, and hypertension.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 had intact cognition. Review of Resident #69's physician order dated 07/22/25 revealed an order for a urinalysis with culture if indicated for dysuria. The nurse was to collect the urine and place in the laboratory refrigerator and follow up with result in three days. Review of a nurses note dated 07/24/25 at 9:01 A.M. revealed the nurse was unable to collect a urinary specimen as Resident #69 was unable to produce enough specimen. The nurse would continue to try and collect a specimen.Review of the nurses notes dated 07/24/25 through 07/29/25 revealed no documentation of further attempts to obtain a urine specimen for Resident #69. There was no documentation the physician was notified the urine specimen had not been obtained. Review of a nurses note dated 07/30/25 at 6:22 P.M. noted to place an order for an urinalysis. Resident #69 had possible symptoms (of a urinary tract infection) and a specimen was obtained. Review of Resident #69's urinalysis laboratory report dated 08/02/25 revealed a urine specimen was collected on 07/30/25 and received by the laboratory on 07/31/25. Further review of the laboratory report revealed the facility was notified on 08/02/25 of the culture and sensitivity laboratory results showing the resident had greater than 100,000 Klebsiella Pneumonia bacteria. The bacteria was resistant to the antibiotic nitrofurantoin (Macrobid) and susceptible to nine other antibiotics including ciprofloxacin.Review of the nurses notes dated 08/02/25 and 08/03/25 revealed no documentation the physician was timely notified of the urinalysis results. Review of a nurses note dated 08/04/25 at 9:46 A.M. revealed the physician was notified of results. Interview on 08/07/25 at 3:30 P.M., [NAME] President of Clinical Operations (VPCS) #400 verified the physician was not timely notified of the laboratory urinalysis results. Interview on 08/07/25 at 4:15 P.M., Registered Nurse (RN) #370 revealed the physician should have been notified when the staff were unable to obtain a urine specimen from 07/24/25 through 07/30/25. RN #370 also verified the physician should have been notified on 08/02/25 when the laboratory results had been received. Review of the policy titled, Notification of Change in Condition, updated 06/2025, revealed the nurse would consult with the resident's physician when there was a significant change in the resident's health status including complications. Also, when there was a need to alter treatment significantly including abnormal laboratory results.

Based on medical record review, review of hospital documentation, review of self-reported incidents, staff interview, and policy reviews, the facility failed to ensure appropriate notifications were made for three (#1, #71, and #56) of seven residents reviewed for resident-to-resident interactions and change in condition. The facility census was 74.Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 05/27/25 with diagnoses of anoxic brain damage, dementia, bipolar disorder, and schizoaffective disorder. Review of the comprehensive admission Minimum Data Set (MDS) assessment, dated 06/03/25, revealed Resident #1 had impaired cognition and impairment to one side of her upper extremity and one side of her lower extremity. Review of the medical record for Resident #71 revealed an admission date of 01/04/22 with diagnoses of neurocognitive disorder, with Lewy bodies, stroke, pseudobulbar affect, dysarthria and anarthria. Review of the quarterly MDS assessment, dated 06/14/25, revealed Resident #71 had impaired cognition, had no impairment to the upper or lower body, used a wheelchair for mobility, was dependent for toileting, required substantial/maximal assistance for sit-to-stand transfers and walking, and was dependent for mobilizing in her wheelchair. Review of the facility's self-reported incident (SRI), Tracking #263493, revealed the facility initiated an SRI for physical abuse when Resident #71 was found lying on the ground in Resident #1's room on 07/30/25. Resident #1 stated she hit Resident #71 because Resident #71 was in her room. The facility determined abuse did not occur as a result of their investigation. Review of the facility's investigation into the incident revealed both residents were assessed for injuries and neither resident was injured. Further review revealed the physician and the manager on duty were notified of the incident. The investigation provided no indication the resident representative for either resident was notified. Interview on 08/12/25 at 6:45 A.M. with Registered Nurse (RN) #366 revealed she was the nurse on duty during the time of the incident between Resident #1 and Resident #71. RN #366 confirmed she did not notify the resident representative for Resident #1 because RN #366 believed Resident #1 had a guardian who was not very involved in Resident #1's care. RN #366 further stated she did not notify Resident #1's representative because Resident #1 was her own person. Review of the facility's abuse policy, reviewed 05/2025, revealed the resident representative, and the resident's attending physician, if appropriate, should be notified of the incident/allegation. 2. Review of the medical record for Resident #56 revealed an admission on [DATE] with diagnoses of paranoid schizophrenia, major depressive disorder, and pseudobulbar affect. Review of the admission MDS assessment dated [DATE] revealed Resident #56 was cognitively intact. Further review of the MDS revealed Resident #56 used a walker to ambulate and required supervision for activities of daily living (ADLs). Review of the care plan dated 07/15/25 revealed Resident #56 was at risk for falls and potential injury related to psychoactive drug use, and staff were to minimize the potential risk factors related to falls. Additional review of the care plan revealed Resident #56 used psychotropic medications related to paranoid schizophrenia, major depressive disorder, and anxiety disorder. Resident #56 was to remain free of drug related complications including gait disturbances. Staff were to report any adverse reactions, including unsteady gait or shuffling gate. Review of the progress note for Resident #56 on 08/11/25 at 6:17 P.M. revealed at 6:15 P.M. Resident #56 was observed running up and down the hallway. Resident #56 had been hallucinating stating the Federal Bureau of Investigation (FBI) was watching her though the walls. Resident #56 believed she needed electric shock therapy. The physician was notified. Review of the progress note for Resident #56 on 08/11/25 at 7:09 P.M. revealed emergency medical services (EMS) was called and Resident #56 was sent out for psychiatric evaluation. Review of the hospital discharge report for Resident #56 on 08/11/25 revealed the resident arrived to the emergency department at 7:40 P.M. A psychiatric evaluation was complete and Resident #56 was discharged with no new orders. Review of the progress note for Resident #56 on 08/12/25 at 3:20 A.M. revealed Resident #56 returned to the facility with no new orders. Interview on 08/12/25 at 10:57 A.M. with Chief Nursing Officer (CNO) #401 confirmed there was no documentation that Resident #56's representative was notified of her recent hospitalization. Furthermore, CNO #401 confirmed the nurse should have contacted Resident #56's representative when she was sent to the hospital and upon return. Review of the policy titled, Notification of Change in Condition, updated 06/2025, revealed the nurse would consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications.

Based on observation, medical record review, and staff interview, the facility failed to adequately assess a resident following an unwitnessed fall and failed to ensure adequate supervision to prevent a resident from consuming food not in their diet. This affected two (#56 and #38) of two residents reviewed for accidents. The facility census was 74.Findings include: 1. Review of the medical record for Resident #56 revealed an admission on [DATE] with diagnoses of paranoid schizophrenia, major depressive disorder, and pseudobulbar affect. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 was cognitively intact. Further review of the MDS assessment revealed Resident #56 used a walker to ambulate and required supervision for activities of daily living (ADLs). Review of the care plan dated 07/15/25 revealed Resident #56 was at risk for falls and potential injury related to psychoactive drug use, and staff were to minimize the potential risk factors related to falls. Additional review of the care plan revealed Resident #56 used psychotropic medications related to paranoid schizophrenia, major depressive disorder, and anxiety disorder. Resident #56 was to remain free of drug related complications including gait disturbances. Staff were to report any adverse reactions, including unsteady gait or shuffling gate. Observation on 08/12/25 at 10:03 A.M. at the Connections nurses station revealed Resident #56 approximately ten feet from the nurse’s station lying on the ground with her walker next to her yelling for help. Licensed Practical Nurse (LPN) #381 was behind the nurse’s station at this time. At 10:05 A.M., Housekeeper #376 came out of a resident room stated to Resident #56, Come on get up, and helped Resident #56 off the floor. Housekeeper #376 then went back into room [ROOM NUMBER] without reporting the incident. Interview on 08/12/25 at 10:07 A.M. with LPN #381 revealed she was unaware Resident #56 was on the floor. LPN #381 heard Resident #56 yelling out but stated she was preoccupied with charting. LPN #381 stated she was unsure where the nurse aides were during this time. Further interview with LPN #381 revealed if a resident was on the floor and it was not witnessed the nurse should complete a head-to-toe assessment, neurological checks, call the doctor and resident representative, tell management, and complete a fall packet. LPN #381 confirmed Housekeeper #376 did not report that Resident #56 was on the ground and was only aware due to being told by this surveyor. Review of the progress note for Resident #56 on 08/12/25 at 10:16 A.M. revealed Resident #56 put herself on the floor in the hallway and housekeeping helped Resident #56 up. Interview on 08/12/25 at 10:48 with Housekeeper #376 revealed she did not see Resident #56 fall and came out of the resident room on 08/12/25 due to hearing Resident #56 yelling. Housekeeper #376 confirmed she did not report it to the nurse. Interview on 08/12/25 at 10:57 A.M. with Chief Nursing Officer #401 confirmed the nurse should complete a fall assessment when a resident has an unwitnessed fall. 2. Review of the medical record for Resident #38 revealed an admission date of 12/28/23 with diagnoses of Alzheimer's disease, dementia, oropharyngeal dysphagia, and schizoaffective disorder. Review of the quarterly MDS assessment, dated 07/07/25, revealed Resident #38 had mildly impaired cognition, used a walker and wheelchair for mobility, was able to eat with supervision or touching assistance, and was able to wheel 50 feet with two turns once seated in her wheelchair. Further review revealed Resident #38 was on a texture modified diet. Review of the physician order dated 01/16/25 revealed Resident #38 was on a regular diet with pureed textures and thin liquids. Review of the care plan, updated 06/05/25, revealed Resident #38 displayed behavioral symptoms, including taking food off other resident trays. Interventions included verbal redirection and intervening when Resident #38 displayed inappropriate behavior. Review of a progress note dated 05/16/25 revealed Resident #38 was at the food cart stealing regular texture food off other residents’ trays. Resident #38 was educated and redirected. Review of a progress note dated 05/27/25 revealed Resident #38 was eating regular food. Resident #38 was educated twice but refused to give the food back to staff. Review of a progress note dated 06/14/25 revealed Resident #38 was caught eating steak out of the trash. Resident #38 was redirected. Review of a progress note dated 07/04/25 revealed Resident #38 took a hamburger off a discharged resident’s food tray. Resident #38 was educated and refused to return the hamburger. Resident #38 consumed the hamburger without issue. Observation on 08/11/25 at approximately 9:05 A.M. revealed [NAME] President of Clinical Services (VPCS) #400 in the nurses station at the medication cart with her back to Resident #38. Further observation revealed Resident #38 opened the tray cart in the hallway and reaching inside, lifting the lid off another resident’s tray, and pulling out two pieces of bacon. Resident #38 then turned in her wheelchair and began to wheel away from the area while eating a piece of the bacon. Interview on 08/11/25 at approximately 9:07 A.M. with VPCS #400 confirmed Resident #38 had bacon. Concurrent observation revealed VPCS #400 removed the bacon from Resident #38’s hands and provided education. Interview on 08/11/25 at 9:08 A.M. with Certified Nurse Aide (CNA) #404 confirmed Resident #38 regularly took food from other residents’ plates. Staff had to monitor Resident #38 closely because of this behavior. Further interview revealed CNA #404 was in the dining room during the observation at approximately 9:05 A.M. when Resident #38 removed bacon from the tray cart. CNA #404 confirmed Resident #38 was on a pureed diet. Further, CNA #404 confirmed the tray Resident #38 removed the bacon from was an untouched tray for a resident who was hospitalized . Interviews on 08/12/25 at 9:51 A.M. with LPN #405 and CNA #371 revealed they were familiar with Resident #38 and her behavior of taking food from other residents’ trays. LPN #405 and CNA #371 stated the expectation was staff would monitor Resident #38 and redirect her when needed. Interview on 08/12/25 at 9:56 A.M. with VPCS #400 and Chief Nursing Officer #401 revealed they were unable to provide any additional interventions developed by the facility to prevent Resident #38, who was on a pureed diet, from obtaining and consuming regular texture foods from other residents’ trays. This deficiency represents non-compliance investigated under Complaint Number OH00166789 (1260025).

Based on medical record review, observation, resident interview, staff interview, and facility policy review, the facility failed to ensure residents received adaptive equipment with meals as ordered. This affected one (#15) of one residents reviewed for adaptive equipment at meals. The facility census was 74.Findings include:Review of the medical record revealed Resident #15 was admitted on [DATE]. Diagnoses included Parkinson's disease with dyskinesia with fluctuations, type two diabetes mellitus, paranoid schizophrenia, essential hypertension, and hypothyroidism. Review of the Minimum Data Set (MDS) assessment, dated 06/28/25, revealed Resident #15 was cognitively intact. Review of the care plan, revised 06/22/25, revealed Resident #15 had a nutritional concern and required adaptive equipment for meals. Interventions included weighted built up utensils, two handled cup, and separate bowl for all meals.Review of the physician order, dated 07/02/25, revealed Resident #15 was ordered a regular diet, regular texture, thin consistency, weighted built up utensils, a two-handled cup with lid, and separate bowls at all meals. Review of the meal ticket, dated for the lunch meal on 08/04/25, revealed Resident #15 was to receive all food in bowls. Interview on 08/04/25 at 11:28 A.M. with Resident #15 revealed meals are to be provided in bowls and last Thursday a meal was not provided in bowls as ordered.Observation on 08/04/25 at 12:38 P.M. of Resident #15's meal tray revealed her meal was provided on a divided plate and not in bowls.Interview on 08/04/25 at 12:39 P.M. with Licensed Practical Nurse (LPN) #383 verified Resident #15's lunch meal was not served in bowls.Review of policy for adaptive devices, revised 09/08/21, verified assistive devices shall be provided to residents who need them.

Based on observation, resident and staff interview, and medical record review, the facility failed to ensure residents received splints and immobilizer devices as ordered by the physician. This affected one (#1) of one residents reviewed for range of motion. The facility census was 74.Findings include:Review of the medical record for Resident #1 revealed an admission date of 05/27/25 with diagnoses of anoxic brain damage, dementia, bipolar disorder, and schizoaffective disorder. Review of the comprehensive admission Minimum Data Set (MDS) assessment, dated 06/03/25, revealed Resident #1 had impaired cognition and an impairment to one side of her upper extremity and one side of her lower extremity. Resident #1 used a wheelchair for mobility.Review of the care plan updated 07/08/25 revealed Resident #1 had limited physical mobility due to decreased range of motion. Interventions included ensuring Resident #1's left arm was in a sling except at bedtime and bathing.Review of a physician order initiated 05/30/25 revealed Resident #1 should receive a Cock-up wrist splint to the left wrist as the resident tolerated with instructions to remove each shift to check skin integrity.Review of a physician order initiated 07/24/25 revealed Resident #1 should receive a sling to her left upper extremity every shift.Review of nursing progress notes dated 07/29/25, 07/30/25, 08/01/25, and 08/04/25 revealed Resident #1's splint and sling were not in place because staff could not find them.Observation on 08/04/25 at approximately 10:00 A.M. revealed Resident #1 interacting with staff in the hallway. Resident #1 was not wearing a splint or sling during the observation.Observation on 08/04/25 at 4:39 P.M. revealed Resident #1 sitting in a wheelchair in the common area. Resident #1 was not wearing a splint or sling on her left arm.Interview on 08/04/25 at 4:41 P.M. with Registered Nurse (RN) #368 confirmed Resident #1 was not wearing the splint or sling on her left arm as ordered by the physician because RN #368 could not locate them. RN #368 stated she had been looking for them since the previous week and confirmed she documented in Resident #1's chart regarding the missing splint and sling.Interview on 08/04/25 at 4:43 P.M. with Resident #1 revealed her left arm felt more comfortable when she wore the splint and sling.Observation on 08/06/25 at 8:56 A.M. revealed Resident #1 standing in the common area wearing a splint and sling on her left hand and arm. Interview on 08/06/25 at approximately 8:58 A.M. with RN #368 stated staff searched in the basement and were able to find a splint and sling for Resident #1. Interview on 08/06/25 at 9:01 A.M. with Resident #1 revealed her left arm still hurt, but felt more comfortable with the splint and sling.Interview on 08/06/25 at 2:30 P.M. with the Director of Nursing (DON) confirmed she read through all residents' progress notes with the interdisciplinary team during morning meetings, generally Monday through Friday. The DON stated she was off work 07/29/25 and 07/30/25 and would not have reviewed the notes in Resident #1's chart indicating the splint and sling were not available. The DON further stated the rest of the team should have read the notes in her absence.Interview on 08/06/25 at 2:52 P.M. with [NAME] President of Clinical Services (VPCS) #400 confirmed the expectation was staff would request a new sling and splint from the therapy department. VPCS #400 stated she read Resident #1's progress notes Monday morning (08/04/25) and retrieved a new splint and sling for Resident #1 when she arrived at the facility the afternoon of 08/04/25. Interview on 08/12/25 at 12:05 P.M. with Occupational Therapist (OT) #350 revealed she was familiar with Resident #1. OT #350 stated Resident #1 came to the facility with orders for the splint and sling to her left hand and arm. OT #350 stated Resident #1 had slight contractures to her left hand and the splint was to prevent worsening of the contractures. OT #350 stated the sling was due to a fractured collar bone Resident #1 suffered prior to admission. Resident #1 refused to attend a follow-up orthopedic appointment; therefore, the recommendation was to continue use of the sling on Resident #1's left arm.

Based on medical record review, resident and staff interview, review of shower schedules, and review of facility policies, the facility failed to ensure residents had the right to choose when they receive their medications to prevent refusal and choose the time they shower. This affected two (#50 and #47) of two residents reviewed for choices. The facility census was 74.Findings include: 1. Review of the medical record for Resident #47 revealed an admission of 06/10/25. Diagnoses included schizoaffective disorder, type two diabetes mellitus, and major depressive disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had severe cognitive impairment. Review of the care plan dated 06/17/25 revealed Resident #47 received psychoactive medication due to alteration in mood and behavior. Resident #47 used psychotropic medication related to schizoaffective disorder. The nurse was to administer medications as ordered. Additional review of the care plan revealed Resident #47 had diabetes mellitus. The nurse was to administer medications as ordered by the doctor and monitor for its effectiveness. Resident #47 had chronic obstructive pulmonary disease (COPD). The nurse was to give aerosol or bronchodilators as ordered. Review of the physician orders for Resident #47 revealed orders for aspirin 81 milligrams (mg) daily in the morning for a preventative, fenofibrate 48 mg one tablet in the morning for hyperlipidemia, furosemide 20 mg one tablet by mouth in the morning for hypertension, Incruse ellipta 62.5 micrograms (mcg) aerosol powder, breath activated one inhalation inhale orally in the morning for respiratory, Lantus insulin subcutaneous solution pen-injector to inject 25 units subcutaneously in the morning for diabetes mellitus type two, levothyroxine 100 mcg by mouth every morning for hypothyroidism, lisinopril 20 mg by mouth every morning for hypertension, metformin 1000 mg by mouth in the morning for diabetes type two, metoprolol 50 mg by mouth in the morning for hypertension, risperidone two (2) mg by mouth in the morning for schizoaffective disorder, Seroquel 100 mg by mouth in the morning for schizoaffective disorder, and Humalog insulin subcutaneous solution pen injector to inject five (5) units subcutaneously with meals for diabetes mellitus along with sliding scale. Review of the medication administration record (MAR) for Resident #47 revealed on 08/04/25 all morning medications were refused. Review of the progress notes dated 08/04/25 at 3:35 A.M. revealed the nurse offered Resident #47 his morning medication a half hour before the progress note was written and Resident #47 refused. Interview on 08/04/25 at 8:15 A.M. with Resident #47 revealed he did not receive his morning medication because the night shift nurse came to his room at 3:00 A.M. to give him his medication and he did not want to take his medication that early. Interview on 08/04/25 at 8:20 A.M. with Licensed Practical Nurse (LPN) #381 revealed the MAR indicated medication can be given early which meant 6:00 A.M. Resident #47 refused his insulin from her due to not receiving his morning medication from the night nurse. LPN #381 stated there was no way for her to administer the medications due to not being able to sign them out since the night shift nurse marked them as refused. Interview on 08/04/25 at 8:26 A.M. with Assistant Director of Nursing (ADON) #370 revealed the early medication administration was between 4:00 A.M. and 6:00 A.M. The early morning medications may be passed by the night shift nurse, and if she was unable to administer them all, then the day shift nurse can finish the medication administration. ADON #370 confirmed 3:00 A.M. was too early for medications to be administered, and Resident #47 was able to receive medications when requested. Review of the facility policy titled, Medication Administration and Documentation, dated 06/26/24, revealed prior to administering medication the nurse must observe the five rights of medication administration which include the right time, verifying that this is the appropriate time for the medication. 2. Review of the medical record for Resident #50 revealed an admission date of 06/20/17. Diagnoses included generalized anxiety disorder, major depressive disorder, and paranoid schizophrenia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #50 had intact cognition. The resident was dependent on staff for bathing and showering. Review of the shower schedule revealed Resident #50 had showers scheduled for Wednesdays and Saturdays on the 12-hour evening shift. Review of the shower task documentation and shower sheets revealed no documentation Resident #50 received showers per her choice on 07/02/25, 07/09/25, 07/16/25, 07/19/25, 07/23/25, 07/26/25, and 07/30/25. Review of the nurses' notes dated 07/10/25 through 08/06/25 revealed no documentation Resident #50 refused any showers. Interview on 08/04/25 at 11:41 A.M., Resident #50 revealed she had not been receiving her showers per her choice on the scheduled shower days. Interview on 08/07/25 at 10:12 A.M., the Director of Nursing (DON) verified there was no documentation Resident #50 had received showers per choice as scheduled on 07/02/25, 07/09/25, 07/16/25, 07/19/25, 07/23/25, 07/26/25, and 07/30/25. Review of the facility policy titled, Bathing Choice Policy, revised 01/01/25, revealed resident's had the choice of bathing frequency.

Based on review of the medical record, observation, resident and staff interview, and review of facility policy, the facility failed to ensure dependent residents received adequate nail care. This affected two (#40 and #45) of three residents reviewed for activities of daily living. The facility census was 74.Findings include: 1. Review of the medical record revealed Resident #40 was admitted on [DATE]. Diagnoses included unspecified dementia with psychotic disturbance, major depressive disorder recurrent severe with psychotic symptoms, anxiety disorder, Alzheimer's disease, and cognitive communication dysfunctions.Review of the Minimum Data Set (MDS) assessment, dated 06/16/25, revealed Resident #40 was unable to complete the assessment interview. Review of the care plan, revised 01/04/24, revealed Resident #40 had a behavior problem including playing in her own feces. Review of the care plan, revised on 11/11/24, revealed Resident #40 had an activities of daily living (ADL) self-care performance deficit. Interventions includes to check nail length, trim, and clean on bath day and as necessary. Observation on 08/04/25 at 12:02 P.M. revealed Resident #40 had dirty fingerprints with a dark brown substance under all nails on both hands.Observation on 08/05/25 at 3:03 P.M. revealed Resident #40 had dirty fingerprints with a dark brown substance under all nails on both hands. Interview on 08/06/25 at 8:09 A.M. with Registered Nurse (RN) #368 verified Resident #40 does put her hands in her feces. It was reported the resident had a bowel movement three times yesterday and the staff had provided care to the resident immediately. Observation on 08/06/25 at 8:12 A.M. revealed Resident #40 eating breakfast in the dining room. Resident #40 was eating breakfast with her right hand, scooping the food directly into her mouth. Resident #40's fingernails were observed to remain dirty with the left hand fingernails more heavily soiled than the right. Interview on 08/06/25 at 8:14 A.M. with Registered Nurse (RN) #368 verified Resident #40's fingernails were dirty with a dark brown substance and was using her hands to eat breakfast. 2. Review of the medical record revealed Resident #45 was initially admitted on [DATE]. Diagnoses included bipolar disorder, type two diabetes mellitus, hypothyroidism, hyperlipidemia, major depressive disorder, essential hypertension, acute ischemic heart disease, and chronic kidney disease stage three. Review of the MDS assessment, dated 06/09/25, revealed Resident #45 was moderately cognitively impaired and required set-up/clean-up assistance with personal hygiene. Review of the care plan, revised 06/17/25, verified Resident #45 had an ADL self care performance deficit with interventions including to check nail length, trim, and clean on bath day and as necessary. Interview on 08/04/25 at 11:04 A.M. with Resident #45 revealed he would like his fingernails trimmed. Subsequent observation revealed Resident #45's fingernails were longer than typical but clean and not jagged. Observation on 08/07/25 at 2:43 P.M. revealed Resident #45's nails remained long. Subsequent interview with the resident revealed he did not like his nails as long as they were and stated he would like them to be trimmed.Interview on 08/07/25 at 2:46 P.M. with Certified Nurse Aide (CNA) #305 acknowledged Resident #45's fingernails were long and verified Resident #45 indicated he wanted them trimmed. CNA #305 stated it was unknown who normally trimmed Resident #45's nails. Review of the policy titled, Activities of Daily Living, revised January 2022, verified staff will carryout the ADL care tasks following the resident's ADL care plan. This deficiency represents non-compliance investigated under Complaint Number 2562969.

Based on review of the medical record, staff interview, and policy review, the facility failed to ensure baseline care plans were developed within 48 hours of admission. This affected three (#52, #15, #53) of 31 residents reviewed for baseline care plans. The facility census was 74.Findings include:1. Review of the medical record revealed Resident #52 had an admission date of 01/10/25. Diagnoses included dementia, depression, anxiety, hypertension, and hemiplegia affecting left non-dominant side. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 had intact cognition. Review of Resident #52's medical record revealed there was no baseline care plan initiated within the first 48 hours of admission to the facility. 2. Review of the medical record revealed Resident #15 was admitted on [DATE]. Diagnoses included Parkinson's disease with dyskinesia with fluctuations, type two diabetes mellitus, paranoid schizophrenia, essential hypertension, and hypothyroidism. Review of the MDS assessment, dated 06/28/25, revealed the resident was cognitively intact. Review of the medical record revealed a care plan was not developed until 03/24/25. 3. Review of the medical record revealed Resident #53 was admitted on [DATE]. Diagnoses included major depressive disorder recurrent, bipolar disorder, unspecified psychosis, and cognitive communication deficit. Review of the MDS assessment, dated 05/26/25, revealed the resident was severely cognitively impaired. Review of the medical record revealed baseline care plan was not completed within 48 hours. Interview on 08/12/25 at 9:22 A.M. with [NAME] President Clinical Services #400 verified baseline care plans were not completed timely for Resident #15, #52, and #53. Review of the policy, Care Plan Policy, dated October 2022, verified a baseline care plan will be developed within 48 hours of admission to address the major areas of a resident's care to provide effective person-centered care, to be used until a comprehensive care plan is completed.

Based on review of the medical record, staff interview, and policy review, the facility failed to ensure an appropriate diagnosis for the use of an antipsychotic medication. This affected one (#6) of five residents reviewed for unnecessary medications. The facility identified 38 residents as receiving antipsychotic medications. The facility census was 74.Findings include: Review of the medical record revealed Resident #6 had an admission date of 04/02/25. Diagnoses included conversion disorder with seizures or convulsions, dementia, Alzheimer's disease, and depression.Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had impaired cognition.Review of a physician order dated 04/02/25 revealed Resident #6 had an order for olanzapine 2.5 milligrams by mouth at bedtime for antipsychotic. Further review of the medical record revealed no documentation of a supporting diagnoses for the use of the antipsychotic medication olanzapine. Interview on 08/06/25 at 1:47 P.M., MDS Licensed Practical Nurse (MDS LPN) #315 revealed Resident #6 had no supporting diagnoses for the use of the antipsychotic medication. Review of the facility policy titled, Psychoactive/Antipsychotic Drugs, revised 01/2021, revealed all residents receiving psychoactive medication would be evaluated for necessity of the drug use per OBRA (Omnibus Budget Reconciliation Act) '90 psychoactive drug monitoring schedule. If appropriate diagnoses to support psychotropic drug use are not on the cumulative diagnosis list, the nurse would contact the physician for appropriate diagnosis or clarification.

Based on review of a personal funds balance statement, staff interview, and policy review, the facility failed to ensure a resident was provided notification of spend down when personal funds were within $200.00 of the resource limit. This affected one (#51) of eight residents reviewed for personal fund accounts. The facility identified 41 residents with personal funds accounts. The facility census was 74. Findings include:Review of the medical record for Resident #51 revealed an admission date of 05/17/22. Diagnoses included schizophrenia, chronic obstructive pulmonary disease, and peripheral vascular disease. Resident #51's primary payer source was Medicaid. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had intact cognition. Review of Resident #51's trial balance fund dated 08/11/25 revealed the resident had a personal funds account balance of $2,293.28. Interview on 08/11/25 at 4:42 P.M. Chief Nursing Officer Registered Nurse (CNORN) #401 verified the facility had no evidence Resident #51 or the resident representative were provided a notification of spend down when the resident was within $200.00 of reaching the $2,000.00 resource limit. Review of the facility policy titled, Managing Resident Personal Funds, revised 07/2025, revealed accumulations above $2,000.00 in a resident personal account may get the resident removed from Medicaid rolls until the money is spent down. The allowable amount set by the state currently was $2,000.00 and the facility would notify the resident when they were within $200.00 of the state limit.

Based on review of the medical record, review of a self-reported incident, review of an incident report, review of hospital records, review of staff statements, staff interview, staff job description, and policy review, the facility failed to ensure staff assisted a resident with safe ambulation, report a resident fall, and ensure a resident was assessed for injuries prior to moving the resident after a fall, and ensure the resident's fall was thoroughly investigated. Additionally, the facility failed to implement fall prevention interventions. This resulted in Actual Harm on 02/12/25 when staff assisted Resident #47 to the bathroom without his walker, staff then picked the resident up off the floor after a fall, toileted the resident, and then walked the resident back to bed further increasing the risk for injury then never reported the fall to the nurse. The oncoming nursing shift later found the resident had bruising to the left lower lip and redness to the left side of the face and a displaced intertrochanteric fracture of the left femur, requiring surgical repair and hospitalization from [DATE] through 02/18/25. This affected one (#47) of three residents reviewed for falls. The facility census was 74. Findings include: Review of the medical record for Resident #47 revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, type two diabetes mellitus, atrial fibrillation, difficulty walking, muscle weakness, osteoarthritis of unspecified hip, hypertension, anxiety disorder, bipolar disorder and vascular dementia. A diagnosis of displaced intertrochanteric fracture of the left femur was added on 02/18/25. Review of the annual Minimum Data Set (MDS) assessment completed 01/21/25 revealed the resident had severe cognitive impairment. The resident required substantial/maximal assistance for toileting, supervision/touching assistance for transfers and ambulation. Review of a fall risk assessment dated [DATE] revealed the resident was at high risk for falls. Review of a physical therapy discharge assessment dated [DATE] revealed the resident could ambulate 150 feet with front wheeled walker and supervision/stand by assist requiring ten percent verbal cues for proper use of walker. Discharge recommendations included the use of a front wheeled walker for ambulation. Review of the physician orders for 02/2025 revealed no orders for assistive mobility devices. Review of the care plan initiated 01/18/24 and last revised on 01/22/25 revealed the resident was at risk for falls due to decline in functional mobility, diagnoses of anxiety, depression and vascular dementia, an elevated body mass index, restlessness, osteoarthritis of the hip, incontinent, use of psychotropic medications and weakness. Interventions included to be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The resident needed prompt response to all requests for assistance. Physical/Occupational evaluation and treatment as indicated. The resident required the assistance one staff for transfers and assistance with toileting as needed. There was no documentation in the care plan for the resident to use a walker. Review of the staff schedule for 02/11/25 revealed Certified Nursing Assistant (CNA) #110 and CNA #112 were assigned to care for residents on the memory care unit including Resident #47 from 02/11/25 at 7:00 P.M. through 7:00 A.M. on 02/12/25. Review of a nurse progress note dated 02/12/25 at 7:50 A.M. revealed the nurse was notified by a nursing assistant that Resident #47 was not able to sit up or get up for breakfast on his own. The nursing assistant went to help the resident and when she touched his leg he yelled out in pain. The progress note stated that when the nurse was notified, the nurse further assessed Resident #47's skin and leg. Resident #47 had swelling to his left hip/leg, and his left leg was rotated outward. Resident #47 also had a swollen bottom lip on the left side, and red bump on his left cheek. The nurse notified nurse practitioner and received a STAT order for a left hip/pelvis X-ray and the rest of his leg if needed. The nurse progress note continued to say Resident #47 was complaining of pain and discomfort, was given medication (scheduled Tylenol), vital signs were within normal limits and the resident will continue to be monitored. Review of a self-reported incident (SRI) report dated 02/12/25 at 10:00 A.M., a facility incident report and subsequent investigation revealed the resident had bruising to left lower lip, left cheek, and noted increased pain to left hip. Resident #47 was unable to give description. Full assessment head to toe completed. Left leg had increased pain and resident was unable to move left leg. Left leg also noted had shorten appearance to it. The nurse contacted the physician and received orders for a STAT x-ray. Physician and guardian notified. Review of the SRI summary of incident revealed the resident was found with an area of discoloration to the left lower lip and left cheek and leg pain. The nurse assessed the resident, and a stat x-ray was ordered showing a left femur fracture. Upon investigation it was reported that staff had assisted the resident to the bathroom in the early morning hours of 02/12/25 and his legs buckled and he went to the floor. The staff assisted the resident off the floor and onto the toilet and back to bed. The staff noticed the resident had difficulty walking and the resident was unable to tell staff what was wrong. The staff were educated on reporting any fall immediately upon discovery. Disciplinary action was taken as appropriate. Further review of the incident report and investigation revealed no documentation regarding what fall interventions were in place prior to the resident's fall including type of footwear worn and environmental conditions of the room. There were also no statements or interviews from the day shift nursing assistant receiving report from the night shift nursing assistant, there was no statement from the nursing assistant who discovered the injury, and no documentation if the resident was using his walker at the time of the fall. Review of a late entry nurses note dated 2/12/2025 at 10:09 A.M. revealed the resident had bruising to left lower lip, left check, left side of head and noted increased pain to left hip. Resident unable to recall events. Full assessment head to toe completed. Left leg has increased pain and resident was unable to move left leg. Left leg also noted with shortened appearance. Nurse contacted physician and received order for STAT X-ray. Review of a nurses note dated 02/12/25 at 11:06 A.M. revealed the results of the x-ray included an acute-appearing fracture of the intertrochanteric left femur. There was a mild displacement of the distal fragment. There were no gross lytic or blastic lesions in the bones. There was no abnormal radiopaque foreign body. There was no dislocation. The joint spaces were unremarkable. Resident was sent out 911. Will continue to monitor. Responsible party was notified. The nurse practitioner and management notified. Review of a late entry nurses note for 2/13/25 at 9:20 A.M. revealed the Interdisciplinary Team (IDT) met to discuss resident related to fall dated 02/12/25. Resident was being assisted to the toilet when his knees buckled causing him to fall to the floor. An x-ray was completed related to leg pain and results showed a left femur fracture. Resident was sent to the emergency room for evaluation and treatment. Review of an undated and unsigned statement by Certified Nursing Assistant (CNA) #110 taken over the phone by the Director of Nursing (DON) revealed on the morning of the resident's accident, CNA #112 and CNA #110 walked the resident to the bathroom. CNA #110 stated the resident made it to the toilet, he went down saying he could not do it. The resident went to the ground, and we let him catch his breath. Afterward, we proceeded to lift him up and place him on the toilet. After the resident was done, we walked him back to bed. Review of an undated and unsigned statement by CNA #112 revealed on the night of the resident's incident, CNA #110 and CNA #112 walked the resident to the bathroom because he had a bowel movement. As they walked the resident to the toilet, the resident buckled to the floor. CNA #110 and CNA #112 helped the resident off the floor. Once the resident caught his breath they continued to take him to the toilet. CNA #110 and CNA #112 cleaned the resident up after using the toilet and walked the resident back to bed. CNA #112 noticed the resident was walking funny and asked him what happened, and the resident stated he did not know. Review of an undated unsigned statement for Registered Nurse (RN) #260 taken by Assistant Director of Nursing (ADON) #214 revealed no staff had reported a fall for Resident #47 on the 12-hour night shift from 02/11/24 into 02/12/25. Review of a skin assessment dated [DATE] revealed Resident #47 's left leg and hip were swollen and turned outward. The resident had a bruised and swollen lip and a red bump on the left cheek. Review of a hospital documentation dated 02/12/25 revealed the resident was admitted to the hospital on 02/12/25 at 11:53 A.M. The resident presented with a fall and hip pain from an unwitnessed fall at the nursing home. The outpatient x-ray showed fracture of the left intertrochanteric femur and mild displacement of distal fragment. The resident was unable to provide any history and believed it was 1978. The resident underwent imaging and found to have a severely comminuted intertrochanteric fracture through the proximal left femur with varus deformity of the proximal left femur. There was mild hemorrhage in the soft tissue surrounding the deformity. The resident denied pain. Review of the hospital imaging/diagnostics report dated 02/12/25 revealed a computed tomography (CT) of the left hip was completed. The resident had an acute severely comminuted intertrochanteric fracture through the proximal left femur with varus deformity of the proximal left femur. There was underlying diffuse osteopenia and mild hemorrhage in the soft tissues surrounding the proximal left femoral fracture deformity. The resident was also noted with mild underlying bilateral hip osteoarthrosis with underlying diffuse osteopenia. Review of the resident's care plan revised on 02/18/25 revealed the resident was at risk for falls and potential injury. Interventions included a low bed, maintain a clear pathway, mat on floor next to bed, non-slip material in chair, turn and reposition, Broda chair per therapy recommendation, call light in reach and encourage use, prompt response for requests for assistance. Review of the care plan for alteration in musculoskeletal status related to the fracture revealed an intervention for an abductor pillow while in bed. Review of corrective action counseling statements dated 02/19/25 for CNA #110 and CNA #112 revealed counseling completed for failure to follow instruction or to perform work according to procedure or policy. Review of a training in-service dated 02/19/25 revealed 74 staff received education on the fall policy. Observation on 03/20/25 at 9:39 A.M. of Resident #47 revealed the resident was in bed with his eyes closed. The bed was in the lowest position but was not a low bed. Resident #47's hip abductor was not in place and there was no floor mat next to the bed. Further observation revealed there was no nonslip material in place in the resident's wheelchair. Interviews on 03/20/25 at 9:39 A.M., CNA #272 verified the resident's hip abductor was not in place and was located in the resident's closet. CNA #272 verified there was no fall mat in place next to the resident's bed. CNA #272 was unaware the resident required a fall mat. CNA #272 verified the resident's bed was in the lowest position. Interview on 03/20/25 at 9:42 A.M., CNA #276 verified there was no nonslip material in place in the resident's wheelchair. CNA #276 revealed another resident must have moved it. Interview on 03/20/25 at 10:09 A.M., CNA #110 revealed on 02/12/25 before 6:00 A.M. CNA #112 assisted him with walking Resident #47 to the bathroom without his walker. CNA #110 revealed they got to the bathroom and the resident began to buckle. CNA #110 revealed CNA #112 and himself were on each side of the resident and lowered the resident to the ground on his buttocks with his legs in front of him in front of the toilet. CNA #110 revealed they got the resident back up and put him on the toilet. CNA #110 revealed the resident had not hit his head. CNA #110 stated four times the resident had not fallen; he was lowered to the ground. CNA #110 verified the incident was not reported to the nurse. During the interview CNA #110 revealed he told CNA #402 on the oncoming shift about lowering Resident #47 to the ground. CNA #110 revealed he was unaware that lowering a resident to the floor was considered a fall. CNA #110 stated he had been educated by the DON. Interview on 03/20/25 at 10:56 A.M., CNA #276 revealed on 02/12/25 her shift started around 7:00 A.M. CNA #276 revealed around 7:30 A.M. Resident #47 requested assistance getting up. CNA #276 revealed as she went to assist the resident, the resident stated, my hip, my hip. CNA #276 revealed seeing a bruise on the resident's lip. CNA #276 revealed she requested the nurse to the room to assess the resident. CNA #276 revealed she wrote a statement. Interview by telephone on 03/20/25 at 11:04 A.M. and 2:49 P.M. was attempted unsuccessfully with CNA #402. Interview on 03/20/25 at 11:11 A.M., the DON revealed on 02/12/25 Resident #47 was found with unexplained injuries and a self-reported incident was reported. The DON revealed she was not in the building on 02/12/25. The DON revealed Resident #47 had a fracture to the left hip/femur. The DON revealed the resident was sent to the hospital where he received surgical repair and returned to the facility on [DATE]. The DON revealed during the investigation it was found that the resident had been assisted to the bathroom by CNA #110 and CNA #112. While in the bathroom the resident's legs buckled and he fell . The staff assisted him up and onto the toilet then walked him back to bed. The DON verified CNA #110 and CNA #112 never reported the fall and received written counseling action. The DON stated CNA #110 and CNA #112 stated the resident fell and never indicated he had been lowered to the floor. CNA #110 and CNA #112 stated if a resident was not injured then why would they report the incident to the nurse. The DON revealed staff were educated to report all falls even if lowered to the floor or change in plane. The DON revealed CNA #110 and CNA #112 stated the resident may have hit his head during the fall. The DON revealed not knowing what kind of footwear the resident was wearing at the time of the fall or if there were any contributing environmental factors. The DON revealed the resident was not care planned for gait belt use but maybe they should have used a gait belt. The DON revealed the incident occurred around 5:00 A.M. The DON verified there was missing information in the investigation, she claims she asked the questions and should have written down all the questions asked and their responses. Further interview with the DON revealed the nursing assistants stated the fall happened around 5:30 A.M. and the oncoming shift noticed around 7:30 A.M. The DON revealed the resident had an x-ray around 11:06 A.M. and was admitted to the hospital at 11:53 A.M. on 02/12/25. The DON verified she could not find a statement by CNA #276 and never interviewed CNA #402 who received report from CNA #110. Further interview on 03/21/25 at 1:18 P.M. the DON verified there was no documentation in the incident report or the investigation whether staff had the resident using his walker at the time of the fall. The DON revealed per therapy the resident should have been using his walker, and it was the safest way to walk Resident #47. The DON revealed the resident would need reminded to use his walker and often would refuse to use the walker. The DON verified there was no documentation in the medical record the resident had refused to use his walker at the time of the fall on 02/12/25. The DON further revealed the use of a walker was not required to be in the physician's orders or care plan. Interview on 03/20/25 at 12:26 P.M., CNA #112 revealed on 02/12/25 around 5:00 A.M. to 5:30 A.M. Resident #47 was in bed and had a bowel movement. CNA #112 revealed CNA #110 and herself walked with the resident to the bathroom to clean him up. CNA #112 revealed they were not using a gait belt or the resident's walker because the resident could walk on his own. CNA #112 revealed they were walking behind the resident and the resident's legs buckled and CNA #110 and herself grabbed the resident's arms and lowered him to the floor on his bottom with his legs in front of him facing the toilet and his back to the door. CNA #112 revealed she had not noticed the resident hitting his head or face on anything. CNA #112 revealed waiting for the resident to catch his breath and then they got him up on the toilet, cleaned him up and walked him back to bed. CNA #112 revealed the resident was walking funny. CNA #112 revealed asking the resident what was wrong with his leg and the resident replied, I don't know. CNA #112 revealed not noticing any bruising or red marks on the resident's face. CNA #112 revealed the incident was not reported to the nurse because the resident had not voiced having pain. CNA #112 revealed the DON educated her for not reporting the incident. Interview follow-up on 03/20/25 at 12:51 P.M., the DON revealed she had just spoken with CNA #112 and CNA #112 told her the resident fell and had hit his head. The DON was not sure why CNA #112 and CNA #110 were inconsistent with their statements when reporting to the surveyor that the resident was lowered to the floor and had not hit his head as she had spoken with both of them earlier in the same day and they told her the resident fell , hit his head, and was not lowered to the floor. Observation and interview on 03/20/25 at 12:58 P.M., the DON verified Resident #47 was not in a low bed. The DON revealed the resident's bed was in the lowest position. The DON revealed the care plan should have stated the bed should be in the lowest position instead of a low bed. The DON revealed a low bed would not be appropriate for Resident #47. Interview on 03/20/25 at 1:15 P.M., ADON #214 revealed initiating the investigation for Resident #47. ADON #214 revealed RN #260 was contacted and knew nothing about a fall from the previous shift. ADON #214 revealed going with RN #300 to assess Resident #47 for a second time around 8:00 A.M. to 8:30 A.M. on 02/12/25. ADON #214 revealed the resident was moaning in pain. The resident had rotation of the left leg with swelling and winced when touched. ADON #214 revealed the resident had bruising on the lip and a red mark on the left cheek. ADON #214 revealed RN #260 and RN #300 were not aware what happened to the resident. ADON #214 revealed attempts were made to contact CNA #110 and CNA #112, but no response was received. Interview on 03/20/25 at 1:08 P.M., Physician #100 revealed he had been notified Resident #47 had a fracture from a fall. Physician #100 revealed typically there would not be a fracture from being lowered to floor unless the resident had osteoporosis. Physician #100 revealed the resident had no bone density test results indicating osteoporosis. Interview on 03/20/25 at 3:29 P.M., RN #260 revealed working the memory care unit on the 12-hour shift from 02/11/25 through 02/12/25. RN #260 could not recall what time she last saw the resident during the shift. RN #260 revealed earlier in the shift the resident was walking around per his normal. RN #260 revealed the nursing assistants never reported the resident had fallen. Interview on 03/20/25 at 3:34 P.M. RN #300 revealed on 02/12/25 CNA #276 was assisting residents with breakfast when Resident #47 asked for assistance to get out of bed. CNA #276 reported the resident stated ow when she tried to assist him. RN #300 revealed CNA #276 called her to the resident's room. RN #300 revealed Resident #47's left leg and hip were rotated outward, there was redness and bruising on the left side of the lip, and redness on the left side of his face. RN #300 revealed the nurse practitioner was notified with new orders received for an x-ray. RN #300 revealed Resident #47's scheduled medications including Tylenol were administered. RN #300 revealed the x-ray technician reported the resident most likely had a fracture. RN #300 revealed 911 was called while awaiting the final x-ray report. RN #300 revealed emergency medical services (EMS) were already in the building when the final x-ray results were received showing the fracture. Interview on 03/21/25 at 1:12 P.M., Physical Therapist (PT) #700 revealed Resident #47 had discharged from therapy with a recommendation for a front wheeled walker. PT #700 revealed staff had been instructed for the resident to use the walker and may require verbal cues to use the walker. PT #700 revealed the resident had dementia and would forget and often get up without his walker. PT #700 revealed the resident should have used the walker with staff. Review of the Certified Nursing Assistant job description revealed the nursing assistant would report all changes in the resident's condition to the nurse supervisor/charge nurse as soon as practical. Report all accidents and incidents observed on the shift they occur. Further review of the job description revealed to follow physician orders and follow directions of the physical therapist. Also, assist resident to walk with or without self-devices as instructed. Review care plans daily to determine if changes in the resident's daily care routine have been made on the care plan. Review of the facility policy Fall Policy, revised 01/03/25, revealed the facility would assure proper review of resident fall risk and implementation of interventions to attempt to prevent or reduce falls and injuries related to falls. Tracking would be done on an incident where a fall has occurred. A fall is when a resident is observed on the floor or when a resident was lowered to the floor with or without injury. Appropriate medical care would be provided as needed, including calling for emergency transport to the emergency room if indicated. Nursing notes would reflect the fall, assessment, care and monitoring provided and notifications. Care plans would be updated with new and discontinued interventions when reviewed and following a fall as appropriate. This deficiency represents non-compliance investigated under Master Complaint Number OH00163072 and OH00162984.

Based on record review, review of the facility policy, review of the Self-Reported Incidents (SRI) database, facility investigation, review of hospital records, resident interviews, and staff interviews, the facility failed to prevent resident-to-resident physical abuse. This resulted in actual harm when Resident #01, a resident with known history of resident-to-resident abuse incidents, struck Resident #02 in the face causing a hematoma (a pool of clotted blood that forms in the tissue) to her face and a closed fracture of the right orbital floor (one or more bones around the eyeball break, often from a blow to the face). Additionally, the facility failed to ensure Resident #03 was free from resident-to-resident physical abuse when Resident #01, who was supposed to be on one-to-one monitoring, struck Resident #03 in the back several times, while Resident #03 was asleep. This affected three (#01, #02 and #03) of six residents reviewed for abuse. The current census is 79. Findings include: 1. Review of the SRI dated 08/14/24 revealed the incident was reported on 08/09/24 at 6:35 P.M., when Resident #01 was seen grabbing Resident #02's hair and punching her in the face. Per the SRI, the facility separated the residents, sent Resident #02 to the hospital, then upon return placed both residents in 15-minute checks until Resident #02 was transferred to another unit. Per the SRI report, the police were notified but no report was made, and no charges were filed. The SRI was unsubstantiated for abuse due to Resident #01's diagnosis of dementia. Review of the facility's investigation into the alleged resident-to-resident abuse dated 08/09/24 to 08/16/24 revealed per the investigation, two nurses and one aide were interviewed after the incident, and there was no information regarding what led up to the incident noted in the interviews. Per the aide's written statements dated 08/09/24, Resident #01 and Resident #02 were sitting in their wheelchairs in the hallway and the aide witnessed Resident #01 grabbing Resident #02 by the hair and punching her in the face. Per the nurses' interviews the aide reported the incident immediately and Resident #02 was able to report to one nurse she was punched by Resident #01 in the face. No other resident interviews were included in the investigation reports. An assessment of Resident #02 revealed the resident had facial swelling and bruising to the right side of her face. Per the investigation Resident #02 was sent to the hospital and was diagnosed with facial swelling and an orbital fracture to her right eye. a. Review of Resident #01's medical record revealed an admitted [DATE]. Diagnoses for Resident #01 included: bipolar disorder, vascular dementia, delirium, and metabolic encephalopathy. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and portrayed physical behaviors towards others during the review period. Review of Resident #01's care plans dated May 2024 and revised on 08/16/24 revealed a focus for behaviors such as physical aggression towards others. Interventions include psychological evaluation, medications per order, talk to resident when being aggressive, and intervene by talking calmly and taking resident to a quiet area when behaviors are observed. Review of the SRI dated 02/22/24 revealed at 8:40 P.M., staff witnessed Resident #01 striking another resident in the face. Per the SRI there was no marks on either resident, and no injuries were noted in the documentation. Per the SRI, staff witnessed Resident #01 near the other resident's room, and he struck her in the mouth with his hand. Per the SRI, the other resident was interviewed and stated she had not done anything to upset Resident #01. Per the SRI, Resident #01 was sent to the hospital for testing, was positive for a urinary tract infection, and was referred to the Senior Wellness Group. The other resident was moved to another unit. Review of Resident #01's behavior assessment dated , 02/23/24 at 12:05 A.M., revealed the resident was having wandering and hitting behaviors. Interventions included redirection and one-to-one interventions. Per the assessment the interventions were effective. Review of Resident #01's physician orders revealed on 06/18/24, the resident was ordered to be seen by psychiatric services. There was no documentation of Resident #01 being seen by a psychiatrist noted in the record until 08/14/24 when the psychologist saw the resident. The order was discontinued on 08/15/24. Review of Resident #01's behavior assessment dated [DATE] at 6:44 P.M., revealed the resident was having cursing, threatening others, and grabbing behaviors. Interventions included redirection and were effective. No behavior assessment was noted in Resident #01's medical records for 08/09/24 for behaviors towards Resident #02. Review of Resident #01's behavior assessment dated [DATE] at 3:15 P.M., revealed Resident #01 was having pacing, wandering, and disrobing in public behaviors. Interventions include one-to-one interventions, redirection, and toileting. Per the assessment the interventions were effective. b. Review of Resident #02's medical record revealed an admitted [DATE]. Diagnoses for Resident #02 included: dementia, dysphagia, anemia, antisocial personality disorder, and bipolar disorder. Review of the comprehensive MDS assessment dated [DATE], revealed the resident had impaired cognition and had no documented behaviors at the time of the review period. Review of Resident #02's care plans dated 04/24/24 revealed the resident did not have any behaviors of aggression towards others. Per the care plan there were no behaviors relating to abuse. Review of Resident #02's assessments revealed the resident denied pain during the assessments dated from 06/01/24 to 08/09/24. Review of the vital sign monitoring revealed on 08/09/24 at 8:13 A.M., the resident denied any pain. On 08/10/24 at 8:43 A.M., Resident #02 reported a pain level of 4 out of 10 (10 rated as the highest pain). On 08/11/24 at 8:26 A.M., Resident #02 reported a pain level of 5 out of 10. Review of the progress note dated 08/09/24 at 6:40 P.M., revealed Resident #02 was being sent to the hospital for evaluation of facial swelling due to an altercation with another resident. Review of Resident #02's hospital documentation dated 08/09/24 at 9:19 P.M., revealed the resident was treated for a hematoma to her face and a fractured orbital space. The hospital diagnosed Resident #02 with a closed fracture of the right orbital floor. Discharge orders included to start taking cephalexin 250 milligrams orally three times a day for 10 days, and to apply ice packs to affected area. Resident #02 was discharged from the hospital back to the facility on [DATE]. Review of the progress note dated 08/10/24 at 2:20 A.M., Resident #02 returned from the hospital to the facility. Observations on 09/04/24 at 10:02 A.M., revealed Resident #02 was observed on another unit than Resident #01. During an attempt to interview Resident #02 on 09/05/24 at 10:05 A.M., Resident #02 did not answer any questions. During the interview attempt, the resident did not appear to be in distress. Interview on 09/04/24 at 10:10 A.M. with State tested Nurse Aide (STNA) #300 revealed she was the aide that had cared for Resident #02 after she returned from the hospital on 08/10/24. Per STNA #300 the resident had bruising under her eye and some swelling. STNA #300 stated she did get the resident ice to place on her face after she reported pain. Interview on 09/04/24 at 11:20 A.M. and on 09/17/24 at 11:02 A.M., with Social Worker (SW) #333 revealed after the incident Resident #02 was moved to another unit when she returned from the hospital on 08/09/24. Per SW #0333, the resident denied any concerns, stating she could not recall what happened or why it happened, and stated she felt safe in the facility. SW #333 stated she did interview Resident #02 on 08/12/24 and the resident stated she had no pain from the incident. Interview on 09/04/24 at 2:15 P.M., with the Director of Nursing (DON) revealed the DON was notified on 08/09/24 around 7:00 P.M., after the incident with Resident #01 and Resident #02 occurred. The DON stated due to Resident #01's dementia abuse could not be substantiated. The DON stated he felt Resident #01 had a 'focus' on Resident #02 which caused the resident to strike her. The DON stated Resident #01 had a 'fixation' on Resident #02 and once she was moved off the unit, there was no other behaviors from Resident #01 to any other resident until the incident on 08/13/24. The DON did not explain what he meant by fixation and there was no other history per records or interviews of Resident #01 and Resident #02 having any issues prior. The DON stated he felt by moving Resident #02 off the unit he had fixed the problem; the DON did not reveal the previous issues Resident #01 had with another resident. The DON verified there was no interviews or assessment included in the investigation regarding the behaviors or factors which could have provoked the incident. The DON stated despite previous allegations of resident-to-resident abuse regarding Resident #01, the DON felt placing Resident #01 back into 15-minute checks was sufficient to ensure the safety of the other remaining residents on the unit. Interview on 09/17/24 at 11:45 A.M. with the DON verified Resident #01 was seen by the psychologist in the facility which was a Certified Nurse Practitioner (CNP), and a social worker who was employed by the psych services. Interview on 09/17/24 at 9:33 A.M., with Licensed Practical Nurse (LPN) #100 revealed she assessed Resident #02 on 08/10/24, after she transferred from another unit. LPN #100 stated the resident did complain of slight pain in her face and was provided ice for discomfort per hospital paperwork. 2. Review of the SRI dated 08/14/24 revealed Resident #03 reported to the nurse on 08/13/24 at 11:38 P.M., Resident #01 had struck him multiple times in the back. Per the SRI the facility reported the incident on 08/14/24 at 10:15 P.M. Per the SRI the facility unsubstantiated the abuse due to Resident #01's dementia. Review of the facility's investigation dated 08/14/24 revealed on 08/13/24 at 11:38 P.M., Resident #03 came to the nurse's station and reported to the nurse that Resident #01 had hit him 5 times in the back. Per the investigation Resident #03 was assessed for injuries and his back was noted to be bruised and swelling. The facility staff reported they separated the residents and notified all parties of the incident. The staff and residents were interviewed. Per the interviews Resident #01 had returned from the hospital and showed no behaviors prior to the incident. All other residents were assessed for injuries, and none were found. Resident #03 refused to be sent to the hospital for evaluation and Resident #01 was placed on one-to-one monitoring until he was transferred to a behavioral facility on 08/14/24. a. Review of Resident #01's medical record revealed a re-admitted [DATE]. Diagnoses for Resident #01 included: bipolar disorder, vascular dementia, delirium, and metabolic encephalopathy. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and portrayed physical behaviors towards others during the review period. Review of Resident #01's care plans dated May 2024 and revised on 08/16/24 revealed a focus for behaviors such as physical aggression towards others. Interventions include psychological evaluation, medications per order, talk to resident when being aggressive, and intervene by talking calmly and taking resident to a quiet area when behaviors are observed. Review of Resident #01's behavior assessment dated [DATE] at 3:15 P.M., revealed Resident #01 was having pacing, wandering, and disrobing in public behaviors. Interventions include one-to-one interventions, redirection, and toileting. Per the assessment the interventions were effective. Review of Resident #01's progress notes revealed on 08/12/24 at 10:35 A.M., the interdisciplinary team added the intervention of 15-minute checks for the resident. The medical record contained no evidence of 15-minute checks being completed. Review of Resident #01's behavior assessment dated [DATE] at 11:38 P.M., revealed Resident #01 was having behaviors of crawling around on the floor. Interventions of redirection were ineffective. No behavioral assessments dated 08/13/24 were noted in Resident #01's medical records after the incident with Resident #03. Review of Resident #01's progress note dated 08/13/24 at 5:34 P.M., Resident #01 was sent to the hospital due to critical laboratory values. Per the note dated 08/13/24 at 11:04 P.M., Resident #01 had returned from the hospital and was being monitored. No behavioral assessments dated 08/13/24 were noted in Resident #01's medical records after the incident with Resident #03. Review of the psych service note dated 08/14/24 at 9:33 A.M., signed by the social worker for psych services revealed the plan listed on the note was to have Resident #01 be seen by psych services 6 visits in 3 months to reach the goal of increasing interpersonal interactions and activities. Therapeutic interventions attempted were listed as supportive therapy. No mention of the aggressive behaviors was noted in the progress note. Review of Resident #01's behavior assessment dated [DATE] revealed the resident exhibited behaviors of being combative with care, hitting and grabbing. Interventions attempted were redirection, one-to-one intervention, and change in scenery. Per the assessments the interventions were ineffective. No documentation was noted in the records in regard to what the staff did if the interventions were ineffective. Review of Resident #01's physician orders revealed on 09/03/24, Resident #01 was to be on one-to-one supervision at all times. No orders predating the 09/03/24 order for one-to-one supervision was noted in the medical record for Resident #01. Observations made on 09/04/24 at 9:44 A.M. and 09/17/24 at 11:00 A.M., of Resident #01 revealed the resident to be resting in his room, and the resident did not respond to questions. A staff member was observed throughout the survey to be sitting in Resident #01's room watching the resident as a one-to-one intervention. b. Review of Resident #03's medical record revealed an admitted [DATE]. Diagnoses for Resident #03 included: chronic obstructive pulmonary disease, heart failure, cognitive communication deficit, and vascular dementia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and had no behaviors during the review period. Review of Resident #03's care plans dated 09/22/23 revealed no focus for behaviors of aggression towards others or himself. Review of Resident #03 medical record revealed no documentation of Resident #03's injuries after the incident on 08/13/24 at 11:52 P.M. No monitoring of the bruising or skin assessment was included in the records. Per Resident #03's vital signs no reports of pain were recorded in the records. Observation and interview on 09/04/24 at 11:03 A.M. with Resident #03 revealed the resident denied any further incidents with Resident #01, after he returned to the facility. Resident #03 could not provide details of the incident on 08/13/24. Interview on 09/04/24 at 3:30 P.M., with Clinical Nurse Manager (CNM) #500 and Regional Registered Nurse (RRN) #555 and the DON revealed after the incidents occurred on 08/09/24 and 08/13/24, all staff were interviewed after the incident regarding the details of each incident. The DON verified there were no assessments or documentation of Resident #01's behaviors prior to the incident. CNM #500 stated Resident #01 was assessed by the facility's psychologist on 08/08/24 and 08/13/24 and was stable with no behaviors. RRN #555 stated the resident was not on one-to-one monitoring despite a history of aggressive behaviors towards other residents due to the psychiatric evaluation of being stable on 08/08/24 and 08/13/24. The DON and CNM #500 verified 15-minute checks were not documented in the records and stated on 08/13/24, Resident #01 returned to the facility around 11:00 P.M., and was not documented as being observed until 11:45 P.M., after Resident #03 had reported he was being hit by Resident #01. Interview on 09/17/24 a 11:45 A.M. with the DON verified Resident #01 was seen by the psychologist in the facility which was a Certified Nurse Practitioner, (CNP), and a social worker who was employed by the psych services. Review of the policy titled, Abuse, Mistreatment, Exploitation, and Misappropriation of Resident Property, dated October 2022, revealed abuse is defined as instances of abuse, irrespective of mental or physical condition causing harm, pain, and/or mental anguish. The policy stated in order to prevent abuse the facility will complete ongoing assessments of behaviors. To protect other residents increased supervision of the alleged perpetrator and/or immediate transfer out of the facility. Per the policy the facility will complete ongoing assessments and care planning for appropriate interventions for monitoring the residents with behaviors. If a resident is accused or suspected of resident-to-resident abuse the facility will ensure all other residents are protected as determined by the circumstances which can include increased monitoring of accused residents and/or the immediate transfer or discharge of the resident. This deficiency represents non-compliance with control numbers OH00156980 and OH00156909.

Based on medical record review, resident interview, staff interview, Self-Reported Incident (SRI) review, facility investigation review and policy review, the facility failed to ensure residents were free of physical restraints. This resulted in psychosocial harm for one resident (Resident #10) when State tested Nursing Assistant (STNA) #142 forced Resident #10 to take oral medications by holding her arms down and squeezing the resident's cheeks to involuntarily open her mouth. Resident #10 felt helpless, intimidated and fought to spit out the medication she had already refused. This affected one resident (Resident #10) of three residents reviewed for abuse. The facility census was 72. Finding Include: Review of the medical record revealed Resident #10 had an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #10's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of five indicating Resident #10 was severely cognitively impaired. Resident #10 displayed no behaviors during the review period. Review of Resident #10's care plan revised 01/09/22 revealed supports and interventions for risk for complications related to use of [CONDITION(S)] medications, required room on the secure unit, anticoagulant therapy, risk for [CONDITION(S)] and confusion, cognitive loss, self-care deficit, at risk for skin impairment, and behavioral problems related to dementia. Review of Resident #10's Assessments revealed Skin Assessments were completed on 12/30/21, 01/05/22, 01/06/22, 01/07/22, 01/08/22, 01/10/22, and 01/11/22. On 12/30/21 Resident #10 had no skin concerns. On 01/05/22 it was noted Resident #10 had scattered bruises across both forearms. Bruising was monitored on 01/06/22, 01/07/22, 01/08/22, 01/09/22, 01/10/22, and 01/11/22 with no additional skin concerns noted. Review of the Self-Reported Incident (SRI) # 3 revealed on 12/31/21 at 7:30 P.M. it was reported Resident #10 arms were held down by a nursing aide in an attempt to administer Resident #10's the medication Resident #10 had refused. Resident #10's medications were noted to have been put in her mouth and Resident #10 spit them out. The facility substantiated the abuse allegation based on evidence. Review of the statements from SRI investigation revealed Resident #12 reported witnessing State tested Nursing Assistant (STNA) #142 holding Resident #10's arms down and forcing her to take medication Resident #10 had refused. Resident #10 reported the same incident details. Resident #10 was assessed, and bruising was found on Resident #10's right forearm. The facility determined abuse had occurred and substantiated the SRI. Interview on 01/12/22 at 9:22 A.M. with the Administrator and Registered Nurse (RN) #240 revealed on 01/01/22 they were informed on 12/31/21 Resident #10 was held down by an agency nurse and was given medications in applesauce. The facility investigated the allegation and determined it had actually been an agency aide. The facility substantiated abuse based on the witness, bruising and interview with Resident #10. Interview on 01/12/22 at 11:42 A.M. with Resident #12 verified she was witness to STNA #142 forcing Resident #10 to take medications in applesauce. Resident #12 reported Resident #10 was held down, forced to take her medication against her will and was physically abused by STNA #142. Interview on 01/12/22 at 11:48 A.M. with Resident #10 verified STNA #142 had held her down by her arms against her will and forced her to take drugs she did not want. She reported she spit them out all over and she felt intimidated by the larger stature of the STNA #142. Review of the facility policy titled, Use of Restraints, revised April 2020 revealed residents had the right to be free from restraints that are not immediately necessary or are used for purposes other than resident benefit and safety. This citation substantiates complaint number OH 071.

Based on medical record review, resident interview, staff interview, Self-Reported Incident (SRI) review, facility investigation review and policy review, the facility failed to ensure residents were free from physical abuse. This resulted in psychosocial harm for one resident (Resident #10) when State tested Nursing Assistant (STNA) #142 forced Resident #10 to take oral medications by holding her arms down and squeezing the resident's cheeks to involuntarily open her mouth. Resident #10 felt helpless, was crying and trying not to take the medication she had already refused. This affected one resident (Resident #10) of three residents reviewed for abuse. The facility census was 72. Finding Include: Review of the medical record revealed Resident #10 had an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #10's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of five indicating Resident #10 was severely cognitively impaired. Resident #10 displayed no behaviors during the review period. Review of Resident #10's care plan revised 01/09/22 revealed supports and interventions for risk for complications related to use of [CONDITION(S)] medications, required room on the secure unit, anticoagulant therapy, risk for [CONDITION(S)] and confusion, cognitive loss, self-care deficit, at risk for skin impairment, and behavioral problems related to dementia. Review of Resident #10's Assessments revealed Skin Assessments were completed on 12/30/21, 01/05/22, 01/06/22, 01/07/22, 01/08/22, 01/10/22, and 01/11/22. On 12/30/21 Resident #10 had no skin concerns. On 01/05/22 it was noted Resident #10 had scattered bruises across both forearms. Bruising was monitored on 01/06/22, 01/07/22, 01/08/22, 01/09/22, 01/10/22, and 01/11/22 with no additional skin concerns noted. Review of the Self-Reported Incident (SRI) # 3 revealed on 12/31/21 at 7:30 P.M. it was reported Resident #10 arms were held down by a nursing aide in an attempt to administer Resident #10's the medication Resident #10 had refused. Resident #10's medications were noted to have been put in her mouth and Resident #10 spit them out. The facility substantiated the abuse allegation based on evidence. Review of the statements from SRI investigation revealed Resident #12 reported witnessing State tested Nursing Assistant (STNA) #142 holding Resident #10's arms down and forcing her to take medication Resident #10 had refused. Resident #10 reported the same incident details. Resident #10 was assessed, and bruising was found on Resident #10's right forearm. The facility determined abuse had occurred and substantiated the SRI. Interview on 01/12/22 at 9:22 A.M. with the Administrator and Registered Nurse (RN) #240 revealed on 01/01/22 they were informed on 12/31/21 Resident #10 was held down by an agency nurse and was given medications in applesauce. The facility investigated the allegation and substantiated abuse based on the witness, bruising and interview with Resident #10. Interview on 01/12/22 at 11:42 A.M. with Resident #12 verified she was witness to STNA #142 forcing Resident #10 to take medications in applesauce. Resident #12 reported Resident #10 was putting her hands up to her face covering her mouth and saying no she didn't want her medication. STNA #142 held Resident #10's arms down away from her face, leaned down over her and tried to force Resident #10's mouth open. Resident #12 reported STNA #142 was able to get Resident #10 mouth open some and forced a spoon into Resident #10's mouth with the medication and applesauce. Resident #12 stated it was a horrible thing to watch. Resident #12 stated STNA #142 shoved the medication down Resident #10's throat and Resident #10 was crying and trying to fight her off. Resident #12 said applesauce was everywhere. Resident #12 reported Resident #10 was held down, forced to take her medication against her will and was physically abused by STNA #142. Resident #12 stated she was just glad she was of sound mind to be able to report what she saw. Resident #12 stated no one deserved to be treated that way. She said it was horrible. Interview on 01/12/22 at 11:48 A.M. with Resident #10 verified STNA #142 had held her down by her arms against her will and forced her to take drugs she did not want. Resident #10 reported she told the nurse she didn't want to take the drugs and STNA #142 forced her mouth open by squeezing her cheeks hard and made her take them anyway. Resident #10 reported she spit the applesauce and drugs out and it was everywhere. She said she was crying, and the aide had hurt her arms and her mouth. Resident #10 showed the faint bruise on her right forearm. Resident #10 reported it was much darker before and there were more bruises on both arms but the faint one was the biggest darkest one so it was still there a little bit. Resident #10 reported she felt abused when she was held down and forced to take drugs she didn't want to take. She reported STNA #142 was a bigger lady, she felt helpless against her, but she fought the best she could and spit the drugs out. Resident #10 said she had never seen abuse like that before. She said that STNA #142 didn't have to do that. She and the nurse should have just let her not take the drugs. Review of the facility policy titled, Abuse, Neglect, and Exploitation Policy, revised June 2021 revealed it was the facility policy to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. It is the intent of the facility to prevent abuse, mistreatment and neglect of residents. This citation substantiates complaint number OH 071.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, resident and staff interview, and review of facility policy, the facility failed to provide a safe mechanical lift transfer for Resident #82. This resulted in Actual Harm when Resident #82 fell to the floor from the mechanical lift and suffered a right tibia fracture. This affected one (#82) of three residents reviewed for falls. The facility census was 84. Findings include: Record review revealed Resident #82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The record was updated on 08/10/17 with a [DIAGNOSES REDACTED]. Review of a care plan, initiated on 05/31/17, revealed Resident #82 had limited physical mobility related to an above the knee left amputation, muscle wasting, and atrophy. Therapy had determined the Hoyer (mechanical lift) to be the safest method for transfer. Resident #82 had difficulty accepting the need for staff assistance and attempted to convince various staff he was able to use the stand up lift. Review of occupational therapy notes, dated 06/21/17, revealed Resident #82 continued to remain appropriate for a Hoyer (mechanical lift) with all functional transfers. Review of the most recent Minimum Data Set (MDS) 3.0 assessment, dated 01/24/18 revealed a Brief Interview of Mental Status (BIMS) score of 15 reflecting the resident was cognitively intact. The MDS 3.0 assessment revealed Resident #82 required total two person staff assist for transfers. Review of a facility progress note dated 08/10/17 for an incident occurring on 08/09/17 at 9:50 P.M. revealed Resident #82 fell during a transfer from the shower chair to the bed while using a mechanical stand up lift. He was found on the floor on his right leg. The progress note revealed the nurse assessed the resident with no obvious injuries. Resident #82 complained of pain to the right leg and knee area. An x-ray conducted at the facility on 08/10/17 revealed a fracture involving the right proximal anterior tibia with no displacement. Resident #82 was sent to the hospital emergency roiagnom on [DATE] for evaluation. He returned to the facility the same day with new orders for a knee immobilizer on at all times and was to be no weight bearing on the right leg. An interview was conducted with Resident #82 on 02/20/18 at 10:00 A.M. in the residents room. During the interview Resident #82 stated he fell during a transfer a few months previous and broke his right leg. Resident #82 stated the fall occurred in the facility because staff used a stand up lift to transfer him and his right ankle was too weak. During an interview with the facility Director of Nursing (DON) on 02/21/18 at 2:49 P.M. the facility fall investigation was reviewed. During the interview the DON revealed State tested Nurses Aide (STNA) #401 and STNA #402 were assisting Resident #82 to transfer on 08/09/17 at 9:50 P.M. using the mechanical stand up lift. Further interview revealed Resident #82 lost his balance and fell resulting in a fracture to the right proximal anterior tibia. The DON revealed STNA #401 and #402 and all facility staff were immediately educated on the use of pink care cards for communication on how to care for a resident. The DON revealed no further mechanical lift incidents had occurred. Review of the facility policy titled Fall Policy, revised 02/2018, revealed it is the policy of the facility to assure proper review of resident fall risk and implementation of interventions to attempt to prevent or reduce falls/accidents and injuries related to falls. Review of the facility policy titled Lift Policy, dated 01/2016, revealed the determination to utilize a mechanical lift is based upon one or more the following indicators: Admission information from the hospital regarding past use of mechanical lift device, current order for such a device, weight bearing status orders and current diagnosis, therapy evaluation recommendations for appropriate mechanical lift device, and interdisciplinary team determination for safety purposes in relation to change of condition. Review of the facility's corrective action revealed the following actions were implemented and the deficiency corrected as of 08/24/17: · The DON and Executive Director were notified of the incident on 08/09/17 at 10:00 P.M. · On 08/09/17 at 10:20 P.M. like residents (seven) were identified. Chart reviews and/or observations were completed to validate the type of mechanical lift required. The initiation of pink care cards for like residents was initiated immediately. · Staff education was initiated on 08/09/17 at 10:25 P.M. by the DON. Education included utilization and review of pink care cards. This was started by face to face with floor staff and calling nursing staff. Staff were not allowed on the floor until they received this education. · Corrective action and education on the use of care cards was provided to STNA #401 and STNA #402 by the DON on 08/10/17. · On 08/10/17 the facility implemented the use of pink care cards to specify resident transfer needs. For all like residents, pink care cards were immediately initiated. · On 08/10/17 the DON implemented immediate education of nursing staff, including 38 STNA's and 20 nurses, regarding immediate initiation and use of pink care cards. The in-service revealed that by the end of August 2017 all residents would have a care card. · Care card audits were performed by the DON five days per week times for a period of two weeks. Audits were completed on 08/10/17, 08/11/17, 08/14/17, 08/15/17, 08/16/17, 08/17/17, 08/18/17, 08/21/17, 08/22/17, 08/23/17 and 08/24/17. No additional concerns were identified as a result of the audits. · Tracking and trending was to monitored and continued in quality assurance (QA).