Every finding on record at Aurora Manor Special Care Cent

Based on interview, facility record review, hospital record review, video recordings, and policy review the facility failed to ensure Resident #159's right lower extremity wound received adequate care to prevent infection and maggot infestation. This affected one resident (Resident #159) out of three reviewed for wounds. The facility census was 58.Findings include:Review of Resident #159's medical record revealed a facility admission date of 05/21/26 with diagnoses of end stage renal disease with dialysis, type 2 diabetes mellitus, anemia, cardiomyopathy, hypertension, encephalopathy, and calciphylaxis.Review of Resident #159's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and assistance was needed with toileting, showers, lower body dressing, and transfers. Resident #159 was noted to have open lesions other than ulcers.Review of Resident #159's comprehensive care plan dated 05/29/26 revealed the resident was admitted to the facility with venous ulcers to bilateral lower extremities with a goal to not increase in size and not show signs and symptoms of infection. Interventions included obtaining labs and diagnostic tests per order and assess routinely and as needed.Review of Resident #159's nursing progress note dated 07/24/26 at 2:39 P.M. revealed a routine lab drawn on 07/24/26 was reported to the nurse practitioner. New orders were received for Doxycycline (antibiotic) 100 milligrams, twice a day for 7 days, and get a wound culture.Review of Resident #159's laboratory results revealed his white blood count was 11.3 on 07/23/26, 12.3 on 07/24/26, 11.1 on 07/27/26, and 13.1 on 08/11/26.Review of Resident #159's physician orders revealed an order for Doxycycline (antibiotic) 100 milligrams twice a day from 07/24/26 through 07/31/26. Also, a wound culture was ordered on 07/27/26.Review of Resident #159's treatment administration record revealed the wound culture was checked off as completed on several dates, however there was no evidence it was completed through a report of culture results. Review of Resident #159's wound note on 08/06/26 revealed the right lower extremity calciphylaxis (a rare and severe medical condition where calcium builds up in small blood vessels, blocking blood flow and causing painful skin ulcers and tissue death) wound bed contained granulation tissue, necrotic tissue, and some edges were lifting. The wound exudate consisted of scant serosanguineous drainage with no signs or symptoms of infection. Review of Resident #159's nursing progress note dated 08/10/26 revealed nurse practitioner was notified wound culture was not obtained and new order for complete blood count.Review of video recordings were provided by Resident #159's family and identified to be taken on 08/11/2 revealed several live maggots on the wound dressing as well as inside of the wound. The video recordings were provided by family and identified to be taken on 08/11/26.Review of Resident #159's nursing progress note date 08/11/26 at 8:06 A.M. revealed despite the facilities attempts the resident's needs cannot be met at this time due to pain and maggots in his wounds. After discussing with his family the choice was made to send to hospital and on-call physician aware. Resident was sent out at 2:05 A.M.Review of Resident #159's nursing progress note dated 08/11/26 at 6:43 P.M. revealed resident was admitted to hospital for wound infection.Review of Resident #159's Cleveland Clinic hospital documentation dated 08/11/26 revealed sudden onset of severe right foot pain and concerns about gangrene. The right lower extremity had a deep wound on the heel with numerous maggots. Numerous maggots/larvae observed within wound. Severe sepsis identified 08/11/26 at 2:46 A.M. with white blood cell count of 15.3. Emergency department clinical impression on 08/11/26 at 4:39 A.M. indicated an infected wound, calciphylaxis, and diabetic polyneuropathy.Review of Resident #159's Cleveland Clinic hospital medical decision-making assessment dated [DATE] revealed acute worsening right foot pain at a chronic lower extremity wound. The exam was notable for extensive wound with necrotic tissue and numerous maggots concerning for infected wound requiring inpatient wound care and debridement. Differential included wound infection, gangrene, and osteomyelitis. Leukocytosis supported infection. Intravenous antibiotics were started and the case was discussed with the facility medical director who admitted the resident to the hospital.Interview on 08/17/26 at 1:00 P.M. with Certified Nurse Practitioner (CNP) #557 revealed she never assessed the wound as the wound provider handled wound care. Also she indicated Resident #159 was started on Doxycycline in July 2026 due to elevated white blood cell count and a wound culture was ordered as well.Interview on 08/18/26 at 9:20 A.M. with the facility's Medical Director revealed he seen Resident #159 in the emergency department on 08/11/26. He indicated the wound was clean and maggots were present which was not surprising as they were attracted to dead tissue.Phone interview on 08/19/26 at 9:04 A.M. with Certified Nurse Assistant #505 revealed she answered Resident #159's call light on 08/11/26 during night shift and he complained his dressing was too tight. She indicated she notified the nurse and was in the resident's room when the dressing was removed and maggots were on the wound dressing and inside the wound.Phone interview on 08/19/26 at 9:13 A.M. with Licensed Practical Nurse #535 revealed on 08/11/26 between 12:00 A.M. and 2:00 A.M. she removed Resident #159's dressing to his right lower extremity that was dated 08/08/26. She indicated at the time there was an odor in the room and when the dressing was removed there were several medium sized maggots on the wound dressing and in the wound.Interview on 08/19/26 at 12:44 P.M. with the Infection Preventionist revealed Resident #159 was ordered Doxycycline for seven days that started on 07/24/26. The Infection Preventionist revealed she was unaware of when or how the wound culture was discovered to not be done.Interview on 08/19/26 at 12:53 P.M. with the Director of Nursing (DON) revealed the wound culture was found not to be done while auditing as the DON was at an orientation when it was ordered. The DON revealed she unsure how the resident developed maggots as the wounds were always covered.Interview on 08/17/26 at 1:28 P.M. with Resident #159's spouse revealed she visited the facility on 08/08/26 and the room had a foul smell. Resident #159 called her on 08/11/26 at 1:30 A.M. that he went to the hospital due to his foot hurting. The facility nurse unwrapped his foot to check it to find maggots of different sizes. Resident #159's spouse revealed the videos of the maggots were taken on 08/11/26 when the nurse unwrapped the dressing at the facility and another video was taken at the hospital on [DATE] when he arrived. Resident #159 was admitted to the hospital due to an extreme right foot infection, started on an antibiotic, and had a right above the knee amputation on 08/15/26.Review of the facility's antimicrobial stewardship program policy revised date 03/20/26 revealed to ensure that clinical and diagnostic testing were performed for specific infections. Also to monitor the resident during antimicrobial course for adverse reactions.Review of the facility pressure injury prevention and management policy dated 12/17/25 revealed residents will be assessed for pressure injury risk on admission, quarterly, and with sig change of condition using the Braden scale. Assessed initially and weekly until closed. Other wound types will be assessed every shift to determine presence of any ordered dressings and wound characteristics if observable. All assessments include location and stage, size, exudate, pain, wound bed, appearance of surrounding tissue, and evidence of infection.This deficiency represents non-compliance investigated under Complaint Numbers 3158250 and 3158289.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on observation of video footage, closed medical record review, Self-Reported Incident review, review of witness statements, policy review, and interview, the facility failed to protect Resident #70's right to be free from physical abuse by Certified Nursing Assistant (CNA) #80. This resulted in Immediate Jeopardy and Actual Harm on 03/02/26 when Certified Nursing Assistant (CNA) #80 was observed via facility video footage physically assaulting Resident #70, a resident who was alert and oriented and totally dependent on staff for all activities of daily living (ADL). On 03/02/26 at approximately 11:35 P.M. facility video footage captured CNA #80 entering Resident #70's room without knocking and proceeding to begin providing Resident #70 incontinence care without permission from the resident. At 11:37 P.M., CNA #80 rolled Resident #70 onto his left side toward the wall and then rolled him onto his back in a rough manner. At 11:38 P.M., CNA #80 struck Resident #70 in the face with her right hand, appeared to be yelling at Resident #70 and pointing her fingers in his face. CNA #80 continued with Resident #70's care and rolled him onto his right side and again rolled him onto his back in a rough manner and struck him in the face a second time. CNA #80 struck Resident #70 a third time in the face and was noted to throw a pillow directly over Resident #70's face during the altercation while continuing to point her finger in his face. As a result of the physical assault/abuse, Resident #70 sustained a bloody right nostril and a deviated nose. Resident #70 was subsequently transferred to the hospital for a nine-day hospital stay and was diagnosed with a comminuted left nasal bone fracture with minimal displacement, nondisplaced right nasal bone fracture, left lateral deviation of the nose, and a perforated nasal septum. On 03/30/26 at 2:54 P.M., the Administrator and Regional Director of Clinical Operations (RDCO) #500 were notified Immediate Jeopardy began on 03/02/26 at approximately 11:35 P.M. when facility video footage captured CNA #80 physically assaulting/abusing Resident #70. Following the incident, CNA #80 continued to work the remainder of her shift. The resident's family member visited the next morning and was informed of the incident by the resident. The CNA was then suspended and subsequently arrested and charged with felonious assault and patient abuse. This affected one resident (#70) of three residents reviewed for abuse. The facility census was 69. The Immediate Jeopardy was removed on 03/03/26 and continued at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was subsequently corrected on 03/06/26 when the facility implemented the following corrective actions: -On 03/03/26 the Regional Director of Clinical Services (RDCS) #501 completed a head to toe assessment on Resident #70 including a pain assessment. -On 03/03/26 the Administrator initiated an investigation, a Self-Reported Incident (SRI) for potential physical abuse was submitted to the State agency at 9:28 A.M., and a statement was obtained from CNA #80. The CNA was suspended pending investigation. The facility concluded their SRI investigation on 03/06/26 at 2:54 P.M substantiating that physical abuse had occurred. CNA #80 was terminated following the conclusion of the investigation. -On 03/03/26 at 8:53 A.M. the Director of Nursing (DON) authored a progress note indicating Resident #70's physician was notified of the physical abuse allegation and the resident asked to go to the hospital. The physician indicated the resident could be transferred to the hospital if he requested to go. -On 03/03/26 at 9:27 A.M. the Administrator notified local police of the incident. The report referenced when staff arrived for day shift on 03/03/26 at approximately 7:00 A.M., they were told by Resident #70 that he had been assaulted by a staff member during the early morning hours. The report indicated Resident #70 named CNA #80 as the staff who had assaulted him and stated she was rough with him and struck him in the nose and face. The police report noted the resident had what appeared to be dried blood in the corner of his right nostril, and his nose appeared to be deviated to the right. The police report noted the resident requested medical attention and facility staff indicated they would arrange transport to the hospital for evaluation. -On 03/03/26 at 1:46 P.M. Resident #70 was transferred to the local hospital for an evaluation of his facial injuries. -On 03/03/26 the Director of Nursing (DON)/designee completed interviews related to abuse and neglect for 45 residents who had a Brief Interview for Mental Status (BIMS) greater than 09. -On 03/03/26 Licensed Practical Nurse (LPN) #419, ADON #510, and Former DON #507 completed a whole house audit of skin assessments to identify any potential injuries or signs of abuse. Out of 64 in-house residents on 03/03/26, 60 skin assessments were completed with Residents #24, #66, #71, and #72 refusing to have their skin assessed. -On 03/03/26 Human Resource (HR) Director #403/designee reviewed all staff files to ensure all staff were currently in good standing to work at the facility. HR Director #403 rechecked all staff through the Nurse Aide Registry. Shift Seekers Agency (CNA #80's employer) completed the same audit. -Beginning on 03/03/26 and completed on 03/06/26 Mobile Administrator and RDCS #500 completed a Root Cause Analysis (RCA) regarding the incident with Resident #70. The root cause noted the facility was unable to prevent resident abuse due to lack of empathy for the resident's condition because she (CNA #80) had a lack of understanding to care for residents with behavioral issues. It stated the staff was unable to separate personal feelings from resident behaviors and there was a lack of comprehension of education. -On 03/03/26 and 03/04/26 the Administrator/designee educated current staff on the facility abuse/neglect policy, including rough care, and reporting protocols. This included the Admissions Director, one dietitian, one security staff, one social service director, two activity staff members, four environmental services staff members, six registered nurses (RN), eight dietary staff, eight licensed practical nurses (LPN), and 23 certified nursing assistants (CNAs). The community's internal agency staff were educated by Shift Seekers management on the abuse/neglect policy, including rough care, and reporting protocols. Those employees not educated during that time would be educated prior to their next shift. New facility and new agency employees would be educated on the facility's abuse procedures during new hire orientation prior to working directly with residents. -Beginning on 03/03/26 the facility implemented a plan to monitor and maintain ongoing compliance. The Director of Nursing (DON)/designee would complete interviews of five capable residents weekly for four weeks then monthly for two months related to abuse and neglect. Negative findings would be addressed and Ad-Hoc education would be completed as needed. The results of the audits would be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. -Beginning on 03/03/26 to monitor and maintain ongoing compliance the Director of Nursing (DON)/designee would complete body checks on five residents who were unable to be interviewed, weekly for four weeks then monthly for two months to ensure there were no signs or symptoms of abuse/neglect. Negative findings would be addressed and Ad-Hoc education would be completed as needed. The results of the audits would be forwarded to the facility QAPI committee for further review and recommendations. -Beginning on 03/03/26 to monitor and maintain ongoing compliance Social Worker (SW) #415/designee would quiz employees weekly for four weeks then monthly for two months to verify understanding of the abuse/neglect policy and reporting requirements. Negative findings would be addressed and Ad-Hoc education would be completed as needed. The results of the audits would be forwarded to the facility QAPI committee for further review and recommendations. -Beginning on 03/03/26 to monitor and maintain ongoing compliance the DON/designee will review behavior observations five days a week for four weeks then monthly for two months to ensure staff provide two caregivers in high behavior situations. Negative findings would be addressed and Ad-Hoc education would be completed as needed. The results of the audits would be forwarded to the facility QAPI committee for further review and recommendations. -On 03/04/26, an Ad-Hoc QAPI meeting was held with the Interdisciplinary Team (IDT) including Medical Director #503, the Administrator, Admissions #464, Minimum Data Set (MDS) Nurse #430, HR #403, ADON #510, Activities #426, Maintenance Director #448, SW #415, and the DON to review the incident/event and the QAPI plan put into place. -On 03/04/26 through 03/05/26 Minimum Data Set (MDS) Nurse #430 and the DON assessed all residents who were considered at high risk for any type of behavior. Ten residents (#20, #29, #33, #44, #50, #54,#62, #65, #66, and #70) were identified with behaviors, with one resident (#66) identified with aggressive behaviors. The resident's care plan was updated to include the requirement for two caregivers in high behavior/aggressive situations. High behavior situations were determined by observations including but not limited to verbal aggression, physical aggression, refusal of care. A list would be maintained at the nurses' stations that identified any residents with behaviors, and this information was also included on the nursing staff's home screen in the electronic medical record (EMR). The facility additionally implemented a behavior charting section for CNAs to chart whether all residents had or did not have behaviors on their shift. -On 03/05/26, the Administrator, DON, Assistant Director of Nursing (ADON) and Corporate Nurse Educator #502 conducted all staff training to the Admissions Director, one dietitian, one security staff, one social service director, two activity staff members, four environmental services staff members, six RNs, eight dietary staff, eight LPNs, and 23 CNAs which included various topics such as customer service, sensitivity training, dignity and respect, deescalation of behaviors, managing of behaviors, and resident rights. The education topics included staff education about the two-caregiver requirement during high behavior situations, how those situations were determined, and that the information was maintained at the nurses' station in the EMR. Additionally, RN #505 from Shift Seekers Agency educated all Shift Seekers staff regarding the same topics. New facility and new agency employees would be educated on the facility's procedures during new hire orientation prior to working directly with residents. -On 03/06/26 CNA #80's employment with Shift Seekers was terminated for reasons of physical and verbal abuse of a resident. Findings include: Review of Resident #70's closed medical record revealed an admission date of 04/01/25 and a discharge date of 03/03/26. Resident #70's diagnoses included multiple sclerosis (MS), quadriplegia, muscle weakness, falls, failure to thrive and dysphagia (difficulty swallowing). Review of the care plan dated 01/14/26 revealed Resident #70 had hearing loss. Interventions included to face the resident when speaking, obtain the resident's attention before speaking, speak clearly and adjust tone as needed. The resident had a plan of care reflecting he was at risk for altered mood related to depression and medical diagnoses. Interventions included administer medications as ordered, allow resident to vent through feelings, approach in a calm and relaxed manner, re-direct when resistive of care, ensure resident was safe and leave for a short period of time and reapproach to assist with care, attempt to reduce stressors as much as possible, explain all procedures and care before beginning to assist and ensure resident feels safe in the environment. Resident #70 had a plan of care related to incontinence of bowel and bladder. Interventions included to check for incontinence at regular intervals and provide incontinence care as needed. Resident #70 also had a plan of care for self-care deficits related to MS and quadriplegia. Interventions included to assist with activities of daily living (ADL) that included dressing, grooming, toileting, and feeding, and mechanical lift transfers. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #70 had intact cognition. The assessment revealed Resident #70 had behaviors that included rejection of care. It noted he was dependent with eating, toileting, bathing and personal hygiene and was incontinent of bowel and bladder. Review of a progress note dated 02/24/26 timed 1:05 P.M. and authored by Former Director of Nursing (DON) #507 revealed Resident #70 had increased behaviors that included cursing at staff upon providing care. Review of the progress note dated 03/03/36 timed 8:31 A.M. and authored by Former (DON) #507 revealed Resident #70's family member had stated at approximately 12:00 A.M. an aide was providing care and was rough while turning him. Resident #70 complained of facial pain specific to his nose area and Resident #70 had alleged the aide had stuck him on the nose. The resident's physician, representative, and police were notified and an investigation had been initiated. Review of the progress note dated 03/03/26 timed 8:53 A.M. authored by Former DON #507 revealed the resident's physician had been notified of the allegation and Resident #70's request to be taken to the hospital. The physician ordered to send Resident #70 to the hospital per the resident's request. Review of facility self-reported incident (SRI) tracking number 271645 dated 03/03/26 revealed Resident #70's family member had reported an aide (identified to be CNA #80) had handled the resident in a rough manner and he had gotten hit in the nose by the aide while she was providing care. Upon assessment, Resident #70 had a small amount of blood under his nostril and his nose appeared to be deviated. Resident #70 was transported to the hospital and was admitted with multiple facial fractures. The SRI facility investigation revealed the facility conducted staff interviews, obtained staff statements, resident interviews and skin assessments, the resident's family and physician were notified, the police were notified, education regarding abuse and neglect was provided to all staff, and CNA #80 was suspended pending the results of the investigation. Additionally, the SRI results substantiated abuse had occurred. Review of police report #26-07370 dated 03/03/26 timed 9:27 A.M. revealed Resident #70 had reported a night shift aide (CNA #80) had punched him in the face. Interview with Resident #70 by the local police revealed Resident #70 was unable to write a statement and spoke in a very low tone equivalent to a whisper. Resident #70 stated just after midnight, CNA #80 had entered his room to change him, and she had been moving in an aggressive manner and Resident #70 had informed CNA #80 she had been rough with him. It noted CNA #80 had struck him in the face, specifically his nose with a closed fist. The report included photos had been taken and Resident #70 had what appeared to be dried blood in the corner of his right nostril and his nose appeared to be deviated to the right. During the on-site investigation, observation of facility video footage timestamped 03/02/26 at 11:35 P.M. (with Regional Director of Clinical Services (RDCO) #500) revealed the facility camera had no audio and was angled in the hallway outside Resident #70's room so there was a view of Resident #70's bed against the wall by the door. Resident #70 was asleep while wearing glasses. CNA #80 entered Resident #70's room, without knocking, used the bed controller to lower the head of the bed and lower the bed toward the ground then removed the sheets and lifted Resident #70's hospital gown exposing his incontinence brief while Resident #70 was still asleep. CNA #80 slightly closed the door; however, Resident #70 and Resident #70's bed could still be viewed from the facility hallway camera. CNA #80 then opened Resident #70's brief while he was still asleep. At 11:37 P.M., CNA #80 rolled the resident on his left side towards the wall, removed the incontinence brief and applied a new incontinence brief underneath him. CNA #80 rolled the resident onto his back in a rough manner as he had quickly fallen onto the mattress, and she secured the brief. At 11:38 P.M., CNA #80 made a swift, swinging motion with both of her hands (unable to determine open palms or closed fists) toward Resident #70's face which resulted in the resident's body and mattress shaking from the force of the slap/hit. CNA #80 stepped out of view of the camera then came back into view and was standing/hovering over Resident #70 and his bed while CNA #80 was pointing her right pointer finger, then appeared to touch his face with her right pointer finger which slightly shook the resident's body from the force. CNA #80 then pointed to herself then back to him while still standing/hovering over him. CNA #80's mouth was moving while pointing at him. CNA #80 adjusted the resident's brief then was observed to slap Resident #70 with an open palm to his upper chest and/or face (unable to determine as the wall was now blocking the view of his head) with her left hand and his body and pillow shook from the force. CNA #80 used both hands to roll the resident on his right side then let go of him to roll him back onto his back, then used a closed left fist to hit his right upper shoulder, right upper chest and/or face (unable to determine as the wall blocked the view of his head). CNA #80 adjusted his brief again and covered his brief with the hospital gown. CNA #80 was then observed to throw a pillow at Resident #70's upper chest and face and left the pillow there as CNA #80 was applying the resident's sheets, she covered his body and the pillow on his face with the sheet. At 11:39 P.M., CNA #80 hit Resident #70 in the chest with the pillow using her left hand, then pointed at him with her left hand while the pillow was removed, then held the pillow with force over his face with her right hand for approximately two seconds then removed her hand; however, she left the pillow on his face. CNA #80 then raised the head of the bed with the pillow still on Resident #70's face. After CNA #80 raised the head of the bed, CNA #80 removed the pillow from Resident #70's upper chest and face area and [NAME] the pillow at the foot of the bed. RN #511 was seen walking from the nurses' station with her hands behind her back towards Resident #70's room then she peeked into Resident #70's cracked doorway. CNA #80 appeared to be wiping Resident #70's face. At 11:40 P.M., RN #511 entered Resident #70's room. CNA #80 pointed her right finger at or on Resident #70's mouth then held up a cloth when it appeared Resident #70 spit at CNA #80. Review of the progress note dated 03/03/26 timed 1:46 P.M. and authored by ADON #510 revealed Resident #70 had been transported to the hospital. Review of the progress note dated 03/03/26 timed 4:40 P.M. and authored by Former DON #507 revealed Resident #70 was admitted to the hospital for facial fractures. Review of hospital paperwork dated 03/03/26 revealed Resident #70 presented to the emergency department with reports of an assault at the facility. Upon admission to the hospital, computed tomography (CT) imaging revealed a comminuted left nasal bone fracture with minimal displacement, nondisplaced right nasal bone fracture, left lateral deviation of the nose and perforated nasal septum. Discharge planning included a request for transfer to a new facility. Review of CNA #80's undated statement revealed she had provided routine care for Resident #70 and at no time had she treated him like a rag doll or hit him. CNA #80 further stated at approximately 7:00 P.M. she had entered Resident #70's room and introduced herself and she proceeded to check if he needed incontinence care and Resident #70 had immediately begun using racial slurs and derogatory language. At 11:00 P.M. CNA #80 stated she had provided Resident #70 with routine care, and he had begun calling her derogatory and racial names and spit on her. CNA #80 stated she had maintained appropriate technique and ensured Resident #70's safety. CNA #80 stated an unnamed nurse had heard Resident #70 and had entered to de-escalate. CNA #80 denied she or the nurse had observed any blood from Resident #70's face. CNA #80 further stated due to Resident #70s' escalating verbal aggression and spitting during her rounds at 4:00 A.M. she had called the unnamed nurse on duty to assist. Upon arriving to Resident #70's room, he had proceeded to call her derogatory names and spit on her at which time the nurse had advised her to discontinue care and they had left the room. Review of Registered Nurse (RN) #511's statement dated 03/04/26 timed 8:42 P.M. revealed on 03/02/26 at approximately 8:30 P.M. she had entered Resident #70's room to administer medications and Resident #70 was calm and cooperative. At approximately 11:00 P.M. she had been informed by CNA #80 that during care, Resident #70 had begun yelling at her. RN #511 stated she had entered Resident #70's room and he had begun to yell at her and CNA #80, and was using inappropriate language and had asked them to leave his room. At approximately 4:45 A.M., RN #511 had returned to Resident #70's room to administer medications; however, Resident #70 was asleep. At 5:15 A.M., RN #511 returned to Resident #70's room per CNA #80's request and Resident #70 was verbally aggressive and had refused his medications and care. The statement documented staff had remained calm and professional throughout the interactions. Review of Former DON #507 undated statement revealed at 8:30 A.M. Resident #70 had been interviewed and alleged a night shift aide had punched him in the nose, stated the aide had thrown me around like a rag roll and Resident #70 had told the aide to take it easy. Resident #70 had communicated as he was laying on his back, the aide had then punched him in the nose. Resident #70 had a small amount of blood underneath his right nostril and his septum was deviated to the right. Review of the termination letter dated 03/06/26 revealed CNA #80 was terminated due to physical or verbal abuse of a resident. Review of an indictment dated 03/19/26 revealed CNA #80 was indicted for knowingly causing serious physical harm to another and was charged with felonious assault, a felony in the second degree, knowingly caused or attempted to cause physical harm to another and the offense was committed by a caretaker against a person with a functional impairment, a felony in the fourth degree and committed abuse against a resident of the facility, an offense in the fourth degree. Interview on 03/30/26 at 10:35 A.M. and 12:15 P.M. with RDCO #500 revealed Resident #70 had a history of behaviors by using explicative language and racial slurs especially towards females and African American females. On the morning of 03/03/26, Resident #70's family member stopped in to visit Resident #70 which was normal for him to do. Resident #70's family member told an unnamed facility staff that Resident #70 stated that an aide was mean and rough with him. Former Administrator #504 interviewed Resident #70 that morning then opened an SRI. RDCO #500 verified the SRI for resident abuse was substantiated after viewing the video footage of CNA #80 and Resident #70. RDCO #500 also verified CNA #80 did not knock on the door prior to entering Resident #70's room, then CNA #80 held a pillow over Resident #70's face, slapped and/or hit Resident #70, and stood over Resident #70 while pointing at him during the altercation. An interview on 04/01/26 at 7:57 A.M. with RDCO #500 revealed she had reviewed the footage and had informed RN #511 of the inconsistencies in her written statement; however, RN #511 continued to state she had assisted CNA #80 with Resident #70's care and abuse had not occurred. RDCO #500 further stated RN #511 had been terminated due to her false statement and not cooperating with the investigation and CNA #80 had also been terminated for resident abuse. RDCO #500 stated the police had been notified of the incident and Resident #70 requested to go to the hospital after he had spoken with the police. RDCO #500 stated Resident #70 was admitted to the hospital for facial fractures and had not returned to the facility. A telephone interview on 04/01/26 at 8:36 A.M. with Resident #70's family member revealed he had arrived at the facility on the morning of 03/03/26 at approximately 8:30 A.M. and Resident #70 had stated at around midnight an aide had been rough with him during care, Resident #70 stated to the aide to settle down and she punched him in the face. Resident #70's family member further stated the resident knew his nose was broken and it was painful and he wanted to go to the hospital. Resident #70s' family member stated he had immediately informed the Administrator of what Resident #70 had said. On 04/01/26 at 9:08 A.M. Resident #70's family member arrived to the facility to speak with the surveyor. The family member was asked how Resident #70 was doing, and he stated he would rather not give any information about where Resident #70 was residing due to Resident #70 was fearful CNA #80 would come to the new facility. Resident #70's family member further stated when he had arrived at the facility [on 03/03/26] he had observed dried blood under Resident #70s' nose but no other apparent injuries. Resident #70's family member divulged that Resident #70 had stated the aide had hit him with a closed fist after he had asked her to take it easy. Resident #70 had stated he wanted to press charges and stated the police were called. Interview on 04/01/26 at 11:27 A.M. with RDCO #501 revealed she had reviewed the camera footage and confirmed she had observed CNA #80 strike Resident #70. RDCO #501 stated Former Administrator #504 had initiated an SRI and the police had been called. RDCO #501 stated staff statements were obtained, and RN #511 had been terminated due to her false statement of being in Resident #70's room during care and stated CNA #80 had also been terminated for resident abuse. A telephone interview on 04/02/26 at 1:16 P.M. with Former DON #507 revealed on the morning of 03/03/26 at approximately 8:30 A.M., Resident #70's family member had informed staff of the allegation of abuse. Former DON #507 stated she immediately went to Resident #70's room and Resident #70 stated at approximately 11:00 P.M. to 11:30 P.M. an aide had punched him in the face. The Former DON stated she had observed a small amount of dried blood under his nose and Resident #70 was asked if he was having pain and had stated Duh. Former DON #507 stated she immediately contacted the police who arrived shortly after and had taken Resident #70's statement. Former DON #507 stated Resident #70 also requested to be taken to the hospital. Former DON #507 stated she reviewed the camera footage and observed CNA #80 strike Resident #70. She further stated she observed RN #511 had not been present in the room during care and CNA #80 and RN #511 had been suspended during the investigation and then were terminated. A telephone interview on 04/02/26 at 2:35 P.M. with RN #511 revealed she had been terminated by the facility because they had said she had lied on her statement regarding the incident with Resident #70. RN #511 stated on the evening of 03/02/26 at approximately 8:30 P.M. she administered Resident #70's medications and he was calm and cooperative. RN #511 stated later in the shift between 11:00 P.M. and 11:30 P.M., CNA #80 informed her Resident #70 was agitated and had been calling her names and refused care. RN #511 stated she had not observed CNA #80 strike Resident #70 or being rough with him and Resident #70 had not expressed any concerns. RN #511 stated she then returned to Resident #70's room with CNA #80 at approximately 4:00 A.M. and Resident #70 was sleeping. She went back to the resident's room at approximately 5:15 A.M. to administer his medications and he refused. RN #511 stated she had not observed any injuries or any blood on his face and Resident #70 had not expressed any concerns. Review of facility policy titled Ohio Resident Abuse Policy reviewed 07/02/25 revealed facility staff must immediately report all allegations to the Administrator and will immediately begin an investigation. Physical abuse was defined as hitting, slapping and included controlling behaviors through corporal punishment. Prevention and identification included the assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors. This deficiency represents non-compliance investigated under Master Complaint Number 2806407 and Complaint Number 2804863.

Based on interview, record review, policy review, and video camera footage. the facility failed to ensure residents were assessed following reported aggressive behaviors. This affected one resident (#70) of three (#11, #66 and #70) reviewed for aggressive behaviors. The facility census was 69.Findings Include:Findings include:Review of Resident #70's closed medical record revealed an admission date of 04/01/25 and a discharge date of 03/03/26. Resident #70's diagnoses included multiple sclerosis (MS), quadriplegia, muscle weakness, falls, failure to thrive and dysphagia (difficulty swallowing). Review of the care plan dated 01/14/26 revealed Resident #70 had hearing loss. Interventions included to face the resident when speaking, obtain the resident's attention before speaking, speak clearly and adjust tone as needed. The resident had a plan of care reflecting he was at risk for altered mood related to depression and medical diagnoses. Interventions included administer medications as ordered, allow resident to vent through feelings, approach in a calm and relaxed manner, re-direct when resistive of care, ensure resident was safe and leave for a short period of time and reapproach to assist with care, attempt to reduce stressors as much as possible, explain all procedures and care before beginning to assist and ensure resident feels safe in the environment. Resident #70 had a plan of care related to incontinence of bowel and bladder. Interventions included to check for incontinence at regular intervals and provide incontinence care as needed. Resident #70 also had a plan of care for self-care deficits related to MS and quadriplegia. Interventions included to assist with activities of daily living (ADL) that included dressing, grooming, toileting, and feeding, and mechanical lift transfers. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #70 had intact cognition. The assessment revealed Resident #70 had behaviors that included rejection of care. It noted he was dependent with eating, toileting, bathing and personal hygiene and was incontinent of bowel and bladder. Review of a progress note dated 02/24/26 timed 1:05 P.M. and authored by Former Director of Nursing (DON) #507 revealed Resident #70 had increased behaviors that included cursing at staff upon providing care. Review of facility self-reported incident (SRI) tracking number 271645 dated 03/03/26 revealed Resident #70's family member had reported an aide (identified to be CNA #80) had handled the resident in a rough manner and he had gotten hit in the nose by the aide while she was providing care. Upon assessment, Resident #70 had a small amount of blood under his nostril and his nose appeared to be deviated. Resident #70 was transported to the hospital and was admitted with multiple facial fractures. The SRI facility investigation revealed the facility conducted staff interviews, obtained staff statements, resident interviews and skin assessments, the resident's family and physician were notified, the police were notified, education regarding abuse and neglect was provided to all staff, and CNA #80 was suspended pending the results of the investigation. Additionally, the SRI results substantiated abuse had occurred. During the on-site investigation, observation of facility video footage timestamped 03/02/26 at 11:35 P.M. (with Regional Director of Clinical Services (RDCO) #500) revealed the facility camera had no audio and was angled in the hallway outside Resident #70's room so there was a view of Resident #70's bed against the wall by the door. Resident #70 was asleep while wearing glasses. CNA #80 entered Resident #70's room, without knocking, used the bed controller to lower the head of the bed and lower the bed toward the ground then removed the sheets and lifted Resident #70's hospital gown exposing his incontinence brief while Resident #70 was still asleep. CNA #80 slightly closed the door; however, Resident #70 and Resident #70's bed could still be viewed from the facility hallway camera. CNA #80 then opened Resident #70's brief while he was still asleep. At 11:37 P.M., CNA #80 rolled the resident on his left side towards the wall, removed the incontinence brief and applied a new incontinence brief underneath him. CNA #80 rolled the resident onto his back in a rough manner as he had quickly fallen onto the mattress, and she secured the brief. At 11:38 P.M., CNA #80 made a swift, swinging motion with both of her hands (unable to determine open palms or closed fists) toward Resident #70's face which resulted in the resident's body and mattress shaking from the force of the slap/hit. CNA #80 stepped out of view of the camera then came back into view and was standing/hovering over Resident #70 and his bed while CNA #80 was pointing her right pointer finger, then appeared to touch his face with her right pointer finger which slightly shook the resident's body from the force. CNA #80 then pointed to herself then back to him while still standing/hovering over him. CNA #80's mouth was moving while pointing at him. CNA #80 adjusted the resident's brief then was observed to slap Resident #70 with an open palm to his upper chest and/or face (unable to determine as the wall was now blocking the view of his head) with her left hand and his body and pillow shook from the force. CNA #80 used both hands to roll the resident on his right side then let go of him to roll him back onto his back, then used a closed left fist to hit his right upper shoulder, right upper chest and/or face (unable to determine as the wall blocked the view of his head). CNA #80 adjusted his brief again and covered his brief with the hospital gown. CNA #80 was then observed to throw a pillow at Resident #70's upper chest and face and left the pillow there as CNA #80 was applying the resident's sheets, she covered his body and the pillow on his face with the sheet. At 11:39 P.M., CNA #80 hit Resident #70 in the chest with the pillow using her left hand, then pointed at him with her left hand while the pillow was removed, then held the pillow with force over his face with her right hand for approximately two seconds then removed her hand; however, she left the pillow on his face. CNA #80 then raised the head of the bed with the pillow still on Resident #70's face. After CNA #80 raised the head of the bed, CNA #80 removed the pillow from Resident #70's upper chest and face area and [NAME] the pillow at the foot of the bed. RN #511 was seen walking from the nurses' station with her hands behind her back towards Resident #70's room then she peeked into Resident #70's cracked doorway. CNA #80 appeared to be wiping Resident #70's face. At 11:40 P.M., RN #511 entered Resident #70's room. CNA #80 pointed her right finger at or on Resident #70's mouth then held up a cloth when it appeared Resident #70 spit at CNA #80. Review of CNA #80's undated statement revealed she had provided routine care for Resident #70 and at no time had she treated him like a rag doll or hit him. CNA #80 further stated at approximately 7:00 P.M. she had entered Resident #70's room and introduced herself and she proceeded to check if he needed incontinence care and Resident #70 had immediately begun using racial slurs and derogatory language. At 11:00 P.M. CNA #80 stated she had provided Resident #70 with routine care, and he had begun calling her derogatory and racial names and spit on her. CNA #80 stated she had maintained appropriate technique and ensured Resident #70's safety. CNA #80 stated an unnamed nurse had heard Resident #70 and had entered to de-escalate. CNA #80 denied she or the nurse had observed any blood from Resident #70's face. CNA #80 further stated due to Resident #70s' escalating verbal aggression and spitting during her rounds at 4:00 A.M. she had called the unnamed nurse on duty to assist. Upon arriving to Resident #70's room, he had proceeded to call her derogatory names and spit on her at which time the nurse had advised her to discontinue care and they had left the room. Review of Registered Nurse (RN) #511's statement dated 03/04/26 timed 8:42 P.M. revealed on 03/02/26 at approximately 8:30 P.M. she had entered Resident #70's room to administer medications and Resident #70 was calm and cooperative. At approximately 11:00 P.M. she had been informed by CNA #80 that during care, Resident #70 had begun yelling at her. RN #511 stated she had entered Resident #70's room and he had begun to yell at her and CNA #80, and was using inappropriate language and had asked them to leave his room. At approximately 4:45 A.M., RN #511 had returned to Resident #70's room to administer medications; however, Resident #70 was asleep. At 5:15 A.M., RN #511 returned to Resident #70's room per CNA #80's request and Resident #70 was verbally aggressive and had refused his medications and care. The statement documented staff had remained calm and professional throughout the interactions. Telephone interview on 04/02/26 at 1:16 P.M. with Former Director of Nursing (DON) #507 revealed RN #511 should have assessed Resident #70 for the aggressive behaviors CNA #80 had reported to her, and she should have also reported his behaviors accordingly. Review of facility policy titled Ohio Resident Abuse Policy reviewed 07/02/25 revealed facility staff must immediately report all allegations to the Administrator and will immediately begin an investigation. Physical abuse was defined as hitting, slapping and included controlling behaviors through corporal punishment. Prevention and identification included the assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors. Review of facility policy titled Behavior Management Program revised 03/02/26 revealed if a resident presents with behaviors that will harm others, the facility will immediately implement keep safe interventions, notify the provider and follow and specific state protocols required.This deficiency represents non-compliance investigated under Complaint Number 2806407.

Based on record review, facility investigation review, policy and procedure review and interview, the facility failed to develop and implement a comprehensive, effective and individualized fall management program to decrease Resident #26's risk of falls and/or accident/injury. This affected one resident (#26) of three residents reviewed for accidents. The facility census was 57. Review of the medical record for Resident #26 revealed an admission date of 06/30/25 with diagnoses including chronic venous insufficiency, osteoarthritis, dementia, muscle weakness, and fracture of pubis with routine healing. Review of the [NAME] Fall Risk assessment dated [DATE] revealed Resident #26 was high risk for falls. Review of the plan of care dated 07/01/25 revealed Resident #26 was at risk for falling related to impaired safety awareness with an intervention (dated 07.06/25) to encourage non-skid socks as tolerated. The care plan also reflected Resident #26's ability for activities of daily living (ADL) (e.g., transfer, walk in room, walk in corridor, dress, eat, toilet, maintain personal hygiene) had deteriorated related to chronic venous statis. Interventions (revised 07/11/25) included providing two staff assistance for transfers and manual wheelchair for mobility with one assist. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had severely impaired cognition, was dependent on staff for toileting and transfers, and required substantial/maximal assistance from staff for bed mobility. Review of a physical therapy Discharge summary dated [DATE] revealed Resident #26 had exhausted insurance benefits. Further progress was limited by cognitive deficits. The discharge summary revealed Resident #26 mostly required minimal assist for functional skills for initiation of task and safety cueing; however, the resident had been observed to self-transfer. The discharge summary included a recommendation for limited assistance for safety due to high fall risk related to age/condition and cognitive deficits. Exact discharge disposition to be determined. Staff were aware of resident's current functional level and needs. Record review revealed no changes were made to the resident's fall/safety plan of care following the resident's discharge from therapy. Review of a progress note dated 08/07/25 at 1:55 A.M. revealed Resident #26 was observed in her room on the floor on her buttocks. Resident #26 stated she did not know what happened. Resident #26 had left elbow skin tear that was cleansed with normal saline (NS) and wrapped. The note indicated Resident #26 was alert and oriented to person and place and vital signs were within normal limits. The resident's power of attorney (POA), physician, and Director of Nursing (DON) were notified. The bed was placed in the lowest position, and the call light was in reach. Review of the facility fall investigation revealed Resident #26 had an unwitnessed fall on 08/07/25 at 1:30 A.M. in the resident's room. Resident #26 was last visualized at 1:00 A.M. in bed. When found, the resident was noted to be barefoot, but the investigation also noted all fall interventions were in place. Review of a written statement by Licensed Practical Nurse (LPN) #336 revealed the resident was heard yelling from her room. The aide informed the nurse the resident was on the floor. Resident #26 was assessed for injuries and assisted into her wheelchair. The assigned nurse was notified and took over from that point. Further review of the written statements revealed no statement was obtained from the aide (CAN #400) who was assigned to Resident #26 during this time. The root cause analysis of the fall noted the resident was old (age included), confused, and unbalanced. The fall investigation did not include information as to why non-skid socks were not in place as care planned at the time the resident was found on the floor.Review of the nursing schedule for 08/06/25 into 08/07/25 revealed CNA #400 worked from 3:00 P.M. to 7:00 A.M. and was assigned to Resident #26. Review of a progress note dated 08/07/25 at 6:45 P.M. revealed Resident #26 transferred to hospital due to obtaining a severe skin tear during transfer. Exposed tissues with continuous bleeding present. Resident #26 currently on Warfarin (Coumadin) (blood thinner). All parties were notified. The progress note did not include any additional information as to how the skin tear occurred during the transfer or what caused the skin tear. Review of an incident investigation related to the resident's skin tear on 08/07/25 revealed a witness statement dated 08/07/25 from CNA #366. The statement revealed while transferring Resident #26 into the bed she bumped her leg against the wheelchair and it started bleeding. The CNA got the nurse, and the nurse evaluated it and notified the nurse practitioner (NP). The NP said to send Resident #26 to the ER. There was no root cause analysis included with the investigation. Review of the hospital record (dated 08/07/25) revealed reason for visit was a fall. Diagnoses included closed nondisplaced pelvic (fracture), multiple skin tears, and fall. Instructions noted two stitches needed to be taken out in seven to ten days, one horizontal mattress suture (stitching technique used to close high-tension wounds) and the other simple suture both were done through steri-strips for better hold. Review of a progress note dated 08/08/25 at 12:17 A.M. revealed report received from the nurse from the local emergency room (ER). Resident #26 had a skin tear to the left leg which required stitches and steri-strips. The progress note also reflected Resident #26 had a pubic [NAME] pelvic fracture. Received Tylenol (analgesic) at the ER. The resident returned to the facility via ambulance at 1:00 A.M. Review of a progress note dated 08/08/25 at 1:51 A.M. revealed Resident #26 returned at 1:30 A.M via ambulance. The resident was transferred into bed by two staff. The laceration to the left anterior shin was redressed. The physician was notified. Resident #26 was resting quietly in bed and denied pain at this time.Review of the quarterly MDS assessment dated [DATE] revealed Resident #26 had severely impaired cognition, required substantial/maximal (staff) assistance for bed mobility, and was dependent on staff for toileting hygiene and transfers. Review of an email dated 09/30/25 at 8:32 P.M. from Licensed Practical Nurse (LPN) #401 to the Director of Nursing (DON) revealed this nurse was notified by CNA #366 of Resident #26 obtaining a severe skin tear during a transfer (on 08/07/25) to bed from the wheelchair. Upon entering resident's room, she noticed the resident was crying and a significant amount of blood was coming from the resident's left lower extremity. CNA #366 assisted with grabbing towels to hold pressure on the area. LPN #401 could not get the bleeding to stop. She wrapped the resident's leg, obtained vital signs, and sent the resident to the ER. A telephone interview on 01/20/26 at 3:31 P.M. with CNA #366 revealed 08/07/25 was the first time she had been assigned to care for Resident #26; although she had previously helped other CNAs with the resident's care. CNA #366 revealed on this date between 5:00 P.M. and 6:00 P.M. she was assisting Resident #26 to bed, because her shift ended at 7:00 P.M. CNA #366 stated while transferring Resident #26 from her wheelchair to bed, the resident scraped her leg on the side of the wheelchair leg rest. CNA #366 stated she was alone when she transferred Resident #26, and she had to go get the nurse. CNA #366 stated Resident #26's leg immediately started bleeding, which was why she went to get the nurse. CNA #366 stated the resident skin was so thin and the nurse called the doctor and they sent the resident out (to the hospital). During the interview, CNA #366 stated the resident was not heavy and she felt due to the resident's weight she could transfer her alone. The CNA did not recall or provide any additional information as to what level of assistance the resident required per her plan of care . A telephone interview on 01/21/26 at 9:51 A.M. with CNA #400 revealed she did not recall Resident #26 having a fall in August 2025 and if there was a fall she stated she would have completed a witness statement. The CNA then revealed the DON had recently called and wanted her to complete a statement for a fall now after all these months later. CNA #400 stated Resident #26 was pretty much total care but could stand depending on her mind set and strength. CNA #400 stated Resident #26 was not able to take off her socks or bottoms and to her knowledge, there were no issues with her wearing (non-skid) socks. CNA #400 stated Resident #26 did not wear shoes due to having very thin skin and easily getting skin tears. Interview on 01/21/26 at 11:32 A.M. with the DON verified there was one aide transferring Resident #26 when the skin tear occurred on 08/07/25, and the care plan in place for the resident identified the resident required two staff assist for transfers. The DON stated the resident had dementia and thin skin. The DON also stated Resident #26 could take off socks and clothes but verified there was no documented evidence related to the resident taking off socks or not wanting socks on. The DON verified there was no statement from CNA (#400) who was assigned to Resident #26 on 08/07/25 following the resident's fall. The DON also verified the incident report indicated Resident #26 was barefoot and the care plan indicated encourage non-skid socks as tolerated. Interview on 01/22/26 at 8:47 A.M. with the DON and Physical Therapist (PT) #402 revealed Resident #26 had been discharged from PT on 07/27/25 with discharge recommendations for minimal assistance from staff, indicating one person assist, for transfers. However, the DON verified the care plan had not been updated to include this change from therapy. The DON stated MDS staff were responsible for updating care plans and when the care plan was updated it would also update the Kardex for the aides. Interview on 01/22/26 at 10:15 A.M. with the DON verified the MDS assessments dated 07/07/25 and 09/26/25 indicated Resident #26 was dependent on staff for transfers. Interviews on 01/22/26 at 10:24 A.M. and at 10:38 A.M. with MDS LPN #302 revealed the MDS assessment data was obtained from the charting by the CNA staff, nurses and therapy. MDS LPN #302 stated dependent on staff indicated two-person assist, and substantial/maximal assistance provided more than 50% of the effort done by staff.Review of the policy Fall Prevention and Management Policy, revised 08/26/24, revealed residents would be assessed for fall risk(s) on admission, quarterly, and as needed. If risks were identified, preventive measures would be in place and care planned. All falls would be reviewed and investigated. This deficiency represents non-compliance investigated under Complaint Number 1306236 (OH00167206).

Based on record review, observation, interview and facility policy review, the facility failed to ensure oxygen tubing was dated as changed weekly for equipment management and infection control. This affected one resident (Resident #56) of nine residents identified as utilizing oxygen (Residents #7, #13, #22, #35, #43, #49, #56, #61 and #73). The facility census was 57.Findings include:A review of the medical records for Resident #56 revealed the date of admission as 08/28/25. Significant diagnoses included multiple sclerosis, chronic respiratory failure with hypoxia (low oxygen level), tracheostomy (a tube inserted through the neck to maintain an airway) status, encephalitis (inflammation of the brain) and encephalomyelitis (inflammation of the brain and spinal cord). Significant orders included oxygen via tracheostomy collar at five liters per minute to maintain an oxygen level of greater than 90 percent, clean oxygen concentrator and filter, change tubing weekly (every seven days) and change out disposable respiratory supplies weekly.A review of the quarterly Minimum Data Set assessment (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00 (Resident rarely understood or severe cognitive deficit). Section O of the MDS revealed Resident #56 utilized oxygen therapy.A care plan reviewed/revised on 11/27/25 revealed Resident #56 required oxygen therapy related to a diagnosis of chronic respiratory failure, presence of tracheostomy and multiple sclerosis. Interventions included changing tubing weekly; cleaning equipment and filters weekly.On 01/20/26 at 1:55 P.M. an observation of Resident #56 revealed them in bed. Oxygen was being administered via a tracheostomy mask. The oxygen tubing was dated 12/25/25. Certified Nurse Aide (CNA) #361 verified the oxygen tubing was dated 12/25/25 at the time of the observation.A review of the facility policy titled; Oxygen Administration (all routes), revised on 06/23/25, revealed licensed clinicians with demonstrated competence will administer oxygen via the specified route as ordered by a provider. The policy further revealed to change tubing, mask, cannula weekly and document in the electronic health record (EHR).This deficiency represents non-compliance investigated under Master Complaint Number 2687582.

Based on record review, observation, interview and facility policy review, the facility failed to ensure medications were not left unattended at the bedside of Resident #55. This affected one resident (#55) of six residents reviewed for medication administration. The facility census was 57.Findings include:Review of the medical record for Resident #55 revealed an admission date of 08/16/24. Diagnoses included spinal stenosis, Alzheimer's disease with late onset, mild dementia with mood disturbance, hyperlipidemia, essential hypertension, major depressive disorder, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 had severely impaired cognition and set up/clean up help for eating, toileting hygiene, bed mobility and transfers. The assessment indicated the resident had no behaviors. Observation on 09/29/25 at 11:43 A.M. in Resident #55's room, observed medicine with cup of medication at bedside. Observation on 09/29/25 at 11:45 A.M. with agency Licensed Practical Nurse (LPN) #383 of Resident #55's room, verified the medication in the medicine cup at the bedside. Agency LPN #383 stated the medication was his blood pressure pills, aspirin, senna, and a multivitamin. Agency LPN #383 stated Resident #55 was usually good about taking his medication. Agency LPN #383 stated when she brought in his morning medications she went to his neighbor, but she asked Resident #55 if took his medications. Agency LPN #383 stated Resident #55 said to her that he took them. Agency LPN #383 stated she was supposed to watch him take them, and the resident did not have an order for self-medication administration. Review of the physician orders for September 2025 revealed active orders for the morning med pass between 7:00 A.M. and 11:00 A.M. noted adult low dose aspirin tablet, delayed release 81 milligrams (mg); Claritin (for allergy) tablet 10 mg; docusate sodium (laxative) capsule100 mg; losartan (for blood pressure) tablet 100 mg; memantine (for Alzheimer/dementia) tablet 10 mg; bupropion HCl (antidepressant) tablet extended release 24 hours 150 mg; omeprazole capsule delayed release 20 mg. There were no orders for self-medication administrator. Reviewed of the facility policy General Dose Preparation and Medication Administration, revised 11/15/24, revealed under 2.8 facility staff should not leave medications or chemical unattended and under 5.9 observe the resident's consumption of the medication(s).

Based on observation, interview, and policy review the facility failed to ensure infection control standards were implemented during incontinence care. This affected one resident (Resident #42) out of four residents reviewed for incontinence care. Findings include:Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with diagnoses including cerebral palsy, high blood pressure, Alzheimer's disease, and history of falling.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had cognitive impairment, was dependent on staff for toileting, and was always incontinent of bowel and bladder.Observation on 12/01/25 at 1:10 P.M. of incontinence care for Resident #42 revealed Certified Nurse Aid (CNA) #128 placed supplies directly onto the bedside table without cleaning the table or placing a barrier. During resident cleansing CNA #128 removed their soiled gloves, went to the resident bathroom to retrieve additional supplies, and then immediately put on a new pair of gloves without hand hygiene before resuming incontinence care.An interview on 12/01/25 at 1:22 P.M. with CNA #128 verified the above findings.Review of the facility policy Hand Hygiene Policy, dated 02/28/2025, revealed hand hygiene is to be completed immediately after glove removal.The following violation was issued relative to incidental findings that were discovered during this complaint investigation completed on 12/01/25.

Based on observations, interview and policy review the facility failed to ensure resident rooms were clean and sanitary for Resident #36, #1, #34, #59 and #50. This affected five residents (#36, #1, #34, #59 and #50) out of eight residents reviewed for physical environment. The facility census was 65. Finding Include: Observation on 11/20/24 at 11:41 A.M. of Resident #36's room revealed a black grimy buildup on the floor showing wheelchair tracks all over the floor, and tables and tops of furniture were dusty. Resident #36 stated they don't clean his room every day and he would like the room cleaned. Observation on 11/20/24 at 11:54 A.M. of Resident #1's room revealed the floor was not swept as there was a build up on dirt in the corners with pieces of paper on the floor and footprints on the floor. Resident #1 stated her room was not cleaned on a daily basis. Interview on 11/20/24 at 12:00 P.M. with Resident #34 revealed housekeeping did not clean her room since she had been there. Observation of her room revealed a build up of dust and dirt around the edge of wall and in corners. Observation on 11/20/24 at 12:03 P.M. of Resident #59's room revealed a plastic bag, paper towels, and an empty wipes container on the floor, and under the bed was food with various debris on the floor in front of bed. Observation on 11/20/24 at 1:06 P.M. of Resident 50's room revealed dried food and drink in front of his bed on the fall matt, food was around the wheels of his bed caked on the floor and in front of his recliner there was dried food stuck to the floor. Resident #50 stated housekeeping would come in but did not really clean and they never clean his bathroom. Observation of the bathroom revealed brown wet liquid around the base of toilet with a brown paper towel in front of toilet soaking up the wetness. The toilet seat was covered with hair and around the base of the toilet was dry brown substance and dust on top of it. Observation was conducted on 11/20/24 at 3:15 P.M. with the Administrator and Director of Nursing (DON) who verified the above findings and verified housekeeping was to clean rooms daily. Interview on 11/21/24 at 10:55 A.M. with Housekeeping Manager (HM) #834 revealed resident rooms were to be cleaned daily. Rooms should be swept and mopped, all high touch areas cleaned, and bathrooms cleaned daily. Deep cleaning was done with room moves and discharges. HM #834 stated there was only one housekeeper working yesterday and there was no second shift housekeeper but the nurse aides could clean any area needing cleaned when the housekeepers are not working. Review of the facility policy Environmental Services: Housekeeping, dated 08/30/22 revealed removal of soiled/used items, clean surfaces with saturated cleaning cloth any soiled surfaces around the room, clean bed rails, overbed table, bedside stand, resident chair, call light devices. Clean sink, bath, shower area and high touch surfaces with disinfectant. Clean toilet bowl with designated cleaner. Sweep and mop floor. This deficiency represents noncompliance identified during investigation of Complaint Number OH00159532.

Based on record review, observation, interview and review of facility policy, the facility failed to ensure Resident #11's family were notified of a change in condition. This affected one resident (Resident #11) of three residents reviewed for notification of change. The facility census was 65. Findings include: Review of the medical record for Resident #11 revealed she admitted to the facility on [DATE] with diagnoses including chronic diastolic congestive heart failure, chronic obstructive pulmonary disease, and dysthymic disorder. Resident #11 was not responsible for herself, and her sister was listed as her responsible party. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 15 indicating she was alert and oriented to person, place, and time. Review of the MDS assessment revealed she was dependent on staff for activities of daily living (ADLs). Review of the care plan dated 06/10/24 revealed Resident #11 was at risk for deterioration in ADLs related to assistance required from staff and altered mood and behaviors related to depression and anxiety with interventions that included provide assistance of two staff and monitor and report any changes. Review of a weekly observation assessment dated [DATE] at 3:35 P.M. revealed Resident #11 was observed to have old bruising above her left eye. Review of the Self-Reported Incident dated 11/14/24 based on the facility investigation revealed Resident #11 had a bruise that was discovered on the left side of her forehead with a small discoloration to forearm. Further review of the investigation revealed Resident #26 hit Resident #11 in the face resulting in a bruise above her left eyebrow. Both Certified Nursing Assistant (CNA) #856 and #900 witnessed the incident and revealed the incident occurred on 11/04/24. Interview and observation on 11/19/24 at 8:43 A.M. with Resident #11 revealed on 11/04/24 Resident #26 approached her near the central nurse's station and punched her in the head after a brief verbal altercation that left bruising to the left side of her head. Resident #11 revealed the nurse, who she did not recall, and Assistant Director of Nursing (ADON) #849 checked on her and she was provided an ice pack and medication to help with the pain. Resident #11 revealed Certified Nursing Assistant (CNA) #801 was present during the alleged incident. Observation of three timestamped photos dated 11/09/24 provided by Resident #11 revealed a bluish-purple discoloration, approximately the size of a half-dollar, located above her left eyebrow. Observation on 11/19/24 at 8:43 A.M. of Resident #11 face, revealed a yellow-brownish discoloration, approximately the size of a half-dollar, located above her left eyebrow. Interview on 11/19/24 at 1:58 P.M. with CNA #801 revealed Resident #11 and Resident #26 was observed calling each other out of their names near the central nursing station on 11/04/24, when Resident #11 hit Resident #26 on the head. CNA #801 revealed she did not recall what staff were present, but she documented the incident on an incident report. CNA #801 revealed that the initial incident report must have been lost, because ADON #849 requested she redo it and the ADON #849 now had a copy. Interview on 11/19/24 at 2:15 P.M. with ADON #849 confirmed and verified Resident #11 had bruising above her left eyebrow related to being hit by Resident #26 on 11/04/24 and the incident was not reported t0 Resident #11's family member. Interview on 11/20/24 at 10:17 A.M. with Resident #11 sister revealed staff did not inform her of the incident of physical abuse between Resident #11 and Resident #26 that occurred on 11/04/24. Resident #11 sister revealed she visited Resident #11 between 11/10/24 and 11/16/24 and another staff member who she could not recall informed her of the incident of physical abuse and explained the bruising to Resident #11's forehead. Interview on 11/21/24 at 11:33 A.M. with the Administrator revealed Resident #26 punched Resident #11 in the head that lead to bruising on 11/04/24. The Administrator revealed staff did not inform her until 11/14/24. The Administrator revealed no one reported the bruising or physical altercation from 11/04/24 to 11/13/24, no one documented the physical altercation, and the incident was not reported to Resident #11 sister. Review of the facility document titled Resident Change in Condition Policy revised 06/27/24, revealed the facility had a policy in place to recognize and intervene in the event of a change in condition and the physician and family and/or responsible party would be notified as soon as the nurse had identified the change in condition and the resident was stable. Review of the document revealed the facility did not implement the policy in regard to the allegation. This deficiency represents non-compliance investigated under Complaint Number OH00159817.

Based on observation, resident medical record review, resident interview, staff interviews, and facility policy review, the facility failed to ensure Resident #11 and #26 were free from abuse. This affected two residents (Resident #11 and #26) of three residents reviewed for abuse. The facility census was 65. Findings include: 1. Review of the medical record for Resident #11 revealed she admitted to the facility on [DATE] with diagnoses that included chronic diastolic congestive heart failure, chronic obstructive pulmonary disease, and dysthymic disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated she was alert and oriented to person, place, and time. Review of the MDS assessment revealed she was dependent on staff for activities of daily living (ADLs). Review of the care plan dated 06/10/24 revealed Resident #11 was at risk for deterioration in ADLs related to assistance required from staff and altered mood and behaviors related to depression and anxiety with interventions that included provide assistance of two staff and monitor and report any changes. Review of the weekly observation assessment dated [DATE] at 3:35 P.M. revealed Resident #11 was observed to have old bruising above her left eye and to the left scapula area. Review of the progress note in Resident #11's medical record dated 11/04/24 at 5:18 P.M. but recorded as a late entry on 11/15/24 at 12:20 P.M. approximately eleven days later, revealed Resident #11 and Resident #26 had a verbal altercation that resulted in Resident #11 stating she and Resident #26 did not get along. Review of the progress note revealed Resident #11 was reminded that she had a behavioral contract in place to stay away from Resident #26. Review of the incident log dated 08/19/24 to 11/19/24, revealed Resident #11 had an incident of alleged abuse dated 11/15/24 at 1:35 P.M. created by the Director of Nursing (DON) with no other incidents listed in regard to physical abuse. Review of the progress note dated 11/18/24 at 1:27 P.M. in Resident #11 medical record revealed the interdisciplinary team (IDT) met and reviewed the allegation of abuse and an investigation was initiated. Review of the progress note revealed Resident #11 received a head-to-to-toe observation with no negative findings. Review of the progress note revealed the documented head-to-toe assessment was incorrect as an observation of Resident #11 on 11/19/24 at 8:43 A.M., one day later, revealed a yellow-brownish discoloration, approximately the size of a half-dollar, located above her left eyebrow. 2. Review of the medical record for Resident #26 revealed he admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, cirrhosis of liver, and bipolar disorder, current episode manic without psychotic features. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #26 had a BIMS score of 10 that indicated he was alert and oriented with cognition impairment. Review of the MDS assessment revealed he was dependent on staff for activities of daily living (ADLs). Review of the care plan dated 04/27/24 revealed Resident #26 was at risk for altered mood and behaviors related to bipolar and depression with interventions that included providing 15-to-30-minute checks or one-on-one as needed. Review of the physician orders dated 08/31/24 revealed Resident #26 had an order in place to protect other residents from harm. Review of the Self-Reported Incident dated 11/14/24 based on the facility investigation revealed Resident #11 had a bruise that was discovered on the left side of her forehead with a small discoloration to forearm. Further review of the investigation revealed after a verbal altercation, Resident #11 made hand gestures near Resident #26 and made contact. Resident #26 then proceeded to make physical contact with Resident #11's face resulting in a bruise above her left eyebrow. Review of the investigation revealed Certified Nursing Assistant (CNA) #856 and #900 witnessed the physical altercation between Resident #11 and Resident #26. CNA #900 revealed Resident #11 slapped Resident #26 and Resident #26 proceeded to punch Resident #11 in the head. CNA #856 revealed Resident #11 verbally threatened Resident #26 and Resident #26 responded by punching Resident #11 in the head. Both CNA #856 and #900 revealed the incident occurred on 11/04/24. Interview on 11/19/24 at 8:34 A.M. with Licensed Practical Nurse (LPN) #872 revealed she worked 7:00 A.M. to 2:00 P.M. on the day the alleged physical abuse occurred between Resident #11 and Resident #26. LPN #872 revealed the physical altercation occurred after she her shift ended, and she had left for the day. LPN #872 revealed she seen the bruise located on Resident #11 forehead above her left eye. LPN #872 revealed she did not document, report or complete an assessment due to being informed that another staff member had completed it on the day it occurred. Interview and observation on 11/19/24 at 8:43 A.M. with Resident #11 revealed on 11/04/24 Resident #26 approached her near the central nurse's station and punched her multiple times in the head after a brief verbal altercation that left bruising to the left side of her head. Resident #11 revealed the nurse, who she did not recall, and ADON #849 checked on her and she was provided an ice pack and medication to help with the pain. Resident #11 revealed CNA #801 was present during the alleged incident. Observation of the three timestamped photos dated 11/09/24 provided by Resident #11 revealed a bluish-purple discoloration, approximately the size of a half-dollar, located above her left eyebrow. Observation on 11/19/24 at 8:43 A.M. of Resident #11 face, revealed a yellow-brownish discoloration, approximately the size of a half-dollar, located above her left eyebrow. Interview on 11/19/24 at 1:50 P.M. with Resident #26 was attempted. However, Resident #26 declined. Interview on 11/19/24 at 1:58 P.M. with CNA #801 revealed Resident #11 and Resident #26 was observed calling each other out of their names near the central nursing station on 11/04/24, when Resident #11 hit Resident #26 on the head. CNA #801 revealed she did not recall what staff were present, but she documented the incident on an incident report. CNA #801 revealed that the initial incident report must have been lost, because ADON #849 requested she redo it and the ADON #849 now had a copy. Interview on 11/19/24 at 2:15 P.M. with ADON #849 revealed she was in the building on the day, 11/04/24, the alleged abuse occurred but she was not aware of the physical altercation that took place. ADON #849 revealed Resident #11 and Resident #26 had a history of not getting along and had behavior contracts in place to stay away from each other. ADON #849 revealed she was not aware of any bruising to Resident #11 face and did not observe any bruising to her face on 11/04/24 and the days after. ADON #849 revealed [NAME] Regional Nurse (SRN) #879 informed her of Resident #11 bruising to her face. ADON #849 revealed she did not recall the day it was brought to her attention. ADON #849 confirmed and verified Resident #11 bruising related to being hit by Resident #26. ADON #849 verified a timely investigation did not occur immediately after the incident between Resident #11 and #26. Interview on 11/19/24 at 2:22 P.M. with the Administrator revealed Resident #11 and Resident #26 had a physical altercation on 11/04/24 and it was reported late to the Ohio Department of Health. Administrator also revealed there was no documentation of the incident and staff present did not follow the abuse procedures and protocols. Interview on 11/19/24 at 2:28 P.M. with SRN #879 revealed she observed an old bruising to Resident #11 face on 11/14/24 and reported it to the Administrator and DON. SRN #879 revealed Resident #11 had discoloration near her left eye and told her that Resident #26 hit her. Interview on 11/20/24 at 8:39 A.M. with LPN #803 revealed she was aware of Resident #11 bruising located above her left eyebrow. LPN #803 revealed when she saw the bruising, approximately 10 days ago, it appeared to not be fresh. LPN #803 revealed the bruise appeared in the shape of a C and was an old, faint, purple, yellow brown in color and was near the end and resolving. Interview on 11/21/24 at 11:33 A.M. with the Administrator revealed Resident #26 punched Resident #11 in the head that lead to bruising on 11/04/24. The Administrator revealed staff did not inform her until 11/14/24, therefore the SRI was initiated late. The Administrator revealed Resident #11 approached Resident #26 and a verbal altercation began, and as a result, Resident #26 punched her in the head. The Administrator revealed both residents had behavior contracts in place in which they were to remain away from each other and staff were to monitor for compliance with the contracts. The Administrator revealed CNA #900 and LPN #901, who were unavailable for interview, both were present at the time of the incident. The Administrator revealed no one reported the bruising or physical altercation from 11/04/24 to 11/13/24, no one documented the physical altercation, staff did not monitor both residents for compliance of behavior contracts, and the incident was reported to the Ohio Department of Health late. The Administrator confirmed and verified the above findings at the time of the interview. Review of the facility document titled Ohio Resident Abuse Policy revised 07/11/24, revealed the facility had a policy in place to investigate all allegations, suspicions, and incidents of abuse. Physical abuse involves hitting, slapping, pinching, kicking and controlling behavior through corporal punishment. Review of the policy revealed the facility staff, which included, but not limited to, employees, consultants, contractors, volunteers and other caregivers who provide care and services to the residents on behalf of the facility, were to immediately report all such allegations to the Administrator. Review of the policy revealed the facility would monitor residents with a history of aggressive behaviors or behaviors and needs that may lead to conflict. This deficiency represents non-compliance investigated under Complaint Number OH00159817.

Based on observation, resident medical record review, resident interview, staff interviews, and facility policy review, the facility failed to ensure the abuse policy was implemented for an incident of abuse involving Resident #11 and #26. This affected two (Resident #11 and #26) of three residents reviewed for abuse. The facility census was 65. Findings include: Review of the medical record for Resident #11 revealed she admitted to the facility on [DATE] with diagnoses that included chronic diastolic congestive heart failure, chronic obstructive pulmonary disease, and dysthymic disorder. Review of the medical record for Resident #26 revealed he admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, cirrhosis of liver, and bipolar disorder, current episode manic without psychotic features. Review of the incident log dated 08/19/24 to 11/19/24, revealed Resident #11 had an incident of alleged abuse dated 11/15/24 at 1:35 P.M. created by the Director of Nursing (DON) with no other incidents listed in regard to the physical abuse. Review of the progress note in Resident #11 medical record dated 11/04/24 at 5:18 P.M. but recorded as a late entry on 11/15/24 at 12:20 P.M. approximately eleven days later, revealed Resident #11 and Resident #26 had a verbal altercation that resulted in Resident #11 stating she and Resident #26 did not get along. Review of the progress note revealed Resident #11 was reminded that she had a behavioral contract in place to stay away from Resident #26. Review of the Self-Reported Incident dated 11/14/24 based on the facility investigation revealed Resident #11 had a bruise that was discovered on the left side of her forehead with a small discoloration to forearm. Further review of the investigation revealed after a verbal altercation, Resident #11 made hand gestures near Resident #26 and made contact. Resident #26 then proceeded to make physical contact with Resident #11's face resulting in a bruise above her left eyebrow. Review of the investigation revealed Certified Nursing Assistant (CNA) #856 and #900 witnessed the physical altercation between Resident #11 and Resident #26. CNA #900 revealed Resident #11 slapped Resident #26 and Resident #26 proceeded to punch Resident #11 in the head. CNA #856 revealed Resident #11 verbally threatened Resident #26 and Resident #26 responded by punching Resident #11 in the head. Both CNA #856 and #900 revealed the incident occurred on 11/04/24. Interview and observation on 11/19/24 at 8:43 A.M. with Resident #11 revealed on 11/04/24 Resident #26 approached her near the central nurse's station and punched her multiple times in the head after a brief verbal altercation that left bruising to the left side of her head. Resident #11 revealed the nurse, who she did not recall, and ADON #849 checked on her and she was provided an ice pack and medication to help with the pain. Resident #11 revealed CNA #801 was present during the alleged incident. Observation of the three timestamped photos dated 11/09/24 provided by Resident #11 revealed a bluish-purple discoloration, approximately the size of a half-dollar, located above her left eyebrow. Observation on 11/19/24 at 8:43 A.M. of Resident #11 face, revealed a yellow-brownish discoloration, approximately the size of a half-dollar, located above her left eyebrow. Interview on 11/19/24 at 1:50 P.M. with Resident #26 was attempted. However, Resident #26 declined. Interview on 11/19/24 at 1:58 P.M. with CNA #801 revealed Resident #11 and Resident #26 was observed calling each other out of their names near the central nursing station on 11/04/24, when Resident #11 hit Resident #26 on the head. CNA #801 revealed she did not recall what staff were present, but she documented the incident on an incident report. CNA #801 revealed that the initial incident report must have been lost, because ADON #849 requested she redo it and the ADON #849 now had a copy. Interview on 11/21/24 at 11:33 A.M. with the Administrator revealed Resident #26 punched Resident #11 in the head that lead to bruising on 11/04/24. The Administrator revealed staff did not inform her until 11/14/24, therefore the SRI was initiated late. The Administrator revealed no one reported the bruising or physical altercation from 11/04/24 to 11/13/24, no one documented the physical altercation, staff did not monitor both residents for compliance of behavior contracts, staff did not follow the abuse policy and protocol, and the incident was reported to the Ohio Department of Health late. The Administrator confirmed and verified the above findings at the time of the interview. Review of the facility document titled Ohio Resident Abuse Policy revised 07/11/24, revealed the facility had a policy in place to investigate and immediately report all allegations, suspicions, and incidents of abuse. Physical abuse was defined as hitting, slapping, pinching, kicking and controlling behavior through corporal punishment. This deficiency represents non-compliance investigated under Complaint Number OH00159817.

Based on resident medical record review, resident interview, staff interviews, and facility policy review, the facility failed to ensure an allegation of abuse was reported to the State Agency. This affected two (Resident #11 and #26) of three residents reviewed for abuse. The facility census was 65. Findings include: Review of the medical record for Resident #11 revealed she admitted to the facility on [DATE] with diagnoses that included chronic diastolic congestive heart failure, chronic obstructive pulmonary disease, and dysthymic disorder. Review of the medical record for Resident #26 revealed he admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, cirrhosis of liver, and bipolar disorder, current episode manic without psychotic features. Review of the incident log dated 08/19/24 to 11/19/24, revealed Resident #11 had an incident of alleged abuse dated 11/15/24 at 1:35 P.M. created by the Director of Nursing (DON) with no other incidents listed in regard to the physical abuse. Review of the progress note in Resident #11 medical record dated 11/04/24 at 5:18 P.M. but recorded as a late entry on 11/15/24 at 12:20 P.M. approximately eleven days later, revealed Resident #11 and Resident #26 had a verbal altercation that resulted in Resident #11 stating she and Resident #26 did not get along. Review of the progress note revealed Resident #11 was reminded that she had a behavioral contract in place to stay away from Resident #26. Review of the Self-Reported Incident dated 11/14/24 based on the facility investigation revealed Resident #11 had a bruise that was discovered on the left side of her forehead with a small discoloration to forearm. Further review of the investigation revealed after a verbal altercation, Resident #11 made hand gestures near Resident #26 and made contact. Resident #26 then proceeded to make physical contact with Resident #11's face resulting in a bruise above her left eyebrow. Review of the investigation revealed Certified Nursing Assistant (CNA) #856 and #900 witnessed the physical altercation between Resident #11 and Resident #26. CNA #900 revealed Resident #11 slapped Resident #26 and Resident #26 proceeded to punch Resident #11 in the head. CNA #856 revealed Resident #11 verbally threatened Resident #26 and Resident #26 responded by punching Resident #11 in the head. Both CNA #856 and #900 revealed the incident occurred on 11/04/24. Interview and observation on 11/19/24 at 8:43 A.M. with Resident #11 revealed on 11/04/24 Resident #26 approached her near the central nurse's station and punched her multiple times in the head after a brief verbal altercation that left bruising to the left side of her head. Resident #11 revealed the nurse, who she did not recall, and ADON #849 checked on her and she was provided an ice pack and medication to help with the pain. Resident #11 revealed CNA #801 was present during the alleged incident. Observation of the three timestamped photos dated 11/09/24 provided by Resident #11 revealed a bluish-purple discoloration, approximately the size of a half-dollar, located above her left eyebrow. Interview on 11/21/24 at 11:33 A.M. with the Administrator revealed Resident #26 punched Resident #11 in the head that lead to bruising on 11/04/24. The Administrator revealed staff did not inform her until 11/14/24, therefore the SRI was initiated late. The Administrator revealed no one reported the bruising or physical altercation from 11/04/24 to 11/13/24, no one documented the physical altercation, staff did not monitor both residents for compliance of behavior contracts, staff did not follow the abuse policy and protocol, and the incident was reported to the Ohio Department of Health late. The Administrator confirmed and verified the above findings at the time of the interview. Review of the facility document titled Ohio Resident Abuse Policy revised 07/11/24, revealed the facility had a policy in place to investigate and immediately report all allegations, suspicions, and incidents of abuse. Physical abuse was defined as hitting, slapping, pinching, kicking and controlling behavior through corporal punishment. This deficiency represents non-compliance investigated under Complaint Number OH00159817.

Based on observation, resident medical record review, resident interview, staff interviews, and facility policy review, the facility failed to ensure an allegation of abuse was thoroughly and timely investigated for Resident #11 and Resident #26. This affected two (Resident #11 and #26) of three residents reviewed for abuse. The facility census was 65. Findings include: 1.Review of the medical record for Resident #11 revealed she admitted to the facility on [DATE] with diagnoses that included chronic diastolic congestive heart failure, chronic obstructive pulmonary disease, and dysthymic disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated she was alert and oriented to person, place, and time. Review of the MDS assessment revealed she was dependent on staff for activities of daily living (ADLs). Review of the care plan dated 06/10/24 revealed Resident #11 was at risk for deterioration in ADLs related to assistance required from staff and altered mood and behaviors related to depression and anxiety with interventions that included provide assistance of two staff and monitor and report any changes. Review of the weekly observation assessment dated [DATE] at 3:35 P.M. revealed Resident #11 was observed to have old bruising above her left eye and to the left scapula area. Review of the progress note in Resident #11 medical record dated 11/04/24 at 5:18 P.M. but recorded as a late entry on 11/15/24 at 12:20 P.M. approximately eleven days later, revealed Resident #11 and Resident #26 had a verbal altercation resulting in Resident #11 stating she and Resident #26 did not get along. Review of the progress note revealed Resident #11 was reminded that she had a behavioral contract in place to stay away from Resident #26. Review of the progress note dated 11/18/24 at 1:27 P.M. in Resident #11's medical record revealed the interdisciplinary team (IDT) met and reviewed the allegation of abuse and an investigation was initiated. Review of the progress note revealed Resident #11 received a head-to-to-toe observation with no negative findings. 2.Review of the medical record for Resident #26 revealed he admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, cirrhosis of liver, and bipolar disorder, current episode manic without psychotic features. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 10 that indicated he was alert and oriented with cognition impairment. Review of the MDS assessment revealed he was dependent on staff for activities of daily living (ADLs). Review of the care plan dated 04/27/24 revealed Resident #26 was at risk for altered mood and behaviors related to bipolar and depression with interventions that included providing 15-to-30-minute checks or one-on-one as needed. Review of the physician orders dated 08/31/24 revealed Resident #26 had an order in place to protect other residents from harm. Review of the incident log dated 08/19/24 to 11/19/24, revealed Resident #11 had an incident of alleged abuse incident dated 11/15/24 at 1:35 P.M. created by the Director of Nursing (DON) with no other incidents listed in regard to the physical abuse. Review of the Self-Reported Incident dated 11/14/24 based on the facility investigation revealed Resident #11 had a bruise that was discovered on the left side of her forehead with a small discoloration to forearm. Further review of the investigation revealed after a verbal altercation, Resident #11 made hand gestures near Resident #26 and made contact. Resident #26 then proceeded to make physical contact with Resident #11's face resulting in a bruise above her left eyebrow. Review of the investigation revealed CNA #856 and #900 witnessed the physical altercation between Resident #11 and Resident #26. CNA #900 revealed Resident #11 slapped Resident #26 and Resident #26 proceeded to punch Resident #11 in the head. CNA #856 revealed Resident #11 verbally threatened Resident #26 and Resident #26 responded by punching Resident #11 in the head. Both CNA #856 and #900 revealed the incident occurred on 11/04/24. Interview on 11/19/24 at 8:34 A.M. with Licensed Practical Nurse (LPN) #872 revealed she worked 7:00 A.M. to 2:00 P.M. on the day the alleged physical abuse occurred between Resident #11 and Resident #26. LPN #872 revealed the physical altercation occurred after she her shift ended, and she had left for the day. LPN #872 revealed she seen the bruise located on Resident #11 forehead above her left eye. LPN #872 revealed she did not document or complete an assessment due to being informed that another staff member had completed it on the day it occurred. Interview and observation on 11/19/24 at 8:43 A.M. with Resident #11 revealed on 11/04/24 Resident #26 approached her near the central nurse's station and punched her multiple times in the head after a brief verbal altercation that left bruising to the left side of her head. Resident #11 revealed the nurse, who she did not recall, and Assistant Director of Nursing (ADON) #849 checked on her and she was provided an ice pack and medication to help with the pain. Resident #11 revealed Certified Nursing Assistant (CNA) #801 was present during the alleged incident. Observation of the three timestamped photos dated 11/09/24 provided by Resident #11 revealed a bluish-purple discoloration, approximately the size of a half-dollar, located above her left eyebrow. Observation on 11/19/24 at 8:43 A.M. of Resident #11 face, revealed a yellow-brownish discoloration, approximately the size of a half-dollar, located above her left eyebrow. Interview on 11/19/24 at 1:50 P.M. with Resident #26 was attempted. However, Resident #26 declined. Interview on 11/21/24 at 11:33 A.M. with the Administrator revealed Resident #26 punched Resident #11 in the head that lead to bruising on 11/04/24. The Administrator revealed staff did not inform her until 11/14/24, therefore the SRI and investigation was initiated late. Review of the facility document titled Ohio Resident Abuse Policy revised 07/11/24, revealed the facility had a policy in place to immediately investigate all allegations, suspicions, and incidents of abuse. This deficiency represents non-compliance investigated under Complaint Number OH00159817.

Based on record review, interview and review of facility policy, the facility failed to ensure Resident #75's physician ordered laboratory services were completed and reported to the physician as required. This affected one resident (Resident #75) of one resident reviewed for laboratory services. The facility census was 65. Findings Include: Review of the medial record for Resident #75 revealed an admitted [DATE]. Diagnoses included cirrhosis of liver, obesity, chronic pain, heart failure and pulmonary edema. Review of a progress note on 10/17/24 at 6:21 P.M. revealed the Nurse Practitioner (NP) #883 was in to see Resident #75 regarding congestions and not feeling well. She ordered Stat (immediately) Basic Metabolic Panel (a blood test which provides information about body fluid balance and metabolism) and a chest x-ray. Review of the labs drawn on 10/17/24 at 1:20 P.M. for the basic metabolic panel (BMP) revealed the specimen hemolyzed (break down of red blood cells causing the specimen to be unusable) so the facility was to reschedule the BMP. Interview on 11/21/24 at 10:27 A.M. with NP #883 revealed she ordered a stat BMP on 10/17/24 for Resident #75. NP #883 verified that the facility should have checked on the Stat BMP and rescheduled the test if the sample was not adequate. Interview on 11/21/24 at 10:35 A.M. with the Director of Nursing (DON) verified Resident #75 had orders for a stat BMP and due to the specimen being hemolyzed the lab was not completed. The nursing staff should have followed up on the lab and reschedule for the lab to be redrawn. Review of the facility policy Resident Change in Condition policy, dated 06/27/24 revealed the nurse would address any emergency care required given the situation and gather information and the most recent labs to the provide/physician. This deficiency identified non-compliance during investigation of Complaint Number OH00159522.

Based on record review, resident interview, staff interview, and review of witness statements, the facility Administrator failed to treat Resident #21 in a dignified and respectful manner. This affected one resident (#21) of three reviewed. The facility census was 56. Findings include: Review of the medical record for Resident #21 revealed an admitted [DATE] with diagnoses including anxiety disorder, major depressive disorder, congestive heart failure, chronic obstructive pulmonary disease, hypertension, and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 08/07/24, revealed Resident #21 had no cognitive impairment. On 08/28/24 at 9:06 A.M., an interview with Resident #21 stated the Administrator yelled at her and argued with her, which Resident #21 felt was inappropriate. On 08/28/24 at 9:55 A.M., an interview with Licensed Practical Nurse (LPN) #214 confirmed they witnessed the Administrator yelling at Resident #21, gesturing at her with her hands and pointing a finger at her. LPN #214 stated this incident occurred in the middle of the building by the nurses station. On 08/28/24 at 3:53 P.M., an interview with Regional Registered Nurse (RN) #242 stated the Administrator was verbally inappropriate with Resident #21, threatening to kick Resident #21 out of the building. Review of Resident #21's signed statement, dated 08/28/24, indicated the Administrator told Resident #21 that she was in charge and she would kick Resident #21 out. Review of LPN #214's signed statement, dated 08/28/24, confirmed the Administrator yelled at Resident #21 and the Administrator told Resident #21 that she could kick Resident #21 out of the facility. LPN #214 further stated it was a bad choice of words and uncalled for. This deficiency represents non-compliance investigated under Complaint Number OH00155871.

Based on record review, resident interview, staff interview, and review of witness statements, the facility failed to ensure allegations of abuse were reported by staff in a timely manner, which led to a delay in the investigation of the alleged incident. This affected one resident (#21) of three reviewed. The facility census was 56. Findings include: Review of the medical record for Resident #21 revealed an admitted [DATE] with diagnoses including anxiety disorder, major depressive disorder, congestive heart failure, chronic obstructive pulmonary disease, hypertension, and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 08/07/24, revealed Resident #21 had no cognitive impairment. On 08/28/24 at 9:06 A.M., an interview with Resident #21 stated the Administrator yelled at her and argued with her, which Resident #21 felt was inappropriate. On 08/28/24 at 9:55 A.M., an interview with Licensed Practical Nurse (LPN) #214 confirmed they witnessed the Administrator yelling at Resident #21, gesturing at her with her hands and pointing a finger at her. LPN #214 stated this incident occurred in the middle of the building by the nurses station a few weeks ago and they reported it to the former Director of Nursing (DON). On 08/28/24 at 2:05 P.M., an interview with Regional Registered Nurse (RN) #242 denied knowledge of anyone accusing the Administrator of verbal abuse. On 08/28/24 at 3:53 P.M., an interview with Regional RN #242 stated it was never reported to the regional team that a resident or staff member had alleged verbal abuse incidents against the Administrator. Regional RN #242 confirmed that the Administrator was verbally inappropriate with Resident #21, threatening to kick Resident #21 out of the building. Review of Resident #21's signed statement, dated 08/28/24, indicated the Administrator told Resident #21 that she was in charge and she would kick Resident #21 out. Review of LPN #214's signed statement, dated 08/28/24, confirmed there was an incident a couple weeks ago when the Administrator yelled at Resident #21 and the Administrator told Resident #21 that she could kick Resident #21 out of the facility. Review of the facility's policy titled Ohio Resident Abuse Policy, dated 07/11/24, revealed facility staff must immediately report all allegations of abuse to the Administrator or Abuse Coordinator. The policy further indicated that all investigations must be completed within five working days of the alleged occurrence. This deficiency represents non-compliance investigated under Complaint Number OH00155871.

Based on record review and staff interview, the facility failed to notify the physician of residents not receiving medications as physician ordered. This affected five (Residents #1, #3, #8, #24, and #55) of 13 residents receiving insulin in the facility. The facility census was 63. Findings include: 1. Review of the medical record for Resident #1 revealed an admitted d 04/25/24. Diagnoses included type II diabetes mellitus and end stage renal failure. Review of the medication administration record (MAR) for May 2024 revealed on 05/05/24 at 9:30 P.M., Resident #1 did not have his blood sugar check and did not receive any insulin as physician ordered. At the bottom of the MAR under reasons not administered on 05/05/24 at 9:30 P.M. stated drug/item unavailable. There was no documentation in the medical record that the physician was notified that Resident #1's insulin and blood sugar check were not administered as physician ordered on 05/05/24. Interview on 05/09/24 at 3:00 P.M. with Regional Nurse #310 verified Resident #1 did not receive insulin due to the resident's blood sugar was not taken and was unable to administer insulin per sliding scale. Regional Nurse #310 verified the physician was not notified. 2. Review of the medical record for Resident #3 revealed an admitted [DATE]. Diagnosis included type II diabetes mellitus. Review of Resident #3's physician orders for 03/28/24 revealed Humalog KwikPen Insulin (short acting insulin) 100 unit/milliliter (ml) give eight units subcutaneous (SQ) before meals and Lantus Soloster U-100 insulin (long-acting insulin) 100 unit/ml, give 18 units SQ at bedtime. Review of the MAR for May 2024 revealed on 05/05/24 at 9:00 P.M., Lantus 18 unit/ml was not administered, and blood glucose was not checked. On 05/06/24 at 7:30 A.M. glucose sugar was not checked, and insulin was not administered. At the bottom of MAR under reason not administered on 05/06/24 at 7:30 A.M. stated no testing strips available. There was no documentation in the medical record that the physician was notified that Resident #3's insulin and blood sugar check were not administered as physician ordered on 05/05/24 and 05/06/24. Interview on 05/09/24 at 3:00 P.M. with Regional Nurse #310 verified Resident #3 did not receive insulin two times due to the resident's blood sugar was not taken and was unable to administer insulin per sliding scale. Regional Nurse #310 verified the physician was not notified. 3. Review of the medical record for Resident #8 revealed an admitted [DATE]. Diagnosis included type II diabetes mellitus. Review of Resident #8's physician orders dated 03/30/24 revealed an order for insulin lispro 100 unit/ml per sliding scale before meals and at bedtime. Review of the MAR for May 2024 revealed on 05/05/24 at bedtime (8:00 P.M. to 10:30 P.M.), Resident #8 did not have his blood glucose taken and no insulin was administered. There was no notation for the reason not administered. There was no documentation in the medical record that the physician was notified that Resident #8's insulin and blood sugar check were not administered as physician ordered on 05/05/24. Interview on 05/09/24 at 3:00 P.M. with Regional Nurse #310 verified Resident #8 did not receive insulin due to the resident's blood sugar was not taken and was unable to administer insulin per sliding scale. Regional Nurse #310 verified the physician was not notified. 4. Review of the medical record for Resident #24 revealed an admitted [DATE]. Diagnosis included type II diabetes mellitus. Review of Resident #24's physician order dated 03/30/24 revealed insulin lispro 100 unit/ml per sliding scale before meals and at bedtime. Review of the MAR for May 2024 revealed on 05/04/24 at bedtime (7:00 P.M.-11:00 P.M.,) on 05/05/24 at morning (6:00 A.M. to 7:00 A.M.) and the bedtime (7:00 P.M.-11:00 P.M.) and on 05/06/24 at morning (6:00 A.M. to 7:00 A.M.), Resident #24's blood sugar was not checked, and no insulin was administered. Insulin was given at other scheduled times and blood glucose was checked. At the bottom of the MAR under reason not administered on 05/06/24 at morning (6:00 A.M. - 7:00 A.M.) stated no testing strips available. There was no documentation in the medical record that the physician was notified that Resident #24's insulin and blood sugar check were not administered as physician ordered on 05/04/24, twice on 05/05/24 and on 05/06/24. Interview on 05/09/24 at 3:00 P.M. with Regional Nurse #310 verified Resident #24 did not receive insulin four times due to the resident's blood sugar was not taken and was unable to administer insulin per sliding scale. Regional Nurse #310 verified the physician was not notified. 5. Review of the medical record for Resident #55 revealed an admitted on 03/27/24. Diagnosis included type II diabetes mellitus. Review of Resident #55's physician orders dated 04/01/24 revealed an order for insulin lispro (short acting insulin) 100 unit/ml per sliding scale before meals and at bedtime. Review of the MAR for May 2024 revealed on 05/05/24 at dinner (4:00 P.M.) and bedtime (9:00 P.M.), Resident #55 did not have their blood sugar checked and was not administered insulin. At the bottom of MAR under on 05/05/24 at 4:00 P.M. stated reason not administered was no testing strips available. There was no documentation in the medical record that the physician was notified that Resident #55's insulin and blood sugar check were not administered as physician ordered on 05/05/24. Interview on 05/09/24 at 3:00 P.M. with Regional Nurse #310 verified Resident #55 did not receive insulin due to the resident's blood sugar was not taken and was unable to administer insulin per sliding scale. Regional Nurse #310 verified the physician was not notified. Interview on 05/13/24 at 8:41 A.M. with Licensed Practical Nurse (LPN) #306 verified she did not notify the physician that the residents did not receive their insulin as physician ordered. This was an incidental finding during the course of the complaint investigation.

Based on record review, observation, and resident and staff interview, the facility failed to administer medications as physician ordered, resulting in significant medication errors. This affected five (Resident #1, #3, #8, #24 and #55) of thirteen residents reviewed for insulin. The facility census was 63. Findings include: 1. Review of the medical record for Resident #1 revealed an admitted d 04/25/24. Diagnoses included type II diabetes mellitus and end stage renal failure. Review of Resident #1's physician order for May 2024 revealed Humalog (insulin) U-100 100 unit per milliliter (ml) before meals and at bedtime. Review of the medication administration record (MAR) for May 2024 revealed on 05/05/24 at 9:30 P.M., Resident #1 did not have his blood sugar check and did not receive any insulin as physician ordered. At the bottom of the MAR under reasons not administered on 05/05/24 at 9:30 P.M. stated drug/item unavailable. Interview on 05/09/24 at 3:00 P.M. with Regional Nurse #310 verified Resident #1 did not receive insulin due to the resident's blood sugar was not taken and was unable to administer insulin per sliding scale. Regional Nurse #310 revealed the next shift blood sugars were taken as ordered the glucometer strips were found. 2. Review of the medical record for Resident #3 revealed an admitted [DATE]. Diagnosis included type II diabetes mellitus. Review of Resident #3's physician orders for 03/28/24 revealed Humalog KwikPen Insulin (short acting insulin) 100 unit/milliliter (ml) give eight units subcutaneous (SQ) before meals and Lantus Soloster U-100 insulin (long-acting insulin) 100 unit/ml, give 18 units SQ at bedtime. Review of the MAR for May 2024 revealed on 05/05/24 at 9:00 P.M., Lantus 18 unit/ml was not administered, and blood glucose was not checked. On 05/06/24 at 7:30 A.M. glucose sugar was not checked, and insulin was not administered. At the bottom of MAR under reason not administered on 05/06/24 at 7:30 A.M. stated no testing strips available. Interview on 05/09/24 at 3:00 P.M. with Regional Nurse #310 verified Resident #3 did not receive insulin two times due to the resident's blood sugar was not taken and was unable to administer insulin per sliding scale. Regional Nurse #310 revealed the next shift blood sugars were taken as ordered the glucometer strips were found. 3. Review of the medical record for Resident #8 revealed an admitted [DATE]. Diagnosis included type II diabetes mellitus. Review of Resident #8's physician orders dated 03/30/24 revealed an order for insulin lispro 100 unit/ml per sliding scale before meals and at bedtime. Review of the MAR for May 2024 revealed on 05/05/24 at bedtime (8:00 P.M. to 10:30 P.M.), Resident #8 did not have his blood glucose taken and no insulin was administered. There was no notation for the reason not administered. Interview on 05/09/24 at 3:00 P.M. with Regional Nurse #310 verified Resident #8 did not receive insulin due to the resident's blood sugar was not taken and was unable to administer insulin per sliding scale. Regional Nurse #310 revealed the next shift blood sugars were taken as ordered the glucometer strips were found. 4. Review of the medical record for Resident #24 revealed an admitted [DATE]. Diagnosis included type II diabetes mellitus. Review of Resident #24's physician order dated 03/30/24 revealed insulin lispro 100 unit/ml per sliding scale before meals and at bedtime. Review of the MAR for May 2024 revealed on 05/04/24 at bedtime (7:00 P.M.-11:00 P.M.,) on 05/05/24 at morning (6:00 A.M. to 7:00 A.M.) and the bedtime (7:00 P.M.-11:00 P.M.) and on 05/06/24 at morning (6:00 A.M. to 7:00 A.M.), Resident #24's blood sugar was not checked, and no insulin was administered. Insulin was given at other scheduled times and blood glucose was checked. At the bottom of the MAR under reason not administered on 05/06/24 at morning (6:00 A.M.-7:00 A.M.) stated no testing strips available. Interview on 05/09/24 at 10:04 A.M. with Resident #24 stated one time the nurse was not able to administered their insulin due to her not having any glucometer strips to test their blood sugar. Later, they must have found the strips because the nurse checked my blood sugar and administered insulin per sliding schedule. Interview on 05/09/24 at 3:00 P.M. with Regional Nurse #310 verified Resident #24 did not receive insulin four times due to the resident's blood sugar was not taken and was unable to administer insulin per sliding scale. 5. Review of the medical record for Resident #55 revealed an admitted on 03/27/24. Diagnosis included type II diabetes mellitus. Review of Resident #55's physician orders dated 04/01/24 revealed an order for insulin lispro (short acting insulin) 100 unit/ml per sliding scale before meals and at bedtime. Review of the MAR for May 2024 revealed on 05/05/24 at dinner (4:00 P.M.) and bedtime (9:00 P.M.), Resident #55 did not have their blood sugar checked and was not administered insulin. At the bottom of MAR under on 05/05/24 at 4:00 P.M. stated reason not administered was no testing strips available. Observation on 05/09/24 at 9:30 A.M. of the medication storage room and the 100-Hall, 200-Hall and 400-Hall medication carts revealed plenty of insulin needles and glucometer strips. Interview on 05/09/24 at 1:25 P.M. with Administrator stated on 05/05/24, Licensed Practical Nurse (LPN) #306 called to yell at her and stated she was going to the police station to turn her keys in. She stated there was no glucose strip in the building. The Administrator told LPN #306 to look in the medication room or storage room. The Administrator stated she told LPN #306 to go look in the supply room and call her back if she did not find any glucometer strips. The Administrator stated the nurse did not call her back. Interview on 05/09/24 at 3:00 P.M. with Regional Nurse #310 verified Resident #55 did not receive insulin due to the resident's blood sugar was not taken and was unable to administer insulin per sliding scale. Regional Nurse #310 revealed the next shift blood sugars were taken as ordered the glucometer strips were found. Interview on 05/13/24 at 8:41 A.M. with LPN #306 revealed she worked on 05/05/24 and she was told by the day shift nurse that there were no glucometer strips in the building so blood sugar could not be taken, and she was trying to reach management all day. LPN #306 stated she tried to call the Administrator and there was no answer. The Administrator called back after she called the police to report she did not have supplies to do her job safely and was going to bring the medication cart keys to them. LPN #306 stated the Administrator was upset and told her to check central supply and medication room for glucometer strips and she could not take the keys to the police station, or she would report her to the board of nursing for abandonment. LPN #306 stated she could not find the glucometer strips. This deficiency represents non-compliance investigated under Complaint Number OH00153676.

Based on closed record review and interview, the facility failed to ensure Resident #65, who had a history of substance use disorder was assessed for these risks and had comprehensive and individualized care planned interventions initiated and implemented to ensure the resident's safety to prevent drug overdose. Actual harm occurred on [DATE] when Resident #65 was found unresponsive in the facility due to a drug overdose. The resident subsequently passed away. This affected one (#65) of one resident reviewed for death. Findings include: Review of Resident #65's Preadmission Screening and Resident Review Result (PASRR) Notice form dated [DATE] revealed the resident did not require level two services. The resident had a diagnosis of a substance use related disorder with the last substance abuse reported as [DATE]. Review of Resident #65's admission hospital paperwork dated [DATE] revealed the resident had a history of substance abuse with last heroin usage reported as [DATE] and last marijuana usage reported as [DATE]. Review of Resident #65's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including anxiety disorder, other psychoactive substance abuse and multiple fractures. The resident was admitted for short term placement for skilled therapy services following a motor vehicle accident. Review of Resident #65's physician's orders revealed the following medication orders: An order dated [DATE] (discontinued [DATE]) for Gabapentin 400 mg (milligrams) give one capsule by mouth every eight hours for pain due at 06:00 A.M., 2:00 P.M. and 10:00 P.M.; an order dated [DATE] (discontinued [DATE]) for Methocarbamol oral tablet 1000 mg give one tablet every six hours for muscle spasms due at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M.; an order dated [DATE] (discontinued [DATE]) for Acetaminophen give 650 mg by mouth every six hours as needed for pain; an order dated [DATE] (discontinued [DATE]) for Oxycodone 5 mg give one tablet every four hours as needed for pain; and an order dated [DATE] (discontinued [DATE]) for Xanax 0.5 mg give one tablet by mouth every 12 hours as needed for anxiety. Review of Resident #65's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #65's Medicine Progress Note form dated [DATE] revealed the resident required pain medications related to multiple fractures but had a history of heroin abuse. A discussion was held with tapering of medications as he heals and discussed the risk of relapse on heroin. The resident was agitated with the discussion and stated he had no interest in using heroin again and only wanted pain control. Review of Resident #65's anxiety care plan dated [DATE] indicated the resident had a history of anxiety and drug use. The plan of care indicated the resident would request pain medications prior to his next scheduled administration and would make accusations that he had never received the medications despite nursing documentation and two staff present during administration. He would attempt to order alcohol from restaurants to be delivered to the facility and became anxious and agitated with staff regarding the pain medications. Review of Resident #65's anxiety care plan interventions included to administer medications, consult pharmacist for gradual dose reductions (GDR), implement non-pharmacological interventions, and refer to psych services. Resident #65's medical record did not include evidence of the resident's substance use was assessed therefore care planned interventions did not address any increased monitoring or supervision to prevent potential behaviors including drug overdose. Review of Resident #65's medication administration record for [DATE] revealed the resident had medications due at 8:00 A.M. and 9:00 A.M. including an iron tablet, Lovenox (anti-coagulant injection) and Lexapro (antidepressant). Record review revealed these medications were not administered as ordered on this date. Review of Resident #65's progress note dated [DATE] at 1:00 P.M. authored by Licensed Practical Nurse (LPN) #813 indicated at approximately 12:10 P.M. the nurse went into the room to medicate the resident. The resident was unresponsive, and the nurse initiated cardiopulmonary resuscitation (CPR) immediately. The nurse called to State tested Nursing Assistant (STNA) to send in another nurse. Review of Resident #65's emergency medical technician squad (EMS) report dated [DATE] revealed the squad arrived for a [AGE] year-old male in full arrest. Upon arrival, the nursing staff provided manual chest compressions and breaths with a bag valve mask (BVM). Per nursing staff, the resident's last known wellness check was around 10:00 A.M. Staff found the resident at noon pulseless and apneic and began CPR. CPR was taken over by EMS. The resident's cardiac rhythm showed asystole. Three rounds of epinephrine as well and two rounds of Narcan were administered. The time of death was pronounced on [DATE] at 12:30 P.M. The report indicated the call was received on [DATE] at 12:13 P.M., the squad dispatched at 12:14 P.M., on scene and in contact with the resident at 12:17 P.M. Review of Resident #65's Coroner Report Form dated [DATE] indicated the police were called to the resident's room following the death and officers advised the coroner that the death was a possible drug overdose. The police had found evidence of drugs found in the resident's room. A wallet was in the room and inside the wallet was a white piece of paper folded up with a white powdery substance in it. There was also a blue piece of paper rolled up with some other white powdery substance. The wallet also contained a very small spoon typically used for drug activity. The basis of examination and/or investigation, in the coroner's opinion, identified the cause of death as acute intoxication by Alprazolam, Fentanyl and Gabapentin. Interview on [DATE] at 8:45 A.M. with the Administrator, Regional Registered Nurse (RN) #812 and the Director of Nursing (DON) indicated Resident #65 had a prior history of drug abuse and he expired in the facility due to an overdose provided by a visitor. Interview on [DATE] at 10:21 A.M. with LPN #813 revealed she did not administer Resident #65's morning medications on [DATE] because she did not come in until 10:30 A.M. She stated she went in to administer the resident noon medications and found the resident unresponsive, still warm and in bed. She stated this was the first time she had attempted to assess the resident on [DATE] because she clocked in late to the facility. Interview on [DATE] at 8:59 A.M. with Coroner Department #831 indicated their department was notified of Resident #65's death on [DATE] at 12:37 P.M. He stated from what their department understood, the deceased died by acute Fentanyl overdose and Gabapentin which were provided by a friend. Interview on [DATE] at 1:32 P.M. with RN Regional #812 confirmed Resident #65 had a prior history of substance abuse. RN Regional #812 confirmed Resident #65's medical record and comprehensive care plans did not include interventions to address the resident's substance abuse history on admission or following the medicine progress note visit on [DATE] when there was discussion related to pain medication. There was no evidence the facility adequately and thoroughly assessed or implemented interventions including but not limited to increased monitoring or supervision of the resident as well as increased supervision of visitors to prevent possible behaviors including a relapse of his substance abuse disorder. Interview on [DATE] at 4:30 P.M. with Licensed Social Worker (LSW) #830 indicated Resident #65 had ordered door dash at some point (unknown date) and had ordered alcohol with the door dash. LSW #830 confirmed the facility talked to the resident and removed the alcohol but did not include increased supervision and monitoring for the resident as part of the resident's care planned interventions to ensure the resident's safety. She stated she was made aware of the incident after it occurred. Interview on [DATE] at 9:49 A.M. with Resident #65's stepmother revealed following admission, the resident had been getting better (with physical therapy). However, the resident's stepmother voiced concerns she felt the resident received inadequate monitoring for drug use related to the resident's history of prior substance abuse. Interview on [DATE] at 10:09 A.M. with Paramedic #830 indicated the staff completed adequate compressions during Resident #65's CPR. Paramedic #830 confirmed the resident was cyanotic and warm with no rigor mortis noticed at the time of the CPR. Paramedic #830 revealed the squad was informed Resident #65 had a visitor earlier in the day and administered the Narcan as a precaution. Interview on [DATE] at 10:40 A.M. with RN Regional #812 revealed Resident #65 had received therapy services on [DATE] from 9:27 A.M. to10:17 A.M. After therapy the resident went back to his room. RN Regional #812 indicated the resident did not request assistance and staff did not go into the room from the end of therapy until the resident was found unresponsive on [DATE] at 12:10 P.M. Review of the Behavior Management Program policy revised [DATE] revealed the goal of the facility was to improve management of behaviors and move closer to the goal of ending any inappropriate or unnecessary use of antipsychotic medications. The facility would assess and track behavior that negatively impacted each resident in regard to their quality of life. This deficiency represents non-compliance investigated under Complaint Number OH00152414.

Based on record review and interview, the facility failed to ensure Resident #65's medications were administered as ordered. This finding affected one (Resident #65) of five residents reviewed for medication administration. Findings include: Review of Resident #65's medical record revealed the resident was admitted on [DATE] with diagnoses including anxiety disorder, other psychoactive substance abuse and multiple fractures. Review of Resident #65's physician orders revealed an order dated 07/01/23 for Lexapro (antidepressant) give 10 mg (milligrams) by mouth one time a day for depression due at 9:00 A.M.; Ferrous Sulfate (iron) 325 mg by mouth two times a day for anemia due at 08:00 A.M. and 08:00 P.M.; and Lovenox injection (anticoagulant) 30 mg/0.3 ml (milliliters) give one vial subcutaneously two times a day for health maintenance due at 08:00 A.M. and 08:00 P.M Review of Resident #65's medication administration records (MARS) from 08/01/23 to 08/21/23 revealed no evidence the resident's Lexapro, iron and Lovenox anticoagulant medications were administered as ordered. Interview on 04/17/24 at 10:21 A.M. with Licensed Practical Nurse (LPN) #813 confirmed she did not administer Resident #65's morning medications as ordered. Review of the General Dose Preparation and Medication Administration policy revised 01/01/13 indicated the facility staff should verify each time a medication was administered that it was the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time and for the correct resident. This deficiency represents non-compliance investigated under Complaint Number OH00152414.

Based on medical record review, medication administration procedure review, Medication Error Investigation Summary review and staff interviews, the facility failed to ensure one resident (Resident #111) received the correct amount of the pain medication, [MEDICATION NAME] oral concentrate, in accordance with the prescriber's order. Facility nurses failed to ensure the written physician's orders [REDACTED].#15 failed to determine the correct dose prior to administering [MEDICATION NAME]. This resulted in Immediate Jeopardy for Resident #111, who was ordered [MEDICATION NAME] oral concentrate for pain management. Resident #111 received 100 milligram (mg) [MEDICATION NAME] oral concentrate instead of the ordered 5.0 mg dose on [DATE] at 6:30 P.M. Serious harm occurred when Resident #111 had a significant change in condition/level of consciousness after the administration of the [MEDICATION NAME] and expired in the facility on [DATE] at 10:00 A.M. This affected one of five residents reviewed for liquid narcotic pain medication administration. The facility census was 62. The Administrator, Director of Nursing (DON), Regional Director of Clinical Services (RDCS) and Regional Director of Operations were notified on [DATE] at 10:30 A.M. that Immediate Jeopardy began on [DATE] at 6:30 P.M., when RN #15 administered 100 mg of [MEDICATION NAME] oral concentrate to Resident #111 instead of the ordered 5.0 mg dose. The Immediate Jeopardy was removed on [DATE] at 8:00 A.M. when the facility implemented the following corrective measures. · On [DATE] at 8:15 P.M., Licensed Practical Nurse (LPN) #20 discontinued the incorrectly transcribed [MEDICATION NAME] order and reentered the correct physician's orders [REDACTED]. · On [DATE] the DON and unit managers (RN #50 and RN #51) began in-servicing all licensed nursing staff in person or via telephone on medication administration, medication errors, types of narcotics and reading and transcribing telephone orders. The education of all licensed nursing staff was completed at 6:00 P.M. · On [DATE] at 8:30 P.M., RN #15 was placed on suspension pending the outcome of the investigation related to the medication error. · On [DATE] beginning at 7:00 A.M. medication administration audits were initiated by the DON and unit managers (RN #50 and RN #51). Every nurse, prior to passing medications independently, would be assessed to ensure they followed the facility policy and procedures for medication administration including reading the medication label, proper documentation, infection control and monitoring for side effects. The audits were to continue two times a week for four weeks, then weekly times two months. · On [DATE] at 8:00 A.M., the DON completed an audit of all residents (Residents #60, #61, #62 and #63) with liquid narcotics ordered to ensure the correct dose was identified and administered. No similar dose discrepancies or errors were found. · On [DATE] unit managers (RN #50 and RN #51) completed change in condition and transcription audits which would continue two times a week for four weeks, then weekly times two months. · On [DATE] night shift nurses were in-serviced by the DON and RDCS on how to review daily orders for accuracy. From [DATE] forward, night shift nurses were to review daily orders for accuracy. The DON or designee were to complete a 24-hour chart check to ensure completion and accuracy, and the clinical team would review new orders daily at risk rounds. · On [DATE] at 7:00 P.M. a Quality Assurance and Performance Improvement (QAPI) meeting was held to discuss, review, and ensure the corrective action plan met quality standards and care would be met at acceptable levels. Attendees included the Regional Director of Operations, RDCS, Administrator and DON. The corrective action plan was reviewed and approved by the chief medical officer. Although the Immediate Jeopardy was removed 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 continued to conduct audits to ensure ongoing compliance regarding the accurate transcribing of medication orders and the administration of medications without error. Findings include: Medical record review revealed Resident #111 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was severely cognitively impaired but able to make her needs known. The resident required supervision for eating, one person assist for dressing and personal hygiene, and two person assist for all other activities of daily living. Review of a nurse's note dated [DATE] at 12:47 P.M., signed by RN #45, revealed Resident #111's family/power of attorney (POA) was contacted regarding the resident's functional decline and end of life hospice care recommendation related to [DIAGNOSES REDACTED]. The resident's family/POA indicated she would like to meet with hospice services. Review of a social service noted dated [DATE] at 2:01 P.M. revealed a hospice referral was initiated for Resident #111. Review of a nursing progress note dated [DATE] at 12:50 P.M. revealed Resident #111 was admitted to hospice service with a [DIAGNOSES REDACTED]. Review of Resident #111's physician orders [REDACTED]. Review of a nurse's order note dated [DATE] at 1:09 P.M., signed by LPN #25, revealed a physician's orders [REDACTED]. Start [DATE]. Daughter aware of new order. Review of the physician's orders [REDACTED].M. revealed an order for [REDACTED]. Review of the Medication Administration Record [REDACTED].M. Review of the Controlled Substance Record for Resident #111 revealed RN #15 administered 5.0 ml (100 mg) of [MEDICATION NAME] concentrate solution on [DATE] at 6:30 P.M. Review of the facility's Medication Error Investigation Summary dated [DATE] revealed an incident description indicating Resident #111 was complaining of back pain and was given liquid [MEDICATION NAME] 5.0 ml instead of 0.25 ml. The report indicated on [DATE] at 6:30 P. M, RN #15 gave Resident #111 a dose of [MEDICATION NAME] and immediately afterward questioned the dose. The supervisor verified the wrong dose was administered. Resident #111 was assessed, the physician, hospice, daughter, on-call assistant director of nursing (ADON) and Administrator were notified. Upon investigation, [MEDICATION NAME] was administered to patient at dose of 100 mg versus prescribed 5.0 mg. The investigation indicated the resident was assessed and vital signs were taken. RN #15 was suspended pending an investigation. Review of a hospice nurse note dated [DATE] at 8:34 P.M. revealed the nurse received a telephone call from the facility regarding a change in Resident #111's condition. Upon arrival, she found the resident minimally responsive with labored breathing, shallow, irregular respirations of eight breaths per minute with periods of apnea (absence of breaths) and cold clammy skin. The family was at the bedside. Review of a nurse's note dated [DATE] at 7:31 A.M., signed by LPN #30, revealed Resident #111 was resting comfortably with family and staff at bedside. Review of a nurse's note dated [DATE] at 8:00 A.M., signed by LPN #35, revealed Resident #111's blood pressure was ,[DATE], apical pulse 34 beats per minute and respirations 20 per minute with intermittent periods of apnea. Resident #111 remained on continuous oxygen at four liters per minute via nasal cannula. LPN #35 notified the on-call hospice nurse of an increase in the resident's oral secretions and received a new order for [MEDICATION NAME] 1%, administer two drops SL every four hours as needed for terminal secretions and to suction as needed. A nurse's note dated [DATE] at 9:00 A.M., signed by LPN #35, revealed the [MEDICATION NAME] and suctioning were effective in managing secretions. Review of a hospice nurse's note dated [DATE] at 9:20 A.M. revealed Resident #111's radial pulse was weak and thready and her respirations were labored and shallow at six breaths per minute with periods of apnea. Care was provided to Resident #111 and support provided to the family during active dying phase. Resident #111 expired in the facility on [DATE] at 10:05 A.M. Interview with the DON and RDCS on [DATE] at 10:30 A.M. revealed on [DATE], RN #15 removed a prefilled bottle of [MEDICATION NAME] concentrate solution 20 mg/ml from the facility's Starter Kit located in the medication storage room. At 6:30 P.M., RN #15 administered 5.0 ml (100 mg) of [MEDICATION NAME] concentrate solution from the bottle labeled [MEDICATION NAME] 20 mg/ml to Resident #111. The DON confirmed Resident #111 was administered 100 mg of [MEDICATION NAME] concentrate solution (5.0 ml) instead of the 5.0 mg of [MEDICATION NAME] concentrate solution (0.25 ml) prescribed by the physician. The DON indicated there was a 10-minute window between when the medication was administered and when RN #15 became aware of the error. The DON confirmed the medication error was significant and put the resident at risk for respiratory arrest and death. The DON stated Medical Doctor (MD) #1 was immediately notified of the error and the hospice nurse and family were notified as well. An interview with LPN #5 on [DATE] at 3:15 P.M. revealed Resident #111 was placed on hospice services due to a decline in her medical condition. Resident #111 was recently diagnosed with [REDACTED]. The resident had become increasingly short of breath and was on four liters per minute of oxygen via nasal cannula continuously. LPN #5 stated Resident #111 was able to verbalize her needs, did not have frequent complaints of pain and received routine Tylenol (non-narcotic pain reliever) for pain. A telephone interview with RN #15 on [DATE] at 3:52 P.M. revealed RN #15 worked a 12-hour shift from 7:00 A.M. to 7:00 P.M. on [DATE] and was assigned to care for Resident #111. RN #15 indicated he administered a dose of [MEDICATION NAME] concentrate solution to Resident #111 due to complaints of back pain. RN #15 indicated he used the 1.0 ml syringe attached to the [MEDICATION NAME] concentrate medication bottle and administered five, 1.0 ml doses of [MEDICATION NAME] concentrate to Resident #111. RN #15 indicated he realized his error within five minutes of administering the medication. RN #15 verified the incorrect dose with RN #10 and then talked to the nursing supervisor, LPN #20. After reviewing the Medication Administration Record [REDACTED]. RN #15 stated after the medication error he and LPN #20 assessed Resident #111 and her vital signs were stable. RN #15 indicated he documented the medication was administered but did not document anything which occurred afterward including the assessment or vital signs that were completed after the error was realized. LPN #20 gave report on Resident #111 to the oncoming shift and RN #15 gave report on the remaining residents in his care. RN #15 indicated he had worked in the facility for two months. He received orientation and worked with a nurse on the floor for four shifts before he became independent. RN #15 shared this was not his first medication error while working at the facility; he had and another error which was also related to an incorrect dose of medication. The unnamed resident was given a lower dose than what was ordered. There was no negative outcome to the resident. The supervisor identified the error and educated RN #15 regarding the error. A telephone interview on [DATE] at 4:44 P.M. with Hospice Nurse #50 revealed she admitted Resident #111 to hospice services on [DATE]. Resident #111 was alert and able to respond appropriately to questions. Resident #111 could identify her pain and was able to help with turning and repositioning. Hospice Nurse #50 described Resident #111 as pretty with it. Hospice Nurse #50 received a call from the facility nurse on [DATE] at 6:50 P.M. regarding a medication error. Resident #111 had received 100 mg (5.0 ml) of [MEDICATION NAME]. Hospice Nurse #50 notified MD #2 (hospice physician) immediately and asked if anything could be done. MD #2 stated [MEDICATION NAME] (used to treat narcotic overdose) was not an option given Resident #111's current condition and organ failure and there was nothing that could be done except to monitor the resident. When Hospice Nurse #50 arrived at the facility on [DATE] at 8:40 P.M., she noted a significant change in Resident #111's condition from [DATE]. She indicated Resident #111 barely opened her eyes and remained non-responsive with labored breathing while she rested until she died on [DATE] at 10:05 A.M. Hospice Nurse #50 informed the family of the medication error and they came and stayed with the resident until 1:00 A.M. on [DATE]. Hospice Nurse #50 left the facility at 1:30 A.M. on [DATE]. Hospice Nurse #50 received a telephone call from the facility at 8:00 A.M. on [DATE] indicating Resident #111 had increased secretions and drooling. Hospice Nurse #50 returned to the facility at 9:00 A.M. and found Resident #111's condition was unchanged. At 9:50 A.M., Resident #111's breathing changed, her blood pressure decreased, and she expired at 10:05 A.M. Hospice Nurse #50 said she kept the facility nurse, LPN #30, updated on the resident's status but the facility let me take the reins during this time which she felt was unusual due to the medication error situation. Hospice Nurse #50 also indicated after MD #2 was informed of Resident #111's death, MD #2 advised her to contact the coroner's office prior to releasing the body due to the excessive dosage of [MEDICATION NAME] the resident received. An officer from the local police department arrived at the facility and took statements from staff. Resident #111's body was released to the funeral home on [DATE] at 1:58 P.M. A telephone interview with MD #2 on [DATE] at 12:55 P.M., revealed he received notification of the medication error from Hospice Nurse #50. MD #2 indicated he would not have expected to receive notification from the facility as they would notify the resident's primary physician. MD #2 stated he did not order further intervention after the 100 mg of [MEDICATION NAME] concentrate solution was administered to Resident #111 because the resident was transitioning to death and death was imminent. MD #2 also indicated it was his understanding the facility did not have [MEDICATION NAME] ([MEDICATION NAME]) available and the family did not want [MEDICATION NAME] to be used as they were comfortable with the outcome. MD #2 indicated by law the coroner had to be notified. Interview with LPN #35 on [DATE] at 2:34 P.M. revealed she worked a 12-hour shift on [DATE] starting at 7:00 A.M. LPN #35 stated she received report from the night shift nurse, LPN #30, that Resident #111 was experiencing [MEDICAL CONDITION] (low heart rate) and episodes of apnea. LPN #35 indicated she was surprised by the significant change in Resident #111's condition and her rapid decline. Resident #111 had a lot of oral secretions and she contacted Hospice Nurse #50 at 8:00 A.M. on [DATE] and received an order for [REDACTED].#35 indicated Hospice Nurse #50 arrived at the facility at 9:00 A. M and took over the resident's care. At 10:06 A.M., Hospice Nurse #50 told her Resident #111 expired at 10:05 A.M. LPN #35 indicated she was told by Hospice Nurse #50 to contact the coroner's office. LPN #35 indicated she was eventually put in contact with the local police department who sent an officer to the facility to take statements from staff prior to releasing the body to the funeral home. An interview on [DATE] at 8:24 A.M. with LPN #30 revealed she worked a 12-hour night shift (7:00 P.M. to 7:00 A.M.) on [DATE] and was assigned to provide care for Resident #111. LPN #30 stated she received report from nursing supervisor, LPN #20, and was informed of the medication error. LPN #30 indicated Resident #111 was resting comfortably when she assessed her at the beginning of her shift and through the shift there was no change in her status. LPN #30 stated Resident #111 had always had respiratory issues and her breathing was unchanged from her baseline which was labored with shortness of breath. LPN #30 indicated Hospice Nurse #50 was not at the bedside when her shift started but she arrived shortly after. LPN #30 stated Hospice Nurse #50 also gave her a report on Resident #111, referencing the medication error. LPN #30 stated she communicated with Hospice Nurse #50 back and forth, off and on throughout the night. LPN #30 provided care to Resident #111 including monitoring vital signs and sitting at the bedside and massaging the resident's body. LPN #30 indicated at the end of her shift, she gave report to LPN #35 regarding the medication error and what had been done throughout the night in reference to monitoring Resident #111. LPN #30 confirmed the medical record did not include documentation of physician notification, any assessments of the resident or care provide to Resident #111 after the medication error. LPN #30 stated I did not document anything and I do not have a reason why. A telephone interview with MD #3 (Resident #111's primary physician) on [DATE] at 12:24 P.M., revealed he was notified Resident #111 had received 100 mg of [MEDICATION NAME] concentrate solution instead of the prescribed 5.0 mg dosage via text message from the physician covering for him. MD #3 indicated his nurse practitioner was also notified. MD #3 did not indicate the time of notification. MD #3 stated he did not give orders for further intervention because of Resident #111's medical condition and imminent death. A telephone interview with LPN #20 on [DATE] at 8:43 A.M. revealed on [DATE], RN #15 approached her five minutes after he had administered 100 mg of [MEDICATION NAME] concentrate solution to Resident #111. He questioned whether he gave the correct dose. LPN #20 confirmed with RN #15 the incorrect dose of [MEDICATION NAME] was administered. LPN #20 and RN #15 assessed Resident #111 and took her vital signs and determined her vital signs were stable. LPN #20 contacted Hospice Nurse #50, the on-call supervisor and the Administrator. LPN #20 said she attempted to contact the physician covering for MD #3 (MD #1) numerous times and left multiple messages but was unable to get a hold of him prior to leaving the facility at 8:42 P.M. LPN #20 did not contact the nurse practitioner. LPN #20 gave report to the on-coming nurse. LPN #20 stated she believed Hospice Nurse #50 contacted MD #1 sometime after 10:00 A.M. on [DATE]. LPN #20 verified she did not document her assessment of Resident #111, the resident's vital signs or attempts to notify MD #1. LPN #20 gave no explanation of why she did not document any information related to the medication error in Resident #111's medical record. A telephone interview on [DATE] at 1:41 P.M. with MD #1 revealed MD #1 could not recall whether the facility notified him regarding the medication error on [DATE]. He indicated he received a telephone call from the facility after Resident #111 had expired. On [DATE] at 11:06 A.M., the Administrator verified via e-mail that [MEDICATION NAME] was available in the Starter Kit in the facility medication room. Review of the facility's Medication Administration Procedure dated [DATE] revealed the nurse was to read the label comparing the label to the MAR before preparing the medication. Review of the facility's Change in Resident Condition policy, revised (MONTH) (YEAR) indicated the charge nurse would recognize and appropriately intervene in the event of a change in resident condition. The physician, family, responsible party would be notified as soon as the nurse identified the change in condition and the resident was stable. The clinical nurse was to record in the resident's clinical chart information relative to change in the resident's medical/mental condition or status. This deficiency substantiates Complaint Number OH 964.

Based on record review and interview, the facility failed to ensure interventions were in place to alert the staff that Resident #73 got up without assistance in order to prevent a fall that resulted in a left hip fracture. This affected one resident of 18 sampled residents. The facility census was 90 residents. Findings include: Resident #73 was admitted on [DATE] with [DIAGNOSES REDACTED]. The admission comprehensive assessment dated [DATE] revealed the resident had fallen within the last 30 days and the last 31-180 days. The fall risk assessment dated [DATE] revealed the resident was high risk for falls. The fall care plan dated 09/30/09 revealed the resident was at risk for falls. The interventions included personal alarms to bed and chair. The investigation summary sheet revealed the resident was found on the floor in front of her bathroom door on 12/21/09 at 2:00 A.M. The resident complained of pain to the left thigh. The left thigh was slightly swollen. The resident was transferred to the hospital. The comprehensive assessment dated [DATE] revealed the resident had fallen within the last 30 days and the last 31-180 days. The assessment also indicated the resident had a hip fracture within the last 180 days. An interview with the director of nursing (DON) on 04/15/10 at 10:00 A.M. verified the resident suffered a left hip fracture as a result of a fall on 12/21/09 at the facility. The DON also verified the personal alarm was not on at the time of the fall as per the fall care plan.