Every finding on record at Aventura at Oakwood Village

Based on record review, resident interview, staff interview, observation, and review of the facility policy, the facility failed to provide foods planned by the Registered Dietitian (RD) as listed on the dietary spreadsheet. This affected all of the residents in the facility who received food from the facility kitchen. The facility census was 109 residents. Findings Include: Review of the menu spreadsheets dated 02/28/26, 03/01/26 and 03/02/26 revealed residents on all types of diets should have received two ounces of scrambled eggs at breakfast. Residents on cardiac diets should receive an egg substitution product and no bacon. There was no notation on the spreadsheets of any food substitutions. Review of Temperature Guide dated 02/28/26 revealed no notation of any food substitutions. Review of Temperature Guide dated 03/01/26 revealed substitute eggs with sausage links. Review of Temperature Guide dated 03/02/26 revealed substituted toast for pancakes and waffles. There was no egg substitution listed. Interview on 03/05/26 at 8:05 A.M. with Resident #106 confirmed he had not received eggs on 02/28/26, 03/01/26 and 03/02/26. He stated he received one piece of toast and two slices of bacon and no scrambled eggs. Resident #106 stated the portion was not enough food and he wanted some type of protein. Interview on 03/05/26 at 8:30 A.M. with Resident #101 confirmed she had not received eggs on 02/28/26, 03/01/26 and 03/02/26. Resident #101 stated she received bacon and toast. Interview on 03/05/26 at 8:45 A.M. with Resident #98 confirmed he had not received eggs on 02/28/26, 03/01/26 and 03/02/26. Resident #98 stated he received bacon which he was not supposed to have because he was on a cardiac diet, and he should have received an egg substitution product on the days when eggs were on the menu. Interview on 03/05/26 at 8:30 A.M. with Certified Nursing Assistant (CNA) #216 stated he observed breakfast on 02/28/26 and 03/01/26 on the skilled unit, and the residents did not receive any eggs or egg products. CNA #216 confirmed the residents received a small portion of toast and bacon, and Resident #98 requested eggs which were not available. Interview on 03/05/26 at 8:35 A.M. with Housekeeper #35 stated the residents on the skilled unit were not served eggs or milk on 03/02/26 and Resident #98 had reported to her there was not enough food at breakfast over the weekend. Housekeeper #35 confirmed on 03/02/26 Resident #98 received two slices of toast and one piece of bacon, but there were no eggs or other protein on the breakfast tray. Interview on 03/05/26 at 9:50 A.M. with Diet Aide (DA) # 93 stated there were no eggs served on 03/02/26 for breakfast because there were no eggs in the kitchen to prepare. DA #93 confirmed staff instead served two slices of bacon to substitute for eggs. DA #93 stated only half of the facility residents received milk at breakfast on 03/02/26 because they ran out of milk in the kitchen. Interview on 03/05/26 at 10:05 A.M. with [NAME] #92 verified on 03/02/26 the kitchen substituted two slices of bacon for eggs and only half of the facility, the first two tray carts, received milk. [NAME] #92 verified eggs were to be served to all diets and stated he did not serve the meals from the spreadsheet of specialized diets and was unaware residents on cardiac diets were not to be served bacon or sausage as a substitute for the egg substitute product. [NAME] #92 stated he did not have a listing of protein substitutes and thought bacon was considered a protein substitute. Interview on 03/05/26 at 10:35 A.M. with Diet Manger (DM) # 90 verified the breakfast meals of 03/02/26 and 03/01/26 had bacon as a substitute for eggs. DM #90 stated he did not know bacon was not a protein substitute for eggs. DM #90 stated the substitutes documented on the temperature log were not recorded accurately and there was no separate substitution log for the listing of food substitutes. DM #90 verified the spreadsheet should be followed by the cooks to ensure specialized diets were provided as planned. Interview on 03/11/26 at 10:35 A.M. with [NAME] #77 verified she had assisted with preparation and service on 03/01/26, and there were no eggs to prepare for breakfast. She stated two slices of bacon were substituted for the egg portion. [NAME] #77 stated she did not know bacon was not a protein substitute for eggs and did not have a listing of appropriate substitute for eggs. She stated the spreadsheet was not used during meal service as a reference for specialized diets. Interview on 03/11/26 at 12:50 P.M. with RD #400 verified bacon was not a nutritionally equivalent substitution for egg protein. RD #400 stated the cooks should follow the approved spreadsheet for specialized diets to ensure residents with specialized diets receive the correct foods including residents on a cardiac diet. 2. Review of the menu spreadsheet dated 03/05/26 revealed all diets were to receive four ounces of mandarin oranges with the breakfast meal. There were no substitutions listed on the spreadsheet or the temperature sheet for mandarin oranges. Observation on 03/05/26 at the breakfast meal service at 8:00 A.M revealed there were no mandarin oranges served to all residents except for residents on pureed diets who were served applesauce. Interview on 03/05/26 at 9:10 A.M. with DA #96 verified mandarin oranges were listed to be served for all residents at breakfast on 03/05/26. DA #96 stated there were no mandarin oranges in the kitchen and there was no time to prepare another substitute. There was no food provided in place of the mandarin oranges except for the residents with pureed consistency diets who received applesauce. Interview on 03/05/26 at 9:50 A.M. with DA # 93 verified no mandarin oranges were provided to any residents on 03/05/26 at breakfast and only the residents on pureed consistency diets received a substitute. Interview on 03/05/26 at 10:35 A.M. with DM # 90 verified there were no mandarin oranges served to any resident on 03/05/26 for breakfast. There had been no food substituted except for residents on puree diet. DM #90 stated there should have been a fruit substituted for the mandarin oranges and noted on a substitution log, as the item was not available for service. Review of the facility policy titled Menu Substitutions undated revealed menu changes shall be made when a menu item is not available for service. This deficiency represents noncompliance investigated under Complaint Number 2794532 and Complaint Number 2737965

Based on medical record review, review of facility Self-Reported Incidents (SRIs), review of facility investigation reports, review of staff witness statements, staff interview, and review of the facility policy, the facility failed to ensure residents were free from unnecessary physical restraints. This affected one (Resident#110) of one resident reviewed for physical restraints. The facility census was 109 residents.Findings include:Review of the medical record for Resident #110 revealed an admission date of 11/06/24 with diagnoses including cirrhosis of the liver with ascites, diabetes mellitus, chronic obstructive pulmonary disease, and depression and a discharge date of 02/20/26. Review of the Minimum Data Set (MDS) assessment for Resident #110 dated 02/05/26 revealed the resident had intact cognition and required partial assistance with activity of daily living (ADLs), supervision with transfers and was independent with bed mobility. Review of the care plan for Resident #110 revealed the resident had the need for restful sleep. Interventions included the following: keep the room quiet, dim lights, offer the resident a back rub, offer a snack. Further review of the care plan revealed the resident was at risk for falls. Interventions included placing a fall mattress on the floor to the side of bed for the resident to be place on a perimeter defining mattress. Review of the nurse progress note for Resident #110 dated 02/15/26 at 11:55 P.M. per Licensed Practical Nurse (LPN) #501 revealed staff called her to Resident #110's room and noted the resident was agitated, restless, combative, was trying to toss herself to the floor, and was yelling for her son. The hospice nurse arrived and assessed Resident #110 and obtained a new order for Ativan every four hours. Resident #110 became calm after Ativan was administered. Review of the facility SRI involving Resident #110 initiated on 02/16/26 revealed on 02/16/26 staff found a mattress against Resident #110's bed with a chair positioned on the other side of the mattress holding the mattress against the resident's bed while the resident was sleeping in the bed. The facility did not substantiate abuse had occurred but did reeducate staff regarding restraint use. Review of the facility investigation report of the incident involving Resident #110 dated 02/16/26 completed per Former Unit Manger (FUM)#500 revealed Resident #110 was combative and agitated during the night hours. Day shift aides reported finding a mattress which had been placed at the side of the resident's bed with two chairs against the bed and a sheet tucked under the mattress to prevent the resident from falling out of bed. Day shift staff removed the sheet, removed the mattress and removed chairs from the bedside. Resident #110 sustained no injuries related to the incident. The facility suspended the staff suspected of having placed the mattress against Resident #110's bed and filed a SRI. Review of the witness statement per Certified Nursing Assistant (CNA) #206 revealed Resident #110 was up in her chair at the beginning of the 11:00 P.M. shift on 02/15/26. The resident was grabbing at the air and not responding to direction from CNA #206, was restless and attempted to throw herself out of the chair. At 5:45 A.M on 02/17/26 CNA #206 transferred Resident #110 into the bed and placed a mattress against the bed which was held in placed with the resident's chair. Review of the witness statement per CNA #203 revealed when she arrived at work on 02/16/26 at 7:15 A.M Resident #110 was in bed with a mattress against one side of the bed with a chair holding up the mattress and the other side of the bed was against the wall. There was a sheet tucked over the resident making it impossible for the resident to exit the bed. There were also two pillows tucked in such way to prevent Resident #110 from exiting the bed. Review of the witness statement per CNA # 217 revealed on 02/16/26 at 7:30 A.M. she observed FR #110 had a mattress against the bed a specialized positioning chair against it. Review of the witness statement per LPN #501 revealed the last time she was in Resident #110's room on 02/16/26 was at 5:15 A.M. and she did not see a mattress against the resident's bed at that time. Review of LPN #501's statement revealed she had no knowledge that staff had placed a mattress against Resident #110's bed. Interview on 03/05/26 at 1:55 P.M. with CNA #217 verified on 02/16/26 at 7:30 A.M. she observed Resident #110 in bed with a mattress against the bed secured by a locked chair against it. CNA #217 stated she had not observed a sheet over the resident. The resident was asleep and had no visible signs of skin injury or discomfort. Interview on 03/05/26 at 2:05 P.M. with the Director of Nursing, (DON) confirmed the facility had verified CNA #206 had restrained Resident #110 in bed on 02/16/26 at approximately 5:45 A.M. when the aide admitted to placing a mattress against the open side of the resident's bed. The DON further confirmed CNAs # 203 and #217 found Resident #110 at 7:30 A.M. in bed with a mattress against the side of the bed held with a locked positioning chair, and other side of the bed against the wall. The resident was unable to exit the bed. Interview on 03/11/26 at 2:25 P.M. with CNA #203 verified on 02/16/26 at 7:15 A.M. she observed Resident #110 in bed asleep with a sheet and blanket over top of the resident and tucked under the mattress. There was a mattress against the bed with a locked chair holding it in place. CNA #203 confirmed Resident #110 would not have been able to exit the bed, as the other side of the bed was against the wall. Interview on 03/11/26 at 3:18 P.M. with CNA #206 verified Resident #110 had been restless and was trying to throw herself out of a positioning chair about 11:00 P.M. on 02/15/26 according to LPN #501. CNA #206 stated at 5:45 A.M. on 02/16/26 she transferred the resident to bed, covered the resident with a bedsheet but denied the sheet was tucked in under the mattress. CNA #206 verified she put a mattress up against the side of the bed held with the locked chair, and the other side of the bed was against the wall. CNA #206 confirmed she checked on Resident #110 prior to leaving the shift at 7:00 A.M. and the mattress was still in place, and the resident was in no distress and not trying to move in the bed. CNA #206 stated she was trying to keep Resident #110 from falling out of bed and stated she should have lowered the bed and put the mattress on the floor, allowing the resident to move on her own. Review of facility policy titled Physical Constraint Consent dated March 2025 revealed the facility would ensure the residents' right to be free from physical restraints. If a physical restraint was ordered the facility would use the least restrictive restraint for the least amount of time and provide ongoing reevaluation of the need for the physical restraint. This deficiency represents non-compliance investigated under Complaint Number 2787363.

Based on medical record review, observation, and staff interview, the facility failed to ensure a medication error rate below five percent (%). The facility had 28 medication opportunities with two medication errors for an error rate of seven This affected one (Resident #39) of six residents observed for medication administration. The facility census was 109 residents.Findings include:Review of the medical record for Resident #39 revealed an admission date of 12/22/25 with diagnoses including type two diabetes mellitus, hypothyroidism, and hypertension. Review of the physician's orders for Resident #39 dated March 2025 revealed orders Synthroid 50 microgram (mcg) one table and glipizide 10 milligrams (mg) every morning. Observation of medication administration for Resident #39 on 03/05/26 at 7:52 A.M. per Registered Nurse (RN) #115 revealed Synthroid was not available in the medication cart or the emergency box for the resident. RN #115 pulled the card of glipizide for Resident #39 from the medication drawer but did not remove the dose before returning the card to the drawer. Prior to administering Resident #39's morning medication the Surveyor intervened and asked RN #115 if she had removed the glipizide from the card for the resident before returning the card to the cart. RN #115 verified she had not dispensed the dose of glipizide for Resident #39 and returned to the cart and retrieved the medication for administration to Resident #39 Interview on 03/05/26 at 8:00 A.M. with RN #115 confirmed Resident #39's Synthroid was not available for administration. RN #115 further confirmed she administered Resident #39's glipizide after the Surveyor intervened and pointed out the nurse had not removed the dose of glipizide from the drawer. Interview on 03/05/26 at 9:45 A.M. with the Director of Nursing (DON) confirmed understanding of the facility's medication error rate for the med pass completed on 03/05/26. The DON confirmed understanding that there were 28 medication opportunities with two medication omission errors (Synthroid and glipizide) for Resident #39 which gave the facility a medication error rate of seven %. This deficiency represents non-compliance investigated under Complaint Number 2737965.

Based on medical record review, observation, staff interview and review of the facility policy, the facility failed to ensure staff performed appropriate hand hygiene during incontinence care and wound care. This affected one (Resident #31) of 88 facility-identified residents who required incontinence care and one (Resident #12) of 18 facility-identified residents with wounds that required a dressing change. The facility census was 109 residents. Findings include: 1.Review of the medical record for Resident #31 revealed an admission date of 01/02/2024 with diagnoses including chronic obstructive pulmonary disease, dementia, aphasia, atrial fibrillation and hypertension. Review of the Minimum Data Set (MDS) assessment for Resident #31 dated 01/27/26 revealed the resident was dependent on staff with personal hygiene, bathing, upper body, and lower body dressing and was incontinent of bladder and bowel. Observation of incontinence care for Resident #31 on 03/05/26 at 9:56 A.M. per Certified Nursing Assistant (CNA) #225 revealed the CNA applied gloves prior to entering the resident's room and used prepackaged wipes to provide incontinence care. CNA #225 removed Resident #31's soiled brief, cleansed the resident's peri area and applied a clean brief. CNA #225 then doffed gloves and disposed of them in the trash and donned clean gloves without performing hand hygiene. CNA #225 then applied lotion to the resident's chest and then doffed the gloves, discarded of the gloves, and donned clean gloves without performing hand hygiene. CNA #225 then assisted Resident #31 with getting dressed. Interview on 03/05/26 at 10:06 A.M. with CNA #225 confirmed he should have performed hand hygiene after doffing gloves and prior to putting on clean gloves. Interview on 03/05/26 at 10:30 A.M. with the Director of Nursing (DON) confirmed staff should at minimum change gloves after performing incontinence care for a resident. 2. Review of the medical record for Resident #12 revealed an admission date of 03/05/18 with diagnoses including senile degeneration of brain, chronic obstructive pulmonary disease, chronic bronchitis, unspecified psychosis, dementia, and hypertension. Review of the MDS assessment for Resident #12 dated 12/04/25 revealed the resident was dependent on staff for activities of daily living (ADLs) and had a stage three pressure ulcer on her coccyx. Review of the physician's orders for Resident #12 revealed an order dated 03/12/26 for the staff change the dressing ot the resident's coccyx once daily which included cleansing the wound, pat dry, apply alginate to wound bed, and cover with dry clean dressing. Observation of wound care for Resident #12 on 03/05/26 at 10:17 A.M. per Licensed Practical Nurse (LPN) #102 revealed the nurse removed the resident's brief and the old wound dressing came off. LPN #102 then sprayed the wound with water, wiped the wound bed with a clean piece of gauze, applied calcium alginate to the wound dressing, applied the dressing to the resident, applied a clean brief to the resident, and repositioned the resident. LPN #102 then doffed the gloves, washed her hands and exited the room.Interview at 10:25 A.M. with LPN #102 confirmed she did not change gloves or perform hand hygiene between at any time during the wound care and dressing change. LPN #102 confirmed she should have doffed gloves and washed hands following the wound cleaning and then donned clean gloves prior to applying the wound dressing. Interview on 03/05/26 at 10:32 A.M. with the DON confirmed the staff were expected to follow handwashing/hand hygiene guidelines when providing wound care. Review of facility policy titled Handwashing/Hand Hygiene dated October 2023 revealed hand hygiene was indicated immediately before touching a resident, before performing a clean task, after contact with bodily fluids or contaminated surfaces, and after touching a resident. Staff were to wash hands with soap and water when hands were visibly soiled and staff should perform hand hygiene after contact with a resident, after touching the resident's environment, before moving from work on a soiled body site to a clean body site on the same resident, and immediately after glove removal.

Based on medical record review, review of statements, staff interview and policy review, the facility failed to ensure residents were free from resident to resident abuse. This affected one (Resident #108) out of three residents reviewed for abuse. The facility census was 100. Based on medical record review, review of statements, staff interview and policy review, the facility failed to ensure residents were free from resident to resident abuse. This affected one (Resident #108) out of three residents reviewed for abuse. The facility census was 100. Findings Include:1. Review of the medical record revealed Resident #107 was admitted on [DATE] and discharged on 11/11/25. Diagnoses included Parkinson's disease, epilepsy, and intellectual disabilities.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #107 was severely cognitively impaired. Resident #107 required setup or clean-up assistance for meals. Resident #107 was substantial to maximal assistance for oral care, toileting hygiene, personal hygiene, bathing, and dressing upper body. Resident #107 was dependent for placing shoes on and off feet and dressing his lower body.Review of the plan of care dated 08/25/25 revealed Resident #107 had problematic behaviors characterized by wandering, verbal and or physical abuse, throwing objects at others, calling out making disruptive noises, and rejection of care related to his intellectual disability. Interventions included approaching the resident slowly and from the front, be cognizant of not invading resident's personal space, be sure you have the resident's attention before speaking or touching, do not ask the resident to make decisions or ask what was wrong, focus on feelings rather than cause. Do not make unrealistic demands of resident, document summary of each episode, note cause and successful interventions, include frequency and duration, if aggressive try and remove from recreational program, provide individualized program, if strategies are not working, reapproach resident at a later time, initiate psychiatric consult as needed, involve family, encourage resident to call upon them and other support, medication as ordered, reapproach resident at a later time when care was rejected, remove resident from public area when behavior was disruptive, talk with resident in a low pitch, calm voice to decrease and eliminate undesired behavior, and provide diversional activity. Review of a progress note dated 08/16/25 written by Licensed Practical Nurse (LPN) #248 documented Resident #107 was very combative and throwing items at staff and other residents. Resident #107 was redirected but continued to throw items at the staff and other residents. Review of a progress note dated 08/16/25 written by Registered Nurse (RN) #260 who documented Resident #107 was aggressive towards residents and staff this morning. Resident #107 took medication appropriately and remained agitated and yelling at staff and residents.Review of a progress note dated 08/17/25 written by RN #260 who documented Resident #107 yelled throughout the morning in the common area, became aggressive with staff and residents.Review of a progress note dated 08/17/25 written by LPN #253 who documented Resident #107 was hitting numerous residents and staff. Resident #107 also yelled and threw magazines at staff. Resident #107 was unable to be redirected. Resident #107 was given toy cars and was unable to be redirected. Resident #107 was given numerous items to assist with behavior. None were effective.Review of a progress note dated 08/18/25 written by Unit Manager #215 who documented Resident #107 attempted to hit residents and staff with magazines. Resident #215 was redirected multiple times, was still showing aggression toward others. Staff notified family, brother started trying and put him to bed. Resident #107 was unable to be redirected.Review of a progress note dated 08/19/25 written by LPN #251 documented while doing the medication pass, continued to redirect Resident #107. Resident #107 was swinging and yelling at all the residents down the hall. Resident #107 came to the front common area with the nurse and continued to yell and raise his hands at staff and residents. When redirected he became very angry and rammed his wheelchair into the back of another resident and when the nurse and multiple aides tried to move Resident #107, he continued to push harder into the other resident. Once separated Resident #107 then took his shirt off and threw it on the ground. He kept picking up the shirt and threw it and kicked it across the floor. The nurse took the shirt to his room. The nurse walked with Resident #107 to his room he kept yelling, he wanted a shirt and he threw the shirt again.Review of a psychiatric note dated 08/22/25 written by Nurse Practitioner #243 who documented Resident #107 was admitted to the facility for respite care which transitioned into long term care. Prior to admission Resident #107 lived at home his entire life. Resident #107 had severe intellectual disability with a mental age of less than two years old. Since 08/14/25 there have been almost daily reports of physical and verbal aggression, including yelling, hitting staff and other residents, and difficulty with redirection. Review of a progress note dated 09/25/25 written by LPN #248 who documented Resident #107 repeatedly struck staff member while he was being changed, the nurse educated Resident #107 on the importance of not hitting staff. Resident #107 continued to hit staff. Resident #107 also verbally assaulted his roommate Resident #108 to the point that the roommate was scared for his own safety in his room.Review of a progress note dated 09/25/25 written by the Unit Manger #215 who documented the Power of Attorney (POA) was made aware of Resident #107's room change and was placed on one-to-one. Resident #107 continued with behaviors toward staff.2.Review of the medical record revealed Resident #108 was admitted on [DATE] and discharged on 11/17/25. Diagnoses included chronic obstructive pulmonary disease, anxiety disorder, and atrial fibrillation.Review of the quarterly MDS dated [DATE] revealed Resident #108 had a Brief Interview of Mental Status (BIMS) of 12 indicating he had moderate cognitive impairment. Resident #108 required set-up or clean-up assistance for meals. Resident #108 was dependent in dressing upper and lower body, toileting hygiene. Resident #108 was substantial to maximal assistance in bathing, personal hygiene, placing shoes on and off feet, and oral hygiene.Review of the plan of care revealed Resident #108 had feelings of sadness, emptiness, anxiety, uneasiness, bodily complaints, characterized by ineffective coping, low self-esteem, tearfulness, motor agitation, weight loss, withdrawal from care, clinical decline affecting dignity. Interventions included conveying acceptance of residents and provide repeated honest appraisals of resident's strengths to residents, encouraging loved ones to keep in contact. Resident #108 had a risk for negative mood or behavior related to major depressive disorder. Interventions included administer medications as ordered, monitor for dose reduction, resident was supported by mental health services, and social service visits as needed to encourage expression of feelings and to provide support and reassurance.Review of a progress note dated 09/25/25 written by LPN #248 who documented Resident #108 stated he was afraid for his safety due to his roommate, Resident #107's violent nature, the nurse asked certified nurse aid to remove Resident #107 from the room to ensure Resident #108's safety.Review of a progress note dated 09/25/25 written by the Corporate Nurse #207 who documented the roommate (Resident #107) was moved to a private room related to Resident #108's concerns.Review of a handwritten statement dated 09/25/25 by Social Worker Director (SWD) #245 documented she went to Resident #107's room to ask about this morning. He said, my neck was hurting. I asked again and he said, my neck was hurting, my birthday was in 18 days. Review of a handwritten statement dated 09/26/25 the Social Worker Director (SWD) #245 documented she had talked to Resident #108 about his concerns. Resident #108 stated his roommate was yelling and hitting the aides and he thought if he could do that to them, he could do that to me. He stated, I felt scared. The roommate moved to a different room yesterday and the resident stated he was happy about that. Resident did state he did not do anything to me; he did it to the staff.Interview on 12/16/25 at 2:13 P.M. Licensed Practical Nurse (LPN) #248 said she went to Resident #108's room because he was calling out to her in the hallway. She went into the room and heard Resident #107 yelling shut up, shut up! Ill kick your expletive! LPN #248 said Resident #108 was concerned about his safety. LPN #248 said she separated both residents.Interview on 12/17/25 at 3:55 P.M. LPN #253 said when she took care of Resident #107 at the facility when residents or staff would walk by or was near, Resident #107 when he was angry would swing and hit everyone who was in the way. This included staff and other residents. LPN #253 stated she could not remember the staff or the residents' names at that time. No one was hurt, but Resident #107 did yell and swing at everyone.Interview on 12/23/25 at 11:25 A.M. the Director of Nursing (DON) said Resident #107 had developmental delays and was used to one-on-one because where he came from. The DON said she was out of the facility and had to ask to see if anyone had investigated the incident. Interview on 12/23/25 at 1:32 P.M. the Corporate Nurse #207 said she was notified by Licensed Practical Nurse (LPN) #248 that Resident #107 and Resident #108 had a possible altercation. The Corporate Nurse #207 asked the residents be separated and made safe and would get back to the LPN. The Corporate Nurse #207 said it was during shift change that morning and she had never told the Administrator.Interview on 12/23/25 at 1:47 P.M. the Unit Manager (UM) #215 it was reported to her and she interviewed Resident #108 that day who said he was not comfortable in the room with Resident #107 and he was scared. The UM #215 said the incident was discussed in our team meeting that morning about what happened with Resident #107 and Resident #108. The UM #215 asked Resident #108 what Resident #107 had said to him. The UM #215 stated Resident #108 had said that Resident #107 kept telling him to shut up, shut up! Resident #108 had stated Resident #107 was cursing and yelling at him. Interview on 12/23/25 at 1:59 P.M. the Social Worker Director (SWD) #245 said she had interviewed Resident #108 who stated to her that Resident #107 had yelled and hit staff, and not him. The SWD #245 said she had not documented a progress note of the interview with Resident #108 as she did not think it was important. The SWD #245 said the facility had not interviewed all residents who had a BIMS of 10 and above, because the facility determined there was no risk for abuse towards other residents.Interview on 12/23/25 at 5:37 P.M. the Administrator said he was never notified of any possible verbal abuse between Resident #107 and Resident #108 on 09/25/25. Review of the facility policy titled Residents Rights to Freedom from Abuse, Neglect, Misappropriation of Residents Property dated 2025 revealed the facility policy was to ensure that residents are free from abuse, neglect, misappropriation of their property, and exploitation.This deficiency represents non-compliance investigated under Complaint Number 2641868.

Based on medical record review, review of statements, staff interview, review of the Self-Reported Incidents and policy review, the facility failed to ensure allegations of resident to resident abuse were thoroughly investigated and reported to the State Agency when Resident #107 verbally assaulted one resident and had physical aggression towards another unknown resident. This affected one (#108) out of three residents reviewed for abuse. The facility census was 100. Based on medical record review, review of statements, staff interview, review of the Self-Reported Incidents and policy review, the facility failed to ensure allegations of resident to resident abuse were thoroughly investigated and reported to the State Agency when Resident #107 verbally assaulted one resident and had physical aggression towards another unknown resident. This affected one (#108) out of three residents reviewed for abuse. The facility census was 100. Findings Include:1. Review of the medical record revealed Resident #107 was admitted on [DATE] and discharged on 11/11/25. Diagnoses included Parkinson's disease, epilepsy, and intellectual disabilities.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #107 was severely cognitively impaired. Resident #107 required setup or clean-up assistance for meals. Resident #107 was substantial to maximal assistance for oral care, toileting hygiene, personal hygiene, bathing, and dressing upper body. Resident #107 was dependent for placing shoes on and off feet and dressing his lower body.Review of the plan of care dated 08/25/25 revealed Resident #107 had problematic behaviors characterized by wandering, verbal and or physical abuse, throwing objects at others, calling out making disruptive noises, and rejection of care related to his intellectual disability. Interventions included approaching the resident slowly and from the front, be cognizant of not invading resident's personal space, be sure you have the resident's attention before speaking or touching, do not ask the resident to make decisions or ask what was wrong, focus on feelings rather than cause. Do not make unrealistic demands of resident, document summary of each episode, note cause and successful interventions, include frequency and duration, if aggressive try and remove from recreational program, provide individualized program, if strategies are not working, reapproach resident at a later time, initiate psychiatric consult as needed, involve family, encourage resident to call upon them and other support, medication as ordered, reapproach resident at a later time when care was rejected, remove resident from public area when behavior was disruptive, talk with resident in a low pitch, calm voice to decrease and eliminate undesired behavior, and provide diversional activity. Review of a progress note dated 08/16/25 written by Licensed Practical Nurse (LPN) #248 documented Resident #107 was very combative and throwing items at staff and other residents. Resident #107 was redirected but continued to throw items at the staff and other residents. Review of a progress note dated 08/16/25 written by Registered Nurse (RN) #260 who documented Resident #107 was aggressive towards residents and staff this morning. Resident #107 took medication appropriately and remained agitated and yelling at staff and residents.Review of a progress note dated 08/17/25 written by RN #260 who documented Resident #107 yelled throughout the morning in the common area, became aggressive with staff and residents.Review of a progress note dated 08/17/25 written by LPN #253 who documented Resident #107 was hitting numerous residents and staff. Resident #107 also yelled and threw magazines at staff. Resident #107 was unable to be redirected. Resident #107 was given toy cars and was unable to be redirected. Resident #107 was given numerous items to assist with behavior. None were effective.Review of a progress note dated 08/18/25 written by Unit Manager #215 who documented Resident #107 attempted to hit residents and staff with magazines. Resident #215 was redirected multiple times, was still showing aggression toward others. Staff notified the family, brother started trying and put him to bed. Resident #107 was unable to be redirected.Review of a progress note dated 08/19/25 written by LPN #251 documented while doing the medication pass, continued to redirect Resident #107. Resident #107 was swinging and yelling at all the residents down the hall. Resident #107 came to the front common area with the nurse and continued to yell and raise his hands at staff and residents. When redirected he became very angry and rammed his wheelchair into the back of another resident and when the nurse and multiple aides tried to move Resident #107, he continued to push harder into the other resident. Once separated Resident #107 then took his shirt off and threw it on the ground. He kept picking up the shirt and threw it and kicked it across the floor. The nurse took the shirt to his room. The nurse walked with Resident #107 to his room he kept yelling, he wanted a shirt and he threw the shirt again.Review of a psychiatric note dated 08/22/25 written by Nurse Practitioner #243 who documented Resident #107 was admitted to the facility for respite care which transitioned into long term care. Prior to admission Resident #107 lived at home his entire life. Resident #107 had severe intellectual disability with a mental age of less than two years old. Since 08/14/25 there have been almost daily reports of physical and verbal aggression, including yelling, hitting staff and other residents, and difficulty with redirection. Review of a progress note dated 09/25/25 written by LPN #248 who documented Resident #107 repeatedly struck staff member while he was being changed, the nurse educated Resident #107 on the importance of not hitting staff. Resident #107 continued to hit staff. Resident #107 also verbally assaulted his roommate Resident #108 to the point that the roommate was scared for his own safety in his room.Review of a progress note dated 09/25/25 written by the Unit Manger #215 who documented the Power of Attorney (POA) was made aware of Resident #107's room change and was placed on one-to-one. Resident #107 continued with behaviors toward staff.2.Review of the medical record revealed Resident #108 was admitted on [DATE] and discharged on 11/17/25. Diagnoses included chronic obstructive pulmonary disease, anxiety disorder, and atrial fibrillation.Review of the quarterly MDS dated [DATE] revealed Resident #108 had a Brief Interview of Mental Status (BIMS) of 12 indicating he had moderate cognitive impairment. Resident #108 required set-up or clean-up assistance for meals. Resident #108 was dependent in dressing upper and lower body, toileting hygiene. Resident #108 was substantial to maximal assistance in bathing, personal hygiene, placing shoes on and off feet, and oral hygiene.Review of the plan of care revealed Resident #108 had feelings of sadness, emptiness, anxiety, uneasiness, bodily complaints, characterized by ineffective coping, low self-esteem, tearfulness, motor agitation, weight loss, withdrawal from care, clinical decline affecting dignity. Interventions included conveying acceptance of residents and provide repeated honest appraisals of resident's strengths to residents, encouraging loved ones to keep in contact. Resident #108 had a risk for negative mood or behavior related to major depressive disorder. Interventions included administer medications as ordered, monitor for dose reduction, resident was supported by mental health services, and social service visits as needed to encourage expression of feelings and to provide support and reassurance.Review of a progress note dated 09/25/25 written by LPN #248 who documented Resident #108 stated he was afraid for his safety due to his roommate, Resident #107's violent nature, the nurse asked certified nurse aid to remove Resident #107 from the room to ensure Resident #108's safety.Review of a progress note dated 09/25/25 written by the Corporate Nurse #207 who documented the roommate (Resident #107) was moved to a private room related to Resident #108's concerns.Review of a handwritten statement dated 09/25/25 by Social Worker Director (SWD) #245 documented she went to Resident #107's room to ask about this morning. He said, my neck was hurting. I asked again and he said, my neck was hurting, my birthday was in 18 days. Review of a handwritten statement dated 09/26/25 the Social Worker Director (SWD) #245 documented she had talked to Resident #108 about his concerns. Resident #108 stated his roommate was yelling and hitting the aides and he thought if he could do that to them, he could do that to me. He stated, I felt scared. The roommate moved to a different room yesterday and the resident stated he was happy about that. Resident did state he did not do anything to me; he did it to the staff.Interview on 12/16/25 at 2:13 P.M. Licensed Practical Nurse (LPN) #248 said she went to Resident #108's room because he was calling out to her in the hallway. She went into the room and heard Resident #107 yelling shut up, shut up! Ill kick your expletive! LPN #248 said Resident #108 was concerned about his safety. LPN #248 said she separated both residents.Interview on 12/17/25 at 3:55 P.M. LPN #253 said when she took care of Resident #107 at the facility when residents or staff would walk by or was near, Resident #107 when he was angry would swing and hit everyone who was in the way. This included staff and other residents. LPN #253 stated she could not remember the staff or the residents' names at that time. No one was hurt, but Resident #107 did yell and swing at everyone.Interview on 12/23/25 at 11:25 A.M. the Director of Nursing (DON) said Resident #107 had developmental delays and was used to one-on-one because where he came from. The DON said she was out of the facility and had to ask to see if anyone had investigated the incident. Interview on 12/23/25 at 1:32 P.M. the Corporate Nurse #207 said she was notified by Licensed Practical Nurse (LPN) #248 that Resident #107 and Resident #108 had a possible altercation. The Corporate Nurse #207 asked the residents be separated and made safe and would get back to the LPN. The Corporate Nurse #207 said it was during shift change that morning and she had never told the Administrator.Interview on 12/23/25 at 1:47 P.M. the Unit Manager (UM) #215 it was reported to her and she interviewed Resident #108 that day who said he was not comfortable in the room with Resident #107 and he was scared. The UM #215 said the incident was discussed in our team meeting that morning about what happened with Resident #107 and Resident #108. The UM #215 asked Resident #108 what Resident #107 had said to him. The UM #215 stated Resident #108 had said that Resident #107 kept telling him to shut up, shut up! Resident #108 had stated Resident #107 was cursing and yelling at him. Interview on 12/23/25 at 1:59 P.M. the Social Worker Director (SWD) #245 said she had interviewed Resident #108 who stated to her that Resident #107 had yelled and hit staff, and not him. The SWD #245 said she had not documented a progress note of the interview with Resident #108 as she did not think it was important. The SWD #245 said the facility had not interviewed all residents who had a BIMS of 10 and above, because the facility determined there was no risk for abuse towards other residents.Interview on 12/23/25 at 5:37 P.M. the Administrator said he was never notified of any possible verbal abuse between Resident #107 and Resident #108 on 09/25/25. Review of the Self Reported Incidents dated from 08/01/25 through 12/24/25 revealed no reports were made for the alleged incidents on 08/19/25 and 09/25/25.Review of the facility policy titled Residents Rights to Freedom from Abuse, Neglect, Misappropriation of Residents Property dated 2025 revealed the facility policy was to ensure that residents are free from abuse, neglect, misappropriation of their property, and exploitation. The facility shall review altercations from resident to resident as a potential situation of abuse. Staff will monitor behaviors that may provoke a reaction by residents including verbal aggressive behavior such as cursing and screaming and physically aggressive behavior including hitting, kicking, throwing objects, and threatening gestures.This deficiency represents non-compliance investigated under Complaint Number 2641868.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure fall interventions were in place for a resident who was at high risk for falls. This affected one (#92) out of three residents reviewed for falls. The facility census was 100. Findings Included:Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure fall interventions were in place for a resident who was at high risk for falls. This affected one (#92) out of three residents reviewed for falls. The facility census was 100.Findings Included:Review of the medical record revealed Resident #92 admitted to the facility on [DATE]. Diagnoses included palliative care, Parkinson's disease, chronic obstructive pulmonary disease, and dementia.Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #92 had an unfinished Brief Interview of Mental Status (BIMS) indicating severe cognitive impairment. Resident #92 required setup and clean-up for meals. Resident #92 was dependent for personal hygiene, placing on and off shoes, bathing, dressing lower body, and toileting hygiene. Resident #92 was substantial maximal assistance for oral hygiene and dressing upper body. Review of the plan of care dated 11/03/25 revealed Resident #92 had a potential for falls related to impulsivity or poor safety awareness. Interventions included assist the resident on and off the toilet, do not leave resident unattended in the bathroom, do not leave unattended in the dining room, a dycem mat in the wheelchair, evaluate medication regimen, fall matt to the left side of the bed, get resident up into wheelchair when restless, keep bed in lowest position, keep call bell within reach, encourage to use call bell, keep environment clutter free, keep room well lighted, make sure wearing proper footwear, and use a gait belt with transfer.Review of the Morse Fall Scale assessment dated [DATE] revealed Resident #92 was a fall risk with a high risk for falling score of 65.0. Resident #92 had fallen before, had more than one diagnoses in chart, had no ambulatory aids, had no intravenous apparatus, was weak, overestimates or forgets limits when alone. The Morse fall scoring was: low risk was 0-24, moderate risk was 25-44, and high risk was a score of 45 and higher.Review of the fall and incident log dated 07/01/25 to current revealed Resident #92 had falls on 07/10/25, 07/11/25, and 07/29/25. Observation on 12/23/25 at 9:30 A.M. Resident #92 had no call light, it was wrapped under the bed wheel. Interview on 12/23/25 at 9:30 A.M. with Certified Nursing Assistant (CNA) #225 verified Resident #92 had no call light in reach and the call light was under the bed wheel. Observation on 12/23/25 at 10:45 A.M. Resident #92 was in her bed that was in the high position. Resident #92's fall mat was located on the right side of the bed. No staff were observed in the room.Interview on 12/23/25 at 11:03 A.M. CNA #220 verified when entering the room Resident #92's bed was in the high position with no staff present in the room. CNA #220 verified that the fall mat was on the right side of her bed.Review of the facility policy titled Accidents and Incidents-Investigation and Reporting dated July 2017 revealed all accidents or incidents involving residents, employees, visitors, vendors, occurring on our property shall be investigated and reported to the administrator. This deficiency represents non-compliance investigated under Complaint Number 2620622 and 2566128.

Based on medical record reviews, observations and staff interviews, the facility failed to ensure the medication error rate did not exceed five percent (%). Three errors occurred within 27 opportunities for an error rate of 11.11%. This affected two (#20 and #21) of two residents reviewed for medication administration. The facility census was 108.Findings include:1. Review of the medical record for Resident #20 revealed an admission date of 11/13/25. Diagnoses included chronic kidney disease and atrial fibrillation. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 had intact cognition. Review of the physician's orders dated 11/14/25 revealed an order for oxybutynin (treats overactive bladder) 10 milligrams (mg) extended release. Give one tablet daily until 11/17/25.Observation on11/18/25 at 8:56 A.M. of medication administration revealed Licensed Practical Nurse (LPN) #100 was administering medications to Resident #20. LPN #100 administered oxybutynin chloride extended release (overactive bladder) 10 milligrams (mg) to Resident #20.Interview on 11/18/25 at 11:42 A.M. with LPN #100 verified the Oxybutynin order was no longer active. 2. Review of the medical record for Resident #21 revealed an admission date of 03/05/25. Diagnoses included stroke, autistic disorder and peripheral vascular disorder. Review of the physician orders dated 11/02/25 revealed an order for Vitamin B6 (vitamin) one tablet by mouth daily and there was no documented dosage. A second order was for Tylenol 1,000 milligrams (mg) by mouth every six hours as needed for pain.Observation on 11/18/25 at 9:27 A.M. of medication administration revealed Licensed Practical Nurse (LPN) #101 administered medications to Resident #21. LPN #101 administered Vitamin B6 100 mg and one Tylenol 325 mg tablet to Resident #21.Interview on 11/18/25 at 11:28 A.M. with LPN #101 verified there was no dosage prescribed for the Vitamin B6 supplement and acknowledged the physician should be called to clarify the order. LPN #101 also verified she had administered one 325 mg Tylenol table when the order was for 1,000 mg.This deficiency represents non-compliance investigated under Complaint Number 2666022.

3. Review of medical record for Resident #32 revealed admission date of 11/12/24 with vascular dementia, chronic obstructive pulmonary disease, hypertension, diabetes mellitus. Review of the quarterly MDS dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. MDS revealed Resident #32 was dependent on staff for toileting, showering, dressing, and personal hygiene. Review of the care plan dated 11/13/24, revised 02/25/25, revealed Resident #32 had a potential for falls related to impaired cognition and weakness, interventions included evaluate medication regimen, fall risk assessment per protocol, hospice to supply Bariatric shower chair, keep environment clutter free, keep room well lighted, nonskid footwear at all times, perimeter mattress, and place resident on get up list. Observation on 05/13/25 at 8:49 A.M. of Resident #32 in her room identified she was sitting on the edge of her bed eating breakfast. Resident #32 did not have a perimeter mattress. Interview with CNA #208 confirmed Resident #32 ate breakfast on the side of her bed, had not been out of bed for the day, and did not have her morning cares completed. Observation on 05/15/25 at 10:25 A.M. of Resident #32's bed revealed a bariatric mattress on the bed, no perimeter mattress was observed on the bed or in the room. Interview on 05/15/25 at 10:29 A.M. with CNA #223 confirmed Resident #32's bed had a bariatric mattress and she has had it for a few months. 2. Review of the medical record for Resident #57 revealed an admission date of 04/19/22. Diagnoses included unspecified dementia, heart disease, spinal stenosis, muscle weakness and unspecified psychosis. Review of the plan of care dated 05/09/22 revealed resident was at risk of falls due to decreased mobility with interventions to keep bed in lowest position and two mattresses to right side of the bed. Review progress notes dated 01/09/25 and 04/29/25 revealed resident had a fall from the bed. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was cognitively impaired with a BIMS of 00 and was rarely if ever understood. Observation on 05/13/25 at 8:52 A.M. Resident #57 was calling out saying, I want to get up, help, and I need the toilet. It was observed that Resident #57's bed was in high position and both fall mats were leaning up against residents recliner several feet from residents bed tilted up on their side. No staff were observed to be monitoring resident and no staff were present at bedside. Continuous observation on 05/13/25 from 8:52 A.M. to 9:21 A.M. with Resident #57 revealed no staff were present and floor mats remained against the recliner. Interview on 05/13/25 at 9:21 A.M. with Licensed Practical Nurse (LPN) #161 confirmed Resident #57's floor mats were not against the bed as per the care plan. Observation and interview on 05/14/25 at 5:15 P.M. with Registered Nurse (RN) #186 revealed the floor mats should be down at all times unless staff are with Resident #57 providing care such as assisting with feeding her. RN #186 also acknowledged staff were disgruntled regarding the double floor mat and were upset about it being in place as they cannot move it easily. RN #186 acknowledged the floor mats were not in place at the time of the observation and meals had not yet been passed out. RN #186 also verified the bed was not in low or lowest position as per the care plan. 4. Review of the medical record of Resident #75 revealed an admission date of 05/02/24. Diagnoses included cerebral atherosclerosis, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, atrial fibrillation, type 2 diabetes mellitus, anxiety, insomnia, major depressive disorder, and dementia. Review of the plan of care dated 05/12/25 revealed Resident #75 had a potential for falls and frequently attempted to transfer herself in and out of bed. Interventions included an air mattress with bolsters, dycem to broda chair, educate dietary staff not to move residents out of the dining room, recline broda chair after finished eating meals, encourage resident to lay down after meals, fall mats times two to the right side of the bed, increase rounding, left side of mattress against the wall, encourage to be in common area when up. Review of the quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognition. Resident #75 was dependent on staff for all activities of daily living. Review of the Morse Fall Scale dated 04/28/25 revealed the resident was at high risk for falling. Further review of all Morse Fall Scale assessments dated 08/20/24 through 04/28/25 revealed the resident was at high risk for falls. Review of the fall investigation dated 08/19/24 revealed the resident sustained an unwitnessed fall at 12:27 P.M. The resident was found laying on the floor next to the bed. The bed was in low position and there were fall mats noted on the floor. The resident was asked if she hit her head and the resident said she did not. The resident was noted with a dark purple bruise to the right forehead. The resident denied pain. The resident was believed to have been attempting to transfer herself. The intervention was to provide a perimeter mattress. The fall investigation was silent for neurochecks being initiated. Review of the fall investigation dated 10/20/24 revealed the resident sustained an unwitnessed fall at 1:00 A.M. The resident was found sitting on her fall mat next to the bed. The bed was in low position. The resident was not able to say how she rolled onto the mat. The resident denied pain. No injuries were noted. The resident was believed to be attempted to transfer herself. The fall investigation did not address whether the perimeter mattress was in place at the time of the fall. The intervention was to provide a perimeter mattress. The fall investigation was silent for neurochecks being initiated. Review of the fall investigation dated 11/01/24 revealed the resident sustained an unwitnessed fall at 12:42 P.M. The resident was found on the floor on the fall mat next to the bed. The bed was in low position. The resident denied hitting her head. The resident did not have any injuries. Neurochecks were noted to be initiated. The investigation did not indicate if the perimeter mattress was in place at the time of the fall. There were no interventions noted to be put into place following the fall. Review of the fall investigation dated 12/06/24 revealed the resident sustained an unwitnessed fall at 1:30 P.M. Resident #75's chair was noted tiled over The resident appeared to have tried to climb out of her geri chair and fell to the floor. The resident complained of pain to her right shoulder and the area was bruised and swollen. Neurochecks were initiated. Review of the fall investigation dated 01/05/25 revealed the resident sustained an unwitnessed fall at 12:00 P.M. The resident was found on the floor on the fall mat next to the bed. The bed was in low position. The resident was believed to have slid out of bed. Neurochecks were initiated. The investigation did not indicate if the perimeter mattress was in place at the time of the fall. Review of a progress note dated 01/05/25 at 1:00 P.M. revealed the hospice nurse visited the resident and received a new order from the hospice physician for haldol 1 milligram every four hours as needed for terminal agitation. Review of the fall follow-up note dated 01/07/25 revealed an intervention of hospice evaluation of medications Review of the fall investigation dated 01/28/25 revealed the resident sustained an unwitnessed fall at 10:15 A.M. The resident was found on the floor in front of her broda chair, which was noted in an upright position. The broda chair was sitting straight up because the resident had been eating breakfast and the resident slid from the broda chair. The resident complained of pain to the right knee and coccyx. Tylenol was administered with positive outcome. The nurse practitioner examined the resident and stated, if pain continued, to send for an x-ray. The investigation did not indicate if the dycem was in place at the time of the fall. The fall investigation was silent for neurochecks being initiated. The intervention was to educate staff to recline broda chair after meals. Review of the fall investigation dated 02/04/25 revealed the resident sustained an unwitnessed fall at 3:15 P.M. The resident as found on the floor at her bedside with her back against the bed. The resident was noted to be looking for her husband who had passed away years ago. The resident was believed to have been trying to get out of bed and slid to the floor onto the mat. Fall mats were noted in place and the bed was in low position. The resident did not have any injuries. Neurochecks were initiated. The intervention was for hospice to evaluate for possible medication changes for anxiety. The investigation did not indicate if the perimeter mattress was in place at the time of the fall. Review of physician orders revealed an order dated 02/08/25 for lorazepam (anti-anxiety medication 0.5 milligrams every 4 hours was ordered as needed. Review of the fall investigation dated 02/15/25 revealed the resident sustained an unwitnessed fall at 3:25 P.M. The resident was found on the floor, laying on her left side, between the bed and the window. The bed was in low position and fall mats were in place. The resident denied hitting her head and did not have any injuries. The resident had last been seen 25 minutes prior. The resident was unable to answer what she was doing at the time of the fall and believed to have rolled out of bed. The investigation did not indicate if the perimeter mattress was in place at the time of the fall. The fall investigation was silent for neurochecks being initiated following the fall. The intervention was to increase rounding. Review of progress notes dated 02/15/25 at 5:50 P.M. and 5:55 P.M. revealed a loud crash was heard in the common area and the resident was found lying on the floor on her left side. The resident had a protruding hematoma measuring 4 centimeters (cm) in length by 3 cm in width by 2 cm in depth. Review of the fall investigation dated 02/15/25 revealed the resident sustained an unwitnessed fall in the common area at 5:50 P.M. The resident was laying on her left side on the floor in front of her broda chair. The resident had last been seen five minutes prior in the dining room for dinner. The resident had a large skin tear noted to her left elbow/forearm and a large, raised bruised area to her left temple. The resident complained of right shoulder pain and was guarding her right arm. The resident was sent to the hospital for evaluation. The intervention was to educate dietary staff to not move the resident from the dining room. The investigation did not indicate if the dycem was in place at the time of the fall. Interview on 05/15/25 at 11:51 A.M. RN #185 stated she was walking toward Resident #75 while she was sitting in the common area and saw her trying to get out of the chair and saw her tip forward and the entire chair tipped forward. RN #185 stated the chair was positioned at a 45 degree angle. RN #185 stated she observed the resident hit her head and one of her arms. RN #185 stated the Resident #75 had a dycem in the wheelchair and the wheelchair was locked. Review of the fall investigation dated 03/10/25 revealed the resident sustained an unwitnessed fall at 4:53 P.M. The resident was found sitting at her bedside on the floor mat. The resident was last seen at 4:30 P.M. The bed was noted in low position. The resident did not have any injuries. The intervention was to place the left side of the bed against the wall. The investigation did not indicate if the perimeter mattress was in place at the time of the fall. The fall investigation was silent for neurochecks being initiated following the fall. Review of the medical record revealed neurochecks were completed for the fall on 12/06/24. There was no evidence of neurochecks being completed at any other time. Interview on 05/15/25 at 1:45 P.M., the Director of Nursing (DON) verified its facility policy to complete neurochecks post fall if the fall is unwitnessed. The DON stated the documentation indicated neurochecks were initiated following most of Resident #75's falls and that sometimes neurochecks are done on paper. The DON confirmed she was not able to locate any neurochecks following Resident #75's falls other than the neurochecks dated 12/06/24. The DON further verified fall investigations did not address whether the perimeter mattress and dycem was in place as appropriate. The DON stated she was not sure if the perimeter mattress was in place at the time of the fall on 10/20/24, however since a perimeter mattress was ordered again, she felt it may not have been in place. The DON verified the fall investigations were not thorough as they did not contain information regarding what interventions were in place at the time of Resident #75's falls. Review of the facility policy titled, Neurological Assessment, dated 10/2010, revealed neurological assessments are indicated following an unwitnessed fall and following a fall involving head trauma. Review of the facility policy titled, Assessing Falls and Their Causes, dated 03/2018, revealed, when a resident falls information should be included in the medical record, including the condition in which the resident was found and interventions. Review of the facility policy titled, Managing Falls and Fall Risk, dated 07/08/24 revealed resident-specific interventions should be documented and placed in the care plan. This deficiency represents non-compliance investigated under Complaint Number OH00164621. Based on medical record review, review of facility investigation, staff interviews, and review of facility policy, the facility failed to ensure staff safely transferred a resident in accordance with the care plan. This resulted in Actual Harm when Certified Nurse Aide (CNA) #250 transferred Resident #149 from the bed to wheelchair on 04/10/25 without a mechanical lift (Hoyer) as care planned and the resident subsequently sustained a fall resulting in bilateral femur fractures. Additionally, the facility failed to ensure fall interventions were in place in accordance with Resident #57 and #32's care plan, failed to ensure Resident #75's falls were thoroughly investigated and failed to implement neurological checks (neurochecks) in accordance with facility policy following Resident #75's falls, which placed the resident's at risk for more than minimal harm. This affected four (#149, #32, #57, and #75) of seven residents reviewed for accidents. The facility census was 104. Findings include: 1. Review of Resident #149's closed medical record revealed an admission date of 12/01/15. Diagnoses listed included hypertension, arthritis, hypothyroidism, dementia, psychotic mood disturbance, and chronic kidney disease. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #149 was totally dependent on staff for transfers, was receiving Hospice services, and was severely cognitively impaired. Review of care plan initiated 12/31/24 revealed Resident #149 was at risk for falls related to weakness, pain, decreased endurance, impaired judgement, and cognitive impairment. Resident #149 had a self-care deficit related to altered cognitive status, altered mobility, pain, weakness, and sensory deficit. Resident #149 required staff assistance with activities of daily living (ADL's) and required two staff members for transfers with a Hoyer. Review of progress notes dated 04/10/25 at 11:30 A.M. revealed Resident #149 was on the floor on her knees. CNA #250 stated she was trying to stand and pivot Resident #149 into the wheelchair. Resident #149 was non-ambulatory and was non-weight bearing. Resident #149 was returned to bed for an assessment and complained of pain in knees and legs. Both of Resident #149's feet were feet were edematous with purple areas. New orders were obtained for stat (as soon as possible) X-radiation (X-ray) of both hips and legs. Review of X-ray results dated 04/10/25 revealed acute fractures of Resident #149's left and right femur. Further review of Resident #149's medical record revealed the resident's bilateral femur fractures were not aggressively treated due to the resident's condition and the resident being on Hospice care. Review of a Fall Investigation revealed Resident #149 obtained fractures to the left and right femur when lowered to the ground by agency CNA #250. When told to get Resident #149's roommate out of bed agency CNA #250 instead attempted to get Resident #149 out of bed and dropped her to her knees. Resident #149 obtained left and right thigh fractures. Interview with the Director of Nursing (DON) on 05/14/25 at 2:33 P.M. confirmed Resident #149 was improperly transferred by Agency CNA #250 on 04/10/25. The DON confirmed Resident #149 was non-weight bearing and fell during transfer by CNA #250. CNA #250 made a mistake and was supposed to get up Resident #149's roommate. The DON confirmed Resident #149 fractured both femurs as a result of the fall. Interview with the DON on 05/15/25 at 10:04 A.M. confirmed CNA #149 did not use a Hoyer or assistance of another staff member when attempting to transfer Resident #149 on 04/10/25. Review of the facility's policy titled, Safe Lifting and Movement of Residents dated July 2017 revealed in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary.

Based on observation, staff review, and policy review, the facility failed to ensure an implement their water management policy to prevent the presence of microorganisms in their water system including legionella. This had the potential to affect all 104 residents residing in the facility. Additionally, the facility failed to ensure staff handled food in an appropriate manner while assisting a resident with a meal. This affected one (#25) out of three residents reviewed for infection control. The facility census was 104. Findings include: Review of the facility's Chlorine Check off Sheet for TCU (transitional care unit) for 01/12/24 through 04/17/25 revealed water flow rate had not been tested since 10/31/24 and hot water temperatures ranged 106-117 degrees Fahrenheit. Review of the facility's Chlorine Check off Sheet for the Care Center for 01/12/24 through 05/15/25 revealed water flow rate had not been tested since 10/31/24 and hot water temperatures ranged 102-120 degrees Fahrenheit. Review of the facility's Chlorine Check off Sheet for the basement for 01/04/24 through 03/31/25 revealed the water flow rate had not been tested since 09/30/24 and hot water temperatures ranged 112-120 degrees Fahrenheit. Interview on 05/15/25 at 12:35 P.M., Maintenance Director (MD) #153 verified the water flow rate had not been checked since 09/30/24 in the basement and 10/31/24 in TCU and the Care Center. MD #152 stated water flow rate should be checked quarterly per the facility policy. MD #153 verified none of the temperatures contained in all three of the Chlorine Check off Sheets were above 122 degrees Fahrenheit. MD #153 stated the water temperatures in resident areas was not to exceed 120 degrees Fahrenheit and was not sure how she could achieve a temperature greater than 122 degrees Fahrenheit. MD #153 verified the facility policy indicated water temperatures needed to be greater than 122 degrees Fahrenheit to prevent the growth of legionella. Review of the facility policy titled, Environmental Control Measures Guidelines, dated 08/03/21, revealed water flow rate should be checked at least quarterly at the change of seasons. Further review revealed water temperatures in the range of 68-122 degrees Fahrenheit encouraged the growth of legionella and other pathogens. 2. Observation on 05/14/25 at 12:37 P.M., revealed Resident #25 was served a hamburger on a bun, cut in half prior to the tray being delivered, mashed potatoes, broccoli, pudding, and watermelon. Observation on 05/14/25 at 12:39 P.M. Certified Nursing Assistant (CNA) #252 removed the bun from the hamburger per Resident #25's request, and picked up the hamburger patty with her bare hand and handed the hamburger patty to the resident. Interview on 05/14/25 at 12:54 P.M., CNA #252 verified she handled the hamburger patty with her bare hand when handing it to Resident #25.

Based on observations, resident and staff interviews and policy review, the facility failed have an effective pest control program. This affected six (#9, #29, #30, #55, #60, and #81) out of six residents reviewed for effective pest control. The facility census was 104. Findings include: Interview on 05/13/25 at 7:37 A.M. revealed Resident #29 has had ants in the room. Ants had been on eyeglasses and on the bed. Resident #29 reported telling staff about the ant concern. Resident #29 had called the Administrator and left a massage about ants. Observation of Resident #29's room during the interview on 05/13/25 at 7:37 A.M. revealed ants on the floor and on the bedside table. Interview with Certified Nurse Aide (CNA) #241 confirmed she had seen ants in Resident #29's room. During an interview on 05/13/25 at 7:50 A.M. the Administrator confirmed ants in Resident #29's room. The Administrator denied receiving a call from Resident #29. A local pest control company will be called to control the ants. Observation of Resident #9's room on 05/13/25 at 7:51 A.M. revealed ants crawling on the floor by an exterior wall. Observation of Resident #30's room on 05/13/25 at 7:58 A.M. revealed ants crawling on the floor by an exterior wall. Observation and interview with Maintenance Director #153 on 05/13/25 at 8:02 A.M. confirmed ants in Resident #9 and #30's rooms. Ants had been a concern due to recent wet weather. Interview with Resident #60 on 05/13/25 at 8:04 A.M. revealed ants have ben terrible. Resident #55 had been present for about two weeks. Resident #60 has had ants in his facial tissue box and on his wheelchair. Observation at the time of interview on 05/13/25 at 8:04 A.M. revealed ants on Resident #60's bedside table and multiple ant traps in the room on the floor and a window seal. Observation of Resident #81's room on 05/13/25 at 8:23 A.M. revealed ants crawling on the floor. Observation of Resident #55's room on 05/13/25 at 08:26 A.M. revealed ants crawling underneath the bed and on the bedside table. Review of the facility's policy titled, Pest Control dated revised may 2008 revealed the facility shall maintain an effective pest control program. The facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on record review, observations, staff and resident interviews and policy review, facility failed to ensure a resident was afforded dignity during a meal when staff did not stand while providing feeding assistance. This affected one (#25) of three residents reviewed for dignity. Facility census was 104. Findings include: Review of the medical record of Resident #25 revealed an admission date of 04/20/22. Diagnoses included parkinsonism and moderate protein-calorie malnutrition. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident #25 had intact cognition. Resident #25 was dependent on staff for all activities of daily living. Observation on 05/14/25 at 12:38 P.M. revealed Certified Nursing Assistant (CNA) #252 delivered a lunch tray to Resident #25, who was resting in bed. CNA #252 set up Resident #25's tray and began to feed her, while standing over her. Observation on 05/14/25 at 12:39 P.M., Resident #25 asked CNA #252 if she was going to sit down. CNA #252 was not observed to respond or acknowledge Resident #25's question and continued to feed Resident #25 while standing. Further observation at the same time revealed there was a chair located behind CNA #252, approximately six feet away. Continued observation on 05/14/25 between 12:40 P.M. and 12:53 P.M. revealed CNA #252 continued to stand over Resident #25 to feed her. Interview on 05/14/25 at 12:54 P.M., CNA #252 verified she stood over Resident #25 during the entire time she fed her lunch. Interview on 05/14/25 at 1:00 P.M., Resident #25 verified she asked CNA #252 to sit down while she was feeding her. Review of the facility policy titled, Resident Rights Policy and Procedure, dated 2025, revealed all staff and associates must treat residents with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.

Based on medical record review, staff interview, and policy review, the facility failed to notify resident responsible party/power of attorney (POA) of significant weight loss. This affected one (#37) of three residents reviewed for weight loss. The facility census was 104. Findings include: Review of the medical record of Resident #37 revealed an admission date of 09/18/20. The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]. Diagnoses included aspiration pneumonia, chronic obstructive pulmonary disease, prostate cancer, type 2 diabetes mellitus, moderate protein-calorie malnutrition, and dementia with behavioral disturbance. Review of the 5-day Medicare Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition. The resident required set-up/clean-up assistance for eating, substantial/maximal assistance with bed mobility, and was dependent on staff for toileting, bathing, dressing, and transfers. Review of weights revealed, on 10/08/24, Resident #37 weighed 146.4 pounds. On 11/06/24, Resident #37 weighed 144.1 pounds. On 01/06/25, Resident #37 weighed 145.4 pounds. On 03/17/25, Resident #37 weighed 146.2 pounds. On 04/07/25, Resident #37 weighed 129.8 pounds. On 04/19/25, Resident #37 weighed 109 pounds. On 05/05/25, Resident #37 weighed 118 pounds. Review of the medical record revealed Resident #37's son was listed as Resident #37's medical POA. Review of the medical record revealed no evidence of the resident's medical POA being notified of Resident #37's weight changes on 04/07/25 (10.9% loss within 1 month), 04/19/25 (25% loss for 1 month), and 05/05/25 (9.2% loss for 1 month, 18% loss for 6 months). Interview on 05/14/25 at 2:49 P.M., Registered Dietitian (RD) #116 verified he had not notified Resident #37's POA of Resident #37's weight changes. RD #116 stated he last spoke with Resident #37's POA during the care conference on 03/28/25 and further verified the resident had not experienced a documented weight change at that time. Review of the facility policy titled, Weight Assessment and Intervention, dated 08/2022, revealed the POA would be notified of any change of 5% or more from the last weight. Severe weight loss was defined as greater than 5% for 1 month and 10% for 6 months.

Based on record review, staff interview and policy review, the facility failed to ensure a resident was free from unnecessary medications by ensuring as needed psychotropic medications were limited to 14 days. This affected one (#61) of five reviewed for unnecessary medications. Facility census was 104. Findings include Review of the medical record for Resident #61 revealed an admission date of 11/01/23. Diagnoses included cerebrovascular disease, hemiplegia and hemiparesis, malnutrition, vascular dementia and unspecified psychosis. Review of the plan of care dated 03/19/24 revealed resident had a history of becoming aggressive and resisting care with interventions to administer medications as ordered and monitor behaviors. The care plan revealed resident used psychotropic medications related to anxiety and depression with interventions to give medications as ordered and monitor for side effects. The care plan also stated residents used antipsychotic's with interventions to consult with pharmacy, give medications as ordered and monitor symptoms. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 was cognitively impaired with a Brief Interview for Mental Status (BIMS) of three out of 15. Review of Resident #61's physician order for 04/25/25 for Ativan oral tablet 0.5 milligrams (MG) with instructions to give one tablet by mouth every four hours as needed for anxiety/dyspnea. Interview on 05/15/25 at 2:00 P.M. with Director of Nursing (DON) confirmed Resident #61 had an order for Ativan PRN from 04/25/25. The DON confirmed the order should have had a stop date and should not been ordered for over 14 days. Review of facility policy titled Medication Management - Psychotropic dated 03/24/25, revealed GDR ' s shall be completed unless contraindicated and psychotropic medications ordered in PRN (as needed) status are limited to 14 days.

Based on observations, staff interviews and record review, facility failed to ensure the activity careplan had appropriate and resident centered interventions. This affected one Resident (#49) of one reviewed for activities. Facility census was 104. Findings include Review of the medical record for Resident #49 revealed an admission date of 07/03/18. Diagnoses included senile degeneration of the brain, unspecified psychosis, anxiety, and spinal stenosis. Review of the activity assessment dated [DATE] revealed resident was alert and oriented with come confusion. Resident reported she was religious (Catholic) and enjoyed baking/cooking, country music, and television, movies and dogs. Review of the plan of care dated 03/03/23 revealed Resident #49 was at risk for alteration in activities with interventions for one on one activities. Review of the activity assessment dated [DATE] revealed resident had unchanged preferences and the preferences were for one to one activity participation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was cognitively impaired with a BIMS of 00 and was rarely if ever understood. Review of the activity participation revealed resident was only offered three one on one visits in 04/2025 and only two visits in 05/2025 with no visits in the previous 10 days. Review of the calendar dated 04/2025 revealed activities ended at 1:30 P.M. for the day except four days that ended at 2:00 P.M. Review of the calendar dated 05/2025 revealed activities ended at 3:00 P.M. with no evening activities planned. Observations on 05/12/25 at 9:20 A.M. and 4:50 P.M. revealed Resident #49 was sitting in her room without any lights on, no television or music was playing and resident was laying in bed staring up at the ceiling. Resident had not been out of bed or to any activities this date. Observations on 05/13/25 from 10:00 A.M. and 3:00 P.M. revealed Resident #49 was sitting in her room without any lights on, no television or music was playing. Resident had not been out of bed or to any activities this date. Staff did not invite or encourage activity attendance prior to any activities this date. Interviews on 05/15/25 at 11:55 A.M. with Activity Coordinator #100 and Activity Aide #101 confirmed the activity care plans were not updated to reflect interests and did not include activity options for a resident with cognitive impairment and decline in health. Review of facility policy titled Activity Evaluation, dated 06/2018 revealed the activity careplan shall include resident needs and allow resident to participate in activities of their interest.

Based on record review, observations, staff interviews and policy review, the facility failed to ensure facility offered a resident activities of interest. This affected one (#49) of one resident reviewed for activities. The facility census was 104. Findings include Review of the medical record for Resident #49 revealed an admission date of 07/03/18. Diagnoses included senile degeneration of the brain, unspecified psychosis, anxiety, and spinal stenosis. Review of the activity assessment dated [DATE] revealed resident was alert and oriented with come confusion. Resident reported she was religious (Catholic) and enjoyed baking/cooking, country music, and television, movies and dogs. Review of the plan of care dated 03/03/23 revealed Resident #49 was at risk for alteration in activities with interventions for one on one activities. Review of the activity assessment dated [DATE] revealed resident had unchanged preferences and the preferences were for one to one activity participation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was cognitively impaired with a BIMS of 00 and was rarely if ever understood. Review of the activity participation revealed resident was only offered three one on one visits in 04/2025 and only two visits in 05/2025 with no visits in the previous 10 days. Review of the calendar dated 04/2025 revealed activities ended at 1:30 P.M. for the day except four days that ended at 2:00 P.M. Review of the calendar dated 05/2025 revealed activities ended at 3:00 P.M. with no evening activities planned. Observations on 05/12/25 at 9:20 A.M. and 4:50 P.M. revealed Resident #49 was sitting in her room without any lights on, no television or music was playing and resident was laying in bed staring up at the ceiling. Resident had not been out of bed or to any activities this date. Observations on 05/13/25 from 10:00 A.M. and 3:00 P.M. revealed Resident #49 was sitting in her room without any lights on, no television or music was playing. Resident had not been out of bed or to any activities this date. Staff did not invite or encourage activity attendance prior to any activities this date. Interviews on 05/15/25 at 11:55 A.M. with Activity Coordinator #100 and Activity Aide #101 revealed facility shall complete activity assessments upon admission, quarterly and annually that would include residents abilities and interests. Activity Aide #101 confirmed staff will be assigned a group of residents for one on one visits and residents should be seen at least weekly four about 10 to 20 minutes. They confirmed Resident #49 only had three visits in 04/2025 and two 05/2025 with no visits in the previous 10 days. They confirmed Resident #49's previous activity assessments when resident was more alert and confirmed facility could have a television or music playing for Resident #49. Review of facility policy titled Activity Evaluation, dated 06/2018 revealed the activity evaluation shall be conducted to reflect interest of the residents. Resident ' s lifelong interests, spirituality, needs and preferences were to be included in the evaluation. The activity care plan shall include resident needs and allow resident to participate in activities of their interest.

2. Review of medical record for Resident # 58 revealed admission date of 02/19/2024 with end stage renal disease, diabetes mellitus type 2, dependence on renal dialysis, heart failure, and chronic obstructive pulmonary disease. Review of the quarterly MDS dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. Review of the care plan dated 03/27/25 revealed Resident #58 had renal insufficiency related to end stage chronic kidney disease stage 3 (CKD-3). Interventions included monitoring, documenting, and reporting to physician as needed the following signs and symptoms. Edema, weight gain of over two pounds a day, neck vein distension, difficulty breathing (dyspnea), increased heart rate (tachycardia), elevated blood pressure (hypertension), skin temperature, peripheral pulses, level of consciousness, monitor breath sounds for crackles. Review of the physician's orders revealed an order for daily weights one time a day for congestive heart failure (CHF) starting 02/27/24. Record review of the February, March, April, and May Medication Administration Record (MAR) revealed daily weights were scheduled for 5:00 A.M. Further review of the MAR for February, March, April, and May revealed weights were not obtained as ordered on 02/01/25, 02/05/25, 02/07/25, 02/12/25, 02/21/25, 02/22/25, 02/28/25, 03/01/25, 03/04/25, 03/05/25, 03/09/25, 03/10/25, 03/11/25, 03/15/25, 03/16/25, 03/17/25, 03/19/25, 03/24/25, 03/26/25, 03/31/25, 04/07/25, 04/09/25, 04/12/25, 04/13/25, 04/14/25, 04/20/25, 04/26/25, 04/28/25, 04/30/25, 05/03/25, and 05/04/25. Interview on 05/15/25 at 2:20 P.M. with the Director of Nursing verified daily weights were not obtained as ordered on 02/01/25, 02/05/25, 02/07/25, 02/12/25, 02/21/25, 02/22/25, 02/28/25, 03/01/25, 03/04/25, 03/05/25, 03/09/25, 03/10/25, 03/11/25, 03/15/25, 03/16/25, 03/17/25, 03/19/25, 03/24/25, 03/26/25, 03/31/25, 04/07/25, 04/09/25, 04/12/25, 04/13/25, 04/14/25, 04/20/25, 04/26/25, 04/28/25, 04/30/25, 05/03/25, and 05/04/25. Review of the facility policy titled Weight Assessment and Intervention dated 08/2022 revealed residents are weighed upon admission and at intervals established by the interdisciplinary team and weights are recorded in the individual's medical record. Based on medical record review, resident and staff interviews, and policy review, the facility failed to ensure weights were obtained in accordance with physician orders or the facility policy. This affected two (#25 and #58) of five residents reviewed for nutrition. The facility census was 104. Findings include: 1. Review of the medical record of Resident #25 revealed an admission date of 04/20/22. Diagnoses included parkinsonism and moderate protein-calorie malnutrition. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was dependent on staff for all activities of daily living. Review of the medical record revealed, on 11/07/24, Resident #25 weighed 128.2 pounds. On 12/07/25, Resident #25 weighed 128.3 pounds. On 01/07/25, Resident #25 weighed 135.6 pounds. On 03/07/25, Resident #25 weighed 135.7 pounds. On 04/07/25, Resident #25 weighed 130.6 pounds. On 05/05/25, Resident #25 weighed 116 pounds. There were no additional weights recorded after 05/05/25. Review of the medical record revealed no evidence of the dietitian acknowledging Resident #25's weight change. Interview on 05/12/25 at 9:50 A.M., Resident #25 stated the last time she had been weighed, the scale was beeping and she was told she had lost weight. Resident #25 stated she wanted to be reweighed, however she had not yet been weighed again. Interview on 05/14/25 at 11:03 A.M., Resident #25 stated she had not been reweighed since being weighed on 05/05/25 and nobody had offered to weigh her. Interview on 05/14/25 at 2:55 P.M., Registered Dietitian (RD) #116 stated he was aware of the 14 pound weight change (11.4% loss) between 04/07/25 and 05/05/25 and had requested for the resident to be reweighed during the prior week, however it had not yet been completed. RD #116 stated his expectation is for a reweight to be completed within 48 hours of his request and verified the reweight had not been completed in a timely manner. Review of the facility policy titled, Weight Assessment and Intervention, dated 08/2022, revealed any weight change of 5% or more since the last weight assessment should be evaluated the the dietitian. The dietitian will notify the nursing staff to obtain a reweight for confirmation.

Based on record review, staff and resident interviews, and policy review, the facility failed to ensure medications were administered as physician ordered. This affected two (#91 and #58) of 12 residents reviewed for medication administration. The facility census was 104. Findings include: 1. Review of medical record for Resident # 58 revealed admission date of 02/19/2024 with end stage renal disease, diabetes mellitus type 2, dependence on renal dialysis, heart failure, and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. Review of the physician orders revealed an order for Renvela (chronic kidney disease with dialysis) 800 milligrams (mg) once daily with a start date of 11/30/24. Record review of the January, February, March, April, and May Medication Administration Record (MAR) revealed Renvela was scheduled for administration at rising. Further review of the MAR for January, February, March, April, and May revealed Renvela was not administered as ordered on 01/10/25, 01/11/25, 01/13/25, 01/14/25, 01/15/25, 01/24/25, 01/25/25, 01/26/25, 01/27/25, 01/29/25, 02/01/25, 02/03/25, 02/05/25, 02/06/25, 02/07/25, 02/10/25, 02/12/25, 02/13/25, 02/14/25, 02/15/25, 02/17/25, 02/19/25, 02/23/25, 02/24/25, 02/27/25, 03/01/25, 03/2/25, 03/03/25, 03/04/25, 03/05/25, 03/08/25, 03/09/25, 03/13/25, 03/14/25, 03/17/25, 03/20/25, 03/23/25, 03/24/25, 03/26/25, 03/27/25, 03/31/25, 04/01/25, 04/03/25, 04/06/25, 04/09/25, 04/30/25, 05/03/25, 05/04/25, 05/06/25, 05/08/25, 05/13/25. Further record review of progress notes revealed Renvela was not available from the pharmacy for administration on the above dates. Interview on 05/15/25 at 2:15 P. M. with the Director of Nursing verified Renvela was not administered as prescribed on 01/10/25, 01/11/25, 01/13/25, 01/14/25, 01/15/25, 01/24/25, 01/25/25, 01/26/25, 01/27/25, 01/29/25, 02/01/25, 02/03/25, 02/05/25, 02/06/25, 02/07/25, 02/10/25, 02/12/25, 02/13/25, 02/14/25, 02/15/25, 02/17/25, 02/19/25, 02/23/25, 02/24/25, 02/27/25, 03/01/25, 03/2/25, 03/03/25, 03/04/25, 03/05/25, 03/08/25, 03/09/25, 03/13/25, 03/14/25, 03/17/25, 03/20/25, 03/23/25, 03/24/25, 03/26/25, 03/27/25, 03/31/25, 04/01/25, 04/03/25, 04/06/25, 04/09/25, 04/30/25, 05/03/25, 05/04/25, 05/06/25, 05/08/25, 05/13/25. Review of the facility policy titled Administering Medications dated 08/2024 revealed medications are administered in accordance with prescriber orders, including any required time frame. 2. Review of the medical record for Resident #91 revealed an admission date of 03/25/25 with diagnoses of unspecified sequelae of cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and anxiety disorder. Review of the Medicare-5 Day MDS dated [DATE] revealed resident had moderate cognitive impairment. Review of the Care Plan, dated 04/15/25 revealed resident is at risk for altered Cardiovascular, has Seizure Disorder/Narcolepsy, uses antidepressant medications related to anxiety depression, and mood disorder, and is at risk for negative mood / behavior related to diagnosis of major depressive disorder. Interventions include administer medications as ordered. Review of the Medication Administration Record (MAR) dated 05/01/25 through 05/31/25 revealed the following medications were not administered on 05/07/25 Metoprolol Tartrate Oral Tablet 25 MG 0.5 tablet with the Code #16, see nurse note. The following medications were not administered on 05/08/25 Pramipexole Dihydrochloride Oral Tablet 1.5 MG 2 tablets and Doxepin HCl Oral Capsule 10 MG 1 capsule with the code #16, see nurse notes. The following medications were not administered on 05/10/25 Citalopram Hydrobromide Oral Tablet 20 MG 1 tablet, Pramipexole Dihydrochloride Oral Tablet 1.5 MG 2 tablets, Metoprolol Tartrate Oral Tablet 25 MG 0.5 tablet, Divalproex Sodium Oral Tablet Delayed Release 250 MG 1 tablet, Atorvastatin Calcium Oral Tablet 40 MG 1 tablet, Doxepin HCl Oral Capsule 10 MG 1 capsule, Apixaban Oral Tablet 5 MG 1 tablet with the code #16, see nurse notes. Review of the nurse's notes revealed on 05/07/25 at 8:44 P.M. Metoprolol Tartrate Oral Tablet 25 MG 0.5 tablet for hypertension was not administered due to await arrival from pharmacy. Review of the nurse's notes revealed on 05/08/25 at 10:08 P.M. Doxepin HCl Oral Capsule 10 MG 1 capsule for depression was not administered due to on order, not available. Review of the nurse's notes revealed on 05/08/25 at 10:09 P.M. Pramipexole Dihydrochloride Oral Tablet 1.5 MG 2 tablets for restless legs syndrome was not administered due to on order, not available. Review of the nurse's noted revealed on 05/10/25 at 1:52 A.M. Apixaban Oral Tablet 5 MG 1 tablet for cardiovascular accident was not administered due to on order. Review of the nurse's noted revealed on 05/10/25 at 1:52 A.M. Doxepin HCl Oral Capsule 10 MG 1 capsule for depression was not administered due to on order. Review of the nurse's noted revealed on 05/10/25 at 1:53 A.M. Atorvastatin Calcium Oral Tablet 40 MG 1 tablet for hyperlipidemia was not administered due to on order. Review of the nurse's noted revealed on 05/10/25 at 1:53 A.M. Divalproex Sodium Oral Tablet Delayed Release 250 MG 1 tablet for narcolepsy was not administered due to on order. Review of the nurse's noted revealed on 05/10/25 at 1:54 A.M. Metoprolol Tartrate Oral Tablet 25 MG 0.5 tablet for hypertension was not administered due to on order. Review of the nurse's noted revealed on 05/10/25 at 1:55 A.M. Pramipexole Dihydrochloride Oral Tablet 1.5 MG 2 tablets for restless legs syndrome was not administered due to on order. Review of the nurse's noted revealed on 05/10/25 at 8:25 A.M. Citalopram Hydrobromide Oral Tablet 20 MG 1 tablet for depression was not administered due to awaiting pharmacy. Interview with Resident #91 on 05/12/25 at 11:02 A.M. confirmed she did not receive her medications over the weekend, specifically on night shift as ordered. Interview on 05/15/25 at 2:48 P.M. with the Director of Nursing confirmed Resident #91 did not received her medications on 05/07/25 at 8:44 P.M., 05/08/25 at 10:08 P.M., 05/08/25 at 10:09 P.M., 05/10/25 at 1:52 A.M., 05/10/25 at 1:53 A.M., 05/10/25 at 1:54 A.M., 05/10/25 at 1:55 A.M., and 05/10/25 at 8:25 A.M. due to not receiving from the pharmacy. Review of the Administering Medications policy, dated 08/2024 revealed it is the policy of the facility to administer medications in a timely and safe manner as prescribed.

Based on medical record review, review of arbitration agreements and staff resident interviews, the facility failed to ensure a resident was capable of understanding an arbitration agreement before signing. This affected one (#90) of three residents reviewed for arbitration agreements. The facility census was 104. Findings include: Review of Resident #90's medical record revealed an admission date of 04/16/25. Diagnoses listed included emphysema, hypertension, malnutrition, and peripheral vascular disease. Review of an admission Minimum Data Set (MDS) dated [DATE] revealed Resident #90 had moderately impaired cognition. Review of progress noted dated 04/16/25 at 7:35 P.M. revealed Resident #90 was alert to self with some confusion. Review of a daily skilled summary dated 04/17/25 at 3:45 A.M. revealed Resident #90 was alert with both long term and short term memory deficits. Resident #90 could probably make limited decision that require simple understanding. Review of a form titled, RESIDENT AND FACILITY ARBITRATION AGREEMENT contained in the admission agreement revealed the parties understand by entering into this agreement, the parties are giving up there constitutional right to have any claim decided in a court before a judge and jury, as well as any appeal from decision or award of damages. Further review review Resident #90 signed the agreement on 04/22/25. A facility representative had not signed the arbitration agreement. Spaces for date and resident name at the top of the form were left blank. During an interview on 05/15/25 at 2:46 P.M. Resident #90 was unable to state the current month or year, how long he had been at the facility, or the name of the facility. Resident #90 was unable to explain what an arbitration agreement was and did not remember signing one at the facility. Interview with Regional Director of Clinical Operations (RDCO) #251 on 05/15/25 at 3:03 P.M. confirmed Resident #90 had impaired cognitional and had signed an arbitration agreement. RDCO #251 stated residents should be capable of understanding arbitration agreements before signing the document.

Based on medical record review, staff interview, and facility policy review, the facility failed to report an incident regarding an injury of unknown origin as required. This affected one (Resident #4) of three residents reviewed for injuries. The census was 108. Findings Include: Resident #4 was admitted to the facility on [DATE], diagnoses included fracture of unspecified part of neck of right femur, cerebrovascular disease, dementia, anxiety disorder, atrial fibrillation, polyneuropathy, atherosclerotic heart disease, brief psychotic disorder, hyperlipidemia, difficulty walking, degenerative disease of nervous system, hypertension, and cognitive communication deficit. Review of the 11/08/24 minimum data set (MDS) assessment revealed the resident had a severe cognitive impairment. Review of Resident #4's progress notes, dated 12/13/24, revealed an incident in which Resident #4 was being transferred via a mechanical lift. During the process, her arm got caught in the machine and sustained a small skin tear. In the progress notes, there was no indication she fell , slipped or injured her legs during this incident. Review of Resident #4's progress notes, dated 12/14/24, revealed she was sent to the emergency room to have an examination completed on her left leg/pelvic area due to swelling and discoloration. Review of Resident #4's hospital documentation, dated 12/18/24, revealed while performing an examination and x-rays, she had a fracture of her right hip. The hospital documentation stated it was an unknown mechanism of injury, and the hospital was considering sending this case to social services for a referral of elder abuse; which was coupled with interview statements from Resident #4's family while in the hospital. There was no documentation to confirm or assist with determining the cause of this injury. Review of Resident #4's facility medical records, dated 11/01/24 to 12/19/24, revealed no documentation to support findings or evidence of how the injury occurred. Review of facility self reported incidents, dated 11/01/24 to 12/19/24, revealed no evidence this injury of unknown origin was reported to the state health agency as required. Interview with Administrator on 12/19/24 at 11:50 A.M. confirmed they did not report the injury to Resident #4 because they had an idea where it came from. She stated they did an initial investigation and determined the only place the injury could have happened was when she slid down the mechanical lift on 12/13/24. Interview with Medical Director #400 on 12/24/24 at 10:59 A.M. confirmed he spoke to the facility about the injury, but never confirmed the injury occurred while Resident #4 was on the mechanical lift. She did not have osteoporosis or osteopenia, there was no evidence there was an impact during the incident, and the information from the hospital and the x-ray results, found that there was calcification around the fractured area; which would indicate the injury happened a while ago. He could not say exactly when it happened, but he is really confident the injury did not occur on 12/13/24. Review of facility Abuse policy, dated July 2022, revealed the policy had no definition for injury of unknown origin. The policy stated, an injury of unknown origin is investigated to rule out the possibility of abuse. It also stated, the administrator, director of nursing, or designee shall notify the department of health, via the event reporting system electronically, or by phone in the event of the electronic system being unavailable. This deficiency confirmed complaint number OH00160794.

Based on medical record review, review of a facility investigation, review of statements from facility staff regarding an incident, staff interview and policy review, the facility failed to ensure the appropriate number of staff were present for a resident being transferred utilizing a mechanical (Hoyer) lift. This resulted in actual harm when one staff member transferred Resident #14 in a Hoyer lift and the resident's leg became caught, subsequently resulting in an acute [MEDICAL CONDITION] intertrochanteric aspect of the left hip. This affected one (#14) of four residents reviewed for accidents. Facility census was 96. Findings include Review of medical record revealed Resident #14 was initially admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. Review of Minimum Data Set 3.0 (MDS) annual evaluation dated 12/14/18 revealed Resident #14 was totally dependent on two staff members for transfers between surfaces, including from bed to chair. The MDS also revealed Resident #14's Brief Interview for Mental Status (BIMS) score was 15 (no cognitive impairment). Resident #14 required extensive assistance to being totally dependent for activities of daily living, with the exception of eating, which required supervision. Review of care plan revealed Resident #14 was at risk for falls related to weakness, and decreased endurance. The care plan did not address the amount of assistance the resident required to transfer between surfaces. Review of an x-ray report dated 12/23/18 revealed an acute [MEDICAL CONDITION] intertrochanteric aspect of the left hip. Review of the facility's investigation revealed a nursing note dated 12/24/18 at 6:57 A.M. was entered as a late entry for 12/22/18. The note revealed State tested Nursing Assistant (STNA) #209 was transferring Resident #14 to the shower chair using the Hoyer lift. The resident yelled out when the left leg pushed back against the chair. STNA #209 immediately returned Resident #14 to the bed and advised Registered Nurse (RN) #230 of the situation. RN #230 assessed the leg and found no bruising nor scratching. The resident felt better back in bed. RN #230 gave Tylenol for pain. A nursing note dated 12/24/18 at 7:13 A.M. was a late entry for 12/23/18 documented Resident #14 complained of left leg and left hip pain when the left leg was moved. Physician #217 was notified and came to the facility to write orders. The resident was notified an x-ray would be done. The resident, resident's emergency contact, and Physician #217 were notified of the x-ray results. Physician #217 wrote an order to transfer Resident #14 to the hospital. Resident #14 returned to the facility on [DATE]. Review of STNA #209's statement of the incident revealed the STNA was getting Resident #14 ready for a shower. The STNA was lifting the resident with the Hoyer lift and placing the resident into the shower chair when the left lateral part of the lift was tightly close to the chair. The resident yelled out in pain and STNA #209 immediately placed the resident back in bed and got RN #230. The shower chair was placed in the middle of the resident's room. Review of Unit Manager (UM) #207's investigative note revealed the UM spoke with Resident #14 on 12/26/18. Resident #14 stated STNA #209 was getting the resident up in the chair and bumped the resident' leg which caused pain, but the pain went away when the resident was placed back in bed. UM #207 educated STNA #209 on always having two staff members present when using the Hoyer lift to transfer a resident. Interview on 03/14/19 at 1:38 P.M. with UM #207 revealed STNA's were educated to always have two staff members present when using the Hoyer lift. If another aide was not available to help, the STNA would need to advise the resident the transfer would be delayed until a second aide could be found to assist. Interview on 03/14/19 at 4:08 P.M. with the Director of Nursing (DON) revealed Restorative STNA (RSTNA) #208 trained the STNA's on using the Hoyer lift and advised the STNA's the facility policy was for two staff members for Hoyer lift transfers. The DON revealed STNA #209 missed competency training this past year on use of the Hoyer lift. The DON also stated when an issue with transfers would come up in the facility the DON would remind the Unit Managers to have the STNA's redo the competency on use of the Hoyer lift. The DON stated the unit managers were not given that reminder following the incident with Resident #14. Review of undated Lift Policy - Senior Health and Housing policy revealed for transfers using the Maxi lift (Hoyer lift) two staff members must be present.

Based on record reviews, observations, staff interviews, and facility policy review, the facility failed to ensure residents were free from physical abuse. This affected one (#66) of three sampled residents. This resulted in harm for Resident #66, when she received an injury to her left shin, after she was kicked by State tested Nurse Aide (STNA) #1. The facility census was 81. Findings include: On 08/05/15, a record review revealed Resident #66 was admitted to the facility on [DATE] with [MEDICATION NAME] degeneration, a closed femur fracture, weakness, difficulty walking, dementia, dysphagia, [MEDICAL CONDITION], [MEDICATION NAME] degeneration, neuromuscular disorder, hypertension, lack of coordination, [MEDICAL CONDITION], impaired vision, hearing and cognitive deficits. The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was cognitively impaired and was an extensive assist with activities of daily living. The physician order sheet dated 07/01/15 revealed an order for [REDACTED]. A review of the facility self-reported incident dated 07/28/15 revealed the facility reported that STNA #1 was observed kicking Resident #66 in the left shin after Resident #66 attempted to kick STNA #1. A large raised hematoma that measures 5 centimeters (cm) x 6 cm was noted on the left shin just below the knee. The nurse's note dated 07/28/15 at 10:30 A.M. revealed Resident #66 was extremely agitated striking out at others. The nurse's note further indicated the resident had stated she kicked me. A large raised hematoma was noted on the left shin. At 9:11 A.M. on 08/05/15 an interview with Licensed Practical Nurse (LPN) #83 revealed STNA #1 reported a hematoma on Resident #66's leg and stated she bumped her leg on the bed and that she was combative. STNA #32 then reported STNA #1 kicked Resident #66. LPN #83 stated she had another STNA watch STNA #1 while the incident was reported to the Director of Nursing. STNA #1 was then sent home and the police were notified. On 08/05/15 at 9:32 A.M., an interview with STNA #32 revealed she had witnessed the event. She stated as she was coming out of the resident's bathroom, she saw Resident #66 attempt to kick out at STNA #1 and miss. STNA #1 was sitting in a chair, stood up and kicked Resident #66 in the left shin. STNA #32 stated it happened quickly. She stated that when STNA #1 saw her, she tried to get her (STNA #32) to say the bruise occurred when Resident #66 hit her leg. STNA #32 stated that Resident #66 did not hit her leg on the bed. STNA #1 left the room and went to the nurse, then returned and told STNA #32 that she had reported the injury. STNA #32 talked to LPN #83 and reported that STNA #1 had kicked Resident #66 in the leg and left a bruise. On 08/05/15 at 1:57 P.M. observations of Resident #66's left shin revealed a healing hematoma approximately 3 cm x 6 cm just below the left knee. Resident #66 was unable to verbalized what had occurred and stated she was sleepy. A review of the facility policy for Abuse, Neglect and Misappropriation of Resident Property dated 03/2014 revealed it was the policy of the facility that all residents be treated with kindness, respect and dignity. This deficiency substantiates Complaint Number OH 193.