Every finding on record at Aventura at West Park

Based on medical record review, observation, and staff interview, the facility failed to ensure resident dignity was maintained when a resident's naked upper body was exposed. This affected one (Resident #10) of three residents reviewed for resident rights. The facility census was 86 residents. Findings include: Review of the medical record for Resident #10 revealed an admission date of 04/30/26 with diagnosis including acute embolism, anorexia, and diabetes. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 05/07/26 revealed the resident had moderate cognitive deficits and required partial to moderate assistance with activities of daily living (ADLs.) Observation on 07/13/26 at 11:05 A.M. from the hallway revealed Resident #10 was in her room with the door fully open. Resident #10 was completely naked from waist up and Certified Nursing Assistant (CNA) #37 was standing in the resident's room. Interview on 07/13/26 at 11:06 A.M. with the Director of Nursing (DON) verified Resident #10's door was wide open and anyone in the hallway could see the resident's naked torso and breasts. The DON stated Housekeeper #100 had seen Resident #10 was exposed and instead of shutting the resident's door to provide privacy, the housekeeper went to get CNA #37 so the aide could assist the resident. When CNA #37 entered Resident #10's room she did not shut the resident's door to provide privacy. Interview on 07/13/26 at 3:25 P.M. with CNA #37 verified earlier in the day when Resident #10 was in her room, the resident's naked torso and breasts were exposed and visible to anyone in the hallway. CNA #37 stated she should have immediately shut the resident's door to provide dignity and privacy to the resident. This deficiency represents noncompliance investigated under Complaint Number 3044231.

Based on medical record review, review of text message communication, review of facility Self-Reported Incidents (SRIs), review of employee written statements, resident interview, staff interview, and review of the facility employee handbook the facility failed to prevent resident financial exploitation. This affected one (Resident #12) of three residents reviewed for financial exploitation. The facility census was 86 residents. Findings include: Review of the medical record for Resident #12 revealed an admission date of 04/23/25 with diagnoses including spinal cord injury, edema, chronic pain, and gout.Review of the Minimum Data Set (MDS) assessment for Resident #12 dated 06/09/26 revealed the resident had no cognitive deficits and required substantial assistance of staff for activities of daily living (ADLs.) Review of a text message dated 06/01/26 at 12:41 P.M. per Certified Nursing Assistant (CNA) #25 to Resident #12 revealed the aide contacted the resident about a truck the aide had purchased from the resident for the aide's son, Dishwasher #27 for a price of one thousand dollars. CNA #25 indicated in the text message that Resident #12 had been calling Dishwasher #27 insisting the employee owed the resident one thousand additional dollars. CNA #25 also indicated the agreed upon price of the car was one thousand dollars and suggested she would return the resident's truck and the resident could give the aide her money back before the resident lied about the transaction and it became a problem. Review of the facility SRI dated 06/03/26 revealed Resident #12 and his family member stated the resident had sold a car to a kitchen employee, and the employee had not paid fully for the car. Resident #12 and his family member had a vehicle parked at the facility that Resident #12 was trying to sell. Resident #12 stated an employee that working in the kitchen bought the vehicle from him for an agreed upon price of two thousand dollars. Resident #12 stated he and Dishwasher #27 went to the Bureau of Motor Vehicles (BMV) together and the resident signed the vehicle title over to Dishwasher #27 and the employee paid him for the car. Resident #12 stated he did not count the money at the time of the transaction, but when he got back and counted he discovered he only received eight hundred and forty dollars from Dishwasher #27.Review of a written statement per CNA #25 dated 06/10/26 revealed on 06/01/25 Dishwasher #27, the aide's son, purchased a truck from Resident #12 for one thousand dollars and she provided the cash for her son to complete the transaction. After the purchase Resident #12 called Dishwasher #27 insisting the employee had not paid the full agreed upon price, two thousand dollars, for the truck. Interview on 07/13/26 at 10:31 A.M. with Resident #12 said his truck was in the last row of the parking lot and CNA #25 was walking by as he was sitting in his truck and Resident #12 asked her if she knew anyone who wanted to buy a truck. Resident #12 stated STNA #25 said yes her son who was a Dishwasher #27 in the facility's kitchen. Resident #12 stated that they exchanged numbers. Resident #12 verbalized Dishwasher #12 kept coming to him to let him know he had the money, so they met at the Bureau of Motor Vehicle (BMV) and Resident #12 sold his truck to Dishwasher #27.Interview on 07/13/26 at 1:03 P.M. with Registered Nurse Manager (RNM) #35 verified employees should never purchase items from residents because that would be considered resident exploitation.Interview on 07/13/26 at 2:08 P.M. with the Director of Nursing (DON) confirmed CNA #25 and Dishwasher #27 purchased a truck from Resident #12 in early June 2026. The DON stated employees should never make financial negotiations with residents.Review of the facility employee handbook dated 03/01/22 revealed under no circumstances may an employee enter into any financial agreement with a resident of the facility. This would apply to current and past residents. Breach of the policy could lead to immediate dismissal and possible criminal charges.This deficiency represents noncompliance investigated under Complaint Number 3051871.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on record review, Self-Reported Incident (SRIs) review, hospital record review, review of emergency medical services (EMS) run sheet review, observation, staff interview, review of the facility investigation, review of the United States Food and Drug Administration (FDA) Guide to Bed Safety: Bed Rails in Hospitals, Nursing Homes and Home Healthcare, review of the Direct Supply Multi-Bed Pivoting Assist Device Owner's Manual, and policy review, the facility failed to thoroughly assess residents for the risk of entrapment and appropriateness for the use of bed rails. This resulted in Immediate Jeopardy and serious life-threatening harm/death when Resident #11's head and neck became wedged between the mattress and the bed rail. Resident #11 asphyxiated and died. This had the potential to affect 40 residents (Residents #4, #5, #12, #16, #20, #21, #22, #26, #30, #33, #35, #36, #37, #39, #40, #42, #43, #46, #48, #51, #53, #54, #57, #63, #67, #70, #74, #75, #77, #80, #85, #86, #88, #89, #91, #94, #95, #98, #99, and #100) with bed rails attached to their beds. The facility census was 93 residents. On 06/02/26 at 4:14 P.M. the Administrator, the Director of Nursing (DON), Regional Director of Operations (RDO) #250, and the Director of Clinical Services (DCS) #251 were notified Immediate Jeopardy began on 05/23/26 at 12:49 P.M. when Resident #11 was discovered sitting on his buttocks next to the left side of the bed with both legs extended toward the window. Resident #11's head and neck were caught between mattress and assist bar with his lower jaw stuck inside the handle of the assist bar. Certified Nursing Assistant (CNA) #138 assisted Registered Nurse (RN) #50 in removing the mattress from the right side of the bed to free Resident #11 and lower him to the floor. RN #50 started cardiopulmonary resuscitation (CPR) until EMS arrived and took over rescue efforts. At approximately 1:05 P.M. EMS advised staff Resident #11 had a pulse and was being transported to a local hospital where the resident was admitted , intubated, mechanically ventilated. Resident #11 expired on 06/01/26. The Immediate Jeopardy was removed on 05/24/26 and continued at a Severity Level 2 (no actual harm with potential for more than minimum harm that is not Immediate Jeopardy) until it was corrected on 05/31/26 when the facility implemented the following corrective actions: On 05/23/26 at 12:50 P.M., RN #50 notified the DON of the incident involving Resident #11. The DON immediately called the Administrator who then notified the appropriate corporate support required. On 05/23/26 the Administrator and the DON completed a root cause analysis of the incident. Contributing factors to the incident included the following: communication between the nursing department and the maintenance department did not occur per the facility's room readiness process, maintenance was not informed the previous resident had discharged from the facility, maintenance did not remove or checked the assist bars on Resident #11's bed, the facility failed to assess Resident #11 for the appropriateness of the use bed rails, the facility did not obtain consent from the resident and/or the resident's representative for the use of bed rails. On 05/23/26 at 2:33 P.M., the Administrator, the DON, and Licensed Practical Nurse (LPN) #203 notified the Medical Director of the incident and the facility's Quality Assurance Performance Improvement (QAPI) Plan to correct. On 05/23/26 at 2:45 P.M., RDO #250 reviewed the facility's policy and procedure for Bed Safety and Assist Rails, process for communication of assist bar needs and ongoing bed inspection form (including side rails) with no revisions deemed necessary. On 05/23/26 at 3:05 P.M, DCS #251 and RDO #250 educated the Administrator and the DON on the following: communication of assist bar needs upon admission and discharge, assessments for side rail/assist bars and appropriate usage/risks, applying side rails/assist bars, consent forms, care plan/kardex accuracy, physician orders, monthly inspection of beds (including side rails/assist bars) On 05/23/26 at 3:40 P.M., the DON initiated education to licensed nurses and CNAs on the following: communication of assist bar needs upon admission and discharge, assessments for side rail/assist bars and appropriate usage/risks, applying side rails/assist bars, consent forms, care plan accuracy, physician orders. Training was completed on 05/24/26 at 4:36 P.M. For staff on leave of absence or vacation, training will be completed in-person before staff begin their next shift. Staff will not be allowed to work until training is completed. Training will also become part of new hire orientation and mandatory for per diem staff before working on the floor. On 05/23/26 at 3:40 P.M., the Administrator educated the Maintenance Director on the following: communication of assist bar needs upon admission and discharge, monthly inspection of beds (including side rails/assist bars) On 05/23/26 at 4:20 P.M., the nursing administration team consisting of the DON, RN #181, and LPN #203 completed walking rounds to identify beds with assist bar(s) in place. On 05/23/26 at 5:20 P.M., the DON, RN #181, and LPN #203 audited bed rail/assist bar assessments, physician orders, bed rail/assist bar consents, and Kardex and care plans to ensure accuracy updating as needed. On 05/23/26 at 5:40 P.M, the Maintenance Director removed the assist bar from Resident #12's bed as they were assessed as not needing the bars. The Maintenance Director then ensured appropriate placement on beds of those who were deemed appropriate with required assessment, physician order and consent with correct measurements according to FDA and Manufacturer Guidelines. On 05/23/26 at 5:50 P.M., the Administrator educated Human Resources Director (HRD) #257 on the required new hire education for nursing and maintenance employees regarding the following: communication of assist bar needs upon admission and discharge, assessments for side rail/assist bars and appropriate usage/risks, applying side rails/assist bars, consent forms, care plan/Kardex accuracy, physician orders, monthly inspection of beds (including side rails/assist bars. On 05/23/26 at 10:03 P.M., the Administrator filed a Self-Reported Incident (SRI) to the Ohio Department of Health (ODH) regarding the incident involving Resident #11. Starting on 05/23/26, the Administrator will audit the monthly bed inspection forms for one month. Starting on 05/24/26, to ensure ongoing compliance, the DON/designee will audit new and re-admissions to ensure the residents were assessed for side rails/assist bars, physician orders, consents, care plan and Kardex accuracy three times per week for a period of four weeks. Starting on 05/24/26, the Administrator/designee will audit rooms ready for admission three times per week for a period of four weeks. On 06/02/26 at 4:35 P.M., the facility held a QAPI Committee meeting to review the Immediate Jeopardy which was called by ODH related to the event on 05/23/26 and to review the corrective action plan the facility initiated on 05/23/26. The following Interdisciplinary Team (IDT) members were in attendance: the Administrator, the Medical Director, the DON, the ADON, the Unit Manager, RDO #250, the Regional Director of Clinical Operations (RDCO), the Activities Director, the Dietary Director, the Social Services Director, the Social Services Assistant, the Marketing Director, the Admissions Coordinator, the Business Office Manager, the Maintenance Director, the Housekeeping Director The QAPI Committee determined no revisions to the corrective action plan were deemed necessary. Starting on 06/02/26, the QAPI Committee will review the IJ corrective action plan weekly for four weeks and then monthly for 90 days to ensure ongoing compliance. Interviews on 06/02/26 and 06/08/26 with LPN #205, RN #8, CNA #104, CNA #180, and Maintenance Assistant (MA) #147 confirmed they received education from the facility regarding bed rails and assist bars in May 2026. Findings include: Review of the medical record for Resident #11 revealed an admission date of 05/22/26 with diagnoses including right hip fracture, anxiety disorder, orthostatic hypotension, depression, and Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had severe cognitive deficits, was dependent on staff for activities of daily living including the ability to roll from lying on back to left and right side and return to lying back on the bed. Review of medical record revealed no documentation that Resident #11 had been assessed to determine the appropriateness for the use of side rails. There were no documented alternatives attempted prior to placing Resident #11 into a bed equipped with bed rails. Review of the nursing note dated 05/23/26 at 3:44 P.M. per RN #50 revealed at approximately 12:49 P.M., CNA #138 called the nurse to Resident #11's room for assistance. Upon entering the room, RN #50 saw Resident #11 sitting on his buttocks next to left side of the bed with his legs extended toward the window. Resident #11's head and neck were caught between the mattress and the assist bar with his lower jaw inside the handle of assist bar. CNA #138 assisted RN #50 in removing mattress from the right side of the bed which allowed staff to free Resident #11 and lower him to the floor. Resident #11 was not breathing and was non-responsive. RN #50 started CPR. CPR continued until EMS arrived at approximately 1:05 P.M. and took over rescue efforts. At 1:21 P.M. EMS advised the nurse Resident #11 had a pulse and would be transported to the hospital. Review of the facility SRI #274903 dated 05/23/26 revealed staff saw Resident #11 resting in bed, but when the staff member returned to the room approximately15-20 minutes later she discovered Resident #11's head was stuck in the bed rail, the resident was unresponsive, and there was feces all over the bed and on the floor next to the resident's body. Staff believed Resident #11 either tried to get up out of bed and passed out due to history of orthostatic hypotension or rolled over and fell out of bed. All staff working at the time of the incident were interviewed with no unusual circumstances or other issues were voiced. The facility did not substantiate neglect or abuse had occurred. Review of a witness statement dated 05/23/26 per CNA #138 revealed around 12:30 P.M. the aide entered Resident #11's room and saw the resident had been incontinent of bowel. The nurse had toileted the resident 15-20 minutes prior. CNA #138 told Resident #11 she was going to get supplies and finish assisting another resident and would come back shortly to help clean the resident. When CNA #138 returned to Resident #11's room, the resident's feet were on the floor. CNA #138 called out Resident #11's name with no response. CNA #138 ran to the other side of the bed and found the resident sitting upright on the side of the bed with his buttocks on the floor and his neck stuck between the side rail and the side of bed. Resident #11 was unresponsive, and CNA #138 called for the nurse and requested immediate assistance. The nurse started compressions and told CNA #138 to call 911 and to call a code blue indicating CPR was in progress. Review of a witness statement dated 05/23/26 per RN #50 revealed at approximately 12:45 P.M. CNA #138 called out to the nurse from Resident #11's room. Upon entering the room, the nurse observed Resident #11 sitting on the floor at his bedside with his legs extended toward the window. Resident #11's jaw was inside the assist bar, and his head and neck were between the mattress and assist bar obstructing his airway. At 12:49 P.M. the nurse contacted the DON and Unit Manager to notify them of incident. CNA #138 assisted RN #50 with removing the mattress from the opposite side of the bed which made it possible to lower Resident #11's upper body to the floor where CPR could be performed effectively. At 12:53 P.M., RN #50 gave two rescue breaths and started chest compressions. The other nurse on the unit called a code blue and brought the crash cart. RN #50 along with other staff continued CPR alternating cycles until paramedics, first responders, and EMS arrived and took over at approximately 1:05 P.M. At 1:21 P.M. EMS staff advised that Resident #11 had a pulse and they were transporting the resident to the hospital. Review of the EMS run sheet dated 05/23/26 revealed upon arrival at the facility EMS staff found Resident #11 lying on his back on the floor. Staff stated they found Resident #11 not breathing with his head stuck between the bed railing and the bed and was not breathing. EMS noted some redness to Resident #11's neck and took over CPR and once they obtained a pulse they transported the resident to the hospital. Review of hospital records for Resident #11 dated 06/01/26 revealed the resident presented to the hospital after being found down in between the bed and an assist rail. Resident #11 was admitted to the hospital, and his status was cardiac arrest with diffuse hypoxic injury. He was intubated and placed on mechanical ventilation. After ongoing discussion with Resident #11's family the resident was transitioned to comfort-focused care and withdrawal of life-supporting measures. Resident #11's code status was changed from full code to do not resuscitate comfort care (DNRCC.) Mechanical ventilation was withdrawn on 05/30/26 and the resident expired on 06/01/26 at 10:14 A.M. During a telephone interview on 06/02/26 at 12:43 P.M., RN #50 stated she was at her cart when CNA #138 hollered for help. RN #50 stated when she entered the room Resident #11 was sitting on the floor with his head and neck between the assist bar and mattress and his neck was hooked on top which obstructed the resident's breathing. RN #50 stated she and CNA #138 removed the mattress in order to free Resident #11 from the assist bar and then lowered the resident to the floor to perform CPR. RN #50 stated Resident #11 did not appear to be agitated that last time she had been in the room. During a phone interview on 06/02/26 at 12:38 P.M., CNA #138 refused to answer any questions regarding Resident #11. During an interview on 06/02/26 at 1:20 P.M., the DON reported staff notified her of Resident #11's head and neck being stuck between the assist bars and bed with his jaw stuck in the rail on 05/23/26 at approximately 1:00 P.M. and she then notified the Administrator. During an interview on 06/03/26 at 11:30 A.M., the DON verified Resident #11 was given a bed with assist rails and Resident #11 had not been properly assessed for the use of the rails. Review of the owner's manual for the Direct Supply Multi-Bed Pivoting Assist Device revealed an optimal bed system assessment should be conducted on each resident by a qualified clinician or medical provider to ensure maximum safety of the resident. The assessment should be conducted within the context of and in compliance with the state and federal guidelines related to the use of restraints and bed system entrapment guidance, including the Clinical Guidance for the Assessment and Implementation of Side Rails published by the Hospital Bed Safety Workgroup of the US FDA. Review of the FDA Guide to Bed Safety and Bed Rails in Hospitals, Nursing Homes, and Home Care, undated, revealed the FDA had issued detailed guidance to help hospitals, nursing homes, and home care providers reduce the risk of bed entrapment (when a patient/resident becomes caught between bed rails and the mattress, or between rails themselves) which could cause strangulation, suffocation, or serious injury. Bed rails could be safe and beneficial when used appropriately, but they must be assessed individually, installed correctly, and maintained to prevent entrapment injuries. Review of the facility policy titled Bed Safety and Bed Rails dated August 2022 revealed the use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. The resident assessment to determine risk of entrapment included the following: medical diagnosis, conditions, symptoms, and/or behavioral symptoms, resident size and weight, sleep habits, medications, acute medical or surgical interventions, underlying medical conditions, existence of delirium, ability to toilet self safely, cognition, communication; mobility (in and out of bed); and risk of falling. The resident assessment also determines potential risks to the resident associated with the use of bed rails, including the following accident hazards; restricted mobility, and psychosocial outcomes. This deficiency represents the noncompliance investigated under Complaint Number 3029840.

Based on observation, staff interview, and policy reviews, the facility failed to ensure garbage cans in the kitchen were covered with lids. This had the potential to affect all of the residents residing in the facility with the exception of three facility-identified residents who did not receive food from the kitchen. The facility census was 88 residents.Findings include: Observations of the kitchen on 05/07/26 at 8:48 A.M. revealed there was a garbage can in the dishwashing area without a lid and garbage can in the food preparation area without a lid. At time of observation neither container was being actively used to dispose of waste. Interview on 05/07/26 at 8:48 A.M. with Corporate Support Manager (CSM) #600 confirmed the garbage cans did not have lids and the cans should be covered. Interview on 05/14/26 at 11:15 A.M. with CSM #600 confirmed the facility did not follow protocol for safe handling of garbage. Review of the facility policy titled Garbage and Rubbish Disposal undated revealed all garbage containers should have tight-fitting lids or covers and such containers must be kept covered when stored or not in continuous use.

Based on record review, employee file review, staff interview, review of online resources from the Centers for Disease Control and Prevention (CDC), and facility policy review, the facility failed to ensure a comprehensive water management plan was implemented to minimize the risk of waterborne pathogens including Legionella. The facility also failed ensure new employees were screened for tuberculosis (TB) and/or were screened annually for TB. This had the potential to affect all residents living in the facility. The facility census was 88 residents.Findings include: 1. Review of the facility's infection control documents revealed they did not include water management plan to prevent the growth of Legionella. Interview on 05/13/26 at 11:47 A.M. with Maintenance Director (MD) #311 verified the facility did not have a water management plan in place to prevent the growth of Legionella. Interview on 05/13/26 at 12:15 P.M. with the Administrator verified the facility did not have a water management plan in place to prevent the growth of Legionella. Review of facility policy titled Legionella Water Management Program undated revealed the facility was committed to the prevention, detection and control of water-borne contaminants, including Legionella. As part of the infection prevention and control program, the facility had a water management program which was overseen by the water management team. The purpose of the water management program was to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. Review of online resources from the CDC at https://www.cdc.gov/control-legionella/php/wmp/wmp-steps.html titled Steps to Develop a Water Management Program revealed development of a water management program was a multi-step process that required continuous review. An approved plan consisted of the following seven steps to build an effective Legionella water management program: establish a water management program team, describe the building water systems, identify areas where Legionella could grow and spread, decide where to apply and how to monitor control measures, establish interventions when control limits aren't met, make sure the program runs as designed and is effective, document and communicate all the activities. 2. Review of employee files revealed the facility failed to complete the TB new hire screening and/or annual screening for the following employees; Registered Nurses (RNs) #345 and #343, Business Office Manager (BOM) #213, the Administrator, Certified Nursing Assistants (CNAs) #473, #381, #393. Interview on 05/12/26 at 2:12 P.M. with Infection Control Preventionist (ICP) #305 confirmed staff are offered testing and screening for TB as part of the new hire process. Infection Control Preventionist (ICP) #305 confirmed each employee should complete a TB risk questionnaire annually as the facility was determined to be at low risk for TB. Interview on 05/14/26 at 3:30 P.M. with Human Resource Manager (HRM) #253 confirmed the facility failed to complete the TB new hire screening or annual screening for the following employees; RNs #345 and #343, BOM #213, the Administrator, CNAs #473, #381, #393. Review of the facility policy titled Tuberculosis, Employee Screening dated January 2026 confirmed all employees are to be screened for latent TB and active TB and TB symptoms prior to beginning employment. Retesting of current employees was based on individual risk factors. This deficiency represents noncompliance investigated under Complaint Number 2786610.

Based on observation, staff interview, and policy review, the facility failed to store food in accordance with professional standards for food service safety. This had the potential to affect all of the residents residing in the facility with the exception of three facility-identified residents who did not receive food from the kitchen. The facility census was 88 residents. Findings include: Observations during initial kitchen tour on 05/07/26 at 8:48 A.M. revealed a rack containing bread products including 4 full bags of hamburger buns, not dated, 2 partial bags of hamburger buns, not dated, one half loaf of bread, not dated. Inside the refrigerator there was a half full bag of Asian stir-fry, not dated, and two bags of tater tots not dated. Interview on 05/07/26 at 8:48 A.M. with Corporate Support Manager (CSM) #600) confirmed the undated foods in the kitchen. Review of the facility policy titled Food Storage (Dry, Refrigerated and Frozen) dated 08/12/23 revealed foods should be dated upon opening. This deficiency represents noncompliance investigated under Complaint Number.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure insulin vials were properly labeled and stored. This affected four (Residents #50, #78, #99 and #107) of 34 residents with medications stored in the rehabilitation medication carts one and two and the fourth floor central-one medication cart. The facility census was 88 residents. Findings include: 1. Review of the medical record for Resident #50 revealed an admission date of 04/27/26 with a diagnosis of diabetes mellitus type two. Review of the physician's orders for Resident #50 revealed an order dated 05/04/26 for insulin lispro inject 10 units subcutaneously before meals and per sliding-scale before meals and at bedtime. Review of the Medication Administration Record (MAR) for Resident #50 dated May 2026 revealed the resident was administered 71 doses of insulin lispro between 05/01/26 and 05/12/26. Observation on 05/12/26 at 1:27 P.M. of the skilled medication cart-1 with Registered Nurse (RN) #347 revealed Resident #50's insulin lispro pen was not dated. Interview on 05/12/26 at 1:27 P.M. with RN #347 verified Resident #50's insulin pen was not dated and should have been dated when removed from refrigerated storage and placed in the medication cart. 2. Review of the medical record for Resident #78 revealed an admission date of 08/09/24 with a diagnosis of diabetes mellitus type two Review of the physician's orders for Resident #78 revealed an order dated 03/04/25 for insulin glargine inject 49 units subcutaneously at bedtime.Review of the MAR for Resident #99 dated May 2026 revealed the resident was administered 11 doses of insulin glargine between 05/01/26 and 05/11/26.Observation on 05/12/26 at 2:01 P.M. of the fourth-floor central-1 medication art with Licensed Practical Nurse (LPN) #287 revealed Resident #78's insulin glargine pen was not dated. Interview on 05/12/26 at 2:01 P.M. with LPN #287 verified Resident #78's insulin glargine pen was not dated and should have been dated when removed from refrigerated storage and placed in the medication cart. 3. Review of the medical record for Resident #99 revealed an admission date of 05/05/26 with a diagnosis of diabetes mellitus type two. Review of the physician's orders for Resident #99 revealed an order dated 05/05/26 for insulin lispro inject five units subcutaneously before meals and at bedtime. Review of the MAR for Resident #99 dated May 2026 revealed the resident was administered 23 doses of insulin lisprobetween 05/06/26 and 05/11/26. Observation on 05/12/26 at 1:17 P.M. of the skilled medication cart-2 with LPN #263 revealed Resident #99's insulin lispro pen was not dated. Interview on 05/12/26 at 1:17 P.M. with LPN #263 verified Resident #99's insulin lispro pen was not dated and should have been dated when removed from refrigerated storage and placed in the medication cart. 4. Review of the medical record for Resident #107 revealed an admission date of 05/11/26 with a diagnosis of diabetes mellitus type two. Review of the physician's orders for Resident #107 revealed an order dated 05/05/26 for insulin lispro inject per sliding scale before meals and at bedtime. Review of the MAR for Resident #107 dated May 2026 revealed the resident was administered four doses of lispro insulin between 05/11/26 and 05/12/26. Observation on 05/12/26 at 1:17 P.M. of the skilled medication cart-2 with LPN #263 revealed Resident #107's insulin lispro pen was not dated. Interview on 05/12/26 at 1:17 P.M. with LPN #263 verified Resident #107's insulin lispro pen was not dated and should have been dated when removed from refrigerated storage and placed in the medication cart. Review of the policy titled facility policy titled Medication Labeling and Storage revised February 2023 revealed multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items.

Based on observation, resident interview, staff interview, and facility policy review, the facility failed to ensure appropriate water temperatures in the north hallway shower room and in individual resident rooms and failed to maintain bathrooms and shower rooms in a clean and sanitary manner. This affected five facility-identified (Residents #12, #42, #55, #82, #90) who use the north hallway shower room and three (Residents #7, #12, #78) and had the potential to affect all of the residents residing in the facility. The facility census was 88 residents. Findings include: 1.Observation on 05/11/26 at 4:27 P.M. with Certified Nurse Aide (CNA) #413 revealed she allowed Resident #7's bathroom sink water to run for several minutes and obtained a water temperature of 83 degrees Fahrenheit (F).Interview on 05/11/26 at 4:27 P.M. with CAN #413 confirmed the water temperature in Resident #7's bathroom sink was 83 degrees F. 2.Observation on 05/11/2026 at 4:31 P.M. with CNA #413 revealed she allowed Resident #12's bathroom sink run for several minutes and obtained a temperature reading of 83 degrees F.Interview on 05/11/26 at 4:31 P.M. with CNA #413 confirmed the water temperature in Resident #12's bathroom sink was 83 degrees F. 3. Observation on 05/11/26 at 2:52 P.M. in the area outside the bathroom door in Resident #78's room revealed the ceiling light was out and the area was darkened. Observation inside Resident #78's bathroom revealed the ceiling light had multiple bugs in the light fixture. Observation after letting the water in Resident #78's bathroom sink run for several minutes revealed the water was cold.Interview on 05/11/26 at 2:52 P.M with Resident #78 confirmed the water in his room was too cold and he did not take a shower because the water in the shower room was also too cold. Resident #78 stated the room was too dark because the light was out and no one had fixed it.Observation on 05/11/26 at 4:35 P.M. with CNA #413 revealed she allowed the water to run from Resident #78's bathroom sink for several minutes and obtained a water temperature of 84 degrees F.Interview on 05/11/26 at 4:35 P.M. with CAN #413 confirmed the water temperature in Resident #78's bathroom sink was 84 degrees F. 4. Observation on 05/11/26 at 4:38 P.M. with CNA #413 confirmed the light to the resident hallway near the entrance to the east shower room was out and this darkened that part of the hallway. The east shower room floor and walls were dirty. The light in the east shower room had multiple insects in the light fixture and one of the light bulbs was not working. There was a buildup of dirt and debris on the fan in the shower room. CNA #413 allowed the shower to run for several minutes with notably weak water pressure and obtained a water temperature reading of 92 degrees F. Interview on 05/11/26 at 4:40 P.M. with CNA #413 confirmed the dirty shower room floor and walls and fan. CNA #413 confirmed the insects in the light fixture and the nonfunctioning light bulb. CNA #413 stated several residents had complained about the water temperature in the shower room, the weak water pressure of the shower, and the general lack of cleanliness to the east shower room. Interview on 05/13/26 at 10:23 A.M. with the Director of Nursing (DON) confirmed the facility had experienced an ongoing concern with water temperatures being cold throughout the facility. Interview on 05/13/26 at 12:15 P.M. with the Administrator confirmed the facility had an ongoing issue with providing residents with appropriate water temperatures. The Administrator stated the facility should be running with three hot water pumps but only had one operating pump. Review of the facility policy titled Resident Environmental Quality undated revealed the facility would provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. The facility would implement preventative maintenance schedules for the maintenance of the building and equipment. All facility personnel were responsible for reporting broken, defective or malfunctioning equipment or furnishings immediately upon identification of the issue. This deficiency represents noncompliance investigated under Complaint Number 1370707 and Complaint Number 1370723 and Complaint Number 2726701 and Complaint Number 2989675.

Based on medical record review, staff interview, review of the facility policy, and review of online guidelines per the National Pressure Injury Advisory Panel (NPIAP), the facility failed to regularly monitor and obtain measurements of resident pressure ulcers. This affected two (Residents #7 and #9) of four residents reviewed for pressure ulcers. The facility census was 88 residents.Findings include:1. Review of the medical record for Resident #9 revealed an admission date of 11/01/23 with diagnoses including cerebral infarction, diabetes, and chronic kidney disease. Review of the readmission note for Resident #9 dated 02/28/26 revealed the resident returned from the hospital with deep tissue injuries (DTIs) noted on the right and left heels. There were no measurements or descriptions of the areas documented. Review of the wound physician note for Resident #9 dated 03/12/26 per Wound Care Physician (WCP) # 703 revealed the resident had a DTI to the left heel that measured 1.1 centimeters (cm) in length by 1.4 cm in width and a DTI to the right heel that measured 2.1 cm in length by 2.7 cm in width. Review of Minimum Data Set (MDS) assessment for Resident #9 dated 04/01/26 revealed the resident required partial to maximum assistance with all activities of daily living and had deep tissue injuries on right and left heels. Review of the interdisciplinary team (IDT) note for Resident #9 dated 04/30/26 revealed the resident refused to be seen by WCP #703 on 03/22/26 and the next visit was scheduled for 05/07/26. Review of the wound physician note for Resident #9 dated 05/12/26 revealed the STI to the resident's left heel was 1.4 cm in length by 2.2 cm in width and the DTI to the right heel was 3.5 cm in length by 3.5 cm in width. Review of the medical record for Resident #9 revealed the only measurements and assessments of the resident's wounds were conducted on 03/12/26 and 05/12/26 per WCP #703. Interview on 05/14/26 at 3:23 P.M. with the Director of Nursing (D0N) confirmed the facility nurse failed to thoroughly describe and measure Resident #9's wounds during the readmission nursing assessment for the resident on 02/28/26. The DON stated it was her expectation for the nursing staff to regularly document a description and measurements of pressure ulcers in the resident medical record. The DON verified the only measurements of Resident #9's wounds from 02/28/26 to 05/14/26 were done by WCP #703. 2. Review of the medical record for Resident #7 revealed an admission date of 03/19/26 with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), and peripheral vascular disease. Review of the admission assessment for Resident #7 dated 03/19/26 revealed the resident was admitted to the facility with wounds to his left and right gluteal folds. The assessment did not include measurements or a description of the wounds. Review of the MDS assessment for Resident #7 dated 03/25/26 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.) Review of the wound assessment for Resident #7 dated 03/25/26 revealed the resident had a stage III pressure ulcer to his right gluteal fold which was present upon admission. The wound measured 1.0 cm in length by 1.1 cm in width by 0.2 cm in depth with 100 percent (%) granulation tissue to the wound bed. Interview on 05/14/26 at 3:24 P.M with the DON confirmed the facility staff did not measure or document a description of Resident #7's pressure ulcer upon admission. Review of the facility policy titled Wound Care undated revealed documentation of a wound should be recorded in the resident's medical record. This documentation should include the type of wound care given and a description of the wound bed color, size of the wound, and the presence of drainage etc. Review of an online resource, the NPIAP guidelines dated 05/07/26 at https://www.internationalguideline.com/assessment#section_2 revealed regular and comprehensive skin and tissue assessment is a key component of pressure injury risk assessment that informs the development and implementation of a pressure injury prevention plan.

Based on medical record review and staff interview facility failed to update resident care plans for weight loss. This is affected one (Resident #57) of four residents reviewed for nutritional care plans. The facility census was 88 residents. Findings include: Review of medical record for Resident #57 revealed an admission date of 06/03/18 with diagnoses including bipolar disorder, Parkinson's Disease, polyneuropathy, anxiety and gastro-esophageal reflux disease. Review of the Minimum Data Set (MDS) assessment for Resident #57 dated 03/30/26 revealed the resident had minimal cognitive impairment and required assistance with activities of daily living (ADLs.) Review of the progress note for Resident #57 dated 04/29/26 per Dietitian #702 revealed Resident #57 had a significant weight loss of 18 pounds in six weeks with a body mass index (BMI) of 18.9. Review of the progress note for Resident #57 dated 05/11/26 per Dietitian #701 revealed resident should be provided with double portions of protein at all meals and offered a house supplement three times per day. Review of the nutritional care plan for Resident #57 revealed it included an intervention for the resident to limit snacking between meals. The care plan did not include the interventions added by Dietitian #701 on 05/11/26 6o include double portions and offer house supplements three times per day. Interview on 05/12/26 at 3:25 P.M.with MDS Nurse #511 verified the nutritional care plan for Resident #57 had not been updated to include interventions to prevent unplanned weight loss recommended by Dietitian #701 nor had the intervention to limit snacking been removed from the care plan.

Based on medical record review, observation, resident interview, staff interview, and facility policy review the facility failed to provide adequate resident supervision to ensure safe smoking. This affected two (Residents #7 and #36) of three residents reviewed for smoking. The facility census was 88 residents. Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 03/19/26 with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), and peripheral vascular disease. Review of the smoking assessment for Resident #7 dated 03/23/26 revealed the resident was a supervised smoker. Review of the Minimum Data Set (MDS) assessment for Resident #7 dated 03/25/26 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.) Review of the comprehensive care plan for Resident #7 revealed it did not include a care plan for smoking. Interview on 05/11/26 at 12:11 P.M. with Resident #7 confirmed he was an independent smoker, and the facility staff permitted him to keep his smoking supplies which included cigarettes and a lighter in his room. Observation on 05/12/26 at 2:29 P.M. of Resident #7's room revealed there was a cigarette lighter on the resident's bedside table. Interview on 05/12/26 at 2:30 P.M. with Certified Nursing Assistant (CNA) #473 confirmed Resident #7 had a lighter on his bedside table. CNA #473 stated Resident #7 was an independent smoker and was permitted to keep his cigarettes and lighter in his room. Interview on 05/12/26 at 2:38 P.M. with MDS Nurse #511 confirmed Resident #7 had been assessed as requiring supervision with smoking. Interview on 05/13/26 at 12:22 P.M. with the Administrator confirmed if a resident was a supervised smoker smoking items (cigarette and lighter) were not permitted to be in a resident. The Administrator stated the smoking items including lighters and cigarettes were to be locked at the nurses' station for safety. 2. Review of the medical record for Resident #36 revealed an admission date of 09/19/25 with diagnoses including congestive heart failure (CHF), hypothyroidism, and diabetes mellitus. Review of the MDS assessment for Resident #36 dated 03/17/26 revealed the resident had impaired cognition and was dependent on staff assistance with ADLs. Review of the smoking assessment for Resident #36 dated 03/24/26 revealed the resident was a supervised smoker. Review of the comprehensive care plan for Resident #36 revealed it did not include a care plan for smoking. Observation on 05/14/26 at 4:46 P.M. revealed Resident #36 was in her room seated on her bed with a cigarette lighter on the bedside table. Interview on 05/14/26 at 4:46 P.M. with Licensed Practical Nurse (LPN) #700 confirmed Resident #36 had a cigarette lighter on her bedside table. LPN #700 stated she mistakenly thought Resident #36 was an independent smoker. Review of the facility policy titled Resident Smoking Policy and Procedure dated 2022 confirmed the facility prohibited smoking except in designated areas. Residents deemed to need assistance to smoke should have a this designated in the care plan. Each resident should be assessed to determine if he/she can safely smoke without supervision.

Based on medical record review, staff interview, and policy review, the facility failed to identify and implement interventions to eliminate or mitigate re-traumatization triggers associated with post-traumatic stress disorder (PTSD) This affected one (Resident #3) of three residents reviewed for PTSD and trauma-informed care. The facility census was 88 residents. Findings include: Review of the medical record for Resident #3 revealed an admission date of 11/07/25 with diagnoses of quadriplegia, chronic kidney disease, and Crohn's disease.Review of the Minimum Data Set (MDS) assessment for Resident #3 dated 11/13/25 revealed the resident had intact cognition and was dependent on staff assistance with activities of daily living (ADLs.) Review of the diagnoses list for Resident #3 revealed the diagnosis of PTSD was added for the resident on 02/03/26. Reviews of the MDS assessments for Resident #3 dated 02/13/26, 03/05/26, and 04/28/26 revealed PTSD was listed as an active diagnosis for the resident. Review of the comprehensive care plan for Resident #3 which was reviewed on 02/24/26 and 04/09/26 revealed there was no care plan for the resident's PTSD diagnosis and/or related goals and interventions for PTSD. Interview on 05/13/26 at 3:43 P.M. with MDS Coordinator #315 verified the Resident #3's comprehensive care plan did not include a care plan with treatment and interventions for the management of PTSD symptoms. Review of the facility policy titled Care Plans, Comprehensive Person-Centered revised March 2022 revealed the facility would develop and implement a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs.

Based on medical record review, resident interview, observation, staff interview, and facility policy review, the facility failed to develop comprehensive resident care plans. This affected two (Residents #7 and #80) of 18 residents sampled. The facility census was 88 residents. Findings include: 1.Review of the medical record for Resident #7 revealed an admission date of 03/19/26 with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), and peripheral vascular disease. Review of the smoking assessment for Resident #7 dated 03/23/26 revealed the resident was a supervised smoker. Review of the Minimum Data Set (MDS) assessment for Resident #7 dated 03/25/26 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.) Review of the comprehensive care plan for Resident #7 revealed it did not include a care plan for smoking. Interview on 05/11/26 at 12:11 P.M. with Resident #7 confirmed he was a smoker. Interview on 05/12/26 at 2:38 P.M. with Minimum Data Set (MDS) Nurse #511 verified Resident #7 was a smoker but his comprehensive care plan did not include a care plan for smoking safety. Review of the facility policy titled Care Plans Comprehensive, Person Centered dated 2001 revealed the facility would develop a resident care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. 2. Review of the medical record for Resident #80 revealed an admission date of 03/13/26 with diagnoses including pyogenic arthritis internal derangement of left knee, chondrocalcinosis of right knee and primary adrenocortical insufficiency. Review of the MDS assessment for Resident #80 dated 03/19/26 revealed the resident was cognitively intact and required staff assistance with ADLs. Review of the medical record for Resident #80 revealed it did not include a comprehensive care plan. Interview on 05/14/26 at 11:30 A.M. with MDS Nurse #511 confirmed Resident #80 had resided in the facility since 03/19/26 but the facility had not yet developed a comprehensive care plan for the resident as required per policy. Review of facility policy titled Care Plans, Comprehensive Person-Centered dated 2001 revealed the comprehensive person-centered care plan should be developed within seven days of the completion of the required MDS assessment and no more than twenty-one days after admission.

Based on medical record review and staff interview, the facility failed to ensure Preadmission Screening and Resident Review (PASARR) assessments were completed as appropriate. This affected one (Resident #3) of two residents reviewed for PASARRs. The facility census was 88 residents.Findings include: Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including quadriplegia, chronic kidney disease, Crohn's disease, and neurogenic bowel and bladder. Review of the PASARRs for Resident #3 dated 10/16/25 and 02/02/26 completed by the hospital prior to admission revealed the resident had no indications of serious mental illness. Review of the diagnosis list for Resident #3 revealed the diagnosis of post traumatic stress disorder (PTSD) was added on 02/03/26. Interview on 05/12/26 at 2:53 P.M. with Social Services Director (SSD) #361 verified the facility failed to complete a new PASARR for Resident #3 that included the resident's diagnosis of PTSD.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure accurate documentation in the medical record. This affected one (Resident #101) of three residents reviewed for documentation. The facility census was 83 residents. Findings include: Review of the medical record for Resident #101 revealed an admission date of 11/19/25 with diagnoses including metabolic encephalopathy, calculus of kidney, severe protein-calorie malnutrition, bipolar disorder, oropharyngeal dysphasia, chronic obstructive pulmonary disease (COPD). Review of the care plan for Resident #101 dated 11/22/25 revealed the resident was at risk for an alteration in nutrition/hydration related to a history of severe malnutrition, altered mental status, dysphagia, a low body mass index, and recent significant weight loss. Review of the Minimum Data Set (MDS) assessment for Resident #101 dated 11/25/25 revealed the resident was cognitively intact. Review of the nutritional assessment for Resident #101 dated 11/28/25 per Registered Dietician (RD) #261 revealed the resident was consuming an average of 25 to 50 percent (%) of the three daily meals. Review of the physician's orders for Resident #101 revealed an order dated 11/29/25 to monitor meal intake. Review of Nursing Assistant (NA) tracking sheets for Resident #101 dated November 2025 and December 2025 revealed there was no record of the resident's meal intake. Review of the dietary progress notes for Resident #101 dated 12/29/25 per RD #262 revealed the resident consumed 25 to 50% of the three daily meals. Interview on 02/03/26 at 3:05 P.M. with RD# 262 confirmed the dietary progress note for Resident #101 dated 12/29/25 was based on the NA tracking sheets for the month of December 2025. Interview on 02/04/26 at 3:03 P.M. with RD# 261 confirmed the nutritional assessment for Resident #101 dated 11/28/25 was based on the NA tracking sheets for the month of November 2025. Interview 02/04/26 at 4:00 P.M. with the Director of Nursing (DON) confirmed the facility was unable to provide documentation of tracking of meal intakes for Resident #101 for November 2025 and December 2025. Record review of the facility policy titled Guidelines for Documentation updated April 2012 revealed the purpose of charting was to provide a complete account of the resident's care , treatment, responses to the care, signs, symptoms of the resident's care, guidance for prescribers, a tool for measuring quality of care and for developing plans of care, and was a legal record that protected the resident, care providers and the facility.

Based on observation and interview, the facility failed to secure all medications in a locked storage area and to limit access to authorized personnel. This had the potential to affect 12 residents (#3, #7, #11, #13, #24, #25, #26, #28, #34, #41, #66 and #74) that are independently mobile on the 400 floor. The facility census was 90. Findings include: Observation of medication administration on 03/27/25 at 8:29 A.M. revealed Licensed Practical Nurse (LPN) #315 to retrieve a medication that needed to be re-stocked on the cart. LPN #315 went to the medication storage room on level 4 of the facility. The door was observed to be unlocked. Interview with LPN #315 on 03/27/25 at 8:29 A.M. revealed that the medication storage room was never locked and had not been since the electronic key pad lock was taken off the door. On 03/27/25 at 8:41 A.M. this surveyor went back to the medication storage room and was able to gain access due to the door not being locked. Observation on 03/27/25 at 8:47 A.M. revealed that the door to the medication storage room was ajar. Interview on 03/27/25 at 8:48 A.M. with Employee #360 revealed that she was restocking a wound supplies cart. Employee #360 revealed that she has keys somewhere if the door gets locked but usually it was left unlocked. Interview with the Director of Nursing (DON) on 03/27/25 at 2:00 P.M. revealed that a key pad lock had been placed on the medication storage room door that day in an attempt to correct the deficiency.

Based on medical record review, physician interview, and staff interview, the facility failed to ensure physician notes were signed at the time service was rendered. This affected three (#51, #52, and #60) of three residents reviewed for physician visits. The facility census was 90. Findings include: 1. Review of the medical record of Resident #51 revealed an admitted [DATE]. Diagnoses included emphysema, dementia, Alzheimers, anxiety, depression, hypertension, gastro-esophageal reflux disease, chronic pain syndrome, and atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition. The resident was independent with eating, supervision with toileting, and partial/moderate assistance with bathing, dressing, bed mobility, and transfers. Review of a physician visit dated 01/27/25 revealed the physician did not sign the progress note until 02/09/25. Interview on 03/27/25 at 1:43 P.M. Physician #340 stated he signs his notes the minute he completes them. Interview on 03/27/25 at 1:58 P.M. the Director of Nursing (DON) verified the physician did not sign his progress note at the time of service. 2. Review of the medical record of Resident #52 revealed an admitted [DATE]. Diagnoses included stage 3 chronic kidney disease, depression, and rheumatoid arthritis. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. The resident required supervision for eating, bed mobility, and transfers, partial/moderate assistance for toileting, substantial/maximal assistance for bathing, and dressing. Review of a physician visit dated 09/10/24 revealed the physician did not sign the progress note until 10/19/24. Review of a physician visit dated 10/07/24 revealed the physician did not sign the progress note until 10/19/24. Interview on 03/27/25 at 1:58 P.M., the DON verified the physician did not sign his progress note at the time of service. 3. Review of the medical record of Resident #60 revealed an admitted [DATE]. Diagnoses included pulmonary embolism, chronic kidney disease, post-traumatic stress disorder, chronic pain syndrome, polyneuropathy, depression, osteoarthritis, hypertension, anxiety, barrett's esophagus, history of bariatric surgery. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. The resident required supervision with eating, bed mobility and transfers, and partial/moderate assistance with toileting, showering, dressing. Review of a physician visit dated 10/21/24 revealed the physician did not sign the progress note until 11/16/24. Interview on 03/27/25 at 1:58 P.M., the DON verified the physician did not sign his progress note at the time of service. This deficiency was an incidental finding that was discovered during the complaint investigation.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of facility Self-Reported Incidents (SRI), staff interview, and policy review, the facility failed to ensure residents were free from verbal abuse. This affected one (#64) of three residents reviewed for abuse. The facility census was 89. Findings include: Review of the medical record of Resident #64 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, anxiety disorder, dementia with behavioral disturbance, rheumatoid arthritis, delusional disorders, essential hypertension, heart failure, benign prostatic hyperplasia, unsteadiness on feet, and major depressive disorder. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition. The resident exhibited fluctuating inattention and continuous disorganized thinking during the assessment period. The resident utilized a walker and required partial/moderate assistance with transfers and supervision or touching assistance for walking 10 feet. Review of the care plan dated 12/21/23 revealed Resident #64 had the potential for behavioral issues related to a diagnosis of Alzheimers dementia with behavioral disturbance and a history of episodes of increased anxiety, agitation, paranoia, and delusions. The resident was noted to attempt to put himself on the floor and say God wanted him to do it. Interventions included to approach in a calm and gentle manner. Review of a progress note dated 10/18/24 at 9:04 A.M. revealed the nursing assistant informed the nurse Resident #64 was on the floor. The resident was observed sitting on the floor, leaning on the couch and the aid stated she was helping him walk from bed to the couch when the resident became aggressive and resistive to care and slid to the floor. The resident was assessed and no injuries were noted. Review of the SRI dated 10/18/24 revealed Resident #64's family alleged State tested Nursing Assistant (STNA) #300 dropped Resident #64 during a transfer. STNA #300 was assisting Resident #64 with personal care and transferring him to his chair when the resident had a behavioral episode and began to stiffen and would not move, stating, God told him to do it. STNA #300 then began trying to move the resident to sit on the couch and the resident began falling to the floor during the transfer stating, God told me to do it. The STNA told the resident to get his behind up and the STNA let go of the resident, as he was already down, and went to get help. As a result of the investigation, physical abuse was not substantiated, however the facility felt STNA #300 was inappropriate with the resident. STNA #300 was suspended immediately upon learning of the incident and was terminated at the conclusion of the investigation. The police were notified. The resident received psychosocial follow-up and staff was educated on the facility abuse policy and transferring a patient. Review of the SRI dated 10/25/24 revealed, through an investigation, it was found an STNA was verbally inappropriate with Resident #64. During the investigation for the SRI dated 10/18/24, the STNA admitted saying, Come on man. Get your ass up. The facility substantiated verbal abuse. Interview on 11/18/24 at 12:55 P.M., the Administrator stated, following the investigation from the first SRI filed, Resident #64's family shared video footage of the incident and stated they felt as if STNA #300 dropped Resident #64. The Administrator stated the video footage was reviewed and did not support the aide dropping the resident, however the aide attempted to get the resident back up without assistance and said, Get your ass up. The Administrator stated STNA #300 had been suspended and then terminated following the first investigation because the aid did not follow policy and attempted to get the resident up without notifying the nurse. Upon review of the video, the Administrator discussed the video footage with STNA #300 and, when questioned, STNA #300 stated she, may have said that. The Administrator stated any swearing to residents is not tolerated. Observation on 11/18/24 at 2:00 P.M. with the Administrator and Director of Nursing (DON) of in-room surveillance video revealed STNA #300 standing behind Resident #64, who was standing at his walker. STNA #300 was assisting the resident to transfer onto his couch when the resident said something (unclear in video footage) and his body went limp and was lowered to the ground. STNA #300 attempted to assist Resident #64 off the floor and stated, Get your ass up, come on man. Interview at the same time, the Administrator verified STNA #300's statement to Resident #64 and verified this was a form of verbal abuse. Review of the facility policy titled, Resident's Right to Freedom from Abuse, Neglect, and Exploitation, dated 2024, revealed the facility residents have the right to be free from abuse, including verbally aggressive behavior such as curing, bossing around, or demanding. The deficient practice was corrected on 10/25/24 when the facility implemented the following corrective actions: -On 10/18/24 at 9:45 A.M., STNA #300 was providing care to Resident #64 in his room when, while walking to the couch, he dropped to his knees, landing his upper body on the couch and knees on the floor, stating God told me to do it. -On 10/18/24 at 9:54 A.M., Resident #64's daughter sent a video to Assistant Director of Nursing (ADON) #533 for review of an interaction between Resident #64 and STNA #300 -On 10/18/24 at 10:00 A.M., STNA #300 went to get LPN #310 and LPN Unit Manager (UM) #193 to come and assist and assess Resident #64 for injury and assist off the floor. Resident #64 did not have any injuries. -On 10/18/24 at 10:00 A.M. ADON #533 went and removed STNA #300 from Resident #64's room and, with the Administrator, took her statement and suspended STNA #300 immediately, pending investigation. -On 10/18/24 at 10:10 A.M., UM #193, LPN #864, and ADON #533 began inservicing staff in the facility regarding the abuse policy, started questioning residents about abuse, and obtained statements from staff. -Interviews on 11/19/24 with STNA #330, Housekeeping Aid #335, STNA #345, LPN #360, and Social Services Assistant #377 confirmed they had received education on the facility abuse policy on 10/18/24. -On 10/18/24 at 10:15 A.M., the Administrator opened an SRI. On 10/18/24 at 10:15 A.M., the Administrator, LPN #864, UM #193, and ADON #533 spoke with Resident #64's family in the facility to discuss the video and how the facility would handle the situation. The family was surprised the aid was suspended and stated they did not want her to lose her job. -On 10/18/24 at 10:30 A.M., UM #193 notified Medical Director #786 of the fall and allegation of abuse of Resident #64. Orders were received for an x-ray of the right ankle (negative results on 10/21/24) and a medication review by psychiatry. -On 10/18/24 at 3:00 P.M., the Clinical Management team conducted a QAPI meeting with Corporate Risk Management to discuss the findings of the investigation. The root-cause analysis of the incident was Resident #64 having behaviors (God told him to do it), which made him drop to the ground. -On 10/19/24 at 2:00 P.M., the Clinical Management team met again to discuss the investigation. The determination was made to terminate STNA #300. -On 10/19/24 at 3:00 P.M., the Administrator and DON terminated STNA #300's employment at the facility. -On 10/21/24 at 11:00 A.M., Social Services employees continued follow-up with Resident #64 for psychosocial follow-up. -On 10/24/24, the DON and Administrator began completing daily audits five days a week, which included rounding the entire facility, talking with residents to ensure they know how to report abuse and asking if there are any concerns. -On 10/25/24, the DON submitted the final SRI unsubstantiating physical abuse. -On 10/25/24, the DON opened an additional SRI for verbal abuse and continued abuse education and psychosocial follow-up on Resident #64. This deficiency represents non-compliance investigated under Complaint Number OH00159133.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interview, review of witness statements, review of a facility Self-Reported Incident (SRI) and policy review, the facility failed to ensure misappropriation of resident funds. This affected three (#21, #22, and #23) residents of the six Residents (#11, #14, #15, #21, #22, and #23) reviewed for resident funds. The facility census was 57. Findings include: Review of the medical record for Resident #21, revealed the resident was admitted on [DATE]. Diagnoses included, but not limited to, acute respiratory failure, paranoid schizophrenia, anxiety, cerebrovascular disease, and acute kidney failure. Resident #21 expired in the facility on [DATE]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was cognitively intact. Review of the medical record for Resident #22, revealed the resident was admitted on [DATE]. Diagnoses included, but not limited to, bipolar, anxiety, paraplegia, pain, and cerebrovascular disease. Resident #22 expired in the facility on [DATE]. Review of the most recent MDS assessment dated [DATE] revealed Resident #22 had mild to moderated cognitive deficits. Review of the medical record for Resident #23, revealed the resident was admitted on [DATE]. Diagnoses included, but not limited to, heart failure, depression, dry eye syndrome, kyphosis, and anxiety. Resident #23 expired in the facility on [DATE]. Review of the most recent MDS assessment dated [DATE] revealed Resident #23 had moderate to severe cognitive deficits. Review of a check dated [DATE], revealed the check was made out to Petty Cash in the amount of $300.00 signed and endorse by Former Business Office Manager (BOM) #61. The memo indicated the check was for account closure (Resident #23). Review of a check dated [DATE], revealed the check was made out to Former BOM #61 in the amount of $567.49 signed and endorsed by former BOM #61. The memo indicated the check was for account closure (Resident #21). Review of check dated [DATE], revealed the check was made out to Receptionist #64 in the amount of $1,548.58 signed by former BOM #61 and endorsed by Receptionist #64. The memo indicated the check was for account closure (Resident #22). Review of a facility SRI dated [DATE] categorized for misappropriation, revealed while the facility was completing a resident trust audit, the facility discovered an employee had written check to themselves out of a residents account who was deceased . Receptionist #64 notified the Administrator about concerns she had with missing resident trust account money. The Administrator began a full comprehensive investigation. Former BOM #61 was suspended while the facility conducted an audit of Resident #21's resident trust account. During the audit, the facility discovered former BOM #61 wrote out a check to herself on [DATE] from Resident #21's trust account in the amount of $567.49 and signed the check. Former BOM #61 then took the check to the bank and endorsed it. Resident #21 was deceased [DATE]. The memo on the check stated account closure. When the Administrator questioned former BOM #16 about the process to close an account, former BOM #61 was not able to give the appropriate steps. The Administrator reminded former BOM #61 that an account needs to be closed and sent to either the funeral home or to the Attorney General's Office in a check format and closed account checks should not be written out to yourself or another employee, cashed and be given to anyone. Former BOM #61 stated understanding. Former BOM #61 has since been terminated from her position. Receptionist #64 was interviewed, but she noted she doesn't touch the checks, so she was not aware of this incident. The [NAME] President of Revenue Operations (VPRO) #60 completed a whole house audit on the resident accounts that were deceased back to [DATE] and there were no further incidents discovered. On [DATE] the Administrator was educated by VPRO #60 on the need to audit resident funds accounts. All staff were educated by the Administrator on abuse and misappropriation. The police were called, and they would conduct an investigation also. The facility substantiated abuse, neglect or misappropriation verified by evidence. After completing a full investigation, the incident was substantiated due to finding a check written to the employee from a deceased resident's account. The local Police Department was called, and a copy of the check was provided to the Police and was instructed a detective would be investigating. An addendum to the SRI was uploaded on [DATE] to indicate the Administrator was informed by VPRO #60 that two more Residents (#22 and #23) had concerns with their closed accounts. Resident #22's account was opened with a personal check on [DATE] and closed on [DATE]. Former BOM #61 issued and signed a check made out to Receptionist #64 for $1,548.58. Receptionist #64 stated the cash was handed to former BOM #61 who was taking it to meet Resident #22's daughter at Walmart. Resident #22 was on Medicaid at time of death. The Administrator called Resident #22's daughters and neither had received any money or met anyone in the Walmart parking lot. Resident #23 expired [DATE] and the account was closed on [DATE] with two checks issued. One check for $330.00 issued to Resident #23's niece and has not been cashed as of yet. VPRO #60 will be putting a stop payment on the check and issuing to estate recovery. The second check was issued to Petty Cash for $300.00, signed and endorsed by former BOM #61. Remaining $1.44 left in the account and need checks issued to estate recovery. Review of a facility documented titled Employee Discipline Notice dated [DATE] revealed former BOM #61 was in violation of the facility's progressive discipline policy. Group IV-Theft, attempted theft, or misuse of facility, employee, resident or visitor property. On [DATE], BOM #61 wrote a check out to herself, and cashed it out of deceased Resident #21's account. Former BOM #61 was terminated. Review of a witness stated dated [DATE] by Receptionist #65, revealed former BOM #61 never asked her to go to the bank to cash any checks at any time. She indicated that she never had checks made out to her for cash, and as of ,d+[DATE] she no longer entered transactions into the Resident Fund Management Service. Review of undated witness statement revealed Receptionist #64 had been the payee at times. Receptionist #64 would go to the bank and bring the money back to the facility. Receptionist #64 had concerns that the resident trust accounts in general were not accurate, so she brought it to the Administrator's attention. Review of an undated witness statement from Receptionist #66 and narrated by the Administrator revealed the Administrator spoke to Receptionist #66 over the phone and she indicated she would only give the residents cash out of the petty cash box and then turn the receipts into the Business office manager. Interview with the Administrator on [DATE] at 3:00 P.M. revealed the former BOM #61 had taken the money, and it has never been recovered. The Administrator stated that the police were notified, and she is still in contact with them on a weekly basis and they going to press charges on former BOM #61. The Administrator stated the money for all three Residents (#21, #22, and #23) has been put back into their accounts and they are waiting for the check signers from the bank so they can sign the checks and sent them where they need to go. Resident #21's money goes to the estate, and Residents #22 and #23 are to be sent to the Attorney General due to being Medicaid. Review of the Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedures (dated 2023) revealed to ensure that all of the facility's residents are free from abuse, neglect, misappropriation of their property, and exploitation. The deficient practice was corrected on [DATE] when the facility implemented the following corrective actions: On [DATE], an SRI was submitted to the State Agency for the allegations of misappropriation. The SRI was completed on [DATE] and the allegations of misappropriation were substantiated. On [DATE], former BOM #61 was terminated. On [DATE], all staff were educated by the Administrator on abuse and misappropriation. On [DATE], the Police were notified and were given a copy of the check. The Police are in the process of investigation and possibly filing formal charges against former BOM #61. On [DATE], An Ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, the Director of Nursing (DON) and the Medical Director. A Root Cause Analysis (RCA) was determined that the former BOM #61 was doing illegal activity with the resident accounts and a working system was not in place. A house wide audit for resident accounts were started on [DATE] and to be completed on [DATE]. Additional QAPI meetings were held on [DATE], [DATE], and [DATE]. Attendees included Administrator, Assisted Living (AL) Director #106, Staffing Coordinator #102, MDS Coordinator#103, Unit Manager / Licensed Practical Nurse (LPN) #104, Activities Supervisor #100, Registered Nurse (RN) #105, and the Medical Director. No additional issues were identified. On [DATE], the Administrator, and two Receptionists (#64 and #65) were educated by VPRO #60 on the need to audit resident fund accounts. On [DATE], a whole house audit of the resident's fund accounts was completed by the Administrator with no issues being identified. On [DATE], the Administrator started weekly audits of five resident fund accounts to ensure that no misappropriation was occurring. The audits will be completed weekly for four weeks then monthly and reported to the QAPI committee to determine the need for further formal audits. Additional audits from [DATE] and [DATE] were reviewed with no issues being identified.

Based on medical record review and staff interview, the facility failed to ensure new residents were provided written Admission Agreements at the time of admission. This affected four (#8610, #8611, #8613 and #8618) of five residents reviewed for admission procedures. The facility census was 66. Findings Include: 1. Review of the medical record for Resident #8610 revealed an admitted [DATE]. Diagnoses included diabetes mellitus type II, lumbar disc degeneration, congestive heart failure and acute myocardial infarction. Resident #8610 was discharged home on 06/14/24. Review of the Minimum Data Set (MDS) Discharge-Return Not Anticipated assessment dated [DATE] revealed Resident #8610 had intact cognition, was occasionally incontinent of bowel and bladder, was independent with eating, oral hygiene and bed mobility, and required set up assistance with toileting, bathing, dressing, personal hygiene and transfers. 2. Review of the medical record for Resident #8611 revealed an admitted [DATE]. Diagnoses included adult failure to thrive, diabetes mellitus type II, non-pressure chronic ulcer of left heel and foot, morbid obesity, acute kidney failure and depression. Resident #8611 discharged to home on 07/08/24. Review of the MDS Discharge-Return Not Anticipated assessment dated [DATE] revealed Resident #8611 had intact cognition, was frequently incontinent of bladder and occasionally incontinent of bowel, required set up assistance for eating and oral hygiene, supervision for personal hygiene and moderate assistance for toileting, bathing, dressing, bed mobility and transfers. 3. Review of the medical record for Resident #8613 revealed an admitted [DATE]. Diagnoses included acute osteomyelitis right ankle and foot, diabetes mellitus type II, morbid obesity, partial traumatic amputation of right foot and polyneuropathy. Resident #8613 discharged to home on 06/22/24. Review of the MDS Discharge-Return Not Anticipated assessment dated [DATE] revealed Resident #8613 had intact cognition, was frequently incontinent of bowel and bladder, was independent with eating, oral hygiene and bed mobility and required supervision with toileting, bathing, dressing, personal hygiene and transfers. 4. Review of the medical record for Resident #8618 revealed an admitted [DATE]. Diagnoses included bilateral osteoarthritis of both hips, morbid obesity and edema. Resident #8618 discharged to home on 07/02/24. Review of the MDS Discharge-Return Not Anticipated assessment dated [DATE] revealed Resident #8618 had intact cognition, was always incontinent of bladder and frequently incontinent of bowel. required set up assistance with eating and oral and personal hygiene, maximal assistance with toileting and bathing, moderate assistance with bed mobility and transfers and was dependent for dressing. A record request was made on 07/17/24 at 10:30 A.M. to the Business Office Manager (BOM) #102 for evidence written Admission Agreements were provided to Residents #8603, #8610, #8611, #8613 and #8618. BOM #102 did not provide the requested evidence. Interview on 07/17/24 at 1:45 P.M. with the Administrator confirmed the facility had no evidence written Admission Agreements were provided to Residents #8610, #8611, #8613 and #8618. Follow-up interview on 07/18/24 at 12:20 P.M. with the Administrator re-confirmed Residents #8610, #8611, #8613 and #8618 did not have Admission Agreements signed upon admission to the facility. This deficiency represents non-compliance investigated under Complaint Number OH00154443.

Based on medical record review, staff interview, Physician Assistant (PA) interview, review of facility witness statements, review of facility policy and review of the American Heart Association (AHA) guidelines, the facility failed to ensure cardiopulmonary resuscitation (CPR) was provided to a resident who was a full code. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm and/or death when Resident #76, who was a full code, was found unresponsive and without vital signs on [DATE] at 7:20 A.M. and staff failed to immediately perform CPR and the resident was subsequently pronounced dead. This affected one (Resident #76) of three residents reviewed for death over the last three months. The facility census was 78. On [DATE] at 1:25 P.M., the Administrator, Regional Director of Clinical Operations (RDCO) #508, the Director of Nursing (DON), and Director of Operations (DO) #517 were notified of the Immediate Jeopardy, which began on [DATE] at approximately 7:20 A.M. when the facility failed to initiate CPR for Resident #76 who was a full code and was found unresponsive and without vital signs. Registered Nurse (RN) #393 was completing morning rounds on [DATE] at 7:20 A.M. when she found Resident #76 unresponsive and absent of all vital signs. RN #393 then called for help and left the room to summon assistance from PA #500. RN #385 called nine-one-one (911). The facility staff did not initiate CPR for Resident #76. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: - On [DATE], Resident #76 expired in the facility and was transferred to the funeral home. - On [DATE], the facility obtained written statements from staff involved in the incident with Resident #76 on the following dates and times: on [DATE] at 7:45 A.M. from Licensed Practical Nurse (LPN) #406, on [DATE] at 8:00 A.M. from RN #385, on [DATE] at 8:15 A.M. from State tested Nursing Assistant (STNA) #432, on [DATE] at 2:50 P.M. from RN #393, on [DATE] at 5:26 P.M. from LPN #341, on [DATE] at 5:54 P.M. from LPN #507, and on [DATE] at 9:00 A.M. from STNA #337. - On [DATE] at 2:00 P.M., [NAME] President of Clinical Operations (VPCO) #510 reviewed the facility policies titled Advanced Directives, Change-in-Condition, and Emergency Procedure-Cardiopulmonary Resuscitation and made no changes or revisions. - On [DATE] starting at 2:45 P.M. to 7:10 P.M., RDCO #508 educated the Administrator and the DON on the facility policies titled Emergency Procedure-Cardiopulmonary Resuscitation and Change in a Resident's Condition or Status. The Administrator and DON educated the management team on the policies. The management team then educated all staff in all departments, excluding agency staff, on the policies. - On [DATE] at 9:30 A.M., the Administrator, the DON, Assistant Director of Nursing (ADON) #392, and LPN #406 started audits five times a week for four weeks to ensure the residents' code status was honored. No additional codes occurred during this time period. The audits were completed on [DATE]. - On [DATE] at 3:00 P.M., the Administrator and the DON educated PA #500 on the facility policies titled Emergency Procedure-Cardiopulmonary Resuscitation and Change in a Resident's Condition or Status. - On [DATE] at 4:27 P.M., the facility held an ad-hoc Quality Assurance Performance Improvement (QAPI) committee meeting to discuss the root-cause of why CPR was not provided to Resident #76 who was a full code status, and to discuss the steps that were necessary to show performance improvement moving forward. The attendees were as follows: the Administrator, the DON, ADON #392, LPN #374, LPN #406, Social Worker (SW) #383, SW #324, LPN #315, Activities Director (AD) #304, Maintenance Director (MD) #307, Human Resources Manager (HRM) #316, Staffing Coordinator (SC) #421, and Medical Director #512 via phone. The committee discussed the results of the interviews with the staff working the night prior to the incident with Resident #76 and with the staff working at the time of the incident and determined the resident had not experienced an obvious change in condition prior to the incident. The committee discussed VPCO #510's review of the facility policies titled Advanced Directives, Change-in-Condition, and Emergency Procedure-Cardiopulmonary Resuscitation, and made no changes to the policies. The committee discussed and assigned audits to the nursing management on ensuring residents' code status was honored and they were to be completed over a four-week period, for four weeks. - On [DATE] at 6:15 P.M., RDCO #508 educated the following members of the management team on the facility's policies titled Emergency Procedure-Cardiopulmonary Resuscitation and Change in a Resident's Condition or Status: the Administrator, the DON, ADON #392, LPN #374, LPN #406, SC #421, AD #304, MD #307, HRM #316, Business Office Manager (BOM) #443, and Speech Therapist (ST) #372. - On [DATE] between 6:30 P.M. and 8:12 P.M., ADON #392, Unit Managers (LPN #406 and LPN #374), and floor nurses (RN #385, LPN #416, LPN #435, LPN #351, and RN #301) evaluated all 76 residents. None of the residents were experiencing an active change in condition that warranted immediate physician intervention. - On [DATE] at 6:45 P.M., the DON completed an audit of all residents' charts to ensure the residents' code status was honored. No additional codes had occurred from [DATE] to [DATE]. - On [DATE] at 7:00 P.M., the management team (the Administrator, the DON, ADON #392, LPN #374, LPN #406, SC #421, AD #304, MD #307, HRM #316, BOM #443, and ST #372) began to educate the line staff on the CPR policy and the Change in Condition policy. If the management team members were unable to reach line staff upon first attempt on [DATE], the staff was educated prior to starting their next scheduled shift. The education provided included the following information: CPR o The resident had the right to formulate an advanced directive. o If a resident was found unresponsive and not breathing and/or had no pulse, a nurse who was certified in CPR/basic life support (BLS) should initiate CPR. All nurses were required to be CPR certified including agency nurses. If nurses were not CPR certified, they would not be permitted to work in the building. o Prior to initiating CPR, the nurse must verify code status in the resident's electronic medical record (EMR) order. CPR should not be performed if the resident had an order for DNR. If resident was a full code, CPR was provided immediately. o Upon finding a resident who was unresponsive and not breathing and/or had no pulse and was a full code, a staff member should page Code Blue overhead and initiate CPR. o A staff member should immediately bring the crash cart to the scene. o A staff member should immediately call 911. o The Nurse should continue CPR until emergency medical personnel arrived and took over CPR. o CPR must continue until a Medical Doctor, PA, Nurse Practitioner (NP) or paramedics pronounced death. Change in Resident Condition of Status o The nurse must promptly notify the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. o If a staff member noted a change in the resident's medical/mental condition and/or status, he/she must immediately inform the nurse. o The nurse must assess the resident, notify the MD/PA/NP of the change in condition, and initiate any new orders received. o Examples of a change in resident condition/status include, but are not limited to, the following: significant change in the resident's physical/emotional/mental condition, abnormal breathing, need to transfer the resident to a hospital, accident or incident involving the resident such as a fall. - On [DATE] at 7:15 P.M., the DON, ADON #392, LPN #406, LPN #374, and SC #421 began to provide education on the facility policies titled Emergency Procedure-Cardiopulmonary Resuscitation and Change in a Resident's Condition or Status to all agency nurses and STNAs prior to their first shift worked. - On [DATE] at 7:45 P.M., the DON educated NP #514 on the facility policies titled Emergency Procedure-Cardiopulmonary Resuscitation and Change in a Resident's Condition or Status. - On [DATE] at 8:03 P.M., the DON educated Medical Director (MD) #513 on the facility policies titled Emergency Procedure-Cardiopulmonary Resuscitation and Change in a Resident's Condition or Status. MD #513 also reviewed the facility's abatement plan. - On [DATE] at 8:30 P.M., HRM #316 completed an audit of all nurses to ensure current CPR certification. LPN #515 who was on leave had expired CPR certification and had not worked since the incident on [DATE]. LPN #515 would not be permitted to return to work until CPR certification was obtained. LPN #317's CPR certification was set to expire on [DATE]. LPN #317 was educated to have new CPR certification prior to the next shift worked. - On [DATE] at 9:05 P.M., LPN/Minimum Data Set (MDS) Coordinator #315 completed a facility-wide audit to ensure reconciliation of the residents' code status orders, code status care plans, and, if applicable, the state of Ohio do not resuscitate (DNR) forms with no issues noted. - Starting on [DATE], the Administrator and nursing management (DON, ADON #392, LPN #374, and LPN #406) began chart audits of advanced directives for all newly admitted residents, five times per week for four weeks. - Starting on [DATE], the Administrator and nursing management (DON, ADON #392, LPN #374, and LPN #406) began chart audits of all residents to ensure resident code status was honored, five times per week for four weeks. They also audited three charts weekly to ensure change in resident condition was addressed appropriately, five time per week for four weeks. - On [DATE] at 6:30 A.M., the DON, ADON #392, LPN #374, and LPN #406 conducted a code blue drill with the following staff members: RN #301, LPN #507, LPN #357, STNA #386, STNA #441, LPN #516, and LPN #351. No issues were identified. - Starting on [DATE], nursing management (DON, ADON #392, LPN #374, LPN #406, RN #335, and RN #302) completed a mock code drill with follow up evaluation and education three times a week for four weeks. The results of the mock code drills would be submitted to the QAPI committee. - Starting on [DATE], the DON began to interview five staff members, three times per week for five weeks, to validate understanding of CPR administration. - On [DATE], LPN #374 and LPN #406 conducted an audit to ensure all emergency equipment used to perform CPR was present and functional with no concerns noted. - Interviews on [DATE] between 11:45 A.M. and 12:10 P.M. with STNAs #349, #355, #367, #381, and #448, LPNs #305, #315, #416, #418, and RN #393 confirmed they had received education regarding CPR and change in condition. Although the Immediate Jeopardy was removed on [DATE], the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that was not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure ongoing compliance. Findings include: Review of the closed medical record of Resident #76 revealed an admitted [DATE]. The resident died in the facility on [DATE]. Diagnoses included left hip fracture, essential hypertension, paralytic ileus, pancytopenia, cachexia, chronic iron deficiency anemia secondary to blood loss, congestive heart failure, adult failure to thrive, severe protein-calorie malnutrition, atrial fibrillation, chronic thromboembolic pulmonary hypertension, and gastro-esophageal reflux disease (GERD). Review of the comprehensive Minimum Data Set (MDS) assessment for Resident #76 dated [DATE] revealed the resident had severe cognitive impairment. Review of the physician orders for Resident #76 revealed an order dated [DATE] for the resident to be a full code. Review of the care plan dated [DATE] revealed the resident was a full code. Review of the nurse's progress note for Resident #76 dated [DATE] timed at 8:06 A.M. per RN #393 revealed the nurse arrived on the unit, received report, and went to assess Resident #76. The nurse called to Resident #76, and he did not respond. Resident #76 was not breathing and did not have a pulse. PA #500 was made aware of Resident #76's condition, 911 was called, and the crash cart was brought to the room. Resident #76 was pronounced expired at 7:20 A.M. Review of the nurse's progress note for Resident #76 dated [DATE] timed at 8:59 A.M. per LPN #404 revealed the nurse arrived on the unit and staff nurses and PA #500 were in Resident #76's room. Resident #76 was absent of breath sounds and had no pulse. 911 had been called and the crash cart was in Resident #76's room. Resident #76's skin was noted to be cold. 911 arrived, hooked the resident to the monitor and had no results. Time of death was called at 7:20 A.M. Review of the progress note for Resident #76 per PA #500 dated [DATE] timed at 3:56 P.M. revealed on [DATE] PA #500 was asked to examine Resident #76 because the resident was not responding. Upon examination, Resident #76 was not responding to verbal or tactile stimuli, was not breathing, and did not have a pulse. 911 was called and the crash cart was obtained. Emergency Medical Services (EMS) arrived, assessed the resident, determined the resident had expired, and EMS left the building. Review of the death certificate for Resident #76 dated [DATE] revealed the cause of the resident's death on [DATE] was determined to be acute respiratory failure with underlying hypoxia. Interview on [DATE] at 11:51 A.M. with RN #393 confirmed she was Resident #76's nurse on the morning he was found not responding, not breathing, and without a pulse. RN #393 confirmed Resident #76 was a full code. RN #393 confirmed CPR was not initiated for the resident. RN #393 stated she asked PA #500 to assess the resident and the PA stated the resident had already died . Interview on [DATE] at 10:22 A.M. with LPN #406 confirmed on the morning of [DATE], she arrived on the unit between 7:15 A.M. and 7:30 A.M. and was alerted there was something going on in Resident #76's room. LPN #406 confirmed as she was walking to Resident #76's room, RN #393 and PA #500 were coming out of Resident #76's room and she heard PA #500 state the resident was gone. LPN #406 stated CPR was not initiated because it was obvious he was gone. A follow-up telephone interview on [DATE] at 10:36 A.M. with RN #393 confirmed upon finding Resident #76 without vital signs on [DATE] she asked PA #500 to come to Resident #76's room to assess the resident. RN #393 stated PA #500 assessed the resident, pronounced the resident's death, and advised RN #393 not to do CPR. RN #393 stated she had directed the staff to call 911 before PA #500 entered Resident #76's room. RN #393 stated she was unsure how long it took for EMS to arrive, but when they arrived, they checked for a pulse and heart rate, and did not do anything further with the resident. Interview on [DATE] at 11:08 A.M. with the DON confirmed if a nurse found a resident who was a full code to be without vital signs, the nurse should immediately initiate CPR. The DON further confirmed the facility staff failed to initiate CPR for Resident #76 who was a full code and was found without vital signs on [DATE]. Telephone interview on [DATE] at 12:57 P.M. with PA #500 confirmed RN #393 asked him to assess Resident #76 and the nurse told the PA the resident was a full code. PA #500 stated he went to assess Resident #76 and told RN #393 to run the code and call 911. PA #500 stated he did not pronounce Resident #76's death. PA #500 stated he then left the room as he felt the situation was under control with the nurses, though he did not witness anybody start CPR on Resident #76. PA #500 confirmed he stopped coming to the facility around [DATE] because the facility had a nurse practitioner who began coming to the facility three times per week. Review of a written statement dated [DATE] per LPN #406 revealed upon arriving on the unit, she was informed Resident #76 had coded. As LPN #406 was on her way to Resident #76's room, PA #500 and nurses were coming out of the room. One nurse was on the phone giving 911 information, and PA #500 stated Resident #76 was gone but he was a full code. Another nurse stated he was cold. LPN #406 asked another nurse to get the crash cart. As the crash cart was being brought up the hall, paramedics arrived on the unit. LPN #406 told the paramedics that PA #500 had stated Resident #76 was deceased , but the resident was a full code. Paramedics went to the room and hooked the resident up to a monitor. After a minute or two, the paramedics removed the monitor and asked what time the nurse found him. The nurse stated 7:20 A.M. The paramedic stated the time of death was 7:20 A.M., and the paramedics left. Review of the facility policy titled Advanced Directives dated [DATE] revealed advanced directives would be respected in accordance with state law and facility policy. Review of the facility policy titled Emergency Procedure-Cardiopulmonary Resuscitation dated [DATE] revealed if a resident was found unresponsive and not breathing normally, a licensed staff member who was certified in CPR/BLS (basic life support) shall initiate CPR. Review of the American Heart Association (AHA) guidelines dated [DATE] revealed the AHA urged all potential rescuers to immediately start CPR unless a valid DNR order was in place or there were obvious clinical signs of irreversible death present (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition) or initiating CPR could cause injury or peril to the rescuer.

Based on record review, observation, staff interview, and review of the facility policy, the facility failed to conduct a thorough investigation to determine root cause analysis to identify potential hazards and resident-specific interventions to reduce and/or eliminate falls and falls with injury and the facility also failed to ensure fall prevention interventions were in place. This resulted in Actual Harm when Resident #38 experienced repeated falls resulting in a fractured femur which required surgery. This affected two (#38, #74) out of three residents reviewed for falls. The facility census was 73. Findings include: 1. Review of the medical record for Resident #38 revealed an admitted [DATE] with a diagnosis of dementia with behavioral disturbance. Review of the Minimum Data Set (MDS) for Resident #38 dated 11/10/22 revealed resident was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADLs.) Review of the fall risk assessment for Resident #38 dated 07/04/22 revealed resident was at a high risk for falling. Review of the care plan for Resident #38 initiated 01/06/22 revealed resident was at risk for falls related to fluctuations in functioning due to health issues, cognitive deficits, mood/behavior issues, impulsivity and use poor safety judgment at times, use of [CONDITION(S)] medications, and history of falls. Interventions included the following: bed against the wall, bed wheels locked and bed in lowest position, enabling devices as needed, keep call light and frequently used items within reach when in room, medications as ordered, notify physician as needed for adverse effects to medications, non-skid footwear, observe for changes in safety and intervene as necessary, pathways well- lit and clutter free, staff to offer/assist with toileting tasks as needed, and therapy services as indicated. Review of the nurse progress note for Resident #38 dated 10/29/22 timed 10:29 A.M. revealed resident was noted on 10/28/22 in the evening in his room bent over and he then went into a squatting position and stating he was looking for his video. Nurse told him he did not have any video and to stand up, but resident stated he wanted to find it. The nurse left the room and then later walked past the resident's room, and he was laying on the floor flat on his back. Resident was unable to stand up and was lifted onto his couch per three staff. Review of note revealed resident complained of pain to his hips and his left hip was swollen and left leg was shorter than the right. Resident reported pain on a level of 8 out of 10 on a scale of 1 to 10 with 10 being the worst pain. The physician was notified and gave an order to send resident to the hospital for an evaluation. Review of the post fall assessment for Resident #38 dated 10/29/22 timed at 11:54 A.M. revealed resident was confused, obeyed commands, had full range of motion to arms, partial range of motion to legs, complained of pain 8 out of 10, and vital signs were as follows: blood pressure 145/78, pulse 84, respirations 18, temperature 98.6, oxygen saturation 95 percent (%.) Review of MDS for Resident #38 dated 10/29/22 revealed resident was discharged to the hospital with a return anticipated. Review of entry MDS for Resident #38 dated 11/05/22 revealed resident was readmitted to the facility. Review of the hospital note for Resident #38 dated 10/29/22 revealed x-ray showed an acute displaced comminuted fracture of the left proximal femur which occurred following a fall in the facility. Resident was admitted and referred to orthopedics for surgical repair of the fracture. Review of the progress note per Nurse Practitioner (NP) for Resident #38 dated 11/07/22 revealed resident was examined for skilled admission follow up for left femur fracture. Resident had a fall on 10/29/22 and was sent out to the hospital. The left leg had two incision sites covered with [MEDICATION(S)]. While in the hospital, the resident had surgery to repair the fracture of the left femur and was to follow up with the orthopedic surgeon in two weeks. Review of the facility incident log dated 09/01/22 through 11/30/22 revealed it did not include Resident #38's fall on 10/29/22. Observation on 12/12/22 at 1:28 P.M. of Resident #38 revealed resident was resting in bed with a fall mat propped against the wall by the window and another fall mat propped against the wall by the door. Interview on 12/12/22 at 1:28 P.M. with Resident #38 confirmed he was not sure why the fall mats were in his room and why they were propped up on the walls. Interview on 12/12/22 at 1:30 P.M. with State tested Nursing Assistant (STNA) #821 confirmed Resident #38 was in bed and had fall mats propped up against his walls. STNA #821 confirmed she was an agency aide, and she was unsure if the mats were supposed to be on the floor while resident was in bed. Interview on 12/12/22 at 1:33 P.M. with Licensed Practical Nurse (LPN) #822 confirmed she was an agency nurse, and she was unsure if the mats propped up on Resident #38's walls were supposed to be on the floor while resident was in bed. Observation on 12/12/22 at 2:02 P.M revealed resident was still resting in bed with fall mats propped against the walls. Interview on 12/12/22 at 3:41 P.M. with the Director of Nursing (DON) confirmed the facility incident log did not include Resident #38's fall on 11/25/22 and the facility had not conducted a fall investigation for Resident #38's fall. DON further confirmed Resident #38 sustained a left femur fracture during the fall on 10/29/22 which required surgical repair. Interview on 12/15/22 at 8:42 A.M. with the DON confirmed Resident #38 did not have an order fall mats to be placed at his bedside when he was in bed nor had this information been added to the resident's care plan. DON confirmed she was not sure when the fall mats were placed in resident's room, but she was going to contact the physician and get an order for fall mats to the bedside while resident was in bed, because she thought it was a good intervention for the resident due to his history of falls. 2. Review of the medical record for Resident #74 revealed an admitted [DATE] with a diagnosis of acute pyelonephritis and a discharge date of [DATE]. Review of the MDS for Resident #74 dated 11/18/22 revealed resident was cognitively intact and required supervision and physical assistance of one staff with ADLs. Review of the fall risk assessment for Resident #74 dated 11/12/22 revealed resident was at high risk for falls. Review of the care plan for Resident #74 dated 11/22/22 revealed the resident was at risk for falls related to confusion and weakness. Interventions included to ensure the call light is within reach. Review of the facility incident log dated 09/01/22 through 11/30/22 revealed it did not include Resident #74's fall on 11/25/22. Interview on 12/12/22 at 3:41 P.M. with the DON confirmed the facility incident log did not include Resident #74's fall on 11/25/22 and the facility had not conducted a fall investigation for Resident #74's fall on 11/25/22. Review of the facility policy titled Managing Falls and Fall Risk dated 08/2022 revealed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. This deficiency represents non-compliance investigated under Complaint Number OH 968.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on medical record review, staff and physician interview, review of hospital records, policy review and review of medication information from Medscape, the facility failed to administer an anti-diarrhea agent ([MEDICATION NAME]) as ordered by the physician resulting in a significant medication error. This resulted in actual harm when staff administered Resident #10's [MEDICATION NAME] routinely rather than as needed (PRN) as ordered by the physician and Resident #10 subsequently developed a bowel impaction requiring removal of the impaction at the emergency room . This affected one (#10) out of three residents reviewed for medication administration. Facility census was 107. Findings include: Review of the closed medical record for the Resident #10, revealed an admission date of [DATE] and a discharge date of [DATE]. [DIAGNOSES REDACTED]. Review of the most recently completed Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 was cognitively intact, had no behaviors, did not reject care, and did not wander. Resident #10 was one person assist and required limited assistance with toileting and extensive or limited assistance with other activities of daily livings (ADLs). Resident was always continent to bowel and bladder with no bowel toileting program. Review of the plan of care dated 10/21/19 revealed the resident was continent of bowel and bladder but needed some increased assistance with toileting tasks. Interventions included check for incontinence every two to three hours and PRN; offer extra fluid every shift; and resident to wear incontinence briefs. The plan of care also revealed the resident had a self-care deficit related to multiple health issues with increased weakness. Interventions included staff to assist resident with toileting every two to three hours and incontinence care PRN. Review of hospital discharge records for Resident #10 dated 10/14/19 revealed there were no orders for [MEDICATION NAME] or other antidiarrheal medications. Review of nurses progress notes for Resident #10 dated 10/15/19 indicated the physician saw the resident for [MEDICAL CONDITION] in the right leg and loose stools. Review of physician progress notes [REDACTED]. Review of the handwritten physician orders [REDACTED]. Review of the Electronic Medical Record (EMR) orders dated 10/16/19 revealed Licensed Practical Nurse (LPN) #31 created, confirmed and revised the order for [MEDICATION NAME] two mg at 1:59 [NAME]M. The orders indicated it was created as a routine order for 12:00 [NAME]M., 6:00 [NAME]M., 12:00 P.M. and 6:00 P.M. Review of the Medication Administration Record [REDACTED]. Resident #10 received three doses of [MEDICATION NAME] on 10/16/19, two doses on 10/17/19, four doses on 10/18/19, two doses on 10/19/19, two doses on 10/20/19, four doses on 10/21/19, two doses on 10/22/19, four doses on 10/23/19, three doses on 10/24/19, four doses on 10/25/19 and 10/26/19, two doses on 10/27/19, one dose on 10/28/19, four doses on 10/29/19, 10/30/19 and 10/31/19, three doses on 11/01/19, and one dose on 11/03/19. Review of (MONTH) and (MONTH) 2019 daily bowel records for Resident #10 revealed a medium bowel movement (BM) on 10/22/19, a large BM on 10/23/19, and a large BM on 10/29/19 and 10/30/19. No other BM's were documented and Resident #10 was discharged on [DATE]. Review of hospital records for Resident #10 dated 11/06/19 at 7:37 P.M. revealed resident had chief complaint of weakness and fatigue. Hospital records indicated Resident #10's abdomen was assessed to be soft, non-tender, had normal bowel sounds, no masses and no organomegaly. Hospital records indicated resident was found to have a fecal impaction and required disimpaction in the emergency room . Interview with the Director of Nursing (DON) on 11/25/19 at 12:25 P.M. revealed LPN #31 entered the order for [MEDICATION NAME] two mg for Resident #10 as a routine order instead of PRN. The DON stated when LPN #31 entered the order for [MEDICATION NAME] two mg, in the EMR, the order showed up on the MAR indicated [REDACTED]. The DON stated she was not alerted of the medication error until the resident was discharged and the resident's daughter called to complain about the medication error. The DON confirmed Resident #10 had a documented BM on 10/30/19 and no further BM's while at the facility. Interview with LPN #30 on 11/27/19 at 10:15 [NAME]M. revealed she worked night shift (7:00 P.M. to 7:00 [NAME]M.) on 10/15/19. LPN #30 stated she found the handwritten physician's orders [REDACTED].M. as a routine order instead of PRN in the EMR. LPN #30 also indicated she did not get the order verified by another nurse before she entered it in the EMR. Interview with Physician #100 on 11/27/19 at 12:05 P.M. indicated he assessed Resident #10 on 10/15/19 and ordered [MEDICATION NAME] two mg every six hours as needed for diarrhea. Physician #100 stated he was alerted of the medication error by the DON after Resident #10 was discharged . Physician #100 indicated he was troubled no staff verified or questioned the order for routine [MEDICATION NAME] during the numerous times it was administered. Interview with DON on 11/27/19 at 12:20 P.M. verified Resident #10 received [MEDICATION NAME] two mg on a routine basis instead of PRN on 53 occasions between 10/16/19 and 11/03/19. The DON stated when she learned of the medication error, she immediately started an investigation and determined that LPN #31 created a transcription error in the EMR by making the order for [MEDICATION NAME] two mg routine instead of PRN. The DON stated as a result of the medication error, she created a timeline of events; reeducated LPN #33 and #34 on transcription of orders; reeducated all nursing staff on transcription of orders, following the bowel movement (BM) protocol, and pharmacological actions were to be considered for all medications administered. The DON stated she also completed audits for medication administration, transcriptions of orders and bowel movements. Review of the policy dated 01/01/19 titled Transcription of Physician order [REDACTED]. Review of the policy dated 07/01/05 titled Bowel and Bladder Management revealed facility to maintain the highest level of bowel and bladder continency and bowel movements will be monitored by the charge nurse. Review of undated facility policy titled Medication Administration General Policies and Procedures revealed medications are administered as prescribed in accordance with nursing principles and practices and the nurse is to check the physician orders [REDACTED]. Review of medication information from Medscape revealed [MEDICATION NAME] is an antidiarrheal medication used to treat acute or chronic diarrhea and should be taken as prescribed by the physician. [MEDICATION NAME] can cause constipation and the medication should be avoided in patients with constipation and should be discontinued promptly if constipation occurs. Review of the facility's corrective action revealed the following actions were implemented and the deficiency corrected as of 11/22/19: · On 11/05/19, the Skilled Manager discovered a transcription error for [MEDICATION NAME] two mg and resident received 48 doses of the medication. · On 11/06/19, the timeline indicated DON noted the medication order was from the facility physician and transcribed incorrectly in the EMR on 10/16/19. · On 11/07/19, DON initiated staff education on: orders must be transcribed accurately and orders should be rechecked at change of shift to verify accuracy with two nurses; Bowel movement sheet must be checked each shift (if no bowel movement in three days or more, resident needs assessed); and pharmacological actions of all medication must be considered when administering all medications. Staff education was completed on 11/09/19. · On 11/08/19, a corrective action plan was developed and implemented. · On 11/08/19, LPN #31 was disciplined and reeducated on orders to be transcribed correctly and timely. RN #21 signed off on LPN #31's training. · On 11/08/19, performance monitoring was initiated for BM data. Performance monitoring was initiated on 11/08/19 and conducted daily until 11/21/19, then five times a week for one week, then three times a week for two weeks, then weekly for one month until the next Quality assurance performance improvement (QAPI) meeting. All results will be reported out in the QAPI meeting · On 11/08/19, performance monitoring was initiated by the DON for order transcription. Performance monitoring was initiated on 11/08/19. New orders will be reviewed on all units by DON or designee, then random units will be audited, twice a week for one week, then twice a week every two weeks for one month, then one time monthly until next QAPI. All results will be reported out in the QAPI meeting. The monitoring was completed through 11/22/19 with no additional concerns identified. · On 11/09/19, LPN #34 was disciplined and reeducated on orders to be transcribed correctly and timely. RN #21 signed off on LPN #34's training. · On 11/12/19, performance monitoring was initiated by the DON for medication administration. Performance monitoring was initiated on 11/12/19 and observed of random nurses by Nurse Managers three times a week for one week, then twice weekly for one week then weekly for one month until the next QAPI meeting. All results will be reported out in the QAPI meeting. The monitoring was completed through 11/22/19 with no additional concerns identified · During the survey two (#15 and #16) additional residents medical records were reviewed and no concerns were identified regarding administration of medications. · On 11/25/19 observations of medication pass revealed there were no medication errors. This deficiency substantiates Complaint Number OH 309.

Based on record review and interview the facility failed to administer narcotic pain medications timely to residents. This affected one Resident #222 of three residents sampled for pain management. This resulted in harm to Resident #222 who remained in pain for five and a half hours without obtaining relief. The resident was in severe pain for over two hours. The facility also failed to follow physicians orders to monitor labs as ordered. This affected one Resident #69 of five residents reviewed for unnecessary medications. This had the ability to affect 65 residents on a pain management program in the facility and 14 residents receiving [MEDICATION NAME] from the facility. Findings include: 1. Review of Resident #222's medical record revealed she was admitted to the facility on [DATE] for rehab after having spinal fusion surgery on 02/28/14. Resident #222's admission assessment dated [DATE] revealed she was alert and oriented with adequate hearing and clear speech. The admission assessment also revealed she had a surgical site to her lower back. Review of Resident #222's cognitively intact pain assessment dated [DATE] revealed the location of her pain was in her back, the pain was new within seven days and that she also had a history of [REDACTED]. Review of Resident #222's medical record revealed she was last medicated for pain by the hospital before transfer to the facility with [MEDICATION NAME] at 4:30 P.M. Review of Resident #222's admission orders [REDACTED]. Review of the Focus Notes dated 03/03/14 at 8:00 P.M. revealed Resident #222 reported a low pain level at that time to the nurse. The focus note did not reveal any medication was offered or the exact level of pain reported by Resident #222. Review of the Focus Notes dated 03/03/14 at 11:30 P.M. revealed Resident #222 was complaining of severe pain (eight on a scale of 1-10). The focus note also revealed Resident #222's pain medications had not yet arrived from pharmacy. The focus note revealed pharmacy was contacted at that time and stated the pain medications would arrive at the facility within 30 minutes. The focus note revealed one hour later the medications had still not arrived and on 03/04/14 at 1:15 A.M. [MEDICATION NAME] 15 mg was removed from the ebox. A review of the medical record revealed no documentation of the exact time the [MEDICATION NAME] was administered after removal from the ebox or of Resident #222's pain level at the time she received the pain medication. During an interview with Licensed Practical Nurse (LPN) #35 on 03/12/14 at 11:30 A.M. she stated the situation of Resident #222 not getting her pain medication on the night of her admission was not the facilities fault but the pharmacy's fault. She stated the resident's prescriptions were sent STAT (immediately) on admission and pharmacy had four hours to deliver them once they were received. She stated pharmacy had to give staff permission to remove medications from the ebox and initially they would not approve using medications from the ebox for Resident #222 because they had said her pain medications were in route. During an interview with Resident #222 on 03/12/14 at 4:34 P.M. she stated on 03/03/14 the hospital medicated her for pain around 4:00 P.M. She stated at the hospital she was receiving her pain medication about every three hours. She stated she first requested pain medications at the facility around 9:00 P.M. on 03/03/14 and was told her medications had not yet arrived. She stated at that time her pain level was low. She stated by 11:30 P.M. her pain was severe. She stated she finally received pain medication around 1:30 A.M. on 03/04/14. She stated between 11:30 P.M. and 1:30 A.M. her pain was unbearable. She stated she could not sleep and was frantic and miserable because of the amount of pain she was experiencing. She stated she contemplated calling her family to come take her home. She stated by the time she received her medication at 1:30 A.M. on 03/04/14 her pain was a ten on a scale of one to ten. During an interview with the Director of Nursing (DON) on 03/12/14 at 3:12 P.M. she confirmed the time lapse of Resident #222 receiving her pain medication was not "ideal". 2. A review of Resident #69's medical record revealed she was admitted to the facility on [DATE] for rehab after a total hip replacement and had [DIAGNOSES REDACTED]. Review of Resident #69's Minimum Data Set ((MDS) dated [DATE] revealed she had a BIMS score of 10. Review of the hospital documentation dated 02/07/14 revealed Resident #69 was started on [MEDICATION NAME] (a blood thinner) for [MEDICAL CONDITIONS] [MEDICATION NAME] and also revealed her target range for her INR (lab value that is affected by [MEDICATION NAME]) to be 2-3. Review of Resident #69's admission physician orders [REDACTED].#69 had been receiving [MEDICATION NAME] but had not yet had any PT/INR levels checked. Review of the physician orders [REDACTED].#69. Review of Resident #69's lab results dated 02/27/14 revealed an INR level of 3.5. Review of the physician orders [REDACTED]. During an interview with Unit Manager #26 on 03/11/14 at 3:23 P.M. she stated the order for PT/INR's to be drawn twice a week on admission was missed and once she realized it she notified the doctor and got a STAT order and that is when the [MEDICATION NAME] was discontinued.

Based on observation, staff interview, and medical record review the facility failed to ensure that one resident (#232) received adequate supervision and assistive devices to prevent a fall resulting in a subdural hematoma, and that one resident (#126) assessed at risk for falls received adequate supervision to prevent potential falls. Lack of fall intervention for residents who used bed alarms involved two (#232 and #126) of three residents sampled for accidents and falls. Resident #232 sustained harm in the fall. The facility identified 48 of their current 108 residents with bed alarms in use. Findings include: 1. Record Review revealed Resident #232 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was readmitted on [DATE] from the hospital after treatment for [REDACTED]. The readmission [DIAGNOSES REDACTED]. Resident #232's initial Minimum Data Set assessment of 12/01/12 revealed a BIMS score of 99 meaning the interview could not be completed. The staff assessed the resident with both short and long term memory issues, inattention, and disorganized thinking. The resident was extensively dependent on staff for bed mobility, transfer, dressing, and bathing. She had no functional limitations but was not able to balance with transfers from surface or surface pivoting, moving from seated to standing, or toileting without human stabilization or assistance. The assessment identified the resident at risk for falls. The only fall noted was the 12/01/12 fall with injury. The assessment stated it was unable to be determined if the resident fell the last two to six months prior to admission. The assessment indicated a wheelchair and a walker as the resident's mobility devices. An Acute/Immediate needs care plan for fall was developed and initiated on 11/24/12. The fall care plan was a preprinted form with boxes to indicate which interventions were initiated with dates. The care plan gave a choice of goals either for the resident to be free of falls or to sustain no injury during a fall. Neither goal was checked or indicated. Interventions included to educated the patient and family on fall strategies, maintain a clutter free environment, maintain equipment in good working order, Maintain use of proper fitting footwear, provide adequate lighting, monitor changes in functional status, make referral to rehabilitation services, remind the resident to change positions slowly, monitor for signs and symptoms of urinary tract infection, assess level of pain, review medications for side effects, encourage safe and supervised activities, orient to call light and keep in reach, orient to surroundings and the use of bed alarms and chair alarms. The resident also had a behavior care plan in place dated 11/26/12. Interventions include that if the resident was anxious and having behaviors staff may have to re-approach at a later time after making sure the resident was safe and alarm use as reminders of need for increased assistance. Review of Resident #232's nursing notes revealed in a late entry dated 12/01/12 at 7:45 A.M. stated that Registered Nurse #8 was walking down the hallway when she observed Resident #232 lying on the floor in her room in front of her bathroom. The resident was laying on her right side with a pool of blood surrounding her head. Resident #232's walker was next to the resident. The resident had one shoe off and one shoe on. The nursing note stated the resident had been up and down all night noncompliant with alarms and the use of her call light. The resident was unable to state how she fell . The resident did not call out for help and she appeared confused and disoriented. The note stated Resident #232's "bed alarm was functioning properly but did not sound". The note stated three staff sat the resident in a chair. Pressure was applied to a laceration on the right side of Resident #232's forehead. The note stated there was a "copious amount of blood loss." The supervisor was notified and she assessed the resident, notified the physician, and sent the resident to the emergency room for evaluation and treatment. The resident was admitted and treated for [REDACTED]. Interview with the Director of Nursing (DON) on 12/13/12 at 7:17 A.M. revealed that per her investigation of the fall the last person to see Resident #232 prior to the fall was Licensed Practical Nurse (LPN) #10. She stated she was not sure if LPN #10 was responding to an alarm or if she was just checking on the resident but she left the resident sitting on the side of the bed in her room. The next person who saw the resident was RN #8 who found the resident on the floor with the alarm not sounding. The bed alarm was checked immediately by putting pressure on it and letting off the pressure. The alarm functioned and sounded when this occurred. The DON stated that she does not know why the alarm did not sound at the time of the incident, but it was on and functioning when it was checked. She stated she did not know why the resident was left on the side of the bed. She stated her understanding was that the resident was very restless, had been up and down all night, and confused and disoriented. Registered Nurse (RN) #13, who was Resident #232's nurse at the time of the fall was interviewed at 7:45 A.M. on 12/13/11. She stated that the night nurse told her the resident was restless all night trying to get up from the chair or the bed. She stated during report she was told the staff had Resident #232 up in a chair throughout the night keeping the resident with them or in her sight. She stated LPN #10 went into the resident's room about 7:15 A.M. and talked to her. She stated that LPN #10 left the resident sitting on the side of the bed. RN #13 stated that later RN#8 walked down the hall before they counted narcotics and found Resident #232 on the floor and called the other nurses for help. She stated LPN #10 went over and checked the bed alarm because it was not sounding. LPN #10 pushed on the surface of the bed alarm, let it up, and it sounded. She stated she felt it was not good idea to leave someone who had been restless all night sitting on the side of the bed unsupervised. RN#13 stated she had not received any in-servicing about alarm placement or function since the fall occurred. Licensed Practical Nurse (LPN) #10 was not working and could not be reached for interview by telephone. Her written statement dated 12/01/12 stated she had checked on the resident at approximately 7:30 A.M. She stated the resident was sitting up in bed, the alarm was on. The lights were on in the room and the call light was in reach. The confused resident told LPN #10 that she needed to get up it was time to go hunting. The nurse stated she responded it was not time to get up, it was time to rest. Interview with the DON on 12/13/12 at 7:17 A.M. revealed she was not sure what happened with that specific alarm. The alarm was bagged with other alarms which had failed to return to the sale representative. She stated he takes the problem alarms and then either returns the ones that are functioning properly or replaces the ones that malfunction. She stated that the alarm had sounded multiple times during the hours previous to the fall and was functioning when tested after the fall. She affirmed there had been no further questioning about the placement of the alarm, the testing of the specific alarm, or in-servicing of staff on alarm use after the incident. Resident #232 was observed on 12/10/12 at 3:20 P.M. sitting up in wheelchair in main area lounge area across from the nursing station. The chair alarm was in place on the back of her chair. RN #21 staff stated this is so they can watch her as she recently sustained a fall that resulted in a subdural hematoma. On 12/11/12 at 7:10 A.M. the resident was sitting in her wheelchair in the main lounge with a book The chair alarm was on the back of the chair. There were no resident observations on 12/12/12 and 12/13/12 as the resident was hospitalized with mental status changes. 2. Resident #126 was admitted to the facility in October of 2009. Review of the resident's medical record and physician assessments revealed the resident had current [DIAGNOSES REDACTED]. The facility completed a comprehensive assessment (MDS 3.0) of Resident #126 with an assessment reference date of 10/31/12. The resident was assessed as having impaired communication and hearing abilities, memory problems, severely impaired cognitive skills for decision making, and required the supervision of one staff person to transfer, for locomotion on the unit, toilet use, and as having limitations in range of motion of her lower extremities. There was also a fall risk assessment completed on 10/31/12 which indicated the resident was at high risk for falling related to cognitive loss, dementia, increased confusion, delusions, and anger with staff. Review of Resident #126's current comprehensive plan of care, and care giver guide, revealed fall prevention interventions for the Resident #126 included the use of chair and bed alarms, and keeping the resident's call light within reach. The bed and chair alarms were added to the plan of care 12/01/12 after the resident sustained [REDACTED]. Review of nursing notes dated 12/01/12 at 1:40 P.M. by RN #11, and interview with RN #20, revealed the resident wheeled herself into the corridor and reported to staff on 12/01/12 and stated that she had fallen. RN #11 documented in the nursing notes that in actuality it appeared the resident bumped her left forearm and left forehead above her left eye as she transferred herself independently from her wheel chair back into bed. The resident sustained [REDACTED]. The resident was not in any distress, neurological checks were initiated, and the resident's physician and family were notified. Interview with RN #20 on 12/12/12 at 3:25 P.M. affirmed the resident had not fallen from the chair, but bruised herself when transferring from her wheel chair into bed, and subsequently injured herself on the helper bar she used to transfer herself in and out of bed. She reported that staff was just outside the resident's room when she claimed she had fallen, and no fall, crashing sound, or thud was heard. RN #20 also stated that if Resident #126 fell out of bed or her wheel chair onto the floor, she would not have been able to transfer herself back into the bed or chair due to physical limitations. On 12/10/12 at 2:50 P.M. a beeping/alarm noise was evident in corridor outside the resident's room. The beeping noise was going unnoticed by staff. The nearest available staff person, Unit clerk/STNA #32 was asked what the noise was. Unit clerk/STNA #32 then entered Resident #126's room to find the resident sitting in an arm chair near her bed, with her wheel chair sitting in front of her with the pressure sensitive alarm pad in the resident's wheel chair sounding. Unit clerk/STNA #32 stated the resident had evidently transferred herself from the wheel chair to the arm chair independently resulting in the alarm in the wheel chair sounding. Where queried where Resident #126's call light was, she investigated and found the call light tied to the light cord along the wall next to the resident's bed. The bed was between the arm chair and wheel chair and the call cord tied to the light cord, placing the call light well out of the resident's reach. Unit clerk/STNA #32 untied the call cord from the light cord and placed it within the resident's reach. The resident stated that she wanted to lay down in bed. The Unit clerk/STNA #32 stated that she would get staff a staff person to assist her, and counseled the resident not to transfer herself without assistance and to use the call light. The resident was noted to have a fading yellowish bruise on her forehead at that time. On 12/12/12 at 5:23 P.M. a beeping/alarm noise was evident in the corridor outside the resident's room, no staff were responding to the sound of the alarm although RN #35 was in the vicinity of the room. From the corridor one could see the Resident #126 was on the toilet. The wheel chair in the bathroom and the chair alarm sounding, the resident had transferred herself to the toilet. RN #35 continued past the room, without checking Resident #126, to assist a resident who was calling out in a nearby room. The beeping/alarm noise from the resident's room stopped then started again as the resident was in the process of transferring herself into bed independently. RN #35 was alerted and entered the resident's room. Resident #126 had already transferred into bed independently. When RN #35 left the resident's room and affirmed the resident had already transferred herself into bed independently, and stated that she had heard the alarm going off but thought a staff person was in the bathroom and room with the resident.